The Care of the Older Person

THE CARE

of the

OLDER PERSON

www.careoftheolderperson.com

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The Care of the Older Person

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ISBN: 978-0-578-58098-2

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CONTENTS

DISCLAIMER

EDITORS/CONTRIBUTORS

CONTRIBUTORS

INTRODUCTION

Frailty

Physical activity as a countermeasure to frailty

Doctor, my wife is getting forgetful

Update on Alzheimer’s disease diagnosis and management

How to diagnose and manage delirium

Why does my patient have gait & balance disorders?

Could my patient be malnourished?

Are the immunizations of my patient up to date?

Management of older patients in the emergency department: this man is old, but is it an emergency?

How to manage type 2 diabetes in frail elderly patients

Cancer in older adults

Cancer screening in the older adult

Psycho oncology: living with the fear of death

Incontinence in older adults

Polypharmacy and deprescribing in the elderly

After the menopause

Elder abuse

An overview of late-life depression

Assessment of decision-making capacity

How do I protect my patient?

Financial guidance for seniors

The role of religious belief in the end-of-life care of older persons

Glossary: Medical terms and their meaning

EDITORS/CONTRIBUTORS

Olivier Beauchet, MD, PhD, Professor of Geriatrics, Dr. Joseph Kaufmann Chair in Geriatric Medicine, Director of centre of excellence on aging and chronic diseases, McGill University

Howard Bergman, MD, FCFP, FRCP(C), Chair, Department of Family Medicine, Professor, Departments of Family Medicine, Medicine, and Oncology, McGill University

Ronald M. Caplan, MD, CM, FACS, FACOG, FRCS(C), Clinical Associate Professor Emeritus Obstetrics and Gynecology, Weill Medical College of Cornell University

Abraham Fuks, MD, CM, FRCP(C), Professor, Department of Medicine, McGill University

Serge Gauthier, CM, CQ, MD, FRCP(C), Director, Alzheimer Disease Research Unit, McGill Center for Studies in Aging, Professor, Departments of Neurology & Neurosurgery, Psychiatry, Medicine, McGill University

Phil Gold, CC, OQ, MD, PhD, FRSC, DSc (Hon), MACP, FRCP(C), Douglas G. Cameron Professor of Medicine, Professor of Physiology and Oncology, McGill University, Executive Director Clinical Research Center (MGH) McGill University Health Centre

Jose A. Morais, MD, FRCP(C), Associate Professor and Director, Division of Geriatric Medicine, McGill University, Associate Director, Quebec Network for Research on Aging

CONTRIBUTORS

Karen C. Altfest, PhD, CFP®, Executive Vice President and Principal Advisor, Altfest Personal Wealth Management, New York City

Guy Hajj Boutros, MSc, Kinesiologist and Research Assistant, Research Institute of McGill University Health Centre

Lysanne Campeau, MDCM, PhD, FRCS(C), Assistant Professor of Surgery, Division of Urology, McGill University

A. Mark Clarfield MD, FRCPC, Professor Emeritus of Geriatrics, Ben-Gurion University, Medical School for International Health, Faculty of Health Sciences, Ben-Gurion University of the Negev

Catherine Ferrier, MD, Assistant Professor, Department of Family Medicine, Faculty of Medicine, McGill University

Catalina Hernandez-Torres MD, FRCP(C), Geriatric Oncology, Ottawa Hospital Cancer Center

Tina Hsu, MD, FRCP(C), Assistant Professor, Division of Medical Oncology, University of Ottawa

Antony Karelis, PhD, Professor, Department of Exercise Science, Universite du Quebec a Montreal

Sathya Karunananthan, PhD, Postdoctoral Fellow, Ottawa Hospital Research Institute

Young-Sang Kim, MD, PhD, Associate Professor, Department of Family Medicine, CHA Bundang Medical Center, CHA University

Cyrille Launay, MD, PhD, department of medicine, division of geriatrics, University Hospital of Lausanne, Switzerland

Artin Mahdanian, MD, MSc, Department of Psychiatry, McGill University

Louise Mallet, B.Sc. Pharm., Pharm.D., BCGP, FESCP, FOPQ, Professor in Clinical Pharmacy, Faculty of Pharmacy, University of Montreal, Pharmacist in Geriatrics, McGill University Health Center

Silvia Monti De Flores, MD, FRCPC, DFAPA, Department of Psychiatry, McGill University

Randy S. Perskin, Esq., JD, Elder Law Attorney, New York

Samer Shamout, MD, MSc, Fellow, Division of Urology, McGill University

Norman Straker, MD, DLFAPA, Clinical Professor Weill Cornell Department of Psychiatry, Consultant, Sloan Kettering Cancer Center, Division of Behavioral Science

Dominique Tessier, MD, CCFP, FCFP, FISTM, Clinical Instructor, Family Medicine Department, University of Montreal, Medical Director, Travel Health Group, Montreal

Doreen Wan-Chow-Wah, MD, FRCPC, Assistant Professor, Faculty of Medicine, Division of Geriatric Medicine, McGill University Health Centre

Mark J. Yaffe, MDCM, Professor of Family Medicine, Department of Family Medicine, St Mary’s Hospital Centre and McGill University

Haibin Yin, MD, CCFP (COE) Assistant Professor, Director of Undergraduate Medical Education, Division of Geriatric Medicine, McGill University

INTRODUCTION

Jose A. Morais, MD, FRCP(C)

Associate Professor and Director,

Division of Geriatric Medicine, McGill University,

Associate Director, Quebec Network for Research on Aging

It is a well-recognized fact that our society is growing older. This aging of the population is observed in developed as well as in developing countries, albeit at a faster pace in the latter. From the days of the Roman Empire to the early XIX century, average life expectancy at birth remained stable at about 45 years. Since then, there has been a progressive increase in life expectancy with the introduction of improved hygiene and availability of food. The improvement in medical care also contributed to improved survival, especially in older individuals with chronic conditions. Nowadays, a cohort of newborns is expected to live an average of 80 years, with an excess of 3-4 years for baby girls compared with boys. The net effect of this increased longevity combined with the decline of birth rates is practically a doubling of the percentage of older adults, to reach about 25% of the population by 2030 in most developed countries. The prevalence of those above 85 years, the so-called old-old will in fact triple to attain 8% of the population. According to the World Health Organization, the aging of the population is an unprecedented phenomenon in human history. Although many anticipate this demographic revolution with apprehension, it is in fact a triumph of humankind over the adversities of the environment. Among many societal challenges posed by the aging of the population is a growing prevalence of multiple chronic diseases and functional impairments of older adults, giving rise to the geriatric syndromes, especially in those above 85 years of age. The shift in the prevalence from acute and communicable diseases to multiple chronic diseases calls for a realignment of the healthcare system that was previously organized to treat acute conditions. The solution resides in an integrated and coordinated system that is more expensive than one dealing with short term interventions, although many inefficiencies in care delivery and inappropriate interventions contribute to heighten the cost.

Why do we age?

Aging is a universal phenomenon defined as a progressive decline in the functional reserves of many body systems and organs once an individual has reached maturity, which in humans occurs between 20 and 30 years of age. These degenerative changes in organs are responsible for the loss of adaptive responses to stress and an increased risk for age-related illness and death. The theory of evolution proposes that the natural forces that shaped life allowed aging to occur because it would be better to perpetuate the species by investing in mechanisms promoting a high reproductive capacity in young individuals rather than in bodily mechanisms that would maintain individuals indefinitely but at greater risk of dying in a hostile environment. There are a number of theories of aging organized in several categories, but those gaining in popularity among scientists fall under the mechanistic theories of aging, grouped as the somatic mutation theory and the free radical theory. Both of these mechanisms are likely to be involved in aging as they implicate basic cellular processes and can explain other derangements at more complex levels of bodily organization such as dysfunction of neuro-endocrine and immune systems. The somatic mutation theory suggests that most somatic cells undergo replication and in this process, acquire damage by spontaneous mutations or by exposure to toxic products. The accumulation of damage will degrade cell function, leading to senescence. The telomere shortening theory can be considered as a special case of the mutation theory. The free radical theory explains that life is a dynamic process requiring metabolized energy that generates free radicals as by-products of normal redox reactions, e.g., reactive oxygen species. Such free radicals are the cause of oxidative damage to cell structures and impair their functions. The mitochondrial theory is considered a subcategory of the free radical theory. Although the body possesses many enzymes and surveillance systems to prevent cellular damage and mutations it is not a foolproof defense mechanism, which is in keeping with the theory of evolution.

What is Geriatrics?

The term Geriatric refers to old age that in most advanced societies has been set arbitrarily at 65 years. It is of interest that this age limit was proposed more than a century and a half ago by a German statesman, Baron Otto von Bismarck, based on the observations that at that time, life expectancy of civil servants aged 65 was on average only 2 years. He calculated that it would be more profitable for the state to offer them a retirement pension and to hire new, more productive young people. Since then however, life expectancy at age 65 has steadily increased in most developed countries to reach current levels of about 20 years for women and 15 years for men. Thus, even at age 65, there is opportunity to introduce preventive medicine and to educate people to adopt healthy and active lifestyles. At the same time, the prevalence of chronic diseases increases steadily with age, giving rise to co-morbidities and functional decline. Among older adults, 40-50 % have arthritis, hypertension and hearing deficiencies, 20-30% suffer from cardiovascular diseases, dementia, cancer, diabetes, chronic respiratory conditions, lack of teeth and impaired vision, and another 5-10% have strokes, Parkinson’s disease and asthma. Hence, concomitant conditions, known as multimorbidity is highly prevalent as are impairments in activities of daily living. For the age group between 70-85 years of age, 25% have 5 or more diseases, another 25% will experience disabilities in basic activities of daily living, while 50% will be deficient in the instrumental activities of daily living. Geriatrics refers to the practice of medicine caring for older adults afflicted with many diseases and functional impairments. Geriatricians and family physicians with experience in the field know that a care plan needs to address not only a specific condition but also the interaction that results from all of them and their combined impact on the patient’s autonomy. Fortunately, there is recent evidence from scientific literature that we are aging better compared with the previous generation with a decline in the incidence of dementia and disability. For many years, there was debate about the different rates at which the decrease in morbidity and mortality would progress. If lower morbidity would outpace mortality, then we would age better and into older years whereas the converse would have the opposite effect. These recent findings are optimistic, in that if further confirmed, persons can expect to live longer with less disability.

Active aging

Aging is a heterogeneous phenomenon that is the result of the interaction between the individual genetic background and environmental factors, not the least of which is the adoption of a healthy lifestyle. Certain families are more prone to develop specific diseases but the appearance of many of them can be delayed or even averted by the adoption of healthy habits. For example onset of type 2 diabetes can be delayed or prevented by regular physical activity and heathy eating habits. There are also several social and psychological determinants of health, including education, income, social status, social participation, perceived control over one’s life, positive attitude, to name but a few. With so many factors at play, it is little wonder that each individual ages at his or her own pace. Gerontology has classified aging into three main categories: active aging (previously called heathy aging or successful aging), normal aging and frail aging. The distribution of these different types of aging varies according to different criteria but the majority falls within the active and normal aging categories with 15-25% considered to be frail. According to WHO (2002), active aging is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. The word active refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labor force. Older people who retire from work, those who are ill or live with disabilities can still remain active contributors to their families, peers, communities and society.

Contribution of older adults to society

Contrary to common beliefs, many older adults are in good health, enjoying life and contributing to society. Such contributions extend to practically all domains of social life despite the challenge of ageism. At the familial level, older persons through their experience of life are of great support to their middle-age children, in counselling on many matters and in the upbringing of the grandchildren. In many instances, they provide financial support to them. At the community level, other than assisting a friend or a neighbor, they participate in organizing cultural and social events, thus to enriching their communities. Volunteering is definitely another non negligible contribution of unremunerated work of older people for the wider community. We all have had the experience of receiving information at the entrance of the hospital by an older person who is volunteering, but they also participate actively on boards of museums, art centers or charitable agencies, or in directly providing services to youth organizations and to more dependent older adults. By so doing, those engaged in volunteering also benefit from being socially active, since outreach and engagement enhance their own well-being and happiness. Finally, remaining part of the workforce is another way of contributing as well as of maintaining physical, cognitive and mental capacities. Society will need to continue its efforts to allow older adults to maintain their societal role as all derive benefits. The change in policies to make retirement age non-compulsory is a first step since we all age differently. Furthermore, facilitating different types of work and adjustments of schedules will permit older people to remain active and to contribute to society.

References

United population world Ageing 1950-2050, Population division, DESA, United nations, 2002, http://​www.​un.​org/​esa/​population/​publications/​worldageing19502050

Brian T. Weinert and Poala S. Timiras. Invited Review: Theories of aging. J Appl Physiol 95: 1706–1716, 2003

Marti G. Parker, Mats Thorslund. Health Trends in the Elderly Population: Getting Better and Getting Worse. The Gerontologist 2007; 47:150–158.

World Report on Aging and Health http://​www.​who.​int/​ageing/​publications/​world-report-2015/​en/​

The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2010: Growing Older – Adding Life to Years. http://​publichealth.​gc.​ca/​CPHOreport

FRAILTY

Sathya Karunananthan PhD

Postdoctoral Fellow

Ottawa Hospital Research Institute

Howard Bergman MD, FCFP, FRCPC

Chair, Department of Family Medicine

Professor of Family Medicine, Medicine and Oncology, McGill University

Mrs. Black is a seventy-one year-old widow with four adult children. Her medical history includes mild osteoarthritis and diabetes, for which she takes acetaminophen as required. She lives alone, tends to be socially isolated, and has mild depressive symptoms. She walks without aids but seems to have slowed down lately. Her cognition is normal, and she is completely independent for all instrumental (IADLs) and basic activities of daily living (ADLs).

Is she frail? What is frailty, and can it be identified in the clinical setting? Are there interventions that effectively delay the onset of frailty or prevent adverse outcomes?

Most geriatricians affirm that they can identify frailty in patients when they see it¹,². Experts generally agree that frailty in older persons refers to a state of vulnerability to adverse health outcomes. It is considered different from aging per se, since some individuals live to an old age without becoming frail. Furthermore, individuals of the same age can be quite different in terms of how frail they are. Frailty would be the opposite of what many consider successful aging³.

However, after three decades of research, there remains considerable uncertainty around the concept of frailty and its clinical usefulness. Conflicting ideas abound on the definition of frailty, what criteria should be used for its recognition, and its relationships with aging, disability, and chronic disease³-⁶ .

Definitions and conceptualizations of frailty

Most experts agree that frailty is the manifestation of impairments in multiple organ systems that results in increased susceptibility to poor health outcomes². The specific characteristics of frailty, however, remain an important point of contention.

Some have proposed that frailty fits the model of a medical syndrome, whereby all of its symptoms are linked through a single underlying biological mechanism. The most widely used definition of frailty fitting that approach includes five criteria:

shrinking (i.e., weight loss)

weakness (i.e., loss of muscle strength)

exhaustion

slowness (i.e., decreased walking speed)

low levels of physical activity.

An individual with any three or more of these five criteria is classified as frail².

Another widely applied approach is to define frailty as an indicator of global health status, whereby an individual’s level of frailty is ascertained through a wide range of factors that may contribute to their well-being. A definition fitting this approach may pull together up to a hundred different characteristics ranging from visual impairment to poor social conditions, chronic diseases, and disability, into a single index of frailty⁷. For each characteristic, an individual is rated as either having a deficit or not. The frailty index is calculated as a proportion representing the number of deficits over the total number of characteristics assessed. By this approach, the more individuals have wrong with them, the more likely they are to be frail.

These approaches represent very different notions of what it is to be frail. The choice of approach has important implications for clinical applicability as well as the potential interventions and prevention of frailty. The number of frailty scores related to these and other approaches is constantly growing. A recent study identified 67 frailty scores with important heterogeneity across scores in the identification of individuals as frail⁵.

What can be done about frailty?

Interventions to prevent or reduce frailty have included physical activity, nutrition, memory training, and individually tailored geriatric care models⁸, ⁹. Effectiveness of these interventions has been mixed and the body of evidence is limited, given that the definition of frailty is not consistent across studies. Furthermore, these interventions largely overlap with those recommended for prevention or management of chronic diseases related to aging. Researchers have yet to establish whether targeting these interventions to frail individuals has added value.

Thus far, research has provided substantial evidence that frailty, however it may be defined, is a risk factor for various poor health outcomes. Individuals identified as frail are more likely to experience medical complications, disability, institutionalization or even death, compared to their non-frail counterparts, especially when exposed to stressors such as surgery, chemotherapy or falls. Based on this, many experts are advocating screening for frailty in all older patients. It has been shown, however, that risk factors that demonstrate high statistical significance may not be good predictors at the patient-level. In fact, very little is known about the contribution of frailty in improving patient-level prediction¹⁰. This needs to be investigated much further in order to justify the adoption of frailty as a clinical tool.

What frailty means to older persons

Older persons themselves may have their own perspectives of what it means to be frail. For example, factors such as mood, have been cited as important to patients and their families; often these are overlooked by clinicians and researchers³, ¹¹. Psychological health plays an important role in older persons’ beliefs about aging successfully. In a study of older persons where only 15% experienced absence of physical illness, 92% reported feeling like they were aging successfully¹².

The research evidence has demonstrated that stereotypes of aging, both positive and negative, are internalized by older persons. This can have both short- and long-term effects on their health¹³. For example, when older adults are exposed to negative aging stereotypes, performance on memory tasks, handwriting and walking speed, as well as physiological measures such as blood pressure, pulse rate, and skin conductance become worse. In fact, in one study, the research showed that an increase in walking speed for those exposed to positive aging stereotypes was comparable to that seen with several weeks of rigorous exercise. Negative stereotypes act as cardiovascular stressors while positive stereotypes reduce evidence of cardiovascular stress. Positive perceptions about aging have impressive long-term effects as well. Individuals with positive self-perceptions of aging have been found to have better functional abilities over a period of eighteen years. These findings should serve as a caution about a potential self-fulfilling prophecy when labelling older persons as frail.

Conclusion

Frailty is believed to be an early sign of declining health. As such, it may serve as a red flag prior to the occurrence of more severe or irreversible conditions, such as disability. In the example of Mrs. Black, the family and doctors would want to identify any factors that are contributing to her declining health and then attempt to address these. The goal is to prevent or at least slow down her decline.

However, after decades of research and discussion among experts, we are still far from a unified definition or diagnostic criteria for frailty. At this time, there is still very limited evidence on the added clinical value of frailty, and currently no evidence-based guidance on how to manage, treat of reverse frailty⁹.

For Mrs. Black, better management of her chronic diseases and interventions to improve her social isolation can contribute to slowing down her decline. A diagnosis of frailty, however it is defined, is not likely to have an impact on the clinical care she receives and may only cause harm related to labeling.

References

Kaethler Y et al. Defining the concept of frailty: a survey of multi-disciplinary health professionals. Geriatric Today: J Can Geriatr Soc. 6: 26-31 (2003).

Fried, L. P. et al. Frailty in older adults: evidence for a phenotype. J. Gerontol. A. Biol. Sci. Med. Sci. 56, M146–156 (2001).

Bergman, H. et al. Frailty: an emerging research and clinical paradigm--issues and controversies. J. Gerontol. A. Biol. Sci. Med. Sci. 62, 731–737 (2007).

Hogan DB,