What about nutrition in older adults?
In general, appetite and
body weight decline with age
and there is this reduction in lean
mass and it’s replaced by fat mass.
That process continues during
middle age through older adulthood
until about age 65 to 70
years when it tends to stabilize.
Unintentional weight loss is a pretty
common condition among older adults
and it is associated with a higher
risk for morbidity and mortality.
So, why do older adults lose weight?
Of course, the big worry is cancer.
So, we have to think about the concept of
an undiagnosed tumor in promoting weight loss.
I think much more commonly,
it's due to psychiatric effects,
depression and cognitive effects, early dementia.
And those are the reasons
we might see some weight loss.
Don't forget about medications cause,
many of which promote nausea or may cause constipation.
That can reduce appetite.
And then social isolation and
changes in their social environment.
I always find that losing a special loved one,
especially if they lived with that individual,
is a high risk for weight loss.
And so, I've definitely seen that multiple times.
And that's where you want your
social worker to be involved
and/or a counselor, mental health professional.
But that said, in nearly 30% of cases,
and depending on what study you’re looking at,
the cause of the weight loss is unexplained.
So, standard workup for these
patients with unexplained weight-loss,
CBC, comprehensive metabolic panel,
a TSH, a sed rate,
lactate dehydrogenase level which is
– can be a sign of tumor breakdown,
So, one thing to consider would be an abdominal
ultrasound for these patients looking for a tumor,
but it’s a also good chance – again, if they have –
particularly, if they have a good
five-year life expectancy,
maybe it's time to go and readdress.
You know, you never did get that
second round of colorectal cancer screening.
We should order today.
Or breast cancer or whatever
cancer has been left unscreened.
Maybe this is a good impetus to do it.
Let’s talk about hearing and
vision among older adults.
Presbycusis is a very common condition.
It almost seems to be
universal among older adults,
and so that's usually associated
with a high frequency hearing loss.
Yet, the Preventive Service Task Force recommends
asking seniors about their hearing,
but no objective testing is
necessary on a broad basis.
For patients who failed –
come in, I can’t hear as well,
you put them through audiometry,
usually it's a high-frequency hearing loss.
They should be referred to otolaryngology
for anything like a failed hearing
test if they have chronic otitis media
or they have – certainly, if they
have sudden hearing loss,
but the treatment is usually going
to be hearing aids for presbycusis.
And then also watch out for conditions
such as macular degeneration for your exam.
It’s very important,
macular degeneration versus a cataract,
which is the central visual loss.
But the Preventive Service Task Force
recommends against routine ophthalmoscopy,
looking for evidence of any of these conditions.
Now, falls are an important cause of
morbidity and mortality among older adults.
In 2014, it’s estimated that
27,000 seniors died related to falls.
And nearly a third of US
seniors experienced a fall in 2014
and a third of those cases
required medical attention.
So, they’re pretty serious.
So, one thing I really like is the
Tinetti balance and gait evaluation.
The get up and go test
is another term for this.
It's sitting in a chair, then getting up,
walking 10 feet in front of you,
turning around, walking
back and sitting down.
So, if the timing on that is
under 16 seconds, that's normal.
There are actually some nomograms that give
patients a little bit more time based on their age.
So if they’re 94, they may not be able to the
Tinetti test in the same time the 68-year-old does it.
But a good general rule on my practice is,
if it's 15 seconds or less, they’re okay.
What does that mean they’re okay?
It means that their risk of falling is lower.
They shouldn’t have a high risk
of falls based on this evaluation.
That test has demonstrated
good sensitivity for fall risk.
What should we be doing to prevent falls?
For those patients with a positive Tinetti
test and/or who have a history of fall,
that's the best predictor
as a history of previous fall.
Think about physical therapy
and activity with targeted training.
So, a lot of times,
they will have to –
it's not just about doing just general exercise.
Try to do some targeted training
and that’s where the physical therapies comes in.
Vitamin D isn't just healthy for bones.
It can actually help prevent falls.
So, these patients
should be taking vitamin –
all older adults should be taking a vitamin D
and getting enough vitamin D in their diet.
And then securing the household environment.
This is something that a home
visit can be really helpful to do.
So, avoiding clutter, avoiding loose rugs,
those things that make people suffer mechanical falls.
And then thinking about assistive devices
as well as equipment in the home
such as a bedside commode,
shower chair and grab bars that can prevent
falls at the most frequent sites of serious falling.
Let’s talk about smart
prescribing among older adults.
So, over a third of adults at age 60 or
more take five or more prescriptions per day.
About half also take
over-the-counter drugs at the same time.
There is a significant risk
of drug-drug interactions.
About 1 in 20 –
if you just take a bunch of random adults
and pluck out their medications,
about 1 in 20 has a risk of
a serious drug-drug interaction.
And it's thought that 30% of
admissions due to delirium and falls
and also unnecessary hospital admissions
are due to inappropriate drug
interactions and/or side effects.