Because Mr. Allen could not rise from his chair without using his upper arms, he has failed the Timed Up and Go test and thus likely had a recent fall due to use of antiarrhythmic and antidepressant medications. One in every three individuals over age 65 years suffers a fall, whereas the prevalence of elder abuse in the community is only 2%–10%. Both selective serotonin reuptake inhibitors (SSRIs) and antiarrhythmic medications are present on the 2012 American Geriatric Society Beers Criteria list and are modifiable risk factors for falls. Tricyclic antidepressants, SSRIs, anticonvulsants, antipsychotics, benzodiazepines, and nonbenzodiazepine hypnotics are to be avoided unless safer alternatives are not available. (pp. 355, 357–359, 362, 365)
Reducing this patient’s diltiazem can help decrease the risk for falls and address his bradycardia. Periodic reassessment of medication lists and deprescribing are recommended when possible to avoid polypharmacy for older adults. Rate control medications and anticoagulation, in the long run, are equal to or better than cardioversion. Compression stockings can be useful when postural hypotension contributes to falls. Reducing the patient’s sertraline, which is included on the 2012 American Geriatric Society Beers Criteria, would not be the first-line treatment due to the patient’s chronic elevated suicide risk (major depressive disorder and previous suicide attempt). (pp. 355–364)
Mr. Allen already exhibits symptoms of falls—bruises, gait, and his failed Timed Get Up and Go test—and also has risk factors such as medications and a multiple-level house that may not be equipped with safety features. Primary prevention avoids disease and disability, whereas secondary prevention targets those (like Mr. Allen) who have risk factors or preclinical disease but who are otherwise asymptomatic. Tertiary prevention involves caring for those with established disease and preventing disease-related complications. Quaternary prevention reduces excessive screening and medical intervention and decreasing harm of medical care. (pp. 16, 355)
Cancer is the most common cause of involuntary weight loss, accounting for 16%–36% of cases. Other causes include medical conditions, psychosocial issues, and medication side effects, can lead to involuntary weight loss (Table 25–1). SSRIs can lead to gastrointestinal upset. Depression, dementia, alcoholism, paranoia, and other psychiatric disorders can also lead to involuntary weight loss. Dysphagia, an inability to feed oneself, and an inability to obtain food can also cause weight loss. (pp. 362, 364)
Medications (e.g., diuretics, serotonin reuptake inhibitors, benzodiazepines, β-blockers, metformin) |
Psychiatric disorders (e.g., dementia, depression, alcoholism, anorexia nervosa, paranoia) |
Difficulty with swallowing or chewing |
Endocrinological disorders (e.g., hyperthyroidism, hypothyroidism, hypoparathyroidism) |
Gastrointestinal problems (e.g., nausea, malabsorption) |
Functional limitations (e.g., inability to feed oneself or obtain food) |
Lower socioeconomic status (e.g., availability and amount of food consumed) |
Screening for adults ages 50–75 is indicated, according to the U.S. Preventive Services Task Force (USPSTF) (Table 25–2). Routine screening is not recommended for adults ages 76–85, although there may be considerations that support colorectal cancer screening for an individual patient. Any kind of screening for colon cancer is not recommended for individuals ages 85 and older. (p. 366)
Cancer screening |
U.S. Preventive Services Task Force (2013)a |
American Geriatrics Societyb |
Breast |
Screen using mammogram biennially women ages 50–74 years Insufficient benefit and harm of screening mammography in women age 75 years or older |
Screen using mammogram annually or biennially until age 75 and at least every 3 years thereafter No upper age limit for women with estimated life expectancy of ≥ 4 years |
Cervical |
Screen with cytology for women ages 21–65 every 3 years, or combination of cytology and human papillomavirus every 5 years Recommend against screening in women older than age 65 years who have had adequate screening and are not otherwise at high risk for cervical cancer |
Screen at 1- to 3-year intervals until at least age 60 Beyond age 70, there is little evidence for or against screening women who have been regularly screened in previous years |
Colon |
Screen using fecal occult blood testing, sigmoidoscopy, or colonoscopy for patients ages 50–75 years Recommend against routine screening for patients ages 76–85 but consider individualized assessment Recommend against screening for patients older than 85 years |
No specific guidelines |
Prostate |
Recommend against screening |
No specific guidelines |
aU.S. Preventive Services Task Force: Recommendation for Adults. Rockville, MD, U.S. Preventive Services Task Force, 2013. Available at: http://www.uspreventiveservicestaskforce.org/adultrec.htm. Accessed May 25, 2013. bAmerican Geriatrics Society: “Breast Cancer Screening in Older Women.” American Journal of the Geriatrics Society 48:842–844, 2000; American Geriatrics Society: “Screening for Cervical Cancer in Older Women.” Journal of the American Geriatrics Society 49:655–657, 2001. |
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Screening questions such as this one can help assess elder maltreatment, which is a concern because this patient’s caregiver has neither refilled the patient’s medications nor taken the patient to his medical appointments. Elder abuse in this case is part of the differential diagnosis and should be assessed. However, screening for elder abuse remains controversial, because there is no standard screening tool, no universal guidance on whom to screen, and no standardized approach when abuse is identified. The USPSTF recommends against screening for someone of this patient’s age (see Table 25–2). Refilling medications may be helpful, and mirtazapine can be used to increase appetite, but this would not be the next best step because this patient’s appetite is already high. Screening for body dysmorphic disorder would not be helpful in this patient because he has no prior history of such a disorder. (pp. 365–368)
Ms. Scott will need Tdap because of a higher prevalence of pertussis infections in recent years (possibly due to attenuation of prior vaccinations) (Table 25–3). The Centers for Disease Control and Prevention recommends not delaying receipt of Tdap in patients over age 65, even if the most recent receipt of Td was within 5 years. Because it is autumn, the patient will also need an influenza vaccine. The live attenuated vaccine is available in an intranasal mist for nonpregnant patients ages 2–49 years old without high-risk medical conditions, and is therefore not recommended for the 66-year-old patient in this case. This patient can use either an intradermal or intramuscular inactivated influenza vaccine. (pp. 218–220, 369)
Vaccine |
≥ 65 years old |
Influenza |
1 dose annually |
Tetanus, diphtheria, pertussis (Td/Tdap) |
Substitute one-time dose of Tdap for Td booster; then boost with Td every 10 years |
Zoster |
1 dose (starting at ≥ 60 years) |
Pneumococcal polysaccharide 23 |
1 dose |
Pneumococcal 13-valent conjugate |
1 dose |
Source. Adapted from Advisory Committee on Immunization Practices Adult Immunization Work Group; Bridges CB, Woods L, et al.: “Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years and Older—United States, 2013. MMWR Surveillance Summary 62(suppl):9–19, 2013. |
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Regular fish consumption or omega-3 fatty acid supplemental intake is associated with decreased risk of all-cause dementia but does not prevent or treat those who already have dementia. The other listed supplements have not been supported in large clinical trials to prevent or delay cognitive decline. (p. 370)
Ms. Scott suffers from age-related macular degeneration and scotomas (blind spots) with decreased fine visual acuity. Also, although unreported, the patient likely has loss of central vision. Cigarette smoking and low levels of antioxidants are risk factors. Vitamins C and E are antioxidants, along with zinc, which can help slow the progression of moderate and advanced cases of age-related macular degeneration. Because this patient is symptomatic, this can be considered tertiary prevention, not primary prevention. An ophthalmology referral may be indicated for assistance with management. (pp. 355, 357, 361)
Although the other listed treatment options may be indicated in the future, the most important action at this time is a complete medication reconciliation. This process can facilitate the discontinuation of inappropriate medications to mitigate harmful side effects and drug-drug interactions. (pp. 360, 362)
This option describes the Timed Get Up and Go test, which is a validated measurement in the prediction of falls in the elderly population (Table 25–4). The other answers have no clear relationship to fall risk. (pp. 355–356, 359)
Test |
Abnormality in performance indicating fall risk |
Gait observation |
Hesitates, stumbles, or grabs or touches objects for support when initiating gait |
Weaves or sways side to side |
|
Scrapes or shuffles and does not clear floor consistently |
|
With turning, stops before initiating turn, staggers, has noncontinuous motion, or grabs objects for support |
|
Timed Get Up and Go test |
Is unable to rise from chair without use of upper arms, walk 10 feet, turn, and return to seated position in chair in < 10 seconds |
One-legged stance |
Unable to maintain stance for 5 seconds |
Source. Adapted from Tinetti ME, Ginter SF: “Identifying Mobility Dysfunction in Elderly Patients.” JAMA 259:1190–1193, 1988. |
|
Lack of memory of falls as well as prodromal symptoms (lightheadedness and palpitations) suggests brief loss of consciousness, or syncope. Eliciting a detailed history from patients and caregivers is very important when assessing the etiology of falls. (pp. 355–356)
At this point, it is important to consider a wide differential diagnosis when evaluating the patient’s social withdrawal. Cognitive impairment, hearing loss (Table 25–5), and vision loss may all be contributors. (pp. 359–360)
Questions |
Examination |
Do you feel you have hearing loss? Would you say you have any difficulty in hearing? |
Whisper test While patient occludes one ear, examiner stands at arm’s length behind patient and whispers 6 letter-number combinations. A positive test is failure to repeat half of the letter-number combinations correctly. |
Finger rub Examiner gently rubs fingers together at a distance of 6 inches from patient’s ear. A positive test is failure to identify rub in > 2 of 6 attempts. |
Open-angle glaucoma is characterized by painless loss of peripheral vision. Patients of African American race are at higher risk than those of other races. See Table 25–6 for characteristics of common causes of visual impairment in elderly patients. (p. 361)
Diagnosis |
Symptoms |
Select risk factors |
Preventive intervention |
Age-related macular degeneration |
Loss of central vision Scotoma (i.e., blind spot) Use of brighter light or magnifying glass for fine visual acuity Distortion of straight lines |
Low levels of antioxidants Cigarette smoking |
Zinc and antioxidants were beneficial in moderate and advanced cases in decreasing progression, but not for mild cases or primary prevention.a |
Cataract |
Loss of central vision Difficulty reading in dim light Glare with night driving |
Cigarette smoking Excess sunlight exposure Corticosteroid therapy Diabetes |
Limited prevention measures |
Glaucoma |
Loss of peripheral vision Painless unless closed-angle glaucoma |
African American Increased intraocular pressure |
Limited prevention measures |
Diabetic retinopathy |
Decreased visual acuity Floaters Curtain falling |
Poorly controlled blood glucose |
Glycemic, blood pressure, and lipid control; eye exam at time of type 2 diagnosis and within 5 years of type 1 diagnosis |
aEvans JR: “Antioxidant Vitamin and Mineral Supplements for Slowing the Progression of Age-Related Macular Degeneration.” Cochrane Database of Systematic Review 11:CD000254, 2012. |
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Ms. Mason has multiple comorbidities and is dependent on caregivers for some of her activities of daily living. Her estimated life expectancy is 2–5 years. Thus, neither colonoscopy nor mammography is likely to be beneficial for her from a risk-benefit perspective. The herpes zoster vaccine is recommended for her age group. The meningococcal vaccine is recommended for adults who are traveling to endemic areas or who have medical risk factors (e.g., splenectomy, complement deficiency). (pp. 220, 368)
Although the USPSTF recommends against routine screening in patients ages 76–86, it suggests consideration of individualized assessment (see Table 25–2). Because this patient lives independently and has a life expectancy greater than 10 years, screening is reasonable. (pp. 364–366)
Mr. Moore is independent in his activities of daily living and instrumental activities of daily living. His chronic medical issues are well managed with medications, and he has no cognitive deficits and minimal physical disability. Primary prevention efforts are often most useful in this group of patients with greater life expectancy. (p. 354)
Rational prescribing principles state that discontinuation of therapies when appropriate can be beneficial to patients (Table 25–7). Omeprazole can be discontinued because the patient is no longer experiencing GERD symptoms. Simvastatin would be recommended in this patient for cardiovascular risk reduction and should not be discontinued. Screening for cognitive impairment in this independent patient who continues to perform well in a demanding job is unlikely to yield useful information. Screening for prostate cancer with PSA is not recommended (see Table 25–2). (pp. 360–363)
Practical steps to consider in optimizing prescribing to older adults |
Comment |
Request patients to “brown bag” their medications and bring them to clinical visits. |
Ask patients to bring in all their prescription and over-the-counter medicines, supplements, and herbal drugs being taken to accurately reconcile medications. |
When starting a new drug, set a 1) therapeutic goal and 2) therapeutic time frame. |
Establish a therapeutic goal and time frame to reassess clinically the efficacy for each medication and reduce polypharmacy. |
Start low and go slow. |
Start medications at low doses and titrate up to the lowest effective dose to limit untoward effects of drugs. |
Avoid prescription cascades. |
Evaluate whether medications may be causing side effects that are misdiagnosed as symptoms, triggering prescription of additional medication to treat the drug’s side effect. |
Look for drug-drug and drug-disease interactions, and potentially inappropriate medications. |
Refer to the Beers Criteriaa and other pharmacology texts. |
Limit medication changes to one or two per clinical encounter. |
Avoid too many medication changes at a single visit because of potential miscommunication and/or adverse drug events. |
Deprescribe when possible.b |
Periodically reassess: ask for patient and/or family preferences, look for clinical indications, review for potential harm, and assess medication utilization. |
aAmerican Geriatrics Society: “American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.” Journal of the American Geriatrics Society 60:616–631, 2012. bBain KT, Holmes HM, Beers MH, et al.: “Discontinuing Medication: A Novel Approach for Revising the Prescribing Stage of the Medication-Use Process.” Journal of the American Geriatrics Society 56:1946–1952, 2008. |
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Any concern for elder abuse should prompt further inquiry (Table 25–8). The question listed above is an appropriate question at this time. If you are unable to elicit further information, it may be appropriate to contact adult protective services. Failure of a health care provider to report suspected elder abuse is a criminal act—not to mention potentially dangerous for the patient. (pp. 365, 367–368)
Who makes up your social support? |
Who makes decisions about your life, such as how you should live or where you should live? |
Do you feel uncomfortable with anyone who is taking care of you? |
Has anyone forced you to do things you did not want to do? |
Has anyone prevented you from getting food, medications, or medical care, or from being with people whom you want to be with? |
Have your belongings been taken from you without your permission? |
Has anyone close to you hurt you or harmed you recently? |
Has someone talked with you who made you feel ashamed or threatened? |
Elder abuse, also called elder maltreatment, is an entity that describes physical, emotional, sexual, or financial abuse of older adults, as well as neglect. Studies of community-dwelling adults have reported prevalence rates of 2%–10%. (p. 365)
Dementia, cognitive impairment, and psychiatric illnesses such as depression are risk factors for elder abuse. None of the other listed options have been shown to be risk factors for elder mistreatment. (p. 368)
In evaluating weight loss in the elderly, it is important to consider a broad differential. It is imperative to conduct a thorough medication reconciliation to evaluate for polypharmacy, as well as a review of systems to evaluate other possible causes of weight loss prior to ordering diagnostic tests. (pp. 362, 364)
The symptoms of palpitations, gastrointestinal disturbance, and rapid weight loss in conjunction with the patient’s chief complaint of worsening anxiety are all concerning for hyperthyroidism. Metoprolol, sertraline, and malignancy are also known causes of weight loss in elderly patients (see Table 25–1 earlier in this chapter). Anorexia of old age may occur in patients with poor functional status and multiple medical comorbidities, which is true of this patient; however, weight loss associated with anorexia of old age is usually not as rapid and is not typically associated with increased anxiety and gastrointestinal disturbance. (pp. 202–203, 206, 362, 364, 394)
According to USPSTF recommendations (see Table 25–2), colon cancer screening is indicated for individuals ages 50–75, and breast cancer screening is indicated for women ages 50–74. Cervical cancer screening is not recommended after age 65 in women who have had adequate screening and are not otherwise at high risk for cervical cancer. (pp. 364–368)
TSH testing is indicated to screen for hyperthyroidism or hypothyroidism in elderly patients who present with worsening cognitive function or worsening mood symptoms. The other tests may relate to risk factors for vascular dementia but are of little use in the workup of worsening cognitive function in this patient. (pp. 206–207)
Recognizing potentially inappropriate medications is important in rational prescribing. According to the 2012 American Geriatric Association Beers Criteria, it is advised to avoid benzodiazepines such as lorazepam for in older adults because of adverse drug events. Polypharmacy is the most likely cause of increased agitation in the setting of a new medication (lorazepam) that was not prescribed by a physician. It is important to educate patients and caregivers on appropriate use of medication. (pp. 360, 362)
This patient, age 79, is due for the influenza vaccination during the current flu season. He will not need another Td boost until 10 years after his last dose. He does not require any more doses of pneumococcal vaccine because he received his last dose after age 65 (see Table 25–3). According to the 2013 USPSTF recommendations, patients should be screened for colon cancer between ages 50 and 75 years but only on a case-by-case basis after age 75. Because this patient did not endorse symptoms consistent with a possible gastrointestinal bleed, there is no indication for colonoscopy. Omega-3 fatty acids may help with prevention of cognitive decline, but research has not shown it to be beneficial at slowing cognitive decline in individuals who already have dementia. (pp. 366, 368–370)
In assessing falls in the elderly, the clinician needs to obtain a thorough history that includes associated symptoms, fall location, and activities at the time of fall, as well as consider modifiable risk factors (Table 25–9). Basic neurological screening for neuropathy and assessments of visual or hearing changes are also important. Vitamin D insufficiency testing can also be considered. Given that Mr. Zima is undergoing palliative chemotherapy and radiation, he is at risk for multiple causes of falls, including postural hypotension, muscle weakness, sensory changes including peripheral neuropathy, and malnutrition in the setting of recurrent vomiting. (pp. 355–358)
Risk factor |
Intervention |
Movement and balance |
|
Gait abnormality |
Group exercise |
Muscle weakness |
Individualized exercise program |
Poor balance |
Tai chi |
Vitamin D insufficiency |
Vitamin D supplementation: ≥ 800 international units daily, unless deficient |
Environmental hazards |
Home safety assessment and modification |
Cardiac arrhythmia |
Cardiac pacemaker or implantable cardioverter defibrillator |
Diminished visual acuity |
|
Cataracts |
Cataract removal surgery |
Use of multifocal glasses |
Single-lens glasses |
Medication |
|
Class of medication |
Reduction in and/or gradual withdrawal of medications, including psychotropics, diuretics, antihypertensives, antiarrhythmics, anticonvulsants, and anticholinergics |
Number of medications |
Four or more medications increase falls |
Podiatric conditions |
|
Foot pain |
Podiatry referral |
Poor footwear |
Discourage walking in high heels, bare feet, or socks indoors; an ideal shoe has a low heel, a supported heel collar, and a thin, firm, and slip-resistant sole |
Postural hypotension |
Reduce offending medication(s) that is affecting blood pressure |
Use compression stockings |
|
Slowly rise, in stages, from supine to seated to standing; perform isometric handgrips when standing; and increase fluid and/or salt intake |
|
Source. Adapted from Gillespie LD, Robertson MC, Gillespie WJ, et al.: “Interventions for preventing falls in older people living in the community.” Cochrane Database System Review 9:CD007146, 2012. |
|
This patient likely has a cardiac arrhythmia, which causes his recurrent falls. Given that his life expectancy is less than 2 years, he would need to understand the risks and benefits associated with any intervention (medication vs. procedures) for his diagnosis. Focus should be on quality of life, and discussion with the patient would be necessary to ascertain his wishes with regard to treatment. (p. 367)
Mr. Zima has a life expectancy of less than 2 years and is nearing the end of life. Given his short life expectancy, vision and hearing screening have a lower priority. The focus should be on his quality of life, and it is not advised to perform cancer screening in older adults with a life expectancy of less than 2 years. Reviewing the medication list and discussing options for possible discontinuation of medication will help focus treatment options toward improving the patient’s quality of life. (pp. 364–365)
USPSTF 2011 guidelines recommend screening using DEXA for all women over age 65 years. DEXA composite scores can be normal, so the lowest two T-scores are recommended to guide therapy. The density of an individual vertebra can be decreased to the osteoporotic range while arthritic changes can increase the bone mass of other vertebra, causing the other T-scores to be higher. Although some evidence exists that computed tomography scans can be used to gauge bone mineral density, there are not yet any validated measures for their use. (pp. 188, 190–191; see also Chapter 13, “Osteoporosis”)
The SSRI escitalopram has been approved by the U.S. Food and Drug Administration (FDA) for major depressive disorder, and the atypical antipsychotic aripiprazole has FDA approval as an adjunct for major depressive disorder. Both of these medications may have an impact on bone metabolism. Antipsychotics may cause hyperprolactinemia, increasing bone resorption and inhibition of sex hormones, which are important for bone homeostasis. The mechanism of action of SSRIs remains unknown; however, serotonin receptors are found on osteoclasts and osteoblasts, suggesting that serotonin may have an important regulatory role in bone metabolism. (p. 186)
The DSM-5 Cultural Formulation Interview can help increase patient-doctor understanding, especially in the context of a patient’s cultural background. In this case, Ms. Quan reveals a significant trauma history in the context of the culturally informed interview. Her missed appointments, previous history of flashbacks, and previous suicide attempts may reveal undiagnosed posttraumatic stress disorder. The patient reveals that she emigrated from Indonesia in 1998, when riots, gang rape of Chinese women, and persecution of Chinese inhabitants occurred in that country. Increased understanding and cultural sensitivity can improve patient engagement in treatment. (pp. 26–27, 194)
Research has shown that increased physical activity is associated with modestly improved cognitive scores. Increased consumption of vegetables is associated with a lower risk of dementia and slowed cognitive decline. Ginkgo biloba and omega-3 fatty acids have not been proven to slow cognitive decline in patients with current cognitive impairment. (pp. 369–370)
Cognitive training, particularly training that focuses on cognitive exercises rather than memory strategies, has been clinically proven to improve memory-related outcomes. Folic acid, vitamin B6, vitamin B12, and antioxidants such as vitamins E and C have not been found to improve cognitive function. (p. 370)
Tertiary prevention would be the most appropriate label because the patient already has mild cognitive impairment. The goal of tertiary prevention is to slow the progression of the already clinically apparent disease or illness. Primary prevention aims to avoid disease and disability, and secondary prevention attempts to target and to treat asymptomatic older adults who have risk factors or preclinical disease. (p. 355)