- Michael Harper, MD
C. Bree Johnston, MD, MPH
C. Seth Landefeld, MD
GENERAL PRINCIPLES OF GERIATRIC CARE
The following principles help in caring for older adults:
- Many disorders are multifactorial in origin and are best managed by multifactorial interventions.
- Diseases often present atypically.
- Not all abnormalities require evaluation and treatment.
- Complex medication regimens, adherence problems, and polypharmacy are common challenges.
ASSESSMENT OF THE OLDER ADULT
Comprehensive assessment addresses three topics in addition to conventional assessment of symptoms and diseases: prognosis, values and preferences, and ability to function independently. Comprehensive assessment is warranted before major clinical decisions are made.
Assessment of Prognosis
When an older person’s life expectancy is > 10 years (ie, 50% of similar persons live longer than 10 years), it is reasonable to consider effective tests and treatments much as they are considered in younger persons. When life expectancy is < 10 years (and especially when it is much less), choices of tests and treatments should be made on the basis of their ability to improve that particular patient’s prognosis and quality of life in the shorter term of that patient’s life expectancy. The relative benefits and harms of tests and treatments often change as prognosis worsens.
When an older patient’s clinical situation is dominated by a single disease process (eg, lung cancer metastatic to brain), prognosis can be estimated well with a disease-specific instrument. Even in this situation, however, prognosis generally worsens with age (especially age > 90 years) and with the presence of serious age-related conditions, such as dementia, malnutrition, or impaired ability to walk.
When an older patient’s clinical situation is not dominated by a single disease process, prognosis can be estimated initially by considering the patient’s age, sex, and general health (Figure 4–1). For example, < 25% of men age 95 years will live 5 years, whereas nearly 75% of women age 70 years will live 10 years.
Figure 4–1. Median life expectancy of older women and men. (Adapted, with permission, from Walter LC et al. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. Am J Med. 2005 Oct;118(10):1078–86.) Copyright © Elsevier.
The prognosis of older persons living at home can be estimated by considering age, sex, comorbid conditions, and function (Table 4–1). The prognosis of older persons discharged from the hospital is worse than that of those living at home and can be estimated by considering gender, comorbid conditions, and function at discharge (Table 4–2).
Table 4–1. Prognostic factors, “risk points,” and 4-year mortality rates for older persons living at home.
Table 4–2. Prognostic factors, “risk points,” and 1-year mortality rates for older patients discharged from the hospital after an acute medical illness.
Assessment of Values & Preferences
Although patients vary in their values and preferences, most frail older patients prioritize maintaining their independence over prolonging survival. Values and preferences are determined by speaking directly with a patient or, when the patient cannot express preferences reliably, with the patient’s surrogate. The clinician might ask a patient considering a hip replacement, “How would you like your hip pain and function to be different? Tell me about the risk and discomfort you are willing to go through to achieve that improvement.”
In assessing values and preferences, it is important to keep in mind the following:
- Patients are experts about their preferences for outcomes and experiences; however, they often do not have adequate information to express informed preferences for specific tests or treatments.
- Patients’ preferences often change over time. For example, some patients find living with a disability more acceptable than they thought before experiencing it.
Assessment of Function
People often lose function in multiple domains as they age, with the results that they may not be able to do some activities as quickly or capably and may need assistance with other activities. Assessment of function improves prognostic estimates (see above). Assessment of function is essential to determining an individual’s needs in the context of their values and preferences, and the possible effects of prescribed treatment.
About one-fourth of patients over 65 have impairments in their IADLs (instrumental activities of daily living: transportation, shopping, cooking, using the telephone, managing money, taking medications, housecleaning, laundry) or ADLs (basic activities of daily living: bathing, dressing eating, transferring from bed to chair, continence, toileting). Half of those persons older than 85 years have these latter impairments.
Functional Screening Instrument
Functional screening should include assessment of ADL and IADL and questions to detect weight loss, falls, incontinence, depressed mood, self neglect, fear for personal safety, and common serious impairments (eg, hearing, vision, cognition, and mobility). Standard functional screening measures may not be useful in capturing subtle impairments in highly functional independent elders. One technique for these patients is to identify and regularly ask about a target activity, such as bowling or gardening. If the patient begins to have trouble with or discontinues an “advanced activity of daily living,” it may indicate early impairment, such as onset of cognitive impairment, incontinence, or worsening hearing loss, which additional gentle questioning or assessment may uncover.
“Frailty” is a term that describes older adults who experience decreased functional reserve. Frailty is characterized by multisystem dysregulation that usually includes chronic inflammation, sarcopenia, and alterations in neuroendocrine function. Persons with frailty are at increased risk for functional decline and death. There is no standard assessment tool for frailty. Elements of the frailty syndrome include slow gait speed, low hand grip strength, weight loss, low energy expenditure, and in some models, cognitive decline. The ideal strategies for preventing and treating the frailty syndrome are unknown. At present, treatment is largely supportive, multifactorial, and individualized based on patient goals, life expectancy, and comorbidities. Exercise, particularly strength and resistance training, is the intervention with the strongest evidence for benefit. Sometimes, transitioning a patient to a palliative approach or a hospice program is the most appropriate clinical intervention when efforts to prevent functional decline fail.
Clegg A et al. Frailty in elderly people. Lancet. 2013 Mar 2; 381(9868):752–62. Erratum in: Lancet.2013 Oct 19; 382(9901): 1328 [PMID: 23395245]
Fried TR et al. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011 May;83(2):278–82. [PMID: 20570078]
Sudore RL et al. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010 Aug 17;153(4):256–261. [PMID: 20713793]
MANAGEMENT OF COMMON GERIATRIC PROBLEMS
ESSENTIALS OF DIAGNOSIS
Progressive decline of intellectual function.
Loss of short-term memory and at least one other cognitive deficit.
Deficit severe enough to cause impairment of function.
Dementia is an acquired persistent and progressive impairment in intellectual function, with compromise of memory and at least one other cognitive domain, most commonly aphasia (typically, word finding difficulty), apraxia (inability to perform motor tasks, such as cutting a loaf of bread, despite intact motor function), agnosia (inability to recognize objects), and impaired executive function (poor abstraction, mental flexibility, planning, and judgment). The diagnosis of dementia requires a significant decline in function that is severe enough to interfere with work or social life.
Dementia has a prevalence that doubles every 5 years in the older population, reaching 30–50% at age 85. Alzheimer disease accounts for roughly two-thirds of dementia cases in the United States, with vascular dementia (either alone or combined with Alzheimer disease) and dementia with Lewy bodies accounting for much of the rest.
Depression and delirium are also common in elders, may coexist with dementia, and may also present with cognitive impairment. Depression is a common concomitant of early dementia. A patient with depression and cognitive impairment whose intellectual function improves with treatment of the mood disorder has an almost fivefold greater risk of suffering irreversible dementia later in life. Delirium, characterized by acute confusion, occurs much more commonly in patients with underlying dementia.
- Cognitive impairment—The Medicare Annual Wellness Visit mandates that clinicians assess patients for cognitive impairment. However, according to the US Preventive Services Task Force, there is insufficient evidence to recommend for or against screening all older adults for cognitive impairment. While there is logic in the argument that early detection may improve future planning and patient outcomes, empiric evidence that demonstrates a clear benefit for either patients or caregivers remains lacking.
When there is suspicion of cognitive impairment, the combination of a three-item word recall with a clock drawing task (also known as the “mini-cog”) is a simple screening test that is fairly quick to administer. Ask the patient to repeat three items followed by instructions to draw the face of a clock. While different methods for administering and scoring the clock draw test have been described, the authors of this chapter favor the approach of pre-drawing a four inch circle on a sheet of paper and instructing the patient to “draw a clock” with the time set at 10 minutes after 11. If the patient recalls all three items after 3 minutes the test is considered normal, and there is no need to score the clock. Conversely, if the patient recalls zero items, the test is considered abnormal, and similarly there is no need to score the clock. When the patient recalls one or two items, the test is normal when the clock is drawn correctly (numbers in the proper position and the time accurately portrayed). When a patient fails this simple screen, further cognitive evaluation with a standardized instrument is warranted. The Montreal Cognitive Assessment (MoCA ©) is a 30-point test that takes about 10 minutes to administer and examines several areas of cognitive function. A score below 26 is considered abnormal. Free downloadable versions in multiple languages are available at http://www.mocatest.org.
- Decision-making capacity—Cognitively impaired elders commonly face serious medical decisions, and the clinicians involved in their care must ascertain whether the capacity exists to make the choice. The following five elements should be considered in a thorough assessment: (1) ability to express a choice; (2) understanding relevant information about the risks and benefits of planned therapy and the alternatives, in the context of one’s values, including no treatment; (3) comprehension of the problem and its consequences; (4) ability to reason; and (5) consistency. A patient’s choice should follow from an understanding of the consequences.
Sensitivity must be used in applying these five components to people of various cultural backgrounds. Decision-making capacity varies over time. Furthermore, the capacity to make a decision is a function of the decision in question. A woman with mild dementia may lack the capacity to consent to coronary artery bypass grafting yet retain the capacity to designate a surrogate decision-maker.
- Symptoms and Signs
The clinician can gather important information about the type of dementia that may be present by asking about: (1) the rate of progression of the deficits as well as their nature (including any personality or behavioral change); (2) the presence of other neurologic symptoms, particularly motor problems; (3) risk factors for HIV; (4) family history of dementia; and (5) medications, with particular attention to recent changes.
Work-up is directed at identifying any potentially reversible causes of dementia. However, such cases are indeed rare. For a detailed description of the symptoms and signs of different forms of dementia, see Chapter 24.
- Physical Examination
The neurologic examination emphasizes assessment of mental status but should also include evaluation for sensory deficits, possible previous strokes, parkinsonism, or peripheral neuropathy. The remainder of the physical examination should focus on identifying comorbid conditions that may aggravate the individual’s disability. For a detailed description of the neuropsychological assessment, see Chapter 24.
- Laboratory Findings
Laboratory studies should include a complete blood count, electrolytes, calcium, creatinine, glucose, thyroid-stimulating hormone (TSH), and vitamin B12 levels. While hypothyroidism or vitamin B12deficiency may contribute to the cognitive impairment, treating these conditions typically does not completely reverse the dementia. HIV testing, RPR (rapid plasma reagin) test, heavy metal screen, and liver biochemical tests may be informative in selected patients but should not be considered part of routine testing. For a detailed description of laboratory findings, see Chapter 24.
Most patients should receive neuroimaging as part of the diagnostic work-up to rule out subdural hematoma, tumor, previous stroke, and hydrocephalus (usually normal pressure). Those who are younger and those who have focal neurologic symptoms or signs, seizures, gait abnormalities, and an acute or subacute onset are most likely to yield positive findings and most likely to benefit from MRI scanning. In older patients with a more classic picture of Alzheimer disease in whom neuroimaging is desired, a noncontrast CT scan is sufficient. For a detailed description of imaging, see Chapter 24.
Older individuals experience occasional difficulty retrieving items from memory (usually manifested as word-finding complaints) and experience a slowing in their rate of information processing. In mild cognitive impairment, a patient complains of memory problems, demonstrates mild deficits (most commonly in short-term memory) on formal testing, but does not meet criteria for dementia. Dementia will develop in more than half of people with mild cognitive impairment within 5 years. Acetylcholinesterase inhibitors have not consistently demonstrated a delay in the progression of mild cognitive impairment to Alzheimer disease. An elderly patient with intact cognition but with severe impairments in vision or hearing commonly becomes confused in an unfamiliar medical setting and consequently may be falsely labeled as demented.
Delirium can be distinguished from dementia by its acute onset, fluctuating course, and deficits in attention rather than memory. Because delirium and dementia often coexist, it may not be possible to determine how much impairment is attributable to each condition until the patient is fully recovered and back in their usual setting. Many medications have been associated with delirium and other types of cognitive impairment in older patients. Anticholinergic agents, hypnotics, neuroleptics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines (including H1 and H2-antagonists), and corticosteroids are just some of the medications that have been associated with cognitive impairment in elders.
Patients and families should be made aware of the Alzheimer’s Association (http://www.alz.org) as well as the wealth of helpful community and online resources and publications available. Caregiver support, education, and counseling may prevent or delay nursing home placement. Education should include the manifestations and natural history of dementia as well as the availability of local support services such as respite care. Even under the best of circumstances, caregiver stress can be substantial. Collaborative care models and disease management programs appear to improve the quality of care for patients with dementia.
- Cognitive Impairment
- Acetylcholinesterase inhibitors—Many experts recommend considering a trial of acetylcholinesterase inhibitors (eg, donepezil, galantamine, rivastigmine) in most patients with mild to moderate Alzheimer disease. These medications produce a modest improvement in cognitive function that is not likely to be detected in routine clinical encounters. Acetylcholinesterase inhibitors may also have similarly modest cognitive benefits in patients with vascular dementia or dementia with Lewy bodies. However, acetylcholinesterase inhibitors have not convincingly been shown to delay institutionalization or functional decline. There is insufficient evidence to recommend their use in mild cognitive impairment to slow the progression toward dementia or to improve cognitive test scores.
Starting doses, respectively, of donepezil, galantamine, and rivastigmine, are 5 mg orally once daily (maximum 10 mg once daily), 4 mg orally twice daily (maximum 12 mg twice daily), and 1.5 mg orally twice daily (maximum 6 mg twice daily). The doses are increased gradually as tolerated. The most bothersome side effects include diarrhea, nausea, anorexia, weight loss, and syncope. Some patients with moderate to severe cognitive impairment continue to experience benefits from acetylcholinesterase inhibitors. In those patients who have had no apparent benefit, experience side effects, or for whom the financial outlay is a burden, the drug should be discontinued.
- Memantine—In clinical trials, patients with more advanced disease have been shown to have statistical benefit from the use of memantine, anN-methyl-D-aspartate (NMDA) antagonist, with or without concomitant use of an acetylcholinesterase inhibitor. Long-term and meaningful functional outcomes have yet to be demonstrated.
- Behavioral Problems
- Nonpharmacologic approaches—Behavioral problems in demented patients are often best managed with a nonpharmacologic approach. Initially, it should be established that the problem is not unrecognized delirium, pain, urinary obstruction, or fecal impaction. It also helps to inquire whether the caregiver or institutional staff can tolerate the behavior, as it is often easier to find ways to accommodate to the behavior than to modify it. If not, the caregiver should keep a brief log in which the behavior is described along with antecedent events and consequences. Recurring precipitants of the behavior are often found to be present or it may be that the behavior is rewarded. Caregivers are taught to use simple language when communicating with the patient, to break down activities into simple component tasks, and to use a “distract, not confront” approach when the patient seems disturbed by a troublesome issue. Additional steps to address behavioral problems include providing structure and routine, discontinuing all medications except those considered absolutely necessary, and correcting, if possible, sensory deficits.
- Pharmacologic approaches—There is no clear consensus about pharmacologic approaches to treatment of behavioral problems in patients who have not benefited from nonpharmacologic therapies. The target symptoms—depression, anxiety, psychosis, mood lability, or pain—may suggest which class of medications might be most helpful in a given patient. Patients with depressive symptoms may show improvement with antidepressant therapy. Patients with dementia with Lewy bodies have shown clinically significant improvement in behavioral symptoms when treated with rivastigmine (3–6 mg orally twice daily).
Despite the lack of strong evidence, antipsychotic medications have remained a mainstay for the treatment of behavioral disturbances, particularly agitation and aggression, largely because of the lack of alternatives. The atypical antipsychotic agents (risperidone, olanzapine, quetiapine, aripiprazole, clozapine, ziprasidone) are reported to be better tolerated than older agents but should be avoided in patients with vascular risk factors due to an increased risk of stroke; they can cause weight gain and are also associated with hyperglycemia in diabetic patients and are considerably more expensive. Both typical and atypical antipsychotics in several short-term trials and one long-term trial increased mortality compared with placebo when used to treat elderly demented patients with behavioral disturbances. Starting and target dosages should be much lower than those used in schizophrenia (eg, haloperidol, 0.5–2 mg orally; risperidone, 0.25–2 mg orally).
Although drivers with dementia are at an increased risk for motor vehicle accidents, many patients continue to drive safely well beyond the time of diagnosis, making the timing of when to recommend that a patient stop driving particularly challenging.
There is no clear-cut evidence to suggest a single best approach to determining an individual patient’s risk, and there is no accepted “gold standard” test. The result is that clinicians must consider several factors upon which to base their judgment. For example, determining the severity of dementia can be useful. Patients with very mild or mild dementia according to the Clinical Dementia Rating Scale were able to pass formal road tests at rates of 88% and 69%, respectively. Experts agree that patients with moderately severe or more advanced dementia should be counseled to stop driving. Although not well studied, clinicians should also consider the effects of comorbid conditions and medications and the role each may play in contributing to the risk of driving by a patient with dementia. Assessment of the ability to carry out IADLs may also add to the determination of risk. Finally, in some cases of mild dementia, referral may be needed to a driver rehabilitation specialist for evaluation. Although not standardized, this evaluation often consists of both off- and on-road testing. The cost for this assessment can be substantial, and it is typically not covered by health insurance. Experts recommend such an evaluation for patients with mild dementia, for those with dementia for whom new impairment in driving skills is observed, and for those with significant deficits in cognitive domains such as attention, executive function, and visuospatial skills.
Clinicians must also be aware of the reporting requirements in their individual jurisdictions. Some states have mandatory reporting laws for clinicians, but in other states, the decision to report an unsafe driver with dementia is voluntary. When a clinician has made the decision to report an unsafe driver to the Department of Motor Vehicles, he or she must consider the impact as a potential breach in confidentiality and must weigh and address, in advance when possible, the consequences from the loss of driving independence.
- Advance Financial Planning
Difficulty in managing financial affairs often develops early in the course of dementia. The patient’s caregiver may seek advice from the patient’s primary care clinician. Although expertise is not expected, clinicians should have some proficiency to address financial concerns. Just as clinicians counsel patients and families about advance care planning, the same should be done to educate about the need for advance financial planning and to recommend that patients complete a durable power of attorney for finance matters (DPOAF) when the capacity to do so still exists. In most states the DPOAF can be executed with or without the aid of an attorney. Other options to assist in managing and monitoring finances include online banking, automatic bill payments, direct deposits and joint bank accounts. A potential risk of the joint account is that the joint account holder has no obligation to act in the best interest of the patient.
No gold standard test is available to identify when a patient with dementia no longer has financial capacity. However, the clinician should be on the lookout for signs that a patient is either at risk for or actually experiencing financial incapacity. Because financial impairment can occur when dementia is mild, making that diagnosis should alone be enough to warrant further investigation. Questioning patients and caregivers about late, missed or repeated bill payments, unusual or uncharacteristic purchases or gifts, overdrawn bank accounts and reports of missing funds can provide evidence of suspected financial impairment. Patients with dementia are also at increased risk for becoming victims of financial abuse and some answers to these same questions might also be signs of potential financial abuse. When financial abuse is suspected, clinicians should be aware of the reporting requirements in their local jurisdictions. Social workers can aid with this reporting.
Life expectancy after a diagnosis of Alzheimer disease is typically 3–15 years; it may be shorter than previously reported. Other neurodegenerative dementias, such as dementia with Lewy bodies, show more rapid decline. Hospice is often appropriate for patients with end-stage dementia.
When to Refer
Referral for neuropsychological testing may be helpful in the following circumstances: to distinguish dementia from depression, to diagnose dementia in persons of very poor education or very high premorbid intellect, and to aid diagnosis when impairment is mild.
Devanand DP et al. Relapse risk after discontinuation of risperidone in Alzheimer’s disease. N Engl J Med. 2012 Oct 18;367(16):1497–507. [PMID: 23075176]
Howard R et al. Donepezil and memantine for moderate-to-severe Alzheimer’s disease. N Engl J Med. 2012 Mar 8; 366(10):893–903. [PMID: 22397651]
Lin JS et al. Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force Ann Intern Med. 2013 November 5;159(9):601–12. [PMID: 24145578]
Russ TC et al. Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database Syst Rev. 2012 Sep 12;9:CD009132. [PMID: 22972133]
Widera E et al. Finances in the older patient with cognitive impairment: “He didn’t want me to take over”. JAMA. 2011 Feb 16; 305(7):698–706. [PMID: 21325186]
ESSENTIALS OF DIAGNOSIS
Depressed elders may not admit to depressed mood.
Depression screening in elders should include a question about anhedonia.
Depressive symptoms—often related to loss, disease, and life changes—may be present in more than 25% of elders; however, the prevalence of major depression is similar in younger and older populations. Depression is particularly common in hospitalized and institutionalized elders. Older single men have the highest suicide rate of any demographic group. Older patients with depression are more likely to have somatic complaints, less likely to report depressed mood, and more likely to experience delusions than younger patients. In addition, depression may be an early symptom of a neurodegenerative condition such as dementia. Depressed patients who have comorbid conditions (such as heart failure) are at higher risk for hospitalization, tend to have longer hospital stays, and have worse outcomes than their nondepressed counterparts.
A simple two-question screen—which consists of asking “During the past 2 weeks, have you felt down, depressed, or hopeless?” and “During the past 2 weeks, have you felt little interest or pleasure in doing things?”—is highly sensitive for detecting major depression in persons over age 65. Positive responses can be followed up with more comprehensive, structured interviews, such as the Geriatric Depression Scale (shttp://www.stanford.edu/~yesavage/GDS.html) or the PHQ-9.
Elderly patients with depressive symptoms should be questioned about medication use, since drugs (eg, benzodiazepines, corticosteroids) may contribute to the clinical picture. Similarly, several medical problems can cause fatigue, lethargy, or hypoactive delirium, all of which may be mistaken for depression. Particularly when delirium is the differential diagnosis, laboratory testing should include a complete blood count; liver, thyroid, and kidney function tests; serum calcium; urinalysis; and electrocardiogram.
Choice of antidepressant agent in elders is usually based on side effect profile, cost, and patient specific factors such as presenting symptoms and comorbidities. Selective serotonin reuptake inhibitors (SSRIs) are often used as first-line agents because of their relatively benign side-effect profiles (see Table 25–7). In general, fluoxetine is avoided because of its long duration of action and tricyclic antidepressants are avoided because of their high anticholinergic side effects. Mirtazapine is often used for patients with weight loss, anorexia, or insomnia. Venlafaxine or duloxetine may be useful in patients who also have neuropathic pain. Regardless of the drug chosen, many experts recommend starting elders at a relatively low dose, titrating to full dose slowly, and continuing for a longer trial (at least 8 weeks) before trying a different medication. For patients experiencing their first episode of depression, drug treatment should continue for at least 6 months after remission of the depression. Recurrence of major depression is common enough among elders that long-term maintenance medication therapy should be considered.
Problem-solving therapy and cognitive behavioral therapy can be effective alone or in combination with medication therapy. Depressed elders may do better with a collaborative or multidisciplinary care model that includes socialization and other support elements than with usual care.
When to Refer
Referral should be considered for patients who have not responded to an initial antidepressant drug trial and for patients with have symptoms of mania, suicidality, or psychosis.
When to Admit
Patients who are suicidal, homicidal, psychotic, or a danger to self or others should be considered for acute psychiatric hospitalization.
Kok RM et al. Continuing treatment of depression in the elderly: a systematic review and meta-analysis of double-blinded randomized controlled trials with antidepressants. Am J Geriatr Psychiatry. 2011 March;19(3):249–55. [PMID: 21425505]
Leontjevas R et al. A structural multidisciplinary approach to depression management in nursing-home residents: a multicentre, stepped-wedge cluster-randomised trial. Lancet. 2013 Jun 29;381(9885):2255–64. [PMID: 23643110]
Prina AM et al. Association between depression and hospital outcomes among older men. CMAJ. 2013 Feb 5;185(2):117–23. [PMID: 23228999]
ESSENTIALS OF DIAGNOSIS
Rapid onset and fluctuating course.
Primary deficit in attention rather than memory.
May be hypoactive or hyperactive.
Dementia frequently coexists.
Delirium is an acute, fluctuating disturbance of consciousness, associated with a change in cognition or the development of perceptual disturbances (see also Chapter 25). It is the pathophysiologic consequence of an underlying general medical condition such as infection, coronary ischemia, hypoxemia, or metabolic derangement. Delirium persists in up to 25% of patients and is associated with worse clinical outcomes (higher in-hospital and postdischarge mortality, longer lengths of stay, greater probability of placement in a nursing facility).
Although the acutely agitated elderly patient often comes to mind when considering delirium, many episodes are more subtle. Such quiet, or hypoactive, delirium may only be suspected if one notices new cognitive slowing or inattention.
Cognitive impairment is an important risk factor for delirium. Approximately 25% of delirious patients are demented, and 40% of demented hospitalized patients are delirious. Other risk factors are male sex, severe illness, hip fracture, fever or hypothermia, hypotension, malnutrition, polypharmacy and use of psychoactive medications, sensory impairment, use of restraints, use of intravenous lines or urinary catheters, metabolic disorders, depression, and alcoholism.
A number of bedside instruments for the assessment of delirium are available. The confusion assessment method (CAM), which requires (1) acute onset and fluctuating course and (2) inattention and either(3) disorganized thinking or (4) altered level of consciousness, is easy to administer and performs well.
A key component of a delirium work-up is review of medications because a large number of drugs, the addition of a new drug, or the discontinuation of a drug known to cause withdrawal symptoms are all associated with the development of delirium. Medications that are particularly likely to increase the risk of delirium include opioids, benzodiazepines, as well as H1- and H2-antihistamines.
Laboratory evaluation of most patients should include a complete blood count, electrolytes, blood urea nitrogen (BUN) and serum creatinine, glucose, calcium, albumin, liver function studies, urinalysis, and electrocardiography. In selected cases, serum magnesium, serum drug levels, arterial blood gas measurements, blood cultures, chest radiography, urinary toxin screen, head CT scan, and lumbar puncture may be helpful.
Prevention is the best approach in the management of delirium. Measures include improving cognition (frequent reorientation, activities, socialization with family and friends, when possible), sleep (massage, noise reduction, minimizing interruptions at night), mobility, vision (visual aids and adaptive equipment), hearing (portable amplifiers, cerumen disimpaction), and hydration status (volume repletion). No medications have been consistently shown to prevent delirium or reduce its duration or severity.
Management of established episodes of delirium is largely supportive and includes reassurance and reorientation, treatment of underlying causes, eliminating unnecessary medications, and avoidance of indwelling catheters and restraints. Antipsychotic agents (such as haloperidol, 0.5–1 mg orally, or quetiapine, 25 mg orally, at bedtime or twice daily) are considered the medication of choice when drug treatment of delirium is necessary. As with dementia, caution should be used when prescribing antipsychotic medications, including checking the QTc interval, eliminating other QTc prolonging medications, and correcting any deficiencies of electrolytes. Benzodiazepines should be avoided except in the circumstance of alcohol or benzodiazepine withdrawal. In ventilated patients in the intensive care unit setting, dexmedetomidine or propofol (or both) may also be useful alternatives or adjuncts to antipsychotic therapy in patients with delirium.
Most episodes of delirium clear in a matter of days after correction of the precipitant, but some patients suffer episodes of much longer duration, and a significant percentage never return to their former baseline level of functioning.
When to Refer
If an initial evaluation does not reveal the cause of delirium or if entities other than delirium are in the differential diagnosis, referral to a neuropsychologist, neurologist, or geropsychiatrist should be considered.
When to Admit
Patients with delirium of unknown cause should be admitted for an expedited work-up if consistent with the patient’s goals of care.
Clegg A et al. Which medications to avoid in people at risk of delirium: a systematic review. Age Aging. 2011 Jan;40(1):23–9. [PMID: 21068014]
Vidal EI et al. Delirium in older adults. BMJ. 2013 Apr 9;346:f2031. [PMID: 23571740]
Although common in older people, reduced mobility is never normal and is often treatable if its causes are identified. Bed rest is an important cause of hospital-induced functional decline. Among hospitalized medical patients over 70, about 10% experience a decline in function, much of which results from preventable reductions in mobility.
The hazards of bed rest in older adults are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate. More striking changes occur in skeletal muscle, with loss of contractile velocity and strength. Pressure ulcers, deep venous thrombosis, and pulmonary embolism are additional serious risks. Within days after being confined to bed, the risk of postural hypotension, falls, and skin breakdown rises rapidly in the older patient. Moreover, recovery from these changes usually takes weeks to months.
Prevention & Treatment
When immobilization cannot be avoided, several measures can be used to minimize its consequences. Skin should be inspected at least daily. If the patient is unable to shift position, staff should do so every 2 hours. To minimize cardiovascular deconditioning, patients should be positioned as close to the upright position as possible, several times daily. To reduce the risks of contracture and weakness, range of motion and strengthening exercises should be started immediately and continued as long as the patient is in bed. Whenever possible, patients should assist with their own positioning, transferring, and self-care. For patients at high risk for venous thromboembolism, antithrombotic measures should be used if that is consistent with the patient’s goals of care (see Chapter 14).
Avoiding restraints and discontinuing intravenous lines and urinary catheters will increase opportunities for early mobility. Graduated ambulation should begin as soon as it is feasible. Advice from a physical therapist is often helpful both before and after discharge. Prior to discharge, physical therapists can recommend appropriate exercises and assistive devices; after discharge, they can recommend safety modifications and maintenance exercises.
Brown CJ et al. Mobility limitation in the older patient: a clinical review. JAMA. 2013 Sep 18;310(11):1168–77. [PMID: 24045741]
Covinsky KE et al. Hospitalization-associated disability: “She was probably able to ambulate, but I ‘m not sure”. JAMA. 2011 Oct 26;306(16):1782–93. [PMID: 22028354]
- Falls & Gait Disorders
About one-third of people over age 65 fall each year, and the frequency of falls increases markedly with advancing age. About 10% of falls result in serious injuries such as fractures, soft tissue injuries, and traumatic brain injuries. Complications from falls are the leading cause of death from injury in persons over age 65. Hip fractures are common precursors to functional impairment, nursing home placement, and death.
Every older person should be asked about falls. Assessment of patients who fall should include postural blood pressure and pulse, thorough cardiac examination, evaluations of strength, range of motion, cognition, and proprioception, and examination of feet and footwear. A thorough gait assessment should be performed in all older people. Gait and balance can be readily assessed by the “Up and Go Test,” in which the patient is asked to stand up from a sitting position without use of hands, walk 10 feet, turn around, walk back, and sit down. Patients who take < 10 seconds are usually normal, patients who take longer than 30 seconds tend to need assistance with many mobility tasks, and those in between tend to vary widely with respect to gait, balance, and function. The ability to recognize common patterns of gait disorders is an extremely useful clinical skill to develop. Examples of gait abnormalities and their causes are listed in Table 4–3.
Table 4–3. Evaluation of gait abnormalities.
Causes of Falls
Balance and ambulation require a complex interplay of cognitive, neuromuscular, and cardiovascular function. With age, balance mechanisms can become compromised and postural sway increases. These changes predispose the older person to a fall when challenged by an additional insult to any of these systems.
A fall may be the clinical manifestation of an occult problem, such as pneumonia or myocardial infarction, but much more commonly falls are due to the interaction between an impaired patient and an environmental risk factor. Falls in older people are rarely due to a single cause, and effective intervention entails a comprehensive assessment of the patient’s intrinsic deficits (usually diseases and medications), the activity engaged in at the time of the fall, and environmental obstacles.
Intrinsic deficits are those that impair sensory input, judgment, blood pressure regulation, reaction time, and balance and gait. Dizziness may be closely related to the deficits associated with falls and gait abnormalities. While it may be impossible to isolate a sole “cause” or a “cure” for falls, gait abnormalities, or dizziness, it is often possible to identify and ameliorate some of the underlying contributory conditions and improve the patient’s overall function.
Medication use is one of the most common, significant, and reversible causes of falling. A meta-analysis found that sedative/hypnotics, antidepressants, and benzodiazepines were the classes of drugs most likely to be associated with falling. The use of multiple medications simultaneously has also been associated with an increased fall risk. Other often overlooked but treatable contributors include postural hypotension (including postprandial, which peaks 30–60 minutes after a meal), insomnia, use of multifocal lenses, and urinary urgency.
Since most falls occur in or around the home, a visit by a visiting nurse, physical therapist, or health care provider for a home safety evaluation reaps substantial benefits in identifying environmental obstacles and is generally reimbursed by third-party payers, including Medicare.
Complications of Falls
The most common fractures resulting from falls are of the wrist, hip, and vertebrae. There is a high mortality rate (approximately 20% in 1 year) in elderly women with hip fractures, particularly if they were debilitated prior to the time of the fracture.
Fear of falling again is a common, serious, but treatable factor in the elderly person’s loss of confidence and independence. Referral to a physical therapist for gait training with special devices is often all that is required.
Chronic subdural hematoma is an easily overlooked complication of falls that must be considered in any elderly patient presenting with new neurologic symptoms or signs. Headache or known history of trauma may both be absent.
Patients who are unable to get up from a fall are at risk for dehydration, electrolyte imbalance, pressure sores, rhabdomyolysis, and hypothermia.
Prevention & Management
The risk of falling and consequent injury, disability, and potential institutionalization can be reduced by modifying those factors outlined in Table 4–4. Emphasis is placed on treating all contributory medical conditions (eg, cataracts), minimizing environmental hazards, and eliminating medications where the harms may outweigh the benefits—particularly those that induce orthostasis and parkinsonism (eg, alpha-blockers, nitrates, antipsychotics). Also important are strength, balance, and gait training as well as screening and treatment for osteoporosis, if present. Falls and fractures may be prevented by prescribing vitamin D at a dose of 800 international units daily or higher.
Table 4–4. Fall risk factors and targeted interventions and best evidence for fall prevention.
Assistive devices, such as canes and walkers, are useful for many older adults but are often used incorrectly. Canes should be used on the “good” side. The height of walkers and canes should generally be about the level of the wrist. Physical therapists are invaluable in assessing the need for an assistive device, selecting the best device, and training a patient in its correct use.
Early surgery for patients with cataracts may reduce falls, but eyeglasses, particularly bifocal or graduated lenses, may actually increase the risk of falls, particularly in the early weeks of use. Patients should be counseled about the need to take extra care when new eyeglasses are being used.
Patients with repeated falls are often reassured by the availability of phones at floor level, a portable phone, or a lightweight radio call system. Their therapy should also include training in techniques for arising after a fall. The clinical utility of anatomically designed external hip protectors in reducing fractures is currently uncertain.
When to Refer
Patients with a recent history of falls should be referred for physical therapy, eye examination, and home safety evaluation.
When to Admit
If the patient has new falls that are unexplained, particularly in combination with a change in the physical examination, hospitalization should be considered.
Chang HJ et al. JAMA patient page. Falls and older adults. JAMA. 2010 Jan 20;303(3):288. [PMID: 20085959]
Moyer VA. Prevention of falls in community-dwelling older adults: U.S. Preventive Health Services Task Force recommendation statement. Ann Intern Med. 2012 Aug 7;157(3):197–204. [PMID: 22868837]
Tinetti ME et al. The patient who falls: “It’s always a trade-off”. JAMA. 2010 Jan 20;303(3):258–66. [PMID: 20085954]
- Urinary Incontinence
ESSENTIALS OF DIAGNOSIS
Involuntary loss of urine.
Stress incontinence: leakage of urine upon coughing, sneezing, or standing.
Urge incontinence: urgency and inability to delay urination.
Overflow incontinence: may have variable presentation.
Incontinence in older adults is common, and interventions can improve most patients. Many patients fail to tell their providers about it. A simple question about involuntary leakage of urine is a reasonable screen: “Do you have a problem with urine leaks or accidents?”
Because continence requires adequate mobility, mentation, motivation, and manual dexterity, problems outside the bladder often result in incontinence. In general, the authors of this chapter find it useful to differentiate between “transient” or “potentially reversible” causes of incontinence and more “established” causes.
- Transient Causes
Use of the mnemonic “DIAPPERS” may be helpful in remembering the categories of transient incontinence.
- Delirium—A clouded sensorium impedes recognition of both the need to void and the location of the nearest toilet. Delirium is the most common cause of incontinence in hospitalized patients; once it clears, incontinence usually resolves.
- Infection—Symptomatic urinary tract infection commonly causes or contributes to urgency and incontinence. Asymptomatic bacteriuria does not.
- Atrophic urethritis or vaginitis—Atrophic urethritis can usually be diagnosed presumptively by the presence of vaginal mucosal telangiectasia, petechiae, erosions, erythema, or friability. Urethral inflammation, if symptomatic, may contribute to incontinence in some women. Some experts suggest a trial of topical estrogen in these cases.
- Pharmaceuticals—Drugs are one of the most common causes of transient incontinence. Typical offending agents include potent diuretics, anticholinergics, psychotropics, opioid analgesics, alpha-blockers (in women), alpha-agonists (in men), and calcium channel blockers.
- Psychological factors—Severe depression with psychomotor retardation may impede the ability or motivation to reach a toilet.
- Excess urinary output—Excess urinary output may overwhelm the ability of an older person to reach a toilet in time. In addition to diuretics, common causes include excess fluid intake; metabolic abnormalities (eg, hyperglycemia, hypercalcemia, diabetes insipidus); and disorders associated with peripheral edema, with its associated heavy nocturia when previously dependent legs assume a horizontal position in bed.
- Restricted mobility—(See Immobility section, above.) If mobility cannot be improved, access to a urinal or commode (eg, at the bedside) may improve continence.
- Stool impaction—This is a common cause of urinary incontinence in hospitalized or immobile patients. Although the mechanism is still unknown, a clinical clue to its presence is the onset of both urinary and fecal incontinence. Disimpaction usually restores urinary continence.
- Established Causes
Causes of established incontinence should be addressed after the transient causes have been uncovered and managed appropriately.
- Detrusor overactivity (urge incontinence)—Detrusor overactivity refers to uninhibited bladder contractions that cause leakage. It is the most common cause of established geriatric incontinence, accounting for two-thirds of cases, and is usually idiopathic. Women will complain of urinary leakage after the onset of an intense urge to urinate that cannot be forestalled. In men, the symptoms are similar, but detrusor overactivity commonly coexists with urethral obstruction from benign prostatic hyperplasia. Because detrusor overactivity also may be due to bladder stones or tumor, the abrupt onset of otherwise unexplained urge incontinence—especially if accompanied by perineal or suprapubic discomfort or sterile hematuria—should be investigated by cystoscopy and cytologic examination of a urine specimen.
- Urethral incompetence (stress incontinence)—Urethral incompetence is the second most common cause of established urinary incontinence in older women. Stress incontinence is most commonly seen in men after radical prostatectomy. Stress incontinence is characterized by instantaneous leakage of urine in response to a stress maneuver. It commonly coexists with detrusor overactivity. Typically, urinary loss occurs with laughing, coughing, or lifting heavy objects. Leakage is worse or occurs only during the day, unless another abnormality (eg, detrusor overactivity) is also present. To test for stress incontinence, have the patient relax her perineum and cough vigorously (a single cough) while standing with a full bladder. Instantaneous leakage indicates stress incontinence if urinary retention has been excluded by postvoiding residual determination using ultrasound. A delay of several seconds or persistent leakage suggests that the problem is instead caused by an uninhibited bladder contraction induced by coughing.
- Urethral obstruction—Urethral obstruction (due to prostatic enlargement, urethral stricture, bladder neckcontracture, or prostatic cancer) is a common cause of established incontinence in older men but is rare in older women. It can present as dribbling incontinence after voiding, urge incontinence due to detrusor overactivity (which coexists in two-thirds of cases), or overflow incontinence due to urinary retention. Renal ultrasound is required to exclude hydronephrosis in men whose postvoiding residual urine exceeds 150 mL.
- Detrusor underactivity (overflow incontinence)—Detrusor underactivity is the least common cause of incontinence. It may be idiopathic or due to sacral lower motor nerve dysfunction. When it causes incontinence, detrusor underactivity is associated with urinary frequency, nocturia, and frequent leakage of small amounts. The elevated postvoiding residual urine (generally over 450 mL) distinguishes it from detrusor overactivity and stress incontinence, but only urodynamic testing differentiates it from urethral obstruction in men. Such testing usually is not required in women, in whom obstruction is rarely present.
- Transient Causes
Each identified transient cause should be treated regardless of whether an established cause coexists. For patients with urinary retention induced by an anticholinergic agent, discontinuation of the drug should first be considered. If this is not feasible, substituting a less anticholinergic agent may be useful.
- Established Causes
- Detrusor overactivity—The cornerstone of treatment is bladder training. Patients start by voiding on a schedule based on the shortest interval recorded on a bladder record. They then gradually lengthen the interval between voids by 30 minutes each week using relaxation techniques to postpone the urge to void. Lifestyle modifications, including weight loss and caffeine reduction, may also improve incontinence symptoms. For cognitively impaired patients and nursing home residents who are unable to manage on their own, timed and prompted voiding initiated by caregivers is effective.
Pelvic floor muscle (“Kegel”) exercises can reduce the frequency of incontinence episodes when performed correctly and sustained. If behavioral approaches prove insufficient, drug therapy with antimuscarinic agents may provide additional benefit. The two oral drugs for which there is the most experience are tolterodine and oxybutynin. Available regimens of these drugs follow: short-acting tolterodine, 1–2 mg twice a day; long-acting tolterodine, 2–4 mg daily; short-acting oxybutynin, 2.5–5 mg twice or three times a day; long-acting oxybutynin, 5–15 mg daily; and oxybutynin transdermal patch, 3.9 mg per day applied twice weekly. All of these agents can produce delirium, dry mouth, or urinary retention; long-acting preparations may be better tolerated. Agents such as fesoterodine (4–8 mg orally once daily), trospium chloride (20 mg orally once or twice daily), long-acting trospium chloride (60 mg orally daily), darifenacin (7.5–15 mg orally daily), and solifenacin (5–10 mg orally daily) appear to have similar efficacy and have not been clearly demonstrated to be better tolerated than the older agents in long-acting form.
The beta-3-agonist, mirabegron, 25–50 mg orally daily, is the first of a novel class of drugs approved for overactive bladder symptoms, which includes urge urinary incontinence. In trials comparing mirabegron with antimuscarinic drugs, the efficacy and safety profiles have been comparable, with less dry mouth reported in persons who received mirabegron. However, because of its potential cardiac effects and the relatively small number of adults over the age of 70 who have been studied in trials, mirabegron’s role in the treatment of urge urinary incontinence in frail older adults or those with hypertension or cardiac conditions remains to be determined.
An alternative to oral agents is an injection of onabotulinumtoxinA into the detrusor muscle. In a head-to-head comparison of onabotulinumtoxinA with antimuscarinic drugs, patients had similar rates of reduction of incontinence episodes. Persons who received onabotulinumtoxinA had higher rates of complete resolution of incontinence and lower rates of dry mouth but were more likely to experience urinary retention and urinary tract infections than those who did not receive onabotulinumtoxinA.
The combination of behavioral therapy and antimuscarinics appears to be more effective than either alone although one study in a group of younger women showed that adding behavioral therapy to individually titrated doses of extended-release oxybutynin was no better than drug treatment alone.
In men with both benign prostatic hyperplasia and detrusor overactivity and who have postvoid residual volumes of ≤ 150 mL, an antimuscarinic agent added to an alpha-blocker may provide additional relief of lower urinary tract symptoms.
- Urethral incompetence (stress incontinence)—Lifestyle modifications, including limiting caffeine intake and timed voiding, may be helpful for some women, particularly women with mixed stress/urge incontinence. Pelvic floor muscle exercises are effective for women with mild to moderate stress incontinence; the exercises can be combined, if necessary, with biofeedback, electrical stimulation, or vaginal cones. Instruct the patient to pull in the pelvic floor muscles and hold for 6–10 seconds and to perform three sets of 8–12 contractions daily. Benefits may not be seen for 6 weeks. Pessaries or vaginal cones may be helpful in some women but should be prescribed by providers who are experienced with using these modalities.
Although a last resort, surgery is the most effective treatment for stress incontinence; cure rates as high as 96% can result, even in older women. Drug therapy is limited. Clinical trials have shown that duloxetine, a serotonin and norepinephrine reuptake inhibitor, reduces stress incontinence episodes in women but efficacy in older women remains unknown. It is approved for use for this indication in some countries but not the United States. Side effects, including nausea, are common.
- Urethral obstruction—Surgical decompression is the most effective treatment for obstruction, especially in the setting of urinary retention due to benign prostatic hyperplasia. A variety of nonsurgical techniques make decompression feasible even for frail men. For the nonoperative candidate with urinary retention, intermittent or indwelling catheterization is used. For a man with prostatic obstruction who does not require or desire immediate surgery, treatment with alpha-blocking agents (eg, terazosin, 1–10 mg daily; prazosin, 1–5 mg orally twice daily; tamsulosin, 0.4–0.8 mg daily) can improve symptoms and delay obstruction. Finasteride, 5 mg daily, can provide additional benefit to an alpha-blocking agent in men with an enlarged prostate.
- Detrusor underactivity—For the patient with a poorly contractile bladder, augmented voiding techniques (eg, double voiding, suprapubic pressure) often prove effective. If further emptying is needed, intermittent or indwelling catheterization is the only option. Antibiotics should be used only for symptomatic upper urinary tract infection or as prophylaxis against recurrent symptomatic infections in a patient using intermittent catheterization; they should not be used as prophylaxis with an indwelling catheter.
When to Refer
- Men with urinary obstruction who do not respond to medical therapy should be referred to a urologist.
- Women who do not respond to medical and behavioral therapy should be referred to a urogynecologist or urologist.
Chapple CR et al. Randomized double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron, a β3-adrenoreceptor agonist, in overactive bladder. Eur Urol. 2013 Feb;63(2):296–305. [PMID: 23195283]
Goode PS et al. Incontinence in older women. JAMA. 2010 Jun 2;303(21):2172–81. [PMID: 20516418]
Visco AG et al. Anticholinergic therapy vs. onabotulinumtoxinA for urgency urinary incontinence. N Engl J Med. 2012 Nov 8;367(19):1803–13. [PMID: 23036134]
- Weight Loss
Weight loss affects substantial numbers of elderly. The degree of unintended weight loss that deserves evaluation is not agreed upon, although a reasonable threshold is loss of 5% of body weight in 1 month or 10% of body weight in 6 months.
Useful laboratory and radiologic studies for the patient with weight loss include complete blood count, serum chemistries (including glucose, TSH, creatinine, calcium, and in men, testosterone), urinalysis, and chest radiograph. These studies are intended to uncover an occult metabolic or neoplastic cause but are not exhaustive. Exploring the patient’s social situation, cognition, mood, and dental health are at least as important as looking for a purely medical cause of weight loss.
Oral nutritional supplements of 200–1000 kcal/d can increase weight and improve outcomes in malnourished hospitalized elders. Megestrol acetate as an appetite stimulant has not been shown to increase body mass or lengthen life in among elders and has significant side effects. For those who have lost the ability to feed themselves, assiduous hand feeding may allow maintenance of weight. Although artificial nutrition and hydration (“tube feeding”) may seem a more convenient alternative, it deprives the patient of the enjoyment associated with eating as well as the social milieu typically associated with mealtime; before this option is chosen, the patient or his or her surrogate should be offered the opportunity to review the benefits and burdens of the treatment in light of overall goals of care. If tube feeding is initiated and the patient makes repeated attempts to pull out the tube, the utility of tube feeding should be reconsidered. Tube feeding is not recommended for patients with end-stage dementia.
Abellan van Kan G et al. The assessment of frailty in older adults. Clin Geriatr Med. 2010 May;26(2):275–86. [PMID: 20497846]
Boockvar KS et al. Chapter 8: Palliative care for frail older adults: “There are things I can’t do anymore that I wish I could…”. In: McPhee SJ et al (editors): Care at the Close of Life: Evidence and Experience. McGraw-Hill, 2010
Srinivas-Shankar U et al. Effects of testosterone on muscle strength, physical function, body composition, and quality of life in intermediate-frail and frail elderly men: a randomized, double-blind, placebo controlled study. J Clin Endocrinol Metab. 2010 Feb;95(2):639–50. [PMID: 20061435]
- Pressure Ulcers
ESSENTIALS OF DIAGNOSIS
Examine at-risk patients on admission to the hospital and daily thereafter.
Pressure ulcers should be described by one of six stages:
- Non-blanchable hyperemia (stage I).
- Extension through epidermis (stage II).
- Full thickness skin loss (stage III).
- Full thickness wounds with extension into muscle, bone, or supporting structures (stage IV).
- If eschar or slough overlies the wound, the wound is unstageable.
- Suspected deep tissue injury is an area of discolored or blistered skin.
The majority of pressure ulcers develop during a hospital stay for an acute illness. Incident rates range from 3% to 30% and vary according to patient characteristics. The primary risk factor for pressure ulcers is immobility. Other contributing risk factors include reduced sensory perception, moisture (urinary and fecal incontinence), poor nutritional status, and friction and shear forces.
Suspected deep tissue injury and unstageable are included in the six pressure ulcer stages. Ulcers in which the base is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) are considered unstageable. Suspected deep tissue injury is an area of purple or maroon discolored intact skin or blood-filled blister. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue.
A number of risk assessment instruments including the Braden Scale and the Norton score can be used to assess the risk of developing pressure ulcers; both have reasonable performance characteristics. These instruments can be used to identify the highest risk patients who might benefit most from scarce resources such as mattresses that reduce or relieve pressure.
While Medicare does not reimburse for hospital-acquired pressure ulcers, there is a higher reimbursement for pressure ulcers present on admission. Therefore, clinicians should include a full skin assessment on every admission evaluation.
Using specialized support surfaces (including mattresses, beds, and cushions), patient repositioning, optimizing nutritional status, and moisturizing sacral skin are strategies that have been shown to reduce pressure ulcers. For moderate- to high-risk patients, mattresses or overlays that reduce tissue pressure below a standard mattress appear to be superior to standard mattresses. The literature comparing specific products is sparse and inconclusive.
Evaluation of pressure ulcers should include patient’s risk factors and goals of care, wound stage, size, depth, presence or absence of exudate, type of exudate present, appearance of the wound bed, and whether there appears to be surrounding infection, sinus tracking, or cellulitis. In poorly healing or atypical pressure ulcers, biopsy should be performed to rule out malignancy or other less common lesions such as pyoderma gangrenosum.
Treatment is aimed toward removing necrotic debris and maintaining a moist wound bed that will promote healing and formation of granulation tissue. The type of dressing that is recommended depends on the location and depth of the wound, whether necrotic tissue or dead space is present, and the amount of exudate (Table 4–5). Pressure-reducing devices (eg, air-fluid beds and low air loss beds) are associated with improved healing rates. Although poor nutritional status is a risk factor for the development of pressure ulcers, the results of trials of nutritional supplementation in the treatment of pressure ulcers have been disappointing.
Table 4–5. Treatment of pressure ulcers.
Providers can become easily overwhelmed by the array of products available for treatment of established pressure ulcers. Most institutions should designate a wound care expert or wound care team to select a streamlined wound care product line that has simple guidelines. In a patient with end-stage disease who is receiving palliative care, appropriate treatment might be directed toward comfort (including minimizing dressing changes and odors) rather than efforts directed at healing.
Pressure ulcers are associated with increased mortality rates, although a causal link has not been proven. Complications include pain, cellulitis, osteomyelitis, systemic sepsis, and prolongation of lengths of stay in the inpatient or nursing home setting.
When to Refer
Ulcers that are large or nonhealing should be referred to a plastic or general surgeon or dermatologist for biopsy, debridement, and possible skin grafting.
When to Admit
Patients with pressure ulcers should be admitted if the primary residence is unable to provide adequate wound care or pressure reduction, if the wound is infected, or for complex or surgical wound care.
Langemo DK et al; National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2010 Feb;23(2):59–72. [PMID: 20087072]
Lohi J et al. Local dressings for pressure ulcers: what is the best tool to apply in primary and secondary care? Wound Care. 2010 Mar;19(3):123–7. [PMID: 20559190]
National Pressure Ulcer Advisory Panel Website: http://www.npuap.org/pr2.htm
- Pharmacotherapy & Polypharmacy
There are several reasons for the greater incidence of iatrogenic drug reactions in the elderly population, the most important of which is the high number of medications that elders take. Drug metabolism is often impaired in this group due to a decrease in glomerular filtration rate as well as reduced hepatic clearance. Older individuals often have varying responses to a given serum drug level. Thus, they are more sensitive to some drugs (eg, opioids) and less sensitive to others (eg, beta-blocking agents). Most emergency hospitalizations for recognized adverse drug events among older persons result from only a few medications used alone or in combination; examples include warfarin, antiplatelet agents, insulins, oral hypoglycemic agents, and to a lesser extent, opioid analgesics and digoxin.
Precautions in Administering Drugs
Nonpharmacologic interventions can often be a first-line alternative to drugs (eg, diet for mild hypertension or type 2 diabetes mellitus). Therapy is begun with less than the usual adult dosage and the dosage increased slowly, consistent with its pharmacokinetics in older patients. However, age-related changes in drug distribution and clearance are variable among individuals, and some require full doses. After determining acceptable measures of success and toxicity, the dose is increased until one or the other is reached.
Despite the importance of beginning new drugs in a slow, measured fashion, all too often an inadequate trial is attempted (in terms of duration or dose) before discontinuation. Antidepressants, in particular, are frequently stopped before therapeutic dosages are reached.
A number of simple interventions can help improve adherence to the prescribed medical regimen. When possible, the clinician should keep the dosing schedule simple, the number of pills low, the medication changes as infrequent as possible, and encourage the patient to use a single pharmacy. Pillboxes or “medi-sets” help some patients with adherence.
Having the patient or caregiver bring in all medications at each visit can help the clinician perform medication reconciliation and reinforce reasons for drug use, dosage, frequency of administration, and possible adverse effects. Medication reconciliation is particularly important if the patient sees multiple providers.
The risk of toxicity goes up with the number of medications prescribed. Certain combinations of medications (eg, warfarin and many types of antibiotics, digoxin and clarithromycin, angiotensin-converting enzyme inhibitors and NSAIDs) are particularly likely to cause drug-drug interactions and should be watched carefully.
Trials of individual drug discontinuation should be considered (including sedative-hypnotics, antipsychotic medications, digoxin, proton pump inhibitors, NSAIDs) when the original indication is unclear, the goals of care have changed, or the patient might be experiencing side effects.
When to Refer
Patients with poor or uncertain adherence may benefit from referral to a pharmacist or a home health nurse.
Budnitz DS et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011 Nov 24;365(21):2002–12. [PMID: 22111719]
Gallagher PF et al. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011 Jun;89(6):845–54. [PMID: 21508941]
Steinman MA et al. Managing medications in clinically complex elders: “There’s got to be a happy medium”. JAMA. 2010 Oct 13;304(14):1592–601. [PMID: 20940385]
- Vision Impairment
Visual impairment due to age-related refractive error (“presbyopia”), macular degeneration, cataracts, glaucoma, and diabetic retinopathy contributes to impaired quality of life for many older adults. The prevalence of serious and correctable visual disorders in elders is sufficient to warrant a complete eye examination by an ophthalmologist or optometrist annually or biannually for most elders. Many patients with visual loss benefit from a referral to a low vision program, and primary care providers should not assume that an ophthalmologist or optometrist will automatically make this referral.
Rosenberg EA et al. The visually impaired patient. Am Fam Physician. 2008 May 15;77(10):1431–6. [PMID: 18533377]
- Hearing Impairment
Over one-third of persons over age 65 and half of those over age 85 have some hearing loss. Hearing loss is associated with social isolation, depression, and an increased risk of cognitive impairment. A reasonable screen is to ask patients if they have hearing impairment. Those who answer “yes” should be referred for audiometry. Those who answer “no” may still have hearing impairment and can be screened by a handheld audioscope or the whispered voice test. The whispered voice test is administered by standing 2 feet behind the subject, whispering three random numbers, and simultaneously rubbing the external auditory canal of the non-tested ear to mask the sound. If the patient is unable to identify all three numbers, the test should be repeated with different numbers, and if still abnormal, a referral should be made to audiometry. To determine the degree to which hearing impairment interferes with functioning, the provider may ask if the patient becomes frustrated when conversing with family members, is embarrassed when meeting new people, has difficulty watching TV, or has problems understanding conversations. Caregivers or family members often have important information on the impact of hearing loss on the patient’s social interactions.
Hearing amplification can improve hearing-related quality of life in patients with hearing loss. However, compliance with hearing amplification can be a challenge because of dissatisfaction with performance; stigma associated with hearing aid use; and cost, since hearing amplification is not paid for under most Medicare plans. Newer digital devices may perform better but are considerably more expensive. Special telephones, amplifiers for the television, and other devices are helpful to many patients. Portable amplifiers are pager-sized units with earphones attached; they can be purchased inexpensively at many electronics stores and can be useful in health care settings for improving communication with hearing impaired patients. In general, facing the patient and speaking slowly in a low tone is a more effective communication strategy than shouting.
Chou R et al. Screening adults aged 50 years or older for hearing loss: a review of the evidence for the U.S. Preventive Service Task Force. Ann Intern Med. 2011 March 1;154(5):347–55. [PMID: 21357912]
Lin FR et al; Health ABC Study Group. Hearing loss and cognitive decline in older adults. JAMA Intern Med. 2013 Feb 25;173(4):293–9. [PMID: 23337978]
Pacala JT et al. Hearing deficits in the older patient: “I didn’t notice anything”. JAMA. 2012 Mar 21;307(11):1185–94. [PMID: 22436959]
- Elder Mistreatment & Self Neglect
Elder mistreatment is defined as “actions that cause harm or create a serious risk of harm to an older adult by a caregiver or other person who stands in a trust relationship to the older adult, or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” Self neglect is the most common form of elder mistreatment and occurs among all demographic strata of the aging population. According to the best available estimates, the prevalence of potential neglect and psychological and financial abuse is about 5% each, with other forms of abuse being less common.
Clues to the possibility of elder abuse include behavioral changes in the presence of the caregiver, delays between occurrences of injuries and when treatment was sought, inconsistencies between an observed injury and associated explanation, lack of appropriate clothing or hygiene, and not filling prescriptions. Many elders with cognitive impairment become targets of financial abuse. Both elder abuse and self neglect are associated with an increased risk of mortality.
It is helpful to observe and talk with every older person alone for at least part of a visit in order to ask questions directly about possible abuse and neglect (Table 4–6). When self neglect is suspected, it is critical to establish whether a patient has decision-making capacity in order to determine what course of action needs to be taken. A patient who has full decision-making capacity should be provided with help and support but can choose to live in conditions of self neglect, providing that the public is not endangered by the actions of the person. In contrast, a patient who lacks decision-making capacity who lives in conditions of self neglect will require more aggressive intervention, which may include guardianship, in-home help, or placement in a supervised setting. Mental state scores, such as the MoCA, may provide some insight into the patient’s cognitive status but are not designed to assess decision-making capacity. A standardized tool, such as the “Aid to Capacity Evaluation,” is easy to administer, has good performance characteristics for determining decision-making capacity, and is available free online at www.jointcentreforbioethics.ca/tools/ace_download.shtml.
Table 4–6. Phrases and actions that may be helpful in situations of suspected abuse or neglect.
When to Refer
The laws in most states require health care providers to report suspected abuse or neglect to Adult Protective Services; agencies are available in all 50 states to assist in cases of suspected elder abuse. The Web site for the National Center for Elder Abuse is http://www.ncea.aoa.gov. When it is unclear whether a patient has decision-making capacity after an initial assessment, or whether an untreated mental health disorder is contributing to the problem, a referral to a mental health professional is appropriate.
When to Admit
Hospital admission is appropriate when a patient is unsafe in the community and an alternate plan cannot be put into place in a timely manner.
Mosqueda L et al. Elder abuse and self-neglect: “I don’t care anything about going to the doctor, to be honest…”. JAMA. 2011 Aug 3;306(5):532–40. [PMID: 21813431]
Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011 July 27;306(4):420–7. [PMID: 21791691]