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Delirium

Introduction Delirium represents an acute disorder of consciousness. Serially time-ordered, organized, and with reflective awareness of self and the environment, consciousness also represents an experience of graded complexity and quality. It follows that disturbance of consciousness as part of delirium is accompanied by impairments in arousal, attention, thinking, perception, and memory. A temporary dissolution of the mind poses grave vulnerability through impaired communication of personal needs…

Frontotemporal Lobar Degeneration

Introduction Frontotemporal lobar degeneration (FTLD) is a neurodegenerative condition that selectively affects the frontal and anterior temporal lobes of the brain, resulting in progressive shortfalls in behavior and language. More than a century ago Arnold Pick, a Czechoslovakian neurologist and psychiatrist, first published a report on FTLD. He described a 71-year-old man who developed dementia with sensory aphasia and behavioral symptoms. Autopsy demonstrated severe atrophy of…

Vascular Cognitive Disorders

The term vascular cognitive disorder (VCD) refers to a hetero­geneous group of disorders in which the salient feature is the presence of cognitive impairment primarily attributable to cerebrovascular disease (CVD). The conceptualization of this disorder has had a checkered history, with a variety of terms used to describe overlapping conditions. VCD is used not only for vascular dementia, including poststroke and multi-infarct dementia, but also for…

Alzheimer Disease

Alzheimer disease (AD) is the most common cause for dementia affecting older adults. The illness was first described by Alois Alzheimer in 1906 in a 51-year-old woman with well-described features of dementia. After death, her brain was examined and found to have numerous cortical plaques and tangles, characteristic of the illness. The disease was thought to be rare for 6 decades until its clinical and neuropathologic…

Neuropsychology in the Diagnosis and Treatment of Dementia

Introduction The aging of the U.S. baby boomer population has given rise to a significant increase in the prevalence of Alzheimer disease, the most common form of dementia in adults older than 65 years. One in three Americans aged 85 and older has Alzheimer disease, and by 2050, up to 16 million are predicted to have Alzheimer disease. Dementia is defined as significant impairment in cog­nitive…

Classification of the Dementias

Overview Dementia is a critical public health problem worldwide, especially as populations age. As a consequence, physicians dealing with a range of other age-associated problems can expect to see such problems in patients with dementia. Dementia diagnosis is evolving. Here, we review recent developments in the syndromic approach to dementia, and then highlight aspects of its differential diagnosis. Dementia generally has been defined in terms of…

Nonobstructive Lung Disease and Thoracic Tumors

Respiratory disease is a major cause of morbidity and mortality, affecting 1 in 10 of the population older than 65 years. The presentation and management of respiratory disease often differs in older adults. This chapter provides some insight into these differences while reviewing current evidence. Respiratory Infections Respiratory infection is common in older adults. Age-related factors include declining lung function and structural changes to the chest…

Asthma and Chronic Obstructive Pulmonary Disease

Diseases of Airflow Obstruction Two common chronic lung diseases found in older adults are characterized by expiratory airflow obstruction on lung function testing: asthma and chronic obstructive pulmonary disease (COPD). In most cases, it is possible to distinguish asthma from COPD on the basis of a thorough clinical assessment ( Table 48-1 ). This discrimination is important, as certain aspects of management of the two conditions…

Venous Thromboembolism in Older Adults

Introduction Venous thromboembolism (VTE) is the third most common cardiovascular disease and an important cause of morbidity and mortality. Older people account for nearly two thirds of episodes. Between 65 and 69 years of age, annual incidence rates per 1000 for deep vein thrombosis (DVT) and pulmonary embolism (PE) are 1.3 and 1.8, respectively, and rise to 2.8 and 3.1 in individuals aged between 85 and…

Vascular Surgery

Introduction As the prevalence of atherosclerosis increases with advancing age, it is hardly surprising that specialists in geriatric medicine frequently find vascular disease in their patients. For many, their overall degree of frailty is such that neither detailed investigation nor vascular surgery will be indicated. However, vascular surgeons now routinely perform procedures in octogenarians and will increasingly do so as the population ages. Older adults suffer…

Syncope

Introduction Definition Syncope is a transient loss of consciousness (TLOC) due to transient global cerebral hypoperfusion and is characterized by rapid onset, short duration, and spontaneous complete recovery. TLOC is a term that encompasses all disorders characterized by self-limited loss of consciousness, irrespective of mechanism. By including the mechanism of unconsciousness—transient global cerebral hypoperfusion—the current syncope definition excludes other causes of TLOC such as epileptic seizures…

Cardiac Arrhythmias

Ventricular Arrhythmias The prevalence of complex ventricular arrhythmia (VA) in older adult patients without cardiovascular disease detected by 24-hour ambulatory electrocardiogram (ECG) was 50% in men and women, 31% in men and women, 30% in men and women, 20% in men and women, 16% in women and 28% in men, and 33% in men and women. The prevalence of complex VA detected by 24-hour ambulatory ECG…

Valvular Heart Disease

Aortic Stenosis Causes and Prevalence Valvular aortic stenosis (AS) in older adults is usually due to stiffening, scarring, and calcification of the aortic valve leaflets. The commissures are not fused, as in rheumatic AS. Calcific deposits in the aortic valve are common in older adults and may lead to valvular AS. Aortic cuspal calcium was present in 295 of 752 men (36%), mean age 80 years,…

Hypertension

Introduction Demographic changes in most Westernized societies have highlighted the increasing number of older and very old (80+ years) adults in the global population, of whom over two thirds will have raised blood pressure (BP) levels. These elevated BP levels cannot be regarded as benign, only reflecting the effects of the natural aging process on the cardiovascular system, because they are associated with significant rates of…

Practical Issues in the Care of Frail Older Cardiac Patients

Introduction Despite a decline in recent decades in overall cardiovascular mortality in developed countries, the overall burden of cardiovascular disease remains substantial. The incidence of coronary artery disease (CAD), acquired valvular heart disease (VHD), and heart failure (HF) increases with age, resulting in significant growth in the prevalence of these conditions in the context of population aging. The lifetime risk for symptomatic CAD after the age…

Diagnosis and Management of Coronary Artery Disease

The most common cause of death in older adults is coronary artery disease (CAD). Coronary atherosclerosis is very common in older adults, with autopsy studies demonstrating a prevalence of at least 70% in persons older than 70 years. The prevalence of CAD is similar in older women and men. In one study, clinical CAD was present in 502 of 1160 men (43%), mean age 80 years,…

Chronic Cardiac Failure

Cardiac failure increases in prevalence and incidence with age. It is a disease of middle and old age, although the underlying causes differ considerably with age. In younger patients with cardiac failure, the cause is frequently coronary artery disease or a cardiomyopathy of uncertain cause, whereas in the older patient, valvular disease and hypertension are more often implicated. Heart failure remains a severely debilitating condition for…

Measuring Outcomes of Multidimensional Geriatric Assessment Programs

Although frailty in older adults may be associated with an underlying loss of complexity in many physiologic systems, the clinical conditions and geriatric syndromes that are commonly present in frail older adults are often highly complex. This clinical complexity, including the presence of multiple interacting medical and social concerns, is the challenge and also the joy of geriatrics. Geriatric services respond to this complexity with comprehensive…

Surgery and Anesthesia in the Frail Older Patient

Introduction In recent years, there has been a growing recognition of the role for geriatric medicine specialists in the care of older surgical patients. This has been fueled in part by the increasing numbers of older people undergoing elective and emergency surgery and in part by the increasing medical complexity of older surgical patients. The increase in numbers is due to changing global demographics, resulting in…

Social Assessment of Older Patients

Social assessment is an integral part of a comprehensive multidimensional assessment of older adult patients. Many studies on the effectiveness of comprehensive geriatric assessment include a social worker on the assessment team, whose mandate typically includes identifying and addressing social and community living needs. Social assessment is a broad construct, encompassing many aspects of an older individual's life. It includes assessment of functional ability, as measured…