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Geriatric concerns
By Dr. Joel Doughten
Preventative Cardiology
Primary prevention is preventing disease by removing
cause. Examples are tobacco smoking cessation.
Secondary prevention is characterizing risk in
asymptomatic patients who have risk factors for
preclinical disease. An example is performing a cardiac
CT calcium score. Tertiary prevention is preventing
further deterioration or reducing complications of
established disease. Examples of this would be
treating myocardial infarction with a Beta-blocker. It
would include exercise, diet, tobacco smoking
cessation, treating modifiable risk factors and
screening for subclinical disease, daily aspirin or
angiotension-converting ezyme inhibitor therapy.
Frailty Syndrome
It includes the loss of muscle mass, unintentional weight loss, poor
exercise tolerance, weakness and exhaustion, slow walking speed,
low levels of physical activity, disability, and risk for
institutionalization and death.
Dynamics of frailty in older persons is characterized by frequent
transitions. One study found that in a 4.5 year period nearly 60% of
people transitioned toward a higher of lower levels of frailty. Frailty
is not irreversible, but it can be modified and risk can be reduced.
Prevalence is uncommon in the age group of 65 to 70 years old and is
more common in people over 90 years of age. The probability of
survival decreases with increased frailty. When discussing
preventive cardiology with frail elderly patients, consider 5 year
survival rate. Only 40% of severely frail individuals are alive at 5
years
Exercise training
It is possible and beneficial for frail elderly patients to improve
cardiovascular risk factors. Randomized placebo-controlled
trials have compared progressive resistance exercise
training (eg. Knee and hip exercises using gym equipment)
to use of nutrient supplements in frail nursing home
residents and found 113% increase in muscle strength in
the exercise group vs 3 in the nonexercising groups. There
was also a nearly 12% increase in gait velocity verse a 1%
decline in the nonexercising groups. Nutritional
supplements had no effect on primary outcomes. There
was no deference between exercise alone and exercise and
nutritional supplements combined. The study found
exercise training improved physical performance, maximum
oxygen consumption and functional status.
ACE Inhibitors
The following are suggested effects of ACE
inhibitors on skeletal muscle. There is a change in
myosin heavy chain toward low fatigability type
leading to improved insulin sensitivity increasing
glucose uptake into the muscle that may increase
metabolic efficiency. There is vasodilatation
increasing blood flow to skeletal muscle.
Antiinflamatory properties may improve skeletal
muscle performance, which may be beneficial for
improving and maintaining muscle strength and
walking speed and retarding frailty in elderly
patients.
Statins
The data in the elderly and frail elderly is minimal. Most studies look at groups with a
mean age of about 65 yo. The Prospective Study of Pravastation in the Elderly at
Risk (PROAPWE) randomized 5804 elderly individuals (70 – 82 yo with a history of
or risk factors for vascular disease. The follow-up for slightly more than 3 years
showed Pravastatin decreased the risk for MI, stroke and cardiovascular death with
a hazard ratio of 0.85 which was highly significant. No significant effect was found
for primary prevention in elderly patients in the study.
In the Cardiovascular Health Study an observational cohort study that was not
randomized, included 1914 individuals older than 65 years of age with no
cardiovascular disease at baseline. A 7 year follow-up found that statin use was
associated with decreased risk for cardiovascular events
A study of 23,000 Medicare patients with a history of MI making it a tertiary
prevention trial have nearly 40% were over 80 years of age. 24% receive a statin at
discharge. It found that with increased age the benefit of a statin becomes
insignificant at age greater than 85 years of age.
A Finnish study of 400 elderly vascular patients randomized to pharmacologic and
nonpharmacologic cardiovascular prevention trial verses usual care. 66% were
women, few smoked, slight hypertension and high cholesterol , 40% had ad an MI,
40% had heart failure, and 15% to 20% had diabetes. At 3 years the intervention
group had higher medication use, lowered blood pressure and cholestrol, but no
significant effect on mortality
Physicians should try to aggressively
treat frailty?
• 1. True
• 2. False
Answer
• 1. True
Progressive resistance training in frail
nursing home residents was shown to
increase muscle strength by as much
as:
a.
b.
c.
d.
33%
53%
73%
113%
Answer
d. 113%
It has been suggested that
angiotension-converting enzyme
inhibitors may have which of the
following effects on skeletal muscles?
a. Change myosin heavy chain toward low
fatigability type
b. Increase glucose uptake into muscle
c. Increase blood flow to skeletal muscle
d. All the above
Answer
d. All the above
The Prospective Study of Pravastation
in the Elderly at Risk (PROSPER)
randomized 5804 elderly individuals
(70 – 82 yo) with a history of or risk
factors for vascular disease over a 3
year period showed a reduction in
cardiovascular events?
• 1. True
• 2. False
Answer
• 1. True
Diabetes in Long-Term-Care Patients
The treatment of diabetes is often viewed by older patients as
burdensome. The treatments medications can be dangerous and
the nursing home populations become increasingly heterogeneous
and requires judgment. Life expectancy varies with differences in
function and coexisting illness.
Many nursing homes have gone to a no concentrated sweet diet on
the basis of most one study on quality of life of nursing home
patients with diabetes.
The result in my opinion is much less control of the blood sugars in
diabetics in most nursing homes as the are routinely fed high
glycemic index carbohydrates like rice, potatoes, bread, and
macaroni and cheese because they are cheap.
It is now hard to order an ADA diet in most nursing homes. Many
patients are in nursing homes for acute rehab and need better
control of their blood sugars.
Goals
Determining what a patient wants is the primary
goal. Studies have show many older adult
diabetics consider injections and selfmonitored blood sugar burdensome.
Consider macrovascular risk and microvascular
risk with a longer duration of diabetes.
Consider the comorbidities and try to avoid
harm.
Risks of Diabetes
Short term consider volume depletion, poor wound healing,
fatigue, and weight loss associated with high serum
glucose. A hemoglobin A1c of greater than 10% or serum
glucose of greater than 300 mg/dl is associated with
polyuria, polydyspsia and correcting this condition may
improve outcomes.
Long term consider cardiovascular risks over a 10 year period
greater than 20% of individuals experience MI or death and
foot ulcers and amputations are common. Blindness is a
5% risk over 10 years and end-stage renal disease is less
common in new-onset diabetes in older adults. Many older
adults have competing diseases like renal disease, chronic
lung disease, HF. Diabetics have higher risk and prevalence
of falls, dementia, incontinence, pain and depression
Treatment
To prevent retinopathy, treating high BP is more effective than intensive serum glucose
control. HT control and lipid management is relatively effective for macrovascular
events. There is no evidence that tight serum glucose control prevents
macrovascular events or all-cause mortality. Controlling BP is most important
followed by lipid management. Treating BP results in reduction of microvascular
complications with 2 to 3 years verse 8 years with tight serum glucose control.
Lipid management and HT control take about 6 years to prevent an MI. The
American Diabetes Association and the American Geriatric society recommend
focusing primarily on serum glucose and also lipid management in patients who
may benefit in 3 to 6 year. They recommend glycemic target according to the life
expectancy. Moderate targets prevent polyuria and weakness, improve wound
healing. This is a hemoglobin A1c of around 8% achieved in weeks to months.
Intensive management would be a hemoglobin A1c of less than 7%. This may take
years to decades to benefit a newly diagnosed diabetic. The overall considerations
are to start with the patient’s preference, to maintain function and reduce burden
as perceived by the patient. This would include excessive insulin injection, selfmonitored glucose, and diet restriction. Consider activities of daily living, geriatric
syndromes like depression and dementia that can dominate care and coexisting
illness and live expectancy.
Risks of therapy
Insulin is the most common drug-related reason
people are seen in the emergency
department. Other risks are pain, burden of
therapy, polypharmacy, muscle pain,
polypharmacy, muscle pain with statins,
complications of orthostatic hypotension and
in a long-term care facility the availability of
and time of the staff.
Special considerations of patients in
long-term care
There is often erratic eating patterns and dependence on
being fed. Transitioning and transferring patients gives rise
to errors in medication dosing and missed meals. The
patient’s inability to report symptoms. Achieving target BP
control in older adults is associated with increased
mortality. There are unproven benefits of statins and
aspirin in patients over 80 years of age. Metformin has a
high incidence of gastrointestinal side effects, but is
relatively safe. It does not cause hypoglycemia, lactic
acidosis is rare, and it does not cause weight gain. Patients
who have a creatinine clearance of less than 30 mL/min or
severe HF may be at higher risk for lactic acidosis.
Sulfonylureas have a high risk for hypoglycemia.
Case 1
An 80 year old woman with diabetes for 15 years who
exercises regularly fell and broke a hip. It was fixed and she
was transferred to long-term care facility for rehabilitation.
At the rehab facility the eating patterns are erratic and
activities are unpredictable. The patient’s lifelong goal was
intensive management of serum glucose. Her average life
expectancy is 13 years but consider risks of erratic eating
and activities. To avoid harm consider moderate control
and reduce doses of insulin or oral medication while under
rehabilitation and discuss resuming intensive management
afterwards. Or consider a reduction in medications that
cause hypoglycemia and continue good control. I prefer
the later.
Case 2
A man 70 years of age who is a resident of a long-term-care
facility has had diabetes for 15 years. He is developing
manifestations of early proliferative retinopathy. Consider
intensive therapy and patient’s preferences. The patients
life expectancy is 7 to 12 years. There is some evidence
that intensive management may prevent blindness in about
4 years. Include intensive BP control because studies show
that intensive BP control is most effective for slowing
diabetic retinopathy. Intensive management and
monitoring of serum glucose is reasonable. Discuss risks,
consider activity level, cardiac and renal and liver function.
Consider the ability to report side effects, aspirin, lipid
management, counseling for cessation of tobacco smoking.
Case 3
A woman 69 years of age with diabetes and moderate
dementia is hospitalized for MI and congestive HF. She
is dependent in ADLs and dislikes finger sticks. She
enjoys a liberal diet and being out with the family.
Management: metformin should not be used if
creatinine is above 1.4. Single sulfonylurea with short
half-life may be used, but they have a risk of
hypoglycemia if given and the patient does not eat.
Insulin glargine with a relatively flat peak may be useful
as baseline to control hyperglycemia. You may get by
with one finger stick per day.
Which of the following is least likely to
occur over a 10 year time in older
adults with now-onset diabetes?
a.
b.
c.
d.
Foot ulcers
Blindness
Myocardial infarction
death
Answer
b. Blindness
Which of the following two drugs most
commonly causes people to present to
the emergency department?
a.
b.
c.
d.
e.
f.
g.
h.
Pravastatin
Metformin
Oral sulfonureas
Actos
Januvia
Precose
Glargine
Short acting insulins
Answer
c. Oral sulfonureas
h. Short acting insulins
Choose the correct statement about
metformin
a. Causes hypoglycemia
b. Associated with a high incidence of lactic
acidosis
c. Associated with a high incidence of
gastrointestinal side effects
d. Causes weight gain
Answer
c. Associated with high incidence of
gastrointestinal side effects
Depression in the very old (greater
than 75 year old)
There is more medical comorbidity. The deferential
diagnosis and treatment are more complicated. There
are age-specific psychosocial differences. The signs,
symptoms, treatment, response and goals of treatment
are similar to those in younger patients. Some
differences may be that the symptoms may be more
somatic and not so specific. They may complain of
being tired, nervous, sick, dizzy, weak, nothing tastes
good. Do not quickly diagnose depression because the
symptoms may be due to other conditions like anemia.
Understand patient as a unique confluence of
historical, biologic, and interpersonal influences.
Criteria for major depression
5 of 9 symptoms for 2 weeks, including loss of interest or
depressed mood. The most specific symptoms include
the feeling of melancholy, sense of subjective loss of
mental and physical energy. Fatigue unable to think
clearly and a tremendous effort needed to move. A
downturn in self-esteem or self-regard. Feelings of
guilt, diurnal pattern of bad feelings. Patients feel
worse in the morning and improve as the day goes on.
A change in sleep pattern and weight loss. In the
elderly you must consider other causes of weight loss
like cancer or rheumatologic disease.
Prevalence
In the community about 15% of older people
have symptoms. Only 2 to 3% of older people
have major depression within the past 6
months. The lifetime prevalence is 10 to 11%.
The prevalence is higher in primary care about
5%. It is higher in those with a chronic illness,
25% of those with a stroke or Parkinson’s
disease and an additional 25% have minor
depression.
Effects of Depression
The 1 year mortality among newly admitted nursing
home residents is substantially higher with
depression. There is increased mortality in
patients with cardiovascular disease and stroke.
The most important psychiatric comorbidity in
older people is the wish to die. In a study of 44
terminally ill persons evaluated for major
depression and the wish to die. 7 passively
wished for early death and 3 actively suicidal. All
10 met the criteria for major depression, which
suggest the wish to die may signal the likelihood
for major depression.
5 Item Geriatric Depression Scale
Are you basically satisfied with your life? Do you
often get bored? Do you prefer to stay home?
Do you often feel helpless? Do you feel pretty
worthless? 2 depressive answers identifies
major depression with a sensitivity of 94% and
specificity of 81%.
Causes of Depression in the Elderly
Multifactorial: 40%% of stroke patients will suffer
from depression within 2 months and 50% within
2 years. A stroke with subcortical vascular lesions
seen on MRI is more likely in the left hemisphere
than in the right hemisphere to be associated
with depression. The severity of the depression
is proportional to the proximity to the frontal
lobe. Other factors that are associated with
depression are poor general health status,
persistent pain, functional impairment including
poor hearing and transitions to a long-term-care
facility.
Treatment
Besides medications you should try to treat as well
as possible all disabling and painful medical
conditions. Try to mitigate sensory and other
functional impairment. Try to enhance the social
support, look at the perceived empathy of
caregivers in nursing homes and the likelihood of
depression. Try to ameliorate loneliness with
formal psychotherapy and related approaches
including cognitive, behavioral and interpersonal
psychotherapies. Reminiscence groups that
discuss the lives of the individuals in groups with
a facilitator.
Antidepressant therapy
There is a 30% remission rate with fluoxetine, sertraline,
or venlafaxine. Very high placebo response rate, but in
severely depressed drugs make a big difference.
STAR*D Trail (Sequenced Treatment Alternative to Relieve
Depression) was the largest trail of its kind. It looked at
effectiveness of treatment for nonpsychotic unipolar
major depression in adults 18 to 75 years of age. At
level I all patients initially treated with citalopram up to
60 mg/day. The response defined as a 50% of more
reduction in symptoms rate was 47%. 40% achieved
remission by week 8. Poor prognostic factors included
longstanding depression, more medical or psychiatric
commorbidity, and low baseline function.
STAR*D Trial
At level 2 patients who did not remit were switched to sertraline,
venlafaxine, or bupropion, or continued on citalopram augmented
with bupropion or buspirone. The remission rate with sertraline
was about 18%, venlafaxine about 25%, bupropion was 21%,
citalopram and bupropion or buspirone was about 30%.
Level 3 patients who did not remit at level 2 either were switched to
mirtazapine or nortriptyline, or continued on the current treatment
augmented with lithium of triiodothyronine T3. The remission rate
with Remeron was 12.3%, nortriptyline 20%. The remission rate of
treatment augmented with lithium was about 16%, with T3 was
about 25%
Level 4 patients who did not remit at level 3 were switched to
tranylcypromine (Parnate) or Effexor, and the remission rate were
low.
Summary
About 50% achieved remission after level 2. 67% of those who
remained in the study. Switching to a different SSRI or non-SSRI are
reasonable options after inadequate response to initial SSRI, but
some needed numerous extended trials. The 1 year follow-up saw
higher relapse rates in patients who entered follow-up in less than
full remission. The relapse rates were also higher in those who
required more steps to achieve remission.
The conclusion was about 33% remit with optimized use of selective
serotonin-reuptake inhibitors and a high dose was often required.
Remission can take as long as 14 weeks. Switching to a different
SSRI or non-SSRI are reasonable options after inadequate response
to an initial SSRI. After level 1 augmentation with bupropion or
buspirone are reasonable options. The likelihood of remission
decreased with each subsequent treatment, but remission is worth
pursing because it predicts lower relapse rates.
According to the Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition, which of the following
criteria must be present for the
diagnosis of major depression?
a.
b.
c.
d.
Loss of interest or depressed mood
Feeling of melancholy
Fatigue
Downturn in self-esteem
Answer
a. Loss of interest or depressed mood
Treatment of depression in the elderly
can include which of the following?
a.
b.
c.
d.
Mitigation of functional impairments
Amelioration of loneliness
Electroconvulsive therapy
All of the above
Answer
d. All of the above.
Which of the following was concluded
from the Sequenced Treatment
Alternative to Relieve Depression trail?
a. About on third of patients remit with
optimized use of selective serotonin-reuptake
inhibitors (SSRIs)
b. Low doses often required for maximum
effect
c. Remission usually takes no longer than 4
weeks
d. Switching SSRIs following inadequate
response to initial SSRI is contraindicated
Answer
a. About one third of patients remit with
optimized use of selective serotonin-reuptake
inhibitors (SSRIs)
True statements about the prevalence
of constipation include all the
following, except:
A) Affects all ages and all sexes
B) More common in women and
increases with age
C) More common in white patients
than nonwhite patients
D) As population ages, sex differences
disappear
Answer
• B) More common in women and increases
with age
The Rome III criteria state that chronic
constipation must include≥2 of which of the
following signs and symptoms?Straining
Lumpy or hard stools
Incomplete evacuation
Sensation of obstructive blockage
Manual maneuvers to assist defecation
Infrequent defecation
A) 1,3,5
B) 2,4,6
C) 1,2,3,4,5
D) 1,2,3,4,5,6
Answer
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Straining
Lumpy or hard stools
Incomplete evacuation
Sensation of obstructive blockage
Manual maneuvers to assist defecation
Infrequent defecation
D) 1,2,3,4,5,6
Which of the following symptoms
differentiate chronic constipation from
irritable bowel syndrome?
Abdominal pain
Nausea
Abdominal bloating
Poor appetite
A) 1,3
B) 2,4
C) 1,2,3
D) 4
Answer
• Abdominal pain
• Abdominal bloating
• A) 1,3
Which of the following is the
only drug approved for chronic
constipation?
A) Polyethylene glycol
B) Bismuth subsalicylate
C) Lubiprostone
D) Tegaserod
Answer
• C) Lubiprostone
In patients who require surgery for
constipation, which of the following
statement(s) is(are) true?
A) Offered only to patients with
documented slow transit by marker study
B) Necessary to exclude disordered
defecation and generalized intestinal
dysmotility
C) Total colectomy procedure of choice
D) All the above
Answer
• D) All the above
True statement(s) about functional
diarrhea include which of the
following?
A) Often correlates with stress
B) Onset may occur after resolved
enteric infection
C) More common after childhood
abuse or neglect
D) All the above
Answer
• D) All the above
Enterotoxigenic Escherichia coli
A) Responsible for outbreaks of
diarrhea on cruise ships
B) Migrates through blood to other
organs, causing abscesses
C) Most common cause of traveler's
diarrhea
D) Usually seen in day care centers
Answer
• C) Most common cause of traveler's diarrhea
Norwalk virus
A) Responsible for outbreaks of
diarrhea on cruise ships
B) Migrates through blood to other
organs, causing abscesses
C) Most common cause of traveler's
diarrhea
D) Usually seen in day care centers
Answer
• A) Responsible for outbreaks of diarrhea on
cruise ships
Entamoeba histolytica
A) Responsible for outbreaks of
diarrhea on cruise ships
B) Migrates through blood to other
organs, causing abscesses
C) Most common cause of traveler's
diarrhea
D) Usually seen in day care centers
Answer
• B) Migrates through blood to other organs,
causing abscesses
Constipation
• Prevalence: affects all ages and all sexes
• more prevalent in women and increases with age
• (irritable bowel syndrome [IBS] seen in younger
women and decreases with age)
• As population ages, sex difference disappears
• constipation associated with decreased quality of life
(QOL Improves with treatment), depression,
immobility, and psychologic distress
• laxatives third and fourth most frequently used
medications in elderly population
• stimulants and bulking laxatives most commonly used
Constipation
• Racial and ethnic incidence: more common in nonwhite than white
patients
• significant economic impact seen
• Perceptions of chronic constipation: physician—frequency based;
• Less than 1 bowel movement (BM) every 3 to 4 days
• patient— symptom-based; quality of defecation, eg, straining, hard stools,
incomplete evacuation
• Definition: Rome III criteria—chronic constipation must include
• 2 of following,
• straining, lumpy or hard stools,
• Non complete evacuation,
• sensation of obstructive blockage
• manual maneuvers to assist defecation
• infrequent defecation
• quality as important as quantity in diagnosis;
• loose stools unusual in chronic constipation, unless patient on laxatives
Clinical evaluation and diagnostic
approach:
• extensive testing Not needed
• ask patient key questions and to describe stool;
• Perform abdominal and digital rectal examinations evaluation
of sphincter
• have patient strain on finger and
• if contracting (rather than relaxing), disordered defecation
present
• key questions—what does the patient mean by constipation
• presence of abdominal pain (to differentiate from IBS) IBS is
painful, chronic constipation has no pain
• what medications is the patient taking
• presence of alarm signs or symptoms
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Constipation
American College of Gastroenterology (ACG) Task Force:
no action necessary, other than empiric treatment, if alarm
signs or features absent
diagnostic studies indicated in patients with alarm signs or symptoms
those >50 yr of age who require colorectal cancer screening
alarm signs and symptoms
Bleeding
family history
Anemia
Persistent condition unresponsive to treatment
new-onset symptoms in elderly patient
unexplained systemic symptoms
Specialized diagnostic tests: colonoscopy
colonic transit studies
marker studies
balloon expulsion test as part of anorectal manometry; if balloon expelled in 3
min, mechanism functioning
if not expelled, disordered defecation probable
colonic manometry
defecography to look for structural disorders
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Treatment
no evidence to support hydration, increased intake of fiber, and exercise, although lifestyle measures
effective
dedicated bathroom time important
probiotics—Align, Activa yogurt, and DanActive shown effective in randomized trials
suppositories and enemas—stimulate rectum
Bulking agents—only psyllium studied;
stool softeners—widely prescribed
not effective
osmotic laxatives—polyethylene glycol (PEG)
lactulose actually prebiotic;
timulant laxatives—for patients on long-term opiates
psyllium—effective, compared to placebo; studied only in short-term trials;
lactulose— effective, but leads to bloating and gas
PEG—effective; approved only for short-term use; over-the-counter if used for 1 wk (prescription required
if used for 2 wk)
data show longterm efficacy in adults (off-label use); effective for 1 yr and longer
tegaserod—off market; available only for life-threateningc ondition;
lubiprostone—only drug approved for chronic constipation; when type 2 chloride channels in intestine
open,
exit of chloride with sodium and water seen
presence of isotonic fluid distends intestine, causing BM
dose for chronic constipation 24 μg bid
IBS-constipation predominant [IBS-C] one-third of dose or 8 μg bid)
50% to 80% of time, BM occurs within first 2 days of starting drug
generally taken on as-needed basis by patients
Choose the correct statement about
risk for falls in elderly patients.
(A) Higher in elderly men than in
women (C) Easy to address 3 risk
factors at a time
(B) Risk for recurrence low (D) Most
risk factors can be addressed and fixed
Answer
• (D) Most risk factors can be addressed and
fixed
When counseling adult children about
caring for aging parents, the caregiver
should be advised against:
(A) Developing a caregiving plan while
older adult still functional
(B) Promising to never place aging parent
in nursing home
(C) Helping aging parents feel as though
they are in control during decision-making
processes
(D) Reinforcing good habits of aging parent
Answer
• (B) Promising to never place aging parent in
nursing home
Which of the following may indicate
that an adult child should consider
caregiving for an aging parent?
(A) Changes in appetite (C) Reluctance
to socialize
(B) Diminished driving skills (D) Any of
the above
Answer
• (D) Any of the above
Which of the following groups of older
adults would most likely benefit from
relocating to a senior housing facility?
(A) Quiet, subdued older adult
(B) Older adult with adult child who
desires relocation
(C) Older adult with cognitive
dysfunction who tends to wander
(D) All older adults would benefit from
relocating to a senior housing facility
Answer
• (C) Older adult with cognitive dysfunction who
tends to wander
Choose the correct statement(s) about
older adults and driving.
(A) Often self-regulate (eg, drive
during day and not at night)
(B) Occupational therapy programs
available for driving rehabilitation and
support
(C) Family members should be asked
about accidents and damage (to, eg,
car, mailbox, fence)
(D) All the above
Answer
• (D) All the above
Stress from caregiving
can affect the caregiver’s
quality of life, morbidity,
and mortality.
(A) True (B) False
Answer
• (A) True
Although multiple definitions of
polypharmacy exist, which of the
following characteristics is most
commonly linked to
all of them?
(A) Use of >4 medications
(B) Use of 2 drugs of same class
(C) Use of >1 pharmacy
(D) Uneasiness and concern about
errors or harm to patient
Answer
• (D) Uneasiness and concern about errors or
harm to patient
Of the following, which is
the most common risk factor
for noncompliance?
(A) Age 30 to 45 yr (C)
Marriage
(B) High education level (D)
Polypharmacy
Answer
• (D) Polypharmacy
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Falls
Falls in older adults are one
of the leading causes of
serious injury and loss of
independence.
The American Geriatrics Society
(AGS) blames falls as the fifth leading cause of death in those
over 65
and a major cause of disability.
two-thirds of all falls are
Preventable
a customized exercise
program can play a big role
in fall prevention.
risk for falls
• risk for falls higher in elderly women than in
men
• falls usually recur
• decreased bone density
• poor exercise habits that result in decreased
muscle tone and strength contribute to falls
• several environmental hazards in home
• (eg, furniture placement, clutter) also contribute
Risk factors
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difficult to address >2 risk factors at a time
chance for independence-threatening falls increases with number of risk factors
most risk factors can be addressed and fixed
osteoporosis—related to changes in intrinsic and extrinsic hormone
nutrition depends on financial status, and poor nutrition can accelerate bone loss
lack of physical activity leads to poor muscle tone, loss of muscle mass, decreased strength,
and accelerated osteoporotic changes
Vision problems—acuity changes with age
cataracts common and can be problematic
glaucoma can reduce peripheral vision
medications—many patients take multiple agents
consider drug interactions
ask about nutritional supplements
consider alcohol use
Medical conditions—arrhythmias
atherosclerotic disease
dementia;
perform echocardiography and electrocardiography (ECG) as indicated
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Fall Prevention
identifying cardiac factors
perform patient history and physical examination
performs vision screening refes to ophthalmologist if indicated)
basic nutrition screening
osteoporosis screening
Questionnaire to identify risk factors
physical and occupational therapists—for patients with mobility problem
formal evaluation of motor strength and cognition
screening test for dementia
exercise and nutrition programs
community clubs (eg, YMCA, YWCA)
Resources for evaluation of overall nutritional state
Social programs available to improve quality of food received
pharmacist—expertise in pharmacy databases essential; reviews medications
check for interactions
determine which medications necessary
addresses drugs that have specific indications and may increase risk for falls (eg, warfarin [eg,
Coumadin] and clopidogrel [Plavix])
Social worker—connects patient to appropriate community resources
evaluate social and family situations
identify possibility of abuse and neglect
perform chemical dependency evaluation
Physical Therapy
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• Education to modify environmental factors
• Flexibility training
• Strength training
• Muscle endurance training
• Gait training—walking speed and step length
• Instruction in a home exercise program
*Instruction in fall techniques, that is how to fall
without injury. A lot of elderly patients fall backwards
and hit the back of their head. I have had several
patients fall and die from subdural hematomas.
Physical Therapy
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Strength
Strength and muscle endurance are critical factors in fall
prevention. Your therapist will test the strength of your legs
and trunk in a variety of ways.
Balance
Efficient interaction between the visual, muscular, and
neurological systems of the body is needed to provide good
body awareness and balance during daily activities. Failure of
any of these systems can contribute to falls. A balance test
followed by a customized treatment program can prevent falls.
Walking Speed and
Step Length
Assessment of walking speed and step length is important
because these have a direct link to falls. Improving walking
speed, distance, and step length will improve safety
and independence.
ENVIRONMENTAL SAFETY CHECKLIST
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Entrances
►Can the person you support enter and exit vehicles with adequate space and on a level surface?
Assure the ground is level, garage is free from clutter, and driveway is clear of loose rocks, etc. If necessary, request help for
vehicle transfers from a therapist.
►Are walking surfaces used to get to and from the car free from cracks, buckling, and clutter?
Repair any cracks or buckling in sidewalk, driveway or garage floor concrete. Remove objects such as excess leaves, garden
hose, and newspapers from walking path.
►Is the path used to walk from the car to the door well-lit?
Add sidewalk lights or a brighter porch or garage light if necessary. Leave porch lights on if leaving/coming home after dark.
►Does the person you support need closer supervision or more assistance when walking on unfamiliar or altered surfaces
(grassy, wet, icy, muddy)?
Provide extra assistance or supervision during inclement weather and on uneven surfaces if the person has altered mobility.
If necessary, request help for appropriate levels of assistance from a therapist.
►If there are stairs to the entrance of the home, are they safe (not broken or worn)?
Repair broken or worn steps. Install handrails on both sides. Also, keep stairs free of clutter.
►Are handrails present on steps and are they stable and in good condition?
Determine if handrails are needed on both sides of steps and assure they are secure and do not move when being used.
Living Areas and Kitchen
►Are rooms, hallways, and stairways in the home well-lit?
Good lighting can reduce the chance of falling especially in hallways and on stairways. Add bright strips of tape to the edge
of each stair where you do not step. They can help you see the stairs better.
Consider adding night-lights where overhead lighting is lacking.
Night lights in the hallway and bathroom can also make night trips to the bathroom easier.
Always keep a charged flashlight near the bed or available for staff for power outages. Another option is night-lights with
battery back-up.
ENVIRONMENTAL SAFETY CHECKLIST
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►If there are throw rugs, are they secured to the floor?
Throw rugs are a tripping hazard. If you do not wish to remove them, they should be securely fastened with an adhesive,
double-stick tape.
►Are floor coverings (carpet, area rugs, and linoleum) free from frayed corners or rolled edges?
Floor coverings should be repaired or replaced if they cannot be securely fastened with an adhesive, double-stick tape.
►Is walking space free from clutter?
Shoes, electrical cords, and magazines can be hazardous in walkways. Always keep walkways clear.
Take extra caution when there are small pets as they can cause the person to trip and fall.
►Are items the person regularly uses within reach?
Put regularly used items on shelves within easy reach between hip and eye level.
A long-handled grasper can be used to reach objects that are on high shelves or on the floor.
►Does the person you support have trouble bending over to pick up objects from the floor?
Plan ahead. Move the object closer to something sturdy to hold onto.
Consider raising object to a higher surface.
►Does the person you support have furniture that is difficult to get in and out of?
Try to purchase furniture with firm cushions, good back support, and armrests to make getting in and out of it easier. If
necessary, request instruction from a therapist to assist the person from sit-stand.
►Does the person you support have trouble walking without holding on to something?
If the person is unsteady without holding on to something, a mobility aid might be indicated (gait belt, cane, or walker).
Consult your doctor or physical therapist.
►Are non-carpeted areas kept clean and dry (entryways, laundry room, bathroom and kitchen floors)?
Be sure to wipe up spills completely and immediately. Use caution with freshly cleaned floors as they are frequently more
slippery.
►Does the person you support have stairs without rails or a broken or missing railing?
Using handrails to go up and down stairs is easier and safer. Add hand rails to all stairs, if possible. Request repairs.
Persons who are at risk to fall should consider a one-level home with no stairs.
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ENVIRONMENTAL SAFETY CHECKLIST
Bedroom
►Can the person get onto and off of his/her bed without difficulty?
If necessary, request instruction from a therapist to assist the person from sit-stand and determine if
assistive devices may be necessary.
►Does the person complain of or appear dizzy when he/she gets up from lying down?
If dizziness is present and persists, consult the person’s physician. Teach the person to sit on the edge of
the bed for a moment before getting up, especially in the middle of the night if using the bathroom.
►Is space around the bed free from clutter and cords, etc.?
Remove excess furniture from the room or arrange the room to assure there is a clear pathway from the
door to the bed.
►Are items that the person needs, within reach without having to get out of bed (eyeglasses, hearing aid,
light and alarm clock)?
Assure the person has a sturdy bedside table on which to place needed items. Provide a light the person
can operate.
Bathroom
►Does the person you support have trouble getting in and out of the bathtub or shower?
If grab bars are present, ensure they are secure and in good repair. Otherwise, consider Installing grab bars
where necessary (in bathtub/shower, along wall outside of tub/shower, along toilet).
Consider a transfer tub bench or a shower chair.
Sometimes a modification called a TubCut can be made by a trained professional allowing the person to
step through the side of a tub instead of over the side of the tub.
In the event none of the above suggestions is appropriate, consider a roll-in shower.
►Is the floor of the tub or shower slippery or does the bathroom floor get wet during the bath/shower?
Always use a non-skid bathtub/shower mat and a securely fastened non-skid rug outside of the
bathtub/shower to avoid slipping on a wet floor. Be sure to dry the bathroom floor before the person
attempts to step out.
ENVIRONMENTAL SAFETY CHECKLIST
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Consider installing a non-skid shower chair or bathtub bench and hand-held shower head so
he/she can sit while bathing or showering. If necessary, consult a therapist.
►Is a towel rack or a bathroom sink used for support to get in/out of the bathtub/shower or
up from the toilet?
Avoid pulling up on the sink or using towel racks to get up from the toilet or bathtub.
Bathroom sinks are generally not securely fastened to the wall or floor, and are not intended
to support a lot of weight. Towel racks can easily come loose from the wall.
►Are items needed during a shower/bath within reach?
Use bath caddies mounted on the wall within reach of the individual to hold needed items,
including a washcloth.
Other Risk Factors to Consider
►Does the person you support wear floppy slippers, flip-flops, ill-fitting shoes, a long
bathrobe, or pants/dresses that are too long?
Wear well-fitting slippers with non-skid soles. Avoid night clothing that drags on the ground.
Keep robe tied. Make sure pants/dresses are not dragging on the floor. Make sure shoes are
secure and fit well.
►Are mobility aids or other assistive technology devices in good working order?
Check equipment and devices to be sure they are not broken or have loose components and
are clean (including hearing aids and glasses).
FALL PREVENTION SCREENING
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QUESTION Yes/No
1. Do you feel unsteady or dizzy?
2. Did you ever fall or feel like you were about to fall?
3. Are you dizzy or unsteady when you first get up?
4. Do you worry that you may fall or hurt yourself?
5. Does moving your head quickly make you dizzy?
6. Does bending over make you dizzy?
7. Does your dizziness or unbalance problem
Interfere with your job or household duties?
• 8. Do you avoid outdoors for fear of falling?
Polypharmacy
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Multiple definitions of polypharmacy
use of more than 4 or 5 medications
use of more drugs than clinically indicated
use of 2 drugs of same class
use of 2 or more drugs for same disease
use of >1 pharmacy
Polypharmacy causes uneasiness and concern
for errors or harm to patient
Polypharmacy
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Evaluation for drug therapy:
ndication (make sure medications appropriate)
Efficacy
safety (no risk for adverse effects or toxicity)
compliance (involves how patient fits in with care
plan
• 33%-50% of patients do not take prescribed
medications)
• convenience (involves how plan fits in with patient’s
life)
• cost (consider affordability of medication)
Concerns of Caregivers for Older
Adults
• many caregivers of older adults feel health care providers
should have “all this information at their fingertips and be
able to help me at a moment’s notice”
• many not prepared for caregiving
• important to help older adults find what makes them feel
successful despite aging
• eg, not getting sick, maintaining function
• challenges to caregiving include
• keeping older adults engaged
• determining and communicating about important issues
• Need for intensity of care forms to be filled out like the POLST
form, durable power of attorney or Five Wishes from.
Caregiving and planning
• adults with aging parents should consider caregiving plan;
• attitude of older adult affects caregiver; reinforce good habits
of older adult;
• consider goals of older adult
• advise adult children to “never say never” (eg, “I will never
put you in a nursing home”) adult children often consult
health care providers
• to identify and meet needs of older adults (helpful
• to obtain information about older adult and
• caregiver)
• caregivers often expect health care providers to intervene
• difficult for older adults to ask adult children for help
• older adults tend to overestimate their ability to function
independently, and often refuse help from adult children
Deciding when to begin caregiving
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consider changes in habits (eg, missing appointments), appetite, and food (eg,
inedible food found in refrigerator)
Mishandled medications and prescription errors
Diminished driving skills
older adults often self-regulate driving (eg, drive during day and not at night)
reluctance to socialize
“My mother won’t do what I tell her to do”
“older adults have right to make stupid decisions just like you did when you were a
teenager”
health care provider often asked to intervene
occasionally, strong, supportive physician-patient relationship may positively
influence outcome
avoid involvement in power struggle between dysfunctional individuals
decision-making patterns— important to know primary people who help make
decisions
helpful to reinforce idea that, “she still sees you as the child” promote autonomy
and independence
help older adult feel as though they are in control during decision-making process
Relocation
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moving older adult from one location to another;
weigh options
“dysfunction is not tempered by need”
families that did not do well before often do not pull together in crisis
situations
adult child’s desire to relocate older adult may not benefit older adult
Consider consulting geriatric care manager
consider coping mechanisms and nature of older adult (eg, quiet, subdued
older adult may not do well in senior housing facility)
reasons to consider relocation—safety issues
Wandering
need for protective presence
Unsound judgment
Health problems in older adults
• distinguish normal aging from disease
• confusion presenting symptom for multiple problems (eg,
urinary tract infection, pneumonia, delirium)
• important to manage sudden changes in cognitive function
• be precise with language
• (eg, “Alzheimer’s disease” vs “dementia”)
• make caregiver aware that some conditions (eg, depression)
• can be treated, while others cannot
• sharing
• health care information—discuss having open honest
dialogues between older adults, caregivers, and health care
providers
Housing and financing care
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be familiar with state regulations
eg, definitions of “assisted living” and “residential care” may differ by state
financing—many programs (eg, Medicare, Medicaid) available
Need to know Medicare requires a 3 day stay in the hospital to cover
nursing home stay.
Medicare only coveres skilled nursing needs in the nursing home setting.
That is treatment that involves IV therapy, PEG tube feeding, need for
acute Physical or Occupational therapy.
If the patient is not progressing or participating in physical therapy,
Medicare will not pay for the nursing home stay.
Medicare covers up to 90 days of care in a nursing home per year, but the
patient has to meet criteria for skilled nursing needs.
Caregivers often ask for information about coverage for various types of
care
eg, hospitalization, observation stays, and nursing home care
Driving
• reporting regulations vary by state
• Califonia requires all persons diagnosed with dementia be reported to
the DMV if they are driving.
• Research about driving and effects of visual ability, cognitive and physical
function, and how far one can turn neck under way
• automakers researching car designs that may be more supportive of older
drivers (eg, addition of mirrors and cameras)
• occupational therapy programs for driving rehabilitation and support
• car insurance discounts for seniors for safe driving
• ask family members about accidents and damage (to, eg, car, mailbox, or
• fence)
• techniques for stopping older adults from
• Driving
• obtain prescription that advises against driving;
• remove parts of car to prevent operation
• use community resources
Personal care and safety
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consider Meals On Wheels,
restaurant plans
congregate dining places
Consider hired help for, eg, helping older adult in and out of
bathtub, cooking meals, cleaning, laundry, shopping etc. This is not
covered by Medicare. Medical may cover some services, but in
order to qualify for medical the patient needs to have no financial
assets. That is they can’t own a home.
• personal safety emergency response systems (eg, Lifeline)
recommended
• advise family members or caregivers to collect relevant financial
information (eg, account numbers, billing information) and put
them in a binder