Transcript geriatrics-1 - WordPress.com

Gerontology:
• Study of the aging process and individuals
as they grow from midlife through later life
including the study of physical, mental and
social changes; the investigation of the
changes in society resulting from our
aging population; the application of this
knowledge to policies, programs, and
practice.
Geriatrics:
• The study of health and disease in later
life; the comprehensive health care of
older persons; and the well-being of their
informal caregivers.
• Geriatrics focuses strictly on the medical
conditions and disease of the aging,
Gerontology is a multidisciplinary study
that incorporates biology, psychology and
sociology.
Aging
• As your body ages, you can expect
gradual changes, at your body's own pace.
How your body ages depends in part on
your family (genetic) patterns of aging. But
your lifestyle choices have a more
powerful impact on how well your body
ages. Fortunately, you can control your
lifestyle choices.
• What is Aging?
Aging
•
is not a disease
• occurs at different rates
–among individuals
–within individuals
• does not generally cause
symptoms
Overview of Aging Physiology
• Skin
•
•
•
•
Body Composition
Vision
Special Senses
Nervous System
Musculoskeletal
System
Renal
GI
Cardiovascular
Aging Skin
Age-Associated Factors - Vision
• visual acuity (cataracts, macular
degeneration)
• dark adaptation
• peripheral vision (glaucoma)
• contrast sensitivity
• accommodation
Age-Associated FactorsSpecial Senses
• Auditory and Vestibular
– Presbycusis: high frequency hearing loss
– Vestibular dysfunction
• Smell
• Oral/Dental
– Teeth: 40% of elderly are edentulous
– Taste
– Salivary function
Age-Associated FactorsNervous System
•
•
•
•
•
•
CNS: decrease in nerve cell number
basal ganglia atrophy
 dopamine and muscular rigidity
 step height
 reaction time
PNS: decreased vibratory sensation
Age-associated Factors:
Musculoskeletal system
•
30% loss in muscle mass 3rd to 8th decade sarcopenia.
• Osteoarthritis
– weight bearing (spine/knees/1st metatarsophalangeals)
– repeated strain (distal interphalanges/1st carpometacarpals)
• Osteopenia/-porosis (80% women >65 y/o
osteopenia)
– decreased activity, dietary calcium, estrogen withdrawal
Aging Renal Physiology
• GFR  30-46%
 Tubular function
• Renal plasma flow  ~50%
• CrCl = [(140 - age) x (BW)]/[72 x SrCr ]
– Multiply x 0.85 for females
– BW in kg (LBW or IBW with edema or obesity)
Absorption: GI Physiology
(gastro intestinal)
• GI absorptive cells
• GI motility

 or normal
• Sphincter activity 
• GI blood flow

• Gastric acid secretion
• Active transport


Afterload: Vascular Changes
• Vascular Smooth Muscle
– Increased thickness of intima and media
– Matrix
• Collagen deposition, increased fibronectin,
crosslinking (AGEs)
• Fragmentation of elastin, calcium deposition
Net result is increased vascular stiffness.
Summary: Age-associated changes in
cardiovascular physiology
• Maintenance of resting left ventricular
function.
• Decreased ability to compensate for
stress or impaired LV function.
– Blunted heart rate response to exercise
requires a compensatory increase in
stroke volume to increase cardiac
output.
Kliknij, aby dodać tekst
Disorders More Common in
Older Adults
A number of disorders are more common in
older adults than in younger persons. They
are not caused
by aging
Kliknij, aby
dodaćitself,
tekstand do not
occur in all older adults.
Anemia
• Using WHO criteria (Hb <120 g per L in women and
<130 g per L in men), the prevalence of anemia in the
elderly ranges from 8 to 44 percent, with the highest
prevalence in men 85 years and older.
Kliknij,
tekst of elderly
• A cause
can beaby
founddodać
in ~ 80 percent
patients.
• The most common causes of anemia are anemia of
chronic disease and iron deficiency, but Vitamin B12
deficiency, folate deficiency, GI bleeding and
myelodysplastic syndrome are also common causes
Atrial Fibrillation (Afib)
• The prevalence of atrial fibrillation increases
with age, about 3% in those in their early 60s,
and is up to 10% in those older than 80.
aby dodać
• AfibKliknij,
is associated
with a tekst
higher risk of
cardiovascular death, congestive heart failure
and peripheral embolic stroke in older
patients.
Cardiovascular Disease
• Cardiovascular disease is the leading cause of death
in older Canadian men and women.
• Hypertension (HTN), the best predictor of coronary
artery disease, increases dramatically in prevalence
with aging;
isolated
HTN
occurs in 34% of
Kliknij,
abysystolic
dodać
tekst
men and 38% of women aged 65 to 74.
• 50% of Canadian seniors are on no treatment at all for
HTN
• Congestive Heart Failure (CHF) is the most common
cause of hospitalization among those aged 65+ in the
US
Cancer
• Lung cancer is the most common cause of cancerrelated deaths in both men and women; 68% of cases
occur in people over 65
• >50% of breast cancer patients are older than 65 at
Kliknij, abydiagnosis
dodać tekst
• Prostate cancer is the most commonly diagnosed
cancer among Canadian men (excluding nonmelanoma skin cancer) over 65, and is the second
most common cause of cancer death (after lung
cancer) in this same group.
Cerebrovascular Disease (Stroke)
• One Canadian study estimated 4.1% of people
aged 65+ in the community are living with the
effects of stroke (CMAJ Sept. 22, 1998; 159).
aby dodaćstroke
tekstmore often
• SeniorsKliknij,
who experienced
reported their health to be "poor" or "fair" than
seniors who had not (69% v. 25%)
Chronic obstructive pulmonary disease
(COPD)
• COPD is the fourth-leading killer disease of
the elderly in Canada.
Kliknij,
abyis dodać
tekst cause in
• Cigarette
smoke
the underlying
~80% to 90% of cases
• Prevalence of COPD for those aged 65-74
years is 5.0%; and for those over 75 years is
6.8%.
Dementia
• Alzheimer Disease (AD) is the leading cause
of dementia in Canada (60-70% of all),
affecting about 160,000 Canadians, or 3-11%
of the general
over
60 years of age
Kliknij,population
aby dodać
tekst
Diabetes Mellitus
• Diabetes has a prevalence of ~13% in persons over 65.
• Type II diabetes mellitus is the most common form of diabetes in
the elderly, accounting for about 92% of cases, and is the 6th
leading cause of death in men over 65.
• The onset of Type II DM occurs 40% of the time after the age of
60, and
there is aby
often adodać
long delaytekst
before diagnosis.
Kliknij,
• Long-term studies have show that 35% of seniors with diabetes
suffer from retinopathy 18% from cardiovascular disease, 30%
from peripheral vascular disease and 12% from nephropathy
Hypothyroidism
• One US survey of community dwelling elders found 7% of women
and 3% of men between 60 - 89 years of age with this hormone
deficiency
• The Canadian Study on Health and Aging (CSHA) found 9% of
their study population had subclinical hypothyroidism.
Kliknij, aby dodać tekst
Osteoarthritis
• 85% of people over the age of 70 suffer from osteoarthritis
• It is the number 1 cause of long-term disability in Canada
Osteoporosis
• Estimates from the Osteoporosis Society of Canada suggest that
1.4 million Canadians have osteoporosis, a leading risk factor for
bone fractures and death or morbidity after a fall.
Parkinson’s Disease (PD)
Kliknij, aby dodać tekst
• Roughly 1/100 persons in North America are affected
• Average age of diagnosis is 60; the rates rise in persons >70.
• Dementia, a feared complication, increases in prevalence with
age; it occurs in approximately 30% of patients with advanced
PD.
Pneumonia
• Influenza/pneumonia is a major contributor to deaths
and hospitalization in the elderly and is the leading
cause of death from infectious disease in Canada.
Kliknij, aby dodać tekst
Prostate Disease
• Symptomatic Benign Prostatic Hypertrophy (BPH) is
very common, affecting 40 to 50% of men aged 51 to
60 years, and ~80% of men by age 80.
Skin Disease
• US datum show that 20% of all GP visits for those 65+
are motivated by a skin problem (i.e. rash, pruritis,
photo aging, cancer)
• Surveys show that 2/3 of those 65+ have at least one
dermatological disorder.
Kliknij,changes
aby dodać
tekst
• Physiological
in aging
skin when
combined with immobility and incontinence
predispose elderly persons to have pressure
ulcers; prevalence rate in acute care range from
3.5% to 30% and in long term care facilities from
2.4% to 23%.
Sexual Dysfunction
• Erectile dysfunction (ED) is the most common
form of sexual dysfunction in elderly men,
affecting nearly 70% of men age 70.
• The prevalence
sexual tekst
dysfunction in
Kliknij, abyofdodać
elderly women is largely unknown, but
reduced libido, inhibited orgasm and
dyspareunia are the most common disorders,
and are largely due to the decline of estrogen
production
Urinary Tract Infections
• Prevalence of asymptomatic bacteriuria in the
elderly range from 15-60% depending on the
study, with twice as many females as men
Kliknij, abyaffected.
dodać tekst
• The annual incidence of symptomatic bacterial
UTIs is estimated to be as high as 10% in
those over 65.
Vision Loss
• Thirteen percent of people over age 65 have some form of visual impairment.
• Almost 8% of seniors over 65 (and 11% if over 80) have impairment
(blindness in both eyes) sufficient to meet the legal definition of blindness
(visual acuity (VA) less than 20/200)
• 11 % of Canadians between 65 to 74 years of age & 30% of persons over the
age of 75 have Age Related Macular Degeneration (ARMD), the most
common cause of irreversible vision loss in seniors.
• Diabetic retinopathy accounts for 35% of all cases of blindness; prevalence
increases with age and the duration of the disease
• The prevalence of lens cataracts sufficient to impair vision (visual acuity less
than 20/30) rises from 1% by age 50 to 100% by age 90.
• Glaucoma is present in less than 1.5% of those under 65, 2-3% in those aged
65-74, and between 2.5-7% for those over 75.
Kliknij, aby dodać tekst
Geriatric Giants
Cognitive Impairments: Dementia, Delirium
Depression
Incontinence
Orthostatic Hypotension
Dizziness
Kliknij,Falls
aby&dodać
tekst
Osteoporosis
Iatrogenesis & Medication Optimization
Pain in the Elderly
Failure to Thrive
Frailty [Under Construction]
Elder Abuse
Cognitive Impairments
Definition: A cognitive impairment is a change in
how a person thinks, reacts to emotions, or
behaves.
The most common differential diagnosis in older
adults of
an acquired
cognitive
impairment
Kliknij,
aby dodać
tekst
includes three major categories:
1. Dementia,
2. Delirium
3. Depression (temporary and a reversible cause of
“pseudodementia”)
Dementia
A diagnosis of dementia is made when newly acquired cognitive
impairments are sufficient to interfere with social or occupational
functioning in a person without depression or delirium. More often it
is other family members, rather than the affected person who
notices the first symptoms of dementia.
There are over 70 different causes of dementia, and each has a
particularKliknij,
pattern of aby
decline,dodać
impairments,
and underlying
tekst
neurohistopathological processes. Alzheimer’s Dementia (AD) is the
most common cause worldwide, and accounts for about 65% of
cases. Vascular Dementia (VaD), mixed vascular and AD, Dementia
Lewy Body (DLB) and Frontotemporal Dementia (FTD) each
account for about 10% of cases
In AD, memory problems usually occur first (losing items,
missing appointments), along with difficulties in the
performance of complex tasks they could normally do
(i.e. complete taxes, driving in strange places, cook a
Thanksgiving meal). Other associated problems include
word finding difficulties, difficulty with names, inability to
Kliknij,
tekst
follow theaby
plot dodać
of a film or
TV 48
show, geographic disorientation (getting lost driving, at the
mall, etc.), apathy and disinterest in surroundings, sleep
disturbance (sleeping much more in the day time) and
difficulties in inhibiting behavior (impulsivity, socially
inappropriate actions).
Criteria for Dementia (based on DSM-IV):
A. Impairment in short- and long-term memory
B. At least 1 of the following:
1.Impairment in abstract thinking
2.Impaired judgment
3.Other disturbances of higher cortical function (agnosia, anomia,
Kliknij,
aby dodać
tekst
& visualospatial
difficulties)
4.Personality change
C. Memory impairment and intellectual impairment cause
significant social and occupational impairments
D. Absence of occurrence exclusively during the course of Delirium
E. Cannot be accounted for by any nonorganic mental disorder*
• Older patients with depressive
symptoms (i.e. hopelessness,
excessive guilt, inertia and suicidality
Kliknij, aby dodać tekst
may be suffering from pseudodementia
(ie, major depression). When the
depression improves with treatment,
the cognitive impairments may resolve.
Potentially Reversible Dementias
Dementias are usually progressive and irreversible. However, there are
a number of conditions that may rarely mimic dementia and may
reverse if identified and properly treated. These “exceptions to the
rule” include:
• Delirium
• Depression: so-called “Pseudodementia”
• Electrolyte disorders (hyponatremia, hypercalcemia, etc.)
• Hypothyroidism
• Wilson’s Disease (rare, and very rarely seen in Geriatric patients!)
• Late onset Psychosis
• Medication side effects (e.g. sedatives, anticonvulsants,
antihypertensives, anticholinergics, first generation neuroleptics)
• ETOH overuse/misuse
Kliknij, aby dodać tekst
• Vitamin deficiencies (B-12, folate)
• Obstructive Sleep Apnea
• Normal Pressure Hydrocephalus (although
few, if any actually reverse with shunting)
Kliknij,•aby
Braindodać
tumourtekst
• Subdural Hematoma (SDH)
• Sub-acute CNS infections (i.e. syphilis)
Diagnosis of Dementia
The diagnosis is made clinically, primarily
from the history provided by the patient
and the caregiver, but also supported by
Kliknij, aby dodać tekst
memory problems demonstrated by the
patient
Delirium
Delirium, or acute confusion, is a common
problem. Up to 60% of older persons
hospitalized for surgery will become delirious.
35% to 65% of elderly patients with hip fractures
dodać
tekst
willKliknij,
becomeaby
delirious
after
surgery.
Why is delirium important?
Mortality is 20%/year for those >70 years
(independent of all other co-morbidities);
Delirium is therefore a MEDICAL EMERGENCY.
DSM IV definition:
Decreased attention & disorganized thinking, with
at least 2 of:
• reduced LOC
• perceptual disturbances
Kliknij, aby dodać tekst
• altered sleep-wake cycle
• disorientation
• memory impairment
• altered psychomotor activity
• with acute onset and fluctuation over time (hours).
Clinical diagnose of Delirium
Method 1. Use the CAM (Confusion Assessment
Method); best, see appendix.
Is there:
Kliknij,
tekst
1. acute
onsetaby
and dodać
fluctuating
course?
2. lack of attention?
3. disorganized thinking?
4. altered Level of Consciousness?
If 1 and 2 are present, and either 3 or 4, the patient is
probably delirious.
Method 2. Use the Digit Span Test
Ask the patient to repeat a sequence of numbers
that you present to them at a rate of one per
second in your normal voice. Start off with a
sequence of 3, then 4, then 5, etc. up to a
maximumKliknij,
if 7 random
numbertekst
sequences. (i.e.
aby
dodać
1-8-5, 6-4-3-7, 2-0-7-1-5, etc.) Do not use
duplicate numbers or group them into obvious
patterns (ie. phone #).
Persons who are not delirious should be able
to repeat 7 (+/- 2) numbers from the
sequence you initially dictate to them.
Risk Factors for Delirium
• Pre-existing dementia (such brains are more
vulnerable and less able to withstand any
form of insult)
Kliknij,
aby dodać
tekst
• Poor vision
(ARMD,
cataracts,
no glasses)
• Poor hearing (absent hearing aid, wax blocked
ears, etc.)
• dehydration
Mnemonic of risk factors commonly associated
with DELIRIUM:
Dementia,
Electrolytes,
Lungs and other organs,
Kliknij, aby
dodać tekst
Infection,
Rx (medications),
Injury (pain and stress),
Unfamiliar environment, and
Metabolic problems
Another mnemonic for causes of delirium is
DEMENTIA
D rugs
E ndocrine
M etabolic, organ failure, etc.
Kliknij,
aby(post
dodać
tekst
E pilepsy
seizure)
N eoplasm
T rauma (head, surgery, etc.)
I nfection
A poplexy or other vascular event.
Depression
Depression is the most common psychiatric illness
in the elderly. Although common, it is NOT a
natural part of aging.
Kliknij,inaby
dodać dwelling
tekst elders
The prevalence
community
range from 8-15%; it rises to as much as 30% of
those in long term care facilities. Depression and
suicide are common in the elderly (especially
older males; those over 75, have the same risk
of suicide as 20-24 year old depressed males).
Mnemonic “Sig. E Caps” (Sig.=from the old Latin way to
prescribe, E=“Energy”, Caps= “Capsules”) as a check list
for Depression:
S uicidal Ideation
I nterest, lack of
G uilt
Kliknij, aby
dodać tekst
E nergy, none
C oncentration, poor
A ppetite(s), altered
P sychomotor changes (slowed or revved up)
S uicide
Screening for Depression
• Ask, "What is wrong?" Or, “Do you often feel downhearted or sad?”
• 15 or 30 item GDS (see below)
• ROS shows up with many somatic complaints in many domains
• Ask about suicidal or pessimistic thoughts
The Geriatric Depression Scale (GDS), is a screening tool for depression,
and does not itself diagnose depression. There are various forms about,
including a 30 question, a 15 question short form (see Appendix) a four
question, and a single question screen (i.e. If you have time to ask only 1
question to screen, ask “Do you feel that your life is empty?”
For short form (15 questions) GDS; >5 points are suggestive for depression,
and scores >10 points are very suggestive for depression [See the appendix
for all the questions].
For the 30 question GDS, >13 points are suggestive, and >15 very suggestive.
Kliknij, aby dodać tekst
Orthostatic Hypotension (OH)
• Also known as postural hypotension, orthostatic hypotension (OH)
is a major and often hidden cause of falls in the elderly!
• Not a specific disease as much as it is a syndrome of abnormal
postural blood pressure response due to one or more underlying
conditions that can affect the normal autonomic reflex arc.
Kliknij, aby dodać tekst
Definition: An excessive drop in Blood Pressure (BP) seen
when changing from a lying/sitting position to assume a
standing and upright posture;
Typically the BP drop is at least 20 mmHg systolic / 10
mmHg diastolic
Warning “Red Flags” for the possibility
of OH
• OH symptoms (dizziness, faints and near
falls/falls) that occurs early each morning
Kliknij,
abythat
dodać
• Symptoms
of OH
occurtekst
on consecutive
days
Aetiology of Orthostatic Hypotension (in order of frequency) 92
• Hypovolemia: diarrhea, hemorrhage, salt losing nephropathy, ETOH,
adrenal insufficiency,.
• Drugs: Antyhypertensives, Diuretics, Vasodilators (nitrates, hydralazine),
Alpha- and beta-blocking agents, barbiturates, opiates, Tricyclic
antidepressants, and ETOH)
• CNS problems: Parkinson’s disease, Parkinson’s Plus syndromes (multisystem atrophy, Shy-Drager), Stroke.
• Autonomic problems associated with Diabetes Mellitus (DM)
• Deconditioning and prolonged bed rest
• Post-prandial (“face down in the corn flakes!”)
• 2o systemic arterial hypertension
• Idiopathic= Bradbury-Egglestone syndrome (this can be distinguished
by measuring supine norepinephrine levels, which are low)
Kliknij, aby dodać tekst
Kliknij, aby dodać tekst
What is Osteoporosis?
• Osteoporosis, “porous bones”, is a
disease that causes bones to become
fragile and brittle and very susceptible to
fractures. These fractures, occur typically
in the hip, spine, and wrist.
Osteoporosis Diagnosis?
• The best method to diagnose osteoporosis is a
bone mineral density test, called a DEXA test. It
is recommended to get a bone density test if:
• a woman age 65 or older
• 60 and at increased risk of osteoporosis
• The results of your bone density test will give
you a T-score. The T-score compares your bone
density with that of an average healthy young
adult of your sex. Below you will see how to
interpret your T-score.
• Above -1 = Your bone density is
considered normal
• Between -1 and -2.5 = Your score is a sign
of osteopenia, a condition in which bone
density is below normal and may lead to
osteoporosis
• Below -2.5 = Your bone density indicates
you have osteoporosis
Other lab tests:
• CBC
• Calcium & albumin (only the ionized calcium is biologically active;
ignoring pH effects, you can roughly calculate ionized calcium by
using: Corrected Calcium = for each fall (or rise) of albumin
by 4 g/L add (or subtract) 0.1 mmol/L to the plasma calcium.
• TSH level
• Alkaline Phosphatase
• Serum Phosphorous and Magnesium
• Creatinine
• Consider serum protein electrophoresis if you suspect multiple
myeloma.
• Consider serum bioavailable testosterone level in a male with a
fracture
Risk Factors of Osteoporosis
• In the past osteoporosis was thought of as
a women’s disease. Now we know that
men also have to worry about weak bones
and are at risk of osteoporosis.In fact, one
in four men over the age of 50 will suffer a
fracture caused by osteoporosis.
• These factors can increase your chances
of developing osteoporosis:
• Your sex – Fractures from osteoporosis
are about twice as common in women as
they are in men.
• Age – Your bones become weaker as you
age.
• Race – Caucasian and Southeast Asians
have a greater risk of osteoporosis, Black
and Hispanic men and women have a
lower but still significant risk.
• Family history – Having a family member
with osteoporosis puts you at greater risk
as osteoporosis is genetic.
• Body size – Individuals who are thin or
have small body frames have a higher risk
because they have less bone mass.
• Smoking – Research has shown that
tobacco use contributes to weak bones.
• Corticosteroid medications – Long-term
use of prednisone, cortisone, prednisolone
and dexamethasone, is damaging to bone.
• Breast cancer – Women who have had
breast cancer are at increased risk of
osteoporosis, especially if they were
treated with chemotherapy
• Diet – A diet lacking in calcium plays a major
role in the development of osteoporosis.
• Lack of Exercise – Exercise throughout life is
important, but you can increase your bone
density at any age.
• Alcohol Abuse – Long term alcohol abuse
reduces bone formation and interferes with the
body’s ability to absorb calcium.
Treatment & Care
• Osteoporosis treatments include the
“basic CDE’s” -- calcium(C), vitamin D
(D), weight-bearing exercise (E),
prevention of Falls (F), and bone-friendly
medicines.
Management:
• Lifestyle
• Nutrition
• Medications
Lifestyle:
• Lifestyle prevention of osteoporosis is in
many aspects the inverse of the potentially
modifiable risk factors. As tobacco
smoking and high alcohol intake have
been linked with osteoporosis, smoking
cessation and moderation of alcohol intake
are commonly recommended as ways to
help prevent it.
• Weight-bearing endurance exercise and/or
exercises to strengthen muscles improve bone
strength in those with osteoporosis. Aerobics,
weight bearing, and resistance exercises all
maintain or increase BMD (bone mineral
density) in postmenopausal women. Fall
prevention can help prevent osteoporosis
complications. There is some evidence for hip
protectors specifically among those who are in
care homes.
Nutrition
• As of 2013 there is insufficient evidence to
determine if supplementation with calcium and
vitamin D results in greater harm or benefit in
men and premenopausal women. Low dose
supplementation (less than 1 g of calcium and
400 IU of vitamin D) is not recommended in
postmenopausal women as there does not
appear to be a difference in fracture risk. It is
unknown what effect higher doses have. There
however may be some benefit for the frail elderly
living in care homes.
• While vitamin D supplementation alone
does not prevent fractures, combined with
calcium it might. There however is an
increased risk of myocardial infarctions
and kidney stones. Vitamin K
supplementation may reduce the risk of
fractures in post menopausal women;
however there is no evidence for men.
Medications
•
Actonel, Binosto, Boniva, and Fosamax (also available
as generic) work by inhibiting cells that break down bone
and slowing bone loss. Actonel, Binosto, and Fosamax
are usually taken once a week, while Boniva is taken
once a month. There are strict ways to take these
medications, since if taken incorrectly, they can lead to
ulcers in the esophagus.
• Another new osteoporosis medication of the same class
is Reclast, which is given as a once-yearly 15-minute
infusion in a vein. Reclast is said to increase bone
strength and reduce fractures in the hip, spine and wrist,
arm, leg, or rib.
• Forteo is a new medication used for the
treatment of osteoporosis in postmenopausal
women and men who are at high risk for a
fracture. A synthetic form of the naturally
occurring parathyroid hormone, Forteo is the first
drug shown to stimulate new bone formation and
increase bone mineral density. It is selfadministered as a daily injection for up to 24
months. Side effects include nausea, leg
cramps, and dizziness.
• Prolia is a so-called monoclonal antibody
-- a fully human, lab-produced antibody
that inactivates the body's bonebreakdown mechanism. It's the first
"biologic therapy" to be approved for
osteoporosis treatment. Prolia is approved
for postmenopausal women with
osteoporosis and high risk of fracture, and
when other osteoporosis medicines have
not worked.
• Menopausal hormone replacement
therapy -- either estrogen alone or a
combination of estrogen and progestin -- is
known to help preserve bone and prevent
fractures. The drug Duavee (estrogen and
bazedoxifene) is a type of HRT approved
to treat menopause-related hot flashes.
Duavee may also prevent osteoporosis in
high-risk women who have already tried
non-estrogen treatment.
!!!
• HRT is no longer prescribed for
osteoporosis alone because of other
health risks long-term hormone therapy
poses. In women who have been on
hormone replacement therapy in the past
and then stopped it, the bone begins to
thin again -- at the same pace as during
menopause.
Urinary Incontinence
Definition: The involuntary loss of urine in sufficient
amount or frequency to constitute a social or
health problem.
Even though there are aging associated changes
in the bladder and the urinary tract
which make the elderly person more prone to
urinary incontinence, the problem is not and
should not be considered as part of ageing.
Causes of Acute, Reversible cause of
Urinary Incontinence: DRIP
D delirium
R restricted mobility, retention.
I infection, inflammation, impaction (faecal).
P polyuria, pharmaceuticals
Causes of Persistent Urinary
Incontinence:
Stress: Involuntary loss of urine (usually small amounts)
with increase in intraabdominal pressure (e.g. cough,
laugh, or exercise).
Urge: Leakage b/c of inability to delay voiding after
sensation of bladder fullness is perceived.
Overflow: Leakage (small amounts) resulting from
mechanical forces on an over-distended bladder or from
other effects of urinary retention on bladder and
sphincter function.
Functional: Leakage assoc. w/ inability to toilet because of
impairment of cognitive and\or physical functioning,
psychological unwillingness, or environmental barriers.
Lab work-up of Urinary
Incontinence
Step I: start with the following
• Urinalysis & urine C&S
• Blood glucose and calcium levels
• Post void residuals (preferably done with bladder scan, or in-andout catheterization)
Step 2: Other tests if the diagnosis not clearly
established:
• Simple urodynamic tests
• Complex urodynamic tests
• Lab studies: renal function, urine cytology,
• Radiological studies: renal U\S, voiding cystourethgraphy
• urological or gynecological evaluation
Failure to Thrive (FTT)
NIA definition (National Institute of
Aging): "a syndrome of weight loss,
decreased appetite, poor nutrition and
inactivity, often accompanied by
dehydration, depressive symptoms,
impaired immune function and low
cholesterol "
Frailty
• Although MDsoften talk about the “frail elderly” there
are unfortunately no clear consensus on the definition
of this term.
• The American Geriatric Society defines it as the
“…clinical expression of cumulative biologic changes
with aging which result in decreased ability to
maintain homeostasis and lead to vulnerability to
stressors.”
• in other words, “frail seniors” are those older adults
who actively demonstrate failure of homeostenosis.
• This is an important area of health care still requiring
further study for the frailest seniors, about 3% of the
total, consume ~30% of Canadian health care
resources, often in the final years of their life
Features of fraility include:
o Unexplained weight loss (>5% over a year)
o Poor endurance and energy (self reported)
o Poor strength (in lowest 20th percentile)
o Slow walking speed (Poor “Get up and Go”
test).
o Low physical activity (lowest 20th percentile)
Pain in the Elderly
• Pain is an unpleasant subjective and personal
experience associated with actual or potential
tissue damage; it is the way your body tells
you to “stop doing that!”.
• Pain increases in incidence and prevalence
after age 60 because of the accumulative
burden of such aging associated illnesses
such as osteoarthritis, compression fractures,
diabetic neuropathy and cancer.
• It is under reported by seniors, who may not tell their
doctors because they fear being labeled as
bothersome, hypochondriacal, or becoming addicted.
• Twenty-five percent to 50% of elderly people in the
community experience pain on a regular basis, and
as many as 85% of the elderly in residential facilities
report continual pain
• Unfortunately, pain is under treated in the oldest-old
(>85) and in patients with dementia who may not
adequately describe their pain.
The most common causes of
pain in the elderly stem from:
• Osteoarthritis (prevalence is 49.5% in those
65+)
• Other joint disorders (Rheumatoid arthritis,
gout/pseudogout, PMR, SLE, etc.)
• Osteoporosis (e.g. vertebral compression
fractures)
• Cancer
• Cardiac ischemia
• Diabetic neuropathy
• Varicella Zoster and post herpatic neuralgia
Assessing Pain in the Elderly
(OLD CART mnemonic)
• Onset: When did it start
• Location
• Duration
• Characteristic of the Pain
• Aggravating Factors
• Relieving factors
• Treatment’s taken or tried
Elder Abuse (Abuse of Seniors)
Elder abuse is defined as any action or inaction that
threatens the well being of an older person. A 1990
national telephone survey of 2,000 seniors showed that
up to 4% of Canadians over the age of 65 may be
abused or neglected. A recent study of 31 Canadian
nursing homes found that 36% of nursing home staff had
witnessed the physical abuse of an older adult in the
preceding year and that 81% had witnessed
psychological abuse. A 1988 Health and Welfare Canada
study found that financial abuse accounted for over 50%
of the documented cases of elder abuse.
Abuse can take many forms, but is usually
grouped in five major categories:
Physical & Sexual abuse
Emotional and psychological abuse
Financial Abuse & material exploitation
Abandonment & Neglect
Medical abuse
Falls & Poor Balance
Falls are a leading cause of morbidity and
mortality in seniors.
It has been reported that:
• 30% of community dwelling elderly persons
fall each year
• 1/2 of these have multiple falls
• 45% of falls occur in residents in Long Term
Care facilities
Why else are falls important?
• Fear of falling restricts activities
• Falls are often marker for underlying disease
• 6th leading cause of death
• 5-15 % falls lead to serious injury
• 1-2% of falls lead to hip fractures.
Aetiology (often multifactorial)
• Accidents and environmental hazards
• Drugs
• Dementia
• Syncope
• Seizures
• Lower limb weakness and deconditioning
• Ddizziness and\or vertigo
• Vestibular disease
• orthostatic hypotension (see OH section for more detail)
• CNS disease
Specialty Testing for Falls
Timed “Get up and go” test,
• This is the time it takes for a person to stand up
from a straight back chair, walk 3 m, and return
and sit down.
• 10 seconds is normal, 11-20 is normal for a frail or
disabled patient, and >20 seconds is abnormal and
warrants further assessment
Management of Falls
• Treat underlying causes (i.e. if suspect Parkinson’s
Disease a trial of levodopa/carbidopa, improve blood
sugar control if DM, start on anticoagulation for 2’
stroke prophylaxis if in atrial fibrillation, if B-12
deficient, start replacement therapy, etc.)
• Review medications and consider their necessity (this
may involving contacting other physicians, such as
the Family MD and other specialists) and whether if
they can be reduced or discontinued.
• Taper sedatives gradually before stopping (with avoid
withdrawal), reduce neuroleptics (or change to a 2nd
generation atypical neuroleptic, etc.), stop
dimenhydrate (Gravol), etc.
• Cut down or stop ETOH if this is playing a role
(falls while inebriated, peripheral neuropathy)
• Rehabilitation with referral to OT (home visit to
examine hazards and to see whether devices
need to be installed or have the environment
modified), PT (for strengthening or balance
exercises), Day Hospital or Falls clinic referral
(for complicated patients who need
interdisciplinary approach)
• Enhance mobility (cane, walker, rails), improve
vision, improve environment
• Consider hip protectors (either hard plastic shell or soft
foam “hockey pants” that protect the femoral heads from
a direct blow if there is a fall).
• Consider getting a BMD, and starting on calcium/vitamin
D; if osteoporosis, start on a bisphosphonate.
• Recommend a “Lifeline” or other device that the older
person can use to signal for help if they’ve fallen and
can’t get up.
• If poor balance or deconditioning, train for preventing falls,
by recommend they start Tai Chi, or joining a seniors
fitness group
Dizziness
Often multi-factorial in aetiology:
• Vertigo
• Presyncope
• dysequilibrium
• anxiety and or depression may be playing a
role
Polypharmacy, Iatrogenesis &
Medication Optimization
Although seniors represent 12% of the Canadian
population, they consume 28% to 40% of all
prescriptions. Unnecessary prescribing, misuse
of medication and inappropriate prescriptions
can contribute to the risk of drug-related illness
and result in unwarranted costs in health care
delivery.
An estimated 5% to 23% of hospital admissions
are due to drug-related illness. Physical
impairments and death (estimated 200,000 per
year in the US) are all too common tragic
results.
Polypharmacy literally means “Many
Drugs”, and it reflects the problems that
occur when persons are taking too many
(or simply too many of the wrong drugs,
which is iatrogenesis); it is an older term
that is falling out of use. Previously defined
as 5 or more new drugs during a given 3
month period, it is estimated that 15% of
patients are at risk of from polypharmacy.
A more current term is Medication
Optimization (since many patients truly
need the many medications for their
plethora of problems), and the thinking has
now shifted from simply reducing
medications, to ensuring than an older
person be on the optimum number and
dose of medication for their problems.
Medications that may have been relatively
benign when the patient was younger, can
accumulate risks as the person ages (and
with that, changes in drug metabolism and
pharmacokinetics). The main concern in
the elderly is that side effects should not
outweigh beneficial effects.
Frequent drug side effects in the
elderly include:
• Falls
• Arrythmias
• Confusion (from sedation, anticholinergic effects)
• Dehydration from diuretics
• Hypotension from many cardiac medications
• NSAID gastropathy
• Digoxin toxicity (even with so-called therapeutic dig
levels)
• Insulin Hypoglycemia
Pressure ulcers = decubitus ulcers
= bedsores
=pressure
sore =
Kliknij, aby
dodać tekst
pressure injuries
Bedsores
• are injuries to skin and underlying tissue
resulting from prolonged pressure on the
skin.
Bedsores – where?
Common sites of pressure sores
For people who use a wheelchair, pressure sores often
occur on skin over the following sites:
• Tailbone or buttocks
• Shoulder blades and spine
• Backs of arms and legs where they rest against the chair
For people who are confined to a bed, common sites
include the following:
• Back or sides of the head
• Rim of the ears
• Shoulders or shoulder blades
• Hip, lower back or tailbone
• Heels, ankles and skin behind the knees
Bedsores – Causes:
Bedsores are caused by pressure against the skin
that limits blood flow to the skin and nearby
tissues. Other factors related to limited mobility
can make the skin vulnerable to damage and
contribute to the development of pressure sores.
Three primary contributing factors are:
• Sustained pressure
• Friction
• Shear
1.
• Sustained pressure. When your skin and the underlying
tissues are trapped between bone and a surface such as a
wheelchair or a bed, the pressure may be greater than the
pressure of the blood flowing in the tiny vessels (capillaries)
that deliver oxygen and other nutrients to tissues. Without
these essential nutrients, skin cells and tissues are
damaged and may eventually die.
1.
• This kind of pressure tends to happen in
areas that aren't well-padded with muscle or
fat and that lie over a bone, such as your
spine, tailbone, shoulder blades, hips, heels
and elbows.
2.
• Friction. Friction is the resistance to
motion. It may occur when the skin is
dragged across a surface, such as when
you change position or a care provider
moves you. The friction may be even
greater if the skin is moist. Friction may
make fragile skin more vulnerable to injury.
3.
• Shear. Shear occurs when two surfaces move
in the opposite direction. For example, when a
hospital bed is elevated at the head, you can
slide down in bed. As the tailbone moves down,
the skin over the bone may stay in place —
essentially pulling in the opposite direction.
• This motion may injure tissue and blood vessels,
making the site more vulnerable to damage from
sustained pressure.
Bedsores - Risk factors:
People are at risk of developing pressure sores if they have
difficulty moving and are unable to easily change position
while seated or in bed. Immobility may be due to:
•
•
•
•
•
•
Generally poor health or weakness
Paralysis
Injury or illness that requires bed rest or wheelchair use
Recovery after surgery
Sedation
Coma
Bedsores - Risk factors:
Other factors that increase the risk of pressure sores
include:
• Age
• Lack of sensory perception
• Weight loss
• Poor nutrition and hydration
• Excess moisture or dryness
• Bowel incontinence
• Medical conditions affecting blood flow
• Smoking
• Limited alertness
• Muscle spasms
• Age. The skin of older adults is generally more
fragile, thinner, less elastic and drier than the
skin of younger adults. Also, older adults usually
produce new skin cells more slowly. These
factors make skin vulnerable to damage.
• Lack of sensory perception. Spinal cord
injuries, neurological disorders and other
conditions can result in a loss of sensation. An
inability to feel pain or discomfort can result in
not being aware of bedsores or the need to
change position.
• Weight loss. Weight loss is common during
prolonged illnesses, and muscle atrophy and
wasting are common in people with paralysis.
The loss of fat and muscle results in less
cushioning between bones and a bed or a
wheelchair.
• Poor nutrition and hydration. People need
enough fluids, calories, protein, vitamins and
minerals in their daily diet to maintain healthy
skin and prevent the breakdown of tissues.
• Excess moisture or dryness. Skin that is
moist from sweat or lack of bladder control is
more likely to be injured and increases the
friction between the skin and clothing or
bedding. Very dry skin increases friction as well.
• Bowel incontinence. Bacteria from fecal matter
can cause serious local infections and lead to
life-threatening infections affecting the whole
body.
• Medical conditions affecting blood flow.
Health problems that can affect blood flow, such
as diabetes and vascular disease, increase the
risk of tissue damage.
• Smoking. Smoking reduces blood flow and
limits the amount of oxygen in the blood.
Smokers tend to develop more-severe wounds,
and their wounds heal more slowly.
• Limited alertness. People whose mental
awareness is lessened by disease, trauma or
medications may be unable to take the actions
needed to prevent or care for pressure sores.
• Muscle spasms. People who have frequent
muscle spasms or other involuntary muscle
movement may be at increased risk of pressure
sores from frequent friction and shearing.
Stage 1
• Stage 1 decubitus ulcers are still intact – they are not
open wounds.
• While the skin remains intact, there may be painful
bruising underneath.
• The stage 1 decubitus ulcer is red when you apply
pressure with your finger and then remove it (called
blanching).
• Nursing home residents with darker skin tone may not
turn red, but the sore will be a noticeably different color
than the surrounding skin.
• Stage 1 bedsores can feel softer or firmer than the
surrounding wound tissue in the resident’s skin
Stage 2
• Stage 2 pressure wounds are open painful sores caused
by unrelieved pressure.
• These preventable decubitus ulcers are a result of
patient being unable to move and staff failing to flip the
patient.
• A stage 2 bedsore can look like a scrape (abrasion),
blister, or a shallow crater in the skin.
• Sometimes this stage looks like a blister filled with clear
fluid.
• At this stage, some skin may be damaged beyond repair
or may die, leaving a permanent wound.
Stage 3
• A stage 3 pressure sore burrows deeper
into the nursing home resident’s skin
tissue than a stage 2.
• The bedsore or pressure wound is open
but the muscle, tendon and bone are not
visible at this stage of the sore.
• A patient’s fatty tissue surrounding the
pressure sore may be exposed at stage 3.
Stage 4
• A stage 4 decubitus ulcer is the deepest most
traumatic stage.
• There is deep damage to skin tissue in the
effected area and often damage to the
surrounding joints and tendons.
• These open festering wounds are an open
invitation to disease and infection and can often
cause death.
• Osteomyelitis, infection of the bone, or Sepsis,
blood infection, are often complications of an
open Stage 4 decubitus ulcer.
• These infections can cause amputation or death.
And once again…
• Pressure sores are graded to four levels,
including:
• Grade I – skin discolouration, usually red, blue,
purple or black
• Grade II – some skin loss or damage involving
the top-most skin layers
• Grade III – necrosis (death) or damage to the
skin patch, limited to the skin layers
• Grade IV – necrosis (death) or damage to the
skin patch and underlying structures, such as
tendon, joint or bone.
Bedsores - Complications
Complications of pressure ulcers include:
•
•
•
•
Sepsis
Cellulitis
Bone and joint infections
Cancer
• Sepsis. Sepsis occurs when bacteria enter the
bloodstream through broken skin and spread
throughout the body. It's a rapidly progressing,
life-threatening condition that can cause organ
failure.
• Cellulitis. Cellulitis is an infection of the skin and
connected soft tissues. It can cause severe pain,
redness and swelling. People with nerve
damage often do not feel pain with this
condition. Cellulitis can lead to life-threatening
complications.
• Bone and joint infections. An infection from a
pressure sore can burrow into joints and bones.
Joint infections (septic arthritis) can damage
cartilage and tissue. Bone infections
(osteomyelitis) may reduce the function of joints
and limbs. Such infections can lead to lifethreatening complications.
• Cancer. Another complication is the
development of a type of squamous cell
carcinoma that develops in chronic, nonhealing
wounds (Marjolin ulcer). This type of cancer is
aggressive and usually requires surgery.
Bedsores - Treatments and drugs:
• Stage I and II bedsores usually heal
within several weeks to months with
conservative care of the wound and
ongoing, appropriate general care. Stage
III and IV bedsores are more difficult to
treat.
Bedsores - Treatment team
• Addressing the many aspects of wound care
usually requires a multidisciplinary approach.
Members of care team may include:
• A primary care physician who oversees the
treatment plan
• A physician specializing in wound care
• Nurses or medical assistants who provide both
care and education for managing wounds
Bedsores - Treatment team
• A social worker who helps family access
appropriate resources and addresses emotional
concerns related to long-term recovery
• A physical therapist who helps with improving
mobility
• A dietitian who monitors your nutritional needs
and recommends an appropriate diet
• A neurosurgeon, orthopedic surgeon or plastic
surgeon, depending on whether you need
surgery and what type
Reducing pressure:
• The first step in treating a bedsore is
reducing the pressure that caused it.
Strategies include the following:
• Repositioning
• Using support surfaces
Repositioning
• If you have a pressure sore, you need to be
repositioned regularly and placed in correct
positions. If you use a wheelchair, try shifting
your weight every 15 minutes or so. Ask for help
with repositioning every hour. If you're confined
to a bed, change positions every two hours.
• If you have enough upper body strength, try
repositioning yourself using a device such as a
trapeze bar. Caregivers can use bed linens to
help lift and reposition you. This can reduce
friction and shearing.
Using support surfaces
• Use a mattress, bed and special cushions
that help you lie in an appropriate position,
relieve pressure on any sores and protect
vulnerable skin. If you are in a wheelchair,
use a cushion. Styles include foam, air
filled and water filled. Select one that suits
your condition, body type and mobility.
Cleaning and dressing wounds:
• Care that helps with healing of the wound
includes the following:
• Cleaning
• Applying dressings
Cleaning
• It's essential to keep wounds clean to
prevent infection. If the affected skin is not
broken (a stage I wound), gently wash it
with water and mild soap and pat dry.
Clean open sores with a saltwater (saline)
solution each time the dressing is
changed.
Applying dressings
• A dressing promotes healing by keeping a
wound moist, creating a barrier against infection
and keeping the surrounding skin dry. Dressing
choices include films, gauzes, gels, foams and
treated coverings. A combination of dressings
may be used.
• selecting a dressing based on a number of
factors, such as the size and severity of the
wound, the amount of discharge, and the ease
of placing and removing the dressing.
Removing damaged tissue
• To heal properly, wounds need to be free of
damaged, dead or infected tissue. Removing
this tissue (debridement) is accomplished with a
number of methods, depending on the severity
of the wound, your overall condition and the
treatment goals.
• Surgical debridement involves cutting away
dead tissue.
• Mechanical debridement
• Autolytic debridement
• Enzymatic debridement
• Mechanical debridement loosens and
removes wound debris. This may be done
with a pressurized irrigation device, lowfrequency mist ultrasound or specialized
dressings.
• Autolytic debridement enhances the
body's natural process of using enzymes
to break down dead tissue. This method
may be used on smaller, uninfected
wounds and involves special dressings to
keep the wound moist and clean.
• Enzymatic debridement involves
applying chemical enzymes and
appropriate dressings to break down dead
tissue.
Other interventions
•
•
•
•
•
•
•
Other interventions that may be used are:
Pain management
Antibiotics
A healthy diet
Management of incontinence
Muscle spasm relief
Negative pressure therapy
• Pain management. Pressure ulcers can be
painful. Nonsteroidal anti-inflammatory drugs —
such as ibuprofen (Motrin IB, Advil, others) and
naproxen (Aleve, others) — may reduce pain.
These may be very helpful before or after
repositioning, debridement procedures and
dressing changes. Topical pain medications also
may be used during debridement and dressing
changes.
• Antibiotics. Infected pressure sores that aren't
responding to other interventions may be treated
with topical or oral antibiotics.
•
A healthy diet. To promote wound healing, your doctor
or dietitian may recommend an increase in calories and
fluids, a high-protein diet, and an increase in foods rich
in vitamins and minerals. You may be advised to take
dietary supplements, such as vitamin C and zinc.
• Management of incontinence. Urinary or bowel
incontinence may cause excess moisture and bacteria
on the skin, increasing the risk of infection. Managing
incontinence may help improve healing. Strategies
include frequently scheduled help with urinating, frequent
diaper changes, protective lotions on healthy skin, and
urinary catheters or rectal tubes.
• Muscle spasm relief. Spasm-related friction or
shearing can cause or worsen bedsores. Muscle
relaxants — such as diazepam (Valium),
tizanidine (Zanaflex), dantrolene (Dantrium) and
baclofen (Gablofen, Lioresal) — may inhibit
muscle spasms and help sores heal.
• Negative pressure therapy (vacuum-assisted
closure, or VAC). This therapy uses a device
that applies suction to a clean wound. It may
help healing in some types of pressure sores.
Surgery
• A pressure sore that fails to heal may require surgery.
The goals of surgery include improving the hygiene and
appearance of the sore, preventing or treating infection,
reducing fluid loss through the wound, and lowering the
risk of cancer.
• If you need surgery, the type of procedure depends
mainly on the location of the wound and whether it has
scar tissue from a previous operation. In general, most
pressure sores are repaired using a pad of your muscle,
skin or other tissue to cover the wound and cushion the
affected bone (flap reconstruction).
Coping and support
Treating and preventing pressure sores is
demanding on you, your family members
and caregivers. Issues that may need to be
addressed by your doctor, the nursing staff
and a social worker include the following:
• Community services
• End-of-life care
• Residential care
• Community services. A social worker
can help identify community groups that
provide services, education and support
for people dealing with long-term
caregiving or terminal illnesses.
• End-of-life care. When someone is
approaching death, physicians and nurses
specializing in end-of-life care (palliative
care) can help a patient and his or her
family determine treatment goals. At this
time, goals may include managing pain
and providing comfort.
• Residential care. People with limited
mobility who live in residential or nursing
care facilities are at increased risk of
developing pressure sores. Family and
friends of people living in these facilities
can be advocates for the residents and
work with nursing staff to ensure proper
preventive care.
Prevention
• Bedsores are easier to prevent than to treat, but
that doesn't mean the process is easy or
uncomplicated. And wounds may still develop
with consistent, appropriate preventive care.
• The members of the care team can help develop
a good strategy, whether it's personal care with
at-home assistance, professional care in a
hospital or some other situation.
• Position changes are key to preventing
pressure sores. These changes need to be
frequent, repositioning needs to avoid
stress on the skin, and body positions
need to minimize pressure on vulnerable
areas. Other strategies include taking
good care of your skin, maintaining good
nutrition, quitting smoking and exercising
daily.
Repositioning in a wheelchair
• Shift your weight frequently. If you use a
wheelchair, try shifting your weight about
every 15 minutes. Ask for help with
repositioning about once an hour.
• Lift yourself, if possible. If you have
enough upper body strength, do
wheelchair pushups — raising your body
off the seat by pushing on the arms of the
chair.
Repositioning in a wheelchair
• Look into a specialty wheelchair. Some
wheelchairs allow you to tilt them, which can
relieve pressure.
• Select a cushion that relieves pressure. Use
cushions to relieve pressure and help ensure
your body is well-positioned in the chair. Various
cushions are available, such as foam, gel, water
filled and air filled. A physical therapist can
advise you on how to place them and their role
in regular repositioning.
Repositioning in a bed
• Reposition yourself frequently. Change
your body position every two hours.
• Look into devices to help you
reposition. If you have enough upper
body strength, try repositioning yourself
using a device such as a trapeze bar.
Caregivers can use bed linens to help lift
and reposition you. This can reduce
friction and shearing.
Repositioning in a bed
• Try a specialized mattress. Use special
cushions, a foam mattress pad, an air-filled
mattress or a water-filled mattress to help with
positioning, relieving pressure and protecting
vulnerable areas. Your doctor or other care team
members can recommend an appropriate
mattress or surface.
• Adjust the elevation of your bed. If your
hospital bed can be elevated at the head, raise it
no more than 30 degrees. This helps prevent
shearing.
Repositioning in a bed
• Use cushions to protect bony areas.
Protect bony areas with proper positioning
and cushioning. Rather than lying directly
on a hip, lie at an angle with cushions
supporting the back or front. You can also
use cushions to relieve pressure against
and between the knees and ankles. You
can cushion or ''float'' your heels with
cushions below the calves.
Skin care
• Protecting and monitoring the condition of your
skin is important for preventing pressure sores
and identifying stage I sores early so that you
can treat them before they worsen.
• Clean the affected skin. Clean the skin with
mild soap and warm water or a no-rinse
cleanser. Gently pat dry.
• Protect the skin. Use talcum powder to protect
skin vulnerable to excess moisture. Apply lotion
to dry skin. Change bedding and clothing
frequently. Watch for buttons on the clothing and
wrinkles in the bedding that irritate the skin.
• Inspect the skin daily. Inspect the skin
daily to identify vulnerable areas or early
signs of pressure sores. You will probably
need the help of a care provider to do a
thorough skin inspection. If you have
enough mobility, you may be able to do
this with the help of a mirror.
• Manage incontinence to keep the skin
dry. If you have urinary or bowel
incontinence, take steps to prevent
exposing the skin to moisture and
bacteria. Your care may include frequently
scheduled help with urinating, frequent
diaper changes, protective lotions on
healthy skin, or urinary catheters or rectal
tubes.
Nutrition
• A doctor, a dietitian or other members of
the care team can recommend nutritional
changes to help improve the health of your
skin.
• Choose a healthy diet. You may need to
increase the amount of calories, protein,
vitamins and minerals in your diet. You
may be advised to take dietary
supplements, such as vitamin C and zinc.
• Drink enough to keep the skin hydrated.
Good hydration is important for maintaining
healthy skin. Your care team can advise you on
how much to drink and signs of poor hydration.
These include decreased urine output, darker
urine, dry or sticky mouth, thirst, dry skin, and
constipation.
• Ask for help if eating is difficult. If you have
limited mobility or significant weakness, you may
need help with eating in order to get adequate
nutrition.
Other strategies
• Quit smoking. If you smoke, quit. Talk to your
doctor if you need help.
• Stay active. Limited mobility is a key factor in
causing pressure sores. Daily exercise matched
to your abilities can help maintain healthy skin. A
physical therapist can recommend an
appropriate exercise program that improves
blood flow, builds up vital muscle tissue,
stimulates appetite and strengthens the body.
The Geriatric Assessment
• The geriatric assessment is a
multidimensional, multidisciplinary
assessment designed to evaluate an older
person's functional ability, physical health,
cognition and mental health, and
socioenvironmental circumstances.
• It is usually initiated when the physician
identifies a potential problem. Specific
elements of physical health that are
evaluated include nutrition, vision, hearing,
fecal and urinary continence, and balance.
• The geriatric assessment aids in the diagnosis
of medical conditions; development of treatment
and follow-up plans; coordination of
management of care; and evaluation of longterm care needs and optimal placement. The
geriatric assessment differs from a standard
medical evaluation by including nonmedical
domains; by emphasizing functional capacity
and quality of life; and, often, by incorporating a
multidisciplinary team.
• It usually yields a more complete and
relevant list of medical problems,
functional problems, and psychosocial
issues. Well-validated tools and survey
instruments for evaluating activities of
daily living, hearing, fecal and urinary
continence, balance, and cognition are an
important part of the geriatric assessment.
• Because of the demands of a busy clinical
practice, most geriatric assessments tend
to be less comprehensive and more
problem-directed. When multiple concerns
are presented, the use of a “rolling”
assessment over several visits should be
considered.
Components of Comprehensive
Geriatric Assessment (CGA):
Component
1.Medical
assessment
2.Assessment of
functioning
3.Psychological
assessment
4.Social assessment
5.Environmental
assessment
Elements
1. Problem list
Comorbid conditions and disease
severity
Medication review
Nutritional status
2. Basic activities of daily living
Instrumental activities of daily
living
Activity/exercise status
Gait and balance
Mental status (cognitive) testing
Mood/depression testing
Informal support needs and assets
Care resource eligibility/financial
assessment
Home safety
Transportation and telehealth
What do we assess using CGA?
Functional Ability
Functional status refers to a person's ability to perform tasks that
are required for living. The geriatric assessment begins with a
review of the two key divisions of functional ability: activities of
daily living (ADL) and instrumental activities of daily living (IADL).
ADL are self-care activities that a person performs daily (e.g.,
eating, dressing, bathing, transferring between the bed and a
chair, using the toilet, controlling bladder and bowel functions).
IADL are activities that are needed to live independently (e.g.,
doing housework, preparing meals, taking medications properly,
managing finances, using a telephone).
Physicians can acquire useful functional information by simply
observing older patients as they complete simple tasks, such as
unbuttoning and buttoning a shirt, picking up a pen and writing a
sentence, taking off and putting on shoes, and climbing up and
down from an examination table. Two instruments for assessing
ADL and IADL include the Katz ADL scale and the Lawton IADL
scale. Deficits in ADL and IADL can signal the need for more indepth evaluation of the patient's socioenvironmental
circumstances and the need for additional assistance.
Physical Health
• The geriatric assessment incorporates all facets of a
conventional medical history, including main problem,
current illness, past and current medical problems, family
and social history, demographic data, and a review of
systems. The approach to the history and physical
examination, however, should be specific to older
persons. In particular, topics such as nutrition, vision,
hearing, fecal and urinary continence, balance and fall
prevention, osteoporosis, and polypharmacy should be
included in the evaluation. Table is an example of a
focused geriatric physical examination.
SCREENING FOR DISEASE
• In the normal aging process, there is often a decline in
physiologic function that is usually not disease-related.
However, treatment of diabetes mellitus, hypertension, and
glaucoma can prevent significant future morbidity. Screening
for malignancies may allow for early detection, and some are
curable if treated early. It is important that physicians weigh
the potential harms of screening before screening older
patients. It is essential to consider family preferences
regarding treatment if a disease is detected, and the patient's
functional status, comorbid conditions, and predicted life
expectancy. If an asymptomatic patient has an expected
survival of more than five years, screening is generally
medically warranted, assuming that the patient is at risk of the
disease and would accept treatment if early disease was
detected.
• The Agency for Healthcare Research and
Quality has developed an online tool
called the Electronic Preventive Services
Selector
(http://epss.ahrq.gov/ePSS/search.jsp)
that can be downloaded to smartphones. It
can assist physicians in identifying ageappropriate screening measures.
NUTRITION
• A nutritional assessment is important because inadequate
micronutrient intake is common in older persons. Several agerelated medical conditions may predispose patients to vitamin
and mineral deficiencies. Studies have shown that vitamins A,
C, D, and B12; calcium; iron; zinc; and other trace minerals
are often deficient in the older population, even in the
absence of conditions such as pernicious anemia or
malabsorption.
• There are four components specific to the geriatric
nutritional assessment: nutritional history performed with
a nutritional health checklist; a record of a patient's usual
food intake based on 24-hour dietary recall; physical
examination with particular attention to signs associated
with inadequate nutrition or overconsumption; and select
laboratory tests, if applicable. One simple screening tool
for nutrition in older persons is the Nutritional Health
Checklist.
VISION
• The most common causes of vision impairment in older
persons include presbyopia, glaucoma, diabetic retinopathy,
cataracts, and age-related macular degeneration.The U.S.
Preventive Services Task Force (USPSTF) found insufficient
evidence to recommend for or against screening with
ophthalmoscopy in asymptomatic older patients. In 1995, the
Canadian Task Force on the Periodic Health Examination
advised primary care physicians to use a Snellen chart to
screen for visual acuity, and recommended that older patients
who have had diabetes for at least five years have an
assessment by an ophthalmologist. Additionally, the task force
advised that patients at high risk of glaucoma, including black
persons and those with a positive family history, diabetes, or
severe myopia, undergo periodic assessment by an
ophthalmologist.
HEARING
• Presbycusis is the third most common chronic condition
in older Americans, after hypertension and arthritis. The
USPSTF is updating its 1996 recommendations, but
currently recommends screening older patients for
hearing impairment by periodically questioning them
about their hearing.Audioscope examination, otoscopic
examination, and the whispered voice test are also
recommended. The whispered voice test is performed by
standing approximately 3 ft behind the patient and
whispering a series of letters and numbers after exhaling
to assure a quiet whisper.
• Failure to repeat most of the letters and numbers indicates
hearing impairment.As part of the Medicare-funded initial
preventive physical examination, physicians are encouraged
to use hearing screening questionnaires to evaluate an older
patient's functional ability and level of safety.Questionnaires
such as the screening version of the Hearing Handicap
Inventory for the Elderly accurately identify persons with
hearing impairment (Table). Additionally, patients' medications
should be examined for potentially ototoxic drugs. Patients
with chronic otitis media or sudden hearing loss, or who fail
any screening tests should be referred to an otolaryngologist.
Hearing aids are the treatment of choice for older persons
with hearing impairment, because they minimize hearing loss
and improve daily functioning.
URINARY CONTINENCE
• Urinary incontinence, the unintentional leakage of urine,
affects approximately million persons in the United States,
most of whom are older. Urinary incontinence has important
medical repercussions and is associated with decubitus
ulcers, sepsis, renal failure, urinary tract infections, and
increased mortality. Psychosocial implications of incontinence
include loss of self-esteem, restriction of social and sexual
activities, and depression. Additionally, incontinence is often a
key deciding factor for nursing home placement.
• An assessment for urinary incontinence should include the
evaluation of fluid intake, medications, cognitive function,
mobility, and previous urologic surgeries.The single best
question to ask when diagnosing urge incontinence is, “Do
you have a strong and sudden urge to void that makes you
leak before reaching the toilet?” (positive likelihood ratio = 4.2;
negative likelihood ratio = 0.48). A good question to ask when
diagnosing stress incontinence is, “Is your incontinence
caused by coughing, sneezing, lifting, walking, or running?”
(positive likelihood ratio = 2.2; negative likelihood ratio =
0.39).
BALANCE AND FALL
PREVENTION
• Impaired balance in older persons often manifests as falls and
fall-related injuries. Approximately one-third of communityliving older persons fall at least once per year, with many
falling multiple times. Falls are the leading cause of
hospitalization and injury-related death in persons 75 years
and older.
• The Tinetti Balance and Gait Evaluation is a useful tool to
assess a patient's fall risk. This test involves observing as a
patient gets up from a chair without using his or her arms,
walks 10 ft, turns around, walks back, and returns to a seated
position. This entire process should take less than 16
seconds. Those patients who have difficulty performing this
test have an increased risk of falling and need further
evaluation.
• Older persons can decrease their fall risk with exercise,
physical therapy, a home hazard assessment, and withdrawal
of psychotropic medications. Guidelines addressing fall
prevention in older persons living in nursing homes have been
published by the American Medical Directors Association and
the American Geriatrics Society.
OSTEOPOROSIS
• Osteoporosis may result in low-impact or spontaneous
fragility fractures, which can lead to a fall. Osteoporosis
can be diagnosed clinically or radiographically.It is most
commonly diagnosed by dual-energy x-ray
absorptiometry of the total hip, femoral neck, or lumbar
spine, with a T-score of –2.5 or below.The USPSTF has
advised routinely screening women 65 years and older
for osteoporosis with dual-energy x-ray absorptiometry of
the femoral neck.
POLYPHARMACY
• Polypharmacy, which is the use of multiple medications
or the administration of more medications than clinically
indicated, is common in older persons. Among older
adults, percent of hospital admissions and many
preventable problems, such as falls and confusion, are
believed to be related to adverse drug effects.The
Centers for Medicare and Medicaid Services encourages
the use of the Beers criteria, which list medication and
medication classes that should be avoided in older
persons, as part of an older patient's medication
assessment to reduce adverse effects.In 2003, a
consensus panel of experts revised the criteria.The
Beers criteria can be found at
http://www.dcri.duke.edu/ccge/curtis/beers.html.
Cognition and Mental Health
• DEPRESSION
• DEMENTIA
DEPRESSION
• The USPSTF recommends screening adults for
depression if systems of care are in place. Of the several
validated screening instruments for depression, the
Geriatric Depression Scale and the Hamilton Depression
Scale are the easiest to use and most widely accepted.
However, a simple two-question screening tool (“During
the past month, have you been bothered by feelings of
sadness, depression, or hopelessness?” and “Have you
often been bothered by a lack of interest or pleasure in
doing things?”) is as effective as these longer scales.
Responding in the affirmative to one or both of these
questions is a positive screening test for depression that
requires further evaluation.
DEMENTIA
• Early diagnosis of dementia allows patients timely
access to medications and helps families to make
preparations for the future. It can also help in the
management of other symptoms that often accompany
the early stages of dementia, such as depression and
irritability. As few as 50 percent of dementia cases are
diagnosed by physicians.There are several screening
tests available to assess cognitive dysfunction; however,
the Mini-Cognitive Assessment Instrument is the
preferred test for the family physician because of its
speed, convenience, and accuracy, as well as the fact
that it does not require fluency in English (Table).
Cognitive Testing
SMMSE (Standardized Mini Mental State Exam)
The Standardized MMSE is a validated and
commonly used screening tool, scored out of 30,
for cognitive impairments for whatever cause.
It does NOT diagnose dementia and is insensitive
to early dementia or frontal lobe dementia.
A common cut-off is a score of 23 or less out of 30
(the caveat being the test is dependent on
language, age, education and ethnicity). Such a
cut off has a sensitivity of 69-100%, and a
specificity of 78-99% (which translates into a
+LR of 9, and a –LR of 0.2
Cognitive Testing - Clock
Drawing Test (CDT)
This is another validated test for cognitive function and is
particularly valuable when used with the SMMSE (which
it is not part of, but is separate test). Draw a large circle,
and ask the patient to place all the numbers in the
correct position on this empty clock face, after which you
will tell them a time to put the hands on their clock. For
hand placement you must use the same time used in the
original studies; “Please set hands of the clock to 10
after 11” (remember, the 10 is a virtual 10 represented by
the 2 on the clock). Rate as Normal, struggle to
complete, or abnormal)
The Positive Likelihood Ratio for cognitive
impairments is 24 if their clock is abnormally
drawn.
Below is an example of a “concrete” clock; persons
who are concrete (i.e. only capable of objects
and concepts perceived by the senses, and
incapable of abstract or imaginary concepts)
from Vad, FTD, or AD will often put the hands at
the 10 AND the 11, which is incorrect. They are
“stimulus bound” by the nearby 10.
Frontal lobe testing
This is done if there is a history of
personality and/or behavioral change more
striking than memory changes, or if the
history suggests greater executive
functioning impairments than the SMMSE
demonstrates (i.e. in vascular (VaD) or
fronto-temporal dementias (FTD).
Frontal lobe testing
1. Word generation (abstract thought test): Ask the patient
to name as many 4 legged animals as they can in sixty
seconds (or vegetables, words beginning with the letter
F, etc.); normal is 15+/- 5.
2. Verbal fluency tests with word pairs (“what is the
difference between a lie and a mistake?”, river/canal?,
child/midget?, etc.).
3. Problem solving: Ask “What would you do if you awoke
in the night and smelled smoke?” ,“What exactly would
you do if you found a flood in your kitchen at home”
4. Fund of knowledge testing: (“What exactly happened on
September 11th, 2001?” “Who is our prime minister?”
“When did WWII start?”)
Socioenvironmental
Circumstances
• According to the U.S. Census Bureau, approximately 70
percent of noninstitutionalized adults 65 years and older
live with their spouses or extended family, and 30
percent live alone.Determining the most suitable living
arrangements for older patients is an important function
of the geriatric assessment. Although options for housing
for older persons vary widely, there are three basic
types: private homes in the community, assisted living
residences, and skilled nursing facilities (e.g.,
rehabilitation hospitals, nursing homes). Factors affecting
the patient's socioenvironmental circumstances include
their social interaction network, available support
resources, special needs, and environmental safety.
Thank You….