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Geriatric Gems & Palliative Pearls


Brought to you by:

The University of Texas Health Science Center at Houston (UTHealth) Medical School
Division of Geriatric and Palliative Medicine Training Excellence in Aging Studies (TEXAS) Program

This program was funded by the Donald W. Reynolds Foundation.



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UTHealth Medical School
Division of Geriatric and Palliative
6431 Fannin, MSB 1.150
Houston, Texas 77030
texas@uth.tmc.edu

Acute Care of the Elderly (ACE) Units
Author: Melanie Zuo, M.D. and Nasiya Ahmed, M.D.

Care System
Key Points     CS01sect1

ACE Units are general medical units specifically for older adults. These units typically have the following components:
  • An interprofessional team –physician, advance practice nurse, physician assistant, physical therapist, occupational therapist, speech therapist, nutritionist, social worker, pharmacist and nurses.

  • Focus on functional ability - daily PT/OT starting on the day of admission

  • Discharge planning – starts on admission day with goal of returning to the community.

  • A thorough pharmaceutical review - usually in conjunction with a pharmacist - to check dosages, therapeutic levels, side effects, and drug interactions

  • A prepared environment designed to facilitate physical and cognitive function – large clocks and calendars, handrails, raised toilet seats, and other environmental modification to assist the older patient.

  1. First started in 1989 at the University Hospitals of Cleveland

  2. Clinical and cost-effective benefits include:

    1. Fewer medications at discharge

    2. Reduced prevalence and duration of delirium

    3. Decreased length of stay

    4. Decreased re-admission rate

    5. Decreased nursing home placement

    6. Better functional capacity including improved ambulation and ability to perform instruments of daily living

    7. Better pain satisfaction scores

  3. Cost savings are realized by increased discharges to home versus long-term care, decreased length of stay, and decreased readmissions.

References     CS01sect2

Ahmed, N.N. & Pearce, S. E. (2010). Acute Care for the Elderly: A Literature Review. Population Health Management:13 (4): 219-225.

Ahmed, N., Taylor, K., McDaniel, Y., Dyer, C.B. (2012). The role of an acute care for the elderly unit in achieving hospital quality indicators while caring for frail hospitalized elders. Population Health Management: 15(4): 236-240.

Flood, K., MacLennan, P., McGrew, D. , et al.(2013). Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions. Journal of the American Medical Association, 173(11):981-987.

Fox, M,T., Sidani, S., Persaud, M., Tregunno, D., Maimets, I., Brooks, D., & O'Brien, K. (2013). Acute Care for Elders Components of Acute Geriatric Unit Care: Systematic Descriptive Review. Journal of the American Geriatrics Society: 61(6): 939–946.

Landefeld, C.S., Palmer, R.M., Kresevic, D.M., Fortnsky, R.H., & Kowal, J. (1995). A Randomized Trial of Care in a Hospital Medical Unit Especially Designed to Improve the Functional Outcomes of Acutely Ill Older Patients. New England Journal of Medicine; 332:1338-1344.



Medical Decision Making
Author: Nasiya Ahmed, MD, Susan Gorman, MSN, RN, GNP, & Rechelle Asirot, MD

Care System
Overview     CS02sect1

Medical law and ethics presume an adult can make medical decisions about their care.

The burden is placed on the responsible physician to determine whether a patient lacks that ability. This joint process involves the patient and physician, and may include advocacy and communication from others.

Executive function is a cognitive ability that involves the planning and execution of goal-directed behaviors, abstract reasoning, and judgment.

Executive function involves decisional capacity beyond medical decision making. The patient must be able to successfully practice self-care and self-protective functions such as activities of daily living (ADL's) and independent activities of daily living (IADL's). ADL's include bathing, grooming, toileting, and eating. IADL's include taking medications appropriately, food preparation, making and keeping medical appointments, fulfilling financial responsibilities and bill paying.


Key Points     CS02sect2

  • Impairment of decision making capacity requires careful investigation of executive function.

  • Capacity and competency are not synonymous. Capacity is a clinical term while competency is a legal term.

  • A competent adult may accept or refuse any or all medical treatment.

  • Decision making capacity is not all or nothing; some decisions are easier than others and the patient should be re-evaluated for each decision.

  • Medical decisions may be made by the patient, surrogate decision maker or an advanced directive.

  • If the patient does not have decision making capacity then refer to his advanced directives, written instructions regarding his medical care preferences.

  • A living will, or health care directive, lists specific medical treatments the patient will or will not allow, such as ventilators, dialysis, and tube feeding.

  • A medical (durable) power of attorney (POA), or health care proxy, designates an individual to make medical decisions if the patient is unable to do so.

  • If a medical POA is not appointed, the decisions default to the patient's spouse, children, parents, and next of kin (in this order). There are individual state differences regarding whom to default to. Health care providers need to be aware of their State Laws.


Assessment     CS02sect3

To establish competence, the patient must:
  • Understand the information (able to correctly paraphrase or summarize what has been discussed),

  • Recognize the consequences of each decision,

  • Deliberate the options logically (the final decision may not be logical), and

  • Consistently communicate his/her final decision.

Try using this easy mnemonic, U R Definitely Capable to remember.

Assessment Tools available for your use in the clinical setting:

  • The MacArthur Competence Assessment Tool-Treatment (MacCAT-T) is a valid and reliable tool by which clinicians and caregivers can assess patients' competence in four areas as described above.

  • The Assessment of Capacity for Everyday Decision-making (ACED) is another instrument in an interview developed to measure capacity to make every day decisions

  • For cases of suspected self-neglect, the Articulate Demonstrate method has been used as a tool to screen for capacity among vulnerable elderly population.



References     CS02sect4

Applebaum, P.S. & Grisso, T. (1988). Assessing Patients' Capacities to Consent to Treatment. New England Journal of Medicine; 319:1635-1638.

Beauchamp, T.L. & Childress, J.F., (Eds.) (2008). Principles of biomedical ethics. New York, NY: Oxford University Press.

Ganzini, L., Volicer, L., Nelson, W. A., Fox, E., & Derse, A.R. (2004). Ten Myths about Decision-Making Capacity. Journal of the American Medical Directors Association; 5(4):263-267.DOI: 10.1097/01.JAM.0000129821.34622.A2

Grisso, T., Appelbaum, P.S., & Hill-Fotouhi, C. (1997). The MacCAT-T: A clinical tool to assess patients' capacities to make treatment decisions. Psychiatric Services; 48:1415–1419.

Lai, J.M. & Karlawish, J.H. (2006). Assessing the capacity to make everyday decisions. American Journal of Geriatric Psychiatry; 15:101–111.

Naik, A.D., Lai, J.M., Kunik, M.E., & Dyer, C.B. (2008). Assessing capacity in suspected cases of self- neglect. Geriatrics; 63:24–31.



Medicare Basic Coverage
Author: Nasiya Ahmed, M.D. & Rechelle Asirot, M.D.

Care System
Medicare is an insurance program of the federal government, funded by the taxes paid by workers and employers, as well as by premiums from Social Security checks. It is under the stewardship of the Centers for Medicare and Medicaid Services (CMS).

Key Points     CS03sect1

  1. A legal resident of the United States is eligible for Medicare if the following criteria are met:
    1. Age > 65 years old and has worked for 10 years (or married to someone who has)
    2. End stage renal disease
    3. Disabled, by Social Security criteria, for at least 24 months

  2. Medicare Part A covers inpatient services, including rehab, skilled nursing facilities, home health, long term acute care, and hospice (not nursing home).

  3. Medicare Part B covers outpatient services, including home health, clinic visits, labs, imaging, and counseling

  4. Medicare Part C includes private health plans that are Medicare approved.

  5. Medicare Part D covers prescription drugs.

  6. Private HMOs, PPOs, and capitated plans also receive money from Medicare to care for patients who have relinquished their right to traditional Medicare. Some things to know:

    1. These plans have varying deductibles and premiums;
    2. These plans differ in the services they cover;
    3. These plans may be advantageous for patients because they offer dental coverage, vision plans, gym memberships, for example;
    4. In-patient hospital coverage varies.

  7. All parts of Medicare have deductibles, premiums, and/or co-pays. These extra costs can be covered by a supplemental or medigap insurance.

  8. Medicare does not cover foot care, hearing aids, acupuncture, cosmetic surgery, routine vision or dental care or custodial care.

  9. It is expected the 2010 Affordable Care Act will be creating reforms to the Medicare plans as the law is implemented.


References     CS03sect2

Medx Publishing. Medicare Coverage Basics. (2013). http://www.medicare.com/medicare-coverage-basics/medicare-coverage-basics.html Accessed: October 15, 2013.

Social Security Administration (2013, May). Social Security Medicare Benefits. http://www.ssa.gov/pubs/EN-05-10043.pdf Accessed: October 15, 2013.


Alcohol Use Disorder among Older Adults
David V. Flores, PhD, LMSW, MPH

Health Promotion
Overview     HP01sect1

Alcohol Use Disorder (AUD) among older adults is on the rise and is poised to overwhelm our national resources (Institute of Medicine, 2012). Individuals 65 and older are projected to increase from 40.3 million in 2010 to 72.1 million by 2030, a 56% increase, and will double to 88.5 million by 2050 (U.S. Census Bureau, 2010). Moreover, those 85 and older are projected to triple from 5.4 million to 19 million by 2050 (Kalapatapu & Sullivan, 2010).

Concomitant with this dramatic population growth is the expected rise in AUD and need for substance use treatment among older adults. This increase in alcohol abuse is directly associated with the retiring "baby boomer" generation (Gfroerer, 2003; Institute of Medicine, 2012). The "baby boomer" generation maintains the highest prevalence of substance use compared to other cohorts (Wang & Andrade, 2013). One in five older adults currently has a mental health or substance abuse condition and healthcare institutions are unable to meet the needs of this population (Institute of Medicine, 2012). Older adults with substance abuse disorders (4.8 million) are projected to double by 2020 and those in need of treatment will escalate to almost 6 million.

The Committee on the Mental Health Workforce for Geriatric Populations assessed the current and future needs of older adults and found significant deficits in geriatric training among healthcare providers and insufficient community resources. Further, the Committee also found a significant lack of specialists engaged in the detection, diagnosis, treatment, care, and management of geriatric conditions (Institute of Medicine, 2012). The lack of a prepared workforce is projected to continue and burdens on the local, state, and national resources will increase exponentially.

The health consequences of long-term AUD for older adults are significant and include both physical and socioeconomic consequences (Substance Abuse and Mental Health Services Administration, 2009). Potential physical consequences include cirrhosis of the liver, cancer, immune system disorders, cardiomyopathy, cerebral atrophy, and cognitive deficits (National Institute on Aging, 2013). Alcohol use also exacerbates preexisting conditions such as osteoporosis, diabetes, high blood pressure, and ulcers (National Institute on Aging, 2013). Older adults seeking hospitalization for alcohol-related conditions do so at rates similar to those admitted for myocardial infarction (Merrick et al., 2008).

Prevalence     HP01sect2

Blazer and Wu conducted a secondary analysis of the National Survey on Drug Use and Health in order to assess prevalence, distribution, and correlates of at-risk alcohol use in the United States among older adults (2009). Researchers found that at risk alcohol misuse and binge drinking are more frequent among individuals 50 to 64 years of age compared to those 65 and older. Furthermore, among those 65 and older, 13% of men and 8% of women were at-risk drinkers and 14% of men and 3% of women were binge drinkers. The study also found that binge drinking among males was associated with higher income, being separated, divorced, or widowed, and being employed. Binge drinking among women was associated with non-medical use of prescription drugs. The use of tobacco and illicit drugs was also associated with binge drinking for both men and women (Blazer & Wu, 2009).

In the Netherlands, Geels and colleagues (2013) found that age, sex, and initiation of cigarette and cannabis use were significant predictors of AUD. For men, frequency of alcohol misuse was highest for older adults aged 65 and over (30.6-32.7% of men and 20.2-22.0% of women). For women, the highest prevalence of excessive drinking (14 and more glasses per week) was reported for those between 55 to 60 years of age. For both men and women 65 years and older, significant factors for abuse included early initiation of regular alcohol use and early age at first intoxication (Geels et al., 2013).

Assessment     HP01sect3

Health care providers should follow clinical guidelines defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2005) and the National Institute on Aging (2013) . These organizations suggest that more than seven drinks per week or more than three drinks on any single day is considered "risky drinking" for individuals over 65; women's alcohol intake should be less than men (National Institute on Aging, 2013; National Institute on Alcohol Abuse and Alcoholism, 2005).

Alcohol use is considered contraindicated for older adults who have health conditions requiring complex medication regimes; thus, abstinence is recommended (Merrick et al., 2008).

The most straightforward method for assessing at-risk drinking or alcohol use disorders is to ask the patient how much they drink and how often the daily maximum number of drinks has been exceeded. This straightforward screening method has been found to be as sensitive and as specific as other alcohol screening methods (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009; Willenbring, Massey, & Gardner, 2009). This method provides an educational opportunity to discuss appropriate alcohol limits (Willenbring et al., 2009).

The 10 item Alcohol Use Disorders Identification Test (AUDIT) is also a useful method for assessing alcohol consumption behaviors and for educating patients (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). You can access this instrument at http://www.integration.samhsa.gov/AUDIT_screener_for_alcohol.pdf

Alcohol Assessment Questions for the Healthcare Practitioner from the Clinical Guidelines of Alcohol Use Disorders (Society of Hosptal Medicine, 2004)

  • What to ask first.
    "Tell me about your use of alcohol, including any beer, wine, or liquor/spirits."

  • Follow up those who have had any alcohol in the last year, by asking
    "On average, how many days per week do you drink alcohol?"
    "On a typical day when you drink, how many drinks do you have?"
    (I drink = 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor/spirits)

  • What is the maximum number of drinks you had on any given occasion during the last month?

  • Then, ask CAGE questions:
    "Have you ever felt that you should Cut down on your drinking?"
    "Have people ever Annoyed you by criticizing your drinking?"
    "Have you ever felt Guilty about your drinking?"
    "Have you ever had a drink (Eye opener) first thing in the morning to steady your nerves or get rid of a hangover?"


Alcohol Use Disorder     HP01sect4

Alcohol abuse and dependence are now considered Alcohol Use Disorder--a subcategory under Substance Related and Addictive Disorders in the DSM 5 (APA, 2013). AUD is defined as a clinically significant impairment or distress due to maladaptive patterns of substance use that often results increased tolerance, increased time spent on substance use activities, withdrawals, craving, increased amounts of the substance, unsuccessful efforts to control use, continued usage despite adverse consequences, and a decrease in social, occupational, or recreational activities.


Intervention     HP01sect5

The health care provider should first assess the patient's motivation for treatment-- "Are you willing to consider changing your drinking habits at this time?" This is important for appropriate referral to treatment.

NIAAA suggests that a combination of medication with a disease management approach has been an effective as alcohol intervention (Smith et al., 2009). If an alcohol problem is suspected the health care provider should clearly communicate consequences of continued alcohol use and recommendations for treatment, and explain the comorbidity of alcohol use with other medical conditions (Willenbring et al., 2009).

The following interventions have been shown to be effective for treating alcohol abuse disorders in older adults:
  • Motivational interviewing
  • Substance use counseling
  • Cognitive behavioral therapy
  • Pharmacotherapy
  • A combination of pharmacotherapy and psychotherapy
  • Alcohol rehabilitation treatment



References     HP01sect6

American Psychiatric Association. (2013). Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th. Retrieved September 20, 2013, 2013, from http://www.dsm5.org/Documents/Substance Use Disorder Fact Sheet.pdf

Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., & Monteiro, M.G. . (2001). AUDIT: The alcohol use disorders identification test, guidelines for use in primary care Paper presented at the World Health Organization, 2 ed., Geneva, Switzerland.

Blazer, Dan G., & Wu, Li-Tzy. (2009). The Epidemiology of At-Risk and Binge Drinking Among Middle-Aged and Elderly Community Adults National Survey on Drug Use and Health. American Journal of Psychiatry, 166(10), 1162-1169. doi: 10.1176/appi.ajp.2009.09010016

Geels, L.M., Vink, J.M., vanBeek, H.D.A.J., Bartels, M., Willemsen, G., & Boomsma, D. (2013). Increases in alcohol consumption in women and elderly groups: evidence from an epidemiological study. BMC Public Health, 13, 207. doi: 10.1186/1471-2458-13-207

Gfroerer, J. (2003). Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort. Drug and alcohol dependence, 69(2), 127-135. doi: 10.1016/s0376-8716(02)00307-1

Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services, . Washington, DC: Institute of Medicine, The National Academies Press.

Kalapatapu, Raj K., & Sullivan, Maria A. (2010). Prescription Use Disorders in Older Adults. American Journal on Addictions, 19(6), 515-522. doi: 10.1111/j.1521-0391.2010.00080.x

Merrick, Elizabeth L., Horgan, Constance M., Hodgkin, Dominic, Garnick, Deborah W., Houghton, Susan F., Panas, Lee, . . . Blow, Frederic C. (2008). Unhealthy Drinking Patterns in Older Adults: Prevalence and Associated Characteristics. Journal of the American Geriatrics Society, 56(2), 214-223. doi: 10.1111/j.1532-5415.2007.01539.x

National Institute on Aging. (2013). Alcohol use in older people. Retrieved from http://www.nia.nih.gov/health/publication/alcohol-use-older-people.

National Institute on Alcohol Abuse and Alcoholism. (2005). Helping Patients Who Drink Too Much. A Clinician's Guide 2005 Edition. Rockville, MD: National Institutes of Health.

Smith, P.C., Schmidt, S.M., Allensworth-Davies, D., & Saitz, R. . (2009). Primary Care Validation of a Single-Question Alcohol Screening Test. Journal of general internal medicine, 24(7), 783-788. doi: 10.1007/s11606-009-0928-6

Society of Hospital Medicine. (2004). Clinical guidelines for alcohol use disorders in older adults. http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clinical_guidelines_alcohol.pdf

Substance Abuse and Mental Health Services Administration. (2009). The NSDUH Report: Illicit Drug Use among Older Adults. Rockville, MD: SAMHSA.

U.S. Census Bureau. (2010). The next four decades: The older population in the United States: 2010 to 2050, current population reports. Washington DC.

Wang, Yuan-Pang, & Andrade, Laura Helena. (2013). Epidemiology of alcohol and drug use in the elderly. Current Opinion in Psychiatry, 26(4), 343-348.

Willenbring, M.L., Massey, S.H., & Gardner, M. (2009). Helping Patients Who Drink Too Much: An Evidence-Based Guide for Primary Care Physicians. Am Fam Physician(80), 44-50.


Caregiver Stress
Author: Sharon K. Ostwald, PhD, RN

Health Promotion
Overview     HP02sect1

In the United States, family members or friends often do informal caregiving. These informal caregivers often accompany older adults, especially those who are frail or have dementia, to their health care appointments. Although most caregivers provide care out of love and/or obligation, many experience stress as the demands become increasingly burdensome. It is important to understand the stressors and demands that are imposed on these informal caregivers, be alert to signs of escalating stress, and initiate interventions that may help to reduce caregiver burden.

Caregiver burden can be objective and subjective. Objective burden relates to those things that can be measured: the number and type of tasks performed; the amount of time spent; and, the financial cost to the caregiver and/or family. Subjective burden may be more difficult to assess, but is even more important to detect. Subjective burden is the psychological, social, and emotional impact that providing care has on the individual caregiver. A meta-analysis of the literature found that caregivers with poor health; those with depression and/or anxiety; and, those who were spending many hours in intensive caregiving activities were most likely to report caregiver burden. (Rigby, Gubitz, & Phillips, 2009).


Key Points     HP02sect2

Family members or friends who provide care for an older adult are often referred to as informal or family caregivers.

Caregivers may spend many hours a day involved in tasks that allow the elderly person to remain semi-independent at home. These tasks may include instrumental activities of daily living (IADL) such as doing the grocery shopping and laundry, cooking and cleaning, handling the finances and medications. Activities may also include direct activities of daily living (ADL) such as bathing, grooming, dressing, and feeding.

Health care providers need to be sensitive to caregiving responsibilities required to maintain their older patients at home and assess the degree of burden that family caregivers may be experiencing.

Caregivers are often the ‘hidden patient' and heath care provider should be aware of the need to assess them for physical and mental stress and intervene, as appropriate.

Caregivers who have high levels of stress, depression, and burden are at considerable risk for increased morbidities, and even for mortality.


Assessment     HP02sect3

A number of short clinically appropriate instruments are available to assess the most common problems encountered by caregivers. Rigby, Gubitz, & Phillips, 2009, review a number of these measures in their meta-analysis. Copies of instruments to assess caregiver depression, strain, burden, and preparedness for caregiving with instruments for use and scoring, and reliabilities are available on the Hartford Institute For Geriatric Nursing, ConsultGeriRN.org website. Copy/paste: http://consultgerirn.org/resources/



Intervention     HP02sect4

Caregivers may benefit from a wide variety of interventions (Brereton, Carroll & Barnston, 2007; Eldred & Sykes, 2008; Rigby, Gubitz, & Phillips, 2009; Smith, Foreter & Young, 2009). Caregivers may benefit from psychological counseling, support groups and educational programs. Community resources can also be beneficial for caregivers. The level of care will vary according to the needs of the loved one. Levels of care include assistance from home-health services, adult day care programs, residential services, assisted living facilities, memory care units, or personal care homes, nursing homes and hospice (when appropriate).

The care management of patients with chronic and disabling diseases and the health of their family caregivers are extremely important in geriatrics. Families cannot be expected to understand the options that are available to them and will need the assistance of the interprofessional health care team in making the best decisions, as the situation changes.


References     HP02sect5

Brereton, L., Carroll, C., & Barnston, S. (2007). Interventions for adult family carers of people who have had a stroke: a systematic review. Clin Rehab, 21, 867-884.

Eldred, C., & Sykes, C. (2008). Psychosocial interventions for carers of survivors of stroke: A systematic review of Interventions based on psychological principles and theoretical frameworks. Br J Health Psychol, 13, 563-581

Rigby, H., Gubitz, G., & Phillips, S. (2009). A systematic review of caregiver burden following stroke. International Journal of Stroke, 4, 285-292.

Smith, J., Foreter, A., Young, J. Cochrane review: Information provision for stroke patients and their caregivers. Clin Rehabil 2009; 23: 195-206



The Influence of Culture, Race, and Ethnicity on Elder Mistreatment
Author: David V. Flores, PhD, LMSW, MPH, CPH

Health Promotion
Overview     HP03sect1

makeup of the older population will be more racially and ethnically diverse than any other older generation in U.S history (Institute of Medicine, 2012; U.S. Census Bureau, 2010). These demographic changes will also result in a shift in cultural norms, perceptions, and traditions.

The National Center on Aging Abuse (2013) defines elder mistreatment (EM) as

"any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult” and “encompasses physical, psychological, sexual exploitation, neglect and self-neglect" (Dyer et al., 2008; Lachs, Williams, O’Brien, Hurst, & Horwitz, 1997; World Healh Organization, 2006).

EM is an independent risk factor for early mortality. Victims have three times the odds of early mortality compared to demographically matched non-victims. The World Health Organization (WHO) has identified common risk factors and co-morbidities for victims including:
  • older age,
  • being female,
  • frailty,
  • dementia,
  • depression,
  • psychosis,
  • loss of executive function,
  • alcohol abuse,
  • inability to perform activities of daily living,
  • social isolation, and
  • being dependent on a caregiver (formal or informal) (World Healh Organization, 2006).

Culture frames perceptions of elder mistreatment regarding causes of, responses to, enabling of, and personal responsibility towards elder mistreatment (Bowes, 2012; Cardona, Meyer, Schiamberg, & Post, 2007; Flores et al., 2013; Prado, Szapocznik, Maldonado-Molina, Schwartz, & Pantin, 2008; Rapoza, 2006).

Studies on the influences of culture, race, and ethnicity on elder mistreatment are limited. Preliminary research indicates that much of what we know about EM comes from international sources and there remains a significant lack of research on the cultural, racial and ethnic influences on elder mistreatment in the U.S.


Key Points     HP03sect2

  • Health care providers' assessment and definition of potential abuse, mistreatment, or self-neglect may not correspond with that of the clients' cultural expectations and cultural experiences.

  • There is great heterogeneity across ethnicity and race among perpetrators and victims of elder mistreatment.

  • Health care providers should learn to recognize different presentations of elder mistreatment across cultural, racial, and ethnically diverse populations.


References     HP03sect3

Bowes, Alison. (2012). Cultural diversity and the mistreatment of older people in Black and minority ethnic communities: Some implications for service provision. Journal of elder abuse & neglect, 24, 251-274.

Cardona, Jose Ruben Parra, Meyer, Emily, Schiamberg, Lawrence, & Post, Lori. (2007). Elder Abuse and Neglect in Latino Families: An Ecological and Culturally Relevant Theoretical Framework for Clinical Practice. Family Process, 46(4), 451-470. doi: 10.1111/j.1545-5300.2007.00225.x

Dyer, C. B., Franzini, L., Watson, M., Sanchez, L., Prati, L., Mitchell, S., . . . Pickens, S. (2008). Future research: a prospective longitudinal study of elder self-neglect. Journal of the American Geriatrics Society, 56 Suppl 2, S261-265. doi: 10.1111/j.1532-5415.2008.01978.x

Flores, D.V., Torres, L.R., Torres-Vigil, I., Bordnick, P.S. , Ren, Y., Torres, M.I.M., . . . Lopez, T. . (2013). From "kickeando las malias" (kicking the withdrawals) to "staying clean": The impact of cultural values on cessation of injection drug use in aging Mexican-American men. Substance Use & Misuse, 48.

Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services, . Washington, DC: Institute of Medicine, The National Academies Press.

Institute of Medicine. (2012). The mental health and substance use workforce for older adults In whose hands? Washington, DC: National Academy of Sciences.

Lachs, M. S., Williams, C., O'Brien, S., Hurst, L., & Horwitz, R. (1997). Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. The Gerontologist, 37, 469-474.

National Center on Aging Abuse. (2013). Major types of elder abuse. Retrieved February 13, 2013, from http://www.ncea.aoa.gov/ncearoot/Main_Site/FAQ/Basics/Types_Of_Abuse.aspx

Prado, Guillermo, Szapocznik, Jose, Maldonado-Molina, Mildred M., Schwartz, Seth J., & Pantin, Hilda. (2008). Drug use/abuse prevelance, etiology, prevention, and treatment in Hispanic adolescents: A cultural perspective. Journal of Drug Issues, 38(1), 5-36.

Rapoza, K.A. (2006). Implicit theories of elder abuse in a sample of European-American descent. Journal of elder abuse & neglect, 18(2/3), 17-32.

U.S. Census Bureau. (2010). The next four decades: The older population in the United States: 2010 to 2050, current population reports. Washington DC.

World Healh Organization. (2006). WHO facts on: Elder abuse and alcohol Alcohol and Violence. Geneva, Switzerland.



Nutrition and Malnutrition in the Elderly
Author: Shannon Pearce, DNP

Health Promotion
Key Points     HP04sect1

Poor nutrition and malnutrition occur in 15 to 50 % of the elderly population, while hospitalized elders have a prevalence of 20 to 60%.

Malnourished elderly are approximately 10 times more likely to die versus those without nutritional deficits.

A diagnostic criterion for significant weight loss includes:
  • 5% unintentional body weight loss in 1 month

  • 10% unintentional body weight loss in 6 months


Overview     HP04sect2

Older persons undergo changes in body composition and age related changes in physiology, metabolism and functional reserve. Consequently the well standardized nutritional requirements for younger and middle aged persons cannot be generalized to the elderly.

The following normal changes in the aging older adult
  • Taste sensation but not discrimination is diminished:
    • Tendency to add more salt & sweetener to food
    • Can discriminate sweet from salty

  • Diminished olfactory function further impairs taste sensation

  • Body composition:
    • Bone mass, lean mass, water content
    • Total body fat, commonly with intra-abdominal fat stores

  • Energy requirements:
    • Reduced basal metabolic rate (BMR) in older adults reflects loss of muscle mass
    • Estimation of energy needs based on body weight: 25 to 30 kcal/kg/day

  • Macronutrient requirements:
    • Protein: 0.8 g/kg/day (1.5 g/kg/day under stress)

  • Micronutrient requirements:
    • Emphasize supplements of calcium, vitamin D, vitamin B12

  • Fluid requirements:
    • Dehydration is the most common fluid or electrolyte disturbance in older adults
    • Decreased perception of thirst is associated with normal aging


Etiology     HP04sect3

The following DETERMINE acronym can be utilized to help discern the cause for malnutrition:
  • Disease
  • Eating poorly
  • Tooth loss
  • Economic hardship
  • Reduced social contact
  • Multiple medications
  • Involuntary weight loss or gain
  • Need for assistance in self-care
  • Elderly age

Etiology of Unintentional Weight Loss in the Elderly: Data from Selected Studies
Incidence of diagnosis (%)
Diagnosis Outpatients
(N = 45)
Nursing home residents
(N = 185)
Inpatients
(N = 154)
Outpatients and inpatients
(N = 91)
No identified cause 24 3 23 26
Psychiatric disorder (including depression) 18 58 8 17
Cancer 16 7 36 19
Benign (nonmalignant) gastrointestinal disorder 11 3 17 14
Medication effect 9 14 NA 2
Neurologic disorder 7 15 5 2
Others (hyperthyroidism, poor intake, tuberculosis, cholesterol phobia, Others (hyperthyroidism, poor intake, tuberculosis, cholesterol phobia, 15 NA 11 20
• NA = not applicable.
• Adapted with permission from Gazewood JD, Mehr DR. Diagnosis and management of weight loss in the elderly. J Fam Pract 1998; 47:19–25.


Nutritional Risk Factors for Elders include:
  • Alcohol or substance abuse
  • Cognitive dysfunction
  • Decreased exercise
  • Depression, poor mental health
  • Functional limitations, limited mobility, transportation
  • Inadequate funds
  • Limited education
  • Medical problems, chronic diseases
  • Medications
  • Poor dentition
  • Restricted diet, poor eating habits

Assessment     HP04sect4

  • The Mini-Nutritional Assessment www.nestle-nutrition.com can be used to screen for malnutrition

  • Anthropometrics
    • Mainstay of nutritional assessments in elders
    • Body mass index (BMI) = weight in kg/height in m2
    • Body mass index (BMI) = weight in kg/height in m2

  • Nutritional intake
    • Defined as average or usual intake of food groups, nutrients or energy below threshold of Recommended Daily Allowance.

  • Diagnostics
    • Albumin
    • Prealbumin
    • Cholesterol
    • Folic Acid
    • Vitamin B12


Prevention Strategies     HP04sect5

MUCH EASIER THAN TREATMENT FOR MALNUTRITION
  • Observe food preferences

  • Avoid restrictive "therapeutic diets" unless clinical value is certains
    • Instead of ADA Diet…       Regular diet with no concentrated sweets
    • Instead of AHA Diet…       Regular diet- low salt renders food unpalatable

  • Provide assistance if needed-
    • A contracted, bed bound patient may be unable to feed him/her self

  • Enhance comfort, taste, appearance of food
    • Pureed diet may appear unpalatable

  • Enhance social aspect; provide adequate time

  • Address dental/oral complaints of chewing discomfort/dysfunction
    • Dentures
    • Oral Health

  • Depression, dementia, and elder abuse are often accompanied by weight loss

  • Examine the oral cavity for gingivitis, thrush, open sores, loose teeth, or edentulism

  • Treatment should be multidisciplinary, including occupational therapy, nutrition, speech therapy, social work and dentistry

  • Most pharmacologic treatment to induce weight gain are of minimal benefit, but nutritional supplements have resulted in weight gain and improved mortality

  • A BMI < 22 kg/m or a Karnofsky score less than 40 is indication for hospice admission for weight loss and failure to thrive


References     HP04sect6

Alibhai, S.M.H. (2005). An approach to the management of unintentional weight loss in elderly people. Canadian Medical Association Journal; 172:773.

GRS 6th edition/Teaching Slides. American Geriatric Society Web site. http://www.frycomm.com/ags/teachingslides . Accessed February 12, 2010.

Huffman, G.B. (2002). Evaluating and treating unintentional weight loss in the elderly. American Journal of Family Physicians; 65(4):640-650.

Maher, D., & Eliade, C. (2013). Malnutrition in the elderly: An unrecognized health issue. RN Journal Online. http://rnjournal.com/journal-of-nursing/malnutrition-in-the-elderly-an-unrecognized-health-issue . Accessed October 30, 2013.

Nutrition Screening: Determine Your Nutritional Health: The Nutritional Screening Initiative Society of Hospital Medicine Web site. http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/determine.pdf . Accessed February 12, 2010.

Verdy, R.B. (1997). Failure to thrive in old age: follow-up on a workshop. Journal of Gerontological A Biol Sci Medical Science; 52:M333-M6.





Obesity in Older Adults
Author: Shannon Pearce, DNP

Health Promotion
Overview     HP05sect1

  • Thirty-three percent of adults age 65 and older were obese in 2007-2010 (Fakhouri, et al, 2012).

  • Obesity is higher in the young old (65-74 years of age) in comparison to persons aged 75 and older (Fakhouri, et al., 2012)

  • Obesity is defined as having a body mass index (BMI) greater than or equal to 30 (National Institute of Health, 1998).

  • Obese older adults are at an increased risk for heart disease, stroke, diabetes mellitus, osteoarthritis, certain cancers, physical and cognitive disability, and increased risk of early death (Decaria, Sharp, & Petrella, 2012).


Key Points     HP05sect2

  • With aging, fat-free mass decreases and fat mass increases and is redistributed in the abdominal area.

  • The loss of skeletal muscle mass with aging coupled with the increasing prevalence of obesity has led to sarcopenic obesity.

  • Several systematic reviews have found that modest weight loss generates a relatively large early reduction in intra-abdominal fat and metabolic improvements. Mood and mobility also improve and there may be the added benefit of being able to come off of certain medications (Houston, Nicklas & Zizza, 2009; Siervo, 2011).

  • Weight loss also appears to be associated with improvements in executive attention/functioning and memory in obese individuals (Houston, Nicklas & Zizza, 2009; Siervo, 2011).


Assessment     HP05sect3

  • To assess an older adult's BMI, do the following:
    • Attain the older adult's height and weight
    • Utilize the NIH electronic calculator located at http://www.nhibi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

  • There are several nutritional assessment instruments available for clinicians:
    • Mini Nutritional Assessment (MNA) instrument: this instrument assesses normal nutritional status. More information on this instrument can be found at www.mna-elderly.com
    • Waist circumference
    • Metabolism Calculator: approximates the patient's basal metabolic rate and calorie needs. This instrument can be found at http://www.webmd.com/diet/healthtool-metabolism-calculator




Intervention     HP05sect4

  • The American Society of Nutrition and the Obesity Society suggest a modest reduction of 500 – 750 kcal/day in energy intake resulting in 1 – 1.5 lbs. /week of weight loss in older adults.

  • Macronutrient distribution should be 15 – 30% of total energy from protein, 40 – 60% from carbohydrates, and 25 – 30% from fats.

  • Particular attention should be paid to ensure protein, vitamin D, vitamin B12, fiber, and fluid requirements are met.

  • In terms of exercise, older adults should engage in moderate-intensity aerobic activity for a minimum of 30 minutes, 5 days each week or vigorous-intensity aerobic activity for a minimum of 20 minutes, 3 days each week.

  • They should also perform strengthening exercises of at least 1 set of repetitions for 8 – 10 muscle groups on 2 – 3 nonconsecutive days per week.

  • At least 10 minutes of flexibility activities are also recommended.




References     HP05sect5

Decaria, J.E., Sharp, C., & Petrella, R. J. (2012). Scoping review report: Obesity in older adults. International Journal of Obesity; 36(9):1141-1150. Doi:10.1038/ijo2012.29.

Fakhouri, T.H.I., Ogden, C.L., Carroll, M.D., Kit, B.K., & Fleqel, K.M. (2012). Prevalence of obesity among older adults in the United States. NCHS Data Brief: U.S. Department of Health and Human Services; 106: 1-8. Retrieved October 25, 2013 at http://www.cdc.gov/nchs/data/databriefs/db106.pdf

Han, T., Tajar, A., & Lean, M. (2011). Obesity and weight management in the elderly. British Medical Bulletin; 97:169–196.

Houston, D., Nicklas, B., Zizza, C. (2009). Weighty concerns: the growing prevalence of obesity among older adults. Journal of American Dietician Association; 109:1886–1895.

National Institutes of Health, (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. Obesity Research 6 Supplemental2:51S–209S. Available from: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf.

Siervo, M., Arnold, R., Wells, J.C.K., Tagliabue, A., Colantuoni, A., Albanese, E., Brayne, C., & Spephan, B.C.M. (2011). Intentional weight loss in overweight and obese individuals and cognitive function: A systematic review and meta-analysis. Obesity Reviews; 12(11): 968-983. Doi: 10.1111/j.1467-789X.2011.00903.x.

Villareal, D.T., Apovian, C.M., Kushner, R.F., & Klein, S. (2005). Obesity in older adults: Technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society. American Journal of Clinical Nutrition; 82: 923-934.



Older Adult Immunization Schedule
Kathleen Pace Murphy, PhD MS, GNP-BC

Health Promotion
Summary     HP06sect1

You're never too old to get immunized.
The Center for Disease Control and Prevention recommends the following immunizations for older adults over age 65 years:

Influenza (flu)
Annual vaccination against influenza is recommended for all persons age 65 years and older. The following CDC website should be consulted for flu vaccine updates:

http://www.cdc.gov/flu/index.htm


Tetanus, diphtheria, pertussis (Td/Tdap)
Give patients a Tdap vaccine once and then a Td booster vaccine every 10 years. The following CDC website should be consulted for tetanus and diphtheria vaccine updates:

Tetanus - http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm
Diphtheria - http://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htm


Zoster (Shingles)
A single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a prior episode of herpes zoster. The following CDC website should be consulted for Zoster vaccine updates:

http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/shingles.html


Pneumococcal (Pneumonia)
There are 2 different types of pneumococcal vaccines (PCV 13 and PPSV 23). Pneumococcal vaccination is recommended for older adults. The following CDC website provides additional information regarding PCV 13 and PPSV 23 to help health care providers determine the specific type of vaccination recommended for patients in differing circumstances.

http://www.cdc.gov/vaccines/vpd-vac/pneumo/default.htm


References     HP06sect2

Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule: United States, 2012. Annals of Internal Medicine, 156; 211-217.

Centers for Disease Control and Prevention (2013). Recommended immunizations for adults by age. Washington, D.C. Retrieved http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy-read.pdf

Centers for Disease Control and Prevention (2011). Epidemiology and Prevention Vaccine-Preventable Diseases. 12th Ed. Washington, DC: Public Health Foundation.




Oral Health and Older Adults

June Sadowsky, DDS, MPH, Laura Niles, MPH, & Kathleen Murphy, PhD, MS

Health Promotion
Key Points     HP07sect1

Good oral health is critically important for older adults.

Epidemiology studies have found a strong association between Periodontal Disease and cardiovascular disease, atherosclerosis, stroke and in the dependent elderly with aspiration pneumonia (Beck & Offenbacher, 2001); Genco, Offenbacher, & Beck, 2002; Jerpenning, 2005).

Individuals living with chronic disease and having poor functional abilities are at a greater risk of having poor oral health. This can serve as a comorbid condition, impacting overall health (Boehm & Scannapeco, 2007).

Assessment     HP07sect2

Major oral health risks in older adults include:

  • periodontal disease
  • cardiovascular disease
  • dental caries
  • medications which reduce saliva flow
  • smoking
  • diabetes mellitus
  • cancer
  • health status, and
  • socio-behavioral and environmental factors ( i.e. fluoridated water, cultural values, stress, sugar consumption)


Peterson Approach to Common Risk Factors

oral health image

Dental Community     HP07sect3

It is imperative that the dental community work to overcome barriers preventing older adults seeking oral health care. Designing or redesigning dental offices to meet the specific needs of an aging population, such as:
  • improved lighting,

  • wider walkways with non-slid flooring,

  • exam chairs that allow access, even with older adults with mobility issues,

  • video and written educational materials pre and post visit to enhance educational learning, and

  • dental home care program (s) for functionally dependent elderly who are aging in place at home.


Prevention     HP07sect4

Preventative dental care is crucial to reduce the risk of decay and disease in older adults.

Maintenance Care     HP07sect5

Regular consistent dental health care is imperative. Barriers that prevent older adults from seeking long term dental health care include:

  • Resource limitations: older adults with limited financial resources often have to make choices between dental health care, medications, paying bills and basic needs such as food.

  • Human resource limitations: dependent older adults may lack formal or informal caregiver support to assist with proper oral health care, as well, as access to oral health (i.e. transportation to and from the office).

  • Solutions: interprofessional team approach can be the solution to these types of problems. For example:
    • utilizing social workers to assist with resource needs;
    • utilizing occupational therapist to assess the older adult's ability to perform activities of daily living, such as tooth brushing;
    • utilizing nursing and occupational therapy to educate formal and informal caregiver to learn proper techniques to assist in daily oral health care needs.


Internet Video Education Resources     HP07sect6

  1. Oral Care for Older adults – http://www.youtube.com/watch?v=AVsMmppYXrl

  2. Elderly Oral Care - http://www.youtube.com/watch?v=XTDsJyqpjZc

  3. Ask the Geriatrician – Daily Oral Care for the Frail Elderly – www.youtube.com/watch?v=aRZ6oVb6zGc


References     HP07sect7

Beck, J.D. & Offenbacher, S. (2001). The association between periodontal disease and cardiovascular disease: A state of the science review. Annals of Periodontal Disease, 16(1), 9-15.

Boehm, J.K. & Scannapeco, F. A. (2007). The epidemiology, consequences and management of periodontal disease in older adults. Journal of the American Dental Association; 138( 9 Supplement), 26S-33S.

Genco, R, Offenbacher, S., & Beck, J. (2002). Periodontal disease and cardiovascular disease: Epidemiology and possible mechanisms. Journal of American Dental Association, 133 (supplement), 14S-22S.

Hung, H.C., Willett, W., Merchant, A., et al. (2003). Oral health and peripheral arterial disease. Circulation, 107, 1152-1157.

Rose, L.F., Mealey, B., Minsk, L., & Cohen, W. (2002). Oral care for patients with cardiovascular disease and stroke. Journal of the American Dental Association, 133, 37S-44S.

Petersen, P. E., & Yamamoto, T. (2005). Improving the oral health of older people: The approach of the WHO Global Oral Health Programme. Community Dentistry and Oral Epidemiology, 33(2), 81-92.

Scannapieco, F.A. (1998). Periodontal disease as a potential risk factor for systemic diseases. Journal of Periodontology, 69(7), 841-50.

Terpenning, M. (2005). Geriatric Oral Health and Pneumonia Risk. Aging and Infectious Disease, 40, 1807-1810.

Terpenning, M., & Shay, K. (2002). Oral health is cost-effective to maintain but costly to ignore. Journal of the American Geriatrics Society, 50(3), 584-585.




Elder Self-Neglect: An overview.
Jason Burnett, PhD & Susan Gorman, MSN, GNP-BC

Health Promotion
Key Points     HP08sect1

Elder self-neglect is broadly defined as the inability or refusal to provide basic self-care and self-protection. (National Center on Elder Abuse, 2011) It is the most common referral to Adult Protective Services (APS) nationwide. The majority of these cases occur in persons 65 years of age or older.

Elder self-neglect is a significant risk factor for mortality independent of medical, social, functional and cognitive problems common in older adults. (Lachs, 1998)

The most recent mortality study reports a 6-fold increase in the odds of mortality within the first year of older adults being reported to APS for self-neglect and a subsequent 2-fold increase in the odds of mortality for the remaining 11 year follow-up compared to non-neglecting older adults. (Dong et al., 2009)

One study by Burnett et al., 2004 reports that elder self-neglecters (91%) have had contact with their primary care physicians within a 3-month period of an APS investigation.

Despite receiving medical care self-neglecters often present with poor hygiene (Dyer et al., 2007), poor medication adherence (Turner et al., 2012), unsanitary living, depression, isolated living, untreated medical conditions (Burnett et al., 2006), decubitus ulcers (Burnett et al., In Press), poor nutritional status and cluttered living environments. More extreme cases often have associated mental health issues.

Four types of elder self-neglect have been detected which include Global Self-Neglect, Environmental Self-Neglect, Financial Self-Neglect and Physical and Medical Self-Neglect. (Burnett et al., 2012)



For further information please see our app titled:

Elder Abuse and Mistreatment (2013)
Author: Nasiya Ahmed, MD, John Halphen, MD, and Kathleen Pace Murphy, PhD, MS, GNP-BC

References     HP08sect2

Burnett J, Mitchell RA Jr., Cloyd EA, Halphen J, Diamond PM, Hochschild AE, Booker JA, & Dyer CB. Forensic Markers Associated with a History of Elder Mistreatment and Self-Neglect: A Case-Control Study. Academic Forensic Pathology, 2013 (In Press)

Burnett, J., Regev, T., Pickens, S., Prati, L. L., Aung, K., Moon, J., Dyer, C.B. (2006). Social networks: a profile of the elderly who self-neglect. Journal of Elder Abuse and Neglect; 18(4), 25-34.

Burnett J., Coverdale J.H., Pickens S, Dyer, C.B. (2006). What is the association between self-neglect, depressive symptoms and untreated medical conditions? (2006). Journal of Elder Abuse and Neglect; 18(4), 24-34.

Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., Hebert, L., et al (2009). Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), 517-526. doi:10.1001/jama.2009.1109

Dyer CB, Goodwin JS, Pickens-Pace S, Burnett J, Kelly PA. (2007). Self-neglect among the elderly: a model based on more than 500 patients seen by a geriatric medicine team. American Journal of Public Health; 97(9); 1671-1676.

Dyer CB, Pickens S, Burnett J. (2007). Vulnerable Elders when it is no longer safe to live alone. Journal of American Medical Association; 298(12); 1448-1450.

Lachs MA, Williams CS, O'Brien S, Pillemer, KA & Charlson ME. (1998). Mortality of elder mistreatment. Journal of the American Medical Association; 280(5), 428-432.

National Center on Elder Abuse. Definitions of elder abuse. www.ncea.aoa.gov/NCEAroot/Main_Site/FAQ/Basics/Types_of_Abuse.aspx. Updated March 17, 2011. Accessed May/17, 2011.

Turner A, Hochschild A, Burnett J, Zulfiquar A, Dyer CB. (2012). High prevalence of medication non-adherence in community-dwelling older adults with Adult Protective Services-validated self-neglect. Aging; 29: 741-749.



Smoking and Older Adults
Jennifer Larson, MSE; Kathleen Pace Murphy, PhD., MS, GNP-BC

Health Promotion
Key Points     HP09sect1

This current generation of older adults in the United States has the highest smoking rate of any generation (The American Lung Association, 2010).

Smoking is the most preventable cause of disease and death in the United States (The American Lung Association, 2010).

Smoking is a strong risk factor for premature mortality in older age and smoking cessation is beneficial at any age (Gellert et al., 2012).

Long-term older adult smokers are at a higher risk for many diseases.

Smoking plays an important role also in the development of other pathological conditions frequently seen in older age such as dementia, heart disease, cancer, lung disease, osteoporosis, diabetes, erectile dysfunction, senile macular degeneration, nuclear cataract and alterations of the skin (Nicita-Mauro et al., 2010).

Smoking can also interfere with the effectiveness of many medications.

Older adults who smoke have been shown to be more successful at quitting than younger smokers.

Intervention     HP09sect2

The United States Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide interventions for users of tobacco products (Zoorob, Kihlberg, & Taylor, 2011).

Secondary prevention modalities such as health care provider reminder systems, decreasing patient out-of-pocket cost for cessation therapies, and multifaceted cessation programs such as telephone support for those attempting to quit are highly recommended (Zoorob, Kihlberg, & Taylor, 2011).

Health care providers play a significant role in helping older adults quit smoking. Older smokers generally make multiple visits to their health care provider, allowing ample opportunity to counsel patients.

Four steps can be easily implemented.
  • Ask about smoking.
  • Advise the patient to quit smoking.
  • Assist the patient in developing a quitting plan.
  • Always arrange for follow-up (Boyd, 1996).
The first requirement of smoking cessation is the smoker's motivation to stop. Without this, any attempt is futile. (Nicita-Mauro, et al. 2010).

Approved pharmacological treatments for cessation include nicotine replacement therapies, bupropion, drugs targeting cannabinoid receptors and newer pharmacological approaches with selective nicotinic partial agonists (Nicita-Mauro et al., 2010).

Effective smoking cessation programs involve a combination of pharmacotherapy and cognitive counseling (Nicita-Mauro et al., 2010).

Historically, Medicare has covered two types of counseling: intermediate cessation counseling (3 to 10 minutes per session) and intensive cessation counseling (greater than 10 minutes per session). Medicare will cover two quit attempts per year. Each quit attempt may include a maximum of four intermediate or intensive counseling sessions, with the total annual benefit covering up to eight sessions in a 12-month period. The health care provider and patient have the flexibility to choose between intermediate and intensive counseling (Center for Medicare & Medicaid Services, 2012).

In addition, Medicare Part D will also cover smoking cessation treatments prescribed by a health care provider. Over-the-counter treatments will not be covered. Individual Medicare coverage is subject to change depending on the patient and current Medicare policy (Centers for Medicare & Medicaid Services, 2012).

References     HP09sect3

Boyd, N. R. (1996). Smoking cessation: A four-step plan to help older patients quit. Geriatrics, 51(11), 52-57.

Centers for Medicare & Medicaid Services. (2012). Tobacco Use Cessation Counseling Services. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/smoking.pdf.

Gellert, C., Schöttker, B., & Brenner, H. (2012). Smoking and all-cause mortality in older people: Systematic review and meta-analysis. Archives of Internal Medicine, 172(11), 837-844. Retrieved from SCOPUS database.

Nicita-Mauro, V., Maltese, G., Nicita-Mauro, C., Lasco, A., & Basile, G. (2010). Nonsmoking for successful aging: Therapeutic perspectives. Current Pharmaceutical Design, 16(7), 775-782. Retrieved from SCOPUS database.

The American Lung Association, (2010). Smoking and older adults. Retrieved from: http://www.lung.org/stop-smoking/about-smoking/facts-figures/smoking-and-older-adults.html.

Zoorob, R. J., Kihlberg, C. J., & Taylor, S. E. (2011). Aging and disease prevention. Clinics in Geriatric Medicine, 27(4), 523-539. Retrieved from SCOPUS database.



Comprehensive Geriatric Assessment
and the Interprofessional Geriatric Team

Nasiya Ahmed, MD & Kathleen Pace Murphy, PhD, MS

Medical
Key Points     MC01sect1

The comprehensive geriatric assessment (CGA) assesses a patient's physical, cognitive, psychological, social and functional status. It is a benchmark that clinicians utilize to assess a patient, determine the plan of care and evaluate outcomes of the plan of care.

The comprehensive geriatric assessment is highly effective for diagnosing and treating geriatric syndromes and co-morbid conditions in older adults. It provides information to understand the impact of illness; assess quality of life; identify needs; and, regulate progress.

Functional decline, a component of the comprehensive geriatric assessment is often the first sign of acute illness. Functional impairments are prevalent among older patients, and can be improved with early recognition and treatment.

The World Health Organization (2010) defined Interprofessional team (IPT) collaborative practice as healthcare providers from a variety of professional backgrounds working together with patients, families, caregivers, and communities to deliver the highest quality of care.

Patient centered care is the goal of Interprofessional team collaborative practice (Interprofessional Education Collaborative, 2011).

Interprofessional team collaborative members interdependently and collectively complete a comprehensive geriatric assessment

Overview     MC01sect2

The foundation of geriatric medicine is the comprehensive geriatric assessment (CGA).

For older adults, the health care needs extend beyond the traditional medical management of illness. Older adults, particularly the frail elderly, require evaluation of multiple issues including physical, cognitive, affective, social, financial, environmental, and spiritual components that influence an older adult's quality of life.

It is strongly recommended that a multidimensional IPT complete the CGA diagnostic process, which can be used to provide targeted interventions based on the assessment findings.

A CGA differs from the standard patient evaluation in three distinct ways:

  1. It focuses on older adults with complex problems;
  2. It emphasizes functional status and quality of life; and,
  3. It involves an interprofessional team of health care providers.


The assessment components of the CGA include social activity, fall risk, vision/hearing, medication review, dentition, functional status, living situation, nutritional assessment, financial situation, cognitive ability, environmental assessment, affect/mood, spiritual belief, sexual function, urinary continence, and advanced care preferences.


Assessment     MC01sect3

The following is a list of commonly used assessment tools.

Nutrition Mini Nutritional Assessment
Functional Status Activities of Daily Living (ADLs) and
Instrumental Activities of Daily Living (IADLs)
Cognitive Status Saint Louis University Mental Status (SLUMS), Confusion Assessment Methods (CAM)
Affect/Mood Geriatric Depression Scale
Medication Review Review prescription and over the counter medications every visit. In-depth review for: >5 prescription drugs or >3 over the counter drugs.
Environmental Assessment Home Safety Evaluation
Fall Risk Get Up and Go



References     MC01sect4

D'Amour, D. & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19(Supplement 1), 8-20.

Dyer, C.B., & Ostwald, S. (2011). Ageing and health: Managing co-morbidities and functional disability in older people. In E. Stuart-Hamilton (Ed.), An introduction to gerontology (pp. 87-125). Cambridge, UK: Cambridge University Press.

Heflin, M.T., & Cohen, H.J. (2010). The Aging Patient. In T. Andreoli and C. Carpenter (Eds.), Cecil essentials of medicine. Philadelphia, PA: Saunders/Elsevier.

Institute of Medicine. (2001). Crossing the quality chasm. Washington, D.C.: National Academy Press.

Interprofessional Education Collaborative (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

Katz, S., Downs, T.D., Cash, H.R., Grotz, R.C. (1970). Progress in development of the index of ADL. Gerontologist; 10: 10-30.

Karnofsky, D.A., Burchenal, J.H. (1949). The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeon, C.M., ed. Evaluation of Chemoterhapeutic Agents. Columbia University Press, p. 196.

Lawton, M.P. & Brody, E.M. (1969). Assessment of older people: Selfmaintaining and instrumental activities of daily living. Gerontologist, 9:179-186

Mann, E., Koller, M., Mann, C., van der Cammen, T., & Steurer, J. (2004). Comprehensive Geriatric Assessment (CGA) in general practice: Results from a pilot study in Vorarlberg, Austria. BMC Geriatrics, 4(1), 4.

Sheikh, J.I. Yesavage, J.A. (1986). Geriatric Depression Scale: Recent evidence and development of a shorter version. Clinical Gerontologist 5: 165-172.

Ward, K.T., & Reuben, D.B. (2012). Up To Date. Comprehensive geriatric assessment. Retrieved from http://www.uptodate.com/contents/comprehensive-geriatric-assessment.

Wieland, D., & Hirth, V. (2003). Comprehensive Geriatric Assessment: Definition and role of Comprehensive Geriatric Assessment. Cancer Control, 10(6), 454-462.

World Health Organization (WHO). (2010). Framework for action on interprofessional education & collaborative practice. Geneva: World Health Organization. Retrieved September 17, 2013 from http://whibdoc.who.int/hq/2qlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf



Conditions of the Cervical Spine
Judy Thomas, MD

Medical
Key Points     MC02sect1

It is common for elderly individuals to experience neck pain.

Majority of neck pain is related to cervical spondylosis or degenerative disease of the spine.

These conditions occur as a result of degeneration of the intervertebral disks, with loss of water content within the disks and subsequent disk collapse.

Common clinical syndromes associated with degenerative disk disease include cervical spondylosis, radiculopathy, and myelopathy.

Overview     MC02sect2

Cervical Spondylosis is the degeneration of the joints of the neck.

  • It most commonly leads to pain and decreased range of motion.

  • Degenerative changes, with osteophytes, narrowing of disk spaces, and disk herniation, may cause encroachment on the spinal nerves or spinal cord and lead to radiculopathy and myelopathy.

Radiculopathy

  • Pain occurs in a specific nerve root distribution.

  • Radiculopathy usually results from disk herniation that impinges on an existing nerve root.

  • In the older adult, the spinal foramina where the nerve root exits is often narrowed due to osteophytes from spondylosis

  • The interspace most commonly involved is the C5-C6 interspace.

Myelopathy

  • This is compression of the spinal cord.

  • Myelopathy is more likely if the spinal canal diameter is less than 10 mm.

  • Radiographs typically show osteophytes and narrowing of disk spaces.

  • Onset is insidious and myelopathy develops over a long period of time.

  • Neurologic findings include lower motor neuron and reflex changes at the level of the lesion and upper motor neuron involvement below the level of lesion.

  • Patients often develop spastic gait or other gait abnormalities.

  • Many patients lose hand dexterity.

  • Bowel and bladder incontinence can also occur.


Diagnosis     MC02sect3

In generating a differential diagnosis in an older individual with neck pain, consider and rule out:

  • Neoplasms, most commonly metastatic tumors in elderly;

  • Sepsis/infection;

  • Shoulder disorders: rotator cuff tendonitis, subacromial bursitis, and acromioclavicular joint problems;

  • Entrapment neuropathies: suprascapular nerve impingement, median and ulnar nerve compression, thoracic outlet syndrome.


Management     MC02sect4

The majority of cervical symptoms in the geriatric patient can be treated with:

  • Physical therapy

  • Pain Medication including acetaminophen and anti-inflammatory medications

  • Careful monitoring

Surgery may be indicated for a patient with:

  • Myelopathy

  • Progressive compression of the spinal cord

  • Significant nerve root encroachment that causes pain and progressive weakness in a specific nerve root distribution

  • Immobilization should be used only if necessary due to risk of further stiffness and muscle atrophy.


Bed rest is NOT a primary treatment.

References     MC02sect5

Kauffman, T.L., Barr, J.O., Moran, M.L. (2007). Geriatric Rehabilitation Manual, 2nd Ed. Lancaster, PA: Churchill Livingstone.



Constipation
Suchitra Kamineni, MD

Medical
Key Points     MC03sect1

Constipation can be a difficult problem to manage.

It is estimated that the prevalence of constipation in North American adults ranges from 2-27 percent and in older adults 24 to 50 percent (Fox-Orenstein, McNally & Odunai, 2008; Talley, 2004).

Laxatives are used daily by 10 to 18 percent of community dwelling older adults and 74 percent of nursing home residents (Ruby, Fillenbaum, Kuchibhatia, & Hanlon, 2003).


Overview     MC03sect2

Primary or idiopathic constipation can be categorized as:
  • Functional chronic idiopathic constipation and constipation-predominant irritable bowel syndrome,

  • Slow-transit constipation (or delayed-transit constipation),

  • Outlet dysfunction (Barish, Drossman, Johanson, & Ueno, 2010).

Secondary etiologies for constipation are:
  • Endocrine or metabolic disorders,

  • Neurologic disorders,

  • Myogenic disorders, and

  • Medications, such as opioid induced constipation.


Assessment     MC03sect3

Detailed history about bowel habits, medication use, hypothyroidism, back trauma or neurologic problems (multiple sclerosis, spinal cord injury), psychiatric disorders and recent immobility.

Perianal inspection for scars, fistulas, fissures, hemorrhoids.

Rectal exam to palpate for mass, stricture, or stool impaction, also note sphincter tone.


Diagnosis     MC03sect4

Patient without alarm symptoms:
  • Routine blood tests, x-rays, or endoscopy not recommended.

  • Secondary cause suspected (or patient is ≥ 50 years old) - consider complete blood count (CBC), basic metabolic panel (BMP) including serum calcium, TSH, blood sugar testing.

Patient with alarm symptoms or patient is ≥ 50 years old, additionally consider
  • Fecal occult blood test

  • Inspection of full length of colon (using colonoscopy or flexible sigmoidoscopy with barium enema)


Intervention     MC03sect5

Non-pharmacological treatment:
  • America Society of Colon and Rectal Surgeons (ASCRS) recommends dietary modifications as initial management, including daily fiber intake of 25 g/day

  • Fluid intake of 1.5- 2 L/day

  • Increase physical activity

  • Other non-pharmacologic Interventions include:

  • Biofeedback in adults with pelvic floor dysfunction;

  • Abdominal massage therapy (Lamas, Lindholm, Stenlund, Engstrom, & Jacobsson, 2009);

  • Surgical consideration for slow-transit constipation unresponsive to other therapy, consider total abdominal colectomy with ileorectal anastomosis.

Pharmacological treatment:
  • Bulk laxatives, e.g., Psyllium and methylcellulose are first line treatment choices;

  • Osmotic laxatives, e.g. Polyethylene glycol, lactulose, are second line treatment choices when first line agents are not effective;

  • Stimulant Laxatives, e.g. senna, bisacodyl, are reserved for utilized when bulking agents and osmotic laxatives fail (Lembro & Camiller, 2003);

  • Lubiprostone is best reserved for patients with severe constipation in whom other approaches have been unsuccessful (Barish, Drossman, Johanson & Ueno, 2010).

Opioid Induced Constipation:
  • Laxatives and stool softener recommended for prevention of constipation in patients taking opioid analgesics;

  • Subcutaneous methyl naltrexone (Relistor) may rapidly relieve opioid-induced constipation without affecting pain relief or opioid withdrawal.


Prevention     MC03sect6

Laxative prophylaxis may prevent constipation in critically ill ventilated patients (Masri, Abubaker & Ahmed, 2010).

Health care providers should consider the following when their patient is taking opioid analgesics:

  • Constipation may occur within 3-5 days, especially in inactive patients;

  • Stool softeners and stimulant laxatives are recommended;
    • Titrate dose to produce one soft bowel movement every 1-2 days;
    • If goal is not attained, add bisacodyl;

  • Reserve enemas for fecal impaction


In older adults, if feasible avoid medications that contribute to constipation, such as, anticholinergics, tricyclic antidepressants, iron, calcium, verapamil.


References     MC03sect7

Barish, C.F., Drossman, D., Johanson, J.F., & Ueno, R. (2010). Efficacy and safety of lubiprostone in patients with chronic constipation. Digestive Diseases Science: 55(4):1090‐1097. Epub 2009 Dec 11.

Dukas, L., Willett, W.C., Giovannucci, E.L. (2003). Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. American Journal of Gastroenterology;98:1790-1796.

Foxx-Orenstein, A.E., McNally, M.A., Odunsi, S.T. (2008). Cleveland Clinic Journal of Medicine; 75(11):813-24.

Lamas, K., Lindholm, L. Stenlund, H., Engstrom, B., & Jacobsson, C. (2009). Effects of abdominal massage in management of constipation--a randomized controlled trial. International Journal of Nursing Studies:46(6): 559-567.

Lembo, A. & Camilleri, M. (2003). Chronic constipation. New England Journal of Medicine: 349(14):1360–1368.

Masri, Y. Abubaker, J., Ahmed, R. (2010). Prophylaxation use of laxative for constipation in critically ill patient. Annual Thoracic Medicine5(4): 228-231.

Rao, S.S. (2003). Constipation: Evaluation and treatment. Clinics of North American;32(2):659-683.

Ruby, C.M., Fillenbaum, G.G., Kuchibhatla, M.N., Hanlon, J.T. ( 2003). Laxative use in community dwelling elderly. American Journal Geriatric Pharmacotherapeutics; 1(1):11-17.

Talley, N.J. (2004). Definitions, epidemiology and impact of chronic constipation. Review Gastroenterology Disorders, 4: Supplement 2: S3-S10

Ternent, C.A., Bastawrous, A.L., Morin, N.A., Ellis, C.N., Hyman, N.H., & Buie, W.D. (2007). Practice parameters for the evaluation and management of constipation. Diseases of Colon and Rectum: 50(12):2013-22.

Ishihara M, Ikesue H, Matsunaga H, Suemaru K, Kitaichi K, Suetsugu K, Oishi R, Sendo T, Araki H, (2012). A multi-institutional study analyzing effect of prophylactic medication for prevention of opioid-induced gastrointestinal dysfunction. Clinical Journal of Pain;28(5):373-81. doi: 10.1097/AJP.0b013e318237d626.



Hypothyroidism
Kathleen Pace Murphy, PhD, MS, GNP-BC

Medical
Key Points     MC04sect1

Hypothyroidism is a deficiency of thyroid hormones.

Approximately 9.6 million Americans have hypothyroidism (Carroll, 2009).

Hypothyroidism is more common in women than in men (Carroll, 2009).


Overview     MC04sect2

Hypothyroidism is common in older adults and increases with age. Hypothyroidism often presents subtle,, non-specific symptoms. (The American Thyroid Association, 2012).

There are four types of hypothyroidism:

  • Primary, the most common due to disease of the thyroid.

  • Secondary hypothyroidism is due to disease in the pituitary.

  • Tertiary hypothyroidism is due to disease of the hypothalamus.

  • Subclinical hypothyroidism is an elevation of thyroid stimulating hormone (TSH) with normal T4 (thyroxine).



Diagnosis     MC04sect3

Contributing factors to hypothyroidism may be:

  • endemic iodine deficiency or iodine excess

  • iatrogenic secondary to thyroid surgery

  • radioablation or radiation to the neck

  • medications, such as amiodarone or lithium

  • congenital absence of the thyroid gland

  • autoimmune disorders such as Hashimoto's thyroiditis


During your review of the system, ask the patient if they are experiencing:

  • lethargy

  • course dry skin

  • fatigue

  • hair loss

  • cold intolerance

  • menstrual irregularities (adult female population)

  • constipation

  • cognitive/ memory changes.


During physical exam, pay particular attention to the following:

General: Weight gain and bradycardia
HEENT: Dull expression, swollen face, periorbital edema, decreased auditory acuity, swollen tongue, hoarseness, enlarged thyroid gland (goiter), glandular atrophy and thyroid nodules.
CV: Bradycardia, LV hypertrophy, mild hypotension or diastolic hypertension, decreased heart sounds.
Respiratory: Bradypnea, diminished vital capacity and total lung capacity, dyspnea
Abdominal: Hypoactive bowel sounds and abdominal bloating
MSK: Swollen hands, swollen feet and leg edema
NEURO: Dementia, paranoid ideation, slow delayed reflexes and cerebellar ataxia
PSYCHE: Depression
SKIN: Dry skin, pale, course dry hair, brittle nails, hair loss, and temporal thinning of eyebrows


Differential diagnosis for hypothyroidism includes:

  • Depression

  • Obesity

  • Dementia

  • Coronary heart disease

  • Congestive heart failure

  • Kidney failure

  • Cirrhosis

  • Nephrotic syndrome

  • Chronic kidney disease


Diagnostic tests to order if you suspect hypothyroidism include:

  • Thyroid panel (TSH, Free T4)-
    • Overt hypothyroidism will demonstrate an increase in TSH and a decrease in T3 and T4 levels
    • Subclinical hypothyroidism may show an increased but normal level of TSH with normal levels of free T4

  • CBC for anemia

  • Electrolytes (hyponatremia)

  • Glucose (hypoglycemia)

  • BUN/creatinine

  • Albumen

  • Lipid panel



Treatment     MC04sect4

  • Daily thyroid replacement

  • Thyroid replacement doses are based on laboratory results

  • Older adults may metabolize T4 more slowly than younger persons. Dosage adjustment may be necessary.

  • When prescribing a daily thyroid replacement remember a few points:
    • Prescribe with caution in older adults with cardiovascular co-morbidities.

    • Educate patients about how to take medications – same time each day, on an empty stomach, full glass of water.

    • Avoid concomitant use with aluminum hydroxide antacids as it prevents absorption of the thyroid replacement.

    • Avoid calcium supplements within 4 hours of thyroid replacement due to decrease in absorption of thyroid replacement.

    • Thyroid replacement may interfere with the MOA of the following medications: tricyclic antidepressants, aminophylline, theophylline, warfarin, phenytoin, carbamazepine, beta blockers, digoxin and testosterone (DeLong, 2012).




References     MC04sect5

Agency for Healthcare Research and Quality (2010). Thyroid function tests: Diagnoses and monitoring of thyroid function disorders in adults. Retrieved from:

http://www.guideline.gov/content.aspx?id=38907&search=hypothyroidism Last accessed November 1, 2013. Carroll, P. (2009). Hypothyroid disease. Evidence –based nursing monographs. Retrieved from http://www.nursingconsult.com/das/news/body/206944645-2/ebnm/0/214405/1.htm Last accessed June 23, 2010.

DeLong, M.F. (2012). Thyroid dysfunction. CME Resource. Retrieved from www.NetCE.com June 23, 2010.

The American Thyroid Association. (2012). Thyroid Disease in the Older Patient. Retrieved from http://www.thyroid.org/patients/patient_brochures/older_patient.html. Last accessed November 1, 2013.



Orthostatic Hypotension
Kathleen Pace Murphy, PhD, MS, GNP-BC

Medical
Key Points     MC05sect1

Orthostatic hypotension is estimated to be present in 20 percent of older adults (Fitzgerald, (2010).

Orthostatic hypotension predisposes older adults to an increased risk of falls.

Orthostatic hypotension may be classified as acute or chronic, and symptomatic or asymptomatic.


Overview     MC05sect2

Orthostatic hypotension is a decrease in systolic blood pressure of greater than or equal to 20 mm of mercury, or a decrease in the diastolic pressure of greater than or equal to 10 mm of mercury when a patient changes from a recumbent or sitting position to a standing position (Lanier, Mote & Clay, 2011).

Normally, when a person assumes an upright position, the autonomic nervous system signals for an increase in lower extremity venous constriction and heart rate to compensate for the postural change. If the patient's autonomic nervous system and/or cardiovascular system do not respond efficiently, the patient may experience a transient decrease in venous return, reduction in cardiac output and a decrease in blood pressure.

Clinical manifestations associated with orthostatic hypotension include dizziness, light-headedness, weakness, headache, fatigue, and in some instances complaints of blurred vision (Fitzgerald, 2010; Lanier et al., 2011).

Causes for orthostatic hypotension include:

  • Dehydration

  • Medications, such as anticholinergics, loop diuretics, tricyclic antidepressants, calcium channel blockers, alpha-adrenergic blockers, centrally acting antihypertensive, narcotics and sedatives.

  • Autonomic insufficiency due to neurological disorder (e.g. Parkinson's Disease, Diabetic autonomic neuropathy)

  • Other disease states, such as aortic stenosis, cardiac arrhythmias, CHF, diabetes mellitus, peripheral vascular insufficiency, electrolyte disturbances

  • Alcohol misuse

  • Prolonged immobility (bed rest)




Assessment     MC05sect3

Attain orthostatic blood pressures:

  • Have your patient assume a supine position for at least 3 minutes.

  • Check the pulse and blood pressure in the supine position.

  • Have your patient assume a standing position for at least 3 minutes.

  • Check the pulse and blood pressure in a standing position.

  • The test is positive if the systolic blood pressure decreases by 20 mm Hg or greater OR the diastolic blood pressure decreases by 10 mm Hg or greater.


Head up tilt table testing can also be utilized for assessment.

Laboratory test to rule out certain medical conditions may be indicated. Examples include basic metabolic panel, complete blood count, glucose and Vitamin B12. ECG or 24 hour Halter monitoring may be indicated when cardiac arrhythmias are suspected.


Intervention     MC05sect4

Non-pharmacologic and pharmacologic interventions to consider include:

  • Medication Review- eliminate medications that may contribute to orthostasis

  • Correct electrolyte imbalances

  • Correct cardiac etiologies, for example, cardiac pace maker

  • Hydration – educate patient on need for hydration and avoidance of dehydration

  • Limit alcohol use

  • Compression hose – decrease lower extremity venous pooling

  • Abdominal binders

  • Postural changes – educate patient on changes in posture; utilizing a multi-step process to go from recumbent to standing position

  • Medications are available if other non-pharmacologic measures are unsuccessful. Medications classifications to consider are Fludrocortisone (mineralcortiocosteriod), and Pyridostigmine (cholinesterase inhibitor).



References     MC05sect5

Fitzgerald, M.A. (2010). Nurse Practitioner. 3rd Edition. Philadelphia: F.A. Davis Company: 308.

Katzung, B. (2007). Special aspects in geriatric pharmacology. In B. Katzung (Ed), Basic and Clinical Pharmacology. 10th Edition. New York, NY: McGraw Medical: 983-990.

Lanier, J.B., Mote, M.B., & Clay, E.C. (2011). Evaluation and management of orthostatic hypotension. American Family Physician; 84(5)527-536.

Stone, L.M. & Stone, P.D. (2007). Syncope. In R.J. Ham, P.D. Sloane, G.A. Warshaw, M.A. Bernard & E. Flaherty (Eds), Primary Care Geriatrics: A Case-Based Approach . 5th Edition. Chapter 20. Philadelphia: Mosby Elsevier.



Osteoporosis
Nahid Rianon, MD, DrPH

Medical
Overview     MC06sect1

Osteoporosis is defined as compromised bone strength that increases risk of fracture (NIH Consensus Conference, 2000). Bone strength is characterized by bone mineral density (BMD) and other bone qualities such as micro-architecture influenced by bone remodeling, bone turnover, mineralization and other factors that are more difficult to quantify, such as "damage accumulation." Decreased BMD with advanced age leads to age-related osteoporosis.

Sixty-five percent of adult bone is mainly composed of minerals such as calcium and phosphorus; 25% is water and the remaining 10% is organic bone matrix made primarily of collagen that provides flexibility. Bone is constantly being remodeled in cycles of formation and resorption by bone cells. Remodeling is in balance without any net change in bone mass before age-related bone loss begins. The state of balance is lost with advanced age with more resorption than formation. The main bone cells involved in the remodeling cycle are osteoblasts (bone formation), osteoclasts (bone resorption), and osteocytes (old osteoblasts – which stimulate osteoblasts when they sense mechanical strain in a bone). Bone cell functions are influenced by age, levels of calcium, vitamin D, parathyroid hormone, hormones, such as, estrogen and androgens and medications, for example glucocorticoids.


Key Points     MC06sect2

Approximately 9 million Americans suffer from osteoporosis. Another 48 million have low bone mass and are at risk of developing osteoporosis (The National Osteoporosis Foundation, 2011), More than 2 million fractures in the USA were attributable to osteoporosis in 2005. One out of two Caucasian women 50 years of age or older experiences a fracture in their lifetimes.

Incidence of fractures in women exceeds that of stroke, MI & breast cancer combined in their lifetime.

Fracture risk in men is higher than that of prostate cancer. Twenty one percent of men, 50 years of age or older, will experience a fracture.

Osteoporotic fractures are a common cause of immobility in the elderly. Vertebral fracture is the most common type and accounts for 27% of all osteoporotic fractures. Wrist and hip fractures account for 19% and 14% of these fractures (Cauley, 2013.) Vertebral fracture may often be silent but can also affect many aspects of quality of life including physical (pain, compressed abdomen, spinal deformity), functional (decreased mobility) and psychosocial (depression). If one survives a fracture, the risk of recurrent vertebral fracture is 5-12 times greater.

Fifty percent of older adults with hip fractures will never walk without assistance and 25% will require long-term care.

Pain and depression associated with immobility often lead to failure to thrive and death. From 2000 through 2009, an estimated $22 billion was spent for osteoporosis and related fractures compared to $7 billion spent on breast cancer in the United States (Blume & Curtis, 2011).


Assessment     MC06sect3

Dual energy x-ray absorptiometry (DXA) assesses bone mineral density (BMD). BMD is the traditional way to diagnose osteoporosis. BMD provides the skeletal measure; however, there are non-skeletal factors that are not captured by the DXA scans. Non-skeletal risk factors include increasing age, female gender, race (Asian or Caucasian), early menopause, low body weight, family history of osteoporosis or fracture, low calcium intake, low vitamin D, alcohol, physical inactivity, high caffeine intake, drug/ steroid use, and smoking.

In addition to the DXA scan, screening for osteoporosis in the older adults should include a detailed history focusing on the risk factors described above. A physical examination will help identify older adults who are at risk of falling. While falls may not be directly linked to osteoporosis, fall prevention helps in fracture prevention.

The World Health Organization (WHO) has developed the Fracture Risk Assessment tool. The FRAX® calculates individual risk of fracture with and without BMD. The FRAX® algorithms provide a 10-year probability of hip fracture and other major osteoporosis related fractures (clinical spine, forearm, hip or shoulder fracture).


Diagnosis     MC06sect4

Osteoporosis-a T- score of <-2.5 for BMD is considered osteoporosis

Osteopenia-a T-score between -1 to -2.5 is considered low bone mass


Intervention     MC06sect5

The main goal of osteoporosis treatment is to prevent fractures. There are two main types of interventions, pharmacological and behavioral.

The National Osteoporosis Foundation (2011) guidelines for pharmacologic intervention with a prescription medication in postmenopausal women and men ≥50 years of age are:

  1. History of hip or vertebral fracture

  2. Other prior fractures and T-score between -1.0 and -2.5 at the femoral neck, total hip, or spine, as measured by dual-energy X-ray absorptiometry (DEXA).

  3. T-score ≤-2.5 (DEXA) at the femoral neck, total hip, or spine, after appropriate evaluation to exclude secondary causes.

  4. T-score between -1.0 and -2.5 at the femoral neck, total hip, or spine and secondary causes associated with high risk of fracture, such as glucocorticoid use or total immobilization

  5. T-score between -1 and -2.5 at the femoral neck, total hip, or spine, and a 10-year probability of hip fracture ≥3 percent or a 10-year probability of any major osteoporosis-related fracture ≥20 percent based upon the US-adapted WHO algorithm.



The decision for treatment should be based on individual patients. FRAX (fracture risk assessment tool) developed by WHO provides some indication based on the patient's age, past medical history and family history with or without a bone mineral density (BMD).

Available pharmacologic interventions are:

Oral Bisphosphonates
:
Alendronate 10 mg/day or 70 mg once weekly
Risedronate 5 mg/day, 35 mg once weekly, or 150 mg once monthly
Ibandronate 150 mg once-monthly or 3 mg intravenously every three months

Intra-venous Bisphosphonates
:
Zoledronic acid 5 mg administered intravenously (IV) once yearly
Ibandronate 3 mg IV every 3 months


Precautions should be taken for side effects of bisphosphonates, e.g., esophagitis for any oral bisphosphonates. Osteonecrosis of the jaw (ONJ; avascular necrosis of the jaw), especially in people with compromised oral hygiene should be discussed at the time of treatment inception. ONJ and atypical fractures (e.g., femur shaft fracture) are also a concern in patients with long term use (> 5 years).

Selective estrogen receptor modulators: Raloxifene is a tissue selective estrogen receptor modulator (SERM) that also reduces the risk of vertebral fractures, lowers risk of breast cancer while it does not stimulate endometrial hyperplasia or vaginal bleeding. But it increases the risk of venous thromboembolism and so is not considered a first line agent for older patients.

Estrogen/progestin therapy: Due to increased risk of breast cancer, stroke, venous thromboembolism, and coronary disease, estrogen/progestin is no longer a first-line approach for the treatment of osteoporosis in postmenopausal women.

Parathyroid hormone: Teriparatide (recombinant human PTH) 20 mcg given subcutaneously daily is not recommended for use for more than 2 years. Patients with a history of cancer or other bone disease with higher bone formation are not candidates for this treatment. Usually, this is given to patients who did not improve on BMD after being on bisphosphonate for at least 2 years or longer.

Denosumab: A humanized monoclonal antibody against RANKL that reduces bone resorption is the newest medication that is given 60 mg sub-cutaneously every six months (to be administered by a trained health care provider).

Calcium and vitamin D supplementation: 500-600mg of calcium + 400 units of vitamin D one tablet twice a day is recommended with any other pharmacological intervention. Normal levels of calcium and vitamin D need to be confirmed to continue supplementation with this dosage.

Testosterone therapy: Hypogonadism is a common cause of osteoporosis in men. While testosterone is not recommended for primary osteoporosis, it is used as needed in men with hypogonadism and secondary osteoporosis. Caution needs to be practiced in patients with history of prostate cancer.

Behavioral interventions include:

Weight bearing exercise: Walking is recommended and suggested with or without pharmacologic intervention.

Smoking cessation: Cessation is recommended for all nicotine users.

Moderate level of alcohol: Less than 3 drinks per day are recommended for promoting bone health.

Fall prevention: Improved balance and muscle strength are keys to preventing osteoporosis related fractures. Calcium and vitamin D supplementation are also recommended.


Prevention     MC06sect6

Prevention of osteoporosis is multifactorial. Calcium and vitamin D supplementation and weight bearing exercise are recommended to prevent fracture and treat osteoporosis. The daily requirement of calcium for an older adult is about 1200-1500 mg. An eight ounce cup/glass of milk or fortified orange juice would provide about 300 mg of calcium. (Sweet et al., 2009; Holick, 2006; National Osteoporosis Foundation, 2011).

The American College of Sports Medicine (Chodzko-Zajko, Proctor, Singh, et al., 2009) recommends at least 2.5 hours of moderate intensity physical activity per week for healthy adults. Walking is a simple and easy way of weight bearing exercise that helps stimulate bone formation to improve balanced remodeling. Brisk walking at about 3.5 miles per hour (approx. 17 min/mi) is the equivalent of 4 METS. A MET is a measure of exercise intensity. MET levels ranging between three and five are considered moderate level physical activity. (Chodzko-Zajko, Proctor, Singh, et al. 2008)

Besides skeletal health, other environmental and behavioral factors, (e.g., fall prevention, smoking cessation) are also key factors for prevention of osteoporosis related fractures.


References     MC06sect7

Blume, S.W.,& Curtis, J.R. (2011). Medical costs of osteoporosis in the elderly Medicare population. Osteoporosis International, 22, 1835-1844.

Cauley, J. (2013). Public Health Impact of Osteoporosis. Journal of Gerontology: Medical Sciences. Doi: 10.1093/Gerona/glt093. E-pub ahead of print.

Carey, J.J. (2005). What is a ‘failure' of bisphosphonate therapy for osteoporosis? Cleveland Clinic Journal of Medicine;72:1033-1039.

Chodzko-Zajko, W.J., Proctor, D.N., Singh, M.A., Minson, C.T., Nigg, C.R., Salem, G.J., and Skinner, J.S. (2009). Exercise and physical activity for older adults. American College of Sports Medicine Science Exercise, 4, 1510-1530.

Holick, M. (2006). High Prevalence of Vitamin D Inadequacy and Implications for Health. Mayo Clinic Procedures;81:353-373.

National Osteoporosis Foundation. (2011). Clinician's Guide to Prevention and Treatment of Osteoporosis. Retrieved from http://www.nof.org/professionals/clinical-guidelines.

National Institutes of Health (2000). Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement 17(1):1e36. Retrieved from: http://consensus.nih.gov/2000/2000Osteoporosis111html.htm.

The National Osteoporosis Foundation (2012). Fast Facts. Retrieved from www.nof.org

Sweet, M.G., Sweet, J.M., Jeremiah, M.P., and Galazka, S.S. (2009). Diagnosis and Treatment of Osteoporosis. Journal of American Family Physician, 79,193-200.



Primary Hyperparathyroidism
Nahid Rianon, MD, DrPH

Medical
Overview     MC07sect1

Primary hyperparathyroidism (PHPT) is characterized by elevated plasma levels of parathyroid hormone (PTH) and calcium with reduced plasma phosphate. PHPT is the third most frequently diagnosed endocrine disorder. It is a silent health problem in the elderly until it becomes apparent with cognitive and physical consequences, for example, mental status change, severe constipation, and fracture.

Risk factors for PHPT include:

  • Post-menopausal state

  • Prolonged severe calcium deficiency

  • Prolonged severe vitamin D deficiency


Rare PHPT risk factors include:

  • Inherited disorder, such as multiple endocrine neoplasia-type I (which usually affects multiple glands)

  • Radiation exposure to head and neck regions

  • Medications, such as lithium, a drug most often used to treat bipolar disorder.



Key Points     MC07sect2

PHPT risk increases with age. It is often diagnosed in the 6th or 7th decade of life.

PHPT prevalence in the elderly is about 1 in every 100 older adults with a ratio of Women: men = 3-5: 1.

Most epidemiologic studies were conducted with Caucasians; there is a lack of ethnicity and race data to determine if ethnic variations exist but clinical experience suggests risk is present in all ethnic/racial groups.

Fifty percent of patients present with mental disturbance, for example, personality change, depression, or psychosis. They may also become frail presenting with sudden fast decline in health and functional abilities.


Diagnosis     MC07sect3

Presenting symptoms may often be confused with other age related disease presentations, specifically in an older patient. Common presenting symptoms include fragility fracture (due to bone loss and osteoporosis), pain due to kidney stones, excessive urination, abdominal pain, weakness, fatigue, depression or forgetfulness, bone and joint pain, frequent complaints of illness with no apparent cause, nausea, and vomiting or loss of appetite.

Asymptomatic PHPT is often diagnosed with incidental laboratory findings and may present as consistently normal calcium with persistently abnormal PTH in the absence of recognizable underlying cause of elevated PTH. Most patients become hypercalcemic at a later time.

After a complete history and physical examination, the following tests are recommended:

  1. Serum calcium, phosphorus, magnesium, alkaline phosphatase, intact PTH, 25-OH vitamin D, urinary calcium and bone markers (resorption markers, e.g., urine NTX), serum creatinine and GFR (for kidney function).

  2. When indicated based on signs and symptoms, a parathyroid nuclear medicine scan will confirm adenoma (85% patients with PHPT usually have single adenoma).




Management     MC07sect4

PHPT complications may include osteoporosis, kidney stones, cardiovascular disease, hypertension, left ventricular hypertrophy, and carotid plaque thickness.

Surgical intervention is the main form of treatment. Surgery is indicated for treatment in elderly patients with serum calcium >1 mg/dl (0.25 mmol/L) above normal range, GFR <60 ml/min/1.73m2 and a T score <-2.5 SD at spine, hip (total or femoral neck) or radius (distal 1/3 site) or presence of fragility fracture.

Expected surgical outcomes include improved symptoms, increased bone mineral density (BMD), fewer renal stones, improved neurocognitive function. Availability of higher quality imaging advances efficacy and safety of surgical techniques. Out-patient minimally invasive surgery support treatment in the elderly.


Case Presentation     MC07sect5

A 70 year old African-American man with a past medical history of hypertension, hyperlipidemia, COPD (a former smoker, currently on steroid inhaler), renal stones (no current symptoms) and recurrent abdominal pain ( due to diverticulitis and chronic constipation for several years that he usually treats himself with OTC medication and lactulose as needed), was being seen in the outpatient clinic. His chief complaint was constipation with no bowel movement for past 5 days associated with abdominal discomfort. He ran out of lactulose and wanted a refill.

He was not taking any multivitamin, or any calcium/vitamin D supplements. He lives alone, independent with ADL and IADL. He has mild cognitive decline on SLUMS.

Laboratory findings demonstrated hypercalcemia (serum calcium 11.1 mg/dl; normal range 8.5-10.5) and vitamin D deficiency (25 hydroxy vitamin D 17 ng/ml) about 3 months ago.

He was treated with ergocalciferol 50,000 IU weekly for 8 weeks, and was started on regular calcium and vitamin D supplements with 1000 mg of calcium and 800 IU of vitamin D daily. His magnesium and phosphate were within normal range; but PTH was 149 pg/ml (normal range 11.1 – 79.5 pg/ml). He had good renal function with a GFR >60. His femoral neck T-score was 0.1 showing no bone loss. He was not taking medications known to alter serum calcium, e.g., HCTZ, Lithium, bisphosphonate. His PTH continued to be high even after vitamin D and calcium normalized.

A parathyroid scan showed Right Inferior Parathyroid Adenoma. Patient was diagnosed with Primary hyperparathyroidism (PHPT) and was referred for further evaluation by an endocrine surgeon.


References     MC07sect6

Adami, S., Marcocci, C., & Gatti, D.. Epidemiology of primary hyperparathyroidsim in Europe. Journal of Bone and Mineral Resaerch 2002;Suppl 2:N18-23.

Bilezikian, J., Khan, A., Potts, T. Jr, (2009). Third International Workshop Asymptomatic Primary Hyperthyroidism. Guidelines for the management of asymptomatic primary hyperparathyroidism: Summary statement. Journal of Clinical Endocrinology & Metabolism; 94:335-339.

Kim, L., Whittier Krause, M., & Kantorovich. (2012). Primary Hyperparathyroidism. Medscape Reference Drugs, Diseases & Procedures. Retrieved from http://emedicine.medscape.com/article/127351-overview#aw2aab6b4.



Wound Care
Shannon Pearce, DNP & Michelle Peck, ANP

Medical
Key Points     MC08sect1

Pressure ulcers are regions of localized damage to the skin and underlying tissues that usually develop over bony prominences such as the sacrum or heels.

Pressure ulcers are often overlooked by providers until significant ischemia and tissue death have occurred.

Most pressure ulcers begin in hospitals and account for the largest amount of money in nursing home legal settlements.

Though a pressure ulcer may progress from a stage I to a stage IV or an unstageable ulcer, a stage IV can never become a III, II, or I (even after healed).

Pressure ulcers are often mismanaged, despite availability of best practices and recommended standards of care.

Avoid using donut-type devices and sheepskin.

Reposition bed-bound persons every 2 hours.

Position chair-bound persons every hour.

Position head of bed at or below 30° whenever possible.


Assessment     MC08sect2

Derived from the Guidelines of the 2009 National Pressure Ulcer Advisory Panel (NPUAP). When assessing a patient's wounds, a complete evaluation includes:

  1. Location

  2. Stage

  3. Size (length, width, depth)

  4. Sinus tracts/tunnels/ Undermining

  5. Exudate - type/amount

  6. Wound base - clean, granulated, eschar, slough

  7. Surrounding skin

  8. Phase of wound healing

  9. Signs/symptoms of infection

  10. Pain


Use validated assessment tools for such as Braden Scale, Norton Scale, or Pressure Ulcer Scale for Healing (PUSH).

Diagnosis     MC08sect3

Stageable Pressure Ulcers

Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stageable Pressure Ulcers Stage 1


Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Stageable Pressure Ulcers Stage 2


Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stageable Pressure Ulcers Stage 3


Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

Stageable Pressure Ulcers Stage 4


Unstageable Pressure Ulcers

Eschar: Named originally from the Greek word eschara (scab). Eschar is a slough/dead tissue that is cast off from the surface of the skin. Eschar development occurs with burns, pressure ulcers necrotizing and other types of wounds.

Deep tissue injury (DTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.


Management     MC08sect4

The management of pressure ulcers requires an interprofessional team approach.

The basic components of wound management include:

  1. The general principle of pressure relief with proper positioning & support surfaces such as static (foam, air, gel) and dynamic support (alternating air, low-air-loss or air-fluidized) surfaces

  2. Evaluating, monitoring and documenting patient progress; location, stage, area, depth, drainage, necrosis, granulation and cellulitis. Document all observations over time.

  3. Identify and treat contributing factors such as medical conditions (e.g., urinary incontinence, diabetes, heart failure, etc.), nutritional status, pain level, and psychosocial health.

  4. Appropriate local wound dressing. Both pressure ulcer stage and amount of exudates should be taken into consideration when dressing wounds. For example, alginates are indicated for heavy exudate only. Hydrocolloids should not be used alone over a stage 2 or 3 wound with heavy exudate. Absorptive substance like calcium alginate (for excessive exudate), Silver Sorb (malodorous wounds), moist gauze (or hydrogel) can be used to pack stage III and stage IV pressure ulcers. Hydrogels are indicated for wound beds that are dry for rehydration or to rehydrate eschar for debridement. Necrotic tissue in pressure ulcers and arterial ulcers should be debrided surgically or enzymatically.



Prevention     MC08sect5

Prevention begins by identifying risk factors. Always perform a complete history and physical. Those at highest risk include patients with immobility and patients with other individual risk factors such as poor nutritional status, decreased arterial pressure. Perform a head to toe skin check, ask about bowel & bladder problems, and ensure nutritional interventions are consistent with goals of care.


References     MC08sect6

Hazzard W, Blass J, Halter J, et al, eds. Principles of Geriatric Medicine & Gerontology, 5th ed. New York, NY: McGraw-Hill; 2008.

National Pressure Ulcer Advisory Panel (200). Pressure Ulcer Assessment Tool. Retrieved from http://www.npuap.org/resources/educational-and-clinical-resources/

National Pressure Ulcer Advisory Panel (2007). Pressure Ulcer Prevention Points. Retrieved from http://www.npuap.org/resources/educational-and-clinical-resources/

Pressure Ulcers. (2013). Kroshinsky, D. & Strazzula, L. The Merck Manual Online. Retrieved from http://www.merckmanuals.com/professional/dermatologic_disorders/pressure_ulcers/pressure_ulcers.html

Pompei P, Murphy J, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th ed. New York, NY: American Geriatrics Society; 2003.

Reddy, M., Gill, S.S., Kalkar,S.R., Wu, W., Anderson, P.J., & Rochon, P.A. (2008). Treatment of Pressure Ulcers: A Systematic Review. Journal of the American Medical Association, 300, 2647-2662.

Reddy M, Gill, S.S, & Rochon P.A. (2006). Preventing Pressure Ulcers: A Systematic Review. Journal of the American Medical Association, 296(8), 974-984.

Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips: 2007-2008, 9th ed. New York, NY: The American Geriatrics Society; 2007.



Beers Criteria: Some Medications to Avoid in the Elderly
John Halphen, MD

Medications
Overview     MI01sect1

There are some medications that should be avoided in the elderly altogether, and some that should be avoided in the presence of certain medical conditions. Some are appropriate to use, but with caution in the elderly. Changes brought about by aging make elders more vulnerable to the harmful effects of some medications.


Key Points     MI01sect2

In older adults, the following physiological changes occur with aging:

  • reduced liver size and liver blood flow with a resulting reduction in liver metabolism.

  • reduced kidney size and blood flow with a resulting reduction in renal clearance.

The central nervous system is more sensitive to the effects of sedating medications such as benzodiazepines. These and anti-cholinergic medications promote delirium. Anti-cholinergic medications also promote sedation, urinary retention, dry mouth, constipation, orthostatic hypotension, and other problems.


Assessment     MI01sect3

  • Beers criteria are guidelines regarding medication usage in elders.

  • These were first issued in 1991 and have been updated repeatedly over the years. Dr. M.H. Beers was the principal author of the original 1991 criteria.

  • Some highlights of the potential medication issues mentioned in the latest version of the Beers criteria include:

AVOID IF POSSIBLE IN THE ELDERLY
Class Drug Prescribing Concern
first generation (sedating) antihistamines diphenhydramine
chlorpheniramine
promethazine
cyproheptadine
clemastine
hydroxyzine
doxylamine (and others)
sedating and strongly anti-cholinergic; promote delirium, falls, urinary retention, dry mouth, constipation; use of diphenhydramine may be appropriate for acute treatment of severe allergic reactions
antispasmodic dicyclomine
hyocyamine
propantheline
oxybutynin (immediate release)
scopolamine
belladonna alkaloids
clinidinium
sedating and strong anti-cholinergic properties; promote delirium, falls, urinary retention, dry mouth, constipation; use of hyocyamine, scopolamine, and belladonna alkaloids to dry secretions in palliative medical care may be appropriate
Tricyclic antidepressants amitriptylinebr
doxepin
imipramine
nortriptyline (and others)
avoid in the elderly; sedating and strong anti-cholinergic properties promote delirium, falls, urinary retention, constipation, and orthostatic hypotension
Anti-cholinergic antiparkinson agent benztropine
trihexyphenidyl
avoid due to sedation, anti-cholinergic properties; not recommended for prevention of antipyramidal side effects from antipsychotic medications and better medications available for Parkinson
muscle relaxants cyclobenzaprine
methocarbamol
carisoprodol
metaxalone (and others)
avoid in the elderly due to sedation and anti-cholinergic properties; questionable effectiveness in tolerable doses, and promotes delirium, sedation, and falls
benzodiazepines alprazolam
lorazepam
diazepam
chlordiazepoxide
chlorazepate (and others)
avoid in the elderly for control of delirium, sleep disorders, or agitation; elders are more sensitive to the delirium promoting and fall promoting side effects of these medications; may be appropriate for some conditions such as alcohol withdrawal, or benzodiazepine withdrawal
Non-benzodiazepine hypnotics Zolpidem (and others) Avoid due to sedation; promotes delirium, falls, and fractures in the elderly like the benzodiazepines do
Antipsychotic agents (atypical and conventional) Haloperidol
Thioridazine
Chlorpromazine
Olanzapine
Quetiapine
Risperidone (and others)
Because of increased risk of stroke and death, avoid for behavioral problems in the elderly unless non-pharmacologic measures have failed and the patient is a risk to themselves or others
Alpha 1 blockers doxazosin
prazosin
terazosin
avoid use as antihypertensive due to high risk of orthostatic hypotension and better agents are available
CNS acting alpha agonist hypotensive agents clonidine
methyldopa
associated with bradycardia, orthostatic hypotension, sedation, delirium, depression; avoid methyldopa and clonidine should not be first-line for hypertension
cardiac glycoside digoxin over 0.125mg daily Higher doses used in heart failure increases risk of toxicity without adding benefit; reduced renal function may increase risk of toxicity
antiarrhythmic drugs amiodarone
flecainide
procainamide
sotalol
quinidine
disopyramide (and others)
risk – benefit analysis favors rate control over rhythm control in most older adults; amiodarone associated with thyroid problems, pulmonary problems and QT prolongation; disopyramide may have a negative ionotropic effect and may precipitate heart failure, it is also anticholinergic
Non-COX selective NSAIDS Aspirin > 325mg/day
Ibuprofen
Naproxen
Piroxicam
Indomethacin (and others)
Avoid chronic use unless other measures fail and can use PPI with it; risk of GI bleeding, reduced renal function, exacerbation of heart failure
Long acting sulfonylureas Chlorpropamide
glyburide
Avoid in the elderly because of increased risk of prolonged hypoglycemia
a urinary anti-infective agent nitrofurantoin contraindicated in those with creatinine clearances below 60ml/min because of failure to reach therapeutic concentrations in the urine and increased risk of nerve and liver toxicity
Table adapted from: Identifying Medications that Older Adults Should Avoid or Use with Caution: the 2012 American Geriatrics Society Updated Beers Criteria. Retrieved from http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublic Translation.pdf

References     MI01sect4

American Society of Health-System Pharmacists (2013). AHFS Drug Information. Bethesda, Maryland: American Society of Health-System Pharmacists.

Avorn, J., (Ed.), (2003). Principles of pharmacology. Geriatric Medicine: An Evidence Based Approach, 4th Ed. New York, NY: Springer-Verlag; 2003:127.

Expert Panel. American Geriatrics Society (2012). Updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of American Geriatric Society; 60(4):616-31.

O'Mahoney, D., & Gallagher, P.F. (2008). Inappropriate prescribing in the older population: Need for new criteria. Age and Ageing; 37(2):138-141.



Illicit Substance Use Disorder Among Older Adults
David V. Flores, PhD, LMSW, MPH and Sara K Flores, M.D.

Medications
Key Points     MI02sect1

  • Illicit substance use among adults 65 and over is rapidly rising, and there will be a significant lack of resources to address this growing public health problem (Institute of Medicine, 2012).

  • An estimated 4.8 million older adults are living with a substance abuse disorder and this number is projected to double by 2020 (Han et al., 2009).

  • The health consequences of illicit substance use can significantly impair or exacerbate co-morbid health conditions in older adults (Wu & Blazer, 2011).

  • The psychosocial, economic, and emotional consequences can be devastating for the individual as well as for their family (Substance Abuse and Mental Health Services Administration, 2009).

  • Physical consequences associated with substance use among older adults include falls, cognitive decline, central nervous system depression, drug poisoning, cirrhosis of the liver, cancer, immune system disorders, cardiomyopathy, cerebral atrophy, and cognitive deficits (National Institute on Aging, 2013).

  • Illicit substance use also exacerbates preexisting conditions such as osteoporosis, diabetes, high blood pressure, and ulcers (Immonen, Valvanne, & Pitkala, 2013; National Institute on Aging, 2013).

  • Increased drug use by older adults is also concomitant with increased rates of admissions for combined alcohol and drug use, for drug use only, and for polysubstance use over time (Wu & Blazer, 2011).

  • Physiological changes associated with aging increase the effects of substance use and can negatively impact the interactions between drugs used for chronic medical or psychological conditions (Dowling et al., 2008; Wu & Blazer, 2011).

  • Drugs of abuse can increase neurotoxicity and alter pharmacokinetics, brain neurotransmission (such as dopaminergic, serotonergic, and glutamatergic systems), drug metabolism especially in older adults (Dowling et al., 2008; Wu & Blazer, 2011).

Overview     MI02sect2

Researchers recently conducted a systematic review of the literature and identified significant correlates of substance abuse to include:

  • male gender

  • aged 50 to 64 years

  • Native American, Alaska native, or Black race (specific to cocaine)

  • never married, separated, divorced or widowed

  • less education

  • lower income status

  • living in the Western region of the United States

  • recent alcohol or tobacco use

  • mental health problems or distress

  • involvement with the criminal justice system, and

  • history of incarceration (Wu & Blazer, 2011).

Protective factors were identified as:

  • being married

  • never using alcohol or tobacco

  • and attending religious services regularly (Wu & Blazer, 2011).


Assessment     MI02sect3

The Consensus Panel of the Treatment Improvement Protocol (TIP) suggest that older adults 60 years and over should be screened for alcohol and prescription drug abuse as a routine part of their regular physical examination. Barriers to assessing substance use and disorders have been found to include denial, insufficient knowledge, limited research, stigma or shame, lack of financial resources, lack of transportation, cognitive impairment, shrinking social support network, and comorbid conditions that accompany diagnosis (Wu & Blazer, 2011).

The opportunity for screening older adults for substance use and referral for appropriate counseling and treatment is increased due to the need of regularly scheduled medical appointments for chronic conditions associated with aging (Wu & Blazer, 2011). Additionally, early onset drug users will present with more medical, psychiatric, and/or social conditions compared to late onset drug users. Several instruments have been developed for quick identification of substance use including The CAGE assessment of drug and alcohol dependence, The Alcohol Use Disorders Identification Test (AUDIT), and The Drug and Alcohol Problem Assessment for Primary Care (DAPA-PC).

If a substance use disorder is identified, the provider should consider also assessing for a co-occurring mental health disorder, as estimates of 39-50% of adults meeting criteria for a mental illness also meet criteria for substance abuse in any given year (National Alliance on Mental Illness, 2013) and persons with mental illnesses are three times more likely to abuse substances than those without mental illnesses (Substance Abuse and Mental Health Services Administration, 2011). Treatment of the underlying or co-occurring mental illness should be factored into the substance abuse treatment planning and recommendations.


Diagnosis of Substance Use Disorder     MI02sect4

Substance abuse disorders create significant impairment in activities of daily living and distress resulting from maladaptive patterns surrounding the use of substances. Symptomatology often includes a combination of withdrawals, increased tolerance, increased time spent on substance use activities, increased amounts of the substance used, unsuccessful efforts to control use, continued usage despite adverse consequences, and a decrease in social, occupational, or recreational activities (American Psychiatric Association, 2000). Moreover, the natural changes in physiology and pharmacokinetics that take place in older adults can increase the older person's sensitivity to substances and manifest as altered physiological or psychological symptomatology (Wu & Blazer, 2011). Substance use disorder in the DSM-5 has combined the DSM-IV categories of substance abuse and substance dependence into a single disorder and is measured along a continuum from mild to severe. Substances are addressed as separate use disorders (e.g., alcohol use disorder, stimulant use disorder, etc.), but are diagnosed based on the same overarching criteria. In previous DSM editions, a diagnosis of substance abuse required only one symptom. Mild substance use disorder in DSM-5 requires two to three symptoms from a list of eleven (American Psychiatric Association, 2013).


Intervention     MI02sect5

The majority of research and literature on substance abuse treatment of older adults has predominantly concentrated on alcohol misuse and has demonstrated greater treatment efficacy and increased outcomes for older women and longer length of treatment (Blow, Walton, Chermack, Mudd, & Brower, 2000). The TIP committee recommends a brief intervention followed by, if necessary, motivational interviewing and contextualized treatment, to include non-confrontational and supportive older adult specific intervention. These contextual strategies should address socioeconomic, psychological, and age specific strategies for the older adult (Center for Substance Abuse Treatment, 2005; Wu & Blazer, 2011). The physician should also assess the patient's motivation for treatment-- "Are you willing to consider changing your substance use habits at this time?" A patient's motivation for change may fall along a continuum from being totally unaware of the problem behavior to being ready to change.

The following interventions have been recommend by the Center for Substance Abuse Treatment and have been shown to be effective for treating substance use disorders in older adults:

  • Capital group-based therapy

  • Motivational interviewing

  • Substance use counseling

  • Cognitive behavioral Therapy

  • Individual counseling

  • Pharmacotherapy to reduce cravings (naltrexone, topiramate, acamprosate), reduce euphoria associated with use (naltrexone, buprenorphine), and deter use with aversive reaction (disulfiram)

  • A combination of pharmacotherapy and psychotherapy

  • Marital and family therapy

  • Institutional substance use rehabilitation treatment

  • Case management/community linked services and outreach


References     MI02sect6

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th. Retrieved September 20, 2013, 2013, from http://www.dsm5.org/Documents/Substance Use Disorder Fact Sheet.pdf

Blow, Frederic C., Walton, Maureen A., Chermack, Stephen T., Mudd, Sharon A., & Brower, Kirk J. (2000). Older adult treatment outcome following elder-specific inpatient alcoholism treatment. Journal of substance abuse treatment, 19(1), 67-75. doi: http://dx.doi.org/10.1016/S0740-5472(99)00101-4

Center for Substance Abuse Treatment. (2005). Substance abuse relapse prevention for older adults: A group treatment approach (U. S. D. o. H. a. H. Services, Trans.). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Han, Beth, Gfroerer, Joseph C., Colliver, James D., & Penne, Michael A. (2009). Substance use disorder among older adults in the United States in 2020. Addiction, 104(1), 88-96. doi: 10.1111/j.1360-0443.2008.02411.x

Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services, . Washington, DC: Institute of Medicine, The National Academies Press.

Intitute of Medicine. (2012). The mental health and substance use workforce for older adults In whose hands? Washington, DC: National Academy of Sciences.

Manchikanti, L. (2006). Prescription Drug Abuse: What is Being Done to Add ress This New Drug Epidemic? Testimony Before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9, 287-321A.

National Alliance on Mental Illness. (2013). Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder. Retrieved September 25, 2013 http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049

National Institute on Aging. (2013). Alcohol use in older people. Retrieved from http://www.nia.nih.gov/health/publication/alcohol-use-older-people.

Substance Abuse and Mental Health Services Administration. (2009). The NSDUH Report: Illicit Drug Use among Older Adults. Rockville, MD: SAMHSA.

Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. (HHS Publication No. (SMA) 11-4658). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Wu, Li-Tzy, & Blazer, Dan G. (2011). Illicit and Nonmedical Drug Use Among Older Adults: A Review. Journal of Aging and Health, 23(3), 481-504.



Geriatric Comprehensive Medication Review
Kathleen Pace Murphy, PhD, MS, GNP-BC; Jennifer Larson, MSE

Medications
Definition     MI03sect1

The National Medical Therapy Management (MTM) Advisory Board's (2011) definition of a Comprehensive Medication (CMR) Review is:

…a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient, caregiver and/or prescriber.

Key Points     MI03sect2

Older adults (aged 65 and older) use approximately 33% of prescription medications and 75% of all over the counter medications in the United States.

Ninety percent of those aged 65 or older take at least one drug per week. Forty percent take five or more drugs per week, and 12% take more than ten medications per week. (Katzung, 2007, Pham & Dickman, 2007).

Age influences medication therapy. As a person ages there are pharmacokinetic alterations that occur, such as, changes in drug absorption, distribution, excretion and metabolism. Advancing age may mean additional co-morbidities, which may further impair drug absorption, distribution, excretion and metabolism.

Socio-economic changes may also affect an older adult's medication therapy plan and adherence. Co-morbidities may mean additional costly medical appointments with specialists as well as primary care physicians. Complicated daily medication routines and pharmaceutical cost can also influence the older adult's adherence and/or compliance to the medication therapy plan.

Self-administration of complementary and over-the-counter medications and herbal remedies may further complicate the medication therapy plan if this information is not freely discussed between the older adult and the health care provider.

Health care providers must utilize their pharmacology knowledge to understand potential adverse drug effects. Asking the right questions is always a good start.


Assessment     MI03sect3

Medication review questions to ask of patients include the following:

  1. Please tell me what prescribed medications you are on and for what problem?

  2. Please tell me about medications that you buy for yourself from the grocery store, drug store, health food store, or your favorite discount store?

  3. Do you ever travel to a foreign country and buy medications there? If so, which medications did you purchase?

  4. Are you using eye drops, creams, lotions or other topical medications that I should know about?

  5. Has your eye doctor, podiatrist or dentist prescribed any medications for you?

  6. I noticed that you also have the following medical problems but are not receiving any medications for them - is that correct?

Medication review questions health care providers must ask themselves

  1. Is there still an indication for this prescribed medication?

  2. Is this prescribed medication appropriate for this specific condition?

  3. Is the efficacy and safety of this prescribed medication satisfactory?

  4. Is this the most cost-effective medication I can prescribe for this older adult?

  5. Does this medication need to be monitored (i.e. blood levels) and if so, do I have the steps in place for this to happen successfully?

  6. Are there duplications in this older adult's medication therapy plan?

  7. Can this medication therapy plan be simplified?

  8. Are there potential drug-drug or drug-illness interactions?


Adapted from Hamdy, Moore, Whalen, Donnelly, Compton, & Testerman, et al., (1995).

Intervention     MI03sect4

The following interventions are simple and easy to follow when caring for an older adult:

  • Brown Bag review – encourage you patient to bring ALL their medications (prescribed, OTC and complementary) with them to their appointment for your review.

  • "Start Low, Go Slow, and Get to Goal"- give the lowest possible starting dose, titrate slowly upward and achieve your stated medical goal.

  • Utilize geriatric resources that may assist you in your medication therapy plan. These resources include:

    • American Geriatric Society Beers Criteria (2012) for Potentially Inappropriate Medication Use in Older Adults http://www.americangeriatric.org/health_care_professionals?Clinical_Practice/clinicalguidelines_recommendations/2012

    • There are many renal related age changes. Creatinine clearance and GFR rates are more accurate measures in the older adult.

    • Utilize the Cockcroft-Gault equation to estimate creatinine clearance. The National Kidney Foundation provides the following: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1853341/

    • Educate, educate, educate!!! The link below is the CHAMPS Geriatric Medication Management Toolkit This excellent website provides health care providers with focused and validated tools for older adults experiencing medication-related problems: strategies to manage medications; communication tools; guidelines and evidence based best practices: http://champ-program.org/page/101/geriatric-medication-management-toolkit



References     MI03sect5

American Geriatric Society (2012). AGS Beers Criteria for potentially inappropriate medication use in older adults. Accessed September 17, 2013 at http://www.americangeriatric.org/health_care_professionals?clinical_practice/clinicalguidelines_recommendations/2012

CHAMP: Advancing Home Care Excellence (2009). Geriatric Medication Management Toolkit. Accessed September 19, 2013 at http://champ-program.org/page/101/geriatric-medication-management-toolkit

Clinical medication review: A practice guide (February, 2013). NHS: Cumbria. Accessed September 18, 2013 at http://cumbria.nhs.uk/ProfessionalZone/MedicineManagement/GuidelinesReview-PracticeGuide2011.pdf

Hamdy, R.C., Moore, S.W., Whalen, K., Donnelly, J.P., Compton, R., Testerman, F., et al. (1995). Reducing polypharmacy in extended care. South Med J, 88, 534–538.

Katzung, B. (2007) Special aspects in geriatric pharmacology. In: Katzung, B. Basic and Clinical Pharmacology. 10th Ed. New York, NY: McGraw Medical; 983-990.

National MTM Advisory Board, (2011). Definition of medication therapy management definition. Accessed September 19, 2013 at http://www.businesswire.com/news/home/20110804006226/en/National-MTM-Advisory-Board-Releases-Pharmacist-Service

Pham, C. B., & Dickman, R. L. (2007). Minimizing adverse drug events in older patients. American Family Physician, 76(12), 1837-1844.



Opioid Toxicity
Grace Varas, DO & Shobha Rao, MD

Medications
Overview     MI04sect1

Knowing the clinical manifestations of opioid toxicity and how to treat these are intricately tied to your ability to use opioids responsibly. Patients at high risk for opioid toxicity are those who receive high doses of opioids for prolonged periods of time or those with severe renal or hepatic impairment. Opioids require dosage adjustment in the elderly and in patients with renal or liver disease.

Generally, opioid toxicity is managed by ensuring adequate hydration, adjusting the dose or rotating to a different opioid.


Key Points     MI04sect2

Opioid toxicity may present as intractable nausea, somnolence, hallucinations, delirium, myoclonic jerk or hyperalgesia.

Sedation often precedes respiratory depression and is a warning sign to decrease the dose or increase the dosing interval.

There is a wide inter-individual variation in the dose of opioids that may cause toxicity and is dependent on pain response, rate of dose titration, concomitant medications, and renal and hepatic function.


Management     MI04sect3

Respiratory depression is managed by giving naloxone slowly over 10-30 minutes to avoid acute painful withdrawal symptoms. The half-life of naloxone is 3 times less than half-life of most opioids. Repeated injections may be needed.

When changing to a different opioid, remember that equianalgesic charts are based on average peak pharmacokinetics and different opioids are recognized by the body as a unique but related molecular configuration, i.e. there is incomplete cross-tolerance between opioids.

Equianalgesia charts are guidelines, as the patient's pharmacodynamics will dictate the response to the drug for that individual. Reduce your new opioid's dose by:

  • 25%, if patient is in mod-severe pain;

  • 50%, if patient's pain is stable and opioid rotation is necessary to minimize adverse effects.


Equivalent pharmacokinetic doses of common opioids:
Medication in milligrams/ route of administration Morphine Hydromorphone Hydrocodone Fentanyl Oxycodone
Parenteral 10 1.5 N/A 0.1
(100 mcg)
N/A
Oral 30 7.5 30 While use of oral fentanyl is highly restricted, an equivalent is the 12 mcg/hr. transdermal patch. 20-30
(references vary)

References     MI04sect4

Doyle D, Hanks G, Cherney N, Calman K, Eds.(2008). Oxford textbook of palliative medicine, 3rd Ed. New York, NY: Oxford Press.

Elsayem A, Driver L, Bruera E, Eds.(2008). MD Anderson supportive and palliative care handbook. Department of Palliative Care and Rehabilitation Medicine, The University of Texas Press.



Prescription Drug Misuse among Older Adults
David V. Flores, PhD, LMSW, MPH

Syndrome
Overview     MI05sect1

Prescription drug misuse among those 65 and older is reaching epidemic proportions in the U.S. and will continue to rise over the next several decades with the aging “baby boomer” population, the cohort with the highest prevalence of substance use historically (Culberson et al., 2011; Institute of Medicine, 2012; Kalapatapu & Sullivan, 2010; Maxwell, 2011; National Institute on Aging, 2013).

Risk Factors for Prescription Drug Misuse

  • Approximately one third of prescriptions issued in the U.S. are used by adults 65 and older and polypharmacy has been cited as one risk factor for misuse (Maxwell, 2011).

  • Older adults are also more likely to use psychoactive drugs and for longer duration than younger adults (Culberson et al., 2011).

  • Drugs often misused by older adults include opioids, stimulants, and benzodiazepines. These drugs are commonly prescribed for chronic pain, chronic health conditions, anxiety, insomnia, and depression (Culberson et al., 2011).

  • Wu and Blazer, using data from the 2002-2006 National Surveys on Drug Use and Health (NSDUH) of non-institutionalized older adults, found that nonmedical prescription drug misuse was associated with recent or current alcohol or drug use, cognitive impairment, chronic pain, long-term use of psychiatric medications, and suicidal ideation (2011).

  • Other comorbid conditions associated with prescription drug misuse include anxiety disorders and depression (particularly among women), chronic medical conditions or diseases (particularly among men), and alcohol abuse or dependence (Wu & Blazer, 2011).

Opioids

  • Among older patients 55 and over, physician prescriptions were the primary source for obtaining prescription opioids (Kalapatapu & Sullivan, 2010).

  • Opioid products most commonly misused include propoxyphene, hydrocodone, oxycodone, and codeine product.

Benzodiazepines

  • One in four older adults has used psychoactive medications in a potentially abusive manner (Simoni-Wastila & Yang, 2006).

  • Benzodiazepines are one of the most commonly prescribed psychiatric medications (Grohol, 2010) and research has found that longer duration of use or use of higher doses increases the likelihood of becoming benzodiazepine dependent (Kan, Hilberink, & Breteler, 2004).

  • Benzodiazepine misuse often occurs with alcohol or other substances (Culberson & Ziska, 2008).

  • Risk factors for benzodiazepine misuse include increasing age, comorbid depression, alcohol dependence, and polypharmacy (Kalapatapu & Sullivan, 2010).

Stimulants

  • Research on prescription stimulant use disorders in older adults is limited.

  • Findings from the 2007 Treatment Episode Data Set found that 7.87% of all admissions were for methamphetamine/amphetamine and 3.8% of those were individuals 50 and over (Substance Abuse and Mental Health Services Administration, 2009).

  • Older adults who chronically misuse amphetamines present with depressed mood, loss of interest, psychomotor slowing, suicidal ideations, and have been found to be resistant to antidepressant medications (Laqueille, Dervaux, El Omari, Kanit, & Bayle, 2005).


Key Points     MI05sect2

Increased prescription drug misuse and need for treatment is expected to rise given the aging of the baby boomer generation, the generation with the highest prevalence of substance use.

The true extent a prescription drug misuse and prescription drug diversion is unknown.

Most commonly misused prescription drugs (Manchikanti, 2006):

  • Oxycodone (Percodan, Percocet, Roxicet, Tylox, OxyContin)

  • Hydrocodone (Vicodin, Vicoprofen, Lorcet, Lortab)

  • Hydromorphone, methadone, morphine (Astramorph, Duramorph, MS Contin, Roxanol)

  • Codeine

  • Benzodiazepines- alprazolam (Xanax), lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin)

  • Carisoprodol (Soma)

  • Stimulants- methylphenidate (Ritalin, Concerta, Focalin), and amphetamine salts (Adderall, Adderall XR, Vyvanse)


Assessment     MI05sect3

The Consensus Panel on the Treatment Improvement Protocol (TIP) makes the following assessment recommendations:

  • Older adults 60 years and over should be screened for prescription drug misuse as a routine part of their regular physical examination.

  • Clinician referral for appropriate counseling and treatment should be conducted at regularly scheduled medical appointments when drug misuse is suspected (Wu & Blazer, 2011).

Several instruments have been developed and can be useful in the identification of prescription drug misuse:

  • The Drug and Alcohol Problem Assessment for Primary Care (DAPA-PC): http://dapaonline.com/

  • The Severity Dependent Scale http://www.who.int/substance_abuse/research_tools/severitydependencescale/en/index.html

  • Pain Assessment and Documentation Tool (PADT): http://www.opioidrisk.com/node/1210

  • http://www.opioidrisk.com/node/1210

  • Screener and Opioid Assessment for Patients with Pain (SOAPP): http://www.inflexxion.com/SOAPP/

  • Current Opioid Misuse Measure (COMM)

  • http://www.inflexxion.com/COMM

  • Opioid Risk Tool (ORT): http://www.opioidrisk.com/node/884


Interventions     MI05sect4

The Center for Substance Abuse Treatment recommends the following non-pharmaceutical interventions for treating substance use disorders in older adults:

  • Capital group-based therapy

  • Motivational interviewing

  • Substance use counseling

  • Cognitive behavioral Therapy

  • Individual counseling

  • A combination of pharmacotherapy and psychotherapy

  • Marital and family therapy

  • Institutional substance use rehabilitation treatment

  • Case management/community linked services and outreach


References     MI05sect5

Culberson, J.W., Ticker, R.L., Burnett, J., Marcus, M.T, Pickens, S.L., & Dyer, C. B. (2011). Prescription medication use among self neglecting elderly. Journal of Addictions Nursing, 221), 63-68.

Culberson, J.W., & Ziska, M. . (2008). Prescription drug misuse/abuse in the elderly. Geriatrics, 63(9), 22-31.

Grohol, J. M.A. (2010). Top 25 Psychiatric Prescriptions for 2009. Retrieved September 26, 2013, from http://psychcentral.com/lib/top-25-psychiatric-prescriptions-for-2009/0003170

Institute of Medicine. (2012a). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services, . Washington, DC: Institute of Medicine, The National Academies Press.

Intitute of Medicine. (2012b). The mental health and substance use workforce for older adults In whose hands? Washington, DC: National Academy of Sciences.

Kalapatapu, Raj K., & Sullivan, Maria A. (2010). Prescription Use Disorders in Older Adults. American Journal on Addictions, 19(6), 515-522. doi: 10.1111/j.1521-0391.2010.00080.x

Kan, C. C., Hilberink, S. R., & Breteler, M. H. . (2004). Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Comprehensive psychiatry, 45(2), 88-94.

Laqueille, X., Dervaux, A., El Omari, F., Kanit, M., & Bayle, F.J. . (2005). Methylphenidate effective in treating amphetamine abusers with no other psychiatric disorder. European Psychiatry, 20(5-6), 456-457.

Manchikanti, L. (2006). Prescription Drug Abuse: What is Being Done to Add ress This New Drug Epidemic? Testimony Before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9, 287-321A.

Maxwell, Jane Carlisle. (2011). The prescription drug epidemic in the United States: A perfect storm. Drug and alcohol review, 30(3), 264-270. doi: 10.1111/j.1465-3362.2011.00291.x

National Institute on Aging. (2013). Alcohol use in older people. Retrieved from http://www.nia.nih.gov/health/publication/alcohol-use-older-people.

Simoni-Wastila, L., & Yang, H. K. . (2006). Psychoactive drug abuse in older adults. American Journal of Geriatric Pharmacotherapy, 4, 380-394.

Substance Abuse and Mental Health Services Administration. (2009). National Admissions to Substance Abuse Treatment Services. Rockville, MD: Treatment Episode Data Set (TEDS). Highlights-2007 Retrieved from http://wwwdasis.samhsa.gov/teds07/tedshigh2k7.pdf.

Wu, Li-Tzy, & Blazer, Dan G. (2011). Illicit and Nonmedical Drug Use Among Older Adults: A Review. Journal of Aging and Health, 23(3), 481-504.



Preventing Polypharmacy
Nasiya Ahmed, MD

Medications
Key Points     MI06sect1

Polypharmacy is the use of multiple medications and/or the administration of more medications that are clinically indicated (Hajjar, Cafiero, & Hanlon, 2007).

Outpatient polypharmacy prevalence is estimated to be 6-42 percent in the elderly population (Slabaugh, Maio, Templin, & Abouzaid, 2011).

Thirty percent of hospital admissions in elderly can be linked to drug related effects and polypharmacy is the 5th leading cause of death for hospitalized elders.

Assessment and Management     MI06sect2

Use non-pharmacologic treatment measures first.

Always check medication regimen for drug-drug interactions.

Before initiating any treatment, make sure that the symptom requiring treatment is not a side effect of another drug.

Check drug levels (remember, toxicity can occur at even normal therapeutic levels in the elderly) and always adjust for creatinine clearance.

When discharging a patient, provide a written medication list and if necessary, instructions about medication changes (new medications, discontinued meds, meds that need monitoring).

Here are some helpful hints for common drug classes:

  • Antibiotics- Fluoroquinolones can cause some mental status changes, dose for creatinine clearance.

  • Anti-Emetics- Zofran is preferred to the more sedating older anti-emetics.

  • Anti-Histamines- Can cause confusion, urinary retention, constipation, somnolence.

  • Benzodiazepines- Avoid if possible, but do NOT stop suddenly.

  • Coumadin- To determine accurate starting doses try using the website.
    http://www.warfarindosing.org/Source/Home.aspx .

  • Diuretics- Beware of dehydration, hyponatremia, and hypotension.

  • Iron- Dose only once a day and for no more than 6 months at a time, beware of constipation.

  • NSAIDS- Increased risk of renal failure and GI bleed in elders.

  • Pain Medication-Stay away from using synthetic drugs such as Demerol.

  • PPIs- Decreased medication absorption and increased risk for clostridium.


References     MI06sect3

Chutka, D.S. (1995). Drug Prescribing in the Elderly. Mayo Clinic Proceedings; 70:685-93.

Fick, D., Semla, T., Beizer, J., Brandt, N., Dombrowski, R., DuBeau, C. E., et al. (2012). American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(4), 616-631. Retrieved from SCOPUS database.

Hajjar, E.R., Cafiero, A.C., & Hanlon, J.T. (2007). Polypharmacy in elderly patients. American Journal of Geriatric Pharmcotherapeuitcs; 5(4):345-351. Doi:10.1016/j.amjopharm.2007.12.002.

Slabaugh, S.L, Maio, V., Templin, M., & Abouzaid, S. (2011). Prevalence and Risk of Polypharmacy among the Elderly in an Outpatient Setting: A Retrospective Cohort Study in the Emilia-Romagna Region, Italy. School of Population Health Faculty Papers. Paper 44.
http://jdc.jefferson.edu/healthpolicyfaculty/44



Delirium
Susan Gorman, MSN, RN, GNP &
Kathleen Pace Murphy, PhD, MS

Neuro-Psych Disorders
Key Points     NS01sect1

  • Approximately 14-56% of all hospitalized older adults experience delirium (Fong, Tubevaev, & Inouye, 2009).

  • Older adults admitted to Intensive Care Units have a 70-80% incidence of delirium (Fong, Tubevaev, & Inouye, 2009).

  • Delirium is associated with up to a 10-fold increase in risk for medical complications, including death (Inouye, 2006).


Overview     NS01sect2

  • Delirium is an acute clinical state with fluctuating change in mental status and varying levels of attention and consciousness.

  • Delirium is often a missed diagnosis.

  • It is important to recognize the signs and symptoms of delirium, determine the causative factor (s) and treat those factor(s).

Delirium may be classified as:
  • Hyperactive (increased activity with agitation);

  • Hypoactive (drowsiness, lethargy); or

  • Mixed states (clinical components of both Hyperactive and Hypoactive).

Delirium is often a symptom of a serious illness in older adults; and sometimes the only presenting symptom.

Delirium is associated with prolonged hospitalization, functional decline, and increased use of chemical and physical restraints.

Factors that precipitate delirium can be remembered using the mnemonic DELIRIUM:

Drug use (hypnotics, anticholinergic)
Electrolyte abnormalities
Lack of drugs (withdrawal)
Infection
Reduced sensory input (blindness, deafness
Intracranial problems (stroke)
Urinary retention and fecal impaction
Myocardial problems (MI, heart failure, arrhythmias).

Assessment     NS01sect3

Delirium assessment includes utilizing the Confusion Assessment Method (CAM) developed by Sharon K. Inouye (2006).

The CAM has 4 Features:

  1. Acute Onset and Fluctuating Course: Is there evidence of an acute change in mental status from patient's baseline? This is usually best answered by someone close to the patient, such as family, a care provider, or a nurse.

  2. Inattention: Did the patient have difficulty focusing? Were they easily distracted or could they not stay awake?

  3. Disorganized Thinking: Was the patient's thinking disorganized or incoherent?

  4. Altered Level of Consciousness: Overall, how would you rate this patient's level of consciousness? The answer should be anything other than alert (normal).


For the CAM to be positive for delirium, it requires the presence of both features 1 and 2, AND either 3 or 4.

The following table is helpful in distinguishing dementia from delirium:

Dementia and Delirium Comparative Table
Dementia Delirium
Onset Insidious Rapid associated with an identified event
Main symptom Loss of memory, especially recent event(s) Inattention
Etiology May be related to underlying brain disorder, such as Alzheimer disease, vascular dementia, or Lewy body dementia Nearly always related to underlying acute change, such as dehydration, infection, or starting or stopping medications
Orientation Impaired Fluctuates
Level of consciousness May be normal until advanced stages Fluctuates
Language May be problematic with word choices Slowed or rapid speech, frequently with incoherent and/or inappropriate language
Progression Slow Causes variations in mental function- people are alert one moment and sluggish and drowsy the next
Development Often permanent Fluctuates; days to weeks to months
Treatment Needed; slows progression but does not cure Immediate; usually reversible
Table Source: Ehlenbach, Hough, Crane, Haneuse, Carson, Randall, & Larson, (2010); Fong, Tubevaev, & Inouye, (2009); Inouye (2006a) (2006b).



Management     NS01sect4

Identify and treat the underlying cause of delirium (i.e. infection, drugs, electrolyte imbalance).

Reassure the patient by having well known family members or caregivers at the bedside.

Discern day from night surroundings (decreased stimulation at night to promote sleep; blinds open during day with more activity).

Avoid bed rest if possible and the use of restraints (chemical or physical).

Encourage interprofessional interventions:

  • physical and occupational therapy (increase ambulation, range of motion, decreasing bed rest time);

  • consult with pharmacist and do a complete medication review (rule out medications that are causing delirium, for example, anti-cholinergic drugs);

  • nursing interventions to insure urinary catheters are removed (prevent urinary tract infections), no fecal impactions, no pressure ulcers, frequent re-orientation, insure patient is wearing glasses and hearing aids (decrease sensory deprivation) and assessment of the patient's cognitive and physical status;

  • dietary consult to insure proper fluid and nutrition (prevent dehydration and low caloric intake).


Additional Web-based educational resources:     NS01sect5


Delirium: Acute Confusional State. Pub Med Health (2013):
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001749/

YouTube: How to recognize delirium
http://www.bing.com/videos/search?q=delirium&FORM=VIRE2#view=detail&mid=62CF4E1FB202267D0DB262CF4E1FB202267D0DB2

References     NS01sect6

Ehlenbach, W.J., Hough, C.L., Crane, P.K., Haneuse, S.J.P.A., Carson, S.S., Randall Curtis, J., & Larson, E.B. (2010). Association between acute care and critical illness hospitalization and cognitive function in older adults. Journal of American Medical Association, 303(8), 763-770.

Fong, T.G., Tubevaev, S.R., & Inouye, S.K. (2009). Delirium in elderly adults: Diagnosis, prevention and treatment. National Review of Neurology, 5(4):210-220. Doi:10.1038/nrneurology.209.24. Retrieve from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/

Inouye, S. (2006a). Delirium in older persons. New England Journal of Medicine, 354(11), 57-65.

Inouye, S. (2006b). Geriatrics At Your Fingertips (9th Ed.) New York: The American Geriatrics Society.



Dementia: A brief overview
Renee Flores, MD & Naysia Ahmed, MD

Neuro-Psych Disorders
Key Points     NS02sect1

Dementia describes a syndrome caused by chronic and/or progressive brain disease affecting higher cortical function.

It is estimated that the prevalence of Alzheimer 's disease will triple by 2050.

Mild cognitive impairment (MCI) may be described as a transition phase between cognitive changes from normal aging and dementia.


Overview     NS02sect2

Dementia is an umbrella term that includes:

  • Alzheimer's Disease
    • Damage to the brain includes development of plaque, neurofibrillary tangles, synaptic loss, neuronal atrophy
    • Clinical manifestations may include impairment of memory, functional impairment, apraxia, aphasia, agnosia, executive function dysfunction
    • Insidious progression

  • Vascular Dementia
    • Accounts for 33% of dementias
    • History or presence of cerebrovascular accident with positive radiologic infarct finding
    • Progression may be both rapid and related to stroke-like event or stepwise delayed recall
    • Concomitant depression is common

  • Frontotemporal Dementia
    • Pathology of frontal and anterior temporal areas; frontotemporal lobar degeneration
    • Early age of onset
    • Early behavioral changes are a red flag: disinhibition, apathy, hyperorality, inappropriate social interaction
    • Poor execute and language function and relatively spared memory

  • Parkinson Disease Dementia
    • Typical subcortical pattern: impairments in attention, executive function and visuospatial function
    • Insidious onset
    • Variable rates of progression
    • Depression is very prevalent (some estimates up to 50%)

  • Dementia with Lewy Bodies
    • Triad of symptoms – fluctuating cognition, Parkinson-like symptoms and visual hallucination
    • Other symptoms may include REM sleep disorders and frequent falls

Risk factors include:

  • Advancing age

  • Family history and genetics

  • History of psychiatric disorders

  • History of head trauma

  • Cardiovascular disease and related risk factors

  • Alcohol misuse, drug misuse, and toxins

  • Vasculitis

  • Endocrine disorders


Assessment     NS02sect3

Assess for delirium before dementia. The CAM is a recommended screening tool:
http://www.pogoe.org/AngelUploads/applications/Dementia/Content/mmse_va.html

Some comparative facts include

Comparing Dementia and Delirium
Dementia Delirium
Onset Insidious, with an uncertain starting point Rapid, usually with a certain starting point
Main symptom Loss of memory, particularly for a recent event(s) Inattention
Cause May be related to an underlying brain disorder, such as Alzheimer disease, vascular dementia, or Lewy body dementia Nearly always related to underlying acute change, such as dehydration, infection, or starting or stopping medications
Orientation Impaired Fluctuates
Level of consciousness May be normal until advanced stages Fluctuates from being lethargic to hyperalert
Language May be problematic with word choices Slowed or rapid speech, frequently with incoherent and/or inappropriate language
Progression Slowly progresses, gradually but eventually greatly impairing all mental functions Causes variations in mental function- people are alert one moment and sluggish and drowsy the next
Development Often permanent Fluctuates; days to weeks to months
Treatment Needed but less urgently; slows progression but does not cure Immediate; usually reversible


Once delirium is ruled out, the next steps are:

  • The evaluation of a patient with suspected dementia should focus upon the history.
    • Family members or other informants who know the patient well are invaluable resources for providing an adequate history of cognitive and behavioral changes.
    • Adequate time should be arranged for a full assessment of cognitive function, followed by a complete physical examination, including neurologic examination.
    • Ask simple yes or no questions

  • Diagnostics include:
    • Neuropsychological testing
    • Cognitive screening tests- St. Louis University Mental Status (SLUMS) or the Mini-Cog
    • Depression screening tests – Geriatric Depression Scale (GDS) or Hamilton Depression Rating Scale (HDRS)
    • Functional Level of Independence – Katz Index of Activities of Daily Living (ADL) or Lawton Instrumental Activities of Daily Living Scale (IADL)
    • Laboratory evaluation – Complete blood count, complete metabolic panel, thyroid screen, Vitamin B12 and folate, C reactive protein, RPR, Lipid panel, HIV screen, sedimentation rate and other test as indicated by the history and physical
    • Neuroimaging, MRI (preferred) or CT to rule out potentially treatable intracerebral lesions (Normal Pressure Hydrocephalus, subdural hematoma) and to rule out cortical and subcortical infarcts, white matter changes, localized atrophy.
    • Other investigations – CSF fluid evaluation, genetic testing, and EEG


Treatment     NS02sect4

  • Dependent on stage and type of dementia

  • Goals include:
    • Stabilize cognitive ability
    • Improve mood
    • Promote autonomy
    • Effective future planning

  • Interprofessional team interventions include both non-pharmacologic and pharmacologic strategies.

References     NS02sect5

Alzheimer's Association (2012). 2012 Alzheimer's Disease Facts and Figures - Alzheimer's Association. Retrieved from http://www.merck.com/mmhe/sec06/ch083/ch083a.html

Alzheimer's Association (2012). Basics of Alzheimer 's disease: What is it and what you can do. Retrieved from http://www.alz.org/national/documents/brochure_basicsofalz_low.pdf . Accessed November 1, 2013.

American Medical Association (2013). Dementia. Retrieved from http://www.ama-assn.org//ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/dementia.page Accessed November 1, 2013.

Feldman, H.H., Jacova, C., & Robillard, A. (2009). Diagnosis and Treatment of Dementia. Canadian Medical Association Journal; 178(7):825-836.

Lawton, M.P., & Brody, E.M. (1969). Assessment of older people: Self-maintaining and instrumental activites of daily living. Gerontologist, 9:179.

Sheikh, J.L. Yesavage, J.A. (1986) Geriatric Depression Scale (GDS): Recent evidence and development of shorter version. Clinical Gerontologist, 5:165.

U.S. Preventative Services Task Force (2003). Screening for dementia: recommendations and rationale. nnals of Internal Medicine; 138: 925-926. http://www.preventive services.ahrq.gov



Depression in the Elderly
Renee Flores, MD

Neuro-Psych Disorders
Key Points     NS03sect1

Depression in the older adult
  • amplifies disability/pain

  • lessens quality of life and increases mortality

  • results in increasing office and emergency department visits

  • results in more prescription and OTC medication use

  • leads to increased alcohol and drug use

  • increases length of hospital stay

Mental health treatment for depressed older adults is delivered over 80% in the primary care setting.

It is estimated that 10-15 percent of older adults with intact cognitive functioning have depression. Health care providers should screen all hospitalized geriatric patients for depression.

Greater than 50% of nursing home residents are depressed.

Dementia syndrome of depression is defined as a cognitive impairment present in an elderly patient with major depression that may have cognitive deficits that develop after the onset of mood symptom.


Assessment     NS03sect2

All older adult patients should be screened for depression.

Assessment of the older adult suspected of being depressed includes:

  • A complete and thorough medical and psychiatric history

    • Presence of suicidal ideation and plan (lethality, intent, and means).

    • Acute suicidal ideation requires urgent psychiatric referral. Unlike the younger population, elderly attempt suicide less often, but are usually more successful.

  • Review of system - ask specifically about hopelessness, insomnia, and psychotic symptoms.

  • Conduct a complete medication review (prescribed, OTC, and homeopathic) evaluating potential side effects that may cause depression.

    • Assess potential drug-drug interactions with substances such as alcohol, opiates, benzodiazepines, and other CNS depressants.

  • Utilize a standardized, reliable and valid geriatric screening tool such as the Geriatric Depression Scale. This scale has a 5, 15 or 30 question scale available for clinicians. See the 5 question scale below:

Use the Geriatric Depression Scale (GDS) to screen for depression (Hoyt et al., 1999):
Are you basically satisfied with your life? Yes No
Do you often get bored? Yes No
Do you often feel helpless? Yes No
Do you prefer to stay at home, rather than going out and doing new things? Yes No
Do you feel pretty worthless the way you are now? Yes No
Two out of five depressive responses ("no" to question 1 or "yes" to questions 2 through 5) suggests the diagnosis of depression.

Interventions     NS03sect3

  • An interprofessional team approach is important to provide support to your patient and their family.

    • Include family members wherever possible in diagnosis and treatment.

    • Utilize Chaplain Services, Social Work, Psychiatry and Psychology to assist with non-pharmacologic services.


  • Psychotherapy and pharmacotherapy may be used as monotherapy or in combination.

    • Elder adults respond well to psychotherapy, although pharmacotherapy or a combination of pharmacotherapy and psychotherapy is recommended for moderate to severe depression.

    • For depressed patients with chronic and or life-threatening illness, use a combination of supportive psychotherapy, cognitive approaches, behavioral techniques, and antidepressant medication.

    • Medicare covers therapy services.


  • Exercise may be effective in the treatment of minor or major depression in the elderly.

    • Patients with major depression, however, may be difficult to engage in an exercise program and would likely benefit from concomitant pharmacotherapy or psychotherapy.

  • Important pharmacologic treatment considerations in the elderly are:

    • Initial medication dosage should be low and then adjusted for the elder adult; typically starting half the usual starting dose for patients (however, full therapeutic doses are often required to achieve the desired responses).

    • Typically take two to four weeks to show efficacy; in older patients a full antidepressant response may not occur until 6 to 8 weeks of therapy.

    • Life-long treatment may be necessary to prevent recurrence.

    • All patients should be followed up within two weeks of initiating medication to discuss tolerance, assess response, monitor for adverse events and adjust dose as indicated.

    • First line: SSRIs are first-line antidepressants because of safety and tolerability.

    • Second line: venlafaxine, duloxetine, mirtazapine, or bupropion.

    • Third line: Consider augmentation of first-or second line antidepressants with aripiprazole or quetiapine, or SSRI with buspirone or bupropion. Alternatively, consider switching to a different classification of medication.

    • Older adults should be assessed for relapse.

    • The table below provides basic information regarding medications for the treatment of depression:


Class Medication Initial Dosage Usual Dosage Formulation Comments
SSRIs Class Adverse Events: EPS, hyponatremia, increased risk of upper GI bleeding, suicide (early in treatment), lower BMD and fragility fractures, risk of toxicity if methylene bile or linezolid co administration. Avoid if history of falls or fractures; caution if history of SIADH
Citalopram (Celera) 10-20 mg po qam 20 mg/day T: 20,40,60
S: 5mg/10ml
20 mg/day is max dose in age >60; concerns about dose-dependent QT interval prolongation that can lead to arrhythmias
Escitalopram (Lexapro) 10 mg po qam 10 mg/day T: 10,20 10 mg/day is max dose in age>60
Fluoxetine (Prozac) 5 mg po qam 5-60 mg/day T: 10 C: 10,20, 40; C SR90
S: 20mg/5ml
Long half-lives of parent and active metabolite; may cause more insomnia than other SSRI
Paroxetine (Paxil) 5 mg po qam
CR: 12.5mg po qam
10-40 mg/day
CR: 12.5-37.5 mg/day
T: 10,20,30,40


CR: T: ER 12.5, 25, 37.5

CR: S: 10mg/ml

CR: Increase by 12.5 mg no faster than once/week
Helpful with anxiety symptoms; increased risk for withdrawal symptoms (dizziness); anticholinergic events
SNRIs Caution with history SIADH. Most common adverse events: nausea, dry mouth, constipation, diarrhea, urinary hesitance; reduce dosage if CrCl 30-60 ml/min; contraindicated if CrCl < 30 ml/min
Duloxetine (Cymbalta) 20 mg po qam, then 20 mg po q12h 40-60 mg q24h or 30 mg q12h C: 20,30,60 Useful in patients with depression and neuropathic pain
Venlafaxine (Effexor) 25-50 mg po q12h



XR: 75 mg po qam
75-225 mg/day in divided doses
XR: 75-225 mg/day
T: 25, 37.5, 50, 75, 100



XR: 37.5, 75, 150
Low anticholinergic activity; minimal sedation and hypotension; may increase BP and QTC; may be useful when somatic pain present; EPS, withdrawal symptoms, hyponatremia
Desvenlafaxine (Pristiq) 60 mg po qam 50-400 mg/day SR T: 50,100 Active metabolite of venlafaxine; adjust for CrCl <30ml/min
TCAs Caution in the elderly due to significant arrhythmic side effects, anticholinergic effects causing urinary retention, orthostasis, and possible exacerbation of dementia.
Desipramine (Norpramin) 10-25 mg po qhs 50-150 mg/day T: 10,25,50,75, 100, 125 Therapeutic serum level >115 ng/ml
Nortriptyline 10-25 mg po qhs 75-150 mg/day C: 10,25,50,75, 100,150
S: 10mg/5ml
Therapeutic window 50-150 ng/ml
Additional Options Consider for SSRI, TCA nonresponders; safe in HR; may be stimulating; can lower seizure threshold.
Buproprion (Wellbutrin) 37.5-50 mg po q12h 75-50 mg q12h T: 75,100
Wellbutrin SR (Zyban) SR: 100 mg po q12h or q24h 100-150 mg q12h T: 100,150,200
Wellbutrin XL 150 mg po qday 300 mg/day T: 150,300
Methylphenidate (Ritalin) 2.5-5 mg po q7am and q12pm 5-10 mg at 7am and 12p T: 5,10,20 Short term treatment of depression or apathy in physically ill older adults; avoid if insomnia; used as adjunct
Mirtazapine (Remeron) 15 mg po qhs 15-45 mg/day T: 15,30,45; ODT (SolTab available) Useful for patients with insomnia, agitation, restlessness, or anorexia and weight loss; sedating


ECT may be effective for the older patient who is unable to tolerate medications or who is not responding to medications. ECT causes transient memory loss.

References     NS03sect4

Alexopoulos, G. (2005). Depression in the Elderly. The Lancet; 365:1961-1970.

Areán, P.A., & Cook, B.L. (2002) Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biological Psychiatry; 52:293.

Bao, Y., Post, E.P., Ten, T.R., et al. (2009). Achieving effective antidepressant pharmacotherapy in primary care: the role of depression care management in treating late-life depression. Journal of the American Geriatric Society; 57:895

Beyer J. (2007). Managing Depression in Geriatric Populations. Annals of Clinical Psychiatry; 19(4):221-238.

Bruce, M.L., Ten Have, T.R., Reynolds, C.F. et al. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. Journal of the American Medical Association; 291:1081.

Delgado-Guay, M., Parsons, H., Li, Z., et al. (2009). The association between anxiety, depression, and physical symptoms in patients with advanced cancer. Support Care Cancer; 17:573-579.

Hoyl, M.T., Alessi, C.A., Harker, J.O., et al. (1999). Development and testing of a five-item version of the Geriatric Depression Scale. Journal of the American Geriatric Society; 47:873.

Licht-Strunk, E., Van Marwijk, H.W., Hoekstra, T., et al. (2009). Outcome of depression in later life in primary care: Longitudinal cohort study with three years' follow-up. British Medical Journal; 338:a3079.

Lloyd-Williams, M., Dennis, M., & Taylor, F. (2004). A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer. Palliative Medicine; 18:558-563.

Pinquart, M., Duberstein, P.R., & Lyness, J.M. (2006). Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry; 163:1493.

Sjösten, N., Kivelä, S.L. (2006). The effects of physical exercise on depressive symptoms among the aged: a systematic review. International Journal of Geriatric Psychiatry; 21:410.

Thielke, S.M., Fan, M.Y., Sullivan, M., & Unützer, J. (2007). Pain limits the effectiveness of collaborative care for depression. American Journal of Geriatric Psychiatry; 15:699.

Vignaroli, E., Pace, E., Willey, J., et al. (2006). The Edmonton Symptom Assessment as a Screening Tool for Depression and Anxiety. Journal of Palliative Medicine; 9:296-303.



Seizures in the Elderly
Melanie Zuo, MD

Neuro-Psych Disorders
Overview     NS04sect1

Nearly 25% of new seizures occur in individuals over the age of 65 years (Leppick & Birnbaum, 2010).

The prevalence rate of epilepsy in community-dwelling elderly is 1.5% (Leppick & Birnbaum, 2010).

Seizures may lead to early loss of independence, emergency department visits, falls, and/or status epilepticus.

The most common causes of seizure in the elderly are:

  • acute stroke,

  • metabolic encephalopathy,

  • medications,

  • dementia,

  • head trauma, and

  • intracranial tumors.

A distinction must be made between seizures arising from brain pathology (epileptic) and those arising due to an alteration in physiology, such as hypoxia (provoked).

Sleep apnea, which is common in the elderly, probably does not cause seizures but may lower the seizure threshold.

Clinical Presentation     NS04sect2

The most frequent seizure type in new onset geriatric epilepsy is complex partial seizures.

Complex partial seizures in the elderly can present atypically with parasthesias, dizziness, muscle cramps, confusion, sleepiness, staring spells, and clumsiness. Tonic-clonic movements and automatisms are usually not seen.

Health care providers should consider seizure when there is a history of recurrent episodes of loss of awareness, confusion, and/or shaking that occurs the same way each time and is not attributable to vascular abnormalities or syncope.

Unrecognized seizures in the elderly can cause memory dysfunction, falls, and lead to incorrect diagnosis of delirium or dementia.


Assessment     NS04sect3

Initial evaluation includes:

  • thorough history to identify precipitating factors;

  • thorough physical exam;

  • geriatric functional assessment;

  • EKG;

  • laboratory tests to evaluate potential metabolic disorders;

  • review of prescription and over-the-counter medications;

  • computerized tomography (CT) scan should be performed, followed by magnetic resonance imaging if no obvious pathology is detected on CT scan; and

  • EEG can detect interictal patterns to confirm an epileptic seizure and provide information on severity of epilepsy.

The presence of cognitive abnormalities, focal abnormality on EEG, and abnormal imaging can increase risk of seizure recurrence.


Treatment     NS04sect4

Consider treating after the first epileptic seizure occurrence in the elderly. When deciding on treatment take into account the adverse effect profile and altered pharmacokinetics in the elderly. Many anti-epileptics can cause sedation.

Treatment suggestions include:

  • Lamotrigene requires a slow titration (over 4-6 weeks duration) starting with 25 mg daily and increasing the dose by 25 mg every 2 weeks for goal of approximately 100 mg daily.

  • Levetiracetam can be started immediately at therapeutic doses. For many elderly adults 250 mg twice daily will be adequate.*

  • Gabapentin should be titrated over 2 weeks beginning with 300 mg at bedtime and increasing to 300 mg twice daily then 300 mg thrice daily for a goal of approximately 600 mg thrice daily. *

  • Carbamazepine has many drug-drug interactions and is not as well tolerated as lamotrigene and gabapentin.

  • Phenytoin is the most commonly prescribed anti-epileptic but has adverse cognitive effects and requires careful dose adjustment. Newer anti-epileptic drugs are more suitable for use in the elderly.

*The dose may need to be adjusted for renal insufficiency by decreasing the goal dose and decreasing the rate of titration. Observe for excess sedation.


References     NS04sect5

Leppik, I.E., & Birnbaum, A.K.(2010). Epilepsy in the elderly. Annals of New York Academy of Sciences: 1184: 208-224

Pugh, M.J., Cramer, J., Knoefel, J., Charbonneau, A., Mandell, Kazis, A., & Berlowitz, L. (2004). Potentially inappropriate antiepileptic drugs for elderly patients with epilepsy. Journal of American Geriatric Society;52 (3): 417-422.

Ramsay, R.E., Rowan, A.J., & Pryor, F.M. (2004). Special considerations in treating the elderly patient with epilepsy. Neurology:62(5 Suppl 2):S24-S29.

Rowan, A.J., Ramsey, R.E., Collins, J.F., Pryor, F., Boardman, K.D., Uthman, B.M., et al., Tomyanovich, M.L., (2005). New onset geriatric epilepsy: A randomized study of gabapentin, lamotrigine, and carbamazepine. Neurology:64(11):1868-1873.



Advance Care Planning
Linh Nguyen, MD

Pallative
Overview     PA01sect1

A patient's medical and end of life preferences are often not known. Predicting what treatment patients will want is complicated by the patient's age, the nature of the illness, the ability of medicine to sustain life, and the emotions families endure when their loved ones are sick and possibly dying.

Health care providers may provide assistance to a patient by explaining the following terms:

Advance directives
Also known as living wills.

These are legal documents authorized by state laws that allow patients to continue personal autonomy and provide instructions for care in case they become incapacitated and cannot make decisions.

An advance directive may also include a durable power of attorney.


Durable power of attorney
Also known as a health care proxy.

This document allows the patient to designate a surrogate, a person who will make treatment decisions for the patient if the patient becomes too incapacitated to make such decisions.


Key Points     PA01sect2

AHRQ-funded research studies have shown the following:

Patients need more effective advance care planning.

Among patients 65 years and older, patient satisfaction is increased when physicians discuss advance care planning and directives.

Acceptance or refusal of invasive and noninvasive treatments under certain circumstances can predict what other choices the patient would make under the same or different circumstances.

Patients were likely to accept or refuse treatment based on how invasive they perceive treatment to be and how long the treatment is expected to last.

Patients were more likely to refuse treatment for a scenario with a worse prognosis.

AHRQ-funded research suggests a five-part process to structure discussion on end-of-life care:

  1. Initiate a guided discussion (see Family Meeting Gem and Pearl).

  2. Introduce the subject of advance care planning and offer information.
    • Patients should be encouraged to complete both advance directive and durable power of attorney.

  3. Prepare and complete advance care planning documents.
    • Advance care planning documents should contain specific instructions. AHRQ studies indicated that standard language contained in advanced directives often is not specific enough to be effective in directing care.

  4. Review the patient's preferences on a regular basis and update documentation.

  5. Apply the patient's desires to actual circumstances.


References     PA01sect3

Advance Care Planning, Preferences for Care at the End of life.
http://www.ahrq.gov/research/findings/factsheets/aging/endliferia/index.html



Debility Unspecified & Failure to Thrive:
Common Hospice Diagnoses

Linh Nguyen, MD

Pallative
Overview     PA02sect1

Debility Unspecified and Failure to Thrive diagnoses allow more patients to appropriately receive hospice benefits.

While not always evident initially, upon further review the patient may have multiple risk factors which, when grouped together, meet hospice criteria.

Multiple risk factors may include sudden or progressive decline in:

  • nutritional intake,

  • function,

  • weight loss, and

  • mental function (disorientation, confusion or delirium).


Diagnostic studies or treatment may have been offered but declined, or not feasible.

Common objective hospice tools may be utilized to show a decline in:

  • body mass index (BMI),

  • palliative performance scale,

  • mid-muscle area measurement,

  • functional assessment scale level,

  • and diagnostic studies including: ejection fraction, glomerular filtration rate, forced expiratory volume in 1 second, or blood studies.


Multiple borderline factors justify hospice admission.

Assessment     PA02sect2

General hospice guidelines

  • Terminal prognosis of 6 months or less and patient/family have elected palliative care

  • Declining functional status

    • Palliative performance scale (PPS) ≤50-60%

    • Dependence in 3 of 6 ADLs


  • Alteration in nutritional status: more than 10% loss of body weight over last 4-6 months

  • Observable and documented deterioration in overall clinical condition in the past 4-6 months, as manifested by at least one of the following

    • Multiple (≥3) hospitalizations or emergency department visits

    • Decrease in tolerance to physical activity

    • Decrease in cognitive ability


  • Other comorbid conditions

See disease-specific guidelines for other hospice diagnoses

Diagnosis of Failure to Thrive and Debility Unspecified     PA02sect3

  • Failure to Thrive

    • Strictly a weight loss diagnosis

    • BMI < 22

    • Unexplained weight loss
    • An obese patient may have BMI > 22 but lost 20% or more their body weight

    • No other medical problems but functional decline


  • Debility Unspecified

    • Used when no other diagnosis for a terminally ill patient is appropriate

    • Has multiple risk factors for decline yet does not meet hospice criteria in any one specific diagnostic category

    • Hospice referral may be made by a primary physician who has known the patient well enough to notice a definite physical or mental decline and strongly believes the patient is at risk of dying

    • Family and caregivers usually confirm the decline

    • The most serious disease is used as a monitoring base



Key Points     PA02sect4

  • Patients who do not meet disease specific guidelines can still receive hospice benefits if they have multiple comorbid conditions that put them at risk of dying.

  • As of May 2013, there was a proposal for Medicare and Medicaid to review these diagnoses; however, the rules have not changed as of this writing.


References     PA02sect5

VITAS. (2013). VITAS Hospice Eligibility Reference Guide [Mobile application software]. Retrieved from http://itunes.apple.com

http://evercarehospice.com/files/7113/7538/1730/HospiceMemo-DebilityAFTT.pdf



Dying Process
Jeanette G. Ferrer, DO

Pallative
Overview     PA03sect1

Each person's physical decline and death are unique experiences. Variations appear to be dependent on the individual's particular disease process. However, the following are objective signs that are commonly seen in patients closer to the end of life.

Early Stage of Dying (weeks to months prior to death)

  • Decreased ambulation, loss of ability to transfer, bed confinement;

  • Withdrawal from surroundings and relationships;

  • Internal reflection of life and initiation of legacy activities;

  • Decreased oral intake;

  • Incontinence of bowel and/or bladder;

  • Increased fatigue.


Middle Stage of Dying (days to weeks prior to death)

  • Episodes of delirium which may include delusions, agitation, confusion, picking/restless behaviors, and alterations of sleep/wake cycle;

  • Less communication: patient may cease to speak;

  • Lower blood pressure;

  • Pulse irregularities;

  • Increasing episodes of sleep;

  • Decreased oral intake and loss of thirst sensation and appetite;

  • Decreased urine output.


Late Stage of Dying (hours to days prior to death)

  • A paradoxical surge of energy: patient may move/talk/eat when previously lethargic;

  • Decreasing level of consciousness;

  • Irregular breathing: a common respiratory pattern is Cheyne-Stokes respiration in which rapid breaths are followed by periods of apnea;

  • Loud, rattled breathing (death rattle) from pooled secretions in the hypopharynx;

  • Hemodynamic changes, weak/thready pulse, cool extremities, and mottling (purplish reticular discoloration of the skin) beginning from distal extremities;

  • The neck may become hyperextended;

  • The face may relax resulting in a loss of wrinkles, especially on the forehead and the nasolabial folds;

  • Perioral, perinasal and periocular pallor is common, eliciting an almost yellow waxen appearance to the face;

  • At a certain point, there will be cessation of cardiac and respiratory function necessary to sustain life.


References     PA03sect2

Kehl, K. A. &Kowalkowski, J.A. (2013). A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. American Journal of Hospice and Palliative Care: 30(6): 601-616.

Lamers, W.(online). Signs of approaching death. Hospice Foundation of America. Retrieved October 16, 2013 at http://www.hospicefoundation.org/deathsigns .

Moneymaker, K.A. (2005). Understanding the dying process: Transitions during final days to hours. Journal of Palliative Medicine, 8 (5):PMID:16238528.

Plonk, W. &Arnold, R. (2005). Terminal care: The last weeks of life. Journal of Palliative Medicine, 8(5): 1042-1054.



Dyspnea
Nneamaka Enwemnwa, MD

Pallative
Overview     PA04sect1

Dyspnea is a subjective sensation of difficulty breathing.

Dyspnea is one of the most common symptoms encountered at the end of life.

The causes are multi-dimensional including:

  • lung or heart conditions,

  • anemia, anxiety,

  • chest wall pathology,

  • electrolyte disturbances,

  • urinary retention or

  • constipation.

Anxiety, fear of impending death and pain contribute to the subjective symptoms of dyspnea.


Management     PA04sect2

Step 1:
Assess intensity via subjective report, visual analog scale, and physical examination. Other evaluation tools include pulse oximetry and if indicated Chest X-Ray.

Step 2:
Treatment of underlying causes as indicated:
  • Pleural effusion: drainage if the effusion is significant

  • Anemia: transfusion of packed red blood cells

  • Airway obstruction by tumor: corticosteroids (e.g., dexamethasone), radiation therapy

  • Carcinomatous lymphangitis: corticosteroids (e.g., dexamethasone)

  • Underlying COPD: optimize use of bronchodilators, addition of steroids

  • Pulmonary embolism: anticoagulant

  • Pneumonia: antibiotics (oral route preferred).

Step 3:
Symptomatic measures may include the following:
  • Supplemental oxygen can be helpful for symptom control. Most patients prefer nasal prongs instead of facial masks.

  • Opioids: Systemic opioids reduce the subjective sensation of dyspnea without reducing respiratory rate or O2 saturation.

  • Diuretics: Patients with congestive heart failure or noncardiogenic pulmonary edema may benefit from furosemide 10 - 20 mg IV/SC.

  • Benzodiazepines: Have not been found in randomized controlled trials to be effective in the management of dyspnea. They can be effective in patients with specific indications, such as major anxiety episodes.


References     PA04sect3

Bruera, E. & Elsayem, E. (2008). The MD Anderson Supportive and Palliative Care Handbook. Houston, Texas.

Doyle, D., Hanks, G.,Cherny, N., et al. (2003). Oxford Textbook of Palliative Medicine, Third edition. Edinburgh, UK: Oxford University Press.

Viola, R., Kileley,C., Lloyd, N.S., Mackay, J.A. et al. (2008). The management of dyspnea in cancer patients: A systematic review. Support Care Cancer;16:329-337.



Family Meeting
Linh Nguyen, MD

Pallative
Overview     PA05sect1

Family meetings are an important strategy for communicating and negotiating goals of care in geriatric and palliative patients.

A family meeting is typically indicated when delivering bad news, prognosis discussions, withholding or withdrawing treatments, or hospice discussions.

Meetings should be proactive when possible and not reactive to crisis situations. Family meetings should be offered routinely and conducted at pertinent times thereafter.

Provide a safe environment that is mutually beneficial.


Intervention/Management     PA05sect2

Six-step patient-centered goal(s) approach:

  1. Prepare and plan:

    • Establish setting

    • Identify key stakeholders

    • Conduct a pre-meeting "huddle" to align agenda - do not have rigid pre-set expectations.


  2. Find out what the patient and family want to know:

    • Provide sufficient time for patients and families to "tell their story"

    • The more patients and families speak early on the better.

    • Build relationships,

    • Actively listen,

    • Respect differing preferences.


  3. Medical review-share information:

    • Discuss prognosis and the benefits and burdens of treatment options,

    • Be mindful of overly optimistic and overly pessimistic predictions,

    • Deliver small amounts of information at a time, and

    • Frequently pause to check for understanding.


  4. After the news-respond empathetically:

    • Listen more than talk, use silence;

    • Acknowledge, legitimize, explore, empathize; convey honesty and reframe hope.


  5. Identify and resolve conflicts:

    • Identify causes of conflict (information gaps, treatment goal confusion, emotions, family dynamics, and team dynamics),

    • Help resolve conflicts and be prepared to make recommendations,

    • Recognize that grief work takes time, and

    • Use "I wish" statements.


  6. Goal setting and future planning:

    • Elicit values and preferences,

    • Establish patient-centered goals,

    • Be prepared to make a recommendation,

    • Ask "What is most important to you?"

    • Summarize, establish and implement plan,

    • Follow-up.



Another way to recall this approach is the "SPIKES" acronym:

Setting up the interview, assessing the patient's

Perception, obtaining the patient's

Invitation, giving

Knowledge and information to the patient, addressing the patient's

Emotions with empathetic response, and

Strategy and summary (Baile, Buckman, Lenzi, Glober, Beale, & Kudelka, 2000).

A good rule to follow - discuss what you can do for the patient and family before discussing what you cannot do (Quill, Holloway, Shah, Caprio, Olden, & Story, 2010).

Key Points     PA05sect3

In family meetings, family satisfaction is significantly associated with an increased proportion of time that the family speaks.(McDonagh, Elliott, Engleberg et al., 2004).


References     PA05sect4

Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A., & Kudelka, A.P. (2000). SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5:302-311.

McDonagh, J.R., Elliott, T.B,. Engleberg, R.A., et al. (2004). Family satisfaction with family conference about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Critical Care Medicine, 32:1484-1488.

Quill, T.E., Holloway, R.G., Shah, M.S., Caprio, T.V., Olden, A.M., Story, C.P. (2010). Chapter 6: Goal Setting, Prognostication, and Self-Care. In Primer of Palliative Care (5th ed., 109-137). Glenview, IL: American Academy of Hospice and Palliative Medicine.



Geriatric Failure to Thrive
Linh Nguyen, M.D.

Pallative
Overview     PA06sect1

The Institute of Medicine‘s definition of geriatric failure to thrive (FTT) is a syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels.

Key Points     PA06sect2

  • Geriatric FTT describes a state of decline that is multi-factorial. Possible causes include but are not limited to concurrent diseases and functional impairments.

  • Geriatric FTT can be a terminal condition which qualifies a patient for hospice care.

  • Geriatric FTT is key decision point in the care of an elderly person. The diagnosis should prompt discussion of end-of-life care options to prevent needless interventions that may prolong suffering.

Assessment     PA06sect3

A complete work up for geriatric FTT should include:

  • evaluate the physical and psychological health of the patient

  • assess physical health with tools such as the Get Up and Go Test

  • the Geriatric Depression Scale or Cornell Scale for Depression in Dementia can be used to assess psychological health

  • assess functional ability

  • complete medication review

    • look for drug side effects or drug interactions

    • cross check medications with the Beers criteria for potentially inappropriate medications in the elderly


  • assess socio-environmental factors

  • assess the impact of existing chronic diseases and nutrition

    • The Mini Nutritional Assessment is a validated tool for assessing nutritional risk in the elderly and is easy to administer


  • laboratory and radiologic evaluations are limited to complete blood count, chemistry panel, thyroid-stimulating hormone levels, urinalysis; other studies appropriate for an individual patient (see Robertson and Montagnini, 2004).

Robertson and Montagnini, 2004 Geriatric Failure to Thrive, is a resource for more detailed information on geriatric failure to thrive and medication.


Diagnosis     PA06sect4

Diagnosis of FTT should prompt end-of-life care options to prevent burdensome interventions that may cause/prolong suffering.

Common medical conditions associated with FTT are:

  • cancer,

  • psychiatric disorders including cognitive loss,

  • chronic infections, and

  • stroke.


Interventions     PA06sect5

Interventions should be directed toward easily treatable causes of FTT with the goal to maintain or improve overall functional status. However, in selected patients based upon the patient's clinical picture and patient's preferences, the goal is to control symptoms, patient/family support at the end-of-life, and to forgo aggressive, life-prolonging, burdensome medical evaluation and treatment.


References     PA06sect6

Bogardus Jr, S. T., Bradley, E. H., Williams, C.S., Maciejewski, P.K., van Doorn, C, & Inouye, S.K. (2001). Goals for the care of frail older adults: do caregivers and clinicians agree? The American Journal of Medicine, 110(2), 97-102

Fink, D.M., Cooper, J.W., Wade, W.E. et al (2003). Updating the Beer's criteria for potentially inappropriate medication use in older people. Archives of Internal Medicine, 163: 2716-2724.

Mini Nutritional Assessment (1998). Nestle Research Center. Nestle Clinical Nutrition. Available at https://www.mna-elderly.com/practice/user_guide.htm

Robertson, R. G., & Montagnini, M. (2004). Geriatric failure to thrive. American Family Physician, 70 (2): 343-350.

Sarkisian, C.A., & Lachs, M.S. (1996). "Failure To Thrive" in Older Adults. Annals of Internal Medicine, 124(12):1072-1078.

Sheikh, J.L. & Yeavage, J.A. (1986). Geriatric Depression Scale (Short Form). Clinical Gerontology, 5:165.



Pain Management
Caroline Ha, MD,

Pallative
Key Points     PA07sect1

Sub-optimally managed pain can increase healthcare utilization and expenditures, contribute to family and caregiver distress, diminish quality of life and functional independence, and affect sleep, appetite, and even cognitive function (Mercadante & Arcuri, 2007; Rastogi & Meek, 2013).

Optimizing pain control in the elderly requires attention to several issues:

  • the objective assessment of functional age,

  • the effect of polypharmacy,

  • the impact of comorbidities, and

  • the need to communicate effectively not only with the patient, but also with caregivers and family members. (Mercadante & Arcuri, 2007).

A comprehensive pain assessment includes evaluation of not only physical pain but also any emotional, spiritual, or social components of pain (Rastogi & Meek, 2013).

In renal insufficiency, the opioids of choice are fentanyl, buprenorphine, and methadone. Hydromorphone, hydrocodone, and oxycodone may be used with careful monitoring; dose reductions may be prudent. Morphine and codeine should have their doses reduced and may be best avoided, due to accumulation of neurotoxic metabolites (Pergolizzi, et al., 2008; Johnson, 2007).

In hepatic insufficiency, acetaminophen usage should be limited to less than 2g/day. Fentanyl may be the opioid of choice (Johnson, 2007; Bosilkovska, Walder, Besson, Daali, & Desmeules, 2012).

"Addiction" is a syndrome of psychological dependence and compulsive drug-seeking behaviors. Although many patients may exhibit physical dependence on opioids—characterized by withdrawal symptoms after sudden discontinuation of the opioid—addiction is infrequent. Patients concerned about opioid addiction should be educated regarding the differences between addiction and physical dependence (Fallon, Cherny, & Hanks, 2011).

Opioids should be initiated at the lowest effective dose in the elderly. A long-acting medication can be added for chronic pain; breakthrough doses used with a long-acting regimen should be 5-15% of the long-acting dose. Total daily doses may be titrated by 30-50% after 24 hours. If opioids need to be switched, the dosage should be reduced by at least 25-50% to account for incomplete cross-tolerance (Rastogi & Meek, 2013; Yennurajalingam, Braiteh, & Bruera, 2005; Fallon, Cherny, & Hanks, 2011)


Overview     PA07sect2

There is a high incidence of pain in the elderly: some sources indicate it is as high as 30-50% of people aged 65 and older, and 50-75% in people over the age of 85. Unfortunately, pain in the elderly often goes unrecognized or inadequately treated (Rastogi & Meek, 2013). Although the response to mild pain in the elderly seems to be blunted, studies indicate that older patients may have increased sensitivity to severe pain (Pergolizzi, et al., 2008).

Pain can be classified as acute or chronic.

  • Acute pain typically occurs in association with tissue injury.

  • Chronic pain is generally defined as pain persisting for over 3 months, or for over 1 month after the acute injury has healed. It may be caused by persistent activation of nociceptors or by peripheral or central nervous system dysfunction. Many older adults have chronic, persistent pain.

Pain can be further categorized as nociceptive, neuropathic, or psychogenic (Portenoy, 2012). These categorizations can be helpful in making treatment decisions. A thorough pain assessment is therefore necessary to optimize pain management.

In elderly patients, there are several other factors that must be considered before instituting a pain regimen.

  • Physiologic changes seen with aging can increase the risk of toxicity and thereby affect the management of analgesics in the elderly.

  • After the age of 50, cardiac index declines by 1% per year. A decreased cardiac index can result in rapid, high medication peaks.

  • Reductions in hepatic blood flow decreases metabolism by 30-40% and may result in drug accumulation.

  • Decreased renal blood flow—and the concomitant renal insufficiency—results in impaired drug elimination.

  • Decreased cerebral blood flow may result in a higher risk of delirium.

  • Increased body fat and decreased body water raise the elderly person's volume of distribution, causing both delayed onset of action and delayed medication elimination (Rastogi & Meek, 2013; Pergolizzi, et al., 2008).


Assessment     PA07sect3

A thorough pain history is essential in identifying the type and cause of pain.

  • The history should include the quality, location, radiation, intensity, duration, onset, pattern, and frequency of the pain, as well as alleviating and exacerbating factors.

  • If an intervention has already been tried, the efficacy of the intervention should be assessed.

Multiple tools have been developed for the assessment of pain intensity:

  • there are categorical and numerical rating scales as well as pictorial scales such as the faces pain scale and pain thermometer (Rastogi & Meek, 2013).

  • Some studies suggest that categorical rating scales—scales with categories ranging from "none" to "severe" pain—have superior reliability and validity in elderly patients (International Association for the Study of Pain, 2006).

  • In patients with severe dementia, the Pain Assessment in Advanced Dementia (PAIN-AD) scale may be utilized.

Categorizing pain as nociceptive, neuropathic, or psychosocial can be helpful since the initial management for these categories differs significantly.

When planning pain management for elderly patients, the patient's functional independence, cognition, and social and family support must be assessed.

If substance abuse is a possibility, a screening tool such as the CAGE questionnaire can be used. It is also useful to investigate the patient's comorbidities and other medications, as these can also affect how the patient responds to any prescribed analgesics (Delgado-Guay & Bruera, 2008).

Additionally, it is important to recognize that in elderly patients—especially frail ones—a "normal" serum creatinine does not rule out the possibility of renal impairment. Therapy may need to be tailored through dose reduction or outright avoidance in the presence of renal insufficiency. (Mercadante & Arcuri, 2007)

Management     PA07sect4

The World Health Organization's analgesic ladder for cancer pain provides a framework for managing cancer pain. Its usage has also been extended to the treatment of non-cancer pain. The ladder recommends step-wise escalation of analgesics. In the elderly, it is good practice to avoid polypharmacy and start or adjust only one medication at a time whenever possible. Medications should be delivered by the least invasive route available—generally oral or transdermal (Pergolizzi, et al., 2008).

Pharmacological therapy is often more effective when combined with non-pharmacological interventions, such as physical therapy, counseling, pain education, and complementary therapies like acupuncture (International Association for the Study of Pain, 2006; Yennurajalingam, Braiteh, & Bruera, 2005).

Step 1, Non-opioid analgesics +/- adjuvants


Acetaminophen has antipyretic and analgesic properties and is generally well tolerated. However, lower doses are recommended for elderly patients, and daily doses should be limited to less than 2 or 3 g/day to reduce the risk of liver injury (Rastogi & Meek, 2013; Bosilkovska, Walder, Besson, Daali, & Desmeules, 2012).

Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause several adverse effects, including liver and kidney injury as well as gastritis and gastrointestinal bleeding, Elderly patients are at increased risk for adverse effects, and chronic NSAID use should be avoided when possible. Elderly patients utilizing chronic NSAID therapy may benefit from a proton pump inhibitor to reduce gastrointestinal adverse effects (Rastogi & Meek, 2013; Portenoy, 2012).

Commonly used adjuvants for pain include tricyclic antidepressants (TCAs), selective serotonin norepinephrine reuptake inhibitors (SNRIs), corticosteroids, and antiepileptic medications. In the elderly, the TCAs are best avoided due to the risk of adverse effects; nortriptyline and desipramine are preferred to amitriptyline if safer options are not available. Corticosteroids can be used in short courses to assist with reducing inflammation and pain, and is also helpful for fatigue and appetite. However, corticosteroids can cause several undesirable effects, including insomnia, gastritis, gastrointestinal ulceration, delirium, osteoporosis, and glucose intolerance, especially when used for prolonged periods.

The antiepileptic medications gabapentin and pregabalin are especially useful for neuropathic pain; however, doses need to be adjusted in renal insufficiency. In the elderly, antiepileptics should be titrated slowly to reduce risk of sedation, dizziness, and falls (Mercadante & Arcuri, 2007; Schmader, et al., 2010). For neuropathic pain, antiepileptics are currently the first line medications. Other medications helpful for neuropathic pain include TCAs, SNRIs, opioids, capsaicin cream, and lidocaine patches.


Steps 2 and 3, Opioid analgesics +/- non-opioid analgesics +/- adjuvants


As a rule, in elderly patients opioid analgesics should be started at the lowest effective dose and titrated slowly and carefully. Patients with continuous pain may be started on a low dose of scheduled short-acting opioid medication. The total daily opioid dose can then be increased by 30-50% every 24 hours if indicated. For patients with chronic pain, a long-acting opioid medication can be initiated after the pain is better controlled; the dose of the long-acting opioid should be based on the total daily dose the patient required of the short-acting opioid. Adding a long-acting medication increases compliance, since fewer scheduled doses are required. Breakthrough pain episodes in patients taking a long-acting opioid chronically can be treated with short-acting opioids. A typical breakthrough pain dose is recommended to be 5-15% of the total daily opioid dose (Zeppetella, 2011).

Notably, cognitive function may be noticeably impaired for up to a week following opioid dose escalations (Pergolizzi, et al., 2008). Furthermore, both physicians and nurses may misinterpret agitated delirium as pain in patients whose pain was well under control before and after the episode of delirium. In these patients, opioid escalation could be detrimental and worsen the patient's cognitive dysfunction (Yennurajalingam, Braiteh, & Bruera, 2005).

When switching from one opioid to another, a published equianalgesic ratio should be applied. The total dose of the new medication should then be reduced by 25-50% in order to account for incomplete cross-tolerance, (Yennurajalingam, Braiteh, & Bruera, 2005) since tolerance to the previous opioid does not confer the same degree of tolerance to a different one. For elderly or cognitively impaired patients, some experts recommend to reduce the dose even further by an additional 15-30% (Rastogi & Meek, 2013).

Concern for addiction is often cited as a reason for not initiating opioid medications. Patients with legitimate pain may limit their own opioid usage, fearing the stigma of addiction. There is a common misconception that the physical dependence often seen with opioid usage is a sign of addiction; however, true addiction is a syndrome characterized by psychological dependence—a craving for the drug—along with compulsive drug-seeking behaviors. True addiction is infrequent and perhaps even overestimated, as patients with undertreated pain may appear to be drug-seeking (Fallon, Cherny, & Hanks, 2011). Educating patients regarding the differences between physical dependence and addiction may increase medication compliance.

Codeine is dependent on conversion to morphine in the liver for analgesic efficacy; therefore, poor metabolizers—who constitute approximately 10% of the studied population—have correspondingly poor pain relief with codeine. (Mercadante & Arcuri, 2007)

Tramadol is also used to mild to moderate pain. In addition to its weak µ receptor activity, it also inhibits monoamine reuptake, which results in a risk of serotonin syndrome and increased seizure risk in the presence of other serotonergic medications. Its metabolism and elimination is dependent on the kidneys and liver, and elderly patients on tramadol should be monitored carefully. In the setting of renal insufficiency, doses of tramadol should not exceed 200 mg/day; for hepatic insufficiency, the dose is limited to no more than 50 mg every 12 hours.

The use of meperidine should be avoided in elderly patients, as normeperidine can rapidly accumulate and cause neurotoxicity, especially in the setting of renal insufficiency (Rastogi & Meek, 2013; Portenoy, 2012).

Hydrocodone is frequently combined with either NSAIDs or acetaminophen, and daily doses should be limited based on the NSAID or acetaminophen content.

Morphine is more likely than the other opioids—with the exception of codeine—to cause histamine release and itching (Portenoy, 2012). These are considered an adverse effect rather than a true allergy, since the histamine release is non-immune mediated. Morphine is metabolized to toxic metabolites in the liver, which are renally cleared. Morphine should be reduced and closely monitored or avoided in renal insufficiency (Fallon, Cherny, & Hanks, 2011).

Oxycodone is 30-50% more potent than morphine in studies. Oxymorphone is 3 times stronger than morphine in the oral form and 10 times stronger in intravenous form. Some studies suggest it may induce less histamine release than morphine (Fallon, Cherny, & Hanks, 2011). Hydromorphone is a strong opioid that is also converted to neurotoxic metabolites that accumulate in renal insufficiency; though it proportionally produces fewer toxins than morphine, close monitoring is still prudent (Johnson, 2007).

The fentanyl transdermal patch should be started at the 12mcg/h dose for opioid naïve patients (Portenoy, 2012). Notably, another analgesic should be provided when initiating the patch, as the patch generally takes 8-12 hours to reach effective analgesic levels. An additional consideration: fentanyl absorption via the patch increases with rising body temperature, and patients should be cautioned regarding hot baths and heating pad usage (Fallon, Cherny, & Hanks, 2011). Fentanyl does not have any active renally cleared metabolites and is one of the preferred opioids in renal insufficiency. Furthermore, fentanyl's pharmacokinetics are unchanged in hepatic insufficiency, and it may be the opioid of choice in hepatic insufficiency, as well (Bosilkovska, Walder, Besson, Daali, & Desmeules, 2012; Johnson, 2007).

Because of its long half-life, methadone requires close monitoring after dose adjustment. The plasma concentration of methadone continues to rise over a prolonged period of time, possibly resulting in delayed adverse effects (Portenoy, 2012; Fallon, Cherny, & Hanks, 2011). Since the potency of methadone increases with escalating doses, methadone management may be best left to pain specialists or other providers experienced in its use.

Lastly, it is very important to initiate laxative therapy when starting patients on opioid medications, as severe constipation can adversely affect the patient's quality of life by decreasing appetite as well as causing nausea and abdominal pain. If left untreated, it can eventually cause overflow diarrhea—often resulting in social withdrawal—and even delirium (Rastogi & Meek, 2013).


References     PA07sect5

Bosilkovska, M., Walder, B., Besson, M., Daali, Y., & Desmeules, J. (2012). Analgesics in Patients with Hepatic Impairment. Drugs, 72(12), 1645-1669.

Delgado-Guay, M., & Bruera, E. (2008). Management of pain in the older person with cancer: Part 1: Pathophysiology, Pharmacokinetics, and Assessment. Oncology, 22, 56-61.

Fallon, M., Cherny, N., & Hanks, G. (2011). Opioid analgesic therapy. In G. Hanks, N. I. Cherny, N. A. Christakis, M. Fallon, S. Kaasa, & R. K. Portenoy, Oxford Textbook of Palliative Medicine (pp. 661-698). New York: Oxford University Press.

International Association for the Study of Pain. (2006). Pain: Clinical Updates; Older People's Pain.

Johnson, S. J. (2007, November 30). Opioid Safety in Patients with Renal or Hepatic Dysfunction. Retrieved from Pain Treatment Topics: www.Pain-Topics.org

Mercadante, S., & Arcuri, E. (2007). Pharmacological Management of Cancer Pain in the Elderly. Drugs Aging, 24, 761-776.

Pergolizzi, J., Boger, R., Budd, K., Dahan, A., Erdine, S., Hans, G., . . . Sacerdote, P. (2008). Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids. Pain Practice, 8(4), 287-313.

Portenoy, R. (2012, February). Pain. Retrieved from The Merck Manual Online: http://www.merckmanuals.com/professional/neurologic_disorders/pain/overview_of_pain.html

Rastogi, R., & Meek, B. (2013). Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control. Clinical Interventions in Aging, 8, 37-48.

Schmader, K. E., Baron, R., Haanpaa, M. L., Mayer, J., O'Connor, A. B., Rice, A., & Stacey, B. (2010). Treatment Considerations for Elderly and Frail Patients with Neuropathic Pain. Mayo Clin Proc, 85(3), S26-S32.

Yennurajalingam, S., Braiteh, F., & Bruera, E. (2005). Pain and Terminal Delirium Research in the Elderly. Clinics in Geriatric Medicine, 21, 93-119.

Zeppetella, G. (2011). Breakthrough Pain. In G. Hanks, N. I. Cherny, N. A. Christakis, M. Fallon, S. Kaasa, & R. K. Portenoy, Oxford Textbook of Palliative Medicine (p. 655). New York: Oxford University Press.



Prognosis
Jenny Wei, DO

Pallative
Key Points     PA08sect1

Prognostication is an important but underused skill in clinical practice. It is a skill that highly impacts medical decision-making in daily clinical practice.

In patients with advanced of terminal illness, prognostication aids in discussions about advanced care planning. With advance care planning, patients and families are better prepared for events that may occur at the end of life. This may help patients and families facing advance illness maintain a sense of control.

Prognostication has influences on clinical administrative issues as well, such as the determination of hospice admission criteria for different disease states.

Prognostication requires the clinician to be aware of the natural progression of diseases, while taking into account other patient-related factors such as comorbidities. An in-depth knowledge about the different therapeutic options, along with the risks and benefits of each option, is also required to determine prognosis.

Another important factor is the communication of prognosis to the patient and family; news about prognosis should be delivered in a clear and compassionate manner.

Clinicians tend to overestimate prognosis. There are many tools that can be used to aid in prognostication in many diseases; the clinician should be aware of the tools and resources to help improve accuracy.


Overview     PA08sect2

The majority of advanced disease trajectories fall into one of three categories.

  • Cancer falls into category A, in which patient are often times able to maintain their functional status for months or even years, until there is an acute event (e.g. infection, pulmonary embolism) that leads to death.

  • The second model (category B) is characterized by slow decline of the patient due to episodes of acute decompensation with recovery to close of baseline. This type of trajectory is commonly seen in patients with congestive heart failure and in chronic obstructive pulmonary disease.

  • The third model (category C) usually has an onset with cognitive or functional deficits such in cases of dementia or some form of neurological disease, which then leads to progressive decline over a variable amount of time (see table below).


Prognosis Image


Prognostication tools     PA08sect3

Several prognostic tools and scales are available. The most commonly used ones are primarily based on the patient's functional status, and they include the following:

  • Eastern Cooperative Oncology Group (ECOG) scale

  • Karnofsky score

  • Palliative Performance Scale

There are several disease-specific prognostication scales that are available for different organ specific diseases that have been validated:

  • Cardiac (NYHA Class, Seattle heart Failure Model)

  • Pulmonary (BODE Index)

  • Dementia (FAST staging, Mortality Risk Index)

  • Renal (age-modified Charleston Comorbidity Index)

  • Hepatic (MELD score in end-stage liver disease)

The use of disease-specific prognostication tools can improve the clinician's accuracy in determining prognosis. In addition to the tools, the other variable that should be accounted for also includes physician experience and intuition.


Approach to discussion about prognosis

First, the clinician should establish patient's desire to discuss prognosis. Next, be sure to address emotional and informational concerns. The clinician should be open and honest, and the information should be delivered in a clear and concise manner. It is often times important and useful to be empathic and acknowledge uncertainty. The other important take-home point is that it is best to deliver prognosis in terms of timeframe, rather than specific time periods. Use terms like "hours to days," "days to weeks," "weeks to months," or "months to years."




References     PA08sect4


Anderson, F., Downing, G.M., Hill, J. (1996). Palliative Performance Scale (PPS): a new tool. Journal of Palliative Care, 12(1): 5-11.

Celli, B.R., Cote, C.G., Marin, J.M., et al. (2004). The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary Disease. New England Journal of Medicine; 350(10) 1005-1012.

Christakis, N.A., Lamont, E.B. (2000). Extent and Determinants of Error in Doctor's Prognoses in Terminally Ill Patients: Prospective Cohort Study. British Medical Journal; 320:469-472.

Glare, P.A., Sinclair, C.T. (2008). Palliative Medicine Review: Prognostication. Journal of Palliative Medicine 11 (1) 84-103.

Hemmelgarn, B.R., Manns, B.J., Hude, H., Ghali, W.A. (2003). Adapting the charlson comorbidity index for use in patients with ESRD. American Journal of Kidney Disease; 42(1): 125–132.

Lamont, E.B., & Christakis, N.A. (2003). Complexities in Prognostication in Advanced Cancer. Journal of the American Medical Association; 290: 98-104.

Mitchell, S.L., Kiely, D.K., Hamel, M.B., et al. (2004). Estimating Prognosis For Nursing Home Residents with Advanced Dementia. Journal of the American Medical Association; 291:2734-2740.

Morita, T., Tsunoda, J., Inoue, S., et al. (1999). Validity of the Palliative Performance Scale from a survival perspective. Journal of Pain Symptom Management,18(1):2-3.

Reisfield, G.M., & Wilson G.R. (2007). Prognostication in Heart Failure. Journal of Palliative Medicine; 10 (1):245-246.

The SUPPORT Principal Investigators (1995). A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPROT). Journal of the American Medical Association; 274: 1591-1598.

Yourman, L.C., Lee, S.J., Schonberg, M.A., Widera, E.W., & Smith, A.K. (2012). Prognostic Indices for Older Adults: A Systematic Review. Journal of American Medical Association; 307(2): 182-192.

Virik, K., Glare, P. (2002). Validation of the Palliative Performance Scale for inpatients admitted to a palliative care unit in Sydney, Australia. Journal of Pain Symptom Management, 23(6):455-7.



Palliative Care
Linh Nguyen, MD

Pallative
Overview     PA09sect1

The World Health Organization (WHO) defines Palliative Care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

The palliative care goal is to improve quality of life for both the patient and the family. Palliative Care provides:
  • relief from pain and other distressing symptoms,

  • affirms life and regards dying as a normal process,

  • intends neither to hasten or postpone death,

  • integrates the psychological and spiritual aspects of patient care,

  • offers a support system to help patients live as actively as possible until death,

  • offers a support system to help the family cope during the patient's illness and in their own bereavement,

  • uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated, and

  • Enhances quality of life, and may also positively influence the course of illness.

Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

Key Points     PA09sect2

Palliative care is not hospice.

Palliative care can be provided any time after the diagnosis of life limiting or life threatening illness.

Hospice care is appropriate when there is prognosis of 6 months or less to live.

The other main difference between palliative care and hospice is that palliative care patients can receive life prolonging treatments while hospice care focuses on comfort and support for the patient and family.


Assessment     PA09sect3

Palliative Care Team can be consulted for providing assessment and developing plans of care for patients with the following problems:

  • pain

  • addiction due to pain

  • pain drug therapy

  • active dying

  • artificial hydration/nutrition

  • constipation

  • dyspnea

  • delirium

  • nausea and vomiting

  • depression or anxiety

  • fatigue

  • anorexia

  • cultural considerations

  • self-care

  • advance care planning, DNR and ethical issues

  • breaking bad news

  • goals of care

  • family conferences

  • hospice and last days care

  • Psychosocial and spiritual care.


Intervention     PA09sect4

Palliative care is not passive care.

It does not ask patients and family to give up on care.

Palliative teams actively work with the patient and family to carry out the patient's wishes.

It is not reserved only for the imminently dying or bedbound patients.

Patients early in the trajectory of a life limiting or life threatening illness and patients with good performance status can benefit from palliative care interventions, for example, as maintaining or improving performance status and adherence with life prolonging treatments, aggressive symptom control, patient and family psychosocial/spiritual support.


References     PA09sect5

World Health Organization. (2013). WHO Definition of Palliative Care. Retrieved from http://www.who.int/cancer/palliative/definition/en.



Elder Abuse and Mistreatment
Nasiya Ahmed, MD, John Halphen, MD, and Kathleen Pace Murphy, PhD, MS, GNP-BC

Syndrome
Key Points     SY01sect1

Elder abuse and neglect are estimated to affect 700,000 to 1.2 million U.S. elders annually.

Although reporting suspected abuse and mistreatment are mandated in most states, research estimates that only 1 in 14 cases of elder abuse are reported (National Research Council, 2003).

Only 7.6 – 10% of elders self-report being abused (Acierno, Hernandez, Armstadter et al, 2010)

The majority of elder abuse survivors are female (65.7 %). Approximately 43% are aged 80 years and older.

The vast majority of elder abuse and mistreatment cases occur in domestic settings (89.3%).

Elders who have been abused are at a 300% higher risk of mortality when compared to non-abused elder cohorts (Dong, Simon, Mendes de Leon, 2009).

Self-neglect is the most commonly reported form of elder abuse or mistreatment and is increasing.

In older adults who self-neglect, African-American older adults had a higher mortality rate compared to whites.

Elder abuse is strongly correlated with low social support and previous traumatic events.


Assessment     SY01sect2

In assessing an elder person for abuse and mistreatment, the health care provider needs to be familiar with the various types of elder mistreatment. There are six major types of elder mistreatment: Physical abuse, sexual abuse, emotional or psychological abuse, neglect, self-neglect and financial exploitation. More than one type of elder abuse can be manifest in the same individual.

Risk factors and warning signs of elder mistreatment include:

  • age over 80

  • dependency in activities of daily living

  • dementia or cognitive impairments

  • depression

  • mental illness or substance abuse by the caretaker

  • financial dependency of the caretaker

  • suspicious transfers of assets

  • new inability to meet expenses

  • poorly explained wounds, bruises or fractures

  • dehydration or malnutrition

  • inappropriate use of medication, especially those that induce sleepiness( i.e. tranquilizers)

Elder mistreatment screening can be done by asking simple questions such as:

  • Do you feel safe where you live?

  • Has anyone ever touched you without your permission?

  • Has anyone made you do things that you did not want to do?

  • Have you ever gone without food?

  • Has anyone threatened, slapped, punched, kicked or hurt you?

Unsatisfactory answers to these questions should prompt further evaluation.

The Elder Assessment Instrument (EAI) is a formal 41 question mistreatment assessment instrument that takes approximately 15 minutes to administer (Fulmer, Pavez, Abraham, and Fairchild, 2000).

An approach to screening and identification of suspected cases of elder mistreatment involves performing a comprehensive history and physical exam, including psychosocial assessments, cognitive assessments, functional assessments, and utilizing information from all reasonably available sources, including reports of family, neighbors and government agencies.

In many instances, capacity assessment is appropriate. The health care provider must provide clear, comprehensive documentation in the medical record, treat underlying medical illnesses and geriatric syndromes, and report suspected cases of abuse or neglect to the appropriate authorities.

Intervention     SY01sect3

If a clinician suspects elder abuse, mistreatment, neglect, self-neglect or exploitation by caretakers, he or she has a duty to report it to the authorities. Not reporting suspected abuse and mistreatment, depending on state law, may result in charges being filed against the health care provider.

In most jurisdictions, good-faith reporters are protected from criminal and civil liability for erroneous reports and testimony. In some jurisdictions, reporting can be anonymous. Verification of the accuracy of the suspicion is not required of the clinician. That is the government agency's job.

All jurisdictions in the United States have an adult protective services agency (APS),

APS takes reports and intervenes in community elder abuse, neglect & exploitation.

Police, as well as APS, should be contacted if immediate jeopardy to the elder exists.

Clinicians should work closely with the authorities and agencies to treat medical issues, determine capacity for self-care and self-protection, and accurately document findings.

Without intervention, all forms of elder mistreatment may lead to adverse health and safety events since these vulnerable elders are often less physically, psychologically, cognitively, socially and financially resilient.


References     SY01sect4

Acierno, R., Hernandez, M.A.., Amstadter, A.B., et al. (2010). Prevalence and correlates of emotional, physical, sexual and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292-297.

Brandl, B., Dyer C.B., Heisler, C.J., Otto, J., Stiegel, L., Thomas, R. (2006). Elder Abuse Detection and Intervention: A Collaborative Approach. Springer Publishing Company.

Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., Hebert, L., et al. (2009) Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), 517-526.

Dyer, C.B., Goodwin, J.S., Pickens-Pace, S., Burnett, J., Kelly, P.A. (2007). Self-Neglect Among the Elderly: A Model Based on More Than 500 Patients Seen by a Geriatric Medicine Team. American Journal of Public Health, 97:1671-1676.

Dyer, C.B., Pickens, S., Burnett J. (2007) Vulnerable Elders: When It Is No Longer Safe to Live Alone. Journal of American Medical Association, 298(12):1448-1450.

Dyer, C.B., Heisler, C.J., Hill, C.A., Kim, L.C. (2005). Community approaches to elder abuse. Clinical Geriatric Medicine; 21:429-447.

Dyer, C.B., Connolly, M.T., McFelley, P. (2003). The clinical and medical forensics of elder abuse and neglect. In: Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, DC: The National Academies Press: 339-381.

Dyer, C.B., Pavlik, V.N., Murphy, K.P., Hyman, D.J. (2000). The high prevalence of depression and dementia in elder abuse or neglect. Journal of American Geriatric Society, 48(2):205-208.

Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. (2003). Washington, DC: National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect.

Fulmer, T., Paveza, G., Abraham, I., Fairchild, S. (2000). Elder neglect in the emergency department. Journal of Emergency Room Nursing, 26(5): 436-443.

Halphen, J.M., Varas, G.M., Sadowsky, J.M.(2009). Recognizing and reporting elder abuse and neglect. Geriatrics. 64(7):13-18.

Lachs, M.S., Pillemer, K. (2004). Elder abuse. Lancet;365(9441):1263-1272.

Naik, A.D., Burnett, J., Pickens-Pace, S., Dyer C.B.(2008). Impairment in instrumental activities of daily living and the geriatric syndrome of self-neglect. Gerontologist;48(3):388-393.

National Research Council. (2003) Elder mistreatment: Abuse, neglect and exploitation in an aging America. Washington, D.C.: The National Academies Press.

Reed, K.(2005). When elders lose their cents: financial abuse of the elderly. Clinical Geriatric Medicine;21(2):365-382.

Stiegel, L., Klem, E.(2007). Explanation of the "Immunity for Good Faith Reporting: Provisions and Citations in Adult Protective Services Laws, by State" and "Immunity for Good Faith Reporting: Criteria in Adult Protective Services Laws, by State" Charts. American Bar Association Commission on Law and Aging . Available at www.ncea.aoa.gov/NCEAroot/Main_Site/Find_Help/APS/Analysis_State_Laws.aspx

Teaster, P.B. (2000). A response to the abuse of vulnerable adults: The 2000 survey of statue adult protective services. Retrieved from http://apsnetwork.org/Resources/docs/2002StateSurvey.pdf.

Texas Human Resources Code, Chapter 48. Investigations and protective services for elderly and disabled persons. http://www.statutes.legis.state.tx.us/



Falls
Kathleen Pace Murphy, PhD MS, GNP-BC; Jennifer Larson, MSE;
and Sharon Ostwald, PhD, RN

Syndrome
Key Points     SY02sect1

An estimated one in three adults, aged 65 years or older, falls each year (CDC, 2013).

Fall rates increase exponentially with age; older adults, age 80 years or older, have a 50% chance of falling each year (de Negreiros Carbral et al, 2013).

Falls are the leading cause of death due to injury in the elderly (CDC, 2013).

The most important risk factor for falling is a history of falls, so health care providers need to ask about falls at every visit!

Adults age 75 and older who fall are 4 to 5 times more likely than their 65-74 year old age cohort to be admitted to a long term care facility for a year or longer following a fall (Stevens & Dellinger, 2002).

Exercise is an effective intervention for falls. Older adults should exercise regularly focusing on increasing core and leg strength, as well as improving balance (CDC, 2013). Tai Chi exercise programs are very effective in meeting these exercise goals.

Interprofessional team work is critical to successful fall protection. Geriatric best practices include preventing polypharmacy, ophthalmology consults to assess for diminishing vision (cataracts) and to update glass prescriptions, dietary consults to insure adequate food intake including calcium and vitamin D, osteoporosis diagnostic work-ups when clinically indicated, physical therapy consults to assess gait and balance dysfunction and provide an exercise therapeutic plan, and interprofessional team home visits to conduct home safety evaluations (Gillespse et al, 2012).


Overview     SY02sect2

Falls are defined as an unintentional lowering to rest from a higher to a lower position, not due to loss of consciousness or violent impact (Kellogg International Work Group on the Prevention of Falls by the Elderly, 1987). Falls often go unrecognized by health care professionals because they are not routinely evaluated while taking a patient’s history or during a physical exam (unless there is frank injury).

Many patients do not admit to falling for fear of losing their independence.

The incidence of falls varies with age. Persons aged 65 to 79 years living at home have a fall incidence of 30-40%. Persons aged 80 years and older living at home have an increased fall incidence of 50%.

Complications resulting from falls are the leading cause of death from injury in men and women aged 65 and older.

Many factors that contribute to fall risk in older adults. The World Health Organization Europe (2004) has characterized risks into two broad categories, intrinsic and extrinsic risk factors for falls.

Intrinsic risk factors include a history of falls, age, gender, medical conditions, impaired mobility and gait, sedentary behavior, psychological status, nutritional deficiencies, impaired cognition, visual impairments and foot problems.

Many older adults have multiple comorbidities including neurological, cardiovascular, metabolic, urinary, musculoskeletal, and psychological disorders that may increase their risk of falls. In addition, medications to treat these conditions may produce side effects that further impair their physical or psychological status.

Extrinsic risk factors for falls include environmental hazards such as uneven surfaces, poor lighting, and unstable or inappropriately placed furnishings, inappropriate assistive devices, ill- fitting clothing and footwear that lacks support.


Assessment     SY02sect3

Falls are multifactorial in nature. Health care providers should always ask patients, aged 65 and older, if they have fallen recently or have a history of falling. If the patient admits to a recent fall, query for specific circumstances surrounding the fall. Inquire about gait and balance dysfunction. A medication review is critical for both prescribed and over the counter medications. Ask your patient about current medical co-morbidities such as cardiovascular disease, musculoskeletal diseases (i.e. arthritis, osteoporosis) and genitourinary (i.e. urinary tract infection, BPH).

For those that have had a fall or a near fall, obtain a functional history. CATASTROPHE (Sloan, 1997) is a mnemonic for a complete functional history.

C Caregiver and housing

A Alcohol (including withdrawal)

T Treatment (i.e. medications)

A Affect (depression or lack of initiative)

S Syncope (any episodes of fainting)

T Teetering (dizziness)

R Recent illness

O Ocular problems

P Pain with mobility

H Hearing (necessary to avoid hazards)

E Environmental hazards


Observing your patient’s gait while entering the room, sitting on the exam table or in the chair, and their ability to move around your examination room will provide a tremendous amount of information. Physical examination should include a detailed assessment of the neurological and musculoskeletal system (gait, balance, ability to ambulate, lower extremity range of motion, muscle strength, assessment of extrapyramidal and cerebellar function). The cardiovascular system should be assessed including orthostatic blood pressure readings and heart rate/rhythm. Vision should be examined for reduced visual acuity (i.e. cataracts). The patient’s feet should be inspected as well as their footwear.

The American Geriatrics Society recommends conducting a fall risk assessment during routine primary care visits. High risk groups should have a more intensive assessment including the Timed Get Up and Go screening test.

Intervention     SY02sect4

Multifactorial and interprofessional interventions are the best approach to fall prevention. Recommendations include:

  1. Exercise has been shown to reduce fall rates and the risk of falling. Exercise can include individual balance, gait training, aerobic and strength exercises, group exercises (Tai Chi) and home based exercise programs designed by a professional.

  2. Interprofessional home safety evaluations for environmental risk for falls with specific recommendations to correct hazards.

  3. Treatment of medical co-morbidities that would increase the elder’s risk factors for falls (i.e. orthostatic hypotension secondary to cardiovascular disease and treatment; visual impairment related to cataracts; podiatry consults for foot problems).

  4. Medication Reviews with the goal of reducing polypharmacy and medications that can increase fall risks (i.e. 4 or more medications, psychotropic medications, hypnotics)

  5. Nutritional assessment especially undernutrition (i.e. low BMI)

  6. Educate the older adult and their family members regarding risk factors and the interventions to reduce both environmental and physical risk factors.


References     SY02sect5

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49,664.

Center for Disease Control and Prevention (2013). Falls among older adults: An overview. Accessed on September 9, 2013 at http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls/html.

Chang, J.T., Morton, S.C., Rubenstein, L.Z., et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medical Journal, 328, 680.

De Negreiros Cabral, K, Perracini, M.R., Soares, A.T. et al. (2013). Effectiveness of a multifactorial fall prevention program in community-dwelling older people when compared to usual care: study protocol for a randomized controlled trial. BMC Geriatrics 13(27) 2-9/ http://www.biomedcentral.com/1471-2318/13/27.

Gillespie, LD, Robertson MC, Gillespie W.J. et al. (2009). Interventions for preventing falls in older people living in the community. Cochrane Database Systematic Review, 2, CD007146.

Graafmans, W.C., Ooms, M.E., Hofstee, H.M., et al. (1996). Falls in the elderly: A prospective study of risk factors and risk profiles. American Journal of Epidemiology, 143, 1129.

Kellogg International Work Group on the Prevention of Falls by the Elderly (1987). The Prevention of Falls in Later Life. Danish Medical Bulletin, 41, 297-308.

Podsiadlo, D., & Richardson, S. (1991). The timed "Up & Go:" A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39,142.

Stevens, J.A. & Dellinger, A.M. (2002). Motor vehicle and fall related deaths among older Americans 199-1998; sex, race and ethnic disparities. Injury Prevention, 8, 272-275.

Summary of the Updated American Geriatric Society/British Geriatrics Society clinical practice guidelines for prevention of falls in older persons: Summary of the Updated American Geriatrics Society/Britissh Geriatrics Society clinical practice guideline for prevention of falls in older persons (2011). Journal of American Geriatric Society, 59(1), 148-157.

Tinetti, M.E. (2003). Preventing falls in elderly patients. New England Journal of Medicine, 348(1), 42-49.

U.S. Census Bureau: An older and more diverse population by mid-century (2008). Book an Older and More Diverse Population by Mid-Century Retrieved from http://www.census.gov/newsroom/releases/archives/population/cb08-123.html

World Health Organization Europe. (2004). “What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls?” Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0018/74700/E82552.pdf



Frailty in Older Adults
Kathleen Pace Murphy, PhD., MS, GNP-BC

Syndrome
Overview     SY03sect1

Frailty is an age related alteration in physiology and pathology that leads to vulnerability, loss of physiological reserve, and a range of poor medical and functional outcomes (Bergman, Ferrucci, Gurainki, et al, 2007).

Frailty prevalence is uncertain. Lekan (2009) reported a 3-7% prevalence in older adults aged 65 to 75 years. Newman Gottdiener, McBurnie, et al (2001) reported in the Cardiovascular Health Study a prevalence of 25% in adults over the age of 85 years. Variations in frailly definitions and the mixing of community versus institutionalized sample cohorts have contributed to the lack of reliable frailty prevalence data (Espinoza & Walston, 2005).

Frailty etiology includes an array of diseases such as malignancy, heart failure, COPD, dementia, stroke, Parkinson’s disease, diabetes mellitus, hypothyroidism, depression, and rheumatic diseases. Other etiologies include inflammatory and immune responses with elevated proinflammatory biomarkers (elevations of Interleukin-6 and C-reactive protein), clotting cascade activation (elevated levels of factor VIII, fibrinogen and D-dimer), serum cortisol elevations, diminished vitamin D levels, growth and sex hormones (decrease in insulin-like growth factor-1(IGF-1), decrease in dehydroepiandosterone sulfate) have all been indicated (Espinoza & Walston, 2005).


Key Points     SY03sect2

Frailty is a syndrome, not a disease, whose prevalence increases with age.

Utilization of Fried’s criteria (Fried, Tangen, Watson et al. (2001) may help a healthcare provider recognize frailty in older adults.

Older adults at risk for frailty include: advanced age, chronic disease, physical inactivity, poor nutritional status, social isolation, psychological distress (depression) and physical stressors (smoking, polypharmacy).

Frail older adults are less able to tolerate disruptions in homeostasis and have poorer outcomes with medical illness exacerbation and hospitalization.

Interprofessional geriatric teams utilizing comprehensive geriatric assessment and modeling are an important intervention in the care of frail older adults.


Diagnosis     SY03sect3

The frailty index is one measurement used to assess this syndrome in the older adult (Fried, Tangen, Walston, et al, 2001). An older adult must have at least 3 of the 5 indices.

The frailty indices include:

Weight Loss: Unintentional weight loss (10 pounds or greater) in the past year.

Exhaustion: Presence of fatigue and tiredness.

Strength: Weakness of grip strength.

Slowness: Slow walking speed.

Low energy expenditure: Inactivity.

If frailty is suspected, healthcare providers are encouraged to conduct a comprehensive geriatric assessment. Assessment should include a functional history (ability to conduct Activities of Daily Living, Instrumental Activities of Daily Living, and history of falls); medications review (i.e. polypharmacy); sensory (visual and hearing), impairments nutritional status (i.e. recent weight loss, eating difficulties, and dietary habits); geriatric depression; cognitive impairment; and social resources.

Review of systems should review current medical conditions. Physical examination should include weight, orthostatic blood pressure checks (supine, sitting and standing), examination of their mouth/dentition, cardiovascular assessment, neuromusculoskeletal assessment and strength testing (grip strength, core truncal strength, quadriceps strength), Get Up and Go test, postural balance, proprioception, and tests for lower extremity s ensory impairment.


Intervention     SY03sect4

Frailty is a syndrome which requires an interprofessional geriatric team approach and a comprehensive plan of care. The interprofessional geriatric team is comprised of a geriatrician, advanced practice nurse or physician assistant, geriatric dentist, dietician, occupational therapist, physical therapist, social worker and speech therapist.

Physical and occupational therapy are instrumental in providing a plan of care to improve gait, muscle strength, and improve functional independence (i.e. activities of daily living).

Dietician consult will provide a nutritional assessment and plan of care to address dehydration, inadequate caloric intake; dietary counseling may be needed for various co-morbidities (i.e. diabetes mellitus, renal disease).

Speech therapy consult will evaluate swallowing problems which may contribute to diminishing weight.

Dental consult will evaluate dental caries, poor fitting dentures and other dental disease which prevent the older adult from adequately eating.

Social work consult provides a social assessment and plan of care as it relates to patient and family support, referrals to community agencies and financial resources.

Frailty is a prognostic indicator for poor clinical outcome. When indicated, requesting a Palliative Care Team consult will provide additional resources (i.e. Chaplain Services and home health nurses who can provide quality of life and comfort support).


Helpful web-based sites to visit include:     SY03sect5

  • National Institute on Aging: http://www.nia.nih.gov

  • American Geriatrics Society Foundation for Health in Aging: http://www.healthinaging.org

  • National Council on Aging: http://www.ncoa.org


References     SY03sect6

Bergman, H., Ferrucci, L. Gurainki, J., et al. (2007). Frailty: An emerging research and clinical paradigm-issues and controversies. Journals of Gerontology; 64A: 731-737.

Espinoza, S., & Walston, J.D. (2005). Frailty in older adults: Insights and interventions. Cleveland Clinic Journal of Medicine, 72(12): 1105-1112.

Fried, L.P., Tangen, C.M., Walston, J., et al. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology; 56A: M1-M11.

Lekan, D. (2009). Frailty and other emerging concepts in the care of the aged. Southern Online Journal of Nursing Research, 9:3.

Newman, A.B., Gottdiener, J.S., McBurnie, M.A., et al. (2001). Associations of subclinical cardiovascular disease with frailty. Journal of Gerontology: Medical Sciences, 56A: M158-M166.



Hip Fractures
Judy Thomas, M.D. & Kathleen Pace Murphy, PhD., M.S.

Syndrome
Key Points     SY04sect1

In 2010, there were approximately 258,000 persons admitted to hospitals with a diagnosis of fractured hips (National Hospital Discharge Survey, 2010).

The most common etiology for fractured hips is falls.

One out five older adults diagnosed with hip fractures will die within the first year of their injury (Farahmand, Michaelsson, Ahlbom et al. 2005).


Overview     SY04sect2

Incidence of hip fractures is bimodal distribution with one peak represented by hip fractures due to high energy trauma in young adults and the larger peak seen in elderly population due to low-energy injury.

The term “hip fractures” encompasses five subtypes of fractures of the proximal femur. The subtypes are:

  • Femoral head

  • Femoral neck

  • Intertrochanteric

  • Trochanteric

  • Subtrochanteric

There are two categories of fractures:

  • Extracapsular fractures

    • Occur in intertrochanteric and subtrochanteric regions of the proximal femur.

    • Most likely occur in patients with a previously stiff hip secondary to arthritis.

    • Blood supply to the femoral head is well preserved.

    • These fractures are generally treated with internal fixation via intramedullary fixation device (cephalomedullary nail) or a sliding hip screw device.

    • Both methods mentioned above have good results, allowing patients to mobilize early and carrying low risk of osteonecrosis.


  • Intracapsular fractures

    • Occur in the femoral neck

    • Present as displaced or undisplaced intracapsular fractures

      • Displaced intracapsular fractures are associated with osteoporosis and characterized by increased incidence of nonunion and osteonecrosis due to damage to the blood supply to the femoral head. Treatment options include internal fixation, hemi-arthroplasty, total hip arthroplasty. There is evidence of better functional outcomes with primary total hip replacement in biologically fit patients.

      • Undisplaced intracapsular fractures have a lower risk of osteonecrosis than displaced fractures. There is a debate over the need for surgical intervention considering older adults with medical co-morbidities are at a higher risk for anesthesia and surgery-related complications. Yet advantages of surgical internal fixation are early patient mobilization and minimal risk of subsequent displacement.




Intervention     SY04sect3

Surgical repair for a hip fracture is usually very effective.

Without surgery, many patients are left with significant pain, a shortened leg and immobility which can lead to complications such as pneumonia, DVT and pressure ulcers.

A conservative approach may be an option in severely demented, very ill, or terminal patients if they are comfortable. In certain cases, internal fixation with pinning can be considered palliative.

Complications following hip fractures include deep vein thrombosis and pulmonary embolism, urinary tract infections, pressure ulcers, pneumonia, and delirium.

Delirium is the most common complication following hip fracture.

Common causes of delirium in post-operative hip fracture patients include:

  • Metabolic disturbance

  • Infection

  • Pneumonia

  • Urinary tract infection

  • Medication/polypharmacy

  • Poor pain control

  • Urinary retention

  • Sleep disturbance

  • Environmental issues – lack of vision and hearing aids

  • Hypoxemia, hypercapnea

  • Myocardial infarction and

  • Pulmonary


References     SY04sect4

Anatapur, P. (2011). Fractures in elderly: When is hip replacement a necessity? Clinical Interventions in Aging:6: 1-7.

Ellis, A.A. & Trent, R.B. (2001). Hospitalized fall injuries and race in California. Injury Prevention;7:316–20.

Farahmand, B.Y., Michaelsson, K., Ahlbom, A., Ljunghall, S., Baron, J.A. (2005). Swedish Hip Fracture Study Group. Survival after Hip Fracture. Osteoporosis International;16(12):1583-90.

Kristensen, M.T. (2011). Factors affecting functional prognosis of patients with hip fractures. European Journal of Physical Medicine and Rehabilitation;47: 257-264.

National Hospital Discharge Survey (NHDS), National Center for Health Statistics. Available at: http://205.207.175.93/hdi/ReportFolders/ReportFolders.aspx?IF_ActivePath=P,18 Accessed August 29, 2013.



Insomnia and Sleeping Difficulties in the
Hospitalized Elderly Patient

Nneamaka Enwemnwa, MD and Kathleen Murphy, PhD, MS

Syndrome
Overview     SY05sect1

Insomnia is a sleep disorder in which a patient suffers from an inability to initiate or maintain restful sleep.

Insomnia is associated with poor quality or quantity of sleep despite adequate opportunity to sleep.

Most cases of insomnia in the elderly are due to secondary causes such as medical conditions, medications, anxiety, depression, behavioral and environmental factors.

Primary Sleep disorders which represent approximately 5-20 percent of the cases include diagnoses such as Circadian rhythm disorders, sleep apnea, restless leg syndrome, and nocturnal myoclonus (Martin, Alam and Alessi, 2007).


Key Points     SY05sect2

Subjective insomnia assessment includes questions regarding depth and quality of sleep as perceived by the patient.

Objective insomnia assessment includes determination of sleep latency, duration and number of arousals and night time awakenings.

Poor sleep can result in cognitive dysfunction, falls, depression, decreased quality of life and increased mortality.


Interventions     SY05sect3

Treatment may be non-pharmacological and pharmacological.

If insomnia is a new complaint, thorough assessment of potential secondary causes is important. Non-pharmacologic intervention may be very effective at this stage.

Examples of non-pharmacologic sleep hygiene interventions include:

  • Management of underlying illness and control of distressful symptoms such as pain and dyspnea.

  • Medication adjustments such as timing and dosing of medication administration.

  • Maintaining patient activity during the day.

  • Avoiding day time napping.

  • Diminishing sleep disturbing environmental factors such as light, noise, bedroom temperature and bed comfort.

  • Avoiding alcohol, caffeine and nicotine before bedtime.

  • Avoiding large meals or fluid intake before bedtime.

  • Minimizing electronic exposure prior to bedtime such as televisions in the bedroom, working on the computer prior to bed and smart phones.

  • ther strategies include warm milk, white sound, muscle relaxation, massage and prayer.

Pharmacological Therapy management includes:

  • Insuring that non-pharmacologic strategies have been implemented and efficacy assessed.

  • Referring to a specialist if there is evidence of sleep disorder breathing, periodic limb movement, or psychiatric etiologies influencing the sleep cycle.

  • After a thorough review of the medications, determining the best chemical class to meet the needs of the patient.

  • Educating patients to avoid over-the-counter sleep aids and sedating antihistamines due to their anticholinergic effects.

  • Melatonin may be helpful for patients with circadian rhythm –related sleep disorders.


References     SY05sect4

Flaherty, J. (2008). Insomnia Among Hospitalized Older Patients. Clinics in Geriatrics Medicine:24:51-67.

Kamel, N.S., & Gammack, J.K. (2006). Insomnia in the elderly: Cause, Approach and Treatment. The American Journal of Medicine 119, 463-469.

Martin, J.L., Alam, T., & Alessi, C.A. (2007). Sleep Disorders. In R. J. Ham, P.D. Sloan, G.A. Warshaw, M.A Bernard & E. Flaherty (Eds). Primary Care Geriatrics: A Case-Based Approach (5th Ed). New York: Mosby Elsevier: pp. 391-400.

Subramanian, S. & Surani, S. (2007). Sleep disorders in the elderly. Geriatrics, 62(12):10-32.



Urinary Incontinence
Shannon Pearce, DNP, APRN, Jennifer Larson, MSE,
Kathleen Pace Murphy, PhD MS, GNP-BC

Syndrome
Overview     SY07sect1

One of the greatest aging myths is that urinary incontinence (UI) is part of normal aging, when, in fact, it is not. UI is defined as the involuntary passage of urine. Older adults are often embarrassed by this problem and are reluctant to discuss this issue with their clinician.

The diagnosis and management of UI can be successfully achieved in the primary care setting and in consultation with an urologist (surgical interventions). It is highly treatable and even curable in many instances (Pompei & Murphy, 2006).

The two main UI etiologies are transient and established incontinence.

Transient incontinence (often reversible) etiologies can be summarized using the DIAPPERS Mnemonic.

Reversible Causes of Urinary Incontinence (DIAPPERS)

Delirium

Infection (UTI)

Atropic

Pharmacological

Psychological

Endocrine/excess urine output

Restricted Mobility

Stool Impaction

Reference: Danforth, Townsend, Lifford et al. (2006), DuBeau, Kuchel, Johnson et al, (2010), & Sampselle, Harlow, Skurnick, et al. (2002).

Established incontinence is caused by a persistent problem affecting nerves or muscles.

There are five types of incontinence:

  • Stress incontinence results from abrupt abdominal pressure such as sneezing, coughing or laughing.

  • Urge incontinence is characterized by uncontrolled leakage with irrepressible need to void.

  • Overflow incontinence is dribbling of urine.

  • Functional incontinence is related to cognitive, physical or environmental impairment.

  • Mixed incontinence is a combination of any of the above types, but most commonly is a combination of stress and urge.


Key Points     SY07sect2

UI is NOT a normal aspect of aging.

There is a large prevalence variation of 8-72% in community based older adults (Zurcher, Saxer, & Schwendiamann, 2011).

UI is greater in women compared to men 80 years of age or younger; prevalence is equal in both genders after 80 years (Minassian, Stewart, & Wood, 2008); Markland, Goode, Redden et al. 2010).

Approximately 35-42% of hospitalized adults are affected by UI (Ko, Lin, Salmon & Bron, 2005).

UI in older adults is treatable and often curable.


Assessment     SY07sect3

Under-reporting of UI is common in older adults. UI screening is an effective method to elicit this information. The following questions will help your assessment process (DeMaagd & Davenport, 2012):

  • General Question – Do you ever leak urine? OR Do you ever lose control of your urine?

  • Stress UI – Do you leak when you cough or laugh? Do you leak on exertion or getting up from a chair?

  • Urge UI - Is the need to go so great that you would leak if you did not get to the toilet immediately?

  • Functional UI – Have you leaked urine because of a problem unbuttoning your pants or adjusting your clothing?

  • Overflow UI – Do you know when you are leaking? Do you strain to pass urine? Do you find that you leak after you think you are finished?


Management     SY07sect4

Successful UI management requires a stepwise approach

Step 1: Functional Management –Use assistive devices (urinals & bedside commode), medication review, eliminate environmental barriers in the path to the toilet, initiate timed voiding schedules (useful in cognitively/physically disabled patient).

Step 2: Hospitalized Older Adults - Complete a continence assessment early in the hospitalization process. Avoid unnecessary indwelling catheters and remove indwelling catheters as soon as possible. Involve interprofessional team members to assess the older adults’ functional abilities (physical & occupational therapy), home visit (nurse and social work assess home for safety and home health needs), and pharmacist (medication review to determine untoward side effects of medications that may be contributing to the older adults UI).

Step 3: Take a thorough history and implement behavioral strategies. Poor hydration causes bladder spasms & increases incidence. Obesity is well cited in the literature to increase urinary incontinence. If weight is an issue, think about a weight management program. Avoiding caffeine can reduce urine leakage 63% (Tomlinson et al., 1999). Other dietary modifications include avoiding alcohol, citrus and spicy foods (Wyman, 2000).

Step 4: Pharmacologic options are available based on the type of the diagnosed UI.

Step 5: Invasive non-surgical management includes Kegel exercises, life style modifications (smoking cessation, fluid restrictions, caffeine reduction, and alcohol reduction), intravaginal weighted cones, pessaries, pelvic floor electrical stimulation, sacral nerve stimulation, and biofeedback.

Step 6: Surgical interventions are also available. Surgical procedures will be determined based on the type of UI but include: sling procedures, other urethral suspension techniques (suprapubic arc, transobturator, and colposuspension [Burch] procedure).


References     SY07sect5

Alhasso, M. & N'Dow, G. (2008). Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults (Review). The Cochrane Collaboration, 3, 1-54.

Danforth, K.N., Townsend, M.K., Lifford, K., et al. (2006). Risk factors for urinary incontinence among middle-aged women. American Journal of Obstetrics and Gynecology, 194 (2): 339-345.

DeMaagd, G.A. & Davenport, T.C. (2012) Management of urinary incontinence. Pharmacy and Therapeutics 37(6), 361B-361H.

DuBeau, C.E., Kuchel, G.A., Johnson, T., et al. (2010). Incontinence in the frail elderly: Report from the 4th International Consultation on Incontinence. Neurological Urodynamics, 29 (1): 165-178.

Ko, Y., Lin, S.J., Salmon, W., & Bron M.S. (2005) The impact of urinary incontinence on quality of life in the elderly. American Journal of Managed Care, 11(4): S103-S111.

Markland, A.D., Goode, P.S., Redden, D.T., et al. (2010). Prevalence of urinary incontinence in men: Results from the national health and nutrition examination survey. Journal of Urology, 84 (3): 1022-1027.

Minassian, V.A., Stewart, W.F., Wood, G.C. (2008). Urinary incontinence in women: Variation in prevalence estimates and risk factors. Obstetrics and Gynecology, 111 (2Part1): 324-331.

Pompei, P., Murphy, J. (Eds.). (2006). Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, (6th Ed.). New York, NY: American Geriatrics Society.

Sampselle, C.M., Harlow, S.D., Skurnick, J., et al. (2002). Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstetrics and Gynecology, 100(6): 1230-1238.

Tomlinson, B.U., Dougherty, M.C., Pendergast, J.F., Boyington, A.R., Coffman, M.A., & Pickens, S.M. (1999). Dietary caffeine, fluid intake and urinary incontinence in older rural women. International Urogynecology, 10, 22-28.

Wyman, J.F. (2000). Management of urinary incontinence in adult ambulatory care populations. In: Fitzpatrick, J.F., Geoppinger, J. (eds.). Annual review of nursing research (vol. 18, pp.171-195). New York, NY: Springer-Verlag.

Zurcher, S., Saxer, S., & Schwendimann, R. (2011). Urinary incontinence in hospitalized elderly patients: Do nurses recognize and manage the problem? Nursing Research and Practice, 2011. Article ID 671302, doi:10.1155.2911.671302, http://dx.doi.org/10.1155/2011/671302



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