Caring for the Geriatric Patient¶

Chapter 489 | Part 18: Aging · Parts 17-18 – Global Medicine & Aging · Chapter 489

Key Clinical Points¶

Aging is not a disease; normal aging changes do not cause symptoms but increase susceptibility to illness due to diminished physiologic reserve.
The '5M's of Geriatrics' (Mentation, Medication, Mobility, Multicomplexity, and Matters Most) provides a person-centered framework for care.
Multimorbidity is common; nearly half of those >80 years old have three chronic conditions, and about one-third have four or more.
Geriatric syndromes (e.g., falls, incontinence, delirium) are often underdiagnosed but require proactive screening using simple tools.
Polypharmacy and potentially inappropriate medications (e.g., benzodiazepines, antipsychotics) must be managed via careful reconciliation and deprescribing.
Comprehensive Geriatric Assessment (CGA) is essential for identifying functional impairments, social support needs, and cognitive/affective disorders.
Cognitive and affective disorders are common; simple screening tools (e.g., Mini-Cog, CAM) should be used early.
Driving assessment must balance the risk of accidents with the impact of social isolation; focus on identifying reversible causes like vision or hearing impairment.
Foot exams are a unique component of CGA to identify mobility barriers and hygiene issues.
Antimicrobials should not be used for asymptomatic bacteriuria unless specific urinary tract symptoms are present.

DEFINITION & OVERVIEW¶

• Aging Status: Not a disease; normal aging changes do not cause symptoms but increase susceptibility to many diseases due to diminished physiologic reserve. • Clinical Approach: Requires a comprehensive approach because acute illnesses are rarely treated in isolation but in the context of multiple comorbidities. • Demographics: Rapid growth in population >80 years; 1 in 6 people worldwide will be ≥65 by 2050.

Principles of Geriatric Care¶

• Multimorbidity: Conditions are often multiple and multifactorial, requiring a comprehensive approach. • Undiagnosed Conditions: Fall risk, urinary incontinence, and elder abuse/neglect are frequently under-evaluated; simple screening tools are essential. • Cognitive/Affective Status: Mild cognitive impairment, dementia, delirium, and depression are common and may be undiagnosed early. • Iatrogenic Risk: Common due to adverse drug reactions, immobility, and related deconditioning. • Goal of Care: Focus on functional ability and quality of life rather than just cure. • 5M's Framework: Organizes care in a person-centered manner: ◦ Mentation: Assessment of cognitive status (delirium, dementia, depression). ◦ Medication: Management of polypharmacy and deprescribing. ◦ Mobility: Critical for function, quality of life, and fall risk. ◦ Multicomplexity: Addressing multiple comorbidities and geriatric syndromes. ◦ Matters Most: Identifying patient goals and preferences.

EPIDEMIOLOGY¶

• Complexity of Care: Wide variations in aging make standard guidelines difficult; acute illnesses must be managed within the context of multiple comorbidities. • Prevalence of Comorbidity: Nearly 50% of those >80 have three chronic conditions; ≈1/3 have four or more. • Disability Prevalence: Increases with age; includes difficulty with self-care, mobility, cognition, vision, and hearing.

ETIOLOGY & PATHOPHYSIOLOGY¶

• Diagnostic Interpretation: Results must be interpreted cautiously due to large variations in normal aging. • Cardiac Monitoring: Arrhythmias must be linked to symptoms/outcomes before considering potentially toxic medications or invasive procedures. • Imaging Findings: ≈20% of incidental findings in the colon, extracolonic structures, ovary, and thyroid gland are malignant; many others are benign. • Routine Labs: Abnormalities in hemoglobin, thyroid function, creatinine clearance (age/sex/weight-adjusted), and LFTs are not results of normal aging but indicate underlying disorders.

Normal Aging vs. Disease¶

• Symptomless Changes: Normal aging does not cause symptoms but reduces physiologic reserve.

CLINICAL FEATURES¶

• Geriatric Syndromes: Focus on falls and incontinence as key indicators of multicomplexity. • Foot Examination: Unique component of CGA to identify barriers to independence. • Cognitive/Affective Disorders: Common; require screening for depression (sadness, loss of pleasure) and delirium (CAM).

Foot Examination¶

• Physical Barriers: Identify improper footwear or painful deformities. ◦ Lack of socks → may indicate difficulty due to hip arthritis or other condition. ◦ Toenail status: Poorly trimmed/fungal nails suggest lack of access to podiatry or help. • Hygiene: Inspection between toes is critical for detecting poor hygiene or ulcers (especially in diabetics).

Driving Assessment¶

• Risk vs. Benefit: Driving is essential for independence; assessment must focus on reversible causes like vision/hearing impairment. • Assessment Focus: Evaluate sensory (vision/hearing), functional, and cognitive impairments. • Medication Risks: Avoid antianxiety agents, narcotic analgesics, antipsychotics, anticonvulsants, and drugs with strong anticholinergic properties in patients who must drive.

DIFFERENTIAL DIAGNOSIS¶

• Iatrogenic Illnesses: Often caused by adverse drug reactions, immobility, and deconditioning. • Geriatric Syndromes: Fall risk and urinary incontinence are primary considerations.

DIAGNOSTIC APPROACH¶

Comprehensive Geriatric Assessment (CGA): Used as a 'geriatric review of systems' to identify functional impairments, social support needs, and cognitive/affective disorders.
Screening Tools: Use validated tools for: ◦ Depression (e.g., Geriatric Depression Scale). ◦ Cognition (e.g., Mini-Cog). ◦ Delirium (Confusion Assessment - CAM).
Specific Screening (Table 489-3): • Colorectal: FIT/Sigmoidoscopy/Colonoscopy; stop if life expectancy <10 years. • Mammography: Every 1–2 years for women 50–74. • Cervical: Pap/HPV every 3–5 years until age 65. • Lung: Low-dose CT for high-risk smokers (30+ pack-year history). • Prostate: PSA screening; stop if age ≥70 (USPSTF) or if severe comorbidity exists (ACS). • Bone Density: DEXA for women ≥65. • Cardiovascular: Carotid ultrasound (age >65 + risk factors), Coronary Calcium Score (not for known CAD), and Abdominal Aortic Aneurysm (men 65–75 who ever smoked). • Metabolic: Annual glucose testing; note that evidence to screen for diabetes after age 70 is lacking.

CGA Screening Tools (Table 489-2)¶

• Social Support: Ask if living alone or having a caregiver → refer to social worker/agency on aging. • Elder Abuse: Ask about safety and theft → refer to adult protective services. • Advance Directives: Offer info on Power of Attorney/Living Wills. • Functional Status: Assess help needed for shopping, finances, bathing → use ADL scales. • Fall Risk: Ask about falls in past year or fear of falling → Get Up and Go test; PT evaluation. • Continence: Ask about bladder issues/pads → 3IQ (women) or AUA 7 symptom inventory (men). • Weight Loss: Check if weight <100 lbs or loss ≥10 lbs in 6 months → refer to dietician. • Sleep: Assess daytime sleepiness/nighttime difficulty → Epworth Sleepiness Scale or Pittsburgh Sleep Index. • Cognition: Screen for memory loss, Mini-Cog (3-item recall + Clock Draw), and CAM for delirium.

MANAGEMENT & TREATMENT¶

Medication Management (Table 489-7): • Evaluate all conditions that benefit from, are harmed by, or influence drug efficacy. • Manage non-drug conditions where possible. • Use Cockcroft-Gault formula for renal adjustment: $(140 - ext{age}) imes ext{bodyweight(kg)} / (72 imes ext{serumcreatinine level})$ (multiply by 0.85 for women). • Start with smaller doses and increase gradually. • Simplify regimens, use consistent schedules, and provide clear instructions to caregivers.
Fall Management (Flowchart 2): • Step 1: Ask all patients about falls in the past year. • Step 2: If "No" → Recommend prevention, education, and exercise program (gait, balance, coordination, strength). • Step 3: If "≥ 1 fall, or difficulty with gait or balance, or seeking medical attention because of fall": ◦ Check for gait or balance problems. ◦ If "One fall past 6 months" OR "No problem" → Proceed to Multifactorial risk assessment → Reassess periodically. • Interventions: Modify medications; prescribe exercise; treat vision problems; manage heart rate/rhythm; supplement Vitamin D; address postural hypotension; reduce environmental hazards; education/training in self-management and behavioral changes.
Delirium Management (Table 489-8): • Drugs: Discontinue or substitute high-risk drugs; check for withdrawal from other meds. • Environment: Adequate lighting, reduced noise, reorient patient frequently. • Other: Treat infections, correct hypoxemia, treat urinary retention/fecal impaction, and provide physical/occupational therapy.
Incontinence Management (Table 489-10 & 12): • Urinary Tract Infection: Antimicrobial therapy. • Atrophic Vaginitis: Topical estrogen (to reduce infection). • Stool Impaction: Disimpaction and laxatives. • Stress Incontinence: Pelic muscle exercises, timed voiding, α-Adrenergic agonists, or surgical options. • Urge/Mixed: Bladder training, double voiding, or β-3-adrenergic drugs.
Sleep Management (Table 489-13): • Sleep Hygiene: Avoid caffeine/alcohol after lunch; limit liquids in evening; regular sleep schedule; limit naps to <30 min. • Stimulus-Control: Only go to bed when sleepy; if awake for >20 min, get out of bed and do something quiet until sleepy again.

Hypertension Management¶

• Target Selection: HYVET supports treatment in patients >80 years if SBP ≥160 mmHg; SPRINT suggests intensive control may reduce dementia risk in selected patients.

Diabetes Medication (Table 489-4)¶

• Metformin: First-line agent; safe for eGFR ≥30 mL/min/1.73 m²; use caution in advanced renal failure or heart failure. • Thiazolidinediones: Use cautiously in those at risk for heart failure, falls, or fractures. • DPP-4 Inhibitors: Few side effects and minimal hypoglycemia.

COMPLICATIONS & PROGNOSIS¶

• Life Expectancy: Screening for chronic diseases (e.g., colon cancer) is not recommended if life expectancy is <10 years due to risk of overdiagnosis. • Care Transitions (Table 489-15): Utilize programs like Project RED or Care Transitions Program to ensure medication reconciliation and coordination with primary care providers.

SPECIAL CONSIDERATIONS¶

• Elder Abuse & Neglect (Table 489-14): ◦ Physical: Look for bruises, fractures, or signs of restraint. Interview patient alone. ◦ Financial: Check for inability to pay for meds/food or sudden changes in caregiver's finances. ◦ Neglect: Identify malnutrition, dehydration, and poor hygiene.

KEY PEARLS & CLINICAL TRAPS¶

• Fall Management: If a patient has ≥1 fall in the past year or difficulty with gait/balance, perform a multi-factorial risk assessment. • Medication Safety: Avoid benzodiazepines and antipsychotics as first-line treatments for insomnia or agitation due to fall and cognitive risks. • Incontinence Differentiation: Use 3IQ to distinguish between Stress (physical activity), Urge (sudden urge), and Mixed types.

Reference Tables¶

Table 489-1 . of Geriatric Assessment addresses all of the components required for conditions and syndromes in older…¶

Harrison's 22e, p.3877

1 9	5 23 5 3	6
9 7 1

Harrison's 22e, p.3879

GERIATRIC ASSESSMENT DOMAINS		RECOMMENDED SCREENS	FURTHER ASSESSMENT FOR POSITIVE SCREEN
LAICOS	Social Support	Do you live alone? Do you have a caregiver? Are you a caregiver?	• Consider referral to a social worker • Refer to area agency on aging
	Elder Neglect/Abuse	Do you ever feel unsafe where you live? Has anyone ever threatened or hurt you? Has anyone been taking your money without your permission?	• Consider referral to a social worker and/or adult protective services
	Advance Directives	Would you like information or forms for a power of attorney for health care? Would you like information on a living will?	• Discussion on advance directives • Physician Orders for Life-Sustaining Treatment (POLST) (or MOLST or POST)
	Functional Status	Do you need assistance with shopping or finances? Do you need assistance with bathing or taking a shower?
	Driving	Do you still drive? If yes: While driving, have you had an accident in the past 6 months? Driving concerns by family member?
	Vision	Do you have trouble seeing, reading, or watching TV? (with glasses, if used)
	Hearing	Do you have difficulty hearing conversation in a quiet room? Unable to hear whisper test 6 inches away?
SEMORDNYS CIRTAIREG	Medications	Do you take five or more routine medications? Do you understand the reason for each of your medications?	• Match medications with diagnoses • Consider reducing doses, stopping drugs, adherence aides, and/or consultation with a pharmacist
	Fall Risk	Have you fallen in the past year? Are you afraid of falling? Do you have trouble climbing stairs or rising from chairs?	• “Get Up and Go” test • Consider full fall assessment • Consider physical therapy evaluation • Consider home safety assessment
	Continence	Do you have any trouble with your bladder? Do you lose urine or stool when you do not want to? Do you wear pads or adult diapers?	• Consider full continence assessment • 3IQ Questionnaire (women) • AUA 7 symptom inventory (men)
	Weight Loss	Weight <100 pounds or Unintentional weight loss ≥10 pounds over 6 months?	• Assess for common risk factors for malnutrition • Consider referral to dietician for nutritional evaluation
	Sleep	Do you often feel sleepy during the day? Do you have difficulty falling asleep at night?	• Epworth Sleepiness Scale or Pittsburgh Sleep Index • Consider referral for sleep evaluation
	Pain	Are you experiencing pain or discomfort?	• Pain assessment
	Alcohol Abuse	Do you drink >2 drinks/day?	• AUDIT-C
	Depression	Do you often feel sad or depressed? Have you lost pleasure in doing things over the past few months?
	Cognition	Self-reported memory loss? Cognitive screen positive? (three-item recall and Clock Draw test “Mini-Cog”) Confusion Assessment (CAM) for delirium

TABLE 489-3 Recommendations for Primary Prevention Screening for Specific Diseases in Older Adults from Different…¶

Harrison's 22e, p.3881

TYPE OF SCREENING	TEST	FREQUENCY	PROFESSIONAL SOCIETY ISSUING RECOMMENDATIONS
			USPSTFa	ACSb	ACPc
Colorectal	Fecal occult blood test or fecal immunochemical test (FIT) or Sigmoidoscopy or Colonoscopy	Annual Every 5 y Every 10 y	Screen all adults age 50–75; prognosis may support screening individuals of age 76–85 if never screened; not recommended for adults over age 85	Screen all adults age >50; discontinuing screening is reasonable in people with severe comorbidity that would preclude treatment	Screen all adults age 50–75 People with life expectancy <10 y should not be screened
	Mammography	Every 1–2 y	Biennial screening of all women age 50–74; evidence of benefits and harms is insufficient for women age >75	Annual screening starting at age 40; continue while in good health	ECOGd
Cervical	Pap smear HPV test	Pap only, every 3 y HPV + Pap, every 5 y	Screen women age 21–65; discontinue at age 65 if adequate prior screening	Screen women age 21–65; discontinue at age 65; discontinue at age 65 if regular screening normal	Screening should stop at age 65 if evidence of negative adequate prior screening
	Low-dose CT scan	Annual	Screen age 55–80 current and former smokers with a 30+ pack-year smoking history; discontinue screening once a person has not smoked for 15 years or develops a health problem that limits their ability or willingness to have curative surgery	Screen 55–74-y-old current and former smokers in good health with a 30+ pack-year smoking history	ACCPe
Prostate	Prostate-specific antigen (PSA)	1–2 y	Do not screen men for prostate cancer with PSA if age 70 y or older	Screen men age 50 and over with a life expectancy >10 y after discussion about the risks, benefits, and uncertainties of PSA screening Follow-up screening should occur annually if PSA >2.5 ng/mL or biennially if PSA <2.5 ng/mL	AUAf
					Biennial PSA screening in men age 55–69 y with life expectancy >10–15 y, after shared decision-making discussions accounting for values and preferences
	Dual-energy x-ray absorptiometry (DEXA) Measure height, preferably with a wall- mounted stadiometer	Perform bone mineral density testing 1–2 y after initiating medical therapy for osteoporosis and every 2 y annually thereafter	USPSTFa	NOFg
			Screen women age 65; the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men
Carotid disease	Carotid ultrasound	Once	SOCIETY OF VASCULAR SURGERY
			Age over 65, coronary artery disease, need for coronary bypass, symptomatic lower extremity arterial occlusive disease, history of tobacco use, and high cholesterol would be appropriate risk factors to prompt ultrasound in patients with a bruit
	Coronary calcium score (CCS)	Once	SCCTh	AHA/ACCi
			Do not use CCS for patients with known CAD
Abdominal aortic aneurysm	Abdominal ultrasound	Once	USPSTFa	AAFPj
			The USPSTF recommends one-time screening for abdominal aortic aneurysm with ultrasonography in men aged 65–75 y who have ever smoked; there is insufficient evidence to recommend screening for women even if they have ever smoked	Recommended for men aged 65–75 y who have ever smoked
	Fasting blood glucose, glucose tolerance test, or hemoglobin A 1c	Annually	USPSTFa	ADAk
			No evidence to screen for diabetes after the age of 70; recommendation being reviewed at the time of this publication

TABLE 489-4 Recommendations and Considerations for Pharmacologic Therapy of Diabetes in Older Adults MEDICATION…¶

Harrison's 22e, p.3882

MEDICATION	RECOMMENDATIONS AND CONSIDERATIONS
Metformin	• Metformin is the first-line agent for older adults with type 2 diabetes • Low risk of hypoglycemia • Recent studies suggest it may be used safely in patients with estimated glomerular filtration rate ≥30 mL/ min/1.73 m2 • Use with caution in patients with advanced renal insufficiency or significant heart failure • Can cause gastrointestinal symptoms with lower appetite
Thiazolidinediones	• If used at all, should be used very cautiously in those with, or at risk for, congestive heart failure and those at risk for falls or fractures
Dipeptidyl peptidase 4 (DPP-4) inhibitors	• Few side effects and minimal hypoglycemia, but costs may be a barrier • No evidence of increase in major adverse cardiovascular events

TABLE 489-5 Evaluating the Older Person Who Falls—Immediate Postfall Evaluation History • Circumstances surrounding the…¶

Harrison's 22e, p.3886

History
• Circumstances surrounding the fall
• Relationship to changes in posture, turning of head, after a meal or medication intake, rushing to the toilet, nocturia, straining to urinate or defecate
• Accidental trip or slip (note that many correctable factors can contribute to a reported “mechanical” fall—see text)
• Hazards in the living environment (loose rugs, cords, unsafe steps, slippery floors, etc.)
• Premonitory or associated symptoms
• Dizziness (lightheadedness vs vertigo); cardiovascular (postural lightheadedness, palpitations, chest pain, shortness of breath); focal neurologic symptoms
suggestive of stroke or transient ischemic attack (weakness, sensory disturbance, dysarthria, ataxia, aphasia); symptoms of a seizure (witnessed clinic
movements, incontinence of urine or stool, tongue biting)
• Symptoms over the previous few days that may have led to volume depletion (poor food/fluid intake, nausea/vomiting, diarrhea, urinary frequency/polyuria)
• Exclude loss of consciousness or seizure (may be difficult without a witness)
• Medications—chronic and within the few hours before the fall
• Diuretics and other antihypertensive drugs
• Nitrates
• Drugs that cause bradycardia—beta blockers; cholinesterase inhibitors
• Psychotropics—antipsychotics, hypnotics, sedatives, antidepressants
• Antiparkinsonian drugs
• Hypoglycemic drugs
• Excessive alcohol intake
Physical Examination
• Exclude physical injury
• Head trauma, hip range of motion, pubic bone tenderness, wrist pain, other signs of trauma
• Bruising in patients on anticoagulants/platelet inhibitors
• Exclude acute illness
• Vital signs
• Postural vital signs (if feasible/safe)
• Fingerstick glucose in diabetics
• Poor skin turgor suggesting volume depletion (over chest; other areas unreliable)
• Signs of an acute respiratory, cardiovascular, or abdominal condition
• Focal neurologic signs suggestive of stroke
• Signs of conditions that increase risk for falls
• Poor visual acuity; use of bifocals
• Limited range of motion of neck (to detect possible cervical arthritis/disk disease)
• Cardiovascular—arrhythmias, carotid bruits, aortic stenosis, mitral insufficiency, heart failure
• Degenerative joint disease in lower extremities causing pain, limited range of motion, and/or deformity
• Podiatric conditions (calluses; bunions; ulcerations; poorly fitted, inappropriate, or unsafe shoes)
• Neurologic signs—lower extremity muscle weakness; peripheral neuropathy; tremor, rigidity, and/or bradykinesia suggestive of undiagnosed Parkinson’s disease;
cerebellar signs (abnormal heel to shin or heel tapping); abnormal reflexes that could reflect upper motor neuron disorder such as spinal cord compression or
subdural hematoma; cognitive deficits that can result in poor judgement
• Observation of gait and balance—simple Get Up and Go test (see text) with observation for short steps, poor foot elevation, wide-based gait, multiple steps to turn
180 degrees; other abnormalities that might suggest normal pressure hydrocephalus (especially in combination with symptoms of incontinence and/or cognitive
impairment)
Laboratory and/or Imaging Studies
• Should be guided by history and physical examination—common examples include:
• Complete blood count, basic metabolic panel to exclude/verify acute illness
• Urinalysis (only when additional symptoms of urinary tract infection present)
• Electrocardiogram (in patients suspected of acute coronary syndrome or with significant known cardiovascular disease)
• X-rays to exclude fractures
• Brain imaging if signs present to exclude subdural hematoma, stroke
• Cardiac monitoring in patients with history suggestive of syncope or near-syncope
• Electroencephalography in patients with history suggestive of seizure

TABLE 489-7 General Recommendations for Geriatric Prescribing 1. Evaluate geriatric patients thoroughly to identify all…¶

Harrison's 22e, p.3887

CAUSES	EXAMPLES OF TREATMENT
Cardiovascular
Arrhythmias	Antiarrhythmic medication, ablation, pacemaker (depending on nature of arrhythmia)

TABLE 489-7 General Recommendations for Geriatric Prescribing

1. Evaluate geriatric patients thoroughly to identify all conditions that could (a) benefit from drug treatment; (b) be adversely affected by drug treatment; and (c) influence the efficacy of drug treatment. 2. Manage medical conditions without drugs as often as possible. 3. Know the pharmacology of the drug(s) being prescribed. 4. Consider how the clinical status (e.g., renal function, hydration) of each patient could influence the pharmacology of the drug(s). 5. Avoid potentially serious adverse drug-drug interactions. 6. For drugs or their active metabolites eliminated predominantly by the kidney, use a formula to approximate age-related changes in renal function and adjust dosages accordingly; the Cockcroft-Gault formula (below) is probably safer as it tends to underestimate creatinine clearance. (140−age) × bodyweight(kg) Creatinineclearance= (×0.85forwomen) 72×serumcreatininelevel 7. If there is a question about drug dosage, start with smaller doses and increase gradually until the drug is effective or intolerable side effects are observed. 8. Drug blood concentrations can be helpful in monitoring several potentially toxic drugs used in the geriatric population. 9. Help to ensure adherence by: a. Making drug regimens and instructions as simple as possible b. Using the same dosage schedule for all drugs whenever feasible (e.g., once or twice per day) c. Timing the doses in conjunction with a daily routine d. Paying attention to impaired cognitive function, diminished hearing, and poor vision when instructing patients and labeling prescriptions e. Instructing relatives and caregivers on the drug regimen f. Enlisting other health professionals (e.g., home health aides, pharmacists) to help ensure compliance g. Making sure the older patient can get to a pharmacist (or vice versa), can afford the prescriptions, and can open the container h. Using aids (e.g., special pillboxes and drug calendars) whenever appropriate i. Performing careful medication adjudication and patient/family education at the time of every hospital discharge j. Keeping updated medication records and review them at each visit k. Reviewing knowledge of and adherence with drug regimens regularly 10. Monitor older patients frequently for adherence, drug effectiveness, and adverse effects, and adjust drug therapy accordingly.
Postural hypotension	Reduce or eliminate hypotensive drugs Hydration, support stockings Medication (Proamatine [midodrine], fludrocortisone, droxidopa) Adaptive behaviors (e.g., pausing and getting up slowly)
Neurologic
Autonomic dysfunction with postural hypotension	As above
Parkinson’s disease	Antiparkinsonian drugs
Seizure disorder	Anticonvulsants
Dementia	Supervised activities Hazard-free environment
Others
Foot disorders	Podiatric evaluation and treatment
Muscle weakness, deconditioning	Lower extremity strength training
Vitamin D deficiency	Vitamin D supplementation

TABLE 489-9 Key Principles in the Management of Dementia Optimize the patient’s physical and mental function through…¶

Harrison's 22e, p.3889

CONTRIBUTING FACTORS	APPROACHES TO EVALUATION AND MANAGEMENT
Drugs	Consider the etiologic role of newly initiated drugs, increased doses, interactions, over-the-counter drugs, and alcohol; consider especially the role of high-risk drugs: lower the dose, discontinue the drug, or substitute a less psychoactive medication. Consider withdraw from chronic medications. Pay special attention to psychotropic medications.

TABLE 489-9 Key Principles in the Management of Dementia

Optimize the patient’s physical and mental function through physical activity and mind plasticity principles and activities Treatment underlying medical and other conditions (e.g., hypertension, Parkinson’s disease, depression) Avoid use of drugs with central nervous system side effects (unless required for management of psychological or behavioral disturbances—see Chap. 31) Assess the environment and suggest alterations, if necessary Encourage physical and mental activity Avoid situations stressing intellectual capabilities; use memory aids whenever possible Prepare the patient for changes in location Emphasize good nutrition Identify and manage behavioral symptoms and complications Driving (consider a formal driving evaluation) Wandering Dangerous driving Behavioral disorders Depression Agitation or aggressiveness Psychosis (delusions, hallucinations) Malnutrition Incontinence Provide ongoing care Reassessment of cognitive and physical function Treatment of medical conditions Provide information to patient and family Nature of the disease Extent of impairment Prognosis Provide social service information to patient and family Local Alzheimer’s association Community health care resources (day centers, homemakers, home health aides) Legal and financial counseling Use of advance directives Provide family counseling for: Setting realistic goals and expectations Identification and resolution of family conflicts Handling anger and guilt Decisions on respite or institutional care Legal concerns Ethical concerns Consideration of palliative and hospice care Protect the caregiver from effects of caregiver stress
Infection	Urinary tract infections, pneumonia, soft tissue infection
Urinary and fecal disorders	Treat urinary retention and fecal impaction
Prevent or Manage Complications
Urinary incontinence	Scheduled toileting
Pressure ulcers	Mobility and repositioning, nutrition
Feeding disorders	Feeding assistance if necessary, aspiration precautions, liberalize diet if possible
Maintain Patient Comfort and Safety
Pharmacologic interventions	Only if patients become a threat to themselves or others and other interventions have failed
Restore Function
Cognitive reconditioning	Reorient patient frequently
Discharge planning	Assess new needs based on predischarge functional status, evaluate social support, coordinate transitions of care, medication reconciliation

TABLE 489-10 Reversible Conditions That Cause or Contribute to Urinary Incontinence and Overactive Bladder Symptoms in…¶

Harrison's 22e, p.3890

CONDITION	MANAGEMENT
Lower urinary tract conditions
Urinary tract infection (symptomatic with frequency, urgency, dysuria, etc.)	Antimicrobial therapy
Atrophic vaginitis/urethritis	Topical estrogen (not a primary treatment for incontinence but may help prevent recurrent infections and ameliorate symptoms of overactive bladder; oral estrogens can cause or worsen incontinence)
Stool impaction with irritation of bladder/urethral innervation and/or partial bladder outlet obstruction	Disimpaction; appropriate use of stool softeners, bulk-forming agents, and laxatives if necessary; implement bowel regimen
Impaired ability or willingness to reach a toilet
Delirium	Diagnosis and treatment of underlying cause(s)
Chronic illness, injury, or restraint that interferes with mobility	Regular toileting Use of toilet substitutes Environmental alterations (e.g., bedside commode, urinal) Remove restraints if possible
Psychological (depression, anxiety)	Appropriate nonpharmacologic and/or pharmacologic treatment

TABLE 489-11 Key Aspects of the History and Physical Examination of an Older Patient with Symptoms of Urinary…¶

Harrison's 22e, p.3892

History
Active medical conditions, especially neurologic disorders, diabetes mellitus, congestive heart failure, venous insufficiency
Medication review for drugs that can contribute (see Table 489-10)
Fluid intake pattern
Type and amount of fluid (especially caffeine and fluids before bedtime)
Past genitourinary history, especially childbirth, surgery, dilatations, urinary retention, recurrent urinary tract infections
Symptoms of incontinence
Onset and duration
Type—stress vs urge vs mixed vs other (see Fig. 489-10)
Frequency, timing, and amount of incontinence episodes and of continent voids (a voiding diary may be useful)
Other lower urinary tract symptoms
Irritative—dysuria, frequency, urgency, nocturia
Voiding difficulty—hesitancy, slow or interrupted stream, straining, incomplete emptying
Other—hematuria, suprapubic discomfort
Other symptoms
Neurologic (indicative of stroke, dementia, parkinsonism, normal-pressure hydrocephalus, spinal cord compression, multiple sclerosis)
Psychological (depression)
Bowel (constipation, stool incontinence)
Symptoms suggestive of volume-expanded state (e.g., lower extremity edema, shortness of breath while horizontal or with exertion)
Environmental factors
Location of bathroom
Availability of toilet substitutes (e.g., urinal, bedside commode)
Perceptions of incontinence
Patient’s concerns or ideas about underlying cause(s)
Most bothersome symptom(s)
Interference with daily life
Severity (e.g., “Is it enough of a problem for you to consider surgery?”)
Physical Examination
Mobility and dexterity
Functional status compatible with ability to self-toilet
Gait disturbance (e.g., that may suggest parkinsonism, normal-pressure hydrocephalus)
Mental status
Cognitive function compatible with ability to self-toilet
Motivation
Mood and effect
Neurologic
Focal signs (especially in lower extremities) that could suggest a central nervous system condition
Signs of parkinsonism
Sacral arc reflexes (e.g., loss of perianal sensation or an anal wink in response to perianal stimulation)
Abdominal
Bladder distensiona
Suprapubic tenderness
Lower abdominal mass
Rectal
Perianal sensation
Sphincter tone (resting and active)
Impaction
Masses
Size and contour of prostate (neither is diagnostic of urethral obstruction)
Pelvic
Perineal skin condition
Perineal sensation
Atrophic vaginitis (friability, inflammation, bleeding)
Pelvic prolapse or mass
Other
Lower extremity edema or signs of congestive heart failure (if nocturia is a prominent complaint)

TABLE 489-12 Primary Treatments for Different Types of Geriatric Urinary Incontinence¶

Harrison's 22e, p.3893

TYPE OF INCONTINENCE	PRIMARY TREATMENTS
Stress	Pelvic muscle (Kegel) exercises
	Other behavioral interventions including timed voiding and double voiding to avoid residual urine
	α-Adrenergic agonist (none are approved by the U.S. Food and Drug Administration for this purpose)
	Topical estrogen to strengthen periurethral tissue (not effective alone; oral estrogens contraindicated)
	Periurethral injections to provide bulking and support
	Surgical bladder neck suspension or sling for severe incontinence, based on patient preference
Incontinence with incomplete bladder emptying	α-Adrenergic antagonists in men with a 5α-reductase inhibitor if the prostate is enlarged); an antimuscarinic or β-3-adrenergic drug can be added if unresponsive to the α-adrenergic agonist
	Bladder training, double voiding
	Intermittent catheterization
	Indwelling catheterization in selected patients in whom risks and discomforts of urinary retention outweigh risks of a chronic indwelling catheter

TABLE 489-13 Nonpharmacologic Management of Insomnia in Older Adults Sleep Hygiene Rules Check effect of medication on…¶

Harrison's 22e, p.3894

Sleep Hygiene Rules
Check effect of medication on sleep and wakefulness
Avoid caffeine, alcohol, and cigarettes after lunch
Limit liquids in the evening
Keep a regular bedtime-waketime schedule
Avoid naps or limit to 1 nap a day, no longer than 30 min
Spend time outdoors (without sunglasses), particularly in the late afternoon or
early evening
Exercise—but limit exercise immediately before bedtime
Instructions for Stimulus-Control Therapy
Only go to bed when tired or sleepy
If unable to fall asleep within 20 min, get out of bed (and bedroom if possible);
while out of bed, do something quiet and relaxing
Only return to bed when sleepy
If unable to fall asleep within 20 min, again get out of bed
Repeat these behaviors until able to fall asleep within a few minutes
Get up at the same time each morning (even if only a few hours of sleep)
Avoid naps

TABLE 489-14 Elder Abuse and Neglect CATEGORY Physical abuse¶

Harrison's 22e, p.3895

CATEGORY	DEFINITION AND EXAMPLES	SYMPTOMS AND SIGNS	KEY ASPECTS OF EVALUATION
Physical abuse	Acts of violence that may result in pain, injury, or impairment • Pushing, slapping, hitting, force-feeding • Improper positioning or use of restraints • Improper use of medications	Abrasions Lacerations Bruises Fractures Use of restraints Burns Pain Depression Delirium or onset or worsening of dementia-related behavioral symptoms	The interview should be conducted alone with the patient; it may reveal discordant histories or findings inconsistent with the history provided by the caregiver. Ankles and wrists should be examined for abrasions suggestive of the use of restraints. Findings that are discordant with the mechanism of injury reported or multiple injuries in various stages of healing should raise the suspicion of abuse. Injuries to the head, neck, and upper arms occur in victims of physical elder abuse but must be distinguished from accidental injuries. Jaw and zygomatic fractures are more likely to be sustained from a punch than from a fall, which more typically result in fractures to orbital and nasal bones.
	Conduct that causes mental or emotional distress • Verbal harassment or intimidation • Threats of punishment or deprivation • Isolation	Direct observation of verbal abuse Subtle signs of intimidation, such as deferring questions to a caregiver or potential abuser Evidence of isolation Depression, anxiety, or both
Financial abuse	Misuse of the person’s income or resources for the financial or personal gain of a caregiver or advisor • Stealing money or possessions • Denying a home • Coercing to sign contracts or spend money	Inability to pay for medicine, medical care, food, rent, or other necessities Failure to renew prescriptions, adhere to medication regimens or other treatments, or keep medical appointments Malnutrition, weight loss, or both, without an obvious medical cause Evidence of poor financial decision-making Firing of home care or other service providers by abuser Unpaid utility bills Initiation of eviction proceedings	Ask about financial exploitation with questions such as, “Has money or property been taken from you without your consent?”; “Have your credit cards or automated teller machine card been used without your consent?”; and “At the end of the month, do you have enough money left for food and other necessities?” Abrupt changes in financial circumstances of the caregiver in either direction may herald an increased risk of financial exploitation or exploitation already under way. Abuse of the power of attorney; if the person with power of attorney or health care proxy is suspected of not acting in the best interest of the patient, documents necessary to ensure that the assumption of fiduciary responsibilities is authorized.
	Sexual coercion or assault	Bruising, abrasions, lacerations in the genital or anal areas or abdomen Newly acquired sexually transmitted diseases, especially in nursing home Urinary tract infection
Neglect (by caregiver or self-neglect)	Failure to provide the materials, supplies, food and drink, or services necessary for optimal functioning or to avoid harm	Malnutrition Dehydration Poor hygiene Pressure ulcers Nonadherence to medication regimen or other treatments Worsening of dementia-related behavioral symptoms	Interview primary caregiver about their understanding of the nature of the patient’s care needs and how well care is being rendered. Neglect by a caregiver may be intentional or unintentional. Assess hygiene, cleanliness, and appropriateness of dress. Examine the skin for pressure ulcers, infections, and infestations. Assess nutrition and hydration, including measuring body mass index and blood urea nitrogen and creatinine to assess hydration.

TABLE 489-15 Examples Care Transitions Interventions INTERVENTION Re-Engineered Discharge (Project RED) (Jack et al…¶

Harrison's 22e, p.3896

INTERVENTION	WEBSITE	CORE INTERVENTIONS
Re-Engineered Discharge (Project RED) (Jack et al: 2009)	https://www.bu.edu/fammed/ projectred/	“Discharge advocate” performs the following: • Facilitates patient education and understanding • Performs medication reconciliation • Coordinates postdischarge appointments and communication with primary care provider (PCP) • Calls patient 2–3 days after discharge
	https://www.nursing. upenn.edu/ncth/ transitional-care-model/
Care Transitions Program® (Coleman et al: 2004)	http://www.caretransitions. org	“Transition coach” performs the following: • Facilitates improved self-management skills including medication management and how to respond to warning signs/symptoms • Makes postdischarge home visits and phone calls
	https://www. hospitalmedicine.org/ clinical-topics/ care-transitions/
Interventions to Reduce Acute Care Transfers (INTERACT) (Ouslander et al: 2013)	http://www.interact-pathway. com	Includes tools for skilled nursing, assisted living, and home health care, including: • Quality improvement • Communication • Decision support • Advance care planning