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Geriatrics - Genesys Family Medi

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					               Geriatrics




Geriatrics
Geriatrics 1
               Demography: Key Indicators
                  Population
                      ―Baby boomers‖ (1946-64) will dramatically
                       change the aging demographics
                      In 2000, 35 million persons 65+ lived in the
                       US. By 2030, this will double to 70 million
                      The 85+ age group is growing faster than
                       any other age group
                      Women make up 58% of those 65+, but
                       70% of those 85+
                      In 1998, 41% of older women lived alone,
                       compared to 17% of older men
Geriatrics 2
                Life Expectancy

               Current age   Males   Females
                 At birth    68.9     76.6
                  55 y       20.6     26.6
                  65 y       13.9     18.3
                  75 y        8.7     11.6
                  85 y        5.5      6.9

Geriatrics 4
               US Census Data and
               Projections
               Year     Pop.        Age 65+    Age 75+
                      (millions)
         1960         181 m        9.2 %      3.1%
         1980         222 m        11.2 %     4.2 %

         2000         260 m        12.2 %     5.5 %

         2020 est.    290 m        15.5 %     5.9%


Geriatrics 5
               Key Indicators of Well-Being
                  Economics
                      Older persons living in poverty declined
                       from 35% in 1959 to 11% in 1998
                      In 1998, Social Security provided >80% of
                       income for older Americans with the lowest
                       levels of income. For those in the highest
                       income category, SS accounted for ~ 20%
                       of income
                      Households headed by older black persons
                       had median net worth of ~ $13K in 1999,
                       compared with ~ $181K headed by older
                       white persons
Geriatrics 6
Percent Distribution by Income: 2000
               Key Indicators of Well-Being
               (Cont’d)
                  Health Status
                      The leading causes of death for older Americans
                       are heart disease, cancer, and stroke
                       (respectively). Mortality rates for heart disease
                       and stroke have declined by about a third since
                       1980. Mortality rates for cancer have risen slightly
                       over the same period
                      In 1995, 58% of persons over 70 reported having
                       arthritis, 45% reported hypertension, and 21%
                       reported heart disease
                      In 1998 4% of persons 65-69 had moderate to
                       severe memory loss compared to 36% of persons
                       85+
                      23% of persons 85+ reported severe symptoms of
Geriatrics 8           depression
               Key Indicators of Well-Being
               (Cont’d)
                  Health Risks and Behaviors
                      The majority of persons 70+ reported
                       engaging in some form of social activity during
                       a 2-week period. 2/3 age 70+ reported
                       satisfaction with their level of social activities
                      In 1995, 1/3 of older Americans reported a
                       sedentary lifestyle
                      Self-reporting re: diet: 21% ―good‖, 67%
                       ―need improvement‖, 13% ―poor‖
                      Older persons are much less likely to be
                       victims of both violent and property crime than
                       persons age 12-64
Geriatrics 9
                Key Indicators of Well-Being
                (Cont’d)
                   Health Care
                       Older persons of all ages are generally satisfied
                        with their health care and few report difficulty
                        obtaining health care services
                       In 1996 average annual expenditure on health
                        care: age 65-69: $5,864; age 85+: $16,465
                       In 1997, 4% of population 65+ resided in
                        nursing homes; ¾ were women
                       Older persons receiving home care in 1994:
                        64% relied exclusively on informal (unpaid)
                        care, 8% received only formal care and 28%
                        received a combo of informal and formal care
Geriatrics 10
                General Principles of Aging:
                Old Foks Are Different
                   Atypical presentation of acute illness
                   Multiple concurrent problems
                   Non-specific symptoms
                   Hidden illness
                   Under-reporting
                   Multiple ―losses‖ condensed into a short
                    time span
                   Expected physiologic aging changes

Geriatrics 11
                Atypical Presentation of
                Acute Illness
                   Only 40% of elderly fit the classic one
                    symptom=one disease model
                       Acute myocardial infarction without chest
                        pain
                       Acute hyperthyroidism without tachycardia,
                        weight loss, etc.
                       Acute infection without rising WBC count or
                        typical fever
                       Fatigue as chief presenting complaint of
                        CHF

Geriatrics 12
                Non-Specific Symptoms
                   Confusion
                   Self-neglect
                   Falling
                   Incontinence
                   Apathy
                   Anorexia/weight loss
                   Dyspnea
                   Fatigue
                   ―Taking to bed‖
Geriatrics 13
                Hidden Illness:
                You Must Ask, They Won‘t Tell!
                   Sexual dysfunction
                   Depression
                   Incontinence
                   Musculoskeletal stiffness
                   Alcoholism
                   Hearing loss
                   Memory loss

Geriatrics 14
                Under-Reporting Due To:
                   Belief that symptoms are due to old age
                   Fear or denial
                   Concern about cost
                   Embarrassment
                   Mental impairment
                   Concern about ill spouse
                   Previous bad experience with health
                    care system
                   Fear of institutionalization
Geriatrics 15
                Multiple Concurrent Losses
                   Loss of physical health
                   Loss social contacts: friends/family die
                   Loss of familiar roles: mother, wife,
                    employed person
                   Loss of financial security: retirement,
                    widowhood
                   Loss of independence and power
                   Loss of mental stability

Geriatrics 16
                Normal Aging vs. Disease
                   Aging is NOT a disease
                   Learn to separate pathologic processes
                    from the ―aging process‖
                   Concentrate on how physical problems
                    interfere with the ability of the person to
                    remain independent (functional in their
                    usual environment)


Geriatrics 17
                Normal Aging vs. Disease
                (Cont’d)
                   Normal aging                  Disease
                       ―Crow‘s feet‖                 Macular
                       Presbycusis                    degeneration
                       Seborrheic                    Tympano-sclerosis
                        keratoses; loss of            Basal cell CA
                        skin elasticity               Dementia
                       Benign forgetfulness          Athero-sclerosis
                       Decreased blood               Hypertension
                        vessel compliance
                                                      Obesity
                       Increase in % body
                        fat
Geriatrics 18
                Laboratory Values that Do Not
                Change with Aging
                   Hepatic function (ALT, AST, GGPT,
                    Bilirubin)
                   Coagulation tests
                   Chemistries: electrolytes, total protein,
                    calcium, phosphorus
                   ABG‘s: pH, PaCO2
                   Hemoglobin, RBC indices, platelet
                    count

Geriatrics 19
                Laboratory Values that Do
                Change with Aging
                   Decreases: Serum albumin ,
                    magnesium, PaO2, T3, T4, Creatinine
                    clearance, white blood cell count
                   Increases: Alkaline Phosphatase, uric
                    acid, blood sugar, TSH,
                    BUN/Creatinine




Geriatrics 20
                Health Maintenance
                in the Elderly
                   Recommend primary and secondary
                    disease prevention screening
                   Review all medications
                   Control all chronic medical problems
                   Optimize function
                   Verify the presence of an adequate
                    support system
                   Discuss and document advanced
                    directives
Geriatrics 21
                Prevention
                   Primary
                       Preventing the occurrence of disease or injury
                       Examples: Immunizations, Safety Equipment or Clean
                        water
                   Secondary
                       Early detection and intervention preferably before the
                        condition is clinically apparent
                       Screening programs:
                          Breast cancer screening

                          BP screening


                   Tertiary
                       Minimizing the effects of disease and disability by
                        surveillance and maintenance aimed and preventing
                        complications
Geriatrics 22
                Primary and Secondary
                Preventions
                  BP screening
                  Influenza, pneumonia, tetanus
                   immunizations
                  Obesity (height and weight)

                  Smoking cessation

                  Consider ASA to prevent MI/CVA

                  Cholesterol screening

                  Diabetes Mellitus screening

                  Osteoperosis screening - females
Geriatrics 23
                Primary and Secondary
                Preventions (Cont’d)
                   Cancer Screening
                       Breast
                       Cervical – ―usually‖ not >65
                       Colorectal
                       Prostate-discussion
                       Skin (Risk-based)
                   Hearing/visual impairment screening
                   Cognitive impairment screening
                   Consider TSH in women


Geriatrics 24
                Iatrogenesis: A Definition
                   Any illness that results from a
                    diagnostic/therapeutic intervention or
                    the omission of such intervention that is
                    not a natural consequence of the
                    patient‘s disease




Geriatrics 25
                Caring for Hospitalized Elderly
                 20-36% of older patients have their
                  hospitalization prolonged by major
                  adverse events
                 One study compared those under 65

                  to those over 65: complication rate
                  was 29% vs. 45%
                 Another study showed hospital

                  related complications in 40.5% of
                  those > 70, and 8.5% of those < 70
Geriatrics 26
                The Hospital Cascade
                of Disasters
                   Hospitalization new environment and
                    new medications acute delirium 
                    more new drugs and/or restraints 
                    more agitation; Foley inserted poor oral
                    intake dehydration IV fluids
                    increased and/or NG tube placed for
                    feeding
                   We now have the potential for congestive
                    heart failure, thrombophlebitis,
                    pulmonary embolism, aspiration
                    pneumonia, falls and fractures, pressure
Geriatrics 27
                    sores, urosepsis, septic shock, etc . . .
                The Hospital is a
                Hazardous Place...
                   Drugs:
                       Polypharmacy
                       Alterations in drug disposition and tissue
                        sensitivity
                       Drug-to-drug interactions
                       Changes in renal/hepatic elimination
                       Medications errors
                       Medication side effects (expected)


Geriatrics 28
                The Hospital is a
                Hazardous Place... (Cont’d)
                   Bed rest and immobility
                       General cardiac and muscle deconditioning
                       Postural lightheadedness, hypovolemia,
                        hypotension
                       Pressure sores
                       Constipation/fecal impaction
                       Atelectasis and pneumonia
                       Thrombophlebitis and thromboembolism
                       Urinary incontinence

Geriatrics 29
                The Hospital is a
                Hazardous Place... (Cont’d)
                   Therapeutic and diagnostic procedures
                       Angiography
                       GI endoscopy and its preparation
                       TUBES: IV‘s, NG‘s, Foley‘s, restraints,
                        dialysis and transfusions
                       Surgery and anesthesia
                   Nosocomial Infections
                       Pneumonia, C. difficile, MRSA


Geriatrics 30
                The Hospital is a
                Hazardous Place... (Cont’d)
                   Under nutrition
                       Cognitive impairment
                       Social isolation
                       Poor dentition
                       Impaired thirst perception
                       Limited access to food and fluids
                       Chronic disease



Geriatrics 31
                Keys to Prevention
                A Checklist to Monitor the Hospitalized
                   Diagnosis
                   Medications
                   Nutrition
                   Continence
                   Cognition
                   Emotional status
                   Mobility
                   The Caregiver

Geriatrics 32
                Diagnosis
                   Keep accurate medical and surgical
                    diagnosis lists
                   Prioritize medical therapies, addressing
                    reversible problems first
                   Clarify the specific medical goals of the
                    hospitalization
                   Carefully select diagnostics: ―Is this
                    procedure necessary and how will it
                    change my management?‖

Geriatrics 33
                Medications
                   Make an accurate list of all medications
                    on admission, including OTC‘s and
                    herbals
                   Always consider adverse drug effects
                    as the cause of new symptoms
                   Monitor appropriate blood levels
                    (Digoxin, dilantin)
                   Try to control pain without narcotics first
                   Monitor/review need for medications
                    daily
Geriatrics 34
                Nutrition
                   Avoid long NPO periods if possible
                   Albumin and total cholesterol signal poor
                    nutritional state
                   Provide vitamin supplementation
                   Adjust fluid therapy on an individual basis
                   Ask about nausea/anorexia, food
                    satisfaction daily
                   The hospital is an excellent place to obtain
                    a professional nutritional consultation

Geriatrics 35
                Continence
                   Maintain mobility and cognitive function
                    to avoid incontinence
                   Reduce IV fluid rates at night
                   Avoid anti-cholinergic medications
                   Reassure the patient that new urinary
                    incontinence is usually temporary
                   Monitor bowel function early and daily to
                    prevent incontinence, constipation and
                    food refusal
Geriatrics 36
                Cognition
                   Premorbid cognitive disorders lead to a
                    very high incidence of delirium--expect it,
                    prevent it
                   Carefully monitor fluids and electrolytes
                   Minimize psychoactive medications
                   Use acetaminophen around the clock to
                    manage fever and/or pain
                   Use environmental strategies (lights,
                    family sitters during the night)
                   Address hearing and vision problems
Geriatrics 37
                Emotional Status
                   Address anxiety, pain and insomnia
                    early
                   Depression common: 20-60% of
                    hospitalized elderly; treat it
                   Frequently update family; hold
                    patient/family conferences to allay fears
                    and clarify ―the plan‖


Geriatrics 38
                Mobility
                   Avoid physical restraints including
                    Foleys
                   Encourage patient range of motion
                    activities and resistive exercises in bed
                   Expect self-sufficiency
                   Enlist PT/OT therapists early for those
                    with poor mobility and transfer skills
                   If bed immobile, inspect for skin
                    pressure areas daily
Geriatrics 39
                The Care Giver
                   Is there a competent, willing and
                    acceptable caregiver?
                   Assess care giver burden/burnout
                   Identify patients at risk for skilled
                    nursing facility placement
                   Anticipate post-hospital needs such as
                    medical equipment, oxygen and home
                    care services


Geriatrics 40
                Drug Therapy in the Elderly
                   Prescription drug expenses make up ~ 7%
                    of total health care spending in elderly
                   65% of Americans age 65+ use at least
                    one prescription medication
                   Elderly (65+) use 30% of Rx drugs and
                    40% of OTC drugs
                   Elderly with drug coverage average-18
                    prescriptions per year
                   Elderly in nursing homes receive an
                    average of 7 different medications
Geriatrics 41
                Pharmacokinetics: Absorption
               Physiologic change           Clinical significance
                   No significant               Little to none
                    change in gastric
                    pH; decreased
                    absorptive surface
                    and splanchnic
                    blood flow;
                    generally preserved
                    gastric emptying
                    time


Geriatrics 42
                Pharmacokinetics: Distribution
                   Increased body fat
                       Significance: Fat soluble drugs cross
                        membranes more easily and spread widely
                        (diazepam)
                   Decreased lean body mass
                       Significance: Water soluble drugs cross
                        barriers less easily and are largely
                        confined to lean body tissue (cimetidine,
                        digoxin, ethanol)


Geriatrics 43
                Pharmacokinetics: Distribution
                (Cont’d)
                   Decreased serum albumin and lower
                    protein binding
                       Significance: Lower protein binding in
                        elderly (theophylline, warfarin, cimetidine)
                       Exception: lidocaine binds primarily to
                        alpha-1-acid-glycoprotein and it shows
                        higher binding in the elderly



Geriatrics 44
                Pharmacokinetics:
                Hepatic Metabolism
         Physiologic change          Clinical significance
               Decreased liver           Phase 1 reactions
                mass and hepatic           altered (oxidation,
                blood flow                 reduction, hydrolysis)
                                          Phase 2 reactions
                                           (conjugation) not
                                           significantly affected



Geriatrics 45
                Pharmacokinetics:
                Renal Elimination
               Physiologic change         Clinical significance
                   Creatinine                 Dose adjustments
                    clearance reduced           required for drugs
                    with aging or               predominantly
                    disease                     excreted by the
                                                kidneys (digoxin,
                                                LMWH)




Geriatrics 46
                Contributors to Noncompliance
                in Older Adults
                   Complex treatment regimens and
                    dosing schedules
                   Medication side effects
                   Physical disability (dysphagia, arthritis)
                   Cognitive impairment
                   Poor communication
                   Inadequate understanding of therapy
                   High cost of medications

Geriatrics 47
                Contributors to Polypharmacy
                   Patient
                       Borrowing or sharing medications
                       Failing to understand instructions
                       Saving medication for later use
                       Combining Rx‘s with OTC‘s and Herbals
                       Visiting more than one physician
                   Doctor
                       Failing to review the patient‘s medications
                       Prescribing medications for common and non-life
                        threatening symptoms
                       Treating multiple symptoms or illnesses with
                        several drugs
Geriatrics 48
                Principles of Appropriate Drug
                Prescribing
                   Be alert to the possibility of drug
                    interactions and adverse drug reactions
                   Consider efficacy, cost (generic vs.
                    brand), and ease of administration
                   Avoid using multiple drugs with similar
                    actions and toxicity
                   Do not prescribe drugs longer than
                    necessary; discontinue if no longer
                    indicated

Geriatrics 49
                Principles of Appropriate Drug
                Prescribing (Cont’d)
                   Keep the drug regimen simple—once or twice
                    daily dosing
                   Be aware that patients may visit other
                    prescibers
                   Initiate therapy with the lowest recommended
                    dose and increase slowly (―Start low, go
                    slow‖)
                   Justify the use of each drug—what is the
                    active problem you are treating??
                   Understand the pharmacokinetics and
                    pharmacodynamics of drugs prescribed
Geriatrics 50
                Principles of Appropriate Drug
                Prescribing (Cont’d)
                   Psychotropic drugs (all of them) and
                    cardiovascular drugs (all of them) cause
                    undesirable side effects. Use them with
                    caution
                   Review all meds at each patient visit (―brown
                    bag test‖) including indications and dosing
                   Ask about the use of OTC‘s and herbals
                   Involve the patient in decision making and
                    maintain open communication
                   Encourage the patient to report any new or
                    unusual symptoms
Geriatrics 51
                Goals of Geriatric Assessment
                   Improve diagnostic accuracy
                   Define functional impairment
                   Limit iatrogenesis
                   Prevent cascade of disasters
                   Recommend optimal living situation
                   Predict outcomes
                   Monitor clinical change over time

Geriatrics 52
                Data-Gathering
                   Listen to patient but verify with competent
                    observers
                   May be very time intensive--use two or
                    more sessions if necessary
                   ―Chief complaint‖ may be misleading
                   Medication history is pivotal—‖brown bag‖
                   Tailor the review of systems
                   Family history often unhelpful
                   Always seek data regarding functional
                    abilities
Geriatrics 53
                Review of Systems/(Function)
                   Appetite/weight             Cough/Dyspnea
                    change                      Constipation/laxativ
                   Fatigue                      e use or abuse
                   Falling/gait/balance        Incontinence
                   Sleep                       Frequency/Nocturia
                   Depression                  Memory
                   Hearing/visual loss          loss/confusion
                   Alcohol use                 Headache
                   Joint pain, stiffness,      Transient weakness
                    ROM                          or visual symptoms
                                                 (TIA‘s)
Geriatrics 54
                Areas of Assessment
                   Functional assessment
                   Mobility, gait and balance
                   Sensory and Language impairments
                   Continence
                   Nutrition
                   Cognitive/Behavior problems
                   Depression
                   Caregivers
See Appendix A at End of Chapter
Geriatrics 55
                Functional Assessment
                   Activities of Daily Living (ADL):
                    Feeding, dressing, ambulating,
                    toileting, bathing, transfer, continence,
                    grooming, communication
                   Instrumental ADL (IADL): Cooking,
                    cleaning, shopping, meal prep,
                    telephone use, laundry, managing
                    money, managing medications, ability
                    to travel
Geriatrics 56
                Mobility, Gait and Balance
                   Get up and go test: rise from a sitting position
                    with arms crossed, walk in a straight line for
                    15-20 feet, turn, return to chair and sit down
                   Maintain standing balance when receiving a
                    slight sternal nudge
                   Bend down and reach as if to pick up an
                    object
                   Shoulder/hand function
                   Feet: structural problems, neuropathy,
                    proper foot wear

Geriatrics 58
                Sensory Impairments
                   Visual testing
                       Read a sentence from the newspaper
                       Pocket Snellen chart
                       Diabetics need annual dilated eye exam by
                        ophthalmologist
                   Auditory Testing
                       Assess hearing during history-taking
                       Whisper words behind the back
                       Finger Friction: rub your thumb and index
                        finger in front of ear
Geriatrics 59
                       Formal audiometric evaluation
                Continence
                   A hidden disease; you must ask
                   Simple screening questions
                   Office evaluation often adequate to
                    make a major difference
                   Incontinence section to follow




Geriatrics 60
                Nutrition
                   Assess any patient admitted to the hospital or
                    nursing home
                   Assess for weight change, anorexia, chewing
                    or swallowing problems
                   Questions about alcohol a MUST (use CAGE)
                   Low albumin and total cholesterol may be
                    clues
                   2-3 day diet journal may be the most helpful
                    screening tool
                   Establish and record serial weights (minimum
                    yearly) and heights (minimum Q3Y)
Geriatrics 61
                Cognitive Problems
                   Goals of cognitive screening
                       Detect unsuspected mental impairment
                       Provide baseline for future encounters
                       Discover those at risk for delirium
                       Provide concrete data for
                        competency/decision-making opinions
                       Dementia section to follow



Geriatrics 62
                Depression
                   Commonly missed
                   Somatic complaints often predominate
                   Many, many drugs should be suspected
                   Suicide in elderly males is high
                   Target your search: recent
                    bereavement, psychosocial losses,
                    dementia, functional impairment, severe
                    illness or surgery
                   Yesavage Geriatric Depression Scale
See Appendix B at End of Chapter
Geriatrics 63
                Care Givers
                   Lack of a willing or capable care giver is
                    a prominent reason for ECF placement
                   Is the care giver acceptable to the
                    elder?
                   Is the care giver evidencing ‗burn-out‘?
                   Is there evidence of elder abuse or
                    neglect?
                   Zarit Burden Interview is a short
                    instrument that can introduce the topic
                    of caregiver stress in a non-threatening
Geriatrics 64       way
                Putting it All Together:
                the Care Plan
                   List all problems (physical, social, functional)
                   List the strengths you find in the present
                    situation and build on them
                   Reduce the list to those problems that are out
                    of control and/or you can remedy
                   Treat acute medical problems with
                    appropriate aggressiveness
                   Manage chronic problems—control, not cure
                   Address routine health maintenance
                   Do the medications relate 1:1 to an active
                    problem?
Geriatrics 65
                The Care Plan (Cont’d)
                   What functional problems are most amenable
                    to intervention?
                   Is there evidence of chronic uncontrolled pain?
                   Is there evidence of dementia or depression?
                    Treat it
                   Are there any geriatric syndromes to address?
                   Is the living situation appropriate?
                   Is there evidence of a willing, capable,
                    appropriate and acceptable care giver?
                   Would any community resources benefit the
                    situation?
Geriatrics 66
                Mistreatment of Elders
                Elder abuse shall mean an act or omission
                which results in harm or threatened harm to
                the health or welfare of an elderly person.
                Abuse includes intentional infliction of
                physical or mental injury; sexual abuse; or
                withholding of necessary food, clothing and
                medical care to meet the physical and mental
                needs of an elderly person by one having the
                care, custody or responsibility of an elderly
                person


Geriatrics 67
                Types of Abuse and Neglect
                   Physical abuse: Intentional infliction of
                    physical discomfort, pain or injury
                       Hitting, slapping, inappropriate use of
                        restraints, sexual assault
                   Psychological abuse: Intentional
                    infliction of mental anguish or
                    provocation of fear of violence or
                    isolation
                       Name-calling, chronic verbal aggression,
                        intimidation, threats of institutionalization,
                        withholding security and affection, withholding
                        contact with family or friends
Geriatrics 68
                Types of Abuse and Neglect
                (Cont’d)
                   Material abuse: misappropriation or
                    misuse of funds or possessions
                       Fraud, theft, extortion/use of undo influence
                        to persuade elderly to relinquish control, use
                        or ownership of funds or possessions
                   Neglect: withholding of physical,
                    material, or emotional necessities of
                    physical and mental health whether
                    intentionally or unintentionally
Geriatrics 69
                Risk Factors for Maltreatment
                   Female, living alone, over age 75
                   Poor health/functional status
                   Cognitive impairment
                   Abuser suffers substance abuse/mental
                    illness
                   Dependence of abuser on victim (such as
                    shared living arrangements)
                   Elder‘s needs exceed caregivers abilities
                   Social isolation
                   History of family violence/antisocial behavior
Geriatrics 70
                Presentations Suggesting
                Abuse
                   Delay between injury/illness and seeking
                    care
                   Disparity in history from patient and
                    suspect
                   Implausible or vague explanations
                    provided by either party
                   Frequent visits to the ER for
                    exacerbations of chronic disease despite
                    a plan for medical care and apparently
                    adequate resources
Geriatrics 71
                Presentations Suggesting
                Abuse (Cont’d)
                   Numerous injuries at various stages of
                    healing
                   Elder presents with poor nutrition,
                    hygiene, or misses appointments
                   Presentation of impaired elder without a
                    caregiver



Geriatrics 72
                Abuse/Neglect Indicators
                   No food, or rotten food in the house
                   Clothes extremely dirty or uncared for
                   Not dressed appropriately for the weather
                   Utilities cut off
                   Gross accumulation of garbage, papers and
                    clutter
                   Large number of pets with no apparent
                    means of care
                   Signs checks over to others; out of money
Geriatrics 73
                    by second week of the month
                Abuse/Neglect Indicators
                (Cont’d)
                   Swollen eyes or ankles, decayed teeth or
                    no teeth
                   Bites, fleas, sores, lacerations
                   Untreated pressure sores
                   Broken glasses frames or lenses
                   Medication non-compliance
                   Refusal to accept presence of visitors
                   Unjustified pride in self-sufficiency
                   Vague health complaints
Geriatrics 74
                AMA Proposed Screening
                Questions
                   Has anyone at home ever hurt you?
                   Has anyone ever touched you without
                    your consent?
                   Has anyone ever made you do things
                    you didn‘t want to do?
                   Has anyone taken anything that was
                    yours without asking?
                   Has anyone ever scolded or threatened
                    you?
Geriatrics 75
                AMA Proposed Screening
                Questions (Cont’d)
                   Have you ever signed any documents
                    that you didn‘t understand?
                   Are you afraid of anyone at home?
                   Are you alone a lot?
                   Has anyone ever failed to help you take
                    care of yourself when you needed help?



Geriatrics 76
                Documentation is Essential
                   Use quotations or verbatim comments
                    made by the patient in describing an
                    event or situation
                   Detail descriptions of all injuries, using
                    body charts and/or color photographs




Geriatrics 77
                Management of Confirmed
                Mistreatment
                   Two pivotal questions:
                       Does the patient accept or refuse
                        intervention?
                       Does the patient retain decision-making
                        capacity?




Geriatrics 78
                Intervention
                   Currently there is no therapy of choice
                   Many victims refuse help
                   Victims often deny abuse
                   Most elderly persons would rather
                    receive inadequate care living with their
                    family than excellent care in an
                    institution
                   Do not attempt or initiate individual
                    heroic rescues
Geriatrics 79
                Intervention (Cont’d)
                   Hospitalize if emergency intervention is
                    required
                   Report incident to Adult Protective
                    Services
                   Decompress the situation: Adult day
                    care, respite housing, counseling,
                    support groups
                   Legal aid
                   Home Health Assistance
Geriatrics 80
                Medical Care in
                the Nursing Home
                   Skilled nursing beds: 1.5-2 million in US
                   5% of those over 65 live in a NH
                   45% of NH residents are over age 85
                   75% of NH residents are female
                   60% have moderate-to-severe dementia
                   50% admitted to NH die there
                   Cost: $20-45K per patient per year

Geriatrics 81
                Types of NH Residents
                   ―Short-stayers‖: 1-6 months
                       Terminally ill
                       Short term rehabilitation
                       Debilitated post-acute care hospitalization
                   ―Long-stayers‖: 6 months to years
                       Primarily cognitively impaired
                       Significant impairments of both cognitive
                        and physical functioning
                       Primarily physically impaired
Geriatrics 82
                Factors Precipitating NH
                Placement
                   Care requirements exceed the ability of
                    care giver
                   Behaviors due to dementia: nocturnal
                    wandering, aggressive behavior,etc
                   Bed bound status requiring total ADL
                    support
                   Bowel and/or bladder incontinence
                   Recurrent falling
                   Insufficient financial resources to
                    maintain help at home
Geriatrics 83
                Physician Duties in the NH
                   Verify transfer or admission orders from
                    the transferring facility
                   Perform history and physical within 48
                    hours of admission
                   Schedule regular reassessments
                    (frequency mandated by the
                    government: q30d x 3, then q60d
                    thereafter
                   Comply with multiple OBRA (1987
                    Omnibus Budget Reconciliation Act)
Geriatrics 84
                    regulations
                Admission Checklist
                   History, physical, labs as needed
                   Tuberculin test
                   Determine functional status: ADL‘s,
                    IADL‘s, Mini-Mental Status, Geriatric
                    Depression Scale
                   Identify medical problems—review old
                    records
                   Medication review: each must correlate
                    to an active medical problem
Geriatrics 85
                Admission Checklist (Cont’d)
                   Assess for presence of pain
                   Establish relationships: patient, family,
                    and staff
                   Establish advance directives
                   Formulate the problem list
                   Formulate the care plan



Geriatrics 86
                Sources of Payment for
                Nursing Home
                   Medicaid—47%
                   Private pay—46%
                   Medicare---<4%
                   Long term care insurance ??




Geriatrics 87
                Social Security Act of 1965
                   Established Medicare and Medicaid
                   Medicare: health insurance for elderly
                    (65); amended in 1970‘s to cover end-
                    stage renal disease (any age) and
                    certain patients on permanent disability;
                    administered by federal government
                   Medicaid: medical insurance covering
                    low income persons of all ages: jointly
                    administered by the federal and state
                    governments
Geriatrics 88
                Medicare Part A –
                Hospital Insurance
                   Most people do not pay a premium because they
                    have (or spouse) 40 quarters of credit
                    (employment)
                   Inpatient hospital care
                   Nursing home care
                   Home health care
                   Hospice care
                   $840.00 deductible per benefit period
                        Begins day of hospital/NH admit
                        Ends when no hospital/NH services for 60 days
                        Co-insurance after 60 days of care
                   Limited nursing home coverage – skilled only
                        Medicare certified
Geriatrics 89
                        After qualifying 3 day hospitalization
                Medicare Part B –
                Supplementary Medical Insurance
                 Physician services
                 Laboratory tests

                 Durable medical equipment

                 Ambulance services

                 Selected preventive services

                 Premium - $58.70/monthly

                 Deductible $100.00/year

                 Patients pay 20% of Medicare approved

Geriatrics 90     amount
                Medicaid
                   Covers approximately 2/3 of all nursing
                    home patients: $39 billion in 1997
                   Persons pay out of pocket (―spend
                    down‖) until income/asset criteria are
                    met; criteria set by each state
                   No national program covers chronic
                    custodial care for elders who remain in
                    the home
                   Some commercial long term care
                    insurance policies now available to cover
Geriatrics 91
                    nursing home care
                Falling: A Geriatric Syndrome
                   30% of persons 65+ fall at home each year
                   50% of persons 80+ fall at home each year
                   66% of fallers will fall again in six months
                   If an elder is hospitalized due to a fall, only
                    50% will be alive in a year
                   Falls are common in the hospitalized, most
                    on the night of admission
                   Falls result in 250,000 hip fractures per year

Geriatrics 92
                Complications of Falls
                   Medical
                       Fractures
                       Subdural hematoma
                       Sprains, bruises, hematomas, lacerations
                   Psychological
                       FFF (3F syndrome): Fear of further falling:
                       Decreased confidence  isolation and
                        withdrawal  depression  reluctance to
                        go outdoors

Geriatrics 93
                Complications of Falls (Cont’d)
                   Social
                       Loss of independence
                       Risk of nursing home placement
                   Increased immobilization
                       Further loss of muscle tone and strength
                       DVT/pulmonary embolism
                       Hypothermia
                       Dehydration
                       Osteoporosis
                       Pulmonary infections
Geriatrics 94
                Medical Risk Factors for Falls
                   Poor vision: cataracts, glaucoma,macular
                    degeneration
                   CV: postural hypotension, syncope,
                    arrhythmias, drop attacks
                   Lower extremity dysfunction: arthritis,
                    weakness, foot problems, peripheral
                    neuropathy
                   Gait and Balance: CVA, Parkinson‘s,
                    myelopathy, cerebellar disorders
Geriatrics 95
                Types of Falls:
                Intrinsic vs. Extrinsic
                   Intrinsic factors:
                       Changes in postural control:
                        Decreased proprioception, righting reflexes,
                        muscle tone and strength; increased
                        postural sway
                       Decreased foot swing height, slower gait
                       Decreased depth perception, clarity, dark
                        adaptation, color sensitivity, visual fields;
                        Increased sensitivity to glare


Geriatrics 96
                Types of Falls (Cont’d)
                   Extrinsic factors
                       Poor lighting
                       Objects on the floor
                        (clutter, pets, throw rugs)
                       Unstable furniture
                       Poor or absent railings
                       Low beds or low toilet seats



Geriatrics 97
                Take a Fall History
                   Inquire about the circumstances of
                    the fall
                   Inquire about injuries or loss of
                    continence
                   Medication history
                   Are there any risk factors?



Geriatrics 98
                Fall-Related Physical Exam
                   Vital signs (postural blood pressure)
                   Assess mobility: ―Get-up-and-go‖ test
                   MMSE
                   Visual exam
                   Cardiac evaluation
                   Neurologic evaluation
                   Musculoskeletal (including feet) exam

Geriatrics 99
                 Management and
                 Prevention of Falls
                    Treat immediate medical problems
                    Assess and alter environment as
                     necessary
                    Attempt to modify any risk factors
                    Consider rehab (strengthening exercises)
                    Prescribe assistive devices, if necessary
                    Teach patient how to get up if they do fall
                    Consider a personal emergency response
                     system (―Help, I‘ve fallen…..‖)
                    Hip protectors reduce fracture incidence
                     by 50%
Geriatrics 100
                 Urinary Incontinence:
                 A Geriatric Syndrome
                    The involuntary loss of urine sufficient in
                     amount or frequency to be a social or
                     health problem. Urinary incontinence
                     (UI) is a symptom, not a specific
                     disease




Geriatrics 101
                 UI: Prevalence
                    15-30% in community dwelling elders
                     (only half report so this is an estimate)
                    30-35% of elderly in acute care
                     hospitals
                    50% of those living in nursing homes
                    UI is never a normal part of aging,
                     despite ubiquitous advertising for
                     absorbents


Geriatrics 102
                 UI: Risk Factors
                    Females 2:1
                    Age
                    Parity
                    Dementia
                    Polypharmacy
                    UI is independently and positively
                     associated with poor self-rated health

Geriatrics 103
                 Basic Bladder Anatomy and
                 Physiology
                    Functionally, urinary incontinence is due
                     to:
                        Failure to store urine (because of bladder
                         OR because of the urethra)
                        Failure to empty urine (because of bladder
                         OR because of the urethra)




Geriatrics 104
                 Physiology
                    Emptying the bladder involves
                     stimulation of cholinergic receptors and
                     inhibition of alpha and beta adrenergic
                     receptors
                    Filling the bladder involves inhibition of
                     cholinergic receptors and stimulation of
                     adrenergic receptors
                    Stimulation of alpha adrenergic
                     receptors increases sphincter and
                     urethral tone, and inhibition decreases it
Geriatrics 105
                 Causes of Transient UI-
                 DIAPERS
                    D: Delirium/confusional states
                    I: Infection—UTI‘s
                    A: Atrophic urethritis/vaginitis
                    P: Pharmaceuticals (hypnotics, diuretics,
                        anticholinergics, alpha-adrenergic agents,
                        calcium channel blockers)
                    P: Psychological
                    E: Excessive urine production
                    R: Restricted mobility
Geriatrics 106      S: Stool impaction
                 General Principles of
                 Diagnosing UI
                    Basic history and physical
                    Urinalysis
                    PVR (post-void residual) determination
                    Voiding diary
                    Labs: BUN, Cr, Glucose, Ca++
                    Imaging tests
                    Urodynamic and endoscopic tests rarely
                     needed to diagnose

Geriatrics 107
                 Types of UI
         Stress           Overflow       Urge            Functional
         (Urethral                       (Detrusor
         insufficiency)                  instability)
         Involuntary      Leakage of     Leakage,        Urine loss due to
         loss of urine,   small amts.    usually large   inability to toilet;
         usually small    resulting      amts, due to    impaired
         amounts          from           inability to    cognition or
         with             mechanical     delay voiding   physical
         increased        forces on an   after           functioning
         intra-           overdis-       sensation of
                                                         Environmental
         abdominal        tended         fullness        barriers
         pressures        bladder


Geriatrics 108
                 Symptoms

            Stress       Overflow     Urge          Functional
            Urine loss   Loss of      Sudden urge   Loss of small
            with         small amts   to urinate.   to large
            coughing,    of urine.    Loss of       amounts
            sneezing,    PVR > 100    moderate
                                                    PVR minimal
            etc.         cc           amts. PVR
                                      < 100 cc




Geriatrics 109
                 Cystometric Findings

         Stress       Overflow        Urge         Functional
         Normal       Little or no   Involuntary   Normal
                      detrusor       detrusor
                      contractions   contractions
                      despite high   that can not
                      bladder        be suppressed
                      volume




Geriatrics 110
                 Common Causes

         Stress            Overflow             Urge                  Functional
       Obesity, laxity    Outlet                Local GU              Physical restraints,
       of pelvic floor,   obstruction           conditions (UTI,      dementia, sedative
       spondylosis        (BPH, fecal           stones,               use, diruetics,
                          impaction),           diverticuli),         arthritis, muscular
       Peripheral
                          urethral stricture,   decreased             weakness, cluttered
       (pudendal)
                          anticholin-ergic      cortical inhibition   home, poor lighting,
       neuropathy
                          meds, diabetic        (CVA, dementia,       neglect of bedbound
       Post-radiation
                          neuropahy,            Parkinson‘s
                          multiple sclerosis    tumor)




Geriatrics 111
                 Primary Treatments

         Stress          Overflow            Urge                  Functional
       Kegel‘s,         TURP,                Bladder training;     Remove or replace
       weight loss,     intermittent cath;   scheduled             offending drugs;
       various          timed voidings;      toileting; trial of   improve patient
       surgical         trial of             antispas-modics;      mobility; night-time
       proceduresest    cholinergic          Kegel exercises       urinal or bed side
       rogens, alpha-   drugs; trial of                            commode;
       adrenergic       alpha-blocker                              scheduled toileting
       agents;          agents; urologic
       pessaries        referral




Geriatrics 112
                 Delirium
                    An acute confusional state
                    Transient reduction in the clarity of
                     awareness of the environment
                    Fluctuating level of consciousness
                    A syndrome, usually referable to an
                     underlying disease process



Geriatrics 113
                 Risk Factors for Delirium in
                 Hospitalized
                    Four strong predictors of delirium
                      Age > 80
                      Prior cognitive impairment

                      Fracture on admission

                      Institutionalization prior to admission


                    Other predictors: Systemic infection,
                     narcotic or neuroleptic use


Geriatrics 114
                 Causes of Delirium
                    Organ Failure
                        Respiratory failure
                        Congestive heart failure
                        Hepatocellular failure
                    Infections
                        Acute bronchitis/Bronchopneumonia
                        Bladder infection
                        Septicemia
                    Metabolic
                        Dehydration
                        Hypo/hypernatremia
Geriatrics 115
                        Hypoxia, uremia, hypo/hyperglycemia
                 Causes of Delirium (Cont’d)
                    Drugs: ANY, ANYTHING NEWLY
                     ADDED
                        Anticholinergics (including anticholinergic
                         antidepressants, and antihistamines)
                        Antibiotics
                        Narcotics
                        Neuroleptics
                        Anticonvulsants
                        Digoxin & other antiarrhythmics
                        Alcohol/alcohol withdrawal
Geriatrics 116
                 Causes of Delirium (Cont’d)
                    Neurologic causes
                        Subdural hematoma
                        CVA
                        Cerebral infections
                        Raised intracranial pressure
                    Miscellaneous
                        Postoperative delirium
                        Sensory deprivation
                        Recent institutionalization
                        Change of living arrangement
Geriatrics 117
                 Assessment of Delirium
                    History
                        Prior functional status: ADLs/IADLs
                        Alcohol use: they won‘t tell you
                        Prior cognitive function
                        Time course of changes in consciousness
                        Medications used, both RX and OTC
                    Physical examination
                        Neurologic examination (including mental
                         status)
                        Rectal (fecal impaction)
Geriatrics 118
                 Assessment/Treatment (Cont’d)
                    Initial labs                     Consider
                        Chem profile                     Ammonia level
                        CBC w. diff                      Blood/urine cultures
                                                          CT/ MRI of head
                        UA
                                                          Drug levels
                        CXR
                                                          Serum/urine drug
                        EKG                               screens (alcohol)
                        Pulse ox or ABG‘s                Thyroid function
                        Serum albumin                    PVR urine
                     Treatment:                           CSF exam
                     See Psychiatry slides 27-30          Folate/B12 levels
Geriatrics 119
                 Dementia
                    Memory impairment
                    Cognitive impairment as evidenced by
                     one of the following: aphasia, apraxia,
                     agnosia, disturbance in executive
                     functioning
                    The cognitive deficit causes significant
                     impairment in social or occupational
                     functioning
                    Does not occur exclusively during the
                     course of delirium
Geriatrics 120
                 Types of Dementia
                    Alzheimer‘s disease (AD)-- > 60%
                    Vascular (multi-infarct) dementia-- 15-
                     20%
                    Mixed dementia: AD + vascular features
                    All others rare: AIDS, Parkinson‘s,
                     Lewy-body dementia, Down‘s syndrome
                    Reversible dementias: depression,
                     thyroid disease, vitamin deficiency,
                     infections, normal pressure
                     hydrocephalus
Geriatrics 121
                 Alzheimer‘s Disease
                    Pathologically deposits of plaques
                     (amyloid) and neurofibrillary tangles
                     (tau protein)
                    Average time between diagnosis and
                     death: 10 years
                    Early: personality changes, irritability,
                     anxiety, depression
                    Late: 50% develop agitation,
                     delusions, hallucinations, or paranoia

Geriatrics 122
                 Vascular Dementia
                    Dementia is present
                    Two or more of the following are
                     present:
                        Focal neurological signs on physical exam
                        Onset was abrupt, step-wise or stroke-
                         related
                        Brain imaging shows multiple strokes
                    Diagnosis requires presence of
                     cardiovascular disease, dementia and a
                     definite temporal relationship between
Geriatrics 123
                     the two
                 Lewy Body Dementia
                    Dementia present
                    Two of the following core features:
                        Fluctuating cognition with pronounced
                         variation in attention and alertness
                        Recurrent well-formed visual hallucination
                        Spontaneous motor features of
                         Parkinsonism
                    Supportive features: repeated falls,
                     syncope, transient LOC, neuroleptic
                     sensitivity, systematized delusions
Geriatrics 124
                 Reversible Dementias
                    Chronic infections
                    Chronic heart failure
                    Chronic obstructive pulmonary disease
                    Drug-induced cognitive impairment
                    Thyroid disease
                    Normal pressure hydrocephalus
                     (cognitive impairment, gait disturbance
                     and urinary incontinence)
                    Alcohol related dementia
                    Vitamin B12 deficiency
Geriatrics 125
                 Depression vs. Dementia
                    Depression can look like dementia
                     (pseudodementia)
                    Duration is weeks to months, not months to
                     years
                    Islands of recent and long term memory loss
                    Language preserved
                    History of depression usually positive
                    Responds to questions with ―I don‘t know‖
                    Patient‘s impression of disability: exaggerated
                    Screen with Yesavage Geriatric Depression
                     Scale
Geriatrics 126
                 Diagnostic Tools
                    Focused medical and family history
                    Physical examination and laboratory
                     tests
                    Functional status examination
                    Mental status examinations
                    Assessment for Depression
                    Brain scans (CT or MRI)
                    Neuropsychological testing usually not
                     needed
Geriatrics 127
                 Common Laboratory Tests:
                 Rule Out Reversible Causes
                    CBC
                    Comprehensive chemistry profile
                    Thyroid function tests
                    Vitamin B12 & Folic acid
                    ESR
                    VDRL
                    HIV if high risk

Geriatrics 128
                 Mental Status Screening Tests
                    Mini Mental Status Exam (Folstein)
                      Considered the ―gold standard‖ screen
                      Maximum score of 30, cut-off of 21-23 for

                       dementia
                      Requires verbal and written responses

                      No time limit

                      Reproducible over time

                      Specificity goes down, sensitivity rises

                       with higher educational levels
Geriatrics 129
                 Mental Status Screening Tests
                 (Cont’d)
                      CAST: Cognitive Assessment
                       Screening Test (AFP 54: 1957-62)
                        Written, self-administered test
                        No time limit

                      Set Test
                        Category fluency: name 10 colors,
                         towns, fruits, animals
                        80% of demented score less than 15/40

                        Considered a measure of executive,i.e.,

                         frontal lobe functioning
Geriatrics 130
                 Mental Status Screening Tests
                 (Cont’d)
                      Clock Drawing
                         Person is presented a paper with a 4-6‖

                          circle drawn and is asked to write the
                          numbers and draw hands of a clock to
                          show ―10 past 11‖
                         Use as a qualitative, not quantitative

                          screen
                      Yesavage Geriatric Depression Screen
                         Previously described




Geriatrics 131
                 Dementia Management
                 (YES, Dementia is Treatable)
                    Maximize function and independence
                    Maintain safe and secure environment
                    Maintain adequate nutrition and
                     hydration
                    Enhance cognition (medications
                     available)
                    Treat mood and behavior problems
                    Educate/support care givers
                    Expect regular physician office visits
Geriatrics 132
                 Cholinesterase Inhibitors
                    Widespread use and multiple trials confirm that
                     these drugs offer a plateau in functional
                     decline and positively influence behavioral
                     manifestations
                    Cognitive decline is postponed, but these
                     drugs do not influence neuronal decline
                    All patients in whom AD is clinically confirmed
                     and categorized as mild to moderate should be
                     offered a long term therapeutic trial
                    Probably help vascular and Lewy body
                     dementia too, though not labeled
Geriatrics 133
                 Cholinesterase Inhibitors
                 (Cont’d)
                    Donepezil: (Aricept) HS dosing, 5-10
                     mg., metabolized by P-450 system
                    Rivastigmine: (Exelon) 1.5-6 mg BID
                     with meals; available in liquid form
                    Galantamine: (Reminyl) 4-12 mg BID
                     with food; avoid with hepatic impairment



Geriatrics 134
                 Other Non-Traditional Drugs
                    Antioxidants (Vitamin E) & Ginkgo
                     Biloba extract: benefit supported by a
                     single clinical trial
                    NSAID‘s and estrogen replacement
                     therapy: benefit supported by
                     epidemiologic evidence but not
                     confirmed by prospective trials


Geriatrics 135
                 Behavioral Modifications
                    Create a predictable schedule: active day,
                     quiet night
                    Maintain a familiar, calm environment
                    Foster reminiscence: photos, music, objects
                    Keep life simple; reduce choices
                    Match activities to capabilities and
                     preferences
                    Avoid overwhelming situations (family
                     reunions) and challenges (shopping)
                    Learn ―dementia speak‖: don‘t reason or
                     argue with a demented person
Geriatrics 136
                 Drug Therapy for Behaviors:
                 The Last Resort
                    Behavior must present clear danger to
                     self or others
                    Behavior prevents necessary care
                     (feeding, hygiene, wound care)
                    Discuss indications in progress notes
                     and with patient advocate
                    Use time-limited medication trials
                        Antipsychotics, benzodiazepines,mood
                         stabilizers

Geriatrics 137
                 End Stage Care
                    Palliative management of medical
                     problems
                    Focus on ―quality of life‖
                    Be firm about ―aggressive‖ medical
                     interventions—these are rarely
                     indicated
                    Institute and follow DNR instructions


Geriatrics 138

				
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