Items in AFP with MESH term: Geriatric Assessment
ABSTRACT: Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. The leading causes of involuntary weight loss are depression (especially in residents of long-term care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can psychotropic medication reduction (i.e., by unmasking problems such as anxiety). A specific cause is not identified in approximately one quarter of elderly patients with unintentional weight loss. A reasonable work-up includes tests dictated by the history and physical examination, a fecal occult blood test, a complete blood count, a chemistry panel, an ultrasensitive thyroid-stimulating hormone test and a urinalysis. Upper gastrointestinal studies have a reasonably high yield in selected patients. Management is directed at treating underlying causes and providing nutritional support. Consideration should be given to the patient's environment and interest in and ability to eat food, the amelioration of symptoms and the provision of adequate nutrition. The U.S. Food and Drug Administration has labeled no appetite stimulants for the treatment of weight loss in the elderly.
ABSTRACT: Family physicians play a key role in assessing and managing patients with Alzheimer's disease and in linking the families of these patients to supportive services within the community. As part of comprehensive management, the family physician may be responsible for coordinating assessments of patient function, cognition, comorbid medical conditions, disorders of mood and emotion, and caregiver status. Suggestions for easily administered and scored assessment tools are provided, and practical tips are given for supporting primary caregivers, thereby increasing efficiency and quality of care for patients with Alzheimer's disease.
ABSTRACT: Gait disorders in the elderly are common and in most cases cannot be treated medically or surgically. Therefore, treatment often relies on ambulatory devices such as canes, crutches, and walkers. Before selecting a device, the patient should be evaluated to define whether one or both upper extremities are required to achieve balance or bear weight. Patients requiring only one upper extremity can use a cane, while patients requiring both upper extremities are best served by forearm crutches or walkers. The patient's need to bear weight through the device will help the physician choose a specific device. When measuring the device, anatomic landmarks and the angle of the elbow must be taken into consideration. Because time often is limited during a routine office visit, a physical therapist often can provide further training for patients learning to use such a device.
ABSTRACT: Compression fracture of the vertebral body is common, especially in older adults. Vertebral compression fractures usually are caused by osteoporosis, and range from mild to severe. More severe fractures can cause significant pain, leading to inability to perform activities of daily living, and life-threatening decline in the elderly patient who already has decreased reserves. While the diagnosis can be suspected from history and physical examination, plain roentgenography, as well as occasional computed tomography or magnetic resonance imaging, are often helpful in accurate diagnosis and prognosis. Traditional conservative treatment includes bed rest, pain control, and physical therapy. Interventional procedures such as vertebroplasty can be considered in those patients who do not respond to initial treatment. Family physicians can help patients prevent compression fractures by diagnosing and treating predisposing factors, identifying high-risk patients, and educating patients and the public about measures to prevent falls.
ABSTRACT: Depression in elderly persons is widespread, often undiagnosed, and usually untreated. The current system of care is fragmented and inadequate, and staff at residential and other facilities often are ill-equipped to recognize and treat patients with depression. Because there is no reliable diagnostic test, a careful clinical evaluation is essential. Depressive illness in later life should be treated with antidepressants that are appropriate for use in geriatric patients. A comprehensive, multidisciplinary approach, including consideration of electroconvulsive treatment in some cases, is important. The overall long-term prognosis for elderly depressed patients is good.
Geriatric Failure to Thrive - Article
ABSTRACT: In elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. Four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment. Initial assessments should include information on physical and psychologic health, functional ability, socioenvironmental factors, and nutrition. Laboratory and radiologic evaluations initially are limited to a complete blood count, chemistry panel, thyroid-stimulating hormone level, urinalysis, and other studies that are appropriate for an individual patient. A medication review should ensure that side effects or drug interactions are not a contributing factor to failure to thrive. The impact of existing chronic diseases should be assessed. Interventions should be directed toward easily treatable causes of failure to thrive, with the goal of maintaining or improving overall functional status. Physicians should recognize the diagnosis of failure to thrive as a key decision point in the care of an elderly person. The diagnosis should prompt discussion of end-of-life care options to prevent needless interventions that may prolong suffering.
Prevention of Falls in Older Patients - Article
ABSTRACT: Falls are one of the most common geriatric syndromes threatening the independence of older persons. Between 30 and 40 percent of community-dwelling adults older than 65 years fall each year, and the rates are higher for nursing home residents. Falls are associated with increased morbidity, mortality, and nursing home placement. Most falls have multiple causes. Risk factors for falls include muscle weakness, a history of falls, use of four or more prescription medications, use of an assistive device, arthritis, depression, age older than 80 years, and impairments in gait, balance, cognition, vision, and activities of daily living. Physicians caring for older patients should ask about any falls that have occurred in the past year. Assessment should include evaluating the circumstances of the fall and a complete history and physical examination, looking for potential risk factors. The most effective fall prevention strategies are multifactorial interventions targeting identified risk factors, exercises for muscle strengthening combined with balance training, and withdrawal of psychotropic medication. Home hazard assessment and modification by a health professional also is helpful.
Geriatric Screening and Preventive Care - Article
ABSTRACT: Preventive health care decisions and recommendations become more complex as the population ages. The leading causes of death (i.e., heart disease, malignant neoplasms, cerebrovascular disease, and chronic lower respiratory disease) among older adults mirror the actual causes of death (i.e., tobacco use, poor diet, and physical inactivity) among persons of all ages. Many aspects of mortality in older adults are modifiable through behavior change. Patients 65 years and older should be counseled on smoking cessation, diets rich in healthy fats, aerobic exercise, and strength training. Other types of preventive care include aspirin therapy; lipid management; and administration of tetanus and diphtheria, pneumococcal, and influenza vaccines. Although cancer is the second leading cause of death in patients 65 years and older, a survival benefit from cancer screening is not seen unless the patient's life expectancy exceeds five years. Therefore, it is best to review life expectancy, functionality, and comorbidities with older patients when making cancer screening recommendations. Other recommended screenings include abdominal aortic aneurysm for men 65 to 75 years of age, breast cancer for women 40 years and older with a life expectancy greater than five years, and colorectal cancer for men and women 50 years and older with a life expectancy greater than five years.
Vision Loss in Older Persons - Article
ABSTRACT: Family physicians have an essential role in assessing, identifying, treating, and preventing or delaying vision loss in the aging population. Approximately one in 28 U.S. adults older than 40 years is visually impaired. Vision loss is associated with depression, social isolation, falls, and medication errors, and it can cause disturbing hallucinations. Adults older than 65 years should be screened for vision problems every one to two years, with attention to specific disorders, such as diabetic retinopathy, refractive error, cataracts, glaucoma, and age-related macular degeneration. Vision-related adverse effects of commonly used medications, such as amiodarone or phosphodiesterase inhibitors, should be considered when evaluating vision problems. Prompt recognition and management of sudden vision loss can be vision saving, as can treatment of diabetic retinopathy, refractive error, cataracts, glaucoma, and age-related macular degeneration. Aggressive medical management of diabetes, hypertension, and hyperlipidemia; encouraging smoking cessation; reducing ultraviolet light exposure; and appropriate response to medication adverse effects can preserve and protect vision in many older persons. Antioxidant and mineral supplements do not prevent age-related macular degeneration, but may play a role in slowing progression in those with advanced disease.
ABSTRACT: Regular exercise provides a myriad of health benefits in older adults, including improvements in blood pressure, diabetes, lipid profile, osteoarthritis, osteoporosis, and neurocognitive function. Regular physical activity is also associated with decreased mortality and age-related morbidity in older adults. Despite this, up to 75 percent of older Americans are insufficiently active to achieve these health benefits. Few contraindications to exercise exist and almost all older persons can benefit from additional physical activity. The exercise prescription consists of three components: aerobic exercise, strength training, and balance and flexibility. Physicians play a key role in motivating older patients and advising them regarding their physical limitations and/or comorbidities. Motivating patients to begin exercise is best achieved by focusing on individual patient goals, concerns, and barriers to exercise. Strategies include the "stages of change" model, individualized behavioral therapy, and an active lifestyle. To increase long-term compliance, the exercise prescription should be straightforward, fun, and geared toward a patient's individual health needs, beliefs, and goals.