3739Caring for the Geriatric Patient CHAPTER 477
Hormetic stressors have been found to influence aging and life span,
presumably by increasing cellular resilience to factors that might contribute to aging such as oxidative stress.
Yeast cells that have been exposed to low doses oxidative stress
exhibit a marked anti-stress-like response that inhibits death following
exposure to lethal doses of oxidants. During ischemic preconditioning in humans, short periods of ischemia protect the brain and the
heart against a more severe deprivation of oxygen and subsequent
reperfusion-induced oxidative stress. Similarly, the lifelong and periodic exposure to various stressors can inhibit or retard the aging
process. Consistent with this concept, heat or mild doses of oxidative
stress can lead to life span extension in C. elegans. CR can also be
considered as a type of hormetic stress that results in the activation of
anti-stress transcription factors (e.g., Rim15, Gis1, and Msn2/Msn4 in
yeast, NRF2 and FOXO in mammals) that enhance the expression of
free radical–scavenging factors and heat shock proteins.
■ CONCLUSIONS
Clinicians need to understand aging biology in order to better manage and care for the older people. Moreover, there is an urgent need
to develop strategies based on aging biology that delay aging, reduce
the onset of age-related disorders, and increase health span for future
generations. Dietary interventions and drugs that act on nutrientsensing pathways are being developed and, in some cases, are already
being tested in humans. Recently, well-controlled human clinical trials
have started to recapitulate the preclinical evidence of intermittent
fasting on obesity, diabetes mellitus, cardiovascular disease, cancers,
and neurologic disorders. While most animal studies show that intermittent fasting improves health throughout the life span, most recent
human studies are focused on relatively short-term interventions over
a few days or months. While intriguing, it remains to be seen whether
people will be willing to maintain strict intermittent fasting regimens
over long periods of time or if there are short-term clinical benefits in
combination with other therapeutic approaches.
■ FURTHER READING
De Cabo R, Mattson MP: Effects of intermittent fasting on health,
aging, and disease. N Engl J Med 381:2541, 2019.
Ferrucci L et al: Measuring biological aging in humans: A quest.
Aging Cell 19:e13080, 2020.
López-Otín C et al: The hallmarks of aging. Cell 153:1194, 2013.
AGING AND GERIATRIC CARE
■ DEMOGRAPHICS OF AGING AND ITS
IMPLICATIONS FOR GERIATRIC CARE
The United States and other countries will continue to experience a
rapid increase in the number of older adults who seek health care. The
most rapidly growing segment of the population in the United States
and many other developed countries is those older than 80 (Fig. 477-1).
According to the United Nations 2019 Aging Report, 1 in 6 people in
the world will be 65 years old or older by the year 2050. Gender composition of the aging population around the world is also expected to
change. Although females outlive males, an improvement in survival of
the oldest-old males could result in more balanced gender distribution
in the geriatric population in the future.
Based on the previously mentioned United Nations report, in
high-income countries, consumption of health care resources will be
477 Caring for the Geriatric
Patient
Joseph G. Ouslander, Bernardo Reyes
1950
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
Years
Percentage of population 80+ years old
0
2
4
6
8
10
12
14
16
Japan
Italy
United Kingdom
United States
China
Mexico
FIGURE 477-1 Percentage of the population age >80 years from 1950 to 2050 in
representative nations. (Updated data available at: https://esa.un.org/unpd/wpp/
Graphs/DemographicProfiles/. Accessed December 30, 2016.)
most affected by the shift in the age distribution of the population over
the next several decades. The World Health Organization continues to
work actively to raise awareness of the changes necessary in current
health care systems beyond increments in their budgets. Planning is
increasingly being based on expected levels of disability and comorbidity. As life span increases, efforts should continue to focus on promoting healthy aging to reduce the burden of disability in health care
systems all over the world.
■ IMPLICATIONS OF THE AGING POPULATION
FOR HEALTH CARE SYSTEMS AND SYSTEM-BASED
PRACTICE
The geriatric population requires different approaches to care for
several reasons. For any variable that can be measured in humans,
the range of variation increases with age. The wide variations seen in
aging make it difficult to develop age-related guidelines for diagnosis
and treatment. For example, acute illnesses are most often not treated
in isolation, but in the context of multiple comorbidities. Close to half
of those older than 80 have three chronic conditions, and about onethird have four or more chronic conditions (Fig. 477-2). Functional
disabilities are prevalent (Fig. 477-3), which require careful attention
in the evaluation of the older patient, along with assessment of social
supports available for assistance when needed for independent and
safe living.
Effectively caring for the geriatric population requires consideration
of several key principles:
1. Aging is not a disease; normal aging changes generally do not cause
symptoms but do increase susceptibility to many diseases and
conditions due to diminished physiologic reserve (which has been
termed homeostenosis).
2. Medical conditions are commonly multiple (“multimorbidity”) and
multifactorial in origin, requiring a comprehensive approach to
evaluation and management.
3. Many potentially reversible and treatable conditions are underdiagnosed and underevaluated in this population, such as fall risk, urinary incontinence, and elder abuse and neglect; simple screening
tools can help detect them.
4. Similarly, cognitive and affective disorders (e.g., mild cognitive
impairment, dementia, depression, anxiety) are common and may
be undiagnosed in early stages; simple screening tools can help
detect them.
5. Iatrogenic illnesses are common, especially related to adverse drug
reactions and immobility and related deconditioning and other
complications.
3740 PART 18 Aging
6. Functional ability and quality of life, as opposed to cure, are key
goals of care.
7. Social history, social support, and patient preferences are critical to
treat older people in a safe and person-centered manner.
8. Effective geriatric care requires interprofessional collaboration
among many different disciplines.
9. Geriatric care is provided largely outside the hospital (e.g., at home,
in skilled nursing and assisted living settings), and attention to care
transitions between settings is essential for effective care.
10. Ethical issues, palliative care, and end-of-life care are critical
aspects of caring for the geriatric population.
Another way to summarize key concepts is using the “5M’s of geriatrics” (mentation, medication, mobility, multicomplexity, and matters
most) (Fig. 477-4). This framework organizes care of older adults in
a person-centered manner instead of disease-driven paradigm. The
intention of the 5M’s is to optimize utilization of existing resources
during hospitalization of older adults, as well as to focus on key geriatric issues in all settings of care. At the core of the 5M’s is what matters
most to the patient when considering diagnostic tests and therapeutic
interventions and planning for future care. Mobility is critical to individual function, quality of life, and fall risk, and ranges from the ability
to move around the community to walking and transferring from a
chair. Because mild cognitive impairment, dementia, delirium, and
depression are all common in older adults, mentation is a core area
for geriatric assessment. Polypharmacy and prescription of potentially
inappropriate and harmful medications remain common; thus, careful
medication reconciliation and consideration of deprescribing are core
aspects of care for all older adults. Many older adults have complex
clinical issues in more than one of the four M’s just discussed, thus
focusing attention on multiples comorbidities and multicomplexity.
In this chapter, these key principles serve as the background for the
clinical recommendations for managing older adults. The reader is
Hearing difficulty
Vision difficulty
Cognitive difficulty
Ambulatory difficulty
Self-care difficulty
Independent living difficulty
Any disability
0 20
36
15
7
9
23
9
15
40 60 80 100
FIGURE 477-3 Percentage of people age 65+ with various disabilities. (Source: U.S. Census
Bureau, American Community Survey, 2013. Available at https://aoa.acl.gov/Aging_Statistics/
Profile/2014/index.aspx. Accessed December 30, 2016.)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Percentage in comorbidity groups
65–69 70–74 75–79
Age group (years)
80–84 85+
Four or more
Three
Two
One
None
Number of chronic diseases
FIGURE 477-2 Prevalence of comorbidity by age group in persons ≥65 years old living in the United States and
enrolled in Medicare Parts A and B in 1999. (From JL Wolff et al: Arch Intern Med 162:2269, 2002.)
referred to textbooks of geriatric medicine for
more details on each of the principles and the
management of common diseases and conditions in this population.
■ MODELS OF GERIATRIC CARE
Several innovative models of care have
been developed over the past three decades
designed to provide high-quality and effective
care for the burgeoning geriatric population
with multimorbidity, functional and cognitive
impairment, and challenges with social support. These include outpatient comprehensive
geriatric assessment programs, inpatient acute
care for the elderly (ACE) units and consultation services, and home-based programs.
These models of care are assuming greater
importance in the emerging era of value-based
purchasing for health care services. While
they may be challenging and inefficient to
implement in fee-for-service–based systems, they may also result in
improved care at a lower cost, as payers shift to other models of reimbursement, such as accountable care organizations, bundled payment
programs, and managed care, in which an increasing number of older
people are being enrolled.
Improving transitions of care between settings has become a major
focus of governments, health systems, hospitals, postacute care (PAC)
and long-term care (LTC) organizations and programs, physicians,
and other health care professionals. Geriatric patients are especially
vulnerable to complications at the time of discharge from an acute
medical or psychiatric hospital, as well as at the time of discharge from
a PAC facility (skilled nursing facility [SNF]; acute rehabilitation or
long-term hospital) or home care program. With the increasing role
of hospitalists and physicians and others who specialize in SNF care,
medical care for geriatric patients has become fragmented at the time
of transitions, creating opportunities for communication problems and
medical errors. Changes in reimbursement and financial penalties for
high rates of hospital readmissions have driven the development of
many care transition interventions (Table 477-1). These interventions
involve interprofessional collaboration and a variety of strategies targeted at making care transitions safer, and reducing unnecessary return
visits to the emergency department, hospital readmissions, and related
complications and costs.
■ INTERPROFESSIONAL TEAMS AND CO-MANAGED
CARE
The complexity of caring for the aging population is more evident
during a hospitalization due to a new acute illness or exacerbation
of preexisting chronic conditions. Interprofessional teams integrate
different areas of expertise with the aim of providing patient-centered
care. Physicians should understand and respect the roles of nurses;
physical, occupational, and speech therapists; nutritionists; pharmacists; psychologists; social workers; clergy; and other direct care staff.
The evolution of interprofessional teams has resulted in a
comprehensive approach to care by opening channels of communication between these health professionals from different
disciplines.
“Huddles” are an integrated mechanism of enhanced communication for interprofessional teams. The implementation
of efficient huddles has been associated with improved safety
and better utilization of resources by predicting patient needs
and making appropriate changes in staffing and care plans.
Huddles can also help identify potential threats to patient care,
such as socioeconomic challenges that can make care plans
ineffective of even harmful.
Another strategy for enhanced communication and collaboration in the care of complex geriatric patients is “co-managed
medicine” of surgical patients. In this model, internists serve
as part of a multispecialty team of physicians (including
3741Caring for the Geriatric Patient CHAPTER 477
surgeons) that provides daily assessments, addresses medical comorbidities, and facilitates transitions of care, thereby enhancing the
typical consultant model. Co-managed medicine is another example of
how enhanced communication between different providers improves
outcomes, avoids common complications, and saves resources. In
the era of person-centered care and value-based medicine, effective
co-managed medicine appears to deliver consistently high-quality
care at a lower cost. Since the rise of hospitalist-based care, the use of
co-managed care has increased significantly. Collaborations between
internists and geriatricians are examples of this strategy. Hip fracture
and trauma co-management programs have been developed in many
academic and community hospitals and are demonstrating some
success in reducing complications and length of stay in older trauma
patients.
■ AGE-FRIENDLY HEALTH SYSTEMS
A new framework for providing comprehensive, integrated, and
person-centered care across settings of care has been developed called
“age-friendly health systems.” Health systems participating in the
development of age-friendly programs focus on the 5M’s discussed
above (Fig. 477-4) as a strategy to achieve high-quality care across
the system. Strategies are implemented to educate and facilitate all
system health care providers to focus on the 5M’s of geriatrics under
the leadership and mentorship of specially trained geriatrics health
professionals.
FUNDAMENTALS OF GERIATRIC CARE
■ PERSON-CENTERED CARE
Person-centered care is a critical concept in caring for older people
because of the complexity of their medical, functional, and psychosocial problems and, in many instances, the lack of rigorous data
on the most effective strategies for caring for specific conditions in
patients with multimorbidity. Thus, decision-making on goals and
approaches to care must account for patient and family preferences
and goals, values, perception of risk, prognosis, financial resources, and
other individual factors. For almost any condition, from common disorders such as hypertension and diabetes, to geriatric syndromes such
as fall risk and urinary incontinence, the answer to how best to treat
medical conditions in an older patient with multimorbidity does not
only depend on evidence-based medicine—it also depends on careful
weighing of the factors listed above. In everyday practice with complex
older patients, a focus on improving or maintaining function and independence, quality of life, comfort, and dignity will be consistent with
patient and family goals.
The American Geriatrics Society (AGS) identifies the following
elements as key to person-centered care: (1) an individualized, goaloriented care plan based on the person’s preferences; (2) ongoing
review of the person’s goals and care plan; (3) continual information
sharing and integrated communication; (4) education and training for
providers and, when appropriate, the person and those important to
the person; and (5) performance measurement and quality improvement using feedback from the person and caregivers. Several tools are
available to assist in implementing person-centered care, including
estimation of prognosis (e.g., “ePrognosis”) and “Choosing Wisely”
recommendations from the AGS and AMDA—The Society for PostAcute and Long-Term Care Medicine. Examples of these recommendations that are relevant to internal medicine practice are illustrated in
Table 477-2.
■ EVALUATION OF THE GERIATRIC PATIENT
Geriatric Assessment A series of screening questions can be
useful as a “geriatric review of systems” in clinical practice with older
patients because of the importance and high prevalence of functional
impairments and disabilities, limited social support to assist with
functional limitations, cognitive and affective disorders, and geriatric
conditions that may go undetected and cause patient safety issues and
complications (Table 477-3). Positive responses to one or more of the
Mobility
Medications
Matters
Multicomplexity
Mentation
FIGURE 477-4 The 5M’s of geriatrics.
TABLE 477-1 Examples Care Transitions Interventions
INTERVENTION WEBSITE CORE INTERVENTIONS
Re-Engineered
Discharge (Project
RED)
(Jack et al: 2009)
https://www.
bu.edu/fammed/
projectred/
“Discharge advocate” performs the
following:
• Facilitates patient education and
understanding
• Performs medication reconciliation
• Coordinates postdischarge
appointments and communication
with primary care provider (PCP)
• Calls patient 2–3 days after
discharge
Transitional Care
Model
(Naylor et al: 2004;
Naylor et al: 1999)
https://www.
nursing.upenn.
edu/ncth/
transitional-caremodel/
Advanced practice nurse performs
the following:
• Coordinates patient care before
and after discharge
• Assesses each patient’s needs;
engages and activates the patient
and family
• Facilitates communication among
patient, family, and health care
providers
• Conducts regular home visits and
telephone support after discharge
Care Transitions
Program®
(Coleman et al: 2004)
http://www.
caretransitions.
org
“Transition coach” performs the
following:
• Facilitates improved selfmanagement skills including
medication management and
how to respond to warning signs/
symptoms
• Makes postdischarge home visits
and phone calls
Better Outcomes for
Older Adults through
Safe Transitions
(BOOST)
(Hansen et al: 2013)
https://www.
hospitalmedicine.
org/clinicaltopics/
care-transitions/
Includes toolkit facilitating the
following:
• Comprehensive identification and
assessment of high-risk patients
• Patient/caregiver education
• Enhanced communication with
posthospitalization care providers
• Follow-up phone call with patient
after discharge
Interventions to
Reduce Acute
Care Transfers
(INTERACT)
(Ouslander et al:
2013)
http://www.
interact-pathway.
com
Includes tools for skilled nursing,
assisted living, and home health care,
including:
• Quality improvement
• Communication
• Decision support
• Advance care planning
3742 PART 18 Aging
TABLE 477-2 Examples of Choosing Wisely Recommendations Helpful
in Implementing Person-Centered Care in Complex Geriatric Patients
• Don’t recommend percutaneous feeding tubes in patients with advanced
dementia; instead, offer oral assisted feeding.
• Don’t use antipsychotics as the first choice to treat behavioral and
psychological symptoms of dementia.
• Avoid using medications other than metformin to achieve hemoglobin A1C <7.5% in most older adults; moderate control is generally better.
• Don’t use benzodiazepines or other sedative-hypnotics in older adults as first
choice for insomnia, agitation, or delirium.
• Don’t use antimicrobials to treat bacteriuria in older adults unless specific
urinary tract symptoms are present.
• Don’t prescribe cholinesterase inhibitors for dementia without periodic
assessment for perceived cognitive benefits and adverse gastrointestinal
effects.
• Don’t recommend screening for breast, colorectal, prostate, or lung cancer
without considering life expectancy and the risks of testing, overdiagnosis,
and overtreatment.
• Don’t routinely prescribe lipid-lowering medications in individuals with a
limited life expectancy.
• Don’t obtain a Clostridioides difficile toxin test to confirm “cure” if symptoms
have resolved.
• Don’t recommend aggressive or hospital-level care for a frail elder without a
clear understanding of the individual’s goals of care and the possible benefits
and burdens.
Source: Adapted from http://www.choosingwisely.org/societies/americangeriatrics-society/ and http://www.choosingwisely.org/societies/amda-the-societyfor-post-acute-and-long-term-care-medicine/amda-choosing-wisely-list/. Accessed
June 1, 2021.
Evaluation of the Older Driver For many older adults in the
United States, driving is essential for maintaining independence and
driving cessation is associated with negative outcomes including social
isolation and depression. On the other hand, older adults are at higher
risk of being involved in fatal crashes than younger counterparts, with
up to a ninefold higher risk for those ≥85 years old. Older people
should be routinely assessed for their driving status and whether they
have been in any car crashes, in addition to assessment for sensory,
functional, and cognitive impairments that can make driving unsafe
(Table 477-3). In addition to common geriatric conditions, several different types of drugs can impair various aspects of driving performance
and should be carefully considered in older people who continue to
drive, including antianxiety agents, narcotic analgesics, antipsychotics,
anticonvulsants, and drugs with strong anticholinergic properties.
Suspected driving impairment can be a source of conflict between
the patient (who wants to maintain independence), the family (who
may want their relative to continue driving due to lack of other transportation, or may be concerned about their safety, or both), and the
physician (who is concerned about the patient’s, passengers’, and other
drivers’ safety). These decisions involve liability, since local governments might not require driving retesting for all older drivers, but in
some states, physicians are required to report older people who they
believe are unsafe drivers. Evaluation of driving should be interprofessional and aimed to first try to correct any reversible causes of losing
driving skills, such as vision and hearing impairment. Although tests
of executive function such as the Trails B have been associated with
poor driving performance, no single screening test predicts unsafe
driving. A combination of neuropsychological testing by a psychologist
and on-road testing by a trained occupational therapist can provide
the physician with essential input in making the difficult decision on
driving cessation. The AGS and the U.S. Department of Transportation’s National Highway Traffic Safety Administration have updated
the “Physician’s Guide to Assessing and Counseling Older Drivers,”
which can be helpful to practicing clinicians and is available on the
AGS website.
Interpretation of Diagnostic Tests Atypical presentations of
medical conditions are a common feature of geriatric medicine. Physiologic changes associated with aging can affect the results of common
diagnostic tests as well. The large variation of many physiologic measures that is associated with normal aging makes establishing what
is “normal” for many tests challenging. For this reason, the results of
several diagnostic tests must be interpreted with caution. Ambulatory
cardiac monitoring may identify a variety of arrhythmias in older
adults. Such arrhythmias must be linked to symptoms or adverse outcomes if left untreated before considering the use of potentially toxic
medications or invasive procedures. Advanced imaging also could
demonstrate incidental abnormalities. Although a significant portion
of these findings are benign, the rate of malignancy among incidental
findings in the colon and extracolonic structures, as well as ovarian
and thyroid gland, is ~20%. Musculoskeletal imaging, such as an MRI
of the spine, may reveal multiple abnormalities that may or may not be
related to symptoms.
For the most part, abnormal diagnostic tests require further evaluation in older patients, unless further evaluation would not lead to
a change in the goals of care and treatment plan. Examples include
low hemoglobin levels, abnormal thyroid function tests, age-/sex-/
weight-adjusted creatinine clearance, and elevated liver function tests.
None of these result from normal aging and generally indicate a physiologic abnormality resulting from a disease or disorder that may or
may not be reversible.
■ PREVENTION IN OLDER ADULTS
Age-Appropriate Screening Screening tests for specific diseases,
as opposed to screening for geriatric conditions, require a careful
person-centered approach. The focus of preventive medicine depends
heavily on the ability to identify those who are at risk for specific
conditions (Chap. 6). Several professional societies have provided
guidance regarding specific tests in older adults (Table 477-4). An
screening questions for each item should prompt consideration of further assessments, many of which can be accomplished using standard
and validated tools available on the Internet, such as activities of daily
living scales, depression scales, sleep questionnaires, and mental status
examinations.
Evaluation of Medical Decision-Making Capacity Key
aspects of decision-making in older adults are illustrated in Fig. 477-5.
Including the patient in the consent process for any treatment is the
foundation of patient autonomy and person-centered care. Because
aging is associated with an increasing potential to develop cognitive
impairment, determination of decision-making capacity is important
not only to protect the patients against potential abuse, but also to
preserve autonomy when possible and, when it is not, to ensure an
appropriate surrogate decision-making process is followed. Assessing
for capacity is usually triggered by specific circumstances (e.g., the
need for invasive diagnostic testing or surgery). Determination of
decision-making capacity limited to medical circumstances should
be differentiated from declaring a patient “incompetent” to make all
decisions. Declaring someone incompetent is a legal definition and
usually is reserved for court settings. Another caveat about evaluating
decision-making capacity is distinguishing lack of capacity from poorly
presented information, sensory impairment, language barriers, and/or
low level of literacy. The clinician should corroborate that the patient
has received all the necessary information, comprehends the information provided, and has no major auditory or visual impairments.
For geriatric patients, it is important to determine if the patient uses
hearing aids of prescription glasses and ensure they are available for
their use.
Standard tests of cognitive function correlate poorly with capacity
to consent for specific interventions. Several standardized tools have
been validated to determine decision-making capacity. The MacArthur
Competence Assessment Tool-Treatment (MacCAT-T) is a structured
tool that has been validated, but it is lengthy and can be difficult to
administer in some patients. The Capacity to Consent to Treatment
Instrument (CCTI) is another tool that has been validated in patients
with mild to moderate Alzheimer’s disease. It is structured in two different vignettes, and the patient is asked to answer a series of questions.
The test has high interrater reliability validity.
3743Caring for the Geriatric Patient CHAPTER 477
important caveat about screening to prevent disease in older patients
(e.g., colonoscopy for colon cancer, Pap smears, prostate-specific antigen testing) is that abnormal results may lead to subsequent testing and
treatment among individuals who will not suffer morbidity or mortality from the disease because of limited life expectancy. Thus, geriatric
patients pose a significant challenge for deciding what screening tests
could offer a reasonable ratio of benefit and risk as well as being
cost-effective. As an example, the U.S. Preventive Services Task Force
recommends colorectal cancer screening up to the age of 75 years. For
those between 76 and 85 years old, the recommendation is to only consider screening colonoscopy if they have never been screened and they
are healthy enough to undergo treatment if colon cancer is detected.
Vaccinations The use of vaccines in older adults is aimed at creating immunity against common infections that could lead to serious
complications and rebuilding previously obtained immunity. The U.S.
Centers for Disease Control and Prevention recommends routine
vaccination against influenza, pneumococcus, and shingles as they are
prevalent in this age group. Other countries in Europe and Asia have
similar trends on vaccinations with small variances.
Sexually Transmitted Diseases Although most sexually transmitted diseases (STDs) occur in younger people (Chap. 136), a portion
of older adults have high-risk sexual behavior. Most Americans remain
sexually active in their 60s and 70s, and up to a quarter of individuals
TABLE 477-3 Examples of Screening Questions and Tools and Strategies for Further Evaluation of Social Support, Functional Status, Geriatric
Syndromes, and Cognition and Affect
GERIATRIC ASSESSMENT DOMAINS RECOMMENDED SCREENS FURTHER ASSESSMENT FOR POSITIVE SCREEN SOCIAL
Social Support Do you live alone?
Do you have a caregiver?
Are you a caregiver?
• Consider referral to a social worker
• Refer to Area Agency on Aging
Elder Neglect/Abuse Do you ever feel unsafe where you live?
Has anyone ever threatened or hurt you?
Has anyone been taking your money without your
permission?
• Consider referral to a social worker and/or Adult
Protective Services
Advance Directives Would you like information or forms for a power of
attorney for health care?
Would you like information on a living will?
• Discussion on advance directives
• Physician Orders for Life-Sustaining Treatment (POLST)
(or MOLST or POST)
FUNCTIONAL
Functional Status Do you need assistance with shopping or finances?
Do you need assistance with bathing or taking a
shower?
• Instrumental Activities of Daily Living (ADL) Scale
• Basic ADL Scale
Driving Do you still drive? If yes:
While driving, have you had an accident in the past
6 months?
Driving concerns by family member?
• Vision testing
• Consider occupational therapy and/or formal driving
evaluation
Vision Do you have trouble seeing, reading, or watching TV?
(with glasses, if used)
• Vision testing
• Consider referral for eye exam
Hearing Do you have difficulty hearing conversation in a quiet
room?
Unable to hear whisper test 6 inches away?
• Check for cerumen in ear canals and remove if impacted
• Hearing Handicap Inventory
• Consider audiology referral
GERIATRIC SYNDROMES
Medications Do you take 5 or more routine medications?
Do you understand the reason for each of your
medications?
• Match medications with diagnoses
• Consider reducing doses, stopping drugs, adherence
aides, and/or consultation with a pharmacist
Fall Risk Have you fallen in the past year?
Are you afraid of falling?
Do you have trouble climbing stairs or rising from
chairs?
• “Get Up and Go” test
• Consider full fall assessment
• Consider physical therapy evaluation
• Consider home safety assessment
Continence Do you have any trouble with your bladder?
Do you lose urine or stool when you do not want to?
Do you wear pads or adult diapers?
• Consider full continence assessment
• 3IQ Questionnaire (women)
• AUA 7 symptom inventory (men)
Weight Loss Weight <100 pounds or
Unintentional weight loss ≥10 pounds over 6 months?
• Assess for common risk factors for malnutrition
• Consider referral to dietician for nutritional evaluation
Sleep Do you often feel sleepy during the day?
Do you have difficulty falling asleep at night?
• Epworth Sleepiness Scale or Pittsburgh Sleep Index
• Consider referral for sleep evaluation
Pain Are you experiencing pain or discomfort? • Pain assessment
Alcohol Abuse Do you drink >2 drinks/day? • AUDIT-C
COGNITION AND
AFFECT
Depression Do you often feel sad or depressed?
Have you lost pleasure in doing things over the past
few months?
• PHQ-9 or Geriatric Depression Scale
• Screen for suicide risk
Cognition Self-reported memory loss?
Cognitive screen positive? (3-item recall and Clock
Draw test “Mini-Cog”)
Confusion Assessment (CAM) for delirium
• Montreal Cognitive Assessment or Mini Mental State
Examination
• If diagnosis is unclear, consider neuropsychological
testing
Abbreviations: 3IQ, Three Incontinence Questions; AUA, American Urological Association; AUDIT-C, Alcohol Use Disorders Identification Test; MOLST, Medical Orders for
Life-Sustaining Treatment; PHQ, Patient Health Questionnaire; POST, Physician Orders for Scope of Treatment.
Source: Adapted from RL Kane et al (eds): Essentials of Clinical Geriatrics, 8th ed. New York, McGraw-Hill, 2017.
3744 PART 18 Aging
in their 80s considers themselves sexually active. Sexually active older
adults may have a lower awareness of the need for safe sexual practices,
such as the risks of multiple sexual partners and condom use. The incidence of STDs in older people is still relatively low. Individuals born in
the United States between 1945 and 1965 are at higher risk of having
hepatitis C due to lack of awareness of the disease and lack of institutions of universal precautions before the 1980s for blood transfusions.
Other factors that could affect such risk are use of intravenous drugs
and unprotected sex with multiple partners. The prevalence of tertiary
syphilis is higher than newly contracted syphilis in older adults. The
incidence of gonococcal infection decreases with age. Nonetheless,
patients presenting with symptoms compatible with syphilis or gonococcal infection (cervicitis, urethritis, proctitis, epididymitis) should be
screened for high-risk sexual behavior and educated if necessary. Clinical symptoms of herpes simplex infection and the possibility of becoming contagious also decrease with age. As ulcerative lesions are less
frequent, herpes simplex virus-2–specific serologic testing should be
considered for patients with recurrent nonspecific genital symptoms.
Therapy should not be started unless the patients are symptomatic.
In the United States alone, 2600 per 100,000 persons above the
age of 50 are infected with HIV. Since the introduction of highly
active antiretroviral therapy, life expectancy of patients with HIV has
increased, resulting in a significant increase in the number of older
adults living with the disease. De novo infections have also contributed to the rising number of HIV cases in older adults. The low rate
of condom use and lack of knowledge of the disease play a key role
in the transmission rate. Age is an independent predictor of HIV
progression and associated mortality. There are no age-specific guidelines for treating HIV. Like all other conditions, a higher incidence of
medication-related side effects is seen in older patients, especially those
with other comorbidities and on multiple other medications, and this
should be considered in treatment decisions.
TREATMENT OF COMMON DISEASES IN
THE GERIATRIC POPULATION
■ HYPERTENSION
In the United States, 70% of older adults have hypertension. Several
clinical trials have demonstrated the benefits of hypertension treatment
on risk reduction of cardiovascular events in older people. Nonetheless,
blood pressure targets remain controversial. The balance between the
cardiovascular protective benefits versus the risk of treatment-related
adverse events must be considered in individual patients based on their
comorbidities and level of function. For example, hypotension and
– Accessibility, setting
– Availability, quality of
relevant support services
(interpreter, social work)
– Decision support and
resources available, at
appropriate health literacy
level
Structure
– Appropriate, informed,
timely decision-making
– Treatment adherence
– Health status
– Satisfaction and
values-based health
outcomes
Outcomes
– Characteristics of provider-
patient relationship,
interaction
– Continuity of care
– Provider decision-making
style, communication
methods, skills
– Provider experience,
education, cross-cultural
training, sensitivity
– Patient prior experiences
with health care, decision
making
Process
– Illness characteristics
– Access to care
– Insurance coverage,
reimbursement
– Patient beliefs, approach
to decision-making
– Family structure, social
support
– Patient motivation, self-
efficacy
– Provider specialty, setting
– Provider and patient
knowledge, expectations
External variables
Provider
Competence
Provider
Trustworthiness
Cultural
Competence
Information
Quality
Patient/surrogate
Competence
Communication with
Patients and Families
Roles and
Involvement
Concepts
FIGURE 477-5 Key aspects of decision-making in older adults. (Reproduced with permission from SM Dy, TS Purnell: Key concepts relevant to quality of complex and
shared decision-making in health care: A literature review. Soc Sci Med 74:582, 2012.)
3745Caring for the Geriatric Patient CHAPTER 477
TABLE 477-4 Recommendations for Primary Prevention Screening for Specific Diseases in Older Adults from Different Professional Societies
TYPE OF
SCREENING TEST FREQUENCY
PROFESSIONAL SOCIETY ISSUING RECOMMENDATIONS
USPSTFa ACSb ACPc
Colorectal Fecal occult
blood test or fecal
immunochemical
test (FIT) or
Sigmoidoscopy or
Colonoscopy
Annual
Every 5 y
Every 10 y
Screen all adults age 50–75;
prognosis may support
screening individuals of age
76–85 if never screened; not
recommended for adults over
age 85
Screen all adults age >50;
discontinuing screening is
reasonable in people with severe
comorbidity that would preclude
treatment
Screen all adults age 50–75
People with life expectancy
<10 y should not be screened
Breast Mammography Every 1–2 y Biennial screening of all women
age 50–74; evidence of benefits
and harms is insufficient for
women age >75
Annual screening starting at age
40; continue while in good health
ECOGd
Annual screening starting at
age 40 y
Cervical Pap smear
HPV test
Pap only, every 3 y
HPV + Pap, every
5 y
Screen women age 21–65;
discontinue at age 65 if
adequate prior screening
Screen women age 21–65;
discontinue at age 65; discontinue
at age 65 if regular screening
normal
Screening should stop at age
65 if evidence of negative
adequate prior screening.
Lung Low-dose CT scan Annual Screen age 55–80 current and
former smokers with a 30+
pack-year smoking history;
discontinue screening once
a person has not smoked for
15 years or develops a health
problem that limits their ability
or willingness to have curative
surgery
Screen 55–74-y-old current and
former smokers in good health
with a 30+ pack-year smoking
history
ACCPe
In settings that can deliver the
comprehensive care provided
to National Lung Screening Trial
participants, offer screening
to people age 55–74 who are
current and former smokers
with 30+ pack-year smoking
history
Prostate Prostate-specific
antigen (PSA)
1–2 y Do not screen men for prostate
cancer with PSA if age 70 y or
older
Screen men age 50 and over
with a life expectancy >10 y
after discussion about the risks,
benefits, and uncertainties of PSA
screening
Follow-up screening should occur
annually if PSA >2.5 ng/mL or
biennially if PSA <2.5 ng/mL
AUAf
Biennial PSA screening in men
age 55–69 y with life expectancy
>10–15 y, after shared decisionmaking discussions accounting
for values and preferences
Osteoporosis Dual-energy x-ray
absorptiometry
(DEXA)
Measure height,
preferably with
a wall-mounted
stadiometer
Perform bone
mineral density
testing 1–2 y
after initiating
medical therapy for
osteoporosis and
every 2 y annually
thereafter
USPSTFa NOFg
Screen women age 65; the
current evidence is insufficient
to assess the balance of
benefits and harms of screening
for osteoporosis to prevent
osteoporotic fractures in men
Screen women age 65 and older and men age 70 and older;
postmenopausal women and men age 50–69, based on risk factor
profile; postmenopausal women and men age 50 and older who have
had an adult-age fracture
Carotid Disease Carotid ultrasound Once Society of Vascular Surgery
Age over 65, coronary artery disease, need for coronary bypass, symptomatic lower extremity arterial
occlusive disease, history of tobacco use, and high cholesterol would be appropriate risk factors to
prompt ultrasound in patients with a bruit
Coronary Artery
Disease (CAD)
Coronary Calcium
Score (CCS)
Once SCCTh AHA/ACCi
Do not use CCS for patients with
known CAD
CCS of 0 may have a strong negative predictive value for coronary
events in older adults
Abdominal Aortic
Aneurysm
Abdominal
ultrasound
Once USPSTFa AAFPj
The USPSTF recommends
one-time screening for
abdominal aortic aneurysm with
ultrasonography in men aged
65–75 y who have ever smoked;
there is insufficient evidence
to recommend screening for
women even if they have ever
smoked
Recommended for men aged 65–75 y who have ever smoked
Diabetes Fasting blood
glucose, glucose
tolerance test, or
hemoglobin A1C
Annually USPSTFa ADAk
No evidence to screen for
diabetes after the age of
70; recommendation being
reviewed at the time of this
publication
Screen people 45 y and older
a
U.S. Prevention Services Task Force. b
American Cancer Society. c
American College of Physicians. d
Eastern Cooperative Oncology Group. e
American College of Chest
Physicians. f
American Urology Association. g
National Osteoporosis Foundation. h
Society of Computed Tomography. i
American Heart Association/American College of
Cardiology. j
American Academy of Family Physicians. k
American Diabetes Association.
3746 PART 18 Aging
TABLE 477-5 Recommendations and Considerations for
Pharmacologic Therapy of Diabetes in Older Adults
MEDICATION RECOMMENDATIONS AND CONSIDERATIONS
Metformin • Metformin is the first-line agent for older adults with
type 2 diabetes
• Low risk of hypoglycemia
• Recent studies suggest it may be used safely in
patients with estimated glomerular filtration rate
≥30 mL/min/1.73 m2
• Contraindicated in patients with advanced renal
insufficiency or significant heart failure
• Can cause gastrointestinal symptoms with lower
appetite
Sodium-Glucose
Cotransporter 2
(SGLT-2) Inhibitors
• Offer an oral route, which may be convenient for
older adults
• Low risk of hypoglycemia
• Strong evidence for renal protection and improved
cardiovascular outcomes
• Caution when combined with other therapies such
as diuretics
Thiazolidinediones • If used at all, should be used very cautiously in those
with, or at risk for, congestive heart failure and those
at risk for falls or fractures
Sulfonylureas • Associated with hypoglycemia and should be used
with caution
• Shorter-duration sulfonylureas such as glipizide are
preferred
• Glyburide is longer duration and contraindicated in
older adults
Dipeptidyl Peptidase
4 (DPP-4) Inhibitors
• Few side effects and minimal hypoglycemia, but costs
may be a barrier
• No evidence of increase in major adverse
cardiovascular events
Glucagon-Like
Peptide 1 (GLP-1)
Agonist
• GLP-1 receptor agonists are injectable, which
requires visual, motor, and cognitive skills
• Associated with nausea, vomiting, diarrhea, and
weight loss, which may not be desirable in some
older patients, particularly those with cachexia
Insulin Therapy • Requires that patients or their caregivers have good
visual and motor skills and cognitive ability
• Insulin doses should be titrated to meet individualized
glycemic targets and to avoid hypoglycemia
• Once-daily basal insulin injection therapy is
associated with minimal side effects and may be a
reasonable option in many older patients
• Multiple daily injections of insulin may be too
complex for the older patient with advanced diabetes
complications, life-limiting comorbid illnesses, or
limited functional status
Source: Based on recommendations from the American Diabetes Association 2020
and JS Custódio Jr et al: Drugs Aging 37:399, 2020.
postural hypotension related to antihypertensive therapy are common
causes of near-syncope and falls and related injuries in the geriatric
population, especially those with multimorbidity. In addition to cardiovascular disease prevention, control of systolic blood pressure (SBP) may
reduce the burden of white matter changes in the brain, which are associated with gait abnormalities and cognitive decline. To date, no studies
in older patients with multimorbidity have documented any beneficial
effects of tight control of hypertension on the incidence of falls and cognitive decline. The European Society of Cardiology/European Society
of Hypertension guidelines recommend pharmacologic treatment for
individuals 80 years old or older if SBP is 160 mmHg or higher. In
contrast, the American College of Physicians recommends starting
treatment if SBP is 150 mmHg or higher.
Two large studies (HYVET and SPRINT) have shed some light
on these issues. HYVET was a multicenter study conducted in several
countries involving ~3800 patients ≥80 years old. The study demonstrated that active treatment of hypertension with a target of ≤150 mmHg
significantly reduced not only the risk of stroke and heart failure but also
the mortality risk. As with other large hypertension studies like ALLHAT, a linear association was noted between blood pressure and stroke
reduction. Nonetheless, in the HYVET study, this association was less
prominent as age increased. SPRINT was another large randomized trial
targeting lowering SBP to targets of <140 versus 120 mmHg (measured
with an automated device) with a subgroup analysis in those aged 75
and older. Significant reductions were documented in the primary endpoint, which was a composite of cardiovascular disease events (including myocardial infarction, acute coronary syndrome, heart failure,
stroke, or death from cardiovascular causes). However, it is critical to
recognize that patients with diabetes, history of stroke or heart failure,
and SBP <110 mmHg after 1 min of standing, as well as people with
several other comorbidities, were excluded from the SPRINT trial, and
aggressive treatment in the setting of these comorbidities may incur
more risk of adverse effects.
Overall, these data strongly suggest a person-centered approach
to hypertension in the heterogeneous older population. For older
patients with minimal comorbidity, no postural hypotension, and low
risk of falls and volume depletion, the benefit-risk ratio favors lower
targets for SBP (<130 mmHg measured by a hand sphygmomanometer). Aggressive targets also may be more beneficial for patients with
concomitant nonvalvular atrial fibrillation or coronary artery disease.
However, for those with diabetes, heart failure, or postural hypotension, careful treatment of blood pressure with higher SBP targets
(<150 mmHg) is probably a safer approach.
■ DIABETES
The prevalence of diabetes in the older adult population is now
>25% and expected to increase due to adverse lifestyle changes and
an increased incidence of obesity. Those between the ages of 65 and
74 have the highest rates of complications associated with diabetes.
Nonetheless, due to a lack of data on patients with multimorbidity and
those age 80 and older, as well as the high incidence of hypoglycemia
in this population when treated with multiple hypoglycemic agents, the
approach to managing diabetes requires a person-centered approach
like that described for hypertension. Older diabetic patients are at significant risk of hypoglycemia because of potential medication errors,
progressive renal insufficiency, and inconsistent oral intake, among
other reasons. Diabetic patients age 75 or older are in fact at twice the
risk of visiting the emergency department due to hypoglycemia. Hypoglycemic episodes are associated with progressive cognitive decline in
older adults, especially those with existing cognitive impairment. On
the other hand, uncontrolled diabetes is associated with an increased
risk of all-cause dementia.
Data from randomized clinical trials suggest that intensive glycemic
control does not reduce major macrovascular events in older adults
for at least 10 years or result in improved microvascular outcomes
for at least 8 years and, at the same time, increases the risk of severe
hypoglycemia by 1.5 to 3 folds. Thus, the AGS guideline on diabetes
in older adults (see “Further Readings”) and the Choosing Wisely
recommendations (Table 477-2) suggest that, in most older adults,
the harms associated with a hemoglobin A1C (HbA1C) target <7.5% are
likely to outweigh the benefits. These recommendations are consistent
with the American Diabetes Association guidelines from 2020 that
recommends an HbA1C target of <7.5% among older adults with intact
cognitive function and functional capacity and few comorbidities. The
goals of treating diabetes in the geriatric population should be tailored to the patient’s functional status, coexisting geriatric syndromes,
social support, personal goals, perception of risk, and life expectancy.
For specifics of treatment options, see Table 477-5. Regardless of the
therapeutic goals for HbA1C, older diabetic patients should be regularly
examined for neuropathy, which can lead to the development of lesions
on the feet that could become infected, as well as for retinopathy and
vision loss that may require ophthalmologic intervention. In addition,
lifestyle management is an important component of the plan of care.
If possible, diabetic older adults should exercise regularly and should
have an adequate protein intake to try maintaining muscle mass. For
3747Caring for the Geriatric Patient CHAPTER 477
patients living in LTC facilities, diabetes education of staff and periodic
revision of individual glucose targets could reduce unnecessary complications associated with diabetes treatment.
■ HYPERLIPIDEMIA
While good evidence exists regarding the benefits of statins on primary
cardiovascular risk prevention in patients ≤75 years old, for those older
than 75, the data are very limited. The use of statins in those older than
75 or 80 for prevention of cardiovascular events and mortality is the
subject of ongoing debate in the geriatric literature. The Prospective
Study of Pravastatin in the Elderly at Risk (PROSPER) demonstrated a
significant reduction in cardiovascular events over a 3.2-year follow-up
among older adults taking statins when compared with those not taking them. Nonetheless, the study failed to demonstrate a mortality benefit. For secondary prevention, a large observational study in Europe
demonstrated that after excluding patients who die within the first
year of a myocardial infarction, those taking statins may have a 37%
reduction in cardiovascular mortality. In contrast, a review published
in 2014 concluded that no evidence from randomized controlled trials
exists to guide statin initiation after age 80 years and that treatment
of hypercholesterolemia for patients at risk of atherosclerotic cardiovascular disease should start before they turn 80 years old. Two other
factors make the use of statins in older adults controversial. First, the
major benefits have been demonstrated over long-term use; thus, life
expectancy is a limiting factor to observe any meaningful change in
outcomes. A substantial proportion of patients are maintained on statins at the end of life, even though such agents can be safely discontinued. Thus, continuing statins in older patients with end-stage illnesses
does not make any clinical sense. On the other hand, statins are safe to
use in older adults, especially at moderate to low doses. Although many
older adults on statins complain of muscle pain, the risk of myositis
and rhabdomyolysis is increased mostly with the coexistence of other
risk factors such as sarcopenia, polypharmacy, and use of high doses
of statins. Adverse effects of statins on cognitive function appear to be
uncommon. Thus, some relatively healthy adults older than 75 with life
expectancy of >10 years may benefit from statin use, and the approach
to hyperlipidemia should be person-centered in this population, as
discussed for both hypertension and diabetes.
■ OSTEOARTHRITIS
The approach to the management of symptomatic osteoarthritis (OA)
in the geriatric population differs from the approach in younger
patients (Chaps. 370 and 371) because of the substantial toxicity of
nonsteroidal anti-inflammatory drugs (NSAIDs) in older patients.
Nonpharmacologic interventions, briefly discussed below, should be
the first line of treatment. While some patients older than 65 can tolerate NSAID use with concomitant protection from gastrointestinal (GI)
bleeding with a proton pump inhibitor (PPI), this regimen exposes
patients to two drugs with numerous potential adverse drug effects.
NSAIDs are well known to be associated not only with GI bleeding
but also with worsening renal function based on multiple potential
mechanisms and with sodium and fluid retention and exacerbation
of hypertension and congestive heart failure. In addition, a substantial
number of older patients are on anticoagulants or platelet aggregation
inhibitors, which could further increase the risk of bleeding from
NSAIDs. PPIs are associated with a higher incidence of pneumonia,
osteoporosis, and Clostridioides difficile–associated diarrhea, and they
may be associated with a higher risk of dementia.
Thus, in older patients with multimorbidity who have painful
OA, the risks of NSAIDs most often outweigh the benefits, and older
patients should be discouraged from taking nonprescription NSAIDs
without consulting their primary care clinician. Topical NSAIDs are
better tolerated, and lidocaine patches and other nonprescription
analgesic creams may also be effective. The AGS guideline on the management of chronic pain recommends that routine acetaminophen in
doses up to 1 g four times daily should be the basis of pharmacologic
treatment. Failure to respond could be followed up with careful trials
of tramadol or a narcotic agent (started in a short-acting preparation)
with appropriate attention to avoiding narcotic-induced constipation.
Although prescription of narcotics is getting increasingly cumbersome
because of high rates of abuse, this should not deter prescription of
these agents to relieve pain and disability in older patients. Despite
recent guidelines from governmental agencies, professional societies
endorse the use of opioids for chronic pain, especially among older
adults in LTC facilities.
Many older patients respond well to a variety of nonpharmacologic
interventions, including stretching, strengthening, timely and appropriate use of heat and ice, massage, swimming and whirlpool therapy,
bracing, acupuncture, and therapeutic electrical stimulation. These
interventions are best carried out under the supervision of physical
therapists or other professionals with appropriate expertise to avoid
injury. Surgical interventions, including replacement of major joints,
has improved over the past several years, and even older patients with
multimorbidity may benefit in terms of function and quality of life.
Total knee replacement, for example, has been shown to be effective in
generally healthy older patients and should be considered in selected
higher risk patients. “Pre-habilitation,” with targeted strengthening
and endurance exercises, and willingness to go through several weeks
of postoperative physical therapy should be prerequisites for referring
older patients for joint replacement.
■ CANCER
More than half of new cases of cancer and mortality associated with
it occur after the age of 65. Data regarding older adults with multiple
comorbid conditions and their response to cancer treatment are limited. While only ~10% of clinical trials have had age-stratification analyses, the available evidence suggests that age alone is not a predictor of
harm. Nonetheless, making treatment decisions is challenging due to
both shorter life expectancy in older adults and the cumulative effect of
multiple comorbidities. Thus, a person-centered approach is essential.
Older adults generally experience decreases in functional status
after receiving chemotherapy. Most of this negative effect appears to
be related to comorbidity and baseline functional status, rather than
due to age alone. For this reason, specialists in geriatric oncology have
proposed using comprehensive geriatric assessment, including many
of the issues addressed in Table 477-3, as a strategy to better predict
which older adults will tolerate and benefit most from cancer treatment. Other considerations before making decisions about treatment
plans should include socioeconomic factors. Lack of social support has
been associated with poor outcomes after radiation and chemotherapy,
especially in older women. Other important issues in cancer treatment
planning include availability of transportation for treatments, economic and insurance status, the patient’s ability to follow treatment
plans, and family and social support available during therapy, when
adverse effects and functional decline may occur.
■ ANEMIA
A low hemoglobin or hematocrit is not a normal age-related change in
older adults. All anemic older adults should have a basic evaluation to
determine the etiology including a complete blood count, examination
of a peripheral red blood cell smear, reticulocyte count, and measurement of iron, iron binding capacity, and transferrin saturation. A
serum ferritin level can help distinguish iron deficiency from anemia
of chronic disease; the two types of anemia occur commonly in older
adults. The prevalence of anemia in older adults varies between 7%
and 47%, with the highest prevalence among nursing home residents.
Even mild anemia is associated with worse overall outcomes in older
adults, including functional and cognitive decline, falls, hospitalization, frailty, and mortality. Microcytic indices suggest occult blood
loss. Iron deficiency is the most common cause, with other nutritional
anemias (e.g., B12 deficiency) and myelodysplasia each accounting for
a small percentage. Anemia of chronic disease is common in older
people who have several chronic illnesses. The etiology of the anemia
in older adults cannot be specifically explained in more than a third of
the cases, and this unexplained anemia is generally normocytic, mild
in degree, with a low reticulocyte count, and associated with normal
or low erythropoietin levels in the face of inadequate production of
new red cells. Red cell life span is not decreased, but the production
3748 PART 18 Aging
of erythropoietin is compromised even in the absence of overt renal
disease. Anemia is frequently asymptomatic, but severe cases could
present with symptoms such as generalized weakness and functional
decline, shortness of breath, chest pain, or syncope. The unexplained
anemia of aging appears to be responsive to erythropoietin, but it is
unclear whether correction of the anemia improves outcomes. Thresholds for transfusion of packed red cells among older adults should
be based on symptoms and associated conditions. For example, for
geriatric patients suffering acute blood loss anemia after an orthopedic
procedure, the trigger for transfusion should be a hemoglobin <8 mg/dL
instead of 7 mg/dL for patients with anemia associated with chronic disease or a myelodysplastic syndrome. Similarly, older patients with active
cardiovascular disease, such as angina or heart failure, may need to be
transfused a levels <8 or 9 mg/dL. For details of the general evaluation
and management of anemia, please refer to the Chap. 63 on anemia.
GERIATRIC SYNDROMES AND CONDITIONS
In this section, selected geriatric syndromes and conditions likely to be
encountered by internists in hospital, clinic, office, PAC, and LTC settings are discussed. For a more thorough discussion of these and other
syndromes and conditions, the reader is referred to textbooks that focus
specifically on geriatrics and gerontology (see “Further Reading”).
■ FALLS
Epidemiology and Impact Among all geriatric syndromes, falls
are probably the most common that internists will encounter. Falls are
responsible for potentially devastating consequences for function and
quality of life, as well as mortality. About one in three older communitydwelling and one in two older LTC facility residents fall annually, with
many more at risk for falls. The consequences of falls include fear of
falling with adverse effects on quality of life, painful injures including
hip and wrist fractures, subdural hematomas, and death. Falls are associated with loss of function and death within the year after a fall. For
these reasons, internists should regularly screen older people for falling
using questions such as, “Have you fallen in the past year?” “Are you
afraid of falling?” “Do you have trouble climbing stairs or rising from
chairs?” (Table 477-3).
Evaluation The risks and causes of falls are multifactorial. Most
older people at risk for a fall or who have suffered a fall have more than
one potential underlying risk factor or cause. Many falls are labeled as
“mechanical” and attributed to simply tripping or slipping. It is essential to recognize, however, that older people who trip or slip may have
a variety of underlying reversible conditions that could have contributed to the event. Thus, a thorough evaluation of all falls is warranted.
In addition to evaluating the patient who has fallen for injury, it is
critical to determine, to the extent possible, whether the patient had a
syncopal episode or a seizure, which dictates a very different approach
to evaluation and management. As many as half of “unexplained falls”
in older people with dementia (e.g., found on the floor) may be due to
near-syncope or syncope related to postural hypotension.
Figure 477-6 illustrates an overview of the approach to an older
person who reports a history of one or more falls in the past 6 months,
Ask all
patients
about falls in
the past year
No
falls
One
fall past
6 months
Gait or
balance
problem
Report >1
fall, or difficulty
with gait or balance,
or seeking medical
attention
because
of fall
No
problem
Recommend fall
prevention, education and
exercise program that
includes balance, gait and
coordination training and
strength training
Multifactorial fall risk
assessment
History of falls
Medications
Gait and balance
Cognition
Visual acuity
Lower limb joint function
Neurological impairment
Muscle strength
HR and rhythm
Postural hypotension
Feet and footwear
Environmental hazards
Check for gait or
balance problems
Reassess periodically
Intervene with identified risks
Modify medications
Prescribe individualized exercise program
Treat vision impairment
Manage postural hypotension
Manage HR and rhythm abnormalities
Supplement vitamin D
Address foot/shoe problems
Reduce environmental hazards
Education/ training in self-management
and behavioral changes
FIGURE 477-6 Algorithm depicting assessment and management of falls in older patients. HR, heart rate. (Reproduced with permission of American Geriatrics Society.
American Geriatrics Society and British Geriatrics Society: Clinical Practice Guideline for the Prevention of Falls in Older Persons. New York, American Geriatrics Society, 2010.)
3749Caring for the Geriatric Patient CHAPTER 477
TABLE 477-6 Evaluating the Older Person Who Falls—Immediate Post-Fall Evaluation
History
• Circumstances surrounding the fall
• Relationship to changes in posture, turning of head, after a meal or medication intake, rushing to the toilet, nocturia, straining to urinate or defecate
• Accidental trip or slip (note that many correctable factors can contribute to a reported “mechanical” fall—see text)
• Hazards in the living environment (loose rugs, cords, unsafe steps, slippery floors, etc.)
• Premonitory or associated symptoms
• Dizziness (lightheadedness vs vertigo); cardiovascular (postural lightheadedness, palpitations, chest pain, shortness of breath); focal neurologic symptoms
suggestive of stroke or transient ischemic attack (weakness, sensory disturbance, dysarthria, ataxia, aphasia); symptoms of a seizure (witnessed clinic
movements, incontinence of urine or stool, tongue biting)
• Symptoms over the previous few days that may have led to volume depletion (poor food/fluid intake, nausea/vomiting, diarrhea, urinary frequency/polyuria)
• Exclude loss of consciousness or seizure (may be difficult without a witness)
• Medications—chronic and within the few hours before the fall
• Diuretics and other antihypertensive drugs
• Nitrates
• Drugs that cause bradycardia—beta blockers; cholinesterase inhibitors
• Psychotropics—antipsychotics, hypnotics, sedatives, antidepressants
• Antiparkinsonian drugs
• Hypoglycemic drugs
• Excessive alcohol intake
Physical Examination
• Exclude physical injury
• Head trauma, hip range of motion, pubic bone tenderness, wrist pain, other signs of trauma
• Bruising in patients on anticoagulants/platelet inhibitors
• Exclude acute illness
• Vital signs
• Postural vital signs (if feasible/safe)
• Fingerstick glucose in diabetics
• Poor skin turgor suggesting volume depletion (over chest; other areas unreliable)
• Signs of an acute respiratory, cardiovascular, or abdominal condition
• Focal neurologic signs suggestive of stroke
• Signs of conditions that increase risk for falls
• Poor visual acuity; use of bifocals
• Limited range of motion of neck (to detect possible cervical arthritis/disk disease)
• Cardiovascular—arrhythmias, carotid bruits, aortic stenosis, mitral insufficiency, heart failure
• Degenerative joint disease in lower extremities causing pain, limited range of motion, and/or deformity
• Podiatric conditions (calluses; bunions; ulcerations; poorly fitted, inappropriate, or unsafe shoes)
• Neurologic signs—lower extremity muscle weakness; peripheral neuropathy; tremor, rigidity, and/or bradykinesia suggestive of undiagnosed Parkinson’s disease;
cerebellar signs (abnormal heel to shin or heel tapping); abnormal reflexes that could reflect upper motor neuron disorder such as spinal cord compression or
subdural hematoma; cognitive deficits that can result in poor judgement
• Observation of gait and balance—simple Get Up and Go test (see text) with observation for short steps, poor foot elevation, wide-based gait, multiple steps to turn
180 degrees; other abnormalities that might suggest normal pressure hydrocephalus (especially in combination with symptoms of incontinence and/or cognitive
impairment)
Laboratory and/or Imaging Studies
• Should be guided by history and physical examination—common examples include:
• Complete blood count, basic metabolic panel to exclude/verify acute illness
• Urinalysis (only when additional symptoms of urinary tract infection present)
• Electrocardiogram (in patients suspected of acute coronary syndrome or with significant known cardiovascular disease)
• X-rays to exclude fractures
• Brain imaging if signs present to exclude subdural hematoma, stroke
• Cardiac monitoring in patients with history suggestive of syncope or near-syncope
• Electroencephalography in patients with history suggestive of seizure
Source: Adapted from RL Kane et al (eds): Essentials of Clinical Geriatrics, 8th ed. New York, McGraw-Hill, 2017.
and Table 477-6 provides more detail on the immediate evaluation of
an older person who has fallen. Chap. 26 provides more detail on the
evaluation of gait and balance disorders.
Management Table 477-7 illustrates approaches to the management of falls. Immediately after a fall, injuries and underlying acute
illnesses should be identified and treated. It is common practice for
older patients who come to an emergency department with a history
of a fall to have a brain imaging study. While this is understandable
from a potential liability standpoint, it is also reasonable to avoid such
studies if no history or signs of head trauma, neurologic symptoms or
signs, or anticoagulation is noted and to monitor the patient carefully
over the next 48–72 h for the development of specific indications for a
brain imaging study.
Because the causes of and risk factors for falls are often multifactorial, management commonly requires multiple interventions in the
same patient. Among the most common and effective interventions are
physical therapy for strengthening and balance; Tai Chi has also been
shown to be effective in multiple trials. Although many older people
who fall are vitamin D deficient, the role of vitamin D replacement in
3750 PART 18 Aging
TABLE 477-7 Examples of Management for Underlying Causes of Falls
in Older Patients
CAUSES EXAMPLES OF TREATMENT
Cardiovascular
Arrhythmias Antiarrhythmic medication, ablation,
pacemaker (depending on nature of
arrhythmia)
Aortic stenosis with syncope or
near syncope
Valve surgery (transcatheter procedure if
appropriate)
Postural hypotension Reduce or eliminate hypotensive drugs
Hydration, support stockings
Medication (Proamatine [midodrine],
fludrocortisone, droxidopa)
Adaptive behaviors (e.g., pausing and getting
up slowly)
Hypertension Manage carefully to avoid hypotension and
near syncope; control may be important in
patients with periventricular white matter
changes in preventing further gait disturbance
Neurologic
Autonomic dysfunction with
postural hypotension
As above
Cervical spondylosis (with
spinal cord compression)
Neck brace; physical therapy; consider
surgery
Parkinson’s disease Antiparkinsonian drugs
Visual impairment Ophthalmologic/optometric evaluation and
specific treatment
Seizure disorder Anticonvulsants
Normal-pressure
hydrocephalus
Surgery (ventricular-peritoneal shunt)
Dementia Supervised activities
Hazard-free environment
Benign positional vertigo Habituation exercises
Anti-vertiginous medication
Others
Foot disorders Podiatric evaluation and treatment
Gait and balance disorders Properly fitted shoes
Physical therapy
Exercise with balance training (including Tai
Chi where available)
Muscle weakness,
deconditioning
Lower extremity strength training
Drug adverse effects
(e.g., sedatives, alcohol,
other psychotropic drugs,
antihypertensive)
Elimination of drug(s) when feasible
Vitamin D deficiency Vitamin D supplementation
Recurrent falls Fall alert system for those who live alone; hip
protectors in selected patients
Source: Reproduced with permission from RL Kane et al (eds): Essentials of Clinical
Geriatrics, 8th ed. New York, McGraw-Hill, 2017.
preventing falls or preventing injuries from falls when combined with
interventions such as strength and balance training is not clear. The
risk/benefit ratio probably favors vitamin D replacement with at least
800 IU per day, but high-dose vitamin D (60,000 IU in one oral dose
monthly) has been associated with an increase in risk of falls. Patients
who suffer a fracture after a fall should be investigated and treated for
osteoporosis. Patients at high risk for recurrent falls and injuries should
be encouraged to use a fall alert system; selected patients may benefit
from hip protectors.
■ POLYPHARMACY
Epidemiology and Impact Polypharmacy is defined as the prescription of multiple medications using various thresholds (generally
ranging from five up to nine simultaneous drugs) and has been identified as a major challenge in the geriatric population for decades.
About 40% of the U.S. population age 65 and older take five to nine
medications, and close to 20% take 10 or more. Polypharmacy is an
increasingly complex challenge because of the rising prevalence of
multimorbidity, a plethora of clinical practice guidelines, proliferation
of medications that can effectively treat common geriatric conditions,
and rising patient and family demand for medications due in part to
television advertising and information available on the Internet. For
example, based on several condition-specific clinical practice guidelines (which do not account for multimorbidity), an 80-year-old person
with multimorbidity including diabetes, chronic obstructive lung disease, hypertension, osteoporosis, and degenerative joint disease might
be prescribed an extremely complicated nonpharmacologic regimen
and over a dozen medications with the potential for multiple drugdrug and drug-disease interactions.
Polypharmacy increases the risks associated with age-related
changes in the pharmacology of many drugs and the risk of adverse
drug events. Such events cause >100,000 hospitalizations per year; the
main culprits are warfarin and other antiplatelet agents and insulin
and other hypoglycemic agents. Other categories of drugs are also
involved, including cardiovascular drugs that can cause electrolyte
and volume disturbances and hypotension, falls, and syncope; central
nervous system drugs associated with altered mental status and falls;
and antimicrobials, which cause allergic reactions, diarrhea, and other
adverse drug effects.
Evaluation All older patients should have careful medication reconciliation at each office or clinic visit and especially at the time of care
transitions, including acute hospitalization, hospital discharge, admission to a PAC facility or home health program, and discharge from a
PAC facility to home. At each transition, all medications should be
considered in terms of unclear diagnosis or indication, uncertain dose
or route of administration, stop date, hold parameters, lab tests needed
for monitoring, dosages different than the last care setting, medication
duplication, medications that should be restarted, and the potential for
drug-drug and drug-disease interactions. At each clinic or office visit
for community-dwelling older people, possible adverse drug effects,
effectiveness of drug therapy, and adherence should be evaluated.
Management Table 477-8 lists several general recommendations
for geriatric prescribing that should help make drug therapy more
effective and safer in older patients, especially those with multimorbidity. Chapter 67 also provides information on general principles
of clinical pharmacology. Because these patients often see multiple
specialists, the internist should serve as the “quarterback” for all
prescribing to help ensure adherence and minimize the potential for
adverse drug effects. In hospital, PAC, and LTC settings, clinical pharmacists can be extremely helpful in achieving these recommendations
and goals.
While undertreatment of certain conditions may occur in older people (such as osteoporosis, depression, and overactive bladder), more
attention is now being paid to “deprescribing.” Deprescribing must be
done carefully, especially at the time of care transitions, when indications for specific drugs and patient preferences may not be clear. The
AGS’s updated Beers criteria includes a comprehensive list of drugs
that may be inappropriate in older people and the rationale for this
rating. The Screening Tool of Older Persons’ Prescriptions (STOPP)
criteria are also useful in identifying drugs that should be reconsidered
on older people.
Several commonly prescribed drugs should be considered for
deprescribing efforts, including (1) diuretics and hypotensive agents
when patients have systolic hypotension or postural hypotension that
can precipitate near-syncope and falls; (2) overreliance on antianxiety
and hypnotic medications, especially benzodiazepines; (3) psychotropic and other drugs with anticholinergic activity that can cause dry
mouth and constipation and increase the long-term risk of cognitive
impairment; (4) PPIs with unclear indications because of numerous
reported potential adverse drug effects, including increased risk of
3751Caring for the Geriatric Patient CHAPTER 477
TABLE 477-8 General Recommendations for Geriatric Prescribing
1. Evaluate geriatric patients thoroughly to identify all conditions that could (a)
benefit from drug treatment; (b) be adversely affected by drug treatment; and
(c) influence the efficacy of drug treatment.
2. Manage medical conditions without drugs as often as possible.
3. Know the pharmacology of the drug(s) being prescribed.
4. Consider how the clinical status (e.g., renal function, hydration) of each
patient could influence the pharmacology of the drug(s).
5. Avoid potentially serious adverse drug-drug interactions.
6. For drugs or their active metabolites eliminated predominantly by the kidney,
use a formula to approximate age-related changes in renal function and
adjust dosages accordingly; the Cockcroft-Gault formula (below) is probably
safer as it tends to underestimate creatinine clearance.
− ×
× Creatinine clearance= × (140 age) body weight (kg)
72 serum creatinine level ( 0.85 for women)
7. If there is a question about drug dosage, start with smaller doses and
increase gradually until the drug is effective or intolerable side effects are
observed.
8. Drug blood concentrations can be helpful in monitoring several potentially
toxic drugs used in the geriatric population.
9. Help to ensure adherence by:
a. Making drug regimens and instructions as simple as possible
b. Using the same dosage schedule for all drugs whenever feasible (e.g.,
once or twice per day)
c. Timing the doses in conjunction with a daily routine
d. Paying attention to impaired cognitive function, diminished hearing, and
poor vision when instructing patients and labeling prescriptions
e. Instructing relatives and caregivers on the drug regimen
f. Enlisting other health professionals (e.g., home health aides, pharmacists)
to help ensure compliance
g. Making sure the older patient can get to a pharmacist (or vice versa), can
afford the prescriptions, and can open the container
h. Using aids (e.g., special pillboxes and drug calendars) whenever
appropriate
i. Performing careful medication adjudication and patient/family education
at the time of every hospital discharge
j. Keeping updated medication records and review them at each visit
k. Reviewing knowledge of and adherence with drug regimens regularly
10. Monitor older patients frequently for adherence, drug effectiveness, and
adverse effects, and adjust drug therapy accordingly.
Source: Reproduced with permission from RL Kane et al (eds): Essentials of Clinical
Geriatrics, 8th ed. New York, McGraw-Hill, 2017.
Women
Men
70–74
0
10
20
Prevalence (%) 30
40
50
75–79
Age
80–84 85–89
FIGURE 477-7 Prevalence of mild cognitive impairment by age and sex in
Olmstead County, MN. (Reproduced with permission from RC Petersen et al:
Prevalence of mild cognitive impairment is higher in men. The Mayo Clinic Study of
Aging. Neurology 75:889, 2010.)
pneumonia, osteoporosis, and dementia; (5) cholinesterase inhibitors
and memantine in patients with severe cognitive impairment who have
been on them for years; (6) hypoglycemic agents in patients with multimorbidity who should not have tightly controlled blood sugar with
increased risk of hypoglycemia; and (7) statins and prophylactic aspirin
in patients with severe chronic illness who are near the end of life.
Careful deprescribing is a critical aspect of person-centered care in
the geriatric population. Several general principles, including some in
Table 477-8, may assist with deprescribing efforts, including the following: (1) ascertain all drugs the patient is currently taking and the
reasons for each one; (2) consider overall risk of drug-induced harm in
individual patients in determining the required intensity of deprescribing intervention; (3) assess each drug as to its current or future benefit
potential compared with current or future harm or burden potential;
(4) prioritize drugs for discontinuation that have the lowest benefitharm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen
based on the pharmacology of the drug being discontinued and monitor
patients closely for improvement in outcomes or onset of adverse effects.
■ COGNITIVE IMPAIRMENT: DELIRIUM AND
DEMENTIA
The reader is referred to other chapters in this text (Chaps. 431–434)
on cognitive impairment. Because these conditions are so prevalent in
the older population, selected aspects highly relevant to geriatrics are
briefly discussed here.
Epidemiology and Impact Delirium occurs in up to 40% of
hospitalized older patients and is associated with increased morbidity,
length of hospital stays, need for institutional care, health care utilization, and mortality in this population. While most episodes of delirium
clear within a few days if the underlying cause(s) is identified and
treated, delirium may persist for weeks or, in a few cases, for months
after an acute hospitalization.
Normal aging does not cause impairment of cognitive function of sufficient severity to render an individual dysfunctional, which is the hallmark of a dementia syndrome. Slowed thinking and reaction time, mild
recent memory loss, and impaired executive function can occur with
increasing age and may or may not progress to dementia. Figure 477-7
illustrates the prevalence of memory impairment with increasing age.
Just over 20% of people over age 70 in the United States have cognitive
impairment without dementia, generally referred to as mild cognitive
impairment (MCI). Up to 15–20% of those diagnosed with MCI will
progress to dementia over the course of a year; thus, most people with
MCI will progress to dementia within 5 years. Therapeutic implications
of MCI are subjects of intensive research. No nonpharmacologic or
pharmacologic intervention has been shown to prevent progression
to dementia.
The definitions of Alzheimer’s disease and related dementias have
been updated by the American Psychiatric Association. The prevalence
of dementia increases with age; by age 85, between 30% and 40% have a
dementia syndrome. Alzheimer’s disease and vascular dementia, which
often occur together based on pathologic studies, account for most
dementias in older people. Dementia with Lewy bodies accounts for
up to 25% of dementia and is characterized by Parkinsonian features
early in the disease (as opposed to dementia in Parkinson’s disease,
which generally occurs years after the onset of Parkinson’s), personality
changes, alterations in alertness and attention, and visual hallucinations that can cause paranoia. Although most dementia syndromes
are slowly progressive over several years, dementia is a terminal illness
among patients who do not succumb to other comorbidities and results
in devastating loss of cognition and function in the later stages.
Evaluation Regardless of setting, the new onset of delirium should
be treated as a medical emergency because it can be the manifestation
of an underlying critical illness. Figure 477-8 illustrates an overview
of the assessment and management of impaired mental status and
delirium in older hospitalized patients. The first step in the evaluation
is to identify predisposing and precipitating factors such as hearing or
visual impairment, symptoms of depression, laboratory abnormalities,
3752 PART 18 Aging
uncontrolled pain, infections, exacerbation of chronic illnesses, and
history of alcohol or other substances use. The most validated evaluation for delirium is the Confusion Assessment Method, which requires
an acute onset and fluctuating course and inattention and disorganized
thinking or altered level of consciousness. Because the causes and risk
factors for delirium are multifactorial, evaluation requires a careful
history, physical examination, and selected laboratory studies based
on the findings.
The benefits of screening older community-dwelling adults for cognitive impairment are controversial, but there are many interventions
that may benefit patients and families early in the course of the disease
(see below). Older patients in outpatient settings with complaints (or
family reports of) early signs of cognitive impairment benefit from
neuropsychological testing, which can help differentiate between MCI
and dementia and identify concomitant factors such as depression and
anxiety. The Mini-Cog is a sensitive screening tool for cognitive impairment, and consists of a three-item recall test and clock drawing. Further
evaluation of dementia includes a comprehensive history and physical
examination, functional status assessment (since the diagnosis depends
on impaired function), a brain imaging study, and selected laboratory
tests, including a complete blood count, comprehensive metabolic
panel, thyroid function tests, vitamin B12 level, and, if suspected, tests
for syphilis and human immunodeficiency virus antibodies.
Management Table 477-9 lists pharmacologic and nonpharmacologic management strategies for various underlying risk factors
and causes of delirium. Every attempt should be made to avoid or
discontinue any medication that may be worsening cognitive function in a delirious geriatric patient. This may not be possible, and in
some patients, psychotropic drugs may be needed to treat delirium if
the patient is a danger to themselves or others. Low-dose haloperidol
(0.25–0.5 mg) is generally recommended; more sedating antipsychotics and benzodiazepines should be avoided unless the goal is to
put the patient to sleep for a short time. If a benzodiazepine is used,
it should be short-acting and in a low dose. Overall, multifactorialproactive interventions and geriatric consultation have been associated with decreased incidence and duration of delirium in the hospital
setting.
Although the benefits of screening for cognitive impairment in
community-dwelling older people are controversial, there are many
nonpharmacologic interventions for older patients, their families, and
other caregivers that may be beneficial (Table 477-10). Four basic
approaches to the pharmacologic treatment of dementia are employed:
(1) avoidance of drugs that can worsen cognitive function, mainly those
with strong anticholinergic activity; (2) use of agents that enhance cognition and function; (3) drug treatment of coexisting depression, which
is common throughout the course of dementia; and (4) pharmacologic
treatment of complications such as paranoia, delusions, psychosis, and
behavioral symptoms such as agitation (verbal and physical). The use
of antipsychotics to treat the neuropsychiatric symptoms of dementia
is controversial. Most experts and guidelines recommend avoiding
these drugs and using nonpharmacologic strategies unless patients are
a danger to themselves and others or if nonpharmacologic interventions have failed. Patients with new or worsening behavioral symptoms
associated with dementia should have a medical evaluation to identify
potentially treatable precipitating conditions. Pain may be especially
hard to detect, and if suspected, a therapeutic trial of acetaminophen
should be considered.
The effectiveness of cholinesterase inhibitors and memantine in
improving function and quality of life in patients with various types of
TABLE 477-9 Evaluation and Management of Delirium
CONTRIBUTING FACTORS
APPROACHES TO EVALUATION AND
MANAGEMENT
Drugs Consider the etiologic role of newly initiated drugs,
increased doses, interactions, over-the-counter
drugs, and alcohol; consider especially the role of
high-risk drugs: lower the dose, discontinue the
drug, or substitute a less psychoactive medication.
Consider withdraw from chronic medications. Pay
special attention to psychotropic medications.
Electrolyte disturbances Assess for and treat, especially dehydration,
hyponatremia and hypernatremia, hypothyroidism
Infection Urinary tract infections, pneumonia, soft tissue
infection
Visual/hearing impairment Encourage the use of glasses and hearing aids if
available.
Urinary and fecal
disorders
Treat urinary retention and fecal impaction
Pulmonary disorders Correct hypoxemia
Prevent or Manage Complications
Urinary incontinence Scheduled toileting
Immobility and falls Encourage early mobilization to maintain baseline
mobility
Pressure ulcers Mobility and repositioning, nutrition
Sleep disturbances Sleep hygiene, avoid sedatives, avoid unnecessary
awakenings
Feeding disorders Feeding assistance if necessary, aspiration
precautions, liberalize diet if possible.
Maintain Patient Comfort and Safety
Behavioral interventions Staff education regarding de-escalation techniques
for treatment of hyperactive delirium, facilitate
family visitation if possible
Pharmacologic
interventions
Only if the patient becomes a threat to himself or
others and other interventions have failed
Restore Function
Hospital environment Adequate lighting, reduce noise
Cognitive reconditioning Reorient patient frequently
Physical reconditioning Physical and occupational therapy
Discharge planning Assess new needs based on predischarge
functional status, evaluate social support,
coordinate transitions of care, medication
reconciliation
Source: Adapted from ER Marcantonio: Delirium in hospitalized older adults. N Engl
J Med 378:96, 2018.
Hospital admission
Assess current and
recent changes
in mental status
Monitor mental status
Prevention
Address risk factors
Improve communication
Improve environment
Early discharge
Avoid psychotropic drugs
Acute
Impaired mental
status
Chronic
Dementia evaluation Cognitive assessment
and delirium evaluation
Identify and address
predisposing and
precipitating risk factors
Provide supportive
care and prevent
complications
Manage symptoms
of delirium
Rule out depression,
mania and psychosis Delirium confirmed
FIGURE 477-8 Algorithm depicting assessment and management of delirium in
hospitalized older patients. (From SK Inouye: Delirium in older persons. N Engl J
Med 354:1157, 2006. Copyright © 2006 Massachusetts Medical Society. Reprinted
with permission from Massachusetts Medical Society.)
3753Caring for the Geriatric Patient CHAPTER 477
TABLE 477-10 Key Principles in the Management of Dementia
Optimize the patient’s physical and mental function through physical activity and
mind plasticity principles and activities
Treatment underlying medical and other conditions (e.g., hypertension,
Parkinson’s disease, depression)
Avoid use of drugs with central nervous system side effects (unless required
for management of psychological or behavioral disturbances—see Chap. 14)
Assess the environment and suggest alterations, if necessary
Encourage physical and mental activity
Avoid situations stressing intellectual capabilities; use memory aids whenever
possible
Prepare the patient for changes in location
Emphasize good nutrition
Identify and manage behavioral symptoms and complications
Driving (consider a formal driving evaluation)
Wandering
Dangerous driving
Behavioral disorders
Depression
Agitation or aggressiveness
Psychosis (delusions, hallucinations)
Malnutrition
Incontinence
Provide ongoing care
Reassessment of cognitive and physical function
Treatment of medical conditions
Provide information to patient and family
Nature of the disease
Extent of impairment
Prognosis
Provide social service information to patient and family
Local Alzheimer’s association
Community health care resources (day centers, homemakers, home health
aides)
Legal and financial counseling
Use of advance directives
Provide family counseling for:
Setting realistic goals and expectations
Identification and resolution of family conflicts
Handling anger and guilt
Decisions on respite or institutional care
Legal concerns
Ethical concerns
Consideration of palliative and hospice care
Protect the caregiver from effects of caregiver stress
Source: Reproduced with permission from RL Kane et al (eds): Essentials of Clinical
Geriatrics, 8th ed. New York, McGraw-Hill, 2017.
dementia is controversial, and the potential benefits of these drugs versus their risks and costs must be weighed carefully to provide optimal
person-centered care. The best evidence for effectiveness of cholinesterase inhibitors is in delaying progression of Alzheimer’s disease and
increasing the time before institutional placement is needed. GI side
effects can be problematic and include nausea, vomiting, and diarrhea;
nightmares can be bothersome as well. In addition to these bothersome
side effects, cholinesterase inhibitors can cause bradycardia and have
been associated with syncope, injurious falls, and pacemaker placement. Memantine can cause dizziness, headache, confusion, and constipation. In one study, vitamin E was more effective than memantine
in preventing functional decline in patients with Alzheimer’s disease.
■ URINARY INCONTINENCE AND OVERACTIVE
BLADDER
Epidemiology and Impact Urinary incontinence is curable or
controllable in many geriatric patients, especially those who have
adequate mobility and mental functioning. Even when it is not curable,
incontinence can be managed in a manner that keeps people comfortable, makes life easier for caregivers, and minimizes the costs of caring
for the condition and its complications. Approximately one in three
women and 15–20% of men older than age 65 years have some degree
of urinary incontinence. Between 5% and 10% of community-dwelling
older adults have incontinence more often than weekly and/or use a
pad for protection from urinary accidents. The prevalence is as high
as 60–80% in many nursing homes, where residents often have both
urinary and stool incontinence. Many older people (~40%) suffer
from “overactive bladder,” which may or may not include symptoms of
incontinence. Symptoms of overactive bladder include urinary urgency
(with or without incontinence), urinary frequency (voiding every 2 h
or more often), and nocturia (awakening at night to void). If nocturia
alone is the predominant symptom, the patient should be asked about
sleep disorders (see next section). The pathophysiology, evaluation,
and management of overactive bladder are essentially the same as for
urge urinary incontinence.
Incontinence is associated with social isolation and depression and
can be a precipitating factor in the decision to seek nursing home care
when it cannot be managed in a manner that maintains hygiene and
safety. In addition to predisposing to skin irritation and pressure ulcers,
the most important potential complications of urinary incontinence
and overactive bladder are falls and resultant injuries related to rushing to get to a toilet. Older people with gait disorders, especially those
who have multiple episodes of nocturia or nocturnal incontinence, are
at especially high risk for injurious. In addition to the bother of the
condition to the older person or a caregiver, fall risk is a compelling
reason for undertaking a diagnostic evaluation and specific treatment
for incontinence and overactive bladder in the geriatric population.
Evaluation Internists should ask older people about symptoms of
urinary incontinence because these symptoms are often hidden out of
embarrassment or fear. Simple questions can help identify incontinent
patients, such as “Do you have trouble with your bladder?” “Do you
ever lose urine when you don’t want to?” “Do you ever wear padding
to protect yourself in case you lose urine?” (Table 477-3). A substantial
number of older people will respond “no” to the first two questions but
“yes” to the third one.
Several points are worth noting for the practicing internist. The
history and physical examination should focus on identifying potentially reversible causes and contributing factors (Table 477-11) and
identifying the specific lower urinary tract symptoms. A simple, threeitem validated questionnaire can assist in distinguishing between the
most common types of incontinence (Fig. 477-9). Key aspects of the
history and physical exam are outlined in Table 477-12. Among older
women, the most common symptoms are a mixture of urge and stress
incontinence (Fig. 477-10); urge is usually the more bothersome.
Stress incontinence can often be objectively observed during a physical
examination with a comfortably full bladder by having the patient
cough in the standing position; leakage of urine simultaneously with
coughing indicates that stress incontinence is present. Older men
commonly have symptoms associated with overactive bladder and/or
symptoms of voiding difficulty (hesitancy, poor or intermittent urinary stream, postvoid dribbling); the overactive bladder symptoms are
usually more bothersome. These symptoms overlap with those of both
benign and malignant disorders of the prostate, and many internists
may choose to consult a urologist for further management (Chap. 87)
because a urinary flow rate and postvoid residual determination, and
further evaluation if malignancy is suspected, are helpful in determining therapy.
Most older patients with symptoms of incontinence should have a
postvoid residual determination, especially men, diabetics, those with
neurologic disorders, and those with symptoms of voiding difficulty,
because incomplete bladder emptying is common in older patients and
is difficult to detect by history and physical examination alone. There
is no specific cutoff for an abnormal postvoid residual; the test must
be done with a full bladder, and straining during the test can alter the
results. In older patients, a postvoid residual between 0 mL and 100 mL
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