Geriatrics

Geriatrics Definition

• Geriatrics is essentially the field of medicine dedicated to providing care for the elderly.
• Geriatricians are physicians who have special training to better understand the unique needs of older adults, which is why they typically prescribe care for adults 65 and older.
• The United Nations (UN) has agreed to a cutoff of 60+ years to refer to the older population.

Read And Learn More: General Medicine Question And Answers

Gerontology

• A gerontologist studies the problems of aging from a broader perspective. Not only our medical issues but all the various problems faced by seniors and the elderly.
• Both are involved with addressing issues related to the aging process, but while geriatric professionals provide immediate care for older adults, gerontologists are focused on studying the aging process in general.

The difference between gerontology and geriatrics has been shown in

Biology Of Aging

Aging

Question 1. What is aging?
Answer:

Definition: Aging can be defined as a gradual, insidious, and progressive decline in structure and function which begins to unfold after the achievement of sexual maturity. Various mechanisms that cause and counteract cellular aging are shown.

Theories of Aging

Question 2. List the common theories of aging.
Answer:

The common theories of aging have been shown.

The biological hallmarks of aging have been shown.

Question 3. Describe and discuss the epidemiology, pathogenesis, clinical evolution, presentation, and course of common diseases in the elderly.
(or)Describe the health problems of the aged population.
Answer:

Changes in Physiologic Function with Age

The changes in physiologic function with age have been shown.

Factors that make the assessment/treatment of the elderly different are presented.

What makes the assessment/treatment of the elderly different?

• Individuals become more dissimilar as they grow.
• Abrupt decline in any system is always due to disease and not due to normal aging.
• Multiple pathologies
• Missing symptoms (Example: angina in an elderly patient with osteoarthritis may not manifest)
• Masking symptoms (Example: history of fall and fracture neck of femur in an elderly female masked a coexistent hemiparesis due to an internal capsule infarct.)

Changes in Physiologic Function with Age-Atypical Disease Presentations in Older Adults

Atypical disease presentations in older adults have been shown.

Comprehensive Geriatric Assessment

Question 4. What is comprehensive geriatric assessment (CGA)? Perform multidimensional geriatric assessment that includes medical, psychosocial, and functional components.
Answer:

• Comprehensive geriatric assessment is a multidimensional, multidisciplinary, diagnostic, and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a coordinated and integrated plan for treatment and follow-up can be developed. Domains assessed and considered in the multidimensional approach of CGA are shown.

• Basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs) are presented. The Barthel Index of Activities of Daily Living (Barthel Index) and Lawton’s Instrumental Activities of Daily Living (IADL) can be used to determine functional status.
• Such assessments may be done by a geriatrician working independently or as part of an interdisciplinary team that often includes specially trained nurses (RNs), occupational therapists (OTs), physical therapists (PTs), social workers (SWs), dietitians, speech-language pathologists (SLPs), and specialty pharmacists.
• How to identify elderly patients who would benefit from such an assessment (i.e., the frail elderly)? Strongly consider if they have three or more of the “Red flags” listed. These red flags are indications to do CGA.

Comprehensive Geriatric Assessment Indications for doing comprehensive geriatric assessments (Red Flags).

• >75 years
• Needs help with BADLs/IADLs from a caregiver
• Lives alone
• Falls
• Delirium/confusion
• Incontinence
• >2 admissions to acute care hospital/year
• “Failure to thrive”

Comprehensive Geriatric Assessment Objective Measures of Physical Function

The objective measures of physical function have been shown.

Comprehensive Geriatric Assessment Common Clinical Problems Of Aging

Comprehensive Geriatric Assessment Geriatric Giants

• It is a term coined by Sir Bernard Isaacs. He recognized that multiple illnesses of his senior years needed a broader perspective in socioeconomic and medical terms.
• “Geriatric giants” or the four I’s:
  • Immobility
  • Instability
  • Incontinence
  • Impairment of intellect
    • Cognitive impairment
    • Delirium
    • Depression
• Newer geriatric giants
  • Frailty
  • Sarcopenia
  • The “anorexia of aging”
  • Mild cognitive impairment (MCI)
• Giants refer to the principal chronic disabilities of old age that have an impact on the physical, mental, and social domains of older adults. Many of these conditions are often wrongly perceived to be an unavoidable part of old age. However, they can be improved.

Dementia

Question 5. List the common causes of dementia.
Answer:

• Dementia is typically progressive and non-reversible. It affects 5–10% of those >65 years and 20–25% >85 years.
• Alzheimer’s disease (AD) was the most common type of dementia in India constituting about 45–50%, the prevalence of vascular dementia was found to be 25% in India as against 5% in the West.
• While the mean age of dementia patients was around 65 years in India, it was 75 years in the West.
• Hypertension, diabetes, cardiovascular diseases, and stroke are among the chief causes for a higher rate of vascular dementia in India.

Dementia Diagnostic Criteria for Dementia (DSM-IV)

The old dementia terminology required the presence of memory impairment for all of the dementias. It has been recognized that memory impairment is not the first domain to be affected. Hence, DSM-5 has subgrouped neurocognitive disorder into minor or major.

Dementia Diagnostic criteria for dementia (DSM-IV).

• Memory impairment: Impaired ability to learn new
• information or to recall old information.
• One or more of the following:
  • Aphasia (language disturbance)
  • Apraxia (impaired ability to carry out motor
  • activities despite intact motor function)
  • Agnosia (failure to recognize or identify objects
  • despite intact sensory function)
  • Disturbance in executive functioning-impaired ability to plan, organize, sequence, abstract.
• Cognitive deficits result in functional impairment (social/occupational).
• Cognitive deficits do not occur exclusively during delirium.
• NOT due to other medical or psychiatric conditions.

Dementia Mild Cognitive Impairment/Prodromal Dementia

• It is a condition in which there is mild memory impairment alone (1.5 standard deviations below that of age-matched controls) in the absence of global cognitive decline or functional disabilities; it can only be diagnosed by sophisticated neuropsychiatric testing. It does not meet the criteria for dementia.
• When memory loss predominates, termed Amnestic MCI, while if other domains are affected with memory being intact its termed non-amnestic MCI
• Dementia will develop in about 30% of those with MCI within 3 years. The remainders have stable, MCIs that do not appear to progress.

Dementia Classification of Dementia

• “Early onset” before the age of 60, often familial, is more common for frontotemporal dementia (FTD)
  • Strong genetic link
  • Tends to progress more rapidly
• “Late-onset” after the age of 60
  • Represents the majority of cases
• Cortical versus subcortical dementia

Dementia Causes of Dementia

Dementia Causes of dementia.

• Degenerative/inherited
• Alzheimer’s disease (60–70%)

Dementia Neurodegenerative disorders: Frontotemporal dementia (including Pick’s disease), Lewy body disease, Parkinson’s disease, Huntington’s disease

Dementia Vascular dementia (10–20%): Diffuse small vessel disease

Dementia Neoplastic: Primary/secondary deposits

Dementia Traumatic: Chronic subdural hematoma, post-head injury

Dementia Infections: Creutzfeldt–Jakob disease, human immunodeficiency virus (HIV), syphilis

Dementia Toxic/nutritional: Alcohol, thiamine deficiency, vitamin B12 deficiency

Dementia Prion diseases

Dementia Reversible dementia

Dementia Modifiable/Reversible Causes of Dementia

The modifiable/reversible causes of dementia have been shown.

Question 6. List the reversible causes of dementia.
Answer:

Alzheimer’s Disease

Question 7. Write a short essay/note on Alzheimer’s disease.
Answer:

Alzheimer’s Disease Introduction and Definition

• Alzheimer’s disease is the most common cause of dementia in the world. It is the most common cause of dementia above the age of 40.
• In India: Most common cause of dementia is AD (60–80%) followed by vascular and dementia with Lewy bodies (DLBs).

Alzheimer’s Disease Etiology

Alzheimer’s Disease Genetic factors

• Genetic factors play an important role and about 15% of AD is familial. Familial cases may be of two main groups:
• Early-onset disease with autosomal dominant mode of inheritance and A later-onset group with polygenic inheritance.

Alzheimer’s Disease Mutations: These can occur in several genes.

• A point mutation in amyloid precursor protein (APP) can cause AD.
• Mutations in the gene presenilin 1 (PS1) and presenilin 2 (PS2). PS1 mutations are implicated in over 50% of
  families with familial AD.
• The inheritance of one of the alleles of apolipoprotein-ε4 (apo-ε4) is associated with an increased risk of AD.

Alzheimer’s Disease Environmental risk factors

• Age: If is the main risk factor and the incidence of AD increases exponentially with age.
• Female gender may also be a risk factor independent of the greater longevity of women.
• Head trauma and vascular risk factors.
• According to some studies, long-term consumption of NSAIDs and acetaminophen has shown protection.

Alzheimer’s Disease Pathology

• Biochemically characterized by a deficiency of acetylcholine, with the cortex, amygdala, and hippocampus all affected
• The basal nucleus of Meynert is depleted of acetylcholine-containing neurons
• In a minority of cases, there is an autosomal dominant inheritance linked to chromosomes 1, 14, or 21 (early onset)
• The Apolipoprotein gene, coded on chromosome 19, when homozygous for allele E4, increases the risk for late-onset AD.

Clinical Features

Question 8. Write a short essay/note on the clinical features of Alzheimer’s disease.
Answer:

Clinical Features The main clinical features are:

• Memory impairment/loss: Early recent (short-term) memory loss is a key feature of AD.
• Language problem: It is the next common symptom, common being anomia and difficulty with word finding is characteristic.
• Apraxia: It is an impaired ability to carry out skilled, complex, organized motor activities.
• Agnosia: It is a failure to recognize familiar objects (For example clothing, places, or people).
• Frontal executive function: It is the impairment of organizing, planning, and sequencing.
• Parietal presentation: Visuospatial difficulties and difficulty with orientation in space.
• Myoclonic jerks (sudden brief contractions of various muscles or the whole body) may occur spontaneously or in response to physical or auditory stimulation. This phenomenon raises the possibility of Creutzfeldt–Jakob disease (CJD), but the course of AD is much more prolonged.
• Generalized seizures may also occur.
• Death usually results from malnutrition, secondary infections, or heart disease.
• The typical duration of AD is 8–10 years, but the course can range from 1 to 25 years.
• The course of the disease
• Mild [Mini-Mental State Examination (MMSE)
  20–24]—primarily memory and visuospatial deficits, mild executive functioning impairment
• Moderate (MMSE 11–20) more pronounced aphasia, apraxia, loss of IADLs, may need increased assistance with BADLs, often exhibiting neuropsychiatric symptoms
• Severe (MMSE 0–10) severe language disturbances, pronounced neuropsychiatric manifestations, neurological
  symptoms (rigidity, incontinence, dysphagia, gait disturbance)
• Death 8-12 years after the diagnosis
• Institutionalization is common with increasing neuropsychiatric symptoms, loss of BADLs, caregiver stress

Clinical Features Diagnostic Criteria for Alzheimer’s Disease

The diagnostic criteria for AD have been shown.

Clinical Features Investigations

The investigation is aimed at excluding other treatable causes of dementia.

• Neuroimaging studies [computed tomography (CT) and magnetic
  resonance imaging (MRI)] are not specific for AD and may be normal early in the course of the disease. As AD progresses, diffuse cortical atrophy becomes apparent, and detailed MRI scans show atrophy of the hippocampus.
• Positron emission tomography (PET) scan: It is the test of choice. It shows hypoperfusion in the bilateral perietotemporal cortex.
• Cerebrospinal fluid (CSF) markers:
• raised tau proteins,
• low beta-42 amyloid, and
• elevated ceramide level.
• Routine investigations: Blood chemistry, a complete blood count, tests for syphilis, serum levels of vitamin B12, and thyroid functions.

Clinical Features Diagnostic criteria for Alzheimer’s disease.

• Memory impairment
• One or more of the following:
• Aphasia
• Apraxia
• Agnosia
• Disturbance in executive functioning.

Clinical Features Treatment for Alzheimer’s Disease

There is no specific treatment and the primary focus is on the long-term amelioration of associated behavioral and neurologic problems

Clinical Features Drugs used: Donepezil, rivastigmine, galantamine, and tacrine are cholinesterase inhibitors. Patients with AD have reduced cerebral content of choline acetyltransferase, which leads to a decrease in acetylcholine synthesis and impaired cortical cholinergic function

• Memantine appears to act by blocking overexcited N-methyl-D-aspartate (NMDA) channels
• Statins may have a protective effect on dementia, especially vascular. Antioxidants (vitamin E, selegiline), estrogen replacement, and Ginkgo biloba have been tried
• Mild-to-moderate depression is common in the early stages of AD and responds to antidepressants. Selective serotonin reuptake inhibitors (SSRIs) are commonly used due to their low anticholinergic side effects
• Recommend psychotherapy, exercise, pleasurable activities, support groups, and memory aids
• Minimize changes in caregivers/environment
• Music therapy is gaining strength as an evidence-based intervention for the treatment of anxiety

Vascular Dementia (Multi-infarct Dementia)

Question 9. Discuss the clinical features of vascular dementia.
Answer:

• A second most common cause of dementia. Found in 15–30% of patients with dementia.
• Risk factors: Male sex, advanced age, diabetes, hypertension, and/or other cardiovascular disorders.
• Abrupt onset of symptoms followed by stepwise deterioration.
• Findings on neurologic examination are consistent with prior stroke(s), and infarcts on cerebral imaging.
• Focal neurologic symptoms: Pseudobulbar palsy, dysarthria, and dysphagia are most common.

Vascular Dementia (Multi-infarct Dementia) NINDS-AIREN Criteria for Vascular Dementia

All the following criteria should be present:

• Dementia
• Focal signs on examination + evidence of cerebrovascular disease by CT or MRI.

A relationship of the two above, with dementia within 3 months of a recognized stroke and/or abrupt deterioration in fluctuation, or fluctuating stepwise progression of cognitive deficits.

Vascular Dementia (Multi-infarct Dementia) Physical examination

• May show increased tone (especially in the legs), exaggerated deep tendon reflexes, and Babinski responses.
• The examination may reveal carotid bruits, fundoscopic abnormalities, and an enlarged heart.
• Gait apraxia (“magnetic” gait) may be seen.
• MRI may reveal hyperintensities and focal atrophy suggestive of old infarctions.

Vascular Dementia (Multi-infarct Dementia) Types of Vascular Cognitive Impairment

The types of vascular cognitive impairment have been shown.

Vascular Dementia (Multi-infarct Dementia) Types of vascular cognitive impairment.

1. Vascular cognitive impairment, no dementia (VCIND)
2. Vascular dementia (VaD)
   • Poststroke dementia (PSD), defined as dementia manifesting within 6 months after a stroke
   • Subcortical ischemic vascular dementia (SIVaD)
   • Multi-infarct (cortical) dementia
3. Mixed vascular cognitive impairment (VCI) plus Alzheimer’s disease (AD)

Vascular Dementia (Multi-infarct Dementia) Treatment

• Control of risk factors such as hypertension, smoking,
  diabetes, hyperlipidemia
• Antiplatelets/statins
• Correction of sources of emboli, endarterectomy, and anticoagulant therapy

Frontotemporal Dementia

Question 10. Write a short essay on the clinical features of frontotemporal dementia.
Answer:

• Characterized by focal atrophy of the frontal and temporal lobes in the absence of Alzheimer’s pathology.
• Pick’s disease was the first recognized subtype of FTD, one that is characterized pathologically by the presence of Pick’s bodies (silver-staining intracytoplasmic inclusions) in the neocortex and hippocampus.
• Clinically, presents initially with language abnormalities and behavioral disturbances.
• Occurs between the ages of 35 and 75 years, and only rarely after age 75; the mean age of onset is the 6th decade.
• Both sexes are equally affected.
• “Walnut brain” as there is a profound loss of matter in the frontal lobes, to a slightly lesser degree in the temporal lobes, in comparison with relatively preserved parietal and occipital lobes.

Frontotemporal Dementia Genetics of Frontotemporal Dementia

• 45% of patients have a family member affected.
• Up to 18% of these have an abnormality on the short arm of chromosome 17 localized near the gene for the microtubule-associated protein, tau.

Blists the core diagnostic features and lists the supportive diagnostic features of FTD.

Frontotemporal Dementia Core diagnostic features of frontotemporal dementia (FTD).

• Insidious onset and gradual progression
• Early decline in social interpersonal conduct
• Early impairment in the regulation of personal conduct
• Early emotional blunting
• Early loss of insight

Frontotemporal Dementia Dementia with Lewy Bodies

• Most common dementia syndrome associated with Parkinsonism.
• A second most common form of neurodegenerative dementia after AD.
• For a probable diagnosis of Lewy body disease, need at least two of the following:
  • Fluctuating cognition with pronounced variations in attention and alertness
  • Recurrent visual hallucinations which are typically wellformed and detailed
  • Spontaneous motor features of Parkinsonism

Frontotemporal Dementia Parkinson’s Disease

• Cardinal motor features
  • Bradykinesia and akinesia
  • Rigidity
  • Resting tremor
  • Postural instability
• Dementia typically occurs in the last half of the clinical course of Parkinson’s disease, whereas it is often one of the presenting features of DLB.

Frontotemporal Dementia Pick’s Disease and Creutzfeldt–Jakob Disease

Salient features of Pick’s disease and CJD are presented in.

Frontotemporal Dementia Features supporting the diagnosis of dementia with Lewy bodies.

• Syncope or transient loss of consciousness (LOC)
• Neuroleptic sensitivity (i.e., new shuffling gait, tardive dyskinesia)
• Systematized delusions
• Hallucinations in other modalities (i.e., smell, hearing, taste)
• Falls

Frontotemporal Dementia Cognitive Testing

• Mini-mental state examination tests a broad range of cognitive functions including orientation, recall, attention,
  calculation, language manipulation, and constructional praxis. Scores can be classified as no cognitive impairment = 24–30; MCI = 18–23; severe cognitive impairment = 0–17.
• Montreal cognitive assessment (MoCA) is a 30-point test that is more sensitive for the detection of MCI, and it includes items that sample a wider range of cognitive domains, including memory, language, attention, visuospatial, and executive functions.
• Mini-Cog combines clock drawing and a three-item memory test.
• Saint Louis University Mental Status (SLUMS).

Frontotemporal Dementia Delirium in the Elderly

Definition: It is an acute syndrome of transient, reversible cognitive dysfunction (details discussed in Chapter 18).

Frontotemporal Dementia Management

Prevention is the best medicine

• Eliminate extra medications, reverse metabolic abnormalities, hydration, and nutrition
• Education of patients and family
• Reorientation by staff, family, sitters, clocks, calendars
• Remove nonessential lines and tubes
• Drug therapy:
  • Delirium that causes injury to the patient or others should be treated with medications
  • The most common medications used are neuroleptics (haloperidol, risperidone, olanzapine)
  • Benzodiazepines (lorazepam) often are used for withdrawal states
  • Thiamine, cyanocobalamin supplementation

Frontotemporal Dementia Depression

• Depression is the most common psychiatric illness in the elderly. Although common, it is not a natural part of aging.
• The prevalence in community-dwelling elders ranges from 8 to 15%; it rises to as much as 30% of those in long-term care facilities. Depression and suicide are common in the elderly (especially older males; those over 75, have the same risk of suicide as 20–24 years old depressed males).
• Depression is NOT present in ALL older adults but is underrecognized and undertreated.

Frontotemporal Dementia Bereavement or grief reaction is commonly misdiagnosed as depression. A normal grief reaction after the death of a spouse or a loved one lasts about 2 months in time, with the mourning process being complete in <2 years. Feelings of sadness and preoccupation with the deceased are not helped by antidepressant medications during this time of mourning.

Frontotemporal Dementia Treatment of depression in the elderly is discussed.

The characteristics of depression, delirium, and dementia have been shown.

Frontotemporal Dementia Incontinence

Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem.

Frontotemporal Dementia Urinary Incontinence

• Urinary incontinence is defined as the involuntary loss of urine. It is a heterogeneous condition that ranges in severity from dribbling small amounts of urine to continuous urinary incontinence.
• The prevalence increases with age, but it is not a part of normal aging. It affects about 25–30% of community-dwelling older women and 10–15% of community-dwelling older men, 50% of nursing home residents; often associated with dementia, fecal incontinence, inability to walk, and transfer independently.
• Consequences:
  • Social stigmata lead to restricted activities and depression
  • Medical complications skin breakdown, increased urinary tract infections
  • Institutionalization urinary incontinence is the second leading cause of nursing home placement.

Frontotemporal Dementia Reversible Conditions Associated with Urinary Incontinence

Potentially reversible causes of urinary incontinence are listed. Medications causing incontinence are listed.

Frontotemporal Dementia Potentially reversible causes.

• “DIAPERS”
• D—Delirium
• I—Infection
• A—Atrophic vaginitis or urethritis
• P—Pharmaceuticals
• P—Psychological disorders
• E—Endocrine disorders
• R—Restricted mobility
• S—Stool impaction

Frontotemporal Dementia DRIP

• D—Delirium
• R—Restricted mobility, Restraint
• I—Infection, Inflammation, Impaction
• P—Polyuria, Pharmaceuticals

Medications causing incontinence.

• Diuretics
• Anticholinergics: Antihistamines, antipsychotics, antidepressants
• Sedatives/hypnotics
• Alcohol
• Narcotics
• α-adrenergic agonists/antagonists
• Calcium channel blockers

Frontotemporal Dementia Categories of Incontinence

• Urge incontinence: Other names: Detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder.
  • Most common cause of urinary incontinence >75 years of age.
  • Abrupt desire to void cannot be suppressed.
  • Usually idiopathic.
  • Causes: Infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinson’s disease, dementia.
• Stress incontinence:
  • Most common type in women <75 years old.
  • Occurs with an increase in abdominal pressure; cough, sneeze, etc.
  • Hypermotility of bladder neck and urethra; associated with aging, hormonal changes, the trauma of childbirth, or pelvic
    surgery (85% of cases).
  • Intrinsic sphincter problems: Due to pelvic/incontinence surgery, pelvic radiation, trauma, and neurogenic causes (15% of cases).
• Overflow incontinence:
  • Overdistention of the bladder.
  • Bladder outlet obstruction; stricture, benign prostatic enlargement (BPH), cystocele, fecal impaction.
  • Noncontractile bladder (hypoactive detrusor or atonic bladder), diabetes, multiple sclerosis, spinal injury, medications.
• Functional incontinence:
  • Does not involve the lower urinary tract.
  • Result of psychological, cognitive, or physical impairment.

A recently defined syndrome, overactive bladder, includes
urinary frequency (more than eight voids per 24 hours), nocturia (awakening at night from sleep to void), and urgency (the acute need to void), with or without incontinence is prevalent in around 31% of women 75 years and older and 42% men 75 years and older.

Frontotemporal Dementia Treatment Options in Urinary Incontinence

General treatment options for urinary incontinence are mentioned.

Frontotemporal Dementia Pharmacological interventions:

• Urge incontinence: Oxybutynin, propantheline, imipramine.
• Stress incontinence: Phenylpropanolamine, pseudoephedrine,
  estrogen (orally, transdermally or transvaginally)

Frontotemporal Dementia General treatment options in urinary incontinence.

• Reduce the amount and timing of fluid intake
• Avoid bladder stimulants (caffeine)
• Use diuretics judiciously (not before bed)
• Reduce physical barriers to the toilet (use bedside commode)
• Bladder training
• Patient Education
• Scheduled voiding
• Positive reinforcement
• Pelvic floor exercises (Kegel exercises)
• Biofeedback
• Caregiver interventions: Scheduled toileting, habit training, prompted voiding

Frontotemporal Dementia Surgical interventions:

• Urethral hypermotility: Marshall–Marchetti–Krantprocedure, needle neck suspension.
• Intrinsic sphincter deficiency: Sling procedure.

Frontotemporal Dementia Other interventions:

Other interventions have been shown

Frontotemporal Dementia Other interventions in urinary incontinence.

• Pessaries
• Periurethral bulking agents (periurethral injection of
  collagen, fat, or silicone)
• Diapers or pads
• Chronic catheterization
  • Perurethral or suprapubic
  • Indwelling or intermittent

Falls in the Elderly

Question 11. Describe and discuss the etiopathogenesis, clinical presentation, identification, functional changes, acute care, stabilization, management, and rehabilitation of falls in the elderly.
Answer:

About 30% of individuals over 65 years of age fall each year. About 10–15% of falls result in serious injury and they are the cause of >90% of hip fractures in this age group. Factors causing falls in the elderly are listed.

Fall risk factors and targeted interventions have been shown.

A multidisciplinary approach to preventing falls has been shown.

Frailty

Question 12. Define frailty. List the diagnostic criteria for frailty.
Answer:

Frailty = Loss of reserve

• Defined as the loss of an individual’s ability to withstand minor stresses because the reserves in the function of several organ systems are severely reduced. describes the pathophysiological basis of frailty.
• Physical frailty/phenotypic or syndromic frailty captures the specific signs and symptoms (fatigue, low activity, weakness, weight loss, and slow gait) of older adults who are vulnerable to adverse health outcomes.
• Deficit accumulation frailty or index frailty is a conceptual framework that helps identify frail, vulnerable older adults through cumulative comorbidities and cumulative illnesses as frail.
• Even a trivial illness/adverse drug reaction (ADR) → organ failure/death.
• Characterized by multisystem dysregulation involving four main domains that include:

1. chronic inflammation,
2. sarcopenia,
3. osteoporosis, and
4. alteration in neuroendocrine function.

• Fried frailty score is non-frail (score 0), pre-frail (score 1–2), and frail (score 3–5).
• Weight loss (≥5% of body weight in the last year)
• Exhaustion (positive response to questions regarding effort required for activity)
• Weakness (decreased grip strength)
• Slow walking speed (gait speed) (>6–7 seconds to walk 15 feet)
• Decreased physical activity (kcals spent per week: males expending <383 kcals and females <270 kcals)

Frailty Treatment

• Address the precipitating acute illness
• Address the underlying loss of reserve
• Exercise—improve musculoskeletal function, balance, and aerobic capacity
• Medication review and deprescribing
• Nutritional support to improve lost weight

Question 13. Discuss failure to thrive, sarcopenia, and anorexia of aging.
Answer:

Failure to Thrive

• It is a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol.
• Affects the following four main domains:
  • Functional: BADL/IADL
  • Malnutrition: Weight trend, body mass index (BMI), lymphocytes, and albumin
  • Depression: ± Geriatric Depression Scale (GDS)
  • Cognition: Confusion Assessment Method (CAM), standardized MMSE

Failure to Thrive Management

• Interdisciplinary assessment and care planning
• Treat the cause

Failure to Thrive Sarcopenia

• Age-related loss of muscle mass
• Increases the risk for falls, fractures, dependency, use of hospital services, institutionalization, poor quality of life, and mortality
• Assessment
  • 5-item SARC-F (strength, assistance in walking, rising from a chair, climbing stairs, and falls) score

Failure to Thrive Management

• Protein supplementation
• Resistance exercises

Failure to Thrive Anorexia of Aging

• The multifactorial decrease in appetite and/or food intake that occurs in late life
• A specific geriatric syndrome that can lead to malnutrition if not appropriately diagnosed and treated
• Failure to Thrive Features:
  • Body wasting (cachexia and sarcopenia)
  • Poor endurance
  • Reduced physical performance
  • Slow gait speed
  • Impaired mobility
• Impacts survival independent of age, gender, and multimorbidity
• Age-related reduction in smell and taste perception → alters food palatability and diet variety
• Decreased gastrointestinal muscle tone and motility
• Causes constipation and flatulence
• Failure to Thrive Risk factors:
  • Functional impairment
  • Chronic medical conditions
  • Polypharmacy
  • Environmental factors—physical limitations causing mobility problems
  • Poor dentition/dentures
  • Depression—refusal to eat
  • Economic inequality
  • Social Isolation—living alone/living in an old age home
  • Assessment—the Simplified Nutritional Assessment Questionnaire (SNAQ) and Functional
• Failure to Thrive Assessment of Anorexia and Cachexia Therapy (FAACT) shortened 12-question version questionnaire

Failure to Thrive Management

• Address reversible contributing factors/ comorbidities
• Prescription review
• Improve food texture and palatability
• Protein supplementation—1–1.2 g/kg body weight

Failure to Thrive Multimorbidity and Polypharmacy

• Multimorbidity: The coexistence of ≥2 chronic conditions, where one is not necessarily more central than the others.
• Polypharmacy: Administration of more medications than clinically indicated, representing unnecessary drug use, i.e., ≥5 drugs during a 3-month period.
• Appropriate polypharmacy: Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimized and where the medicines are prescribed according to the best evidence.
• Problematic polypharmacy: The prescribing of multiple (medicines) inappropriately, or where the intended benefit of the [medicines is] not realized.

Failure to Thrive Guidelines For Drug Therapy In The Elderly

• There are several reasons for the greater incidence of iatrogenic drug reactions in the elderly, the most important of which is the high number of medications that are taken by elders, especially those with multiple comorbidities.
• Guidelines for drug therapy in the elderly.

Failure to Thrive Recommended approach

• Use nonpharmacologic approaches whenever possible. Avoid routine use of “as needed” drugs for sleep, anxiety, and pain.
• Choose the drug with the least toxic potential. Substitute less toxic alternatives whenever possible (antacid or sucralfate for an H 2-blocker or proton pump inhibitors, Metamucil or Kaopectate for imodium, scheduled acetaminophen regimen for pain management).
• Reduce the dosage. “Start low and go slow”. Start with 25–50% of the standard dose of psychoactive drugs in the elderly. Titrate the drug slowly.
• Set realistic endpoints: Titrate to improvement, not elimination of symptoms. Keep the regimen simple. Regularly reassess the medication list. Re-evaluate long-time drug use because the patient is changing.
• Review over-the-counter medication use.
• Deprescribing—discontinuing a therapy prescribed for an indication that no longer exists, discontinuing therapy with side effects that may be contributing to frailty symptoms, substituting a therapy with a potentially safer agent.

Failure to Thrive Medication optimization is defined as a person-centered approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines. Medicine optimization applies to people who may or may not take their medicines effectively.

Shared decision-making is an essential part of evidence-based medicine, seeking to use the best available evidence to guide decisions about the care of the individual patient, taking into account their needs, preferences, and values.

Question 14. Enumerate and describe the social problems in the elderly including isolation, abuse, change in family structure, and their impact on health.
Answer:

Elder Abuse

• More than a million people world over the age of 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection. Neglect is the most common form of abuse followed by financial and emotional abuse.
• Elder abuse can be suspected when the patient exhibits behavioral changes in the presence of the caregiver, delays between the occurrence of injuries and sought treatment, inconsistencies between an observed injury and associated explanation, lack of appropriate clothing or hygiene, and not filling prescriptions.
• Many elders with cognitive impairment become targets of financial abuse.
• Abuse and self-neglect have increased the risk of mortality.
• Who are the abusers?
  • Domestic elder abuse (caregivers/distant relatives)
  • Institutional elder abuse
  • Self-abuse/neglect
• Reasons for abuse
  • Caregiver stress/burnout
  • Impairment of dependent elder (i.e., dementia)
  • Transgenerational “cycle of violence”
  • Material or other gain
• About half of the elderly population in the country face some form of abuse, more in the case of women than men

Elder Abuse Major Forms of Abuse

1. Physical and sexual abuse: Any act of violence or rough treatment, whether or not actual physical injury results, in slapping, punching, kicking, pinching, burning, or restraints.
2. Emotional and psychological abuse: Any act that diminishes dignity and self-worth, Examples: confinement, isolation, verbal assault, humiliation, and infantilization.
3. Financial abuse and material exploitation: Any improper conduct that results in a monetary or personal loss for the older adult.
4. Abandonment and neglect
   • Active neglect: Intentional (deliberate) withholding of basic necessities and/or care for physical or mental health.
   • Passive neglect: Not providing basic necessities and care. There is no conscious attempt to inflict distress.
5. Medical abuse: Any medical procedure or treatment is done without the permission of the older person or their Power of Attorney or substitute decision maker.

Indicators of abuse are listed.

Elder Abuse Indicators of Abuse.

• Unexplained physical injury
• Unexplained malnutrition/decubitus ulcers
• Unkempt appearance
• Failure of a medical condition to improve or the continued presence of pain
• Fear of certain family members, friends, or caregivers
• The older person is largely ignored or treated passively by caregivers or others
• Caregivers who are entirely ignorant of the medical problems or treatments for the older person they are directly caring for.