Caring for Older Adults
- In the US, over 20% of the population will be > 65 years of age by 2030.
- Many factors affect the functional status of individuals in this age group:
- 80% of individuals have at least 1 chronic condition and 50% have at least 2 chronic conditions.
- Geriatric syndromes (e.g., falls, vision, and hearing impairment) impair function.
- Apart from addressing chronic conditions, comprehensive preventive care with functional and psychosocial evaluation are essential in improving geriatric well-being.
Assessment of older adults
Care for the elderly is a team-based approach that involves various professionals (e.g., physicians, social workers, nutritionists, physical therapists) working together to assess the following:
- Physical health:
- Address and manage current chronic conditions (e.g., heart failure, hypertension, diabetes, CKD).
- Discuss nutrition and medication use.
- Appropriate screening for other diseases
- Update the necessary vaccinations.
- Functional ability:
- Ask about impairments in activities of daily living (ADLs).
- Address any limitations in their physical and mental abilities:
- Check for cognitive decline and memory disturbances.
- Hearing and vision assessment
- Driving assessment
- Falls and other incidents contributing to functional limitations
- Psychosocial health:
- Depression may go undetected, as symptoms present in atypical ways.
- Suicide rate is higher in the elderly than in the general population.
- Social environment:
- Inquire about family members and support groups.
- Home safety
- Screen for any mistreatment.
- Screen for financial constraints (directly affects health).
- Advanced care planning
- Appetite and body weight generally decline with age.
- Lean mass decreases and fat mass usually increases in this population.
- Unintentional weight loss occurs in 15%–20% of older adults.
- Associated with higher risks for morbidity and mortality
- Major causes include:
- Psychiatric or cognitive conditions
- Medication side effects
- Changes in social environment or isolation
- Proceed with workup of unintentional weight loss based on presentation (e.g., labs, imaging studies, and cancer screening, if not yet completed).
Alcohol and tobacco use
- Alcohol use:
- Approximately 50% of adults > 65 years of age consume alcohol.
- Alcohol use in older adults is associated with:
- Increased risk of falls
- Negative effects on function, cognition, and general overall health
- The American Geriatrics Society recommends asking older adults specific questions regarding the frequency and quantity of alcohol consumption.
- Tobacco use:
- Older adults should be asked about tobacco use.
- If current smokers, counseling on smoking cessation and methods of quitting should be offered.
- Exercise is recommended for all adults and is associated with better overall health, decreased healthcare costs, and fewer mobility limitations.
- Generally, the American Heart Association recommends the following regimen for adults:
- At least 150 minutes of moderate-intensity exercise every week OR
- 75 minutes of vigorous activity 3 days a week
- Strength training (e.g., weight training, resistance training, or weight-bearing calisthenics) to maintain or improve strength
- A gradual increase in time and intensity is recommended.
- Routine testing such as ECG or stress testing is not recommended for asymptomatic older adults prior to initiating an exercise program.
- Medical clearance is recommended prior to commencing an exercise program:
- In symptomatic individuals (e.g., with a complaint of chest pain or dyspnea)
- In individuals with known heart disease or with renal or metabolic disease (factoring in the desired exercise intensity)
- Age-related changes can affect drug absorption, distribution, metabolism, and excretion as well as physiologic effects in older adults:
- The volume of distribution may increase with age, secondary to a relative increase in body fat and a decrease in lean muscle mass.
- Drug metabolism may be impaired by a decline in hepatic function.
- Decreased drug clearance due to a natural, age-related decline in renal function
- Increased sensitivity to the effects of a medication may be seen with increasing age.
- Caution with polypharmacy (the use of 5–10+ medications), which is associated with:
- ↑ Risk of adverse events
- ↑ Risk of hospital admissions
- ↓ Physical and cognitive functioning
- Monitor for drug-drug interactions and adverse effects:
- Ask about herbal medicines, supplements, and over-the-counter medications due to potential interactions.
- Closely monitor for adverse effects when initiating a new medication.
- Avoid “prescribing cascades” (adding a medication to treat a new symptom), as they can have adverse effects.
- Safe prescribing practices include:
- Regular review of current medications
- Stopping unnecessary medications
- Using the minimal dose required for clinical benefit
- Considering nonpharmacological approaches when possible
- The most widely used criteria developed to reduce potentially inappropriate prescribing and harmful polypharmacy in the geriatric population
- Provides a list of drugs that can pose a risk to the elderly due to adverse effects, drug-drug interactions, and drug dose adjustments
- Over-the-counter medications are included.
- NSAIDs are the most commonly used medications that are considered potentially inappropriate.
|Glyburide||Long-acting sulfonylurea associated with a high risk of hypoglycemia|
|Benzodiazepines||Increased risk of delirium, sedation, and falls|
|Opioids||Increased risk of delirium, sedation, falls, constipation, urinary retention, and respiratory depression|
|Anticholinergics (includes some antidepressants and antihistamines)||Increased risk of delirium, sedation, falls, constipation, and urinary retention|
|α-Blockers||Increased risk of hypotension|
|Proton pump inhibitors (PPIs)|
Screenings in the elderly population should consider risk factors beyond merely the individual’s age. The elderly individual and/or caregivers should be involved in decision-making about pursuing screening. Most screenings are generally not indicated if the life expectancy is < 5 years.
Abdominal aortic aneurysm
Men between 65 and 75 years of age with a history of tobacco use should undergo abdominal ultrasound screening once.
Based on the US Preventive Services Task Force (USPSTF):
- Women between 50 and 74 years of age: mammography screening every 2 years
- Women > 75 years of age: insufficient evidence to support screening (American Cancer Society suggests the option of screening if life expectancy > 10 years)
- Screening for hypertension:
- Hypertension is a major risk factor for ischemic heart disease and stroke.
- USPSTF: screen all adults > 18 years of age for blood pressure at the clinic.
- Confirm diagnosis with outside blood pressure measurements (before initiation of treatment).
- Screening for diabetes mellitus:
- Part of cardiovascular risk assessment
- The USPSTF recommends diabetes screening for individuals who are 40–70 years of age and those who are overweight or obese (BMI ≥ 25).
- Fasting glucose or HbA1c screening (abnormal result needs a repeat test for confirmation)
- Screening for lipids:
- Formal cardiovascular risk assessment for all individuals who are 40–79 years of age:
- Includes identifying risk factors: hypertension, diabetes mellitus, smoking, obesity, family history of CVD and elevated cholesterol, CKD
- Obtain lipid profile.
- No definite studies that indicate the appropriate age to stop screening
- If > 1 prior lipid profiles have been normal, screening can be stopped at 65 years of age.
- Formal cardiovascular risk assessment for all individuals who are 40–79 years of age:
- Aspirin use is considered on a case-to-case basis (due to the risk of bleeding).
- Population at risk:
- For 30‒65 years of age, the options are:
- Cervical cytology every 3 years
- High-risk HPV (hrHPV) screening every 5 years
- Cytology with hrHPV co-testing every 5 years
- Screening ends at age 65 years of age in the case of adequate negative screening, which is defined as:
- 3 consecutive negative cytology results, with the last result within the past 3 years
- 2 consecutive negative co-test results within the past 10 years, with the most recent test within the past 5 years
- 2 consecutive negative primary HPV tests within the past 10 years, with the most recent test within the past 5 years
- For 30‒65 years of age, the options are:
- If adequate screening has not been performed, continue annual screening with co-testing for 3 years and then every 5 years until 80 years of age.
- The decision to continue depends on whether the life expectancy is ≥ 10 years and a discussion with the individual.
- May be discontinued in individuals who have had a total hysterectomy:
- With cervix removed for benign causes
- Without a history of cervical cancer or cervical intraepithelial neoplasia (CIN)
- 45–75 years of age: routine screening recommended for everyone
- 76–85 years of age: selective screening (decision to continue based on individual preferences, prior screening results, and overall health status/comorbidities)
- Screening may be discontinued if the life expectancy is < 10 years.
- Screening options:
- Annual high-sensitivity guaiac fecal occult blood test (HSgFOBT)
- Annual fecal immunochemical test (FIT)
- Stool DNA (sDNA)-FIT test every 3 years
- Flexible sigmoidoscopy every 5 years (limited to the distal part of the colon)
- Flexible sigmoidoscopy every 10 years + annual FIT
- Colonoscopy every 10 years
- CT colonography every 5 years
- 55–80 years of age: annual screening using low-dose CT of the chest for the following individuals:
- 20 pack-year smoking history
- Current smokers
- Have quit within the past 15 years
- Screening is discontinued when:
- Age ≥ 80 years
- The individual has not smoked for 15 years.
- Life expectancy is limited.
- Women ≥ 65 years of age: Bone mineral density (BMD) screening is recommended.
- The USPSTF states that there is not enough evidence to support screening in men.
- However, other organizations (e.g., American College of Physicians, Endocrine Society) recommend BMD screening in men > 70 years of age.
- The most commonly used test is the central dual-energy X-ray absorptiometry (DXA) of the hip and lumbar spine.
- 2nd-most common cancer diagnosis in men; however, most men will die of another cause due to the typically slow growth of prostate cancer. Thus, screening is controversial.
- Men aged 55‒69 years:
- Decision to screen is based on preferences, risk factors, and potential risks/benefits.
- If elected, a blood test to detect PSA alone is recommended as a screening strategy every 1‒2 years.
- Digital rectal examination (DRE) is not recommended as a screening method with or without a PSA test.
- Age ≥ 70 years: PSA screening is not recommended.
Herpes zoster vaccine
- CDC recommends that adults ≥ 50 years of age should decrease the risk of developing herpes zoster (shingles) and postherpetic neuralgia.
- Vaccination should be performed irrespective of previous vaccination status or disease history:
- Shingrix vaccine requires 2 doses that are 2–6 months apart.
- Zostavax (live-attenuated vaccine) is no longer used in the US as of 2020 but is still used in other countries.
- > 90% of influenza-related deaths occur in individuals > 60 years of age.
- Influenza vaccine should be given to all adults annually unless there is a history of allergic reactions to vaccine components.
- Reduces the risk of pneumococcal infections, particularly with Streptococcus pneumoniae, which is the leading cause of bacterial pneumonia
- In all immunocompetent adults ≥ 65 years of age:
- 1 dose of pneumococcal polysaccharide vaccine (PPSV)23 is recommended.
- If PPSV23 was given before the individual attained 65 years of age, give due dose at least 5 years after the previous dose.
- Pneumococcal conjugate vaccine (PCV)13 in adults ≥ 65 years of age:
- PCV13-type disease has declined significantly among individuals ≥ 65 years of age due to pediatric vaccinations.
- Shared decision-making is recommended in the case of PCV13 vaccination (if with risk factors, immunocompromising diseases, and impaired splenic function).
- If PCV13 is to be administered, it is given 1st followed by PPSV23 after ≥ 1 year.
Tetanus and diphtheria toxoids (Td) or Tdap
- Approximately 60% of all tetanus cases in the US occur in individuals > 60 years of age.
- Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis)
- In the US:
- Tdap or Td is given intramuscularly every 10 years to all adults with complete prior immunization to tetanus and diphtheria.
- If an adult has not been vaccinated against tetanus and diphtheria, a 3-vaccine series is initiated with Tdap as the preferred 1st dose, followed by Td or Tdap.
- Older adults:
- Likely to have decreased antibodies either from not having received the initial vaccine or the subsequent booster doses
- Tdap is important for older adults, especially those in contact with children < 1 year of age:
- Tdap may be given once instead of the Td booster.
- Tdap can be administered regardless of the interval since the last Td booster.
- Functional status is divided into 3 levels of ADLs:
- Basic ADLs: self-care tasks such as bathing, dressing, feeding, and toileting
- Instrumental ADLs (IADLs): complex skills to maintain independence such as driving, preparing meals, shopping, managing finances, and performing housework
- Advanced ADLs: ability to fulfill various societal and familial roles and participate in recreational and occupational tasks
- Screen for impairments in ADLs via direct questioning or based on standardized screening tools.
- Assess driving ability and safety in individuals > 70 years of age (group with increased risk for motor vehicle accidents and higher risks of mortality).
- Screening is recommended for individuals with memory complaints using validated tools (e.g., Mini-Mental State Examination (MMSE), Mini-Cog, clock-drawing test).
- Cognitive screening is not recommended for asymptomatic individuals.
- Hearing loss:
- 3rd-most common chronic condition (after hypertension and arthritis) among older adults in the US
- Associated with cognitive decline, depression, social isolation, and functional disability
- Sensorineural hearing loss is caused by natural aging of the auditory system.
- The USPSTF has no recommendations for or against screening for hearing loss in asymptomatic older adults.
- Clinically recommended screening for hearing loss in individuals ≥ 65 years of age:
- Pure tone audiometry:
- Gold standard to screen for hearing loss
- Not readily available in primary care offices
- Whispered-voice test:
- Stand behind the individual (to prevent them from lip-reading) and mask the hearing in 1 ear.
- A sequence of letters and numbers is whispered and the individual is asked to repeat them.
- Pure tone audiometry:
- Refer to otolaryngology for any failed hearing test, chronic otitis media, and sudden hearing loss.
- Hearing aids for treatment
- Older adults are at a higher risk of visual impairments from conditions such as macular degeneration and cataracts.
- The USPSTF has no recommendations for or against routine vision screening in asymptomatic adults.
- Clinically, vision assessment is recommended for individuals with visual complaints, recent cognitive decline, functional impairments, or falls.
- An important cause of morbidity and mortality among older adults
- Approximately ⅓ of community-dwelling older adults > 65 years of age have a fall each year.
- Evaluate the risk of falls:
- Tinetti assessment tool:
- Also called Performance-Oriented Mobility Assessment (POMA) tool
- Assesses balance and gait, scale-based scoring
- Timed Up and Go (TUG) test:
- Ask the individual sitting on a chair to stand, walk 10 feet forward, turn around, walk back, and sit down.
- In general, ≥ 12 seconds suggests a high risk of falls.
- Factors affecting results (e.g., age, joint problems, underlying conditions such as Parkinson’s disease) should be considered during the assessment.
- Tinetti assessment tool:
- PT and targeted training activity
- Vitamin D supplementation
- Securing the household environment (e.g., no clutter or loose rugs)
- Use of assistive devices and equipment (e.g., walkers, bedside commode, shower chair, grab bars)
- A cause of major social and emotional distress in the geriatric population
- Obtain a targeted history and conduct an examination:
- Inquire about the presence or absence of urinary incontinence biannually.
- Determine the onset of urinary incontinence (acute or chronic), type (e.g., urge, stress, overflow, mixed), and precipitating factors (e.g., cough, medications).
- For signs of fluid overload
- Pelvic (genital and rectal) area
- Neurologic evaluation
- Urine and blood tests as indicated, depending on the presenting factors
- Routine urodynamic testing is not recommended.
- The USPSTF recommends screening all adults for depression.
- Short screening tools, such as Patient Health Questionnaire-2, are available.
- Refer to appropriate services when screening results are positive.
Financial and social support
- Ask about financial and social resources.
- Limited resources directly impact an individual’s health.
- Provide information regarding the availability of assistance for the elderly in the community (e.g., food pantries, centers for seniors, organizations helping with prescriptions).
- Up to 8% of older adults are affected by elder abuse.
- USPSTF: Ask older individuals specific questions about abuse.
- Further inquiry and referral to social services are required if the individual exhibits the following signs of abuse and/or neglect:
- Contusions, burns, bite marks
- Genital or rectal trauma
- Pressure ulcers
- BMI < 17.5 (without clinical explanation)
- It is important to have discussions with older adults regarding advanced care directives while they still have the cognitive capacity to make decisions.
- Preferences regarding specific treatments, end-of-life interventions, and the appointed healthcare proxy should be documented.
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