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Falls Prevention and Management

VIEWS: 18 PAGES: 108

									The Geriatric Giants

 Dr Hannah Seymour
 Consultant Geriatrician
Aknowledge slides from

• Dr Kate Ingram
• Dr Mark Donaldson
• Dr Chris Beer
• Dr Sean Maher

        • Immobility
        • Instability
        • Intellectual Impairment
        • Incontinence
        • Iatrogenesis
I’m going to talk about

• Cognition – Forgetfulness vs Delirium vs Dementia
• Falls – Reversible causes in the community
• Immobility – How to avoid and manage it
• Incontinence – Especially reversible causes
• Iatrogenic Conditions – Especially Polypharmcy &
Cognitive Screening Tests

• Screening
   Detection amongst “healthy” community members of
     (unsuspected) disorders or risk factors

• Case Finding
   Detection of cognitive impairment where high
     probability of disease in particular population or
Cognitive Screening Tests

 • Normal ageing vs MCI vs early dementia?
 • No perfect test for early detection
 • Case for detection of mild cognitive impairment unclear
    Risks vs benefits, costs, no effective therapies
    May change with new therapies
 • Emphasis on detection of dementia
    Benefit from interventions
 • Should always be done if memory complaints or history
   suggestive of dementia
Cognitive Screening Tests

• Detect cognitive impairment from any cause

• Don‟t diagnose dementia!

• Generally test orientation, recall of short and long term
  memory, personal information, attention and other
  domains eg visuospatial
Cognitive Screening Tests: MMSE

•Standardised MMSE Molloy    •Orientation
et al 1991
                             •Registration, Recall
•Floor and ceiling effects
•Western background,
education, language
•No test of executive
function                     •Visual construction
Cognitive Screening Tests: Geriatric
Depression Scale (GDS) Yesavage 1983

•30 Questions               •Yes or No responses to questions
                            about depression symptoms
    Cut off 11
                            •Depression an important cause
        Sens 84%
                            of cognitive impairment
        Spec 95%
    Cut off 14
        Sens 80%
        Spec 100%
•15 Question version
•4 & 10 Question versions

• Global cognitive impairment
• Irreversible
• Clear sensorium
• Usually progressive
Dementia: Causes

•Alzheimer‟s                                                  •Cushing‟s, Addison‟s, Thyroid,
•Lewy Body                                                    parathyroid, diabetes

•Frontotemporal                                               •Vitamin B12, thiamine, nicotine
                                                              •Normal pressure hydrocephalus,
•Other extrapyramidal
syndromes                                                     Head injury, space occupying
                                                              lesion, multiple sclerosis
                                                              •Syphilis, HIV, encephalitis, CJD
      Small vessel ischaemia
Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, O’Brien & Ames
Dementia: Some “Reversible or
partly reversible” Causes

•Drugs                                                   •Liver disease
•Depression                                              •Normal pressure hydrocephalus
•Metabolic causes                                        •Subdural haematoma
•Thyroid Disease
•Vitamin B12 deficiency

Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, O’Brien & Ames
Dementia: Diagnostic features

•development of multiple                                        •memory impairment
cognitive deficits
                                                                •And at least one of:
•impairment in
occupational or social                                                 aphasia
•decline from a previously
higher level of functioning                                            agnosia
                                                                       disturbance in executive
 Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Memory

 •Memory impairment needed for diagnosis
 •early prominent symptom
 •new learning impaired
 •forgets previously learned material
 •loses valuables, forget food cooking, lost in
 unfamiliar territory, poor medication compliance
 •forgets personal details eg family, occupation,
 address, own name

  Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Aphasia

•Language difficulty
       •Loss of complexity
       •Naming people or objects
       •Comprehension (verbal and
       •eventually mute

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Apraxia
•Difficulty performing motor task despite intact

 •Trouble with everyday tasks eg cleaning teeth,

 Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Agnosia

•Difficulty recognising objects or people

•Trouble recognising ordinary objects, family
members, even themselves in photographs or mirrors

 Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
   Diagnostic features: Executive
•ability to think abstractly
•judgement, reasoning, insight
•plan, initiate, sequence, monitor, and stop complex behaviour
•difficulty coping with novel tasks or complexity
•poor choices
•financial problems
•at risk behaviour due to lack of insight

    Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Behaviour

•Delusions, especially paranoia                                 •Social withdrawal
•Hallucinations, especially visual                              •Neglect of personal care, home,
•Irritability, aggression (verbal
and physical)                                                   •Apathy
                                                                •Sleep disturbance
                                                                •Mood disturbance
•Agitation, wandering, getting
lost                                                                   Anxiety
                                                                •Demanding, attention seeking,
 Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Assessment
 • History – most important
 • Examination
 • Neuropsychometric testing
 • Laboratory tests
    FBP, U&E, TFT, B12, folate, BSL, syphilis serology,
      ESR, Urinalysis, calcium +/- lumbar puncture, EEG
 • Imaging
    CT, MRI
Dementia: Alzheimer’s Disease
• Accounts for 60% of Dementia in Australia
• Neuronal degeneration with plaques of beta amyloid
  and neurofibrillary tangles
• Early onset forms due to gene mutations
• Main feature is memory loss, plus other domains,
  gradually progressive
• Treatment with cholinesterase inhibitors (donepezil,
  galantamine, rivastigmine) or memantine
• New therapies seem promising

 Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Alzheimer’s Disease: Natural

Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Lewy Body Disease

• Lewy bodies = neuronal inclusions of neurofilament protein
• Found in basal ganglia in PD, diffusely through cerebral cortex in
  DLB - spectrum of same disease?
• Classic features of cognitive impairment plus
      Fluctuation in cognition, alertness, attention
      Visual hallucinations
• Respond to cholinesterase inhibitors
• Very sensitive to antipsychotics => rigidity
 Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Vascular Dementia
• Cognitive impairment due cerebrovascular disease
      Small vessel ischaemic changes - gradual decline
      Recurrent stroke - stepwise deterioration
• Evidence of vascular changes on CT/MRI
• Vascular risk factors - HTN, cholesterol, diabetes, smoking, existing
  cardiac disease
• Often early onset gait disturbance (balance and/or gait dyspraxia),
  falls, urinary incontinence
• Often frontal lobe features, emotional lability, pseudobulbar palsy
  with speech/swallowing problems

 Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Frontotemporal
• Probably represents several diseases
• Early loss of personal and social awareness
• Disinhibition often prominent
• Mental rigidity, inflexibility, “concrete”
• Depression and anxiety prominent
• Speech and language disturbance
      Reduced in complexity
      Echolalia, stereotypy
• Early primitive reflexes and urinary incontinence
• Late rigidity, tremor
 Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Management

• Treat reversible causes!
• Education
• Cholinesterase inhibitors (AD, LBD)
• Control of vascular risk factors
• Maintain cognitive and physical activity
• Treat depression
 Dementia: Practical Issues
•Education                                                      •Memory aids
•Counselling                                                    •Home safety

•Community Resources                                            •Driving

    Alzheimer‟s Assoc                                           •Enduring Power of attorney
                                                                •Testamentary capacity
    Respite in home, day centres &
    residential                                                 •Advanced directives
    Crisis Care                                                 •Continence

    Care packages                                               •Residential Care

•Strategies for managing behaviour

 Adapted from Hecker J Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
 Dementia: Take home messages
• Cognitive screening tools only detect cognitive impairment -
  they don‟t diagnose
• History suggestive of dementia or abnormal cognitive test
  result should result in suggestion for further evaluation
• A diagnosis of dementia requires decline in occupational
  and social functioning, at least one other cognitive domain
  impaired (aphasia, agnosia, apraxia, executive
  dysfunction), as well memory
• Interventions usually beneficial
• Carer support vital to management
Delirium in Older People
Delirium: Definition

• de lira “to wander”
• Clinical syndrome characterised by
   rapid onset of altered consciousness
   and cognition
   that fluctuates
Delirium: Epidemiology

• Prevalence in elderly hospital admissions
    10 - 24%
• Incidence during hospital stay
    6 - 56%
• Post operative incidence
    10 - 61%
Delirium: Aetiology

• Geriatric syndrome
• Multiple factors acting in concert
• Patient vulnerability
• Predisposing factors
• Precipitating factors
Delirium: Predisposing factors

•Dementia                  •Advanced age
•Multiple medications      •Neurological damage
•Visual and hearing        •Functional disability
                           •Alcohol abuse
•Severe/multiple chronic
medical conditions         •Depression
•Dehydration               •Chronic renal impairment
Delirium: Clinical Features

• Prodrome sometimes recognised
   irritable, angry, evasive, bewildered
• Develops over hours to days
• Fluctuates
   lucid periods during day
   maximal disturbance at night
Delirium: Clinical Features

  • Inattention
  • Disorientation
  • Short term memory impairment
  • Thinking is disordered
  • Speech rambling and incoherent
  • Delusions, misperceptions and visual hallucinations
  • Distress
Delirium: Clinical Features

• Disturbance of consciousness
• Hyperactive delirium
   Repetitive behaviours e.g. plucking at sheets,
     wandering, verbal and physical aggression
• Hypoactive delirium
   quiet, withdrawn patient, often mistaken for
• Mixed pattern
Delirium: Detection

• Delirium often missed
• 32 – 67% of delirious patients are not diagnosed
• Cognitive assessment should be standard
• Serial testing to monitor progress and to detect delirium
  arising during an admission
• Mental status = a “vital sign”
Delirium: Detection

Confusion Assessment Method
   (Inouye et al Ann Int Med 1990;113:234-42)
 1 Acute onset and fluctuation of cognition
 2 Inattention
      with EITHER
 3 Disorganised thinking
 4 Altered level of consciousness
Delirium: Management

• Treat underlying causes
• Correct dehydration
• Review medications
• Non Pharmacological
• Pharmacological
• Monitor progress
Delirium: Outcomes

• More persistent than previously realised
• up to one week in 60%
• two weeks in 20%
• four weeks in 15%
• more than four weeks in 5%
• Others report delirium still present at 6 months
   O'Keeffe S The prognostic significance of delirium in older hospital patients J of the
      Am Geriatr Soc 1997;45(2):174-8
Delirium: Outcomes
Cognitive decline

• Early cognitive impairment unmasked by acute illness

• May be acute and permanent deficits due to ischaemia,
  hypoxia or mediated by glucocorticoids or cytokines

   Francis J Prognosis after hospital discharge of older medical patients with
      delirium. J Am Geriatr Soc 1992;40(6):601-6
Delirium: Take Home Messages

• Common
• Distressing
• Often Missed
• Cognitive testing should be routine
• Complex Geriatric Syndrome
• Preventable
• Predicts adverse outcomes
Falls -Prevention and

• “A fall occurs when environmental hazards or demands
  exceed an individual‟s ability to maintain postural

Mary Tinetti ASGM ASM 2001
Enormity of the Problem

• 33% over 65yrs fall annually
• 50% of these have repeat falls
• In nursing homes 50-65% fall annually
• 10-15% of falls result in serious injury
• 1% hip fracture rate
Breakdown of Discussion

• Falls in community dwelling elderly

• Compliance problems

• Unanswered questions
Modifiable Risk Factors for Falls
in the Community
•Psychotropic drugs – especially benzodiazepines
•Multiple drugs
•Postural Hypotension
•Environmental hazards
•Poor balance or gait
•Poor functioning with ADLs
Preventing Falls in the
• Independence model of care
• Screening of home environment by OT / health worker
• Psychotropic medication withdrawal
• Medication review/ minimization
• Appropriate vision aids & footwear
• Balance and exercise program
• Avoiding Injury - Treating Osteoporosis
Falls Clinic Process
Multidisciplinary- everyone assessed by the following:
• Geriatrician- full history, examination, investigation, including
  osteoporosis workup
• Nurse-lying and standing BP, vision, continence, community
• Physiotherapist- administers Fallscreen, ?need for walking aid,
  teaches patient to get up off floor, strength and balance
  exercise program, sets home program, general footwear advice
• OT- ADL assessment, 50% get home visit, group education

+/- social work assessment for package of care, hostel/ N/H
+/- clinical psychologist to address fear of falling or podiatry
Falls Clinic Process                     Contd.

 • All new patients discussed at a multidisciplinary meeting at the
   end of the clinic, and management plan formulated

 • Length of time attending the clinic approx 6-10 weeks.

 • On discharge, given home exercise program

 • Followed up 4 months following discharge
What about in the Kimberley

• No research in remote or Indigenous settings
• Moving to single multiskilled professional in metro areas
• Can do great functional assessments and improve
  reversible risk factors
• Independence model of care very important
Who Should Have a Comprehensive Falls
  • All older persons to be asked once a year about falls

  • If 1 fall -GP assessment, and observe the „Get up and
    go” test

  • Triggers for further assessment
     >1 fall in last year
     A fall resulting in injuries
     Abnormalities in gait or balance
     Symptoms of dizziness
     Evidence of a fear of falling
Hip Protectors

• Reduce hip fracture rate (by 50%) for those in nursing
  homes with a high risk of falling
• Compliance is problematic- 38 –57% in various studies
Vitamin D Deficiency and Falls

• Causes muscle weakness and probably falls
• Leads to osteoporosis and increased risk of fracture
• Very common in elderly, community dwelling
  population (? Indigenous)
• Almost universal in residential care
• Replacement with calcium reduces fractures in
  residential care and in those who are deficient in the
Patient Compliance with Fall Initiatives
 • Survey in Aust (Whitehead, 2003)
    72% reluctant to do exercises
    57% reluctant to stop sleeping tablets
    43% reluctant to have a home assessment

 • Campbell, JAGS, 1999
    Study demonstrated reduced falls with psychotropic
      withdrawal program and home based exercises
    47% had restarted their psychotropics within 1 mth
Patient Compliance with Fall Initiatives

• Simpson
   UK study investigated barriers to a falls program
   The elderly patients involved had reduced
     understanding of the benefits of exercise
   Home visits were considered intrusive, and felt that
     there was inadequate negotiation about the
     necessary changes resulting in resentment
• Falls are a hallmark of the frail elderly

• Falls are usually multifactorial in origin

• DON‟T be pessimistic- multidisciplinary
  treatment can prevent up to 60% of falls

• The elderly have the most to gain by treating
  their osteoporosis
How to avoid it?

• Encourage functional mobility
• Educate family and carers
• Early rehabilitation
• Appropriate use and maintenance of mobility aids
• Physiotherapy if possible
Management of the Immobile Patient

• Ensure no reversible causes can be identified

• Encourage Independence within limits of mobility
Avoiding Pressure Ulcers

• Regular assessment of bony prominences
• Regular turning to relieve pressure – ideally 2 hourly
• Use pillows if no air mattresses available
• Avoid friction and shearing forces (safe manual
• Skin Hygeine and Moisture
• Leave blisters intact
• Get help early – for example Donna Angel at RPH will
Urinary Incontinence in
the Elderly
Incontinence in the Elderly

  • Prevalence in community dwelling elderly
        -women 30%
            -men 15%
  • 60% of nursing home residents
  • Risks
        -parity (association is weak in women over
Continence requires:

       • Adequate mobility
       • Mentation
       • Motivation
       • Manual dexterity
       • Intact lower urinary tract function
Medical Complications

   • Rashes
   • Pressure ulcers
   • UTI
   • Falls
   • Fractures
Psychosocial complications

     • Embarrassment
     • Stigmatisation
     • Isolation
     • Depression
     • Institutionalisation risk
A Normal Bladder

• First urge to void occurs when bladder volume is 150 –
• Normal bladder volume 300 – 600mls
• Bladder capacity declines with age and post void
  bladder volumes increases (up to 50 – 100 mls)
• Involuntary bladder contractions also increase with age
• Lose the ability to concentrate urine at night (ADH
  secretion) with nocturia 1 – 2 x)
Causes of Transient Incontinence

• Delirium
• Infection (symptomatic UTI)
• Atrophic vaginitis/ urethritis
• Pharmaceuticals
• Psychological
• Excessive urine output
• Restricted mobility
• Stool impaction
Drugs Affecting Continence

   • Diuretics
   • Anticholinergics
   • Psychotropics
   • ACE inhibitors (cough)
   • Narcotics
   • Alpha blockers (urethral relaxation)
   • B agonists (retention)
   • Calcium channel blockers (retention)
Persistent Incontinence

• Involuntary loss of urine (usually small amounts) with
  increases in intra- abdominal pressure (coughing,
  sneezing, laughing, exercising)

• In women, causes include lack of oestrogen, obesity,
  previous vaginal deliveries, previous surgery

• In men (rare) causes include radiotherapy and
Persistent Incontinence

• Leakage of urine (larger volumes) due to inability to
  delay voiding after sensation of bladder fullness is felt
• Associated symptoms include nocturia, urinary
• Causes
   Ideopathic (Detrusor overactivity)
   Local pathology- tumour, stone, diverticuli, outflow
   CNS disorders- stroke
Detrusor hyperactivity with Impaired
Contractility (DHIC)

• A subset of patients will have this, emptying less than
  1/3 of bladder volume

• Are predisposed to urinary retention
Persistent Incontinence

• Leakage of urine (small amounts) resulting from
  mechanical forces on an overdistended bladder
• Causes
   Anatomical obstruction by prostate, stricture,
   Acontractile bladder associated with diabetes or spinal
     cord injury
   Medication related
  • History
     Characteristics of incontinence
     Medical problems, medications, bothersomeness
  • Bladder chart
  • Examination
     General- esp CCF, venous insufficiency
     lumbosacral innervation
     In women- inspect for prolapse, cough test,
       atrophic vaginitis
     Assessment of mental state and mobility
  • Urinalysis
     the relationship of asymptomatic bactiuria with
       incontinence is controversial.
     No benefit from treating the nursing home
     ? Eradicate bactiuria once and assess it effect on
  • Post Void Residual Volume – Important to rule out
    significant retention
     <100 mls normal
     >200 mls abnormal
Assessment- selected patients

   • Urine culture, cytology
   • Blood glucose, calcium, renal function
   • Abdominal ultrasound
   • Urodynamics
      Recent data suggest that it has little clinical
        utility in urge incontinence
  • Supportive measures
  • Education
  • Environmental changes eg toilet light on
  • Use of toilet substitutes eg bottle, commode
  • Modification of fluid intake patterns
  • Alcohol, caffeine avoidance
  • Management of constipation
  • Smoking cessation, treatment of cough
Management- Behavoural

  • Pelvic floor exercises- useful for urge
    and stress incontinence

  • Bladder Retraining
       Urge incontinence
       Progressive lengthening of intervoiding interval
Management- Behavoural

  Institutionalised patients
  • Scheduled toiletting- 2 hrly during day, 4 hrly at
  • Habit training- variable schedule depending on
    patients voiding patterns
  • Prompted toiletting- prompted to toilet 2 hrly,
    only toiletted on request, positive reinforcement
    (25 -40% of nursing home residents respond)
Management Urge Incontinence- Drugs

• Anticholinergics eg. Oxybutinin 2.5- 5 mg tds
   have 60 – 70% reduction in frequency of incontinence
   Probably work via afferent pathways
   S/Es: dry mouth, constipation, confusion, urinary

• Oestrogen vaginal cream 0.5-1g nightly for 1 month,
  then 2-3x/ week (NB oral oestrogens worsened
  incontinence in the WHI study)
Management Stress Incontinence- Drugs

Little role for medications
   Imipramine 25-50 mg tds (anticholinergic as well, so
     there is an argument for using it for mixed urge/
     stress incontinence) Efficacy date is lacking, though
     and has side effects ++ in elderly
   Duloxitene- serotonin and noradrenaline reuptake
     inhibitor (results in 50-54% reduction in frequency of
     incontinence). Causes initial nausea
Management of Overflow Incontinence

 Catheter if significant retention then:
 Refer to urology who may advise medication and or
 Drugs - Prazosin, Tamsulosin, Terazosin
Management- other strategies

 • Surgery    - TURP
              - Bladder neck elevation, peri-urethral
                     collagen injections
 • Catheters- IMCs, IDCs
 • Botulinum toxin injection into detrusor muscle or
   bladder neck
 • Continence pessaries- for women with large prolapses
   when surgery is contraindicated
 • Desmopressin for large volume nocturia
Iatrogenic Problems

• Understand why Polypharmacy is common in older
• Identify the problems caused by polypharmacy in older
• Monitor and manage Polypharmacy
• Understand inappropriate versus appropriate
The Challenge of Geriatric Clinical

‘to balance an incomplete evidence base for efficacy
  in frail, older people against the problems related to
  adverse drug reactions without denying older people
  potentially valuable pharmacotherapeutic
                               Le Couter et al

• 5 or more drugs

• 20-40% of older people
Causes of Polypharmacy

•Prescriber (what influences prescribers?)
•Reluctance to cease another prescriber‟s prescription
•„Rational Polypharmacy‟
Risks of Polypharmacy

 • Adverse drug reactions common cause of
    hospital admission
    morbidity and mortality
 • Falling, delirium and the other geriatric syndromes may
   be drug-related
 • Medication errors

 polypharmacy, per se, appears to be a risk factor for
   adverse outcomes
What are the goals of care?

• Often different in frail person

• Risks of polypharmacy higher in frail person with limited
  homeostatic reserve
   Eg antihypertensives
Weigh risks and benefits

                 •Risk of ADR
                 •Pt wishes
Common difficult areas

• Include Benzodiazepine and psychotropic polypharmacy
• Antihypertensives

  Medication Withdrawal Can be Achieved
Is Discontinuation Safe?

•Psychotropic withdrawal
•Anti anginals
•Anticonvulsant medications
Other Difficult Areas - Under

• Analgesics
• Osteoporosis therapy

(ACE-inhibitors and B-blockers)
Under treatment Continued

•Ca and Vit D (v bisphosphonates)
Reviewing Medications

• View and Record all medications, including OTC‟s,
  herbs, dietary supplements

• Ask about other prescribers

• Cautious medication withdrawal where indicated
Use aids

•Simplify regimens

•Medication cards

•Dosette Boxes

•„Webster Pack‟

•Supervised medications

•Involving caregivers

• Avoid polypharmacy

• Weigh risks and benefits

• Scrutinise all medication prescriptions critically

• Monitor therapy carefully in elderly patients

• Increases with frailty and physical dependance
• Estimated 4.8% recipients of domiciliary aged care
• 27.7% Sub-acute crae
• More GP consultations
• More prescriptions
• Higher hospital admission rate
• Increased risk of:
     Prolonged hospitalisation
     Pressure Ulcers
Nutritional Frailty

• Disability due to unintentional loss of body weight and
• Search for medical causes
• Low Socioeconomic status significant risk factor
• As are poor health, polypharmacy, low mood, low
Non Physiological Causes

• Social Factors – Poverty, Inability to shop, cook or feed
• Psychological Factors – Alcohol, Depression, Dementia
• Medical Factors – Cancer, Chronic Disease
• Medications – Side Effects common

• Two Question Rapid Screen
   Positive if :   Body Mass Index <22kg/m 2
                   Weight loss > 7.5% over 3 months

• Treat/Manage reversible causes
• Educate individual and family –
• Oral supplements with macronutrients
• Lack of evidence for most vitamin supplements

• Ref : Malnutrition in older people - Australian Family Physician Vol 33, No 10
  October 2004

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