In patients with this condition, a pathologic fracture may precede a fall. In the absence of universally accepted criteria for the assessment of bone mineral density, screening should be directed at a risk assessment for osteoporosis Table 2.
Extrinsic factors that contribute to falls include poor lighting, obtrusive furniture, slippery floors, loose floor coverings and bathrooms without handrails or grab bars. A comprehensive risk assessment for falls incorporates a review of all potential intrinsic and extrinsic factors, as well as a focused physical examination Table 3.
The effectiveness of the test for predicting falls can be enhanced by timing the process, with more than 16 seconds suggesting an increased risk of falling. Behavioral recommendations, such as ankle pumps or hand clenching, and elevating the head of the bed. Decrease in the dosage of a medication that may contribute to hypotension; if necessary, discontinuation of the drug or substitution of another medication. Home safety assessment with appropriate changes, such as removal of hazards, selection of safer furniture correct height, more stability and installation of structures such as grab bars or handrails on stairs.
Environmental alterations, such as installation of grab bars or raised toilet seats. Impairment in leg or arm muscle strength or impaired range of motion hip, ankle, knee, shoulder, hand or elbow.
Exercises with resistive bands and putty; resistance training two or three times a week, with resistance increased when the patient is able to complete 10 repetitions through the full range of motion. A multifactorial intervention to reduce the risk of falling among elderly people living in the community.
N Engl J Med ;—7. Changes in vision and hearing occur as patients age. Because these changes can have a great impact on well-being, the USPSTF recommends regular vision and hearing screening for patients 65 years of age and older. One study found that 72 percent of community-based patients more than 64 years of age had impaired vision as tested with a Snellen eye chart. The most common causes of visual impairment in the elderly include presbyopia, cataracts, glaucoma, diabetic retinopathy and age-related macular degeneration.
Changes in vision can cause a significant number of problems for elderly patients, including an increased risk for falls. The Snellen eye chart is an appropriate tool for visual acuity screening in the elderly. The USPSTF found insufficient evidence to recommend for or against screening with ophthalmoscopy performed by primary care physicians in asymptomatic elderly patients.
However, patients at high risk for glaucoma i. The optimal frequency for glaucoma screening in these patients is uncertain. The prevalence of hearing loss in the geriatric population ranges from 14 to 46 percent, 17 , 18 but only 20 percent of primary care physicians routinely screen elderly patients for hearing loss.
Presbycusis, a progressive high-frequency hearing loss, is the most common cause of hearing impairment in geriatric patients.
Combining the HHIE—S questionnaire with pure tone audiometry has been shown to improve screening effectiveness. The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. Appropriate interventions include periodic screening to provide early detection of hearing impairment, cautious use or avoidance of ototoxic drugs, and support for the obtainment and continued use of hearing aids.
Malnutrition and undernutrition are common yet frequently overlooked problems in the geriatric population. Elderly patients with a compromised nutritional state require longer hospital stays and develop more complications. One simple screening device for geriatric nutrition is the Nutritional Health Screen Figure 2.
Adapted with permission from The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention.
June The USPSTF recommendation for encouraging regular tooth brushing, flossing and dental visits gains importance in the elderly. A report 24 indicated that fewer than 30 percent of adults had received updated tetanus-diphtheria, influenza and pneumococcal immunizations.
The poor compliance rate was determined to be secondary to patients' concerns about adverse reactions to immunizations and physicians' overlooking the need for such immunizations.
In recent years, however, immunization rates in adults have improved. Data from the Centers for Disease Control and Prevention indicated that the rates for influenza and pneumococcal vaccinations were Primary care physicians must be diligent in assessing the immunization status of geriatric patients and providing the recommended vaccines.
Patients over 65 years of age should also receive at least one pneumococcal vaccination in their lifetime, with high-risk patients receiving a second immunization in six years. The tetanus-diphtheria Td toxoid should be given every 10 years. Although the tempo and intensity of sexual activity may change over time, problems that relate to a person's ability to have and enjoy sexual relations should not be considered part of the normal aging process.
Studies show that 74 percent of married men and 56 percent of married women over 60 years of age remain sexually active. Common problems affecting sexual functioning include arthritis, diabetes, fatigue, fear of precipitating a heart attack and side effects from alcohol, prescription drugs and over-the-counter medications. Incontinence is estimated to occur in 11 to 34 percent of elderly men and 17 to 55 percent of elderly women.
The first step in screening for urinary incontinence is to ask the patient if he or she is experiencing any problems in this area.
In this situation, further evaluation is necessary. The assessment for urinary incontinence should include an evaluation of cognitive function, fluid intake, mobility, medication side effects and previous urologic surgeries. A rectal examination can determine the presence of fecal impaction, and a simple urinalysis can be used to screen for infection or glycosuria.
Changes in mental status can have a profound impact on elderly patients and their families. Two of the more common changes are cognitive decline and depression. Dementia is chronic and progressive, and it is characterized by the gradual onset of impaired memory and deficits in two or more areas of cognition, such as anomia, agnosia or apraxia.
For the diagnosis of dementia to be established, these deficits must be present with no alteration of consciousness and no underlying medical cause that would better explain the deficits.
J Psychiatr Res ;— Depression significantly increases morbidity and mortality. The Geriatric Depression Scale, shown in Figure 4 , 39 is a good screening tool to use in older patients. Clin Gerontol ;— An assessment for suicide risk is important in geriatric patients who appear depressed. The best way to accomplish this task is to ask direct, yet nonthreatening questions.
An effective interview progression might be to begin by asking patients if they are concerned that they are becoming a burden to their family and if they have ever felt that their family might be better off without them. This is followed by questions about active suicidal ideation. Because multiple aspects of the social situation can influence functional ability, efficient use of time can be made by asking patients and family members if any recent changes have occurred in living arrangements, finances or activities.
Actual or potential care-givers can provide information about a patient's social network and support system, as well as the availability of care. Other issues that need to be addressed with patients and caregivers include advance directives, the living will and the durable power of attorney.
Finally, the USPSTF recommends that all family members of geriatric patients receive training in cardiopulmonary resuscitation. Remaining as independent as possible for a long as possible is a primary concern for most elderly patients. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist ;— One recent study indicated that short-term memory and orientation are the domains most closely associated with ADL dependence.
The study findings suggested that a shortened version of the Mini-Mental State that included only the recall of three words and the orientation to month, year and address could be a valid and time-efficient assessment tool. Geriatric patients present multiple challenges to primary care physicians. Using a standard assessment plan, which might include a chart-based checklist of counseling topics Figure 7 , 6 as well as a brief screening list Table 5 , 47 physicians can prevent or delay some of the major causes of morbidity and mortality in their older patients.
The assessment can be performed over time and during multiple visits. By performing comprehensive health screening, physicians can provide appropriate interventions and improve quality of life for their geriatric patients. Areas of assessment in a systematic approach to maintaining healthy geriatric patients. Information from U. Preventive Services Task Force.
Guide to clinical preventive services: report of the U. Use an audioscope set at 40 dB. Test the patient's hearing using 1, and 2, Hz. Inability to hear 1, or 2, Hz in both ears or inability to hear frequencies in either ear.
Then walk 20 feet briskly, turn, walk back to the chair and sit down. Screening for common problems in ambulatory elderly: clinical confirmation of a screen instrument. Am J Med ;— Copyright , with permission from Excerpta Medica Inc. Already a member or subscriber? Log in. Alzheimer's disease is incurable; therefore, mental stimulation, exercise, and a balanced diet are often recommended, as both a possible prevention and a sensible way of managing the disease.
Delirium is temporary disorder of the mental faculties, as in fevers, disturbances of consciousness, or intoxication, characterized by restlessness, excitement, delusions, hallucinations, etc. Delirium itself is not a disease, but a syndrome, which may result from an underlying disease. It has three main characteristics: disturbance of consciousness there is reduced clarity of awareness of the environment, with a decreased ability to focus, sustain, or shift attention , change in cognition problem-solving impairment or memory impairment or a perceptual disturbance, and onset of days to hours with the tendency to fluctuate.
Falls occur frequently and are a major cause of disability and death in senior citizens. More than one third of people over the age of 65 have at least one fall each year. Injuries sustained in a fall may range from trivial bruises to life-threatening trauma. Head injuries and fractures of long bones for example, hip fractures lead the list. There may be a delay in the onset of the effects of head injury.
Even falls that do not lead to injury can have a negative effect on older adults. After a fall, elderly patients often voluntarily restrict their activity because they fear another fall. This reduction in exercise leads to further weakness that, in turn, increases the risk of another fall - a vicious cycle. Everyone is at risk and risk for falls increases through age.
Polypharmacy by definition means "many drugs". So, is there a need to define old age? Yes, and some examples include: in epidemiological studies to monitor disease patterns with relation to age, to use age as one of the variables to study outcomes, effect of age on treatment outcomes, impact of age on symptoms etc.
I suggest we define chronological old age as above 75, old-old as above 85 and oldest old as above 95 in developed countries, even though there might be concerns about its impact on the retirement age, pensions and other benefits linked with old age like free bus pass. Since there is no consensus in the Western literature, I call upon the expertise of the BGS, celebrating its 70th anniversary to take forward the process of redefining old age with a clear emphasis that it should not provide a political cause for depriving the social care for people who need it most.
Home Blog Is it time to redefine old age? Is it time to redefine old age? He tweets adhiyamanv Western literature arbitrarily defines old age as people above the age of 65 Oxford textbook of geriatric medicine , Wikipedia etc.
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