Comprehensive Elderly Care

7/28/2019 Comprehensive Elderly Care

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Elderly care

Dr HananAbbas

assistantprofessor of

of Family


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y

The number of persons 65 years ofage and older continues to increasedramatically. Comprehensiveapproach is an important task forprimary care physicians.

As outlined by the U.S. PreventiveServices Task Force, assessmentcategories unique to elderly patientsinclude sensory perception andinjury prevention.


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Interventional areas includeimmunizations, diet and exercise.

Mental health issues should also beevaluated Using an organized approach can

improve care provided for older

patients


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Falls Falls result in accidental death amongpersons 75 years of age and older andsignificant mortality and morbidity.

Multifactorial A fall is 'an event which results in a

person coming to rest inadvertently onthe ground and other than a consequenceof 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.


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Frequently, older persons are notaware of the risk factors and do not

report falling unless an injury hasoccurred.

Identifying and targeting the

population at greatest risk withmultifactorial interventions isessential to the prevention andreduction in the incidence of fallsand fall-related injuries in older


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Epidemiology In the United States, accidents are thesixth leading cause of death in personsover the age of 65 and falls account for

two-thirds of these deaths. The annual incidence of falls ranges from30 % in persons over the age of 65 to 50per cent in persons over 80 years of age.

Rates of fall-related deaths for olderpersons increase sharply with advancingage and are consistently higher amongmen than women.

Due to the higher prevalence of co-

morbid illness among men than women ofsimilar a e.


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Approximately 1 % of these fallsresult in hip fracture, 3 5 % in other

types of fractures, and an additional5 % result in severe soft tissueinjury, such as haemarthroses, jointdislocations, sprains, andhaematomas.


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Hospitalization rates for hip fractureincrease with advancing age for

both sexes but are consistentlyhigher for women in all agecategories.

This gender difference may berelated to the prevalence ofosteoporosis in older woman.


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Falls are also an important marker offrailty.

Of older persons who arehospitalized for a fall, only about onehalf are alive 1 year after.

This indicates the seriousness ofunderlying disease and the need toameliorate the symptoms of chronic

illness to prevent further risks of


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Case 1 An 81 yo female is brought to your office

by her daughter, the elderly mother hasbeen falling for at least 3 months. Thefalling has been getting progressivelyworse, and her daughter has beenconcerned regarding her mother breaking

her hips. On exam, the pt is a frail elderlyfemale in no distress, she appearssomewhat depressed. The pt BP 180/75,her pulse is 84 and regular, no other

abnormalities are found.


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Intrinsic Extrinsic1. Age

2. Cognitive impairment

3. Muscle weakness4. Foot problems (callouses, bunions, or anatomical

deformities)

5. Polypharmacy (sedatives, tranquillizers,antidepressants, antihypertensive, and diuretics)

6. Sensory impairment (macular degeneration,

cataracts, and glaucoma)7. Gait and balance impairment (Parkinson's dis.,

seizures, Lower extremity neuropathies,dementia, TIAs)

8. Acute disease (pneumonia, urinary tractinfections)

9. Chronic disease (cardiovascular dis., neurologicaldis., dementia, depression, visual problems,osteoporosis)

10. Depression

11. Postural hypotension

1. Environmental hazards

2. Inadequate lighting

3. Slippery surfaces

4. Loose rugs

5. Low toilet seat

6. Low chairs

7. High stairs

8. Ill fitting shoes


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Assessment assessment of basic neurologic functionincluding mental status, muscle strengthand tone, lower extremity peripheral

nerves, proprioception, deep tendonreflexes, and cerebellar function.

A cardiovascular examination shouldinclude heart rate, postural pulse and

blood pressure (lying and standing with a5-min interval between each reading).

Visual screening and an examination ofthe lower extremities, especially the feet,

for deformities, and ulcerations


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The 'get up and go test' of mobilityis a simple screening tests that can

be administered in the clinicalsetting.

The older person is asked to rise

from the chair, to stand momentarilywith eyes opened and closed, thennudged on the sternum, to walk 10ft, and to return and sit in the chair.


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It may be useful to obtain a completeblood count, thyroid function tests, anddrug levels if the history and physical

examination indicate a potential problemin these areas.

Electrocardiogram may be considered if acardiac arrhythmia is suspected.

Neuroimaging may be helpful for olderpersons with neurological deficits and gaitabnormalities.

Referral to specialists such as aneurologist, cardiologist, ophthalmologist,


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Management

The goal of management is to minimizethe risk of falling without compromisingmobility, functional activities, personal

independence, and an acceptable qualityof life.

Treatment is focused on eliminating ormodifying risk factors.

Initial treatment of acute or reversibledeficits such as urinary tract infections,pneumonia, congestive heart failure,metabolic disturbances, or medication

side-effects may result in major'


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Recommendations for a communitypopulation should include:

gait training review modification of medications.

Exercise programme, with balancetraining as one of the components,

treatment of postural hypotension,modification of environmentalhazards( adequate lighting, avoid slipperyfloors, loose rugs,..)


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Gait disorders Normal balancerequire integration ofposition sense, the

visual system,vestibular organs,motor strength, andmotor functioncoordination.

Decline in theirfunction leads togeneral motorslowing.

Age-related motor


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Presentation to primarycare

feeling unsteady, shuffling feet, posturalchanges, or falls.

VestibularA history of vertigo localizes to the

vestibular apparatus. The patient may have asensation of 'waves'. Often, these patients willhave transient dizzy feelings on rising from alying position or with turning the head quickly.

VisualGait changes associated with visual

dysfunction may be due to change in visualacuity such as cataracts and maculardegeneration, or visual field loss.

Occasionally, patients are unaware of a visualfield deficit until detected by the examiner.


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MotorStroke, myopathy, or peripheralneuropathy all cause muscle weaknessaffecting gait. The hemiparetic gait seenin stroke with foot drop.

Proximal lower extremity weakness seen

in myopathy results in inability to standfrom a seated position without pushing offwith the hands.

If there is weakness of the hip

musculature (especially the hipabductors), the gait will appear 'waddling'like a duck.

Foot drop is typically due to a root orperipheral nerve disorder. So the footdoes not catch on the ground, there is


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Sensory impairmentLoss of position sense alsoresults in gait difficulty, especially in the dark, asthe visual system is not able to compensate forimpaired proprioception.

The loss of vibration sense in the lower limbs ispart 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 withgait difficulty. Mechanical involvementArthritis is common in

the elderly and contributes to gait difficulty byaffecting the axial skeleton lower limb

musculature.

a cu y s ue o one


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a cu y s ue o oneor 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 ofinvoluntary movements which

interfere with gait; lack of proper coordination of movements; inability to stop intended movements; or impaired central mechanisms for gait

integration.


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History

The following leading questions shouldbe asked:

Are you having pain which prevents youfrom walking normally?

Are your legs so weak that they may giveout when you walk?

Do you have a feeling that objects aregoing around or moving when you walk?

Is the difficulty in walking present

regardless if you walk in the light or in thedark?


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Pain in the hip, knee, or foot which makeswalking difficult may be due to bursitis orarthritis.

Gait difficulty due to vestibular andcerebellar function abnormalities ispresent in the light as well as in the dark.

In the case of vestibular dysfunction,patients frequently experience dizzinesswhen turning in bed, sitting up quickly, oron sudden turning of the head to one side

or the other.


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Physical examination

Normal elderly people have a flexedposture and shorter length compared toyounger persons. Flexed posture greater

than expected by age is seen inParkinson's syndrome (PS).

Parkinsonian gaitis characterized by a

narrow base, reduced armswing (oftenasymmetric), and exaggerated flexion atthe waist and neck. The gait is 'shuffling'because of reduced stride length and

problems picking the feet off the ground.


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Cerebellar disorders has a wide base.

Cerebellar gait is unsteady.

Features supportive of a cerebellardisorder include limb ataxia, dysarthria,and nystagmus.

Romberg testingis performed by asking

the patient to stand with eyes closed andfeet together. A positive test requires thatthe patient break his/her stance; PositiveRomberg is a sign ofimpaired positionsense .


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Investigations

vestibular dysfunction needs anotologic assessment.

Imaging studies to rule outcerebellar masses or atrophy.


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Principles of managementin gait disorder

treat the underlying cause (s)supportive care for pt and caregivermaking the home environment safer

Home environments often have to bemodified stairs, light, rugs, slippery floor,high chair, low toilet seat.Referral to a specialist is appropriate if

the diagnosis is uncertain, if there is apoor response to medical therapy, or ifinvestigations are not available to theprimary care physician (i.e. imagingstudies).

In Western countries, referrals are often


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Urinary incontinence

Urinary incontinence, defined as theinvoluntary loss of urine, is a major

problem affecting many elderlypeople.

1530 % of elderly people living

independently suffer fromincontinence

14 % of women aged 65 years andolder are troubled daily by


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Case 2

An 88 yo female pt who you care for,residing with her daughter is having

increasing difficulties with bedwetting, she is embarrassed to talkabout this, but her daughter informsyou that this problem is gettingworse, at that time the pt had beencontinuously incontinent for 6 days.


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Possible causes

Bladder capacity, the ability to postponemicturition, and bladder contractility alldecrease.

Uninhibited detrusor contractionsincrease and there is a slight rise in theresidual volume.

In women, the maximum urethral closurepressure and the length of the urethradecrease.

In the majority of elderly men, theprostate becomes enlarged and the urine


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In most cases, involuntary urine lossis related to disturbances in the

continence mechanism of thebladder itself.


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Urge incontinence

Urge incontinence is the involuntaryloss of urine concomitant with a

sudden intense urge to urinate.Other common symptoms arefrequency and nocturia. Urgeincontinence is usually accompaniedby urodynamic findings ofdetrusorhyperactivity.


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Stress incontinence

Stress incontinence is theinvoluntary loss of urine duringcoughing, sneezing, laughing, orother physical activities that causean increase in intra-abdominalpressure.

The most common cause of stressincontinence is hypermobility of theurethra and bladder neck. This isthe result of a weak pelvic floor,

probably caused by childbirth and


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Overflow incontinence

It is involuntary urine loss accompaniedby overfilling of the bladder. The patientgenerally suffer from very frequent to

continuous loss of small volumes of urine(continuous leakage), 'bearing-down'while urinating, incomplete voiding andweak stream.

Overflow incontinence can be causedby two factors:

a hyperactive or non-active detrusor

bladder neck or urethral obstruction.


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A hyperactive or non-active detrusorcan be caused by:

medication, faecal impaction,diabetic neuropathy.

In men, obstruction is mostly caused

by prostate hypertrophy, lesscommonly by prostate cancer,orfaecal impaction.


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Functional incontinence

When involuntary urine loss is caused byfactors outside the lower urinary tract,such as limitations in physical or cognitive

functioning, this is referred to asfunctional incontinence.

Hip arthrosis, muscle weakness, hand

problems, and tremors can hinder theelderly person's self-care: climbing out ofbed unaided, going to the toilet, undoingclothes, and sitting down to urinate,

communication and cognitive


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History:

The characteristic clinical symptomof stress incontinence is the loss ofsmall volumes of urine duringactivities that increase the intra-abdominal pressure, such assneezing, coughing, jumping,

laughing, lifting, and sport. Thepatient does not feel the urge tourinate before leakage occurs. Assoon as the increased pressure

ceases, the urine loss also ceases.


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the patients feel an urgent need tourinate that they can no longer

reach the toilet in time.Once micturition has started, it isvery difficult to stop the flow, often

accompanied by frequency andnocturia.

When pain is present, it is anindication of infection.


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Reversible and other contributingfactors in incontinence

Possible reversible factors:Conditions: delirium, faecal impaction, depression, symptomaticUTI.Environment: impaired locomotion, lack of access to toilet,restrictive clothing.

Excessive intake of caffeinated beverages or other bladderirritants.Diagnoses: diabetes, CHF, CVA, Parkinson's disease, and otherneurological diseases affecting motor skillsMedication: diuretics, antiparkinsonian, antispasmodics,antihistamines, and other anticholinergicsDrugs that stimulate or block sympathetic nervous system:calcium-channel blockers, narcoticsPsychoactive medication: antianxiety agents, antidepressants.Other contributing factors:Conditions: pain, excessive orinadequate urine output, atrophic vaginitis, cancer of the bladderor prostate, urethral obstruction, disorders of the brain or spinalcord.

Abnormal laboratory values: elevated blood glucose or calcium


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In women, vaginal palpation and speculumexamination , signs of atrophic vaginitis, uterineprolapse 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 inthe rectum.

In men, the surface and consistency of theprostate should be examined.


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Tests

urine test & culture

Ultrasound of bladder to exclude

urine retention.If obstruction or retention issuspected, kidney function tests

should be performed and in ofpolyuria and/or nocturia, glucoseand electrolytes should bemonitored.


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Management:

Stress incontinence:

pelvic muscles exercises, Alpha

adrenergic agonists, Behavioraltraining, Supplemental estrogen


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Urge incontinence

Bladder relaxants & training,Estrogen supplements, Behavioral

therapy, Surgical removal ofobstruction


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Overflow incontinence

Surgical removal of obstruction,Intermittent catheterization,

Indwelling catheterization) increasedrisk of urinary tract infection, therisk of injury and stricture of theurinary tract).


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Functional incontinence

Behavioral therapy (prompt voiding,habit training, environmental

manipulation, scheduled toileting,incontinence pads).

External collection devices,indwelling catheters.


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Case 3 daughter is caring for her elderly mother at home. Mom has a

variety of medical issues and is taking a number ofmedications. The doctor prescribes for mom's anxiety. Overa period of months the mother becomes sleepy all the time

and can't seem to concentrate. She will even fall asleep whilesomeone is talking to her. The doctor and family initiallyattribute 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 isconfirmed. After some research the doctor suspects the

prescription might be causing sodium depletion. He removesthe mother from the medicine and she becomes normal again.


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Medications and the Elderly

Facts about Medications and theElderly

Older Americans comprise about13% of the population but they

consume over 30% of allprescription drugs. It is estimated that 30% of the

older population takingmedications have had an adversedrug reaction.

Up to 20% of hospitaladmissions for the elderly aredue to adverse drug reactions.

It is estimated that over half ofthe deaths attributed to adverse

drug reaction are for people age60 and above.


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Old age is associated with areduction in glomerular filtration

rate, a decrease in renal plasma flowand decreased tubular reabsorptivecapacity. The net effect of this is adecrease in renal clearance of drugs

that are hydrophilic in nature, forexample digoxin. Such drugs shouldeither be avoided or given at lower

dosages.


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Possible reasons for increased

prescribing in the elderly

Evidence showing benefits of drug use inthe elderly, e.g. the use of warfarin inpatients with atrial fibrillation

Increase in the numbers of elderly andvery elderly patients, with a consequentincrease in morbidity

Increase in screening and detection ofasymptomatic conditions, e.g.hypertension Increased patientexpectations

The practice of defensive medicine


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A survey of 805 people was particularly

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

Most of the drugs being taken by

the elderly are prescribed on along-term basis, with 59 per centhaving been prescribed for morethan 2 years;

Eighty-eight per cent of all drugsprescribed were by repeatprescription; and

forty per cent had not discussed


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The inter-relationship between polypharmacy

and poor compliance, resulting in a vicious cycle

that leads to a prescribing cascade


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A75-year-old woman was diagnosed as having hypertension. She

was started on capozide by her doctor. Two weeks later, aroutine blood test showed her to have a potassium level of 2.9mmol/l. She was prescribed potassium replacement therapy inform of slow release potassium tablets to be taken together withcapozide. At the next visit 2 weeks later, her potassium levelhad come up to 3.4 mmol/l, and she was continued on slow

potassium. She presented 2 months later with a history of severeheartburn; a gastroscopy showed her to have an oesophagealulcer. This was blamed on slow potassium, which was stopped.The patient was started on omeprazole. Unfortunately, after afew days treatment she developed diarrhoea. The doctorcontinued the omeprazole in order to relieve the oesophageal

ulcer, and prescribed codeine phosphate for the diarrhoea. Aftertwo doses of codeine phosphate, the patient developeddizziness, had a fall, and was admitted to a hospital with afractured left hip.


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Reasons for inappropriate prescribing

in the elderly Incremental prescribing, with side-

effects being treated with otherdrugs, rather than discontinuation of

the original drug Therapeutic enthusiasm, with use of

drugs as first line treatment withoutconsidering the use of non-drug

therapies Failure to adequately assess

patients' needs and individualizetreatment

Unrealistic expectations on the part


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A strategy to improveprescribing in the elderly

Careful clinical assessment of the patientand an evaluation of the riskbenefitratio of starting drug therapy.

Start at low doses, and increase dosegradually. Remember that the elderlyoften require lower doses.

Use one drug if possible, and avoidpolypharmacy.

Keep the drug prescribing regime simple.

Give clear, and if possible, writteninstructions on how to take the


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Undertake a regular review ofmedications, and stop medicineswhen necessary.

Review and improve repeatprescribing system, if necessary. Letpatients know what to do when their

medicines run out, and how todispose of medicines that are nolonger necessary.

Consider drug (s) as the cause ofnew s m toms and si ns arisin in


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Ensure communication betweenhospital and primary care is up-to-

date. In the future, this may befacilitated by the use of individualsmart cards or electronic patientrecords.

Multidisciplinary team working withpharmacists and nurses will help inmany of the objectives outlined

above.


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Giving in to pressure from relatives,patients and other health care

professionals to prescribe Inadequate review of medicines,

leading to continuation of drugs thatare no longer necessary

Governmental pressure to meettargets


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Use sources of information such asformularies in order to appropriately

prescribe in patients with renal andliver impairment, and to avoid theuse of interacting drugs.

Remember that in the elderly, anormal serum creatinine does notindicate normal renal function.

Five key dimensions of the


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yageist bias in which healthcare

fails older persons

Healthcare professionals do not receive enoughtraining in geriatrics to properly care for many older

patients.

Older patients are less likely than younger people toreceive preventive care.

Older patients are less likely to be tested or screenedfor diseases and other health problems.

Proven medical interventions for older patients areoften ignored, leading to inappropriate or incompletetreatment.

Older people are consistently excluded from clinical

trials, even though they are the largest users of

R d ti f


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Recommendations forcaregivers

Make sure an elderly one has challengingactivities throughout the day instead of simplywatching TV (challenging home orientedactivities).

Give them responsibility for taking care ofplants . This strategy is used often in nursinghomes to reduce depression in the elderly and toactually improve their health as well.

Provide opportunities for family and friends to

come by and visit and encourage or evenarrange such encounters. Provide opportunities for the older person to

interact, teach and nurture children such asgrandchildren. This is an extremely effectivestrategy for helping the older person feel that heor she has a meaningful existence. And it has a


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Design or arrange an exercise program andcome up with a way to encourage the olderperson to follow it.

Understand the nutrition needs of an older one,

especially the need for vitamins and mineralsincluding iron.. Make sure the person takes careof him or herself and eats properly. Many elderlypeople neglect their own nutrition. Poor nutritioncan cause all kinds of mental and physicalproblems in the elderly.

Make sure an older person has opportunity tolook good . Make sure the person gets out inpublic, and going to a public event and can feelgood about his or her appearance.


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Documents

Comprehensive Elderly Care