Geriatric Patients

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[edit] Geriatric Patients

Sharon A. Levine

Patricia P. Barry

[edit] DEMOGRAPHICS

Life expectancy has improved dramatically during the twentieth century in the United States, largely because of decreases in deaths from acute illness, infectious diseases, and accidents and better prevention of chronic disease. In 1900, 3.1 million Americans, or about 4% of the population, were 65 or older. At present the number is more than 34 million, or 12.5% of the population. By 2050 the group is projected to grow to 78.9 million. The oldest old are the fastest growing population segment. The survivors of the baby-boom generation will become a great-grandparent boom, resulting in a huge increase in the number of people aged 85 and older. That cohort is expected to number 18 million, or 5% of the population, by 2050. Centenarians, 100 years and older, are expected to increase dramatically in number, from 32,000 in 1982 to 597,000 in 2040. The ranks of the elderly are therefore increasing both in absolute terms and relative to the population (Fig. 8-1).

Figure 8-1 Number (in millions) of persons 65 years of age and older from 1900 to 2030, based on data from the U.S. Bureau of the Census. Note that increments in years are uneven.

A person who turned 65 in 1900 had a life expectancy of 76.9 years; in general a 65 year old in 1995 had a life expectancy of 82.4 years. Whites outlive African-Americans: life expectancy in 1996 was 79.6 years for white women, 74.2 for African-American women, 73.8 for white men, and 66.1 for African-American men.

The gender gap in life expectancy means a preponderance of women in the elderly population. The gender ratio for elderly persons, or the number of men per 100 women, has been dropping over recent decades. It also decreases dramatically with age. As a result, elderly women are more likely than men to be living alone and to depend on nonspousal family or formal supports for care.

Despite decreased mortality and longer life, chronic illnesses continue to have a major impact on the elderly. Chronic conditions such as arthritis, hypertension, hearing impairments, and heart disease represent 60% of ailments plaguing community-dwelling elderly patients. In addition to addressing the three major causes of death in older Americans—cardiovascular disease, cancer, and stroke, which account for almost 80% of deaths among elderly persons—primary care physicians of the twenty-first century must confront issues of dependency and functional impairment in an older, sicker patient population with a multitude of coincident problems. Even without providing cures for chronic illnesses, a physician who improves sight, hearing, ambulation, or continence may enable a patient to remain in the community and avoid long-term institutionalization.

Many functionally impaired elderly currently reside in the community and are in need of primary care: only 5% of people over 65 are in nursing homes, and most of these are older than 85. Although the majority of noninstitutionalized elderly people function well physically, dependency needs do increase with age. Long-term care survey data indicate that 9.5 million people older than 50 living in the community have limitations in one or more of their activities of daily living (ADLs), which include bathing, toileting, feeding, and dressing, or instrumental activities of daily living (IADLs), which enable elders to live independently in the community and include managing finances, taking medications, preparing meals, housekeeping, and shopping.^[1]

For those aged 65 to 74, only 6.7% depend on others for care. At 85 or older that number soars to 44%. In this age group, personal care assistance is required by 9.6% of those living alone, 18.8% of those who live with a spouse, and 25% of those living with others. Caregiver stress among family members on whom these elders depend has been well documented. Spouses often are elderly and disabled themselves, and children juggle work and childrearing with providing care for aging parents. The primary care physician must be sensitive to the burdens placed on family and friends. The physician should function as a resource for community services and exploration of possible long-term institutionalization.

[edit] APPROACH TO THE ELDERLY PATIENT

[edit] Environment

The environment where the history and physical examination take place should be adapted for the elderly patient. Rooms should be warm so that patients can comfortably disrobe. Lighting should be adequate, with minimal shadows and glare, to maximize sight for visually impaired patients. Rooms should be located away from noisy corridors and have adequate sound insulation so that hearing-impaired patients are not at a disadvantage. Doorways should be wide enough to accommodate adaptive devices such as wheelchairs. Chairs should have firm backs, high seats, and arms that make sitting and rising easy, especially for patients with arthritis or proximal lower extremity muscle weakness. Examination tables should be low enough for patients to mount and dismount safely. Pillows can be used to elevate the heads of patients with kyphoscoliosis.

Patients should be encouraged to wear eyeglasses and hearing aids. Amplification aids can be kept in the office for hearing-impaired patients. The use of adaptive aids such as walkers, canes, and wheelchairs should be encouraged and provided for those who need them.

[edit] History Taking

In eliciting the history from an older person, the physician should consider the maxim of geriatric medicine that atypical presentation of disease is typical. Many conditions, such as myocardial infarction, pneumonia, and sepsis, develop without their familiar symptoms or present as vague discomfort. Nonspecific complaints (e.g., malaise, fatigue, weakness) often are the only symptoms of potentially serious conditions. New confusion, falls, incontinence, or other subtle changes from the patient's baseline must alert the physician to possible underlying illness presenting atypically.

The examiner should speak slowly and clearly. Providers with high-pitched voices should be aware that high-frequency hearing loss is common among persons and should lower their voice accordingly. History taking can be time-consuming. The patient should first be interviewed alone to allow an opportunity for discussion of private matters. Well-meaning family members may try to answer questions posed to cognitively impaired or frail patients, but an attempt should be made to use the patient as a primary source when possible. It is also important, however, to gather data from medical records, family members, friends, and formal caregivers. Family observations are particularly significant, and when cognitive impairment is present, these may be much more sensitive than general screening tests for intellectual function.

When taking the history, the physician should adapt the usual format in order to focus on specific issues of the elderly. The social history should be expanded and functional status carefully assessed. The history should include a targeted review of systems and questions about nutrition, medications, immunizations, and advance directives (Table 8-1).

Table 8-1 Adaptation of Medical History for Geriatric Patients

[edit] Affect Measurement

Affect measurement usually attempts to identify depression, which is common, treatable, and an important cause of dysfunction in elderly persons. The geriatric depression scale (GDS) has been validated in the clinical setting and was developed specifically for elderly patients (Fig. 8-2).

Figure 8-2 Geriatric depression scale (GDS), with points for “No”(N) and “Yes” (Y) responses. (Modified from Yesavage JA et al: J Psychiatr Res 17:37, 1982.)

[edit] Physical Examination

The examiner should note the patient's personal hygiene and mood, which can provide clues to overall functional status (Box 8-1).

Height and weight should be recorded at the first visit and weight at subsequent visits to uncover problems with nutrition and to monitor fluid overload or overdiuresis in patients with congestive heart failure. Unintentional weight loss may indicate abuse, neglect, underlying malignancy, thyroid disease, or depression.

Postural blood pressure and pulse are noted. Postural hypotension, although present in 10% of healthy community-dwelling elderly, may indicate changes in volume status or medication side effects, both of which may predispose the patient to falls. Orthostatic hypotension is defined as a 20–mm Hg decrease in systolic pressure or a 10–mm Hg decrease in diastolic pressure 3 minutes after the patient has risen from supine to standing. Systolic hypertension is a systolic blood pressure of 160 mm Hg or greater; diastolic hypertension is 90 mm Hg or above. Stiff, atherosclerotic brachial arteries may give elevated blood pressure measurements even when intraarterial measurements are normal (pseudohypertension). Osler's maneuver should be employed when pseudohypertension is suspected. To perform the maneuver, the cuff should be inflated above the first Korotkoff sound. If the radial or brachial artery does not collapse and is still palpable, this may indicate rigid arteries mimicking hypertension. This maneuver is especially helpful in a patient who has no retinal findings or cardiac changes suggestive of longstanding hypertension.

Visual acuity should be assessed with a Snellen eye chart. The prevalence of cataracts, glaucoma, macular degeneration, and refractive errors increases with age. Examination of gross visual fields by confrontation may reveal deficits caused by glaucoma, cerebrovascular events, or mass lesions. Ectropion (eversion of the eyelid) or entropion (inversion of the eyelid) may be present. Arcus senilis (depigmentation of the iris) occurs with normal aging. Dilated funduscopic examination may reveal increased cup-to-disc ratios associated with glaucoma or retinopathy from diabetes or hypertension.

Hearing can be assessed by the whisper test or a hand-held audioscope, which has excellent specificity and sensitivity. External auditory canals should be examined for cerumen impaction. Inspection and palpation of the oral cavity include evaluation of dentition and detection of gum disease, poorly fitting dentures, and abnormal lesions or masses.

Examination of the neck includes range of motion, which is important for driving skills and may give clues to vertebrobasilar insufficiency in patients with falls or near-syncope. The thyroid should be inspected and palpated for nodules or goiter. Auscultation of the carotids can reveal bruits or radiation of cardiac murmurs.

Because of the increasing incidence of breast cancer with age, yearly breast examinations for elderly women are important. Intertriginous areas also should be inspected for dermatitis or fungal infection.

Chest examination includes inspection for kyphosis and scoliosis and palpation of vertebral spines for tenderness. Otherwise the examination is the same as for younger adults.

The cardiac examination commonly reveals systolic murmurs, which occur in 30% to 80% of patients 65 and older. The differential diagnosis includes aortic sclerosis, aortic stenosis, idiopathic hypertrophic subaortic stenosis, and mitral regurgitation. Aortic sclerosis usually has an early peaking systolic murmur that may radiate to the carotids. The murmur of aortic stenosis is late peaking, radiates to the carotids, and may be associated with delayed carotid upstroke and an S₄ heart sound. Delayed upstroke suggests significant aortic stenosis and should be documented promptly by echocardiography, since advanced age is not a contraindication to aortic valve replacement. In elderly patients, however, the carotid upstroke may be brisker than expected because of stiff arteries, and significant aortic stenosis may be associated with an apparently normal carotid upstroke. An S₄ sound is often found in healthy elderly persons and is caused by decreased ventricular compliance. For a patient who is unable to squat, the physician can simply raise the patient's lower extremities to increase venous return as a way of determining the characteristics of a murmur. Diastolic murmurs are never considered normal in elderly patients.

The abdomen should be inspected for scars, which may indicate surgery that the patient has neglected to mention. An aortic aneurysm can be detected as a pulsatile mass greater than 3 cm, often with an associated bruit. The bladder can be palpated to assess for urinary retention when the history suggests this. Inguinal canals and femoral triangles should be examined for hernias. Yearly digital rectal examinations (DREs), which can be comfortably performed with the patient in the left lateral decubitus position, may detect prostate nodules and hyperplasia in men and fecal impaction, rectal masses, and occult blood in all elderly patients. Pathology in the prostate's median lobe, which is not accessible to the examining finger, may be missed on DRE. Prostate size on DRE does not correlate with outlet obstruction.

The gynecologic examination is still part of the routine evaluation of the elderly woman. For a patient with kyphosis a pillow under the head and neck makes the examination more comfortable. For patients with degenerative joint disease who cannot tolerate the dorsal lithotomy position even with leg-rest extenders, the left lateral decubitus position is helpful. The patient should be examined for the presence of atrophic vaginitis, cystocele, rectocele, urethrocele, and uterine prolapse. All women should have speculum examinations even if they have undergone hysterectomies, since in the past many hysterectomies were performed as supracervical procedures, leaving an intact cervix in which a carcinoma may develop. Frequency of Pap smears is discussed in Chapter 4 . In a normal elderly woman the ovaries should be nonpalpable; if appreciated on bimanual examination, there may be ovarian malignancy.

Extremities should be inspected and joints put through active and passive range of motion. Common skin findings such as venous stasis changes, including hyperpigmentation and stasis ulcers, may be noted. Peripheral pulses should be assessed, and if absent, the distal extremity should be examined for signs of arterial insufficiency, such as pallor, dependent rubor, or coolness. Pitting edema below the knees may indicate right-sided heart failure, venous stasis, or diseases associated with hypoalbuminemia. The podiatric examination includes evaluation for corns, calluses, bunions, hammer toes, plantar warts, tinea pedis, and nails infected by fungus or simply overgrown. Determining the condition of the feet is essential in the evaluation of falls and gait disturbances. In addition, diabetic patients and others with peripheral neuropathies may be unaware of potentially dangerous foot ulcers or sores. Patients should be examined with and without shoes to ensure that the shoes fit properly and are in good repair.

The neurologic examination should include an office assessment of mental status, such as the Folstein Mini-Mental State Examination (Box 8-2), during which subtle well- compensated dementia can be unmasked and severe memory impairment recognized and quantified. Such instruments enable the physician to establish a baseline and follow cognitive function objectively over time. The cranial nerve, sensorimotor, and reflex examinations are performed as usual. Common findings in healthy elderly persons include primitive reflexes such as the snout, glabellar, and palmomental reflexes, which are nonpathologic in the absence of other findings, and symmetrically diminished vibratory sense and ankle jerks. Cranial nerve changes include diminished accommodation, pupillary response to light, and upward gaze.

Although motor strength is decreased in the elderly, this finding should not have clinical manifestations unless the patient has joint pain, decreased range of motion, or weakness. The neuromuscular examination may be normal in patients who have functional limitations. For example, hip and knee flexors may be normal in patients who have difficulty sitting down. Therefore it is imperative to use performance-based assessments to identify patients with functional disability, especially those who fall or have gait and balance problems. The Tinetti Performance-Oriented Assessment of Gait and Balance can easily be performed during an office evaluation with little time added to the visit (see Falls).

Skin should be inspected for xerosis, cellulitis, stasis dermatitis and ulcers, actinic keratoses, basal cell carcinomas, malignant melanoma, and pressure sores.

[edit] ASSESSMENT OF GERIATRIC CONDITIONS

Many older patients suffer from multiple disabilities and illnesses. Because of the complexity of their problems, a diagnosis-oriented approach may be inadequate for assessing and maintaining overall health and functional status. The physician needs information not only about individual ailments, but also about their interacting physical, mental, and social aspects. To answer that need, a coordinated multidisciplinary approach has evolved, known as geriatric assessment, which typically involves a physician, nurse, and social worker. Information is obtained and organized regarding five basic domains: (1) physical health, (2) performance of ADLs (basic and instrumental), (3) mental health, (4) socioeconomic resources, and (5) the patient's environment, with special emphasis on the relationships among the factors. Techniques for assessing the first four of these have been previously described (see Approach to the Elderly Patient).

The environmental assessment covers factors such as the convenience, safety, and availability of services and social supports. A home visit by the physician or other health care professional often provides essential information regarding the need for specific interventions, including physical equipment (ramps, grab bars), special services (homemakers, meals), and increased social activity (visitors, day care) (see Home Care).

In 1988 the National Institutes of Health sponsored the Consensus Development Conference on Geriatric Assessment Methods for Clinical Decision-Making. The consensus statement noted that the goals of assessment often are interdependent; diagnostic accuracy leads to appropriate interventions and better use of available services, resulting in improved function and optimal patient placement. Geriatric assessment should be performed in many different clinical settings, both institutional and community. The consensus statement pointed out that two aspects of geriatric assessment are particularly important: (1) targeting patients most likely to benefit, especially those who are frail but not terminally ill and those at critical transition points (e.g., change in living situation, loss of loved one or caregiver), and (2) linking assessment with care management and follow-up services to implement the recommendations resulting from assessment. Geriatric assessment is thus a process involving referral, collection of information, assessment, and development and implementation of a care plan, with periodic reassessment and modification of that plan.

In the past decade, geriatric assessment programs have been implemented and evaluated in inpatient units, outpatient and home care programs, and long-term care facilities. Well-designed studies have demonstrated the value of assessment in improving diagnostic and therapeutic outcomes in some settings, usually involving assessment by multidisciplinary teams and follow-up case management. Evaluation of geriatric assessment in outpatient settings has yielded inconsistent results. A 1993 meta-analysis of 28 controlled trials of five types of geriatric assessment concluded that some programs linking evaluation with strong long-term management are effective for improving survival and function in older persons.^[2] However, comprehensive geriatric assessment is not widely available and is not adequately reimbursed.

The impact on outcome depends on the ability to target appropriate patients and to identify resources and services necessary for follow-up care. A better understanding of which components are likely to yield the most information is needed. Techniques that facilitate evaluation and management by primary care physicians should be developed before geriatric assessment is widely implemented in primary care.

[edit] FALLS

Falls are a common and morbid problem among both community-dwelling and institutionalized elderly. Falls can result in minor to severe acute injuries, prolonged physical and psychologic disability, institutionalization, and death. As with many geriatric conditions, causes of falls are often multifactorial and reversible with intervention. The tendency to fall represents a confluence of factors, including physical illness, disability, medications, and environmental hazards, often with a minor event tipping the balance. Most recent geriatrics literature uses the Kellogg International Work Group definition, in which the term falls excludes incidents resulting from intrinsic factors (e.g., syncope, stroke) or sequelae of violent acts (e.g., blows to head).^[3]

[edit] Epidemiology

Worldwide, approximately one third of community-dwelling elderly over age 65 fall each year. That percentage rises with advancing age; the rate approaches 50% for those 80 and older. The number also rises with institutionalization: these patients have an average of 1.6 to 2.0 falls per year. Women fall more often than men until age 75, when the frequencies become the same, but men die more often from their falls. Half of those who fall do so more than once. Falls precipitate most injuries in people over 65, an age group for whom injuries are the seventh leading cause of death.

About 5% to 10% of falls lead to serious soft tissue injury, such as bruises, lacerations, hematomas, sprains, and joint dislocations. About 5% of falls result in fractures, usually of the hip, pelvis, wrist, or humerus. One in 100 falls results in a hip fracture, with this morbid and sometimes fatal complication occurring in one in 10 elderly over age 80 who fall. In one study, 12% of falls that did not cause serious injury resulted in the individual being on the floor at least 30 minutes, which creates a risk for rhabdomyolysis, pressure sores, pneumonia, and dehydration.^[4]

Perhaps as devastating as the physical injuries and disabilities caused by falls are the psychologic and social sequelae. Fear of falling develops in almost 50% of those who have fallen, and 26% curtail their activities because of fear.^[5] They withdraw from activities, losing functional ability, becoming further deconditioned, and increasing their risk of falling. This cycle can be a contributing factor in the ultimate institutionalization of a patient. One study of a cohort of older adults (mean age 80) found that those who had one fall without serious injury during the previous 3 months were 3.1 times more likely to be admitted to a skilled nursing facility than those who had not fallen during that period. Patients who had more than two such falls were 5.5 times more likely, and those who had falls with serious injuries during the 3-month period were 10.2 times more likely to be admitted to such a facility. The risks were adjusted for multiple confounders.^[6]

[edit] Pathophysiology and Risk Factors

Falls are often caused by a complex interaction of intrinsic age-related or disease-related changes and extrinsic or environmental factors (Box 8-3). Gait, balance, and the capacity to avoid a fall by regaining stability are affected by interrelated changes in the visual, neurosensory, and musculoskeletal systems. Gait changes include short steps, decreased velocity, decreased step height, and decreased arm swing. A senile gait is described as small stepped and wide based, with decreased arm swing and stooped posture, flexed hips and knees, uncertainty and stiffness in turning and sometimes difficulty initiating steps, and a tendency to fall without a clear reason.

Aging results in increased sway and decreased balance on one leg, but conditions such as Parkinson's disease, hemiplegia, neuropathies, myelopathies, and severe orthopedic deformities of feet, knees, and hips also affect gait (see Chapters 156 , 163 , and 169 ). There is a 20% to 40% decrease in isometric strength for ages 60 to 80.

Changes in vision caused by normal aging include decreased accommodation, acuity, contrast sensitivity, and adaptation to dark as well as glare intolerance. This situation is worsened by pathologic conditions commonly found in the elderly, such as presbyopia, cataracts, macular degeneration, retinopathy, and glaucoma. Vestibular function may decline from age-related changes such as disruption of vestibuloocular reflexes. Vestibulospinal function may be altered in patients with peripheral and central lesions from vestibulotoxins, including furosemide, aminoglycosides, aspirin, quinine, and ethanol. Proprioception may be affected by loss of proprioceptors in cervical or weight-bearing joints. Older persons' peripheral nervous systems have delayed motor and sensory nerve conduction velocities compared with those in young persons. The same is true of somatosensory-evoked potentials. Decreased vibration in toes and ankles has been documented. However, peripheral neuropathies from vitamin B₁₂ deficiency, diabetes, alcoholism, and syphilis are common in the elderly and may contribute to problems with gait and balance.

Cognitive impairment can lead to loss of awareness of the environment and predispose people to falls. Falls occur three times more frequently in patients with senile dementia of the Alzheimer type (SDAT) than in healthy elderly.

Orthostatic hypotension occurs in 10% of community- dwelling elderly and is associated with 2% to 15% of falls. Causes of postural hypotension include autonomic dysfunction due to age, central nervous system damage, diabetes mellitus, hypovolemia, and decreased cardiac output. Metabolic and endocrine disorders, including Addison's disease, can cause orthostasis. Age-related physiologic changes, such as decreased renin-angiotensin response and decreased baroreceptor sensitivity, may contribute. Postprandial hypotension has been well documented. Drop attacks, reportedly associated with up to 10% of falls, result in sudden falls while walking or standing, without loss of consciousness. These may be caused by vertebral artery insufficiency secondary to atherosclerosis or compression by cervical spondylosis.

Several medications have been implicated in falls (Box 8-4). A recent systematic review and meta-analysis of 40 studies (not randomized controlled trials) of psychotropic drug use and falls in older people showed a small but consistent association between increased risk of falls and use of neuroleptics, antidepressants (mostly tricyclics), sedatives/hypnotics, and benzodiazepines. The use of more than one psychotropic drug increased the risk.^[7] A similar review of 29 studies (also not randomized controlled trials) critically evaluating the evidence linking cardiac and analgesic drugs to falls showed that digoxin, diuretics, and type IA antiarrhythmics (antidysrhythmics) were associated with falls. The use of more than three or four drugs increased the risk of falls.^[8] This meta-analysis indicated that no other class of cardiovascular drugs or analgesics was associated with increased risk of falls. In other studies, however, calcium channel blockers, β-blockers, centrally acting α-adrenergic agents, and narcotics have been implicated in falls.

From 40% to 50% of accidental falls are related to environmental hazards.^[5] Furthermore, falls resulting in injury are more often related to environmental causes than falls that do not produce injury, particularly in younger and more active patients. Environmental factors include stairs (descent is especially hazardous where edges of steps are unclear); slippery, icy, uneven, or wet surfaces; poor lighting; unexpected obstacles such as children, toys, and pets; poorly fitting footwear and trousers; low beds, chairs, and toilets; loose rugs; wire; and clutter.

However, falls are usually caused by the combined effects of many factors. Sedatives, cognitive impairment, disability to the lower extremities, presence of a palmomental reflex, abnormalities of gait and balance, and foot problems pose the greatest risks. In addition, the risk of falling increases linearly with the number of these risk factors.

[edit] History

Questions about falls should be part of a routine history in patients 65 and older. A detailed history, including the what, when, where, and why of a fall, can reveal high-risk conditions or behaviors as well as patterns for recurrent problems. Open-ended questions such as, “Tell me about this fall and others you have had,” may be very revealing. It is helpful to ask for a demonstration of the patient's positions before, during, and after a fall. The examiner also should ask about problems with gait, balance, or walking secondary to joint or foot conditions. Premonitory symptoms such as dizziness, lightheadedness, and vertigo can indicate hypotension, vestibular problems, hypoglycemia, or drug side effects. Incontinence causes falls by creating slippery surfaces. Chest pain associated with arrhythmias (dysrhythmias) or ischemia can cause hypotension. Questions about eyesight, hearing, sensation, memory problems, and depression also are relevant. If a patient is too cognitively impaired to give a meaningful history, information should be obtained from family, friends, and caregivers. Review of all over-the-counter and prescription drugs is essential. Questions about recreational drugs and alcohol are important. A medical history covering all medical and surgical conditions may identify patients who are at high risk.

[edit] Physical Examination

Supine-to-standing blood pressure after a 3-minute interval should be obtained to rule out symptomatic postural hypotension. Skin examination for turgor, pallor, and trauma is necessary. The head examination should include tests for visual acuity and fields, gaze preferences, nystagmus, and hearing loss. During the neck examination the physician should listen for carotid bruits and check for range of motion at the cervical spine. Pulmonary status can be assessed by listening for rales or egophony. The cardiac examination includes appreciation of murmurs, especially aortic stenosis, dysrhythmias, and gallops. Extremities should be evaluated for joint deformities, range of motion, corns, calluses, ulcers, bunions, long toenails, poorly fitting shoes, and signs of fractures. Range of motion and stability of the thoracic and lumbar spine also are important.

A neurologic evaluation for mental status, focal motor deficits, paresis, tremor, rigidity, decreased proprioception, and vibration should be carefully performed, although the standard neuromuscular examination may not reveal functional impairments. For example, knee and hip flexion may be normal most of the time, even when a patient remains functionally impaired and has difficulty sitting or standing. It is therefore important to perform functional assessments of gait and balance required for daily activities. In the “Get Up and Go” test the patient is instructed to arise from a chair without using the hands, walk 15 to 30 m, return, stand still, and then sit down. This test or the Tinetti Performance-Oriented Assessment of Gait and Balance can be performed easily in a few minutes during a home or office evaluation (Boxes 8-5 and 8-6).

[edit] Environmental Assessment

Because the majority of falls in community-dwelling elderly persons occur at home during normal ADLs and because 40% to 50% of accidental falls are related to environmental hazards, a home evaluation by a physician, nurse, or physical therapist is essential in the workup of falls. Falls by healthier older adults often are associated with environmental factors. This group also has a higher frequency of falls that lead to injuries. Environmental checklists have been designed to evaluate the home for safety hazards (Box 8-7).

[edit] Laboratory Tests and Diagnostic Evaluation

The diagnostic workup should be guided by the history and physical examination (Box 8-8). Holter monitoring has not been shown to be useful in the routine evaluation of nonsyncopal episodes without cardiac symptoms; both fallers and nonfallers have a high incidence of ventricular and supraventricular dysrhythmias, and treatment of unclear value is fraught with side effects that can lead to falls.

[edit] Management and Interventions

Since up to 10% of falls unrelated to syncope are related to atypical presentation of acute illnesses in elderly patients, such as pneumonia, stroke, anemia, or dehydration, it is important to rule out illness in a patient who suddenly starts falling. Patients at high risk for falls because of their physical or mental status or environmental factors should have their charts flagged for intervention. When prescribing medications, the physician should weigh the benefits of treatment with possible reactions affecting gait, balance, and mental status and should adjust dosages based on age-related changes in drug metabolism (see Drug Prescribing, p. 84). The physician should carefully review all over-the-counter, recreational, and prescribed drugs.

Patients who fall should also be treated for underlying dysrhythmias clearly associated with the fall, heart block, volume loss, and Parkinson's disease. Patients with orthostatic hypotension should receive education about raising the head of the bed to decrease the incidence of hypotensive falls on standing. These patients may find it helpful to wear graded pressure stockings to decrease venous pooling, to sit at the edge of the bed before standing, and to liberalize dietary salt. Mineralocorticoids may be helpful. Osteoporosis should be treated to help prevent fractures from falls. Drop attacks from vertebrobasilar insufficiency may be helped by a cervical collar. Glasses, hearing aids, new shoes, and assistive devices should be supplied when necessary.

Education regarding community services (e.g., adult day care, social senior centers) where patients can be more closely supervised, transportation, medical alert devices, and nutrition and alcohol counseling should be initiated. Physical or occupational therapy and specific strength and balance training may be beneficial. A meta-analysis of the effect of the multisite FICSIT (Fraility and Injuries: Cooperative Studies of Intervention Techniques) study showed that general exercise and balance training decreased the risk of falls by 10% and 17%, respectively.^[9] In one of the FICSIT sites a multidisciplinary risk abatement program resulted in a reduction of falls by 31% at 1 year. The 301 subjects ages 70 and older were randomized to receive either home interventions to identify risk factors or social visits. Interventions included an environmental hazards assessment, medication review, treatment of postural hypotension, and physical therapy to improve strength, balance, and gait.^[10] The study's success shows the need for a multidisciplinary approach to the primary and secondary prevention of falls. Finally, the patient should be instructed in how to arise from a fall and should be provided with a medical alert device.

[edit] URINARY INCONTINENCE

[edit] Epidemiology

Urinary incontinence represents a major cause of disability, social isolation, and institutionalization in elderly patients. It affects 5% to 15% of those over age 65 living in the community and 50% or more of those living in long-term care facilities. Neurologic impairment, immobility, and female gender are the major independent risk factors. Some 40% of hospitalized elderly are reported to be incontinent; much of this is transient and reversible if recognized and appropriately evaluated. Urinary incontinence is frequently cited by families as the major factor leading to the decision to place an elder in a nursing home. Institutionalized incontinent patients are much more difficult to care for than continent patients because of increased secondary problems (e.g., falls, skin breakdown) and expanded nursing care needs.

[edit] Pathophysiology

Continence requires structurally intact and functional detrusor and sphincter muscles as well as the reflexes that coordinate them. The onset of urinary incontinence is not part of normal aging, but age-related physiologic changes may predispose to incontinence (Box 8-9). Any of these in combination with another medical or physiologic problem may result in incontinence.

Proper function of the lower urinary tract depends greatly on normal function of the autonomic nervous system. The detrusor and sphincter are innervated by parasympathetic cholinergic fibers that emerge from the spinal cord at the S2-S4 level and travel via the pelvic splanchnic nerves, as well as sympathetic noradrenergic fibers via the paraaortic sympathetic chain. Parasympathetic stimulation results in detrusor contraction, sphincter relaxation, and voiding. Sympathetic stimulation inhibits detrusor contractions and increases the tone of the involuntary sphincter, thus promoting the storage of urine. The balance between the two sides of the autonomic nervous system and thus the control of the micturition reflex is mediated by several micturition centers located in the lower spinal cord, brainstem, and cerebral cortex. The cerebral cortex is the site of voluntary control and exerts an inhibitory influence on voiding. Injury, disease, or pharmacologic side effects at any point in the neurologic circuit can result in a disorder of either storage or voiding of urine and therefore can cause incontinence.

[edit] History and Physical Examination

The initial evaluation of the elderly incontinent patient includes a thorough history and physical examination, which often includes obtaining information from family members. The history should focus on the frequency, timing (diurnal versus nocturnal), volume, and symptoms associated with incontinence episodes. An incontinence chart or diary can be useful diagnostically and in the development of a treatment plan (Fig. 8-3).

Figure 8-3 Bladder record for outpatient settings.

Urinary incontinence can be triggered or perpetuated by a broad variety of medical and psychologic illnesses, most of which are not directly related to the function of the lower urinary tract. Because local structural and neurologic abnormalities frequently coexist with and contribute to incontinence, however, the physician should be particularly attentive to certain aspects of the neurologic and abdominopelvic examination. Sacral levels 2 through 4, which carry parasympathetic fibers to the detrusor and sphincter, can be examined by assessing rectal tone, perianal sensation, and the bulbocavernosus reflex. Abnormalities suggest significant spinal cord or cauda equina pathology. The abdomen should be carefully palpated and percussed for a suprapubic mass suggestive of a distended bladder. The rectal, and in women pelvic, examination is essential in excluding causes such as fecal impaction, rectal or pelvic masses, pelvic floor abnormalities (e.g., uterine prolapse), and cystocele or urethrocele. Vaginal infection should be excluded or treated and atrophic changes noted. Laboratory evaluation should include urinalysis and culture as appropriate. Chemistries to evaluate the patient's metabolic status, especially blood sugar and calcium, and renal function are important.

Careful review of medications and their indications is essential to any initial evaluation. Many prescription and over-the-counter drugs affect detrusor and sphincter function and may cause subtle degrees of delirium and cognitive dysfunction (Box 8-10).

[edit] Classification and Etiology

Transient incontinence accounts for approximately 75% of new-onset incontinence and is most likely to have a reversible cause. The etiology usually is not readily referrable to the urinary tract, with the notable exception of urinary tract infection. Transient incontinence is common in elderly hospitalized patients. The DIAPPERS mnemonic helps in recalling the common causes of transient incontinence (Box 8-11).

Established incontinence refers to chronic incontinence caused by dysfunction of the detrusor, the outlet, or the neurologic pathways controlling them. Established incontinence is commonly divided into three general clinical syndromes to provide a framework for diagnosis and management: (1) urge (from detrusor overactivity with uninhibited bladder contractions), (2) stress (from failure of the sphincter to remain closed during bladder filling), and (3) overflow (from impaired detrusor contractility, bladder obstruction, or both).

Incontinence that may be transient can become established if not promptly identified and managed or if assumed to be established from the outset. Established incontinence is less likely to be completely reversible, although management can ameliorate symptoms and reduce social impairment.

[edit] Urge Incontinence.

Urge incontinence represents the most common clinical incontinence syndrome in the elderly. The history reveals a warning sensation occurring seconds to minutes before the involuntary voiding of moderate to large volumes of urine. Increased urinary frequency and nocturnal incontinence are common features. The postvoid residual (PVR) is typically low, and cystometry demonstrates contraction at low bladder volumes. The physician may find no objective neurologic signs, although this clinical pattern of incontinence is commonly associated with an underlying neurologic problem.

The cause of urge incontinence is usually detrusor overactivity (DO), either primary or secondary. Primary DO is an age-related change. The differential diagnosis of secondary DO includes stroke, Alzheimer's disease, parkinsonism, central nervous system tumors, and local bladder irritation (e.g., infection, stones, inflammation, tumors). DO may coexist with impaired detrusor contractility (detrusor hyperactivity with incomplete contractions, or DHIC). There is an increased PVR without outlet obstruction.

The evaluation of a patient with urge incontinence begins with a routine urinalysis and, if indicated, urine culture. The evaluation of women includes a pelvic examination with attention to contributory conditions, such as infectious or atrophic vaginitis. When infection or atrophy is diagnosed and treated, incontinence may resolve or greatly improve. For men a DRE with careful palpation of the prostate gland is essential. Although the size of the prostate gland correlates poorly with the presence or absence of outlet obstruction, the finding of a large gland is usually important. In addition, any finding of asymmetry, nodularity, or stony hardness warrants further investigation with prostate-specific antigen (PSA) testing and possible referral for transrectal ultrasound (TRU) and biopsy, if appropriate.

In most patients the initial evaluation of urge incontinence should also include a PVR volume determination. Volumes greater than 100 ml may indicate DHIC or obstruction and should prompt consideration of further investigation or referral. An empiric pharmacologic trial in such a setting carries a high risk of inducing urinary retention in male patients and is probably best avoided; for female patients there is much less risk. The finding of a normal PVR (less than 50 ml) is reassuring but does not exclude the possibility that urinary retention will occur, especially in men, in whom a normal PVR can be seen with significant prostate enlargement. Devices that measure urine flow during voiding can be used to screen for male patients with significant mechanical obstruction before a drug trial. When such measurements are not possible, men should be referred for cystoscopy and urodynamics before any pharmacologic intervention.

A bedside urodynamics test may detect DO and determine bladder capacity. A Foley catheter is inserted into the patient's bladder and attached to a syringe, which is used to fill the bladder with saline. A rise in the salination level in the syringe column is used to diagnose DO. Although bedside cystometry is moderately sensitive and specific for DO, itsusefulness is unclear. When the diagnosis is uncertain, patients should be referred for formal testing.

The management of urge incontinence is aimed at treating underlying predisposing conditions when possible or appropriate; otherwise, treatment is aimed at managing symptoms. Assistive devices such as bedside commodes and urinals help to manage nocturnal symptoms. Toileting regimens based on completion of an incontinence chart are often effective for patients who can cooperate (see Fig. 8-3). Instructing patients to limit fluids, especially caffeinated beverages and alcohol, can restore control and confidence. Diuretic use should be avoided or minimized.

A logical clinical approach leads to the satisfactory management of most patients without referral, as well as the appropriate referral of a subset of patients who need further investigation. Table 8-2 provides evidence supporting the efficacy of various pharmacologic and behavioral treatments used for urge incontinence. Randomized controlled trials have shown that behavioral management for DO decreases incontinence episodes.^[11] Patients who are cognitively intact can employ timed voiding while awake and can suppress precipitant urges through visualization and concentration. For patients with cognitive impairment, habit training, scheduled voiding, and prompted voiding are successful techniques. Empiric pharmacologic intervention is effective in urge incontinence if implemented with appropriate caution (Box 8-12).

Table 8-2 Efficacy of Behavioral and Pharmacologic Treatments for Urge Incontinence

✢A, Randomized controlled studies; B, case-control studies; C, case descriptions or expert opinion.

Therapy is aimed at decreasing the contractility and suppressing spontaneous contractions of the detrusor. This can be accomplished with drugs such as oxybutynin and tolterodine, which have been shown to result in fewer episodes of incontinence compared with placebo in randomized controlled trials. Other drugs that have been shown to decrease incontinence in case-control studies include anticholinergics and tricyclic agents such as imipramine.^[11] The selection of an agent depends on consideration of side effects and cost, as well as comorbid conditions. Dosing should be initiated at the lower end of the stated range for each agent until symptoms are ameliorated, side effects are encountered, or the upper end of the dosage range is reached without discernible effect.

[edit] Stress Incontinence.

Stress incontinence is the most common presenting pattern of urinary incontinence in women. It is relatively uncommon in men, unless traumatic or surgical damage has occurred to the urinary sphincter. Patients complain of intermittent leakage of small amounts of urine associated with laughing, coughing, or lifting heavy objects. The cause is usually related to impaired urethral closure from a postmenopausal decrease in estrogen, with subsequent atrophy and thinning of the urinary sphincter and pelvic floor muscles. The bladder neck and sphincter, which are normally located within the pelvis and are therefore intraabdominal, can descend out of the pelvis. In this situation, transient increases in intraabdominal pressure, rather than reinforcing the resting tone of the urinary sphincter, instead overwhelm it, resulting in the expulsion of urine.

Another variant of stress incontinence is stress-induced DO, in which coughing, laughing, lifting, or other maneuvers that produce a sudden rise in intraabdominal pressure result in an uninhibited contraction of the bladder. Several features distinguish this condition from simple stress incontinence: (1) the volume leaked is moderate to large; (2) nighttime incontinence is more common; (3) a brief but detectable delay may occur between the stress-inducing maneuver and the passage of urine; and (4) the patient may experience urgency.The diagnosis of stress incontinence is based largely on history and physical examination. Pelvic and rectal examinations are indicated to detect evidence of estrogen deficiency and to exclude anatomic problems such as urethrocele or vesicocele, which might warrant surgical intervention. During the examination the patient should be asked to strain or cough, and the leakage of any urine should be noted. The patient then can be asked to repeat the maneuver after the examiner has inserted a finger in the vagina and elevated the bladder neck by exerting gentle pressure anteriorly. In a positive test the leakage of urine is corrected by bladder elevation.

The management of stress incontinence depends on the underlying cause, and the majority of patients respond to conservative therapy. Weight loss is indicated in obese patients and results in decreased pressure on the pelvic floor. The patient should be taught pelvic muscle exercises (PMEs), which involve isometric contraction of the pelvic sling muscles and can increase the strength and resting tone of the urinary sphincter. In randomized controlled trials, PMEs have resulted in 56% to 95% decreases in incontinence episodes. Biofeedback used in conjunction with PMEs has resulted in 50% to 87% reductions.^[11]

Estrogen therapy, either topical or systemic, has been effective in case-control studies, especially for women with clinical evidence of estrogen deficiency, such as atrophic vaginitis and hot flashes. In patients who do not respond to these therapies a trial of α-adrenergic agonists, such as long-acting phenylpropanolamine, can be given (Box 8-13). However, the side effects of these agents in elderly patients can be considerable. Estrogen plus an α-adrenergic agonist is more effective than an α-agonist alone. Table 8-3 provides evidence supporting the efficacy of behavioral and pharmacologic treatments for stress and mixed stress and urge incontinence. In mixed stress and urge incontinence a sudden rise in intraabdominal pressure triggers detrusor contractions. The management is essentially the same as for urge incontinence, although the diagnosis is frequently difficult to make clinically. This is because the delay between the stress and the detrusor contraction may be extremely brief, although the volume voided usually is greater than with pure stress incontinence. Imipramine may be effective in the treatment of stress-induced DO because it combines sympathomimetic effects on the urinary sphincter with anticholinergic effects on the detrusor. The data on imipramine for mixed stress and urge incontinence, however, are insufficient at this time.

Table 8-3 Efficacy of Behavioral and Pharmacologic Treatments for Stress and for Mixed Urge and Stress Incontinence

A variety of surgical procedures are available for selected patients who fail medical management. When surgery is not possible, a vaginal pessary or penile clamp may restore continence.

[edit] Overflow Incontinence.

Overflow incontinence refers to incontinence that occurs in the setting of abnormally high bladder volumes and incomplete emptying. The most common underlying condition in men is mechanical outlet obstruction, usually benign prostatic hypertrophy, but other causes include urethral stricture and prostate cancer. An underactive detrusor may result from fibrotic tissue replacement of the detrusor or neurologic disease. Neurologic causes include peripheral neuropathy (from alcoholism, diabetes, pernicious anemia, or tabes dorsalis) or damage to spinal detrusor afferent nerves. By definition the PVR is high, and patients report constant or frequent dribbling, which may be exacerbated by stress, and decreased force of the urinary stream. Patients also may report the sensation of incomplete bladder emptying and the need to strain to void. Physical findings may include a palpable bladder or suprapubic dullness to percussion in addition to any underlying neurologic deficits. As determined by DRE, prostate size correlates poorly with the presence of outlet obstruction. If the PVR is greater than 200 ml, hydronephrosis should be excluded by ultrasound, and tests for renal function should be done to rule out renal failure.

The performance of urodynamics is particularly important in suspected overflow incontinence. Peak flow urine rates greater than 12 ml/second exclude obstruction. Cystoscopy is necessary to determine the presence and site of a mechanical obstruction. Management includes eliminating medications that decrease detrusor contractility or increase external sphinctor tone, if possible. Mechanical obstruction with acute urinary retention should be relieved by medical or surgical means, followed by a voiding trial. If the bladder does not regain contractility, continued catheterization (preferably intermittent) may be necessary. Management may also include cholinergic agents to increase bladder contractility (if the patient must continue taking antipsychotic or antidepressant medications with anticholinergic properties) and α-adrenergic blockers to decrease resting sphincter tone and decrease prostatic obstruction.

[edit] Functional Incontinence.

Functional incontinence refers to incontinence that occurs because an individual has lost the capacity to move to an appropriate place to void in a timely manner. This definition incorporates both individuals with normally functioning urinary tracts and those with impaired function. An obvious example would be a patient who is hospitalized with a hip fracture and is placed in traction with an intravenous infusion. The patient is likely to become incontinent unless supplied with aids such as a bedside urinal or bedpan, prompt assistance from hospital staff, and aggressive restorative services such as physical and occupational therapy. Although usually less overt, global functional problems such as visual and auditory impairment, mobility problems, and deconditioning are frequently contributory factors in both transient and established incontinence. Identification and management of these functional difficulties are essential.

[edit] Use of Assistive Devices

The judicious use of adult incontinence briefs can provide substantial independence and prevent homeboundedness, functional decline, and institutionalization. Overuse can lead to skin maceration and breakdown, along with urinary and vaginal infections. The use of an indwelling or suprapubic Foley catheter should be reserved for patients in whom all other approaches have failed or are unacceptable. For those with hypocontractile bladders and retention as a cause of their incontinence, intermittent self-catheterization is a preferred method, with a lower infection rate.

Given the potential complications and loss of dignity, the use of Foley catheters and adult incontinence garments in acutely ill patients with transient incontinence is rarely appropriate, since the risk usually outweighs the benefit. Such management should not be invoked only for the convenience of the hospital or nursing home staff.

[edit] DRUG PRESCRIBING

The elderly use a disproportionately high volume of medications; the elderly constitute13% of the U.S. population but consume about 30% of all prescription drugs. Thus the primary care physician who has older patients is likely to encounter problems of adverse drug reactions (ADRs) and polypharmacy. The higher probability of ADRs in old age seems to relate more to clinical status than chronologic age, with an increased number of medications used in patients reflecting poorer clinical status.^[12] Data on drug effects in elderly patients are limited because drug trials often exclude women and older persons.^[13] Also, since the majority of studies have surveyed hospital admissions or inpatient populations, limited information is available on ADRs in outpatients. The most important factor in ADRs is the number of medications taken.

Idiosyncratic and allergic reactions appear to occur with the same frequency in elderly patients as in younger adult patients. Toxicity and side effects, however, are more common in older patients. Some elderly patients have diminished physiologic reserves because of disease, leading to decreased ability to tolerate stress and to respond appropriately to medications. Also, disease is more prevalent in the elderly, resulting in the need for more therapeutic interventions. Deficits in memory, sensation, and function increase the likelihood that patients will make medication errors. Certain illnesses appear to increase the risk of ADRs, including sensory loss, cognitive dysfunction, and diseases of the kidneys, liver, and heart.

Polypharmacy adds another dimension to the problem of ADRs. It increases the risk of individual ADRs and the likelihood of drug-drug interactions. If multiple drugs are prescribed and regimens are complex, prescribing errors (e.g., incorrect dosages) are also more likely to occur, and patients have more difficulty with adherence (see Chapter 3 ).

Drug responses are influenced by altered pharmacokinetics and pharmacodynamics. Pharmacokinetic changes with aging have been well described (Box 8-14). Since most drugs are absorbed by passive diffusion, absorption is generally unchanged if gastric mucosa is intact, but many poorly absorbed drugs have not been studied. Changes in body composition may affect drug distribution: lipid-soluble drugs may have a larger volume of distribution and thus a prolonged duration of action; water-soluble drugs may have a decreased volume of distribution, resulting in higher concentrations at standard dosages. The most important changes with age are those that affect drug clearance. Decreased phase I hepatic metabolism has variable effects and is influenced by other factors (e.g., smoking, alcohol consumption) but may result in prolonged clearance of active forms of many drugs. Phase II metabolism, such as conjugation, shows little or no change with aging. Renal elimination, correlated with creatinine clearance, may be decreased with age, resulting in higher concentrations of many drugs.

Pharmacodynamic effects depend on drug action at the receptor site and have not been well studied in the elderly. In general, most drug effects are similar to or greater than those in younger patients; effects may be magnified when disease states further alter drug elimination or response. For example, although cardiovascular β-adrenergic receptors appear to be less responsive, central nervous system receptors are often more sensitive, especially in patients with dementia.^[14]

Sedation and confusion are common drug complications in elderly patients, especially from medications with anticholinergic effects and sedative-hypnotics that affect the central nervous system. Other disturbances that suggest ADRs include orthostasis, falls, depression, urinary retention or incontinence, constipation, anorexia, and metabolic abnormalities, such as hypoglycemia, hypokalemia or hyperkalemia, hyponatremia or hypernatremia, and azotemia. Box 8-15 lists useful guidelines in prescribing drugs for elderly patients.

[edit] HOME CARE

Until the 1940s, primary care was often delivered in the home. As medical technology grew more complex and patients became more mobile, care switched to hospitals, clinics, and offices; the prevalence of house calls gradually diminished. With prospective payment systems now encouraging early discharge and Medicare allowing home services without prior hospitalization, the provision of home care is rising meteorically. The home care industry has been the fastest growing U.S. service industry. From 1990 to 1997, Medicare home care expenditures increased from $3.9 billion to an estimated $17.2 billion. At the same time, because of a demographic increase in the number of elderly, more functionally impaired elders are residing in the community. About 9.5 million older people with limitations in their ADLs are currently noninstitutionalized. Survey data show that these elders and their families prefer the home as the primary site for care.^[15]

Home care is the provision of a wide range of services and equipment to the patient in the home setting to restore and maintain the maximal level of comfort, function, and health. Homebound patients are community-dwelling individuals who depend on the assistance of others to perform some ADLs because of acute or chronic medical conditions or disabilities. In the absence of this help, they would be at high risk of institutionalization. An impressive array of professional, ancillary, and diagnostic services can be provided in the home, as well as advanced technology (Box 8-16). Funding for these services comes from a variety of sources, including federal and state governments (e.g., Medicare [Box 8-17], Medicaid, Title XX of Social Security Act, Title III of Older Americans Act, Veterans Administration, research and demonstration grants), charities, Blue Cross and other commercial carriers, and private out-of-pocket payments.

Indications for a home care referral include advanced age and frailty, multiple comorbidities, recurrent and frequent admissions, homeboundedness, and impaired psychosocial or functional status. Often the first sign of decline in status is the inability to keep scheduled office or clinic appointments. A house call as part of comprehensive geriatric assessment helps to identify medical, psychosocial, and environmental factors that affect functional ability (Box 8-18). In a randomized controlled trial with 1-year follow-up, veterans 70 or older were screened by a physician assistant or registered nurse for medical, functional, and social problems. The results included the discovery of four new or suboptimally treated problems in each patient, on average, and an improvement in immunization rate and IADL scores.^[16] The house call can be used for diagnostic purposes, for emergency evaluations that otherwise would require a trip to the emergency department, or for ongoing primary care of the homebound population, including home hospice care.

The home is the ideal nonthreatening location to identify the elder's strengths, abilities, and formal and informal supports. These factors are important in developing a care plan that can be put into operation realistically and complies with the patient's and family's wishes. A team approach and use of a home care coordinator for case management are essential in implementing complex plans, which may include referrals, services, and patient and family education. These approaches also allow continuous assessment of outcomes over time so that the plan can be revised as the patient's needs and health status change. A prospective randomized trial using a nurse-directed multidisciplinary intervention in patients 70 or older hospitalized for congestive heart failure resulted in better survival in the intervention group, fewer readmissions, better quality of life scores, and lower costs.^[17]

[edit] ELDER MISTREATMENT

[edit] Epidemiology and Definition

Mistreatment of the elderly is found among all racial, ethnic, and socioeconomic groups and occurs in both community and institutional settings. Incidence and prevalence rates in the community vary, largely because of the lack of uniform definitions of elder abuse and neglect, particularly among states and municipalities where reporting is mandatory. Lack of awareness or denial of this problem by public and health care professionals can result in underreporting. Victims who require heavy care may not report abuse or neglect for fear that they will hasten their placement in nursing homes, or they may be embarrassed to admit to mistreatment. Studies indicate that 1 to 2 million elderly per year are victims of abuse (physical, psychologic, financial) or neglect. Inclusion of those receiving inadequate care, which is a less restrictive definition, expands these numbers substantially.

Abuse or neglect can be active, as in the conscious withholding of food, clothing, shelter, or medicine, or passive, perhaps because the caregiver is unable to bathe, dress, or feed the patient. A less judgmental approach is to regard the situation as a mismatch between the elderly person's care needs and the services received. The problem of inadequate care must be dealt with, however, regardless of the cause.

[edit] Etiology

Several theories explain abuse and neglect. The dependency theory states that the more physically and mentally impaired the patient, the greater the risk for abuse, although dependency alone is an insufficient cause. The stressed-caregiver theory proposes that a threshold is exceeded by care needs, and this triggers abusive behavior. Superimposed external stresses, such as job loss or illness, exacerbate these caregiving burdens to the point where abusive behavior is triggered. The transgenerational family violence theory holds that children who are abused learn violence as a behavior and abuse their own children and elderly parents. Social isolation can set the stage, since patients have little access to social supports or confidants. The pathologic abuser theory states that the psychopathology of the abuser is the etiology of family violence, especially when alcohol, substance abuse, or psychiatric illness is involved.

No difference exists between the incidence in women and that in men, and age and level of cognition do not appear to be factors. The most significant risk factors are a history of previous family violence and evidence of substance abuse in the perpetrator. These risk factors, superimposed on an elderly person with heavy care needs, limited family resources, and stresses from juggling job and care duties, can lead to a multifactorial etiology for the abuse.

[edit] History

Several clues from the patient history may be of help in the diagnosis of elder abuse and neglect. Inconsistent or implausible explanations for disease or injury should alert the astute physician to possible elder mistreatment. Several hospital admissions or emergency room visits (often to different facilities) for illness or trauma, with explanations such as the elderly person being accident prone, should raise a red flag. The caregiver's insistence on providing the history or refusal to leave the room should also arouse suspicion. The patient's functional status in terms of ADLs and IADLs is important. Recent family stresses, such as loss of a loved one or job, the presence of family violence, and substance abuse, also indicate high-risk patients.

The patient should be interviewed in private so as not to be intimidated by possibly abusive caregivers. Specific questions should be asked about being hit, kicked, restrained, unfed, or left in soiled clothes. A sexual history, including questions about rape and incest, should also be elicited. A nonjudgmental, nonaccusatory interview with the suspected abuser should also occur in private. It is important to know if the alleged abuser is the patient's caregiver. The health care provider should determine the degree of the patient's dependence on the caregiver, as well as whether a fiduciary relationship exists (i.e., whether the provider is reimbursed for care or depends on the elderly person's income).

[edit] Physical Examination

Careful documentation of injuries and appearance should be recorded with narrative, drawings, or photographs. Dementia or delirium should be determined by mental status examination at the outset with an instrument such as the Folstein Mini-Mental State Examination (see Box 8-2). Box 8-19 lists signs of abuse.

[edit] Intervention and Treatment

The approach to elder abuse, neglect, and inadequate care usually involves a multidisciplinary team, including the skills of physicians, nurses, and social workers. Health professionals are mandated to report suspected cases of mistreatment in most states. State agencies often support elderly protective service programs that employ workers to make home assessments. These visits can be made under the guise of assessing care needs that may be met by outside agencies. If needs are not being met and the competent patient wants to be relocated or separated from an abuser, arrangements can be made to find alternate living situations or to remove the perpetrator. If the patient is competent and resists intervention (which is often the case), the health care provider must clarify that the person need not remain in such an environment and that help can be provided. This assistance can be home care services (e.g., home health aides, visiting nurses, delivered meals) or can involve respite, counseling, and education for the caregiver. If the patient does not have the mental capacity for decision making, a court-appointed guardian or conservator may be necessary. Often, education, counseling, and support services for a stressed caregiver, even one who cares for a patient with severe dementia, can end the cycle of abuse. For an elder who lives with a pathologic abuser, interventions aimed at the abuser (e.g., counseling, job training, order to evacuate) may be necessary.

The American Medical Association has provided guidelines to the diagnosis and treatment of elder abuse.^[18] Many complex ethical issues in the evaluation and treatment of elder abuse involve the patient's autonomy and right to refuse treatment as well as the confidentiality of the physician- patient relationship.

[edit] REFERENCES