Common Geriatric Problems Flashcards
3 major obstacles to receiving appropriate preventative care for seniors:
Access
Cost
Ageism
Main preventative healthcare measures:
Smoking cessation
Nutrition
Exercise and mobility
Safety programs
The following conditions are extremely common in the geriatric population:
► Hypertension ► Urinary incontinence ► Falls ► Osteoporosis ► Dementia
Hypertension
1970s - ignore elevated blood pressures in the elderly,
1980s - docs did not believe that antihypertensive drugs could improve outcome in the elderly
NOW:
effective treatment of isolated systolic or systolic/diastolic hypertension can reduce the morbidity and mortality of coronary heart disease. Elevated systolic blood pressure in the elderly is more significant than elevated diastolic blood pressure.
**check every geriatric patient for orthostatic changes. If orthostatic changes are apparent, always check that patient’s BP in the standing position, whenever possible.
Causes of 2ndary HTN
Renal disorders: Renal artery stenosis due to atherosclerosis, Renal parenchymal disease, Renal neoplasms
Endocrine disorders
Drugs
Atherosclerotic disease
Dx of 2ndary HTN
Systolic blood pressure is > or equal to 140mm Hg and/or diastolic pressure is > or equal to 90mm Hg, documented on at least three separate occasions, with at least two separate measurements on each occasion.
Tx of 2ndary HTN
Tx of HTN in elderly patients = greater potential for adverse effects, such as predisposition to:
heart failure, stroke, renal failure, CAD and peripheral artery disease.
treatment goal: decrease the risk of developing these complications.
Lifestyle Modifications HTN
initiated with all patients even if starting them on drug therapy.
Limit salt intake under 2.3 g daily exercise diet (non-packaged foods) smoking cessation decrease alcohol intake
Drug Therapy HTN
BP reduction with the use of any drug or drug combination compared with either placebo reduces cardiovascular morbidity and mortality.
The magnitude of the benefit is proportional to the reduction in systolic BP and is greater in the elderly than in younger patients.
All of the commonly used antihypertensive drug classes, with one exception, the beta-blockers, appear to be equally effective in reducing outcomes.
Diuretics and beta blockers both reduce the occurrence of adverse events related to cerebrovascular disease however diuretics are more effective in reducing events related to coronary heart disease. Treated patients are less likely to develop severe hypertension or congestive heart failure.
In most instances, low-dose diuretic therapy should be used as initial antihypertensive therapy in the elderly
Thiazide diuretics
Beta Blockers
Beta-blocker use in the treatment of hypertension in the elderly has come into question in large part because of the:
Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) trial, which was stopped early because of increased mortality in the beta-blocker (Atenolol)-diuretic arm vs. the CCB-ACE inhibitor arm and the
Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) trial, in which Losartan-based therapy outperformed Atenolol-based therapy despite equivalent BP reductions.
Furthermore, meta-analyses has shown that beta-blocker (principally Atenolol)-based treatment was less effective than other treatments and only slightly better than placebo in preventing most cardiovascular disease outcomes.
Coupled with their unfavorable metabolic profile (i.e., reduced insulin sensitivity and increased incidence of new-onset diabetes) and a constellation of adverse effects:
erectile dysfunction
cold extremities
depression/lack of energy
weight gain
These outcome findings have caused beta-blockers to lose their favored status as initial therapy for hypertension.
When would beta blockers be indicated? What specific patient population?
When would beta blockers be contraindicated?
Initial drug therapy per Up to date:
For older hypertensive patients who require medication and who do not have an indication for a specific drug, the following is recommended as initial monotherapy (preferred):
low-dose thiazide-type diuretic or
long-acting calcium channel blocker* or
angiotensin-converting enzyme (ACE) inhibitor/angiotensin II receptor blocker (ARB).
dosing
Elderly patients are more prone to orthostatic and/or postprandial hypotension.
Therefore, in the absence of a hypertensive emergency, blood pressure reduction should always be gradual in older adults.
Days to weeks to attain desirable result
BP GOALS
Generally, a blood pressure goal is to attain:
a systolic pressure of 125 to 135
Should you wean a geriatric patient off their drug therapy once optimal blood pressure is obtained and maintained?
BP - NATUROPATHIC
Hibiscus Tea?
Celery: 4 – 6 daily; contains 3n-butylthalide; acts as a diuretic
DASH-s – 50% of population is salt-responsive
Encourage Mg (dark leafy greens), Ca, K, CoQ10 (200-300mg), Fish Oil (1.5g of EPA daily – likely 3g daily based off of CA research)
Arginine more useful in younger population rather than elderly (CI in CA - inc vascular growth)
Decrease alcohol and caffeine
Cardiotone (for hard/tricky cases) – includes Raulfia
Hawthorne – 1 tsp daily; Garlic (CI anticoags)
Other common geriatric problems
Urinary incontinence, osteoporosis, falls, and dementia have three major things in common.
These conditions are more prevalent in the geriatric population then in younger patients.
They can result from physiologic and pathologic changes that occur with age.
They can result in significant functional decline of the individual
Urinary Incontinence
Urinary incontinence is the involuntary loss of urine in a quantity or frequency great enough to cause either a social or health problem.
The development of incontinence is not considered to be a normal part of aging.
Urinary incontinence is a major factor in the decision to pursue nursing home placement for a chronically ill patient.
Urinary incontinence is a largely neglected problem which can be successfully treated or cured.
Incontinent patients are predisposed to skin breakdown and pressure sores, social isolation and depression, urinary tract infection and falls (especially in nocturnal trips to the bathroom).
Categorized as acute or chronic
Epidemiology of Urinary Incontinence
Urinary incontinence occurs in an estimated 15% to 40% of individuals greater then 65 years of age living on their own outside of a care facility.
Up to 35% to 60% of acutely hospitalized geriatric patients are found to be incontinent.
Approximately 40% to 80% of elderly patients in long-term care are diagnosed as having urinary incontinence.
It is estimated that only 20% of all individuals with incontinence ever seek medical evaluation of their condition.
Acute Incontinence
Acute incontinence: defined as being transient, reversible and likely due to an external cause DIAPPERS Delirium Infection Atrophic urethritis and vaginitis Pharmaceuticals Psychiatric disorders (esp depression) Excessive urine output Restricted mobility Stool impaction
Chronic Urinary Incontinence
Chronic urinary incontinence is generally divided into four/five categories:
Stress incontinence – MC due to pelvic muscle weakness
Tx: pelvic floor exercises (kegels)
Urge incontinence
Overflow incontinence
Detrusor underactivity
Functional incontinence
Stress Incontinence (outlet incontinence)
Stress incontinence is the leakage of urine which can follow any increase in intra-abdominal pressure: coughing, sneezing laughing or bending over.
Stress urinary incontinence is usually due to pelvic floor muscle weakness and diminished resistance to pressure by the urinary sphincters.
Urge Incontinence (detrusor overactivity)
Urge incontinence is an involuntary loss of urine while suddenly feeling the need or urge to urinate.
Urge incontinence is generally due to involuntary and inappropriate detrusor muscle contractions due to damage to the nerves to the bladder, damage to the central nervous system or to a problem with the muscles themselves.
Irritation to the bladder wall can also result in urge incontinence.
Urge incontinence is also described as “spastic bladder” or “overactive bladder”.
Tx: treat the underlying cause – think other concomitant diseases (such as – neuro adverse effects – MS, stroke, parkinsons, alzheimers, things that cause irritation – infection, bladder CA, stones
Overflow incontinence (outlet obstruction)
Overflow incontinence is leakage of urine from a distended bladder.
Bladder enlargement may be due to outlet obstruction as can be seen in men with prostatic hypertrophy or in woman with obstruction due to pelvic mass or urethral fibrosis.
Overflow incontinence can be seen in spinal cord patients or patients with diabetic neuropathy (neurogenic or atonic bladder).
The anal reflex and “saddle” sensation are usually absent.
Medications such as the narcotics or anticholinergics can also result in an atonic bladder
Detrusor Underactivity
Causes urinary retention and overflow incontinence
Causes:
Injury to the nerves supplying the bladder
Autonomic neuropathy of diabetes
Parkinson’s
Alcoholism
Men with chronic outlet obstruction
Detrusor Underactivity
Causes urinary retention and overflow incontinence
Causes:
Injury to the nerves supplying the bladder
Autonomic neuropathy of diabetes
Parkinson’s
Alcoholism
Men with chronic outlet obstruction
Questions around incontinence
Questions regarding urination should include the frequency and pattern of urination (periodic/constant/day/night, with stress/at rest/ with coughing, sneezing or laughing?)
> 7 voids daily = frequency
2+ voids nightly = nocturia
Any sense of urgency, hesitancy, dribbling interrupted stream, or sense of incomplete void?
Current pattern of bowel regularity.
Medication list
Fluid intake
Caffeine use – if so, amount/ time of day
ETOH use – if so, amount and time of day
Distance to toilet
Ease in use of toilet
Consider asking the patient to return with a 1 to 3 day voiding diary.
Time of day, approximate amount, are their pants wet or dry by the time they get to the restroom, other comments
Objective Eval of Incontinence
Abdominal Neuro Rectal (impaction, BPH) Pelvic (prolapse, vaginal tone) Functional status – gait, balance,
Labs for incontinence
The initial lab evaluation for all patients with incontinence is a urine analysis to rule out cystitis.
Check for markers of infection such as leukocyte esterase or nitrite. If positive, send urine for culture and sensitivity.
Also assess for the presence of hematuria, glycosuria and proteinuria.
Tx of incontinence
Treatment is aimed at first treating the reversible causes.
Simple behavioral maneuvers such as establishing a toilet regimen.
Kegel exercises should be practiced for all causes of incontinence.
Topical estrogen is a treatment option in women with stress incontinence related to vaginal atrophy.
Good perineal care may prevent local irritation.
Recommend the decreased use or avoidance of alcohol and caffeine, particularly if nocturia is a problem.
Always consider food sensitivities.
Eliminate the use of NutraSweet.
Always consider referral to a urologist.
Additional evaluation can include abdominal/ pelvic ultrasound, MRI, cystoscopy, measurement of bladder volume, and I.V.P.
Kegels
Kegel exercises involve repetitive contractions of pelvic floor muscles.
Maneuvers such as valsalva and urine flow interruption allow for identification of target muscles.
Patients are then instructed to contract and release the pelvic floor muscles.
10 repetitions constitute a set – consider a regimen of 3 to 5 sets a day.
Pelvic floor PT
Vaginal cones with weights – twice a day for 15 – 20 mins
Bot Med Tx of Urinary Incont
Botanical “urinary sedatives” include but are not limited to: Althea officinalis - marshmallow Equisetum arvense - horsetail Hypericum – St. john’s Wort Sambucus nigra - elderberry Serenoa repens – saw palmetto Zea mays – corn silk Piper methysticum – kava kava Scutellaria spp. – skullcap Gylcyrrhiza glabra – licorice Mullien root
Bening Prostatic Hypertrophy Bot Med
Herbal options for BPH include but are not limited to:
Pygeum africanum: extract (standardized to 14% triterpenes) 50 – 100 mg BID
Serenoa repens – saw palmetto: 30 mg BID.
Urtica dioica
Zn (15 – 30 mg; with long term use, also supplement Cu)
Omega 3s, Flax Seeds – inc SHBG – binds testosterone
omeopathy: urge to urinate
Apis Argentum nitricum Belladona Causiticum Chimaphila Kali carbonicum Merc-c
Behavior Activity - Detrusor Overactivity
This is the cornerstone to treatment of incontinence
Bladder retraining regimens
If nocturia is present, consider catheterization prior to bed eliminate residual urine
Conventional Tx for Urge Incont
Pharmacological intervention can augment behavior therapy but not replace it.
Anticholinergic meds:
Oxybutynin (Ditropan): 2.5 to 5 mg BID–QID
Propantheline (ProBanthine): 7.5 to 30 mg TID
Lavoxate (Urispas): 100 to 200 mg TID or QID
Common adverse effects associated with oxybutynin and other anticholinergics include: altered mental status, dry mouth, difficulty in initiating urination, constipation, blurred vision, drowsiness and dizziness
CI: acute angle glaucoma, partial or complete GI obstruction, inhibited peristalsis, severe colitis, megacolon/toxic/complicated UC, myasthenia gravis
FALLS
Falls go unrecognized by health care practitioners because intakes typically lack a specific evaluation or questionnaire surrounding them.
Many elderly individuals may be reluctant to discuss a fall with their physician as they are concerned about the possible restrictions in activities it may bring.
Falls are the most frequent cause of accidental death and the 7th cause of death in persons 65 years old and older
Approximately 60% of falls in the elderly result in injury, but only 6% of all falls result in major injury.
Do most falls occur inside or outside? Inside (bathroom, bedroom, kitchen, 10% on stairs and usu first step)
FALL - etiology
The cause of falls is often complex, involving the interaction of age-related physiologic changes, disease-related factors and environmental factors
Maintenance of postural and gait stability requires sensory input, central nervous system integration and musculoskeletal effector components.
Fluctuations in blood pressure, orthostatic hypotension, and post-prandial hypotension may contribute to both postural instability and gait instability which may lead to falls.
Several studies show that at least of 50% of all elderly people who have fallen report that they fear falling again and an estimated 25% of elderly patients that have sustained a fall report that their fall has caused them to limit further activity
A 70 year old male has glaucoma and he tripped over a rug while walking to the bathroom at night.
Falls - PE
Cardiovascular BP: Orthostatic hypotension Vision screen MSK Neurological exam balance Gait Mental status Hearing test
Reducing risk of Falls
Whenever possible, address all known predisposing factors.
Help the patient (and caregiver if applicable) to adapt to age related physiologic changes and disease related changes using physical therapy, occupational therapy and assistive devices when such services are available.
Seek increased patient supervision during times of acute illness.
Optimize lighting
Balance exercises
Walking aids
Good footwear
Home safety assessment
Best Way to get up after a fall?
Hands and knees, find the most sturdy thing nearby
Pulling up may be the most tricky part.
Monitoring – have frequent contact with friends and family.
Osteoporosis
Osteoporosis literally means “porous bone’
After the age of 40 years, there is a decline in bone mass in both sexes.
Osteoporosis involves the loss of both mineral and non-mineral (primarily protein) components of bone.
Generalized osteoporosis may be either primary or secondary.
Primary osteoporosis is the term used to describe osteopenia (bone thinning) that is due to advanced age and/ or menopause.
Secondary osteoporosis implies that the decreased bone mass is due to other conditions, medications, malabsorption, or prolonged immobilization.
In the U.S., Osteoporosis is felt to be the underlying problem involved in more than 1.5 million fractures annually including:
Over 300,000 hip fractures.
Approximately 700,000 vertebral fractures.
Approximately 250,000 wrist fractures.
Approximately 300,000 fractures at other sites.
Osteoporosis/Fall Risk Calculators
Based upon several criteria, including BMD, age, smoking, alcohol usage, weight, and gender:
There are several recognized calculators that may be found on-line including:
FRAX
Dubbo.
Risk Factors for Osteoporosis
Young or elderly (over 65)?
Female or male?
Caucasian or African American?
Early or late menopause?
Low body weight or obese?
Alcohol intake > 3 drinks per day or < 3 drinks a day?
Smoker or non-smoker?
Inadequate or adequate physical activity?
Prolonged immobilization?
FHx of hip fracture, osteoporosis, kyphosis and pathological fx or no FHx?
High or low caffeine intake?
Poor nutritional status (low calcium, low vit D) or adequate nutritional status?
Malabsorption or adequate nutrient absorption?
Osteoporosis - PE
Observation Spine deformity Pain immobility Height measurement Women: >4cm height loss since age 25 years Men: >6cm height loss since age 25 years Some use 1.5 inches for criteria If your patient meets this criteria, what would you do next? What test would you order?
Diagnostic Criteria for Osteoporosis
DEXA. The World Health Organization (WHO) has established the following classifications to categorize patients by standard deviation from established measurement standards. Normal : T-score greater than –1 Osteopenia: T-score between –1 and –2.5 Osteoporosis: T-score below –2.5
What is the difference between a T score and a Z score?
thirTy and ageZ
Goal of Tx - Osteoporosis
inhibit bone resorption and restore the equilibrium between osteoblast and osteoclast activity.
N-terminal telopeptide (NTx)
Type I collagen, which makes up 90% of the organic matrix of bone, consists of numerous cross-linked protein strands.
This cross-linkage make the structure unique and especially durable compared to other proteins.
NTx is a small, cross-linked portion of collagen’s amino terminus that is a stable and a specific breakdown product of bony collagen.
The urine NTx test uses a monoclonal antibody and ELISA method with readout by spectrometry (values are normalized with respect to urine creatinine)
The NTx assay has been validated for prediction of osteoporosis as well as response to therapy.
While the definition of osteoporosis still depends on cumulative demineralization measured by densitometry, NTx assesses the rate of bone matrix loss, which can be useful to identify patients most at risk for osteoporosis.
An elevated NTx level therefore correlates with diminishing bone density over time.
The dynamic nature of NTx levels makes it possible to monitor patients on a much more reduced timescale and without the x-ray exposure of a DEXA scan.
NTx levels can be measured in either urine or serum.
FRAX
FRAX is a diagnostic tool used to evaluate 10 year probability of bone fracture risk.
It was developed by the World Health Organization Collaborating Center for Metabolic Bone Diseases.
FRAX integrates clinical risk factors with bone mineral density at the femoral neck to calculate the 10-year probability of hip fracture as well as spine, shoulder and extremity fracture.
Incidence of Osteoporosis
Peak bone mass occurs between what ages? Normal bone density loss is 1% per year. Age 50: Osteopenia in Men = 33-47% Osteoporosis in Men = 4-6% Age 65 Men and women have similar rates of decline Age 75 Dramatic increase in incidence of hip fracture in men. Why do you think this is? Age 80 90% of Women have osteoporosis 50% of Men have osteoporosis
Diet - Osteoporosis
High meat diet vs low meat diet? Vegetarian vs non-vegetarian?
Avoid excessive caffeine intake – some studies have shown that increased caffeine consumption induced negative calcium balance in women, lower BMD and more rapid bone loss or increased risk of hip fracture.
Soy protein?
Milk?
Coffee?
Soft drinks?
Smoking - Don’t do it!
Alcohol – limit it.
Exercise - Osteoporosis
What to do and what to avoid.
Primary Prevention: Regular Weight bearing activities: Jogging Walking Hiking Stair Climbing Secondary and Tertiary Prevention: Improve balance and maintain strength, function Weight bearing aerobic activity Progressive Resistance Training Flexibility
AVOID: High impact which can lead to greater risk of fractures: Running/jogging, Twisting and bending activities, Golfing/tennis, Sit ups, Rowing machines, bowling
Calcium
The summary of evidence indicates the benefit of calcium supplementation for preventing and treating osteoporosis.
Different studies have produced conflicting results on which type of calcium is best absorbed.
It is generally accepted that low stomach acid decreases the rate of calcium absorption.
Calcium citrate, calcium lactate and calcium gluconate may be more readily absorbed in patients with diminished levels of stomach acid.
Daily dose of Calcium?
Vit D
MAO: promotes the absorption and utilization of calcium
Protective against fractures by decreasing bone loss but also due to enhancing muscle strength and balance thus decreasing falls in the elderly.
Daily dose of Vitamin D?
Higher amounts of vitamin D increase the risk for developing elevated serum calcium levels and patients require frequent monitoring of serum calcium if taking large amounts of vitamin D.
Calcitriol
A number of vitamin D derivatives have been developed in the hope of preventing as well as treating osteoporosis.
Calcitriol (Rocaltrol) is a prescription-form of vitamin D that can increase bone mass and decrease the rate of spinal fractures
Mg
Co-factor for alkaline phosphatase
Can increase trabecular bone density.
Daily dose?
Vit K
Vitamin K is a group of structurally similar, fat soluble vitamins that the human body needs for:
synthesis of certain proteins required for blood coagulation
certain proteins that the body uses to manipulate binding of calcium in bone and other tissues
Vitamin K deficiency may impair the activity of vitamin K dependent proteins (VKDPs) and thereby increase the risk of osteoporosis and fractures.
Other Nutrients to Consider
Strontium: 2-6mg/day Vitamin B6: 10-25mg/day Folic Acid: 0.4-5.0mg/day Vitamin B12: 20-1500mcg/day Vitamin C: 100-500mg/day Zinc: 10-30mg/day Copper: 1-3mg/day Manganese: 3-20mg/day Boron: 1-3g/day Silicon: 1-5mg/day
HRT
HRT is now, as you well know, a somewhat controversial treatment option.
Women with lowered estrogen levels in the post-menopausal state are felt to make osteoclasts more sensitive to PTH, resulting in accelerated bone breakdown.
A risk vs. benefit analysis for HRT should be made on a case by case basis in every patient in which this treatment option is considered.
The Women’s Health Initiative Study on hormone replacement was the first large scale randomized controlled trial to asses the effect of HRT in women in an age range from 50 to 79 years.
A statistically significant increase in heart disease was found to occur in women on hormone replacement therapy.
However, the advantages of HRT as far as osteoporosis were also evidenced by the findings Women’s Health Initiative Study.
Hip and vertebral fractures were decreased by 34% in the hormone replacement therapy group.
An overall reduction in fracture risk of 24% was seen in the HRT group.
Bisphosphonates
The bisphosphonates inhibit osteoclast activity, increase bone mass, and are among the primary drugs used to treat osteoporosis in postmenopausal women and in people taking corticosteroids or hormonal agents that suppress estrogen.
Bisphosphonates have been shown to reduce the risk of both spinal and hip fractures, including women who have had prior bone fractures.
Increases bone density 5-6%/year
Potential side effects are multiple:
GI: especially stomach ache, heartburn, nausea and possibly esophagitis.
Osteonecrosis of the jaw
Myalgias.
SERMs
A number of drugs known as selective estrogen-receptor modulators (SERMs) have been designed with the goal of producing the same benefits that estrogen can confer upon bone density without increasing the risk for development of hormone-related cancers.
Raloxifene/Evista
Raloxifene was specifically developed to maintain the beneficial estrogenic activity on bone and lipids and to have anti-estrogenic activity on endometrial tissue and breast tissue.
Raloxifene is now indicated for the treatment and prevention of osteoporosis in postmenopausal women as well as for the treatment of invasive breast cancer.
Expensive
Side effects: hot flashes, arthralgias, myalgias, edema, pruritis and a small but definite increased risk for development of DVT and subsequent PE.
Denosumab/Prolia/Xgeva
Denosumab is an IM injectable drug that is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture.
The FDA defined “high risk for fracture” as individuals with a prior history of osteoporotic fracture, multiple risk factors for fracture or patients who have failed or are intolerant to other available forms of medications used to treat osteoporosis.
Sufficient calcium and vitamin D levels must be reached before starting on Denosumab therapy.
Denosumab is contraindicated in patients with hypocalcemia.
Similarly to the bisphosphonates, Denosumab appears to be implicated in increasing the risk of developing osteonecrosis of the jaw following extraction of a tooth or other surgical procedures involving the teeth.
Cost may be in excess of $1000 a dose.
Other Txs of Osteoporosis
Calcitonin (Miacalcin)
Synthetic Parathyroid hormone
Dementia
Dementia is defined as the loss of intellectual function (i.e. thinking, remembering and reasoning) that is of sufficient severity to interfere with a person’s daily functioning.
The symptoms of dementia may also include changes in personality, mood and behavior.
Poor memory alone is not dementia, and some declines in short-term memory are considered normal as people age.
Although dementia is more common in older adults, it is not a normal consequence of aging.
Dementia: s/sxs
Gradually increasing memory loss
Confusion
Unclear thinking, including a loss of problem-solving skills or becoming lost in formerly familiar circumstances.
Loss of interest in daily or usual activities.
Agitated behavior or delusions.
Several diseases can cause dementia, but the two most common forms of dementia are:
Alzheimer’s disease
Multi-infarct dementia (also referred to as vascular dementia).
Alzheimer’s disease is the most common cause of dementia and is the most common reason for someone to be admitted to a nursing home
Alzheimer’s
Three distinct stages:
Stage !: usually lasts two to four years
subtle changes can be noted, such as a lack of energy and zest for life, decreased interest in family life, friends and other favorite pastimes.
Family and friends may report personality changes.
the patient shows a loss of short term memory although past memories may remain unaffected.
Toward the end of the first stage of Alzheimer’s disease, the person often becomes more disoriented – with a diminished sense of time, direction, and recognition of previously familiar persons and places.
As long as long-term memory appears intact, the patient is still felt to be in the first stage of Alzheimer’s disease.
Alzheimer’s Stage 2
Middle stage: usually lasts several years
long term memory fails and is gradually erased from the mind.
characterized by extreme confusion and difficulty in coping with new situations.
Delusions become more common.
Hallucinations may begin to occur. wandering and getting lost can become more frequent occurrences.
Sundowning, a phenomenon associated with extreme restlessness and agitation in the late afternoon or early evening may become a daily occurrence as the second stage of Alzheimer’s disease progresses.
Alzheimer’s Last Stage
Last stage of Alzheimer’s: lasts only one or two years
the deterioration of the individual becomes much more dramatic.
the victim usually cannot remember faces - even his or her own face.
Nervous system regulation deteriorates with resultant development of altered levels of consciousness, incontinence and difficulty in coordinating body movements.
Patients often show no interest in eating or drinking fluids.
Patients often becomes emaciated as they enter a vegetative state.
The most common cause of death in these patients is due to infections such as pneumonia or urinary tract infection.
Alzheimer’s Dx
The diagnosis of Alzheimer’s disease relies on a number of factors:
Family members or care givers should be interviewed in order to more accurately document the history.
A complete physical exam must be performed along with blood tests to rule out other causes of dementia.
A mini mental status exam is used to evaluate memory and cognitive function.
Brain imaging tools such as MRI and PET scans may be used to help make a medical diagnosis.
Several lab tests have been developed but there is no consensus on a definitive test for outside of brain biopsy or post-mortem autopsy
Alzheimer’s Caregiver
Dementia impacts the entire family .
Caregiver burden = the emotional, social, medical and financial impact this disease has on the caregiver.
It is important to ensure the caregiver is receiving support and healthcare (assess for depression, isolation, stress-related illnesses and poverty).
Alzheimer’s Tx
The FDA has approved several drugs that improve cholinergic function by inhibiting the actions of cholinesterase.
Drugs such as Tacrine (Cognex), Donepezil (Aricept), Rivastigmine (Exelon), and Galantimine (Reminyl) may modestly slow the progression of Alzheimer’s disease by preserving acetylcholine levels in the brain.
Antidepressants and antipsychotic are also used.
Namenda, a non-competitive N-methyl-D aspartate (NMDA) antagonist is the first drug approved for the treatment of moderate to severe Alzheimer’s disease.
Guidelines for approp prescribing
Appropriateness: benefit vs risk assessment
Polypharmacy
Underuse: i.e. anti-depressants use, dose and duration in nursing homes
Patient and caregiver issues: assess adherence and intervene when necessary (i.e. pill containers).
Pharmacokinetics
Absorption: Decrease in small bowel surface area
Increase in stomach pH
However, changes in drug absorption tend to be minimal and inconsequential
Distribution:
Decrease in total body water higher blood concentrations of some water soluble drugs
Increase in total percent body fat increases the volume of distribution for lipophilic drugs and may result in increased elimination half-lives
Decrease in serum albumin may enhance drug effects because serum concentrations of unbound drug in increased
Hepatic metabolism:
Decreased hepatic mass and hepatic blood flow
CYP 450 does not appear to decrease with age
Overall hepatic metabolism of many drugs by the enzymes is reduced clearance decreases 30-40% and therefore drug doses should be reduced this amount
Analgesics/anti-inflammatory drugs
Cardiovascular drugs
Psychoactive
Renal elimination:
Decreased renal mass and renal blood flow decreased renal elimination of drugs
Creatinine clearance is used to guide drug dose
Antibiotics
Cardiovascular drugs
Diuretics
Adverse Drug Effects
The elderly are at risk of toxicity for certain drugs which may be a results of altered pharmacokinetics/pharmacodynamics.
Drug-disease interactions: exacerbation of a disease from a drug
Drug-drug interactions:
Few drug-drug interaction prospective studies have been done in the elderly
Effective Pharmacotherapy
Efficacy and safety
Risk benefit ratio
Use most effective drug with lowest toxicity
Complexity of drug regimens
Can you use one drug to treat two conditions?
Dosing 1-2 times a day is easier than three or more
Dose
Typically stating doses are _________ to __________ the usual adult dose
Compliant
__________percent of elderly do not take their medications as prescribed
Screenign sources for geriatric pts
CDC
United States Preventive Services Task Force (USPSTF)
American Cancer Society
American Family Physician
CDC Immunization recommendations
60 years and older Influenza Td or Tdap Pneumococcal Zoster
Nutrition
Can not be evaluated in isolation. The following need to be evaluated together: Nutritional intake Exercise/Activity Disease burden Age
Preservation of Muscle Mass and Strength
Studies show that as little as 1-2 weeks of bedrest or inactivity can result in significant muscle mass loss, loss of strength and function even when dietary intake is adequate.
Muscle synthesis declined by 30%
Nutrient requirements and the ability to metabolize these nutrients are effected by: Disease suppression of appetite Maldigestion Malabsorption Loss of normal swallowing mechanism Dry mouth Loss of taste/smell Loss of self-feeding ability
Age related changes that affect nutrition
Loss of lean body mass
Increase in fat mass
Loss of taste, smell and appetite
Zinc deficiency
Niacin deficiency
Vitamin B12 deficiency
Infections/endocrine/CNS/Head and Neck/medication
GI
Overly active stretch receptors of stomach leading to sensation of early satiety?
Delayed gastric emptying
Increased release of or greater response to gastric hormones (leptin, ghrelin, cholecystokinin) induces satiation?
Psychological, Socioeconomic and Cultural Influences
Depression
Bereavement
Poverty
Limited mobility
Feeding dependency
Eating alone is associated with decreased intake
The most common micronutrient deficiencies found in the elderly:
Vitamin C Vitamin D Vitamin E Vitamin B12 Thiamine Folic acid Calcium Magnesium Zinc
Prealbumin
Has a moderate specificity as a nutritional indicator Half life of 2 days, which makes it more sensitive to changes in nutrient intake and disease activity Low levels: End-stage liver disease Iron deficiency Nutrient deprivation Elevated levels: Renal failure High dose steroid therapy
