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Elderly care
Dr HananAbbas
assistantprofessor of
of Family
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y
The number of persons 65 years ofage and older continues to increasedramatically. Comprehensiveapproach is an important task forprimary care physicians.
As outlined by the U.S. PreventiveServices Task Force, assessmentcategories unique to elderly patientsinclude sensory perception andinjury prevention.
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Interventional areas includeimmunizations, diet and exercise.
Mental health issues should also beevaluated Using an organized approach can
improve care provided for older
patients
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Falls Falls result in accidental death amongpersons 75 years of age and older andsignificant mortality and morbidity.
Multifactorial A fall is 'an event which results in a
person coming to rest inadvertently onthe ground and other than a consequenceof the following: loss of consciousness,sudden onset of paralysis as in a stroke,or epileptic seizures'.
As a result of impaired gait and balance,medical illnesses, and environmental
factors.
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Frequently, older persons are notaware of the risk factors and do not
report falling unless an injury hasoccurred.
Identifying and targeting the
population at greatest risk withmultifactorial interventions isessential to the prevention andreduction in the incidence of fallsand fall-related injuries in older
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Epidemiology In the United States, accidents are thesixth leading cause of death in personsover the age of 65 and falls account for
two-thirds of these deaths. The annual incidence of falls ranges from30 % in persons over the age of 65 to 50per cent in persons over 80 years of age.
Rates of fall-related deaths for olderpersons increase sharply with advancingage and are consistently higher amongmen than women.
Due to the higher prevalence of co-
morbid illness among men than women ofsimilar a e.
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Approximately 1 % of these fallsresult in hip fracture, 3 5 % in other
types of fractures, and an additional5 % result in severe soft tissueinjury, such as haemarthroses, jointdislocations, sprains, andhaematomas.
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Hospitalization rates for hip fractureincrease with advancing age for
both sexes but are consistentlyhigher for women in all agecategories.
This gender difference may berelated to the prevalence ofosteoporosis in older woman.
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Falls are also an important marker offrailty.
Of older persons who arehospitalized for a fall, only about onehalf are alive 1 year after.
This indicates the seriousness ofunderlying disease and the need toameliorate the symptoms of chronic
illness to prevent further risks of
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Case 1 An 81 yo female is brought to your office
by her daughter, the elderly mother hasbeen falling for at least 3 months. Thefalling has been getting progressivelyworse, and her daughter has beenconcerned regarding her mother breaking
her hips. On exam, the pt is a frail elderlyfemale in no distress, she appearssomewhat depressed. The pt BP 180/75,her pulse is 84 and regular, no other
abnormalities are found.
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Intrinsic Extrinsic1. Age
2. Cognitive impairment
3. Muscle weakness4. Foot problems (callouses, bunions, or anatomical
deformities)
5. Polypharmacy (sedatives, tranquillizers,antidepressants, antihypertensive, and diuretics)
6. Sensory impairment (macular degeneration,
cataracts, and glaucoma)7. Gait and balance impairment (Parkinson's dis.,
seizures, Lower extremity neuropathies,dementia, TIAs)
8. Acute disease (pneumonia, urinary tractinfections)
9. Chronic disease (cardiovascular dis., neurologicaldis., dementia, depression, visual problems,osteoporosis)
10. Depression
11. Postural hypotension
1. Environmental hazards
2. Inadequate lighting
3. Slippery surfaces
4. Loose rugs
5. Low toilet seat
6. Low chairs
7. High stairs
8. Ill fitting shoes
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Assessment assessment of basic neurologic functionincluding mental status, muscle strengthand tone, lower extremity peripheral
nerves, proprioception, deep tendonreflexes, and cerebellar function.
A cardiovascular examination shouldinclude heart rate, postural pulse and
blood pressure (lying and standing with a5-min interval between each reading).
Visual screening and an examination ofthe lower extremities, especially the feet,
for deformities, and ulcerations
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The 'get up and go test' of mobilityis a simple screening tests that can
be administered in the clinicalsetting.
The older person is asked to rise
from the chair, to stand momentarilywith eyes opened and closed, thennudged on the sternum, to walk 10ft, and to return and sit in the chair.
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It may be useful to obtain a completeblood count, thyroid function tests, anddrug levels if the history and physical
examination indicate a potential problemin these areas.
Electrocardiogram may be considered if acardiac arrhythmia is suspected.
Neuroimaging may be helpful for olderpersons with neurological deficits and gaitabnormalities.
Referral to specialists such as aneurologist, cardiologist, ophthalmologist,
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Management
The goal of management is to minimizethe risk of falling without compromisingmobility, functional activities, personal
independence, and an acceptable qualityof life.
Treatment is focused on eliminating ormodifying risk factors.
Initial treatment of acute or reversibledeficits such as urinary tract infections,pneumonia, congestive heart failure,metabolic disturbances, or medication
side-effects may result in major'
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Recommendations for a communitypopulation should include:
gait training review modification of medications.
Exercise programme, with balancetraining as one of the components,
treatment of postural hypotension,modification of environmentalhazards( adequate lighting, avoid slipperyfloors, loose rugs,..)
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Gait disorders Normal balancerequire integration ofposition sense, the
visual system,vestibular organs,motor strength, andmotor functioncoordination.
Decline in theirfunction leads togeneral motorslowing.
Age-related motor
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Presentation to primarycare
feeling unsteady, shuffling feet, posturalchanges, or falls.
VestibularA history of vertigo localizes to the
vestibular apparatus. The patient may have asensation of 'waves'. Often, these patients willhave transient dizzy feelings on rising from alying position or with turning the head quickly.
VisualGait changes associated with visual
dysfunction may be due to change in visualacuity such as cataracts and maculardegeneration, or visual field loss.
Occasionally, patients are unaware of a visualfield deficit until detected by the examiner.
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MotorStroke, myopathy, or peripheralneuropathy all cause muscle weaknessaffecting gait. The hemiparetic gait seenin stroke with foot drop.
Proximal lower extremity weakness seen
in myopathy results in inability to standfrom a seated position without pushing offwith the hands.
If there is weakness of the hip
musculature (especially the hipabductors), the gait will appear 'waddling'like a duck.
Foot drop is typically due to a root orperipheral nerve disorder. So the footdoes not catch on the ground, there is
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Sensory impairmentLoss of position sense alsoresults in gait difficulty, especially in the dark, asthe visual system is not able to compensate forimpaired proprioception.
The loss of vibration sense in the lower limbs ispart of normal ageing; position sense, however,remains intact in normal old age. Therefore,examination of position sense at the toes is a
critical part of the assessment in patients withgait difficulty. Mechanical involvementArthritis is common in
the elderly and contributes to gait difficulty byaffecting the axial skeleton lower limb
musculature.
a cu y s ue o one
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a cu y s ue o oneor a combination of the
following difficulty regaining balance after postural
displacement; focal or generalized change in posture;
major change in tone; inability to initiate movement; reduced speed of movement; presence ofinvoluntary movements which
interfere with gait; lack of proper coordination of movements; inability to stop intended movements; or impaired central mechanisms for gait
integration.
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History
The following leading questions shouldbe asked:
Are you having pain which prevents youfrom walking normally?
Are your legs so weak that they may giveout when you walk?
Do you have a feeling that objects aregoing around or moving when you walk?
Is the difficulty in walking present
regardless if you walk in the light or in thedark?
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Pain in the hip, knee, or foot which makeswalking difficult may be due to bursitis orarthritis.
Gait difficulty due to vestibular andcerebellar function abnormalities ispresent in the light as well as in the dark.
In the case of vestibular dysfunction,patients frequently experience dizzinesswhen turning in bed, sitting up quickly, oron sudden turning of the head to one side
or the other.
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Physical examination
Normal elderly people have a flexedposture and shorter length compared toyounger persons. Flexed posture greater
than expected by age is seen inParkinson's syndrome (PS).
Parkinsonian gaitis characterized by a
narrow base, reduced armswing (oftenasymmetric), and exaggerated flexion atthe waist and neck. The gait is 'shuffling'because of reduced stride length and
problems picking the feet off the ground.
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Cerebellar disorders has a wide base.
Cerebellar gait is unsteady.
Features supportive of a cerebellardisorder include limb ataxia, dysarthria,and nystagmus.
Romberg testingis performed by asking
the patient to stand with eyes closed andfeet together. A positive test requires thatthe patient break his/her stance; PositiveRomberg is a sign ofimpaired positionsense .
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Investigations
vestibular dysfunction needs anotologic assessment.
Imaging studies to rule outcerebellar masses or atrophy.
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Principles of managementin gait disorder
treat the underlying cause (s)supportive care for pt and caregivermaking the home environment safer
Home environments often have to bemodified stairs, light, rugs, slippery floor,high chair, low toilet seat.Referral to a specialist is appropriate if
the diagnosis is uncertain, if there is apoor response to medical therapy, or ifinvestigations are not available to theprimary care physician (i.e. imagingstudies).
In Western countries, referrals are often
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Urinary incontinence
Urinary incontinence, defined as theinvoluntary loss of urine, is a major
problem affecting many elderlypeople.
1530 % of elderly people living
independently suffer fromincontinence
14 % of women aged 65 years andolder are troubled daily by
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Case 2
An 88 yo female pt who you care for,residing with her daughter is having
increasing difficulties with bedwetting, she is embarrassed to talkabout this, but her daughter informsyou that this problem is gettingworse, at that time the pt had beencontinuously incontinent for 6 days.
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Possible causes
Bladder capacity, the ability to postponemicturition, and bladder contractility alldecrease.
Uninhibited detrusor contractionsincrease and there is a slight rise in theresidual volume.
In women, the maximum urethral closurepressure and the length of the urethradecrease.
In the majority of elderly men, theprostate becomes enlarged and the urine
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In most cases, involuntary urine lossis related to disturbances in the
continence mechanism of thebladder itself.
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Urge incontinence
Urge incontinence is the involuntaryloss of urine concomitant with a
sudden intense urge to urinate.Other common symptoms arefrequency and nocturia. Urgeincontinence is usually accompaniedby urodynamic findings ofdetrusorhyperactivity.
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Stress incontinence
Stress incontinence is theinvoluntary loss of urine duringcoughing, sneezing, laughing, orother physical activities that causean increase in intra-abdominalpressure.
The most common cause of stressincontinence is hypermobility of theurethra and bladder neck. This isthe result of a weak pelvic floor,
probably caused by childbirth and
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Overflow incontinence
It is involuntary urine loss accompaniedby overfilling of the bladder. The patientgenerally suffer from very frequent to
continuous loss of small volumes of urine(continuous leakage), 'bearing-down'while urinating, incomplete voiding andweak stream.
Overflow incontinence can be causedby two factors:
a hyperactive or non-active detrusor
bladder neck or urethral obstruction.
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A hyperactive or non-active detrusorcan be caused by:
medication, faecal impaction,diabetic neuropathy.
In men, obstruction is mostly caused
by prostate hypertrophy, lesscommonly by prostate cancer,orfaecal impaction.
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Functional incontinence
When involuntary urine loss is caused byfactors outside the lower urinary tract,such as limitations in physical or cognitive
functioning, this is referred to asfunctional incontinence.
Hip arthrosis, muscle weakness, hand
problems, and tremors can hinder theelderly person's self-care: climbing out ofbed unaided, going to the toilet, undoingclothes, and sitting down to urinate,
communication and cognitive
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History:
The characteristic clinical symptomof stress incontinence is the loss ofsmall volumes of urine duringactivities that increase the intra-abdominal pressure, such assneezing, coughing, jumping,
laughing, lifting, and sport. Thepatient does not feel the urge tourinate before leakage occurs. Assoon as the increased pressure
ceases, the urine loss also ceases.
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the patients feel an urgent need tourinate that they can no longer
reach the toilet in time.Once micturition has started, it isvery difficult to stop the flow, often
accompanied by frequency andnocturia.
When pain is present, it is anindication of infection.
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Reversible and other contributingfactors in incontinence
Possible reversible factors:Conditions: delirium, faecal impaction, depression, symptomaticUTI.Environment: impaired locomotion, lack of access to toilet,restrictive clothing.
Excessive intake of caffeinated beverages or other bladderirritants.Diagnoses: diabetes, CHF, CVA, Parkinson's disease, and otherneurological diseases affecting motor skillsMedication: diuretics, antiparkinsonian, antispasmodics,antihistamines, and other anticholinergicsDrugs that stimulate or block sympathetic nervous system:calcium-channel blockers, narcoticsPsychoactive medication: antianxiety agents, antidepressants.Other contributing factors:Conditions: pain, excessive orinadequate urine output, atrophic vaginitis, cancer of the bladderor prostate, urethral obstruction, disorders of the brain or spinalcord.
Abnormal laboratory values: elevated blood glucose or calcium
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In women, vaginal palpation and speculumexamination , signs of atrophic vaginitis, uterineprolapse or cystocoele/rectocoele, tumours,fistulae, vaginal discharge, and signs of
infection.Rectal palpation: tone of the sphincter.
If the patient is able to contract the sphincter,then this is strong evidence against disrupted
innervation of the bladder neck and bladder.Attention should be paid to faecal impaction inthe rectum.
In men, the surface and consistency of theprostate should be examined.
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Tests
urine test & culture
Ultrasound of bladder to exclude
urine retention.If obstruction or retention issuspected, kidney function tests
should be performed and in ofpolyuria and/or nocturia, glucoseand electrolytes should bemonitored.
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Management:
Stress incontinence:
pelvic muscles exercises, Alpha
adrenergic agonists, Behavioraltraining, Supplemental estrogen
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Urge incontinence
Bladder relaxants & training,Estrogen supplements, Behavioral
therapy, Surgical removal ofobstruction
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Overflow incontinence
Surgical removal of obstruction,Intermittent catheterization,
Indwelling catheterization) increasedrisk of urinary tract infection, therisk of injury and stricture of theurinary tract).
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Functional incontinence
Behavioral therapy (prompt voiding,habit training, environmental
manipulation, scheduled toileting,incontinence pads).
External collection devices,indwelling catheters.
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Case 3 daughter is caring for her elderly mother at home. Mom has a
variety of medical issues and is taking a number ofmedications. The doctor prescribes for mom's anxiety. Overa period of months the mother becomes sleepy all the time
and can't seem to concentrate. She will even fall asleep whilesomeone is talking to her. The doctor and family initiallyattribute it to her age. Finally the daughter decides there must
be something wrong and she insists the doctor look into it.Tests are conducted and low blood level of sodium isconfirmed. After some research the doctor suspects the
prescription might be causing sodium depletion. He removesthe mother from the medicine and she becomes normal again.
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Medications and the Elderly
Facts about Medications and theElderly
Older Americans comprise about13% of the population but they
consume over 30% of allprescription drugs. It is estimated that 30% of the
older population takingmedications have had an adversedrug reaction.
Up to 20% of hospitaladmissions for the elderly aredue to adverse drug reactions.
It is estimated that over half ofthe deaths attributed to adverse
drug reaction are for people age60 and above.
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Old age is associated with areduction in glomerular filtration
rate, a decrease in renal plasma flowand decreased tubular reabsorptivecapacity. The net effect of this is adecrease in renal clearance of drugs
that are hydrophilic in nature, forexample digoxin. Such drugs shouldeither be avoided or given at lower
dosages.
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Possible reasons for increased
prescribing in the elderly
Evidence showing benefits of drug use inthe elderly, e.g. the use of warfarin inpatients with atrial fibrillation
Increase in the numbers of elderly andvery elderly patients, with a consequentincrease in morbidity
Increase in screening and detection ofasymptomatic conditions, e.g.hypertension Increased patientexpectations
The practice of defensive medicine
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A survey of 805 people was particularly
informative regarding the use of drugs in theelderly in the United Kingdom
Most of the drugs being taken by
the elderly are prescribed on along-term basis, with 59 per centhaving been prescribed for morethan 2 years;
Eighty-eight per cent of all drugsprescribed were by repeatprescription; and
forty per cent had not discussed
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The inter-relationship between polypharmacy
and poor compliance, resulting in a vicious cycle
that leads to a prescribing cascade
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A75-year-old woman was diagnosed as having hypertension. She
was started on capozide by her doctor. Two weeks later, aroutine blood test showed her to have a potassium level of 2.9mmol/l. She was prescribed potassium replacement therapy inform of slow release potassium tablets to be taken together withcapozide. At the next visit 2 weeks later, her potassium levelhad come up to 3.4 mmol/l, and she was continued on slow
potassium. She presented 2 months later with a history of severeheartburn; a gastroscopy showed her to have an oesophagealulcer. This was blamed on slow potassium, which was stopped.The patient was started on omeprazole. Unfortunately, after afew days treatment she developed diarrhoea. The doctorcontinued the omeprazole in order to relieve the oesophageal
ulcer, and prescribed codeine phosphate for the diarrhoea. Aftertwo doses of codeine phosphate, the patient developeddizziness, had a fall, and was admitted to a hospital with afractured left hip.
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Reasons for inappropriate prescribing
in the elderly Incremental prescribing, with side-
effects being treated with otherdrugs, rather than discontinuation of
the original drug Therapeutic enthusiasm, with use of
drugs as first line treatment withoutconsidering the use of non-drug
therapies Failure to adequately assess
patients' needs and individualizetreatment
Unrealistic expectations on the part
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A strategy to improveprescribing in the elderly
Careful clinical assessment of the patientand an evaluation of the riskbenefitratio of starting drug therapy.
Start at low doses, and increase dosegradually. Remember that the elderlyoften require lower doses.
Use one drug if possible, and avoidpolypharmacy.
Keep the drug prescribing regime simple.
Give clear, and if possible, writteninstructions on how to take the
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Undertake a regular review ofmedications, and stop medicineswhen necessary.
Review and improve repeatprescribing system, if necessary. Letpatients know what to do when their
medicines run out, and how todispose of medicines that are nolonger necessary.
Consider drug (s) as the cause ofnew s m toms and si ns arisin in
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Ensure communication betweenhospital and primary care is up-to-
date. In the future, this may befacilitated by the use of individualsmart cards or electronic patientrecords.
Multidisciplinary team working withpharmacists and nurses will help inmany of the objectives outlined
above.
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Giving in to pressure from relatives,patients and other health care
professionals to prescribe Inadequate review of medicines,
leading to continuation of drugs thatare no longer necessary
Governmental pressure to meettargets
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Use sources of information such asformularies in order to appropriately
prescribe in patients with renal andliver impairment, and to avoid theuse of interacting drugs.
Remember that in the elderly, anormal serum creatinine does notindicate normal renal function.
Five key dimensions of the
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yageist bias in which healthcare
fails older persons
Healthcare professionals do not receive enoughtraining in geriatrics to properly care for many older
patients.
Older patients are less likely than younger people toreceive preventive care.
Older patients are less likely to be tested or screenedfor diseases and other health problems.
Proven medical interventions for older patients areoften ignored, leading to inappropriate or incompletetreatment.
Older people are consistently excluded from clinical
trials, even though they are the largest users of
R d ti f
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Recommendations forcaregivers
Make sure an elderly one has challengingactivities throughout the day instead of simplywatching TV (challenging home orientedactivities).
Give them responsibility for taking care ofplants . This strategy is used often in nursinghomes to reduce depression in the elderly and toactually improve their health as well.
Provide opportunities for family and friends to
come by and visit and encourage or evenarrange such encounters. Provide opportunities for the older person to
interact, teach and nurture children such asgrandchildren. This is an extremely effectivestrategy for helping the older person feel that heor she has a meaningful existence. And it has a
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Design or arrange an exercise program andcome up with a way to encourage the olderperson to follow it.
Understand the nutrition needs of an older one,
especially the need for vitamins and mineralsincluding iron.. Make sure the person takes careof him or herself and eats properly. Many elderlypeople neglect their own nutrition. Poor nutritioncan cause all kinds of mental and physicalproblems in the elderly.
Make sure an older person has opportunity tolook good . Make sure the person gets out inpublic, and going to a public event and can feelgood about his or her appearance.
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