Elderly care

Dr Hanan
Abbas
Lecturer of
Family
Medicine
 The number of persons 65 years of
age and older continues to increase
dramatically. Comprehensive
approach is an important task for
primary care physicians.
 As outlined by the U.S. Preventive
Services Task Force, assessment
categories unique to elderly patients
include sensory perception and
injury prevention.
 Interventional areas include
immunizations, diet and exercise.
 Mental health issues should also be
evaluated
 Using an organized approach can
improve care provided for older
patients
 Falls
 Falls result in accidental death among persons
75 years of age and older and significant
mortality and morbidity.
 Multifactorial
 A fall is 'an event which results in a person
coming to rest inadvertently on the ground and
other than a consequence of the following: loss
of consciousness, sudden onset of paralysis as
in a stroke, or epileptic seizures'.
 As a result of impaired gait and balance,
medical illnesses, and environmental factors.
 Frequently, older persons are not aware of the
risk factors and do not report falling unless an
injury has occurred.
 Identifying and targeting the population at
greatest risk with multifactorial interventions is
essential to the prevention and reduction in the
incidence of falls and fall-related injuries in older
persons.
 Epidemiology
 In the United States, accidents are the sixth
leading cause of death in persons over the age of
65 and falls account for two-thirds of these deaths.
 The annual incidence of falls ranges from 30 % in
persons over the age of 65 to 50 per cent in
persons over 80 years of age.
 Rates of fall-related deaths for older persons
increase sharply with advancing age and are
consistently higher among men than women.
 Due to the higher prevalence of co-morbid illness
among men than women of similar age.
 Approximately 1 % of these falls
result in hip fracture, 3– 5 % in other
types of fractures, and an additional
5 % result in severe soft tissue
injury, such as haemarthroses, joint
dislocations, sprains, and
haematomas.
 Hospitalization rates for hip fracture
increase with advancing age for
both sexes but are consistently
higher for women in all age
categories.
 This gender difference may be
related to the prevalence of
osteoporosis in older woman.
 Falls are also an important marker of frailty.
 Of older persons who are hospitalized for a
fall, only about one half are alive 1 year
after.
 This indicates the seriousness of underlying
disease and the need to ameliorate the
symptoms of chronic illness to prevent
further risks of falling.
Case 1
 An 81 yo female is brought to your office by her
daughter, the elderly mother has been falling
for at least 3 months. The falling has been
getting progressively worse, and her daughter
has been concerned regarding her mother
breaking her hips. On exam, the pt is a frail
elderly female in no distress, she appears
somewhat depressed. The pt BP 180/75, her
pulse is 84 and regular, no other abnormalities
are found.
 Intrinsic Extrinsic
1. Age 1. Environmental hazards
2. Cognitive impairment 2. Inadequate lighting
3. Muscle weakness 3. Slippery surfaces
4. Foot problems (callouses, bunions, or anatomical 4. Loose rugs
deformities)
5. Low toilet seat
5. Polypharmacy (sedatives, tranquillizers,
antidepressants, antihypertensive, and diuretics) 6. Low chairs
6. Sensory impairment (macular degeneration, 7. High stairs
cataracts, and glaucoma) 8. Ill fitting shoes
7. Gait and balance impairment (Parkinson's dis.,
seizures, Lower extremity neuropathies, dementia,
TIAs)
8. Acute disease (pneumonia, urinary tract infections)
9. Chronic disease (cardiovascular dis., neurological
dis., dementia, depression, visual problems,
osteoporosis)
10. Depression
11. Postural hypotension
 Assessment
 assessment of basic neurologic function
including mental status, muscle strength and
tone, lower extremity peripheral nerves,
proprioception, deep tendon reflexes, and
cerebellar function.
 A cardiovascular examination should include
heart rate, postural pulse and blood pressure
(lying and standing with a 5-min interval
between each reading).
 Visual screening and an examination of the
lower extremities, especially the feet, for
deformities, and ulcerations
 The 'get up and go test' of mobility is a
simple screening tests that can be
administered in the clinical setting.
 The older person is asked to rise from
the chair, to stand momentarily with
eyes opened and closed, then nudged
on the sternum, to walk 10 ft, and to
return and sit in the chair.
 It may be useful to obtain a complete blood
count, thyroid function tests, and drug levels if
the history and physical examination indicate a
potential problem in these areas.
 Electrocardiogram may be considered if a
cardiac arrhythmia is suspected.
 Neuroimaging may be helpful for older persons
with neurological deficits and gait abnormalities.
 Referral to specialists such as a neurologist,
cardiologist, ophthalmologist, may be indicated if
the older person needs further evaluation for
specific problems identified on the assessment.
 Management
 The goal of management is to minimize the risk of falling
without compromising mobility, functional activities,
personal independence, and an acceptable quality of life.
 Treatment is focused on eliminating or modifying risk
factors.
 Initial treatment of acute or reversible deficits such as
urinary tract infections, pneumonia, congestive heart
failure, metabolic disturbances, or medication side-
effects may result in major improvements in the older
person's gait and balance.
 Recommendations for a community
population should include:
 gait training review
 modification of medications.
 Exercise programme, with balance training as
one of the components, treatment of postural
hypotension, modification of environmental
hazards( adequate lighting, avoid slippery
floors, loose rugs,…..)
 Gait disorders
 Normal balance require integration of
position sense, the visual system,
vestibular organs, motor strength,
and motor function coordination.
 Decline in their function leads to
general motor slowing.
 Age-related motor decline is
symmetrical
 Gait disorders impact functional
independence.
 Presentation to primary
care
 feeling unsteady, shuffling feet, postural changes, or
falls.
 Vestibular—A history of vertigo localizes to the vestibular
apparatus. The patient may have a sensation of 'waves'.
Often, these patients will have transient dizzy feelings on
rising from a lying position or with turning the head
quickly.
 Visual—Gait changes associated with visual dysfunction
may be due to change in visual acuity such as cataracts
and macular degeneration, or visual field loss.
 Occasionally, patients are unaware of a visual field deficit
until detected by the examiner.
 Motor—Stroke, myopathy, or peripheral neuropathy all
cause muscle weakness affecting gait. The hemiparetic
gait seen in stroke with foot drop.
 Proximal lower extremity weakness seen in myopathy
results in inability to stand from a seated position without
pushing off with the hands.
 If there is weakness of the hip musculature (especially
the hip abductors), the gait will appear 'waddling' like a
duck.
 Foot drop is typically due to a root or peripheral nerve
disorder. So the foot does not catch on the ground, there
is exaggerated hip flexion and elevation of the leg. The
front of the foot strikes the ground before the heel. This
characteristic gait is called 'steppage' gait.
 Sensory impairment—Loss of position sense also results in gait
difficulty, especially in the dark, as the visual system is not able to
compensate for impaired proprioception.
 The loss of vibration sense in the lower limbs is part of normal
ageing; position sense, however, remains intact in normal old age.
Therefore, examination of position sense at the toes is a critical
part of the assessment in patients with gait difficulty.
 Mechanical involvement—Arthritis is common in the elderly and
contributes to gait difficulty by affecting the axial skeleton lower
limb musculature.
 Arthritis of the hip and knee joints becomes a common problem
which produce painful interference in walking.
Gait difficulty is due to one
or a combination of the
following
♦ difficulty regaining balance after postural
displacement;
♦ focal or generalized change in posture;
 major change in tone;
♦ inability to initiate movement;
♦ reduced speed of movement;
♦ presence of involuntary movements which
interfere with gait;
♦ lack of proper coordination of movements;
♦ inability to stop intended movements; or
♦ impaired central mechanisms for gait integration.
 History

The following leading questions should be

asked:
 Are you having pain which prevents you from
walking normally?
 Are your legs so weak that they may give out
when you walk?
 Do you have a feeling that objects are going
around or moving when you walk?
 Is the difficulty in walking present regardless if
you walk in the light or in the dark?
 Pain in the hip, knee, or foot which makes
walking difficult may be due to bursitis or
arthritis.
 Gait difficulty due to vestibular and cerebellar
function abnormalities is present in the light as
well as in the dark.
 In the case of vestibular dysfunction, patients
frequently experience dizziness when turning in
bed, sitting up quickly, or on sudden turning of
the head to one side or the other.
Physical examination

Normal elderly people have a flexed posture

and shorter length compared to younger
persons. Flexed posture greater than expected
by age is seen in Parkinson's syndrome (PS).
Parkinsonian gait is characterized by a
narrow base, reduced armswing (often
asymmetric), and exaggerated flexion at the
waist and neck. The gait is 'shuffling' because of
reduced stride length and problems picking the
feet off the ground.
Cerebellar disorders has a wide base.
Cerebellar gait is unsteady.
Features supportive of a cerebellar disorder
include limb ataxia, dysarthria, and nystagmus.
Romberg testing is performed by asking the
patient to stand with eyes closed and feet
together. A positive test requires that the patient
break his/her stance; Positive Romberg is a sign of
impaired position sense .
 Investigations

vestibular dysfunction needs an

otologic assessment.
Imaging studies to rule out
cerebellar masses or atrophy.
Principles of management
in gait disorder
treat the underlying cause (s)
supportive care for pt and caregiver
making the home environment safer
Home environments often have to be modified stairs,
light, rugs, slippery floor, high chair, low toilet seat.
Referral to a specialist is appropriate if the diagnosis
is uncertain, if there is a poor response to medical
therapy, or if investigations are not available to the
primary care physician (i.e. imaging studies).
In Western countries, referrals are often patient
driven.
 Urinary incontinence
Urinary incontinence, defined as the
involuntary loss of urine, is a major problem
affecting many elderly people.
15–30 % of elderly people living
independently suffer from incontinence
14 % of women aged 65 years and older are
troubled daily by incontinence.
Case 2
An 88 yo female pt who you care for,
residing with her daughter is having
increasing difficulties with bed
wetting, she is embarrassed to talk
about this, but her daughter informs
you that this problem is getting
worse, at that time the pt had been
continuously incontinent for 6 days.
 Possible causes
Bladder capacity, the ability to postpone micturition,
and bladder contractility all decrease.
Uninhibited detrusor contractions increase and there is
a slight rise in the residual volume.
In women, the maximum urethral closure pressure and
the length of the urethra decrease.
In the majority of elderly men, the prostate becomes
enlarged and the urine outflow decreases.
In most cases, involuntary urine loss
is related to disturbances in the
continence mechanism of the
bladder itself.
 Urge incontinence

Urge incontinence is the involuntary

loss of urine concomitant with a
sudden intense urge to urinate.
Other common symptoms are
frequency and nocturia. Urge
incontinence is usually accompanied
by urodynamic findings of detrusor
hyperactivity .
 Stress incontinence

Stress incontinence is the involuntary loss of urine

during coughing, sneezing, laughing, or other
physical activities that cause an increase in intra-
abdominal pressure.
The most common cause of stress incontinence is
hypermobility of the urethra and bladder neck . This
is the result of a weak pelvic floor, probably caused
by childbirth and decreased post-menopausal
oestrogen levels.
 Overflow incontinence

It is involuntary urine loss accompanied by

overfilling of the bladder. The patient generally
suffer from very frequent to continuous loss of
small volumes of urine (continuous leakage),
'bearing-down' while urinating, incomplete voiding
and weak stream.
Overflow incontinence can be caused by two
factors:
a hyperactive or non-active detrusor
bladder neck or urethral obstruction.
A hyperactive or non-active detrusor
can be caused by:
medication, faecal impaction,
diabetic neuropathy.
In men, obstruction is mostly caused
by prostate hypertrophy, less
commonly by prostate cancer,or
faecal impaction.
 Functional incontinence
When involuntary urine loss is caused by factors
outside the lower urinary tract, such as limitations in
physical or cognitive functioning, this is referred to
as functional incontinence.
Hip arthrosis, muscle weakness, hand problems, and
tremors can hinder the elderly person's self-care:
climbing out of bed unaided, going to the toilet,
undoing clothes, and sitting down to urinate,
communication and cognitive disturbances.
:History
The characteristic clinical symptom of stress
incontinence is the loss of small volumes of urine
during activities that increase the intra-abdominal
pressure, such as sneezing, coughing, jumping,
laughing, lifting, and sport. The patient does not
feel the urge to urinate before leakage occurs. As
soon as the increased pressure ceases, the urine
loss also ceases. The remaining micturition pattern
is normal.
the patients feel an urgent need to
urinate that they can no longer reach
the toilet in time.
Once micturition has started, it is very
difficult to stop the flow, often
accompanied by frequency and nocturia.
When pain is present, it is an indication
of infection.
Reversible and other contributing
factors in incontinence
Possible reversible factors:
Conditions: delirium, faecal impaction, depression, symptomatic UTI.
Environment: impaired locomotion, lack of access to toilet, restrictive
clothing.
Excessive intake of caffeinated beverages or other bladder irritants.
Diagnoses: diabetes, CHF, CVA, Parkinson's disease, and other
neurological diseases affecting motor skills
Medication: diuretics, antiparkinsonian, antispasmodics, antihistamines,
and other anticholinergics
Drugs that stimulate or block sympathetic nervous system: calcium-
channel blockers, narcotics
Psychoactive medication: antianxiety agents, antidepressants.
Other contributing factors: Conditions: pain, excessive or inadequate
urine output, atrophic vaginitis, cancer of the bladder or prostate, urethral
obstruction, disorders of the brain or spinal cord.
Abnormal laboratory values: elevated blood glucose or calcium
In women, vaginal palpation and speculum
examination , signs of atrophic vaginitis, uterine
prolapse or cystocoele/rectocoele, tumours, fistulae,
vaginal discharge, and signs of infection.
Rectal palpation: tone of the sphincter.
If the patient is able to contract the sphincter, then
this is strong evidence against disrupted innervation
of the bladder neck and bladder.
Attention should be paid to faecal impaction in the
rectum.
In men, the surface and consistency of the prostate
should be examined.
 Tests
urine test & culture
Ultrasound of bladder to exclude urine
retention.
If obstruction or retention is suspected,
kidney function tests should be
performed and in of polyuria and/or
nocturia, glucose and electrolytes
should be monitored.
 :Management
Stress incontinence:
pelvic muscles exercises, Alpha
adrenergic agonists, Behavioral
training, Supplemental estrogen
 Urge incontinence
 Bladder relaxants & training,
Estrogen supplements, Behavioral
therapy, Surgical removal of
obstruction
 Overflow incontinence
Surgical removal of obstruction,
Intermittent catheterization,
Indwelling catheterization) increased
risk of urinary tract infection, the
risk of injury and stricture of the
urinary tract).
 Functional incontinence
 Behavioral therapy (prompt voiding,
habit training, environmental
manipulation, scheduled toileting,
incontinence pads).
 External collection devices,
indwelling catheters.
Case 3
 daughter is caring for her elderly mother at home. Mom has a
variety of medical issues and is taking a number of
medications. The doctor prescribes for mom's anxiety. Over
a period of months the mother becomes sleepy all the time
and can't seem to concentrate. She will even fall asleep while
someone is talking to her. The doctor and family initially
attribute it to her age. Finally the daughter decides there must
be something wrong and she insists the doctor look into it.
Tests are conducted and low blood level of sodium is
confirmed. After some research the doctor suspects the
prescription might be causing sodium depletion. He removes
the mother from the medicine and she becomes normal again.
 Medications and the Elderly
Facts about Medications and the Elderly
 Older Americans comprise about 13% of
the population but they consume over
30% of all prescription drugs.
 It is estimated that 30% of the older
population taking medications have had
an adverse drug reaction.
 Up to 20% of hospital admissions for the
elderly are due to adverse drug reactions.
 It is estimated that over half of the deaths
attributed to adverse drug reaction are for
people age 60 and above.
 Old age is associated with a reduction in
glomerular filtration rate, a decrease in
renal plasma flow and decreased tubular
reabsorptive capacity. The net effect of
this is a decrease in renal clearance of
drugs that are hydrophilic in nature, for
example digoxin. Such drugs should either
be avoided or given at lower dosages.
Possible reasons for increased
prescribing in the elderly
 Evidence showing benefits of drug use in the
elderly, e.g. the use of warfarin in patients
with atrial fibrillation
 Increase in the numbers of elderly and very
elderly patients, with a consequent increase
in morbidity
 Increase in screening and detection of
asymptomatic conditions, e.g. hypertension
Increased patient expectations
 The practice of defensive medicine
A survey of 805 people was particularly
informative regarding the use of drugs in the
elderly in the United Kingdom
 Most of the drugs being taken by the elderly are
prescribed on a long-term basis, with 59 per cent
having been prescribed for more than 2 years;
 Eighty-eight per cent of all drugs prescribed
were by repeat prescription; and
 forty per cent had not discussed their treatment
with their doctor in the last 6 months.
The inter-relationship between polypharmacy
and poor compliance, resulting in a vicious cycle
that leads to a prescribing cascade
A 75-year-old woman was diagnosed as having hypertension. She was
started on capozide by her doctor. Two weeks later, a routine blood
test showed her to have a potassium level of 2.9 mmol/l. She was
prescribed potassium replacement therapy in form of slow release
potassium tablets to be taken together with capozide. At the next
visit 2 weeks later, her potassium level had come up to 3.4 mmol/l,
and she was continued on slow potassium. She presented 2 months
later with a history of severe heartburn; a gastroscopy showed her to
have an oesophageal ulcer. This was blamed on slow potassium,
which was stopped. The patient was started on omeprazole.
Unfortunately, after a few days treatment she developed diarrhoea.
The doctor continued the omeprazole in order to relieve the
oesophageal ulcer, and prescribed codeine phosphate for the
diarrhoea. After two doses of codeine phosphate, the patient
developed dizziness, had a fall, and was admitted to a hospital with a
fractured left hip.
Reasons for inappropriate prescribing
in the elderly
 Incremental prescribing, with side-effects being
treated with other drugs, rather than
discontinuation of the original drug
 Therapeutic enthusiasm, with use of drugs as
first line treatment without considering the use
of non-drug therapies
 Failure to adequately assess patients' needs
and individualize treatment
 Unrealistic expectations on the part of both
patient and doctor
 A strategy to improve
prescribing in the elderly
 Careful clinical assessment of the patient and an
evaluation of the risk–benefit ratio of starting drug
therapy.
 Start at low doses, and increase dose gradually.
Remember that the elderly often require lower doses.
 Use one drug if possible, and avoid polypharmacy.
 Keep the drug prescribing regime simple.
 Give clear, and if possible, written instructions on how
to take the medicines.
 Undertake a regular review of medications, and
stop medicines when necessary.
 Review and improve repeat prescribing system,
if necessary. Let patients know what to do when
their medicines run out, and how to dispose of
medicines that are no longer necessary.
 Consider drug (s) as the cause of new symptoms
and signs arising in the patient.
 Ensure communication between hospital and
primary care is up-to-date. In the future, this
may be facilitated by the use of individual
smart cards or electronic patient records.
 Multidisciplinary team working with
pharmacists and nurses will help in many of
the objectives outlined above.
 Giving in to pressure from relatives,
patients and other health care
professionals to prescribe
 Inadequate review of medicines, leading
to continuation of drugs that are no
longer necessary
 Governmental pressure to meet targets
 Use sources of information such as
formularies in order to appropriately
prescribe in patients with renal and liver
impairment, and to avoid the use of
interacting drugs.
 Remember that in the elderly, a normal
serum creatinine does not indicate
normal renal function.
 Five key dimensions of the
ageist bias in which healthcare
fails older persons
 Healthcare professionals do not receive enough training in geriatrics
to properly care for many older patients.
 Older patients are less likely than younger people to receive
preventive care.
 Older patients are less likely to be tested or screened for diseases
and other health problems.
 Proven medical interventions for older patients are often ignored,
leading to inappropriate or incomplete treatment.
 Older people are consistently excluded from clinical trials, even
though they are the largest users of approved drugs."
 Recommendations for
caregivers
 Make sure an elderly one has challenging activities throughout the day
instead of simply watching TV (challenging home oriented activities).
 Give them responsibility for taking care of plants . This strategy is
used often in nursing homes to reduce depression in the elderly and to
actually improve their health as well.
 Provide opportunities for family and friends to come by and visit and
encourage or even arrange such encounters.
 Provide opportunities for the older person to interact, teach and
nurture children such as grandchildren. This is an extremely effective
strategy for helping the older person feel that he or she has a
meaningful existence. And it has a dramatic impact on improving and
maintaining health.
 Design or arrange an exercise program and come up with
a way to encourage the older person to follow it.
 Understand the nutrition needs of an older one, especially
the need for vitamins and minerals including iron.. Make
sure the person takes care of him or herself and eats
properly. Many elderly people neglect their own nutrition.
Poor nutrition can cause all kinds of mental and physical
problems in the elderly.
 Make sure an older person has opportunity to look good .
Make sure the person gets out in public, and going to a
public event and can feel good about his or her
appearance.