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. P. Q. R. S.
Respiratory Conditions Dermatological Conditions Metabolic/Endocrine Conditions Safe Medication Use Family Caregiving
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 selfreliance 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 blueprint 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 downgrading. 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 shortterm 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 courtappointed 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 costeffective. 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 decisionmaking 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. Openended 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 frontto-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 lowgrade 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 highlevel 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 agerelated 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-thecounter 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.
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 antiinflammatory 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 tumorinduced 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. Alphamethyl-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 antiinflammatory 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 ageadjusted 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 thyroidbinding 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 lownormal 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 chemicalinduced 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 βcell 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 angiotensinconverting 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.
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.
• http://longevity.about.com/od/longevity101/a/why_we_age.htm • HANDBOOK OF THE BIOLOGY OF AGING E.Schneider/J.Rowe (Editors) 1996 • ANNUAL REVIEW OF GERONTOLOGY AND GERIATRICS (V.21) V.Cristofalo 2001 • Hamilton, Sandy "Detecting dehydration & malnutrition in the elderly". Nursing. FindArticles.com. 10 Jul, 2009. http://findarticles.com/p/articles/mi_qa3689/is_200112/ai_n9016339/ • http://findarticles.com/p/articles/mi_qa3689/is_200112/ai_n9016339 /pg_2/?tag=content;col1 • Harrison TR, Fauci AS. Harrison's Principles of Internal Medicine. th 14 Edition. New York: McGraw-Hill, Health Professions Division; 1998. • Stephen CR, Assaf RAE. Geriatric Anesthesia: Principles and Practice. Boston: Butterworths; 1986. • Anderson, JR. Cognitive Psychology & Its Implications. 4th Edition. W.H. Freeman; 1995. • Dempster FN, Brainerd CJ. Interference and Inhibition in Cognition. San Diego: Academic Press; 1994. • Ricklefs RE, Finch CE. Aging: A Natural History. New York: Scientific American Library: W.H. Freeman; 1995. • Snyder DL, Roberts J, Friedman E. Handbook of Pharmacology of Aging. 2nd Edition. Boca Raton, Fla.: CRC Press, Inc; 1996. • Mahoney DJ, Restak RM. The Longevity Strategy: How to Live to 100 Using the Brain-Body Connection. New York: Dana Press: J.Wiley; 1998. • Matthews & Larson, 1995; Koenig, George, Meador, Blaazer, & Dyck, 1994; Idler & Kasl, 1992. • Baillie, V., Norbeck, J., & Barnes, L. (1988). Stress, social support, and psychological distress of family caregivers of older persons. Nursing Research, 37, 217-222. • http://www.ninr.nih.gov/NR/rdonlyres/87C83B44-6FC6-4183-96FE67E00623ACE0/4776/FamCare.pdf •