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Geriatrics NFMBR 2011


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This is the updated slideshow for the 2011 NFMBR presentation of Geriatrics. We apologize sincerely for the error in the manual, you can both view the slideshow online or download it to your computer and view with PowerPoint.

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Geriatrics NFMBR 2011

  1. 1. Geriatrics Geriatrics
  2. 2. Demographic Trends <ul><li>“ Baby boomers” (1946-1964) are dramatically changing the aging statistics; In 2000, 35 million persons 65+ lived in the U.S.; by 2030, this will double to 70 million </li></ul><ul><li>The 85+ age group is growing faster than any other age group </li></ul><ul><li>Women make up 58% of those 65+, but 70% of those 85+ </li></ul><ul><li>About 5% of the 65+ population reside in a NH at any one time; ¾ are women </li></ul><ul><li>Older persons living in poverty are declining </li></ul>Geriatrics
  3. 3. <ul><li>% reporting difficulty with IADLs (Instrumental Activities of Daily Living) and ADLs (Activities of Daily Living) – 5.6% </li></ul><ul><ul><li>1 to 2 ADL difficulties - 20% </li></ul></ul><ul><ul><li>3 to 6 ADL difficulties - 12% </li></ul></ul><ul><ul><li>IADL difficulties only - 14% </li></ul></ul><ul><li>Prevalent conditions (in rank order highest to lowest) </li></ul><ul><ul><li>Arthritis </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Hearing impairment </li></ul></ul><ul><ul><li>Cataracts </li></ul></ul><ul><ul><li>Orthopedic impairment </li></ul></ul>Demographic Trends (Cont’d) Geriatrics
  4. 4. <ul><li>Life expectancy at birth </li></ul><ul><ul><li>Males - 69 years </li></ul></ul><ul><ul><li>Females - 77 years </li></ul></ul><ul><li>Life expectancy at age 85 </li></ul><ul><ul><li>Males - 5.5 years </li></ul></ul><ul><ul><li>Females - 7 years </li></ul></ul><ul><li>The age 65+ and especially 75+ is a rapidly increasing percentage of the total population </li></ul>Demographic Trends (Cont’d) Geriatrics Year Age 65 + Age 75 + 1960 9.2 % 3.1 % 2020 (est.) 15.5 % 5.9 %
  5. 5. Characteristics of Aging <ul><li>Atypical presentation of acute illness </li></ul><ul><li>Multiple concurrent problems </li></ul><ul><li>Non-specific symptoms </li></ul><ul><li>Hidden illnesses </li></ul><ul><li>Under-reporting of symptoms or concerns </li></ul><ul><li>Multiple “losses” in a short time span </li></ul><ul><li>Expected physiologic aging changes </li></ul>Geriatrics
  6. 6. Atypical Presentation of Acute Illness <ul><li>Only 40% of elderly fit the classic one symptom=one disease model e.g. </li></ul><ul><ul><li>Acute myocardial infarction without chest pain </li></ul></ul><ul><ul><li>Hyperthyroidism without tachycardia, weight loss, etc. </li></ul></ul><ul><ul><li>Infection without rising WBC count or fever </li></ul></ul><ul><ul><li>Fatigue as presenting complaint of CHF </li></ul></ul>Geriatrics
  7. 7. Non-Specific Symptoms <ul><li>Confusion </li></ul><ul><li>Falling </li></ul><ul><li>Incontinence </li></ul><ul><li>Apathy </li></ul><ul><li>Anorexia/weight loss </li></ul><ul><li>Vague dyspnea </li></ul><ul><li>Fatigue </li></ul><ul><li>“ Taking to bed” </li></ul>Geriatrics
  8. 8. Hidden Illnesses: You Must Ask, They Won’t Tell! <ul><li>Sexual dysfunction </li></ul><ul><li>Depression </li></ul><ul><li>Urinary Incontinence </li></ul><ul><li>Musculoskeletal stiffness </li></ul><ul><li>Alcoholism </li></ul><ul><li>Hearing loss </li></ul><ul><li>Memory loss </li></ul>Geriatrics
  9. 9. Under-Reporting Due To: <ul><li>Belief that symptoms are due to old age </li></ul><ul><li>Fear or denial </li></ul><ul><li>Concern about cost </li></ul><ul><li>Embarrassment </li></ul><ul><li>Mental impairment </li></ul><ul><li>Concern about ill spouse </li></ul><ul><li>Bad experience with health care system </li></ul><ul><li>Fear of institutionalization </li></ul>Geriatrics
  10. 10. Multiple Concurrent Losses <ul><li>Loss of physical health </li></ul><ul><li>Loss of social contacts: friends/family die </li></ul><ul><li>Loss of familiar roles: parent, spouse, employed person </li></ul><ul><li>Loss of financial security: retirement, spouse’s death </li></ul><ul><li>Loss of independence and power </li></ul><ul><li>Loss of mental stability </li></ul>Geriatrics
  11. 11. Normal Aging vs. Disease <ul><li>Aging is NOT a disease </li></ul><ul><li>Separate pathologic processes from the “aging process” </li></ul><ul><li>Concentrate on how physical problems interfere with the ability of the person to remain independent (function in their usual environment) </li></ul>Geriatrics
  12. 12. Normal Aging vs. Disease (Cont’d) <ul><li>Normal aging </li></ul><ul><ul><li>Crow’s feet” </li></ul></ul><ul><ul><li>Presbycusis </li></ul></ul><ul><ul><li>Seborrheic keratoses; loss of skin elasticity </li></ul></ul><ul><ul><li>Benign forgetfulness </li></ul></ul><ul><ul><li>Decreased blood vessel compliance </li></ul></ul><ul><ul><li>Increase in % body fat </li></ul></ul><ul><li>Disease </li></ul><ul><ul><li>Macular degeneration </li></ul></ul><ul><ul><li>Tympano-sclerosis </li></ul></ul><ul><ul><li>Basal cell CA </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Atherosclerosis </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Obesity </li></ul></ul>Geriatrics
  13. 13. Laboratory Values that Do Not Change with Aging <ul><li>Hepatic function (ALT, AST, GGPT, bilirubin) </li></ul><ul><li>Coagulation tests </li></ul><ul><li>Chemistries: electrolytes, total protein, calcium, phosphorus </li></ul><ul><li>ABGs: pH, PaCO2 </li></ul><ul><li>Hemoglobin, RBC indices, platelet count </li></ul>Geriatrics
  14. 14. <ul><li>Decreases: Serum albumin, magnesium, PaO2, T3, T4, creatinine clearance, white blood cell count </li></ul><ul><li>Increases: Alkaline phosphatase, uric acid, blood sugar, TSH, BUN/creatinine </li></ul>Laboratory Values that Do Change with Aging Geriatrics
  15. 15. <ul><li>Comorbidities, functional status and life expectancy will form the framework for individualized decision-making in offering screening tests and other preventive therapies </li></ul><ul><li>Life expectancy markedly varies depending on functional status and comorbidities—examples: </li></ul><ul><li>Many recommendations assume “average health” in terms of functional status and comorbidities. 10 year life expectancy—age 75; 5 year life expectancy—age 85 </li></ul>Geriatric Health Maintenance Geriatrics Good functional status and no major comorbitities (women/men) Significant functional impairment and comorbidities (women/men) 70 21/18 yrs 10/7 yrs 75 17/14 yrs 7/5 yrs 80 13/11 yrs 5/3 yrs 85 10/8 yrs 3/2 yrs 90 7/6 yrs 2/1 yrs 95 5/4 yrs 1/1 yrs
  16. 16. Primary Prevention (Avert Disease Development) <ul><li>Maintain Physical Activity </li></ul><ul><li>Eliminate Tobacco Use </li></ul><ul><ul><li>Cessation at 65 years leads to increased life expectancy of 1.5-4 yrs </li></ul></ul><ul><li>Alcohol Use in moderation ( < 1/day women; < 2/day men) </li></ul><ul><ul><li>15% of adults over 65 experience alcohol health problems </li></ul></ul>Geriatrics
  17. 17. Primary Prevention (Avert Disease Development) <ul><li>Aspirin for Primary Prevention </li></ul><ul><ul><li>USPSTF “strongly recommends” that clinician discuss when 5 yr risk of CVD ≥ 3% </li></ul></ul><ul><ul><li>Risk of GI bleeding well documented with low-dose aspirin </li></ul></ul><ul><ul><li>Risk factors for GI bleeding </li></ul></ul><ul><ul><ul><li>Age > 75 </li></ul></ul></ul><ul><ul><ul><li>Warfarin use </li></ul></ul></ul><ul><ul><ul><li>History of Peptic Ulcer Disease or GI bleeding </li></ul></ul></ul><ul><ul><ul><li>Chronic steroid use </li></ul></ul></ul>Geriatrics
  18. 18. Primary Prevention (Avert Disease Development) (Cont’d) <ul><li>Tetanus Vaccine – 2 options </li></ul><ul><ul><li>Every 10 years (give TdaP for one booster then give Td) </li></ul></ul><ul><ul><li>Single booster after age 50 in those who completed primary series </li></ul></ul><ul><li>Influenzae Vaccine </li></ul><ul><ul><li>Annually </li></ul></ul><ul><li>Pneumococcal Vaccine </li></ul><ul><ul><li>Once at age 65 – never repeated </li></ul></ul><ul><ul><li>If received 1 st dose before age 65 give one booster after age 65 when it has been > 5 years since 1 st dose </li></ul></ul><ul><li>Herpes Zoster Vaccine </li></ul><ul><ul><li>All immunocompetent adults > 60 years </li></ul></ul><ul><ul><li>Approved for age 50 – 60 years old </li></ul></ul>Geriatrics
  19. 19. Secondary Prevention (Early Detection and Treatment of Disease) <ul><li>Cancer Screening </li></ul><ul><ul><li>Assess the benefits and risks on a individual basis </li></ul></ul><ul><ul><ul><li>Will the patient survive long enough to benefit? </li></ul></ul></ul><ul><ul><ul><li>What are the potential harms of screening? </li></ul></ul></ul><ul><ul><li>Colon Cancer </li></ul></ul><ul><ul><ul><li>Offer to those with > 5 yr life expectancy </li></ul></ul></ul><ul><ul><li>Breast Cancer </li></ul></ul><ul><ul><ul><li>Mammograms – perform every 1-2 yr for those with >4 yr life expectancy </li></ul></ul></ul><ul><ul><li>Prostate Cancer </li></ul></ul><ul><ul><ul><li>Evidence insufficient for screening </li></ul></ul></ul><ul><ul><ul><li>No screening after 75 years old </li></ul></ul></ul><ul><ul><li>Cervical Cancer </li></ul></ul><ul><ul><ul><li>Routine screening when > 65 and 3 Pap smears previously normal not recommended </li></ul></ul></ul>Geriatrics
  20. 20. Secondary Prevention (Early Detection & Treatment of Disease) (Cont’d) <ul><li>Blood Pressure measurement </li></ul><ul><ul><li>Annually </li></ul></ul><ul><li>Lipid Screening </li></ul><ul><ul><li>Continue to screen based on risk of CAD, age, comorbidities and functional status </li></ul></ul><ul><li>Osteoporosis </li></ul><ul><ul><li>DEXA (see Endocrine section) </li></ul></ul><ul><li>Abdominal Aortic Aneurysm </li></ul><ul><ul><li>One time screen for men between age 65 - 75 who ever smoked </li></ul></ul>Geriatrics
  21. 21. Iatrogenesis: A Definition <ul><li>Any illness that results from a diagnostic/therapeutic intervention or the omission of such intervention that is not a natural consequence of the patient’s disease </li></ul><ul><li>20-36% of older patients have their hospitalization prolonged by major adverse events </li></ul>Geriatrics
  22. 22. The Hospital is a Hazardous Place Because Of: <ul><li>Medication side effects </li></ul><ul><li>Bed rest and immobility </li></ul><ul><li>Therapeutic & diagnostic procedures </li></ul><ul><li>Nosocomial infections </li></ul><ul><li>Under-nutrition </li></ul>Geriatrics
  23. 23. Keys to Prevention: Checklist to Monitor the Hospitalized <ul><li>Confirm Diagnosis </li></ul><ul><li>Verify need for all medications </li></ul><ul><li>Monitor Nutritional intake </li></ul><ul><li>Be informed about incontinence </li></ul><ul><li>Monitor Cognition </li></ul><ul><li>Assess Emotional status </li></ul><ul><li>Encourage Mobility </li></ul><ul><li>Assess the Caregiver stress level </li></ul>Geriatrics
  24. 24. Preventing the Cascade <ul><li>Keep medical & surgical diagnosis lists current </li></ul><ul><li>Prioritize medical therapies, addressing reversible problems first </li></ul><ul><li>Clarify the medical goals of the hospitalization </li></ul><ul><li>Carefully select diagnostics: “Is this procedure necessary and how will it change my management?” </li></ul>Geriatrics
  25. 25. <ul><li>Review Medication Administration Record daily </li></ul><ul><li>Avoid NPO periods ASAP, ask about food acceptance daily </li></ul><ul><li>Monitor bowel and bladder function daily </li></ul><ul><li>Anticipate/prevent delirium </li></ul><ul><li>Address anxiety, pain and insomnia issues aggressively </li></ul><ul><li>Inspect all skin surfaces daily if immobile in bed </li></ul>Specific Strategies Geriatrics
  26. 26. Specific Strategies (Cont’d) <ul><li>Avoid restraints; expect self-sufficiency, PT assistance with ambulation and ROM activities if in bed </li></ul><ul><li>Update family frequently; make calls to them proactively </li></ul><ul><li>Identify patients early who will need a Skilled Nursing Facility (SNF) </li></ul><ul><li>Anticipate post-hospital needs such as medical equipment, oxygen and home care services </li></ul>Geriatrics
  27. 27. Appropriate Prescribing in the Elderly <ul><li>First Take a Complete Drug History </li></ul><ul><li>Prescriptions (yours and other prescribers) </li></ul><ul><li>Over-the-counter medicaitons </li></ul><ul><li>“ Nutriceuticals” </li></ul><ul><li>Assess tobacco and alcohol intake </li></ul>Geriatrics
  28. 28. Choosing an Appropriate Drug <ul><li>Has established efficacy </li></ul><ul><li>Has acceptable safety/side effect profile </li></ul><ul><li>Half life < 24 hr with no active metabolites </li></ul><ul><li>Elimination that doesn’t change with age </li></ul><ul><li>Convenient dosing, 1-2 x per day </li></ul><ul><li>Affordable (improves compliance) </li></ul>Geriatrics
  29. 29. Age-Associated Changes <ul><li>Absorption: Rate/extent usually unaffected - little clinical significance </li></ul><ul><li>Distribution: Increased fat:water ratio with aging; decreased plasma protein, especially albumin  Fat soluble drugs more widely distributed; protein bound drugs have a greater active concentration </li></ul>Geriatrics
  30. 30. Age-Associated Changes (Cont’d) <ul><li>Metabolism: Decrease in liver mass and blood flow may decrease metabolism  lower doses may be therapeutic </li></ul><ul><li>Elimination: Mostly renal; decreased GFR with aging; function best estimated with the formula: [Cockcroft & Gault] </li></ul><ul><li>Cr Cl = IBW (140-age) (0.85 if female) </li></ul><ul><li>72 x Creatinine </li></ul>Geriatrics
  31. 31. Drug Interactions <ul><li>Drug-Food: Warfarin--Vitamin K containing foods </li></ul><ul><li>Drug-Drug </li></ul><ul><ul><li>Warfarin—NSAID </li></ul></ul><ul><li>Drug-Disease </li></ul><ul><ul><li>Asthma--  -blockers </li></ul></ul><ul><ul><li>BPH--Anticholinergics </li></ul></ul>Geriatrics
  32. 32. Conclusions <ul><li>Justify each drug with a firm diagnosis </li></ul><ul><li>Use one drug to treat 2 or more diseases (  -blocker for BPH + HTN) </li></ul><ul><li>Review medications every three months and especially after acute hospitalization </li></ul><ul><li>Know action, adverse effects and interactions of each drug </li></ul><ul><li>Initiate therapy at lowest recommended dose and titrate up (“start low, go slow”) </li></ul><ul><li>Educate patients with written instructions </li></ul>Geriatrics
  33. 33. Clinical Approach To Older Patients <ul><li>Discover patient “reliability” ASAP - verify with competent family/observers </li></ul><ul><li>“ Chief Complaint” often frustrating; instead ask: “What interferes most with your day-to-day activity?” </li></ul><ul><li>Establish problem list from patient, family & old medical records </li></ul><ul><li>Family history unhelpful except for dementia and depression </li></ul>Geriatrics
  34. 34. Functional Assessment <ul><li>PULSE mnemonic </li></ul><ul><ul><li>P (physical condition) </li></ul></ul><ul><ul><li>U (upper limb function) </li></ul></ul><ul><ul><li>L (lower limb function) </li></ul></ul><ul><ul><li>S (sensory) </li></ul></ul><ul><ul><li>E (environment) </li></ul></ul>Geriatrics
  35. 35. Review of “Function” <ul><li>Appetite/weight change </li></ul><ul><li>Fatigue </li></ul><ul><li>Hearing/visual changes </li></ul><ul><li>Bowel patterns </li></ul><ul><li>Memory loss </li></ul><ul><li>Depression </li></ul><ul><li>Sleep patterns </li></ul><ul><li>Falls/gait problems </li></ul><ul><li>Joint pain/stiffness </li></ul><ul><li>Urinary patterns </li></ul><ul><li>Cardiac symptoms </li></ul><ul><li>Transient weakness/headache </li></ul><ul><li>Pain </li></ul>Geriatrics
  36. 36. Areas of Assessment <ul><li>Functional assessment </li></ul><ul><li>Mobility, gait and balance </li></ul><ul><li>Sensory and language impairments </li></ul><ul><li>Continence difficulties </li></ul><ul><li>Nutrition </li></ul><ul><li>Cognitive/behavior problems </li></ul><ul><li>Caregivers stress </li></ul><ul><li>Pain </li></ul>Geriatrics
  37. 37. Functional Assessment <ul><li>Activities of Daily Living (ADLs) </li></ul><ul><ul><li>Feeding </li></ul></ul><ul><ul><li>Dressing </li></ul></ul><ul><ul><li>Ambulating </li></ul></ul><ul><ul><li>Toileting </li></ul></ul><ul><ul><li>Bathing </li></ul></ul><ul><ul><li>Transferring </li></ul></ul><ul><ul><li>Continence </li></ul></ul><ul><ul><li>Grooming </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><li>Instrumental ADL (IADLs) </li></ul><ul><ul><li>Cooking </li></ul></ul><ul><ul><li>Cleaning </li></ul></ul><ul><ul><li>Shopping </li></ul></ul><ul><ul><li>Meal preparation </li></ul></ul><ul><ul><li>Telephone use </li></ul></ul><ul><ul><li>Laundry </li></ul></ul><ul><ul><li>Managing money </li></ul></ul><ul><ul><li>Managing meds </li></ul></ul><ul><ul><li>Ability to travel </li></ul></ul>Geriatrics
  38. 38. Mobility, Gait and Balance <ul><li>Get up and go test: </li></ul><ul><ul><li>Rise from a sitting position with arms crossed </li></ul></ul><ul><ul><li>Walk in a straight line for 15-20 feet, turn, return to chair </li></ul></ul><ul><ul><li>Sit down again </li></ul></ul><ul><li>Maintain standing balance when receiving a slight sternal nudge </li></ul><ul><li>Bend down and reach as if to pick up an object </li></ul><ul><li>Assess shoulder/hand function </li></ul><ul><li>Assess feet for structural problems, neuropathy, proper foot wear </li></ul>Geriatrics
  39. 39. Sensory Impairments <ul><li>Visual testing </li></ul><ul><ul><li>Read a sentence from the newspaper </li></ul></ul><ul><ul><li>Pocket Snellen chart </li></ul></ul><ul><ul><li>Diabetics need annual dilated eye exam by qualified eye professional </li></ul></ul><ul><li>Auditory Testing </li></ul><ul><ul><li>Assess hearing during history-taking </li></ul></ul><ul><ul><li>Whisper words behind the back </li></ul></ul><ul><ul><li>Finger Friction: rub your thumb and index finger in front of ear </li></ul></ul><ul><ul><li>Formal audiometric evaluation </li></ul></ul>Geriatrics
  40. 40. Incontinence <ul><li>A hidden disease; you must ask </li></ul><ul><li>Simple screening questions </li></ul><ul><li>Office evaluation often adequate to make a major difference </li></ul>Geriatrics
  41. 41. Nutrition <ul><li>Assess any patient admitted to the hospital or nursing home </li></ul><ul><li>Assess for weight change, anorexia, chewing or swallowing problems </li></ul><ul><li>Questions about alcohol a MUST (use CAGE) </li></ul><ul><li>Establish and record serial weights (minimum yearly) and heights (minimum Q3Y) </li></ul>Geriatrics
  42. 42. <ul><li>No uniform definition </li></ul><ul><ul><li>For Community-dwelling consider if: </li></ul></ul><ul><ul><ul><li>Involuntary weight loss >10 lb/6 months, >4%/1 yr </li></ul></ul></ul><ul><ul><ul><li>Hypoalbuminemia </li></ul></ul></ul><ul><ul><ul><li>Hypocholesterolemia </li></ul></ul></ul><ul><ul><li>For Hospitalized consider if: </li></ul></ul><ul><ul><ul><li>Dietary intake <50% estimated needs </li></ul></ul></ul><ul><ul><li>For Nursing home residents consider if: </li></ul></ul><ul><ul><ul><li>Involuntary weight loss > 5%/30 days </li></ul></ul></ul><ul><ul><ul><li>> 10%/6 months </li></ul></ul></ul><ul><ul><ul><li>Dietary intake <75% at most meals </li></ul></ul></ul>Malnutrition Criteria Geriatrics
  43. 43. <ul><li>Evaluation </li></ul><ul><ul><li>Economic barriers or lack of available food </li></ul></ul><ul><ul><li>Assess for dental problems </li></ul></ul><ul><ul><li>Consider medical illness that: </li></ul></ul><ul><ul><ul><li>Interfere with digestion or absorption </li></ul></ul></ul><ul><ul><ul><li>Increase caloric requirements </li></ul></ul></ul><ul><ul><ul><li>Require dietary restriction </li></ul></ul></ul><ul><ul><li>Assess current & past appetite </li></ul></ul><ul><ul><li>Depression screening </li></ul></ul><ul><ul><li>2-3 day diet journal may be most helpful screening tool </li></ul></ul>Nutrition Assessment ( Cont’d) Geriatrics
  44. 44. <ul><li>Biochemical markers </li></ul><ul><ul><li>All serum proteins may drop precipitously because of trauma, sepsis, infection, surgery or critical illness </li></ul></ul><ul><ul><li>Poor prognostic value with low albumin and low cholesterol </li></ul></ul><ul><ul><li>Prealbumin with half-life of 48 hours may be more valuable in monitoring nutritional status in recovery than albumin (half-life of 18-20 days) or transferrin (half-life of 7 days) </li></ul></ul>Nutrition Assessment ( Cont’d) Geriatrics
  45. 45. Cognitive Problems <ul><li>Goals of cognitive screening </li></ul><ul><ul><li>Detect unsuspected mental impairment </li></ul></ul><ul><ul><li>Provide baseline for future encounters </li></ul></ul><ul><ul><li>Discover those at risk for delirium </li></ul></ul><ul><ul><li>Provide concrete data for competency/decision-making opinions </li></ul></ul>Geriatrics
  46. 46. <ul><li>Commonly missed </li></ul><ul><li>Somatic complaints often predominate </li></ul><ul><li>Many, many drugs should be suspected </li></ul><ul><li>Suicide in elderly white males is high </li></ul><ul><li>Target your search: recent bereavement, psychosocial losses, dementia, functional impairment, severe illness or surgery </li></ul><ul><li>Yesavage Geriatric Depression Scale </li></ul><ul><ul><li>3 minutes </li></ul></ul><ul><ul><li>15 questions </li></ul></ul><ul><ul><li>See Appendix A </li></ul></ul>Depression Geriatrics
  47. 47. Caregiver Assessment <ul><li>Lack of a willing or capable caregiver is a prominent reason for ECF placement </li></ul><ul><li>Is the caregiver acceptable to the elder? </li></ul><ul><li>Is the caregiver evidencing ‘burn-out’? </li></ul><ul><li>Is there evidence of elder abuse or neglect? </li></ul><ul><li>Zarit Burden Interview is a short instrument that can introduce the topic of caregiver stress in a non-threatening way </li></ul>Geriatrics
  48. 48. Geriatric Persistent Pain <ul><li>American Geriatric Society – 2009 </li></ul><ul><ul><li>Persistent pain is common and if ignored or incorrectly treated may cause falls, functional impairment, disruptions in sleep, depression, anxiety, and increased healthcare costs </li></ul></ul><ul><ul><li>For most seniors, acetaminophen (Tylenol) should be considered as initial and ongoing therapy </li></ul></ul><ul><ul><li>Opioids may be safer than long-term NSAID secondary to NSAID cardiovascular and gastrointestinal toxicity </li></ul></ul>Geriatrics
  49. 49. Geriatric Persistent Pain (Cont’d) <ul><li>Guideline Summary </li></ul><ul><ul><li>NSAID and COX-2 selective inhibitors may be considered “rarely and with extreme caution” </li></ul></ul><ul><ul><li>Proton pump inhibitor or misoprostol for GI protection should be used in those taking nonselective NSAID; also those taking COX-2 and aspirin </li></ul></ul><ul><ul><li>Those using NSAID/COX-2 should be routinely assessed for GI and kidney toxicity, hypertension, heart failure, drug-drug, and drug-disease interactions </li></ul></ul><ul><ul><li>Patients with moderate to severe pain, pain related functional impairment or diminished quality of life consider opioid therapy </li></ul></ul><ul><ul><li>Tertiary tricyclic antidepressants (Amitriptyline, Impramine, Doxepin) should be avoided because of anticholinergic effects and cognitive impairment </li></ul></ul>Geriatrics
  50. 50. The Care Plan <ul><li>List all problems (physical, social, functional) </li></ul><ul><li>Treat acute medical problems with appropriate aggressiveness </li></ul><ul><li>Manage chronic problems—control, not cure </li></ul><ul><li>Address routine health maintenance </li></ul><ul><li>Do the medications relate 1:1 to an active problem? </li></ul><ul><li>What functional problems are most amenable to intervention? </li></ul>Geriatrics
  51. 51. <ul><li>Is there evidence of chronic uncontrolled pain? </li></ul><ul><li>Is there evidence of dementia or depression? </li></ul><ul><li>Is the living situation appropriate? </li></ul><ul><li>Is there evidence of a willing, capable, appropriate and acceptable caregiver? </li></ul><ul><li>Would any community resources benefit the situation? </li></ul>The Care Plan (Cont’d) Geriatrics
  52. 52. Elder Abuse <ul><li>An act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Includes: </li></ul><ul><ul><li>Physical abuse </li></ul></ul><ul><ul><li>Sexual abuse </li></ul></ul><ul><ul><li>Psychological abuse </li></ul></ul><ul><ul><li>Material abuse: misappropriation of funds or possessions </li></ul></ul><ul><ul><li>Neglect, whether intentional or not </li></ul></ul>Geriatrics
  53. 53. Risk Factors for Abuse <ul><li>Female, living alone, over age 75 </li></ul><ul><li>Poor health/functional status </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Caregiver suffers substance abuse/mental illness </li></ul><ul><li>Dependence of abuser on victim (such as shared living arrangements) </li></ul><ul><li>Elder’s needs exceed caregiver’s abilities </li></ul><ul><li>Social isolation </li></ul><ul><li>History of family violence/antisocial behavior </li></ul>Geriatrics
  54. 54. Presentations of Possible Abuse <ul><li>Delay between time of injury/illness and seeking care </li></ul><ul><li>Numerous injuries at various stages </li></ul><ul><li>Disparity in history between patient and caregiver </li></ul><ul><li>Implausible or vague explanations of injuries </li></ul><ul><li>Frequent ER visits, despite apparent adequate care plan and resources </li></ul><ul><li>Presentation of an impaired elder without a caregiver </li></ul>Geriatrics
  55. 55. <ul><li>Has anyone at home ever hurt you? </li></ul><ul><li>Has anyone ever scolded or threatened you? </li></ul><ul><li>Are you afraid of anyone at home? </li></ul><ul><li>Has anyone made you do things you did not want to do? </li></ul><ul><li>Are you receiving enough care at home? </li></ul>AMA Proposed Screening Questions Geriatrics
  56. 56. <ul><li>Perform in-depth interview and document physical and psychological findings </li></ul><ul><li>Report to adult protective service - do not attempt or initiate individual rescues </li></ul><ul><li>If immediate danger, create a safety plan </li></ul><ul><li>42 states have mandatory reporting laws; see </li></ul><ul><li>Victims often deny abuse and/or refuse help </li></ul><ul><li>Most elderly would rather receive inadequate care from family than excellent care in an institution </li></ul>Intervention Geriatrics
  57. 57. Medical Care in the Nursing Home <ul><li>Skilled nursing beds: 1.5-2 million in US </li></ul><ul><li>5% of those over 65 live in a NH </li></ul><ul><li>20% lifetime individual chance </li></ul><ul><li>45% of NH residents are over age 85 </li></ul><ul><li>75% of NH residents are female </li></ul><ul><li>60% have moderate-to-severe dementia </li></ul><ul><li>50% admitted to NH die there </li></ul>Geriatrics
  58. 58. Types of NH Residents <ul><li>“ Short-stayers”: 1-6 months </li></ul><ul><ul><li>Terminally ill </li></ul></ul><ul><ul><li>Short-term rehabilitation </li></ul></ul><ul><ul><li>Debilitated post-acute care hospitalization </li></ul></ul><ul><li>“ Long-stayers”: 6 months to years </li></ul><ul><ul><li>Primarily cognitively impaired </li></ul></ul><ul><ul><li>Significant impairments of both cognitive and physical functioning </li></ul></ul><ul><ul><li>Primarily physically impaired </li></ul></ul>Geriatrics
  59. 59. Factors Precipitating NH Placement <ul><li>Care requirements exceed the ability of caregiver </li></ul><ul><li>Behaviors due to dementia: nocturnal wandering, aggressive behavior, etc. </li></ul><ul><li>Bed bound status requiring total ADL support </li></ul><ul><li>Bowel and/or bladder incontinence </li></ul><ul><li>Recurrent falling </li></ul><ul><li>Insufficient financial resources to maintain help at home </li></ul>Geriatrics
  60. 60. Physician Duties in the NH <ul><li>Verify transfer or admission orders from the transferring facility </li></ul><ul><li>Perform history and physical within 48 hours of admission </li></ul><ul><li>Schedule regular reassessments (minimum frequency mandated by the government: q30d x 3, then q60d thereafter) </li></ul><ul><li>Comply with multiple OBRA (1987 Omnibus Budget Reconciliation Act) regulations </li></ul>Geriatrics
  61. 61. Admission Checklist <ul><li>History, physical, labs as needed </li></ul><ul><li>Tuberculin test </li></ul><ul><li>Determine functional status: ADLs, IADLs, Mini-Mental Status, Geriatric Depression Scale </li></ul><ul><li>Identify medical problems—review old records </li></ul><ul><li>Medication review: each must correlate to an active medical problem </li></ul>Geriatrics
  62. 62. Admission Checklist (Cont’d) <ul><li>Assess for presence of pain </li></ul><ul><li>Establish relationships: patient & family </li></ul><ul><li>Inquire about advance directives </li></ul><ul><li>Formulate the problem list </li></ul><ul><li>Formulate the care plan </li></ul>Geriatrics
  63. 63. Medication Use in NHs Geriatrics <ul><li>Regulated by CMS (OBRA-1987) </li></ul><ul><li>Appropriate use of antipsychotics </li></ul><ul><ul><li>Agitated behavior that is a clear danger to self or staff providing ADL care </li></ul></ul><ul><ul><li>Psychotic symptoms (hallucination, paranoia) </li></ul></ul><ul><ul><li>Continuous (24 hr) crying out or screaming </li></ul></ul><ul><li>Requires attempt at dose reduction within 6 months, unless documented why not </li></ul><ul><li>Inappropriate for pacing, uncooperative behavior, insomnia, unsociability, etc. </li></ul>
  64. 64. Medication Use in NHs (Cont’d) <ul><li>Anxiolytics </li></ul><ul><ul><li>Daily use for less than 4 months unless documented unsuccessful attempt at dose reduction </li></ul></ul><ul><ul><li>CMS discourages use of barbiturates and long-acting benzodiazepines </li></ul></ul><ul><li>Hypnotics </li></ul><ul><ul><li>Allowed for 10 continuous days </li></ul></ul><ul><ul><li>If 3 unsuccessful attempts at dose reduction, clinically contraindicated to reduce dose </li></ul></ul>Geriatrics
  65. 65. Inappropriate Drugs <ul><li>BEERS list of Drugs – these drugs may be potentially when used by the elderly </li></ul>Geriatrics Drugs to Avoid Concerns Alternatives Benadryl(diphenhydramine) Confusion, sedation, anticholinergics Allegra, Claritin Muscle relaxants (Flexeril, Soma) Anticolinergic effects, sedation NSAID, Tylenol Cimetidine (Tagamet) CNS adverse effects Zantac, Pepcid
  66. 66. Medicaid <ul><li>Covers approximately 2/3 of nursing home patients </li></ul><ul><li>Persons pay out of pocket (“spend down”) until income/asset criteria are met; criteria set by each state </li></ul><ul><li>No national program covers chronic custodial care for elders in the home </li></ul><ul><li>Some commercial long-term care insurance policies now available to cover nursing home care </li></ul>Geriatrics
  67. 67. Geriatric Syndrome: Falling <ul><li>Definition: Coming to rest inadvertently on the ground or a lower level </li></ul><ul><li>Excludes falls due to seizure, stroke, syncope or overwhelming trauma </li></ul><ul><li>30-40% of community dwelling elderly (65+) fall annually </li></ul><ul><li>If hospitalized due to a fall, only 50% will be alive in a year </li></ul>Geriatrics
  68. 68. Complications of Falls <ul><li>Medical </li></ul><ul><ul><li>Fractures </li></ul></ul><ul><ul><li>Subdural hematoma </li></ul></ul><ul><ul><li>Sprains, bruises, hematomas, lacerations </li></ul></ul><ul><li>Psychological </li></ul><ul><ul><li>FFF (3 F syndrome): F ear of F urther F alling: </li></ul></ul><ul><ul><li>Decreased confidence  isolation and withdrawal  depression  reluctance to go outdoors </li></ul></ul>Geriatrics
  69. 69. Complications of Falls (Cont’d) <ul><li>Social </li></ul><ul><ul><li>Loss of independence </li></ul></ul><ul><ul><li>Risk of nursing home placement </li></ul></ul><ul><li>Increased immobilization from fear </li></ul><ul><ul><li>Further loss of muscle tone and strength </li></ul></ul><ul><ul><li>Increased risk of DVT/pulmonary embolism </li></ul></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Pulmonary infections </li></ul></ul>Geriatrics
  70. 70. Falls: Etiology <ul><li>Typically many factors </li></ul><ul><li>Intrinsic: age-related declines, chronic diseases </li></ul><ul><li>Extrinsic: polypharmacy </li></ul><ul><li>Environmental: poor lighting, lack of appropriate railings, elevated seats, loose carpets, low-lying objects, pets </li></ul>Geriatrics
  71. 71. Falls: Evaluation <ul><li>History </li></ul><ul><ul><li>Circumstances of the fall, associated symptoms, relevant medical illnesses, previous falls, medications </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>Asses mental status, compare to previous </li></ul></ul><ul><ul><li>Vital signs including postural blood pressure changes or orthostatic symptoms </li></ul></ul><ul><ul><li>Visual exam </li></ul></ul><ul><ul><li>Musculoskeletal exam </li></ul></ul><ul><ul><li>Neurological exam </li></ul></ul><ul><ul><li>Cardiovascular exam </li></ul></ul>Geriatrics
  72. 72. Falls: Prevention/Management <ul><li>Annual case-finding: “Have you fallen in the past year?” </li></ul><ul><li>Assess/alter home environment </li></ul><ul><li>Modify risk factors </li></ul><ul><li>Exercise program including gait training and advice on assistive devices </li></ul><ul><li>Review/modify medications </li></ul><ul><li>Treat CV disease: postural BP, arrhythmias </li></ul>Geriatrics
  73. 73. Falls: Prevention/Management (Cont’d) <ul><li>Teach patient how to get up if they do fall </li></ul><ul><ul><li>Role to their side, push up with arm </li></ul></ul><ul><li>Consider a personal emergency response system </li></ul><ul><li>Hip protectors may reduce hip fracture incidence by 50% in nursing home patients </li></ul>Geriatrics
  74. 74. Geriatric Syndrome: Urinary Incontinence (UI): <ul><li>The involuntary loss of urine sufficient in to be a social or health problem. </li></ul><ul><ul><li>Urinary incontinence (UI) is a symptom, not a specific disease </li></ul></ul><ul><li>Never a part of normal aging </li></ul><ul><li>Prevalence </li></ul><ul><ul><li>15-30% community dwellers, but under-reported by 50% </li></ul></ul><ul><ul><li>30-35% in acute care hospitals </li></ul></ul><ul><ul><li>50%+ in nursing homes </li></ul></ul>Geriatrics
  75. 75. Basic Bladder Anatomy and Physiology (Cont’d) <ul><li>Filling the bladder involves: </li></ul><ul><ul><li>Inhibition of cholinergic receptors </li></ul></ul><ul><ul><li>Stimulation of alpha- and beta-adrenergic receptors </li></ul></ul><ul><li>Emptying the bladder involves: </li></ul><ul><ul><li>Stimulation of cholinergic receptors </li></ul></ul><ul><ul><li>Inhibition of alpha- and beta-adrenergic receptors </li></ul></ul><ul><li>Stimulation of alpha-adrenergic receptors increases sphincter and urethral tone, and inhibition decreases it </li></ul>Geriatrics
  76. 76. Types of Established UI <ul><li>Stress (“urethral insufficiency”): Involuntary loss of small amounts with increased intra-abdominal pressure </li></ul><ul><li>Overflow : Leakage of small amounts resulting from mechanical forces on an over-distended bladder </li></ul><ul><li>Urge (“detrusor instability”): Leakage of large amounts due to inability to delay voiding after a sensation of fullness </li></ul><ul><li>Functional : Urine loss due to inability to toilet </li></ul>Geriatrics
  77. 77. UI: Common Causes <ul><li>Stress : Obesity, multiparity, pelvic floor surgery, peripheral (pudendal) neuropathy, post-radiation </li></ul><ul><li>Overflow : Outlet obstruction (BPH, impaction) anticholinergic meds, diabetic neuropathy, MS </li></ul><ul><li>Urge: Local GU conditions, uninhibited cortical stimulation (CVA, PD, dementia) </li></ul><ul><li>Functional : Physical restraints, sedatives, diuretics, OA, weakness, neglect </li></ul>Geriatrics
  78. 78. <ul><li>Abrupt onset </li></ul><ul><li>Moderate to large leakage </li></ul><ul><li>Associated with urinary frequency and nocturia </li></ul><ul><li>Uninhibited bladder contractions </li></ul><ul><li>May be associated with or caused by: </li></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Bladder irritation – stones, infection, tumor </li></ul></ul><ul><ul><li>Increasing age </li></ul></ul><ul><ul><li>Idiopathic </li></ul></ul><ul><ul><li>Interstitial cystitis – consider in young women with dysuria </li></ul></ul><ul><li>In the elderly detrusor hyperactivity with impaired contractility (DHIC) is common </li></ul>Urge Incontinence Geriatrics
  79. 79. Causes of Transient UI-”DIAPPERS” <ul><li>D: Delirium/confusional states </li></ul><ul><li>I: Infection — UTIs </li></ul><ul><li>A: Atrophic urethritis/vaginitis </li></ul><ul><li>P: Pharmaceuticals (hypnotics, diuretics, anticholinergics, alpha-adrenergic agents, calcium channel blockers) </li></ul><ul><li>P: Psychological </li></ul><ul><li>E: Excessive urine production </li></ul><ul><li>R: Restricted mobility </li></ul><ul><li>S: Stool impaction </li></ul>Geriatrics
  80. 80. <ul><li>Usually H & P, post-void residual and UA/UC are sufficient to provide diagnosis </li></ul><ul><li>Voiding record </li></ul><ul><ul><li>Times incontinent </li></ul></ul><ul><ul><li>Amount of Leakage </li></ul></ul><ul><ul><li>Special circumstances – cough, medications, urge </li></ul></ul><ul><li>Postvoid residual (PVR) </li></ul><ul><ul><li>>50 ml – abnormal </li></ul></ul><ul><ul><li>>200 ml – suggest detrusor weakness or obstruction </li></ul></ul>Diagnostic Evaluation of Incontinence Geriatrics
  81. 81. <ul><li>Labs/imaging </li></ul><ul><ul><li>Renal function, glucose, calcium </li></ul></ul><ul><ul><li>Urine culture if abnormal UA </li></ul></ul><ul><ul><li>Cytology – urine and cystoscopy if hematuria or pelvic pain </li></ul></ul><ul><li>Urodynamic testing </li></ul><ul><ul><li>Not routinely recommended </li></ul></ul>Diagnostic Evaluation of Incontinence (Cont’d) Geriatrics
  82. 82. UI: Cystometric Findings Geriatrics Urinary Incontinence Cystometric Findings Stress Normal Overflow Little or no detrusor contractions despite high bladder volume Urge Involuntary detrusor contracitons that cannot be suppressed Functional Normal
  83. 83. UI: Primary Treatments <ul><li>Stress : Weight loss, surgery, Kegel’s, pessaries,  -adrenergic agents </li></ul><ul><li>Overflow : TURP, intermittent cath, timed voidings, cholinergic drugs,  -blockers </li></ul><ul><li>Urge : Kegel’s, bladder training, scheduled toileting, anti-spasmodics </li></ul><ul><li>Functional : Replace offending drugs, improve patient mobility, scheduled toileting </li></ul>Geriatrics
  84. 84. Urinary Catheter Care <ul><li>Use only for chronic retention, non-healing pressure ulcers in the incontinent, or at patient request for comfort care </li></ul><ul><li>Use closed drainage system only; silver hydrogel catheters reduce UTI 27-73% </li></ul><ul><li>Bacteriuria is universal; treat only if symptomatic </li></ul><ul><li>Culture from port, not the bag. </li></ul><ul><li>Routine replacement q 4-6 weeks to prevent blockage is reasonable although not proven necessary or beneficial </li></ul>Geriatrics
  85. 85. Geriatric Syndrome: Pressure Ulcers <ul><li>Any lesion caused by unrelieved pressure that results in damage to underlying soft tissue, when the tissue is compressed between a bony prominence and an external surface </li></ul><ul><li>Former terms: Bedsore, decubitus ulcer </li></ul>Geriatrics
  86. 86. Pressure Ulcers (Cont’d) <ul><li>Prevalence </li></ul><ul><ul><li>10% Acute Care Hospital </li></ul></ul><ul><ul><li>3-30% Long Term Care </li></ul></ul><ul><ul><li>5-15% Home Care </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Localized cellulitis/osteomyelitis </li></ul></ul><ul><ul><li>Bacteremia </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Depression </li></ul></ul>Geriatrics
  87. 87. Risk Factors <ul><li>Intrinsic </li></ul><ul><ul><li>Age > 70 </li></ul></ul><ul><ul><li>Poor nutritional status </li></ul></ul><ul><ul><li>Impaired mobility </li></ul></ul><ul><ul><li>Low BMI </li></ul></ul><ul><ul><li>Altered mental status </li></ul></ul><ul><li>Extrinsic </li></ul><ul><ul><li>Pressure </li></ul></ul><ul><ul><li>Sheer </li></ul></ul><ul><ul><li>Friction </li></ul></ul><ul><ul><li>Moisture (UI and fecal incontinence) </li></ul></ul>Geriatrics <ul><ul><li>Incontinence </li></ul></ul><ul><ul><li>Chronic Disease Burdens </li></ul></ul><ul><ul><ul><li>Circulatory issues </li></ul></ul></ul><ul><ul><ul><li>Neurologic disease </li></ul></ul></ul>
  88. 88. The Braden Scale <ul><li>Most commonly used prediction tool for development of pressure ulcers </li></ul><ul><li>Rates patients in 6 subscales: sensory perception, moisture, activity, mobility, nutrition, friction/sheer </li></ul><ul><li>Maximum score is 23 </li></ul><ul><li>A score of 16 or less indicates high-risk </li></ul>Geriatrics
  89. 89. Staging System – 6 options Geriatrics Staging Option Description Stage I Pressure related change of intact skin, usually appearing as a persistent, non-blanchable redness for 1 hour after pressure relief Stage II Skin loss involving epidermis and dermis; superficial abrasion, blister, or shallow crater Stage III : Full thickness tissue loss, including subcutaneous tissue down to, but not through, fascia Stage IV Full thickness damage including muscle, bone and supporting tissues
  90. 90. Staging System – 6 options Geriatrics Staging Option Description Unstageable Covered by slough and/or eschar Suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure or shear
  91. 91. Pressure Ulcer Prevention <ul><li>Pressure relief – most important factor </li></ul><ul><ul><li>Proper patient positioning </li></ul></ul><ul><ul><ul><li>Bed-bound patients – regular turning every 2 hours </li></ul></ul></ul><ul><ul><ul><li>Turn from back, to left, and then to right </li></ul></ul></ul><ul><ul><ul><li>30 ° angle while lying on their side to avoid direct pressure on greater trochanter </li></ul></ul></ul><ul><ul><ul><li>Heels require special attention </li></ul></ul></ul><ul><ul><ul><li>Chair repositioning – every 1 hour </li></ul></ul></ul><ul><ul><li>Pressure reducing devices </li></ul></ul><ul><ul><ul><li>Dynamic support devices (air suspension beds) odd reduction of 80% possible. </li></ul></ul></ul>Geriatrics
  92. 92. Pressure Ulcer Prevention (Cont’d) <ul><li>Proper skin care – avoidance of moisture and daily inspection </li></ul><ul><li>Avoidance of friction </li></ul><ul><li>Adequate nutrition </li></ul><ul><li>Education – clinical staff, patients, families </li></ul><ul><li>Can all pressure ulcers be prevented? </li></ul><ul><ul><li>Patients may be at such high risk that the ulcer is unavoidable </li></ul></ul>Geriatrics
  93. 93. <ul><li>Nutritional support </li></ul><ul><ul><li>1-1.2 gm/protein/kg/day </li></ul></ul><ul><ul><li>Possible vitamin C and zinc supplements, if deficient </li></ul></ul><ul><li>Tissue pressure reduction </li></ul><ul><li>Wound debridement </li></ul><ul><ul><li>Necrotic tissue promotes bacterial overgrowth and impairs wound healing </li></ul></ul><ul><ul><li>Types </li></ul></ul><ul><ul><ul><li>Mechanical (wet-to-dry, wound irrigation) </li></ul></ul></ul><ul><ul><ul><ul><li>Wound irrigation: 19 gauge needle; 30 cc syringe and use of normal saline </li></ul></ul></ul></ul><ul><ul><ul><li>Sharp debridement </li></ul></ul></ul><ul><ul><ul><li>Enzymatic </li></ul></ul></ul><ul><ul><ul><li>Autolytic </li></ul></ul></ul><ul><ul><li>Debridement should stop once necrotic tissue is removed and granulation tissue is present </li></ul></ul>Treatment of Pressure Ulcer Geriatrics
  94. 94. Treatment of Pressure Ulcer (Cont’d) <ul><li>Treatment of wound infection </li></ul><ul><ul><li>Recognized by purulent exudate, erythema, foul odor, tenderness </li></ul></ul><ul><ul><li>Currettage of ulcer base after debridement or tissue biopsy more reliable but generally not needed unless ulcer not responding to topical antibacterials </li></ul></ul><ul><ul><li>Systemic antibiotics for cellulitis, sepsis, osteomyelitis </li></ul></ul><ul><ul><li>Increased WBC + increased sed rate or C-reactive protein + positive radiographs predictive of osteomyelitis </li></ul></ul>Geriatrics
  95. 95. Treatment of Pressure Ulcer (Cont’d) <ul><li>Maintain a moist environment </li></ul><ul><ul><li>Wound fluids contain tissue growth factors </li></ul></ul><ul><ul><li>Promote wound healing </li></ul></ul><ul><li>Pain control </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Most ulcers are managed without surgery </li></ul></ul><ul><ul><ul><li>70% - stage 2, 50% - stage 3, 30% - stage 4 healed at six months without surgery </li></ul></ul></ul><ul><ul><ul><li>70-80% stage 4 healed at 2 years without surgery </li></ul></ul></ul><ul><ul><li>Consider if quality of life would be markedly improved by rapid wound closure </li></ul></ul><ul><ul><li>Ulcer recurrence 15-60%! </li></ul></ul>Geriatrics
  96. 96. Treatment of Pressure Ulcer (Cont’d) <ul><li>Other treatments </li></ul><ul><ul><li>Growth factors – expensive </li></ul></ul><ul><ul><li>Negative pressure wound therapy </li></ul></ul><ul><ul><li>Hyperbaric oxygen </li></ul></ul><ul><li>Prognosis – approximately 2-3 times more likely to die but after adjusting for other risk factors, it is a weak predictor of mortality </li></ul>Geriatrics
  97. 97. <ul><li>Common disorder: up to 30% of elders in the hospital or acutely ill </li></ul><ul><li>An acute (hours to days) disorder of: </li></ul><ul><ul><li>Consciousness--reduced attention and awareness of environment </li></ul></ul><ul><ul><li>Cognition--memory deficit, disorientation, language disturbance </li></ul></ul><ul><li>A syndrome, usually referable to an underlying disease process </li></ul>Delirium Geriatrics
  98. 98. Risk Factors for Delirium in Hospitalized <ul><ul><li>Four strong predictors of delirium </li></ul></ul><ul><ul><ul><li>Age > 80 </li></ul></ul></ul><ul><ul><ul><li>Prior cognitive impairment </li></ul></ul></ul><ul><ul><ul><li>Fracture on admission </li></ul></ul></ul><ul><ul><ul><li>Institutionalization prior to admission </li></ul></ul></ul><ul><ul><li>Other predictors: systemic infection, narcotic or neuroleptic use </li></ul></ul>Geriatrics
  99. 99. Causes of Delirium <ul><li>Organ Failure </li></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Hepatocellular failure </li></ul></ul><ul><li>Infections </li></ul><ul><ul><li>Acute bronchitis/bronchopneumonia </li></ul></ul><ul><ul><li>Bladder infection </li></ul></ul><ul><ul><li>Septicemia </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Hypo/hypernatremia </li></ul></ul><ul><ul><li>Hypoxia, uremia, hypo/hyperglycemia </li></ul></ul>Geriatrics
  100. 100. Causes of Delirium (Cont’d) <ul><li>Drugs: ANY, ANYTHING NEWLY ADDED </li></ul><ul><ul><li>Anticholinergics (including anticholinergic antidepressants and antihistamines) </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><li>Narcotics </li></ul></ul><ul><ul><li>Neuroleptics </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Digoxin & other antiarrhythmics </li></ul></ul><ul><ul><li>Alcohol/alcohol withdrawal </li></ul></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><li>OTC (cough and cold medicines, etc.) </li></ul></ul>Geriatrics
  101. 101. Causes of Delirium (Cont’d) <ul><li>Neurologic causes </li></ul><ul><ul><li>Subdural hematoma </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul><li>Cerebral infections </li></ul></ul><ul><ul><li>Raised intracranial pressure </li></ul></ul><ul><li>Miscellaneous </li></ul><ul><ul><li>Postoperative delirium </li></ul></ul><ul><ul><li>Sensory deprivation </li></ul></ul><ul><ul><li>Recent institutionalization </li></ul></ul><ul><ul><li>Change of living arrangement </li></ul></ul>Geriatrics
  102. 102. Assessment of Delirium <ul><li>History </li></ul><ul><ul><li>Compare to prior functional status: ADLs/IADLs </li></ul></ul><ul><ul><li>Ask about alcohol use: they won’t tell you </li></ul></ul><ul><ul><li>Determine prior cognitive function </li></ul></ul><ul><ul><li>Verify time course of changes in consciousness </li></ul></ul><ul><ul><li>Inquire about any medications, both RX & OTC </li></ul></ul><ul><li>Physical examination </li></ul><ul><ul><li>Neurologic examination (including mental status) </li></ul></ul><ul><ul><li>Rectal (fecal impaction) </li></ul></ul>Geriatrics
  103. 103. Assessment of Delirium (Cont’d) <ul><li>Initial labs </li></ul><ul><ul><li>Chem profile </li></ul></ul><ul><ul><li>CBC w. diff </li></ul></ul><ul><ul><li>UA </li></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>EKG </li></ul></ul><ul><ul><li>Pulse ox or ABGs </li></ul></ul><ul><ul><li>Serum albumin </li></ul></ul><ul><li>Consider </li></ul><ul><ul><li>Ammonia level </li></ul></ul><ul><ul><li>Blood/urine cultures </li></ul></ul><ul><ul><li>CT/ MRI of head </li></ul></ul><ul><ul><li>Drug levels </li></ul></ul><ul><ul><li>Serum/urine drug screens (alcohol) </li></ul></ul><ul><ul><li>Thyroid function </li></ul></ul><ul><ul><li>PVR urine </li></ul></ul><ul><ul><li>CSF exam </li></ul></ul><ul><ul><li>Folate/B12 levels </li></ul></ul>Geriatrics
  104. 104. Delirium: Treatment <ul><li>Remove “cause” if found </li></ul><ul><li>Environmental/behavioral interventions </li></ul><ul><ul><li>Decrease stimulation </li></ul></ul><ul><ul><li>“ Talking down” </li></ul></ul><ul><ul><li>Calm support </li></ul></ul><ul><ul><li>Family assistance helpful </li></ul></ul><ul><li>Medication intervention </li></ul><ul><ul><li>Alcohol withdrawal – benzodiazepine p.o./i.m./i.v. </li></ul></ul><ul><ul><li>All others </li></ul></ul><ul><ul><ul><li>Atypical antipsychotic p.o./i.m. </li></ul></ul></ul><ul><ul><ul><li>Haloperidol +/- Lorazepam </li></ul></ul></ul><ul><ul><ul><li>Add mood stabilizers +/- beta-blockers </li></ul></ul></ul>Geriatrics
  105. 105. Dementia: DSM IV Criteria <ul><li>Memory and learning impairment </li></ul><ul><li>Cognitive impairment as evidenced by one of the following: aphasia, apraxia, agnosia, disturbance in executive functioning </li></ul><ul><li>The cognitive deficit causes significant impairment in social or occupational functioning </li></ul><ul><li>Does not occur exclusively during the course of delirium </li></ul>Geriatrics
  106. 106. Depression Vs. Dementia <ul><li>Depression can look like dementia (pseudodementia) </li></ul><ul><li>Depression is weeks to months, not months to years </li></ul><ul><li>Islands of recent and long-term memory loss </li></ul><ul><li>Language preserved </li></ul><ul><li>History of depression usually positive </li></ul><ul><li>Responds to questions with “I don’t know” </li></ul><ul><li>Patient’s impression of disability: exaggerated </li></ul><ul><li>Screen with Yesavage Geriatric Depression Scale </li></ul>Geriatrics
  107. 107. Mild Cognitive Impairment (MCI) <ul><li>Criteria </li></ul><ul><ul><li>Age >50 </li></ul></ul><ul><ul><li>Memory complaint </li></ul></ul><ul><ul><li>Objective memory impairment </li></ul></ul><ul><ul><li>Intact activities of daily living </li></ul></ul><ul><ul><li>Not demented </li></ul></ul><ul><li>Conversion to Alzheimer’s Disease increased </li></ul><ul><ul><li>5-12% vs. 1-2% per year for normal elderly </li></ul></ul><ul><ul><li>Risk increases with other diseases </li></ul></ul><ul><ul><ul><li>HTN, increased cholesterol, DM, etc., which are other markers for increased risk of dementia </li></ul></ul></ul>Geriatrics
  108. 108. Dementia <ul><li>Prevalence – 1% prevalence at 60-69% and doubles every 5 years to a prevalence of about 39% at age 90-95 years </li></ul><ul><li>Dementia Syndromes </li></ul><ul><ul><li>Alzehimer’s; 50-80% </li></ul></ul><ul><ul><li>Frontotemporal; 12-25% </li></ul></ul><ul><ul><li>Mixed etiologies; 10-30% </li></ul></ul><ul><ul><li>Vascular; 10-20% </li></ul></ul><ul><ul><li>Lewy Body; 5-10% </li></ul></ul><ul><li>“ Potentially” Reversible Dementias </li></ul><ul><ul><li>Medication-induced </li></ul></ul><ul><ul><li>Alcohol-related </li></ul></ul><ul><ul><li>Metabolic (thyroid, B 12, hepatic, renal) </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>CNS Neoplams, SDH, chronic meningitis </li></ul></ul><ul><ul><li>Normal pressure hydrocephalus (NPH) </li></ul></ul>Geriatrics
  109. 109. Clinical Features of Cognitive Disorders Geriatrics Age-Related Cognitive Decline (ARCD) Subjective Memory Impairment (SMI) Mild Cognitive Impairment (MCI) Dementia Patient Concerns Often present Present May be absent May be absent Observer Concerns Typically not present Typically not present Present Present Memory Impairment Recall of experiences, events, names – mild impairment Subjectively present not demonstrated on testing Present Present sufficiently to impair function Non-memory Impairment Mild decline processing speech, preserved language and attention span, conceptual and factual knowledge intact Complaints on individual tasks of daily living Present, but intact function Present sufficiently to impair function Functional impairment No No Mild, if present Present Behavioral abnormalities No May be present– depression/anxiety Often present- depression, anxiety, apathy Often present-depression, anxiety, apathy, agitation
  110. 110. Alzheimer’s Disease <ul><li>Pathological deposits of plaques (amyloid) and neurofibrillary tangles (tau protein) </li></ul><ul><li>Insidious onset with a smooth decline </li></ul><ul><li>Average time between diagnosis and death: 10 years </li></ul><ul><li>Early: personality changes, irritability, anxiety, depression </li></ul><ul><li>Late: 50% develop agitation, delusions, hallucinations or paranoia </li></ul>Geriatrics
  111. 111. Vascular Dementia <ul><li>Sudden onset, fluctuating course with temporary improvements or a long plateau </li></ul><ul><li>Multiple infarcts, white matter lesions </li></ul><ul><li>Diabetes, CV disease present </li></ul><ul><li>Focal neurological deficits </li></ul>Geriatrics
  112. 112. Lewy Body Dementia <ul><li>Two of the following core features: </li></ul><ul><ul><li>Fluctuating cognition with pronounced variation in attention and alertness </li></ul></ul><ul><ul><li>Recurrent well-formed visual hallucinations </li></ul></ul><ul><ul><li>Spontaneous motor features of Parkinsonism </li></ul></ul>Geriatrics
  113. 113. Lewy Body Dementia <ul><li>Supportive features: </li></ul><ul><ul><li>Repeated falls </li></ul></ul><ul><ul><li>Syncope </li></ul></ul><ul><ul><li>Transient LOC </li></ul></ul><ul><ul><li>Adverse response to typical antipsychotics </li></ul></ul><ul><ul><li>Systematized delusions </li></ul></ul>Geriatrics
  114. 114. Frontotemporal Dementia <ul><li>Two classic presentations </li></ul><ul><ul><li>Personality change – either quiet and apathetic or disinhibited, impulsive and socially inappropriate </li></ul></ul><ul><ul><li>Speech disturbances – loss of fluency and ability to communicate well with others </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Medical history to rule out other etiologies </li></ul></ul><ul><ul><li>Neuropsychiatric assessments </li></ul></ul><ul><ul><li>Neuroimaging </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Cholinesterase inhibitors – ineffective or harmful </li></ul></ul>Geriatrics
  115. 115. <ul><li>Triad </li></ul><ul><ul><li>Gait disturbance </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><ul><li>Cognitive dysfunction </li></ul></ul><ul><li>Miller Fisher Test – objective gait assessment after removal of 30 ml of spinal fluid </li></ul><ul><li>MRI/Radioisotope diffusion studies of CSF help confirm the diagnosis </li></ul>Normal Pressure Hydrocephalus Geriatrics
  116. 116. Diagnostic Approach to Dementia <ul><li>History </li></ul><ul><ul><li>History from family members/friends/caregivers is paramount </li></ul></ul><ul><ul><li>Medication history </li></ul></ul><ul><li>Cognitive testing and mini-mental status testing </li></ul><ul><li>USPSTF found insufficient evidence to recommend for or against routine screening for dementia in older adults </li></ul>Geriatrics
  117. 117. Mental Status Screening Tests <ul><ul><li>Mini Mental Status Exam (Folstein) </li></ul></ul><ul><ul><ul><li>Considered the “gold standard” screen </li></ul></ul></ul><ul><ul><ul><li>Maximum score of 30, cut-off of 21-23 for dementia </li></ul></ul></ul><ul><ul><ul><li>Requires verbal and written responses </li></ul></ul></ul><ul><ul><ul><li>No time limit </li></ul></ul></ul><ul><ul><ul><li>Reproducible over time </li></ul></ul></ul><ul><ul><ul><li>Specificity goes down, sensitivity rises with higher educational levels </li></ul></ul></ul><ul><ul><ul><li>Average decline of 4 points/year </li></ul></ul></ul><ul><ul><ul><li>See Appendix B </li></ul></ul></ul>Geriatrics
  118. 118. Mental Status Screening Tests (Cont’d) <ul><ul><li>Cognitive Assessment Screening Test (CAST) </li></ul></ul><ul><ul><ul><li>Written, self-administered </li></ul></ul></ul><ul><ul><ul><li>No time limit </li></ul></ul></ul><ul><ul><li>Set Test </li></ul></ul><ul><ul><ul><li>Category fluency: Ask patient to name 10 colors, towns, fruits, animals </li></ul></ul></ul><ul><ul><ul><li>80% of demented score less than 15/40 </li></ul></ul></ul><ul><ul><ul><li>Considered a measure of executive, i.e., frontal lobe functioning </li></ul></ul></ul>Geriatrics
  119. 119. Mental Status Screening Tests (Cont’d) <ul><li>Clock Drawing </li></ul><ul><ul><li>Person is presented a paper with a 4-6” circle drawn and is asked to write the numbers and draw hands of a clock to show 11:10 </li></ul></ul><ul><ul><li>Use as qualitative, not quantitative screen </li></ul></ul><ul><li>Yesavage Geriatric Depression Screen </li></ul><ul><ul><li>Rules out depression </li></ul></ul>Geriatrics
  120. 120. Sensitivity and Specificity of Diagnostic Tests for Dementia Geriatrics * Diagnosis of dementia ** Diagnosis of Alzheimer’s Disease Diagnostic Test Sensitivity Specificity Mini-Mental Status Exam 87% 82% Short Portable Mental Status Questionnaire* Any Dementia Mild Dementia 82% 55% 92% 96% NINCDS Criteria** 92% 65% DSM-IV Criteria** 76% 80% Clinical Judgment** 85% 82%
  121. 121. <ul><li>Physical exam to rule out atypical presentation of a medical illness </li></ul><ul><li>Laboratory testing </li></ul><ul><ul><li>“ Reversible” cause detected <1% </li></ul></ul><ul><ul><li>Identifies co-morbid condition with sub-optimal control </li></ul></ul><ul><ul><li>Cost-effectiveness – questioned </li></ul></ul><ul><ul><li>B 12 , thyroid function testing, CBC, comprehensive metabolic panel </li></ul></ul><ul><ul><li>HIV/VDRL if “at risk” </li></ul></ul><ul><ul><li>Genetic testing of apolipoprotein E epsilon 4 allele not recommended </li></ul></ul><ul><ul><li>CSF analysis for elevated levels of tau protein and beta-amyloid ending at amino acid 42 of unknown value </li></ul></ul>Diagnostic Approach to Dementia (Cont’d) Geriatrics
  122. 122. <ul><li>Neuroimaging </li></ul><ul><ul><li>Controversial </li></ul></ul><ul><ul><li>Recommended if age <60, focal neurologic signs, or short duration of symptoms </li></ul></ul><ul><ul><li>American Academy of Neurology recommends noncontrast CT or MRI </li></ul></ul><ul><ul><li>PET scanning – expensive </li></ul></ul><ul><ul><ul><li>Clinical role may not be better than clinical diagnosis </li></ul></ul></ul>Diagnostic Approach to Dementia (Cont’d) Geriatrics
  123. 123. Quality Dementia Care <ul><li>Maximize function and independence </li></ul><ul><li>Maintain safe and secure environment </li></ul><ul><li>Maintain adequate nutrition and hydration </li></ul><ul><li>Treat mood and behavior problems </li></ul><ul><li>Educate/support caregivers </li></ul><ul><li>Expect regular physician office visits </li></ul><ul><li>Palliative medications </li></ul>Geriatrics
  124. 124. <ul><li>ACP and AAFP published guidelines in 2008. </li></ul><ul><li>The decision to initiate treatment, and the choice of agent, must be individualized -- quality of life, treatment goals, potential benefit, adverse effects, and cost must all be taken into account </li></ul><ul><li>Number Needed to Treat (NNT) </li></ul><ul><ul><li>For any improvement on a global assessment – 12 </li></ul></ul><ul><ul><li>For marked improvement globally – 42 </li></ul></ul><ul><ul><li>For clinically significant cognitive benefit – 10 </li></ul></ul><ul><li>Benefit from pharmacotherapyshould be seen within 3 months </li></ul><ul><li>If benefit is noted, therapy duration is unclear. When slowing decline is no longer a goal, therapy should be discontinued </li></ul>Palliative Medications Geriatrics
  125. 125. Cholinesterase Inhibitor Dosage Schedule <ul><li>Donepezil: (Aricept) </li></ul><ul><ul><li>Start: 5 mg daily </li></ul></ul><ul><ul><li>Titrate: 4-6 weeks by 5 mg </li></ul></ul><ul><ul><li>Maximum: 10 mg daily </li></ul></ul><ul><li>Rivastigmine: (Exelon) </li></ul><ul><ul><li>Start 1.5 mg bid </li></ul></ul><ul><ul><li>Titrate: 2 weeks by 1.5 mg bid </li></ul></ul><ul><ul><li>Maximum: 6 mg bid </li></ul></ul><ul><li>Galantamine: (Razadyne) </li></ul><ul><ul><li>Start: 4 mg bid with food </li></ul></ul><ul><ul><li>Titrate: 4-6 weeks by 4 mg bid </li></ul></ul><ul><ul><li>Maximum: 12 mg bid </li></ul></ul>Geriatrics
  126. 126. Other Agents <ul><li>Memantine (Namenda) </li></ul><ul><li>Vitamin E </li></ul><ul><ul><li>1000 IU p.o. BID </li></ul></ul><ul><ul><li>Growing concerns regarding the increased risk of mortality </li></ul></ul><ul><ul><li>Not recommended for routine prevention treatment </li></ul></ul><ul><ul><li>Consider in Alzheimer patients who have no significant heart disease </li></ul></ul><ul><li>Ginkgo biloba </li></ul><ul><ul><li>Inconsistent and unconvincing evidence </li></ul></ul>Geriatrics
  127. 127. Behavioral Modifications <ul><li>Create a predictable schedule: active day, quiet night </li></ul><ul><li>Maintain a familiar, calm environment </li></ul><ul><li>Foster reminiscence: photos, music, objects </li></ul><ul><li>Keep life simple; reduce choices </li></ul><ul><li>Match activities to capabilities and preferences </li></ul><ul><li>Avoid overwhelming situations (family reunions) and challenges (shopping) </li></ul><ul><li>Learn “dementia speak”: don’t reason or argue with a demented person </li></ul>Geriatrics
  128. 128. Antipsychotic Drugs in Dementia <ul><li>Used to treat the psychiatric and behavioral symptoms that affect 60-90% of patients </li></ul><ul><li>Modest benefit NNT – 5 to 6 </li></ul><ul><li>Risks </li></ul><ul><ul><li>Death: analysis of 17 placebo controlled trials (modal duration of 10 weeks) of atypical antipsychotics 4.5% died in drug treated vs 2.6% placebo. Haldol associated with similar risk. Deaths appeared to be cardiovascular (heart failure, sudden death) or infectious (pneumonia) </li></ul></ul><ul><li>Increased risk for cerebrovascular events (strokes, TIA, syncope), metabolic syndrome, diabetes or exacerbation of diabetes </li></ul>Geriatrics
  129. 129. Antipsychotic Drugs in Dementia (Cont’d) <ul><li>Many suggest monitoring for adverse outcomes </li></ul><ul><li>Weight (BMI) </li></ul><ul><ul><li>Q 4 weeks x3, q 3 months thereafter </li></ul></ul><ul><ul><li>If >5% weight gain consider switching </li></ul></ul><ul><ul><li>Counsel regarding need to monitor/decrease caloric intake (500 kcal) and increase physical activity </li></ul></ul><ul><li>Blood pressure: baseline, 3 mo and annually </li></ul><ul><li>Diabetes </li></ul><ul><ul><li>Increased monitoring of existing diabetics </li></ul></ul><ul><ul><li>Non-diabetes: baseline, 3 mo, annually and as needed (symptoms, weight gain) </li></ul></ul><ul><ul><li>Lipid: baseline, 3 mo, annually </li></ul></ul><ul><li>Clinical practice considerations </li></ul><ul><ul><li>“ Not contraindicated” </li></ul></ul><ul><ul><li>Treat when “harm” to patient or others present or when “distress” is significant </li></ul></ul><ul><ul><li>Routine assessment for continual need; attempt medication taper every 6 months </li></ul></ul>Geriatrics
  130. 130. Protocol for the Treatment of Psychiatric and Behavioral symptoms of Dementia Geriatrics
  131. 131. Palliative and End-of-Life Care
  132. 132. <ul><li>“ The active total care of patients, controlling pain and minimizing emotional, social and spiritual problems at a time when disease is not responsive to active treatment” WHO, 1990 </li></ul><ul><li>Principles </li></ul><ul><ul><li>Support and educate patient, family, and other health care workers </li></ul></ul><ul><ul><li>Address physical, psychological, social and spiritual needs </li></ul></ul><ul><ul><li>Multidisciplinary team </li></ul></ul><ul><ul><li>Symptom management, comfort, quality not quantity </li></ul></ul><ul><ul><li>Care available 24 hours/day, 7 days/week </li></ul></ul><ul><ul><li>Bereavement support </li></ul></ul>Palliative and End-of-Life Care Geriatrics
  133. 133. Curative and Palliative Care <ul><li>Not mutually exclusive </li></ul><ul><li>Based on a continuum with palliative care increasing importance as patient’s illness progresses or curative options are not feasible </li></ul>Geriatrics Curative Care Palliative Care Hospice
  134. 134. Hospice <ul><li>One way to deliver palliative care </li></ul><ul><li>Currently 20-30% of those that died were receiving hospice care </li></ul><ul><li>Physician’s order is required </li></ul><ul><li>Appropriate when curative treatment isn’t goal and life expectancy estimated <6 months </li></ul><ul><li>Provides </li></ul><ul><ul><li>Palliative medicines </li></ul></ul><ul><ul><li>Durable medical equipment </li></ul></ul><ul><ul><li>Team member services - physicians, nurses, social workers, chaplains, home health aides </li></ul></ul><ul><ul><li>Respite care </li></ul></ul>Geriatrics
  135. 135. <ul><li>Usually provided in the home but can be delivered elsewhere (long-term care, assisted living, inpatient in contracted facility) </li></ul><ul><li>Paid for by Medicare Hospice benefit </li></ul><ul><ul><li>Medicare will still pay for covered benefits for any health problems that aren’t related to your terminal illness </li></ul></ul><ul><li>Motto “neither hasten nor postpone death, to live until you die, no longer seeking a cure but comfort” </li></ul>Hospice (Cont’d) Geriatrics
  136. 136. Demographics of Death and Dying in the United States <ul><li>Over 2 million deaths per year </li></ul><ul><li>75% occur in persons > 65 years of age </li></ul><ul><li>Leading causes of death (% of total deaths) </li></ul><ul><ul><li>Heart disease 30% </li></ul></ul><ul><ul><li>Cancer 23% </li></ul></ul><ul><ul><li>Cerebrovascular 7% </li></ul></ul><ul><ul><li>Chronic respiratory disease 5% </li></ul></ul><ul><ul><li>Accidents 4% </li></ul></ul><ul><li>Location of death </li></ul><ul><ul><li>Hospital 56% </li></ul></ul><ul><ul><li>Home 21% </li></ul></ul><ul><ul><li>Nursing homes 18% </li></ul></ul><ul><ul><li>Other 4% </li></ul></ul>Geriatrics
  137. 137. Prognosis of Death <ul><li>Majority die of chronic diseases (CHF, COPD) where death often occurs suddenly and unpredictably </li></ul>Geriatrics <ul><li>Death can’t be consistently and accurately predicted for many chronic diseases </li></ul>
  138. 138. Cultural Differences <ul><li>Never assume, many variations; important not to stereotype </li></ul><ul><li>Hindus </li></ul><ul><ul><li>Respect medical opinion and may request the physician to be ‘health care proxy’ </li></ul></ul><ul><ul><li>Prefer to die at home </li></ul></ul><ul><ul><li>Autopsy is considered distasteful </li></ul></ul><ul><ul><li>Cremation </li></ul></ul><ul><li>Asian cultures </li></ul><ul><ul><li>Decision making often entrusted to eldest son </li></ul></ul><ul><ul><li>May ask not to inform patient of terminal illness </li></ul></ul>Geriatrics
  139. 139. Futile Treatment <ul><li>Most risk-versus-benefit decisions regarding medical care are based on the ethical principles of autonomy, the patient’s values come first </li></ul><ul><li>Some authorities argue that objective standards for futility are impossible and that physicians should not make such judgments </li></ul>Geriatrics
  140. 140. Futile Treatment (Cont’d) <ul><li>Limiting treatment </li></ul><ul><ul><li>Communication is paramount </li></ul></ul><ul><ul><ul><li>Not “Do you want to continue life sustaining treatment of the ventilator? If we stop, your dad will die.” </li></ul></ul></ul><ul><ul><ul><li>But “We hoped that the ventilator would help Frank achieve his goals of going home, but that hope is not working. Frank wanted us to concentrate on his comfort and dignity.” </li></ul></ul></ul>Geriatrics
  141. 141. <ul><li>Assisting in patient’s willing ending of their life; a criminal offense in nearly all states </li></ul><ul><li>June 1977 United States Supreme Court ruled that there is no constitutional right to physician-assisted suicide </li></ul><ul><ul><li>Authority delegated to individual states </li></ul></ul><ul><li>Oregon legalized physician-assisted suicide and use of prescriptions for self-administered, lethal medications </li></ul><ul><ul><li>Accounts for 9 per 100,000 deaths from any cause </li></ul></ul>Assisted Suicide Geriatrics
  142. 142. <ul><li>Physical symptoms </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Trouble with breathing </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Nausea and vomiting </li></ul></ul><ul><li>Emotional and psychological </li></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Cognitive Impairment </li></ul></ul><ul><ul><li>Fear </li></ul></ul>Common Symptoms of the Dying Geriatrics <ul><ul><li>Sleeplessness </li></ul></ul><ul><ul><li>Loss of appetite </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Agitation </li></ul></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Delirium </li></ul></ul>
  143. 143. Pain <ul><li>Can’t be measured objectively </li></ul><ul><li>Opioids are standard choice </li></ul><ul><li>Undertreatment is common due to: </li></ul><ul><ul><li>Reduced confidence & competence of prescribers in pain assessment & treatment </li></ul></ul><ul><ul><li>Patients fear of “addiction” or dislike of medication or side effects </li></ul></ul>Geriatrics
  144. 144. Dyspnea <ul><li>Treat underlying reversible causes </li></ul><ul><ul><li>Blood transfusion for anemia </li></ul></ul><ul><ul><li>Oxygen for hypoxia </li></ul></ul><ul><ul><li>Thoracentesis/chest tube/pleurodesis for pleural effusions </li></ul></ul><ul><ul><li>Diuresis for CHF </li></ul></ul><ul><li>Nonspecific treatments </li></ul><ul><ul><li>Pursed-lip breathing </li></ul></ul><ul><ul><li>Diaphragmatic breathing </li></ul></ul><ul><ul><li>Cool-air ventilation </li></ul></ul>Geriatrics <ul><ul><li>Nasal oxygen </li></ul></ul><ul><ul><li>Opioids </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul>
  145. 145. Cough <ul><li>Productive cough </li></ul><ul><ul><li>Chest physiotherapy </li></ul></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Humidity </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><li>Nonproductive cough </li></ul><ul><ul><li>Bronchodilators </li></ul></ul><ul><ul><li>Opioids </li></ul></ul><ul><ul><li>Nonopioid antitussives </li></ul></ul>Geriatrics <ul><ul><li>Anticholinergics </li></ul></ul><ul><ul><li>Opioids </li></ul></ul><ul><ul><li>Antihistamines </li></ul></ul><ul><ul><li>Antibiotics for infection </li></ul></ul><ul><ul><li>Nebulized anesthetic (bupivacaine) </li></ul></ul>
  146. 146. Fatigue <ul><li>Frequently undiagnosed or ignored </li></ul><ul><li>Misinterpreted by family/friends as giving up or depression </li></ul><ul><li>Treat reversible causes </li></ul><ul><ul><li>Depression/anxiety </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><li>Nonpharmacologic treatment </li></ul><ul><ul><li>Explain to family & patient “permission” to be tired </li></ul></ul><ul><ul><li>Structure activities to conserve energy </li></ul></ul><ul><li>Pharmacologic treatment </li></ul><ul><ul><li>Dexamethasone </li></ul></ul><ul><ul><li>Methylphenidate (Ritalin) </li></ul></ul><ul><ul><li>Antidepressants (SSRI usually) </li></ul></ul>Geriatrics <ul><ul><ul><li>Sleeplessness </li></ul></ul></ul><ul><ul><ul><li>Anemia </li></ul></ul></ul>
  147. 147. Anorexia and Cachexia <ul><li>Often a concern of family and friends not the patient. </li></ul><ul><ul><li>They should be reassured that anorexia is usually not associated with suffering and patients rarely feel hunger or thirst and may develop a euphoria from anorexia </li></ul></ul><ul><li>Usually not reversible with improved nutrition </li></ul>Geriatrics
  148. 148. <ul><li>Treatable causes - chronic pain, constipation, mucositis </li></ul><ul><ul><li>Nonpharmacological therapies </li></ul></ul><ul><ul><ul><li>Eliminate dietary restrictions </li></ul></ul></ul><ul><ul><ul><li>Have patient eat favorite foods and whenever desired </li></ul></ul></ul><ul><ul><ul><li>Address emotional and spiritual issues </li></ul></ul></ul>Anorexia and Cachexia (Cont’d) Geriatrics
  149. 149. Anorexia and Cachexia (Cont’d) <ul><li>Pharmacologic therapies </li></ul><ul><ul><li>Dexamethasone 2-20 mg orally each morning </li></ul></ul><ul><ul><li>Megestrol (Megace) 200 mg 3-4 x/daily </li></ul></ul><ul><ul><li>Cannabinoids </li></ul></ul><ul><li>Tube feedings for those cognitively impaired (Alzheimer’s Disease) have not been shown to </li></ul><ul><ul><li>Decrease aspiration pneumonia </li></ul></ul><ul><ul><li>Increase comfort </li></ul></ul><ul><ul><li>Prolong survival </li></ul></ul>Geriatrics
  150. 150. <ul><li>Central nervous system control </li></ul><ul><ul><ul><li>Chemoreceptor trigger zone - base of 4th ventricle </li></ul></ul></ul><ul><ul><ul><li>Vestibular apparatus </li></ul></ul></ul><ul><ul><ul><li>Cortex </li></ul></ul></ul><ul><ul><li>Gastrointestinal tract </li></ul></ul><ul><ul><li>Stimulation of vomiting mediated by multiple neurotransmitters </li></ul></ul><ul><ul><ul><li>Serotonin - CNS and gastric lining </li></ul></ul></ul><ul><ul><ul><li>Acetylcholine & histamine - vestibular apparatus </li></ul></ul></ul><ul><ul><ul><li>Dopamine – in chemoreceptor trigger zone and the most common form of nausea </li></ul></ul></ul>Nausea and Vomiting Geriatrics
  151. 151. Nausea and Vomiting (Cont’d) <ul><ul><li>Management depends on etiology </li></ul></ul><ul><ul><ul><li>Constipation - laxatives </li></ul></ul></ul><ul><ul><ul><li>Mechanical obstruction by tumor </li></ul></ul></ul><ul><ul><ul><ul><li>Surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Steroids </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Octreotide </li></ul></ul></ul></ul><ul><ul><ul><li>Opioids </li></ul></ul></ul><ul><ul><ul><ul><li>Antidopamine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anticholinergics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Laxatives </li></ul></ul></ul></ul><ul><ul><ul><li>Metastases </li></ul></ul></ul><ul><ul><ul><ul><li>Increased intracranial pressure - steroids </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Antidopamine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Antihistamine </li></ul></ul></ul></ul>Geriatrics <ul><ul><ul><ul><li>Scopolamine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fluids </li></ul></ul></ul></ul>
  152. 152. Nausea and Vomiting (Cont’d) <ul><li>Medications </li></ul><ul><ul><li>Serotonin antagonists - ondansetron (Zofran), granisetron (Kytril), dolasetron (Anzemet) </li></ul></ul><ul><ul><li>Antihistamines - diphenhydramine (Benadryl), meclizine (Antivert), hydroxyzine (Atarax, Vistaril), promethazine (Phenergan) </li></ul></ul><ul><ul><li>Dopamine antagonists - haloperidol (Haldol), prochlorperazine (Compazine) </li></ul></ul><ul><ul><li>Anticholinergic - scopolamine (Transderm Scop) </li></ul></ul><ul><ul><li>Others - dexamethasone, benzodiazepines, octreotide </li></ul></ul>Geriatrics
  153. 153. Constipation <ul><li>Many medications can cause constipation, especially opioids </li></ul><ul><ul><li>Patients started on opioids should be given prophylactic treatment for constipation including stool softeners and stimulant laxatives </li></ul></ul><ul><ul><li>Progressive bowel regimen: </li></ul></ul><ul><ul><ul><li>Docusate 100 mg p.o. bid </li></ul></ul></ul><ul><ul><ul><li>Senna 1 qd to 4 bid </li></ul></ul></ul><ul><ul><ul><li>Bisacodyl suppository 1-4 after breakfast </li></ul></ul></ul><ul><ul><ul><li>Lactulose or sorbitol 15 ml bid to 30 ml qid or polyethylene glycol (Miralax) </li></ul></ul></ul>Geriatrics
  154. 154. <ul><li>May be an irreversible part of dying </li></ul><ul><ul><li>Manifested as escalating restlessness, agitation, and/or hallucinations </li></ul></ul><ul><ul><li>Benzodiazepines commonly used because of their anxiolytic, amnesic and muscle relaxation effects </li></ul></ul>Terminal Delirium Geriatrics
  155. 155. <ul><li>Shut off and remove monitors and alarms </li></ul><ul><li>“ Clean” the room to remove encumbering equipment that impairs family/friends contact with the patient </li></ul><ul><li>Invite family members to be present </li></ul><ul><li>Turn Fi O 2 down to 21%; treat any developing symptoms usually I.V opioids and/or benzodiazepines </li></ul><ul><li>Remove endotracheal tube </li></ul><ul><li>Offer bereavement support </li></ul><ul><li>Debrief staff </li></ul>Terminal Wean from Mechanical Ventilation Geriatrics
  156. 156. Syllabus Extras Approach to Fever and Infection in the Nursing Home Sexuality and the Aging Approach to the Older Driver
  157. 157. Approach to Fever and Infection in the Nursing Home <ul><li>Statistics </li></ul><ul><ul><li>Prevalence </li></ul></ul><ul><ul><ul><li>5-30 infections per 100 residents per month </li></ul></ul></ul><ul><ul><li>Incidence </li></ul></ul><ul><ul><ul><li>10-20 infections per 100 residents per month </li></ul></ul></ul><ul><ul><li>Types of infection </li></ul></ul><ul><ul><ul><li>Respiratory (pneumonia, bronchitis) </li></ul></ul></ul><ul><ul><ul><ul><li>Most common nonbacteremic cause </li></ul></ul></ul></ul><ul><ul><ul><li>Urinary tract (cystitis, pyelonephritis) </li></ul></ul></ul><ul><ul><ul><ul><li>Most common bacteremic cause </li></ul></ul></ul></ul><ul><ul><ul><li>Skin/soft tissue (infected pressure ulcer, cellulitis) </li></ul></ul></ul><ul><ul><li>Mortality rate ranges from 12-35% </li></ul></ul>Geriatrics
  158. 158. <ul><li>Cardinal manifestation of infection </li></ul><ul><li>Definition >100 ° F </li></ul><ul><li>Most common reason is infectious and bacterial in nature </li></ul><ul><li>Degree of fever not related to severity of infection </li></ul><ul><li>25% of elderly don’t respond to infection with a febrile response </li></ul><ul><li>A rise of 2.4 ° F from baseline readings important – usefulness of baseline temp on residents </li></ul>Fever Geriatrics
  159. 159. Clinical Clues to Infection <ul><li>Fever > 100 ° F </li></ul><ul><li>Change in baseline temp > 2.4 ° F </li></ul><ul><li>Delirium or acute confusion </li></ul><ul><li>Unexplained behavioral change </li></ul><ul><li>Low appetite </li></ul><ul><li>Weakness </li></ul><ul><li>Lethargy </li></ul><ul><li>Urine incontinence </li></ul><ul><li>Falls </li></ul><ul><li>Tachypnea </li></ul><ul><li>Orthostasis </li></ul><ul><li>Differentials for these signs/symptoms are various and require astute evaluation </li></ul>Geriatrics
  160. 160. Diagnostic Approach <ul><li>75% of all infections occur in respiratory, urinary tract, and skin; therefore, these areas should be of prime importance </li></ul><ul><li>Nursing evaluation </li></ul><ul><ul><li>Careful and succinct past medical history </li></ul></ul><ul><ul><ul><li>Major medical problem </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Advance directives </li></ul></ul></ul>Geriatrics
  161. 161. Diagnostic Approach (Cont’d) <ul><li>Nursing evaluation (Cont’d) </li></ul><ul><ul><li>Current symptoms </li></ul></ul><ul><ul><li>P.E. mental status </li></ul></ul><ul><ul><ul><li>Vital signs – temp, pulse, respiratory rate, BP </li></ul></ul></ul><ul><ul><ul><li>Oral cavity </li></ul></ul></ul><ul><ul><ul><li>Skin </li></ul></ul></ul><ul><ul><ul><li>Chest </li></ul></ul></ul><ul><ul><ul><li>Heart </li></ul></ul></ul><ul><ul><ul><li>Abdomen </li></ul></ul></ul><ul><ul><ul><li>Genitalia/perirectal </li></ul></ul></ul><ul><ul><li>Call provider </li></ul></ul>Geriatrics
  162. 162. Laboratory Studies <ul><li>CXR </li></ul><ul><li>UA/UC </li></ul><ul><li>CBC </li></ul><ul><li>Blood cultures if shaking chills or requiring antibiotics </li></ul><ul><li>Hospitalization </li></ul><ul><ul><li>Depends on advance directives and severity of illness </li></ul></ul><ul><ul><li>For terminally ill – not usually appropriate </li></ul></ul><ul><ul><li>Alternative is diagnostic evaluation and empiric antibiotics </li></ul></ul><ul><li>Antipyretics </li></ul><ul><ul><li>Since fever is a host defense mechanism against infection and is generally associated with improved mortality and morbidity, treatment should be only for patient’s discomfort and not routine </li></ul></ul>Geriatrics
  163. 163. <ul><li>Mortality rate may reach 40% </li></ul><ul><li>Most cases result of aspiration </li></ul><ul><li>Antibacterial treatment should be against </li></ul><ul><ul><li>S. pneumoniae </li></ul></ul><ul><ul><li>Gram-negative bacilli </li></ul></ul><ul><ul><li>H. influenzae </li></ul></ul><ul><ul><li>S. aureus </li></ul></ul><ul><li>Empiric </li></ul><ul><ul><li>2nd generation cephalosporin (Cefuroxime) </li></ul></ul><ul><ul><li>3rd generation cephalosporin (Ceftriaxone) </li></ul></ul><ul><ul><li>Ampicillin – sulbactam (Unasyn) </li></ul></ul><ul><ul><li>Ticarcillin – clavulanic acid (Timentin) </li></ul></ul><ul><ul><li>Quinolone (Levaquin, Avelox, Tequin) </li></ul></ul><ul><li>Duration – 7-14 days </li></ul><ul><ul><li>May change to p.o. when improved </li></ul></ul>Pneumonia Geriatrics
  164. 164. Urinary Tract Infections <ul><li>Residents with asymptomatic bacteriuria with or without a chronic bladder catheter, with or without pyuria, generally do not warrant treatment </li></ul><ul><li>Don’t assume the source to be urinary in nature with an evaluation 2 ° to a baseline high prevalence of asymptomatic bacteria </li></ul><ul><li>Symptomatic infection should be promptly treated </li></ul>Geriatrics
  165. 165. Urinary Tract Infections (Cont’d) <ul><li>Gram stain of urine – may identify Gram- positive bacteria (Enterococcus) in 25% of catheterized patients </li></ul><ul><li>Blood cultures are important </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Catheterized </li></ul></ul><ul><ul><ul><li>Change catheter prior to urine culture collection </li></ul></ul></ul><ul><ul><ul><li>Treatment should cover Enterococci </li></ul></ul></ul><ul><ul><ul><li>Treatment duration: 7-14 days (usually 14 days if septic) </li></ul></ul></ul><ul><ul><ul><li>Post-therapy cultures not useful </li></ul></ul></ul>Geriatrics
  166. 166. <ul><li>Cellulitis </li></ul><ul><ul><li>More common 2 ° peripheral vascular disease, chronic venous stasis, edema, trauma </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><ul><li>Dicloxacillin </li></ul></ul></ul><ul><ul><ul><li>Augmentin </li></ul></ul></ul><ul><ul><ul><li>1 st generation cephalosporins </li></ul></ul></ul><ul><li>Infected pressure ulcers </li></ul><ul><ul><li>Usually polymicrobial in nature </li></ul></ul><ul><ul><li>Local wound care is most effective </li></ul></ul><ul><ul><li>Antibiotics indicated for cellulitis, sepsis, or osteomyelitis </li></ul></ul>Skin Geriatrics
  167. 167. Skin (Cont’d) <ul><li>Scabies </li></ul><ul><ul><li>Severely pruritic crusted papular lesion found on hands, wrists, elbows, axilla, buttocks, genitals, umbilical area </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>5% permethrin cream (Elimite) </li></ul></ul></ul><ul><ul><ul><li>8-12 hour application from neck down </li></ul></ul></ul><ul><ul><ul><li>Retreatment in 1 week </li></ul></ul></ul><ul><ul><ul><li>Contacts should be treated </li></ul></ul></ul>Geriatrics
  168. 168. Methicillin-Resistant Staphylococcus Aureus Infection (MRSA) <ul><li>Colonization is increasingly common </li></ul><ul><ul><li>10-25% of all residents </li></ul></ul><ul><li>Carriage rate increases with: </li></ul><ul><ul><li>Bedridden status </li></ul></ul><ul><ul><li>Poor functional status </li></ul></ul><ul><ul><li>Feeding tubes </li></ul></ul><ul><ul><li>Urinary catheters </li></ul></ul><ul><ul><li>Open wounds </li></ul></ul><ul><li>Despite high carriage rate, infection rate 3-5% </li></ul><ul><li>Treatment of colonization not recommended </li></ul>Geriatrics
  169. 169. Methicillin-Resistant Staphylococcus Aureus Infection (MRSA) (Cont’d) <ul><li>Isolation procedures for MRSA-colonization remain controversial </li></ul><ul><ul><li>Colonized MRSA patients may be in the same room with noncolonized patients who are low-risk for developing MRSA infection </li></ul></ul><ul><li>MRSA infection – usually vancomycin for serious infections </li></ul>Geriatrics
  170. 170. <ul><li>Caused by reactivation of varicella-zoster virus </li></ul><ul><li>Almost exclusively disease of the elderly </li></ul><ul><li>Post-herpetic neuralgia (PHN) increases with age: </li></ul><ul><ul><li>50% age 60 and older </li></ul></ul><ul><ul><li>75% age 70 and older </li></ul></ul><ul><li>Clinical course </li></ul><ul><ul><li>Prodrome 3-5 days of pain or paresthesia of a dermatomal pattern </li></ul></ul><ul><ul><li>Maculopapular rash – develops to vesicles </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Prevention of PHN if treated within 48 hours of onset of rash </li></ul></ul><ul><ul><li>Routine use of corticosteroids – not indicated </li></ul></ul>Herpes Zoster (Shingles) Geriatrics
  171. 171. Influenza <ul><li>Common setting for outbreaks with attack rates of up to 30-60% and fatality rates as high as 30% </li></ul><ul><li>90% of all influenza-associated hospitalizations and deaths from age 65 or older </li></ul><ul><li>Transmitted by “droplet” </li></ul><ul><li>Vaccine effectiveness in nursing home residents: </li></ul><ul><ul><li>30-40% effective in preventing respiratory illness </li></ul></ul><ul><ul><li>50-60% effective in preventing serious complications and hospitalization </li></ul></ul><ul><ul><li>80% effective in preventing influenza-associated deaths </li></ul></ul><ul><ul><li>Vaccination of staff, family/visitors and residents important to develop hard immunity </li></ul></ul>Geriatrics
  172. 172. Influenza Surveillance <ul><li>Early recognition of influenza is critical </li></ul><ul><li>CDC recommends that chemoprophylaxis be started as early as possible when influenza outbreaks are confirmed or suspected </li></ul><ul><li>“ Outbreak” criteria </li></ul><ul><ul><li>No consensus </li></ul></ul><ul><ul><li>Cluster of 3 or more individuals on the same nursing unit with new onset of respiratory illness </li></ul></ul><ul><ul><li>When present, surveillance testing is warranted by: </li></ul></ul><ul><ul><ul><li>Rapid influenza testing </li></ul></ul></ul><ul><ul><ul><li>Culture </li></ul></ul></ul>Geriatrics
  173. 173. Influenza Surveillance (Cont’d) <ul><li>Sporadic cases of respiratory illness should be evaluated for influenza when influenza is prevalent in the community </li></ul><ul><li>Rapid influenza testing </li></ul><ul><ul><li>Sensitivity 70-85% </li></ul></ul><ul><ul><li>Specificity 90% </li></ul></ul><ul><ul><li>Predictive value depends on the prevalence of the disease </li></ul></ul>Geriatrics
  174. 174. Control of Influenza Outbreaks <ul><li>Chemoprophylaxis recommended when outbreaks occur </li></ul><ul><ul><li>All residents regardless of vaccination status should receive chemoprophylaxis </li></ul></ul><ul><ul><li>Continued for at least 2 weeks or until 1 week after the end of the outbreak (generally 4-6 weeks) </li></ul></ul><ul><ul><li>Offer to unvaccinated staff </li></ul></ul><ul><li>Isolation and physical separation of symptomatic residents </li></ul><ul><li>Cohorting of staff and residents from outbreak units where feasible </li></ul>Geriatrics
  175. 175. Control of Influenza Outbreaks (Cont’d) <ul><li>Adjusting/canceling of group activities </li></ul><ul><li>Use of masks by symptomatic staff </li></ul><ul><li>Staff encouraged to take sick time if presence of respiratory illness </li></ul><ul><li>Notices to visitors with respiratory symptoms to postpone visits </li></ul>Geriatrics
  176. 176. <ul><li>Amantadine (Symmetrel) and rimantadine (Flumadine) 70-90% effective in preventing influenza A. Not recommended for use in U.S. in 2005 secondary to increased resistance </li></ul><ul><li>Zanamivir (Relenza) and oseltamivir (Tamiflu) 80-90% effective in preventing influenza A & B </li></ul><ul><li>Side effects of amantadine and rimantadine include anxiety, depression, insomnia and other CNS symptoms - 10% and 2% respectively. Nausea, vomiting, dyspepsia in less than 2% </li></ul>Antiviral Drugs Used in Influenza Geriatrics
  177. 177. Antiviral Drugs Used in Influenza (Cont’d) <ul><li>Cost for 5-day course of treatment </li></ul><ul><ul><li>Amantadine $2 </li></ul></ul><ul><ul><li>Rimantadine $20 </li></ul></ul><ul><ul><li>Oseltamivir $55 </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Effective if given within 36-48 hours after onset </li></ul></ul><ul><ul><li>Duration 3-5 days or 1-2 days after end of symptoms </li></ul></ul><ul><li>Typically </li></ul><ul><ul><li>Amantadine for prophylaxis 100 mg/day </li></ul></ul><ul><ul><ul><li>Effective, inexpensive </li></ul></ul></ul><ul><ul><li>Oseltamivir (Tamiflu) for treatment </li></ul></ul><ul><ul><ul><li>Reduced resistive strain </li></ul></ul></ul>Geriatrics
  178. 178. Sexuality and Aging <ul><li>“ The integration of somatic, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and enhance personality, communication, and love” </li></ul><ul><ul><li>-World Health Organization </li></ul></ul>Geriatrics
  179. 179. Myths of Sexual Aging <ul><li>Elderly persons have no interest in sex </li></ul><ul><li>Sexual expression is taboo in old age </li></ul><ul><li>Elderly women do not wish to discuss their sexuality with a professional </li></ul><ul><li>Masturbation is an immature activity for adolescents and teens only </li></ul><ul><li>Menopause indicates the death of sexuality for women </li></ul>Geriatrics
  180. 180. Facts of Sexual Aging <ul><li>Sexual behavior continues into old age as long as the physical health of an individual is maintained </li></ul><ul><li>Even frail elders, while not able to participate in overt sexual behavior, will demonstrate sexual feelings and needs </li></ul><ul><li>Frequency of sexual intercourse diminishes from 2-3x/week at age 20, to 0.5 x/week at age 60 </li></ul>Geriatrics
  181. 181. Survey Shows… (800 Persons Age 60-91) <ul><li>Like sex: 95% </li></ul><ul><li>Want sex: 99% </li></ul><ul><li>Orgasm important: 70% </li></ul><ul><li>Sexually active men: 79% </li></ul><ul><li>Woman orgasmic at least some of the time: 99% </li></ul><ul><li>Masturbation: Accept in principle - 82%; practice - 46% </li></ul><ul><li>Satisfaction same or better than when young: 75% </li></ul>Geriatrics
  182. 182. Normal Age-Related Changes: Female <ul><li>Vagina shortens/narrows </li></ul><ul><li>Vaginal mucosa thins, becoming less elastic </li></ul><ul><li>Increased vag pH = increased infections </li></ul><ul><li>Diminished vag lubrication = takes more stimulation </li></ul><ul><li>Strength of orgasmic contractions diminished </li></ul><ul><li>Orgasmic phase shorter in duration </li></ul><ul><li>In resolution phase, vasocongestion of clitoris/vagina subsides quickly </li></ul>Geriatrics
  183. 183. Normal Age-Related Changes: Male <ul><li>Spontaneous erection takes longer </li></ul><ul><li>Firmness of erection decreased </li></ul><ul><li>Ability to maintain erection without ejaculation is prolonged </li></ul><ul><li>Volume of ejaculate decreased </li></ul><ul><li>Force of ejaculate decreased; may be only seepage </li></ul><ul><li>Post-orgasm erection fades quickly </li></ul><ul><li>Refractory period may be up to 24 hours </li></ul>Geriatrics
  184. 184. Causes of Sexual Dysfunction <ul><li>Illness (HTN, DM, TURP, OA, Depression) </li></ul><ul><li>Drugs: MANY </li></ul><ul><li>Psychogenic factors (boredom, illness of spouse, overindulgence in food or drink) </li></ul><ul><li>Environmental (lack of privacy, lack of willing or capable partner, socially unacceptable relationship [women]) </li></ul>Geriatrics
  185. 185. Evaluation <ul><li>You must ask, they won’t tell you – BUT, be prepared and comfortable dealing with answers </li></ul><ul><li>Good open-ended questions best presented during review of systems: </li></ul><ul><ul><li>“ Tell me about the sexual part of your life” </li></ul></ul><ul><li>Anticipate the need to discuss physiologic changes and misconceptions </li></ul>Geriatrics
  186. 186. Specific Interventions <ul><li>Female </li></ul><ul><ul><li>Hormone replace, Replens, AminoCerv 5.5 </li></ul></ul><ul><ul><li>Masturbation </li></ul></ul><ul><ul><li>Mechanical stimulation </li></ul></ul><ul><li>Male </li></ul><ul><ul><li>Sexual counseling (usually for “loss” issues, not just sex) </li></ul></ul><ul><ul><li>Viagra, external vacuum, penile injection therapy, implant surgery </li></ul></ul>Geriatrics
  187. 187. Sexual Counseling of the Coronary Patient <ul><li>Most are curious, but distressed by the lack of specific recommendations from the medical staff after an MI </li></ul><ul><li>Address when to resume – generally when physically able to climb two flights of stairs or walk several blocks at a brisk pace </li></ul><ul><li>CABG patients, due to sternal incision, may be counseled that female-on-top may be more comfortable at first </li></ul>Geriatrics
  188. 188. Approach to the Evaluation of Older Drivers <ul><li>More fatal car crashes per mile driven except teenagers </li></ul><ul><li>Failure to yield right of way and failure to obey a traffic sign most common </li></ul><ul><li>Elderly drivers should be kept on the road as long as they are “safe” </li></ul><ul><li>No one effective test of driver safety </li></ul><ul><li>Risk Factors </li></ul><ul><ul><li>History of falls in past 2 years </li></ul></ul><ul><ul><li>Decreased useful field of vision </li></ul></ul><ul><ul><ul><li>Measure how well one can pay attention to a large area all at once </li></ul></ul></ul><ul><ul><li>Cognitive decline </li></ul></ul><ul><ul><li>Medication use – benzodiazepines, antidepressants (beta-blockers protective – decreased anxiety and tremor) </li></ul></ul>Geriatrics
  189. 189. Approach to the Evaluation of Older Drivers (Cont’d) <ul><li>Evaluation </li></ul><ul><ul><li>Muscle strength > 35 lb. grip strength </li></ul></ul><ul><ul><li>Mobility </li></ul></ul><ul><ul><li>Hearing – able to distinguish sounds </li></ul></ul><ul><ul><li>Visual acuity and attention – 20/40 in better eye </li></ul></ul><ul><ul><li>Peripheral vision - > 120 ° horizontal </li></ul></ul><ul><ul><li>Cognitive function MMSE >23, especially copying of pentagon figure </li></ul></ul>Geriatrics
  190. 190. Approach to the Evaluation of Older Drivers (Cont’d) <ul><li>State license renewal </li></ul><ul><ul><li>Different requirements </li></ul></ul><ul><ul><ul><li>New Hampshire and Illinois require yearly vision and on-the-road testing to renew license after age 75 </li></ul></ul></ul><ul><ul><ul><li>Florida – drivers >70 may renew by mail for 2 renewal periods (8 years) </li></ul></ul></ul><ul><ul><li>Driving competency testing available </li></ul></ul><ul><ul><ul><li>Vision </li></ul></ul></ul><ul><ul><ul><li>On-the-road exams </li></ul></ul></ul>Geriatrics
  191. 191. Approach to the Evaluation of Older Drivers (Cont’d) <ul><li>Legal issues </li></ul><ul><ul><li>Six states (California, Delaware, Nevada, New Jersey, Oregon, Pennsylvania) have mandatory reporting requirement regarding unsafe drivers </li></ul></ul><ul><li>Useful approach </li></ul><ul><ul><li>Talk with older driver and family </li></ul></ul><ul><ul><li>Give recommendations </li></ul></ul><ul><ul><li>Document in medical record </li></ul></ul><ul><ul><li>Most will agree with recommendations </li></ul></ul><ul><ul><li>If disagreement, confidential reporting to Department of Motor Vehicles is suggested </li></ul></ul>Geriatrics
  192. 192. Geriatrics Score 1 point for each “depressed” answer (no on 1, 5, 7, 11, 13; yes no others) Normal: 3 + 2 Mildly Depressed: 7 + 3 Very Depressed: 12 + 2 *Adapted from Sheikl, Jl, Yesavage, JA, Brooks, JO 3d, et al. Int Psycogeriatr 1991; 3:23.
  193. 193. Geriatrics Positive answers for depression are “no” to the first question and “yes” to the other questions. Two or more positive answers are indicative of depression. *Adapted from Rinaldi, P, Mecocci, P, Benedetti, C, et al. J AM Geriatr Soc 2003; 51:694.
  194. 194. Geriatrics Appendix B - Mini-Mental State Examination