Principles of Geriatric Care Fran E. Kaiser, MD • The Increase In the numbers of elderly in the United States, and their projected continued increase to 21% or more of the population by 2030, has provided impetus for the growth of geriatrics. Recognition of change that is age-related rather than disease-related, and the ways In which the elderly differ from their young counterparts is vital In the care of the elderly. A functional approach and appropriate geriatric assessment have been shown to be beneficial to the individual. © 1990 by the National Kidney Foundation, Inc. INDEX WORDS: Geriatrics; assessment.
THE "GERIATRIC IMPERATIVE"
N 1900, approximately 3.1 million people or 4% ofthe population were "senior citizens." In 1986,29.2 million, one in every eight individuals, or 12% of the population were over 65. The projection for the year 2030 is for approximately 65 million or 21% of the population to be over 65. 1 The rates of growth for the age group over 75 and those over 85 years are even higher. By the end of this century, the number of people over 85 is expected to double due to a decline in mortality for the "very 0Id."2 This 12% geriatric segment of our population accounts for one of three health care dollars spent, 33% ofphysician time, and 40% of acute hospital admissions. Five percent (1.5 million) of the elderly population, and 23% of those over 85, reside in nursing homes. 3 This percentage is projected to increase by at least 50% by the year 2000. The majority of elderly individuals live in the community, most in a family setting; however, approximately 30% of elderly community dwellers live alone. Declining health increases with age. In many elderly, physical activity is subject to limitations imposed by chronic conditions. Despite the fact that 80% of people over 65 have at least one chronic condition, and 20% have a mild degree of disability, four of five individuals assess their health as good to excellent. 4 Overall, about 20% of community-living elderly and 48% of
I
From the Department of Medicine, Division of Geriatric Medicine , St Louis University School of Medicine , St Louis , MO. Address reprint requests to Fran E. Kaiser, MD, St Louis University, School of Medicine, Division of Geriatric Medicine, 1402 S Grand Blvd, RoomM238, St Louis, M063104. © 1990 by the National Kidney Foundation, Inc. 0272-6386/90/ 1604-f)()19$3 .00/0 354
those over 85 need assistance in personal care or home-related tasks. The scope of services required to maintain an individual in the community varies from none to very few services for a healthy elderly person, to use of multiple social, medical, or home services in more disabled persons (Table 1). The challenge of this graying America and the use of health and social services by this population have created a "geriatric imperative." Attention to meeting the specialized medical care needs of the elderly is emphasized by the emergence of geriatrics as a newly recognized specialty. 5 AGING FACTORS AND PHYSIOLOGIC CHANGE What a cunning and insidious thing, in its approach is old age! How it steals upon you in the night! How carefully it looks you over before it strikes! Confronting you like a cunning antagonist, it fences cautiously until it sees where your guard is weak; it toys and feels with its point, for some opening where, in careless youth, you removed the shield of health and did not replace it. .. . John Sergeant Wise Diomed
Older individuals differ from their younger counterparts by more than just age and a shorter life expectancy. Multiple factors implicated in the aging process include altered gene expression, mutation, effects due to toxins, and alterations in immune/or neuroendocrine function.f>.8 Research has begun to elucidate the physiology of aging as distinct from the pathology of aging. 9 Growing older is not automatically associated with disease, depression, and dementia, and one needs to be aware of the ageism that fosters a contrary view. 10 The physiologic alterations that are associated with aging include change in body composition (with a decrease in lean body mass); a decrease in maximal oxygen consumption with exercise (which is somewhat less in
American Journal of Kidney Diseases, Vol XVI, No 4 (October), 1990: pp 354-359
355
PRINCIPLES OF GERIATRIC CARE
Table 1. Support Services for the Elderly Social Friendly visitors Transport to social/recreational centers/senior citizen centers Individual activity programs Medical and Health Professionals Physician services Nursing services (including home nursing) Physical therapy Pharmacy services Dental care Respiratory therapy Comprehensive assessment Monitoring Health education Home services Meals-on-Wheels Homemaker services Repair/chore services Environmental safety aid services
those who remain physically active); and increased collagen cross-linking, with attendant resistance to movement. 11·13 Aging alterations in the kidney include decreased number of glomeruli, decreased number and size of tubules, and in most individuals, a decrease in glomerular filtration rate (although in 36% of subjects, no change in GFR was noted). 14- 16 In the aging heart, a decreased or unchanged cardiac output at rest, and a slight decrease in heart rate, offset by an increase in stroke volume, and a decrease in the left ventricular filling rate, may occur. 17-19 Changes in the respiratory system include decreased chest wall compliance and loss of some elastic recoil ofthe lungs, as well as alterations in pulmonary function resulting in decreased vital capacity, and decreased FEV I. 20 There is no organ system that is immune to age-related effects, but the inherent reserve in most systems allows for maintenance of basal function. While these basal functions may be intact, small perturbations secondary to "stressors" (physical, chemical, social, economic, and psychologic) can result, along with a decrement in coping skills and mechanisms (homeostasis), in major alterations in overall function of the individual (Fig 1). For example, an elderly individualliving alone severely injures his foot, resulting in an inability to ambulate. He cannot get his groceries or even get out of his house to seek attention for this injury. He begins to suffer the effects of poor nutrition and infection of the
Information/referral services Caregiver support Community linkage Telephone reassurance Health aides Speech therapy Medical equipment Medication Occupational therapy Psychologists Care planning Primary health care Nutrition counseling Personal care Respite care for caregiver Transportation Legal/financial counseling
injured area, resulting in weakness, weight loss, alterations in mental status, and so on ... , until he finally has lost his ability to function independently in his home environment. This type of cascading effect, of one problem resulting in a host of others, is often seen in the elderly. It is helpful to remember some of the "i's" of geriatrics: iatrogenesis, immobility, instability, Physical changes
Social changes
Economtc changes
LOSS OF COPING SKILLS
1
FUNCTIONAL ALTERATIONS Fig 1. The path to impairment/loss of function.
356
inanition, intellectual impairment, impaired vision and/or hearing, isolation (depression), incontinence, impotence, and infection 21 (Table 2). The elderly often bear the burden of not just their diseases, but the multiple medications that are prescribed for those diseases. Elderly patients often take 3 to 12 medications at the same time. 22 Iatrogenic disease may result from inappropriate medication use, including inappropriate or overprescribed drugs and drug side effects. Estimates of adverse drug effects are as high as 1 in 20 drug exposures. Alterations in pharmacokinetics due to changes in drug absorption, distribution, binding, or elimination have a great impact on drug effect and drugdrug interactions. 23,24 Drugs may affect nutrition by causing anorexia (as may occur with digoxin) or alterations in nutrient absorption. 25 Hospitalization may result in confusion, inanition, and/or incontinence as an individual is moved to alien surroundings. Iatrogenic problems may be compounded by the use of physical or chemical restraints to quiet a disoriented, agitated or frightened patient, who then becomes more confused. 26 The patient is then labeled (often incorrectly) as "demented." Immobility in the elderly may also be the result of multiple problems. The incidence of hip fractures rises with increasing age, reaching 2% per year in women over 80. It is associated with marked disability, with less than 25% of those with hip fractures returning to their previous level offunctionY Arthritis, Parkinson's disease, stroke, fear of falling, malnutrition, pain, and depression may all result in impaired mobility. Furthermore, immobility may begin a cascade of untoward events, such as pressure sores, deconditioning, orthostasis, depression, and delirium. Gait instability and falls are common, with 30% of community dwelling elderly over 65 reporting falls each year.28 Approximately 5% of falls result in fractures, and an equal number result in disabling soft-tissue injury. Sedative use, cognitive impairment, and lower extremity disability increase the risk for falls. 29 Inanition in the elderly is common. Sixteen percent of individuals older than 65 ingest fewer than 1,000 calories per day. 30 Seventeen percent to 65% of acutely hospitalized elderly patients
FRAN E. KAISER
Table 2. The "1'5" of Geriatrics latrogenesis Immobility Inanition Intellectual impairment Impaired vision and/or hearing Isolation Incontinence Impotence Infection Modified with permission. 21
and up to 59% of institutionalized elderly have malnutrition. 31 -32 Intellectual impairment is not severe enough in normal aging to cause most individuals to be dysfunctional. Cognitive function is mildly impaired in 10% to 15% of those over 65, but severely impaired in 5%, and is severely impaired in 20% of those over 80. Dementia is present in over 50% of institutionalized elderly. Delirium with its acute onset, fluctuation of symptoms, clouding of consciousness, and improvement when the underlying condition is remedied, must be distinguished from dementia. Dementia, a chronic progressive loss of intellectual function and memory sufficient to cause dysfunction, must further be distinguished from depression. Alzheimer's disease and multiinfarct dementia account for most cases of dementia. Reviews of cognitive alterations have been previously published. 32-34 Decreases in visual acuity, the development of presbyopia, decreased tearing, and presbycusis, a sensorineural hearing loss that affects 60% of those over age 60, may result in a decrease or loss of functional activity, isolation, and depression. Sensory loss may be mistaken for impaired cognitive function . Isolation (depression) occurs in about 5% of communitydwelling elderly,35 but does not appear to be higher than in other age groups. Suicide is high in elderly white males, especially when spousal loss has occurred. Somatic signs (such as anorexia, insomnia, fatigue) may mimic organic disease, which should be ruled out. Additionally, the confusion and deficits of cognitive testing that may occur in depression may be mistaken for dementia. Incontinence increases with age, and is a heterogeneous disorder that can range from rare dribbling to constant loss of urine with concom-
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PRINCIPLES OF GERIATRIC CARE
itant fecal incontinence. Incontinence occurs in as many as 30%36 of noninstitutionalized elderly and over 50% of nursing home patients. Restriction of access to toileting, urinary outlet obstruction, delirium, infection, and drug effects, as well as alterations in bladder/muscle functions, are among the causes ofthis problem. Incontinence at home may result in nursing home placement. Impotence is a common occurrence in the aging male, with Kinsey et al noting that 55% of men reported impotence by age 75,31 Organic causes with age-related hormonal (decreased bioavailable testosterone) and vascular alterations playa major role in sexual dysfunction, but there may be an overlay of psychologic factors.38 Recent advances such as intracavernosal injections, penile prostheses and vacuum tumescent devices, have now made this a more readily treatable condition. 39 Infections such as pneumonia and urinary tract infections occur with increased frequency in the elderly, and mortality from infection is considerably higher than in younger groups. 40 Atypical presentation such as lack or blunting of fever, or alteration of mental status as the only symptom, may delay diagnosis and treatment. 41 Once again, it is a case of "if you don't suspect it, you won't find it!" THE GERIATRIC DATA BASE AND GERIATRIC ASSESSMENT
The hallmark of geriatrics is to deliver comprehensive care that enhances and allows maximal health, comfort, function, and independence. The medical history may be secondhand from family or others involved in the care of the elderly individual. Disease presentation is often atypical. As described above, an infected foot may present as a mental status change. The elderly tend to underreport problems or describe nonspecific symptoms. In addition to a careful medical history, an accurate drug history is vital. A careful and thorough physical examination, with special attention to areas that playa role in the "i's" of geriatrics must be done. In some elderly individuals, additional "layers" of evaluation and assessment should be performed (Table 3) for recognition and diagnosis of problems in function and the development of a care plan. Assessment also al-
Table 3. Geriatric Assessment Medical Atypical presentation of illness Nutritional status Senory (hearing and vision) assessment Medication Functional Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Tinetli gait and balance Environmental assessment Psychosocial Folstein Mini-Mental Status Yesavage Geriatric Depression Scale Quality of life Aggressive intervention status (resuscitation)
lows a way to measure the impact of intervention. A multidisciplinary geriatric assessment team, composed of medical, nursing, and social service professionals, and ideally, geropsychiatry, geropharmacy, physical, and occupational therapy health professionals may provide service that is greater than the sum of its parts.42 Social factors play an important role in understanding the patient in context. The loss of a social network, spousal support, income, activities, and on occasion, image, when one retires, the burden of care that may be placed on family members by an elderly individual, and the adequacy of the environment, all constitute part of the social fabric that must be investigated in an individual. A patient's support system can sometimes determine whether that individual can continue living in a community setting, or must be placed in an institutional setting in order to have care needs met. Cognitive function measurements (such as the Folstein Mini-Mental Status Examination), measures of the activities of daily living (ADLs) and the need for assistance (bathing, dressing, toileting, transferring, continence, and feeding), and measures of the instrumental activities of daily living (lADLs) (using the telephone, shopping, meal preparation, housework, laundry, ability to use transportation, ability to handle medication and finances) all aid in the evaluation of how well the patient can function at any given time. 43-46 Assessment of gait and balance aid in understanding problems of mobility.47 Functional ability is a strong predictor of hospital length of stay, mortality, and nursing home
358
FRAN E. KAISER
placement. 48 The demonstrated merits of geriatric assessment programs include increased diagnostic recognition (new diagnoses that had previously gone unnoted), improved functional state, decreased hospital/nursing home utilization, reduction in the numbers of medications used by an individual, overall improvement in quality of life, and a net cost reduction for
care. 48 -50 Programs such as Geriatric Evaluation Units, and home care programs such as the Copenhagen study,51 which target appropriate individuals for assessment and intervention, can clearly impact the quality of life and even mortality.51.52 To paraphrase Henriksen, et al,51 "the impact of geriatrics is to add life to the years of older individuals, not just years to their lives."
REFERENCES I. US Bureau ofthe Census: Decennial Census; 19001980 Projections of the population of the United States. 1982-2050. Current Population Report, No 922, October 1982, Middle series projection, p 25 2. Fingerhut LA: Changes in mortality among the elderly: United States 1940-1948. National Center for Health Statistics (PHS) 82-1406, Washington, DC, US Government Printing Office, 1982 3. National Center for Health statistics: Use of Nursing Home by the Elderly: Preliminary data from the 1985 National Nursing Home Survey. Advance Data from Vital and Health Statistics 135. DHHS, vol no (PHS) 87 - 1250. Hyattsville, MD, Government Printing Office, 1987 4. Schick FL: Health Aspects, in Schick FL (ed): Statistical Handbook on Aging Americans. Phoenix, AZ, Oryx, 1986, pp 99-135 5. Committee on Leadership for Academic Geriatric Medicine: Report of the Institute of Medicine: Academic geriatrics for the year 2000. J Am Geriatric Soc 35:773-791, 1987 6. Hart RW, Turtorro A: Theories of aging, in Rothstein M (ed): Review of Bilogical Research in Aging, vol 1. New York, NY, Liss, 1983, pp 5-17 7. Masoro EJ: Biology of aging. Current state of know1edge. Arch Intern Med 147: 166-169, 1967 8. Cutler RG: Peroxide producing potential of tissues: Inverse correlation with longevity of mammalian species. Proc Natl Acad Sci USA 82:4798-4802, 1985 9. Rowe JW: Health care for the elderly. N Engl J Med 312:827-835,1985 10. Butler RN: Age-ism: Another form of bigotry. Gerontologist 9:243-246, 1969 11. Williams ME: Clinical implications of aging physiology. Am J Med 76: 1049-1054 1984 12. Fulop T Jr, Worum I, Csongor J, et al: Body composition in elderly people. Gerontology 31:6-14, 1985 13. Dehn MM, Bruce RA: Longitudinal variations in maximal oxygen intake with age and activity. J Appl Physiol 33:805-807, 1972 14. Lindeman RD, Tobin J, Shock NW: Longitudinal studies on the rate of decline in renal function with age. J Am Geriatric Soc 33:278-285, 1985 15. Darmady EM, OfferJ, Woodhouse MA: The parameters of the aging kidney. J PathoI109:195-207, 1972 16. RoweJW, Andres R, TobinJD,etal: The effect of age on creatinine clearance in men: A cross-sectional and longitudinal study. J GerontoI31:155-163, 1976 17. Rodeneffer RJ, Gerstenblith G, Becker L, et al: Exercise cardiac output is maintained with advancing age in
health human subjects: Cardiac dilatation and increased stroke volume compensate for a diminished heart rate. Circulation 69:203-212, 1984 18. Fleg JL, Lakatta EG: Aging of the normal cardiovascular system, in Coodley E (ed) Geriatric Heart Disease. Littleton, MA, PSG, 1985, pp 39-52 19. Morley JE, Reese SS: Clinical implications of the aging heart. Am J Med 86:77 -86, 1989 20. Krumpe PE, Knudson RJ, Parsons G, et al: The aging respiratory system. Clin Geriatr Med 1: 143-175, 1985 21. Kane RL, Ouslander JG, Abrass 18: Essentials of Clinical Geriatrics. New York, NY, McGraw-Hili, 1989 22. Lamy PP: Prescribing for the Elderly. Littleton, MA, PSG, 1980 23. Goldberg PB, Roberts J: Pharmacologic basis for developing rational drug regimens for elderly patients. Med Clin North Am 67:315-331, 1983 24. Ouslander JG: Drug therapy in the elderly. Ann Intern Med 95:711-722, 1981 25. Lye MDW: Cardiovascular system: digitalis Glycosides, in Brocklehurst JC (ed): Geriatric Pharmacology and Therapeutics. Oxford, England, Blackwell Scientific 1984, pp71-86 26. Steel K, Gertman PM, Crescenzi C, et al: Iatrogenic illness on a general medical service at a university hospital. N Engl J Med 304:638-642, 1981 27. Cobey JC, Cobey JH, Conant L, et al: Indicators of recovery from fractures of the hip. Clin Orthop 117:258262, 1976 28. Campbell AJ, Reinken J, Allan BC, et al: Falls in old age: A study offrequency and related clinical factors. Age Aging 10:264-270, 1981 29. Tinetti ME, Speechly M, Ginter SF: Risk factors for falls among elderly persons living in the community. N Engl J Med 319:1701-1707,1988 30. Abrahams S, Carroll MD, Dresser CM, et al: Dietary intake of persons 1- 74 years of age in the United States. Advance Data from Vital and Health Statistics of the National Center for Health Statistics. No.6, US Dept of Health Education and Welfare. DHEW Publ no. (PHS) 771647, Rockville, MD, US Department of Health Education and Welfare, 1977 31. Agarwal N, AcevedaF, CaytenCG, etal: Nutritional status of the hospitalized very elderly from nursing homes and private homes. Am J Clin Nutr43:659-669, 1986 32. Cummings JL: Multi-infarct dementia: Diagnosis and management. Psychosomatics 28: 117-126, 1987 33. La Rue A: Memory loss and aging distinguishing dementia from benign senescent forgetfulness and depressive
PRINCIPLES OF GERIATRIC CARE
pseudodementia. Psychiatr Clin North Am 5:89-104, 1982 34. Mace NL, Rabins PV: The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer's Disease, Related Dementing Illnesses and Memory Loss in Later Life . Baltimore, MD, Johns Hopkins University, 1981 35. Gurland BJ, Cross PS: Epidemiology of psycholopathology in old age: Some implications for clinical services. Psychol Clin North Am 5: 11-26, 1982 36. Diokno AC, Brock GM, Brown MB: Prevalance of ordinary incontinence and other urological symptoms in noninstitutionalized elderly. J Urol 136: 1022-1025, 1986 37. Kinsey A, Pomeroy W. Martin C: Sexual Behavior in the Human Male. Philadelphia, PA, Saunders, 1948 38. Kaiser FE, Viosca Sp, Morley JE , et al: Impotence and aging: Clinical and hormonal factors . JAm Geriatr Soc 36:511-519, 1988 39. Morley JE, Kaiser FE: Testicular function in the aging male, in Armbrecht HJ (eds): Endocrine Function and Aging. New York, NY, Springer-Verlag, 1990 40. Yoshikawa TT, Norman DC: Aging and Clinical Practice: Infectious Diseases. Diagnosis and Management. New York, NY, Igaku-Shoin, 1987 41. Gleckman R, Hibert D: Afebrile bacteremia: A phenomenon in geriatric patients. JAMA 248 : 1478-1483, 1981 42. Campbell U , Cole KD: Geriatric assessment teams. Clin Geriatr Med 3 :99-117, 1987 43. Folstein M, Folstein S, McHugh P: "Mini mental state" : A practical method for grading the cognitive state of
359 patients for the clinician. J P sychiatr Res 12: 189-198, 1975 44. Katz S, Down TD, Cash HR, et al: Progress in the development of the index of ADL. Gerontologist 10:20-30, 1970 45 . Lawton MP, Brody EM: Assessment of older people: Self-monitoring and instrumental activities of daily living. Gerontologist 9: 179-186, 1969 46. Yesavage J, Brink T, Rose T: Development and validation of a geriatric screening scale: A preliminary report. J Psychiatr Res 17:37-49, 1983 47. Tinetti M: Performance oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 34: 119-126, 1986 48. Rubenstein LZ: Comprehensive geriatric assessment, in Solomon DH (moderator): New Issues in geriatric care. Ann Intern Med 108:718-732, 1988 49. Williams TF, Hill JG, Fairbank ME, et al : Appropriate placement of the chronically ill and aged : Asuccessful approach by evaluation. J Am Geriatr Soc 226: 1332-1335, 1973 50. Rubenstein LZ, Josephson KR, Wieland GD, et al: Effectiveness of a geriatric evaluation unit: A randomized clinical trial. N Engl J Med 311: 1664-1670, 1984 51. Hendriksen C, Lunc E, Stromgard E: Consequences of assessment and intervention among elderly people: A three year randomized controlled trial. Br Med J (Clin Res) 289: 1522-1524, 1984
THE "GERIATRIC IMPERATIVE"
N 1900, approximately 3.1 million people or 4% ofthe population were "senior citizens." In 1986,29.2 million, one in every eight individuals, or 12% of the population were over 65. The projection for the year 2030 is for approximately 65 million or 21% of the population to be over 65. 1 The rates of growth for the age group over 75 and those over 85 years are even higher. By the end of this century, the number of people over 85 is expected to double due to a decline in mortality for the "very 0Id."2 This 12% geriatric segment of our population accounts for one of three health care dollars spent, 33% ofphysician time, and 40% of acute hospital admissions. Five percent (1.5 million) of the elderly population, and 23% of those over 85, reside in nursing homes. 3 This percentage is projected to increase by at least 50% by the year 2000. The majority of elderly individuals live in the community, most in a family setting; however, approximately 30% of elderly community dwellers live alone. Declining health increases with age. In many elderly, physical activity is subject to limitations imposed by chronic conditions. Despite the fact that 80% of people over 65 have at least one chronic condition, and 20% have a mild degree of disability, four of five individuals assess their health as good to excellent. 4 Overall, about 20% of community-living elderly and 48% of
I
From the Department of Medicine, Division of Geriatric Medicine , St Louis University School of Medicine , St Louis , MO. Address reprint requests to Fran E. Kaiser, MD, St Louis University, School of Medicine, Division of Geriatric Medicine, 1402 S Grand Blvd, RoomM238, St Louis, M063104. © 1990 by the National Kidney Foundation, Inc. 0272-6386/90/ 1604-f)()19$3 .00/0 354
those over 85 need assistance in personal care or home-related tasks. The scope of services required to maintain an individual in the community varies from none to very few services for a healthy elderly person, to use of multiple social, medical, or home services in more disabled persons (Table 1). The challenge of this graying America and the use of health and social services by this population have created a "geriatric imperative." Attention to meeting the specialized medical care needs of the elderly is emphasized by the emergence of geriatrics as a newly recognized specialty. 5 AGING FACTORS AND PHYSIOLOGIC CHANGE What a cunning and insidious thing, in its approach is old age! How it steals upon you in the night! How carefully it looks you over before it strikes! Confronting you like a cunning antagonist, it fences cautiously until it sees where your guard is weak; it toys and feels with its point, for some opening where, in careless youth, you removed the shield of health and did not replace it. .. . John Sergeant Wise Diomed
Older individuals differ from their younger counterparts by more than just age and a shorter life expectancy. Multiple factors implicated in the aging process include altered gene expression, mutation, effects due to toxins, and alterations in immune/or neuroendocrine function.f>.8 Research has begun to elucidate the physiology of aging as distinct from the pathology of aging. 9 Growing older is not automatically associated with disease, depression, and dementia, and one needs to be aware of the ageism that fosters a contrary view. 10 The physiologic alterations that are associated with aging include change in body composition (with a decrease in lean body mass); a decrease in maximal oxygen consumption with exercise (which is somewhat less in
American Journal of Kidney Diseases, Vol XVI, No 4 (October), 1990: pp 354-359
355
PRINCIPLES OF GERIATRIC CARE
Table 1. Support Services for the Elderly Social Friendly visitors Transport to social/recreational centers/senior citizen centers Individual activity programs Medical and Health Professionals Physician services Nursing services (including home nursing) Physical therapy Pharmacy services Dental care Respiratory therapy Comprehensive assessment Monitoring Health education Home services Meals-on-Wheels Homemaker services Repair/chore services Environmental safety aid services
those who remain physically active); and increased collagen cross-linking, with attendant resistance to movement. 11·13 Aging alterations in the kidney include decreased number of glomeruli, decreased number and size of tubules, and in most individuals, a decrease in glomerular filtration rate (although in 36% of subjects, no change in GFR was noted). 14- 16 In the aging heart, a decreased or unchanged cardiac output at rest, and a slight decrease in heart rate, offset by an increase in stroke volume, and a decrease in the left ventricular filling rate, may occur. 17-19 Changes in the respiratory system include decreased chest wall compliance and loss of some elastic recoil ofthe lungs, as well as alterations in pulmonary function resulting in decreased vital capacity, and decreased FEV I. 20 There is no organ system that is immune to age-related effects, but the inherent reserve in most systems allows for maintenance of basal function. While these basal functions may be intact, small perturbations secondary to "stressors" (physical, chemical, social, economic, and psychologic) can result, along with a decrement in coping skills and mechanisms (homeostasis), in major alterations in overall function of the individual (Fig 1). For example, an elderly individualliving alone severely injures his foot, resulting in an inability to ambulate. He cannot get his groceries or even get out of his house to seek attention for this injury. He begins to suffer the effects of poor nutrition and infection of the
Information/referral services Caregiver support Community linkage Telephone reassurance Health aides Speech therapy Medical equipment Medication Occupational therapy Psychologists Care planning Primary health care Nutrition counseling Personal care Respite care for caregiver Transportation Legal/financial counseling
injured area, resulting in weakness, weight loss, alterations in mental status, and so on ... , until he finally has lost his ability to function independently in his home environment. This type of cascading effect, of one problem resulting in a host of others, is often seen in the elderly. It is helpful to remember some of the "i's" of geriatrics: iatrogenesis, immobility, instability, Physical changes
Social changes
Economtc changes
LOSS OF COPING SKILLS
1
FUNCTIONAL ALTERATIONS Fig 1. The path to impairment/loss of function.
356
inanition, intellectual impairment, impaired vision and/or hearing, isolation (depression), incontinence, impotence, and infection 21 (Table 2). The elderly often bear the burden of not just their diseases, but the multiple medications that are prescribed for those diseases. Elderly patients often take 3 to 12 medications at the same time. 22 Iatrogenic disease may result from inappropriate medication use, including inappropriate or overprescribed drugs and drug side effects. Estimates of adverse drug effects are as high as 1 in 20 drug exposures. Alterations in pharmacokinetics due to changes in drug absorption, distribution, binding, or elimination have a great impact on drug effect and drugdrug interactions. 23,24 Drugs may affect nutrition by causing anorexia (as may occur with digoxin) or alterations in nutrient absorption. 25 Hospitalization may result in confusion, inanition, and/or incontinence as an individual is moved to alien surroundings. Iatrogenic problems may be compounded by the use of physical or chemical restraints to quiet a disoriented, agitated or frightened patient, who then becomes more confused. 26 The patient is then labeled (often incorrectly) as "demented." Immobility in the elderly may also be the result of multiple problems. The incidence of hip fractures rises with increasing age, reaching 2% per year in women over 80. It is associated with marked disability, with less than 25% of those with hip fractures returning to their previous level offunctionY Arthritis, Parkinson's disease, stroke, fear of falling, malnutrition, pain, and depression may all result in impaired mobility. Furthermore, immobility may begin a cascade of untoward events, such as pressure sores, deconditioning, orthostasis, depression, and delirium. Gait instability and falls are common, with 30% of community dwelling elderly over 65 reporting falls each year.28 Approximately 5% of falls result in fractures, and an equal number result in disabling soft-tissue injury. Sedative use, cognitive impairment, and lower extremity disability increase the risk for falls. 29 Inanition in the elderly is common. Sixteen percent of individuals older than 65 ingest fewer than 1,000 calories per day. 30 Seventeen percent to 65% of acutely hospitalized elderly patients
FRAN E. KAISER
Table 2. The "1'5" of Geriatrics latrogenesis Immobility Inanition Intellectual impairment Impaired vision and/or hearing Isolation Incontinence Impotence Infection Modified with permission. 21
and up to 59% of institutionalized elderly have malnutrition. 31 -32 Intellectual impairment is not severe enough in normal aging to cause most individuals to be dysfunctional. Cognitive function is mildly impaired in 10% to 15% of those over 65, but severely impaired in 5%, and is severely impaired in 20% of those over 80. Dementia is present in over 50% of institutionalized elderly. Delirium with its acute onset, fluctuation of symptoms, clouding of consciousness, and improvement when the underlying condition is remedied, must be distinguished from dementia. Dementia, a chronic progressive loss of intellectual function and memory sufficient to cause dysfunction, must further be distinguished from depression. Alzheimer's disease and multiinfarct dementia account for most cases of dementia. Reviews of cognitive alterations have been previously published. 32-34 Decreases in visual acuity, the development of presbyopia, decreased tearing, and presbycusis, a sensorineural hearing loss that affects 60% of those over age 60, may result in a decrease or loss of functional activity, isolation, and depression. Sensory loss may be mistaken for impaired cognitive function . Isolation (depression) occurs in about 5% of communitydwelling elderly,35 but does not appear to be higher than in other age groups. Suicide is high in elderly white males, especially when spousal loss has occurred. Somatic signs (such as anorexia, insomnia, fatigue) may mimic organic disease, which should be ruled out. Additionally, the confusion and deficits of cognitive testing that may occur in depression may be mistaken for dementia. Incontinence increases with age, and is a heterogeneous disorder that can range from rare dribbling to constant loss of urine with concom-
357
PRINCIPLES OF GERIATRIC CARE
itant fecal incontinence. Incontinence occurs in as many as 30%36 of noninstitutionalized elderly and over 50% of nursing home patients. Restriction of access to toileting, urinary outlet obstruction, delirium, infection, and drug effects, as well as alterations in bladder/muscle functions, are among the causes ofthis problem. Incontinence at home may result in nursing home placement. Impotence is a common occurrence in the aging male, with Kinsey et al noting that 55% of men reported impotence by age 75,31 Organic causes with age-related hormonal (decreased bioavailable testosterone) and vascular alterations playa major role in sexual dysfunction, but there may be an overlay of psychologic factors.38 Recent advances such as intracavernosal injections, penile prostheses and vacuum tumescent devices, have now made this a more readily treatable condition. 39 Infections such as pneumonia and urinary tract infections occur with increased frequency in the elderly, and mortality from infection is considerably higher than in younger groups. 40 Atypical presentation such as lack or blunting of fever, or alteration of mental status as the only symptom, may delay diagnosis and treatment. 41 Once again, it is a case of "if you don't suspect it, you won't find it!" THE GERIATRIC DATA BASE AND GERIATRIC ASSESSMENT
The hallmark of geriatrics is to deliver comprehensive care that enhances and allows maximal health, comfort, function, and independence. The medical history may be secondhand from family or others involved in the care of the elderly individual. Disease presentation is often atypical. As described above, an infected foot may present as a mental status change. The elderly tend to underreport problems or describe nonspecific symptoms. In addition to a careful medical history, an accurate drug history is vital. A careful and thorough physical examination, with special attention to areas that playa role in the "i's" of geriatrics must be done. In some elderly individuals, additional "layers" of evaluation and assessment should be performed (Table 3) for recognition and diagnosis of problems in function and the development of a care plan. Assessment also al-
Table 3. Geriatric Assessment Medical Atypical presentation of illness Nutritional status Senory (hearing and vision) assessment Medication Functional Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Tinetli gait and balance Environmental assessment Psychosocial Folstein Mini-Mental Status Yesavage Geriatric Depression Scale Quality of life Aggressive intervention status (resuscitation)
lows a way to measure the impact of intervention. A multidisciplinary geriatric assessment team, composed of medical, nursing, and social service professionals, and ideally, geropsychiatry, geropharmacy, physical, and occupational therapy health professionals may provide service that is greater than the sum of its parts.42 Social factors play an important role in understanding the patient in context. The loss of a social network, spousal support, income, activities, and on occasion, image, when one retires, the burden of care that may be placed on family members by an elderly individual, and the adequacy of the environment, all constitute part of the social fabric that must be investigated in an individual. A patient's support system can sometimes determine whether that individual can continue living in a community setting, or must be placed in an institutional setting in order to have care needs met. Cognitive function measurements (such as the Folstein Mini-Mental Status Examination), measures of the activities of daily living (ADLs) and the need for assistance (bathing, dressing, toileting, transferring, continence, and feeding), and measures of the instrumental activities of daily living (lADLs) (using the telephone, shopping, meal preparation, housework, laundry, ability to use transportation, ability to handle medication and finances) all aid in the evaluation of how well the patient can function at any given time. 43-46 Assessment of gait and balance aid in understanding problems of mobility.47 Functional ability is a strong predictor of hospital length of stay, mortality, and nursing home
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placement. 48 The demonstrated merits of geriatric assessment programs include increased diagnostic recognition (new diagnoses that had previously gone unnoted), improved functional state, decreased hospital/nursing home utilization, reduction in the numbers of medications used by an individual, overall improvement in quality of life, and a net cost reduction for
care. 48 -50 Programs such as Geriatric Evaluation Units, and home care programs such as the Copenhagen study,51 which target appropriate individuals for assessment and intervention, can clearly impact the quality of life and even mortality.51.52 To paraphrase Henriksen, et al,51 "the impact of geriatrics is to add life to the years of older individuals, not just years to their lives."
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pseudodementia. Psychiatr Clin North Am 5:89-104, 1982 34. Mace NL, Rabins PV: The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer's Disease, Related Dementing Illnesses and Memory Loss in Later Life . Baltimore, MD, Johns Hopkins University, 1981 35. Gurland BJ, Cross PS: Epidemiology of psycholopathology in old age: Some implications for clinical services. Psychol Clin North Am 5: 11-26, 1982 36. Diokno AC, Brock GM, Brown MB: Prevalance of ordinary incontinence and other urological symptoms in noninstitutionalized elderly. J Urol 136: 1022-1025, 1986 37. Kinsey A, Pomeroy W. Martin C: Sexual Behavior in the Human Male. Philadelphia, PA, Saunders, 1948 38. Kaiser FE, Viosca Sp, Morley JE , et al: Impotence and aging: Clinical and hormonal factors . JAm Geriatr Soc 36:511-519, 1988 39. Morley JE, Kaiser FE: Testicular function in the aging male, in Armbrecht HJ (eds): Endocrine Function and Aging. New York, NY, Springer-Verlag, 1990 40. Yoshikawa TT, Norman DC: Aging and Clinical Practice: Infectious Diseases. Diagnosis and Management. New York, NY, Igaku-Shoin, 1987 41. Gleckman R, Hibert D: Afebrile bacteremia: A phenomenon in geriatric patients. JAMA 248 : 1478-1483, 1981 42. Campbell U , Cole KD: Geriatric assessment teams. Clin Geriatr Med 3 :99-117, 1987 43. Folstein M, Folstein S, McHugh P: "Mini mental state" : A practical method for grading the cognitive state of
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