GERIATRIC CONCERNS
From the 34th Annual Current Concepts in Geriatrics, sponsored by the Johns Hopkins School of Medicine,
Baltimore, MD
| PREVENTIVE CARDIOLOGY IN THE FRAIL ELDERLY— Roy Ziegelstein, MD, Professor, Department of Medicine,
Johns Hopkins School of Medicine, Baltimore, MD
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| Preventive cardiology: primary prevention—preventing disease by removing cause, eg, tobacco smoking cessation;
secondary prevention—characterizing risk in asymptomatic patient who has risk factors or preclinical disease, eg, performing
cardiac computed tomography (CT); tertiary prevention—preventing further deterioration or reducing complications
of established disease, eg, treating myocardial infarction (MI) with β-blocker; features—exercise; diet; tobacco
smoking cessation; treating modifiable risk factors; screening for subclinical disease; daily aspirin or angiotensin-converting
enzyme (ACE) inhibitor therapy
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| Frailty syndrome: loss of muscle mass; unintentional weight loss; poor exercise tolerance; weakness and exhaustion;
slow walking speed; low levels of physical activity; disability; risk for institutionalization and death; dynamics of
frailty—frailty among older persons characterized by frequent transitions; study found that in 4.5 yr, ≈60% of people
transitioned toward higher or lower levels of frailty; frailty not irreversible; prevalence—high; fairly uncommon in age
group 65 to 70 yr; more common in people ≥90 yr of age; frailty increases with age; when discussing preventive cardiology
with frail elderly patient, consider 5-yr survival rate (≈70%); probability of survival decreases with increased frailty;
40% of severely frail individuals alive at 5 yr; ability to predict death “not very good”
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| Exercise training: possible and beneficial to frail elderly patients; improves cardiovascular risk factors; randomized
placebo-controlled trial compared progressive resistance exercise training (eg, knee and hip exercises using gym equipment)
to use of nutrient supplements in frail nursing home residents, and found 113% increase in muscle strength in exercise
group (vs 3% in nonexercising groups; highly statistically significant); also, nearly 12% increase in gait velocity (vs
1% decline in nonexercising groups); nutritional supplements had no effect on primary outcomes; no difference between
exercise alone and exercise and nutritional supplements combined; study found exercise training improved physical performance,
maximum oxygen consumption (VO2max ), and functional status
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| ACE inhibitors: suggested effects of ACE inhibitors on skeletal muscle—change in myosin heavy chain toward low
fatigability type; improved insulin sensitivity (increasing glucose uptake into muscle may increase metabolic efficiency); vasodilation
(increased blood flow to skeletal muscle may be beneficial); anti-infammatory properties may improve skeletal muscle
performance; possibly beneficial for improving or maintaining muscle strength and walking speed and retarding frailty in
elderly patients (data weak)
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| Statins: data on elderly and frail elderly minimal; most studies look at groups with mean age <65 yr; Prospective Study
of Pravastatin in the Elderly at Risk (PROSPER)—randomized controlled trial; 5804 elderly individuals (70-82 yr of
age) with history of or risk factors for vascular disease; combination of primary and secondary prevention trial; pravastatin
40 mg vs placebo; follow-up slightly >3 yr; pravastatin decreased risk for MI, stroke, and cardiovascular death (hazard
ratio 0.85; highly significant); data for secondary prevention stronger; no significant effect on primary prevention in
elderly patients randomized to pravastatin vs placebo; Cardiovascular Health Study—observational cohort study (not
randomized controlled trial) of 1914 individuals >65 yr of age with no cardiovascular disease at baseline; 7-yr follow-up
found statin use associated with decreased risk for cardiovascular events (highly significant); prevalence of statin use
2.6% in 1313 users (matched group of 1313 non-statin–users, but not matched for risk factors and comorbidities); found
significant association between decreased death and statin use (consider that trial not randomized placebo-controlled, and
statin users slightly healthier and younger); study of 23,000 Medicare patients with history of MI; tertiary prevention
trial; nearly 40% >80 yr of age; 24% received statin at discharge; found that with increased age, benefit of statin becomes
insignificant (eg, at age >85 yr, no significant benefit from statin after MI); Finnish study—400 elderly vascular patients
randomized to pharmacologic and nonpharmacologic cardiovascular prevention trial vs usual care; 66% women,
few tobacco smokers, slight hypertension (HT) and high cholesterol; ≈40% had MI, ≈40% had heart failure (HF), and
15% to 20% had diabetes; found medication use at 3 yr higher in intervention group than in control group for most prevention
therapies; interventions lowered blood pressure (BP) and cholesterol, but no significant effect on mortality (in
proportion without cardiovascular event)
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| DIABETES IN LONG-TERM-CARE PATIENTS —Samuel C. Durso, MD, Clinical Director of Geriatric Medicine and
Gerontology, Johns Hopkins School of Medicine, Baltimore, MD
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| Introduction: treatment for diabetes often viewed by older patients as burdensome; treatment medications can be dangerous;
nursing home populations becoming increasingly heterogeneous (requires judgment in prioritizing care); in any
age cohort, life expectancy varies with differences in function and coexisting illness
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| Goals: determining what patient wants primary goal; studies show many older adult diabetics consider injections and self-
monitored blood sugar burdensome; glycemic control; consider macrovascular risk and microvascular risk with longer
duration of diabetes; consider comorbidities; avoid harm
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| Risks of diabetes: short-term—volume depletion, poor wound healing, fatigue, and weight loss associated with high
serum glucose (ie, hemoglobin A1c >10% or serum glucose >300 mg/dL); associated with polyuria; correcting condition
may improve outcomes; long-term—cardiovascular risks; over 10-yr period, >20% of individuals experience MI or
death, and foot ulcers and amputations common; blindness (5% risk over 10 yr) and end-stage renal disease less common
in new-onset diabetes in older adults; many older adults have competing diseases (eg, renal failure, chronic lung disease,
HF); diabetics have higher risk and prevalence of falls, dementia, incontinence, pain, and depression
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| Treatment: to prevent retinopathy, treating high BP more effective than intensive serum glucose control; HT control and lipid
management relatively effective for macrovascular events (no evidence that tight serum glucose control prevents macrovascular
events or all-cause mortality); controlling BP most important, followed by lipid management, for all-cause mortality; treating
BP results in reduction of microvascular complications within 2 to 3 yr, vs 8 yr with tight serum glucose control (may be
longer in new diabetics or shorter in patients with preexisting microvascular disease); lipid management and HT control take
≈6 yr to prevent MI; American Diabetes Association and American Geriatric Society recommend focusing primarily on serum
glucose and also lipid management in patients who may benefit in 3 to 6 yr; glycemic targets characterized as moderate (prevent
polyuria and weakness; improve wound healing; hemoglobin A1c ≈8%; achieved in weeks to months) or intensive
(hemoglobin A1c <7%; may take years to decades to benefit newly diagnosed diabetics); overall considerations—start
with patient’s preference; maintain function and reduce burden (eg, insulin injection, self-monitored glucose, diet restriction);
consider activities of daily living (ADL), geriatric syndromes (eg, depression, dementia) that dominate care, coexisting illness,
and life expectancy
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| Risks of therapy: insulin most common drug-related reason people seen in emergency department; pain; burden of therapy;
polypharmacy; muscle pain with statins; complications of orthostatic hypotension; in long-term care, availability of
time and staff (eg, for tube-feeding)
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| Special considerations for patients in long-term care: erratic eating patterns and dependence on being fed; transitioning
and transferring patients gives rise to errors in medication dosing and to missed meals; patient’s inability to report
symptoms; achieving target BP in older adults associated with increased mortality (look at individual’s needs);
unproven benefits of statins and aspirin in patients >80 yr of age; metformin—high incidence of gastrointestinal side effects;
relatively safe (does not cause hypoglycemia); lactic acidosis rare; does not cause weight gain; patients who have
creatinine clearance <30 mL/min or severe HF may be at higher risk for lactic acidosis; sulfonylureas have high risk for
hypoglycemia
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| Case 1: woman 80 yr of age with diabetes for 15 yr; exercised regularly; fell and broke hip; transferred to long-term-care
facility for rehabilitation; eating patterns erratic and activities unpredictable; management—patient’s lifelong goal intensive
management of serum glucose; average life expectancy 13 yr, but consider risks (erratic eating and activities); to
avoid harm, consider moderate control (reduce doses of insulin or oral medication) while woman under rehabilitation,
and discuss resuming intensive management afterwards
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| Case 2: man 70 yr of age; resident of long-term-care facility; diabetes for 15 yr; developing manifestations of early proliferative
retinopathy; management—consider intensive therapy and patient’s preferences; life expectancy 7 to 12 yr
(some evidence that intensive management may prevent blindness in ≈4 yr); options include intensive BP control primarily
(studies show intensive BP control most effective for slowing diabetic retinopathy); intensive management and monitoring
of serum glucose reasonable; discuss risks; consider activity level, cardiac and renal and liver function, and ability
to report side effects; aspirin; lipid management; counseling for cessation of tobacco smoking
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| Case 3: woman 69 yr of age with diabetes and moderate dementia; hospitalized for MI and congestive HF; dependent in
ADL; dislikes finger sticks; enjoys liberal diet and being out with family; management —metformin and insulin relatively
contraindicated; single sulfonylurea with short half-life preferable; if insulin indicated, insulin glargine with relatively
flat peak may be useful as baseline to control hyperglycemia; 1 finger stick daily
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| DEPRESSION IN THE VERY OLD —Robert P. Roca, MD, MPH, Associate Professor of Psychiatry, Johns Hopkins
School of Medicine, Vice President and Medical Director, Sheppard Pratt Health System, Baltimore, MD
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| Depression in very old (≥75 yr of age) patients: more medical comorbidity; differential diagnosis and treatment
more complicated; problems of age-specific psychosocial differences (existential and life-phase issues); signs, symptoms,
treatment and response, and goals similar to those in younger patients; symptoms—somatic (tired; nervous; sick;
dizzy; weak; “nothing tastes good”); symptoms not specific (do not quickly diagnose depression; symptoms may be due
to other conditions [eg, anemia]); diagnosis—classify patient; empathic formulation (understand patient as unique confluence
of historical, biologic, and interpersonal influences)
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| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression: ≥5 of 9
symptoms for 2 wk, including loss of interest or depressed mood; most specific symptoms include feeling of melancholy
(distinguishable from grief; indifference to sources of pleasure), sense of subjective mental and physical anergy (fatigue;
unable to think clearly; tremendous effort needed to move), downturn in self-esteem or self-regard (feelings of guilt), diurnal
pattern of bad feelings (patients feel worse in morning and improve as day goes on)
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| Prevalence: community population—≈15% of older people have symptoms; only 2% to 3% of older people had major
depression within past 6 mo; lifetime prevalence 10% to 11% (lowest rate in any age cohort); clinical population—
prevalence higher; ≈5% in primary care (higher in chronic illness); 25% in patients with stroke or Parkinson’s disease (additional
25% have minor depression); major depression substantial in clinical populations, but not normal in older patients in
general
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| Effects of depression: suffering and disability; 1-yr mortality among newly admitted nursing home residents substantially
higher with depression; increased mortality in patients with cardiovascular disease and stroke; most important psychiatric
comorbidity in older people who commit suicide; suicide and terminal illness—44 terminally ill persons evaluated for
major depression and wish to die; 7 passively wished for early death and 3 actively suicidal (all 10 met criteria for major depression);
suggests wish to die may signal likelihood of major depression
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| 5-item geriatric depression scale: are you basically satisfied with your life? do you often get bored? do you prefer
to stay home? do you often feel helpless? do you feel pretty worthless? 2 depressive answers identifies major depression
with sensitivity of 94% (specificity 81%)
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| Causes of depression in elderly: multifactorial; medical—subcortical vascular lesions seen on magnetic resonance
imaging (MRI); more likely in left hemispheric stroke than in right hemispheric stroke (severity proportional to proximity
to frontal pole); poor general health status; persistent pain; functional impairment (eg, poor hearing); psychosocial
and existential—eg, transitioning to long-term-care facility
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| Treatment: good general medical attention; treatment of disabling and painful medical conditions; mitigation of sensory
and other functional impairments; psychosocial interventions—enhancement of social support; correlation between
perceived empathy of caregivers in nursing homes and likelihood of depression; amelioration of loneliness; formal psychotherapy
and related approaches (cognitive, behavioral, and interpersonal psychotherapies); reminiscence groups (ie,
discussing lives in groups with facilitator); antidepressant pharmacotherapy or electroconvulsive therapy (ECT)
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| Antidepressant therapy: ≈30% remission rates with fluoxetine (eg, Prozac), sertraline (Zoloft), or venlafaxine (Effexor);
in some studies, remission rates with drug exceeded those with placebo (statistically significant; but not seen in one major
study); high placebo response rates in many studies; “mixed story”; citalopram (Celexa) study—in patients ≥75 yr of age,
remission rate after 8 wk ≈35% (33% with placebo); in primary analysis, no difference between Celexa and placebo at 8 wk; in
secondary analysis, significant difference between drug and placebo in patients more severely depressed (Hamilton Rating
Scale for Depression [HRSD] score >24); placebo response rate lower; suggests drug makes difference if patient severely depressed
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| Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial: largest trial of its kind; looked at
effectiveness of treatment for nonpsychotic unipolar major depression in adults 18 to 75 yr of age; level 1—all patients
initially treated with citalopram (≤60 mg daily); response (defined as ≥50% reduction in symptoms) rate 47%; remission
(reduction in HRSD score to <7) rate 28% to 33%; 40% achieved remission at >8 wk; poor prognostic factors included
longstanding depression, more medical or psychiatric comorbidity, and low baseline function; level 2—patients who did
not remit switched to sertraline, venlafaxine, or bupropion (eg, Wellbutrin), or continued citalopram augmented with bupropion
or buspirone (BuSpar); remission rate with sertraline ≈18%, venlafaxine ≈25%, Wellbutrin ≈21%, citalopram and
bupropion (or buspirone) ≈30%; level 3—patients who did not remit at level 2 either switched to mirtazapine (Remeron)
or nortriptyline, or continued current treatment augmented with lithium or triiodothyronine (T3 ); remission rate with Remeron
12.3%, nortriptyline ≈20%; remission rate of treatment augmented with lithium ≈16%, with T3 ≈25%; level 4—
patients who did not remit at level 3 switched to tranylcypromine (Parnate) or Effexor; remission rates low; summary—
>50% achieved remission after level 2; 67% of those who remained in study achieved remission, but some needed numerous
extended trials; 1-yr follow-up saw higher relapse rates in patients who entered follow-up in less than full remission;
rates also higher in those who required more steps to achieve remission; conclusion—≈33% remit with optimized use of
selective serotonin-reuptake inhibitor (SSRI); high dose often required; remission can take as long as 14 wk; switching to
different SSRI or non-SSRI reasonable options after inadequate response to initial SSRI; after level 1, augmentation with
bupropion or buspirone reasonable options (bupropion probably better tolerated); likelihood of remission decreased with
each subsequent treatment, but remission worth pursuing (predicts lower relapse rates)
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Suggested Reading
Brown JH et al: Is it normal for terminally ill patients to desire death? Am J Psychiatry 143:208, 1986; Fagot-Campagna
A et al: Burden of diabetes in an aging population: prevalence, incidence, mortality, characteristics and quality of
care. Diabetes Metab 31 Spec No 2:5S35, 2005; Fiatarone MA et al: Exercise training and nutritional supplementation
for physical frailty in very elderly people. N Engl J Med 330:1769, 1994; Fried LP et al: Frailty in older adults: evidence
for a phenotype. J Gerontol A Biol Sci Med Sci 56:M146, 2001; Gill TM et al: Transitions between frailty states among
community-living older persons. Arch Intern Med 166:418, 2006; Hierholzer R: Remission rates for depression in
STAR*D study. Am J Psychiatry 163:1293; author reply 1293, 2006; Maurer MS et al: Diabetes mellitus is associated
with an increased risk of falls in elderly residents of a long-term care facility. J Gerontol A Biol Sci Med Sci 60:1157, 2005;
McNabney MK et al: Differences in diabetes management of nursing home patients based on functional and cognitive
status. J Am Med Dir Assoc 6:375, 2005; Rockwood K et al: A global clinical measure of fitness and frailty in elderly
people. CMAJ 173:489, 2005; Rush AJ: STARD: what have we learned? Am J Psychiatry 164:201, 2007; Schneider
LS et al: An 8-week multicenter, parallel-group, double-blind, placebo-controlled study of sertraline in elderly outpatients
with major depression. Am J Psychiatry 160:1277, 2003; Shepherd J et al: Pravastatin in elderly individuals at risk of
vascular disease (PROSPER): a randomised controlled trial. Lancet 360:1623, 2002; Tollefson GD et al: A double-
blind, placebo-controlled clinical trial of fluoxetine in geriatric patients with major depression. The Fluoxetine Collaborative
Study Group. Int Psychogeriatr 7:89, 1995.
Educational Objectives
| The goal of this program is to improve the overall care of elderly patients, especially the frail elderly (via preventive
cardiology), those with diabetes in long-term care facilities, and the very old with major depression. After hearing
and assimilating this program, the participant will be better able to:
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 | 1. Assess the level of frailty and life expectancy in elderly patients when considering preventive cardiology.
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| 2. Counsel frail patients about risks and benefits of exercise and medications.
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| 3. List short- and long-term risks of diabetes in patients in long-term care facilities.
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| 4. Choose effective treatments for diabetes, based on patients’ individual preferences and needs.
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| 5. Evaluate findings from major studies, such as the Sequenced Treatment Alternatives to Relieve Depression
(STAR*D) trial.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Ziegelstein, Durso, and Roca spoke in Baltimore, MD, at the 34th Annual Current Concepts in Geriatrics, presented
February 15-17, 2007, by the Johns Hopkins School of Medicine. The Audio-Digest Foundation thanks the speakers and the
Johns Hopkins School of Medicine for their cooperation in the production of this program.
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