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Part 2 book “Essentials of clinical geriatrics” has contents: Falls, immobility , cardiovascular disorders, decreased vitality, sensory impairment, drug therapy, drug therapy, health services, ethical issues in the care of older persons, palliative care.
229 Chapter Falls AGING AND INSTABILITY Several age-related factors contribute to instability and falls (Table 9-2) Most “accidental” falls are caused by one or a combination of these factors interacting with environmental hazards Aging changes in postural control and gait probably play a major role in many falls among older persons Increasing age is associated with diminished proprioceptive input, slower righting reflexes, diminished strength of muscles important in maintaining posture, and increased postural sway All these changes can contribute to falling—especially the ability to avoid a fall after encountering an environmental PART II Falls are a major cause of morbidity in the geriatric population Close to onethird of those age 65 years and older living at home suffer a fall each year Among nursing homes residents, as many as half suffer a fall each year; 10% to 25% cause serious injuries Accidents are the fifth leading cause of death in persons older than age 65, and falls account for two-thirds of these accidental deaths Of deaths from falls in the United States, more than 70% occur in the population older than age 65 Fear of falling can adversely affect older persons’ functional status and overall quality of life Repeated falls and consequent injuries can be important factors in the decision to institutionalize an older person Table 9-1 lists potential complications of falls Fractures of the hip, femur, humerus, wrist, and ribs and painful soft tissue injuries are the most frequent physical complications Many of these injuries will result in hospitalization, with the attendant risks of immobilization and iatrogenic illnesses (see Chapter 10) Fractures of the hip and lower extremities often lead to prolonged disability because of impaired mobility A less common, but important, injury is subdural hematoma Neurological symptoms and signs that develop days to weeks after a fall should prompt consideration of this treatable problem Even when the fall does not result in serious injury, substantial disability may result from fear of falling, loss of self-confidence, and restricted ambulation (either self-imposed or imposed by caregivers) Many studies suggest that some falls can be prevented The potential for prevention together with the use of falling as an indicator of underlying risk for disability make an understanding of the causes of falls and a practical approach to the evaluation and management of gait instability and fall risk important components of geriatric care Similar to many other conditions in the geriatric population, factors that can contribute to or cause falls are multiple, and very often more than one of these factors play an important role in an individual fall (Fig 9-1) 230 Differential Diagnosis and Management TABLE 9-1 Complications of Falls in Elderly Patients PART II Injuries Painful soft tissue injuries Fractures Hip Femur Humerus Wrist Ribs Subdural hematoma Hospitalization Complications of immobilization (see Chap 10) Risk of iatrogenic illnesses (see Chap 5) Disability Impaired mobility because of physical injury Impaired mobility from fear, loss of self-confidence, and restriction of ambulation Increased risk of institutionalization Increased risk of death hazard or an unexpected trip Changes in gait also occur with increasing age Although these changes may not be sufficient to be labeled truly pathologic, they can increase susceptibility to falls In general, elderly people not pick their feet up as high, thus increasing the tendency to trip Elderly men tend to develop wide-based, short-stepped gaits; elderly women often walk with a narrow-based, waddling gait These gait changes have been associated with white matter changes in the brain on magnetic resonance imaging (MRI) and with subsequent development of cognitive impairment Intrinsic factors Extrinsic factors Medical and neuropsychiatric conditions Impaired vision and hearing Age-related changes in neuromuscular function, gait, and postural reflexes FALLS Medications Improper prescription and/or use of assistive devices for ambulation Environmental hazards FIGURE 9-1 Multifactorial causes and potential contributors to falls in older persons Falls 231 Table 9-2 Age-Related Factors Contributing to Instability and Falls Orthostatic hypotension (defined as a drop in systolic blood pressure of 20 mm Hg or more when moving from a lying to a standing position) occurs in approximately 20% of older persons Although not all older individuals with orthostatic hypotension are symptomatic, this impaired physiological response could play a role in causing instability and precipitating falls in a substantial proportion of patients Older people can experience a postprandial fall in blood pressure as well People with orthostatic and/or postprandial hypotension are at particular risk for near syncope and falls when treated with diuretics and antihypertensive drugs Several pathologic conditions that increase in prevalence with increasing age can contribute to instability and falling Degenerative joint disease (especially of the neck, the lumbosacral spine, and the lower extremities) can cause pain, unstable joints, muscle weakness, and neurological disturbances Healed fractures of the hip and femur can cause an abnormal and less steady gait Residual muscle weakness or sensory deficits from a recent or remote stroke can also cause instability PART II Changes in postural control and blood pressure Decreased proprioception Slower righting reflexes Decreased muscle tone Increased postural sway Orthostatic hypotension Postprandial hypotension Changes in gait Feet not picked up as high Men develop flexed posture and wide-based, short-stepped gait Women develop narrow-based, waddling gait Increased prevalence of pathologic conditions predisposing to instability Degenerative joint disease Fractures of hip and femur Stroke with residual deficits Muscle weakness from disuse and deconditioning Peripheral neuropathy Diseases or deformities of the feet Impaired vision Impaired hearing Impaired cognition and judgment Other specific disease processes (eg, cardiovascular disease, parkinsonism—see Table 9-3) Increased prevalence of conditions causing nocturia (eg, congestive heart failure, venous insufficiency) Increased prevalence of dementia 232 Differential Diagnosis and Management PART II Muscle weakness as a result of disuse and deconditioning (caused by pain and/or lack of exercise) can contribute to an unsteady gait and impair the ability to right oneself after a loss of balance Diminished sensory input, such as in diabetes and other peripheral neuropathies, visual disturbances, and impaired hearing diminish cues from the environment that normally contribute to stability and thus predispose to falls Impaired cognitive function may result in the creation of, or wandering into, unsafe environments and may lead to falls Podiatric problems (bunions, calluses, nail disease, joint deformities, etc.) that cause pain, deformities, and alterations in gait are common, correctable causes of instability Other specific disease processes common in older people (such as Parkinson disease and cardiovascular disorders) can cause instability and falls and are discussed later in the chapter CAUSES OF FALLS IN OLDER PERSONS Table 9-3 outlines the multiple and often interacting causes of falls among older persons More than half of all falls are related to medically diagnosed conditions, emphasizing the importance of a careful medical assessment for patients who fall (see below) Several studies have found a variety of risk factors for falls, including cognitive impairment, impaired lower extremity strength or function, gait and balance abnormalities, visual impairment, nocturia, and the number and nature of medications being taken Frequently overlooked, environmental factors can increase susceptibility to falls and other accidents Homes of elderly people are often full of environmental hazards (Table 9-4) Unstable furniture, rickety stairs with inadequate railings, throw rugs and frayed carpets, and poor lighting should be identified on home visits Several factors are associated with falls among older nursing home residents (Table 9-5) Awareness of these factors can help prevent morbidity and mortality in these settings Several factors can hinder precise identification of the specific causes for falls These factors include lack of witnesses, inability of the older person to recall the circumstances surrounding the event, the transient nature of several causes (eg, arrhythmia, transient ischemic attack [TIA], postural hypotension), and the fact that the majority of elderly people who fall not seek medical attention Somewhat more detailed information is available on the circumstances surrounding falls in nursing homes (see Table 9 - 5) Close to half of all falls can be classified as accidental Usually an accidental trip or a slip can be precipitated by an environmental hazard, often in conjunction with factors listed in Table 9 - 2 Addressing the environmental hazards begins with a careful assessment of the environment Some older persons have developed a strong attachment to their cluttered surroundings and may need active encouragement to make the necessary changes, but many may simply take such environmental risks for granted until they are specifically identified Syncope, “drop attacks,” and “dizziness” are commonly cited causes of falls in older persons If there is a clear history of loss of consciousness, a cause for true syncope should be sought Although the complete differential diagnosis of syncope is beyond the scope of this chapter, some of the more common causes of syncope in Falls 233 Table 9-3 Causes of Falls TIA, transient ischemic attack PART II Accidents True accidents (trips, slips, etc.) Interactions between environmental hazards and factors increasing susceptibility (see Table 9-2) Syncope (sudden loss of consciousness) Drop attacks (sudden leg weaknesses without loss of consciousness) Dizziness and/or vertigo Vestibular disease Central nervous system disease Orthostatic hypotension Hypovolemia or low cardiac output Autonomic dysfunction Impaired venous return Prolonged bed rest Drug-induced hypotension Postprandial hypotension Drug-related causes Antihypertensives Antidepressants Antiparkinsonian Diuretics Sedatives Antipsychotics Hypoglycemics Alcohol Specific disease processes Acute illness of any kind (“premonitory fall”) Cardiovascular Arrhythmias Valvular heart disease (aortic stenosis) Carotid sinus hypersensitivity Neurological causes TIA Stroke (acute) Seizure disorder Parkinson disease Cervical or lumbar spondylosis (with spinal cord or nerve root compression) Cerebellar disease Normal-pressure hydrocephalus (gait disorder) Central nervous system lesions (eg, tumor, subdural hematoma) Urinary Overactive bladder Urge incontinence Nocturia 234 Differential Diagnosis and Management TABLE 9-4 Common Environmental Hazards Old, unstable, and low-lying furniture Beds and toilets of inappropriate height Unavailability of grab bars Uneven or poorly demarcated stairs and inadequate railing Throw rugs, frayed carpets, cords, wires Slippery floors and bathtubs Inadequate lighting, glare Cracked and uneven sidewalks Pets that get under foot PART II older people include vasovagal responses, carotid sinus hypersensitivity, cardiovascular disorders (eg, bradycardia, tachyarrhythmias, aortic stenosis), acute neurological events (eg, TIA, stroke, seizure), pulmonary embolus, and metabolic disturbances (eg, hypoxia, hypoglycemia) A precise cause for syncope may remain unidentified in 40% to 60% of older patients Drop attacks, described as sudden leg weakness causing a fall without loss of consciousness, are often attributed to vertebrobasilar insufficiency and often precipitated by a change in head position Only a small proportion of older people who fall have truly had a drop attack; the underlying pathophysiology is poorly understood, and care should be taken to rule out other causes Dizziness and unsteadiness are common complaints among elderly people who fall (as well as those who not) A feeling of light-headedness can be associated with several different disorders but is a nonspecific symptom and should be interpreted with caution Patients complaining of light-headedness should be carefully evaluated for postural hypotension and intravascular volume depletion Vertigo (a sensation of rotational movement), on the other hand, is a more specific symptom and is probably an uncommon precipitant of falls in the elderly It is most TABLE 9-5 Factors Associated with Falls Among Older Nursing Home Residents Recent admission Dementia Hip flexor muscle weakness Certain activities (toileting, getting out of bed) Psychotropic drugs causing daytime sedation Cardiovascular medications (vasodilators, antihypertensives, diuretics) Polypharmacy Low staff-patient ratio Unsupervised activities Unsafe furniture Slippery floors Falls PART II commonly associated with disorders of the inner ear, such as acute labyrinthitis, Ménière disease, and benign positional vertigo Vertebrobasilar ischemia and infarction and cerebellar infarction can also cause vertigo Patients with vertigo caused by organic disorders often have nystagmus, which can be observed by having the patient quickly lie down and turning the patient’s head to the side in one motion Many older patients with symptoms of dizziness and unsteadiness are anxious, depressed, and chronically afraid of falling, and the evaluation of their symptoms is quite difficult Some patients, especially those with symptoms suggestive of vertigo, will benefit from a thorough otological examination including auditory testing, which may help clarify the symptoms and differentiate inner ear from central nervous system (CNS) involvement Orthostatic hypotension is best detected by taking the blood pressure and pulse rate in supine position, after minute in the sitting position, and after and 3 minutes in the standing position A drop of more than 20 mm Hg in systolic blood pressure is generally considered to represent significant orthostatic hypotension In many instances, this condition is asymptomatic; however, several conditions can cause orthostatic hypotension or worsen it to a severity sufficient to precipitate a fall These conditions include low cardiac output from heart failure or hypovolemia, overtreatment with cardiovascular medications, autonomic dysfunction (which can result from diabetes or Parkinson disease), impaired venous return (eg, venous insufficiency), and prolonged bed rest with deconditioning of muscles and reflexes Simply eating a full meal can precipitate a reduction in blood pressure in an older person that may be worsened when the person stands up and lead to a fall Drugs that should be suspected of playing a role in falls include diuretics (hypovolemia), antihypertensives (hypotension), antidepressants (postural hypotension), sedatives (excessive sedation), antipsychotics (sedation, muscle rigidity, postural hypotension), hypoglycemics (acute hypoglycemia), and alcohol (intoxication) Combinations of these drug types may greatly increase the risk of a fall Many older patients are on a diuretic and one or two other antihypertensives, with consequent hypotension or postural hypotension that may precipitate a fall Psychotropic drugs are commonly prescribed and appear to substantially increase the risk of falls and hip fractures, especially in patients concomitantly prescribed antidepressants Many disease processes, especially of the cardiovascular and neurological systems, are associated with falls Cardiac arrhythmias are common in ambulatory elderly persons and may be difficult to associate directly with a fall or syncope In general, cardiac monitoring should document a temporal association between a specific arrhythmia and symptoms (or a fall) before the arrhythmia is diagnosed (and treated) as the cause of falls Syncope is a symptom of aortic stenosis and is an indication to evaluate a patient suspected of having significant aortic stenosis for valve replacement Aortic stenosis is difficult to diagnose by physical examination alone; all patients suspected of having this condition should have an echocardiogram 235 236 Differential Diagnosis and Management PART II Some elderly individuals have sensitive carotid baroreceptors and are susceptible to syncope resulting from reflex increase in vagal tone (caused by cough, straining at stool, micturition, etc.), which leads to bradycardia and hypotension Carotid sinus sensitivity can be detected by bedside maneuvers (see below) Cerebrovascular disease is often implicated as a cause or contributing factor for falls in older patients Although cerebral blood flow and cerebrovascular autoregulation may be diminished, these aging changes alone are not enough to cause unsteadiness or falls They may, however, render the elderly person more susceptible to stresses such as diminished cardiac output, which will more easily precipitate symptoms Acute strokes (caused by thrombosis, hemorrhage, or embolus) can cause, and may initially manifest themselves in, falls TIAs of both the anterior and posterior circulations frequently last only minutes and are often poorly described Thus, care must be taken in making these diagnoses Anterior circulation TIAs may cause unilateral weakness and thus precipitate a fall Vertebrobasilar (posterior circulation) TIAs may cause vertigo, but a history of transient vertigo alone is not a sufficient basis for the diagnosis of TIA The diagnosis of posterior circulation TIA necessitates that one or more other symptoms (visual field cuts, dysarthria, ataxia, or limb weakness, which can be bilateral) are associated with vertigo Vertebrobasilar insufficiency, as mentioned earlier, is often cited as a cause of drop attacks; in addition, mechanical compression of the vertebral arteries by osteophytes of the cervical spine when the head is turned has also been proposed as a cause of unsteadiness and falling Both of these conditions are poorly documented, are probably overdiagnosed, and should not be used as causes of a fall simply because nothing else can be found Other diseases of the brain and CNS can also cause falls Parkinson disease and normal-pressure hydrocephalus can cause disturbances of gait, which lead to instability and falls Cerebellar disorders, intracranial tumors, and subdural hematomas can cause unsteadiness, with a tendency to fall A slowly progressive gait disability with a tendency to fall, especially in the presence of spasticity or hyperactive reflexes in the lower extremities, should prompt consideration of cervical spondylosis and spinal cord compression It is especially important to consider these diagnoses because treatment may improve the condition before permanent disability ensues Urinary tract disorders including overactive bladder, urgency incontinence, and nocturia are also associated with falling Urinary urgency may cause a distraction, similar to the “dual-tasking” studies mentioned earlier, and thereby predispose to falls Awakening at night to void, especially among people who have taken hypnotics or other psychotropic drugs, may substantially increase the risk of falls Despite this long list, the precise causes of many falls will remain unknown, even after a thorough evaluation The ultimate test of the etiology for falls is its reversibility As noted earlier in the text, we are often better at finding putative causes of geriatric conditions than in correcting them EVALUATING THE ELDERLY PATIENT WHO FALLS Updated quality indicators for the identification, evaluation, and management of vulnerable elderly people with falls and mobility problems have recently been Falls PART II published as a component of the Assessing Care of Vulnerable Elders (ACOVE) project (Chang and Ganz, 2007) Older patients who report a fall (or recurrent falls) that is not clearly the result of an accidental trip or slip should be carefully evaluated, even if the fall has not resulted in serious physical injury A jointly developed set of recommendations for assessing people who fall has been issued by the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons (2010) A thorough fall evaluation basically consists of a focused history, targeted physical examination, gait and balance assessment, and, in certain instances, selected laboratory studies The history should focus on the general medical history and medications; the patient’s thoughts about what caused the fall; the circumstances surrounding it, including ingestion of a meal and/or medication; any premonitory or associated symptoms (such as palpitations caused by a transient arrhythmia or focal neurological symptoms caused by a TIA); and whether there was loss of consciousness (Table 9-6) A history of loss of consciousness after the fall (which is often difficult to document) is important and should raise the suspicion of a cardiac event (transient arrhythmia or heart block) that caused syncope or near-syncope or a seizure (especially if there has been incontinence) Falls are often unwitnessed, and older patients may not recall any details of the circumstances surrounding the event Detailed questioning can sometimes lead to identification of environmental factors that may have played a role in the fall and to symptoms that may lead to a specific diagnosis Many older patients will not be able to give details about an unwitnessed fall and will simply report, “I just fell down; I don’t know what happened.” The skin, extremities, and painful soft tissue areas should be assessed to detect any injury that may have resulted from a fall Several other aspects of the physical examination can be helpful in determining the cause(s) (Table 9-7) Because a fall can herald the onset of a variety of acute illnesses (premonitory falls), careful attention should be given to vital signs Fever, tachypnea, tachycardia, and hypotension should prompt a search for an acute illness (such as pneumonia or sepsis, myocardial infarction, pulmonary embolus, or gastrointestinal bleeding) Postural blood pressure and pulse determinations taken supine, sitting, and standing (after and minutes) are critical in the diagnosis and management of falls in older patients As noted earlier, postural hypotension occurs in a substantial number of healthy, asymptomatic elderly persons as well as in those who are deconditioned from immobility or have venous insufficiency This finding can also be a sign of dehydration, acute blood loss (occult gastrointestinal bleeding), or a drug side effect (especially with cardiovascular medications and antidepressants) Visual acuity should be assessed for any possible uncorrected vision impairment that may have contributed to instability and falls The cardiovascular examination should focus on the presence of arrhythmias (many of which are easily missed during a brief examination) and signs of aortic stenosis Because both of these conditions are potentially serious and treatable, yet difficult to diagnose by physical examination, the patient should be referred for continuous monitoring and echocardiography if they are suspected If the history suggests carotid sinus 237 238 Differential Diagnosis and Management TABLE 9-6 Evaluating the Elderly Patient Who Falls: Key Points in the History PART II General medical history History of previous falls Medications (especially antihypertensive and psychotropic agents) Patient’s thoughts on the cause of the fall Was patient aware of impending fall? Was it totally unexpected? Did patient trip or slip? Circumstances surrounding the fall Location and time of day Activity Situation: alone or not alone at the time of the fall Witnesses Relationship to changes in posture, turning of head, cough, urination, a meal, medication intake Premonitory or associated symptoms Light-headedness, dizziness, vertigo Palpitations, chest pain, shortness of breath Sudden focal neurological symptoms (weakness, sensory disturbance, dysarthria, ataxia, confusion, aphasia) Aura Incontinence of urine or stool Loss of consciousness What is remembered immediately after the fall? Could the patient get up, and if so, how long did it take? Can loss of consciousness be verified by a witness? sensitivity, the carotid can be gently massaged for seconds to observe whether this precipitates a profound bradycardia (50% reduction in heart rate) or a long pause (2 seconds) The extremities should be examined for evidence of deformities, limits to range of motion, or active inflammation that might underlie instability and cause a fall Special attention should be given to the feet because of deformities; painful lesions (calluses, bunions, ulcers); and poorly fitting, inappropriate, or worn-out shoes are common and can contribute to instability and falls Neurological examination is also an important aspect of this physical assessment Mental status should be assessed (see Chapter 6), with a careful search for focal neurological signs Evidence of muscle weakness, rigidity, or spasticity should be noted, and signs of peripheral neuropathy (especially posterior column signs such as loss of position or vibratory sensation) should be ruled out Abnormalities in cerebellar function (especially heel-to-shin testing and heel tapping) and signs of Parkinson disease (such as resting tremor, muscle rigidity, and bradykinesia) should be sought 492 Index INDEX DLB See dementia with Lewy bodies donepezil, 151 DR See dietary restriction drug therapy adherence’s role in successful, 362f, 363, 364t adverse reactions/interactions to, 364–365, 366t, 368–369, 369t in chronic disease management, 361 complex regimes of, 361 diagnosis for, 361 effective, 361 electronic databases for, 368–369 factors interfering with successful, 362f in geriatric patients safety/effectiveness, 361, 362f medication records for, 365 nonpharmacological factors influencing, 361, 364t, 365 pharmacodynamic changes and, 372 polypharmacy and, 362–363, 365 renal function and, 371–372, 372t tissue sensitivity and, 372 drugs See also antimuscarinic drugs; drug therapy absorption of, 370 adverse reactions to, 364–365, 366t–369t, 368–369 aged persons’ problems with, 123 antipsychotic, 373, 375t antithyroid, 315 behavioral interventions prescribed in conjunction with, 216 for constipation treatment, 224, 225t delivery system of, 370 dementia as treated with, 149, 151–152 dementia/delirium contributed to/caused by, 139, 140t depression symptoms caused by, 169t depression treated with, 151 direct-to-consumer advertising of, 362 distribution of, 370–371 excretion of, 371–372, 372t falls and, 235 geriatric patients treatment with, 216, 220 hip fractures associated with psychotropic, 376 hypnotics, 373, 375t immobility contributed to by side effects of, 249 incontinence treatment with, 216, 217t–219t, 220 interactions among, 365, 368 interactions of drug to, 368t–369t Medicare covering prescription, 389 metabolism, 371 as metabolized, 123 misuse of psychotropic, 373–376 for osteoporosis treatment, 120–121 for pain, 265, 266t pharmacodynamics, 361 pharmacokinetics, 361 pharmacology and, 369–370, 370t psychotropic, 365, 373–376 second-generation antipsychotic, 376–377 sedatives, 235, 373 sensitivity to effects of, 372 duloxetine, 178, 181, 220 dyslipidemia, 290 dyspnea, 477 E echocardiography, 292, 293 edema, 52t, 295 elder abuse risk factors for, 63 screening for, 63 electrocardiogram, 53t electrolytes, 53t electromyography (EMG), 211 EMG See electromyography end-of-life (EOL) care, 467, 469t See also hospice ADs and, 450, 452 clinician’s role in, 457–459 communication in, 458 death as discussed in, 75 decisions in, 456 for dementia patients, 460 goals of, 457t laws for, 454 legal myths about, 459 nursing home residents’ decisions about, 459–460 physical concern with patient’s functioning in, 75 values and, 458 endocrine disease, carbohydrate metabolism and, 303–308 endocrine system, aging related changes to, 8t environment aging and factors of, assessment of, 58 dementia treated with alterations in physical, 152 function barriers, 54 as function’s principle force, 119 of geriatric patients, 18, 58 Index physiological/functional changes with age to, 341–342, 342t tear secretion function of, 341–342 F falls age-related factors contributing to, 229–232, 233t causes of, 229–236, 230f, 233t–234t, 244t complications of, 229, 230t consciousness loss after, 237 disease processes associated with, 235 drop attacks causing, 232, 234 drugs and, 235 environmental hazards for, 232, 234t evaluation of geriatric patient who, 236–239, 238t–239t, 240t–241t, 242 fear of, 229 feet and, 238 gait/balance assessment after, 239, 240t–241t, 242 hip fractures from, 229 history in evaluating, 238t management of patient with history of, 242–243, 243t neurological examination following, 238 in nursing homes, 232, 234t physical examination of aged persons who, 237, 239t physical therapy for, 243 polyneuropathy increasing risk of, 356 prevention, 229 syncope and, 235 treatment for underlying causes of, 244t unwitnessed, 237 vertigo and, 234–235 famciclovir, 330 fatigue, 48 fear, of falls, 229 fecal impaction, 196 feeding, artificial, 460 feet, 238 fever, 168 fiber, dietary, 324 fibroblasts, 11 FIM See Functional Independence Measure folate deficiency, 320–321 foster care See adult foster care homes frailty causes of, 471 indicators of, 472 palliative care focus and, 471–472, 471t symptoms of, 471, 471t INDEX immobility from changes in, 247, 249 of immobilized patient, 251 influencing, 123 psychological, 119–120 EOL See end-of-life care eplerenone, 284 Epo See erythropoietin error catastrophe theory, 10–11 erythropoietin (Epo) anemia and, 321 levels, 321–322 escitalopram, 178 estrogen, 151 oral, 220 for stress incontinence, 220 therapy, 280 ethics ageism and, 447 of autonomy, 447 of caregivers, 462–463 committees, 455, 460 in geriatrics, 447 laws v., 454 of medicine, 456 evaluation See also assessment; geriatric assessment; preoperative evaluation for dementia, 145–149, 146t, 148t dietary, 319 essential aspects of geriatric, 41–44, 42f, 43t of gait, 49 of geriatric patient who falls, 236–239, 238t–239t, 240t–241t, 242 of hearing aids, 355–356, 355t of hypertension, 279–280, 279t of incontinence patients, 199–206, 200t, 202f–203f, 204t, 207t–208t, 209f strategies for geriatric, 44 evolution theory, as theory of aging, 10 examination See mental status examination; physical examination exercise, 66–67 benefits of, 117, 267–268 in depression treatment, 177 diabetes and, 304 for geriatric patients, 116 for immobility prevention, 267–268 for PD therapy, 260 pelvic muscle, 209–210, 211 types of, 116, 117t eyes age-related macular degeneration, 345–346 corneal endothelium, 341 493 494 Index Framingham Eye Study, 342, 344, 345 function assessment tools for status of geriatric, 56–58 environment as principle force of, 119–120 environmental barriers to, 54 in geriatrics as preserved, 119 as geriatrics component, 52 hip fractures causing decline in, 256 improvement/preservation of, 119 as influenced, 52–54 measuring physical, 56–57, 56t mental, 56–58 motivation and, 54 organ, physical barriers to, 119 principal forces of, 119 psychological barriers to, 54 psychological environment for, 119–120 testicular, 318 functional incontinence, 199 Functional Independence Measure (FIM), 57 G INDEX gabapentin, 330 gait changes in, 230, 233t evaluation of, 49 after fall as examined, 239, 240t–241t, 242 training, 243 galantamine, 151 gastrointestinal system, aging-associated changes with, 7t genes aging regulated by, 11 Alzheimer disease and, 13 cloning, 12 genetics in biological aging regulation, hormone signaling and, 13 geriatric assessment approaches to, 42–43 common physical findings in, 50t–52t controlled trials of, 42, 43t effectiveness of, 43 environmental assessment in, 58 of functional abilities, 42 functional assessment in, 49–58, 55t histories as taken in, 44–48, 46t–47t in-home, 42 laboratory assessment in, 49, 53t nutritional assessment in, 59–61, 60t–61t perspective required for, 41 physical exam in, 49, 50t–52t, 53t sensitivity during, 41 setting of, 41 social history as component of, 48 techniques for, 42 term as used, 43 as tested, 42 geriatric care communication in, 383 normal v pathologic aging and, team care implied by, 383 geriatric consultation comprehensive, 61, 63 request for, 61, 63, 64t–67t for specific clinical issues, 61, 63, 64t–67t systematic screening strategy for, 64t geriatric disease management end-of-life care in, 75–76 specific areas of, 75–76 geriatric patients antidepressants for, 179t–180t, 373 bipolar affective disorder in, 160 cognitive impairment exhibited by, 133 demography of, 23–38 depression in, 114–115 diabetic retinopathy in, 346–347 drug therapy adherence by, 363, 364t drug therapy’s safety/effectiveness for, 361, 362f drug treatment for, 216, 220 environment of, 58 as evaluated after falls, 236–239, 238t–239t, 240t–241t, 242 evaluation of, 41–67 exercise for, 116 factors influencing, 41–42 federal programs for, 393t–395t functional assessment in population of, 55t glaucoma in, 344–345 growth in number of, 25–28, 26t histories of, 44 insomnia in, 377 laboratory assessment of, 49, 53t LTC of, 392, 396 muscle strength as graded in immobilized, 252t nonpharmacological approaches, 376 occupational therapy in immobility management of, 269, 270t physical appearance of depressed, 162–164 preoperative evaluation of, 63, 66–67, 66t rehabilitation of, 268t–270t risk-benefit ratio of treatments for, 71, 72f Index H handicaps, disabilities v., 29 health-care nature of, 383–384 public programs for, 384 spending on, 383–384, 383f health-care providers See nurse practitioners; physicians health promotion popularity of, 93 web-based resources for, 16t healthy people report card, 95t hearing See also hearing aids aging-related changes to, 8t, 347, 349, 350f, 352–353, 352t aspirin caused impairment of, 354 assessment, 351–352, 351t aural rehabilitation for, 355–356 binaural tests for, 351, 351t cerumen and loss of, 354, 354t cochlear implants for, 356 communication difficulty from loss of, 355 consonant sounds, 352 difficult speech tests for, 351, 351t disorders, 352–355, 354t impaired, 135 loss screening tests, 347, 349 loudness and, 351–352 loudness as perceived in, 353 middle ear implant, 356 progression of loss of, 352 sensitivity, 353 sound localization and, 353–354 for speech, 352 standard tests for, 351, 351t tinnitus and, 354 tympanic membrane scarring caused loss of, 354 hearing aids counseling for, 355 evaluation of, 355–356, 355t expectations for, 355 use of, 355–356 Hearing Handicap Inventory for the ElderlyScreening, 347, 349 heart disease, 28 ischemic, 67 risk factors for, 118 heat stroke complications of, 333t as defined, 332 mortality for, 332 hepatocytes, 11 herpes zoster (HZ) aging increasing incidence of, 330 pain and, 330 high-risk patients identifying, 79 interventions for, 79–80 INDEX risk factors for functional decline in hospitalization, 126t social history of, 48 young patients v., 71 geriatric prescribing as difficult, 373 general principles for, 373, 374t geriatrics ethics in, 447 function as component of, 52 function as preserved in, 119 functional assessment concepts in, 55t infections in, 18 mobility in, 247 presenting problems in, 19–20 public programs in, 384–392 syndrome, 18–19 gerontological aging, GH See growth hormone ginko biloba, 151 glaucoma angle-closure, 344–345 blindness caused by, 342 as characterized, 344 chronic open-angle, 345 in geriatric patients, 344–345 primary, 344 treatment for, 345 glucosamine, 253 glucose, 53t glucose intolerance aging and, 303 diabetes and, 303 goiter, 311, 315 gout acute phase of, 254 as characterized, 254 definitive diagnosis of, 255 treatment of, 255 growth hormone (GH), 13 as antiaging treatment, 13 signaling, 13 Guillain-Barré syndrome, 356 495 496 Index INDEX hip fractures, 120 anthroplasty and, 257 from falls, 229 functional decline following, 256 location of, 256, 256f management of, 257 prophylaxis in patients with, 257 psychotropic drugs associated with, 376 subcapital, 256 histories See also medical histories; social history in fall evaluations, 238t of incontinence patients, 200, 201t HNK coma See hyperosmolar nonketotic coma home care eligibility for, 412 growth of, 413 independent vendors for, 413–414 Medicaid funds for, 412–413 under Medicare, 412 services for, 412 services received in, 412 types of care involved in, 411, 411t hormone replacement therapy (HRT), 116, 121 hormone signaling, genetics and, 13 hormones See anabolic hormones; growth hormones; hormone replacement therapy; thyroid-releasing hormone; thyroidstimulating hormone hospice creation of, 75–76 evaluating, 75 movement, 75 palliative care v., 467 services, 467, 468t hospital discharge diagnoses and procedures, 33t hospitals barriers presented by, 125 bathing in, 126 children in, 127 dependency bred by, 126 discharge planners of, 127–129 discharge to nursing homes, 127–128 geriatric units of, 127 hazards for patients in, 124, 125t medical errors in, 124 Medicare and stay in, 385–386 special risks of, 124–127, 124t–126t sundowning in, 125 HRT See hormone replacement theory hydralazine, 284 hypercalcemia, 196 hypercholesterolemia, 289 hyperchromasia, 321 hyperglycemia, 196 hyperosmolar nonketotic (HNK) coma, 308, 311t hyperparathyroidism, 168, 280 age of patients with, 316 laboratory tests in, 317t surgery for, 316 symptoms of, 316 hypersegmented neutrophils, 321 hypersexuality, 160 hypertension, 67, 117 ACE inhibitors and, 282, 284 as coronary artery disease risk factor, 289 defined, 278 diagnosis of, 279 diet and, 281 estrogen therapy and, 280 evaluation of, 279–280, 279t as ischemic stroke risk factor, 285 lifestyle changes for, 281 medications for, 281–282, 281t, 283t, 284 as remediable, 277 renovascular, 280 as risk factor, 278 risk factors for, 281 secondary forms of, 280, 280t specific therapy for, 281–282, 284 systemic, 292 thiazide diuretics and, 281, 281t treatment of, 280–281 hyperthermia clinical presentation of, 332t complications from, 332 manifestations of, 332 prevention of, 334 hyperthyroidism, 168 See also subclinical hyperthyroidism diagnosis of, 315 masked, 315 symptoms of, 315 therapy for, 315 hypnotics, 373, 375t hypoglycemics, 235 hyponatremia, 168, 220 causes of, 317 hypotension, orthostatic, 235 hypothermia clinical spectrum of, 330–331, 331t complications with, 331 as defined, 330 diagnosis of, 331 Index hypothyroidism and, 331 mortality for, 332 passive rewarming and, 332 therapy for, 331–332 hypothyroidism, 168 age of patients with, 311 diagnosis of, 311, 312t hypothermia and, 331 iodide-induced, 311 laboratory abnormalities accompanying, 312 prevalence of, 312 subclinical, 313 symptoms of, 312 tests for, 312t therapy for, 313 TSH stimulation test for, 312 undiagnosed, 312 hypoxia, 168 HZ See herpes zoster I INDEX IADL See instrumental activities of daily living iatrogenesis in geriatrics, 18 prevention of, 121–124, 123f risk of, 19 iatrogenic diseases, prevention of, 93 idiopathic hypertrophic subaortic stenosis (IHSS) documentation of, 293 as misdiagnosed, 293 symptoms of, 293 IGF-1 See insulin-like growth factor-1 IHSS See idiopathic hypertrophic subaortic stenosis immobility See also bed rest assessing patients with, 251–253, 251t, 252t bone turnover exacerbated by, 249 causes of, 19, 247–249, 248t complications of, 249–250, 250t constipation and, 250 as defined, 247 depression in patients with, 249 DJD and, 247 drugs’ side effects contributing to, 249 environment of patient with, 251 environmental causes of, 247, 249 exercise for preventing, 267–268 in geriatrics, 18 management of, 253–257, 254t, 256f, 258t–259t, 260–264, 262t, 263t, 264–266, 266t, 267–271, 268t–270t muscle strength as graded in geriatric patients with, 252t musculoskeletal complications associated with, 249 occupational therapy for management of, 269, 270t pain as cause of, 264 physical changes causing, 247, 249 physical examination for patients with, 251 prevention, 267–268 psychological factors for, 247, 249 skin management in patients with, 249, 252, 261, 263t after stroke, 247 immune deficiency, in geriatrics, 18 immunization, 113 for influenza, 328 impotence, in geriatrics, 18 incontinence acute, 192, 195t adverse affects of, 187, 188t age-related changes contributing to, 191, 193f artificial urinary sphincter and, 221 bacteriuria and, 202–203 behavioral interventions for, 208–211, 212t–213t, 213–216 bladder capacity and, 191 bladder record and, 202f bladder training for, 208, 211, 213 caregiver-dependent interventions for preventing, 213–216 catheters in management of, 221–222, 223t causes of, 190–193, 193f, 194t–195t, 195–196, 198t characteristics of, 200 as defined, 187 drug treatment for, 216, 217t–219t, 220 estrogen for stress, 220 evaluation of patients with, 199–206, 200t, 202f–203f, 204t, 207t–208t, 209f external catheters for intractable, 221 factors contributing to, 206 fecal, 222–226, 224t fecal impaction and urinary, 196 functional, 199 general principles of management of, 206, 208 geriatric assessment and, 48 in geriatrics, 18 history of patients with, 200, 201t identifying, 199–200 impact of, 200, 201t involuntary detrusor contractions and, 192 497 498 Index INDEX incontinence (Cont.): management of, 206–222, 210t–211t, 212t–213t, 215t, 217t–219t, 223t medications causing, 196 medications for, 195t monitoring record for, 203f neurological disorder causing fecal, 222 nocturnal, 220 as nursing home placement factor, 37t overactive bladder v., 198–199 overflow, 196, 197f, 220 pathophysiology of geriatric, 188 pelvic muscle exercises for, 209–210, 211 persistent, 196–199, 197f, 198t, 200t physical exam for, 201, 204, 204t postvoiding residual determination, 204 prevalence of urinary, 187, 188f reversible factors contributing to, 192–193, 194t–195t, 195–196 screening for, 199 self-monitoring for urinary, 208 severity of, 187 social perception of, 187 stress, 190, 191, 196, 197, 197f, 220 surgery for urinary, 221 treatment options for, 206, 210t–211t types of, 196, 198t, 199 types of persistent, 196, 198t undergarments/pads for, 206 urgency, 197, 197f, 216, 220 urinary retention with overflow, 196 urological v neurological disorders causing, 190 incretin mimetics, 305 independence, 15 See also Functional Independence Measure of residents in assisted living, 410 infections in aged persons, 326–330, 326t factors predisposing aged persons to, 326t in geriatrics, 18 immunosuppression as predisposing factor for, 326 morbidity associated with, 327 pathogens causing common, 327–328, 328t presentation of, 327 primary, 329 urinary tract, 327 influenza, 28 immunization against, 328 informed consent, 455 competence and, 448–450 insight, as assessed, 134 insomnia depression and, 165–166 evaluating complaint of, 165t factors underlying, 165t in geriatrics, 18, 377 instability age-related factors contributing to, 229–230, 233t aging and, 229–232, 233t in geriatrics, 18 instrumental activities of daily living (IADL) independence, 15 tasks included in, 29–30 insulin therapy, for diabetes, 307, 309f–310f insulin-like growth factor-1 (IGF-1), 317 insurance decision to purchase, 391 Medigap, 387 private, 391 integumentary system, aging-associated changes with, 6t intellectual impairment, in geriatrics, 18 interventions behavioral, 176, 208–211, 212t–213t, 213–216 for depression, 176, 184 drugs in conjunction with behavioral, 216 for high-risk patients, 79–80 for incontinence, 208–211, 212t–213t, 213–216 lifestyle, 15 for OA, 253 for slowing aging, 13 intraocular lens, 344 intrinsic sphincter deficiency (ISD), 197 iodide, 311 iron, 53t See also total iron-binding capacity anemia caused by deficiency of, 319 dietary evaluation for, 319 identifying deficiency in, 319 replacement for deficiency in, 319 treatment of deficiency in, 319 ischemic stroke, risk factors for, 285, 286t, 288 ISD See intrinsic sphincter deficiency J judgment, as assessed, 134 justice, principle of, 447, 448t, 456 Index L laboratory assessment in geriatric assessment, 49, 53t parameters of, 53t laws AD and, 455 for end-of-life care, 454 ethics v., 454 leukopenia, 321 levodopa, 257 life expectancy, life span v., 3–4 lifestyle behaviors, interventions and aging, 15 lip reading, 353 living will AD v., 450, 452 power of attorney component of durable, 451t, 452 long-term care (LTC), 30f community, 414t dynamic nature of, 404, 404t family as heart of, 30 nursing home in, 35 quality of, 82–84 spending on, 399f types of, 403f women as caregivers for, 30 loudness as perceived in hearing, 353 recruitment, 353 LTC See long-term care lung disease, 67 lymphocytes, 12 M INDEX macrocytosis, 321 macrovascular disease, 307 macula, degeneration of, 345–346 macular, degeneration, 342 magnetic resonance imaging (MRI), 144 malnutrition, 60–61 assessing for, 61t in geriatrics, 18 protein-energy, 60 risk factors for, 61t mammalian TOR (mTOR), 14 managed care for nursing home patients, 408 potential of, 387 MCI See mild cognitive impairment MDRD See Modification of Diet in Renal Disease MDS See minimum data set Medicaid coverage of, 384, 385f, 388 expenditures, 386f, 390 home care funded by, 412–413 Medicare v., 35, 384 nursing home payments by, 390 reimbursement policies of, 424–425 sentiment around, 390–391 as welfare program, 389 medical care cost of, 25 cure v., 73, 73f expectations of, 381 observed v expected outcomes of, 381, 382f office visits for, 34t technology’s growth in, 32 therapeutic model driving, 381 medical futility, 456 medical histories aspects of geriatric, 46t–47t, 48 in dementia evaluation, 145–147, 147t difficulties in taking, 45t in geriatric assessment, 44–48, 46t–47t of geriatric patients, 44 pain and, 59t techniques for taking, 44 medical orders for life-sustaining treatment (MOLST), 453–454 Medicare, 381 beneficiaries, 26, 27t, 387–388 coverage, 384, 386f, 388 as designed, 384 eligibility for, 385–387 as in flux, 384 home care under, 412 hospital/posthospital stay paid for by, 386 Medicaid v., 35, 384 outpatient prescriptions covered by, 363 payment system of, 384 physicians and, 388 PPS with, 32 prescription drugs covered by, 389 preventive services covered by, 96t–110t, 112–113 public dollars for, 27 readmissions, 32 reimbursement policies of, 424–425 Medicare Modernization Act, 389 499 500 Index INDEX medications See also antidepressants; drug therapy; drugs antiaging, 13 cost of, 111 for dementia, 149, 151–152 for hypertension, 281–282, 281t, 283t, 284 inappropriate prescribing of, 364–365 for incontinence, 195t incontinence caused by, 196 management, 19 for OA, 253 ophthalmic, 349t ototoxic, 354 for PD, 257, 258t–259t prevention strategy with, 111 prophylactic management of, record, 362, 363f, 365 medicine, ethics of, 456 Medigap insurance, 387 meglitinide analogues, 305 memory components of, 134 loss, 152 mental status examination abnormal thought content in, 134 cognitive functioning in, 134 judgment/insight as assessed in, 134 key aspects of, 133–134, 134t mood/affect of patient during, 135 meperidine, 267 metabolic bone diseases, 316, 317t metabolism See also carbohydrate metabolism; oxidative metabolism drug, 371 metformin, 305 methylnaltrexone, 475 MI See myocardial infarction middle-ear disease, 352 mild cognitive impairment (MCI), 135 dementia v., 140 mini-cog, 133, 145 Minimum Data Set (MDS), 57 mirtazapine, 178, 181 mitral insufficiency, 293 mitral ring calcification, 292 mitral valve, prolapse, 293 mobility in geriatrics, 247 optimizing, 247 Modification of Diet in Renal Disease (MDRD), 372 MOLST See medical orders for life-sustaining treatment motivation function and, 54 in prevention, 120 MRI See magnetic resonance imaging mTOR See mammalian TOR muscle, weakness, 52t, 231 musculoskeletal system, aging associated changes with, 7t myocardial infarction (MI), 168 acute, 290 frequency of, 289 risk of stroke after, 288 symptoms of, 290, 290t myxedema coma care of patients with, 315 cases of, 313, 314t therapy for, 315 N nausea and vomiting causes of, 476 management of, 476–477 treatment for, 476–477 neurologic system, aging associated changes with, 6t nonmaleficence, principle of, 447, 448t nonsteroidal anti-inflammatory drugs (NSAIDs), 253, 255, 265 short-term, 255 normal aging changes associated with, 4–5 pathologic aging v., nortriptyline, 330 NSAIDs See nonsteroidal anti-inflammatory drugs nurse practitioners in nursing homes, 434, 438–439 prevention and, 112 primary care by, 73 nursing home care, 31, 78 clinical aspects of, 421–422, 422t–423t goals of, 419–420, 420t improving, 401 process of, 424–425, 426t–429t, 430 special care units, 152 staff limitations in, 430 nursing homes admission to, 402, 402f, 404, 420–421 ADs in context of, 460 alternatives to, 400 Index caloric needs in, 324 deficiency and physiological impairments, 323–324 dietary restrictions and, 324–325 food additives and, 324–325 supplementation for, 324 O OA See osteoarthritis OASIS See outcome and assessment information set obesity bariatric surgery for, 325–326 diabetes and, 304 health risks of, 325 lifestyle change and, 325 prevalence of, 325 therapy for, 325–326 observation stays, in nursing homes, 36 obstructive sleep apnea (OSA) development of, 166 risks associated with, 166 occult coronary artery disease, 277, 278t occupational therapy in immobility management of geriatric patients, 269, 270t results of, 117, 119 octreotide, 473 Old Age Assistance, 389 older persons See aged persons olfactory bulbs, 356 ophthalmopathy, 315 opioids, 330 organ systems, function loss of, orthostatic hypotension, 231 OSA See obstructive sleep apnea osteoarthritis (OA) arthroscopic interventions for, 253 BMD and, 15 as characterized, 253 inflammatory arthritis v., 254, 254t pharmacological management of, 253–254 plain film radiography for assessing, 253 progression, 253 treating, 253 osteoporosis, 4, 323 delaying course of, 121 drugs for treating, 120–121 management of, 120–121 screening, 121 treatments, 120–121, 122t otosclerosis, 354 INDEX assessment approach for care in, 407, 408t care as improving in, 401 chronic catheterization patients in, 222 clinical care of residents in, 419 clinical ethical decisions about residents of, 459 common clinical disorders in population of, 421–422, 423t dementia special care units in, 152 depression in, 373 documentation practices in, 431, 432f–433f, 434 end-of-life care decisions by residents of, 459–460 ethical issues in, 442–443, 443t ethics committee of, 460 factors for placement in, 36, 37t falls in, 232, 234t in health-care delivery, 401–402, 402f, 404–406, 409 hospital discharge to, 127–128 long-stay v short-stay residents in, 35 in LTC, 35 managed care program for patients of, 408 Medicaid payments for, 390 nature of, 128 need for, 31, 36–37 nurse practitioners in, 434, 438–439 operation of, 409 patients as admitted to, 127 patients in, 71 payment systems for, 386 payments for, 406–407 physicians role in, 407 placement from hospitals to, 36 policies of, 390 postacute care and, 439, 441–442 preventive practices in, 434 pricing system used by, 386–387 regulation of, 402 residents as grouped in, 420, 420f residents of, 404–406, 405t rooms shared in, 402 strategies for improving medical care in, 430–431, 432f–433f, 434, 434t, 435t–438t, 438–439, 440f in system of care, 400 use of, 35–38, 36f, 37t nutrition See also malnutrition of aged persons as assessed, 322 aged persons requirements of, 322–323, 322t aging and, 322–323, 322t assessment, 59–61, 60t–61t, 62t 501 502 Index outcome and assessment information set (OASIS), 57 data system for, 80 outcomes in chronic care role for assuring quality, 80–81, 81t–82t, 83 components of, 83 introducing, 81 monitoring, 80 rationale for using, 81t as term, 80 use of approach of, 82–83 oxidative metabolism, 11 by-products of, 11 P INDEX PACE See Program of All-inclusive Care of the Elderly pain in aged persons, 264 antidepressants for, 265 assessment for, 58–59, 59t, 60f characterizing, 264 differentiating, 265, 266t drug therapy for, 265, 266t history aspects in assessment of, 59t HZ and, 330 immobility caused by, 264 intensity of, 60f management, 264–266, 266t, 267, 473 persistent, 58, 264, 265 as underdiagnosed, 264 palliative care, 469–470 constipation treatment, 473, 475–476 cultural challenges and, 472 diarrhea, 476 establishing, 472 frailty and focus of, 471–472, 471t hospice v., 467 management of symptoms, 473, 475–478 pain management, 473 slow medicine, 470 understand and decide on, 470–471 parathyroid disease, 316 Parkinson disease (PD), 135 dopamine-producing cells lost with, 257 exercise therapy for, 260 management of, 257, 258t–259t, 260 pharmacological treatment of, 257, 258t–259t recognizing, 257 surgery for, 260 symptoms of, 257 parkinsonism, 257 paroxetine, 178 pathologic aging, normal aging v., Patient Protection and Affordable Care Act (PPACA), 25, 381 Patient Self-Determination Act, 462 patients See geriatric patients; high-risk patients peripheral vascular disease prevalence of, 296 risk factors for, 296 screening for, 297 treatment of, 298 pets, 120 pharmacology, aging and, 369–370, 370t pheochromocytoma, 280 physical activity, benefits of regular, 15 physical examination in geriatric assessment, 49, 50t–52t of geriatric patient who falls, 237, 239t for immobile patients, 251 for incontinence, 201, 204, 204t interpreting, 49 physical therapists, 269, 368 physical therapy, for falls, 243, 269t physician orders for like-sustaining treatment (POLST), 453–454 physicians assisted suicide, 459 attitudes of, 120 as authority figures, 120 death and, 75 Medicare and, 388 in nursing homes, 407 plasticity, of older adults, 14–15 pneumonia, 28 PNH See postherpetic neuralgia POLST See physician orders for like-sustaining treatment polymyalgia rheumatica symptoms of, 254 treatment of, 254 polyneuropathy chronic, 356 demyelinating, 356 diabetes and, 356 diagnostic approach to, 357f epidemiological data on, 356 fall risk increased with, 356 symptoms of, 356 treatment of, 358 polypharmacy, 362–363, 365 Index efficacy of efforts in, 113 enthusiasm for, 112 of falls, 229 forms of, 93 generic approaches, 116–118 goals pursued in, 94 of iatrogenesis, 121–124, 123f of iatrogenic diseases, 93 of immobility, 267–268 medication in strategies of, 111 motivation in, 120 nurse practitioners and, 112 primary, 93, 111, 112 proactive primary care as, 93 screening and medicare coverage, 96t–110t secondary, 93 social support for, 118 strategies, 112 strategies for older persons in, 95t of strokes, 286–287 term as used, 93 tertiary, 93 value of, 112, 113 primary care by nurse practitioners, 73 prevention through proactive, 93 probability of repeat admissions (Pra), 65t, 79 problem-solving therapy (PST), 177 Program of All-inclusive Care of the Elderly (PACE), 382 prospective payment system (PPS) introduction of, 32 postacute care and, 32, 35 prostatic hypertrophy, 327 proteins, 322 pseudoephedrine, 220 PST See problem-solving therapy psychiatric symptoms, 478 psychopharmacology, geriatric, 373–374, 376–377 psychotherapy, for depression, 177 pyridoxine, 320 Q QALYs See quality-adjusted life years quality-adjusted life years (QALYs), 28, 461 quality of life defining, 28 geriatric assessment and, 48 maximizing, 399 questran, 476 INDEX polyuria, 196 postacute care, 32, 34t, 35 See also nursing homes delirium in settings of, 136 market for, 384 postherpetic neuralgia (PNH), 330 postvoiding residual (PVR) determination, 204 power of attorney, living will and, 451t, 452 PPACA See The Patient Protection and Affordable Care Act PPS See prospective payment system Pra See probability of repeat admissions pramlintinde, 307 prediabetes, as identified, 303 pregabalin, 330 preoperative evaluation by geriatricians, 63, 66–67, 66t summarizing results of, 65t prescriptions See also geriatric prescribing of behavioral interventions, 216 inappropriate, 364–365 Medicare covered outpatient, 363 Medicare covering drug, 389 presenilin early-onset familial Alzheimer disease and, 13 role of, 13 presenilin identification of, 13 role of, 13 President’s Council on Bioethics, 456 pressure sores development of, 261 documentation of, 264 shearing forces and, 261 pressure ulcers See also pressure sores characteristics of, 262t as classified into stages, 261 as defined, 261 management of, 261–264 prevention of, 261 risk factors for, 261 topical therapy for, 264 treatment of, 262–264 prevention, 122t activities for, 93 behavior change as component of, 115, 115f characteristics, 111–113 considerations in assessing, 94t cost v benefit in techniques of, 118 of disability, 119–120 effectiveness in older people of, 112, 113–116, 115f 503 504 Index R radiographs, chest, 53t rapamycin, 14 RBRVS See Resource-Based Relative Value Scale rehabilitation acute level of, 269 aural, 355–356 benefits of, 270–271 of geriatric patients, 268–270, 268t–270t goals of, 268 location of, 269–270 after strokes, 260–261, 288–289, 288t–289t rehabilitation therapists, 58 renal function aging effecting, 371–372, 372t drug therapy and, 371–372, 372t reproductive system, aging associated changes with, 7t Resource-Based Relative Value Scale (RBRVS), 388 resource utilization group (RUG), 425 respiratory system, aging associated changes with, 6t restless leg syndrome (RLS) incidence of, 166 sensations with, 166 Reuben’s physical performance test, 57 rigidity, 376 risk factors for AD, 143 for elder abuse, 63 for geriatric patients’ function decline in hospitalization, 126t for heart disease, 118 of iatrogenesis, 19 for malnutrition, 61t rivastigmine, 151 RLS See restless leg syndrome rotigotine transdermal patch, 260 RUG See resource utilization group INDEX S sclerosis, aortic valve, 291 screening for blindness causes, 342 for cancer, 114 for delirium, 133 for depression, 169–170, 173t diabetes, 303 for disease, 112 for elder abuse, 63 hearing loss, 347, 349 for incontinence, 199 ophthalmological, 342, 343t osteoporosis, 121 routine, 115 for tuberculosis, 329 value of, 114 sedatives, 235, 373 selective serotonin reuptake inhibitors (SSRIs), depression and, 176, 178, 179t self-help groups, 120 senile cataracts, cause of, 342 sensitivity to drug’s effect, 372 in geriatric assessment, 41 hearing, 353 tissue, 372 sensory system, aging-associated changes with, 8t serotonin syndrome, 180, 184 serum albumin, 370 serum creatinine, setraline, 178 sexual dysfunction, geriatric assessment and, 48 Short Form-36, 57 shortness of breath, 477 sick sinus syndrome diagnosis of, 295 manifestations of, 295t sirtuin, 14 sitagliptin, 305 skin friction on, 261 management in immobile patients of, 252, 261, 263t thrombosis of small blood vessels destroying, 261 slow medicine, 470 smoking, cessation of, 116–117 social history dementia and, 147 in geriatric assessment, 48 Social Security Act, 384 Social Services Block Grants, 392, 393t–395t social support for prevention, 118 systems, 118 sodium levothyroxine (Synthroid), 313 speech audiogram, 353 hearing for, 353 lip reading, 353 rapid, 353 speech therapists, 269 Index T tacrine, 151 tardive dyskinesia, 376 taste aging and, 356 aging-related changes to, 8t TCAs See tricyclic antidepressants technology computer, 84–86 in medical care, 32 for quality of care improvement, 84–86 teeth, missing, 51t telomerase, 11 temperature regulation See also heat stroke; hyperthermia; hypothermia of aged persons, 330 disorders, 330–332, 331t, 334 pathophysiology of disorder of, 330 tendinitis, 255 testicular function, decline with aging of, 318 testosterone, supplementation, 318 thiazide, 281, 281t, 282 thiazolidinediones, 305 thrombocytopenia, 321 thyroid aging and function of, 308, 311, 311t hormones, 311 thyroid-releasing hormone (TRH), test, 311–312 thyroid-stimulating hormone (TSH), 174, 311 thyrotoxicosis, 315 TIAs See transient ischemic attacks tincture of time, in geriatrics, 470 tinnitus hearing and, 354 prevalence of, 354 tissue plasminogen activator, for strokes, 286 tissues, aging, 11 total iron-binding capacity (TIBC), 319 touch, aging-related changes to, 8t tramadol, 267 transient ischemic attacks (TIAs), 285 presenting symptoms of, 287t transitional care, 74 treadmill, training, 260 TRH See thyroid-releasing hormone tricyclic antidepressants (TCAs), 179t, 181 depression and, 176, 178 pain and, 265 TSH See thyroid-stimulating hormone INDEX SSRIs See selective serotonin reuptake inhibitors Staphylococcus aureus, 326 statins, cardiovascular disease and, stem cells, therapy, 13 stress decreased response to, estrogen and, 220 incontinence, 190, 191, 196, 197, 197f, 220 response to, 17 strokes, 28, 118 See also ischemic stroke acute, 236 aspirin and, 286, 288 carotid endarterectomy and, 288 diagnosis of, 286 immobilization after, 247 incidence of, 284–285 management of, 260–261 muscle reeducation after, 289 outcomes for survivors of, 285, 285t prevention of, 286–287 rehabilitation after, 288–289, 288t–289t rehabilitative therapy for, 260–261 TIAs and, 285 tissue plasminogen activator for, 286 treadmill training in patients after, 260 treatment for, 286–288 types of, 285, 285t subclinical hyperthyroidism, 316 cause of, 316 therapy for, 316 subdural hematoma, 229 suicide, by aged persons, 160 sulfonylureas, 304 sundowning, 125, 138 surgery artificial urinary sphincter implantation through, 221 bariatric, 325–326 bladder, 221 cataract, 343 coronary artery, 290 for hyperparathyroidism, 316 for PD, 260 for urinary incontinence, 221 syncope, 232, 234 falls and, 235 Synthroid See sodium levothyroxine systolic murmurs, 51t differentiation of, 292t location of, 291 505 506 Index tuberculosis incidence of, 329 screening for, 329 tympanic membrane, scarring, 354 U ulcerations, 50t ulcers See pressure ulcers ultraviolet light, in cataract development, 343 undergarments, for incontinence patients, 206 urethra, weak, 197 urgency incontinence, 197, 216 urinalysis, 53t urinary system, aging-associated changes with, 7t urinary tract disorder, 236 urinary tract infection, 327 urination See also incontinence continence requirements, 188 normal, 188–190, 190f, 192f peripheral nerves and, 191f US Preventative Services Task Force, for screening older adults and medicare coverage, 94, 96t–110t, 113 V vaccines, 113 valacyclovir, 330 valvular heart disease, management of, 291–294 vascular disease, 352 vasopressin basal, 316 hypertonic saline and, 316 plasma, 316 secretion, 316–317 venlafaxine, 178, 181 verteporfin photodynamic therapy, 346 vertigo, 234–235 viscosupplementation, 253 vision See also eyes aging-related changes to, 8t aid to maximize function of, 349t blindness, 342, 343t after cataract surgery, 344, 344t contact lenses for, 344 functional changes in, 341–342 physiological changes in, 341–342 problems’ sign/symptoms in aged persons, 347, 348t problems with, 342 visual impairment See blindness vitality, decreased, 303–308, 306t, 309f–310f, 311, 311t–312t, 313–332, 314f, 314t, 317t, 318t, 320t, 322t, 326t, 332t vitamin(s) antioxidant, 116 supplements, 322 vitamin B, deficiency, 320–321 vitamin D, 4, 251 deficiency, 322 functions of, 323 vitamin E, 151 W Wagner model, in chronic disease management, 71 warfarin, 288 weight, 60 See also obesity changes, 50t diabetes and, 304 hypertension and, 118 loss, 117, 477 reduction, 304 Werner syndrome, 12 women, as caregivers, 30 World Health Organization, 94 INDEX ... prevention of falls in older persons 20 10 Available at: http://www.americangeriatrics.org/health_care_professionals /clinical_ practice /clinical_ guidelines_recommendations /20 10 Accessed June 16, 20 12 Bischoff-Ferrari... and vitamin D (Bischoff-Ferrari et al., 20 04; Chang et al., 20 04; Coussement et al., 20 07; Cameron et al., 20 10; Kalyani et al., 20 10; Leung et al., 20 11, Sherrington et al., 20 11) When specific... education Arch Intern Med 20 05;165 :22 93 -22 98 Ray WA, Taylor JA, Meador KG, et al A randomized trial of a consultation service to reduce falls in nursing homes JAMA 1997 ;27 8:557-5 62 Sawka AM, Boulos