THE WOES OF GROWING OLD
| TOP 10 PROBLEMS IN THE ELDERLY —Charles H. Stern, MD, Assistant Professor, Department of Family and Community Medicine, and Medical Director, Scott & White Clinic, Waco, Texas |
| 10) Polypharmacy: more comorbidities in elderly patients; higher likelihood of impairment (eg, cognitive dysfunction, dementia, depression); significant functional, social, and financial issues; age-related physiologic changes may affect drug metabolism; 30% of all pharmaceuticals consumed by elderly; most older adults take 3 to 5 medications daily; increased use of alternative medicines; adverse drug reactions—bleeding (eg, upper gastrointestinal [GI] bleeding with use of nonsteroidal anti-inflammatory drugs [NSAIDs]); hypoglycemia; 27% of adverse drug reactions in elderly preventable, 38% serious or life-threatening; study found 40% of nursing home patients on ≥1 inappropriate drug; ≤25% of hospitalizations in patients ≥80 yr of age related to adverse drug reactions |
 | Factors leading to polypharmacy and adverse drug reactions: multiple providers; lack of patient education about medications; inappropriate dose or medication; nonadherence or noncompliance; ordering errors (due to, eg, abbreviations); monitoring errors |
| Reducing polypharmacy: have patients bring all medications (including herbal and over-the-counter medications) to each visit; identify drugs by generic names and drug classes; write indication for each drug on prescription; know side-effect profiles; understand changes in pharmacokinetics with increasing age; stop any drug with no known benefit; try to substitute less toxic drugs; be aware of “prescribing cascade” (ie, continued treatment of side effects as symptoms, resulting in use of more medications); “1 disease, 1 drug, once a day” |
| 9) Malnutrition: reported in 5% to 12% of community-dwelling elderly and most hospitalized and institutionalized elderly patients; affects healing, response to antimicrobials, mobility, and rehabilitation; risk factors—low income; restrictive diets; eating alone; poor dentition; polypharmacy; screening—ask, “have you lost ≥10 lb in past 6 mo without trying to do so?”; nutritional health questionnaire on finances, alcohol use, diet, and medications |
| 8) Vision problems: affect >70% of senior citizens; presbyopia most common cause of diminished visual acuity; significant negative impact on quality of life; increases risk for falls; age-related macular degeneration—80% dry type, 20% wet type (similar to diabetic retinopathy; neovascularization on retina affects macula); new treatment affects vascular endothelial growth factor; refer to ophthalmologist; advise patients to stop tobacco smoking, control blood pressure (BP) and cholesterol, and take antioxidant vitamin preparation; cataracts—common; reversible with low-risk surgery; glaucoma—common in blacks; leading cause of blindness; screen black patients and patients with positive family history; diabetic retinopathy—can cause blindness; preventable; screening—ask, “because of your eyesight, do you have any trouble reading, watching television, driving a car, or doing any of your daily activities?” check visual acuity |
| 7) Hearing problems: presbycusis—most common; bilateral; affects higher frequencies (ie, not conversation-level frequencies); most patients complain of inability to distinguish language from high background noise; can affect physical, social, and cognitive well-being; prevention—hearing protection; avoidance of ototoxic drugs (eg, aminoglycosides and some chemotherapeutic drugs); NSAIDs may cause tinnitus and hearing loss (reversible); screening—ask, “have you noticed any changes in your hearing over the past 6 mo?”; Hearing Handicap Inventory for the Elderly questionnaire focuses on psychosocial and functional impact of hearing loss; pure- tone audiometry; whisper test; check for cerumen impaction; refer patients who desire hearing aids to reliable audiologist; patients with acute unilateral hearing loss and vertigo or other cerebellar signs require immediate evaluation and neuroimaging studies |
| 6) Falls: occur in 25% of persons 65 to 79 yr of age per year, 50% in persons ≥80 yr of age; factors contributing to falls—problems with postural control; balance and gait disturbance; impaired coordination; osteoporosis; visual and other sensory deficits; decreased motor strength and endurance; poor sleep hygiene and insomnia; environmental hazards—leading cause of falls; poor lighting; obstructive furniture; slippery or loose floor coverings; pets; slippery footwear; medications (eg, diuretics, benzodiazepines, antiarrhythmics) that alter postural control or sensory or motor function or cause orthostasis or sedation; assessing mobility and dexterity—ask, “have you fallen to the ground in the past 12 mo?” get-up-and-go test (observe and time as patient gets up from chair, walks, and returns to chair; <15 sec implies low risk for falls); functional reach test (measure length patient able to reach); check orthostatic vital signs in patients complaining about dizziness or ataxia; prevention—eliminate environmental hazards; gait, strength, and balance training (eg, tai chi); muscle toning and coordination exercises; eliminate potentially offending drugs and substitute less toxic medications; adequate sleep hygiene; caretaker education |
| 5) Urinary incontinence: compromises social and emotional function; occurs in 34% of elderly men, 55% of older women; screening—ask, “in the past year, have you ever lost urine or gotten wet?” ask whether incontinence occurred on ≥6 separate days; ask how many times patient gets up at night to urinate; evaluate fluid intake, mobility, cognitive function, medication side effects, and surgical history; types—stress incontinence due to failure of sphincter mechanism to remain closed during bladder filling; urge incontinence due to detrusor overactivity (“I feel the urge to go, but I can’t quite make it in time”); overflow incontinence due to impaired detrusor contractility (as with, eg, neurogenic bladder) or bladder outlet obstruction; functional incontinence due to patient’s motor and cognitive dysfunction |
| Management: Kegel exercises beneficial for stress incontinence; estrogen controversial; biofeedback; surgery (rare); urge incontinence—bladder relaxants (be aware of anticholinergic side effects); biofeedback; surgery to remove irritating lesions (eg, bladder stones); overflow incontinence—surgical removal of obstructions if patients have significant benign prostatic hyperplasia (BPH) refractory to medications; intermittent self-catheterization; indwelling catheter; functional incontinence—scheduled use of restroom (eg, hourly); environmental manipulations (eg, bedside commode); bladder relaxants; indwelling catheters rarely used |
| 4) Dementia and depression: memory loss more insidious in patients with dementia (onset more rapid in patients with depression); concerns brought up by family members of patients with dementia (depressed patients usually initiate concerns); patients with dementia try hard on Mini-Mental Status Examination (MMSE) but respond incorrectly (depressed patients show psychomotor slowing or agitation and perform poorly); problems—difficulty learning and retaining new information, handling complex tasks (eg, balancing check book), and reasoning (eg, unable to cope with unexpected events); impaired spatial ability and orientation; language problems (eg, word finding); behavior disturbance (eg, belligerence, agitation) |
| Types of dementia: Alzheimer’s dementia most common (60%-80%); vascular dementia; Parkinson’s and Lewy body dementia (patients tend to be hypersomnolent and extremely sensitive to neuroleptic medications); causes of potentially reversible dementia—alcohol (acute intoxication or withdrawal); medications; metabolic disorders (eg, thyroid disease, vitamin B12 deficiency); normal-pressure hydrocephalus (NPH; early-onset dementia reversible); benign central nervous system (CNS) neoplasm; depression |
| Screening: dementia—ask, “are you having any problems with your memory?” clock-drawing test; 3-item recall test; MMSE (sensitivity 87%, specificity 82%); Informant Questionnaire of Cognitive Decline completed by caretaker or family member about patient’s functional history (less precise but not affected by patient’s educational level); depression—ask, “in the past month, have you been bothered by feeling down, depressed, or hopeless?” or “in the past month, have you noticed that you have little interest or pleasure in doing things?” Geriatric Depression Scale |
| 3) Functional ability: obtain baseline for functional ability to perform activities of daily living |
| 2) Advanced directives: ask patients whether they have living will or advanced directive; identify and respect patient’s values and goals; review patient’s desires about nutrition, infection management, and dialysis; discuss early in course (ie, before crisis or hospitalization) of chronic progressive illness; discuss timeline and natural course of disease; make sure patient conveys wishes to family or durable health care attorney and paperwork available |
| 1) Social support: ask, “who would help you if you became ill?” document contact information; ask who has durable power of attorney or health care power of attorney; learn about community resources for patients and caretakers |
| ALZHEIMER’S DISEASE —Robert Burns, MD, Associate Professor of Medicine, University of Tennessee, Health Science Center, College of Medicine, Memphis, and President, Geriatrics Group of Memphis |
| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for Alzheimer’s disease (AD): multiple cognitive deficits manifested by memory impairment and other cognitive disturbances (eg, asphasia, apraxia, agnosia); significant decline in function; gradual course with continued deterioration; deficits not due to systemic illness, not drug-induced, and do not occur during course of delirium |
| Symptoms: mild short-term memory loss (eg, “I can’t remember where I put my keys”); getting lost; decline in functional independence; incontinence; behavioral disturbances; mild —missed appointments with physician; improper usage of medications; weight loss; moderate—greater impairment and dependency at home; severe—patients require help walking, bathing, and dressing |
| Costs: $100 billion per year; average nursing home costs in United States $45,000 to $60,000 per year |
| Risk factors for dementia: increased age; female sex; positive family history (increased risk with apolipoprotein E [APOE] epsilon 4 genotype); history of head trauma; low educational level; cardiovascular—long duration of hypertension; elevated homocysteine level; no good evidence that use of statins and lowering cholesterol in older adults with dementia affects risk for AD |
| Stages of AD: mild—forgetfulness; ask about finances (eg, bill paying); driving problems (eg, getting lost, accidents, or traffic tickets); depressive symptoms; moderate—greater short-term memory loss; difficulty with or forgetting to perform tasks; inadequate grooming; poor judgment (especially with finances); severe—unable to recognize family members; minimal communication; patients require help with activities of daily living |
| Potentially reversible dementia: uncommon; may be due to long-term medication use; consider anticholinergic drugs, centrally acting drugs (especially for hypertension), benzodiazepines, sedatives, and hypnotics; causes—depression (pseudodementia); endocrine disorders; thyroid disease; metabolic disorders; infections; structural lesions (eg, NPH, tumors) |
| Vascular dementia: overdiagnosed; focal neurologic sign or symptom with onset of memory loss |
| Diagnostic work-up: interview patient and determine onset of symptoms; talk to caregiver and family members; ask about personality changes; full physical and neurologic examination; cognitive assessment (eg, MMSE to assess orientation and recall); blood test; check for metabolic problems (rare); check vitamin B12 and folate; elevated homocysteine (>14 µmol/L implies deficit); noncontrast computed tomography (CT) to look for structural lesions; consider positron emission tomography (PET) for patients with mild disease, high MMSE score, and subtle deficits; clock-drawing test; MMSE does not diagnose dementia but sensitivity good; animal fluency test (patients must name as many animals as they can in 1 min; naming <12 abnormal) |
| Lewy body dementia: patients have vivid visual hallucinations early in course of dementia; patients have parkinsonian symptoms and cognitive impairment; alertness and cognition fluctuate |
| Frontotemporal dementia: includes frontal and temporal lobe disease and Pick’s disease; lack of distinctive histopathology; early behavioral changes include impulsiveness and disinhibition; occurs in patients <65 yr of age; disease progresses rapidly |
| Management goals: maintain quality of life; maximize functional and cognitive abilities; treat mood and behavior problems; educate and counsel caregivers (caregivers at increased risk for depression, sleep disturbance, and anxiety); provide referral to support groups |
| Treatment of dementia: vitamins (vitamin E may increase risk for stroke); no evidence of efficacy of alternative therapies (eg, ginkgo [Gingko biloba]); multivitamins and folic acid; estrogen—shown in epidemiologic studies to decrease risk for AD in younger women; higher risk for stroke and dementia in older women; NSAIDs—shown to decrease risk for AD in younger patients; no evidence of effect in patients with dementia; N-methyl-D-aspartate (NMDA) antagonists (eg, memantine [Namenda]) shown effective; cholinesterase inhibitors—tacrine (Cognex; effective but no longer actively marketed due to high hepatotoxicity); donepezil (Aricept; 5 mg or 10 mg with or without food); rivastigmine (Exelon; titrate to 6 mg bid or 12 mg daily; take with food to decrease nausea, vomiting, and diarrhea); galantamine (Reminyl; 8 mg twice daily taken with full meal); consider patient’s and caregiver’s response to drugs; drugs equally effective; GI side effects; initiate therapy early; educate caregivers about expected response; treatment decreases behavioral disturbances; follow up after 6 to 8 wk |
| Summary of treatment strategies: early diagnosis and drug therapy; modify risk factors; encourage physical activity and cognitive activity (eg, puzzle books); discuss advanced life planning; discuss ability to drive |
Educational Objectives
| The goal of this program is to educate the listener about problems in the elderly and Alzheimer’s disease (AD). After hearing and assimilating this program, the participant will be better able to: |
| 1. List factors leading to common problems in the elderly such as polypharmacy and malnutrition. |
| 2. Counsel patients about reducing risk for falls. |
| 3. Select appropriate therapy for urinary incontinence. |
| 4. Distinguish between different types of dementia. |
| 5. Screen for and manage AD and dementia. |
Discussed on This Program
Cisplatin (CDDP) [Platinol-AQ] Cyanocobalamin (B12 ) [Big Shot B-12, Crystamine, Crysti 1000, Cyanoject, Cyomin, Nascobal, Rubesol-1000] Donepezil HCl [Aricept] Erythromycin (several trade names) Esterified estrogens and methyltestosterone [Estratest, Estratest H.S.] Fluorouracil (5-fluorouracil, 5-FU) [Adrucil, Carac, Efudex, Fluoroplex] Folic acid (folacin; pteroylglutamic acid; folate) [Folvite] Galantamine HBr [Reminyl] Ginkgo (Ginkgo biloba) Hydroxocobalamin, crystalline (vitamin B12 ) [Hydro Cobex, Hydro-Crysti-12, LA-12] Memantine HCl [Axura, Namenda] Oncovite (multivitamins) Rivastigmine tartrate [Exelon] Synthetic conjugated estrogens, B [Enjuvia] Tacrine HCl (tetrahydroacridinamine; THA) [Cognex] Tetracycline HCl (several trade names) Vitamin E (several trade names)
Suggested Reading
Ackermann RJ: Withholding and withdrawing life-sustaining treatment. Am Fam Physician 62:1555, 2000; Bak TH et al: Cognitive bedside assessment in atypical parkinsonian syndromes. J Neurol Neurosurg Psychiatry 76:420, 2005; Cook S et al: Improving medical care of persons with Alzheimer disease through clinical teaching: the IMPACT program. Gerontol Geriatr Educ 24:9, 2004; Gurwitz JH et al: Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289:1107, 2003; Gwyther LP: Family care and Alzheimer's disease: what do we know?. What can we do? N C Med J 66:37, 2005; Jellinger KA: Pathology and pathophysiology of vascular cognitive impairment. A critical update. Panminerva Med 46:217, 2004; Overshott R et al: Nonpharmacological and pharmacological interventions for symptoms in Alzheimer's disease. Expert Rev Neurother 4:809, 2004; Quillen DA: Common causes of vision loss in elderly patients. Am Fam Physician 60:99, 1999; Richter RW: Alzheimer's disease: clinical evaluation and disease management--update. J Okla State Med Assoc 97:546, 2004; Rodriguez KL et al: Patients' and healthcare providers' understandings of life-sustaining treatment: Are perceptions of goals shared or divergent?. Soc Sci Med, 2005; Willlams CM: Using medications appropriately in older adults. Am Fam Physician 66:1917, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed: Dr. Burns is on the Speakers’ Bureau for Forest Laboratories and Pfizer US Pharmaceutical Group.
Dr. Stern spoke in Austin at the 21st Annual Family Medicine Review, presented April 6-9, 2005, by Scott & White Clinic and Texas A&M University System Health Science Center, College of Medicine. Dr. Burns was recorded in Memphis on March 14, 2005, at the University of Tennessee Health Science Center College of Medicine’s 38th Annual Review Course for the Family Physician. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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