GERIATRIC CONCERNS: DEMENTIA/FALLS
From University of Miami Miller School of Medicine’s Internal Medicine Update
| AN APPROACH TO DEMENTIA WITH A FOCUS ON ALZHEIMER’S DISEASE —Michael J. Mintzer,
MD, Associate Professor of Medicine, University of Miami Miller School of Medicine
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| Definition of dementia: criterion A—impaired memory (reduced ability to learn new information or recall
previously learned information; hallmark clinical finding); plus 1 of following—disturbance in executive
functioning (inability to execute plan, eg, simple household task); aphasia (language disturbance);
apraxia (impaired ability to carry out motor activities despite intact motor function); agnosia (failure to
identify objects despite intact sensory function); criterion B—above cognitive deficits together cause
significant impairment in social or occupational function; criteria C, D, E, and F—refer to excluding
other illnesses as cause of cognitive deficits
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| Etiologies: degenerative (within brain; Alzheimer’s disease [AD] prototype); vascular (brain deprived of
blood); multi-infarction dementia (MID); large stroke; Binswanger’s disease; metabolic (hypothyroidism;
vitamin B12 deficiency; uncommon); infectious (AIDS; syphilis); hypoxia (sequela of cardiopulmonary
resuscitation [CPR]; possibly sequela of surgery or radiation therapy); toxic (eg, environmental heavy
metals); intracranial lesion; head trauma
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| Causes in elderly: AD (≥50% of cases); diffuse Lewy body disease (DLBD; 15%-20%); vascular dementia
(15%-20%); Parkinson’s dementia (1%-2%; appears late in disease); frontotemporal dementia (eg,
Pick’s disease; rare); all others (<10%)
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| Reversible or not: permanence not addressed in definition of dementia, opening door to confusion in terminology;
eg, dementia seen in depression called “reversible” in psychiatry and pseudodementia in neurology;
reversible dementias in elderly probably <1% (vascular and degenerative dementias not reversible);
comorbid conditions (apparent dementia resolves after acute illness); more useful terms—arrestable or remediable
dementias; untreated vascular disease one of major risk factors for dementia, and treating vascular
disease can prevent and arrest development of dementia
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| Minimum cognitive impairment (MCI): new term for type of forgetfulness lasting ≥6 mo but not meeting
criteria for dementia; characterized by permanent inability to retrieve lost memories; distinguished from
“forgetfulness of aging,” in which lost memory eventually returns; diagnosis of MCI associated with
10% to 15% annual rate of progression to dementia
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| Clinical clues to diagnosis: AD (patient brought in after some incident overwhelms family coping mechanism;
memory overwhelmingly early and key indicator); DLBD (vivid hallucinations early in course of
disease; mild parkinsonian symptoms intensified by antipsychotic therapy); vascular (focal signs of
stroke near time signs of dementia appear); frontotemporal (behavioral and social problems)
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| Alzheimer’s disease: characterized by—extracellular diffuse β-amyloid deposition in senile plaques, often
around blood vessels; intracellular neurofibrillary tangle formation and neuronal death; brain shrinkage
(especially cortex)
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| Risk factors for AD: age (prevalence doubles every 5 yr after 60 yr of age); family history (4-fold increased
risk with apo E4 allele); probably more common in women; head trauma; Down syndrome; associated
with lower educational level (or reduced mental activity); estrogen plus progesterone doubles risk;
associated risk uncertain—environmental factors; hypertension; elevated cholesterol; depression
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| Medications for AD: acetylcholinesterase inhibitors (ACIs)—prolong acetylcholine activity; for mild-to-
moderate dementia; memantine (Namenda)—blocks excitotoxic effects of glutamate; for moderate-to-severe
dementia; normally used with ACIs; therapeutic considerations—ACI effectiveness in dispute; family
members find ACIs helpful; ACIs delay nursing home admissions by ≈2 yr; ACIs produce little gain
on standardized cognitive tests; speaker recommends basing treatment decisions on family’s experience;
statins—reduce cholesterol levels; cholesterol appears to affect production of β-amyloid soluble fraction
(precursor to β-amyloid deposition in brain; target of investigational drug therapies); cholesterol level
>240 mg/dL at 40 to 50 yr of age predicts increased risk of AD 30 yr later; however, recommendation to
use statins for AD requires well-controlled studies; additional considerations—empiric therapy with ACIs
and memantine found effective for MID (drugs may have additional mechanism of action or may act at
final common pathway for dementia)
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| Advising family: discuss advance directives for care in early stages of dementia; offer education on what to
expect; assess caregiver burden; reserve investigation of nursing homes until necessary
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| A DOWN-TO-EARTH APPROACH TO FALLS —Miguel Paniagua, MD, Clinical Assistant Professor of
Medicine, Division of Gerontology and Genetics, University of Miami Miller School of Medicine
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| Definition of fall: event that results in person’s inadvertently coming to rest on ground or lower level with
or without loss of consciousness or injury
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| Impact of falls on elderly: in United States, one older adult dies every hour as result of fall; half of those
who suffer hip fracture as result of fall never regain previous level of functioning; ≈33% of community-
dwelling persons >65 yr of age fall each yr (50% at 80 yr of age); falls leading cause of accidental death
in patients >65 yr of age; 50% of elderly hospitalized after fall die within 1 yr
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| Risk factors associated with falls: intrinsic factors—within individual; balance and gait abnormalities (increased
postural sway; decreased righting reflexes); cognitive impairment; muscle and joint abnormalities;
(antalgic gait in osteoarthritis); dizziness; vertigo; syncope; medications; extrinsic factors—in home
and residential institutions; stairs (particularly first and last in home); transferring from wheelchair to
bed or toilet in institution; potentially modifiable risk factors—muscle weakness; gait or balance deficits;
use of assistive devices; visual deficits; arthritis; cognitive impairment; depression (risk factors additive)
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| Complications of falls: hip fractures (falling to side more common in institutions); wrist or arm fractures
(falling backward or forward more common in community-dwelling elderly); soft tissue injuries (suspect
fall in patients presenting with lacerations, abrasions, or contusions); mortality; post-fall syndrome (fear
of falling; fall may have been noninjurious; patients may not mention fear; leads to social isolation, decreased
mobility, greater dependence in activities of daily living [ADL])
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| Patient evaluation: history—ask about history of falls (how recent; what circumstances; how long down);
physical examination—blood pressure; heart rate; orthostatic functioning; patients with diabetes (look for
neuropathy; evaluate lower extremity vibratory sensation; check proprioception); in patients with osteoarthritis
(assess muscle weakness in lower extremities); testing based on presentation—
electrocardiography (ECG) for abnormality on auscultation; imaging of head in patients with evidence
of facial trauma or loss of consciousness
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| Timed up-and-go test: detects risk of fall with sensitivity and specificity near 90%; predicts recovery after
hospitalization; patient instructed to rise from chair at “go,” walk to marker (3 m away), turn around, return
to chair, and sit down; risk based on time; low risk—≤10 sec; increased risk—11 to 29 sec; significantly
increased risk—>30 sec; risk almost 100% in ≤1 yr; alternatively, observe patients—moving from
waiting room to examining room; look for antalgic gait, pushing off from chair, use of assistive device,
using hands to right themselves in space
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| Fall prevention measures: discontinue medications associated with falls—tricyclic antidepressants and benzodiazepines
(reduces risk ≈50%); if possible, diuretics and antiarrhythmics; refer patients—with history of
fall, to exercise program or gait and balance training; after ≥2 falls, for focused risk-factor assessment;
after hospitalization, for home-hazard assessment, for visual evaluation (visual acuity; depth perception;
contrast sensitivity; presbyopia; cataracts)
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| Other options for risk reduction: bed alarms in institutions; avoid patient restraints (harmful to patients;
can cause death; increase confusion); tai chi exercises; home-based assessment (indicated when targeted
interventions prove inadequate)
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 | Hip protectors: mainly used in institutions; protect greater trochanter; benefits depend on ability of patient
to wear (difficulties include bulkiness, tightness); may increase problems with incontinence (trap
doors available in newer models)
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| Questions and answers: atypical antipsychotics for agitation—effective; use increased but uncertain whether
more beneficial than older drugs; nighttime confusion—major problem; characteristic of sundowning syndrome;
drug selection based on trial and error; need to balance side effects of medications with inability
of family to sleep (if unresolved, eventually leads to nursing home placement); involve family in evaluating
effects of medication and in setting therapeutic goals involving ability to sleep; sundowning considered
type of delirium (consider factors underlying delirium, eg, pain, medications, environment, acute
illness); “falling is normal”—as bipeds, humans fall first time they stand and continue falling during life;
goal not so much preventing falls themselves as preventing injuries from falling; caregiver stress—may
lead to elder neglect or abuse (associated with different pattern of injury from falls); important to maintain
open communication with family; make family aware of your recognition of problems without provoking
undue fear of being reported to social services; available resources—Alzheimer’s Association
(helpful for families); geriatricweb.sc.edu (online peer-reviewed resource for physicians)
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Educational Objectives
| The goal of this program is to provide internists with contemporary approaches to dementia and falls in geriatric
patients. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Diagnose dementia, recognizing the various etiologies and their presentations.
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| 2. Manage drugs for treating dementia.
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| 3. Enable patients and their families to make informed decisions on optimal care.
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| 4. Evaluate elderly patients for risk of falling.
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| 5. Recommend measures demonstrated to prevent falls.
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Suggested Reading
Agostini JV et al: Drugs and falls: rethinking the approach to medication risk in older adults. J Am Geriatr
Soc 50:1744, 2002; available. Battaglia J: Pharmacological management of acute agitation. Drugs 65:1207,
2005; Bullock R: Treatment of behavioural and psychiatric symptoms in dementia: implications of recent
safety warnings. Curr Med Res Opin 21:1, 2005; Carrington Reid M et al: Depressive symptoms as a risk
factor for disabling back pain in community-dwelling older persons. J Am Geriatr Soc 51:1710, 2003;
Cherry DL et al: Interventions to improve quality of care: the Kaiser Permanente-alzheimer's Association
Dementia Care Project. Am J Manag Care 10:553, 2004; Chong MS et al: Preclinical Alzheimer's disease:
diagnosis and prediction of progression. Lancet Neurol 4:576, 2005; Doody RS: Refining treatment guidelines
in Alzheimer's disease. Geriatrics Suppl:14, 2005; Finucane TE: Drug therapy in Alzheimer's disease.
N Engl J Med 351:1911, 2004; Fortinsky RH et al: Fall-risk assessment and management in clinical practice:
views from healthcare providers. J Am Geriatr Soc 52:1522, 2004; Gill TM et al: Environmental hazards
and the risk of nonsyncopal falls in the homes of community-living older persons. Med Care 38:1174,
2000; Nnodim JO et al: Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk
in older adults. Geriatrics 60:24, 2005; Ray WA et al: Prevention of fall-related injuries in long-term care:
a randomized controlled trial of staff education. Arch Intern Med 165:2293, 2005; Tinetti ME et al: Modifiable
impairments predict progressive disability among older persons. J Aging Health 17:239, 2005; Tinetti
ME: Clinical practice. Preventing falls in elderly persons. N Engl J Med 348:42, 2003; Turner S: Behavioural
symptoms of dementia in residential settings: a selective review of non-pharmacological interventions.
Aging Ment Health 9:93, 2005; Vickery K: New dementia care guidelines issued. Provider 31:41,
2005; Yaffe K et al: The metabolic syndrome, inflammation, and risk of cognitive decline. JAMA
292:2237, 2004.
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. For this issue, the faculty reported nothing to disclose.
Drs. Mintzer and Paniagua were recorded at Internal Medicine Update, sponsored by the University of Miami Miller
School of Medicine, January 31-February 4, 2004, in Miami Beach, Florida. The Audio-Digest Foundation thanks the
speakers and the sponsor for their cooperation in the production of this program.
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