1.

Nutrition
Malnutrition a state in which deficiency, excess or imbalance of energy, protein and other nutrients cause adverse
effects on the body form, function and clinical outcome

Biological Changes
Neurodegeneration of the aging enteric nervous system
o Esophageal motility decreases leaded to dysphagia
o Gastric motility can be impaired with aging leaded to gastroenteroreflux
o Colonic motility can also be reduced leading to constipation
Reduced gastric acid secretions (hypochlorhydia) occurs for a variety of reasons: chronic gastritis, chronic use of
PPIs, procedures like vagotomies
o This often leads to bacterial overgrowth in the gut and small bowel
The pancreas will decrease its normal secretion of lipase, chymotrypsin and bicarbonate
The liver decreases in size and blood flow
The small intestine can decline in its number of crypts and villi as well as loss of villi height

Physiological Changes
Anorexia of aging
o This is a process in which the decrease in energy intake is greater than the decrease in energy expenditure
and body weight is lost
o Most of the normal age-related decrease in energy response is due to a normal decrease in activity
(however weight should not be necessarily lost)
o Factors contributing to anorexia of aging include: decreased energy expenditure, decreased exercise,
physiological changes with aging and pathological changes with aging
Changes in Body Weight and Body Composition
o Body weight and BMI increase with age until approximately 50 to 60 years after which they both decline
o There is a J shaped curve associated with mortality and body weight with increased mortality with low and
High BMIs
! At a BMI < 22 there is steady increase in mortality
o With age body fat increases and fat-free mass decrease because of a loss of skeletal muscle due to:
decreased physical activity, decreased growth hormone secretion, decreased sex hormones and a decreased
metabolic rate
Etiologies of Weight Loss: there are 3 distinct mechanisms of weight loss in older people
o Wasting an involuntary loss of weight mainly due to poor dietary food intake
o Cachexia an involuntary loss of fat free mass or body cell mass, it is caused by catabolism and results in
changes in body composition
! Cytokines released in an acute immune response (IL-1, IL-6, TNF-alpha) can drive this process and
can be seen in chronic disease such as heart failure or RA as well as malignancies
o Sarcopenia a decline in skeletal muscle mass
! Has many causes such as decline in muscle use/activity, increased acute phase reactants breaking
down muscles, neuronal loss
Physiological anorexia contributing factors
o Diminished sense of smell and taste
o Increased cytokine activity
o Delayed gastric emptying = leads to quicker sensation of fullness
o Altered gastric distention = receptive relaxation may be impaired
o Hormonal
! CCK and PPY are increased in older patients and both slow Antral emptying and can inhibit the
release of NPY (which mediates hunger and inhibits satiety at the hypothalamus)
! Older people also have higher levels of leptin (probably due to their higher body fat content) which
also decrease hunger

Aging is also associated with reduced glucose tolerance and higher insulin levels which amplify the
leptin signal

Nutritional Assessment
Dietary assessment
o This is best done by a dietitian
o Initially a 24 hour recall can be done, however a 7 day journal is much better and gets rid of the bias of day
to day changes in diet
Clinical assessment
o Clinical signs of nutritional deficiencies: a wasted thin individual, dry scaly skin, poor wound healing, thin
hair, nails are spooned and depigmented, bone/joint pain, edema.
Screening Tools
o Malnutrition Universal Screening Tool (MUST) is a 5 step screening tool to ID adults who are malnourished
or at risk of becoming malnourished
! 3 components = BMI, Hx of unexplained weight loss and acute illness effects
o Mini Assessment (MNA) and Malnutrition Risk Scale (SCALES) were designed for older patients
! Relies on physical signs of undernutrition and patient history and does not require laboratory
findings
! S sadness, C cholesterol, A albumin, L loss of weight, E eating problem/cognitive, S
shopping problems
Anthropometric assessment
o BMI body mass index which is calculated using the Quetelet index comparing weight (kg) to the square of
height (m2) and is predictive of disease risk in those termed underweight and those who are obese
! BMI < 18.5: underweight, BMI 18.5 24.9: normal, BMI 25-29.9: overweight
! BMI 30-30.0: obese, BMI > 40: extreme obesity
o Skinfold measurement using tricipital skinfold is particularly important together with arm circumference
and can be used to calculate muscular circumference of the arm (an indication of lean mass)
! Normal is 23 cm in males and >22 cm in females
o Biometric impedance analysis = it is a non-invasive and inexpensive method for estimating totally body
water, extracellular water, fat-free mass and body cell mass
! Done by measuring the bodies resistance to an electrical current
! Low body cell mass is predictive or malnourished patients
o Biochemical markers usually serum proteins that are synthesized by the liver
! Serum albumin most commonly used and is predictive of mortality in older patients however
inflammation and infection can disrupt accurate measures
! Transferrin is more sensitive for looking at protein-energy malnutrition but it is affected by
pregnancy, iron deficiency, hypoxia
! Low total serum cholesterol levels have been associated with an increased risk of malnutrition
o Pathological and Non-Pathological causes of weight loss
! We already talked about physiological causes
! Pathological causes are most likely treatable by a variety of methods depending on the etiology
ranging from medical to psychological to social

Nutrition
Macro/Micronutrients
o The recommended daily allowance (RDA) of protein is 0.8 g protein/kg body weight per day regardless of
age, this is the minimum amount of protein intake required to avoid progressive loss of lean body mass
o Intake greater than the RDA helps to improve muscle mass, strength, functioning, wound healing and blood
pressure in older people
o In older patients it is recommended to have an RDA of 1.5 g protein/kg body weight per day
o Reduced intake and unbalanced diets can predispose older people to vitamin and nutritional deficiencies,
drugs can affect absorption and hepatic function as well

Reduced Vitamin D
o Caused by reduced consumption, GI and renal disease
o Leads to osteomalacia, rickets, myopathy and decreased bone density
Vitamin B12 deficiency
o Leads to macrocytic anemia, Subacute degeneration of the spinal cord, neuropathies, ataxia, glossitis and
dementia
o Increases levels of homocystine which increases risk of cardiovascular diseases
o Causes in the elderly include atrophic gastritis, pernicious anemia, strict vegetarian diets, poor diets, lack of
absorption post gastrectomy/ileostomy

Folate deficiency
o Causes macrocytic anemia, increased homocystine levels, increased risk of cancers, cognitive impairment
and depression.

Fluids and Electrolytes older people are more susceptible to problems with fluid and electrolyte balance
o The older population have demonstrated that despite physiological needs they do not consume adequate
amounts of fluids to maintain ideal the ideal fluid/electrolyte balances

Nutrition therapy
o Reduced intake due to medical, social and physiological factors should be addressed
! Deal with problems like difficulty chewing, difficulty swallowing, physical needs and social
services
o The main goal should be to help improve oral food intake
! Size fortified menus
! Fortified snacks
! Supplements for nutritional deficiencies
! Oral liquid, energy dense high quality protein supplements for critically ill patients

Overnutrition in older people
In 2000 58% of US citizens aged > 65 y/o had a BMI > 25
Older people with higher BMI suffer from symptomatic osteoarthritis, increased rates of cataracts, mechanical
injury, bladder problems, sleep apnea and respiratory problems
Weight loss is safe and beneficial, however make sure to look at their total body mass, lean body mass and other
factors when determining a safe weight, do not just use their body weight.
Weight loss should include diet as well as regular exercise in order to prevent further muscle loss
Weight loss supplements are not well studied in older patients and could interact with many medications as well

2. Alzheimer Disease

Introduction
The principle risk factor for Alzheimers disease is age
o Incidence of disease doubles every 5 years after age 65
It is the most common form of dementia
It is a deterioration of memory and other cognitive domains that leads to death within 3 to 9 years after diagnosis
An accumulation of misfolded proteins in the aging brain results in oxidative and inflammatory damage, which leads
to energy failure and synaptic dysfunction

Pathological features of Alzheimers Disease
Cerebral plaques laden with -amyloid and dystrophic neuritis in neocortical terminal fields as well as prominent
neurofibrillary tangles in medical temporal-lobe structures as well as loss of neurons and white matter, congophilic
(amyloid) angiopathy, inflammation and oxidative damage are also present

Protein Abnormalities in Alzheimers Disease
-amyloid peptide (A)
o A peptides are natural products of metabolism and come in many forms
! A40 = monomers are much more prevalent
! A42 = aggregate-prone and damaging form
o A originate from proteolysis of amyloid precursor protein by the sequential enzymatic action of multiple
enzymes
o An imbalance between production, clearance and aggregation of peptides leads to A accumulation and this
excess is believed to be the initiation factor of Alzheimers disease according to the amyloid hypothesis
o A will spontaneously self aggregate into multiple forms including fibrils which arrange themselves into -
pleated sheets to form insoluble fibers (amyloid plaques)
o Soluble oligomers and intermediate amyloids are neurotoxic with dimers and trimers being specifically toxic
to synapses
o We do have proteins in our body that naturally break down A peptides such as Neprilysin and thiol
metalloendopeptidase = a reduction in either of these will lead to a buildup of A peptides

Tau Neurofibrillary Tangles
o Neurofibrillary tangles are filamentous inclusions in pyramidal neurons and the number of tangles is a
pathological marker of the severity of the disease
o The tangles major component is abnormally hyperphosphorylated and aggregated forms of tau
o Normally tau promotes assembly and stability of microtubules however when hyperphosphorylated it loses
its normally affinity for microtubules and self associates
o Intermediate aggregates of abnormal tau are cytotoxic and impair cognition
o Tau mutation are known to occur in frontotemporal dementia and parkinsonism but not in Alzheimers
disease
o Evidence shows that A peptide accumulation drives tau aggregation

Increased oxidative stress, the impaired protein-folding function of the endoplasmic reticulum and deficient
proteasome-mediated and autophagic mediated clearance of damaged proteins (all of which are associated with
aging) accelerate the accumulation of A and tau proteins in Alzheimers disease
The Synapse in Alzheimers Disease
Synaptic Failure
o Hippocampal synapses begin to decline in patients with mild cognitive impairment while remaining synaptic
profiles show an increase in size
o In mild Alzheimers disease there is a reduction of about 25% in the presynaptic vesicle protein
synpatophysin and with advancing disease synapses are lost disproportionality relative to neurons
! Long term potentiation is lost and even some signaling molecules are inhibited

Endocytosis of NMDA surface receptors and others weaken synaptic activity and create an imbalance
between potentiation and depression.

Depletion of Neurotrophin
o Neurotrophins promote proliferation, differentiation and survival of neurons and glia, and they mediate
learning, memory and behavior
! Levels of neurotrophin receptors in cholinergic neurons of the basal forebrain are reduced in late
stage Alzheimers disease
o In Alzheimers disease levels of brain-derived neurotrophic factor (BDNF) are depressed
o The deficiency of cholinergic neuron projections in this disease have been associated with buildup of A and
tau
! These proteins inhibit nicotinic acetylcholine receptors, this could lead to a lack of acetylcholine
mediated nerves in the brain
! M1 receptor stimulation leads to activated of protein C which leads to processing of amyloid
precursor proteins leading to less A formation and also limits tau phosphorylation.

Mitochondrial dysfunction
o A is potent mitochondrial toxin that attaches multiple proteins in the mitochondria (cytochrome c oxidase
is specifically attacked) leading to disruption of electron transport, oxygen consumption and mitochondrial
membrane potential
! This also leads to increased oxidative damage to the mitochondria and its DNA which is very
susceptible to mutations
! You end up with increased mitochondrial superoxide radical formation and conversion into hydrogen
peroxide causing oxidative stress, release of cytochrome c and apoptosis
o Oxidative Stress
! The dysfunctional mitochondria release oxidizing free radicals
! A peptides potentiate this mechanism
! Elevated levels of free divalent transitional metal ions (iron, copper and zinc) and aluminum are
linked with reactive oxygen species-mediated damage and neurodegeneration in several ways
! They promote tau changes
! Zinc may block A channels for removal of the toxin.

Insulin-Signaling Pathway
o Subgroups of Alzheimers patients have high fasting insulin and low rates of glucose disposal (peripheral
resistance)
o Glucose interolerence and type II DM are risk factors for dementia
o Resistance to insulin renders neurons energy-deficient and vulnerable to oxidizing or other metabolic insults
and impairs synaptic plasticity.
o

Vascular Effects
o Vascular injury and parenchymal inflammation perpetuate the cycle of protein aggregation and oxidation in
the brain
o More than 90% of patients with Alzheimers disease have capillary abnormalities, disruption of the blood
brain barrier and large vessel atheroma
o One theory states that the clearance of A along diseased perivascular channels and through the blood-
brain barrier is impeded in Alzheimers disease (this could be a source of A protein build up)

Inflammation
o Activated microglia and reactive astrocytes localize to fibrillar plaques and their biochemical markers are
often elevated in patients with Alzheimers disease
! Both of these cells are drawn to tau as well as A peptides and release cytokines that only potentiate
inflammation and lead to breakdown of vasculature and build-up of more inflammatory factors

Normally these cells should clean up excess A peptides but in the Alzheimers disease patients they
are often overwhelmed and their release of pro-inflammatory molecules ends up causing more
damage.

Calcium
o Elevated levels of cytosolic calcium stimulate A aggregation and amyloidogenesis
o Presenilins modulate calcium balance and mutations of them are seen in early onset familial Alzheimers
disease (<1%)
o Increased levels of A42 leads to excess calcium in the ER and eventually excess cytosolic calcium
o Chronic activation of glutaminergic receptors leads to increased cytosolic calcium as well
Axonal-Transport Deficits
o We know that amyloid precursor protein, BACE-1 and presenilin 1 were reported to undergo fast
anterograde transport, and it has been theorized that impairment of transport causes amyloid precursor
protein, vesicle and kinesin accumulations in axonal swellings leading to A deposition and
neourdgeneration
! Remember that microtubules in the neurons require tau to form cross bridges to stabilize them.

Aberrant Cell-Cycle Reentry: a failure in the normal suppression of the cell cycle in Alzheimers disease has been
hypothesized and markers of aberrant cell cycle reentry are detected in all stages of Alzheimers disease
o This is most prominent at the G1-S phase transition.

Cholesterol Metabolism
o A defect in cholesterol metabolism is an appealing hypothesis because it ties together APOE risk, amyloid
production, aggregation and vasculopathy of the disease
o A generation and aggregation is promoted when there is an overabundance of esterified cholesterol and
decreased membrane lipid turnover
! Studies have shown that high midlife cholesterol levels are associated with an increase in risk of
Alzheimers disease
o APOE inheritance is also a predictor of late-onset Alzheimers, if you inherit a E4 allele your risk increases
greatly

3. Mild Cognitive Impairment

The Clinical Problem
Mild cognitive impairment represents an intermediate state of cognitive function between the changes seen in aging
and those fulfilling the criteria for dementia and often Alzheimers disease
Most people experience gradual decline in cognition but it does not compromise the ability to function
2 Subtypes of Mild Cognitive Impairment
Amnestic this is mild cognitive impairment has clinically significant memory impairment that does not
meet the criteria for dementia
! Usually both the patient and the family are aware of the decline
! Other cognitive capacities such as executive function, language, visospatial skills and functional
activities are preserved, except for some mild deficiencies
! Many of these patient will progress to Alzheimers disease
Nonamnestic this is characterized by a subtle decline in functions not related to memory, it affects
attention, use of language or visospatial skills
! These patients may progress to non-Alzheimers like dementias such as frontotemporal lobar
degeneration of dementia with lewy bodies
Experienced by 10-20% of the population over 65 years old
Studies have shown that those with mild cognitive impairments have a high risk of developing dementia
Some people can revert back to normal however these rates are as low as 25-30% and may even be lower than that
as studies continue to come in on the topic.

Strategies and Evidence
Differentiating Mild Cognitive Impairment from Normal Aging
People who experience normal age related memory loss often have subtle forgetfulness, lost words and
forget where they may have placed things
Those with MCI will forget important information they would have normally remembered easily such as
appointments, telephone conversations or recent events that would normally interest them (also these
people usually have all other functions in tact)
! This forgetfulness is apparent to those close to the patient and not the casual observer
Neuropsychological testing is usually in order to corroborate the decline
! Using a brief mental status evaluation such as the mini-mental status exam or using short tests of
mental status and the Montreal Cognitive assessment can be helpful in the dx
Remember that reversible MCI may be present and could be brought on by things like depression or
medications so always take a good history and have caretakers/family present if possible
Differentiating Mild Cognitive Impairment from Dementia
Patients with dementia have cognitive deficits that affect their daily functioning to the extent that here is a
loss of independence in the community
A diagnosis can be support with tests such as the Function Activities Questionnaire, and again make sure to
take a good history

Prediction and Risk Factors
Those diagnosed with a more sever MCI have a higher risk of progression
Those that carry the APOE 4 allele are more likely to progression to dementia
The use of MRI to measure the volume of the hippocampus shows that those who fall below the 25th percentile have
a 2-3X greater risk of progression in the next two years
Functional imaging such as FDG-PET can look at brain metabolism and those with hypometabolism in the temporal
and parietal regions have a higher risk of progression of MCI to Alzheimers
Measuring the CSF also has some predictive use in that those MCI patients who had low levels of beta-amyloid 42
and high levels of tau in the CSF where more likely to progress
Molecular imaging can also use PET scans to look at the amount of amyloid in the brain using amyloid-binding
carbon 11 labeled Pittsburgh compound B, and those with more had a faster progression to Alzheimers

Management
Patients with MCI should not be labeled as having some kind of early form of Alzheimers and you should let them
know that their disease is an abnormal condition and the precise outcome is not certain
As of now the FDA has not approved any medications for MCI but there are some that are used
MCI patients treated with Alzheimer drugs (donepezil, galantamine, rivastigmine) had lower levels of progression
MCI patient treated with high does Vit E and donepezil had reduced risk for the first 12 months, but no effect in 36
months
! Vit E did not significantly reduce the progression at any time point assessed
There is some evidence that patients can get benefit from cognitive rehabilitation (mnemonics, association and
computer assistance training)
The presence of cardiovascular risk factors also worsens progression and exercise has been shown to preserve some
cognitive function

4. Depression
Introduction
Depressive disorders, which are syndromes characterized by impairment of mood regulation, most commonly
include major depression and dysthymia, a disorder characterized by chronic low mood
o In older adults (age > 65) these disorders may also be characterized by impairment in cognition, a syndrome
sometimes referred to as pseudodementia and by psychomotor agitation or retardation
o Depressive disorder are frequently masked in older adults and may initially appear to be cognitive
impairment or an early sign of neuroendocrine and related chronic disorders
By 2020 depression will be the second leading cause of disease worldwide
Depression characteristically complicates the course and outcome of other illnesses among older adults
Research shows that the prevalence of major depression is generally lower among older adults than among young
adults
o However suicide rates are higher in this age group (age > 65) than in any other, suggesting that significant
depressive symptoms may indicate a serious threat to the health and survival of older adults

Diagnostic Criteria for Depression
The diagnosis of major depression can be made if a patient has five or more of the following symptoms during the
same 2-week interval with at least one of the symptoms being either depressed mod or loss of interest or pleasure
in activities that were previously pleasurable:
o Depressed mood
o Loss of interest or pleasure in previously pleasurable activities
o Significant weight gain or loss
o Insomnia or hypersomnia
o Psychomotor agitation or retardation
o Fatigue
o Feelings of worthlessness or inappropriate guilt
o Impaired concentration
o Recurrent thoughts of death

Diagnostic Criteria for Dysthymia
A diagnosis of dysthymia requires only two or more of the following symptoms:
o Poor appetite or overeating
o Insomnia or hypersomnia
o Fatigue
o Low self-esteem
o Impaired concentration
o Feelings of hopelessness
A diagnosis of dysthymia also requires that the person experiences depressed mood for most for the day, more than
not, across an interval of at least 2 years, and not be asymptomatic for larger than 2 months during the 2 year
course of the illness
o Thus dysthymia follows are more chronic course than major depression but comprises fewer disabling
symptoms
Double depression is major depression combined with dysthymia " these patients have higher rates of
hopelessness than did people with a diagnosis of just one of these illnesses

Prevalence, Comorbidity and Risk Factors
Major depression has been found to be less prevalent among older adults living in communities than among
younger community residents
o Although depressive disorders may not be highly prevalent among older adults, they pose serious
consequences to health and functioning
o It increases the risk for inability to perform daily activities as well as increased risk for mobility
impairment

The living environment of older adults appears highly relevant to the prevalence of depressive disorders
o There are higher rates of depression among older adults receiving home care or living in institutions
o Comorbidity in people in these groups may be a risk factor for depression
The prevalence of symptoms of depressive disorder are found to be much higher in respondents with chronic
disease than for those without chronic disease (asthma, COPD, arthritis, gastric problems, heart failure)
o Chronic diseases frequently reported by older adults may increase the likelihood of depressive disorder
Depressive disorders themselves are associated with risk factors for chronic disease in older adults
o Longitudinal research has established that long term symptoms of depressive disorder are inversely related
to health among older residents of communities
o Depression is associated with disability in the cognitive and physical activities of daily living
Serebruany et al noted that the diagnosis of depression is an independent risk factor for mortality among patients
with acute coronary syndrome (ACS)
o SSRIs are thought to inhibit platelet activity and may protect the heart independent of its anti-depressant
use (so use this drug to help reduce depression and protect against heart disease), and has been found to
benefit the following groups of patients: patients with episodes of depression preceding ACS, patients with
a history of depression and patients whose episodes were severe

Public Health Impact and Impediments to Intervention
Unfortunately, detecting depressive disorders in older adults may be difficult because symptoms may be masked as
physical complaints, particularly among frail older adults
o Brief assessment tools such as the Psychological Distress Inventory may be useful in reducing undiagnosed
psychological disorders
o Other risk factors for nontreatment or inadequate treatment of depression in older adults include: being
male, being African American, being Latino, experiencing fewer than two previous depressive episodes and
expressing a preference for counseling instead of antidepressant medication
o Because older adults are usually no longer employed, the cost of depression and the efficacy of its
treatment often receive little consideration
Older adults with chronic disease and depressive disorder may experience increased symptoms of disease and
depression is an independent risk factor for mortality
o Older adults with increased symptoms of depressive disorder are less mobile and report fewer social
contacts than non-depressed peers
IMPACT (Improving Mood Promoting Access to Collaborative Training)
o A collaborative care approach for the management of depression and diabetes in older adults
o Older adults are assigned depressive care managers who provide structured activities, including exercise
o Participants may choose either problem-solving treatment or antidepressant treatment, both from a PCP
o During a 24 month period participants in the IMPACT program had a mean of 115 more depression-free days
than did participants receiving usual care
Unfortunately the stigmatization of mental illness and the cost of medication keep many older people from adhering
to treatment for depression

5. Delirium
Introduction
Delirium is an acute state of confusion marked by sudden onset, fluctuation course, inattention and at times an
abnormal level of consciousness
o Deliriums manifestations can range from acute agitation (less than 25% of all cases) to the much more common
but less frequently recognized hypoactive, or quite, variant
o Delirium is an acute change in mental status, whereas dementia is a characterized by a slower chronic
progression
o It is extremely common and can be a challenge to diagnose
Mounting evidence indicates that delirium is strongly and independently associated with poor patient outcomes
o In the hospital it is associated with a 10 fold increase in death, and 2-5 fold increase in nosocomial
complications, prolonged length of stay, and greater need for nursing home placement after stay
o Even after discharge a patient who had delirium in the hospital is more likely to have poor functional and
cognitive recovery and is at increased risk for death for up to 2 years

Screening and Prevention
Which patients are at risk for delirium and what are the common precipitating factors?
o Predisposing factors = chronic factors that increase a patients vulnerability to delirium
! Advanced age
! Impaired vision
! Preexisting dementia
! Impaired hearing
! History of stroke
! Functional impairment
! Parkinson disease
! Male sex
! Multiple comorbid conditions
! History of alcohol abuse
o Precipitating factors = acute conditions or events that initiate delirium
! New acute medical problem
! Pain
! Exacerbation of chronic medical
! Environmental change
problem
! Urine retention/fecal impaction
! Surgery/anesthesia
! Electrolyte disturbances
! New psychoactive medication
! Dehydration
! Acute stroke
! Sepsis
o The more predisposing factors you have the less precipitating factors you need to initiate an attack of
delirium

Should Doctors screen for delirium and if so how?
o 50-80% of cases go unrecognized and undocumented and trials have assessed the effectiveness of systematic
programs to improve case finding and treatment of delirium showing significantly improved detection rates and
modest improvements in outcomes = it is prudent to screen hospitalized patients who are at risk for delirium
o The briefest screening method is the Confusion Assessment Method (CAM) which looks at 4 key features of
delirium: (1) acute change in mental status and fluctuating course, (2) inattention, (3) disorganized thinking and
(4) abnormal level of consciousness
! To make a diagnosis you need features 1 and 2 and either 3 or 4
! CAM alone probably is not sufficient and standardized mental status assessment should be done to
improve sensitivity
! CAM-ICU uses nonverbal responses to assess attention, thinking and level of consciousness
ICU patients should be screened daily
o The mini mental status exam can also be used to assess consciousness as well as the RASS

Are there effective strategies for prevention?
o Among all interventions for delirium the strongest evidence supports the effectiveness of prevention
o Examples of preventative strategies
! Hospital Elder Life Program (HELP)

Targeted 6 risk factors of delirium which were assessed at admission and the patients who had
one or more received targeted interventions to address them
Delirium in the intervention group was significantly reduced
! Proactive geriatrics consultation in elderly patients undergoing hip fracture repair
The proactive geriatric consult group had a 36% reduction in the incidence of delirium
Strategies that did not reduce the incidence of delirium but reduced the severity and/or duration
! Reorganization of hospital staff in order to focus on patient centered care and the reduction of
factors that precipitate delirium
! Administration of low does haloperidol (0.5 mg 3 times daily for 3 days)
! These strategies may have a limited use because they often just reduce the positive symptoms, like
agitation, in the patients and it has been shown that patients with hypoactive delirium may have
equal or worse outcomes than those with hyperactive delirium

Diagnosis
When should clinicians consider a diagnosis of delirium?
o Delirium should be considered in any confused hospitalized patient and in high risk patients with confusion in
any setting
What elements of the history and physical examination indicate delirium?
o The diagnosis of delirium is based entirely on the story and physical examination
! No laboratory tests, imaging studies, or other tests are more accurate than clinical assessment
o The H and P have 2 roles in evaluation of delirium
! Confirmation of diagnosis
! Identification of potential causes and contributors
o The History is mostly obtained through caregivers or family members and its very important to gain the
timeline of the mental status change (as well as any fluctuations that occurred in mental status)
o The key aspect of the physical exam is evaluating the mental status
! The most important aspect of this is to determine
the level of consciousness and attention
o Once you have the H and P you can diagnose the patient via the
CAM Diagnostic Algorithm
o Another important element of the history and physical
examination is evaluating for underlying causes
! This included medical history, vital signs, general
medical examination and especially and medications
that effect consciousness or the CNS

What is the role of laboratory testing, brain imaging, and EEG in
the dx and evaluation of delirium?
o These tests do not substitute for a good history and physical
examination but they can be useful for diagnosis the cause of
delirium and correctable contributing factors
o Cerebral imagine and EEG are useful if there is intracranial
cause, seizure activity or if you think the delirium is due to a
stroke

What should be on the differential for Delirium?
o Differential for delirium = depression, dementia and subsyndromal delirium also known as the partial syndrome
of delirium
o The most diagnostic issue is whether the newly presenting confused patient has dementia, delirium or both
! To make the differentiation the physician must know the baseline evaluation
! Acute changes are more likely to be associated with delirium as are fluctuations in mental status
Although be aware that lewy body associated dementia can present similarly
o Depression can be confused with hypoactive delirium

It is best to assume hyperactive delirium over other acute psychiatric syndromes in the acute care setting
Patients who present with some but not all of the diagnostic features of delirium have subsyndromal delirium

When should subspecialty consultation be considered for patients with delirium?
o The PCP is usually best suited to guide the diagnosis and evaluation of delirium, because of their knowledge of
the patients baseline
o If consult is needed go to: geriatric medicine, psychiatry, neurology or medical surgical intensive care
o
o

Treatment
When should hospitalization be considered?
o The decision to hospitalize a patient with delirium requires looking at multiple factors: timeliness of dx
evaluation, clinical stability and social support
! Outpatient care can be done if it is something simple like a drug interaction
! Hospitalization is required in conditions where there is destabilizing medical illness (MI) or sepsis

Nonpharmacological measures useful in treatment of delirium:
o Identification and treatment of the underlying disease comes first as well as removal and reduction of associated
contributing factors
o Psychoactive medications are among the most important reversible contributors to delirium and therefore
warrant particular attention
! Such drugs are: Meperidine, Benzodiazepines
o Make sure to do your best to avoid iatrogenic complications in these patients as well

Possible drug therapy for delirium
o There are no FDA approved drugs for delirium, however off label drugs uses are used by physicians to control
symptoms like delusions or hallucinations
o Be careful not to drug them to much or cause the patient to have prolonged delirium or changes in type of
delirium
! However realize that verbal comfort and reassurance is often preferable to drug therapy
o Drugs used
! Low does Haloperidol " make sure to assess for akathisia (motor restlessness)
Avoid in patients with Parkinson ds, Lewy body dementia
Also watch for QT prolongation, torsades de pointes, neuroleptic malignant syndrome and
withdrawal dyskinesias.

Are physical restraints every appropriate?
o Physical restraints are always objectionable but may be required to control violent behavior or to prevent
removal of important devices
! Remember in these cases calm reassurance by a sitter or family may be more affective

When should be consider specialty consultation?
o Most cases can be managed by the PCP or hospital generalist
o Geriatrics consultations may be helpful if the patient is frail or older
o Psychiatric consultation is particularly helpful for younger patients especially if they have severe agitation

Is recurrence a problem and should patients be followed?
o Patients with delirium often remain vulnerable even after confusion clears, so clinicians should develop both a
short-term and long-term monitoring plan for patients with delirium
o Those who get delirium should have their baseline monitoring done regularly to look for changes
o Any medical conditions that contributed to delirium may require follow up testing
! Electrolytes, heart failure, infections
o Assessment of Activities of Daily Living (ADL) is particularly useful for monitoring functional recovery from
delirium

6. AGS Beers Criteria

Introduction
PMIs = potentially inappropriate medications
ADEs = adverse drug events
Methods to address medication related problems include implicit and explicit criteria
o Explicit criteria = identify high risk drugs from a list of PMIs that have been identified and they risks outweigh
their benefits in older patients and alternatives should be considered for treatment
o Implicit criteria = may include factors such as therapeutic duplication and drug-drug interactions

Intent of the Beers Criteria
The 2012 AGS Beer Criteria are intended for use in all ambulatory and institutional settings of care for populations
aged 65 and older in the United States
The intentions of the criteria include
o Improving the selection of prescription drugs by clinicians and patients
o Evaluating patterns of drug sue within populations
o Educating clinicians and patients on proper drug usage
o Evaluating health-outcome, quality of care, cost and utilization data
The goal of the 2012 AGS Beers Criteria is to improve care of older adults by reducing their exposure to PIMs

Clinical Application of the Criteria
Thoughtful application of the criteria will allow for
o Closer monitoring of drug use
o Application of real-time e-prescribing and intervention to decrease ADEs in older adults
o Better patient outcomes
53 medications/medication classes encompass the final updated 2012 AGS Beers Criteria
o There are 3 categories that where organized based on major therapeutic classes and organ systems
! 1st are 34 potentially inappropriate medication and classes to avoid in older adults
Megestrol, glyburide, sliding scale insulin
Avoid all of these in favor of safer medications or nondrug approaches to therapy
! 2nd there is table of drugs that should be avoided in older adults with certain diseases and syndromes
that can be exacerbated by or exacerbate drug effects
Thiazolidinedione or giltazones with heart failure
Acetylcholinesterase inhibitors with a history of syncope
SSRIs in patients with fractures
! 3rd there is a list of medications that should be used with caution in older adults
Antithrombotics in adults aged 75 or older

7. Prescribing in Elderly People

Introduction
Elderly patients are at a high risk of drug interactions due to their frequent taking of many drugs, having several
comorbidities and the fact that they may not be maintaining adequate nutritional status. There are also many
patients with chronic disease such as HIV, transplants and mental health problems that make drug interactions more
common

Categories of drug interactions that may occur in elderly patients
Drug-Drug interactions which can be either pharmacodynamics or pharmacokinetic in nature
o Pharmacokinetics (what the body does to the drug) involves the effects of one drug on the absorption,
distribution, metabolism or excretion of another drug
o Pharmacodynamics (what the drug does to the body) involves synergistic effects or antagonism of effects
making drugs less effective or dangerous
Drug-Nutritional status interactions
Drug-Herbal product interactions
Drug-Alcohol interactions
Drug-Disease or Drug-Patient interactions: takes place when a drug has the potential to exacerbate an underlying
disease or medical disorder

Why are elderly patients at higher risk of drug interactions?
Patient factors such as age, metabolism, lifelong habits, environments and genetics
Prescriber factors, a good example is if you have many physicians prescribing medications and they themselves may
be unaware of all the meds the patient is on
Inefficient communication between health care and patients: such as patients not listing all the drugs they are on or
not taking all the drugs that they are listed to be taking

Clinical approach to address drug interactions in elderly people
1st Category common drug interactions
o Drug-drug interactions are frequent when drugs with a narrow therapeutic index, inhibitors/inducers of CYP450
enzymes, and patients with certain disorders (constipation, hypotension, dementia)
2nd Category complex interactions
o Patients taking 9 or more drugs fall and with 5 or more comorbidities into this category
o , Make sure to look at the overall health of the patient and make the sure the combined effect of the drugs is
having a good outcome for the patient
rd
3 Category cascade interactions
o This occurs when an adverse drug interaction is misinterpreted as a new medical disorder, which leads to more
drugs being given and this could lead to more ADRs.
o A complete and careful history of the onset of a patients symptoms and recent treatment changes are usually
diagnostic.

Can information technology software help clinicians manage drug interactions?
Potential drug interactions can be checked by submitting lists of drugs to computer assisted analysis
o This is most helpful at the time when electric prescription is occurring
There are drawbacks such as to many interactions listed, the need for constant updating and the lack of these
systems to have focused information regarding geriatrics

How can Clinicians help to decrease drug interactions in elderly people?
Remember to take a good H/P and be aware of drug-drug interactions when seeing new patients or prescribing new
medications
Older patients do best when their care is managed by a multidisciplinary team including a geriatrician, nurse and
pharmacist
Questions/Steps to help the clinician detect drug interactions

o
o
o
o

Identification of the nature of the interaction

Understanding the mode of action of the interaction
Identification of the potential or real clinical outcomes for the patient
Monitoring and follow-up or potential drug interactions

7. Falls
Introduction
Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity,
mortality and use the health care services
Most of these falls are associated with one or more identifiable risk factors and research has shown that attention to
these risk factors can significantly recue rates of falling
The most effect fall reduction programs involve a systemic fall risk assessment and targeted interactions, exercise,
environment modification and hazard reduction
Background and Epidemiology
Unintentional injuries are the 5th leading cause of death in older adults and falls comprise 2/3 of these incidents
In the U.S. about of deaths due to falls occur in patients older than 65 years = indicating that this is primarily a
geriatric syndrome
Of those admitted to a hospital after a fall only about will be alive a year later and repeated falls are a common
precipitator of nursing home admission
Rates of falls and associated complications rise with age and falls among those in institutions also tend to result in
more serious complications
The problem with falls in the elderly is that you have a combination of higher incidence with high susceptibility to
injury
o Recovery from fall injury is often delayed in older persons and this in itself increases risk of subsequent falls
through deconditioning
Falls are among the largest single cause of restricted activity days among older adults
It has been estimated that 2/3 of deaths due to falls are potentially preventable

Causes for Falls
Accident/Environment Related (31%) = this is due to many factors such as that older patients are weaker, have poor
gait, are less coordinated, worse sight and sense
Gait/Balance Disorders or Weakness (17%) = therapeutic approaches can be very effective in reducing these
problems
Dizziness/Vertigo (13%) = nonspecific symptom with many etiologies (cardiovascular disease, hyperventilation,
orthostatic effects, drug effects)
Drop attacks (9%) = sudden falls without loss of consciousness or dizziness, usually the patient will have abrupt leg
weakness which is attributed to transient vertebrobasilar insufficiency and other diverse mechanisms
Others = Syncope, Confusion, Postural Hypotension, Visual disorders

Risk Factors for Falls
The most important ones are muscle weakness and problems with gait and balance
o Others include: visual defects, mobility limitations, cognitive impairment, impaired functional status and
postural hypotension
Among the most widespread of the risk factor reduction strategies involve regular exercises to improve strength,
gait and balance

Evaluating the Fall patient
Obtaining a full report of the circumstances and symptoms surrounding the fall is crucial
o Symptoms experienced near the time of falling may also point to a potential cause
o Medications and concomitant medical problems may be important contributors
Focus on findings that may have directly contributed to the fall and not risk factors for falls
o You can attempt to reproduce the circumstances that precipitated the fall
Gait and stability should be assessed = notice how they walk, turn, get up, sit down etc
o You can use a formal gait assessment such as the Tinetti balance and gait instrument
Lab tests are not often done, however a full blood count, serum electrolytes and ECG often disclose contributory
abnormalities


Therapeutic and Preventative Approaches
Once the causes and or risk factors are determined appropriate a specific treatment can be started
o This is easy if the person has a treatable condition such as an arrhythmia, dehydration
o For those with gait problems assistive devices can be helpful as well as physical therapy
Autonomic dysfunction leading to postural hypotension can be treated with
o Sleeping in bed with head raised
o Wearing elastic stockings
o Rising slowly from bed
o Increasing blood volume (taking in more salt)
o Raising blood pressure with medications
Physicians should caution patients to eliminate home hazards such as loose frayed rugs, trailing electrical cords and
unstable furniture
o You should also tell your patient about pertinent environment improvements such as: good lighting, bathroom
grab rails, raised toilet seats, raising/lowering beds and easily accessible alarm systems
Exercise programs that improve strength, balance and endurance have been particularly promising in reducing falls

8. Frailty Syndrome
Pathophysiology of Frailty
Age-related changes to multiple physiological systems are fundamental to the development of frailty, particularly
the neuromuscular, neuroendocrine and immunological systems.
o These changes end up in a cumulative decline in physiological and function reserve and when a cumulative
threshold is reached the ability of the individual to resist minor stressors and maintain physiological homeostasis
is compromised
o Such people are predisposed to adverse health consequences, particularly falls and delirium following relatively
minor stressor events
The Frailty phenotype includes
o Sarcopenia (loss of skeletal muscle mass and
o Fatigue
strength)
o Risk of falls
o Anorexia
o Poor physical health
o Osteoporosis
Frailty illustrates a person who is functionally independent but through the combined process of aging, chronic
disease and deconditioning is so close to a theoretical line of decompensation that only a small amount of stress
results in a sudden and disproportionately sever health state change

The Frailty cycle
The interactions that lead to frailty result in a self-perpetuating cycle whereby increased frailty gives rise to
increased risk of further decline towards disability and greater frailty

Detection of Frailty
The Fried Frailty Model
o When the identified 5 key components are presented in combination they have the potential to interact and
cause a critical mass that comprises frailty syndrome
! None of five indicators = roust older people
! 1-2 indicators = intermediate and pre-frailty group
! 3-5 indicators = frailty syndrome patients

The Edmonton Frail Scale (EFS)
o This is a diagnostic tool designed to identify frail older
people in clinical settings
o Used to measure frailty in an acute hospital inpatient
setting

Epidemiology of frailty
UK study found rates of: 8.5% in Women and 4.1% in Men between ages of 64-74 years old
We know that frailty increases in incidence with are
Older people defined as being frail according to the Fried criteria were at significantly increased risk of disability,
hospitalization and death

Frailty treatment interventions
Sarcopenia and chronic undernutrition accompany frailty and are natural targets for treatment
Physical Activity
o Strength and balance training have been successful at improving muscle strength and function abilities in frail
people
o And there is good evidence that individual or group exercise programs are both acceptable and effective in
improving mobility and other daily living tasks in this vulnerable population
Nutrition
o These appear to be less effective and nutritional supplementation does not appear to be independently
effective for improving functional abilities of rail older people as compared to exercise and nutritional therapy
combined
Pharmacological
o Several pharmacological agents (anabolic steroids, statins, ACEi) have actions and effects that would limit the
development and progression of frailty
o However evidence of a beneficial effect from these agents has not yet been reliably demonstrated

9. Osteoporosis
Introduction
There has been a shift in the treatment of osteoporosis and fractures with the focus now on preventing frailty
fractures and their negative consequences, rather than on treating low bone mineral density (which is viewed as
only one of several risk factors for fracture)
2010 guidelines concentrate on the assessment and management of women and men over age 50 who are at high
risk of fragility fractures and the integration of new tools for assessing the 10 year risk of fractures into overall
management
Fragility fractures, the consequence of osteoporosis, are responsible for excess mortality, morbidity, chronic pain,
admission to institutions and economic costs
o They represent 80% of all fractures in menopausal women over age 50
Fewer than 20% of women and 10% of men receive therapies to prevent further fractures
The target population for these guidelines is women and men over age 50, because of the overall burden of illness in
that age group.

Who should I assess for osteoporosis and fracture risk?
Women and men over age 50 should be assessed for risk factors for osteoporosis and fracture to identify those at
high risk for fractures
o Individuals over age 50 who have experience a fragility fracture should be assessed as well

How do you assess for osteoporosis and facture risk?
A detailed history and a focused physical examination are recommended to identify risk factors for low bone mineral
density, falls and fractures as well as undiagnosed vertebral fractures
In select individuals bone mineral density should be measured
o Measure height annually to assess presence of vertebral fractures
o Assess history of falls in the past year

What investigations should I order initially?
For most patients with osteoporosis, defined as bone mineral density of 2.5 or more standard deviations below the
peak bone mass for young adults (T score < -2.5), only limited laboratory investigations are usually required
o Calcium (corrected for albumin), CBC, Creatinine, Alkaline phosphatase, Thyroid-stimulating hormone, serum
protein electrophoresis (for those with vertebral fractures) and 25-Hydroxyvitamin D " doing this can help to
rule out secondary causes to osteoporosis
Make sure to measure serum 25-hydroxyvitamin D in individuals who will receive pharmacotherapy for
osteoporosis, have sustained recurrent fractures or have bone loss despite treatment
o Measure this again after 3-4 months of treatment and repeat if not at optimal levels (>75 nmol/L)

Make sure to perform lateral thoracic spine and lumbar spine radiography or vertebral facture assessment via dual-
energy x-ray absorptiometry if there is clinical evidence of a vertebral facture

How do I assess 10-year fracture risk?
There are two different tools that can be sued and both use bone mineral density or T-score for the femoral neck
only
o The Canadian Association of Radiologist and Osteoporosis Canada tool (CAROC)
o The WHO Fracture Risk Assessment tool (FRAX-WHO)
CAROC:
o This stratifies patients into 3 zones of risk for major osteoporotic fractures within the next 10 years
! Low - < 10%
! Moderate 10-120%
! High - > 20%
o Initial risk category is based on age, sex, and T score of femoral neck
o The presence of either a prior fragility fracture before age 40 or prolonged use of systemic glucocorticoids raises
the individuals risk to the next risk category
! When both are present the patient is considered to have a high risk regardless of the bone mineral
density scan
FRAX-WHO
o Uses age, sex, BMI, prior fracture, parental hip fracture, prolonged glucocorticoid use, RA, smoking, alcohol
intake and bone mineral density of the femoral neck
The choice of tool is largely a matter of personal preference
Neither of the models should be applied to individuals younger than 50 years of age

What are the Therapeutic Options?
Exercise and Prevention of Falls
o Exercise improves quality of life for those with osteoporosis particularly in the domains of physical function and
pain and it improves muscle strength and balance
! Resistance training, exercise for increasing core strength/stability and exercises that focus on balance
(tai chi, balance or gait training) are all good options
o Home safety assessment was only effective for those with severe visual impairment and those at high risk for
falls
o Use of hip protectors should be considered for older adults residing in long-term care facilities who are at high
risk for fracture

Calcium and Vitamin D
o The total daily intake of calcium for individuals over age 50 should be 1200mg
o For healthy adults at low risk of vitamin D deficiency supplementation with 400-1000 IU is recommended
o For adults over 50 at moderate risk for vitamin D deficiency supplementation with 800-100 IU is recommended
! Doses up to 2000 IU are safe and dont mandate monitoring
o For individuals receiving pharmacologic therapy for osteoporosis, measurement of serum 25-hydroxyvitamin D
should follow 3-4 months of treatment and be repeated if optimal concentration s are not met (> 75 nmol/L)

Pharmacological therapy
o 1st line drugs for prevention of hip, nonvertebral and vertebral fractures in menopausal women = alendronate,
risedronate, zoledronic acid and denosumab
o 1st line drug for prevention of vertebral fractures in menopausal women = raloxifene
o 1st line drug for treatment of osteoporosis in combination with treatment for vasomotor symptoms = hormonal
therapy
o For menopausal women who cant tolerate 1st line drugs calcitonin or etidronate can be considered for
prevention of vertebral factures
o For men you can use alendronate, risedroante and zoledronic acid
! Testosterone is not recommend for treatment of osteoporosis in men

Adverse Effects of Pharmacologic Treatments

High does calcium supplementation may increase the risk of renal calculi and cardiovascular events
Bisphosphonates may cause self-limiting flu symptoms, especially after the first dose of zoledronic acid by infusion
o Whether bisphosphonates increase risk of osteonecrosis of the jaw, atypical fractures of the femur, esophageal
cancer or atrial fibrillation remains controversial
Denosumab may increase the risk for cellulitis
Raloxifene and hormone therapy increase the risk for thromboembolic events, including PE
Teriparatide can cause hypercalcinuria and hypercalcemia both are mild and will discontinue if they stop taking
calcium supplements
In general for patients at high 10 year fracture risk the benefits of pharmacological therapy far outweigh the
potential risks
o Potential benefits and risks of the agents should be discussed before therapy is initiated

Special Groups
Bone loss associated with glucocorticoid therapy develops quickly, within 3-6 months and the risk of fracture
increases with doses as low as 2.5-7.5 mg/day
o Long term glucocorticoid treatment has resulted in a 30%-50% incidence of fractures
o For individuals over 50 who are on longer term glucocorticoid therapy (greater than 3 months and dose > 7.5
mg/day) start them on a bisphosphonate (alendronate, risedronate, or zoledronic acid)
! Start the medication at the onset of treatment and continue for at least the duration of treatment
o Teriparatide should be considered for those at high risk of fracture and are taking glucocorticoids
o If a patient cant take one of the first line therapies calcitonin or etidronate may be considered
Women who are taking aromatase inhibitors and men undergoing androgen-deprivation therapy sh0uld be assessed
for fracture risk and therapy should be considered

Risk Stratification and Treatment
For all patients regular weight bearing exercise, balance and strengthening exercise, smoking cessation and
optimization of total dietary calcium/Vit D are recommended
For patients at risk of falls, fall-prevention strategies should be implemented
High Risk Patients
o Pharmacologic therapy should be offered to patients at high risk (>20% chance over next 10 years)
! This includes individuals over the age of 50 who have had fragility fractures of the hip or vertebra,
those who have had more than fragility fracture and those at high risk

Moderate Risk Patients
o These patients should be considered for pharmacological treatment, make sure to look at additional risk factors
as well as patient preference

Low Risk Patients
o Pharmacological treatment is usually not required and in general lifestyle measures are sufficient

Monitoring Therapy
o For patients who are undergoing treatment, repeat measures of bone mineral density should be initially
performed after one to three years and the testing interval can be increased once therapy is shown be effective

Combination therapy?
o Individuals at high risk should not take drug holidays
o Clinicians should avoid prescribing more than one antiresportive agent for fracture reduction

Remember that patients may benefit from referral to physician with expertise in osteoporosis and always know your
limitations especially if the patient is not responding to therapy, cant take the medications, has a secondary cause
of osteoporosis or has an extremely low bone mineral density

10. Deficits in Communication and Information Transfer

Introduction
The discharge summary is the most common method for documenting a patients diagnostic findings, hospital
management and arrangements for post-discharge follow up
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that discharge summaries be
completed within 30 days of hospital discharge and that they include the following elements
o Reason for hospitalization significant findings, procedures performed and care, treatment/services provided, the
patients condition at discharge and information provided to the patient and family as appropriate

Deficits in Communication and Information Transfer
The most common formats for communicating information about the hospitalization where discharge summaries
(physician-dictated, transcribed reports) and discharge letters (handwritten or types narratives)
This study found that only 3% of PCP reported being involved in discussion about discharge and 17%-20% reported
always be notified about discharges
PCPs generally rated the following information as most important for providing adequate follow up care: main dx,
pertinent physical findings, results of labs/procedures, discharge medications and reasons to changes, details about
follow up, information given to patient/family, test results pending and specific follow up needs
o Despite agreement from hospital physicians on the importance of this content audits of discharge documents
show frequent lack of this important information as well as other medical and administrative information
The study has shown that patients often contact or are treated by their PCP before the PCP received a discharge
letter or detailed summary
Outpatient physicians estimated that there follow-up management was affected adversely in about 24% of cases by
delayed or incomplete discharge communications
o Communication of diagnostic test results, presented another patient safety concern with microbiological and
radiological studies posing the greatest problems

Interventions to Improve Information Transfer at Hospital Discharge
On the day of discharge, a summary document should be sent to the primary care physician by e-mail, fax, or mail. If
a complete discharge summary cannot be sent on the day of discharge, then an interim discharge note should be
sent. At minimum, it should include the diagnoses, discharge medications, results of procedures, follow-up needs,
and pending test results.
Discharge summaries should be structured with subheadings to organize and highlight the information most
pertinent to follow-up care and to ensure that all essential topics are addressed.
To the extent possible, hospitals should use information technology to extract information into discharge summaries
to ensure accuracy (eg, medication names and doses) and to facilitate rapid completion of summaries.
If possible, patients should be given a copy of the discharge summary or note and told to bring it to their follow-up
visit.

11. Elder Maltreatment

Introduction
The AMA defines elder maltreatment as an act or omission that results in harm or threatened harm to the health or
welfare of an elderly person
Up to 5% of community-dwelling elders are victims of maltreatment and studies have found that only 1 of every
13/14 cases of elder abuse is every reported
Elder Maltreatment can be classified into 6 categories: Physical abuse, Sexual abuse, Neglect, Psychological abuse,
Financial and Material Exploitation, Violation of rights

Typical Victim
The typical victim in this age group is older than 75 years, often older than 80 years
o Most studies show that men and women are equally likely to be abused however some recent studies show
higher rates in women
o Some studies show that whites are more likely to be abused as well (up to 77% of victims in one study where
white)
The victim is usually social isolated and lives close to the perpetrator, has a personal relationship with them and is in
some way dependent on them
The maltreatment is most likely to occur in either the victims or perpetrators home

Typical Perpetrator
There seems to be a large amount of transgenerational violence in these cases set up around revenge
o Abused spouses abuse spouses later, children abuse parents later
The typical perpetrator is a relative who lives near the elder
3 characteristics that are risks factors in the potential perpetrator
o A history of mental illness and or substance abuse
o Excessive dependence on the elder for financial support
o A history of violence within or outside of the family
2/3 of perpetrators where spouses, while 1/3 where adult children
Male victims are most likely abused by their wives and female victims are most likely abused by their children (male
> female)

Physical Abuse
Physical abuse is an act carried out with the intention of causing physical pain or injury
o Slapping, blunt force trauma, bites, pinching, traumatic alopecia, burns, scalds, force feeding, overmedication,
undermedication, improper medication and improper use of physical restraints
Worrisome traumatic injuries are ones that occur in areas not commonly impacted during daily activity or even
secondary to accidental trauma
o Inner thigh, top of feet, inner ankle, inner wrist, palms and soles, pinna, posterior neck, mastoid region and axilla
o Look for patterns left by trauma
The given history will usually not correlate with the physical findings
Make sure to investigate any injuries to the head and neck
Financial exploitation can lead to abuse to get money, using money meant for meds for other things or the abuses
taking the patients meds themselves

Sexual Abuse
Also called molestation consists of contact with the genitalia, anus, breast or mouth
Most sexual assault occurs when the patient is at home
The victims are often women and the perpetrators are male
Most elder women sustain anogenital injury
o They are prone to vaginal injury secondary to decreased estrogen atrophy, vaginal dryness, and a thinning wall
A significant amount of trauma can also be to the nongenital sights such as bite marks, blunt force trauma, hard and
soft palate trauma, injuries secondary to restraints and signs of asphyxia

Neglect
The failure of a caregiver to provide basic are to a patient and to provide goods and services necessary to prevent
physical harm or emotional discomfort
This is the most common form of elder maltreatment and can be either active or passive
o Active neglect = when the caregiver intentionally fails to meet his or her obligations toward the elder
o Passive neglect = the failure is unintentional
Findings of neglect include malnutrition, starvation, dehydration, poor hygiene and untreated decubiti
o Malnourishment = encompasses starvation as well as improper diet and is suspected in cases of decreased body
mass, loss of muscle mass, recurrent infections, decreased total protein and decreased total iron binding
capacity
o Dehydration = one may see dry mucous membranes, dry serosal surfaces, sunken eyes and decreased skin
turgor
o Decubitus ulcers = ulcerations outside of the lumbar and sacral areas may indicate unusual positioning or
improper restraint
o Poor hygiene = lying in urine/feces, increased skin breakdown and infections
Medical neglect is when the caretaker does not seek medical treatment, delays in seeking treatment, does not
provide medication or does not care for the elders organic diseases

Abuse in Institutions
Remember that the major of abuse occurs at home
The perpetrator of abuse in these situations may be a staff member, another resident or a visitor
One half of nursing home residents suffer from dementia and are unable to voice their abusive situation or seek help
One study found that 10% of nursing aids reported committing at least 1 act of physical abuse in the preceding year
and 40% reported committing at least one act of psychological abuse

Ancillary Studies
The following studies are often useful for evaluation cases of possible elder maltreatment
o Full body radiography
o Microbial cultures of blood, lung and wounds
o Blood or Vitreous humor analysis for electrolytes, glucose and ketones
Swabs of the anorectum, cervicovaginal and mouth

Age-Related Changes and Mimickers of Abuse
Skin and Soft Tissue - As we age we notice decreased elasticity, decreased collagen, decreased epidermal
proliferation flattened dermal epidermal junction, vascular fragility and weakened supporting structures
o Some things that can be confused for abuse are senile purpura, the fact that elders cant detect temperature as
well and the fact they are prone to decubitus ulcers
Bleeding - Many elders have acquired bleeding tendencies from coagulopathies of aging, anticoagulant treatments
and chronic diseases such as cirrhosis
o Hematomas are more likely to form from little trauma, certain areas are prone to bleeding like the nose and falls
can increase the likely hood of subdural hemorrhages (due to loss of proprioception, vision)
Fractures - Elders have decreased bone mass and osteopenia and osteoporosis are prevalent leading to increased
likelihood of fractures
Malnutrition - With a decrease in basal metabolic rate, decreased adipose tissue and muscular atrophy the elderly
are more likely to appear cachectic and malnourished
Anogential findings we mentioned some changes that can occur in women during aging these changes could lead
to local trauma from accidental pelvic trauma or consensual sex
o Bowel diseases and constipation can lead to anal fissures and excoriation mimicking sexual abuse

12. Pressure Ulcers

Introduction
A pressure ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of
unrelieved pressure and can range in severity from reddening of the kin to severe deep craters with exposed muscle
or bone
Pressure ulcers significantly threaten the well-being of patients with limited mobility
70% of ulcers occur in person older than 65 years of age

Etiology
Pressure ulcers are caused by unrelieved pressure applied with great force over a short period (or with less force
over a longer period) that disrupts blood supply to the capillary network, impeding blood flow and depriving tissues
of oxygen and nutrients
o The external pressure must be greater than the arterial capillary pressure to lead to local ischemia and tissue
damage
The most common sites of pressure ulcers are the sacrum, heels, ischial tuberosities, greater trochanters and lateral
malleoli

Prevention Risk Assessment
The Barden Scale b: is the most commonly used tool for predicting pressure ulcer risk
o Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category, which is rated on a 1-3
scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a
pressure ulcer and vice-versa. A score of 23 means there is no risk for developing a pressure ulcer while the
lowest possible score of 6 points represents the severest risk for developing a pressure ulcer.
Braden Scale assessment score scale:
o Very High Risk: Total Score 9 or less
o High Risk: Total Score 10-12
o Moderate Risk: Total Score 13-14
o Mild Risk: Total Score 15-18
o No Risk: Total Score 19-23
Categories: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.

Pressure Ulcer Risk Factors
Risk factors are classified as intrinsic and
extrinsic
o Intrinsic risk factors
! Limited mobility (Spinal cord
injury, Cerebrovascular accident,
Progressive neurologic disorders
(Parkinson disease, Alzheimer
disease, multiple sclerosis), Pain,
Fractures, Postsurgical
procedures, Coma or sedation,
Arthropathies)
! Poor nutrition (Anorexia,
Dehydration, Poor dentition,
Dietary restriction, Weak sense
of smell or taste, Poverty or lack
of access to food)
! Comorbidities (Diabetes
mellitus, Depression or
psychosis, Vasculitis or other
collagen, vascular disorders, Peripheral vascular disease, Decreased pain sensation,

Immunodeficiency or use of, corticosteroid therapy, Congestive heart failure, Malignancies, End-
stage renal disease, Chronic obstructive pulmonary disease, Dementia)
! Aging skin (Loss of elasticity, Decreased cutaneous blood flow, Changes in dermal pH, Flattening of
rete ridges, Loss of subcutaneous fat, Decreased dermal-epidermal blood flow)
o Extrinsic risk factors
! Pressure from any hard surface (e.g., bed, wheelchair, stretcher)
! Friction from patients inability to move well in bed
! Shear from involuntary muscle movements
! Moisture (Bowel or bladder incontinence, Excessive perspiration, Wound drainage)

Prevention Interventions
Preventive measures should be used in at risk patients, with pressure reduction being the mainstay of preventative
therapy
o Patients who are bedridden should be repositioned every 2 hours
o To minimize shear the head of the bed should not be elevated more than 30 degrees
Pressure reducing devices
o Static = foam, water, gel and air mattresses or mattress overlays
o Dynamic = such as alternating pressure devices and low-air-loss and air-fluidized surfaces, use a power source to
redistribute localized pressure
! Consider these if the patient cant reposition him or herself
Other preventative interventions include nutritional and skin care assessments
o Nutritional Assessment
! Documentation is limited as to the effects of adequate nutrition, however there is much
observational and expert opinion on this and it is mainstay of care
! Encourage adequate dietary intake using the patients favorite foods, mealtime assistance and snacks
throughout the day
! 1.25-1.5 g/kg/day
! Protein, Vitamin C and Zinc supplements should be considered if intake is insufficient and deficit is
present

Assessment
A comprehensive history includes onset and duration of ulcers, previous wound care, risk factors and a list of health
problems and medications
o Other factors such as psychological health, behavioral and cognitive status, social and financial resources and
access to caregivers are critical tin the initial assessment
The physician should note the number, location and size of the ulcers and assess for the presence of exudate, odor,
sinus tracts, necrosis or eschar formation, tunneling, undermining, infection, healing (granulation and
epithelialization) and wound margins
Most importantly the physician should determine the stage of each ulcer
Remember that the stage of the ulcer cannot be determine until enough slough or eschar is removed to expose the
base of the wound

Management:
Complications
o Non-infectious: amyloidosis, heterotopic bone formation, perineal-urethral fistula, pseudoaneurysm, marjoin
ulcer, systemic complications of topical treatment
o Infectious complications: bacteremia, sepsis, cellulitis, endocarditis, meningitis, osteomyelitis, septic arthritis,
sinus tracts and abscesses

12. Palliative Care

Introduction
Studies suggest that medical care for patients with serious and advanced illnesses is characterized:
o Undertreatment of symptoms
o Conflict about who should make decisions about the patients care
o Impairments in caregivers physical and psychological health
o Depletion of family resources

The Role of Palliative Care
There are many reasons why patients who have advanced illnesses receive inadequate care, but most those reasons
are rooted in a medical philosophy that is focused almost exclusively on curing illness and prolonging life, rather
than on improving the quality of life and relieving suffering
o Often the decision to focus on reducing suffering is made only after life-prolonging treatment has been
ineffectual and death is imminent
o Patients would benefit most from care that included a combination of life-prolonging treatment (when possible
and appropriate), palliation of symptoms, rehabilitation and support for caregivers
Palliative care aims to relieve suffering and improve the quality of life for patients with advanced illnesses and their
families through specific knowledge and skills, including communication with patients and family members;
management of pain and other symptoms; psychosocial, spiritual and bereavement support; and coordination of an
array of medical and social services
o Palliative care should be offered simultaneously with all other medical treatment

Physician-Patient Communication
Communicating with patients is a core skill of palliative medicine
Evidence shows that the effectiveness of clinicians use of specific communication skills in enhancing disclosure, of
the issue of concern to patient, decreasing anxiety, assessing depression, and improving a patients well-being and
the level of the patients and the familys satisfaction
These communication skills include making eye contact with patients, asking open-ended question, responding to a
patients affect and demonstrating empathy
o When a physician is informing a patient about a poor prognosis a patient centered interview has been
associated with improved satisfaction on the parts of the patients and families
! This means that there is an emphasis on empathy, openness and reassurance

Palliative care begins with the establishment of goals
Outlining realistic and attainable goals assumes an increased importance in the setting of advanced disease in which
treatment focused on prolonging life may be more burdensome than beneficial
Studies suggest that most seriously ill patients want is to have their pain and other symptoms relieved, improving
their quality of life, avoid being a burden to their family, have a closer relationship with loved ones, and maintain a
sense of control
Establishing clear goals can facilitate decision making requiring treatment
Clinicians can assist patients and their family members in establishing their own goals by means of open-ended and
probing questions
Once goals are established, they can be used to construct advanced directives about the types of care that patient
wants
A recent report suggested that eth focus of advanced care planning should shift from discussing specific treatment
to defining an acceptable quality of life and setting goals for care under various likely clinical scenarios
Assessment and Treatment of Symptoms
A fundamental goal of palliative care is the relief of pain and other symptoms
Relief of suffering begins with routine and standardized symptom assessment with sue of validated instruments
Improved treatment of symptoms has been associated with the enhancement of patient and family satisfaction,
functional status, quality of life and other clinical outcomes

Psychosocial, Spiritual and Bereavement Support
Providing psychosocial, spiritual and bereavement support to patients and caregivers is a key component of
palliative care
o Those who experience the above stresses are more likely to express the desire of death and their family
members are more likely to have complicated and extended grief and bereavement
Support groups for the patient are recommended
Those who get hospice care report lower morbidity and mortality, better emotional support in family members of
hospice patients than there non-hospice counterparts


Coordination of Care:
Palliative care programs, Hospice services, Programs that coordinate home care for patients with chronic conditions
and the Program of All-Inclusive Care for the Elderly (PACE) area all options that can be used to coordinate the care
of elderly patients seeking palliative care

Guidelines: Coordination of Care at Various Stages of Serous Chronic Illness

Conclusions
The aim of palliative care is to relieve suffering and improve the quality of life for patients with advanced illnesses
and their families
The following approach is suggested
o If available consult with a palliative care team
o Once the patient is comfortable discuss realistic goals
! This discussion should be summarized in a treatment directive and that a health car proxy form be
completed
o The patients discharge services will depend on goals, the patients insurance coverage and financial resources
and available home care services

o
o
o

A referral to a hospice should be considered and if this cant be done that refer to a case management program
such as PACE or a certified home care agency
Before discharge a home safety and home needs evaluation should be performed either by an occupational
therapist or a structured interview with the patients caregiver
Finally, a regular system of communication should be established between the treating physician and the home
care team.