Elderly care Dr Hanan Abbas assistant professor of of Family

The number of persons 65 years of age and older continues to increase dramatically. Comprehensive approach is an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients include sensory perception and injury prevention.

Interventional areas include immunizations, diet and exercise. Mental health issues should also be evaluated Using an organized approach can improve care provided for older patients

Falls

Falls result in accidental death among persons 75 years of age and older and significant mortality and morbidity. Multifactorial A fall is 'an event which results in a person coming to rest inadvertently on the ground and other than a consequence of the following: loss of consciousness, sudden onset of paralysis as in a stroke, or epileptic seizures'. As a result of impaired gait and balance, medical illnesses, and environmental factors.

Frequently, older persons are not aware of the risk factors and do not report falling unless an injury has occurred. Identifying and targeting the population at greatest risk with multifactorial interventions is essential to the prevention and reduction in the incidence of falls and fall-related injuries in older

Epidemiology

In the United States, accidents are the sixth leading cause of death in persons over the age of 65 and falls account for two-thirds of these deaths. The annual incidence of falls ranges from 30 % in persons over the age of 65 to 50 per cent in persons over 80 years of age. Rates of fall-related deaths for older persons increase sharply with advancing age and are consistently higher among men than women. Due to the higher prevalence of comorbid illness among men than women of similar age.

Approximately 1 % of these falls result in hip fracture, 3 5 % in other types of fractures, and an additional 5 % result in severe soft tissue injury, such as haemarthroses, joint dislocations, sprains, and haematomas.

Hospitalization rates for hip fracture increase with advancing age for both sexes but are consistently higher for women in all age categories. This gender difference may be related to the prevalence of osteoporosis in older woman.

Falls are also an important marker of frailty. Of older persons who are hospitalized for a fall, only about one half are alive 1 year after. This indicates the seriousness of underlying disease and the need to ameliorate the symptoms of chronic illness to prevent further risks of

Case 1

An 81 yo female is brought to your office by her daughter, the elderly mother has been falling for at least 3 months. The falling has been getting progressively worse, and her daughter has been concerned regarding her mother breaking her hips. On exam, the pt is a frail elderly female in no distress, she appears somewhat depressed. The pt BP 180/75, her pulse is 84 and regular, no other abnormalities are found.

Intrinsic
1. 2. 3. 4. 5. 6. 7.

Extrinsic
1. 2. 3. 4. 5. 6. 7. 8.

8. 9.

10. 11.

Age Cognitive impairment Muscle weakness Foot problems (callouses, bunions, or anatomical deformities) Polypharmacy (sedatives, tranquillizers, antidepressants, antihypertensive, and diuretics) Sensory impairment (macular degeneration, cataracts, and glaucoma) Gait and balance impairment (Parkinson's dis., seizures, Lower extremity neuropathies, dementia, TIAs) Acute disease (pneumonia, urinary tract infections) Chronic disease (cardiovascular dis., neurological dis., dementia, depression, visual problems, osteoporosis) Depression Postural hypotension

Environmental hazards Inadequate lighting Slippery surfaces Loose rugs Low toilet seat Low chairs High stairs Ill fitting shoes

Assessment

assessment of basic neurologic function including mental status, muscle strength and tone, lower extremity peripheral nerves, proprioception, deep tendon reflexes, and cerebellar function. A cardiovascular examination should include heart rate, postural pulse and blood pressure (lying and standing with a 5-min interval between each reading). Visual screening and an examination of the lower extremities, especially the feet, for deformities, and ulcerations

The 'get up and go test' of mobility is a simple screening tests that can be administered in the clinical setting. The older person is asked to rise from the chair, to stand momentarily with eyes opened and closed, then nudged on the sternum, to walk 10 ft, and to return and sit in the chair.

It may be useful to obtain a complete blood count, thyroid function tests, and drug levels if the history and physical examination indicate a potential problem in these areas. Electrocardiogram may be considered if a cardiac arrhythmia is suspected. Neuroimaging may be helpful for older persons with neurological deficits and gait abnormalities. Referral to specialists such as a neurologist, cardiologist, ophthalmologist,

Management

The goal of management is to minimize the risk of falling without compromising mobility, functional activities, personal independence, and an acceptable quality of life. Treatment is focused on eliminating or modifying risk factors. Initial treatment of acute or reversible deficits such as urinary tract infections, pneumonia, congestive heart failure, metabolic disturbances, or medication side-effects may result in major

Recommendations for a community population should include: gait training review modification of medications. Exercise programme, with balance training as one of the components, treatment of postural hypotension, modification of environmental hazards( adequate lighting, avoid slippery floors, loose rugs,..)

Gait disorders

Normal balance require integration of position sense, the visual system, vestibular organs, motor strength, and motor function coordination. Decline in their function leads to general motor slowing. Age-related motor

Presentation to primary care

feeling unsteady, shuffling feet, postural changes, or falls. VestibularA history of vertigo localizes to the vestibular apparatus. The patient may have a sensation of 'waves'. Often, these patients will have transient dizzy feelings on rising from a lying position or with turning the head quickly. VisualGait changes associated with visual dysfunction may be due to change in visual acuity such as cataracts and macular degeneration, or visual field loss. Occasionally, patients are unaware of a visual field deficit until detected by the examiner.

MotorStroke, myopathy, or peripheral neuropathy all cause muscle weakness affecting gait. The hemiparetic gait seen in stroke with foot drop. Proximal lower extremity weakness seen in myopathy results in inability to stand from a seated position without pushing off with the hands. If there is weakness of the hip musculature (especially the hip abductors), the gait will appear 'waddling' like a duck. Foot drop is typically due to a root or peripheral nerve disorder. So the foot does not catch on the ground, there is

Sensory impairmentLoss of position sense also results in gait difficulty, especially in the dark, as the visual system is not able to compensate for impaired proprioception. The loss of vibration sense in the lower limbs is part of normal ageing; position sense, however, remains intact in normal old age. Therefore, examination of position sense at the toes is a critical part of the assessment in patients with gait difficulty. Mechanical involvementArthritis is common in the elderly and contributes to gait difficulty by affecting the axial skeleton lower limb musculature.

Gait difficulty is due to one or a combination of the following

difficulty regaining balance after postural displacement; focal or generalized change in posture; major change in tone; inability to initiate movement; reduced speed of movement; presence of involuntary movements which interfere with gait; lack of proper coordination of movements; inability to stop intended movements; or impaired central mechanisms for gait integration.

History
The following leading questions should be asked: Are you having pain which prevents you from walking normally? Are your legs so weak that they may give out when you walk? Do you have a feeling that objects are going around or moving when you walk? Is the difficulty in walking present regardless if you walk in the light or in the dark?

Pain in the hip, knee, or foot which makes walking difficult may be due to bursitis or arthritis. Gait difficulty due to vestibular and cerebellar function abnormalities is present in the light as well as in the dark. In the case of vestibular dysfunction, patients frequently experience dizziness when turning in bed, sitting up quickly, or on sudden turning of the head to one side or the other.

Physical examination
Normal elderly people have a flexed posture and shorter length compared to younger persons. Flexed posture greater than expected by age is seen in Parkinson's syndrome (PS). Parkinsonian gait is characterized by a narrow base, reduced armswing (often asymmetric), and exaggerated flexion at the waist and neck. The gait is 'shuffling' because of reduced stride length and problems picking the feet off the ground.

Cerebellar disorders has a wide base. Cerebellar gait is unsteady. Features supportive of a cerebellar disorder include limb ataxia, dysarthria, and nystagmus. Romberg testing is performed by asking the patient to stand with eyes closed and feet together. A positive test requires that the patient break his/her stance; Positive Romberg is a sign of impaired position sense .

Investigations
vestibular dysfunction needs an otologic assessment. Imaging studies to rule out cerebellar masses or atrophy.

Principles of management in gait disorder

treat the underlying cause (s) supportive care for pt and caregiver making the home environment safer Home environments often have to be modified stairs, light, rugs, slippery floor, high chair, low toilet seat. Referral to a specialist is appropriate if the diagnosis is uncertain, if there is a poor response to medical therapy, or if investigations are not available to the primary care physician (i.e. imaging studies). In Western countries, referrals are often

Urinary incontinence
Urinary incontinence, defined as the involuntary loss of urine, is a major problem affecting many elderly people. 1530 % of elderly people living independently suffer from incontinence 14 % of women aged 65 years and older are troubled daily by

Case 2
An 88 yo female pt who you care for, residing with her daughter is having increasing difficulties with bed wetting, she is embarrassed to talk about this, but her daughter informs you that this problem is getting worse, at that time the pt had been continuously incontinent for 6 days.

Possible causes
Bladder capacity, the ability to postpone micturition, and bladder contractility all decrease. Uninhibited detrusor contractions increase and there is a slight rise in the residual volume. In women, the maximum urethral closure pressure and the length of the urethra decrease. In the majority of elderly men, the prostate becomes enlarged and the urine

In most cases, involuntary urine loss is related to disturbances in the continence mechanism of the bladder itself.

Urge incontinence
Urge incontinence is the involuntary loss of urine concomitant with a sudden intense urge to urinate. Other common symptoms are frequency and nocturia. Urge incontinence is usually accompanied by urodynamic findings of detrusor hyperactivity .

Stress incontinence
Stress incontinence is the involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that cause an increase in intra-abdominal pressure. The most common cause of stress incontinence is hypermobility of the urethra and bladder neck . This is the result of a weak pelvic floor, probably caused by childbirth and

Overflow incontinence
It is involuntary urine loss accompanied by overfilling of the bladder. The patient generally suffer from very frequent to continuous loss of small volumes of urine (continuous leakage), 'bearing-down' while urinating, incomplete voiding and weak stream. Overflow incontinence can be caused by two factors: a hyperactive or non-active detrusor bladder neck or urethral obstruction.

A hyperactive or non-active detrusor can be caused by: medication, faecal impaction, diabetic neuropathy. In men, obstruction is mostly caused by prostate hypertrophy, less commonly by prostate cancer,or faecal impaction.

Functional incontinence
When involuntary urine loss is caused by factors outside the lower urinary tract, such as limitations in physical or cognitive functioning, this is referred to as functional incontinence. Hip arthrosis, muscle weakness, hand problems, and tremors can hinder the elderly person's self-care: climbing out of bed unaided, going to the toilet, undoing clothes, and sitting down to urinate, communication and cognitive

:History
The characteristic clinical symptom of stress incontinence is the loss of small volumes of urine during activities that increase the intraabdominal pressure, such as sneezing, coughing, jumping, laughing, lifting, and sport. The patient does not feel the urge to urinate before leakage occurs. As soon as the increased pressure ceases, the urine loss also ceases.

the patients feel an urgent need to urinate that they can no longer reach the toilet in time. Once micturition has started, it is very difficult to stop the flow, often accompanied by frequency and nocturia. When pain is present, it is an indication of infection.

Reversible and other contributing factors in incontinence

Possible reversible factors: Conditions: delirium, faecal impaction, depression, symptomatic UTI. Environment: impaired locomotion, lack of access to toilet, restrictive clothing. Excessive intake of caffeinated beverages or other bladder irritants. Diagnoses: diabetes, CHF, CVA, Parkinson's disease, and other neurological diseases affecting motor skills Medication: diuretics, antiparkinsonian, antispasmodics, antihistamines, and other anticholinergics Drugs that stimulate or block sympathetic nervous system: calcium-channel blockers, narcotics Psychoactive medication: antianxiety agents, antidepressants. Other contributing factors: Conditions: pain, excessive or inadequate urine output, atrophic vaginitis, cancer of the bladder or prostate, urethral obstruction, disorders of the brain or spinal cord. Abnormal laboratory values: elevated blood glucose or calcium

In women, vaginal palpation and speculum examination , signs of atrophic vaginitis, uterine prolapse or cystocoele/rectocoele, tumours, fistulae, vaginal discharge, and signs of infection. Rectal palpation: tone of the sphincter. If the patient is able to contract the sphincter, then this is strong evidence against disrupted innervation of the bladder neck and bladder. Attention should be paid to faecal impaction in the rectum. In men, the surface and consistency of the prostate should be examined.

Tests
urine test & culture Ultrasound of bladder to exclude urine retention. If obstruction or retention is suspected, kidney function tests should be performed and in of polyuria and/or nocturia, glucose and electrolytes should be monitored.

:Management
Stress incontinence: pelvic muscles exercises, Alpha adrenergic agonists, Behavioral training, Supplemental estrogen

Urge incontinence

Bladder relaxants & training, Estrogen supplements, Behavioral therapy, Surgical removal of obstruction

Overflow incontinence
Surgical removal of obstruction, Intermittent catheterization, Indwelling catheterization) increased risk of urinary tract infection, the risk of injury and stricture of the urinary tract).

Functional incontinence

Behavioral therapy (prompt voiding, habit training, environmental manipulation, scheduled toileting, incontinence pads). External collection devices, indwelling catheters.

Case 3

daughter is caring for her elderly mother at home. Mom has a variety of medical issues and is taking a number of medications. The doctor prescribes for mom's anxiety. Over a period of months the mother becomes sleepy all the time and can't seem to concentrate. She will even fall asleep while someone is talking to her. The doctor and family initially attribute it to her age. Finally the daughter decides there must be something wrong and she insists the doctor look into it. Tests are conducted and low blood level of sodium is confirmed. After some research the doctor suspects the prescription might be causing sodium depletion. He removes the mother from the medicine and she becomes normal again.

Medications and the Elderly

Facts about Medications and the Elderly Older Americans comprise about 13% of the population but they consume over 30% of all prescription drugs. It is estimated that 30% of the older population taking medications have had an adverse drug reaction. Up to 20% of hospital admissions for the elderly are due to adverse drug reactions. It is estimated that over half of the deaths attributed to adverse drug reaction are for people age 60 and above.

Old age is associated with a reduction in glomerular filtration rate, a decrease in renal plasma flow and decreased tubular reabsorptive capacity. The net effect of this is a decrease in renal clearance of drugs that are hydrophilic in nature, for example digoxin. Such drugs should either be avoided or given at lower dosages.

Possible reasons for increased prescribing in the elderly

Evidence showing benefits of drug use in the elderly, e.g. the use of warfarin in patients with atrial fibrillation Increase in the numbers of elderly and very elderly patients, with a consequent increase in morbidity Increase in screening and detection of asymptomatic conditions, e.g. hypertension Increased patient expectations The practice of defensive medicine

A survey of 805 people was particularly

informative regarding the use of drugs in the elderly in the United Kingdom

Most of the drugs being taken by the elderly are prescribed on a long-term basis, with 59 per cent having been prescribed for more than 2 years; Eighty-eight per cent of all drugs prescribed were by repeat prescription; and forty per cent had not discussed

The inter-relationship between polypharmacy and poor compliance, resulting in a vicious cycle that leads to a prescribing cascade

A 75-year-old woman was diagnosed as having hypertension. She was started on capozide by her doctor. Two weeks later, a routine blood test showed her to have a potassium level of 2.9 mmol/l. She was prescribed potassium replacement therapy in form of slow release potassium tablets to be taken together with capozide. At the next visit 2 weeks later, her potassium level had come up to 3.4 mmol/l, and she was continued on slow potassium. She presented 2 months later with a history of severe heartburn; a gastroscopy showed her to have an oesophageal ulcer. This was blamed on slow potassium, which was stopped. The patient was started on omeprazole. Unfortunately, after a few days treatment she developed diarrhoea. The doctor continued the omeprazole in order to relieve the oesophageal ulcer, and prescribed codeine phosphate for the diarrhoea. After two doses of codeine phosphate, the patient developed dizziness, had a fall, and was admitted to a hospital with a fractured left hip.

Reasons for inappropriate prescribing in the elderly

Incremental prescribing, with sideeffects being treated with other drugs, rather than discontinuation of the original drug Therapeutic enthusiasm, with use of drugs as first line treatment without considering the use of non-drug therapies Failure to adequately assess patients' needs and individualize treatment Unrealistic expectations on the part

A strategy to improve prescribing in the elderly

Careful clinical assessment of the patient and an evaluation of the riskbenefit ratio of starting drug therapy. Start at low doses, and increase dose gradually. Remember that the elderly often require lower doses. Use one drug if possible, and avoid polypharmacy. Keep the drug prescribing regime simple. Give clear, and if possible, written instructions on how to take the

Undertake a regular review of medications, and stop medicines when necessary. Review and improve repeat prescribing system, if necessary. Let patients know what to do when their medicines run out, and how to dispose of medicines that are no longer necessary. Consider drug (s) as the cause of new symptoms and signs arising in

Ensure communication between hospital and primary care is up-todate. In the future, this may be facilitated by the use of individual smart cards or electronic patient records. Multidisciplinary team working with pharmacists and nurses will help in many of the objectives outlined above.

Giving in to pressure from relatives, patients and other health care professionals to prescribe Inadequate review of medicines, leading to continuation of drugs that are no longer necessary Governmental pressure to meet targets

Use sources of information such as formularies in order to appropriately prescribe in patients with renal and liver impairment, and to avoid the use of interacting drugs. Remember that in the elderly, a normal serum creatinine does not indicate normal renal function.

Five key dimensions of the ageist bias in which healthcare fails older persons

Healthcare professionals do not receive enough training in geriatrics to properly care for many older patients. Older patients are less likely than younger people to receive preventive care. Older patients are less likely to be tested or screened for diseases and other health problems. Proven medical interventions for older patients are often ignored, leading to inappropriate or incomplete treatment. Older people are consistently excluded from clinical trials, even though they are the largest users of

Recommendations for caregivers

Make sure an elderly one has challenging activities throughout the day instead of simply watching TV (challenging home oriented activities). Give them responsibility for taking care of plants . This strategy is used often in nursing homes to reduce depression in the elderly and to actually improve their health as well. Provide opportunities for family and friends to come by and visit and encourage or even arrange such encounters. Provide opportunities for the older person to interact, teach and nurture children such as grandchildren. This is an extremely effective strategy for helping the older person feel that he or she has a meaningful existence. And it has a

Design or arrange an exercise program and come up with a way to encourage the older person to follow it. Understand the nutrition needs of an older one, especially the need for vitamins and minerals including iron.. Make sure the person takes care of him or herself and eats properly. Many elderly people neglect their own nutrition. Poor nutrition can cause all kinds of mental and physical problems in the elderly. Make sure an older person has opportunity to look good . Make sure the person gets out in public, and going to a public event and can feel good about his or her appearance.