Geriatric Gems

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					           Geriatric Gems

“Sex after ninety is like trying to shoot pool with
 a rope. Even putting my cigar in its holder is a
             thrill.” --George Burns

Let’s start with the 5 vital signs in the elderly—T,
                P, R, BP, and weight

        Temperature patterns in the elderly

• Loss of diurnal variation
• Contributes to sleep problems—diurnal variation and
  melatonin secretion
• May not rise as rapidly with infections or as high
• A rise of greater than 1.5° C within 2 hours—consider sepsis
• Patients on neuroleptic drugs (central dopamine blockers)
  such as haloperidal and/or the atypical antipsychotics*, tend
  to have lower basal temperatures (always complaining of
  “feeling cold”)
• *higher mortality rates in elderly on antipsychotics

       Temperature patterns in the elderly

• Loss of subcutaneous fat (actually you don’t
  LOSE the fat, you just move it to the internal
  visceral organs) with age--difficulty
  maintaining internal temperatures with
  extremes of ambient temperature
• Hypothermia/hyperthermia
• “You’re not dead until you’re warm and dead.”
• Always check the thyroid gland—myxedema
  coma + cold ambient temperature

  Pulse-temperature dissociation
• Legionnaire’s (Legionella pneumoniae)
  disease—atypical pneumonia characterized by
  a pulse-temperature dissociation (pulse 80
  with temp of 39.8°C [103.6°F]) + low serum
  phosphorus and elevated LFT (Legionnaire’s
  “triad”)—macrolides Rx of choice or
  doxycycline vs. PCN for Strep pneumonia

                 Pulse/heart rate
• Bradycardia—hypothyroidism, dig, beta blockers (even topical
  beta blocker eyedrops {Timoptic, Betoptic, etc.) can cause
  bradycardia), calcium channel blockers such as verapamil and
  diltiazem, and cholinergic drugs for AD--galantamine
  (Razadyne), rivastigmine (Exelon), donepezil (Aricept)
• Palpitations with CHF, hyperthyroidism, AF
• Unexplained tachycardia (60 to 80 is the normal resting heart
  rate)—consider hyperthyroidism, atrial fibrillation (which can
  also be caused by hyperthyroidism)
• Tachycardia (loss of vagus nerve due to autonomic
  neuropathy) and silent ischemia in diabetics

Anti-cholinergic drugs cause tachycardia and may precipitate
   chest pain in the elderly patient with angina—normal
                  functions of acetylcholine

•   Mentation (CNS)
•   Pupillary constriction (PNS)
•   Decreases heart rate (PNS)
•   Increases salivation (PNS)
•   Increases peristalsis (PNS)
•   Loosens urinary sphincter (PNS)

      Anti-cholinergic drugs—side effects

• Confusion
• Pupillary dilation (blurred vision, glaucoma)
• Tachycardia (angina, possible MI)
• Decreased salivation (dry mouth)
• Decreased peristalsis in GI tract
• Tighten urinary sphincter (urinary retention)

     Drugs for OAB (overactive bladder)—
            anticholinergic effects
• oxybutynin (Ditropan)(Gelnique—topical
  gel)(Oxytrol patch)
• Toterodine (Detrol LA); fesoterodine (Toviaz)
• Darifenacin (Enablex); solifenacin (Vesicare)
• Trospium (Sanctura)
• (Prescriber’s Letter, June 2009;16(6):36

Anti-cholinergic drugs—the usual suspects and some

• Amitryptyline (Elavil)—the higher the dose, the
  higher the risk of anti-cholinergic effects; Rx for
  neuropathic pain vs. Rx for depression
• Hyoscyamine (Anaspaz, Atropine)
• Doxepin (Sinequan)
• Meclizine (Antivert)
• Captopril (Capoten), nifedipine (Procardia)
• Prednisolone
• dig, dipyridamole (Persantine)
• warfarin
• Furosemide (Lasix)
• isosorbide dinitrate (Isordil)
                  And then some…
•   Paroxetine (Paxil)
•   Codeine
•   Oxycodone
•   Diphenhydramine
•   Fexofenadine (Allegra)
•   Hydroxyzine (Atarax)
•   Loratadine (Claritin)
•   dicyclomine (Bentyl)
•   Cimetidine (Tagamet), ranitidine (Zantac)
•   Haloperidol (Haldol)

• Tagamet (cimetidine) and morphine—increased
   bioavailability of morphine with a possible reduction in
  respiratory rate to 4-6 per minute
• Fever and tachypnea in the older adult—consider an acute
  pulmonary syndrome—
• Pulmonary embolism (over 85? 700 PE/100,000)
• Pneumonia—confusion, tachypnea, fever and shoulder pain—
  referred pain due to a big “wet” lung*
• Pneumococcus (strep pneumoniae) is the most prevalent
  pathogen; Strep pneumoniae and Legionella are the most
  serious; (pneumococcal vaccine @ 65)
• Let’s go back to referred pain for a momento…

Referred pain…Let’s go back about 80 years…to
                the embryo.
• Embryologic development and the
  diaphragm—C3, C4
• Shared sensory afferents with somatic
• Diaphragm and the shoulder

Blood pressure—Ideal? 120/80, BUT…
• Depending on co-morbidities it may be kept
  slightly higher in the elderly to avoid
  hypotension, falls, and a broken hip
• But not TOO high as it is the MAJOR risk factor
  for strokes (besides AGE)—66% of all strokes
  are due to hypertension
• Keeping the blood pressure BELOW 140/90
  prevents strokes, ACS, CHF, dementia, and
  renal failure

• Systolic rises with age, diastolic tends to plateau or even
  decrease during 6th decade
• Isolated systolic (ISH) is common (S > 140; D< 90) pulse
  pressure increases in the same manner; high S, normal or low
  D; elevated pulse pressure is increasingly recognized as an
  important predictor of CAD/CVD
• Postural/orthostatic hypotension common—drop of > 20
  mmHg S or 10 mm Hg D when rising from sitting position (one
  of early signs of Parkinson’s disease)

Weight as a vital sign in the elderly
• Weight is a vital sign in the elderly
• Weight loss defined as? (≥ 5% of usual body weight over 12
  months or less)
• Drugs and weight loss (dig, metformin, chemo)
• Drugs and weight gain-- insulin, sulfonylureas, SSRIs
  (paroxetine/Paxil; fluoxetine/Prozac), corticosteroids, atypical
  antipsychotics—clozapine/Clozaril and olanzepine/Zyprexa,
• Heart failure and weight gain

“The leading cause of hospitalization due to deteriorating heart failure
  is excessive sodium intake.” (Arch Int Med 2001;161(19):2337-42)

• Weight gain and CHF—greater than 1 kg (2
  lbs) per day—adjust diuretics; ?sign of
  worsening heart failure or too much salt in the
• Diuretics should be adjusted to maintain
  euvolemia as reflected by daily-recorded
  weights that are within 1 kg (2.2 lbs) of the
  patients predetermined dry weight

        What is senescence??
• The rate of deterioration of the structure and
  function of body parts
• The 1% rule
• Functional reserve of tissues is 4-10 x greater
  than baseline (the amount needed just to
• Peak functional capacity at 24
• 6 good years
Senescence and normal aging...
•      Peak at 24, 6 good years, gradual decline to baseline; more rapid decline
    with chronic disease (DM, COPD)


           Baseline function

          1yr                  30                  75 yrs

Senescence and normal aging...
•   More rapid decline with chronic disease (DM, COPD)


           Baseline function

          1yr                  30               75 yrs

Senescence and normal aging...
•         Gender differences—the ovary (51.3 +/- 2.7)


           Baseline function

          1yr                  30                  75 yrs

         Example of livin’ “on the
• One of the compensatory mechanisms in
  heart failure is an adrenal surge of
  epinephrine to boost the strength of
  contraction and increase the heart rate
• However, epinephrine also “remodels” the
  heart…remodel = enlarge…resulting in
  cardiomegaly and an increased risk of sudden
  cardiac death due to ventricular dysrhythmias )

        Beta blocker use in CHF
• Traditionally beta blocker use was a big “no, no”
  for patients with heart failure…why would you
  want to decrease the strength of contraction and
  decrease the heart rate in a failing heart…
• In the “old” days, beta blockers were known to
  precipitate heart failure in patients with
  hypertension…one of the reasons that beta
  blockers are no longer first line therapy for
• BUT…
      Beta blockers to the rescue
• Beta blockers (“olols, alols, ilols”) may initially
  worsen heart failure symptoms when they are
  used to prevent “remodeling” of the heart
  post-MI or in the patient with CHF
• However, beta blockers actually improve
  survival rates and quality of life when used in
  CHF patients
• Carvedilol (Coreg), metoprolol succinate

 Example of “livin’ on the edge…”
• Acetylcholine in the CNS is the
  neurotransmitter of cognition; as we
  age the blood-brain barrier becomes
  more lipid-soluble and drugs can enter
  the brain with greater ease
• Drugs with “anti-cholinergic” effects can
  cause confusion and memory loss

           RENAL FUNCTION…
• Glomerular filtration rate (GFR)—120-125 ml/min at
  age 25; decreases by ~1% per year;
  – 75-year-old = 1.2 mL/min x 45 years = 53
     mL/min; 120-53=67 mL/min in a HEALTHY 75-
     year-old (not taking into account weight,
     ethnicity, or gender)
  – BUT, a GFR of 60-89 mL/min=mild renal
  – a GFR of less than 60 mL/min/1.73 m2 represents
     a loss of more than half of normal kidney
 Nephrotoxic drugs and the elderly
• Antibiotics (aminoglycosides)
   (the ears and the kidneys)
• Radiocontrast dyes (Metformin)
• ACE inhibitors (“prils”) are especially dangerous if
  renal blood flow is compromised—renal artery
  atherosclerosis (stenosis)
• NSAIDs combined with ACE inhibitors in the elderly
  may precipitate acute renal failure—HOW?

                 The healthy kidney
•   Afferent arteriole
  (normally vasodilated
  (via prostaglandins)           Prostaglandins –
• Blood entering                 blocked by NSAIDs

• Glomerulus→filter                filter

• Efferent arteriole
  (normally vasoconstricted
  (via angiotensin 2)         Angiotensin   Toilet
                              by ACE --

  The combination of ACE inhibitors and NSAIDs can
           precipitate acute renal failure

• NSAIDs block prostaglandins and vasoconstrict the
  afferent arteriole decreasing blood flow to the
  glomerulus (prostaglandins are more important in
  the aging kidney than in younger kidneys—hence the
  high risk with NSAIDs in the elderly and not in a 20-
• ACE inhibitors block ACE and the production of
  angiotensin 2—blocking angiotensin 2 vasodilates
  the efferent arteriole of the kidney
• Decreased blood IN and increased blood OUT =
  decreased filtration and acute renal failure

  More on NSAIDs in the elderly…
• NSAIDs and fluid retention (due to vasoconstriction
  of the afferent arteriole)—especially the long-acting
  nonselective NSAIDs (piroxicam/Feldane)
• NSAIDs can counteract the positive effects of thiazide
  diuretics for blood pressure control
• Why? Opposing actions
• NSAIDs can exacerbate HF symptoms due to sodium
  and water retention (+peripheral edema); can also
  increase K+ levels

    More on NSAIDS in the elderly…
• In addition to all of the above, one must worry about the GI
  effects of the NSAIDs…the older the patient, the higher the
  risk, especially with the non-selective NSAIDS
• GI complications are 3-10x more common in users of
  nonselective NSAIDs than in nonusers
• Use celecoxib (selective COX-2) if possible (also decreases risk
  of lower GI bleeding as well as perforations, obstructions and
  bleeds in upper GI)
• Use PPI with nonselective NSAIDS and coxib if over 75
• Celecoxib does NOT affect platelets so can be used up to and
  following surgical procedures
•   (Stillman MJ, Stillman MT. Choosing nonselective NSAIDs and selective COX-2
    inhibitors in the elderly: A clinical use pathway. Geriatrics 2007;62(2):26-34.

   (In addition to NSAIDs), certain calcium channel
blockers can also cause/exacerbate peripheral edema

• Peripheral calcium channel blockers cause
  peripheral edema due to their strong
  peripheral vasodilating effects (the “dipines”)
• Felodipine (Plendil) is the worst of the bunch;
  amlodipine (Norvasc) is the best of the bunch

            Water loss and aging
• Decrease in total body water stores
• Decreased volume of distribution
• Increased drug toxicity with water-soluble drugs—dig for
• Encourage fluid intake
(loss of response to thirst receptors)
• Exception: patients w/ CKD or CHF (not more than 800 - 1500
   mL per day for CHF patients)

             Herbal products…
• Have your patients taken any herbal products that
  can interfere with diuretics or dig? Most of the
  herbal diuretics can cause low sodium (seizures), low
  potassium (muscle cramping, arrhythmias), and low
  magnesium (arrhythmias)
• Dandelion (Pissenhüt), licorice, St. John’s wort
• Herbal laxatives also decrease total body K+ stores
  and can cause dig toxicity
• (K+ and dig compete for receptors on myocardium—
  dig toxicity with hypokalemia)

      Dehydration in the elderly
• Decreased collagen, elastic tissue, and water
• FYI, estrogen maintains collagen health
• (Wolff EF, et al. Long-term effects of hormone
  therapy on skin rigidity and wrinkles. Fertility
  Sterility 2005 Aug; 84:285-8.)
• What are the signs and symptoms of
  dehydration in the elderly?

    Decreased collagen and elastic tissue with aging

•   Shrunken eyeballs?
•   Poor skin turgor?
•   Where do you check skin turgor in the elderly?
•   What are some other consequences of the loss of
    collagen, elastic tissue and water?

 Intervertebral discs are made from collagen, elastic
                   tissue and water
• Loss of collagen, water, and elastic tissue
  resulting in disc shrinkage
• Loss of height (change in size and shape of
  chest cavity)
• How many inches can you lose with disc

  Combine the disc shrinkage with compression
fractures of osteoporosis—loss of trabecular bone

Compression fracture of vertebrae
• Vertebral bodies with the loss of height with
  compression fractures
• How many inches can you lose with vertebral
  compression fractures?
• Vertebral compression fractures + disc
  shrinkage =

       Other fractures due to osteoporosis

• Neck of the femur—broken hip
• What is the prognosis after a broken hip?
• Radius of the wrist (Colles fracture of the wrist)
• Do men have osteoporosis? YES, and they have a
  worse prognosis after a hip fracture
• One in 2 women and one in four men over age 50
  will have an osteoporosis-related fracture in her/his
  remaining lifetime

• Skin, aging and vitamin D conversion
• Check Vitamin D levels! Low vitamin D =
  increased risk for balance problems and falls
  (and joint and muscle pain)
• Vitamin D deficiency—levels of 25-
  hydroxyvitamin D below 25 ng per milliliter
  are associated with an increased risk of hip
  fracture in men and women older than 65
• Muscle aches, bone aches, joint aches and
  pains may be due to low vitamin D

   Digression--prevention and treatment of
• Weight-bearing exercise 5 x per week
• Stimulates bone remodeling with osteoblasts
  and osteoclasts

Prevention/treatment of osteoporosis

• Calcium—1200-1500 mg/day; best way to get
  calcium is to eat calcium-fortified foods
• Vitamin D—1000-2000 IU per day
• Foods—broccoli florets, sardines, milk, yogurt
• Calcium supplements are only beneficial if taken
• Calcium supplements interfere with synthroid

    Drugs to prevent and treat osteoporosis

• Alendronate (Fosamax) (most potent
• Risedronate (Actonel)
• Ibandronate (Boniva)
• Can your patient follow directions for the

       Bisphosphonate therapy
•   EXPERIENCE-BASED MEDICINE—give a 1-year holiday to
    relatively low risk women (no fx, young and healthy,
    active, with BMD that is not horribly low
•   2) Do NOT tend to stop risedronate as it has a shorter
    half-life and there are NO DATA on cessation except
    after 3 years of use and BMD goes down rapidly after
•   3) 5 years on ALN then stop for up to 5 years without
    losing too much BMD; after stopping measure urinary
    NTX or serum CTX in 6 months; if elevated above ideal,
    restart ALN. If ok, she starts ALN after a one year
    holiday. ALN is retained longer in bone than other BS
    Carolyn Becker, MD, Master Clinician, Harvard University,
    Cambridge MA                                                45
    Other drugs for osteoporosis
• Evista (raloxifene)—antagonist in breast and
  uterus; agonist in bone; increased risk of DVT
• What about tamoxifen? Antagonist in breast
  and brain; agonist in uterus and bone: not
  approved for osteoporosis
• Calcitonin (Miacalcin)—has some opiod-like
  properties and is useful for the pain of
  vertebral fractures
     Other drugs for osteoporosis
• Forteo (teriparatide)—for treatment of osteoporosis
  and for use in preventing steroid-induced
  osteoporosis (boosts osteoblasts and blocks steroids
  effects on the bone)(better results compared to
• Reclast (zoledronic acid)—15’ infusion x 1 per year
  decreases vertebral fractures by 70%; hip by 41%
• Denosumab (Prolia) – new monoclonal antibody to
  boost bone building
• And don’t forget the best bone builder of all
1% rule and the INCREASE in size of the prostate
• Benign prostatic hypertrophy—alpha one receptors
  on the smooth muscle of the prostate
• Treatment of BPH—alpha one blockers—tamsulosin
  (Flomax)** generic; silodosin (Rapaflo), doxazosin ER
  (Cardura XL)
• Prostate cancer—risk increases with age
• Protect that prostate!
• Vitamin D and prostate protection

   PSA testing for prostate cancer
• The controversy continues
• What are the cut-off levels?
• A PSA of greater than 4 ng/mL is generally accepted
  as the cutoff level for biopsy in the general
• Age-adjusted PSA cutoff values are as follows:

                     PSA testing
• 2.5 to 3.5 ng/mL and over for 41- 50-year old patients
• 3.5 to 4.5 ng/mL and over for patients who are 50-60-years
• 4.5 to 5.5 ng/mL and over for those who are 60 to 70 years
• 5.5-6.5 ng/mL for men in their 70s
• For African-American men, the diagnostic range is shifted
• PSA velocity

    PSA velocity and percent free PSA
• Measures changes in PSA concentrations over time
• A level of 0.75 ng/mL/y and over is an indication for a biopsy
• A low value for the percent free PSA means that more of the
  increased PSA is present in bound form. This indicates a
  greater likelihood of cancer, because most of the increased
  PSA present in prostate cancer is in the bound, not unbound
• Biopsy and tissue histology make the diagnosis
• The above tests help guide the decision to perform a bx

(J Urol Oct 2004;172:1297; Patient Care Sept 1, 2005))
      1% rule—but instead of a decrease, an
    INCREASE by 1% per year of clotting factors

•   Increased risk of clotting in the elderly
•   Biological rhythms and clotting—early a.m.
•   DVTs most common in elderly; increased risk for PE
•   7:30 a.m. for PE symptoms
•   7-10 a.m. for MI presentation
•   Wake up with a “stroke in progress”
•   Window for tPA for ischemic strokes
•   Warfarin (Coumadin) is a VERY popular drug in the
    over 70 group
    Triple antithrombotic therapy
• Scenario—72 y.o. patient who needs clopidogrel
  and aspirin after a coronary stent; plus warfarin
  for atrial fibrillation, DVT, and a mechanical heart
• Red clots—RBCs and fibrin that form in veins and
  the atrium (DVT and mural thrombus)—treat w/
• White clots—triggered by platelet aggregation in
  the arteries
• Warfarin? ASA? And clopidogrel (Plavix)?
• Aim for the lower end of the INR target of 2.0 to
• Try to stop clopidogrel as soon as it’s safe—often
  after 4 weeks after a bare-metal stent or one year
  for a drug-eluting stent—this can vary
• Use the low-dose 81 mg of aspirin
• Prescribe GI prophylaxis for patients with risk
  factors of GI bleeding
• PPIs and clopidogrel
(Prescriber’s Letter, September 2009)

  1% rule—an increase in body fat
• Retention of lipid-soluble drugs
• Half-life (T1/2) of diazepam (Valium) is the
  patient’s “age, in hours”
     25-year old = 25 hours
     75-year old = 75 hours
Use shorter-acting benzodiazepines should be used
  in the elderly (Restoril, Serax, Ativan (lorazepam),
  Xanax, Halcion (triazolam)
Start low and go slow…(heard that before?)

          Neurology of aging…
• 5% loss of cerebral weight in females by 70
• 10% loss in men (men start out with a bigger
  brain, however)
• By 80, 17-20% loss
• Selected areas are the frontal lobes and the
  medial temporal lobes

 Loss of hippocampal cell function
• Loss of recent memory
• This is the first neurologic function to go with
  the aging process
• Benign forgetfulness
• Mild cognitive impairment

    What is mild cognitive impairment? (MCI)

• Borderline state—individuals are not demented, but they
  perform worse than their peers
• They sense that they are forgetful, and somebody close to
  them has probably noticed it, too; (repetition of questions
  and comments; misplacing things—relying more on notes
  and calendars, forgetting meds, familiar persons; word
  finding difficulties;
• Demanding task – new technology may prove challenging;
  10-15% per year evolve to clinical Alzheimer’s disease vs.
  normal elderly who do so at a rate of 1-2% per year
• Should we use rivastigmine/ Exelon or donepezil/Aricept or
  galantamine/Razadyne?? Memantine/Namenda? Ongoing
  study at the National Institute of Aging
• Montreal Cognitive Assessment (

           What can you do?
• What drugs accelerate the process? Booze,
  nicotine, marijuana
• Hypertension accelerates the process
• Can anything help? Lower BP; B vitamins?
  Omega-3 fatty acids? Blueberries? Olive oil?
  Use it or lose it? Do all of those crossword
  puzzles REALLY work?
• Do the “statin” drugs help?

            What can you do?
• Exercise? YES (increase blood flow to brain
  boosts neurogenesis)
• Brain food? YES, foods that protect against
  oxidative stress and foods that protect against

 Reduction in prefrontal lobe function with the
                 aging brain…

• Personality changes
• Decreased ability to concentrate on the
  task at hand
• Anti-social, regressive behavior (the loss
  of tact)
• Hostile behavior

      “MOTHER” is responsible for your
 behavior…your prefrontal lobe is your “mom”
• What’s the only word a mother needs to
• NO, Stop, Don’t, Negative…she is inhibitory
• Socialization, judgment, insight
• You learn through inhibitory influences

     With a dementing process…
• Mom is no longer responsible for “sociable
  behavior” (bilateral frontal lobes)
• Sexual indiscretions
• The world becomes the bathroom
• Clothing is optional

      Alzheimer (s) disease or DAT
•   The Alzheimer’s brain
•   Cortical atrophy
•   Sulcal widening
•   Atrophy of gyri
•   “feathering”
•   Brain weight
•   90% decline in Ach

•   Do all of those crossword puzzles really work?
•   Exercise?
•   Mediterranean diet?
•   Turmeric? Curry?
•   Statin drugs? Neurogenesis?
Pathology—5 to 20 years before the 1st
      symptom of memory loss
• Beta-amyloid plaques (BAP)—sticky globs
  outside the cells; abnormal processing and
  cleaving of amyloid precursor protein—
  earliest indication of the development of

  It takes “tau” to tangle…1 to 5 years
           before first symptom

• Neurofibrillary tangles—tangled microtubules inside
  the cells; tau protein helps to stabilize the
  microtubules and thus, maintain the integrity of the
• Neuronal degeneration
• Tau and FTD

• BAPtists vs TAUists

           Alzheimer’s…risk factors
•   Aging? YES
•   Genetics? Yes
•   Chromosomes 1, 7, 14, 21
•   APOE4
•   Early onset (before 50)and late onset (65 and older)
•   Shared risk factors with cardiovascular disease
•   Hypertension
•   Inflammation
•   Oxidation
•   Estrogen/Testosterone?

         Diagnostic features…
• Hallmark is memory impairment
• Apraxia—inability to carry out a motor
  function in the absence of paralysis
• Auditory and/or visual agnosias
• Impaired executive functioning—planning,
  organizing, abstracting (judgment/problem
• Abstraction
• Significant impairment in occupational
  functioning                                 69
           Other causes of dementia
• Vascular dementia—severe depression is
  more common in patients with vascular
  dementia; psychotic symptoms, particularly
  delusions have been described in vascular
• Binswanger’s dementia—hx of hypertension;
  progressive motor, cognitive, mood and
  behavioral changes over 5-10 years; apathetic;
  disoriented, vague, inattentive, early-onset
  urinary incontinence and gait disturbances
• Pick’s disease (fronto-temporal dementia)
      Other causes of dementia
• Parkinson’s dementia
• Lewy-Body dementia—recurrent visual
  hallucinations; fluctuating cognitive
  impairment; Parkinsonism features
• Creutzfeldt-Jakob disease—myoclonus,
  seizures, ataxia; rapid progression

       Other causes of dementia
• Nutritional dementia (B12 deficiency)--(B12 --lower
  limits 200 pg/mL but patients with dementia and
  levels less than 300 pg/mL should be given a trial of
  B12); reversible
• Hypothyroidism
• Cancer
• Neurosyphilis—Argyll-Robertson pupil;
  accommodates but doesn’t react to light
• Huntington’s disease

         Evaluation of dementia
• Toxic/metabolic (B12, folic acid, TSH, RPR, glucose),
  (Lyme, HIV, liver toxicity)
• Structural – MRI, CT scan (tumors, strokes, normal
  pressure hydrocephalus), PET, SPECT studies
• Psychiatric illness
• Neurodegeneration – neuropsychiatric testing for
  brain mapping (Alzheimer’s and hippocampal loss—
  difficulty encoding new information; FTD—frontal w/
  violence, mood swings)

     Treatment for acetylcholine deficiency…

• Acetylcholinesterase inhibitors such as donepezil (Aricept)—
  inhibit the breakdown of ACH in the brain; helps about 50-70
  percent of the patients, but effects are modest; think back to
  what the patient was doing 7-8 months ago; reprieve only
  lasts a few months
• Others—galantamine (Razadyne, Razadyne ER), rivastigmine
  (Exelon)(patch is well-tolerated)
• Reminyl was renamed Razadyne to avoid errors with the
  diabetes drug, Amaryl (glimepiride)…mistakes led to
  hospitalizations and deaths
• Donepezil and rivastigmine—vascular/Parkinson’s, LBD;
  galantamine w/ vascular dementia

      Benefits of cholinesterase inhibitors?

• Many clinicians doubt the practical significance of
  response to ChEIs; however, other reports show that
  ChEIs have significant efficacy in the treatment of
  neuropsychiatric symptoms in AD patients.
• A meta-analysis involving 7954 patients
  demonstrated that the numbers needed to treat
  (NNT) for 1 additional patient to experience benefit
  in the area of cognition were 7 for stabilization or
  better, 12 for minimal improvement or better, and 42
  for marked improvement.

       Benefits of cholinesterase inhibitors?

• Other tangible clinical outcomes:
   delayed nursing home admission by as much as 21
  months with donepezil (Aricept); Donepezil (Aricept) ;
  also slows the progression of atrophy of the
  hippocampus in the brains of patients with AD—
  suggesting a neuroprotective effect of this particular

• Galantamine (Razadyne) and donepezil (Aricept) have
  also been shown to be neuroprotective by preventing
  neuronal apoptosis (programmed cell suicide).

         Namenda (memantine)
• Namenda, {Ebixa }(memantine)—decreases excessive
  activation of NMDA receptor by glutamate; offers
  modest benefits to patients with Alzheimer’s disease
• Who is glutamate? Excitatory transmitter that plays a
  major role in memory and learning; continuous
  stimulation of the NMDA receptor leads to increased
  calcium influx and ultimate damage to the neuron;
  Memantine allows normal glutamate fx; blocks
  excessive excitation
• Mild to severe AD as an add-on

        Delirium—key features
• Disturbance of consciousness and attention
• Change in cognition not better accounted for
  by dementia
• Symptoms and signs developing over a short
  period of time (hours to days)
• Fluctuation of symptoms and signs
• Evidence that the disturbances are caused by
  the physiological consequences of medical
        Delirium in the elderly
• 1-2% of community dwelling; 10-22% of
  hospitalized inpatients, 58% of nursing home
• 15-26% of elderly with delirium die
• Cause of death is the underlying cause of
• Treating delirium improves cognitive

     Pathophysiology of Delirium
• Widespread reduction in oxidative
  metabolism leading to neurotransmitter
  deficiency and/or dysfunction
• Increased levels of cytokines (acute
  inflammatory mediators released by the
  immune system—IL-1, IL-2, IL-6, TNF-alpha)
  caused by illness, physical stresses or both—
  leading to impaired neurotransmitter

          Suspect delirium if…
• The patient is unable to focus attention on the
  conversation you initiate
• The patient gives bizarre answers to questions
• The patient cannot spell the word “WORLD”
  forward and backwards (inattention)
• Forget the “serial 7s”—try for 3s OR
• Ask the patient to add a quarter, dime, nickel,
  and penny
 “Assume that the onset of delirium in the old
person is due to infection.”—Clifton Meador, M.D.

• Pneumonia—decreased oxygenation to brain
• Listen to the base of the lungs
• A few basilar crackles can be normal in the
  very old patient
• “hairy backs”

    Also consider a urinary tract infection as the
             cause of acute delirium…
• Check the urinary tract
• Urinalysis
• WBCs in urine, WBC casts in the urine
• Estrogen and the urinary tract; pH of urine
  and pH of vagina
• Topical estrogen and a reduction in urinary
  tract infections

     Polypharmacy and delirium…
• The blood brain barrier in the elderly is more permeable to
• Narcotics
• Benzodiazepines (a note on Valium and Librium in the elderly)
• Any drugs with “anti” as their first name…Anticholinergics,
  anti-histamines, antihypertensives, antipsychoticcs,
  antiparkinsonism, antianxiety, antidepressants
• And more…
• Tagamet, steroids, acetaminophen, diuretics, meperidine,
• Sudden withdrawal of drugs

    Other causes of delirium…check lab tests for…

•   Low sodium
•   High or low potassium
•   High calcium (cause in elderly?)
•   Hypoglycemia (insulin, sulfonylureas—not metformin
    alone); hyperglycemia
•   TSH —hyper/hypo
•   LFTs
•   BUN, Creatinine
•   Hypoxia, hypercarbia
•   MI, Stroke with aphasia                          85
        Other considerations…
• ETOH withdrawal—3rd to 5th day after last
  drink—due to dopamine rebound (11 th-14th
  day increased risk of thromboembolism)
• Fecal impaction
• Urinary retention
• Transfer to unfamiliar surroundings—ICU,
  hospital, nursing home
• Sundowning –sensory deprivation in
  unfamiliar surroundings
• More common than dementia
• Often co-exists with dementia
• May appear withdrawn, uncooperative or
  intermittently agitated
• Functionally or cognitively impaired
• May prolong recovery from illness due to lack
  of cooperation

   The usual neurovegetative signs of depression are
      unreliable in the elderly…(The SALSA signs)

• Sleep disturbances, appetite changes, low, self
  esteem, and anhedonia (lack of interest in day-to-day
• There is NO significant illness or medical condition in
  late life that does NOT impinge upon sleep, appetite
  or energy or sense of vitality
• Usual aging also brings changes in sleep patterns and
  energy expenditure…
• If within 10 minutes…
• Geriatric Depression Scale

         Stroke and depression
• Left cerebral cortex with damage to frontal
  pole=depression (especially seen with stroke
  patients; high risk within 1st 2 years after
• SSRIs for ischemic stroke patients
• Sertraline (Zoloft) and escitalopram (Lexapro)
  are excellent choices

           Movement disorders…
• The basal ganglia—
• Paired nuclei at the base of
  the brain
                                 Caudate nucleus
• 50:50 balance between
  acetylcholine and dopamine
• Gamma-amino butyric acid
                                        Globus pallidus
  (GABA) keeps dopamine in
                                 Substantia nigra

                                  Subthalamic nucleus

         The BASAL GANGLIA…
• Control of movement, initiation and cessation
  of movement
• Postural reflexes—the righting reflex
• Dopamine levels decrease with aging
  gradually—we all slow down
• Dopamine loss of greater than 80% results in
  signs and symptoms of Parkinson’s disease

             Clinical symptoms
• Anosmia (loss of smell)(may predate Parkinson’s
  disease by a decade)
• Resting tremor (70%)—unilateral or bilateral
• Rigidity (vs. spasticity of stroke patients)
• Loss of voluntary movements (spontaneous)
• Bradykinesia (check gait)
• Postural instability (sternal push)
• Progression to dementia is common (40-60%)

     Peripheral neuropathy--stocking glove
     distribution—dermatone distribution
• 3 major causes in the elderly?

• DM, B12 deficiency, B1 (thiamine deficiency)

  Exam for peripheral neuropathy
• Check the DTRs (50% of the elderly have lost
  the Achilles reflex)
• Acute tendonitis with the fluoroquinolones
  (the “floxacins”)
• Loss of lower motor neurons in the lumbar
  area of spinal cord greater than loss in cervical
  area—weaker legs than arms with aging
• Get up out of a chair? Use arms? Check gait.

      Herpes zoster—Shingles—Hell’s fire

• Treat acute pain? One of the “cyclovirs” +
• Treat chronic pain? Post-herpetic neuralgia;
  try single therapy first with either
Gabapentin (Neurontin) or
  (nortriptyline)(Pamelor/ Norpramin)
• If they don’t work as single therapy, combine
  the two drugs for better response

           Zostavax at age 60; why?
•   10—0.5%
•   20—1.3%
•   30—2.7%
•   40—4.8%
•   50—7.5%
•   60—11.9%
•   70—19.7%
•   80—31.8%
•   90—46.1%
•   Donahue JG, et al. Archives of Internal Medicine, 1995.

             Special senses…
• Vision—accelerated loss between 50-69
• Loss of retrobulbar fat and reduction of eye
• Shrunken eyeballs—loss of upward gaze and
  peripheral vision
• Decreased lens elasticity with presbyopia

• Greater than 25% of all patients over 65 have a
  significant hearing loss
• Accelerated loss after 40; greater loss of high
  frequency tones; sound localization problems
• Selective hearing loss; wearing a hearing aid; public
• The evolution of hearing products:
  17th century, The Ear Horn; wearable hearing aid in
  1935, weighed 2.5 pounds

                Taste and smell…

• Questionable loss of taste;
• Decreased number of taste buds
• Decreased saliva
• Atrophy of the olfactory bulbs (90 percent of
  what we perceive as taste is actually smell)
• Smell and memory

     The Cardiovascular system and aging

• Increased prevalence of CV disease with age
• Persons over 65 account for 65% of all
  cardiovascular hospitalizations

           The aging heart…
• 1% rule--maximal O2 consumption and cardiac
  output decrease by 1% per year;
• Heart rate does not decrease with age
• Decreased heart rate reserve and maximum
  attainable heart rate; decreased contractile
  reserve—increased risk of CHF

      The aging heart and vascular system

• Decline in sinus node function—increased risk
  for sick sinus syndrome; increased risk for
  atrial fibrillation and atrial flutter; impaired
  chronotropic responsiveness—increased need
  for pacemaker
• Endothelial dysfunction—increased risk for
  atherosclerosis; increased risk of heart
  disease and cerebrovascular disease

      The aging heart and vascular system…

• Increased vascular stiffness—increased
  systolic BP with widened pulse pressure;
  increased afterload
• Increased myocardial stiffness—impaired LV
  filling; increased risk for diastolic heart failure
  with preserved LV systolic function

          Chronic heart failure
• Compensatory mechanisms—KIDNEY senses
  low volume, low pressure
• Increased renin-angiotension-aldosterone—
  resulting in increased preload and afterload
• The failing heart cannot tolerate the increased
  preload and afterload—enter the ACE
  inhibitors and spironolactone (Aldactone) to
  inhibit angiotensin and aldosterone

    Pitting edema—consider CHF
• Pitting at the ankles
• 4.5 kg of excess fluid (10 pounds)

    Fluid overload—jugular vein distention

• Check the RIGHT jugular vein in the older
• The left inominate vein dumps into the left
  jugular; this vein may be compressed between
  an elongated and unfolded aortic arch and the
  back of the sternum; increased mechanical
  pressure of the inominate vein may lead to
  increased left jugular vein distention
  continuously—i.e. falsely distended
  “Funny things happen in the middle of the
• Nocturia
• Paroxysmal nocturnal dyspnea
• Orthopnea

       Other signs of heart failure
•   Pulmonary rales
•   Hepatojugular reflex
•   Hepatomegaly
•   S3 (third heart sound)
•   Listening to heart sounds

A quick primer on listening to the heart…the
       easy way (5th ICS, MCL for S2)

        Listening to the heart…
• S3 heard immediately after S2
• In other words, it is a diastolic sound
• Indicates an elevated left ventricular diastolic
• Nothin’ that a little Lasix won’t cure

               The valves…
• Calcification with aging
• Aortic and mitral valves primarily
• Which valve is the most diseased valve?
• New valves before 60 think rheumatic heart
• 60-70 think congenital heart disease
• After 70—plumb tuckered out…

                  Atrial fibrillation
• Greater than 10% over 80; median age 75; AF reduces CO by
  10-15 %
• Fibrillation potentiates clot formation and results in 2-5 fold
  greater risk for embolic stroke (embolism)
• % of strokes attributable to atrial fibrillation is < 2% under 60;
  20% over 80
• Can occur as a part of normal aging via minor, patchy scarring
  that occurs in the atria; these areas of scarring disrupt the
  normal circuitry
• Other causes—hyperthyroidism, hypertension, CHF, valvular
  heart disease (mitral and aortic), electrolyte imbalances
  (check Mg+), diabetes, rheumatic heart disease, ETOH (2% AF
  due to 2 drinks daily in women), congenital abnormalities

             Goals of treating AF
• Controlling heart rate rather than rhythm
• Optimal rate at rest—60-80; with mod. exertion 90-115
• Controlling rate reduces complications, and is better
  tolerated than controlling rhythm
• Approach applies mainly to newly detected atrial fib
• Beta blockers—atenolol (Tenormin), metoprolol (Lopressor,
  Toprol), diltiazem or verapamil (too much constipation—not
  a good choice)—slow conduction through the AV node
• Digoxin is a secondary choice

               Goals of treating AF
• Antiarrhythmics are also an option—mostly for patients who
  are highly symptomatic when they aren’t in normal sinus
  rhythm—amiodarone (Cordarone, Pacerone)—most effective,
  but serious side effects; very long half life (1-2 months); takes
  days or even weeks before a therapeutic level is reached;
  reserved for patients who don’t respond to other drugs,
  propafenone (Rhythmol), flecainide (Tambocor), sotalol
  (Betapace), dofetilide (Tikosyn)
• And, as always, warfarin…long-term anticoagulation with
  warfarin reduces risk of stroke by 66%;
• INR – 2-3; mitral valve disease or mechanical prosthetic
  valves—INR 2.5 to 3.5
• ASA 325 mg/day with net reduction of stroke of ~20%

    Warfarin (Coumadin)/dabigatran
• Atrial fibrillation, prevention of DVT and PE
• When adding or subtracting a drug, check the
  INR within 4 days
• Usual maintenance dose is 2-10 mg/day

  Coumadin (warfarin sodium)…
• Drugs that are sulfa-based knock Coumadin
  off its binding sites—TMP/SFX
  (Septra/Bactrim), celecoxib (Celebrex),
  thiazide diuretics, and more…can make
  Coumadin more “toxic”—increased bleeding
• Conazoles and Coumadin—even topical
  miconazole can increase the INR and cause
  bleeding (Heart Watch. May 2001)
• The “green stuff” and warfarin

               Kiss my aspirin…
• Aspirin is indicated for all patients with acute CHD regardless
  of age and should be continued indefinitely in all patients with
  documented CHD; 81.5 – 100 mg per day for chronic use
• Recommended dosage in acute setting is 160-325 mg daily
• How about healthy postmenopausal women and aspirin?
• Overall protection for strokes, but appeared to be highest
  protection in 65 and older; also significantly reduced MI in
  over 65 group (N Engl J Med, March 31, 2005)
• ASA is absolutely recommended in women and men with
  established heart disease, regardless of age

• Can ibuprofen be used with aspirin?
• Take aspirin first thing in a.m. (note: evening
  dose may reduce BP in hypertensive patients)
• Take ibuprofen 2 hours later
• Use Aleve (naprosyn) if an NSAID is required
  on a daily basis

          Clopidogrel (Plavix)
• Inhibits ADP-induced platelet aggregation via
  the glycoprotein IIb IIIa complex
• Irreversible action
• Reduces CV events in established CVD
  patients—75 mg daily
• Give to patients with ACS (unstable angina
  and NSTEMI patients)—300 mg loading dose
  and then 75 mg daily with 75-325 mg of ASA
• Losec (omeprazole) and esomeprazole
  (Nexium) and clopidogrel (other PPIs?)
     Nitroglycerin—can I blow up with NTG?

• Oral, extended release (Nitro-Bid, Nitroglyn, Nitrong,
  Nitrong SR, Nitro-Time
• Sublingual NTG—NitroQuick, Nitrostat
• Translingual—Nitrolingual
• IV—Nitro-Bid IV, Tridil
• Topical—Deponit, Minitran, Nitrodisc, Nitro-Dur,
• Transmucosal—Nitrogard
• Cannot use with the ED drugs

• The combination of an ED drug with a nitrate
  can be deadly

               The ED drugs
• Side effects
• Can you have a heart attack during sex?
• Only if…

 A major reproductive difference…
• Women get all the eggs they are ever
  going to have prior to birth
  (not exactly, but almost--)
• However, our ovaries die at 51.3 +-2.7


•   At 6 months gestation ________________
•   At birth _____________
•   At age 30 ___________
•   At age 50 __
•   The age of an egg is YOUR age!
•   Could you possibly get pregnant at 50?
•   How do eggs meet their demise? Apoptosis
    and primary ovarian failure—as the follicles
    drop out, the FSH rises—trying to stimulate
    the ovary to produce more eggs…rising FSH
    levels signal impending doom of the ovary      124
Do guys get all the sperm they’re going to get at
• Nooooooooooo…
• Men produce sperm PRN until the day they
• Sperm is only 75-90 days old when freshly
• However, there are some interesting

• The sperm of a 20-year-old vs. the sperm of an 80-
• Swimming prowess
• The germ cells that make the sperm and DNA
• Older fathers and mental illness

   Gender-specific aging changes
Estrogen has over 300 functions in the body
Reproductive functions
Skin integrity
Boosts HDLs, decreases LDLs
Builds bone
Calms the hypothalamus
           The Endocrine system
• Type 2 diabetes—aging and pancreatic islet cell
  dysfunction; insulin resistance and beta cell
• 50% are over 60; 18% are 65-75; 40% over 80 have
• DM type 2 is also considered a Cardiovascular
  disease—signs and symptoms of atherosclerosis
• 4 out of 5 diabetics die from CV complications—
  heart failure, MI, stroke, peripheral arterial disease

 The Geriatric Patient and blood glucose control
• Blood sugars? (may want to keep the HbA1C in
  the 7-8 range)—hypoglycemia can break a hip
• Consider co-morbidities before aggressively
  treating—8 years needed benefit of glycemic
  control in reducing microvascular complications
• 2-3 years for benefit from BP and lipid control for
  reducing macrovascular complications
• Life expectancy?

           The Endocrine system
• Hypothyroidism—20% of women over 65; what are
  the first clinical signs of hypothyroidism?
  Cardiovascular and neurologic
• Synthroid and drugs and supplements
• Hyperthyroidism—consider hyperthyroidism as an
  underlying cause of atrial fibrillation in the elderly—
  weight loss, fatigue and atrial fibrillation—usually
  due to a multinodular goiter

              The GI system
• The acute abdomen—abdominal pain is the
  second most common medical complaint in ER
  in patients over 65

• Appendicitis—rate of perforation in the
  elderly is 50%; may NOT have “board-like”

      The GI system—the acute abdomen

• Biliary tract disease—some researchers
  suggest that biliary tract disease is the most
  common diagnosis in elderly patients
• Bowel obstruction--~12% of cases of
  abdominal pain in elderly persons; large
  bowel? Cancer; small bowel? Adhesions from
  previous surgeries and hernias

        The GI system—the acute abdomen

• Gastroenteritis—should be considered as first and foremost a
  diagnosis of exclusion in the elderly patient with vomiting and
• approx. 50% of the cases of missed appendicitis were initially
  thought to be simple gastroenteritis; serious morbidity in
  patients over 70 (2/3 of gastroenteritis deaths occur in
  patients over 70)
• Malignancy--~10% of patients discharged from the ED with
  nonspecific abdominal pain will eventually receive a diagnosis
  of cancer (deDombal FT, Matharu SS, Staniland JR, et al.
  Presentation of cancer to hospital as ‘acute abdominal pain’.
  Br J Surg. 1980;67(6):413-416.

      The GI tract--constipation
• Definition? 3 per day to 3 per week
• Constipation—causes?
  Drugs—anticholinergic, opiods
  fluid and fiber intake?
  laxative abuse—prune abuse
  dementia-- “the neglect of the call to stool”…
  cancer of the colon
  decreased activity

             Respiratory system
•   Increased risk of pneumonia
•   Tuberculosis—cardinal symptoms?
•   COPD and dyspnea
•   The BNP test to differentiate dyspnea from
    CHF vs. COPD

  BNP—B-type natriuretic peptide
• Peptide produced by the heart in response to fluid build-up
  secondary to inefficient pumping; determines whether COPD
  or CHF is the cause of dyspnea—15 minute blood test
  correctly diagnoses CHF in 95% of the cases without ordering
  CXR or ECG
• BASEL study (Brain Natriuretic Peptide for Acute Shortness of
  Breath Evaluation)—heart failure ruled out if BNP level was
  less than 100 pg/mL; if BNP greater than 500 pg/mL heart
  failure was the most likely cause of symptoms
• Prognostic value?—35% increase in mortality for every 100
  pg/mL increase in BNP levels among heart failure patients
  (Doust JA, et al. BMJ 2005 Mar 19;330:625-33)
• Nesiritide –Natrecor infusions—vasodilation and natriuresis

         Cancer in the elderly
• Accumulation of DNA mutations over the
• Skin—sun exposure over the years; squamous
  cell carcinoma, basal cell carcinoma, and
  malignant melanoma

      ABCDEFs…of malignant melanoma

• Asymmetry; appearance of a new lesion (over
• Border—irregular, notched; bleeding
• Color variation, change in size, shape, color
• Diameter—6mm or more
• Elevation, Erythema
• Funny feeling

                Lung cancer
• Umbrella term--bronchogenic carcinoma
• Non-small cell carcinomas
  Squamous cell carcinoma
  Large cell
• Small cell (oat cell)

               Colon cancer
• Time of day for colonoscopy is important
• Starting at age 50

    Breast cancer—3 major risks
• Being female
• Family history of premenopausal breast
  cancer—mother, sister, daughter

   Breast ductal linings—prolonged hormone
Age 20 – 1/2044
Age 30 – 1/249
Age 40 – 1/67
Age 50 – 1/36
Age 60 – 1/29
Age 70 – 1/24
Age 80 – 1/11
Age 90 – 1/8

• LIFETIME exposure to
  hormones—womb to tomb

 Thank you… stay healthy, age well, and have a
                  nice day.
• Barb Bancroft, RN, MSN