Topic and articleKey recommendations
Falls
Preventing Falls in Older Persons*Community-dwelling older persons at high risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs.
Older persons at risk of falls who are hospitalized in an acute setting or for an extended time in a subacute setting should receive a multifactorial risk assessment and intervention tailored to their needs.
Nursing home residents at risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs and administered by a multidisciplinary team.
Components to include in multifactorial interventions for falls in older persons:

  • Exercise, particularly balance, strength, and gait training

  • Vitamin D3 supplementation of at least 800 IU daily

  • Withdrawal or minimization of psychoactive and other medications

  • Adaptation or modification of the home environment for those who have fallen or have visual impairment

  • Management of foot problems and footwear

  • Management of postural hypotension

Dual chamber cardiac pacing should be considered in patients with carotid sinus hypersensitivity who experience unexplained recurrent falls.
Geriatric Assistive Devices Assistive devices can be prescribed to improve balance, reduce pain, and increase mobility and confidence.
Because most patients obtain their assistive device without recommendations or instructions from a medical professional, assistive devices should be evaluated routinely for proper fit and use.
When only one upper extremity is needed for balance or weight bearing, a cane is preferable. If both upper extremities are needed, crutches or a walker is more appropriate.
The correct height of cane or walker is at level of the patient's wrist crease. Measure with patient standing upright with arms relaxed at sides. When holding the device at this height, patient's elbow is naturally flexed at 15- to 30-degree angle.
Gait and Balance Disorders in Older Adults Gait and balance disorders are usually multifactorial in origin and require a comprehensive assessment to determine contributing factors and targeted interventions.
Older adults should be asked at least annually about falls, and older adults who report a fall should be observed for any gait or balance disturbances.
Exercise and physical therapy can help improve gait and balance disorders in older adults.
Declining functional status
Functional Decline in Older Adults Evaluate new or progressive disability in older adults with careful assessment for underlying health conditions, impairments, and contextual factors.
Treatment of disability: use strategies to increase the patient's capacity to respond to environmental challenges, and to reduce task demand.
Exercise Prescriptions in Older Adults For older adults, any physical activity is better than being sedentary. Reducing sedentary time has cardiovascular, metabolic, and functional benefits.
Resistance training preserves muscle strength and physical functioning in older adults.
Aim for at least 150 minutes of moderate-intensity aerobic activity and two or more days of resistance training per week.
Flexibility exercises improve and maintain joint range of movement in older adults.
Balance exercises (e.g., tai chi, yoga) can improve/maintain physical function, and reduce falls in older adults at risk of falling.
Polypharmacy
Reducing the Risk of Adverse Drug Events in Older Adults Limit the use of antipsychotics, antidepressants, benzodiazepines, and sedative/hypnotics in older adults to reduce the risk of falls.
Limit the number of medications used by older adults; each new medication adds more than one adverse drug event each year, and taking six or more medications increases the risk fourfold.
Ideally, the primary care physician should prescribe all medications, because each additional prescriber increases the risk of adverse drug events in older adults by 30%.
Patients with several chronic health conditions should be asked often about adverse drug events; the odds of an event double for four or five conditions and triple for six or more.
Depression
Depression in Later Life: A Diagnostic and Therapeutic Challenge Depression in older persons is widespread, often undiagnosed, and usually untreated.
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 older patients.
A comprehensive, multidisciplinary approach, including consideration of electroconvulsive treatment in some cases, is important.
Weight loss and malnutrition
Unintentional Weight Loss in Older Adults Unintentional weight loss of more than 5% within six to 12 months is associated with increased morbidity and mortality in older adults and should prompt evaluation.
Conduct a baseline evaluation for unexplained, unintentional weight loss in older adults: history, physical examination, laboratory tests, chest radiography, fecal occult blood testing, and possibly abdominal ultrasonography.
If baseline test results are negative, close observation for three to six months is justified.
Appetite stimulants have not been shown to reduce mortality in those with unintentional weight loss.
Hearing loss
Caring for Older Patients Who Have Significant Hearing Loss [Curbside Consultation] To address communication barriers, face the patient, make eye contact, and talk clearly at a normal pace.
Incorporate visual aids.
Ensure hearing amplification is used by the patient, if it is an option.
Hearing Loss in Older Adults Older patients who report hearing loss can be referred directly for audiometry.
Magnetic resonance imaging with gadolinium contrast media is recommended for patients presenting with idiopathic sudden sensorineural hearing loss to identify serious underlying pathologic conditions.
Provide appropriate counseling to patients with hearing loss; patient perceptions and expectations are the most important factors in the acquisition and use of hearing aids.
Referral for assessment for assistive listening devices should be considered in patients with hearing loss who are unable to use hearing aids.
Visual impairment
Vision Loss in Older Adults Daily AREDS or AREDS2 vitamin supplementation delays vision loss in patients with age-related macular degeneration.
Intravitreal injection of a vascular endothelial growth factor inhibitor, such as bevacizumab (Avastin), ranibizumab (Lucentis), or aflibercept (Eylea), can stabilize vision in patients with neovascular age-related macular degeneration or diabetic macular edema.
Fenofibrate (Tricor) may slow the progression of diabetic retinopathy.
Medical testing before cataract surgery does not improve outcomes and is not recommended.
Counsel older adults who smoke to quit; smoking increases the risk of vision loss associated with age-related macular degeneration and cataracts.
Cognitive impairment
Evaluation of Suspected Dementia Perform formal cognitive testing in patients with abnormal results on initial dementia screening.
Perform routine blood work (i.e., complete blood count; complete metabolic panel; and measurement of thyroid-stimulating hormone, vitamin B12, folate, and calcium levels) in patients with suspected dementia.
Consider additional testing (e.g., neuroimaging, cerebrospinal fluid analysis, human immunodeficiency virus testing, Lyme titer, rapid plasma reagin test) in patients with suspected dementia and specific risk factors or symptoms.
Incontinence
Diagnosis of Urinary Incontinence Consider using a three-day voiding diary in the initial assessment for urinary incontinence symptoms.
A positive cough stress test result is the most reliable clinical assessment for confirming stress incontinence.
Perform postvoid residual urine measurement in select high-risk patients (e.g., persons with overflow incontinence).