22-32 Ageing and disease
32 Ageing and disease
Ageing and disease MD Witham Comprehensive Geriatric Assessment 1302 Demography 1304 Functional anatomy and physiology 1304 Biology of ageing 1304 Physiological changes of ageing 1305 Frailty and multimorbidity 1306 Investigations 1306 Comprehensive Geriatric Assessment 1306 Decisions about investigation and treatment 1306 Presenting problems in geriatric medicine 1307 Falls 1308 Dizziness 1309 Delirium 1309 Urinary incontinence 1309 Prescribing and deprescribing 1310 Other problems in old age 1311 Rehabilitation 1311
1302 • AGEING AND DISEASE Insets (Wasted hand, kyphosis) From Afzal Mir M. Atlas of clinical diagnosis, 2nd edn. Edinburgh: Saunders, Elsevier Inc.; 2003; ( Senile purpura) Forbes CD, Jackson WF. Clinical medicine, 3rd edn. Edinburgh: Mosby, Elsevier Inc.; 2004; (Venous ulceration) Mosti G. Compression and venous surgery for leg ulcers. Clin Plast Surg 2012; 39:269–280. Pulse Atrial fibrillation Hydration Skin turgor Oedema Erect and supine blood pressure Postural hypotension Hearing Wax Hearing aid used Muscle Wasting Strength Per rectum Faecal impaction Prostate size/consistency in men Anal tone Nutrition Body mass index (Height calculated from arm demispan or knee height to compensate for loss of vertebral height) Recent weight loss, e.g. loose skin folds Dentition/oral hygiene Joints Deformity Pain Swelling Range of movement Skin Wounds/ulcers Infection Swelling Gait and balance Get up and go test (see opposite) Walking aid used Vision Visual acuity Glasses worn/present Cataract Cognitive function Mini-mental state examination (see Ch. 28) Measurement of knee height (see Ch. 19) Severe kyphosis Wasting of small muscles of hands in rheumatoid arthritis Cataract Senile purpura Venous ulceration Full systems examination with particular attention to the above
Comprehensive Geriatric Assessment
Comprehensive Geriatric Assessment • 1303
1304 • AGEING AND DISEASE to live for a further 10 years. However, rates of disability and chronic illness rise sharply with ageing and have a major impact on health and social services. In the UK, the reported prevalence of a chronic illness or disability sufficient to restrict daily activities is around 25% in those aged 50–64, but 66% in men and 75% in women aged over 85. Although the proportion of the population aged over 65 years is greater in developed countries, two-thirds of the world population aged over 65 live in developing countries at present, and this is projected to rise to 75% in 2025. The rate of population ageing is much faster in developing countries (Fig. 32.1) and so there will be less time to adjust to its impact. Functional anatomy and physiology Biology of ageing Ageing can be defined as a progressive accumulation through life of random molecular defects that build up within cells and tissues. Eventually, and despite multiple repair and maintenance mechanisms, these result in age-related functional impairment of tissues and organs. There is evidence that variants in many genes contribute to ageing. The implicated genes include those that are involved in regulation of DNA repair, telomere length (p. 41) and insulin signalling. Genetic factors only account for around 25% of the variance in human lifespan, however; nutritional and environmental factors determine the rest. At a cellular level, production of reactive oxygen species is thought to play a major role in ageing. These molecules cause oxidative damage at a number of targets: • Nuclear chromosomal DNA, causing mutations and deletions that ultimately lead to aberrant gene function and potential for malignancy. • Telomeres, the structures at the ends of chromosomes that shorten with each cell division because telomerase (which copies the end of the 3′ strand of linear DNA in germ cells) is absent in somatic cells. When telomeres are sufficiently eroded, cells stop dividing. It has been suggested that telomeres represent a ‘biological clock’ that prevents uncontrolled cell division and cancer. Telomeres are particularly shortened in patients with Fig. 32.1 Number of people aged 65 years and over projected in the world population. Millions
Year World Developing countries Developed countries 32.1 Mean life expectancy in years, UK and India Males Females UK India UK India At birth 79.1 65.1 83.0 67.2 At 60 years 22.8 16.7 25.5 18.9 At 70 years 15.0 10.9 17.1 12.4 At 80 years 8.7 7.5 9.9 8.0 Sweeping demographic change has meant that older people now represent the core practice of medicine in many countries. A good knowledge of the effects of ageing and the clinical problems associated with old age is therefore essential in most medical specialties. The older population is extremely diverse; a substantial proportion of 90-year-olds enjoy an active healthy life, while some 70-year-olds are severely disabled by chronic disease. The terms ‘chronological’ and ‘biological’ ageing have been coined to describe this phenomenon. Biological rather than chronological age is taken into consideration when making clinical decisions about, for example, the extent of investigation and intervention that is appropriate. Geriatric medicine is concerned particularly with frail older people, in whom physiological capacity is so reduced that they are incapacitated even by minor illness. They frequently have multiple comorbidities, and acute illness may present in non-specific ways, such as delirium, falls or loss of mobility and day-to-day functioning. These patients are prone to adverse drug reactions, partly because of polypharmacy and partly because of age-related changes in responses to drugs and their elimination (p. 32). Disability is common, but patients’ function can often be improved by the interventions of the multidisciplinary team (p. 1303). Older people have been neglected in research terms and, until recently, were rarely included in randomised controlled clinical trials. Accordingly, there is often little high-quality evidence on which to base practice. Demography The demography of all countries has changed rapidly in recent decades. For example, in the UK, the total population has grown by 11% over the last 30 years, but the number of people aged over 65 years has grown by 24%. The steepest rise occurred in those aged over 85 – from 600 000 in 1981 to 1.5 million in 2011; this number is projected to increase to 2.4 million by 2026, while the working-age population (20–64 years) is expected to grow by only 4% between 2011 and 2026. Similarly, the proportion of people over 65 in India has increased by 35.5% from 76 million in 2000 to 103 million in 2011, which is almost twice the rate of growth of the general population over this period. In both of these countries and many others across the world, the old-age dependency ratio, which is the ratio of people of working age for each person over retirement age, has substantially increased. Since young people support older members of the population both directly and indirectly through taxation and pension contributions, the consequences of a reduced ratio are far-reaching. It is important to emphasise, however, that many older people support the younger population, through the care of children and other older people. Life expectancy in the developed world is now prolonged, even in old age (Box 32.1); women aged 80 years can expect
Functional anatomy and physiology • 1305
the effects of pathology from those due to age alone. The fraction of older people who age without disease ultimately declines to very low levels, however, so that use of the term ‘normal’ becomes debatable. There is a marked increase in inter-individual variation in function with ageing; many physiological processes deteriorate substantially when measured across populations but some individuals show little or no change. This heterogeneity is a hallmark of ageing, meaning that each person must be assessed individually and that the same management cannot be applied unthinkingly to all people of a certain age. Although some genetic influences contribute to heterogeneity, environmental factors, such as poverty, nutrition, exercise, cigarette smoking and alcohol misuse, play a large part, and a healthy lifestyle should be encouraged even when old age has been reached. The effects of ageing are usually not enough to interfere with organ function under normal conditions but reserve capacity is significantly reduced. Some changes of ageing, such as depigmentation of the hair, are of no clinical significance. Figure 32.2 shows the many changes that occur with ageing that are clinically important. premature ageing due to Werner’s syndrome, in which DNA is damaged due to lack of a helicase. • Mitochondrial DNA and lipid peroxidation, resulting in reduced cellular energy production and ultimately cell death. • Proteins, especially those that are modified by glycosylation due to spontaneous reactions between proteins and sugars. These damage structure and function of the affected protein, which becomes resistant to breakdown. The rate at which damage occurs is variable and this is where the interplay with environment, and particularly nutrition, takes place. There is evidence in some organisms that this interplay is mediated by insulin signalling pathways. Chronic inflammation also plays an important role, again in part by driving the production of reactive oxygen species. Physiological changes of ageing The physiological features of normal ageing have been identified by examining disease-free populations of older people to separate Respiratory system • Reduced lung elasticity and alveolar support • Increased chest wall rigidity • Increased V/Q mismatch • Reduced cough and ciliary action CNS and muscle • Neuronal loss • Cochlear degeneration • Increased lens rigidity • Lens opacification • Anterior horn cell loss • Dorsal column loss • Slowed reaction times • Loss of type II muscle fibres • Reduction in muscle satellite cell numbers Cardiovascular system • Reduced maximum heart rate • Dilatation of aorta • Reduced elasticity of conduit/ capacitance vessels • Reduced number of pacing myocytes in sinoatrial node Endocrine system • Deterioration in pancreatic β-cell function Renal system • Loss of nephrons • Reduced glomerular filtration rate • Reduced tubular function Gastrointestinal system • Reduced motility Bones • Reduced bone mineral density Respiratory system • Reduced vital capacity and peak expiratory flow • Increased residual volume • Reduced inspiratory reserve volume • Reduced arterial oxygen saturation • Increased risk of infection CNS • Increased risk of delirium • Presbyacusis/high-tone hearing loss • Presbyopia/abnormal near vision • Cataract • Muscle weakness and wasting • Reduced position and vibration sense • Increased risk of falls Cardiovascular system • Reduced exercise tolerance • Widened aortic arch on X-ray • Widened pulse pressure • Increased risk of postural hypotension • Increased risk of atrial fibrillation Endocrine system • Increased risk of impaired glucose tolerance Renal system • Impaired fluid balance • Increased risk of dehydration/overload • Impaired drug metabolism and excretion Gastrointestinal system • Constipation Bones • Increased risk of osteoporosis and fracture Clinical consequences Changes with ageing • • Fig. 32.2 Features and consequences of normal ageing.
1306 • AGEING AND DISEASE cardiac investigation and drug treatment, but may benefit even further from an exercise programme to improve musculoskeletal function, balance and aerobic capacity, with nutritional support to restore lost weight. Establishing a patient’s level of frailty also helps inform decisions regarding further investigation and management, and the need for rehabilitation. Investigations Comprehensive Geriatric Assessment One of the most powerful tools in the management of older people is the Comprehensive Geriatric Assessment, which identifies all the relevant factors contributing to their presentation (p. 1302). Comprehensive Geriatric Assessment is in fact a misnomer; it is not merely an assessment, but a process of identifying and managing all relevant factors affecting the health and well-being of older people. It is iterative in nature, management being followed by reassessment and a new management plan. In frail patients with multiple pathology, it may be necessary to perform the assessment in stages to allow for their reduced stamina. The outcome should be a management plan that not only addresses the acute presenting problems but also improves the patient’s overall health and function. Comprehensive Geriatric Assessment is performed by a multidisciplinary team (p. 1303). Such an approach was pioneered by Dr Marjory Warren at the West Middlesex Hospital in London in the 1930s; her comprehensive assessment and rehabilitation of supposedly incurable, long-term bedridden older people revolutionised the approach of the medical profession to frail older people and laid the foundations for the modern specialty of geriatric medicine. There is excellent evidence from systematic reviews that Comprehensive Geriatric Assessment, when performed by a specialist team on a specialist geriatric medicine ward, reduces death or deterioration, increases the chances of living independently at home, and may also improve cognitive function in the short to medium term. Current evidence suggests that the process works when delivered on a specialist inpatient unit, but the evidence for effectiveness when it is delivered by a visiting team or in the community is less strong. Decisions about investigation and treatment Accurate diagnosis is important at all ages but frail older people may not be able to tolerate lengthy or invasive procedures, and diagnoses may be revealed for which patients could not withstand intensive or aggressive treatment. On the other hand, disability should never be dismissed as due to age alone. For example, it would be a mistake to supply a patient no longer able to climb stairs with a stair lift when simple tests would have revealed osteoarthritis of a hip and vitamin D deficiency, for which appropriate treatment would have restored his or her strength. So how do doctors decide when and how far to investigate? The views of the patient and family Older people may have strong views about the extent of investigation and the treatment they wish to receive, and these should be sought from the outset. A key issue is to establish what the patient wants from investigation and treatment. Many Frailty and multimorbidity Frailty is defined as the loss of an individual’s ability to withstand minor stresses because the reserves in function of several organ systems are so severely reduced that even a trivial illness or adverse drug reaction may result in organ failure and death. The same stresses would cause little upset in a fit person of the same age. It is important to understand the difference between ‘disability’, ‘multimorbidity’ and ‘frailty’. Disability indicates established loss of function while frailty indicates increased vulnerability to loss of function. Disability may arise from a single pathological event (such as a stroke) in an otherwise healthy individual. After recovery, function is largely stable and the patient may otherwise be in good health. When frailty and disability coexist, function deteriorates markedly even with minor illness, to the extent that the patient can no longer manage independently. Multimorbidity (the number of diagnoses present) is also not equivalent to frailty; it is quite possible to have several diagnoses without major impact on homeostatic reserve. Multimorbidity is, however, an important concept in its own right and is an almost invariable accompaniment to advanced age. Recent Scottish population-based data show that 60% of those aged 65 and over have at least two chronic diseases. Multimorbidity is a driver for future disability, hospitalisation and death, and often leads to polypharmacy, as multiple medications are used to treat each chronic disease individually. Current health-care systems are poorly equipped to manage multimorbidity; each disease is dealt with by a separate team of specialists, which at best places a high burden on the patient, and at worst leads to mutually incompatible approaches to management of each disease. Unfortunately, the term ‘frail’ is often used rather vaguely, sometimes to justify a lack of adequate investigation and intervention in older people. It can be specifically identified, however, by assessing function in a number of domains. Two main approaches to evaluating frailty exist: measurement of physiological function across a number of domains, an example being the Fried Frailty score (Box 32.2), or use of a score based on the number of deficits or problems, such as the Rockwood score. Frail older people particularly benefit from a clinical approach that addresses both the precipitating acute illness and their underlying loss of reserves. It may be possible to prevent further loss of function through early intervention; for example, a frail woman with myocardial infarction will benefit from specific Varies between populations. Grip cut-off is 30 kg for men and 18 kg for women in US adults; 5 m walk time cut-off is 7 seconds in US adults for both sexes. 32.2 How to assess a Fried Frailty score • Hand grip strength in bottom 20% of healthy elderly distribution • Walking speed in bottom 20% of healthy elderly distribution* • Self-reported exhaustion • Physical inactivity • At least 6 kg weight loss within 1 year Patient is defined as frail if 3 or more factors are present; 1–2 factors indicate a ‘pre-frail’ state.
Presenting problems in geriatric medicine • 1307
Presenting problems in geriatric medicine Characteristics of presenting problems in old age Problem-based practice is central to geriatric medicine. Most problems are multifactorial and there is rarely a single unifying diagnosis. All contributing factors have to be taken into account and attention to detail is paramount. Two patients who share the same presenting problem may have completely disparate diagnoses. A wide knowledge of adult medicine is required, as disease in any, and often many, of the organ systems has to be managed at the same time. There are a number of features that are particular to older patients. Late presentation Many people (of all ages) accept ill health as a consequence of ageing and may tolerate symptoms for lengthy periods before seeking medical advice. Comorbidities may also contribute to late presentation; in a patient whose mobility is limited by stroke, angina may only present when coronary artery disease is advanced, as the patient has been unable to exercise sufficiently to cause symptoms at an earlier stage. Atypical presentation Infection may present with delirium and without clinical pointers to the organ system affected. Stroke may present with falls rather than symptoms of focal weakness. Myocardial infarction may present as weakness and fatigue, without chest pain or dyspnoea. The reasons for these atypical presentations are not always easy to establish. Perception of pain is altered in old age, which may explain why myocardial infarction presents in other ways. The pyretic response is blunted in old age so that infection may not be obvious at first. Cognitive impairment may limit the patient’s ability to give a history of classical symptoms. Acute illness and changes in function Atypical presentations in frail elderly patients include ‘failure to cope’, ‘found on floor’, ‘delirium’ and ‘off feet’, but these are not diagnoses. The possibility that an acute illness has been the precipitant must always be considered. To establish whether the patient’s current status is a change from his or her usual level of function, it helps to ask a relative or carer (by phone if necessary). Investigations aimed at uncovering an acute illness will not be fruitful in a patient whose function has been deteriorating over several months but are important if function has suddenly changed. Multiple pathology Presentations in older patients have a more diverse differential diagnosis because multiple pathology is so common. There are frequently a number of causes for any single problem, and adverse effects from medication often contribute. A patient may fall because of osteoarthritis of the knees, postural hypotension due to diuretic therapy for hypertension, and poor vision due to cataracts. All these factors have to be addressed to prevent further falls and this principle holds true for most of the common presenting problems in old age. older people do not desire prolongation of life; rather they aspire to maintain physical function, gain relief from symptoms, and preserve the ability to live independently. Such aims differ widely between patients, however, and a careful exploration of what is important to the individual is essential. If the patient wishes, the views of relatives can also be taken into account. If the patient is not able to express a view or lacks the capacity to make decisions because of cognitive impairment or communication difficulties, then relatives’ input becomes particularly helpful. They may be able to give information on views previously expressed by the patient or on what the patient would have wanted under the current circumstances. However, families should never be made to feel responsible for difficult decisions. The patient’s general health Does this patient have the physical and mental capacity to tolerate the proposed investigation? Do they have the aerobic capacity to undergo bronchoscopy? Will delirium prevent them from remaining still in the magnetic resonance imaging (MRI) scanner? The more comorbidities a patient has, the less likely he or she will be able to withstand an invasive intervention. Will the investigation alter management? Would the patient be fit for, or benefit from, the treatment that would be indicated if investigation proved positive? The presence of comorbidity and frailty is more important than age itself in determining this. When a patient with severe heart failure and a previous disabling stroke presents with a suspicious mass lesion on chest X-ray, detailed investigation and staging may not be appropriate if they are not fit for surgery, radical radiotherapy or chemotherapy. On the other hand, if the same patient presented with dysphagia, investigation of the cause would be important, as they might be able to tolerate endoscopic treatment (for example, to palliate an obstructing oesophageal carcinoma). Will management benefit the patient? It is important to consider whether interventions that might be considered as standard-of-care for younger people are likely to be beneficial in frail older people. For example, while oral anticoagulation might be indicated by guidelines for a patient with atrial fibrillation, such treatment may not accord with the wishes of a patient in a care home who finds regular blood tests distressing, or who is more worried about bleeding than about avoiding a stroke. Another example would be the use of anti-osteoporosis medications to reduce the risk of fracture in very old patents, where the risk of death from other causes would be greater than the risk of fracture. Advance directives Advance directives or ‘living wills’ are statements made by adults at a time when they have the capacity to decide about the interventions they would refuse or accept in the future, should they no longer be able to make decisions or communicate them. An advance directive cannot authorise a doctor to do anything that is illegal and doctors are not bound to provide a specific treatment requested if, in their professional opinion, it is not clinically appropriate. However, any advance refusal of treatment, made when the patient was able to make decisions based on adequate information about their implications, is legally binding in the UK. It must be respected when it clearly applies to the patient’s present circumstances and when there is no reason to believe that the patient has changed his or her mind.
1308 • AGEING AND DISEASE in anyone falling over; people who lose consciousness do not always remember having done so. If loss of consciousness is suggested by the patient or witness, it is important to perform appropriate investigations (pp. 181 and 1080). Mechanical and recurrent falls Among patients who have tripped or are uncertain how they fell, those who have fallen more than once in the past year and those who are unsteady during a ‘get up and go’ test (p. 1303) require further assessment. Patients with recurrent falls are commonly frail, with multiple medical problems and chronic disabilities. Obviously, such patients may present with a fall resulting from an acute illness or syncope but they will remain at risk of further falls even when the acute illness has resolved. The risk factors for falls (Box 32.4) should be considered. If problems are identified with muscle strength, balance, vision or cognitive function, the causes of these must be identified by specific investigation, and treatment commenced if appropriate. Careful assessment of the patient’s gait may provide important clues to an underlying diagnosis (Box 32.5). Common pathologies identified include cerebrovascular disease (Ch. 26), Parkinson’s disease (p. 1112) and osteoarthritis of weight-bearing joints (p. 1007). Calculation of fracture risk using tools such as FRAX or QFracture should be performed and dual X-ray absorptiometry (DXA) bone density scanning considered in patients with a 10-year risk of major fracture of more than 10%. Prevention of falls and fractures Falls can be prevented by multiple risk factor intervention (Box 32.6). The most effective intervention is balance and strength training by physiotherapists or exercise practitioners; an alternative with good evidence is tai chi training. An assessment of the Approach to presenting problems in old age For the sake of clarity, the common presenting problems are described individually but, in reality, older patients often present with several at the same time, particularly delirium, incontinence and falls. These share some underlying causes and may precipitate each other. The approach to most presenting problems in old age can be summarised as follows: • Obtain a collateral history. Find out the patient’s usual status with regard to mobility and cognitive function from a relative or carer. Call these people by phone if they are not present. • Check all medication. Have there been any recent changes? • Search for and treat any acute illness (Box 32.3). • Identify and reverse predisposing risk factors. These depend on the presenting problem. Falls Around 30% of those over 65 years of age fall each year and this figure rises to more than 40% in those aged over 80. Although only 10–15% of falls result in serious injury, virtually all fragility fractures in the elderly are caused by falls. Age-related osteoporosis contributes to the dramatic rise in hip and other fragility fractures that occurs with ageing but the most important contributory factor is an increased risk of falling (Fig. 32.3). Falls also lead to loss of confidence and fear, and are frequently the ‘final straw’ that makes an older person decide to move to institutional care. Management will vary according to the underlying cause. Acute illness Falls are one of the classical atypical presentations of acute illness in frail people. The reduced reserves in older people’s neurological function mean that they are less able to maintain their balance when challenged by an acute illness. Suspicion should be high when falls have suddenly occurred over a period of a few days. Common underlying illnesses include infection, stroke, metabolic disturbance and heart failure. Thorough examination and investigation are required (Box 32.3). It is also important to establish whether any drug that precipitates falls, such as a psychotropic or hypotensive agent, has been started recently. Once the underlying acute illness has been treated, falls may stop. Blackouts A proportion of older people who ‘fall’ have, in fact, had a syncopal episode. A collateral history from a witness is of utmost importance Fig. 32.3 Age and bone mineral density (BMD) interact to influence fracture risk. Femoral neck BMD (g/cm2) Age 80 years 0.5
0.6 0.7 0.8 0.9 1.0 1.1 Age 70 years Age 60 years Hip fracture/100000 population 32.3 Screening investigations for acute illness • Full blood count • Urea and electrolytes, liver function tests, calcium and glucose • Chest X-ray • Electrocardiogram • C-reactive protein: useful marker for occult infection or inflammatory disease • Blood cultures if pyrexial 32.4 Risk factors for falls • Muscle weakness • History of falls • Gait or balance abnormality • Use of a walking aid • Visual impairment • Arthritis • Impaired activities of daily living • Depression • Cognitive impairment • Age over 80 years • Psychotropic medication
Presenting problems in geriatric medicine • 1309
Dizziness Dizziness is very common, affecting at least 30% of those aged over 65 years in community surveys. It can be disabling in its own right and is also a risk factor for falls. Acute dizziness is relatively straightforward and common causes include: • hypotension due to arrhythmia, myocardial infarction, gastrointestinal bleed or pulmonary embolism • posterior fossa stroke onset • vestibular neuronitis. Although older people more commonly present with recurrent dizzy spells and often find it difficult to describe the sensation they experience, the most effective way of establishing the cause(s) of the problem is nevertheless to determine which of the following is predominant (even if more than one is present): • lightheadedness, suggestive of reduced cerebral perfusion • vertigo, suggestive of labyrinthine or brainstem disease (p. 1086) • unsteadiness/poor balance, suggestive of joint or neurological disease. In lightheaded patients, structural cardiac disease (such as aortic stenosis) and arrhythmia must be considered, but disorders of autonomic cardiovascular control, such as vasovagal syndrome and postural hypotension, are the most common causes in old age. Antihypertensive medications may exacerbate these conditions. Further investigation and treatment are described on page 181. Vertigo in older patients is most commonly due to benign positional vertigo (p. 1086), but if other brainstem symptoms or signs are present, MRI of the brain is required to exclude a cerebello-pontine angle lesion. Delirium Delirium is a syndrome of transient, reversible cognitive dysfunction that affects 30% of older hospital inpatients. Differential diagnosis, assessment and management are discussed on page 183. Urinary incontinence Urinary incontinence is defined as the involuntary loss of urine and comes to medical attention when sufficiently severe to cause a social or hygiene problem. It occurs in all age groups but becomes more prevalent in old age, affecting about 15% of women and 10% of men aged over 65. It may lead to skin damage if severe and can be socially restricting. While agedependent changes in the lower urinary tract predispose older people to incontinence, it is not an inevitable consequence of ageing and requires investigation and appropriate treatment. Urinary incontinence is frequently precipitated by acute illness in old age and is commonly multifactorial (Fig. 32.4). The initial assessment should seek to identify and address contributory factors. If incontinence fails to resolve, further diagnosis and management should be pursued, as described on page 437. • Urge incontinence is usually due to detrusor over-activity and results in urgency and frequency. • Stress incontinence is almost exclusive to women and is due to weakness of the pelvic floor muscles, which allows leakage of urine when intra-abdominal pressure rises, such as on coughing. It may be compounded by atrophic 32.6 Interventions to reduce the risk of falls and fractures • Exercise (should include components of lower limb strength and balance training): Multimodal group exercise and tai chi both effective • Calcium and vitamin D supplementation: Evidence of effectiveness only in patients in institutional care Large doses of vitamin D may increase risk of falls and fractures • Home environment assessment and modification • Medication review: Particularly medications with central actions such as hypnotics but also those with anticholinergic and hypotensive actions • Cataract surgery: Effective if for first cataract Other vision interventions ineffective and may increase falls risk • Anti-slip shoes: Effective only in icy conditions • Cardiac pacemaker for carotid sinus hypersensitivity 32.5 Abnormal gaits and probable causes Gait abnormality Probable cause Antalgic Arthropathy Waddling Proximal myopathy Stamping Sensory neuropathy Foot drop Peripheral neuropathy or radiculopathy Ataxic Sensory neuropathy or cerebellar disease Shuffling/festination Parkinson’s disease Marche à petits pas Small-vessel cerebrovascular disease Hemiplegic Cerebral hemisphere lesion Apraxic Bilateral hemisphere lesions patient’s home environment for hazards should be undertaken by an occupational therapist, who may also provide personal alarms so that patients can summon help, should they fall again. Rationalising psychotropic medication may help to reduce sedation, although many older patients are reluctant to stop hypnotics. If postural hypotension is present (defined as a drop in blood pressure of > 20 mmHg systolic or > 10 mmHg diastolic pressure on standing from supine), reducing or stopping hypotensive drugs may be helpful. Evidence supporting the efficacy of other interventions for postural hypotension is lacking but drugs, including fludrocortisone and midodrine, are sometimes used to try to improve dizziness on standing. Other interventions, such as cataract extraction and podiatry, can also have a significant impact on function in those who fall. If osteoporosis is diagnosed, specific drug therapy should be considered (p. 1046). In the frailest patients, such as those in institutional care, calcium and vitamin D3 administration has been shown to reduce both falls and fracture rates, probably by exerting positive effects on bone mineral density and on neuromuscular function. Supplementation does not reduce falls risk beyond this very frail group, however, and very high doses of vitamin D may paradoxically increase the risk of falls and fractures. In the UK, government policy and National Institute for Health and Clinical Excellence guidelines (www.nice.org.uk) for falls prevention have led to the development of specific Falls and Fracture Prevention Services in many parts of the country.
1310 • AGEING AND DISEASE diseases (Box 32.7). However, the more drugs that are taken, the greater the risk of an adverse drug reaction (ADR). ADRs and the effects of drug interactions are discussed on page 21. They may result in symptoms, abnormal physical signs and altered laboratory test results (Box 32.8). ADRs are the cause of around 5% of all hospital admissions but account for up to 20% of admissions in those aged over 65. The risk of polypharmacy is compounded by age-related changes in pharmacodynamic and pharmacokinetic factors (p. 14), and by impaired homeostatic mechanisms, such as baroreceptor responses, plasma volume and electrolyte control. Older people are thus especially sensitive to drugs that can cause postural hypotension or volume depletion (Box 32.8). Non-adherence to drug therapy also rises with the number of drugs prescribed. The clinical presentations of ADRs are diverse, so for any presenting problem in old age the possibility that the patient’s medication is a contributory factor should always be considered. Failure to recognise this may lead to the use of a further drug to treat the problem, making matters worse, when the better vaginitis, associated with oestrogen deficiency in old age, which can be treated with oestrogen pessaries. • Overflow incontinence is most commonly seen in elderly men with prostatic enlargement, which obstructs bladder outflow. In patients with severe stroke disease or dementia, treatment may be ineffective, as frontal cortical inhibitory signals to bladder emptying are lost. A timed/prompted toileting programme may help. Other than in overflow incontinence, urinary catheterisation should never be viewed as first-line management, but may be required as a final resort if the perineal skin is at risk of breakdown or quality of life is affected. Prescribing and deprescribing The large number of comorbidities that accompany ageing often leads to polypharmacy. This has been defined as the use of four or more drugs, and is associated with several adverse outcomes including falls, hospitalisation and increased risk of death. While some of these outcomes are caused by drug–drug interactions and adverse effects, others are as much due to the underlying multimorbidities for which the drugs were prescribed in the first place In view of this, it is essential for prescribing for older people to be appropriate. For many older people, taking multiple drugs is appropriate, as such therapy is required to treat multiple Fig. 32.4 Assessment and management of urinary incontinence in old age. See also page 436 and NICE guideline on the Management of Incontinence in Women: nice.org.uk. (UTI = urinary tract infection) Urinary incontinence Overflow (residual volume > 100 mL) Surgical relief of obstruction (prostatectomy) Intermittent catheterisation if no obstruction Stress Pelvic floor muscle training Surgical intervention if unsuccessful If still incontinent: • Establish the pattern of urinary loss (diary is helpful) • Measure residual urine volume (by ultrasound) • Assess for vaginal prolapse and atrophic vaginitis (women) • Assess prostate by rectal examination (men) Address contributory factors: • UTI • Severe constipation • Diuretics • Hyperglycaemia • Hypercalcaemia • Restricted mobility • Acute delirium Urge Bladder retraining Antimuscarinic drugs (solifenacin, tolterodine) 32.8 Common adverse drug reactions in old age Drug class Adverse reaction NSAIDs Gastrointestinal bleeding and peptic ulceration Renal impairment Diuretics Renal impairment, electrolyte disturbance Gout Hypotension, postural hypotension Warfarin Bleeding ACE inhibitors Renal impairment, electrolyte disturbance Hypotension, postural hypotension β-blockers Bradycardia, heart block Hypotension, postural hypotension Opiates Constipation, vomiting Delirium Urinary retention Antidepressants Delirium Hyponatraemia (SSRIs) Hypotension, postural hypotension Falls Benzodiazepines Delirium Falls Anticholinergics Delirium Urinary retention Constipation (ACE = angiotensin-converting enzyme; NSAIDs = non-steroidal anti-inflammatory drugs; SSRIs = selective serotonin re-uptake inhibitors) 32.7 Factors leading to polypharmacy in old age • Multiple pathology • Poor patient education (see Box 2.20, p. 31) • Lack of routine review of all medications • Patient expectations of prescribing • Over-use of drug interventions by doctors • Attendance at multiple specialist clinics • Poor communication between specialists
Rehabilitation • 1311
Rehabilitation Rehabilitation aims to improve the ability of people of all ages to perform day-to-day activities and to optimise their physical, mental and social capabilities. Acute illness in older people is often associated with loss of their usual ability to walk or care for themselves, and common disabling conditions such as stroke, fractured neck of femur, arthritis and cardiorespiratory disease become increasingly prevalent with advancing age. Doctors tend to focus on health conditions and impairments but patients are more concerned with the effect on their activities and ability to participate in everyday life. The rehabilitation process Rehabilitation is a problem-solving process focused on improving the patient’s physical, psychological and social function. It entails: • Assessment. The nature and extent of the patient’s problems can be identified using the International Classification of Functioning, Disability and Health framework, which focuses on health conditions (such as stroke), the associated physical impairments (such as arm weakness caused by the stroke), the effect on activity (such as the inability to dress oneself due to arm weakness) and restriction of participation in activities (such as inability to go out of the house due to the inability to dress oneself). Such an approach helps to ensure a whole-person approach to participation in society, rather than a focus merely on disease. Specific assessment scales, such as the Elderly Mobility Scale or Barthel Index of Activities of Daily Living (Box 32.10), are useful to quantify components of disability but additional assessment is needed to determine the underlying causes or the interventions required in individual patients. • Goal-setting. Goals should be specific to the patient’s problems, realistic, and agreed between the patient and the rehabilitation team. • Intervention. This includes the active treatments needed to achieve the established goals and to maintain the patient’s health and quality of life. Interventions include hands-on treatment by therapists using a functional, task-orientated approach to improve day-to-day activities, and also psychological support and education. The emphasis on the type of intervention will be individualised, according to the patient’s disabilities, psychological status and progress. The patient and carer(s) must be active participants. • Re-assessment. There is ongoing re-evaluation of the patient’s function and progress towards the goals by the rehabilitation team, the patient and the carer. Interventions may be modified as a result. Multidisciplinary team working The core rehabilitation team includes all members of the multidisciplinary team (p. 1303). Others may also be involved, such as audiometrists to correct hearing impairment, podiatrists for foot problems, and orthoticists where a prosthesis or splinting is required. Good communication and mutual respect are essential. Regular team meetings allow sharing of assessments, agreement on rehabilitation goals and interventions, evaluation of progress and planning for the patient’s discharge home. Rehabilitation is not when the doctor orders ‘physiotherapy’ or ‘a home visit’ and takes no further role. course would be to stop or reduce the dose of the offending drug or to find an alternative. Appropriate prescribing and deprescribing The key to appropriate prescribing is first to ensure that medications are started only for reasons that accord with the patient’s goals and wishes. Thoughtless adherence to guidelines quickly leads to polypharmacy that may be inappropriate. Some medications (such as chronic use of non-steroidal anti-inflammatory medications) are much less suitable for older people because of the much higher risk of side-effects. Other medications, such as statins and bisphosphonates, lack evidence of efficacy in very old people, who may not live for long enough to derive benefit. Deprescribing is as important as prescribing in older people. Regular review of medications should be undertaken to ensure that medications are still required, to establish that they are still working, to check that they are not causing side-effects, and to ascertain whether the patient is actually taking them. If any of the above issues is problematic, the medication should be deprescribed. This may need to be done in a controlled manner, with dose reduction to ensure that rebound symptoms or withdrawal effects do not occur. The patient or carer should therefore be asked to bring all medication for review rather than the doctor relying on previous records; such reviews should take place regularly, not just at a point of crisis such as after a fall or on hospital admission. Other problems in old age A vast range of other presenting problems in older people present to many medical specialties. End-of-life care is an important facet of clinical practice in old age and is discussed on page 1354. Relevant sections in other chapters are referenced in Box 32.9. Within each chapter, ‘In Old Age’ boxes highlight the areas in which presentation or management differs from that in younger individuals. 32.9 Other presenting problems in old age • Hypothermia p. 166 • Dizziness and blackouts p. 181 • Delirium p. 183 • Infection pp. 218 and 228 • Fluid balance problems p. 360 • Heart failure p. 466 • Atrial fibrillation p. 472 • Hypertension p. 512 • Under-nutrition p. 710 • Diabetes mellitus p. 732 • Peptic ulceration p. 801 • Anaemia p. 954 • Painful joints p. 992 • Bone disease and fracture pp. 994 and 1049 • Stroke p. 1147 • Dementia p. 1191
1312 • AGEING AND DISEASE Rehabilitation outcomes There is evidence that rehabilitation improves functional outcomes in older people following acute illness, stroke and hip fracture. It also reduces mortality after stroke and hip fracture. These benefits accrue from complex multicomponent interventions, but occupational therapy to improve personal ADLs and individualised exercise interventions have now been shown to be effective in improving functional outcome in their own right. Further information Websites americangeriatrics.org American Geriatrics Society: education, careers vignettes from geriatricians, advocacy and clinical guidelines. bgs.org.uk British Geriatrics Society: useful publications on management of common problems in older people and links to other relevant websites. cochrane.org Cochrane review CD006211 Comprehensive geriatric assessment for older adults admitted to hospital; CD007146 Interventions for preventing falls in older people living in the community. eugms.org European Union Geriatric Medicine Society: research, position papers and educational resources. iagg.info International Association of Gerontology and Geriatrics: promoting care of older people and the science of gerontology globally; research, policy and educational resources. knowledge.scot.nhs.uk/effectiveolderpeoplecare.aspx Collates and summarises the Cochrane evidence for best practice in the healthcare and rehabilitation of frail older people. profane.co Prevention of Falls Network Earth: focuses on the prevention of falls and improvement of postural stability in older people. qfracture.org Fracture risk calculator validated in the UK population. Includes a wider range of risk factors than FRAX. shef.ac.uk/FRAX/tool.jsp Fracture risk calculator: can be used to calculate risk in several populations. Includes option to calculate with or without measurement of hip bone mineral density. The 20-point version is illustrated. The total score reflects the degree of dependency; scores of 14 and above are usually consistent with living in the community; scores below 10 suggest the patient is heavily dependent on carers. 32.10 How to assess dependency using the Modified Barthel Index Mobility Independent = 3 Needs help = 2 Wheelchair independent = 1 Immobile = 0 Stairs Independent = 2 Needs help = 1 Unable = 0 Transfers (e.g. from bed to chair) Independent = 3 Needs minor help = 2 Needs major help = 1 Unable = 0 Bladder Continent = 2 Occasional incontinence = 1 Incontinent = 0 Bowels Continent = 2 Occasional incontinence = 1 Incontinent = 0 Grooming Independent = 1 Needs help = 0 Toilet use Independent = 2 Needs help = 1 Unable = 0 Feeding Independent = 2 Needs help = 1 Unable = 0 Dressing Independent = 2 Needs some help = 1 Completely dependent = 0 Bathing Independent = 1 Needs help = 0
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