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Gerontological Nursing

Focuses on theoretical and practical information about basic and complex


concepts and issues relevant to the nursing care of older people across the
continuum of care.

Course Outcomes:

1. Incorporates clinical assessment skills specific to older adults in the


context of families, groups, and diverse communities.
2. Understands the major roles of the gerontological nurse in a variety of
clinical settings from a holistic framework.
3. Reads and reports on evidence based research findings relevant to
gerontological nursing practice.
4. Identifies complex nursing care needed to accomodate older adults with
acute and chronic illnesses in the context of hospitals, home, or community
settings.
5. Maintains accountability to professional nursing values and standards.
6. Communicates effectively with older adult clients, their families, health
care professionals, faculty, and other students.
7. Shows respect and demonstrates a caring way of being with the older
adult population.
8. Demonstrates critical thinking and good judgment.
9. Promotes health of older adults, demonstrating sensitivity and
understanding of their learning needs.
10. Incorporates clinical assessment skills into practice.
11. Provides holistic nursing care safely and competently.

Course outline:
A. The Aging Population
B. Theories of Aging
C. Common Aging Changes
D. The Specialty of Gerontological Nursing
E. Gerontological Nursing Practice
F. Ethics of Caring and Legal Aspects of Gerontological Nursing
G. Spirituality
H. Respiration/Circulation
I. Hydration/Nutrition
J. Elimination
K. Movement
L. Infections
M. Cancer
N. Cardiovascular Conditions
O. Respiratory Conditions
P. Dermatological Conditions
Q. Metabolic/Endocrine Conditions
R. Safe Medication Use
S. Family Caregiving
A. The Aging Population

THE AGING POPULATION


Although individuals age at an inevitable and steady pace from birth to
death, the aging of society is neither inevitable nor uniform. Populations age
when the proportion of older people relative to that of younger people increases.

Aging of population (also known as demographic aging, and population


aging) is a summary term for shifts in the age distribution (i.e., age structure) of a
population toward older ages. A direct consequence of the ongoing global
fertility transition (decline) and of mortality decline at older ages, population aging
is expected to be among the most prominent global demographic trends of the
21st century. Population aging is progressing rapidly in many industrialized
countries, but those developing countries whose fertility declines began relatively
early also are experiencing rapid increases in their proportion of elderly people.
This pattern is expected to continue over the next few decades, eventually
affecting the entire world. Population aging has many important socio-economic
and health consequences, including the increase in the old-age dependency
ratio. It presents challenges for public health (concerns over possible bankruptcy
of Medicare and related programs) as well as for economic development
(shrinking and aging of labor force, possible bankruptcy of social security
systems).

THE NURSE’S ROLE IN HEALTH PROMOTION FOR OLDER ADULTS


The aging of our society is the dominant demographic phenomenon of our
time. Three of the four most common causes of death among older adults—heart
diseases, cancer, and stroke—are the result of an unhealthy lifestyle. However,
the gloomy image of an aging nation of sedentary, chronically ill older adults is
gradually being replaced by new concepts such as successful aging, and
compression of morbidity. Within the context of these new concepts, health
protection and health promotion have emerged as appropriate frameworks for a
care of older adults. Professionals caring for older adults are recognizing that
prevention for a 65-year-old person, who can be expected to live another 17.5
years, is a necessary component of health care.

Who are Older Adults?


Development of this approach required consideration of who older adults
are and what constitutes successful aging, as well as health promotion and
prevention for this segment of the population. We know that older adults are a
heterogeneous group. Each older adult represents a unique set of goals,
experiences, values and attitudes.
What is Health?
Age alone is an adequate predictor of health status, primarily because
one’s definition of health changes with age. The traditional definition of health as
the absence of disease or infirmity is clearly inappropriate for many older adults,
for whom chronic disease has become a way of life. This definition implies both
that the absence of disease occurs in poor quality of life. Nothing could be further
from the truth. Older adults clearly do not view this stage of their life in this
manner. Self-ratings of health among older adults often reflect such qualities as
feeling good, being able to do things that are important, coping with life’s
demands, and achieving one’s potentials. One definition of health for older adults
is “the ability to live and function effectively in the society and to exercise self-
reliance and autonomy to the maximum extent feasible, but not necessarily as
total freedom from disease.” Health for older adults is a complex interaction of
physical, functional and psychosocial factors.

What is Successful Aging?


Successful aging is defined as “the ability to maintain three key behaviors
or characteristics: a low risk of disease and disease-related disability; high
mental and physical function; and active engagement in life.” These three
aspects are not unrelated. Rather, the combination of all three represents the
concept of successful aging most clearly. Avoiding disease and disability places
an emphasis on the role of lifestyle factors in the development of chronic
diseases such as diabetes, hypertension, osteoporosis, and heart disease.

Maintaining mental and physical function is critical to remaining


independent in all activities of daily living. Continuing to be engaged in life
captures the essence of the needs of the human spirit—to be connected to
others in a meaningful and satisfying manner. Nursing practice in this segment of
the population must incorporate these parameters.

B. Theories of Aging

There are many theories of aging, but few are widely accepted. Aging
proceeds at different rates in different species. Even within a species, aging
proceeds at different rates among individuals. A reasonable conclusion is that
aging must be genetically controlled, at least to some extent. Both within and
between species, lifestyle and exposures may alter the aging process.

Some theories of aging focus on what controls the degenerative and


entropic processes that occur with aging and why the controls exist as they do.
Other theories focus on the evolutionary origins of senescence. All of these
theories generally agree that senescence does not offer a genetic advantage and
developed mainly because it is not selected against.
BIOLOGICAL THEORIES
Biological theories attempt to explain the physical process of aging,
including alterations in structure and function, development, longetivity and
death. It also attempts to explain why people age differently over time and what
factors affect longetivity, resistance to organisms, and cellular alterations or
death. An understanding of the biological perspective can provide the nurse with
knowledge about specific risk factors associated with aging and about how
people can be helped minimize or avoid risk and maximize health..

Genetic Theory
Some scientists regard this as a Planned Obsolescence Theory because it
focuses upon the encoded programming within our DNA. Our DNA is the blue-
print of individual life obtained from our parents. It means we are born with a
unique code and a predetermined tendency to certain types of physical and
mental functioning that regulate the rate at which we age.
But this type of genetic clock can be greatly influenced with regard to its
rate of timing. For example, DNA is easily oxidized and this damage can be
accumulated from diet, lifestyle, toxins, pollution, radiation and other outside
influences.
Thus, we each have the ability to accelerate DNA damage or slow it down.
One of the most recent theories regarding gene damage has been the
Telomerase Theory of Aging. First discovered by scientists at the Geron
Corporation, it is now understood that telomeres (the sequences of nucleic acids
extending from the ends of chromosomes), shorten every time a cell divides. This
shortening of telomeres is believed to lead to cellular damage due to the inability
of the cell to duplicate itself correctly. Each time a cell divides it duplicates itself a
little worse than the time before, thus this eventually leads to cellular dysfunction,
aging and indeed death.

Wear and Tear Theory


The Wear and Tear Theory proposes that the cumulative damage to vital
irreplaceable body parts leads to the death of cells, tissues, organs, and finally
the whole body. Thus, cumulative damage to DNA leads to a decline in cell
function. The problem with this theory is that there are no research models that
give credible support at this time.

Environmental Theory
According to this theory, factors in the environment (e.g., industrial
carcinogens, sunlight, trauma, and infection) bring about changes in the aging
process. Although these factors are known to accelerate aging, the impact of the
environment is a secondary rather than a primary factor in aging. Nurses can
have a profound impact on this aspect of aging by educating all age groups
about the relationship between environmental factors and accelerated aging.
Science is only beginning to uncover the many environmental factors that affect
aging.

Immunity Theory
As the body ages, the immune system is less able to deal with foreign
organisms & increasingly make mistakes by identifying ones own tissues as
foreign (thus attacking them). These altered abilities result in increased
susceptibility to disease & to abnormalities that result form autoimmune
responses.

Neuroendocrine Theory
First proposed by Professor Vladimir Dilman and Ward Dean MD, this
theory elaborates on wear and tear by focusing on the neuroendocrine system.
This system is a complicated network of biochemicals that govern the release of
hormones which are altered by the walnut sized gland called the hypothalamus
located in the brain.

The hypothalamus controls various chain-reactions to instruct other


organs and glands to release their hormones etc. The hypothalamus also
responds to the body hormone levels as a guide to the overall hormonal activity.

But as we grow older the hypothalamus loses it precision regulatory ability


and the receptors which uptake individual hormones become less sensitive to
them. Accordingly, as we age the secretion of many hormones declines and their
effectiveness (compared unit to unit) is also reduced due to the receptors down-
grading.

PSYCHOSOCIOLOGICAL THEORIES
These theories focus on behavior and attitude changes that accompany
advancing age, as opposed to the biological implications of anatomic
deterioration.

Disengagement Theory
Refers to an inevitable process in which many of the relationships
between a person and other members of society are severed & those remaining
are altered in quality. Withdrawal may be initiated by the aging person or by
society, and may be partial or total. It was observed that older people are less
involved with life than they were as younger adults. As people age they
experience greater distance from society & they develop new types of
relationships with society. In America there is evidence that society forces
withdrawal on older people whether or not they want it. Some suggest that this
theory does not consider the large number of older people who do not withdraw
from society. This theory is recognized as the 1 st formal theory that attempted to
explain the process of growing older.
Activity Theory
This is another theory that describes the psychosocial aging process.
Activity theory emphasizes the importance of ongoing social activity. This theory
suggests that a person's self-concept is related to the roles held by that person
i.e. retiring may not be so harmful if the person actively maintains other roles,
such as familial roles, recreational roles, volunteer & community roles. To
maintain a positive sense of self the person must substitute new roles for those
that are lost because of age. And studies show that the type of activity does
matter, just as it does with younger people.

Continuity Theory
This theory states that older adults try to preserve & maintain internal &
external structures by using strategies that maintain continuity. It means that
older people may seek to use familiar strategies in familiar areas of life. In later
life, adults tend to use continuity as an adaptive strategy to deal with changes
that occur during normal aging. Continuity theory has excellent potential for
explaining how people adapt to their own aging. Changes come about as a result
of the aging person's reflecting upon past experience & setting goals for the
future.

C. Common Aging Changes

One can catalog changes that typically occur with age.

For people of developed countries age changes include: A loss of hearing


ability, particularly for higher frequencies. There is a decline in the ability to taste
salt&bitter (sweet&sour are much less affected). There is a reduction of the
thymus gland to 5−10% of its original mass by age 50. Levels of antibodies
increase with aging. One third of men and half of women over 65 report some
form of arthritis. About half of those aged 65 have lost all teeth. The elderly
require twice as much insulin to achieve the glucose uptake of the young. There
is reduced sensitivity to growth factors & hormones due to fewer receptors and
dysfunctional post-receptor pathways. The temperature needed to separate DNA
strands increases with age. Weight declines after age 55 due to loss of lean
tissue, water and bone (cell mass at age 70 is 36% of what it is at age 25). Body
fat increases to age 60. Muscle strength for men declines 30−40% from age 30
to age 80. Reaction time declines 20% from age 20 to 60. Elderly people tend to
sleep more lightly, more frequently and for shorter periods — with a reduction in
rapid eye-movement (REM) sleep.

Neurogenesis in the hippocampus declines with age. Degree of saturation


of fats drops by 26% in the brains of old animals. Presbyopia (reduced ability to
focus on close-up objects) occurs in 42% of people aged 52−64, 73% of those
65−74 and 92% of those over age 75. Most people over age 75 have cataracts.
About half of those over 85 are disabled (defined as the inability to use public
transportation). Over 75% of people over 85 have 3−9 pathological conditions,
and the cause of death for these people is frequently unknown.

Aging changes are frequently associated with an increase in likelihood of


mortality, but this is not necessarily the case. For example, graying of hair is a
symptom of aging, but graying does not increase likelihood of mortality. Aging
changes which are not associated with a specific disease, but which are
associated with a generalized increase in mortality would qualify as biomarkers
of aging — and would distinguish biological age from chronological age.
Biomarkers would be better predictors of the increased likelihood of mortality
(independent of specific disease) than the passage of time (chronological age).
Cross-linking of collagen, insulin resistance and lung expiration capacity have
been proposed as candidates but, as yet, no biomarkers of aging have been
validated and universally accepted.

D. The Specialty of Gerontological Nursing

Clinical specialists in gerontologic nursing (often referred to as


gerontologic or geriatric clinical nurse specialists) are registered nurses who
have a master's or higher degree in nursing and who specialize in care of the
elderly. Gerontologic clinical nurse specialists have substantial clinical
experience with patients and their family members; they have expertise in
formulating health and social policies and in planning, implementing, and
evaluating health problems. They can also take histories, perform physical
examinations, and manage medical and nursing problems. Unlike nurse
practitioners, clinical nurse specialists usually cannot diagnose and cannot
prescribe drugs.

Most gerontologic clinical nurse specialists work in hospitals as


consultants to interdisciplinary teams. They consult for and advise staff nurses
about problems common among the elderly and provide continuing education
about new research findings. Gerontologic clinical nurse specialists also help
staff nurses by serving as liaisons between the hospital and nursing homes or
community health agencies. They may make home visits after a patient is
discharged from the hospital and manage and coordinate care as a patient
moves between several care settings.

Gerontologic clinical nurse specialists sometimes teach and train staff


nurses more formally, as in the geriatric resource nurse program, which includes
participation in interdisciplinary geriatric care rounds. After completing this
training program, staff nurses are recognized as geriatric resource nurses,
although no certification occurs. In addition to providing expert care for elderly
patients, geriatric resource nurses provide information and support for other staff
members caring for elderly patients and for patients and their family members.
Geriatric resource nurses also act as advocates for elderly patients.

E. Gerontological Nursing Practice

GERONTOLOGICAL NURSING PRACTICE


Gerontologic (geriatric) nurse practitioners are registered nurses with a
master's degree from a nurse practitioner program that focuses on care of the
elderly. In 2004, only about 4,000 of > 100,000 certified nurse practitioners were
certified gerontologic nurse practitioners. However, many certified family nurse
practitioners and adult nurse practitioners also provide care for the elderly. The
curriculum for gerontologic nurse practitioners focuses on normal aging, common
problems of old age and their management, and detection of complex problems
that typically require referral.

Gerontologic nurse practitioners perform many functions previously


performed only by physicians. They perform physical examinations, diagnose
disorders, order laboratory and other diagnostic tests, develop and implement
treatment plans for patients with certain acute or chronic disorders, prescribe
certain drugs, teach and counsel patients, provide long-term monitoring, consult
with other health care practitioners, and refer patients to specialists. Nurse
practitioners may practice in collaboration with physicians or other health care
practitioners.

Many gerontologic nurse practitioners work in nursing homes or for


physicians with practices in nursing homes. Others work in acute care settings or
in primary care offices. Community health services (eg, home care agencies,
hospices, clinics) may be managed primarily by gerontologic nurse practitioners.
Nursing roles have expanded because basic health care services are lacking in
certain areas, especially rural areas and inner cities, and because few physicians
make home visits. Many gerontologic nurse practitioners provide primary care in
the community.

F. Ethics of Caring and Legal Aspects of Gerontological Nursing

The most common legal and ethical issues in geriatric care involve
assessment of decisional capacity and competence, identification of decision
makers, resolution of conflicts about care, disclosure of information, termination
of treatment at the end of life, and decisions about long-term care. Although the
approach to resolution of these issues is similar for all age groups, the
physiologic, psychologic, and social reserves of the elderly place them at greater
risk of adverse outcomes. The fact that the elderly often lack the support of family
and friends makes them especially vulnerable to the automatic and sometimes
unthoughtful process of the health care system.

Although aging may pose some special challenges, it is unfair to make


assumptions about a person's abilities or needs based on age alone. Rather,
physicians should assess each elderly patient individually and delineate
treatment options accordingly. Physicians must also advocate for their patients'
ethical interests and legal rights, especially in the medical context, about which
patients are often ill-informed or misled.

Elderly patients are often targets of unscrupulous schemes to defraud


them of property or money. Health care practitioners may be the first to recognize
such schemes and should offer help and referral for legal assistance. Attorneys
knowledgeable about elder law can defeat these schemes with timely and
effective legal intervention through services provided by the local agency on
aging.

Capacity
A clinical determination of a patient's ability to make decisions about
treatment interventions or other health-related matters.

Capacity is determined by the health care practitioner or, ideally, by the


health care team with the aid of cognitive testing, discussion over time, and
observation. Capacity is related to memory but is not extinguished by memory
loss.

Persons are considered to have decisional capacity if they can


understand their health condition; can consider the benefits, burdens, and risks
of care options; can weigh the consequences of treatment against their
preferences and values; can reach a decision that is consistent over time; and
can communicate that decision to others.

Elderly patients with decisional capacity have the same rights as other
adults to make choices about their care. Because many elderly patients can
make some decisions but not others, capacity is considered decision-specific.
Thus, a patient may be capable of choosing between relatively benign
alternatives that may have few serious consequences but may not be capable of
evaluating and choosing alternatives in a life-threatening circumstance.

For the elderly, who are often deprived of the opportunity to make any
decision when they are unable to make some, the notion of partial capacity is
especially important. Many elderly patients have diminished or fluctuating
capacity and can be supported in their exercise of some autonomous decision
making. For example, patients who become confused at the end of the day
(sundowning) can make health care decisions when they are lucid. These
decisions can then be recorded in the patient's medical chart. Patients with short-
term memory loss may still be able to judge the appropriateness of a suggested
intervention, especially if they have shown a long-standing pattern of stable
choices that can be corroborated. If, however, patients must retain current
information to choose among treatment options, then short-term memory loss is
relevant (eg, if memory is needed for compliance with certain rehabilitation
regimens, then it is relevant).

A patient's autonomous right to make health care decisions may be


compromised by a physician's finding that the patient lacks capacity. The patient
may therefore be at risk of disempowerment, especially in acute care settings. In
this setting, the effects of illness, drugs, or postsurgical delirium can exclude
patients from discussions about care plans. In addition, hospitalization, which
may scare, confuse, or intimidate the patient, can compound common problems
of aging (eg, loss of hearing or sight). For the already incapacitated patient,
hospitalization may precipitate a crisis for which surrogates must be identified,
hastily assembled, informed of choices, and helped to sort through care options
preferred by or in the best interest of the patient.

The burden of making decisions for an incapacitated patient falls heavily


on both family and care providers. Therefore, whenever possible, health care
professionals should discuss treatment options and preferences while the patient
still is capable of making and communicating informed choices. These expressed
preferences should be recorded in the patient's medical chart and documented in
an advance directive.

Competence
A legal designation that recognizes that persons beyond a certain age
generally have the cognitive ability to negotiate certain legal tasks, such as
entering into a contract or making a will.

In most states, persons are declared competent at age 18, at which time
they can vote, sign binding contracts, and otherwise make legally binding
decisions about their lives. The concept of generic competence reflects a societal
determination to include or exclude certain persons from full participation and
therefore does not reflect a focused assessment of the abilities or disabilities of
an individual.

The concept of competence, however, raises the possibility of


incompetence(ie, the judgment that a lack of certain abilities limits a person's
legal rights). Incompetence can only be decided by a court of law.
Before the 1990s, a person could be deemed incompetent by virtue of
belonging to a particular category (eg, the elderly, the mentally ill, the physically
addicted). However, most states have since revised the statutes that determine
incompetency and now require a functional assessment of the person's abilities
and disabilities. This focused review becomes the basis from which a court crafts
orders tailored to meet the person's functional deficits and demonstrated needs.

All adult patients who are not mentally retarded or who have not been
declared incompetent by a court have the same legal rights. Elderly patients,
however, are at greater risk of having their legal rights abrogated because they
are more likely to be isolated, poor, demented or confused, or institutionalized.
They may be less able to advocate for their beliefs and desires and tend to have
a smaller support network. Health care practitioners, therefore, need to identify
and support the rights and interests of elderly patients and guard against their
being accidentally or deliberately disempowered.

When the court declares a person incompetent or functionally unable to


act in certain areas, it appoints a guardian, who is responsible for making some
legally binding decisions for the incompetent person, or ward. The areas in which
the court has found functional incompetence define the powers given to the
guardian. The elderly may be in jeopardy of inappropriate attempts to appoint a
guardian because a few states still stipulate that old age itself is an acceptable
ground for instituting such actions and for a legal finding of diminished ability.

Informed Consent
A decisionally capable patient's legally binding treatment decision reached
voluntarily and based on information about risks, benefits, and alternative
treatments gained from discussion with a health care practitioner.

Several legal principles form the basis for informed consent. The right of
knowledgeable self-determination and choice obligates the health care
practitioner to inform patients of the risks and benefits of alternative treatments.
The constitutional right to privacy, as well as the concept of personal liberty and
restraints on state interference with independent action and choice, allows
capacitated persons to choose individually appropriate medical care from among
available treatment options.

Self-determination (the concept that "every adult of sound mind has the
right to decide what shall be done with his own body"), or autonomy, is the
foundation of the legal and ethical doctrine of informed consent. When decision
making is preceded by discussion with a health care practitioner who provides
the patient with the information necessary for choosing among options, the
patient's consent or refusal is said to be informed and is ethically valid and legally
binding. All states require that informed consent of the capacitated patient
precede medical intervention. The patient has the legal and ethical right to make
an informed choice, ie, to consent to or refuse care, even if the likely outcome of
the refusal is death. The physician is legally and ethically obligated to promote
this right to all patients, even to those who are unsophisticated or difficult to
inform.

Informed consent arises from discussion between the patient and


physician. The patient asks questions that elicit relevant information, and the
physician shares facts and insights along with support and advice. Treatment
decisions belong to the patient or surrogate, but the physician has a
responsibility to offer guidance.

The process of informed consent may be more arduous for elderly


patients than for younger patients because of age-related conditions, such as
sensory deficits or impaired cognition. For example, many elderly patients who
cannot understand or evaluate alternatives are treated as if they can because
they nod in agreement or do not actively question a proposed intervention. Such
consent is rarely valid but is rarely questioned. Conversely, patients with hearing
deficits are difficult to reach in conversations and thus are sometimes bypassed
in the decision-making process. In addition, patients may be overly influenced by
family members, by the process of "learned helplessness" during
institutionalization (a special problem in long-term care facilities), or by the
physician.

One way to augment the patient's voice is to allow sufficient time for
discussion of preferences. Another is to talk with the patient alone, although
many elderly patients, out of dependence or suspicion, request that a family
member be present. If the patient exercises autonomy by delegating decisional
authority, then that decision should be respected. For example, if the patient says
in response to questions, "Do whatever my daughter wants," then the physician
should consult the daughter. Even so, the physician should periodically attempt
to inform the patient and include him in discussions.

The right of informed consent carries the implicit right of informed


refusal. A decision to refuse treatment--even if seemingly senseless--does not
mean that the patient is incompetent or insane. The most common reasons for a
patient's refusal of care are misunderstanding and miscommunication between
the physician and patient. The first sign of reluctance, therefore, should not be
taken as a final refusal of care; rather, an initial refusal that seems contrary to the
patient's best interest is reason to continue rather than conclude the discussion.
Physicians are ethically bound to encourage acceptance of the therapeutic
recommendation judged to be in the patient's best interest, and most patients'
refusals are reversed with attention, extended discussion, and even some
cajoling. Advocacy, however, even in the patient's best interest, must stop short
of coercion, duplicity, or deceit. Almost never does a court order intervention over
a capable patient's clear and consistent refusal.

A patient's refusal of treatment does not constitute attempted suicide, nor


does a physician's compliance with a capacitated patient's decision to refuse or
reject life-sustaining treatment constitute physician-assisted suicide. Rather, the
subsequent death is considered to result from the underlying disease process
rather than from an affirmative action causing death. The patient's right to choose
almost always supersedes the physician's responsibility to provide customary
and indicated medical care.

Intractable conflicts between physicians and patients about appropriate


treatment are relatively rare and should be approached first as events to be
negotiated or mediated. If these actions fail, the physician may need to help the
patient find a new physician and then withdraw from the case. A new physician
with a different philosophy, personal ethic, and temperament may be able to
relate more easily to the patient.

In some states, an exception to the informed consent process, called


therapeutic privilege, allows a physician to withhold information when, in the
physician's judgment, the patient would suffer direct and immediate harm as a
result of the disclosure. This doctrine is rarely used, however; mere upset or
even anguish over grim news does not qualify. When the doctrine is used, the
physician should frequently reevaluate the patient's state of mind to ensure that
disclosure is made as soon as the danger of serious adverse effects has abated
sufficiently.

Confidentiality and Disclosure


Ethical oaths and specific statutes protect the confidentiality of
physician-patient communication, an ethical and legal bedrock of the therapeutic
relationship. Even well-meaning family involvement without the patient's consent
violates the patient's right of confidentiality. Protection of private patient
information is essential to encouraging patient candor in revealing symptoms and
behaviors relevant to diagnosis and treatment. Protection of a patient's secrets,
private thoughts, and feelings is also required by decency.

Patient utterances are also protected by the doctrine of privilege, which


grants patients the right to exclude otherwise relevant and admissible testimony
in a court of law. This privilege can be invoked only by the patient. Additionally,
most states have professional licensing statutes that incorporate the ethical and
legal confidentiality mandates and make them a clear part of professional
practice. All patients are entitled to confidentiality unless they give permission for
disclosure or they clearly can no longer express a preference (eg, a severely
confused, comatose, or decisionally incapacitated patient). Even in these cases,
secrets should be guarded, although decisions about care may require
discussion with appropriate surrogates. When a patient can no longer make
health care decisions, prior expressed preferences should be respected
whenever possible.

Advance Directives
Legal statements that allow persons to articulate values and establish
treatment preferences to be honored in the future when capacity has lapsed.

All states have laws permitting and governing advance directives, but
there is variability in some of the details, and some states have special rules for
certain interventions. New York, for example, requires that the patient specifically
address the issue of artificially administered food and fluid if the surrogate is to
be able to refuse this care.

The Patient Self-Determination Act of 1990 requires that all patients


entering federally funded hospitals, nursing homes, or home health care
agencies be afforded the opportunity to execute an advance directive if none
exists. In most states, the legal requirements are so simple that an attorney's
services are unnecessary. Ideally, the directives should be in writing and signed
by the patient. Out-of-hospital advance directive forms are available in many
communities. The two types of advance directives are living wills and health care
proxy appointments, also called a durable power of attorney for health care
decision making.

Living Wills
A living will lists the interventions the patient would request, accept, or
reject in the future, usually at the end of life. Physicians often have difficulty
accepting a patient's choice to abandon aggressive care and permit death.

Most patients use living wills to refuse life-sustaining care when the
prognosis for improvement or recovery is hopeless and the ability to relate to
others is severely diminished or destroyed. However, as managed care becomes
more pervasive and as patients become concerned about being denied care,
living wills that request care are becoming more common.

The living will specifies a set of circumstances followed by a set of


consequences (eg, "If I am hopelessly ill and my physicians say that I will not
recover, then..." or "If I am not able to recognize and relate to family and friends
and my physicians say that I will not recover, then..."). The consequences specify
the interventions the patient would or would not want (eg, intubation,
resuscitation, dialysis, surgery, antibiotic therapy). The document usually states
that, despite these specific refusals, all measures necessary for comfort should
be provided. The goal of the most usual type of living will--prospective refusal--is
to ensure that invasive, aggressive, and life-sustaining treatments will not be
used if they would merely prolong the dying process or support a vegetative
state. Some living wills limit their applicability to terminal illness; thus a patient
desiring to refuse care if in a vegetative state or deep coma should not use this
restricted type of living will.
Durable Power of Attorney for Health Care
A durable power of attorney for health care differs from a regular power of
attorney, which addresses decision making concerning financial matters or
property rights (eg, the right to sell a car or manage stocks).

A durable power of attorney for health care, or health care proxy, is a legal
document that allows the patient to appoint a person, called a health care agent
or proxy, to make health care decisions should the patient become temporarily or
permanently incapacitated or be declared legally incompetent. This legal
appointment places a loving, concerned, trusted person in a dialogue with the
physician to reach an appropriate decision. The agent's decisions are guided by
specific instructions from the patient, by notions of substituted judgment (what
the patient would likely want under the circumstances), and by the concept of
best interest. The agent can discuss the patient's diagnosis, prognosis, treatment
alternatives, and likely outcomes with the physician, respond to the patient's
changing condition, and base a decision on current circumstances in light of
known patient preferences and values.

Prior discussions between patient and agent provide the agent with a
richer understanding of the patient's values and preferences, allowing more
nuanced decisions to be made later. This opportunity for dialogue generally
results in a better decision than could have been reached by following the static
directives in a living will.

Surrogate Decision Making


A surrogate is a statutorily designated health care decider or an informally
identified person, such as a close family member or friend. The more informal the
appointment, the less likely the surrogate will be able to refuse life-sustaining
treatment, especially in states with very restrictive laws. If the patient is
incapacitated and no advance directive exists, some other person or persons
must provide the direction (either a loved one or the medical staff).

Most hospitals and physicians accept consent to provide care from a


spouse, an adult child, a close friend, a clergy member, or even a distant and
uninvolved relative, although in most states, none of these persons is legally
empowered to consent on a patient's behalf without being appointed by a court.
However, accepting the judgment of a close relative or friend over that of a
distant relative or total stranger makes practical and ethical sense. Thus, a
decision agreed on by hospital, physician, and family almost always constitutes
the basis for providing care, although it may not be legally adequate if
challenged.

Elderly patients without family or close friends may receive a court-


appointed guardian, who is often disinterested and serves a perfunctory role.
Some institutions and jurisdictions are experimenting with the appointment of
public guardians and patient advocates, which may prove appropriate and cost-
effective.

When surrogates attempt to refuse treatment by deciding to withhold or


withdraw interventions (an often articulated distinction without any substantial
legal or ethical difference), legal concerns increase because of the possibility of
death. The initial questions in these circumstances are (1) Who decides? (2) On
what basis is the decision made? and (3) What possibilities exist for appeal and
review? Answers vary widely among the states. In New Jersey hospitals, for
example, if an ethics or prognosis committee determines that the prognosis is
hopeless (and, in the case of elderly residents in long-term care, the state Office
of the Ombudsman determines that the decision does not constitute abuse), a
specially appointed guardian may opt to withhold treatment. Conversely, in New
York, surrogates who have not been appointed by the patient have very limited
ability to withhold care unless the patient has addressed a similar circumstance
when capacitated and has left explicit instructions to be followed. The problem is
that these practices assume that continued existence is the desired state. Under
certain circumstances, however, permitting death is not incompatible with a
patient's best interest nor with the state's usual interest in preserving life.

Unless there is a durable power of attorney for health care, the choice of a
surrogate may be unclear. Once identified, the surrogate bases a decision on
one of three standards, in the following hierarchy:

• Explicit directive, ie, the instructions expressed by the patient when


capacitated
• Substituted judgment, ie, inferences about what the patient would likely
want in this situation based on what is known about his prior behavior
and decision making
• Best interest, ie, what the surrogate and health care team believe is
best for the patient

Explicit directive, the first standard, is usually determined by a written


document (eg, a living will) but can also be fulfilled by discussions with the
patient as reported by the surrogate or others, particularly by close family
members. Statements to health care practitioners, especially when documented
in the medical chart, can also be important in determining the patient's
preferences.
Substituted judgment, used when no explicit directives exist, poses
various questions to try to discern what the patient would have wanted. What sort
of person was this patient when capacitated? What was his lifestyle and pattern
of decision making? What did he find rewarding or unacceptable? How did he
evaluate the quality of life and define a meaningful existence? How did he feel
about diminished capacity, dependence, and confinement?

Finally, best interest is resorted to when the patient's history, wishes, and
values are unknown. This judgment is informed by the clinical evaluations of the
health care team about prognosis and the likely outcome of treatment, some
notion of what a reasonable person in the patient's situation would want, and an
evaluation of the benefits and burdens of care in maximizing the patient's comfort
and function. Especially when making decisions based on substituted judgment
and best interest, the surrogate must not confuse the patient's perspective of
quality of life with some arbitrary judgment about the value of the patient's life to
others.

In making life-or-death decisions for the incapacitated patient, the proxy or


surrogate may feel unsupported or even abandoned by the physician or by family
members. Making decisions for another, especially life or death ones, can be
anguishing. Ideally, the physician's responsibility of informing and supporting the
patient would be transferred to the surrogate. However, the physician-surrogate
relationship is sometimes strained, due in part to the physician's notion that
family members cause trouble after the patient has died, the complexity and
fragmentation of care, and the physician's discomfort with decisions that refuse
care and permit death. Even when one member of a family is chosen by the
patient to be the legally appointed proxy, the family dynamic has an independent
existence. If a parent has appointed one child, that person must still relate to the
others in the family and circle of friends. Family dynamics among siblings and
between generations may be played out in the context of old grievances and
present fears and may require support to resolve conflicts.

Tensions and disagreements between and among physicians, nursing


staff, surrogate, and family members may be managed and resolved through
mediation leading to consensus. The mediator, a bioethics consultant or ethics
committee member, informs the surrogate and family of their options, empowers
the surrogate to question the health care team's judgment, and ensures that all
parties are heard. Once a consensus on the best plan of care is reached,
especially if that consensus leads to withdrawing or withholding care, the
mediator ensures that everyone is as comfortable as possible with the plan and
that the plan is carried out according to the agreement. Finally, the mediator
follows up to ensure that the family is comfortable with the outcome and that
health care practitioners can use this experience in future cases.
In mediation of bioethical disputes, the process is as important as the
ultimate decision. The way in which issues are explored and the fact that the
health care team and family members reach a consensus are enormously helpful
to everyone involved. As conflict is resolved, the surrogate feels more
comfortable with his decision.

Do-Not-Resuscitate Orders
A statement in the medical record that cardiopulmonary resuscitation will
not be performed.

The do-not-resuscitate (DNR) order, which averts CPR in cases of


cardiopulmonary arrest, has been particularly useful in preventing unnecessary
and unwanted invasive intervention at the end of life. Currently, resuscitation is
attempted except in cases in which it would not be effective or that are not in
accordance with the desires or best interests of the patient. This default position
evolved slowly over recent decades. There is a question of whether the decision
to issue the order not to resuscitate belongs to the physician or patient. The New
York statute, for example, permits the patient or surrogate to choose
resuscitation even if health care practitioners believe it will result in extremely
poor subsequent quality of life. Conversely, interpretation by the New York State
Department of Health provides for physicians to write a DNR order over patient
or family objections in the rare cases of "DNR futility," referring to the very
specific circumstances in which resuscitation would be physiologically ineffective.
However, even if the physician claims futility as a basis for overriding the
patient's or surrogate's decision, the issue must be raised first with the patient or
his guardian. In most other jurisdictions, the policies and procedures related to
DNR orders are somewhat less demanding. Most hospitals, nursing homes, and
home health care agencies have policies for situations in which the likely benefit
of CPR is so slim and the burden on the patient so great that a DNR order is
appropriate. Most institutions require that resuscitation be discussed with the
patient or family, although not that it be raised as a question open for their
decision.

Physicians should discuss the possibility of cardiopulmonary arrest with


patients, describe CPR procedures, and elicit patients' preferences about
interventions. Ideally, discussion takes place in an outpatient setting or early in
hospitalization as part of a discussion of general treatment preferences. Under
these circumstances, patients are more likely to be mentally alert and relaxed,
which helps ensure understanding and thoughtful participation in the decision-
making process. Subsequent periodic discussions can determine if the patient
has changed his mind due to changes in his condition or in treatment
alternatives.
If a patient is incapable of making a decision about CPR, the surrogate
may make the decision based on the patient's previously expressed preferences
or, if such preferences are unknown, in accordance with the patient's best
interests.

No matter who decides, some system should exist for communicating,


recording, and reviewing the decision. There is no widely recognized case in
which a physician or institution was found liable for respecting a DNR order that
was authorized after being discussed with the patient and family and being
recorded in the patient's medical record.

It is essential to clarify that DNR does not mean do not treat. Only CPR
will not be performed. Other treatments (eg, antibiotics, transfusions, dialysis,
ventilatory support) may and should still be provided if indicated. More specific
orders are required to indicate whether the person should be hospitalized,
treated in an intensive care unit, or subjected to other interventions.

Many hospitals and long-term care facilities have policies to guide


decisions about resuscitation. These policies vary widely; some reserve the
decision for the physician, whereas others allow patients or designated
surrogates to decide. Hospital medical staffs should periodically review their
experience with DNR orders, revise their DNR policies as appropriate, and inform
physicians about their role in the decision-making process.

Euthanasia, Assisted Suicide, and Palliation


Euthanasia, an action taken by a health care practitioner intended to
result in a patient's death, is illegal in the USA. Some patients whose life
expectancy is reduced and who are suffering severely request euthanasia.
Traditionally, euthanasia has been forbidden in medical practice, and purposeful
intervention to end life disturbs most physicians and patients. However, in certain
clinical situations involving hopelessness and suffering, death is the end of pain,
not of meaningful life.

Assisted suicide, an action taken by a patient intended to cause his own


death with drugs supplied by a physician, is illegal in all states except Oregon.
Physicians can provide treatment intended to minimize physical and emotional
suffering, even if a secondary result is the shortening of life, but they cannot
specifically intend to hasten death.

The issue of palliation, or pain relief, is inextricable from that of assisted


suicide for two reasons: (1) many dying patients have unrelieved pain or other
intolerable symptoms, and (2) most patients requesting assisted suicide do not
want to die; they just want the suffering to stop. The U.S. Supreme Court has
emphasized the relevance and importance of the doctrine of double effect,
which states that an intervention intended to relieve pain but that incidentally
hastens death is still appropriate. If the physician's goal is to relieve suffering,
then the action is protected.

Discharge and Placement


Physicians and family members routinely make decisions about discharge
and placement without adequately consulting the patient and often over the
patient's objections. Just as capacitated patients have the right to consent to or
refuse treatment, they also have the right to choose their living arrangements and
outpatient care. This right, however, is not as tied to the singular interests of the
patient as are the rights of informed consent and refusal of treatment. The legal,
financial, practical, and quality-of-life interests of family and neighbors as well as
of the patient may be affected and even compromised by the patient's return
home.

Despite the family members' best efforts, they may be unable to meet the
safety or health care needs of the elderly person. Whereas the patient's decision
to consent to or refuse care is determined by patient autonomy, the decision to
accept or refuse care is governed by the notion of accommodation, ie, the rights
and interests of others may be directly affected by the patient's discharge choice.
For example, a patient wishing to live with his daughter may not be able to do so
if the daughter has other demands on her time and energy.

Even if residing with family or residing alone poses a greater risk than
living in a long-term care facility, the patient has the right to choose either.
Decisionally capacitated patients can assume the risks of discharge options.
Many elderly persons choose to return home even when health care practitioners
believe that residential treatment is medically and socially preferable. Some
patients even choose to return home when the possible result is death. If the
patient is decisionally capacitated and appreciates and accepts the
consequences, this choice can be legally and ethically supportable. A
decisionally capacitated patient cannot be placed in a residential facility over his
objection without a court order. Overriding a patient's discharge preferences may
require petitioning the court for a general or a limited guardianship.

Discharge and Placement


Physicians and family members routinely make decisions about discharge
and placement without adequately consulting the patient and often over the
patient's objections. Just as capacitated patients have the right to consent to or
refuse treatment, they also have the right to choose their living arrangements and
outpatient care. This right, however, is not as tied to the singular interests of the
patient as are the rights of informed consent and refusal of treatment. The legal,
financial, practical, and quality-of-life interests of family and neighbors as well as
of the patient may be affected and even compromised by the patient's return
home.

Despite the family members' best efforts, they may be unable to meet the
safety or health care needs of the elderly person. Whereas the patient's decision
to consent to or refuse care is determined by patient autonomy, the decision to
accept or refuse care is governed by the notion of accommodation, ie, the rights
and interests of others may be directly affected by the patient's discharge choice.
For example, a patient wishing to live with his daughter may not be able to do so
if the daughter has other demands on her time and energy.

Even if residing with family or residing alone poses a greater risk than
living in a long-term care facility, the patient has the right to choose either.
Decisionally capacitated patients can assume the risks of discharge options.
Many elderly persons choose to return home even when health care practitioners
believe that residential treatment is medically and socially preferable. Some
patients even choose to return home when the possible result is death. If the
patient is decisionally capacitated and appreciates and accepts the
consequences, this choice can be legally and ethically supportable. A
decisionally capacitated patient cannot be placed in a residential facility over his
objection without a court order. Overriding a patient's discharge preferences may
require petitioning the court for a general or a limited guardianship.

G. Spirituality

With the high prevalence of physical and mental health conditions that beg
for the attention of nurses who work with older adults, spiritual needs are often
overlooked in geriatric care. Yet more than any other time in life, the relationship
between spirituality and the general state of health and well-being is greatest in
advanced years.

When the body no longer functions as it did when it was younger, when
taking medications and addressing other care needs becomes a pervasive daily
routine, and when the feeling prevails that one is viewed as a Model T in a
NASCAR society, the essence of being---the spirit---can provide a safe haven.
Even for the senior who is blessed with fine health and has been afforded and
taken advantage of opportunities to be fully engaged in society, reflection on the
purpose and value of life becomes significantly more common and acute than
was often apparent during the younger years when one’s doing often masked the
importance of one’s being.

Developmental Tasks
For some time, it has been recognized that psychological growth
continues into old age. Erik Erikson (1950) was among the earliest psychologists
to consider generational cycles and the mapping of a sequence of stages
through which individuals progress over the life cycle. The eighth and final stage
of the model he offered was Integrity vs. Despair. Erikson described ego integrity
as the acceptance of one’s life as something that had to be, inclusive of joys and
sufferings, accomplishments and failures.

Robert Peck refined Erikson’s description of the last stage of life by


discussing the specific challenges older people faced that influenced their ability
to achieve ego integrity. He offered these as (Peck, 1968):
• Ego differentiation vs. role preoccupation: to develop satisfaction from the
essence of who one is rather than through parental or occupational roles
• Body transcendence vs. body preoccupation: to find psychological pleasures
rather than become defined and limited by physical limitations imposed by aging
or illness
• Ego transcendence vs. ego preoccupation: to achieve satisfaction by reflecting
on one’s past life rather than to be absorbed and discouraged with the limited
numbers of years remaining
Robert Butler and Myrna Lewis (1982), among their contributions to gerontology,
built on previous theorists’ descriptions as they summarized major late life tasks
as:
• Adjusting to one’s infirmities
• Developing a sense of satisfaction with the life that has been lived
• Preparing for death

Most of these developmental tasks considered an integration process that


required reflection on one’s circumstances within the world as it has been.
Consideration of looking forward, redefining reality, and seeing a “self” separate
from the physical body was introduced with the theory of gerotranscendence.

Gerotranscendence suggests that there is a shift from a materialistic and


pragmatic view of the world to a more cosmic and transcendent vision (Tornstam,
1994). Engaging in affairs of more significance and establishing meaningful
connections with others become more significant than accumulating material
possessions and wealth, engaging in superficial relationships, and being
absorbed with self-interests.

Religion and Spirituality


Before launching into a discussion of spirituality and spiritual needs, it will
do well to differentiate spirituality from religion. Spirituality is the essence of our
being that transcends us as individuals and connects us to God or other higher
power (hereafter referred to as Spirit) and other living organisms. The nature of
spirituality is like the air we breathe: unseen, pervasive, boundless, and essential
to life. Religion is a structure of symbols and rules created by humans with which
we choose to identify and whose rituals we practice. There are a variety of
religions that can be adopted, each with its own specific set of beliefs and
practices.

When the holistic model of unified body, mind, and spirit is considered, it is
easy to see that Spirit is an integral part of each human being. A specific religion
may be selected as an expression of one’s spirituality; however, spirituality exists
with or without adherence to the doctrines and practices of a religion. Spirituality
provides the means for older adults to transcend the changes and limitations that
may be present to realize the worth, joy, and meaning of their lives. A connection
with Spirit affords people an important place in the universe as they view
themselves in relationship with other human beings, nature, and the
environment. Peace and comfort can be gained through the assurance that Spirit
enhances individuals’ own strengths to face suffering and hardship. Courage and
empowerment abound when people feel that their journey has purpose and is not
being made alone.

Major Religions :
Buddhism
Christian
Protestant
• Assemblies of God (Pentecostal)
• Baptist
• Christian Church (Disciples of Christ)
• Church of the Brethren
• Church of the Nazarene
• Episcopal (Anglican)
• Lutheran
• Mennonite
• Methodist
• Presbyterian
• Quaker (Friends)
• Salvation Army
• Seventh-Day Adventist
Roman Catholic
Eastern Orthodox
Other Christian Religions
• Christian Science
• Jehovah’s Witnesses
• Mormons (Church of Jesus Christ of Latter Day Saints)
Hinduism
Islam (Muslim)
Judaism
• Orthodox
• Conservative
• Reform
Other
• Baha’i
• Nation of Islam
• Scientology
• Shinto
• Taoism
• Unitarian Universalist
• Zoroastrianism

Faith and Health


There was a time when many health professionals believed the benefits of
supporting a patient’s faith rested in the comfort it brought the patient and the
respect it showed for the individual’s religious preferences. However, increasing
evidence supports that the beneficial impact of religious commitment and
practices on health and healing goes beyond the placebo effect.

Religious commitment and prayer have shown to improve health care


outcomes, reduce complications, decrease the risk of psychopathology, and
enhance the elderly’s functional ability
Possible Components of Prayer

• Expressing gratitude
• Praising attributes of God/Spirit
• Confessing
• Petitioning
• Intercessing
• Listening for guidance, answers

Spiritual Needs
Regardless of age, people have basic spiritual needs that include love,
meaning and purpose, hope, dignity, forgiveness, gratitude, transcendence, and
the expression of faith (Eliopoulos, 2005). In fact, some of these needs may take
on greater significance for older adults in light of the growing risk and prevalence
of chronic conditions and the heightened awareness of the finiteness of life.

Love
Of all spiritual needs, the exchange of love is perhaps the most significant.
This is hardly surprising when we consider that humans are relational beings.
People normally value being cared about and valued by others, and having
others for whom they can care.
Love, from a spiritual perspective, is unconditional, reliable, and genuine.
It does not depend on what one looks like or can offer. Instead, it is a deep
feeling that rests on appreciation of the person within… a heart to heart to
connection.

In the changing world of the elder individual, multiple losses are faced:
loved ones, personal health and function, financial security, home, roles. The
exchange of love fills in the void left by losses and gives reason to face another
day. Love is healing at many levels; conversely, the lack of love can interfere with
optimal health and well being, as is profoundly witnessed in the Failure to Thrive
Syndrome.

Meaning and Purpose


To accept that everything served a purpose helps the elderly realize that
their lives were not lived in vain. Although they may not have achieved the fame
and fortune that they once dreamed of, they can appreciate that their lives made
a difference, be it through supporting and raising a family or making something a
little better than it was before their involvement.

Hope
Hope is the expectation that something will happen in the future. It is not
merely the desire for something to happen, but rather, the belief that it actually
will. That “something” can range from having ample provisions to keeping a roof
over one’s head to finding a treatment that will control a disease to having eternal
life. Hope is derived from a relationship with Spirit that is not limited by the
constraints of this world, but for whom all things are possible.

The elder with hope sees life as an unfolding of new experiences. Life is
dynamic, not static. Lost roles and relationships can be replaced by new ones. In
the presence of pain and suffering, hope for relief and a better tomorrow can
motivate a person to face a new day and continue engaging in life.

Dignity
It is natural for people to want to be valued and respected, and although
this need is not diminished with age, it can become more of a challenge. In our
society, older adults have a risk of having stereotypes applied to them on the
basis of their age. This is apparent in statements such as “most old people are in
nursing homes,” “people lose interest in sex as they grow old,” and “older
workers aren’t as productive as younger workers.” These views can result in
prejudicial treatment of elderly individuals, a process that a few decades ago was
given the label ageism (Butler, Lewis, and Sutherland, 1991). Ageism erodes the
self-worth of older adults.
A relationship with Spirit offers a means to preserve dignity in light of
societal ageism. God and many other higher powers value the intrinsic worth of
every human being regardless of age or other characteristic.

Forgiveness
Humans are imperfect beings and will err. With the volume of interactions
that people typically experience by the time they reach old age, being the
perpetrator and recipient of wrongs is hardly uncommon. Carrying resentment
and grudges for these wrongs is a significant burden that can deplete emotional
resources. Forgiveness is crucial to peace of mind and healing. This implies not
only forgiveness of others, but also, forgiveness of self.

Gratitude
It tends to be common for people to take the blessings in their lives for
granted. Many people forget to appreciate the profound gifts of good health,
shelter, independence, freedom, and opportunities. Instead, there is the
temptation to be resentful for what one doesn’t have. Good health is ignored as
people complain of having wrinkles and fat thighs. A comfortable home is
minimized by resentment that there isn’t a pool in the backyard. The good
fortunate at having a child who is healthy and happy is overlooked by criticisms
that the child didn’t make straight A’s. An attitude of thankfulness nourishes the
spirit and, in turn, heightens spiritual awareness so that gratitude can be felt for
the ordinary.

Transcendence
Some of the mystery of life can be accepted when people feel there is a
reality beyond their own physical beings. The connection to Spirit offers a source
of strength that is unable to be realized independently. Difficult and confusing
circumstances can be understood as serving a purpose in a larger plan, guided
by the hands of a higher, wiser power.

Expression of Faith
It is important for people of faith to express that faith in the manner they
desire. For many people, this encompasses prayer, which can take many forms
(Display 2). Prayer can be individual or communal, silent or spoken, at specific
times or whenever the mood strikes, conversational with Spirit or a recitation of
scripture verse.

Some people may quietly kneel or sit with head bowed, while others may
walk or sing.
In addition to prayer, faith is expressed through worship, scripture reading,
celebration of specific holy days, and the practice of rituals (e.g., lighting candles,
fasting).
Assessing Spiritual Needs
The complexity, diversity, and individual meaning of spirituality limit the
usefulness of objective assessment tools in identifying spiritual needs. Open-
ended questions, life review, and intentionality are beneficial approaches for
exploring spiritual needs.

Spiritual needs can be revealed with the use of questions that open the
door for sharing and discussion.
With a keen ear for what is implied and omitted, the nurse needs to use
responses to these questions as guides for additional inquiry.
In gerontological nursing, the value of life review has been recognized and
discussed for some time (Butler and Lewis, 1982; Webster and Haight, 2002).
This therapeutic reflection on one’s life aids the elder in interpreting and refining
past experiences as they relate to self-concept and life purpose. Life review can
be facilitated through a variety of strategies, including:

• Discussions: introduce a specific topic such as World War II, immigration to


America, differences in raising children when they were parents vs. now, career
(old magazines, music, and films can be used also)
• Oral history: ask the elder to share the story of his or her life from earliest
memories to the present
• Book of life: suggest that the older person imagine that he or she is writing an
autobiography and to create chapter titles that indicate highlights of life
• Time line: draw a time line that begins with the decade of birth and ask the
person to share significant events and memories from each decade of life.

The nurse may be able to identify certain themes or feelings that arise
during the life review. For example, the elder may share the multiple burdens he
faced throughout life and his ability to carry them. This could open a discussion
of what the person believes helped him get through those times. Current
challenges, losses, and impending death can be better tolerated when put in
perspective of one’s total life. Intentionality is clear, focused thinking that exceeds
merely feeling kindly toward another person. The nurse makes a planned effort to
connect with the person in a healing relationship. The difference between a nurse
assessing with intentionality versus collecting data for an assessment tool is
similar to a friend listening to your story verses a bank manager asking you the
questions on a loan application. It entails attentive listening and encouraging
sharing of stories. Often, it requires the nurse to silently be with the person---
perhaps massaging shoulders, holding a hand, or sitting alongside---as those
individual journeys through the labyrinth of feelings and memories. The important
work of unfolding one’s soul cannot be rushed.

Questions Useful in Spiritual Assessment


• Is there a faith or religion that you believe in? If so, describe how you practice
this.
• Do you believe in God or a higher power? Describe what this means to you.
• Do you pray? What is the nature of your prayers? How are your prayers
answered?
• What gives your life meaning and purpose?
• Could you describe what or who is your source of strength or support?
• What brings you joy?
• Do you have peace? How is this reflected in your life?
• In looking back on your life, what has been most meaningful?
• What is your source of love?
• Who are the recipients of your love?
• Ho do you feel connected to other people?
• Is there anyone, including yourself, who you have not been able to forgive? If
so, please describe this.
• Do you have any regrets? If so, please tell me about them.
• How has aging affected your outlook on life?
• What do you desire for the future?

Care of the Spirit

Preparing self
Perhaps it is possible to effectively administer a medication or change a
dressing without connecting to all facets of the person---body, mind, and spirit---
however, spiritual care demands heart to heart connections that rest on the nurse
entering the dance of the person’s life. And just as the graceful dancer prepares
before taking a partner’s hand, the nurse prepares prior to engaging with the
person.

The nurse’s own spiritual practices contribute to a wholeness that enables


him or her to engage with intentionality and connect with others. These spiritual
practices, like those of clients, can vary and include prayer, meditation, scripture
reading, and planned periods of solitude, drumming, chanting, and worship. It is
tempting for some nurses to omit such practices from their regular schedules due
to the demands of more concrete needs; however, this eventually will impact
optimal whole-person health and well-being. The ability to center, focus, cope,
and be fully available is significantly affected by spiritual self-care.

The availability to connect with another person’s heart and spirit begins
before physical contact is made by the nurse shifting focus to the individual.
Before entering the person’s room, the nurse can take a deep breath and think
about the individual. Affirmations such as I am here to serve this person and this
person will have my undivided attention can be useful. Associating deep
breathing and focusing shifts to the act of hand washing between clients can help
to make physical, mental, and spiritual preparation for the next care encounter a
routine.

Supporting faith practices


The assessment should provide an understanding of the way faith is
expressed in the person’s life. The individual’s beliefs and practices are more
significant than mere knowledge of religious orientation as people of similar faith
may engage in vastly different activities.

Nurses should assure that a person’s desire for a special diet, prayer
times, dress style, and restrictions to activities are incorporated into the care plan
and respected. The person’s desire for visits from clergy or other members of his
or her faith community should be facilitated.

Noise, interruptions, clutter, and odors are among the features in many
hospital and long-term care facility rooms that can affect a person’s ability to
engage in spiritual practices. Nurses can assist a person in creating a “sacred
space” within these settings by establishing a personal private time for the
person and assuring that during that period the room is fresh, Bibles or other
desired materials are available, and privacy is afforded. Appropriate music and
aromatherapy with relaxing scents can assist in creating the right atmosphere.

Seeking hope and meaning in difficult situations


Changes in appearance and function… retirement… reductions in income…
losses of loved ones… threatened independence… ageism…. There are many
circumstances in late life that threaten the well-being of the body, mind, and
spirit. Superimposed on this is the reality that in most circumstances when
nurses encounter older adults, it is in situations in which they are receiving
services due to a health condition. Some older adults may be discouraged that
on top of all other challenges, they have to deal with a disease, or they may
question why they are suffering when they have tried to be a good person. They
may be angry with God or feel that God has abandoned them.

Nurses need to encourage the expression of feelings and maintain an open,


nonjudgmental attitude. Statements such as “it isn’t all that bad,” “you’re better off
than many people,” and “God wouldn’t send you more than you can handle”
serve little purpose and can heighten the distress that is felt. Instead, nurses can
listen and allow feelings to be vented. Realistic hope can be offered. For
instance, telling someone with terminal cancer that they shouldn’t think about
their illness of limited benefit, whereas it would be helpful to assure them that
their pain will be managed so that they can enjoy their final days.

Listening is important as individuals process the reality of their life


circumstances. Attentive listening is fostered by the nurse allocating time and
space when the person can talk. Interruptions and distractions must be controlled
as much as possible. Even if it is only for five minutes, the person should have
the nurse’s undivided attention during that time. It is important for the nurse to
establish a comfortable psychological space in which any feeling can be
communicated and to be sensitive to verbal and nonverbal cues. The nurse
needn’t feel pressured to structure or control the conversation but rather, to allow
it to flow. There is no need to fill silent periods; considerable communication can
occur without a word being spoken. Offering the gift of unconditional listening
demonstrates appreciation of the person as a spiritual being.

Addressing spiritual distress


When there is a disruption in the relationship individuals have with Spirit or
their spiritual needs are not satisfied, they are in a state of spiritual distress.
Factors that contribute to this state include new or worsened illness, losses,
inability to engage in religious or spiritual practices, caregiver stress, and feelings
that their current problems are the result of sin or inadequate faith.

Signs of spiritual distress could include:


• crying
• depression, withdrawal
• expression of hopelessness, powerlessness
• sarcasm, cynicism
• noncompliance with care
• suicidal thoughts or plans
• physical symptoms: poor appetite, sleep disturbances, fatigue, sighing

Effective communication skills can assist in assessing factors that


contribute to spiritual distress.

Once these factors are identified, specific interventions can be planned;


these interventions could include referral to clergy/spiritual leader, assisting with
participation in religious or spiritual practices (e.g., reading the Bible, affording
periods of solitude), arranging for prayer. A person’s desire not to engage in
religious practices or to reject visits from clergy should be respected, even if this
is out of character for the individual.

Praying with and for


As discussed earlier, prayer can be comforting and therapeutic. It can be
quite powerful for a person who is frightened or suffering to have a caregiver hold
his or her hand and offer a prayer, or to know that someone is offering prayers on
his or her behalf. Nurses who are comfortable doing so should feel free to pray
with and for the people they serve. Conversely, if there are nurses who are not
comfortable offering prayer, they should not feel compelled to do so, but rather,
find a coworker or volunteer who can provide prayers.
Awareness that a spiritual self exists separate from the physical body
enables elders to find meaning, purpose, and satisfaction in the presence of the
illness, losses, and declining function. Helping older individuals to achieve that
awareness and fulfill spiritual needs are essential components of holistic geriatric
nursing care. Caring for the spirit causes nurses to walk on new paths. They
learn to accept the mystery of life that not everything can be explained by
science and reason, and trust that their presence and intention can be as healing
as any prescribed procedure they may perform.

H. Respiration/Circulation
The lungs have two primary functions: to acquire oxygen from the air,
which is required for life, and to remove carbon dioxide from the body. Carbon
dioxide is a byproduct of many of the chemical reactions that sustain life.
During breathing, air enters and exits the lungs. It flows in through
increasingly smaller airways, finally filling tiny sacs called alveoli. Blood circulates
around the alveoli through capillaries (tiny blood vessels). Where the capillaries
and alveoli meet, oxygen crosses into the bloodstream. At the same time, carbon
dioxide crosses from the bloodstream into the alveoli to be exhaled.
The lungs are continuously being exposed to particles in the air, including
smoke, pollen, dust, and microorganisms. Some of these inhaled substances can
cause lung disease if enough is inhaled or if the body is particularly sensitive to
them.

AGING CHANGES
People normally make new alveoli until about age 20. After that, the lungs
begin to lose some of their tissue. The number of alveoli decreases, and there is
a corresponding decrease in lung capillaries. The lungs also become less elastic
(able to expand and contract) due to various factors including the loss of a tissue
protein called elastin.
Changes in the bones and muscles increase the front-to-back size of the
chest. Loss of bone mass in the ribs and spine bones (vertabrae), and mineral
deposits in the rib cartilage, change the curve of the spine. There may be front-
to-back curvature (kyphosis or lordosis) or side-to-side curvature (scoliosis).
The maximal force you can generate when breathing in (inspiration) or
when breathing out (expiration) decreases with age, as the diaphragm and
muscles between the ribs (intercostals) become weaker. The chest is less able to
stretch to breathe, and the pattern of breathing may change slightly to
compensate for this decreased ability to expand the chest.

EFFECT OF CHANGES
Maximum lung function decreases with age. The amount of oxygen
diffusing from the air sacs into the blood decreases. The rate of air flow through
the airways slowly declines after age 30. And the maximal force you can
generate on inspiration and expiration decreases. However, even elderly people
should have adequate lung function to carry out daily activities, because we have
"extra" lung function in our youth. This is why normal people can tolerate surgical
removal of an entire lung and still breathe reasonably well.
An important change for many older people is that the airways close more
readily. The airways tend to collapse when an older person breathes shallowly or
when they're in bed for a prolonged time. Breathing shallowly because of pain,
illness, or surgery causes an increased risk for pneumonia or other lung
problems. As a result, it is important for older people to be out of bed as much as
possible, even when ill or after surgery. When this is not possible, it is helpful to
do "incentive spirometry." This involves blowing into a small device to help keep
the airways open and clear of mucus.
Normally, breathing is controlled by the brain. It receives information from
various parts of the body telling it how much oxygen and carbon dioxide are in
the blood. Low oxygen levels or high carbon dioxide levels trigger an increased
rate and depth of breathing. It is normal for even healthy older people to have a
reduced response to both decreased oxygen and increased carbon dioxide
levels.
The voice box (larynx) also changes with aging. This causes the pitch,
loudness, and quality of the voice to change. The voice may become quieter and
slightly hoarse. The pitch may be decreased (becoming lower) in women and
increased (becoming higher) in men. The voice may sound "weaker," but most
people remain quite capable of effective communication.

I. Hydration/Nutrition
By recognizing a potential problem early, you may save an elder adult
from a debilitating complication. Here's what you need to know.

Whether one works in a hospital, long-term care, or home health care,


you've undoubtedly encountered an elderly patient who's dehydrated or
malnourished. Confusion and disorientation, which aren't normal at any age, may
have been your first clues.

Because dehydration and malnutrition can have such serious


consequences in older patients, make early recognition and treatment a priority.
Use the following information and guidelines to assess for problems and
intervene appropriately.

Why dehydration threatens


Physiologic changes related to aging make an elderly adult especially
prone to dehydration. She has about 10% less body fluid than a younger adult,
so she has less fluid reserve to start with. Because her sense of taste diminishes
with age, food may become unappetizing. Consequently, she may eat less and
use more salt, raising her body's need for water. At the same time, however, her
thirst response can diminish, so she may not recognize the need to drink more.
For these reasons, an elderly adult may become severely dehydrated very
quickly, before she feels thirsty or anyone notices symptoms.

Fever can contribute to dehydration. Because an elderly adult's normal


body temperature may be lower than 98.6deg F (37deg C), a temperature
increase may be undetected at first. Always check the patient's temperature
against her baseline. A temperature of 98deg F (36.7deg C) is a lowgrade fever
for someone whose temperature is normally 97deg F (36.1deg C). Generally, 1
degree of fever increases total body water needs by 10%.

A fever can be a consequence of dehydration as well as a cause: A low-


grade fever develops if the patient doesn't have enough fluid to adequately cool
her body. The result is a downward spiral of dehydration and increasing body
temperature, further raising fluid needs and compounding dehydration.

Signs and symptoms of dehydration include irritability, confusion,


tachycardia, low urine output, dry skin, constipation, fecal impaction, dizziness,
hypotension, infection, bowel blockage, and skin breakdown. If allowed to
continue unchecked, dehydration may lead to falls, stroke, renal failure, and
death.

You can classify patients at highest risk for dehydration into groups based
on underlying cause:
• mechanical impairments, such as mechanical ventilation, which
prevent patients from drinking
• functional impairments, such as coma or paralysis. Also at risk are
patients who are kept N.PO. for tests, especially if the tests are rescheduled
several times.
• physiologic factors, such as medications that increase fluid loss
(diuretics and laxatives) or that inhibit the thirst response or another
mechanism that helps maintain fluid balance. Some enteral and total
parenteral nutrition alter the fluid balance of the intracellular and intravascular
spaces. Draining wounds or fistulas also increase fluid output, raising the
patient's risk of dehydration.
• psychological factors, such as depression, which can cause a loss of
appetite and fluid intake. Elderly patients also may purposefully decrease
their fluid intake to eliminate frequent trips to the bathroom or to control
incontinence.

Looking for problems


Whenever you assess an elderly patient, look for the following signs of
dehydration:
• poor skin turgor on the forehead or sternum-not the hand or arm.
Because of skin changes that occur with aging, skin turgor on the arm
is an unreliable indicator of dehydration.
• sunken eyes
• dry mucous membranes
• irritability
• confusion
• dizziness
• muscle weakness
• acute weight loss of 2 or more pounds (0.9 kg); 2.2 pounds (1 kg)
equals about 1 liter of fluid over a few days
• decreased urine output
• increased heart rate
• orthostatic hypotension
• fever
• unexplained elevations in key lab studies, such as urine specific
gravity, blood urea nitrogen, electrolytes, or hemoglobin values.

Monitor fluid intake and output, weigh the patient daily, and watch for
ominous trends: decreasing intake, increasing output, changes in lab results, and
changes in emotional or mental status. If you suspect dehydration, review her
care plan for anything that may be contributing to a fluid imbalance, such as
N.P.O. status, fluid restrictions, or diuretic use. When, for whatever reason, a
patient can't reach for and hold a glass of water, include ways to encourage fluid
intake in the care plan. For example, set up a schedule for offering fluids.

Know your patient's medications and their potential for adverse effects and
interactions. Be alert to medications, such as diuretics, that can lead to
dehydration.

Finally, educate staff, patients, and family members on the causes and
symptoms of dehydration, what signs and symptoms to watch for, and how to
avoid problems.

Spotting malnutrition
Even if she's eating regularly, an elderly patient is also at higher risk for
malnutrition because of physiologic changes of aging. Nearly 30% of people over
age 65 have a diminished ability to produce stomach acid, which impairs
absorption of many important nutrients, such as folic acid, vitamin B12, iron, and
calcium. A diminished sense of taste and smell make food less appetizing, and
dental problems can make chewing difficult.
As the elderly patient loses weight, she also loses muscle mass and
strength, becoming more frail. Her immune system may become impaired,
opening the door for disease. Continued illness can lead to depression, causing
loss of appetite and further weight loss. Besides hampering the body's ability to
heal, reduced serum albumin levels decrease the number of binding sites
available to protein-binding medications. This puts the patient at risk for toxic
reactions to relatively low doses of some medications.

Some of the signs of malnutrition, such as disorientation, are erroneously


considered normal signs of aging, so consider the degree and the number of
signs you see. The more signs the patient has and the more rapidly they
developed, the higher the probability that she's malnourished. For signs and
symptoms, see Malnutrition's Clues.

Albumin and prealbumin levels can help identify the presence and severity
of malnutrition. If the patient is also dehydrated, these values may appear
elevated. Once she's hydrated, however, plasma protein levels are usually low,
as are hemoglobin and hematocrit. Don't be fooled by normal hemoglobin and
hematocrit levels if serum osmolality indicates a fluid deficit. These values will fall
once she's hydrated.

Lack of vitamin A, though rare, can impair the patient's sense of taste and
smell. Combined with the natural decline in the sense of taste in the elderly, this
could make food taste like sawdust.

ASSESSMENT

Assess for these signs of malnutrition:

• an emaciated appearance or being underweight (defined as 15% to


20% below ideal body weight)
• muscle wasting or loss of subcutaneous fat
• poor coordination
• muscle weakness fatigue
• dry, brittle, or thinning hair or hair loss
• dry skin with poor coloring
• patchy dermatosis
• dry, cracked lips
• swollen red tongue (glossitis)
• reddened, swollen, or receding gums
• poor wound healing
• reduced resistance to infection.
NURSING MANAGEMENT
If your patient is malnourished, obtain a dietary consult and enlist the help
of the entire care team. Along with serum albumin and prealbumin levels, obtain
a calorie count to determine the patient's calorie intake and help plan dietary
interventions. If indicated, have a speech therapist evaluate her ability to swallow
and her aspiration risk.

Frequent, small meals throughout the day may be more appealing to the
patient than three larger ones. Also offer liquid supplements between meals.

If the patient can't eat enough to correct malnutrition, she may require
enteral feedings. Explain your concerns to the patient and her family; if she's
alert, she'll need to consent to enteral tube insertion and feedings. If she can eat,
schedule tube feedings at night and encourage her to eat meals during the day.

J. Elimination

Aging results in both structural and functional changes in the kidney that
effect drug metabolism and kinetics as well as predisposing the patient to fluid
and electrolyte abnormalities.

Between the ages of 40 and 80, the kidney loses approximately 20


percent of its mass, primarily from the cortex. Microscopically there is a reduction
in the number of functional glomeruli, but the size and capacity of the remaining
nephrons increase to partially compensate for this loss. Vascular changes also
occur in the aging kidney, and after the age of 30 years renal blood flow (RBF)
declines progressively at a rate of 10 percent per decade. Most of the decline in
RBF occurs in the cortex with a relative increase in blood flow to the
juxtamedullary region. The glomerular filtration rate (GFR) decreases by
approximately 1 ml/min/year beginning by age 40. However, this decline in GFR
is accompanied by a gradual loss of muscle mass and is rarely associated with
an increase in serum creatinine. Thus, serum creatinine is a poor indicator of
GFR in the elderly patient. Dosing intervals for drugs that are excreted by the
kidney, such as aminoglycoside antibiotics, digoxin and pancuronium need to be
adjusted and drug levels closely monitored.

Under normal circumstances, age has no effect on electrolyte


concentrations or the ability of the individual to maintain normal extracellular fluid
volume. However, the adaptive mechanisms responsible for regulating fluid
balance are impaired in the elderly and the aging kidney has a decreased ability
to dilute and concentrate urine. This problem is compounded by the fact that
older individuals have a decreased thirst perception and fail to increase water
intake when dehydrated. Age also interferes with the kidneys ability to conserve
sodium. The geriatric patient excretes a sodium load more slowly and has a
decreased ability to conserve sodium if dietary sodium is restricted, possibly
predisposing the elderly patient to hemodynamic instability. Thus, fluid and
electrolyte status should be carefully monitored in the elderly patient.

K. Mobility

Gait Disorders
A slowing of gait speed or a deviation in smoothness, symmetry, or
synchrony of body movement.

For the elderly, walking, standing up from a chair, turning, and leaning are
necessary for independent mobility. Gait speed, chair rise time, and the ability to
perform tandem stance (one foot in front of the other) are independent predictors
of the ability to perform instrumental activities of daily living (IADLs)--eg, the
ability to shop, travel, and cook. Gait speed, chair rise time, and balance are also
predictors of the risk of nursing home admission and death.

Walking without assistance requires the effective coordination of adequate


sensation, musculoskeletal and motor control, and attention.

Normal Age-Related Changes in Gait


Gait velocity (the speed of walking) remains stable until about age 70; it
then declines about 15% per decade for usual gait and 20% per decade for
maximal gait. Velocity is lower because elderly people take shorter steps.
Several explanations have been proposed for the shortened step length.

Cadence (the rhythm of walking) does not change with age. Each person
has a preferred cadence, which relates to leg length and usually represents the
most energy-efficient rhythm for individual body structure. Tall people take longer
steps at a slower cadence; short people take shorter steps at a faster cadence.

Double stance (when both feet are on the ground--also referred to as


double support) increases with age--from 18% in young adults to >= 26% in
healthy elderly persons. During double stance, the center of mass is between the
feet, which is a stable position. Increased time in the double stance position
reduces momentum and therefore reduces time for the swing leg to advance and
contributes to short step length. Increased double stance may be needed on
uneven terrain or with impaired balance so that step length is sacrificed for
stability. Elderly persons with a fear of falling increase their double stance time.
Double stance time is a strong predictor of gait velocity and step length.

Walking posture (the body position during walking) changes only slightly
with age. Unless elderly persons have diseases such as osteoporosis with
kyphosis, they walk upright, with no forward lean. They walk with greater anterior
(downward) pelvic rotation, which results in an increase in lumbar lordosis
possibly due to a combination of increased abdominal fat, abdominal muscle
weakness, and tight hip flexor muscles. Elderly persons also walk with about a 5°
greater "toe out," possibly due to a loss of hip internal rotation or to a strategy to
increase lateral stability. Foot clearance in swing is the same in elderly as in
younger persons.

Joint motion changes with age. Ankle plantar flexion is reduced during
the late stage of stance (just before the back foot lifts off), although maximal
ankle dorsiflexion is not reduced. The overall motion of the knee is unchanged.
Hip motion is unchanged in the sagittal plane but in the frontal plane shows
greater adduction. Pelvic motion is reduced in the frontal and transverse planes,
and transverse plane rotation is reduced.

Step length is shorter in the elderly. One explanation is that calf muscles
are weak and cannot produce sufficient plantar flexion. Another is that elderly
persons are reluctant to generate plantar flexion power because of poor balance
and poor control of the center of mass during single stance.

Etiology and Symptoms


In health, the movement of the body is usually symmetrical. Step length,
cadence, torso movement, and ankle, knee, hip, and pelvis motion are equal on
the right and left sides.

Symmetry of motion and timing between left and right sides is often
lost, producing regular asymmetry with unilateral neurologic or musculoskeletal
disorders. Symmetric short step length usually indicates a bilateral problem.
Unpredictable or highly variable gait cadence, step lengths, and stride widths
indicate breakdown of motor control of gait due to a cerebellar or frontal lobe
syndrome.

Pseudoclaudication symptoms--pain, weakness, and numbness with


walking that improves when sitting down--may be caused by spinal stenosis.
Spinal stenosis may be due to pressure or tension on portions of the spinal cord
in the cervical or lumbar region.

Difficulties in initiation of gait may represent isolated gait initiation


failure, evidence of Parkinson's disease, or evidence of frontal or subcortical
disease. The prevalence of parkinsonian signs (bradykinesia and rigidity) is high
in the elderly, increasing sharply after age 75. Once gait is initiated, steps are
continuous, with little variability in the timing of the steps. Freezing, stopping, or
almost stopping usually suggests a cautious gait, a fear of falling, or a frontal gait
disorder.
Gait initiation failure due to high-level sensorimotor (frontal lobe or white
matter) disorder may progress to other abnormalities, including stiff posture with
short steps, retropulsion (falling backward) in stance, weak or poor corrective
responses to perturbations of balance when walking, and a highly variable and
unstable gait pattern. Normal-pressure hydrocephalus should be considered if
cognitive deficits and urinary incontinence are present in combination with high-
level sensorimotor gait disorders. CT or MRI helps determine if lacunar infarcts,
white matter disease, or focal atrophy is present and can help determine if
normal-pressure hydrocephalus should be considered.

Footdrop secondary to anterior tibialis weakness or reduced knee flexion


may cause low foot swing. The cause may be spasticity or lowering of the pelvis
due to muscle weakness of the proximal muscles on the stance side (particularly
gluteus medius).

Short step length is nonspecific and may represent a fear of falling or a


neurologic or musculoskeletal problem. The side with short step length is usually
the healthy side, and the short step is usually due to a problem during the stance
phase of the opposite leg. For example, a patient with a weak or painful left leg
spends less time in single stance on the left leg and develops less power to
move the body forward. A shorter swing time for the right leg and a shorter step
result. The normal right leg propels the left side forward; a normal single stance
duration provides a normal swing time for the left leg, and the forward propulsion
of the body by the hip and ankle results in a longer step for the left leg than for
the right leg.

Irregular and unpredictable trunk instability can be caused by


cerebellar, subcortical, and basal ganglia dysfunction. A consistent or predictable
trunk lean to the side of the stance leg may be a strategy with which to reduce
joint pain due to hip arthritis or, less commonly, knee arthritis (antalgic gait). In a
hemiparetic gait, the trunk may lean to the strong side. In this pattern, the patient
leans to lift the pelvis on the opposite side to permit the limb with spasticity
(inability to flex the knee) to clear the floor during the swing phase.

Deviations from path are strong indicators of motor control deficits. Wide
stride width can be caused by cerebellar disease, if the width is consistent.
Variable stride width suggests poor motor control, which may be due to frontal or
subcortical gait disorders.

Diagnosis
Diagnosis is best approached in four parts:
• Discuss the patient's complaints, fears, and goals related to mobility
• Observe gait with and without an assistive device (if safe)
•Assess all components of gait
•Observe gait again with a knowledge of the patient's gait
components

The goal is to determine as many potential contributing factors to gait


disorders as possible. A performance-oriented assessment tool may be helpful,
as may other tests (eg, a screening cognitive examination for patients with gait
problems due to frontal lobe syndromes).

Clinical examination: Routine assessment can be performed by a


primary care physician; an expert may be needed for complex gait disorders.
Assessment requires a straight hallway without distractions and a stopwatch for
timing. A measuring tape and a T square or ruler with a right angle may be
needed to measure stride length. Measurement of gait kinetics can only be
performed reliably in a few laboratories with advanced computer and video
technology.

The patient should be prepared for the examination--he should be wearing


pants or shorts that reveal the knees. He should be informed that several
observations may be needed and should be allowed to rest if fatigued.

Assistive devices provide stability but also affect gait. Use of walkers often
results in a flexed posture and discontinuous gait, particularly if the walker has no
wheels. If safe to do so, the health care practitioner can instruct the patient to
walk without an assistive device, while remaining close. If a patient uses a cane,
the health care practitioner can walk with the patient on the cane side or take his
arm and walk with him.

Balance is impaired if the patient is unable to perform tandem stance or


single leg stance for >= 5 seconds.

Proximal muscle strength is tested by having the patient get out of a chair
without using his arms.

Gait velocity is measured using a stopwatch. A fixed distance (preferably 6


or 8 meters) is marked. Gait velocity in healthy elderly persons ranges from 1.5
to 1.1 meters/second.

Cadence is measured as steps/minute. Cadence varies with leg length--


from about 90 steps/minute for tall adults (72 inches) to about 125 steps/minute
for short adults (60 inches).

Step length (the distance from one heel strike to the next) can be
measured or observed. Because shorter people take shorter steps and foot size
is directly related to height, the easiest way to gauge step length is to measure or
calculate the patient's foot length; normal step length is three foot lengths. The
following equation calculates average step length in centimeters: 10 × velocity ×
time to take 10 steps. An equivalent calculation is 0.16 × velocity × cadence
(steps/minute).

Step height can be assessed by observing the swing foot; if it touches the
floor, the patient may trip. Some patients with fear of falling or a cautious gait
syndrome will purposefully slide their feet over the floor surface.
Asymmetry or variability of gait rhythm can be detected when the health
care practitioner whispers "dum...dum...dum" to himself with each of the patient's
foot contacts. Some health care practitioners have a better ear than an eye for
rhythm.

Prevention and Treatment


Although no large-scale prospective studies have confirmed the effect of
increasing physical activity on gait and independence, prospective cohort studies
provide convincing evidence that high levels of physical activity help maintain
mobility, even in patients with disease. Walking may be the most important
training to prescribe. The importance of deconditioning and the effects of
inactivity cannot be overstated. A regular walking program of 30 minutes/day is
the best single activity for maintaining mobility. A safe walking course should be
recommended. The patient should be instructed to increase gait speed and
duration over 4 months. Patients using assistive devices need to be trained by
therapists.

Prevention also includes stretching, resistance training, and balance


exercises for joint range of motion, muscle power, and motor control. The
positive psychologic effects are difficult to measure but are probably just as
important.

Although determining why gait is abnormal is important, interventions to


alter gait are not always indicated. A slowed, aesthetically abnormal gait may
enable the elderly person to walk safely and without assistance.

Frail elderly persons with mobility problems achieve modest improvements


with exercise programs. Knee pain lessens in elderly persons with arthritis; gait
may improve with regular walking or resistance exercises.

Resistance exercises, implemented by physical therapists, can improve


strength and gait velocity, especially in frail patients with slowed gait. Two or
three training sessions a week are usually needed; resistance exercises consist
of three sets of 8 to 14 repetitions during each session. The load is increased
every week or two until a plateau of strength is reached.
Leg press machines train all the large muscle groups of the leg and
provide back and pelvic support during lifting. However, these machines are not
always accessible to elderly patients. Chair rises with weight vests or weights
attached to the waist are alternatives. Instructions are required to reduce the risk
of back injury due to excess lumbar lordosis. Step-ups and stair climbing with the
same weights are also useful. Ankle plantar flexion can be performed with the
same weights.

Using knee extension machines or attaching sandbag weights to the ankle


strengthens the quadriceps. The usual starting weight for frail persons is 3 kg.
Resistance for all exercises should be increased every week until the patient
reaches a plateau of strength.

Many patients with balance deficits benefit from balance training. Good
standing posture and static balance are taught first. Patients are then taught to
be aware of the location of pressure on their feet and how the location of
pressure moves with slow leaning. Leans forward, backward (with a wall directly
behind), and to each side are then practiced. The goal is to stand on one leg for
at least 10 seconds.

Dynamic balance training can involve slow movements in single stance,


simple tai chi movements, tandem walking, turns, slow forward lunges, and slow
dance movements. Multicomponent balance training is probably most effective in
improving balance.

Assistive devices can help maintain the patient's mobility and quality of
life. New motor strategies must be learned. Ideally, physical therapists should
prescribe assistive devices.

Canes are particularly helpful for pain caused by knee or hip arthritis.
Canes, especially quad canes, can stabilize the patient. Canes are usually used
on the side opposite the painful or weak leg. Many store-bought canes are too
long. Although a cane can be purchased in a pharmacy, it should be adjusted to
the correct height by cutting a wooden cane or moving the pin settings on an
adjustable one. To achieve maximal support, the patient should flex his elbow 20
to 30° when holding the cane.

Walkers can reduce the force and pain at arthritic joints more than a cane,
assuming adequate arm and shoulder strength. Walkers provide good lateral
stability and moderate protection from forward falls but little or no help preventing
backward falls for patients with balance problems. When prescribing a walker,
the physical therapist should consider the sometimes competing needs of
providing stability and maximizing efficiency (energy efficiency) of walking. Four-
wheeled walkers with larger wheels and brakes maximize gait efficiency but
provide less lateral stability. These walkers have the added advantage of a small
seat to sit on if the patient is fatigued.

Chronic Dizziness and Postural Instability


Dizziness is a vague term describing various sensations, including a
subjective feeling of uncertainty, postural instability, or motion in space. It also
encompasses other sensations (eg, light-headedness, wooziness, near fainting).
The elderly often use the term even more broadly to include weakness, fatigue,
and myriad other symptoms. Dizziness can be classified, somewhat arbitrarily, as
acute (present for < 1 month) or chronic (present for > 1 month). Because the
causes, diagnosis, and treatment of acute dizziness are similar for all adults, this
chapter discusses only chronic dizziness and postural instability. The prevalence
of chronic dizziness among the elderly ranges from 13 to 30%.

Dizziness is divided by history of sensation into five categories: (1)


vertigo: a rotary motion, either of the patient with respect to the environment
(subjective vertigo) or of the environment with respect to the patient (objective
vertigo), the key element being the perception of motion; (2) dysequilibrium
(unsteadiness, imbalance, gait disturbance): a feeling (primarily involving the
trunk and lower extremities rather than the head) that a fall is imminent; (3)
presyncope (faintness, lightheadedness): a feeling that loss of consciousness is
imminent; (4) mixed dizziness: a combination of two or more of the above types;
and (5) nonspecific dizziness: a sensation of instability that does not fit readily
into any of the previous categories.

In the standard clinical approach, dizziness is considered a symptom of


one or more discrete diseases. It is further assumed that the categories of
dizziness correspond to diseases within specific systems (eg, vestibular,
proprioceptive, cardiovascular). These assumptions work well for younger
patients and for patients of all ages with acute dizziness. However, among
elderly patients with chronic dizziness, the relationship between categories and
specific systems or etiologies is less consistent. Using the standard approach,
many elderly patients with chronic dizziness are left undiagnosed (and
untreated), or the diagnoses made by physicians from different specialties are
variable and inconsistent. For these reasons, chronic dizziness might better be
considered a geriatric syndrome--a condition resulting from multiple diseases and
impairments--rather than solely a symptom of discrete diseases.

Etiology and Pathophysiology


Although the reported prevalence for specific causes varies widely, the
most commonly reported discrete disorders causing chronic dizziness include
peripheral vestibular disorders (eg, benign paroxysmal positional vertigo,
neurolabyrinthitis, Meniere's disease); cervical disorders, particularly spondylosis;
cerebrovascular disorders, including vertebrobasilar insufficiency and brain stem
infarcts; carotid hypersensitivity; and psychiatric disorders, particularly
depression and anxiety.

Chronic dizziness and postural instability most often result from the
combined effects of disorders and impairments in the multiple systems
contributing to stability and equilibrium. The sensation of equilibrium requires
input from complex networks of sensory, motor, and central integrative
neurologic systems. These systems are, in turn, influenced by cardiovascular,
respiratory, metabolic, and psychologic factors. Chronic dizziness may occur
when there is overwhelming dysfunction of one system or, probably more often,
when there is impairment or dysfunction within several systems.

The visual, auditory, vestibular, and proprioceptive systems are


responsible for orienting a person in space. These systems interact and can have
multiple interconnections. Age-related visual changes include decreased acuity,
adaptation to darkness, sensitivity to contrast, and accommodation. In addition,
ocular diseases, including macular degeneration, glaucoma, and cataracts, are
common. Hearing contributes directly to stability through detection and
interpretation of auditory stimuli, which help localize and orient a person in space,
especially when other senses are impaired. Decreased hearing is also often a
marker of vestibular dysfunction, which is difficult to test clinically.

The vestibular system contributes to spatial orientation at rest and during


acceleration and deceleration and is responsible for visual fixation during head
and body movements. Age-related decline in vestibular function can be due to
changes in the otoconia (tiny calciferous granules that form part of the receptor
mechanism in the otolith apparatus), perhaps due to osteoporosis or saccular
degeneration. Benign paroxysmal positional vertigo and is thought to result from
changes in the otoconia.

The vestibular nerve, which connects the vestibular system to the central
nervous system (CNS), is particularly sensitive to hypoglycemia and drugs
(aminoglycosides, aspirin, furosemide, quinine, quinidine, and perhaps tobacco
and alcohol). Head trauma, mastoid or ear surgery, and middle ear infections
may also damage the vestibular nerve.

The proprioceptive system (comprised of peripheral nerves, the


mechanoreceptors located in apophyseal joints, the posterior columns in the
spinal cord, and multiple CNS connections) orients a person in space during
position changes and while walking on uneven surfaces. Abnormalities in any
component of the system may cause or exacerbate dysequilibrium. Whether age-
related changes occur in peripheral nerves is unknown, although peripheral
neuropathy is common in the elderly, especially from diabetes or vitamin B12
deficiency.

The contribution of cervical mechanoreceptors to proprioception is not


widely appreciated. The loss of normal afferent input from mechanoreceptors
may result in a disturbance of postural sensation (sense of balance) and of
kinesthesia (awareness of head and neck movement), on which precise control
of voluntary movements such as walking depend. Whiplash injuries and cervical
degenerative diseases (eg, spondylosis) may impair functioning of the cervical
mechanoreceptors.

The CNS channels input data from the senses to the appropriate efferents
in the musculoskeletal system. Given the multiple connections and their
complexity, essentially any CNS disorder may contribute to instability or
dizziness.

Systemic disorders may contribute to instability or dizziness by affecting


the sensory, central, or effector components. In addition, systemic disorders may
result in decreased cerebral perfusion or oxygen delivery, fatigue, confusion, or
shortness of breath, which, in turn, may result in instability or dizziness. Common
examples include electrolyte disorders, anemia, hypothyroidism, and acid-base
disturbances. Cardiac arrhythmias or heart failure may compromise cerebral
blood flow. Drugs may cause dizziness through several mechanisms, including
postural hypotension, fatigue, dehydration, electrolyte disturbance, and disruption
of CNS function.

Diagnosis
Diagnosis is best begun by considering, based on history and
examination, whether a single cause is likely, in which case specific diagnostic
testing is warranted. If the history and examination do not suggest a specific
cause, it is unlikely that exhaustive diagnostic testing will be helpful. The goal in
most patients, therefore, is to identify and eliminate or ameliorate as many
contributing factors as possible. This approach is based on the following
assumptions: (1) the relative importance of individual contributors to dizziness
often cannot be determined; (2) the presentation often does not permit
identification of a specific cause, thus therapeutic trials are often the best way to
determine significant contributors; and (3) ameliorating even a subset of
contributors may reduce the dizziness.

History: The patient should be asked to describe the nature of the


dizziness, including sensation, frequency and duration, any associated
symptoms, any precipitating or provoking factors, and any predisposing
exposures and diseases. However, patients often report more than one
manifestation or a vague sensation. The patient should be screened for
depression and anxiety, which may provoke or exacerbate the dizziness. A
thorough review of all drugs, including over-the-counter drugs (especially
hypnotics, analgesics, and drugs used for colds and allergies), is also important.

Physical examination: Vestibular system abnormalities are difficult to


detect clinically. The examiner should look for nystagmus occurring
spontaneously or in response to changes in eye or body position. Because visual
fixation can suppress nystagmus, Frenzel glasses (high-diopter lenses in a frame
with a light source) are used if available. Two other methods of detecting
vestibular dysfunction are checking visual acuity during head shaking and testing
balance (eg, one leg or tandem stand) while standing on thick foam with eyes
closed. However, the sensitivity and specificity of these two tests have not been
determined.

Blood pressure and heart rate measurements should be taken after at


least 5 minutes of quiet lying and then at 0 and 2 minutes after standing. A
change of >= 20% in mean postural blood pressure is most significant.

Neck range of motion, preferably in a standing position, should be


determined. Decreased range of motion--with or without symptoms of dizziness
or unsteadiness--may be due to a cervical process or, secondarily, to vestibular
dysfunction (the sensation of dizziness on head turning can lead to decreased
range of motion secondary to prolonged neck immobilization). Decreased head
turning can interfere with central compensation; recognizing it is important
because vestibular rehabilitation is helpful.

Balance and gait should be evaluated, although most findings are


nonspecific. On testing, a performance that is poorer with eyes closed than with
eyes open suggests a vestibular or proprioceptive problem. A steppage gait
suggests proprioceptive deficits, as does an improvement in gait when the
patient touches his fingertip to the examiner's fingertip. Vibratory testing is more
sensitive than position sense testing for assessing proprioception.

Provocative tests: Attempts can be made to induce dizziness through


various maneuvers. Hyperventilation is not particularly helpful because it may
induce dizziness in many elderly patients, with or without a history of chronic
dizziness. The Hallpike maneuver involves a rapid change in position from
seated to supine with the head hanging 45° to the right or left. The occurrence of
nystagmus (and often vertigo), which lasts 10 to 30 seconds, after a few seconds
of latency indicates a positive response. A positive response in any of the head
positions confirms the suspected diagnosis of benign paroxysmal positional
vertigo.
Laboratory evaluation and specialized testing: A CBC, thyroid function
tests, and glucose and vitamin B12 levels should be obtained for all elderly
persons presenting with chronic dizziness. Indications for ECG, However,
abnormal findings are common among elderly patients with or without dizziness,
and abnormal results may or may not correspond to the complaint of dizziness in
this age group. Cerebral CT or MRI should be performed only if the history and
physical examination suggest a cerebral lesion. Audiometry is useful in
identifying the severity and type of hearing loss; specific findings may also
indicate Meniere's disease or acoustic neuroma.

Vestibular testing, including caloric testing, electronystagmography,


rotational testing, and computerized posturography, can be considered in
patients with history or physical examination findings suggestive of vestibular
disease.

Caloric testing assesses the symmetry of vestibular function. Each ear is


stimulated with 250 mL of first warm (44° C [111° F]) and then cool (30° C [86°
F]) water, each instilled over 40 seconds. The ear that shows a shorter duration
or lower frequency of nystagmus is presumed to be the diseased ear.

Rotational testing uses a series of well-controlled rotational stimuli to


provoke nystagmus. Findings can reveal the degree of peripheral or central
vestibular dysfunction; serial measurements can be used to detect worsening of
the dysfunction.

Electronystagmography, in which eye movements are recorded on an


ECG-like tracing from electrodes placed around the eyes, is used to observe
vestibular nystagmus during provocative testing.

In computerized posturography, the patient stands on a platform that is


imbedded with four sensors to monitor sway. Testing with the eyes closed or with
a moving screen while the platform is synchronized to patient movement
eliminates visual and proprioceptive information. This approach examines
balance that is principally dependent on vestibular input. Other testing
combinations examine visual and proprioceptive inputs to balance. Functional
deficits defined by posturography can thus indicate visual, proprioceptive, or
vestibular deficits, which require further testing to determine specific diagnoses.

Prognosis and Treatment


Although chronic dizziness may be a symptom of significant disease, it
does not per se increase the risk of death. However, it does have adverse
physical, psychologic, and social consequences. It increases the risk of falls and
fear of falling, decreases performance in activities of daily living, and reduces
participation in social activities. The primary goal of treatment is to reduce
dizziness sufficiently to minimize the physical, psychologic, and social morbidity.

Treatment is ideally directed toward a specific cause. However, because


the etiology is usually multifactorial, the most effective treatment is often to
ameliorate one or more contributing factors. Even partial amelioration of the
dizziness may help. Because adverse drug effects may contribute to many cases
of chronic dizziness, attempts should be made to eliminate as many drugs as
possible, to substitute less offending ones, or to reduce the doses.

Drugs: Vestibular depressants (eg, meclizine, diazepam) have little role in


the treatment of chronic dizziness. Because of their effects on the CNS and
because they may suppress central adaptation, these drugs may even
exacerbate dizziness. However, patients with severe unilateral peripheral
vestibular dysfunction may benefit from a benzodiazepine.

Rehabilitation and exercise: Vestibular rehabilitation includes


combinations of exercises involving head and eye movements while sitting or
standing. It also involves various dynamic balance exercises and exercises to
improve gait stability during head movement, visual and vestibular interactions,
and vestibular spinal responses. Initially, the exercises may worsen the
dizziness, but over time (weeks to months) movement-related dizziness
improves, likely because of central adaptation. Vestibular rehabilitation has been
shown to be effective in most vestibular disorders of central or peripheral origin.
Vestibular rehabilitation can be administered in a classroom setting or one to one
with a physical therapist. Alternatively, patients can perform the exercises
independently at home after being instructed by a physical therapist, who must
ensure that the patient can adhere to the program safely and effectively.

Cervical exercises may be effective for patients with cervical spondylosis.


Progressive, competency-based balance exercises have proved effective at
enhancing the sense of stability and may be useful for patients with dizziness
related to sensory and/or motor deficits. When proprioception is impaired, the
use of a cane is indicated to provide stability.

Patient education: Patients should be reminded to avoid over-the-


counter drugs that may exacerbate dizziness. If postural hypotension is
identified, patients should be instructed to rise slowly (the time required for
stabilization varies from a few seconds to several minutes). Hand clenching and
ankle dorsiflexion exercises performed before standing and the use of support
stockings may also help. These patients should also be taught to avoid hot
showers or baths and to reduce salt restriction in situations that might lead to
dehydration (eg, hot weather, diarrhea, vomiting).
Patients should be instructed on which activities to avoid. Movements
such as looking up, reaching up, or bending down are to be avoided, in part by
storing items at home strategically. However, patients should be cautioned not to
habitually avoid other movements, such as head turning. Avoiding these
movements may compromise central adaptation, thereby exacerbating dizziness.

L. Infections

Immune senescence (a progressive dysfunctioning of the immune


system) results from loss of some immunologic activities with simultaneous
increase of others. Immune senescence leads to an inappropriate, inefficient,
and sometimes detrimental immune response. Clinically, immune senescence
has been implicated in an increasing number of age-related disorders.

Two complementary forms of immunity rid humans of pathogens and


cancer cells: natural (innate) immunity and adaptive (acquired) immunity. Natural
immunity provides a rapid but incomplete defense against threatening agents
until the slower, more definitive adaptive immune response develops. Natural
immunity has a relatively rigid structure, whereas adaptive immunity, supported
by T and B lymphocytes, is infinitely versatile and adaptable. Other aspects of
the immune response include mucosal immunity and allergic reactivity.

Clinical Effects of Immune Senescence


Immune senescence usually develops insidiously; its effect on health often
manifests during intense physiologic stress (eg, surgery, multiple organ failure,
protein-energy malnutrition, dehydration). Many chronic illnesses common in old
age may adversely affect immune function in elderly persons and should be
diagnosed and treated when possible. Genetic and environmental factors also
probably play a significant role in the occurrence of immune dysfunction.

The clinical significance of increased autoantibodies in the elderly is


unknown. Paradoxically, autoimmune disorders peak in middle age and are less
common in elderly persons, which would not be expected considering what is
known about decreased tolerance to self with age. On the other hand,
autoantibodies may play a role in some of the degenerative diseases of aging.

Because immune senescence results from dysfunction rather than from


definitive exhaustion of the immune system, it may theoretically be reversed.
Hormonal and nonhormonal drug treatment (eg, growth hormone,
dehydroepiandrosterone, melatonin, zinc, vitamin E) has shown promising results
and may help restore efficient immune function in the elderly.
Infectious diseases: A causal relationship between immune senescence
and the reactivation of infectious diseases (eg, herpes zoster, tuberculosis) is
clearly established. The incidence of herpes zoster increases fivefold between
the ages of 45 and 85 in association with an age-related loss of cellular immunity
to the varicella-zoster virus. There is also endogenous reactivation of latent
Epstein-Barr virus infection in institutionalized elderly patients. Age-related
decreases in specific antibody production may partly account for the high
incidence and extreme mortality associated with pneumonia, influenza, infectious
endocarditis, and tetanus among the elderly. Although the etiology of nosocomial
infections is complex, age-related decreases in antibody response probably play
some role in the fact that 65% of all nosocomial infections occur in patients > 60.
Elderly persons are also more susceptible to parasitic infections, especially those
caused by metazoan and protozoan parasites.

However, the risk of infectious diseases attributable to immune


senescence is difficult to differentiate from that attributable to the various
pathophysiologic structural and functional alterations of different organs, which
probably determine the specific location of some infections. For example, an
impaired cough reflex, reduced mucociliary clearance, altered microbial flora, and
increased colonization of the oropharynx lead to severe respiratory tract
infections independent of immune function. The loss of bacteriostatic properties
of urine together with reduced kidney ability to acidify urine and incomplete
bladder emptying render elderly persons particularly susceptible to urinary tract
infections. Age-related changes in the gastrointestinal tract (eg, achlorhydria,
diverticula) may predispose to the development of gastrointestinal infection.

Response to immunization: Production of specific antibody is decreased


when vaccines containing antigens (eg, tetanus toxoid, hepatitis B virus) are
given to elderly recipients who had no prior immunity induced by natural
infection. The effect of immune senescence on the antibody response to
vaccines in patients with prior immunity induced by natural infection or previous
immunization (eg, influenza and pneumococcal vaccines) is difficult to evaluate.
As many as 30 to 40% of healthy elderly persons may not develop protective
immunity after immunization with influenza vaccine. Pneumococcal vaccines are
also less effective among elderly persons than among healthy younger persons.
Cancer: Immune senescence may impair the recognition and elimination
of tumor cells, but there is no compelling evidence that failure of immune
surveillance contributes to the increased incidence of cancer in the elderly.

Antigen-driven clonal expansion followed by neoplastic transformation


may be involved in the aging-related development of chronic lymphocytic
leukemia (CLL). CLL is characterized by a clonal outgrowth of B lymphocytes
and accompanied by severe immunologic disturbances (eg,
hypogammaglobulinemia, autoimmune manifestations).
Monoclonal gammopathy: The frequency of idiopathic paraproteinemia
increases from < 1% at age 50 to 20% at age 90. Animal studies have shown an
age-related increase in homogenous immunoglobulin levels after thymectomy,
suggesting that T-lymphocyte dysfunction is involved in the pathogenesis of
dysglobulinemia.

Degenerative diseases of aging: Immune senescence may contribute to


many age-related degenerative diseases that are not ordinarily considered
immunologic in etiology.

Autoantibody production tends to increase in the presence of chronic


diseases that are prevalent in the elderly and is sometimes associated with organ
dysfunction or with a specific disease. For example, high levels of autoantibodies
directed toward components of the thyroid, pancreatic, adrenal, and pituitary
glands have been associated with the respective hormone deficiency and
associated diseases (eg, hypothyroidism, diabetes, hypopituitarism).
Autoimmunity to heparin sulfate proteoglycan has also been associated with
vascular disease in the elderly.

This link with specific diseases may explain why the presence of
autoantibodies in the elderly is associated with reduced life expectancy.
Conversely, the lack of organ-specific autoantibodies (ie, the absence of
autoreactivity) after age 80 may represent a survival advantage.

Other altered immunologic activities may be implicated in several


pathologic conditions typically associated with aging. For example, activated
lymphocytes are found in atheromatous lesions and probably participate in
atherosclerosis. The presence of T lymphocytes near neuritic plaques indicates
that some type of immunologic response occurs in Alzheimer's disease. Also, the
association of complement protein with senile plaques suggests that activation of
complement pathways may contribute to neuronal cell death in Alzheimer's
disease. The age-related increase in IL-6 production, a lymphokine that induces
bone resorption, may be involved in the development of osteoporosis and may, if
excessive, be part of the pathogenesis of late-life lymphoma, myeloma, and
Alzheimer's disease.

M. Cancer

Although cancer occurs in persons of every age, it is fundamentally a


disease of aging. Sixty percent of new cancer cases and two thirds of cancer
deaths occur in persons > 65 years. The incidence of common cancers (eg,
breast, colorectal, prostate, lung) increases with age. However, incidence of
many cancers levels off after age 80, suggesting the possibility of intrinsic
resistance to the development of cancer in late life or some selection bias.

The age-related increase in cancer incidence predicts that as the U.S.


population ages, cancer incidence will continue to increase. There are several
theoretical reasons why cancer incidence increases in the elderly): age-related
alterations in the immune system (decreased immune surveillance);
accumulation of random genetic mutations leading to oncogene activation or
amplification or decreased tumor-suppressor gene activity; lifetime carcinogen
exposure (especially for colorectal and lung cancers); hormonal alterations or
exposure; and long latency periods. There may be increased susceptibility to
carcinogens, possibly caused by decreased DNA repair. Multiple genetic
changes are necessary for the development of cancer, most clearly exemplified
by the stepwise genetic changes shown by many colon polyps progressing to
cancer. The exponential rise in many cancers with age fits with an increased
susceptibility to the late stages of carcinogenesis by environmental exposures.
Lifetime exposure to estrogen may lead to breast or uterine cancer; exposure to
testosterone, to prostate cancer. The decline in cellular immunity may lead to
certain types of cancer that are highly immunogenic (eg, lymphomas,
melanoma).

Controversy continues over whether cancer is less aggressive in the


elderly. Growth and metastasis of several types of cancer (breast, colon, lung,
prostate) appear to be slower in the elderly. Yet, death occurs with smaller tumor
burdens. Reasons for the difference in mortality appear to be complex: Diagnosis
is often made later, treatment tends to be less aggressive, and competing causes
of death are more likely; all of these factors result in shorter survival in older
patients.

Risk Factors and Prevention


The part of cancer prevention we know the most about is the avoidance of
toxins that induce or promote cancer. Induction refers to the earliest genetic
change induced by a carcinogen. Promotion refers to cell growth induction that
fixes and then further alters the genetic abnormality. Carcinogens may alter
normal growth-promoting genes (proto-oncogenes), which are permanently
turned on. They may also damage growth-suppression genes (tumor
suppressors) such that they become permanently turned off. Both may be
necessary to create a cancer. Since prolonged exposure is one of the necessary
ingredients to both induction and promotion, prevention of cancer in the elderly
must begin before people become old. The best evidence strongly recommends
avoiding smoking, overuse of alcohol, and exposure to known toxic chemicals.
Maintaining a low-fat, high-fiber diet may be helpful.
Hormonal exposure is implicated in the development of breast, prostate,
and uterine cancers. Studies have been inconsistent as to whether exogenous
estrogen exposure increases breast cancer risk, but the relative risk is probably
in the range of 1.3. Early menarche, late menopause, and late or no pregnancies
are confirmed risk factors. Estrogenic stimulation of the endometrium, when
allowed to go unchecked, increases the risk of uterine cancer 2- to 2.5-fold.

Drugs may also reduce the risk of some cancers. Tamoxifen has recently
been approved for breast cancer prevention. Aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs) appear to reduce the risk of colon cancer.
Retinoids may be helpful in reducing the risk of new primary squamous cell
cancers in persons with previous such cancers related to tobacco use. The role
of antioxidants in preventing cancers remains unclear. Inhibiting the conversion
of testosterone to 5- -dihydroxytestosterone may prevent prostate cancer.

Screening
Because cancer is more common in the elderly than in younger
populations, screening is more likely to detect cancer in older populations.
Cancers for which screening has proved beneficial in reducing mortality include
breast, cervical, and colon cancer. It is unclear whether immune surveillance of
early cancers is effective. Most cancers are poorly immunogenic and are unlikely
to raise an immune response with low tumor volumes. With prostate-specific
antigen (PSA) testing, prostate cancer is detected at an earlier stage, but most
studies have not shown that screening with PSA reduces mortality. Screening for
ovarian cancer, even in high-risk women, has proved disappointing.

Most published recommendations for cancer screening focus on


populations younger than considered here. Thus, the main concern regarding the
elderly is when to discontinue routine screening. No studies show benefit of
screening past age 75 for any cancers. Despite the lack of data,
recommendations on cancer screening in the elderly have been.

Treatment
Research that focuses on cancer in younger populations may not be
applicable to the elderly, the segment of the population at highest risk for cancer,
leaving us with a paucity of knowledge on how best to manage cancer in the age
group that experiences it most.

Treatment goals must be individualized based not only on treatability of


the cancer, but also on comorbid conditions, functional status (one of the best
predictors of response and tolerance and, social situation (which may preclude
treatments involving travel or expense), and willingness of the patient to tolerate
side effects of treatment. Surgery, chemotherapy, radiation therapy, and
hormonal therapy are the mainstays of treatment. However, symptomatic and
supportive therapy with analgesics, antidepressants, anxiolytics, and antiemetics,
as well as support groups and individual and family counseling, must be
integrated into treatment programs. Access to support services and to trained
health care practitioners varies depending on the patient's geographic location,
financial resources, mobility, and support of family and friends. Referral to major
cancer centers may prolong survival but may not be the most humane course of
action for debilitated and relatively immobile patients.

Age per se is not usually the deciding factor as to whether aggressive


treatment is warranted: that decision must assess the likelihood that the cancer
will respond to treatment, the extent of spread, comorbid conditions that could
limit therapy, and the patient's wishes. Chemotherapy or radiation therapy should
be strongly considered in clinical situations in which cure, prolonged survival, or
definable palliation can be achieved with these modalities.

Chemotherapy
A variety of older chemotherapeutic drugs remain effective and useful. In
addition, newer antineoplastics are becoming more commonly used in the
treatment of cancer in the elderly. Chemotherapy may be less well tolerated by
elderly patients because of kinetic and dynamic changes that occur with age,
decreased organ reserve, and poorer wound healing. Comorbid conditions such
as diabetic neuropathies, renal insufficiency, heart failure, and decubitus ulcers
may contraindicate specific treatments. However, nausea and vomiting from
chemotherapy tend to be less intense in the elderly.

Age-related decreases in liver size, blood flow, and metabolic reserve and
use of drugs that inhibit cytochromes may inhibit drug metabolism. The
neurotoxicity of drugs such as vincristine, cisplatin, and paclitaxel is especially
troublesome in the elderly, and severe neuropathies or constipation may result.
Hematopoietic toxicity of most drugs and of radiation therapy is increased to
some degree. Gastrointestinal toxicities of 5-fluorouracil and doxorubicin may be
increased, and frail patients are less able to tolerate short episodes of diarrhea or
decreased oral intake from mucositis. Reduced cardiac reserve makes it more
difficult for the elderly to tolerate anthracyclines, and decreased renal reserve
decreases tolerance to platinum drugs and methotrexate, requiring adjustments
in dose or choice of drug. With curable malignancies, great care must be taken
not to reduce doses without documented need.

Advancements in hematologic manipulation have made the use of


chemotherapy safer in the elderly. For example, granulocyte colony-stimulating
factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF)
diminish duration of chemotherapy-induced neutropenia. Erythropoietin is often
effective in treating chemotherapy-induced anemia and is well tolerated.
Oprelvekin, a nonspecific growth factor for megakaryocytes, has been approved
for preventing and treating severe thrombocytopenia associated with
chemotherapy. However, oprelvekin prevents, at most, 30% of needed platelet
transfusions and often causes significant adverse effects (edema, dyspnea,
tachycardia). It should be used with caution in patients at risk of heart failure or
with central nervous system tumors. Pamidronate is effective treatment of tumor-
induced hypercalcemia. Other bisphosphonates may be as effective.

Antiserotonin antiemetics (ondansetron, granisetron, dolasetron) are more


effective than older drugs and have few side effects. Dolasetron may cause a
prolonged QT interval and therefore must be used with caution in patients at risk
of ventricular arrhythmias. Expense is a major deterrent to the use of the
antiserotonin antiemetics, and they lose effectiveness 48 to 72 hours after
chemotherapy. Phenothiazines, benzodiazepines, and dexamethasone are more
effective for delayed nausea.

Amifostine is a chemoprotectant that is beneficial in treating neurotoxicity


and nephrotoxicity caused by cisplatin. Dexrazoxane is a cardioprotectant used
with anthracyclines. The clinical usefulness of amifostine and dexrazoxane has
not been fully defined.

Radiation therapy
This modality has become more tolerable and safer with newer
technologies and improved techniques, such as high-energy linear accelerators,
better control of target areas, three-dimensional CT planning, and improved
dosimetry. Patients who have conditions such as arthritis, kyphoscoliosis,
parkinsonism, or dementia may require special positioning or immobilization. The
elderly appear to be at increased risk of radiation lung damage, coronary artery
injury, esophagitis, and enteritis, necessitating precise planning and dosimetry.
Mucositis, esophagitis, or enteritis may lead to more rapid dehydration in the
elderly. Despite these problems, some seemingly frail elderly patients can
tolerate radiation therapy.

Pain control
Pain control is especially important in the care of elderly cancer patients.
Although pain control is often considered part of end-of-life care, persons with
cancer may have chronic pain or intermittently painful complications of cancer
during any stage of their disease and it may continue over the course of many
years. The goal is to achieve an acceptable level of pain control with tolerable
adverse effects. Comfort must be emphasized and the patient reassured that
pain will be aggressively managed. Treating the source of pain is important.
Radiation therapy to painful bony or other lesions should be considered.
Chemotherapy may be of palliative benefit.
Opioids are used to treat severe pain not relieved by NSAIDs. Addiction
should not be an issue for prescribers, and patients should be reassured that fear
of addiction should not affect their use of the drug. Timed-release morphine and
oxycodone as well as transdermal fentanyl relieve baseline pain. Fast-acting
drugs, such as hydrocodone, oxycodone, morphine, hydromorphone, and
transmucosal fentanyl lollipops, relieve intermittent or breakthrough pain.
Fentanyl clearance is decreased in the elderly. Methadone, meperidine,
pentazocine, and propoxyphene should not be used in the elderly. Stimulant
laxatives are essential for an elderly patient receiving opioid therapy.

Elderly patients may become somnolent while being treated with opioids.
Methylphenidate, taken periodically at a dose of 5 to 10 mg, is often useful,
especially for those patients desiring more social interaction when taking opioids.

Pain not relieved by opioids requires adjunctive treatment.


Antidepressants, anticonvulsants, or antiarrhythmics may be used for
neuropathic pain. Epidural or intrathecal opioids or clonidine infusion may be
extremely effective without causing side effects. Nerve blocks may be helpful for
intra-abdominal or dermatomal distribution pain.

Pamidronate given intravenously monthly is effective at reducing bone


pain in metastatic breast cancer, multiple myeloma, and probably prostate
cancer. Radioactive strontium or samarium localizes in blastic bone metastases
and reduces bone pain, but results have been less promising than first expected.

Nursing Issues

Oncology nursing is now a specialization of nursing. Oncology nurses


educate and counsel patients and their families as well as administer
chemotherapy, interpret and manage treatment-related side effects, coordinate
community and medical services, and provide palliative care. Triage and initial
management of problems in elderly cancer patients are often handled by nursing
personnel with the use of standard protocols. The nurse must be able to
recognize the altered presentations of illness and side effects in the elderly as
well as pharmacologic differences in the use of commonly prescribed drugs.
Examples of enhanced side effects of drugs used in the elderly include increased
risk of disorientation, light-headedness or falls from the use of antiemetics or
opioids, and increased risk of dehydration from drugs that cause vomiting and
diarrhea in elderly patients with decreased thirst response. The oncology nurse is
a key provider in assessing and managing pain because of the prolonged contact
with patients in a variety of settings. The oncology nurse is also on the front lines
of managing nutritional support and other symptoms.
Social Issues

Many social issues arise in the care of elderly cancer patients. These
issues often become complex and require the expertise of a social worker or an
interdisciplinary team. Services may have to be coordinated to help with home
care, travel, meal preparation, and drug adherence. Counseling may be
warranted to help patients and their families cope with the seriousness of the
illness. Efforts to overcome these difficulties frequently require alterations in
treatment plans and interdisciplinary approaches.

Finances may pose problems as well. Oral chemotherapy drugs are


covered 80% by Medicare if there is also an approved IV form of the drug. Other
drugs taken orally, including pain medications (especially timed-release
formulations), can be very expensive and are not covered by Medicare. Most
pharmaceutical companies have indigent patient programs.

End-of-Life Issues
It must not be forgotten that cancer is often fatal. Sometimes treatment
becomes futile, exposing an elderly patient to suffering that outweighs any
potential benefit. Even at the time of initial diagnosis, treatment is not always
warranted. An honest discussion of what is likely to be gained and what the side
effects of treatment are likely to be is the best course of action. Most patients
understand when it is time to make a transition to more palliative goals of care
(palliative care is defined by the World Health Organization as the active total
care of patients whose disease is not responsive to treatment). This
understanding can be fostered by direct and forthright discussions regarding
prognosis and benefits and risks of therapy and is enhanced by a trusting
physician-patient relationship.

Involvement of hospice services early in the course of palliative care can


be helpful. The financial benefits alone of switching to the Medicare hospice
benefit may be substantial. Hospice personnel have expertise in preparing
patients and families spiritually, financially, and legally for the end of life.

Most patients wish to remain at home. Every effort should be made to


accommodate this wish, but attention needs to be paid to caregiver burden. Short
stays in a hospital or nursing home, which are covered by Medicare, may be
necessary for respite to caregivers. Interventions and clinic visits should be kept
to the minimum necessary for palliation. Although Medicare reimburses
physicians for time spent on hospice issues, the reimbursement is rarely
adequate and does not compensate for the amount of documentation required.
N. Cardiovascular Conditions
Cardiac function is altered in an age-related manner and cardiovascular
diseases increase with increasing age in North American populations. The
purpose of this brief overview is 1) to identify cardiac changes which are
characteristic of physiologic aging (i.e., not disease), 2) highlight the altered
presentation and modifications of therapy for older patients with common
cardiovascular diseases such as hypertension, atrial arrhythmias, and coronary
artery disease, and 3) identify cardiovascular diseases and treatments which are
unique to older populations.
Cardiovascular changes with Physiologic Aging vs. Disease (see Table for
summary)

Rhythm

Heart Rate
Resting heart rate is not generally affected by aging; however, decreased
heart rate in response to exercise and stress (esp. beta-adrenergically mediated)
is characteristic of healthy aging. The clinical consequence of this is that maximal
heart rate on treadmill is decreased (220-age) and the heart rate response to
fever, hypovolemia, and postural stress is also decreased with healthy aging.
The response to beta-adrenergic blockade (as well as stimulation) is also
reduced with healthy aging. Daytime bradycardia with heart rates < 40 bpm and
sinus pauses of over 3 seconds are not seen with healthy aging.

Atrioventricular Conduction
The time for conduction through the atrioventricular (AV) node is
increased with healthy aging. Therefore, the P-R interval on the ECG increases
with age and the upper limit of normal for people >65 is 210-220 milliseconds
(not 200 ms). Second and third degree AV block are not normal consequences of
aging. Right bundle branch block is seen more frequently in older compared to
younger populations but has not been shown to identify increased risk for further
conduction abnormalities. A gradual leftward shift of the QRS axis is observed
with aging and left anterior hemiblock is seen with increasing frequency in older
populations. Isolated left anterior hemiblock is not an independent predictor of
cardiovascular morbidity or mortality in otherwise healthy elderly. Combined right
bundle branch block and left anterior fascicular block is associated with
cardiovascular disease in 75% of older patients and only 25% with this finding
have otherwise normal hearts. Left bundle branch block is not associated with
normal aging and is associated with cardiovascular disease and risks for cardiac
events.

Arrhythmias
Atrial premature contractions increase with age and are frequent in up to
95% of older healthy volunteers at rest and during exercise in the absence of
detectable cardiac disease. Atrial fibrillation is usually associated with coronary,
hypertensive, valvular, sinus node disease or thyrotoxicosis but may occur in
older patients with no other detectable diseases (1/5 of older men and 1/20 of
older women with atrial fibrillation). Similarly, isolated and even multiform
ventricular ectopy has been reported in up to 80 % of older men and women
without detectable cardiac disease.

Cardiac Contractility/ Left Ventricular Function at Rest and During Exercise

In contrast to the decline in skeletal muscle mass seen with aging in


healthy populations, left ventricular mass is preserved or increased with age.

Systolic Function
Resting left ventricular systolic function (ejection fraction and/or stroke
volume) is not altered by aging in most studies of subjects rigorously screened to
exclude coronary artery disease; however, a few studies report declines of stroke
volume with sedentary older populations. Cardiac output is equal to stroke
volume x heart rate. So, resting cardiac output and left ventricular ejection
fraction do not usually decrease with normal aging. Contractile responses to
beta-adrenergic responses are decreased with aging. Therefore, exercise
cardiac output may be reduced due to both the decrease in maximal heart rate
and a limit to the ability to increase contractility (stroke volume) in response to
beta-adrenergic blockade in the elderly. The age-associated decline in maximal
cardiac output and cardiovascular reserve capacity may not limit usual ability in
otherwise healthy elderly because the vast majority of daily activiies are
performed at low and submaximal workloads. In addition, the age-related decline
in exercise capacity can be attenuated by physical conditioning.

Diastolic Function
The time for cardiac relaxation and for ventricular filling are prolonged with
aging leading to altered early diastolic filling times on echocardiography and
nuclear studies. The etiology of the prolonged time for relaxation may be
multifactorial--increased ventricular mass, collagen infiltration, or altered
myocardial calcium handling. Prolonged filling times may limit cardiac output with
increased heart rates. While altered diastolic function accompanies aging,
congestive heart failure is not a normal consequence of the prolonged times
required for cardiac relaxation or diastolic filling.

Valvular Changes
Degenerative calcification (leading to sclerosis) and myxomatous
degeneration (which can lead to regurgitation) affect the aortic and mitral valves
with aging. These changes are considered "secondary" to aging and differ from
the primary changes due to rheumatic heart disease or congenital valve
abnormalities. These changes can progress to impair the function of the valve;
then the changes are considered pathologic and no longer "normal aging".
Table 1
Age-Related Changes vs. Cardiovascular Disease
Decreased Heart Rate Sinus Pauses
Response
Longer P-R Intervals Second and Third Degree AV Block
Right Bundle Branch Left Bundle Branch Block
Block
Increased Atrial Ectopy Atrial Fibrillation
Increased Ventricular Sustained Ventricular Tachycardia
Ectopy
Altered Diastolic Decreased Systolic Function (Ejection Fraction)
Function
Aortic Sclerosis Aortic Stenosis, Aortic Regurgitation
Annular Mitral Mitral Regurgitation, Stenosis Systolic Hypertension
Calcification Diastolic Hypertension

Common Cardiovascular Diseases and Management in Older Patients

Atrial Fibrillation
The prevalence of chronic atrial fibrillation rises from <1 per 1000 people
at 25-35 years of age to about 40 per 100 at ages 80-90 (Framingham data,
Baltimore Longitudinal Study, Cardiovascular Health Study). Chronic atrial
fibrillation has been shown to be an important risk factor for cerebrovascular
accidents (strokes) and control of rate is associated with better exercise
tolerance. The goals of therapy in an individual patient may vary and include rate
control, prevention of stroke, or restoration of sinus rhythm.

Rate control
Immediate or long-term rate control can be achieved with the use of
digoxin, beta-blockers, calcium antagonists (verapamil or diltiazem), or
amiodarone in refractory cases. There is less experience with the use of new
Class III agents (ibutelide). The adequacy of rate control must be assessed with
activity--more active patients are less likely to have adequate rate control with
digoxin alone. Drug doses should be adjusted for age and disease state and one
must remember that adequate rate control may be lost during acute illnesses
such as pneumonia, but will be regained with treatment of the acute illness.

Prevention of stroke
With acceptable risk benefit ratios can be achieved with anticoagulation
with coumadin. However, the optimal therapy to prevent stroke for the older
patient with atrial fibrillation has not been found. This author favors
anticoagulation with coumadin to a target INR of 2-2.5 with close monitoring in
elderly patients without contraindications to anticoagulation, esp. in patients with
additional risk factors for stroke (hypertension, vascular disease, prior CVA).
Aspirin alone is not a reasonable choice in the latter group.

Restoration of sinus rhythm


Should be considered in patients with abnormal cardiovascular function
(esp. in the setting of aortic stenosis or hypertrophic cardiomyopathy), atrial
fibrillation which is not of long-standing, or is difficult to control. This goal is more
frequently sought in younger patients. Anticoagulation must be instituted prior to
cardioversion and continue during the period of highest risk for fibrillation
recurrence (3mos). Analyses of risk of recurrence based on age alone have not
been performed.

Hypertension

The prevalence of hypertension--esp. systolic-- increases with aging in


North American men and women. This increase in systolic pressure is thought to
be due to thickening of the arterial wall which makes it less distensible and less
able to buffer the rise in pressure that occurs with cardiac ejection. These
changes result in an elevated systolic blood pressure with a relatively unchanged
diastolic blood pressure. A large body of data have now demonstrated that
cardiovascular morbidity and mortality increase with increasing systolic as well as
diastolic blood pressure in the elderly. Furthermore, treatment of both diastolic
and isolated systolic hypertension has been shown to decrease mortality and
morbidity in both older men and women--there is a decrease in adverse events
for every degree of blood pressure reduction toward the normal range. Treatment
goals are now the same for older patients as they are for younger patients---
systolic blood pressure < 140 mmHg and diastolic pressure < 90 mmHg.

Treatment begins with diet (weight reduction if obese; low sodium for all,
and < 1 oz of alcohol/day) and exercise. The long-term benefits of
antihypertensive therapy in the elderly have been demonstrated for thiazide
diuretics (chlorthalidone 12.5-25 mg/day, hydrochlorothiazide 25 mg/day) alone
or in combination with beta-blockers (atenolol 50 mg/day, metoprolol 50 mg/day).
Thiazide diuretics and/or beta blockers are recommended as first-line
pharmacologic therapy for the older patient with hypertension (and no other
diseases) because of demonstrated longevity benefit and lower cost. Alpha-
methyl-dopamine and reserpine have also shown mortality benefits but are less
widely used secondary to side effects. Calcium channel blockers, angiotensin
converting enzyme (ACE) inhibitors, alpha-blockers, and angiotensinogen II
inhibitors are highly effective in lowering blood pressure in older patients and
may have advantages in hypertensive patients with multiple diseases (i.e.,
calcium channel blockers for coronary artery disease, cerebrovascular disease,
diabetes, chronic obstructive pulmonary disease, diabetes with renal disease;
ACE inhibitor for congestive heart failure, diabetic with renal failure, etc.; alpha
blocker for prostate disease). Similarly, beta-blockers have an advantage in the
post-myocardial infarction patient. No adverse effects on quality of life or mood
have been demonstrated with the use of beta-blockers in the elderly in
randomized clinical trials. All drug dosages should be adjusted for age and
disease-related changes.

Coronary Artery Disease

It has long been recognized that the prevalence of coronary artery disease
rises with increasing age and that multi-vessel disease in older patients with
coronary artery disease is more common. The age-related increase in coronary
artery disease occurs in women as well as men but begins at a later age in
women. The same risk factors that predict atherosclerosis in younger adults (lipid
abnormalities, smoking, hypertension, diabetes) are predictive in older individuals
as well. Modification of these risk factors is effective in reducing the risk of
atherosclerosis in older patients. Therefore, preventive strategies for the older
patient include stopping smoking, blood pressure control, control of lipid
abnormalities, and treatment of diabetes.

The approach to diagnosis in the elderly is similar to that in the younger


patient. The history may be somewhat more difficult to interpret because exercise
may be limited by other factors (arthritis, pulmonary disease, etc.) and chest
discomfort may be atypical because of the prevalence of diabetes (10% of the
elderly) and the greater preponderance of women in the older populations. ECG
criteria for the diagnosis of coronary artery disease are also not as reliable in
women of any age as in men. Nuclear imaging (usually thallium) with or without
pharmacologic stress is often used to overcome the limits of ECG interpretation,
but again is not as good in women as men (estimated 20% false positives).
Because the prevalence of coronary artery disease is high in the elderly, the goal
of diagnostic testing may be to quantify the amount of ischemia rather than to
diagnose its presence and perfusion imaging allows localization, quantification,
and differentiation between infarcted and ischemic myocardium. Pharmacologic
stress testing combined with echocardiography may also have some advantages
in the older patient since it can provide assessment of valvular function, left
ventricular function, and the presence and extent of wall motion abnormalities
indicative of ischemia or infarction. Angiography is of value for both assessment
and as a prelude to interventions. Slightly greater complications are seen in older
patients than in younger patients (local bleeding, stroke) but remain low. This
should be recognized but should not preclude procedures.

Treatment considerations for coronary artery disease in the older patient


do not differ from those in the younger patient with coronary artery disease with
the exception of the elderly diabetic patient with coronary artery disease (see
below). The therapeutic choices include medications (nitrates, beta-blockers,
calcium blockers), lipid lowering regimens (effective in older patients as well as
young) and revascularization procedures. Note that resting heart rates should not
be used as an indication of beta blockade or as a contraindication of beta
blockade. Revascularization procedures (angioplasty or surgery) may be of
greater benefit than pharmacologic therapy in patients with multivessel disease
and decreased left ventricular function. In the elderly diabetic with multivessel
disease, surgical intervention has a more favorable outcome than angioplasty.
Complication rates for angioplasty and surgery are slightly higher in the older
patient but still relatively low. It has been noted that fewer women than men have
been treated with angioplasty or surgery and that women undergoing such
procedures have more advanced disease. This finding could represent atypical
presentation or failure of the medical community to recognize the prevalence of
coronary artery disease in older women. Another current issue is the possible
decrease in cognitive function in older patients undergoing coronary artery
bypass graft procedures.

Myocardial infarction
The older patient with myocardial infarction also benefits from the same
therapies as the younger patient and age >75 alone should not be a
contraindication to thrombolytic therapy. Beta blockers and aspirin should be
administered post-infarction. ACE inhibitors are also of probable benefit if given
in lower doses and not during the immediate acute MI period. However, goals of
the post-MI period may differ for the older patient vs. the younger patient. All
physiologic processes related to healing and stress appear to be attenuated with
aging, so timing for diagnostic testing after the acute event may need to be
slightly later in older patients. In addition, the probability of post-MI ischemia is
greater in the older patient because of the higher incidence of multivessel
disease. No studies of predominantly older patients have been performed to
identify the best post-MI strategy for further risk stratification and to guide in
clinical decision making regarding medical vs. revascularization strategies.
Therapy should therefore be individualized and it is not appropriate to consider
the older patient, esp. in the presence of multiple diseases, as a "routine" post-MI
pathway patient.

Congestive Heart Failure

Systolic
The therapy of congestive heart failure due to systolic dysfunction does
not differ in the older patient. The mainstays of therapy are digoxin, diuretics, and
esp. angiotensin converting enzyme inhibitor drugs. Renal function and
potassium may need to be monitored more closely in the older patient because
of the likely concomitant administration or ingestion of nonsteroidal anti-
inflammatory drugs (high incidence of arthritis in the older population) and the
additive effects of NSAID's to lower renal perfusion and potassium excretion. The
role of beta blockers in the management of patients with congestive heart failure
is just emerging and there are no data regarding the older patient.

Diastolic
Congestive heart failure with preserved left ventricular systolic function is termed
"diastolic heart failure" and is more prevalent in the older population, may
account for one half of the older population with congestive heart failure, and
may be more common in women than men. The prognosis of patients with CHF
due to diastolic dysfunction is less ominous than in patients with systolic
dysfunction yet the morbidity can be high with frequent treatment failures and
hospital readmissions. No long-term studies of drug therapies for diastolic
congestive heart failure have been performed. Drugs which selectively affect
diastolic filling and relaxation (calcium channel antagonists or beta-adrenergic
blockers) can alter these parameters after short-term administration and might
provide a specific therapy. However, one of the more surprising findings from a
recent trial was the lower incidence of recurrent hospitalizations and death in
patients with congestive heart failure who received digoxin (vs. placebo) in
combination with diuretics and ACE inhibitors. This was true for CHF patients
with both decreased and preserved systolic function. Thus, optimal management
of the older patient with diastolic congestive heart failure is evolving. Control of
hypertension, prevention of myocardial ischemia, treatment of congestive heart
failure symptoms, and maintenance of normal sinus rhythm have received
emphasis. It appears that digoxin and diuretics do play a role and that beta
blockers and/or calcium blockers may also play a role. Treatment of acute
exacerbation of congestive heart failure or pulmonary edema in the setting of
diastolic heart failure focuses on diuretics and, if needed, positive inotropes on a
short-term basis. The role of ACE inhibitors is unclear unless used for the
treatment of hypertension or to attempt regression of hypertrophy.

Multidisciplinary team approach


The concept of a team approach for the care of the patient with congestive
heart failure is rapidly gaining favor. The team compositions vary but usually
consist of physicians and nurses and other health professionals (dieticians, social
workers, physical therapists, or exercise technicians) who focus not only on
medication prescribing but patient and family dietary education, close follow-up of
weight and symptoms of patients in the home (phone or home care), with a goal
of improving CHF and preventing hospitalizations. In a recently completed trial of
older patients with congestive heart failure, the team care patients had fewer
hospitalizations, improved perceived quality of life, and lower medical costs for
up to one year after randomization, compared to the conventional care group.
These data suggest that the geriatric multidisciplinary team approach is
beneficial for cardiac diseases in the older patient.

Valvular Diseases
Aortic Stenosis
The frequency of aortic stenosis increases with age and it is the most
clinically significant valvular lesion in the elderly. Progressive degenerative
calcification is now the most common cause, as opposed to rheumatic disease.
The calcification occurs along the margins of the valve leaflet (vs. commisural
fusion in rheumatic fever) and thus does not affect valve opening or closing
during the early stages but will produce a murmur. Because of the stiffened
peripheral arteries in the older patient, the carotid pulse may feel normal to
palpation even in the presence of significant aortic stenosis. Other physical
findings associated with critical aortic stenosis due to rheumatic heart disease
are often absent with calcific aortic stenosis (decreased S1 and S2). The
intensity of the murmur does not correlate with the severity of stenosis.
Progression to critical aortic stenosis is often gradual but is unpredictable.

Therefore, diagnostic testing is essential for the diagnosis or evaluation of


a symptomatic elderly patient with an aortic systolic murmur. Fortunately,
noninvasive echocardiographic and Doppler testing can now accurately assess
the severity of obstruction as well as define the aortic valve. About 20% of elderly
patients with aortic disease have a rheumatic etiology--these patients usually
have associated mitral valve disease and should receive antibiotic prophylaxis
before all invasive procedures including dental procedures. The only effective
treatment for critical aortic stenosis is surgical. Aortic valve replacement, even in
older patients, improves survival and quality of life. Experience with aortic balloon
valvuloplasty shows that re-stenosis occurs frequently within months and it has
thus been largely abandoned.

Aortic Regurgitation
The most common cause of aortic regurgitation in the elderly is aortic root
dilation secondary to the age-related rise in blood pressure and increased
peripheral resistance. With the advent of widespread echocardiography, mild
degrees of aortic regurgitation are diagnosed frequently and are usually not of
clinical significance. Aortic regurgitation due to rheumatic valvular disease or
associated with disease of a bicuspid valve is more likely to progress to clinically
significant disease. When significant aortic regurgitation is present, therapy is
aimed at afterload reduction and clinical symptom relief with monitoring for
definitive surgical intervention prior to left ventricular failure.

Mitral valve disease


Mitral regurgitation accounts for 2/3 of mitral valve disease in the elderly.
The etiologies include rheumatic disease (usually with concomitant aortic
disease), papillary muscle dysfunction due to ischemia or infarction, calcification
of the mitral annulus (more common in women than men), and myxomatous
degeneration causing mitral valve prolapse. Medical management centers on
maintenance of sinus rhythm or control of atrial fibrillation, afterload reduction
and prevention of infection by use of prophylactic antibiotic regimens before all
invasive procedures (including dental). The subset of patients with significant
mitral regurgitation and mitral valve prolapse may have an increased risk for
stroke and should be considered for anticoagulation. Acute symptoms may also
benefit from diuretics. As disease progresses, the ventricle dilates and pulmonary
hypertension develops and medical treatment is no longer effective. Surgical
interventions have the best results prior to the development of ventricular
dysfunction or marked dilation. Operative results to date show return toward
normal pressures and ventricular size, but improvement is not as marked as that
seen after aortic valve replacement. Therefore, optimal surgical timing has not
been identified but morbidity and mortality are high once left ventricular failure
occurs. Surgical repair as opposed to replacement is currently being used and
evaluated for patients with regurgitation and noncalcified, nonstenotic valves.

This may preclude the need for anticoagulation with mechanical valves,
which could potentially be of clinical advantage in the older patient since surgical
mitral valve replacement (whether it is a tissue or mechanical valve) requires
lifelong high intensity anticoagulation. The management of the less common
mitral stenosis in the elderly also targets control of heart rate and symptoms
(digoxin and diuretics), anticoagulation to prevent emboli, and antibiotic
prophylaxis to prevent infections. Surgical therapy is the only definitive therapy.
Valvuloplasty is seldom of long- term benefit.

Summary

It is important to differentiate the cardiac manifestations of normal aging


which do not require medical management from cardiac disease in the older
patient. A rationale for greater utilization of diagnostic techniques can be made in
the older patient who may present with atypical symptoms, multiple confounding
medical problems, and age-related alterations in physical findings of some
cardiac diseases. The management of most cardiac diseases in the older patient
is similar to that of the younger patient, with the important recognition of the need
to reduce medication dosages and be aware of the increased risk of adverse
effects or drug interactions. Age should not be a contraindication to invasive
procedures or surgical procedures or thrombolytic therapy, since when properly
selected, they benefit older patients to the same or greater degree as younger
patients. For several diseases unique to aging (i.e., diastolic heart failure or atrial
fibrillation), optimal therapeutic strategies are still evolving.

O. Respiratory Conditions
Elderly people are at increased risk for lung infections. The body has
many ways to protect against lung infections. With aging, these defenses may
weaken.

The cough reflex may not trigger as readily, and the cough may be less
forceful. The hairlike projections that line the airway (cilia) are less able to move
mucus up and out of the airway. In addition, the nose and breathing passages
secrete less of a substance called IgA (an antibody that protects against viruses).
Thus, the elderly are more susceptible to pneumonia and other types of lung
infections.

Common lung problems in the elderly include chronically low oxygen


levels (which reduces tolerance to illness), decreased ability to exercise,
abnormal breathing patterns including sleep apnea (episodes of stopped
breathing during sleep), increased risk of lung infections such as pneumonia or
bronchitis, and diseases caused by tobacco damage (such as emphysema or
lung cancer).

PREVENTION
Avoiding smoking is the most important way to minimize the effect of
aging on the lungs. Exercise and good overall fitness improve breathing capacity.
Exercise tolerance can be affected by changes in the heart, blood vessels,
muscles, and skeleton, as well as in the lungs. However, studies have shown
that exercise and training can improve the reserve capacity of the lungs, even in
elderly people.

Second, more than any other group the elderly need to be aware of the
need to be up and about and should consciously try to increase deep breathing
during illness or after surgery.

Continued use of the voice helps maintain overall vocal performance.

P. Dermatological Conditions

Geriatric Essentials
• The overall result of age-related structural changes is an increase in skin
dryness, roughness, wrinkling, and laxity, and a decrease in skin elasticity.
• The overall result of age-related functional changes is a decline in skin
barrier function, mechanical protection, sensory perception, wound
healing, immunologic responsiveness, thermoregulation, and vitamin D
production.
Aging leads to many changes in the skin, hair, and nails. These changes
can be broadly categorized as either age-related or photoaging. Age-related
changes are presumed to be due to age alone, whereas photoaging is due to
chronic exposure to ultraviolet (UV) radiation superimposed on aging itself.
Popular notions of "old skin" often correspond more closely to photoaging than to
aging itself, and dramatic differences between aged skin protected from UV light
and younger unprotected skin are evident to patients and clinicians alike. Other
factors that affect the skin include smoking, which accelerates wrinkle
development, and disease, most notably connective tissue disorders.

Age-Related Changes in Skin Structure and Function


The overall result of structural changes is an increase in skin dryness,
roughness, wrinkling, and laxity, and a decrease in skin elasticity. The overall
result of functional changes is a decline in skin barrier function, mechanical
protection, sensory perception, wound healing, immunologic responsiveness,
thermoregulation, and vitamin D production. Aging may also affect the absorption
of some topical drugs, although clinically important differences have not been
identified.

Epidermis: The epidermis gives rise to the outer barrier layer of dead
cells, the stratum corneum, through terminal differentiation of keratinocytes, the
predominant cell type. The epidermis recognizes invading pathogens and other
foreign substances and generates abundant cytokines. Melanocytes reside in the
epidermal basal layer, producing and distributing photoprotective melanin to the
keratinocytes.

With aging, the dermal-epidermal junction flattens--the number of


interdigitations dramatically decreases--resulting in a smaller contact surface
area between the dermis and epidermis. As a result, dermal-epidermal
separation occurs more readily in elderly skin, and elderly skin is more likely to
tear or blister. The change probably also compromises communication and
nutrient transfer between epidermis and dermis, affecting the mechanical, barrier,
and immunologic functions of the epidermis.

Elderly skin often appears dry and flaky, especially over the lower
extremities, at least partly due to a dramatic age-associated decrease in
epidermal filaggrin, a protein required for the binding of keratin filaments into
macrofibrils.

Epidermal turnover rates decrease by about 30 to 50% between a


person's 20s and 70s. This decrease slows the replacement rate of the stratum
corneum, likely resulting in a rougher skin surface and a less adequate barrier.
Slow replacement of the surface layer is also thought to be responsible for the
prolonged healing times for epidermal wounds as well as the decreased barrier
function that results from slow replacement of neutral lipids. The number of active
melanocytes decreases by about 10 to 20% per decade, probably explaining in
part the increased vulnerability to ultraviolet (UV) radiation in old age. An
accompanying age-associated decline in DNA repair capacity compounds the
loss of melanin protection and increases the risk for developing skin cancers.
The prevalence of melanocytic nevi also declines, from a peak between ages 20
and 40 to near zero after age 70.
Vitamin D production, which depends on sun exposure, declines with
aging, possibly because of a 75% decrease between early and late adulthood in
the amount of epidermal 7-dehydrocholesterol, the immediate biosynthetic
precursor of vitamin D. Decreased vitamin D production is often compounded by
reduced outdoor activity, leading to insufficient sun exposure.

Dermis: The dermis contains the blood vessels, lymphatics, nerves, and
deeper portions of the hair follicles and glands that arise from the epidermis. It is
composed largely of extracellular matrix and gives skin its strength and elasticity.
Dermal thickness decreases by about 20% in the elderly and often even
more in photodamaged areas. UV damage produces hyperplastic changes
initially, followed by atrophic changes, particularly in fair-skinned people. These
opposing changes probably explain observed variations in the effects of
photodamage.

Even when elderly skin has been consistently protected against the sun,
within the dermis there is about a 50% decrease in mast cells and a 30%
decrease in venular cross-sectional area. Basal and peak levels of cutaneous
blood flow are reduced by about 60%. As a result of these decreases, there is a
decrease in release of histamine (a mast cell product) and other measures of
inflammatory response after exposure to UV radiation or immune challenge.
Vascular responsiveness during injury or infection is also compromised. The
striking involution of vertical capillary loops in dermal papillae is thought to
account for the pallor, decreased temperature, and impaired thermoregulation
found in elderly skin. As well, the decline in vascular supply to hair bulbs and to
the eccrine, apocrine, and sebaceous glands may contribute to their senescence.

Reduced synthesis and increased degradation of collagen, the major


component of the dermal matrix, probably contribute to impaired wound healing
in the elderly. Elastic fibers decrease in number and diameter with aging,
accounting for decreased elasticity in elderly skin. Fragmentation, progressive
cross-linkage, and calcification of elastic fibers also occur. Alterations of
mucopolysaccharides that normally bind water in the dermal matrix may affect
skin turgor.

Subcutaneous fat: Subcutaneous fat acts as a shock absorber,


protecting the body from trauma, and plays a role in thermoregulation by limiting
conductive heat loss. The overall volume of subcutaneous fat usually diminishes
with aging. Distribution changes as well; eg, there is a relative decrease in
subcutaneous fat on the face and hands but a relative increase on the thighs and
abdomen. These changes can alter the appearance of the face and hands and
reduce the pressure diffusion over bony areas that prevent some pressure ulcers
and fractures.
Hair: Hair substantially grays in about 50% of people by age 50,
apparently due to loss of melanocytes. Although the degree of hair graying often
runs in families, the responsible genes are unknown.

Linear growth rate decreases with aging because the follicular


keratinocytes that normally differentiate to form the hair shaft proliferate more
slowly. Hair loss (more correctly, conversion from terminal to vellus hairs) in the
vertex and frontotemporal regions (androgenetic alopecia) in men begins
between the late teens and the late 20s; by the time they reach their 60s, 80% of
men are substantially bald. In women, the same pattern of hair loss may occur
after menopause, although it is rarely pronounced. Hair thinning, or diffuse hair
loss, sometimes termed female alopecia, is more correctly termed miniaturization
of hairs. The cause is a shortened anagen (growth) phase and decreased
proliferation of follicular keratinocytes. Diffuse hair loss normally occurs in both
sexes with aging and should be distinguished from diffuse hair loss caused by
iron deficiency, hypothyroidism, chronic renal failure, undernutrition, and use of
certain drugs (especially anabolic steroids and antimetabolites).

Excessive or unwanted hair growth becomes common after menopause in


women as a result of altered estrogen-androgen balance in hormonally sensitive
hair follicles. The most distressing symptom may be the appearance of scattered
terminal hairs in the beard area. Men may notice excessive hair growth in the
eyebrows, nares, or ears.

Nails: Linear growth rate and thickness ("strength") of nails decreases


with aging because of a decrease in the proliferative rate of nail matrix
keratinocytes, which differentiate to form the nail plate. Nails become dry and
brittle and flat or concave instead of convex, often with longitudinal ridging.
Longitudinal pigment banding, common among blacks, often becomes more
pronounced with aging. Nail color may vary from yellow to gray, reflecting
changes in the nail bed. The lunulae can become poorly defined. Occasionally,
the nails become grossly thickened and distorted (onychogryphosis).

Lamellar dystrophy manifests as brittle nails with split ends or layering and
commonly occurs in elderly people, though it may also occur in middle-aged
women.
Nerves and glands: The density of cutaneous sensory end organs
decreases progressively between the ages of 10 and 90 by about 1/3. The result
is an age-related reduction in sensations of light touch, vibration, corneal
sensitivity, 2-point discrimination, and spatial acuity. The cutaneous pain
threshold increases by about 20%.

Eccrine glands decline in number by an average of 15% during adulthood.


Decreased gland secretion results in marked decreases in spontaneous sweating
in response to dry heat. These changes, compounded by decreased cutaneous
vascularity, make the elderly more vulnerable to heat. Apocrine glands also
decrease in size and function with aging, but these changes do not appear to
have any clinically significant effect (except possibly a decline in body odor).

The size and number of sebaceous glands do not appear to decrease with
aging. However, sebum production decreases by about 23% per decade,
beginning in early adulthood, probably due to the concomitant decrease in
production of gonadal or adrenal androgens, to which sebaceous glands are
exquisitely sensitive.

Immunologic function: The number of epidermal Langerhans' cells


(immune cells in skin responsible for antigen presentation) decreases by 20 to
50% during adulthood. Alterations in the production of ILs and cytokines by other
cells such as keratinocytes may also contribute to overall immunologic decline
observed in the elderly. The result is presumed to be increased susceptibility to
infections and increased incidence of neoplasms.

Q. Metabolic/Endocrine Conditions

Impaired homeostatic regulation, a hallmark of aging, occurs in many


endocrine functions but may become manifest only during stress. For example,
fasting blood glucose levels change little with normal aging, increasing 1 to 2 mg
per dL per decade of life. In contrast, glucose levels after a glucose challenge
increase much more in healthy older persons than in young adults. In some
cases, a loss of function in one aspect of endocrine function may result in a
compensatory change in endocrine regulation and associated alterations in
catabolism that maintain homeostasis. For example, the reduction in testicular
testosterone production that occurs in many older men may be partially
compensated for by an increase in pituitary luteinizing hormone secretion and a
decrease in testosterone metabolism. In other instances, compensatory changes
or alterations in hormone catabolism do not fully offset age-related impairment in
endocrine functions, as illustrated by the age-related decline in basal serum
aldosterone levels. In this case, a decline in aldosterone clearance fails to offset
the decrease in aldosterone secretion.
As with diseases in other organ systems, endocrine disorders in older
adults often present with nonspecific, muted, or atypical symptoms and signs.
Some of these presentations are well-defined syndromes that are seen almost
exclusively in older adults, such as apathetic thyrotoxicosis or hyperosmolar
nonketotic state in patients with diabetes mellitus. However, more commonly,
endocrine disorders present with subtle, nonspecific symptoms, such as
cognitive impairment, or an absence of any complaints. For example, “silent”
presentation of myocardial infarction is more likely to occur in older than in
younger patients with diabetes mellitus. Indeed, the diagnosis of
endocrinopathies such as hyperparathyroidism, diabetes mellitus,
hypothyroidism, and hyperthyroidism in older adults is commonly established as
a result of abnormalities found on routine laboratory screening.

Laboratory evaluation of older adults for endocrine disorders may be


complicated by coexisting medical illnesses and medications. For example, the
presence of serious acute nonthyroidal illness may lead to the mistaken
impression of a thyroid disorder, because of the reduction in free thyroxine (T 4)
levels and sometimes increased or decreased thyrotropin (TSH) levels in sick but
euthyroid older patients. Furthermore, ranges of normal laboratory values for
endocrine testing are commonly established in younger adults, and even age-
adjusted norms for laboratory tests may be confounded by the inclusion of older
adults who are ill. Therefore, normal ranges for healthy older people are not
available for most laboratory tests.

THYROID DISORDERS

With aging, a reduction in T4 secretion is balanced by a decrease in T4


clearance, resulting in unchanged circulating T4 levels. Triiodothyronine (T3)
levels are unchanged until extreme old age, when they decrease slightly.
However, T3 levels are commonly reduced in the setting of nonthyroidal illness
because of decreased T4-to-T3 conversion. TSH levels are unchanged or
minimally changed in healthy older people.

Because nonspecific, atypical, or asymptomatic presentations of thyroid


disease are common in older adults, laboratory testing is the most reliable way to
identify cases of hypothyroidism or hyperthyroidism in this age group. Given a
1.4% prevalence of thyroid disease in ambulatory women aged 50 and over,
some clinicians recommend routine screening with a highly sensitive TSH test,
but treatment may not affect outcomes. In addition, the prevalence of
hypothyroidism or hyperthyroidism is sufficiently high to warrant TSH testing in all
older adults with a recent decline in clinical, cognitive, or functional status, or
upon admission to the hospital or nursing home. However, the results of thyroid
function testing may be confusing in euthyroid patients with significant concurrent
illnesses, as discussed below.

Hypothyroidism
Most prevalence estimates of hypothyroidism in older adults range from
0.5% to 5% for overt disease, and from 5% to 10% for subclinical
hypothyroidism, depending on the population studied. As in younger people,
most cases of hypothyroidism in elderly people are due to chronic autoimmune
thyroiditis.

Symptoms of hypothyroidism are often muted, nonspecific, or atypical in


older adults. Some clinical features of hypothyroidism (eg, dry skin, decreased
skin turgor, slowed mentation, weakness, constipation, anemia, hyponatremia,
arthritis, paresthesias, gait disturbances, elevated myocardial band of creatine
phosphokinase) may misleadingly suggest other diseases. Furthermore, these
symptoms usually have an insidious onset and a slow rate of progression. As a
result, the diagnosis of hypothyroidism is recognized on clinical examination in
only 10% to 20% of cases in older adults, and laboratory screening is necessary
to detect most cases of hypothyroidism in this population. In addition, elderly
patients with mild hypothyroidism who develop serious nonthyroidal illness may
rapidly become severely hypothyroid, and older adults are more susceptible to
myxedema coma in this setting. Demented older people with hypothyroidism
rarely recover normal cognitive function with thyroid replacement, but cognition,
functional status, and mood may improve with treatment of the hypothyroidism.

Subclinical hypothyroidism, with elevated serum TSH and normal free T4


levels, occurs in up to 15% of people aged 65 and over, and is more common in
women. Data indicate that subclinical hypothyroidism is an important risk factor
for atherosclerosis and myocardial infarction in elderly women. The presence of
elevated thyroid antimicrosomal antibody titers portends the eventual
development of thyroid failure and overt hypothyroidism, and it is appropriate to
initiate T4 replacement therapy in these patients. Alternatively, if antibody titers
are low or are not obtained, patients should be followed with serial TSH levels
and observed for the development of symptoms and signs of hypothyroidism.
Hormone replacement is warranted in older adults with progressively increasing
TSH levels or a TSH level persistently above 10 mIU/L.

By itself, an increased TSH level is usually due to primary hypothyroidism,


but TSH levels may be transiently elevated during recovery from acute illnesses.
Therefore, the diagnosis of hypothyroidism should be confirmed with the
combination of an elevated TSH level and a decreased free T4 or free T4 index,
or by the demonstration of a persistently increased TSH level, or both. Other
potentially confusing scenarios in the diagnosis of hypothyroidism include the low
T4 syndrome, seen in euthyroid patients with severe nonthyroidal illnesses and
presenting with a decreased free T4 index without an increase in TSH levels.
Free T4 levels are usually normal in the low T4 syndrome, with elevated levels of
reverse T3. Thyroid hormone supplementation has not been shown to be
beneficial in these patients. A normal (or low) TSH together with a low free T4
level may also suggest secondary hypothyroidism, which is differentiated from
the low T4 syndrome by the presence of hypopituitarism (deficiencies in other
pituitary hormones) and decreased reverse T3 levels. Finally, older people with
primary hypothyroidism may also present with inappropriately normal TSH levels
resulting from suppression of TSH by fasting, acute illnesses, and medications
such as dopamine, phenytoin, or glucocorticoids. However, it is uncommon for
TSH levels to be suppressed into the normal range in these patients.

T4 replacement is usually initiated at a low dosage (eg, 25 μg per day) in


older adults, increasing the dose every few weeks until TSH levels normalize.
However, in patients with cardiac disease, it is prudent to begin replacement
therapy at even lower dosages (eg, 12.5 μg per day). In these patients, thyroid
replacement should not be withheld for fear of exacerbating cardiac disease;
instead, the goal is to reduce or eliminate symptoms of hypothyroidism without
causing intolerable exacerbation of symptoms, such as angina. Older adults who
are severely hypothyroid at presentation should receive larger initial T4
replacement doses of 50 to 100 μg, or as high as 400 μg intravenously for those
with myxedema stupor or coma, even if there is preexisting heart disease. Such
patients should also receive testing to exclude concomitant adrenal insufficiency
as well as stress doses of glucocorticoids prior to receiving T4 to avoid
precipitating an adrenal crisis with T4 replacement.

Thyroid hormone requirements decrease with aging because of a


reduction in clearance rate, and T4 replacement doses are as much as a third
lower in elderly than in younger adults. The average T4 replacement dosage in
older adults is approximately 110 μg per day. Overreplacement of thyroid
hormone should be avoided, because osteopenia related to increased bone
turnover and exacerbation of heart disease may occur. With correction of the
hypothyroid state, the clearance rate of medications such as anticonvulsants,
digoxin, and opiate analgesic agents may be affected, necessitating dosage
adjustments. T4 supplementation may have beneficial effects on some
parameters of cognitive and cardiac function in some older adults with subclinical
hypothyroidism, although randomized trials of such treatment have yielded mixed
results. Finally, elevations in total and low-density lipoprotein cholesterol levels in
hypothyroid patients may resolve with restoration of the euthyroid state,
suggesting that T4 replacement may reduce the risk of atherosclerotic vascular
disease in older adults with good long-term survival prospects.
Hyperthyroidism
Hyperthyroidism develops in 0.5% to 2.3% of elderly people, and 15% to
25% of all cases of thyrotoxicosis occur in adults aged 60 and over. In the United
States, most cases in older adults are due to Graves’ disease, but toxic
multinodular goiter and autonomously functioning adenomas are more common
in older than in young adults, especially in populations with low iodine intake.

Hyperthyroidism often presents with vague, atypical, or nonspecific


symptoms in frail older patients. Many findings that are common in younger
adults (eg, tremor, heat intolerance, tachycardia, ophthalmopathy, increased
perspiration, goiter, brisk reflexes) are less common or absent in older persons,
whereas other manifestations, such as atrial fibrillation, congestive heart failure
signs and symptoms, constipation, anorexia, muscle atrophy, and weakness, are
more common in older adults. Older persons may present with apathetic
thyrotoxicosis, a well-known clinical presentation of hyperthyroidism that is rarely
seen in younger persons, in which the usual hyperkinetic presentation is replaced
by depression, inactivity, lethargy, or withdrawn behavior, often in association
with symptoms such as weight loss, muscle weakness, or cardiac symptoms. A
low TSH level is associated with a threefold higher risk of developing atrial
fibrillation within 10 years, and hyperthyroidism is present in 13% to 30% of older
people with atrial fibrillation. Hyperthyroidism is a cause of secondary
osteoporosis and should be considered in the evaluation of patients presenting
with decreased bone mass.

A highly sensitive TSH test is adequate as an initial test for


hyperthyroidism in relatively healthy older patients, but the diagnosis should be
confirmed with a free T4 test. Most asymptomatic older adults with low serum
TSH levels are euthyroid and have normal T4 and T3 levels, with normal TSH on
repeat testing 4 to 6 weeks later. In addition, serious illnesses, malnutrition, and
medications such as glucocorticoids, dopamine agonists, and phenytoin may
suppress TSH levels. T3 thyrotoxicosis, with elevated T3 but normal T4 levels,
occurs in a minority of hyperthyroid patients, but it is more common with aging,
especially in patients with toxic adenomas or toxic multinodular goiter. However,
in contrast to young adults, many older persons with hyperthyroidism do not have
increased T4 or T3 levels, probably because of decreased conversion of T4 to T3
associated with aging and nonthyroidal illness. Diagnostic confusion may
occasionally occur in euthyroid patients with conditions or medications causing
elevated T4 levels (high T4 syndrome). The high T4 syndrome may occur with
drugs or illnesses that decrease T4-to-T3 conversion (high-dose glucocorticoids or
β-blocking agents, acute fasting) or that increase circulating levels of thyroid-
binding globulin (estrogens, clofibrate, hepatitis).

Subclinical hyperthyroidism is present in less than 2% of elderly people


and is associated with adverse cardiovascular events such as atrial fibrillation,
osteoporosis, and neuropsychiatric effects. Accordingly, treatment for this
condition may be justifiable, but there is a lack of data from randomized,
controlled trials to support this approach.
Thyroid scanning and measurements of radioactive iodine uptake may be useful
in confirming hyperthyroidism and defining the cause. Radioactive iodine therapy
is the treatment of choice for most older people with hyperthyroidism. Higher or
repeated doses are often necessary for patients with toxic multinodular goiter.
Antithyroid drugs such as propylthiouracil are given prior to radioactive iodine, to
control symptoms and to avoid a worsening of thyrotoxicosis due to transient
release of thyroid hormone after radioactive iodine. β-Blocking agents are helpful
to manage symptoms such as tachycardia, tremor, and anxiety, but patients
should be monitored for changes in cardiopulmonary function. Following
radioactive iodine therapy, patients should be followed with serial TSH levels for
the eventual development of hypothyroidism, or persistent or recurrent
hyperthyroidism. With resolution of hyperthyroidism, the clearance rate of other
drugs may decrease, necessitating dosage adjustments to avoid excessive drug
levels.

Nodular Thyroid Disease and Thyroid Cancer


The incidence of multinodular goiter increases with aging, and
approximately 90% of women aged 70 years and over, and 60% of men aged 80
years and over have thyroid nodules. Most of these are nonpalpable.
Multinodular goiters often have autonomously functioning areas, but
administration of exogenous thyroid hormone to suppress these goiters may
cause iatrogenic hyperthyroidism. Older persons with multinodular goiter may
develop iodine-induced thyrotoxicosis after receiving radiocontrast or
amiodarone.

Solitary thyroid nodules are more likely to be malignant in people over 60


years of age, especially men. The incidence of differentiated thyroid cancers is
similar in older and younger adults, whereas anaplastic thyroid carcinomas occur
almost exclusively in older adults. However, even well-differentiated papillary and
follicular carcinomas are more aggressive and are associated with increased
mortality in older persons. Accordingly, a new solitary nodule or an enlargement
of an existing nodule warrants a careful evaluation, including a fine-needle
aspiration.

DISORDERS OF PARATHYROID AND CALCIUM METABOLISM

Important changes occur with aging in several systems that regulate


calcium homeostasis, ultimately leading to a reduction in bone mass and in some
cases osteoporosis in older people. The net effect of these changes is to
increase circulating levels of parathyroid hormone (PTH), which increases 30%
between 30 and 80 years of age. Serum calcium levels remain normal as a result
of the increase in PTH, but the balance between bone resorption and bone
formation is altered in favor of resorption, resulting in a decrease in bone mass
and an increased risk of osteoporosis with aging.
When dietary calcium intake is low, older people are less able than younger
adults to compensate by increasing their intestinal absorption of ingested
calcium. Older adults are therefore more dependent on an adequate dietary
calcium intake, yet most take in far less calcium than they need. In addition,
vitamin D deficiency is extremely common in older adults, occurring in a third to
over half of medical inpatients, nursing-home residents, and older homebound
community-dwelling adults. However, adequate dietary calcium and vitamin D
supplementation may reverse age-related hyperparathyroidism, increase bone
mineral density, and reduce osteoporotic fracture rates.

Hypercalcemia
Primary hyperparathyroidism and malignancy-associated hypercalcemia
are the most common causes of hypercalcemia in older adults. The annual
incidence of primary hyperparathyroidism is approximately 1 per 1000, and the
disease is threefold more prevalent in women than in men. Most patients with
primary hyperparathyroidism are asymptomatic, and the diagnosis is made after
an incidental finding of hypercalcemia. When the disease is symptomatic, older
persons are more likely than younger adults to present with neuropsychiatric
symptoms such as depression and cognitive impairment, neuromuscular
symptoms such as proximal muscle weakness, or osteoporosis. In addition to
hypercalcemia, laboratory findings of primary hyperparathyroidism may include
low to low-normal phosphate, elevated alkaline phosphatase levels, and
hypercalciuria. The diagnosis is confirmed with an elevated or high normal PTH
level by the use of an assay for intact PTH, in the presence of hypercalcemia.
Surgery is the treatment of choice for primary hyperparathyroidism with serum
calcium levels > 12 mg/dL, 24-hour urine calcium levels > 400 mg, and overt
manifestations including markedly decreased cortical bone density or
nephrolithiasis. Patients with serum calcium levels < 12 mg/dL who are
asymptomatic and managed conservatively should avoid thiazide diuretics,
dehydration, and immobilization; serum calcium, 24-hour urine calcium,
creatinine clearance, and bone densitometry should be monitored. In addition,
these patients should be followed clinically for the development of nephrolithiasis,
minimal trauma fractures, and neuropsychiatric or neuromuscular symptoms.
Medical management options for hyperparathyroidism also include β-blocking
agents, estrogens in women, oral phosphate in patients with low serum
phosphate levels and good renal function, and possibly bisphosphonates.

Patients with nonparathyroid causes of hypercalcemia have undetectable


or markedly decreased PTH levels. In hospitalized patients, the most common
cause of hypercalcemia is a malignancy that produces PTH-related peptide, with
hypercalcemia resulting primarily from increased net bone resorption. The
presence of an underlying cancer is usually evident on examination and routine
diagnostic testing. Squamous cell cancers of the lung or head and neck are
common causes of hypercalcemia due to PTH-related peptide production. Other
common malignancies associated with hypercalcemia include breast cancer,
lymphoma, and myeloma, although the mechanism of the hypercalcemia is
different for many of these cancers. Acute treatment for hypercalcemia includes
volume replacement with intravenous saline, followed by diuresis with a loop
diuretic when rehydration is complete. A parenteral bisphosphonate such as
pamidronate should be given, along with treatment of the underlying malignancy,
if possible. In addition to their usefulness in the treatment of hypercalcemia,
bisphosphonates may decrease bone pain and the risk of pathologic fractures in
patients with osteolytic bone metastases from a variety of cancers.

Paget’s Disease of Bone


Paget’s disease is characterized by localized areas of increased bone
remodeling, resulting in a change in bone architecture and an increased
tendency to deformity and fracture. Its prevalence increases with aging, affecting
2% to 5% of people aged 50 years and over. Paget’s disease is usually
asymptomatic and is often diagnosed as an incidental finding on radiographs or
during evaluation for an unexplained elevation in serum alkaline phosphatase.
The most commonly affected sites are the pelvis, spine, femur, and skull. When
Paget’s disease is symptomatic, pain is the most common presenting symptom,
either localized to the affected bones or resulting from secondary osteoarthritic
changes, often in the hips, knees, and vertebrae. When bone deformities occur,
the long bones of the lower extremities are usually affected, often with a bowing
of the involved extremity. Skull involvement may result in compression of the
eighth cranial nerve and sensorineural hearing loss. Treatment is not usually
necessary for asymptomatic disease, unless there is concern for hearing loss
from skull involvement, nerve root or spinal cord compression from vertebral
involvement, or hip fracture from femoral neck involvement. Bisphosphonates
suppress the accelerated bone turnover and bone remodeling that is
characteristic of this disease, and they are the treatment of choice. During
treatment, patients should be monitored clinically for changes in bone pain, joint
function, and neurologic status, and with biochemical indices of bone formation
(eg, serum osteocalcin or bone-specific alkaline phosphatase) or resorption (eg,
urinary N-telopeptide), or both.

HORMONAL REGULATION OF WATER AND ELECTROLYTE BALANCE

Unlike young adults, older persons are predisposed to both volume


depletion and free water excess. This impairment in regulation of volume status
and osmolality is multifactorial, reflecting alterations in antidiuretic hormone
(ADH) secretion, osmoreceptor and baroreceptor systems, urine-concentrating
capability, renal hormone responsiveness, and thirst sensation. ADH secretion
tends to be excessive in older people, with normal to elevated basal ADH levels,
increased ADH responses to osmoreceptor stimuli such as hypertonic saline
infusion, and decreased ethanol-induced inhibition of ADH secretion. This state
of relative ADH excess with aging, together with the common occurrence of renal
insufficiency, congestive heart failure, hypothyroidism, and diuretic use,
predisposes older adults to hyponatremia by impairing free water clearance.

Under other circumstances, older people are at increased risk of volume


depletion. With aging, basal aldosterone secretion declines disproportionately to
the decrease in clearance, with a net reduction in circulating aldosterone levels of
about 30% by the age of 80 years. At the same time, atrial natriuretic hormone
secretion (and renal responsiveness to this hormone) increases with aging. Atrial
natriuretic hormone inhibits aldosterone production and causes natriuresis and
diuresis through its effects on the kidneys. Taken together, these changes
predispose older people to volume depletion by decreasing the ability of the
kidneys to conserve sodium under conditions of fluid deprivation. Baroreceptor
ADH responses to hypotension and hypovolemia are decreased in elderly
people, placing them at additional risk of dehydration. Moreover, renal
responsiveness to ADH is decreased with aging, resulting in a decreased ability
of the kidneys to maximally concentrate urine. Finally, even healthy older adults
have decreased thirst sensation and may not be aware that they are becoming
dehydrated. Demented and immobile older people are at the highest risk for
severe dehydration.

In addition to predisposing to volume depletion, age-related


hyporeninemic hypoaldosteronism also increases the risk of hyperkalemia,
especially in patients with diabetes mellitus or renal insufficiency. The addition of
angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs,
β-blocking agents, and diuretics with aldosterone-antagonist properties may lead
to potentially lethal hyperkalemia in some of these patients.

DISORDERS OF THE ADRENAL CORTEX

Basal serum cortisol levels do not change with aging, because decreased
cortisol secretion is balanced by a decrease in clearance. Adrenocorticotropic
hormone (ACTH) stimulation of cortisol production is unchanged, and cortisol
and ACTH responses to stress and secretagogues are unimpaired with aging.
Clinically, acute cortisol responses to stress may be higher and more prolonged
in elderly than in younger adults. Accordingly, unless it is emergent, adrenal
function testing should be deferred at least 48 hours after major stressors, such
as surgery or trauma. In older patients with a normal ACTH stimulation test in
whom adrenal insufficiency is suspected, endocrinology consultation is
recommended to assist with further testing.
Hypoadrenocorticoidism
Chronic glucocorticoid therapy is also the most common cause of adrenal
failure in older adults, because of chronic suppression of adrenal function.
Recovery of adrenal axis function is variable and may take several months to
occur. Autoimmune-mediated adrenal failure is less common in older than in
younger adults, but tuberculosis, adrenal metastases, and adrenal hemorrhage in
anticoagulated patients are more common causes of adrenal insufficiency in
older persons. Older patients with chronic adrenal insufficiency may present with
nonspecific symptoms such as anorexia, weight loss, or impaired functional
status, and hyperkalemia may not be present initially. Accordingly, a high index
of suspicion is required to make the diagnosis. When adrenocortical insufficiency
is suspected, the ACTH stimulation test should be performed and therapy
initiated. In older people who are stopping chronic glucocorticoid therapy, the
replacement regimen should be tapered gradually, and stress dose coverage
should be given for major surgery and other acute physiologic stresses until
adrenocortical function has normalized.

Hyperadrenocorticoidism
Exogenous glucocorticoids are the most common cause of Cushing’s
syndrome in older adults, often causing adverse effects, including psychiatric and
cognitive symptoms, osteoporosis, myopathy, and glucose intolerance. For
patients beginning long-term glucocorticoid therapy, baseline and follow-up bone
densitometry measurements are indicated, and calcium, vitamin D, and
antiresorptive treatments such as bisphosphonates should be initiated.

Adrenal Androgens
In contrast to cortisol, circulating levels of the principal adrenal androgen,
dehydroepiandrosterone (DHEA), decline progressively with aging and are only
10% to 20% of young adult levels in octogenarians. Low DHEA levels are
associated with poor health, whereas DHEA levels are positively correlated with
some measures of longevity and functional status. Given these associations,
there is considerable interest in the potential therapeutic effects of DHEA
administration in older adults.

Some trials of up to 6 months of DHEA therapy in middle-aged and older


adults reported subjective improvements in physical and psychologic well-being,
increased serum insulin-like growth factor-I levels, and, at supraphysiologic
doses, increased lean body mass and some measures of muscle strength.
However, DHEA was found to decrease circulating high-density lipoprotein
cholesterol levels, suggesting potential long-term atherogenic effects.
Furthermore, DHEA is metabolized to estrogens and to androgens, including
testosterone and dihydrotestosterone, and its effects on the risk of breast cancer
in women and prostate cancer in men are unknown. Finally, higher doses of
DHEA may cause androgenization in some women and gynecomastia in men.
Thus, although these data are intriguing, the safety and efficacy of DHEA
supplementation have not been established, and its use is inappropriate outside
of clinical studies.

TESTOSTERONE

Despite former controversy, there is now general agreement that total and
free testosterone levels and testosterone secretion are lower in healthy older
men than in younger men. Many healthy older men exhibit moderate primary
testicular failure, with decreased sperm production, testosterone levels, and
testosterone secretory responses to gonadotropin administration. In addition,
many of these men have inappropriately normal (ie, not increased) gonadotropin
levels in the presence of low testosterone levels, suggesting secondary
(hypothalamic or pituitary) testicular failure. Overt testicular failure is common in
chronically ill and debilitated older men, manifested by total testosterone levels
well below the normal range and symptoms suggesting androgen deficiency,
including decreased libido and potency, gynecomastia, and hot flashes.
Testosterone replacement therapy is generally warranted in these patients, as in
hypogonadal young men. However, it is more common to encounter older men
with low-normal or mildly decreased serum testosterone levels and nonspecific
manifestations, such as decreased libido, weakness, decreased muscle mass,
osteopenia, and memory loss. In most cases, these manifestations have multiple
causes, but it has been hypothesized that declining testosterone levels with
aging contribute to their development, and that testosterone supplementation
may help to prevent or treat these disorders.

Men with suspected hypogonadism should be evaluated with a serum free


or bioavailable (non–sex hormone–binding globulin-bound) testosterone level,
either measured by equilibrium dialysis or calculated from measurements of total
testosterone and sex hormone–binding globulin. Concentrations of sex
hormone–binding globulin, the main circulating binding protein for testosterone,
increase with age. Therefore, the age-related decline in serum free or
bioavailable testosterone is greater than that of total testosterone, and total
testosterone measurements do not accurately reflect the decrease in biologically
active testosterone with aging. Direct radioimmunoassays using “analog” kits for
free testosterone are widely used but are not recommended because they may
underestimate androgen deficiency in elderly men and overestimate androgen
deficiency in men with low sex hormone–binding globulin (eg, moderately obese
men). Luteinizing hormone and follicle-stimulating hormone levels should be
obtained. In addition, a review (and if possible, discontinuation) of medications
that may suppress gonadotropins (eg, glucocorticoids and central nervous
system–active drugs) and a prolactin level are indicated if gonadotropins are low-
normal or low in the presence of low testosterone levels. High prolactin levels
inhibit gonadotropin secretion and could be due to either a pituitary adenoma or
hypothalamic disorder. Further studies may be warranted in such patients,
including magnetic resonance imaging of the pituitary fossa and assessment of
other pituitary functions (eg, cortisol response to ACTH and T 4). Baseline bone
densitometry measurements should be obtained in men with decreased
testosterone levels to exclude osteoporosis.

Small controlled studies of testosterone supplementation in older men of


up to 3 years’ duration have reported improvements in muscle strength, lean
body mass, bone mass, cognitive functioning, and sense of well-being. However,
it is unknown whether these benefits are clinically important, or whether the
benefits outweigh the potential risks. Bearing these uncertainties in mind, a trial
of androgen supplementation may be appropriate in older men with serum total
testosterone levels < 3.0 ng/mL and clinical features suggesting hypogonadism
(eg, osteoporosis, muscle wasting or weakness, mild anemia of unclear cause,
loss of libido). However, androgen replacement therapy is inappropriate in
asymptomatic older men with low-normal total testosterone levels. In the
absence of decreased libido, erectile dysfunction in older men does not usually
respond to testosterone therapy. Men should be monitored closely for adverse
androgenic effects of treatment, including polycythemia and potential
exacerbation of prostatic disease. However, there is no direct evidence that
testosterone therapy increases the risk of prostate cancer or symptomatic benign
prostatic hyperplasia. (See also Disorders of Sexual Function.)

GROWTH HORMONE
Growth hormone secretion declines with aging, and by 70 to 80 years of
age, about half of adults have no significant growth hormone secretion over 24
hours. A corresponding decline occurs in levels of insulin-like growth factor 1,
which mediates most of the effects of growth hormone and falls to levels
comparable to growth hormone–deficient children in 40% of adults 70 to 80 years
of age.

Adults with growth hormone deficiency due to hypothalamic pituitary


disease exhibit decreased muscle strength, lean body mass, and bone density;
increased abdominal obesity; unfavorable lipid profiles; and an increased risk of
cardiovascular disease; all are reversible with growth hormone replacement.
Older adults without hypothalamic pituitary disease have many of the same
conditions, leading to the hypothesis that growth hormone supplementation may
have a beneficial effect on these clinically important age-related disorders.

Small randomized trials of growth hormone supplementation in older


adults have reported increased lean body mass and bone density, and
decreased fat mass, but no improvements in functional status were
demonstrated. Furthermore, significant side effects were common, including
carpal tunnel syndrome, arthralgias, edema, and gynecomastia. Short-term
growth hormone supplementation may improve nitrogen balance in older persons
with severe illness and catabolic states. However, growth hormone is very
expensive, and at present it is not recommended for clinical use in older people
without established hypothalamic pituitary disease.

MELATONIN
Melatonin is a hormone secreted by the pineal gland that is thought to be
involved in the regulation of circadian and seasonal biorhythms. Melatonin
secretion is inhibited by exposure to light, resulting in a marked circadian
variation in circulating melatonin levels, and its sedative effects suggest a role in
sleep induction. Production of melatonin gradually decreases throughout life after
early childhood, but the physiologic significance of this decline in melatonin
secretion is unclear. Numerous claims have been made in the lay press
regarding the “anti-aging” benefits of melatonin supplementation for various
conditions, including insomnia, immune deficiency, cancer, and the aging
process itself. Although melatonin may have sleep-inducing properties in older
people with insomnia, the long-term risks and benefits of melatonin
supplementation have not been established for insomnia or any other indication.

DIABETES MELLITUS
Diabetes mellitus is a group of metabolic diseases characterized by
hyperglycemia due to abnormalities in insulin secretion, insulin action, or both. It
is one of the most common chronic diseases affecting older persons. Estimates
of the prevalence among persons aged 65 years and over range between 15%
and 20%, with the higher rates associated with persons over age 75. Because
the disease may be asymptomatic for many years, it is estimated that one third of
older adults with diabetes mellitus are unaware of their condition. Despite the
early asymptomatic period, diabetes mellitus is a serious condition associated
with significant morbidity and a shortened survival. Older persons with diabetes
can expect a 10-year reduction in life expectancy and a mortality rate nearly
twice that of persons without this disease. When the diabetes is poorly controlled,
hyperglycemia alone can be the cause of insidious decline in an older patient,
characterized by fatigue, weight loss, muscle weakness, and functional
impairments. Complications of this disease over the longer term include loss of
vision, renal insufficiency, atherosclerosis, and neuropathies. The rates of
myocardial infarction, stroke, and renal failure are increased approximately
twofold, and the risk of blindness is increased approximately 40% in older
persons with diabetes.

Pathophysiology and Diagnosis


The American Diabetes Association classifies diabetes mellitus affecting
older adults into three types. Type 1 is the result of an absolute deficiency in
insulin secretion due to autoimmune destruction of the β cells of the pancreas.
Type 2 is most commonly due to tissue resistance to insulin action and relative
insulin deficiency. A third category is reserved for other specific types of
diabetes, such as injuries to the exocrine pancreas; endocrinopathies
characterized by excesses of hormones, such as growth hormone, cortisol,
glucagon, and epinephrine, which antagonize insulin action; drug- or chemical-
induced diabetes; infections leading to the destruction of the β cells of the
pancreas. In about 90% of cases, older adults with diabetes have the type 2 form
of the disease. This is the form in which hyperglycemia is characteristic, but
ketosis is not a common part of the clinical syndrome. The reasons for the
increased prevalence of type 2 diabetes among older persons are not fully
known; there appears to be an interaction among several factors, including
genetics, life style, and aging influences. There is a strong genetic predisposition
to type 2 diabetes. Obesity and decreased physical activity, common among
older persons, contribute to impairments in insulin action. Glucose intolerance
has also been shown to be related to aged-associated decline in pancreatic β-
cell function and to reductions with aging of the insulin-signaling mechanisms
that limit the mobilization of glucose transporters needed for insulin-mediated
glucose uptake and metabolism in muscle and fat. The heterogeneity in the
severity of hyperglycemia among older patients with type 2 diabetes is related to
the varying contributions of each of these factors in each individual.

The pathophysiology of the complications of diabetes is similar in younger


and older persons. Prolonged hyperglycemia leads to glycosylation of proteins;
the accumulation of these abnormal proteins can cause tissue damage. Also,
metabolic products of the aldose-reductase system, such as sorbitol, accumulate
in the presence of hyperglycemia. These products can impair cellular energy
metabolism and contribute to cell injury and death.
The American Diabetes Association diagnostic criteria for diabetes
mellitus published in 2001 do not include any adjustments based on age. Three
ways to establish the diagnosis of diabetes mellitus are possible, and each must
be confirmed, on a subsequent day, by any one of three methods:

• Symptoms of polyuria, polydipsia and unexplained weight loss plus a


casual plasma glucose concentration of ≥ 200mg/dL (11.1 mmol/L).
Casual is defined as any time of day without regard to time since last
meal.
• A plasma glucose concentration after an 8-hour fast ≥ 126 mg/dL (7.0
mmol/L).
• A plasma glucose concentration of ≥ 200 mg/dL (11.1 mmol/L) measured
2 hours after ingestion of 75 g of glucose in 300 mL of water administered
after an overnight fast.

During the comprehensive evaluation of a patient with suspected diabetes


mellitus, several issues deserve special attention. A drug history is important
because certain medications can contribute to hyperglycemia (eg, diuretics,
adrenergic agonists, glucocorticoids, caffeine, nicotine, alcohol, and phenytoin).
Because of the genetic determinants of diabetes, a family history of the disease
can provide useful information. Diabetes is a well-established risk factor for
atherosclerotic cardiovascular disease, so other risk factors such as smoking,
family history, hypertension, and hyperlipidemia should also be explored.

Management
The principles of managing diabetes mellitus are similar to those of
managing many other chronic illnesses. As the evidence of benefit among older,
particularly frail persons is less compelling than among Type 1 and younger Type
II diabetics, attention to tradeoffs between risk and benefit is particularly
important. It is important that the patient understands the mechanisms of the
metabolic derangements and their management, becomes fully involved in
monitoring and treating the disease and its complications, and, in conjunction
with the treating physician, sets realistic goals. These goals may vary, depending
on the patient’s preferences, level of commitment, and life expectancy, the
number and severity of coexisting health problems, and the availability of
supportive services. Other health professionals such as diabetes educators,
nurses, dietitians, pharmacists, and social workers may play an important role in
formulating a comprehensive treatment plan and in providing education and
support.

Diet and physical activity remain cornerstones of the initial and ongoing
management of patients with diabetes. The specific dietary recommendations
must be tailored for each individual, but there are guidelines that are widely
applicable. Moderate caloric restriction of 250 to 500 kcal less than usual daily
intake is a reasonable goal, unless the patient is significantly undernourished. A
low-fat diet in which calories from fat are limited to 25% to 30% of total calories is
advisable. It is often recommended that meals, especially carbohydrate intake,
be spaced throughout the day to avoid large caloric loads. Physical activity
programs should also be individualized; however, at a minimum, it is reasonable
to follow the recommendations of the Surgeon General’s Report on Physical
Activity and Health that a person accumulate at least 30 minutes of moderate
physical activity on most days.

There are many options for drug therapy in older persons with type 2
diabetes and no clearly preferred algorithm. Regimens can consist of any of the
classes of drugs, used alone or in combination. It is common to adjust the
regimen over the course of the illness as goals change, the disease progresses,
or complications develop. Sulfonylurea preparations have a long record of safety
and effectiveness. Hypoglycemia is an important side effect, and these drugs
must be used cautiously in patients with significant renal and hepatic
insufficiency, since the liver is the primary site of metabolism and they are
excreted by the kidneys. α-Glucosidase inhibitors impair the breakdown of
carbohydrates in the gut and limit absorption. The residual carbohydrates in the
intestinal lumen are responsible for diarrhea in about 25% of patients who use
this drug. The biguanide preparations also have gastrointestinal side effects and
can cause lactic acidosis in patients with renal insufficiency. It is recommended
that metformin not be prescribed to patients with a serum creatinine of 1.5 mg/dL
or greater. The thiazolidinedimes are generally well tolerated, but there is a risk
of idiosyncratic hepatic toxicity. Finally, insulin can be used effectively in patients
with type 2 diabetes. It is often possible to achieve good glycemic control with
one or two injections a day of an intermediate-acting insulin preparation. The
greatest risk of insulin therapy is hypoglycemia, which can be managed with
either oral glucose solutions or injectable glucagon.

One of the primary reasons for treating diabetes is to avoid the long-term
complications of the metabolic abnormalities. Patients with diabetes can be
asymptomatic for many years, making it difficult to date the onset of the
condition. For this reason, as soon as the diagnosis of diabetes has been
established, it is appropriate to examine the patient for early signs of
complications. Hypertension should be aggressively controlled; the Sixth Report
of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure recommends maintaining the blood pressure
below 130/85. A referral to ophthalmology is recommended to monitor the patient
for retinopathy due to diabetes, an important cause of blindness. Because
diabetes is an important risk factor for atherosclerosis, a careful examination of
the heart and peripheral blood vessels, with special attention to the feet, is very
important. Symptoms and signs of neuropathy should be explored, again, with
special attention to early sensory changes in the feet, such as loss of light touch
sensation or proprioception. Genitourinary complaints, such as recurrent cystitis,
urinary incontinence, and sexual dysfunction, can be related to diabetes. Since
the kidney is an organ commonly affected by diabetes, it is important to screen
for early glomerulopathy by measuring albumin secretion. Glomerular disease
should be suspected if more than 30 mg of albumin are measured in a 24-hour
collection of urine. It is also possible to calculate the albumin-to-creatinine ratio in
a random urine specimen. A ratio exceeding 30 μg of albumin per mg of
creatinine is considered consistent with nephropathy. If microalbuminuria is
confirmed by a second measurement within 3 to 6 months, an angiotensin-
converting enzyme inhibitor should be started in an effort to slow the progression
of renal disease. Serum lipids should also be measured to complete the detailed
evaluation of cardiovascular risk factors in patients with diabetes. According to
the National Cholesterol Education Program, among patients with diabetes, the
target low-density lipoprotein cholesterol concentration is less than 100 mg/dL.
In the United States, diabetes mellitus is a very common chronic disease among
older adults. There may be a prolonged asymptomatic period before the illness is
detected. Once it is recognized, careful attention to glycemic control and
managing the related comorbid conditions will offer the best opportunity for
minimizing the complications and extending the years of high-quality life for
patients with this disease.

R. Safe Medication Use


Pharmacotherapy in the elderly is complicated by multifactorial issues,
including age-related physiologic changes, the presence of multiple chronic
disease states, functional changes in neuropsychiatric and physical abilities, and
the patient's desire versus ability to comply with recommended therapy. Adverse
drug reactions and interactions are more common than in the general population.
Geriatric clinical syndromes such as falls, fecal impaction, incontinence, etc., can
be induced or exacerbated by prescribed and OTC pharmaceuticals as well as
"natural" or herbal supplements. Withdrawal of pharmaceuticals may also result
in significant illness.

1. Start low, go slow. Start psychotropics at ¼ to ½ of the "recommended"


starting dose.
2. Avoid drugs with a prolonged half-life when possible. Oxazepam is the
preferred benzodiazepine in older patients.
3. Review both prescribed and OTC medications/ vitamins/ herbs with the
patient on each visit.
4. Give the patient and/or the family a written list of medications, the purpose
of the drug, dosing intervals and potential side effects. Strive for once or
twice a day dosing.
5. Make sure that for every medication taken (prescribed or OTC) there is an
indication.
6. Encourage the patient (or family) to report problems with compliance, (e.g.
medication expense, personal fears of taking drugs, symptoms that may
be side effects of the medications).
7. Consider the use of anticonvulsants (e.g., valproate sodium) instead of
antipsychotics in dementia patients with overtly aggressive behavior.
8. Try to tailor a drug's known side effects to a patient's needs; for instance,
trazodone may be the ideal selection for a patient with hypertension,
insomnia/anxiety, depression and chronic pain or neuropathy.
9. When a patient has new complaints, remember that drugs can cause
illness.

S. Family Caregiving
In the past two decades, the role of informal caregivers in providing care
to older persons and the relationship of informal caregivers to nurses and other
health care providers have undergone changes as a result of sociopolitical
trends. Shifting demographic patterns have resulted in a growing number of
elders who require acute and long-term care. The change in the Medicare
system from a retrospective cost-reimbursed system to a prospective fixed
payment system has shifted the responsibility for care during recuperation,
rehabilitation, and long-term disability from institutions to individuals and families
in the community. Because of these changes, the long-term care system would
not be able to meet the needs of older persons without the services provided by
family and other lay caregivers. Consequently, informal caregivers have come to
be viewed legitimately as nurse-extenders. Informal caregivers provide most of
the nursing care to elderly in long-term care; improving the quality of that care
requires an empirically-based understanding of the structures, processes, and
outcomes of family and informal caregiving as well as the ways in which nurses
can work with informal caregivers and effect change within the caregiving
relationship.

Quality of Family Caregiving


Although most long-term home care is provided by informal care
providers, no external regulatory mechanisms exist to monitor the quality of this
care. Substantial evidence suggests that the quality of informal home care is
adequate to meet the needs of some care recipients; the quality of informal home
care, however, varies widely. Research indicates that: 1) the quality of care is
less than optimal for many care recipients, resulting in unmet physical, emotional,
and social needs; and 2) some care recipients are at high risk for abuse, neglect,
and other forms of maltreatment by their informal care providers (Giordano &
Giordano, 1983).

The study of quality of care is complicated by several factors. Researchers


and clinicians have failed to define operationally both extremes of the quality of
care continuum for informal care providers. By default, adequate to excellent
care has been defined by the absence of abuse or neglect. Operational
definitions for abuse and neglect, however, are neither definitive nor clear and,
clinically, these definitions are known to be confounded by legal issues such as
degree of intent, amount of harm, and assignment of blame (Johnson, 1986;
Phillips, 1989a). Some clinicians have tried to circumvent these problems by
defining quality of informal home care by the degree to which the recipient's
needs for physical and/or emotional support are met by the informal care
providers (O'Malley et al., 1983; Phillips, 1989a). There is, however, no
appropriate measurement standard against which the care provided by informal
care providers can be judged.

Without a measurement standard, judgments about the adequacy of home


care will continue to be confounded by variables such as socioeconomic status,
ethnicity, and the care recipient's personal characteristics. Unlike care provided
in hospitals, care outcomes in the home rely primarily on the skills and expertise
of family members and secondarily on the counseling and educational roles of
the nurse (Baines, 1984). This presents a special dilemma for the evaluation of
quality indicators. Although quality of home care has recently been discussed in
the literature, articles focus primarily on evaluating the care provided by
professionals or nonprofessional staff (Daniels, 1986; Mumma, 1987).

Other factors also contribute to the problems of studying the quality of


informal home care. For example, there are currently no acceptable alternatives
for the service provided by the informal care system. Therefore, substandard
care generally is tolerated and, to some degree, supported if identifying that care
as less than adequate could jeopardize the living arrangements and autonomy or
independence of the care recipient. In addition, prevailing social attitudes dictate
against questioning the "good intentions" of family members or violating the
sanctity of the home setting. Monitoring the quality of home care generally is
viewed as the responsibility of the care recipient and/or the care recipient's family
regardless of whether they are physically or emotionally capable of assuming
that responsibility. These factors have made it difficult to estimate the scope of
the problem of poor quality informal home care. Some research has focused on
identifying the incidence of frank elder abuse with estimates ranging from 4
percent (Pillemer & Finkelhor, 1988) to 23 percent (Steinmetz, 1983). From
clinical observations and from discussions with home health nurses and adult
protective service workers, it is clear that although these figures provide some
information about the incidence of frank abuse, they seriously underestimate the
incidence of poor quality informal home care.

Despite the complications involved in studying the quality of informal home


care, some efforts have been made to study both process and outcome. There
are several reasons why study of the processes of informal caregiving is
particularly appropriate for nurse-researchers. First, nursing is process and the
ability of nurses to effect positive caregiving outcomes is related to how care is
provided as much as to what is actually done. Second, most in-home care is
done by lay caregivers who must be taught both what to do and how to do it.
Thus, effecting positive outcomes for homebound elders is possible only if care
processes can be clearly identified and effectively taught to lay caregivers.

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