Colleen Christmas
Thomas E. Finucane
Geriatric patients differ from younger patients in ways that impact on their medical care. First, much of the ambulatory health care of geriatric patients is focused on management of chronic problems. Data from 1999 Medicare claims indicate that more than 75% of all Medicare beneficiaries suffer from at least one, and approximately 33% suffer from four or more, chronic conditions (1). Almost 50% of the population older than age 65 years has osteoarthritis, 40% has hypertension, nearly 33% has chronic heart disease, and more than 25% suffers from hearing impairment. Although seniors comprise approximately 13% of the population, they consume nearly 33% of all prescription medications.
Second, aging is accompanied by a decreasing ability to tolerate disturbances in homeostasis (so-called homeostenosis). Disease in the elderly may present as a change in functional or cognitive status rather than with the typical presentation seen in younger patients. This concept is also important to consider in contemplating the responses to therapies and in weighing the risks of treatments.
Third, because of disease burden and aging changes, many syndromes of old age, such as frailty, falls, and delirium, result from the cumulative effects of many factors. Because most geriatric syndromes are multifactorial in etiology, they often benefit from multifactorial interventions involving multidisciplinary teams of care providers addressing the biologic, psychological, spiritual, and social needs of the individual.
Finally, while quality of life is important at all ages, the contribution of this value to decision making in older individuals may be relatively greater than in younger individuals.
Demographic Changes
In 2000 there were approximately 35 million people in the United States age 65 years or older; by 2030 this number is expected to double. Ambulatory adult medicine in the United States is already geriatric medicine to a great extent, and it is likely to become increasingly geriatric in the next several decades. On average, seniors visit a physician nine times a year, a rate that is nearly double that of younger adults. In 1999, a quarter of primary care physician's visits were from patients older than age 65 years, and the rate of growth of outpatient visits to specialists had started to outpace those to generalists (2).
These observations result from two distinct phenomena. First, at every age, life expectancy is increasing (Table 12.1). In 1980, a 65-year-old American could expect, on average, to live another 16.4 years. By 1997, this number has increased to 17.6 years. An 85-year-old woman today has a life expectancy of 6.6 years, 1 more year than a man at the same age. The “oldest old,” older than age 85 years, are a special challenge to society as a whole and to physicians in particular. They are predominantly women, and as a group they are exceedingly frail, requiring a great deal of medical and social support. Of people 65 years old in 1980, 25% are expected to survive to age 90. By the year 2050, more than 40% will survive to age 90, based on moderately optimistic assumptions about mortality rates (3,4).
The second important phenomenon is the postwar baby boom of children born between 1945 and 1965. From 2010 to 2030, the U.S. population ages 65 to 84 years will
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increase 80%, whereas the population younger than age 65 years will increase only 7%. Thereafter, baby boomers will become “old,” older than age 85 years. In 1990 there were 3 million old Americans. In 2010 there will be 6 million, and in 2050, 19 million people will be older than age 85 years (3).
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TABLE 12.1 Life Expectancy of Older Americans in 1900, 1950, and 1997 |
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The challenge for physicians will be sharpened by three additional effects: the increasing rates of disability, poverty, and ethnic diversity among the elderly. Disability arises from concomitant chronic medical illnesses, cognitive deficits, and depressive symptoms, in addition to underlying frailty. The percentage of people who need assistance with everyday activities rises steeply with age. Among the “young old,” age 65 to 75 years, approximately 10% require assistance, whereas among the old, nearly 50% do. These figures are higher for African American and Hispanic elders. Thus, although large numbers of caregivers will be needed at the same time, data suggests that the number of available caregivers is declining. Defining poverty in the United States is arbitrary, but 2002 Census Bureau data showed that 7.8% of men and 14.1% of women age 75 and older were poor. On the average, in 2001, out-of-pocket health care spending totaled 22% of income in the lowest income quintile of households headed by an older person (4). Fifty-six percent of this spending was for the purchase of prescription drugs. All aspects of the U.S. population are becoming increasingly ethnically diverse. Whereas whites comprised 84%, blacks 8%, Asians and Pacific Islanders 2%, and Hispanics 6% of the elderly population in 2000, by 2050 the projections for these demographics are 64%, 12%, 7%, and 16%, respectively (5).
Care of the old, and especially the very old, requires special awareness of the progressive socioeconomic and physiologic vulnerability of old age. More than knowledge of specific disease states, awareness of the extreme frailty of the very old defines clinical geriatrics.
Public Policy
Medicare
Medicare was intended as hospital insurance for the elderly, regardless of income, covering a period of acute illness and subsequent convalescence. Eligibility depends on age or other qualifying condition (e.g., end-stage renal disease) but not on income. In general, Part A pays institutions for hospital inpatient care, brief posthospital care (whether institutional or provided by a home health agency), and Medicare hospices. Part B pays physicians and providers of outpatient services, such as independent laboratories, mental health services, and rehabilitation services. Durable medical equipment is also covered by Part B. Some preventive services are covered under Medicare, including influenza and pneumococcal vaccines, screening mammograms every 12 months, screening Papanicolaou (Pap) smears every 3 years, colonoscopy every 10 years, and dual-energy x-ray absorptiometry (DEXA) bone mineral density measurements every 2 years. In January 2006, the largest change to occur in Medicare since its inception began when Medicare enrollees became eligible for various forms of prescription drug benefits. It is yet too soon to understand the impact of this change in Medicare. The most up-to-date information about the prescription drug plans available through Medicare is found at http://www.medicare.gov.
In 1996 Medicare indicated that it would cover inpatient hospital admissions for symptom palliation in terminally ill patients (6). For their services, hospice programs receive a prearranged payment to cover medical care, medications, and supplies related to the terminal diagnoses in the dying patient. Much of the debate about the most recent reform proposals has been driven by the escalating costs of health care; this is emphasized by the name Balanced Budget Act of 1997. This Act has had widespread fundamental effects on medical care in America. Its implementation has meant changes to Medicare support of graduate medical education, attempts at increasing choices for health care plans (Medicare health maintenance organizations), and the restructuring of reimbursement schedules for physician services and home health care (7). On the other hand, long-term care will likely remain beyond Medicare's purview. Chronically ill patients in nursing homes are generally not covered. Short-term stays for rehabilitation after hospitalization are reimbursed, but Medicare coverage ends, as a rule, once the patient stops improving.
Medicare has grown in size (to more than 34 million beneficiaries) and in complexity since its inception in 1965. More changes are anticipated in the coming years.
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Effective care of the geriatric population entails continual efforts at keeping up-to-date with these and future amendments to Medicare. Detailed information on Medicare benefits for individuals is available from the federal government (see Preretirement Counseling and Planning later in this chapter).
Medicaid
Both Medicare and Medicaid are federally funded with oversight from the Center for Medicare and Medicaid Services (formally Health Care Financing Administration). However, unlike Medicare, Medicaid administration is left largely to the individual states. Each state sets its own policies within certain federal guidelines. To be eligible for Medicaid, it is necessary, but not sufficient, to be impoverished; age and other criteria such as disability must be met. In general, Medicaid offers more benefits than those covered by Medicare and traditional insurance plans. These benefits can include prescription drugs, prosthetics, hearing aids, and both inpatient and outpatient services. Although more than 41.3 million Americans participate in this program, with many now enrolled in Medicaid managed-care plans, less than half of poor Americans are actually covered by Medicaid. In 1997 alone, $159.9 billion dollars were spent for its services (8).
Most Medicaid dollars are spent on long-term care in nursing homes, and about half of nursing home revenue comes from Medicaid. Eligibility for nursing home placement is defined by the states and depends on functional disability and medical illness. Medicaid pays for nursing home care only if the person is indigent. Thus, a person with assets may qualify in one of two ways. He or she may spend the assets on nursing home care until impoverished or divest the assets by giving them to adult children. Rules about divestment are changing, but a “look back” period is common: Any assets given away in the previous 30 months, for example, may be counted as current assets. The issue of divestment is extremely divisive, as it is mainly the well off who can plan ahead to this extent. Increased authority and responsibilities have been parceled to the states since welfare reform. Because the program is in a period of change, practitioners should seek specific advice about nursing home placement and Medicaid eligibility from state and local sources.
Home Health Care
Home health care refers, broadly, to care, formal or informal, provided in the home. Nonetheless, this term is often used to refer to a specific Medicare benefit.
Part A Medicare certifies home health agencies and pays them for in-home care, primarily by nurses and aides. In keeping with Medicare philosophy, the program was intended to facilitate hospital discharge planning and to manage episodes of acute illness at home, thus shortening, or even preventing, some hospital admissions.
During chronic illness, spouses, adult children, other relatives, and sometimes friends have assumed most of the caregiving responsibilities for community-dwelling adults. In recent years, families have shared more of these tasks with help from paid formal home care. Increased caregiver stress, increased family and occupational responsibilities of caretakers, and perhaps some overall increase in the financial resources of older adults, may have played roles in this trend.
From 1988 to 1997, home health agency reimbursements grew from $2 billion to more than $17 billion. By 1997, 1 in 10 Medicare recipients had received home health care, accumulating an average of 80 home visits (7). Although the intent of the home health care program was to substitute or complement acute hospital care, 61% of all visits were to enrollees receiving services for 6 months or more. In fact, geographic areas with high rates of home care use do not have lower rates of hospitalization or shorter lengths of stay (9). The need for chronic care among community-dwelling elderly, along with several other factors, simply was not foreseen in the original design of Medicare. The criteria for Medicare coverage for homebound patients with unstable medical conditions and for hospice patients are summarized inChapters 9 and 13, respectively.
Public policy about medical care of the elderly, especially the poor and frail elderly, is in flux. Out-of-pocket costs are rising, as are government expenditures. Federal scrutiny and demands on provider documentation will continue as definitions of eligible services become more refined. A broad-based plan for efficacious health care in the home may one day inspire more physician house calls (already reimbursable under Medicare) and perhaps usher in the concept of the home-based hospital (10).
Agencies on Aging
The Administration on Aging was born in 1965 out of President Johnson's Great Society program, with the purpose of establishing federal legislative agendas to serve the needs and improve the quality of life of Americans age 60 years and older. Through the Older American Act and its subsequent amendments, the Administration on Aging has since mandated the establishment of Units on Aging within all states. These Units allocate federal moneys to Area Agencies on Aging. Today there are 57 Units on Aging; they oversee more than 655 Area Agencies on Aging and 223 tribal organizations that help patients access resources within communities. The challenge has been to provide appropriate guidance to an increasingly diverse elderly population. For the more functional elders, services include assistance with finding employment and locating senior activity centers. Frail elderly are eligible for services such as home-delivered meals, advice on planning for long-term
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care, and support for caregivers. It is likely that comprehensive primary care of elderly patients will increasingly rely on referrals to the Area Agencies on Aging (11).
Evaluating Older Patients
Several aspects of the clinical evaluation of older patients deserve emphasis. When possible, old records should be obtained before the first visit. If it is not possible to obtain them before the first visit, they should be requested at the first visit. Patients should routinely bring all their medications to appointments, including over-the-counter medications and herbal supplements; these should be carefully reviewed for continued indication, tolerance, and adherence.
Attention should be paid to the physical environment. Bright, direct light is often uncomfortable for patients with cataracts. Prolonged sitting on a backless examining table or in a chilly room can be uncomfortable. Making a patient comfortable probably improves the quality of the medical history. For patients with presbycusis, it is more important to face the patient and speak slowly and clearly than it is to speak loudly. Also, the practitioner should have an assistive listening device (see Chapter 110) available for use by the patient when needed. Patients with marked kyphosis can often lie down more comfortably if a rolled-up sheet is placed on the pillow under the occiput.
Some form of mental status examination should be included in the initial evaluation of every older patient (see Chapter 26). Clinicians’ impressions have been shown to be insensitive in detecting mild cognitive impairment (12). The incidence of Alzheimer disease increases greatly with age, from approximately 1% per year at ages 60 to 65 years to 6.5% per year in the 85-years-and-older age group (13). Because symptoms of disease in the elderly may be absent, atypical, muted, or ignored by the physician, subtle deterioration of cognitive or functional capacity, which may be the only indication of a serious pathologic condition, should be actively sought out.
In general, more time is needed for the evaluation of an elderly patient than for a younger patient. The former often has multiple problems, including sensory and mobility impairments that require a slower evaluation. Diagnostic testing should be highly selective. Stressful tests (which may include radiographic studies for a frail person with a mobility disorder) should have an expected therapeutic implication and should be explained thoroughly to the patient and, when applicable, to the caregiver. Extensive evaluation may require several visits. The highly streamlined evaluations so characteristic of modern medicine are simply too stressful and unrevealing for many ill elderly patients. Empathy and compassion are essential in high-quality care for a frail older patient. Several 30- or 60-minute visits may be more easily tolerated than a single, longer encounter, provided it is not too difficult for the patient and family to come to the office. However, too short an encounter (e.g., 10 to 20 minutes) may be disappointing, inadequate for proper care, and difficult for many elders, particularly those who have difficulty communicating their needs or understanding explanations and instructions. Patients with communication challenges may benefit from having a trusted family member or friend accompany them to the visit and the provision of written instructions for the plan of care.
Standardized Approaches to Functional Assessment
The traditional problem-oriented approach to medical care focuses primarily on medical diagnoses. Functional assessment is intended to measure the impact of disease and aging on a patient's ability to care for him- or herself, to live in the community, and to accomplish goals that are meaningful to the patient.
Frailty
The syndrome of frailty has many definitions, including decreased resilience in the face of external stress, difficulty in maintaining homeostasis, and vulnerability to adverse events. Declines in lean body mass, strength, endurance, balance, and walking performance and lower levels of activity are observed in frail older adults. A proposed definition is that individuals are frail if they meet three or more criteria related to weight loss, weakness, endurance, slowness, or low level of activity (Table 12.2) (14). Frail
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individuals have higher rates of disability, hospitalization, and mortality, and are more likely to have coexisting cardiovascular diseases. This phenotype of frailty may represent a unique physiologic syndrome. Related biochemical markers and immunologic correlates of frailty are being sought. Targeted interventions that improve outcomes in frail patients may emerge (14).
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TABLE 12.2 Characteristics of Frailtya |
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TABLE 12.3 Areas and Levels of Assessment in the Katz Index of Independence in Activities of Daily Living |
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Disability
Living independently requires the performance of certain basic activities. Essential goals of caring for an elderly person are to identify and minimize his or her dependence on others for these activities. The Katz index of activities of daily living (ADLs) outlines tasks that are fundamental to independent living (Table 12.3). A patient's ability to bathe, dress, toilet, transfer, feed, and maintain continence enables a clinician to deploy targeted interventions that meet the patient's current functional needs. Comparing ADL scores obtained before and after certain interventions (e.g., physical and occupational therapy for a patient after a stroke) allows the clinician to track the degree of functional improvement. Improvement in ADL scores, however, is not realistic in some patients. Poor performance of the Katz ADLs correlates with increased mortality, nursing home placement, and inadequate recovery from hip fracture (15,16). The Barthel index is another instrument with well-documented reliability and validity that has been used to quantify (via a 0 to 100 scoring scale) degrees of disability. Scores from the Barthel index correlate with recovery from stroke. Physicians caring for ambulatory patients often underestimate or overlook important disabilities in their patients (17).
Instrumental ADLs require a higher level of function and include abilities to travel outside the home, shop, prepare meals, do housework, or handle finances (18). Fried and Guralnik have elegantly summarized the evidence base for the assessment, natural history, demography, and impact of disability, and for interventions to prevent disability (19).
Overall understanding of a patient's level of functional ability, as well as the patient's capability to function in home, can enrich a physician's understanding of the goals of treatment for that patient. Several tools are available to assist with this task (20).
Geriatric Assessment
Comprehensive geriatric assessment is usually a multidisciplinary and always a multidimensional assessment of frail elderly patients and their support systems. It is occasionally confused with functional assessment, which was described in the prior section. Although it has received a great deal of favorable attention, geriatric assessment lacks a precise definition, and data supporting its usefulness are conflicting. The referral source and initial characteristics of patients, the nature of interventions (e.g., whether inpatient, in the office, or in the home, and whether consultation or ongoing therapy), and the measured outcomes have varied from study to study (21, 22, 23, 24). In terms of outcomes, caregivers and clinicians often do not agree on perceived goals of care for frail elderly patients (25). Despite these limitations, outpatient and home assessments of elderly patients seem to have some benefits. Studies of outpatient geriatric evaluation and management (24), case finding and surveillance (26), postdischarge assessment (27), and pharmacy assessment (28) done in the home have demonstrated improved outcomes in terms of functional ability, duration of hospital stays, nursing home admissions, and medication errors, respectively.
Table 12.4 lists the central elements of geriatric assessment. Assessments performed in the above-cited studies generally contain these elements. Medicare currently does not provide specific compensation for multidisciplinary comprehensive geriatric assessment.
Medication Use in the Elderly
One way of conceptualizing the aging process is as a gradual decline in the organism's ability to respond to perturbation and stress. At rest, for example, the body temperature, serum sodium, glucose, and heart rate of healthy younger
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patients are about the same as those of older patients. When stressed by environmental temperature extremes, free-water load, glucose challenge, or exercise, however, the older patient will have a wider excursion from normal, will take longer to recover equilibrium, and is more likely to get sick, even in the absence of underlying disease. Medications can be seen as a perturbation. Most younger people can recover from this perturbation safely, but the elderly are more likely to have adverse effects as a result.
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TABLE 12.4 Some Important Components of the Initial Geriatric Assessment |
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Elderly Americans take large numbers of drugs. Although some drugs are clearly beneficial, many others have little or no evidence of efficacy. Risks to the elderly patient from imprecise drug use can be substantial. A majority of physicians are inaccurate in reporting what medications their patients are taking, even when questioned in clinic or using the clinic chart to determine the medication regimen (29,30). In an epidemiologic study of over-the-counter medication use in the United States, 87% of independent elderly were taking at least one nonprescription medication and 6% were taking five or more (31). Complementary and alternative medications are popular (see Chapter 5). A useful clinical strategy is to insist that all medications, including over-the-counter and complementary medications, are brought to each visit and then to consider the justification for each drug.
Studies of drug disposition in the elderly demonstrate wide heterogeneity in several important physiologic functions. Although drug absorption is unimpaired in general, distribution within the body compartments may be different in older than in younger subjects. In older subjects, muscle mass, bone mass, body water, and some serum proteins are lower, whereas body fat content is higher. Hepatic drug clearance, in simplest terms, depends on hepatic blood flow, serum protein binding, and the intrinsic capacity of the hepatocyte mass. The first two of these factors may decrease with age, resulting in impaired drug metabolism in some patients. Renal glomerular rate can fall approximately 30% from the third decade to the eighth. The fall in glomerular filtration rate may not be accompanied by a rise in serum creatinine because muscle mass is falling concomitantly. Because of variability among subjects, prediction of drug levels from dosage is unreliable.
In many cases, very low dosages of medication may be effective, such as 12.5 mg of hydrochlorothiazide per day and beginning dosages of 0.25 mg haloperidol or 10 mg imipramine or nortriptyline per day. Unless the clinical situation requires otherwise, drugs should be started at low dosages in the elderly and titrated carefully upward during frequent, early followup. When available, drug levels are useful in monitoring the patient.
New drugs pose particularly serious risks for the elderly. In general, the U.S. Food and Drug Administration (FDA) approves new drugs after safety has been demonstrated in relatively small trials (32). Once the drugs are released, however, they are often used widely by the frail elderly, and serious but uncommon toxicities become apparent. Approximately 10% of all new drugs are withdrawn or have a “black box” warning added in the year they are placed on the market. Because older individuals are more often harmed by adverse drug reactions, new drugs should be tried carefully in older patients only after more standard drugs have been tried unsuccessfully or when the new drug presents a significant proven therapeutic advancement. Older drugs have more well-established safety profiles and are generally less expensive. Claims about the safety or the lack of side effects of newly released drugs should be viewed simply as advertising techniques.
Some specific drugs, selected because of their widespread use in the elderly, are considered here. Guiding principles of prescribing are avoid giving a medication to treat the side effects of another medication or where
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nonpharmacologic alternatives are available and strive to reach the least number and lowest doses of medications effective for each patient. Specific medications to avoid in the elderly have also been described (33).
Neuroleptics
Neuroleptics are often used to treat the behavioral complications of dementia, although the evidence base behind this approach is lacking. Of 100 demented patients treated with standard neuroleptics, 18 could be expected to benefit beyond placebo, according to a meta-analysis, and no one neuroleptic has been shown to be more effective than another (34), yet prices vary widely. The newer “atypical” antipsychotics are very expensive and large-scale randomized trials of their use for dementia are not available, although they are no more effective than standard neuroleptics in treatment of schizophrenia (35). Furthermore, a retrospective cohort study of the use of atypical antipsychotics for dementia failed to demonstrate a significant reduction in parkinsonism over standard neuroleptics (36). In 2005, the FDA placed a black box warning on atypical antipsychotics, citing a consistent finding of 60% to 70% increased risk of death in patients taking these drugs compared to placebo. However a recent retrospective study suggested that typical and atypical antipsychotics may pose equal risks of mortality in the elderly (37). If neuroleptic drugs are prescribed, evidence of good effect should be sought. If they provide nothing more than sedation (assuming sedation is desirable), other drugs should be used instead, such as short-acting benzodiazepines, although their use is also problematic in this age group. The properties of available antipsychotic drugs are described in Chapter 25, and the practical use of psychoactive drugs in the elderly is discussed fully in Chapter 26.
Nonsteroidal Anti-Inflammatory Drugs
For treatment of inflammatory conditions, nonsteroidal anti-inflammatory drugs (NSAIDs) are an excellent choice, although they can present serious toxicity in this age group and thus should only be used short-term, if at all. When they are used as analgesia for noninflammatory chronic pain, their considerable toxicities may outweigh their benefit. Current users of NSAIDs are almost five times more likely to have a fatal upper gastrointestinal hemorrhage when compared with former users or subjects who have never used them (38). Frail, elderly, white women are especially at risk. Renal and central nervous system toxicities are well known (see Chapter 77 for a full discussion on NSAIDs). In many cases of pain with or without underlying inflammation, acetaminophen may have a superior risk-to-benefit profile. Where the risk outweighs the benefit of NSAIDs and acetaminophen is ineffective, low-dose narcotic analgesics should be considered (potentially accompanied by a bowel regimen).
The cyclooxygenase-2 (COX-2)-specific NSAIDs have been heavily advertised, widely prescribed, and are extremely expensive. In recent years, some have been removed from the market because of demonstrated cardiovascular risks associated with their use. They should largely be avoided unless their safety profile is more firmly established. The FDA does not allow the claim that they are more effective than conventional NSAIDs.
Cold Remedies
There is no cure for the common cold, but there is a multimillion-dollar market in remedies. Common treatments bring the risk of antihistaminic or narcotic sedation, sympathomimetic stimulation, or a combination of the two. Decongestants and antihistamines are occasionally discovered to have fatal toxicities, as with phenylpropanolamine and terfenadine. Substantial amounts of alcohol are often included: Vicks NyQuil, for example, is 50 proof. Many common combinations are irrational, even contradictory. Clinicians should discourage their elderly patients, who are likely to be susceptible to anticholinergic and sympathomimetic effects, from buying these nostrums, many of which contain a variety of useless ingredients. Treatments for the common cold are discussed in Chapter 33.
Sleeping Pills
Disrupted sleep is common in old age (see Fig. 7.1), and the electroencephalogram of a normal elderly patient looks very different from that of a normal younger patient. In addition, some of the cognitive changes that occur in old age resemble the changes of sleep deprivation, such as slowed reaction time and slower learning of new material. It is unreasonable to expect, and it is not true, that any sedative hypnotic can convert the blunted and simpler sleep electroencephalogram of an older person to the complex and delicate electroencephalogram of a younger person. In fact, no sleeping pill improves alertness or daytime problem solving when given to patients with insomnia. This is true of even the newest sleeping pills available in 2005. The side effects can be very serious. Both benzodiazepine and nonbenzodiazepine sedatives are strongly associated with an increase risk of hip fracture (39). A randomized trial showed that teaching about sleep hygiene is as effective as giving sleeping pills and has more long-lasting effect (40). Cognitive behavioral therapy may be even more effective (41). Despite these findings, efforts to increase sales of hypnotics are vigorous. When insomnia is a symptom of depression, sleep quality does improve with treatment of the depression.
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Drug–Drug Interactions
Elderly patients who take many medications are at high risk for drug–drug interactions. The strongest independent risk factor for an adverse drug event is the total number of drugs concurrently prescribed (42). Physicians should become familiar with and use a small number of medications. Warfarin (Coumadin) is increasingly used in elderly patients and its effect on coagulation can be affected by many drugs (seeChapter 57).
Neglect and Abuse in the Elderly
Most dependent elderly live in the community and are cared for by relatives. In most of these cases, excellent loving care is provided. In some cases, however, there is frank abuse or neglect, and in some the situation is ambiguous. The number of older Americans who are abused is likely to increase. This is thought to be partly a result of the national trend toward smaller families, as well as the rapidly increasing numbers of the very old, who are no longer wage earners and are more likely to be frail and dependent. Clear-cut examples of physical and emotional violence, sexual abuse, financial exploitation, and harmful neglect of frail elderly people have been reported.
Defining abuse can be difficult. Victims are often competent adults who choose to continue living in a suboptimal relationship with a caregiver. Neglect is also often difficult to define, especially in a relationship in which the caregiver has no legally defined responsibility. Furthermore, some situations offer only tragic options. If a single working mother cares for her demented mother who repeatedly wanders or urinates in closets, is it abuse if the daughter uses physical restraints? Suppose neither mother nor daughter will accept a nursing home and employment of professional caregivers is not financially feasible. Is it abuse if the daughter uses physical restraints?
Diagnosis is difficult because both abuser and victim may deny or minimize abuse. Consequently, diagnosis is often inferential. Treatment may be problematic in all but extreme cases. Remedies might include an alternative environment that is healthy, supportive, and acceptable to the victim or the provision of services that can relieve a stressed caregiver. Such treatment is often unavailable. Table 12.5 lists the risk factors for abuse (43,44).
Clinicians may be reluctant to become involved in a situation in which there is little reward, poor reimbursement, and potential liability. State statutes vary in defining the physician's responsibility and liability. The Council on Scientific Affairs of the American Medical Association has published a useful report on this subject. The report outlines several strategies for prevention and intervention (43). (The full report is available by writing to the Council on Scientific Affairs, AMA, 535 N. Dearborn St., Chicago, IL 60610.) In severe cases, however, legal advice should be sought and state and local agencies, such as Adult Protective Services, should be involved.
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TABLE 12.5 Risk Factors for Elder Abuse |
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Falls
Falls are common in the elderly and often have serious consequences, including death. It is estimated that 35% to 40% of community-dwelling adults age 65 years and older have at least one fall annually.
Falls are a typical geriatric syndrome: their etiology is often multifactorial and treatments are most effective when targeting several of these factors. Risk factors, such as the environment, medications, sensory impairment, dementia, depression, and deconditioning—as well as specific neurologic, cardiovascular, or musculoskeletal diseases—can be identified (45).
At least once yearly assessment of falls has been advocated. Evaluation should focus on the number of falls, events leading up to and after the falls, and environmental circumstances surrounding the falls. Moreover, the practitioner should screen for known intrinsic and extrinsic risk factors. This screening includes an assessment of prescription and alternative medicines; examination of vision, gait, balance, strength and flexibility of lower extremity; and evaluation of cardiovascular, neurologic, and other medical problems that may have caused the patient to fall. Mobility function may be determined by observing the patient as he or she stands up from a chair without assistance, walks several steps, turns, and returns to sit in the chair (46,47). Environmental factors such as dim lighting, steep stairs, loose carpeting, or small pets should be sought and, when possible, remedied.
Those who have fallen or have risk factors for falls are candidates for further interventions. For example, some exercise programs, particularly those including balance exercise (e.g., tai chi), reduce risk of falls by 10% to 17% (48). Home environmental assessments and subsequent
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modifications are also effective, as are treatment of cataracts, participation in a physical therapy program, and review and modification of medication regimens of those who have fallen (especially if they take more than four medications). A multifactorial intervention program targeting four specific risk factors in a vulnerable population reduced falls during 1 year of followup from 47% to 35% (49). The risk factors were postural hypotension, use of sedatives, use of four or more prescription medications, and impairment in arm or leg strength or range of motion, transfer skills, or gait skills (49). Finally, hip protectors and identification and treatment of osteoporosis may be helpful adjuncts in preventing potentially serious fractures, although there are other important consequences of falls (such as prolonged psychological impact and decrements in physical functioning) that are not benefitted. In a randomized controlled study that recruited ambulatory frail elderly persons, those who wore hip protectors had their risk for hip fractures after a fall reduced by 66% over an 18-month period. Once convinced to wear them, study participants kept them on 50% of the possible time (74% had them on during the falls) (50). These protectors are becoming commercially available, but compliance remains problematic. Whether vitamin D supplementation reduces fractures is debated, but many authorities advise supplementation with calcium and vitamin D for those who are at risk for falls and fractures. For a careful review of falls in elderly outpatients see King and Tinetti (51).
Nutrition
For a variety of reasons, precise definition of dietary requirements for ambulatory elderly people is difficult. The elderly are physiologically and metabolically an extremely diverse group with a variety of illnesses, taking a variety of medicines. Absorptive function in the aging gut is poorly studied. However, recommended daily allowances for the elderly are extrapolated from data collected in studies of younger people. Recommended daily allowances based on age alone are imprecise. Basic principles of nutrition for persons of all ages are discussed inChapter 15.
Two general principles have been demonstrated. First, most elderly Americans who seek medical attention are not undernourished. Second, desirable body weight for the elderly may be somewhat heavier than previously determined on the basis of insurance company tables of mortality and body mass index (BMI). These tables do not consider age. Based on independent analysis of insurance company data, Andres (52) calculated mortality ratios in various age groups according to BMI. This analysis suggests that the BMI associated with the lowest mortality rate varies with age. The older the age group, the higher the BMI associated with the longest survival. For example, the BMI associated with the lowest mortality among 25-year-old men is 21.4. For a 6-foot-tall man, this corresponds to a weight of 158 pounds. For a 65-year-old man, the best BMI is 26.6, 196 pounds for the same 6-foot-tall man. Roughly speaking, these tables allow a gain of approximately 1 pound per year throughout adult life. Several studies of long-term weight change tend to confirm that modest weight gain during adult life is associated with lower mortality (53). These tables do not apply to patients with diseases that are related to weight. For patients with type II diabetes mellitus, osteoarthritis, hypertension, and hyperlipidemia, weight loss is often a central part of treatment.
The pattern of body fat distribution is associated with several important diseases and with mortality. In women, high waist-to-hip circumference ratio is more strongly associated with death than is BMI (see Chapter 83) (54).
A variety of psychosocial factors (e.g., isolation, alcoholism, depression, low income) and physiologic changes (e.g., diminished taste and smell sensation, dental problems, dementia, dysphagia, side effects of medications) may contribute to a diminished intake of nutritious meals. The effects of multivitamin supplements are unknown. Trials of supplementation with certain specific vitamins (carotene and tocopherol) have shown no benefit (55,56). Although risks are low when vitamins are taken in moderation, costs can be high. Data are inconclusive about canned “complete” nutritional products provided to alert patients as a supplement to or substitute for regular food. Several studies suggest that intake of canned oral nutritional products offsets the intake of food at meals. These products are more costly than food, and unlikely to be superior to it.
Weight loss can result from a variety of causes, some trivial and some lethal. In general, the known causes of weight loss can be classified as decreased intake, reduced absorption, and increased use. Involuntary weight loss can be troubling in the elderly. In approximately 25% of cases, no cause is discovered despite intensive evaluation (57). Almost all the remaining causes can be found with a careful history and physical examination and judicious use of the laboratory. In the elderly, decreased intake should be carefully sought, with particular attention to medications, problems accessing food, depression, and oral hygiene. The search for malignancy during a careful history and physical examination and the exclusion of hyperthyroidism with appropriate laboratory investigation are also an important part of the evaluation. A chest radiograph may be useful if the patient has ever been a smoker, but nonspecific computerized tomography (CT) scans are not cost-effective and are low yield.
When inflammatory illness and cachexia are present, there are very few data to show that increasing nutrient intake benefits the patient. So-called markers of nutritional status, while frequently linked to poor outcome, may simply signal the presence of inflammatory illness rather than a situation that is improved with enhanced nutritional
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intake. As with oral nutritional supplements, appetite stimulants have not been shown to provide functional benefit or improved survival for patients with undiagnosed involuntary weight.
Exercise and the Elderly
Benefits from exercise are now incontrovertible and include improvements in bone density, sleep (58), risk of falls (48), disability and pain from knee arthritis (59), cardiovascular risk factors and disease (60), weight reduction (61), and rate of disability (14). Although not yet demonstrated in the elderly, studies in younger adults show that moderate exercise improves mood in depressed individuals. Moderate levels of resistive and aerobic exercises confer benefit. In fact, leisure-time physical activities ranging from walking to yard work and tai chi or calisthenics may suffice. Nonetheless, as with other age groups, older Americans as a whole maintain a relatively sedentary lifestyle. Barriers to attaining the above goals range from realistically grounded concerns (e.g., unsafe neighborhood, fear of exacerbating underlying illness) to attitudes and preferences (e.g., lack of time). Exploring these barriers in the sedentary older person and assessing the level of motivation seem to be reasonable initial steps in encouraging exercise in the sedentary older adult. Adherence to an exercise prescription may also correlate with activities that are enjoyable to the individual, take place in a preferred setting, and fit into his or her schedule.
For those who are inactive, it is reasonable to begin by finding ways to reduce inactivity (e.g., reducing time spent watching television) and suggesting some ways to augment baseline activities (e.g., taking stairs rather than escalator, establishing the habit of taking walks). Gradually, the intensity and duration of physical activities may be increased. The adage for medications applies here as well: start low, go slow. Two suggestions may be useful. First, the pace of walking should be slow enough that the elderly person can converse comfortably. Second, competition between walkers should be specifically discouraged. Shopping malls are good places to walk. The goal for the initially sedentary person is 30 cumulative minutes a day of moderately intense activities on most days of the week (61,62). This may be achieved, for example, by several 10-minute walks. For older adults who exercise already, emphasis might be placed on injury prevention and proper exercise techniques (e.g., avoidance of inadvertent Valsalva maneuvers that may induce hypotension) and benefits of both aerobic and resistive (strength training) programs. Fruitful followup visits usually incorporate continual encouragement, assessment and reassessment of attainable goals, careful questioning for symptoms of ischemic heart disease, and attention to any concerns of pain and injuries (61).
Patients with cardiac risk factors or established cardiovascular disease require careful evaluation, and perhaps in part for medicolegal reasons, a stress test should be considered before engaging in moderate or vigorous exercise. Lifestyle modification (i.e., reducing sedentariness) can safely be incorporated without any special cardiac testing. Those with an abnormal cardiac response to exercising (abnormally high blood pressure of >250/120 mm Hg, decrease in systolic blood pressure of >20 mm Hg, heart rate increase >90% of age-specific maximum) are not suited for moderate or vigorous exercise programs (63). The risk of an exercise-related cardiac event has been evaluated in those older than age 70 years (64). As expected, the rate of myocardial infarction occurrence is higher after vigorous exercise than after moderate exercise in those older than age 75 years. Although vigorous exercise does incur a higher relative risk of ensuing myocardial infarction than moderate exercise in those older than age 70 years, this relative risk was not significantly different from those who were younger than age 70 years. Nonetheless, most previously sedentary seniors age 75 years and older do not begin and seldom end up with a high-intensity aerobic program (65).
The value of exercise testing for apparently healthy elderly patients who want to begin an exercise program remains uncertain. Routine testing of all healthy older persons wanting to exercise may prove to be expensive, and the cost may be an unexpected barrier to starting an exercise program. Both the American Heart Association and the American College of Sports Medicine recommend exercise stress testing for sedentary older people before starting a vigorous exercise program, even in the absence of suspected or known underlying cardiovascular disease. In the case of moderate exercise for these individuals, the American College of Sports Medicine recommends testing if certain symptoms and signs suggestive of underlying cardiovascular disease (but otherwise relatively nonspecific) are present (66). However, neither organization addresses the usefulness of exercise stress testing before resistive exercise programs. Meaningful interpretation of treadmill testing is often undermined by the resting electrocardiogram abnormalities commonly seen in older persons. Moreover, the ability to successfully complete the exercise stress test diminishes with age; compared with 30% of those between ages 75 and 79, only 9% of those older than age 85 years who agreed to undergo exercise stress testing completed the test. If available guidelines were followed, one might expect a high rate of additional followup cardiac testing, potentially exposing patients to the inherent risks and costs of these procedures (61).
A reasonable approach to preexercise assessment starts with a complete history and physical. The physician should first screen for patients with overt cardiac disease or potential contraindications to exercising outside of a monitored setting (i.e., overt congestive heart failure, uncontrolled
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hypertension, angina, or myocardial infarction within the previous 6 months). This may be followed by an assessment of resting electrocardiogram (for new Q waves, ST-T segment abnormalities) and cardiac reserve before prescribing exercise regimens. Simple office-based maneuvers were previously proposed to evaluate cardiac reserve, including getting up and down from the clinic examination table, walking a distance of 15 m, climbing a flight of stairs, and cycling in the air for 60 seconds while sitting or lying on the examination table. In the absence of worrisome findings, a prescription for an exercise program may then be given, tailored to the interested individual (61).
Elderly Drivers
Physicians are increasingly asked to provide guidance on the issue of driving to older adults and their families. Driving helps keep elderly persons connected to friends and resources. It may impart a sense of independence. For some (especially rural dwellers), driving may be the sole means of transportation. Public transportation may be limited, unreliable, or unsafe for others.
Drivers older than age 65 years can be a potential safety concern. They are involved in 8% of all nonfatal traffic accidents and account for 12% of traffic fatalities. Rather than high speed and alcohol intoxication as in younger drivers, the causes of accidents at the hands of older drivers are frequently related to turning (especially to the left), lane changes, backing up, and nonobservance of traffic signs. The per mile fatality rate of those older than age 75 years is higher than that of any other adult age group; this rate is highest in drivers older than age 85 years, exceeding even that recorded for teens. Older drivers who sustain similar injuries as their counterparts also are more likely to die as a result. Unlike those involving younger drivers, accidents with older drivers occur at intersections, close to home, and usually take place during the day in good weather (67).
Potential barriers for the older driver include age-associated physiologic changes such as slower reaction time, lower visual acuity, and decreased joint mobility. Use of alcohol and some medications increases the risk of accidents. Several common chronic illnesses (such as Alzheimer dementia, depression, arthritis, diabetes mellitus, and cerebrovascular accidents) are associated with an increased likelihood of motor vehicle accidents (68). Many older adults avoid accidents by driving shorter distances, stopping more on longer trips, and picking less busy thoroughfares. Some may avoid driving on unfamiliar roads, or during rush hour, nighttime, and inclement weather. Others simply stop driving voluntarily. Women are more likely than men to do this. Those who no longer drive tend to be older, nonwhite, and have vision and/or functional impairments (69).
An office assessment of the older driver should elicit data to identify risks for underlying driving impairment. This may include screening for alcohol or substance abuse, causes of daytime somnolence (some medications, sleep apnea), and predisposition to hypoglycemic episodes, seizures, and syncopal events. Moreover, one should note that visual acuity below 20/50 falls below legal limits in many states. Predictors of adverse driving outcomes include impaired ability to copy a design on the Mini Mental State Examination, walking less than a block per day, foot and leg abnormalities (toe deformities, bunions, knee contractures, slowed toe tapping, or impaired toe walk), heart disease, and hearing deficit (70). The use of long-acting benzodiazepines has been associated with an increased risk of motor vehicle crash among the elderly (71). Concerns about driving ability are often first voiced by family members rather than patients. Asking them and the patient to recount specific incidences of problematic driving and traffic violations add to the understanding of the issues at hand. Seat belt use, whether as a driver or passenger, should be encouraged.
Some physicians have used office- or hospital-based computerized simulators to help tailor their assessment. Unfortunately, there is, as yet, no available standardization of these models, and they cannot realistically be expected to gauge all necessary skills required on the road. Other physicians screen for higher risk drivers and send them to occupational therapy-based assessment programs when available. These programs attempt to assess the impact of physical or cognitive deficits on driving. Therapies are then tailored with the goal of modifying underlying deficits via rehabilitation and fitting of adaptive equipment. Medicare reimbursement of these programs is uncertain.
Which 90-year-old drivers are more dangerous than 16-year-old drivers? When should the freedom to drive be coercively limited? These are complex questions. Medical, legal, and ethical considerations interact, and laws vary from state to state. The American Geriatrics Society and the American Association of Retired Persons cosponsor the 55 Alive Driver Safety Program. Information is available at AARP 55 Alive, 601 E. Street NW, Washington, DC 20049 (1-888-227-7669 to find a nearby class or http://www.aarp.org/ drive for more information on safe driving tips and the driving programs).
Hospitalization
In planning a course of care for a sick elderly patient, hospitalization is often an option. However, the incidence of adverse events in hospitalized patients is well documented, and elderly patients are at particular risk. Patients older than age 65 years have more than twice the risk of adverse effects in the hospital compared with those ages 16 to 44 years. These patients also have the highest rates of adverse
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effects caused by negligence among all age groups (72). Moreover, rates for every category of procedure-related and drug-related adverse event are highest in patients older than age 65 years (72). In one study, iatrogenic causes comprised 11% of the admissions to an intensive care unit, with older age and higher number of drugs being the main risk factors (73).
The in-hospital effects of prolonged immobilization on ventilation, bone metabolism, plasma volume, and muscle strength and the risks of sensory deprivation, and physical restraints, have been well described (74). Bedsores, diminished functional status, nosocomial infection with resistant organisms, delirium, weight loss from hospital diets, and trauma are all further risks of hospitalization. Falls are common, and commonly harmful, immediately after hospital discharge (75). Efforts to take care of many moderately ill elderly patients at home are likely to develop further, independent of payer considerations.
Preventive Geriatrics
Rowe and Kahn distinguish usual from successful aging (76). In a group of usual aging Americans, for example, bone and muscle mass fall and glucose tolerance worsens with age. However, regular exercise is associated with improved glucose metabolism, increased bone mass, and muscle strength and thus modifies “usual” aging.
Although available data do not permit clear-cut recommendations, most authorities believe that the well elderly should receive periodic testing similar to that of younger patients (see Chapter 14), particularly when the projected life expectancy is estimated to be more than 5 years. Elderly patients with marked cognitive impairment or severe chronic diseases make up a separate group of patients for whom the value of screening is less certain. Decisions about cancer screening for very frail elderly people are particularly complex. Life expectancy, quality of life, willingness and ability to accept treatments, and burdens of testing and subsequent treatments, as well as patient preferences, should be factored into the decision whether or not to initiate screening. Moreover, one should also consider the impact of the target disease if diagnosed late versus the overall effects of treatment regimens if the target disease is diagnosed early. Consent for screening and treatment of newly identified diseases from a cognitively impaired patient is a particularly vexing problem.
Data show that although elderly women visit physicians more often than younger women, they are less likely to have a pelvic examination and Pap smear and less likely to be diagnosed with uterine, ovarian, or cervical cancer in a localized (and potentially curable) stage (77). The prevalence of abnormal Pap smears among elderly women was 13.5 per 1,000 in one study, and the death rate from cervical cancer is highest in women older than age 65 years (78). Chapters 14 and 104 provide guidelines for gynecologic cancer screenings. A discussion of the controversy concerning screening for prostate disease in men is provided in Chapter 53; current guidelines are presented in Chapters 14and 53. Life expectancy, rates of cancer death, and number needed to screen to prevent one death have been tabulated in a highly useful format for various types of cancer (79).
In patients at high risk for vertebral compression or hip fracture and for those with established kyphosis, a survey of the house for environmental hazards is recommended; such patients also should not lift heavy objects, including grandchildren. Adjunctive DEXA scanning may confirm osteoporosis, which can be treated with pharmacologic and nonpharmacologic interventions. Prevention of falls is discussed earlier in this chapter, and specific treatment of osteoporosis is discussed in Chapter 103.
Screening for and treating hyperlipidemia in elderly patients is a controversial topic; it is discussed in Chapter 82. Screening methods for visual loss and hearing loss are discussed in Chapters 107 and 110, respectively.
The benefits of discontinuing cigarette smoking among the elderly are probably substantial. Although several studies of smoking cessation among the elderly show little effect on primary prevention of coronary heart disease, smoking cessation reduces the risk of myocardial infarction and death in those with established disease (80). Cessation is a key step in the primary prevention of lung and other cancers and the primary or secondary prevention of obstructive lung disease, peripheral vascular disease, and peptic ulcer disease. Reducing the number of cigarettes smoked daily leads to a measurable reduction in the risk of lung cancer as well (81). A full discussion of strategies for smoking cessation is presented in Chapter 27.
The routine use of aspirin in older women continues to provoke considerable scrutiny. Its efficacy in reducing coronary events in older men is well established. Immunization information is provided in Chapter 18.
Preretirement Counseling and Planning
Several problems related to retirement can be minimized if they are anticipated and planned for well in advance. Books are available to help the older person in planning (see General References). Large corporations, senior citizen centers, and several colleges offer courses in preretirement counseling and planning. Fee-for-service care management services are mushrooming across the country, touting their expertise in coordinating home services; serving as a conduit between patients, families, and care providers; and helping with the search for appropriate senior housing and institutions. The Administration on Aging has a wide range of materials to assist in such planning. Information is available at: http://www.aoa.gov/eldfam/Money_Matters/Money_Matters.asp.
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Important topics for the older person to consider include anticipated economic changes, preparation of wills and estate planning, changes in tempo and nature of activities, the importance of developing hobbies and activities for leisure time, health care resources, and systems of health care and social support. As noted in Chapter 13, advance directives guiding medical therapy in the event of debilitating illness can be extremely valuable and are important for every adult to consider. Long-term care insurance is becoming more available, although there are disparities in cost, eligibility, and scope of coverage from one company policy to the next. An understanding of the Medicare program is important for every elderly citizen. Medicare's website (http://www.medicare.gov) is a comprehensive, user-friendly source of consumer information about the Medicare program. However, Medicare covers only 44% of total health expenditures for the elderly, so the aging patient and his or her family will need sound advice to plan properly for potential health care needs. The physician should encourage young elderly patients to investigate all these resources before they attain the age at which frailty is more common.
Special Housing and Other Community-Based Programs
Housing programs that are primarily for the elderly are increasingly available. Many states or local governments have developed programs in the setting of a congregate facility in which support services such as eating programs or housekeeping are provided. These programs may be called sheltered housing or elder housing and are generally available only to people who are able to satisfy an economic means test. Information regarding such programs can be obtained through the state or regional office on aging.
Continuing care retirement communities are increasingly available. These require that an elder move (usually while still functionally independent) to a residential community. Several types of retirement communities exist. Some provide comprehensive services, including nursing home, personal care, and medical service, meals, and programs for an inclusive entrance and monthly fee. Others provide only housing and access to additional services that may be purchased on an a la carte basis. Cost varies tremendously. Patients who ask about entering such a community should be advised to analyze carefully the services included in the fee, review the record of the community with the state office on aging, and review the contract with a lawyer before agreeing to sign it. Some people are exuberant about such retirement communities, arguing that they provide excellent socialization and the reassurance that providing care in the event of dependency will never be a direct burden to one's family members. Others describe these retirement communities as simply ghettos for the frail elderly. Because of the expense, only a small portion of the elderly population could ever consider such an option.
In part because of the high cost of community care retirement communities, programs are being developed to provide similar support services while patients remain in their own homes. Such programs, typically called social health maintenance organizations or life care at home programs, are still experimental. One such model, On Lok, developed in the late 1970s in San Francisco, is now being replicated at a number of sites around the country. This program for all-inclusive care for the elderly provides comprehensive care on a capitated basis for individuals who are dually eligible for Medicare and Medicaid, features adult medical daycare, and, in many sites, special housing programs.
Medical and social daycare centers are available in many communities. The state, county, or city Area Office of Aging will have information about these programs. Generally, such programs provide an opportunity for daytime socialization or medical care and surveillance. Importantly, they also provide an opportunity for caregivers to have a respite from their care responsibilities. Unfortunately, medical daycare programs are not covered by most private insurance programs or Medicare (except for those who receive it under a Medicare/Medicaid waiver, e.g., via the Program for All-Inclusive Care for the Elderly). Medicaid does provide reimbursement for medical daycare services in some states, but with means testing. For others, medical daycare is an out-of-pocket expense that, although expensive, is usually about half the cost of nursing home care. Social daycare programs (sometimes known as senior centers) are less expensive but usually require that a person be functionally totally independent and often do not provide transportation services to the facility. Social daycare programs (as opposed to medical daycare) are often sponsored by churches, local government, or other organizations, which usually help offset the cost.
Assisted living facilities are a popular option for seniors. In addition to housing arrangements, they usually offer some additional services such as transportation, social activities, and prepared meals. Basic nursing support is sometimes available. Some facilities are built with the intention of serving cognitively impaired seniors. All 50 states have some form of regulations and licensure requirements for these facilities, and proposals for a national standard for quality are being devised. Quality of care and scale of operation vary greatly. Well-run operations may be found in a variety of settings, from modified homes operated by individual providers to gated communities with a multitude of amenities constructed by large corporations. As a whole, residents of assisted living facilities have multiple medical problems yet wish to maintain some levels of independence in a residential type of community. These facilities may increasingly become a viable arena for physicians interested in providing home-based medical care to the elderly.
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TABLE 12.6 Some Helpful Internet Resources |
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Other Important Problems of the Elderly Patient
The following problems are discussed in detail elsewhere in this book: constipation (Chapter 46), diverticular disease (Chapter 46), musculoskeletal problems (Section 10), menopause (Chapter 106), osteoporosis (Chapter 103), hearing loss (Chapter 110), skin problems (Section 17), dental problems (Chapter 112), disorders of the feet (Chapter 73), hypertension (Chapter 67), cataracts and macular degeneration (Chapter 107), psychiatric illnesses of old age such as dementia and delirium (Chapter 26), depression (Chapter 24), bereavement (Chapters 13 and 24), and urinary problems such as infection (Chapter 36), retention (Chapter 53), and incontinence (Chapter 54).
Additional Information and Resources
Table 12.6 lists some governmental agencies and other organizations that offer information and resources to health care providers, caregivers, and the elderly.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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