Geriatrics

1

What changes in organ function occur in advanced age?

See Table 18.1 .

2

How does change in body composition with aging affect drug treatment?

A marked increase in fat mass and decrease in lean body mass associated with aging leads to an altered volume of distribution of some drugs. Patients who appear trim may still have these changes. As a result, water-soluble (hydrophilic) drugs such as digoxin or lithium have higher concentrations owing to a lower volume of distribution. Fat-soluble (lipophilic) drugs such as benzodiazepines or thiopental have a higher volume of distribution and will have longer times for steady-state concentration and elimination.

3

How does sleep change with aging?

Sleep latency (time to fall asleep) increases, and sleep efficiency (time asleep divided by time in bed) decreases. Elder patients tend to have an earlier bedtime, earlier morning awakening, more nocturnal arousals, and more daytime napping. Sleep structure changes include a notable decline in stage N3 (deep sleep) and an increase in stages N1 (transitional sleep) and N2 (intermediate sleep).

4

What are the essential elements of an evaluation for an elderly patient with recurrent falls?

• History: Focused on the circumstances of the fall and associated symptoms

• Gait: Assessed with get-up-and-go test

• Balance: Tested by observing side-by-side, semi-tandem, and tandem stance

• Muscle strength: Including quadriceps, hip flexors, abductors and extensors, and foot dorsiflexion

• Vision

• Feet and footwear: Inspected for any deformities

• Orthostatic blood pressure measurement: If history suggests postural weakness or lightheadedness

• Dix-Hallpike maneuver: If positional vertigo suspected

• Home safety evaluation: If appropriate

5

What is the “get-up-and-go” test?

A maneuver to assess the ease with which the patient can:

• Rise from a chair without using arm supports

• Stand still momentarily

• Walk a short distance (∼10 feet)

• Turn around

• Walk back to the chair

• Turn around

• Sit down in the chair without using the arm supports

The test is scored both on qualitative observations of ability to perform the task and an age-adjusted time.

Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: The “get-up and go” test. Arch Phys Med Rehabil. 1986;67:387–389.

6

What is the Dix-Hallpike maneuver?

A procedure to reproduce positional vertigo. The physician supports the patient while the patient goes from a sitting to a supine position with head tilted back approximately 20 degrees below shoulder level and turned 45 degrees to one side. The eyes are observed for rotatory nystagmus, and the patient is asked about reproduction of symptoms. The patient then returns to the sitting position, and the maneuver is repeated on the opposite side.

7

Describe the usefulness of an assessment of function and activities of daily living (ADLs)

To provide insight into the symptomatic impact and current status of the patient’s various health problems that allows the provider to monitor the trajectory of a patient’s health and ensures attention is given to maximizing quality of life. Many older patients value quality of life over quantity of life. Also, a change in function is often the first sign of decompensation of a medical problem.

8

How is such a functional assessment performed?

By evaluating whether there are any recent changes in the patient’s ability to perform ADLs (bathing, dressing, toileting, maintaining continence, grooming, feeding, and transferring) or whether the patient now needs assistance or has difficulty with some ADLs. Some of these observations are best made by others.

9

What are the essential aspects of evaluating driving safety in an older adult?

• Vision: Including a formal eye examination (Snellen chart)

• Cognition: Using the clock drawing test

• Neuromuscular status: Including active range of motion of the feet, shoulders, hands, and neck

• Referral to a driver rehabilitation specialist if indicated

10

How can one assess driving safety in a patient with dementia?

The following may indicate higher risk of unsafe driving:

• Clinical dementia rating score ≥ 2.0

• Assessment by caregiver that patient’s driving is unsafe

• History of traffic citations

• History of crashes

• Voluntary reduction of driving mileage by patient

• Voluntary avoidance of certain situations by patient

• Mini-Mental State Examination (MMSE) score ≤ 24

• Aggressive or impulsive personality characteristics

Iverson DJ, Gronseth GS, Roger MA, et al. Practice parameter update: evaluation and management of driving risk in dementia. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74:1316–1324.

Morris JC. The clinical dementia rating (CDR): current version and scoring rules. Neurology. 1993;43:2412–2414.

Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc. 1992;40:922–935.

11

A patient with severe dementia has recurrent admissions with pneumonia, likely due to aspiration. Will gastrostomy tube placement prevent further pneumonias?

No. Aspiration is considered an expected consequence of advanced dementia. Oral secretions are often aspirated even in patients not fed by mouth. There is currently no evidence that a gastrostomy tube prevents aspiration or pneumonias in advanced dementia. Caregivers should be instructed on techniques to help reduce the risk of aspiration such as sitting up at 90 degrees when eating and tipping the chin forward.

12

Is megestrol useful and effective in increasing lean body mass in underweight older patients?

No, because of numerous side effects. Although megestrol often increases appetite, the weight gain is due to an increase in fat mass with decline of skeletal muscle mass in many patients. Megestrol can also blunt the beneficial effects of resistance exercise on strength. In addition, megestrol causes a decline in testosterone concentration in men to castrated levels and has catabolic effects from its glucocorticoid properties. Other side effects include Cushing syndrome, adrenal suppression, hyperglycemia, and thromboembolism.

13

For most oral supplements and enteral feeding tube products, how many calories are there in each milliliter?

Around 1 kcal/mL. As a result, most cans of oral supplement, which are usually 8 ounces in volume, contain roughly 250 calories. Patients subsisting just on enteral feeds will typically require 1400–2000 mL of enteral feeding per day to meet their caloric needs. Calorically dense products containing 2 kcal/mL are available.

14

What are appropriate hemoglobin A _1c targets in older patients?

The American Geriatrics Society advises that reasonable targets would be 7.0–7.5% in healthy older adults with long life expectancy, 7.5–8.0% in those with moderate comorbidity and a life expectancy less than 10 years, and 8.0–9.0% in those with multiple comorbid conditions and shorter life expectancy. Tight control has been shown to produce higher rates of hypoglycemia in older adults, and there is no evidence that using medications to achieve tight glycemic control in most older adults is beneficial.

American Geriatrics Society. Choosing wisely. Available at: www.choosing wisely.org/societies/american-geriatrics-society/ . Revised 4/23/15. Accessed October 1, 2016.

15

What are the physiologic changes that predispose older people to dehydration?

• Diminution of thirst perception in response to volume depletion or hyperosmolality

• Decline in basal and stimulated renin levels with reduction in aldosterone secretion

• Reduced renal responsiveness to antidiuretic hormone (ADH)

• Impaired sodium conservation by kidneys when salt intake is restricted

16

What laboratory tests best determine dehydration?

Blood urea nitrogen (BUN), which is usually elevated. Other indicators include a BUN-to-creatinine ratio > 20 or a BUN greater than twice the baseline BUN.

17

What is the significance of severe hypernatremia in frail elderly patients?

As a sign of severe dehydration. In mobile patients, hypernatremia induces the thirst response that leads to increased fluid intake. Frail elders may have inadequate intake of free water owing to immobility or cognitive impairment, leading to more severe hypernatremia. An elder with severe hypernatremia may be neglected, and the physician should look for other signs or symptoms of elder abuse or neglect.

18

Does serum creatinine accurately reflect changes in glomerular filtration rate (GFR) in the elderly?

No. The aging process is accompanied by a significant deterioration of the renal function. On average the GFR declines by ∼8 mL/min/1.73 m ² per decade after the fourth decade of life. The age-related reduction in creatinine clearance is accompanied by a reduction in the daily urinary creatinine excretion owing to reduced muscle mass. Accordingly, the relationship between serum creatinine and creatinine clearance changes. The net effect is near-constancy of serum creatinine (S _Cr ) while true GFR (and creatinine clearance) declines, and consequently, substantial reduction of GFR despite a relatively normal S _Cr level occurs.

Pompei P. Preoperative assessment and perioperative care. In: Cassel C, Leipzig R, Cohen H, et al, eds. Geriatric Medicine: An Evidence-Based Approach. 4th ed. New York: Springer-Verlag; 2003. p 213–227.

19

What are “red flag” symptoms that raise suspicion for malignancy in an older patient with back pain?

• Unexplained weight loss

• >1-month duration of symptoms

• No relief of pain by lying down (suggesting cancer or infection)

• History of cancer

• Focal neurologic deficit

20

How is an acute vertebral compression fracture managed?

With pain management and brief bed rest. Symptomatic acute vertebral fractures are a common problem for osteoporotic patients. Pain at the site of the fracture is often severe and requires initial bed rest and occasionally even hospitalization. Pain control is normally achieved with nonopioid analgesics, opioids, and nasal calcitonin spray. Imaging studies (including magnetic resonance imaging [MRI]) should be obtained if neurologic examination suggests radiculopathy or if malignancy is suspected. Older patients with uncontrolled focal back pain related to a nonmalignant vertebral compression fracture may benefit from balloon kyphoplasty or vertebroplasty; however, these procedures are invasive and should be reserved for older patients who did not respond well to conservative management. Clinical trials show only mild benefit compared to a sham procedure.

21

If temporal arteritis is suspected, how soon must one perform a temporal artery biopsy?

The pathologic changes of temporal arteritis remain present for at least 2 weeks, even with corticosteroid treatment. Corticosteroid treatment should be initiated immediately when temporal arteritis is suspected, and the biopsy can be scheduled when convenient.

22

How long do most temporal arteritis patients require drug treatment?

One to 2 years. Patients receiving corticosteroids for this lengthy period benefit from early bisphosphonate therapy to prevent osteoporosis. Because prolonged corticosteroid therapy is associated with significant risks and side effects, the diagnosis of temporal arteritis should be confirmed to avoid unnecessary treatment.

23

Does Medicare routinely cover screening bone mineral density (BMD) scans for older men and women?

Yes, every 2 years for women 65 years and older. BMD scans are covered for older men only if there is an underlying suspicion for osteoporosis such as vertebral abnormalities on x-ray studies or treatment with corticosteroids for over 3 months.

24

Should we screen older men for osteoporosis?

Maybe. Health advisory organizations have issued recommendations regarding screening men. The U.S. Preventive Services Task Force (USPSTF) gives a grade I, meaning current evidence is insufficient to assess the balance of benefits and harms of screening older men. The National Osteoporosis Foundation recommends BMD testing for all men older than 70 years and men aged 50–69 years based on risk factors. The American College of Physicians recommends assessing older men for risk factors. Men who are considered at increased risk (and who are candidates for drug therapy) should be screened with a BMD scan.

25

What are the risk factors for fractures for older men?

• Previous minimal trauma fracture

• Glucocorticoid therapy

• Low body weight

• Current cigarette smoking

• Excessive alcohol use

• Rheumatoid arthritis

• Hypogonadism

• Malabsorption syndromes

• Chronic liver disease

• Parental history of hip fracture

26

What is a T score?

The number of standard deviations the patient’s bone density is above or below the average value for a young adult of the same sex. Osteoporosis is defined by the World Health Organization as a T score < – 2.5.

27

What is sarcopenia? How can it be prevented?

Loss of muscle mass related to aging and physiologic changes seen with muscle disuse. Sarcopenia significantly contributes to disability in the elderly and can be prevented with physical activity, especially moderate- to high-intensity resistance exercise.

28

What laboratory test measures vitamin D levels in the body?

25-Hydroxyvitamin D (25-OH-D). According to a 2011 Institute of Medicine report, levels > 20 ng/mL are adequate for bone health.

IOM (Institute of Medicine). Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press; 2011.

29

Why is vitamin D deficiency important to diagnose in older adults?

Because vitamin D deficiency is common in elders and can contribute to osteoporosis, fractures, muscle weakness, and falls. Active people get most of their vitamin D from sun exposure, because few foods contain or are fortified with vitamin D. Many older adults who get little skin exposure to the sun have insufficient vitamin D levels.

30

What are the recommended daily dietary allowances for calcium and vitamin D in older adults?

1200 mg of calcium/day in adults older than 50 years and 800 IU of vitamin D/day for adults older than 71 years. An 8-ounce glass of milk has 300 mg of calcium and 100 IU of vitamin D.

31

Does calcium supplementation affect the absorption of other medications?

Yes. Supplements such as calcium and iron (which are divalent cations) can reduce the absorption of commonly used medications such as levothyroxine and some quinolone antibiotics. Patients taking such medications should take the medications and supplements at least 2 hours apart.

32

Why is lumbar spinal stenosis (LSS) sometimes misdiagnosed as claudication associated with peripheral vascular disease?

Because spinal stenosis symptoms of leg pain increase with walking (neurogenic claudication), as do those of vascular claudication. LSS in older adults is most commonly caused by degenerative bone disease and is a common cause of disability. Treatment may involve spine surgery. Typical symptoms of LSS include pain in the buttocks or upper legs associated with sensory loss and weakness. Many patients also have associated low back pain. Symptoms tend to increase with walking, standing, and back extension and tend to improve with lying, sitting, and back flexion. Vascular claudication is usually described as calf tightness and cramps on exertion that typically resolve immediately after rest. Neurogenic claudication symptoms are relieved within minutes of sitting/lying but persist with standing erect.

33

In an older patient with chronic atrial fibrillation (AF), is “rate control” or “rhythm control” preferable?

Rate control. Randomized trials have shown that outcomes with a “rhythm control” strategy are no better than with a “rate control” strategy, and in some aspects, outcomes are inferior. For rhythm control, one attempts to convert the rhythm to sinus. For rate control, the rhythm remains AF, but the ventricular rate is controlled to a resting rate of less than 100 beats per minute (bpm) with beta blockers and calcium channel blockers. Unless a patient has significant symptoms, such as bothersome palpitations or exercise intolerance, treatment should focus on controlling ventricular rate both at rest and with exertion.

34

Elderly people often fall every few months. Are oral anticoagulants for AF contraindicated in such patients?

No. Advanced age is considered one of the major risk factors for thromboembolic events in patients with AF. Studies comparing the protective effect of warfarin versus antiplatelet therapy in elderly patients with AF have shown significantly higher risk reduction of cardioembolic events with warfarin. Advanced age is also considered a risk factor for bleeding with anticoagulation therapy, and therefore, older patients should have a risk of bleeding assessment before initiation of therapy. Elderly people tend to have multiple episodes of falls, but studies have shown only a small risk for intracranial hemorrhages with the use of anticoagulation. As a general rule, anticoagulant use is not contraindicated in elderly people who fall on occasion. Warfarin or novel oral anticoagulants (NOACs) are options for anticoagulation.

Mant J, Hobbs FD, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (The Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomized controlled trial. Lancet. 2007;370:493–503.

Hart RG, Pearce LA, Aguilar MI. Adjusted-dose warfarin versus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern Med. 2007;147:590–592.

Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians’ fears often unfounded. Arch Intern Med. 2003;163:1580–1586.

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