Ebook Essentials of clinical geriatrics (7/E): Part 2

Part 2 book “Essentials of clinical geriatrics” has contents: Falls, immobility , cardiovascular disorders, decreased vitality, sensory impairment, drug therapy, drug therapy, health services, ethical issues in the care of older persons, palliative care.

one-of life Repeated falls and consequent injuries can be important factors in the sion to institutionalize an older person.

deci-Table 9-1 lists potential complications of falls Fractures of the hip, femur, humerus,

wrist, and ribs and painful soft tissue injuries are the most frequent physical cations Many of these injuries will result in hospitalization, with the attendant risks

compli-of immobilization and iatrogenic illnesses (see Chapter 10) Fractures compli-of the hip and lower extremities often lead to prolonged disability because of impaired mobility

A less common, but important, injury is subdural hematoma Neurological toms and signs that develop days to weeks after a fall should prompt consideration

symp-of this treatable problem

Even when the fall does not result in serious injury, substantial disability may result from fear of falling, loss of self-confidence, and restricted ambulation (either self-imposed or imposed by caregivers)

Many studies suggest that some falls can be prevented The potential for tion together with the use of falling as an indicator of underlying risk for disability make an understanding of the causes of falls and a practical approach to the evalua-tion and management of gait instability and fall risk important components of geri-atric care Similar to many other conditions in the geriatric population, factors that can contribute to or cause falls are multiple, and very often more than one of these factors play an important role in an individual fall (Fig 9-1)

preven-AGING AND INSTABILITY

Several age-related factors contribute to instability and falls (Table 9-2) Most dental” falls are caused by one or a combination of these factors interacting with environmental hazards

“acci-Aging changes in postural control and gait probably play a major role in many falls among older persons Increasing age is associated with diminished propriocep-tive input, slower righting reflexes, diminished strength of muscles important in maintaining posture, and increased postural sway All these changes can contribute

to falling—especially the ability to avoid a fall after encountering an environmental

Complications of immobilization (see Chap 10)

Risk of iatrogenic illnesses (see Chap 5)

Disability

Impaired mobility because of physical injury

Impaired mobility from fear, loss of self-confidence, and restriction of ambulation Increased risk of institutionalization

Increased risk of death

Intrinsic factors

Medical and neuropsychiatric conditions

Impaired vision and hearing

Age-related changes

in neuromuscular function, gait, and postural reflexes

Environmental hazards

Improper prescription and/or use of assistive devices for ambulation

Medications

FALLS

Extrinsic factors

hazard or an unexpected trip Changes in gait also occur with increasing age Although these changes may not be sufficient to be labeled truly pathologic, they can increase susceptibility to falls In general, elderly people do not pick their feet up as high, thus increasing the tendency to trip Elderly men tend to develop wide-based, short-stepped gaits; elderly women often walk with a narrow-based, waddling gait These gait changes have been associated with white matter changes in the brain on magnetic resonance imaging (MRI) and with subsequent development of cognitive impairment

Orthostatic hypotension (defined as a drop in systolic blood pressure of 20 mm

Hg or more when moving from a lying to a standing position) occurs in mately 20% of older persons Although not all older individuals with orthostatic hypotension are symptomatic, this impaired physiological response could play

approxi-a role in capproxi-ausing instapproxi-ability approxi-and precipitapproxi-ating fapproxi-alls in approxi-a substapproxi-antiapproxi-al proportion of patients Older people can experience a postprandial fall in blood pressure as well People with orthostatic and/or postprandial hypotension are at particular risk for near syncope and falls when treated with diuretics and antihypertensive drugs

Several pathologic conditions that increase in prevalence with increasing age can contribute to instability and falling Degenerative joint disease (especially

of the neck, the lumbosacral spine, and the lower extremities) can cause pain, unstable joints, muscle weakness, and neurological disturbances Healed frac-tures of the hip and femur can cause an abnormal and less steady gait Residual muscle weakness or sensory deficits from a recent or remote stroke can also cause instability

TABLE 9-2 Age-Related Factors Contributing to Instability and Falls

Changes in postural control and blood pressure

Decreased proprioception

Slower righting reflexes

Decreased muscle tone

Increased postural sway

Orthostatic hypotension

Postprandial hypotension

Changes in gait

Feet not picked up as high

Men develop flexed posture and wide-based, short-stepped gait

Women develop narrow-based, waddling gait

Increased prevalence of pathologic conditions predisposing to instability

Degenerative joint disease

Fractures of hip and femur

Stroke with residual deficits

Muscle weakness from disuse and deconditioning

Peripheral neuropathy

Diseases or deformities of the feet

Impaired vision

Impaired hearing

Impaired cognition and judgment

Other specific disease processes (eg, cardiovascular disease, parkinsonism—see

to falls Impaired cognitive function may result in the creation of, or wandering into, unsafe environments and may lead to falls Podiatric problems (bunions, calluses, nail disease, joint deformities, etc.) that cause pain, deformities, and alterations in gait are common, correctable causes of instability Other specific disease processes common in older people (such as Parkinson disease and cardiovascular disorders) can cause instability and falls and are discussed later in the chapter.

CAUSES OF FALLS IN OLDER PERSONS

Table 9-3 outlines the multiple and often interacting causes of falls among older

persons More than half of all falls are related to medically diagnosed conditions, emphasizing the importance of a careful medical assessment for patients who fall (see below) Several studies have found a variety of risk factors for falls, including cognitive impairment, impaired lower extremity strength or function, gait and bal-ance abnormalities, visual impairment, nocturia, and the number and nature of medications being taken Frequently overlooked, environmental factors can increase susceptibility to falls and other accidents Homes of elderly people are often full

of environmental hazards (Table 9-4) Unstable furniture, rickety stairs with equate railings, throw rugs and frayed carpets, and poor lighting should be identi-fied on home visits Several factors are associated with falls among older nursing home residents (Table 9-5) Awareness of these factors can help prevent morbidity and mortality in these settings Several factors can hinder precise identification of the specific causes for falls These factors include lack of witnesses, inability of the older person to recall the circumstances surrounding the event, the transient nature

inad-of several causes (eg, arrhythmia, transient ischemic attack [TIA], postural sion), and the fact that the majority of elderly people who fall do not seek medical attention Somewhat more detailed information is available on the circumstances surrounding falls in nursing homes (see Table 9 - 5)

hypoten-Close to half of all falls can be classified as accidental Usually an accidental trip or a slip can be precipitated by an environmental hazard, often in conjunc-tion with factors listed in Table 9 - 2 Addressing the environmental hazards begins with a careful assessment of the environment Some older persons have developed

a strong attachment to their cluttered surroundings and may need active agement to make the necessary changes, but many may simply take such environ-mental risks for granted until they are specifically identified

encour-Syncope, “drop attacks,” and “dizziness” are commonly cited causes of falls in older persons If there is a clear history of loss of consciousness, a cause for true syncope should be sought Although the complete differential diagnosis of syncope

is beyond the scope of this chapter, some of the more common causes of syncope in

True accidents (trips, slips, etc.)

Interactions between environmental hazards and factors increasing susceptibility

(see Table 9-2)

Syncope (sudden loss of consciousness)

Drop attacks (sudden leg weaknesses without loss of consciousness)

Dizziness and/or vertigo

Impaired venous return

Prolonged bed rest

Specific disease processes

Acute illness of any kind (“premonitory fall”)

Cardiovascular

Arrhythmias

Valvular heart disease (aortic stenosis)

Carotid sinus hypersensitivity

Normal-pressure hydrocephalus (gait disorder)

Central nervous system lesions (eg, tumor, subdural hematoma)

TABLE 9-4 Common Environmental Hazards

Old, unstable, and low-lying furniture

Beds and toilets of inappropriate height

Unavailability of grab bars

Uneven or poorly demarcated stairs and inadequate railing

Throw rugs, frayed carpets, cords, wires

Slippery floors and bathtubs

Inadequate lighting, glare

Cracked and uneven sidewalks

Pets that get under foot

TABLE 9-5 Factors Associated with Falls Among Older Nursing Home Residents

Recent admission

Dementia

Hip flexor muscle weakness

Certain activities (toileting, getting out of bed)

Psychotropic drugs causing daytime sedation

Cardiovascular medications (vasodilators, antihypertensives, diuretics)

Dizziness and unsteadiness are common complaints among elderly people who fall (as well as those who do not) A feeling of light-headedness can be associated with several different disorders but is a nonspecific symptom and should be interpreted with caution Patients complaining of light-headedness should be carefully evaluated for postural hypotension and intravascular volume depletion

Vertigo (a sensation of rotational movement), on the other hand, is a more specific symptom and is probably an uncommon precipitant of falls in the elderly It is most

Orthostatic hypotension is best detected by taking the blood pressure and pulse rate in supine position, after 1 minute in the sitting position, and after 1 and

3 minutes in the standing position A drop of more than 20 mm Hg in systolic blood pressure is generally considered to represent significant orthostatic hypo-tension In many instances, this condition is asymptomatic; however, several con-ditions can cause orthostatic hypotension or worsen it to a severity sufficient to precipitate a fall These conditions include low cardiac output from heart failure

or hypovolemia, overtreatment with cardiovascular medications, autonomic function (which can result from diabetes or Parkinson disease), impaired venous return (eg, venous insufficiency), and prolonged bed rest with deconditioning

dys-of muscles and reflexes Simply eating a full meal can precipitate a reduction in blood pressure in an older person that may be worsened when the person stands

up and lead to a fall

Drugs that should be suspected of playing a role in falls include diuretics volemia), antihypertensives (hypotension), antidepressants (postural hypotension), sedatives (excessive sedation), antipsychotics (sedation, muscle rigidity, postural hypotension), hypoglycemics (acute hypoglycemia), and alcohol (intoxication) Combinations of these drug types may greatly increase the risk of a fall Many older patients are on a diuretic and one or two other antihypertensives, with consequent hypotension or postural hypotension that may precipitate a fall Psychotropic drugs are commonly prescribed and appear to substantially increase the risk of falls and hip fractures, especially in patients concomitantly prescribed antidepressants

(hypo-Many disease processes, especially of the cardiovascular and neurological systems, are associated with falls Cardiac arrhythmias are common in ambulatory elderly persons and may be difficult to associate directly with a fall or syncope In gen-eral, cardiac monitoring should document a temporal association between a specific arrhythmia and symptoms (or a fall) before the arrhythmia is diagnosed (and treated)

as the cause of falls

Syncope is a symptom of aortic stenosis and is an indication to evaluate a patient suspected of having significant aortic stenosis for valve replacement Aortic stenosis

is difficult to diagnose by physical examination alone; all patients suspected of having this condition should have an echocardiogram

Some elderly individuals have sensitive carotid baroreceptors and are susceptible

to syncope resulting from reflex increase in vagal tone (caused by cough, straining at stool, micturition, etc.), which leads to bradycardia and hypotension Carotid sinus sensitivity can be detected by bedside maneuvers (see below)

Cerebrovascular disease is often implicated as a cause or contributing factor for falls

in older patients Although cerebral blood flow and cerebrovascular autoregulation may be diminished, these aging changes alone are not enough to cause unsteadiness

or falls They may, however, render the elderly person more susceptible to stresses such as diminished cardiac output, which will more easily precipitate symptoms Acute strokes (caused by thrombosis, hemorrhage, or embolus) can cause, and may initially manifest themselves in, falls TIAs of both the anterior and posterior circu-lations frequently last only minutes and are often poorly described Thus, care must

be taken in making these diagnoses Anterior circulation TIAs may cause unilateral weakness and thus precipitate a fall Vertebrobasilar (posterior circulation) TIAs may cause vertigo, but a history of transient vertigo alone is not a sufficient basis for the diagnosis of TIA The diagnosis of posterior circulation TIA necessitates that one or more other symptoms (visual field cuts, dysarthria, ataxia, or limb weakness, which can be bilateral) are associated with vertigo Vertebrobasilar insufficiency, as mentioned earlier, is often cited as a cause of drop attacks; in addition, mechanical compression of the vertebral arteries by osteophytes of the cervical spine when the head is turned has also been proposed as a cause of unsteadiness and falling Both

of these conditions are poorly documented, are probably overdiagnosed, and should not be used as causes of a fall simply because nothing else can be found

Other diseases of the brain and CNS can also cause falls Parkinson disease and normal-pressure hydrocephalus can cause disturbances of gait, which lead to instabil-ity and falls Cerebellar disorders, intracranial tumors, and subdural hematomas can cause unsteadiness, with a tendency to fall A slowly progressive gait disability with

a tendency to fall, especially in the presence of spasticity or hyperactive reflexes in the lower extremities, should prompt consideration of cervical spondylosis and spi-nal cord compression It is especially important to consider these diagnoses because treatment may improve the condition before permanent disability ensues

Urinary tract disorders including overactive bladder, urgency incontinence, and nocturia are also associated with falling Urinary urgency may cause a distraction, similar to the “dual-tasking” studies mentioned earlier, and thereby predispose to falls Awakening at night to void, especially among people who have taken hypnotics

or other psychotropic drugs, may substantially increase the risk of falls

Despite this long list, the precise causes of many falls will remain unknown, even after a thorough evaluation The ultimate test of the etiology for falls is its reversibility

As noted earlier in the text, we are often better at finding putative causes of geriatric conditions than in correcting them

EVALUATING THE ELDERLY PATIENT WHO FALLS

Updated quality indicators for the identification, evaluation, and management

of vulnerable elderly people with falls and mobility problems have recently been

Older patients who report a fall (or recurrent falls) that is not clearly the result of

an accidental trip or slip should be carefully evaluated, even if the fall has not resulted

in serious physical injury A jointly developed set of recommendations for assessing people who fall has been issued by the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons (2010) A thorough fall evaluation basically consists of a focused history, targeted physical examination, gait and balance assessment, and, in certain instances, selected laboratory studies

The history should focus on the general medical history and medications; the patient’s thoughts about what caused the fall; the circumstances surrounding it, including ingestion of a meal and/or medication; any premonitory or associated symptoms (such as palpitations caused by a transient arrhythmia or focal neuro-logical symptoms caused by a TIA); and whether there was loss of consciousness (Table 9-6) A history of loss of consciousness after the fall (which is often dif-ficult to document) is important and should raise the suspicion of a cardiac event (transient arrhythmia or heart block) that caused syncope or near-syncope or a sei-zure (especially if there has been incontinence) Falls are often unwitnessed, and older patients may not recall any details of the circumstances surrounding the event Detailed questioning can sometimes lead to identification of environmental factors that may have played a role in the fall and to symptoms that may lead to a specific diagnosis Many older patients will not be able to give details about an unwitnessed fall and will simply report, “I just fell down; I don’t know what happened.” The skin, extremities, and painful soft tissue areas should be assessed to detect any injury that may have resulted from a fall

Several other aspects of the physical examination can be helpful in determining the cause(s) (Table 9-7) Because a fall can herald the onset of a variety of acute illnesses (premonitory falls), careful attention should be given to vital signs Fever, tachypnea, tachycardia, and hypotension should prompt a search for an acute ill-ness (such as pneumonia or sepsis, myocardial infarction, pulmonary embolus, or gastrointestinal bleeding) Postural blood pressure and pulse determinations taken supine, sitting, and standing (after 1 and 3 minutes) are critical in the diagnosis and management of falls in older patients As noted earlier, postural hypotension occurs in a substantial number of healthy, asymptomatic elderly persons as well as

in those who are deconditioned from immobility or have venous insufficiency This finding can also be a sign of dehydration, acute blood loss (occult gastrointestinal bleeding), or a drug side effect (especially with cardiovascular medications and anti-depressants) Visual acuity should be assessed for any possible uncorrected vision impairment that may have contributed to instability and falls The cardiovascular examination should focus on the presence of arrhythmias (many of which are eas-ily missed during a brief examination) and signs of aortic stenosis Because both of these conditions are potentially serious and treatable, yet difficult to diagnose by physical examination, the patient should be referred for continuous monitoring and echocardiography if they are suspected If the history suggests carotid sinus

TABLE 9-6 Evaluating the Elderly Patient Who Falls: Key Points in the History

General medical history

History of previous falls

Medications (especially antihypertensive and psychotropic agents)

Patient’s thoughts on the cause of the fall

Was patient aware of impending fall?

Was it totally unexpected?

Did patient trip or slip?

Circumstances surrounding the fall

Location and time of day

Premonitory or associated symptoms

Light-headedness, dizziness, vertigo

Palpitations, chest pain, shortness of breath

Sudden focal neurological symptoms (weakness, sensory disturbance, dysarthria, ataxia, confusion, aphasia)

Aura

Incontinence of urine or stool

Loss of consciousness

What is remembered immediately after the fall?

Could the patient get up, and if so, how long did it take?

Can loss of consciousness be verified by a witness?

sensitivity, the carotid can be gently massaged for 5 seconds to observe whether this precipitates a profound bradycardia (50% reduction in heart rate) or a long pause (2 seconds) The extremities should be examined for evidence of deformities, limits to range of motion, or active inflammation that might underlie instability and cause a fall

Special attention should be given to the feet because of deformities; painful lesions (calluses, bunions, ulcers); and poorly fitting, inappropriate, or worn-out shoes are common and can contribute to instability and falls

Neurological examination is also an important aspect of this physical assessment Mental status should be assessed (see Chapter 6), with a careful search for focal neurological signs Evidence of muscle weakness, rigidity, or spasticity should be noted, and signs of peripheral neuropathy (especially posterior column signs such

as loss of position or vibratory sensation) should be ruled out Abnormalities in cerebellar function (especially heel-to-shin testing and heel tapping) and signs of Parkinson disease (such as resting tremor, muscle rigidity, and bradykinesia) should

be sought

is the most practical and useful assessment technique The “get up and go” test and other practical performance-based balance and gait assessments have been developed (Table 9-8) While timing of this test has been used in research, tim-ing in clinical practice is not essential and may distract the observer from careful

TABLE 9-7 Evaluating the Elderly Patient Who Falls: Key Aspects of the Physical

Signs of aortic stenosis

Carotid sinus sensitivity

Muscles (weakness, rigidity, spasticity)

Peripheral innervation (especially position sense)

Cerebellar (especially heel-to-shin testing)

Resting tremor, bradykinesia, other involuntary movements

Observation of gait and balance

Get up and go test (Table 9-10)

Evaluation of assistive devices for hazards, such as missing tips on canes and walkers,

impaired locking devices, or broken footrests on wheelchairs

Differential

TABLE 9-8. Example of a Performance-Based Assessment of Gait and Balance (Get Up and Go)

upright

Leans, slides down in chair

movement without using arms

Uses arms (on chair or walking aid) to pull or push up and/or moves forward in chair before attempting to rise

Multiple attempts required

or unable without human assistance

Immediate standing balance

(first 3-5 s)

Steady without holding onto walking aid or other object for support

Steady, but uses walking aid or support grabbing objects for support

Any sign of unsteadiness (eg, other object for staggering, more than minimal trunk sway)

together without holding onto

an object for support

Steady, but cannot put feet together

Balance with eyes closed

(Romberg test)

Steady without holding onto any object with feet together

needs to hold onto an object Nudge on sternum (patient

standing with eyes closed;

examiner pushes with light,

even pressure over sternum

three times; reflects ability to

withstand displacement)

able to maintain balance

Begins to fall, or examiner has

to help maintain balance

Walking (usual pace with

assistive device if used)

onto furniture

Decreased step height and/or step length; unsteadiness or staggering gait

PA

RT

need to hold onto any objects;

steps are continuous (turn is a flowing movement)

(patient puts one foot completely on floor before raising other foot)

holds onto an object; more than four steps to turn 360°

Neck turning (patient asked

to turn head side to side and

look up while standing with

feet as close together as

possible)

Able to turn head at least halfway side to side and able to bend head back to look at ceiling;

no staggering, grabbing, or symptoms of light-headedness, unsteadiness, or pain

Decreased ability to turn side to side to extend neck, but no staggering, grabbing, or symptoms

of light-headedness, unsteadiness, or pain

Any sign of unsteadiness or symptoms when turning head or extending neck

Back extension (ask patient to

lean back as far as possible,

without holding onto object if

Will not attempt, no extension seen, or staggers

Reaching up (have patient

attempt to remove an object

from a shelf high enough

to necessitate stretching or

standing on toes)

Able to take down object without needing to hold onto other object for support and without becoming unsteady

Able to get object but needs

to steady self by holding onto something for support

Unable or unsteady

Bending down (patient is

asked to pick up small

objects, such as pen, from the

floor)

Able to bend down and pick up the object and able to get up easily in single attempt without needing to pull self up with arms

Able to get object and get upright in single attempt but needs to pull self up with arms or hold onto something for support

Unable to bend down or unable to get upright after bending down or takes multiple attempts to upright self

movement

Needs to use arms to guide self into chair or not a smooth movement

Falls into chair, misjudges distances (lands off center)

assessment of gait and balance Abnormalities on this assessment may be helpful

in identifying patients who are likely to fall again and potentially remediable problems that might prevent future falls

There is no specific laboratory workup for an elderly patient who falls Laboratory studies should be ordered based on information gleaned from the history and physi-cal examination If the cause of the fall is obvious (such as a slip or a trip) and no suspicious symptoms or signs are detected, laboratory studies are unwarranted If the history or physical examination (especially vital signs) suggests an acute illness, appropriate laboratory studies (eg, complete blood count, electrolytes, blood urea nitrogen, chest film, electrocardiogram) should be ordered Because evidence sug-gests that vitamin D may be helpful in preventing falls (Bischoff-Ferrari et al., 2004; Kalyani et al., 2010), evaluating patients who fall recurrently for vitamin D defi-ciency is appropriate If a transient arrhythmia or heart block is suspected, ambula-tory electrocardiographic monitoring should be done Although the sensitivity and specificity of this procedure for determining the cause of falls in the elderly are unknown, and many elderly people have asymptomatic ectopy, cardiac abnormali-ties detected on continuous monitoring that are clearly related to symptoms should

be treated

Because it is difficult to diagnose aortic stenosis on physical examination, diography should be considered in all patients with suggestive histories and a systolic heart murmur or those who have a delay in the carotid upstroke If the history sug-gests anterior circulation TIA, noninvasive vascular studies should be considered to rule out treatable vascular lesions Computed tomography (CT) scans or MRI scans should be reserved for patients in whom there is a high suspicion of an intracranial lesion or seizure disorder

echocar-MANAGEMENT

Table 9-9 outlines the basic principles of managing elderly patients with instability

and a history of falls Assessment and treatment of physical injury should not be overlooked because it may be helpful in preventing recurrent falls The American Geriatrics Society has updated its clinical practice guideline on falls (American Geriatrics Society and British Geriatrics Society Panel on Prevention of Falls in Older Persons, 2011), and several meta-analyses have documented the effectiveness of a variety of interventions, including multicomponent programs, exercise, tai chi, and vitamin D (Bischoff-Ferrari et al., 2004; Chang et al., 2004; Coussement et al., 2007; Cameron et al., 2010; Kalyani et al., 2010; Leung et al., 2011, Sherrington

et al., 2011)

When specific conditions are identified by history, physical examination, and ratory studies, they should be treated in order to minimize the risk of subsequent falls, morbidity, and mortality Table 9-10 lists examples of treatments for some of the more common conditions This table is meant only as a general outline; most

labo-of these topics are discussed in detail in general textbooks labo-of medicine Because the cause of a fall in an individual person is often multifactorial, multicomponent interventions are often necessary to reduce fall risk

TABLE 9-9 Principles of Management for Elderly Patients with Complaints of

Instability and/or Falls

Assess and treat physical injury

Treat underlying conditions (Table 9-10)

Prevent future falls

Provide physical therapy and education

Gait and balance retraining

Muscle strengthening

Aids to ambulation

Properly fitted shoes

Adaptive behaviors

Alter the environment

Safe and proper-size furniture

Elimination of obstacles (loose rugs, etc.)

Proper lighting

Rails (stairs, bathroom)

Physical therapy and patient education are important aspects of the management Gait training, muscle strengthening, the use of assistive devices, and adaptive behav-iors (such as rising slowly, using rails or furniture for balance, and techniques of getting up after a fall) are all helpful in preventing subsequent morbidity from insta-bility and falls

Environmental manipulations can be critical in preventing further falls in vidual patients The environments of the elderly are often unsafe (see Table 9 - 4), and appropriate interventions can often be instituted to improve safety (see Table

indi-9 - 10) Physical restraints (eg, vests, belts, mittens, geri-chairs) have been used in institutional settings for those felt to be at high risk of falling, but research dem-onstrating no benefit or increased risk with restraints (Tinetti, Liu, and Ginter, 1992; Neufeld et al., 1999) and federal nursing home regulations and quality improvement initiatives have led to dramatically reduced use of these devices in many institutional settings; most nursing homes now aspire to be restraint free Multifaceted interventions for fall prevention in long-term care settings have been designed and tested, but the results of these trials have been mixed (Ray et al., 1997; Taylor, 2002; Ray et al., 2005; Rask et al., 2007)

For elderly patients who are at high risk for falls and hip fractures, the use of hip protectors should be considered Numerous clinical trials and meta-analyses (Kannus et al., 2000; Parker, Gillespie, and Gillespie, 2003; Honkanen et al., 2006; Kiel et al., 2007; Sawka et al., 2007; van Schoor et al., 2007), have not shown definitive evidence that hip protectors reduce morbidity in a population

of fallers However, in individual high-risk patients who will wear them, hip protectors may be a simple and relatively inexpensive preventive intervention to consider

TABLE 9-10 Examples of Treatment for Underlying Causes of Falls

Condition and cause potential treatment

Drug-related Elimination of drugs(s) that may contribute

Intravascular volume depletion Rehydrate as appropriate

With venous insufficiency

Evaluate for blood loss if indicated Support stockings

Leg elevation Adaptive behaviors Neurologic

Autonomic dysfunction or

idiopathic

Support stockings Mineralocorticoids Midodrine hydrochloride Adaptive behaviors (eg, pausing and getting up slowly)

Cervical spondylosis (with spinal

cord compression)

Physical therapy Neck brace Surgery Parkinson disease Antiparkinsonian drugs

Visual impairment Ophthalmological evaluation and specific treatment

Normal-pressure hydrocephalus Surgery (shunt) †

Hazard-free environment Benign positional vertigo Habituation exercises

Antivertiginous medication Others

Foot disorders Podiatric evaluation and treatment

Gait and balance disorders

(miscellaneous)

Properly fitted shoes Physical therapy Exercise with balance training (eg, tai chi) Muscle weakness, deconditioning Lower extremity strength training

Drug overuse (eg, sedatives,

alcohol, other psychotropic

drugs, antihypertensives)

Elimination of drug(s)

Vitamin D deficiency Vitamin D supplementation

Recurrent falls in high-risk patients Consider hip protectors

* These treatments may be indicated only if the cardiac disturbance is clearly related to symptoms.

† Risk–benefit ratio must be carefully assessed.

TIA, transient ischemic attack.

Cameron ID, Murray GR, Gillespie LD, et al Interventions for preventing falls in older

peo-ple in nursing care facilities and hospitals Cochrane Database Syst Rev 2010;1:CD005465.

Chang JT, Ganz D Quality indicators for falls and mobility problems in vulnerable elders

J Am Geriatr Soc 2007;55:S327-S334.

Evidence Summary

Do’s

• Distinguish between falls, syncope, and seizure.

• Distinguish between “dizziness” and true vertigo.

• Assess for correctable underlying causes of falls by history and targeted physical

examination.

• Pay particular attention to:

• Uncorrected vision impairment

• Postural vital signs

• A simple “get up and go” test on all patients who have fallen

• Ensure safety in recurrent fallers by urgent intervention(s) to prevent injury.

• Refer patients to rehabilitation therapists (physical and occupational) whenever

appropriate for detailed environmental and safety assessments, strengthening, and

proper prescription and use of assistive devices.

• Prescribe vitamin D in doses of at least 800 IU per day.

Chang JT, Morton SC, Rubenstein LZ, et al Interventions for the prevention of falls in older

adults: systematic review and meta-analysis of randomised clinical trials BMJ 2004;328:680.

Coussement J, De Paepe L, Schwendimann R, et al Interventions for preventing falls in

acute- and chronic-care hospitals: a systematic review and meta-analysis J Am Geriatr Soc

2007;56:29-36.

Honkanen LA, Mushlin AI, Lachs M, et al Can hip protector use cost-effectively prevent

frac-tures in community-dwelling geriatric populations? J Am Geriatr Soc 2006;54:1658-1665.

Kannus P, Parkkari J, Niemi S, et al Prevention of hip fracture in elderly people with use of a

hip protector N Engl J Med 2000;343:1506-1513.

Kalyani RR, Stein B, Valiyil R, et al Vitamin D treatment for the prevention of falls in older

adults: systematic review and meta-analysis J Am Geriatr Soc 2010;58:1299-1310.

Kiel DP, Magaziner J, Zimmerman S, et al Efficacy of a hip protector to prevent hip fracture in

nursing home residents: the HIP PRO randomized controlled trial JAMA 2007;298:413-422.

Leung DP, Chan CK, et al Tai chi as an intervention to improve balance and reduce falls in

older adults: a systematic and meta-analytical review Altern Ther Health Med 2011;17:40-48.

Neufeld RR, Libow LS, Foley WJ, et al Restraint reduction reduces serious injuries among

nursing home residents J Am Geriatr Soc 1999;47:1202-1207.

Parker MJ, Gillespie LD, Gillespie WJ Hip protectors for preventing hip fractures in the

elderly Cochrane Database Syst Rev 2003;3:CD001255.

Rask K, Parmelee P, Taylor JA, et al Implementation and evaluation of a fall management

program J Am Geriatr Soc 2007;55:342-349.

Ray WA, Taylor JA, Brown AK, et al Prevention of fall-related injuries in long-term care:

a randomized controlled trial of staff education Arch Intern Med 2005;165:2293-2298.

Ray WA, Taylor JA, Meador KG, et al A randomized trial of a consultation service to reduce

falls in nursing homes JAMA 1997;278:557-562.

Sawka AM, Boulos P, Beattie K, et al Hip protectors decrease hip fracture risk in elderly

nurs-ing home residents: a Bayesian meta-analysis J Clin Epidemiol 2007;60:336-344.

Sherrington C, Tiedemann A, Fairhall N, et al Exercise to prevent falls in older adults: an

updated meta-analysis and best practice recommendations N S W Public Health Bull

2011;22:78-83.

Taylor JA The Vanderbilt fall prevention program for long-term care: eight years of field

experience with nursing home staff J Am Med Dir Assoc 2002;3:180-185.

Tinetti ME, Liu W, Ginter SF Mechanical restraint use and fall-related injuries among

resi-dents of skilled nursing facilities Ann Intern Med 1992;116:369-374.

van Schoor NM, Smit JH, Bouter LM, et al Maximum potential preventive effect of hip

protectors J Am Geriatr Soc 2007;55:507-510.

SUGGESTED READINGS

Agostini JV, Baker DI, Bogardus STJ Prevention of Falls in Hospitalized and Institutionalized

Older People: Making Health Care Safer: A Critical Analysis of Patient Safety Practices

Rockville, MD: Agency for Healthcare Research and Quality; 2001.

Alexander N Gait disorders in older adults J Am Geriatr Soc 1996;44:434-451.

National Council on Aging Falls Free™ National Action Plan: A Progress Report Washington,

DC: National Council on Aging; 2007.

Tinetti ME Preventing falls in elderly persons N Engl J Med 2003;348:42-49.

Tinetti ME, Williams CS, Gill TM Dizziness among older adults: a possible geriatric

syn-drome Ann Intern Med 2000;132:337-344.

in older individuals that produce further pain, disability, and impaired quality of life Optimizing mobility should be the goal of all members of the health-care team work-ing with older adults Small improvements in mobility can decrease the incidence and severity of complications, improve the patient’s well-being, and decrease the cost and burden of caregiving.

This chapter outlines the common causes and complications of immobility and reviews the principles of management for some of the more common conditions associated with immobility in the older population

CAUSES

Immobility can be caused by a wide variety of factors The causes of immobility can

be divided into intrapersonal factors including psychological factors (eg, depression, fear of falling or getting hurt, motivation), physical changes (cardiovascular, neu-rological, and musculoskeletal disorders, and associated pain), and environmental causes Examples of these physical, psychological, and environmental factors include inappropriate caregiving, paralysis, lack of access to appropriate assistive devices, and environmental barriers such as lack of handrails on stairs or grab bars around a commode (Table 10-1)

The incidence of degenerative joint disease (DJD) is particularly high in older adults, although symptoms of disease may not manifest in all individuals who have radiographic changes (Lawrence et al., 2008) The pain and musculoskeletal changes associated with DJD can result in contractures and progressive immobility if not appropriately treated In addition, podiatric problems associated with degenerative changes in the feet (eg, bunions and hammertoes) can likewise cause pain and con-tractures These changes can result in painful ambulation and a subsequent decrease

in the older individual’s willingness and ability to ambulate Patients who have had

a stroke resulting in partial or complete hemiparesis/paralysis, spinal cord injury resulting in paraplegia or quadriplegia, fracture or musculoskeletal disorder limiting function, or prolonged bed rest after surgery or acute illness are considered immobi-lized Approximately 8% of older adults in the 60- to 79-year age group experience a stroke, and this rate doubles in adults age 80 and above (American Heart Association and the American Stroke Association, 2012) About half of the individuals who suf-fer a stroke have residual deficits for which they require assistance, and often these deficits result in immobility Parkinson disease (PD), another common neurological

pro-Severe congestive heart failure, coronary artery disease with frequent angina, peripheral vascular disease with frequent claudication, orthostatic hypotension, and severe chronic lung disease can restrict activity and mobility in many elderly patients because of lack of cardiovascular endurance Peripheral vascular disease, especially in older diabetics, can cause claudication, peripheral neuropathy, and altered balance, all of which limit ambulation.

TAblE 10-1 Common Causes of Immobility in Older Adults

Congestive heart failure (severe)

Coronary artery disease (frequent angina)

Peripheral vascular disease (frequent claudication)

Pulmonary disease

Chronic obstructive lung disease (severe)

Sensory factors

Impairment of vision

Decreased kinesthetic sense

Decreased peripheral sensation

Environmental causes

Forced immobility (in hospitals and nursing homes)

Inadequate aids for mobility

Acute and chronic pain

to recovery) can all influence mobility in older adults Both the social and cal environment can have a major impact on mobility Well-meaning formal and informal caregivers may provide care for older individuals rather than help the indi-vidual optimize their underlying function Inappropriate use of wheelchairs, bathing, and dressing of individuals who have the underlying capability to engage in these activities results in deconditioning and immobility Lack of mobility aids (eg, canes, walkers, and appropriately placed railings), cluttered environments, uneven surfaces, and the shape of and positioning of chairs and beds can further lead to immobility Negotiating stairs can be a special challenge.

physi-Drug side effects may also contribute to immobility Sedatives and hypnotics can result in drowsiness, dizziness, delirium, and ataxia, and can impair mobility Antipsychotic drugs (especially the typical antipsychotic agents) have prominent extrapyramidal effects and can cause muscle rigidity and diminished mobility The treatment of hypertension can result in orthostatic hypotension or brady-cardia such that the individual experiences dizziness and is unable to ambulate independently

COMPlICATIONS

Immobility can lead to complications in almost every major organ system (Table 10-2) Prolonged inactivity or bed rest has adverse physical and psychological consequences Metabolic effects include a negative nitrogen and calcium balance and impaired glu-cose tolerance Older individuals can also experience diminished plasma volume and subsequent changes in drug pharmacokinetics Immobilized older patients often become depressed, are deprived of environmental stimulation, and, in some instances, become delirious Deconditioning can occur rapidly, especially among older individuals who have little physiological reserve

Musculoskeletal complications associated with immobility include loss of muscle strength and endurance; reduced skeletal muscle fiber size, diameter, and capillarity; contractures; disuse osteoporosis; and DJD The severity of muscle atrophy is related

to the duration and magnitude of activity limitation If left unchecked, this muscle wasting can lead to long-term sequelae, including impaired functional capacity and permanent muscle damage Moreover, immobility exacerbates bone turnover by resulting in a rapid and sustained increase in bone resorption and a decrease in bone formation The impact of immobility on skin can also be devastating Varying degrees

of immobility and decreased serum albumin significantly increase the risk for pressure ulcer development Prolonged immobility results in cardiovascular deconditioning; the combination of deconditioned cardiovascular reflexes and diminished plasma volume can lead to postural hypotension Postural hypotension may not only impair reha-bilitative efforts but also predispose to falls and serious cardiovascular events such as stroke and myocardial infarction Likewise, deep venous thrombosis and pulmonary embolism are well-known complications Immobility, especially bed rest, also impairs

TAblE 10-2 Complications of Immobility

Altered body composition (eg, decreased plasma volume)

Negative nitrogen balance

Impaired glucose tolerance

Altered drug pharmacokinetics

Psychological

Sensory deprivation

Delirium

Depression

ASSESSING IMMObIlE PATIENTS

Several aspects of the history and physical examination are important in assessing immobile patients (Table 10-3) Focused histories should address the intrapersonal aspect as well as the environmental issues associated with immobility It is important

to explore the underlying cause, or perceived cause, of the immobility on the part

of the patient and caregiver Specific contributing factors to explore include cal conditions, treatments (eg, medications, associated treatments such as intrave-nous lines), pain, psychological (eg, mood and fear) state, and motivational factors Nutrition status, particularly protein levels and evaluation of 25-hydroxy vitamin D,

medi-is particularly useful to consider when evaluating the older patient because these have been associated with muscle weakness, poor physical performance, balance prob-lems, and falls An assessment of the environment is critical and should include both the patient’s physical and social environment (particularly caregiving interactions) Any and all of these factors can decrease the individual’s willingness to engage in activities Although a comprehensive assessment is critical, other members of the health-care team (eg, social work, physical therapy) can facilitate these evaluations and provide at least an aspect of that assessment

TAblE 10-3 Assessment of Immobile Older Patients

History

Nature and duration of disabilities causing immobility

Medical conditions contributing to immobility

Pain

Drugs that can affect mobility

Motivation and other psychological factors

Muscle tone and strength (see Table 10-4 )

Joint range of motion

Foot deformities and lesions

Gait (see Chap 9)

Pain with movement

A detailed musculoskeletal examination, including evaluation of muscle tone and strength, evaluation of joint range of motion, and assessment of podiatric problems that may cause pain, should be performed Standardized and repeated measures of muscle strength can be helpful in gauging a patient’s progress (Table  10-4) The neurological examination should identify focal weakness as well as cognitive, sen-sory, and perceptual problems that can impair mobility and influence rehabilitative efforts.

Most importantly, the patient’s function and mobility should be assessed and reevaluated on an ongoing basis Assessments should include bed mobility; transfers, including toilet transfers; and ambulation and stair climbing (see Table 10-3) Pain, fear, resistance to activity, and endurance should simultaneously be considered dur-ing these evaluations As previously noted, other members of the health-care team (eg, physical therapy, occupational therapy, and nursing) are skilled in completion

of these assessments and are critical to the comprehensive evaluation of the patient

TAblE 10-4 Example of How to Grade Muscle Strength in Immobile Older Patients

0 = Flaccid

1 = Trace/slight contractility but no movement

2 = Weak with movement possible when gravity is eliminated

3 = Fair movement against gravity but not against resistance

4 = Good with movement against gravity with some resistance

5 = Normal with movement against gravity and some resistance

Upper extremity:

Shoulder extension: Have the individual hold up their arm at 90 ° Place your hand on the

individual’s upper arm between elbow and shoulder and tell the individual not to let you push down their arm.

Elbow flexion: Have the individual bend their elbow fully and attempt to straighten the arm out while telling the individual not to let you pull the arm down.

Elbow extension: While the individual still has the elbow flexed, tell them to try and straighten out the arm while you resist.

Ankle dorsiflexion: Have the individual pull their foot up against your hand.

Arthritis includes a heterogeneous group of related joint disorders that have a variety

of causes such as metabolism, joint malformation, joint trauma, or joint damage The pathology of osteoarthritis (OA) is characterized by cartilage destruction with subsequent joint space loss, osteophyte formation, and subchondral sclerosis OA is the most common joint disease among older adults and is the major cause of knee, hip, and back pain OA is not, by definition, inflammatory, although hypertrophy of synovium and accumulation of joint effusions are typical It is currently believed that the pathogenesis of OA progression revolves around a complex interplay of numer-ous factors: chondrocyte regulation of the extracellular matrix, genetic influences, local mechanical factors, and inflammation

Plain film radiography has been the main diagnostic modality for assessing the severity and progression of OA Magnetic resonance imaging (MRI) and ultra-sound, however, have been noted to be more accurate and comprehensive measures

of joint changes Once diagnosed, a wide variety of modalities can be used to treat

OA as well as other painful musculoskeletal conditions Treatment can be separated into three different categories: nonpharmacological, pharmacological, and surgical Nonpharmacological management should be the focus of interventions and include weight loss, physical therapy to strengthen related musculature, use of local ice and heat, acupuncture, and use of exercise programs to maintain strength and function.Pharmacological management is targeted toward symptomatic relief and includes use of analgesics (discussed further later), nonsteroidal anti-inflammatory drugs (NSAIDs), intraocular steroid injections, and viscosupplementation In addition, topical nonsteroidals, arthroscopic irrigation, acupuncture, and nutraceuticals, which are a combination of pharmaceutical and nutritional supplements, have also been used The most common nutraceuticals include glucosamine and chondroitin (Simon

et al., 2010) Although there may be a placebo effect resulting in benefit to patients using glucosamine and chondroitin, there is no evidence of a significant improvement

in pain (Simon et al., 2010) Likewise there is no evidence that vitamin D decreases pain or facilitates repair of structural damage among individuals with OA (Felson

et al., 2007) Arthroscopic interventions have been recommended for situations in which there is known inflammation and when other noninvasive interventions have failed Options include debridement and lavage, osteotomy, cartilage transplant,

and arthroplasty There is little evidence, however, to support their efficacy (Moseley

et al., 2002) Joint replacement should be reserved for individuals with severe tomatic disease who do not respond to more conservative interventions Patients referred for joint replacement should have stable medical conditions and be encour-aged to lose weight and strengthen relevant muscles before the procedure Optimal management often involves the use of multiple treatment modalities, and the best combination of treatments will vary from patient to patient

symp-Treating arthritis optimally requires a differential diagnosis because there are tiple different types of arthritic conditions and treatments may vary For example, polymyalgia rheumatica is a common musculoskeletal problem for older women with symptoms that include weight loss; fever; muscle pain; aching of the neck, shoulder, and hip; and morning stiffness Treatment involves use of steroids, such as prednisone, although methotrexate has been used as a corticosteroid-sparing agent and may be useful for patients with frequent disease relapses and/or corticosteroid- related toxicity Conversely, infliximab has not been shown to be beneficial in terms of pain management or disease progression and thus is not currently rec-ommended (Hernández-Rodríguez et al., 2009) Because of the close association between polymyalgia rheumatica and temporal arteritis, any symptoms suggestive

mul-of involvement mul-of the temporal artery—headache, jaw claudication, recent changes

in vision—especially when the sedimentation rate is very high (>75 mm/h), should prompt consideration of temporal artery biopsy Acute treatment of temporal arteri-tis with high-dose steroids is needed to prevent blindness The history and physical examination can be helpful in differentiating OA from inflammatory arthritis (Table 10-5); however, other procedures are often essential

Gout, one of the oldest recognized forms of arthritis, is characterized by articular monosodium urate crystals Gout generally presents as acute, affecting the first metatarsal phalangeal joint, mid foot, or ankle, although the knee, elbow, or wrist can also be involved Tophi, which are subcutaneous urate deposits on extensor surfaces, can develop in later phases of the disease and are sometimes confused with rheumatoid arthritis and associated nodules Radiographs may reveal well-defined

intra-TAblE 10-5 Clinical Features of Osteoarthritis Versus Inflammatory Arthritis

Clinical feature Osteoarthritis Inflammatory arthritis

night

reaction

Very common, with synovial proliferation and thickening

In addition to making specific diagnoses of rheumatological disorders whenever possible, careful physical examination can detect treatable nonarticular conditions such as tendinitis and bursitis Bicipital tendinitis and olecranon and trochanteric bursitis are common in geriatric patients Dramatic relief from pain and disability from these conditions can be achieved by local treatments such as the injection of steroids.

Carpal tunnel syndrome is another common musculoskeletal disorder among older adults and can be confused for gout, rheumatoid arthritis, or pseudogout Carpal tunnel syndrome involves the entrapment of the median nerve where it passes through the carpal tunnel of the wrist and thereby causes nocturnal hand pain, numbness, and tingling affecting the median nerve distribution in the hand Further atrophy of the thenar eminence can develop when there has been persistent nerve compression Nerve conduction studies are needed to make the diagnosis, and surgical intervention is often needed to relieve the nerve compression For more conservative interventions, cock-up wrist splints, usually worn at night, isometric flexion exercises of metacarpal phalangeal joints, and steroid injections have been implemented

■Hip Fracture

Worldwide, the total number of hip fractures is expected to surpass 6 million by the year 2050 This varies, however, based on country and demographic factors such as gender and ethnicity Recent evidence suggests, however, that there is a decline in incidence of hip fracture among both men and women in the United States and that mortality rates associated with these events are likewise decreasing (Brauer et al., 2009) It is not clear why these declines have occurred, although there is speculation that this is associated with the increased use of bisphosphonates for osteoporosis

In the first year post hip fracture, older adults have a five- to eight-fold increased risk for all-cause mortality Excess annual mortality persists over time for both women and men, but at any given age, excess annual mortality after hip fracture is higher in men than in women (Haentjens et al., 2010) and higher in the first year

after fracture One year after hip fracture, approximately half of affected individuals

do not regain their prefracture function with regard to activities of daily living or their ability to ambulate After 3 months, there is generally no further improvement

in overall function Individuals do, however, improve their ability to ambulate across the first 12-month recovery period The assessment and management of falls, the major cause of hip fracture, are discussed in Chapter 9

The degree of immobility and disability caused by a hip fracture depends on eral factors, including coexisting medical conditions, patient motivation, the nature

sev-of the fracture, and the techniques sev-of management Preexisting comorbid conditions such as OA, heart failure, or stroke make the recovery process all the more challeng-ing Patients with these underlying conditions and those with dementia are at espe-cially high risk for poor functional recovery There is evidence, however, that those with cognitive impairment who are exposed to rehabilitation services do improve functionally in a manner similar to those without impairment (Muir and Yohannes, 2009) The location of the fracture is especially important in determining the most appropriate management plan (Fig 10-1) Subcapital fractures (which are inside the joint capsule) disrupt the blood supply to the proximal femoral head, thus resulting

in a higher probability of necrosis of the femoral head and nonunion of the ture Replacement of the femoral head is often warranted in these cases Inter- and

Femoral head Joint capsule

Major vascular supply

Generally, the current trend in hip fracture management is to stabilize any ated comorbid or acute medical conditions; surgically repair the hip, ideally with spinal anesthesia; and encourage early ambulation and aggressive rehabilitation The current standard of care is for patients to receive prophylactic anticoagulation

associ-to prevent thromboembolic complications (Falck-Ytter et al., 2012) using molecular- weight heparin; fondaparinux; dabigatran, apixaban, or rivaroxaban (for total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all grade 1B);

low-or an intermittent pneumatic compression device flow-or those who refuse treatment low-or are at increased risk for bleeding Treatment should be for at least 10 to 14 days and ideally up to 35 days

■Parkinson Disease

The first step in successful management of Parkinson Disease (PD) is to recognize its presence Pathologically, PD is associated with a progressive loss of dopamine-producing cells, especially in the substantia nigra, which sends dopamine to the corpus striatum These structures, located in the basal ganglia, are stimulated by the neurotransmitter dopamine and are responsible for planning and controlling auto-matic movements of the body, such as walking, writing, or rising from a seated posi-tion Once the level of dopamine loss has reached a threshold, individuals typically develop a triad of symptoms: bradykinesia (slow movement) or akinesia (absence of movement), resting tremor, and muscle rigidity Many elderly patients, especially

in long-term care institutions, have undiagnosed, treatable forms of parkinsonism Some of these individuals have drug-induced parkinsonism resulting from the extra-pyramidal side effects of antipsychotics (see Chapter 14) Nonmotor symptoms of

PD are also common and include depression, psychosis, anxiety, sleep disturbances, dysautonomia, dementia, and others Left untreated, parkinsonian patients eventu-ally become immobile and can develop flexion contractures, pressure sores, malnutri-tion, and aspiration pneumonia

Pharmacological treatment of PD is based on an attempt to increase the ratio of dopamine to acetylcholine in the central nervous system, specifically the nigros-triatal system There are many drugs that are used in the treatment of the disease including amantadine, anticholinergic drugs, levodopa, monoamine oxidase inhibi-tors B (MAO-B), catechol O-methyltransferase (COMT), and dopamine agonists (Table 10-6) Clinical response may take several weeks; side effects are common and often limit pharmacological treatment Wide variations in response can also occur, including morning akinesia, peak-dose dyskinesias, and freezing episodes (sometimes referred to as the “on–off phenomenon”) Excessive dopamine can also cause sleep disturbances, delirium, and psychosis Alternative modes of drug delivery have been

Differential

TAblE 10-6. Drugs Used to Treat Parkinson Disease

divided doses*

Increases dopamine availability and decreases peripheral dopamine metabolism

Nausea, vomiting, anorexia Dyskinesias

Orthostatic hypotension Behavioral disturbances Vivid dreams and hallucinations

gradually increase to maximum

of 30-40 mg in divided doses

Directly activates dopaminergic receptors

Behavioral changes Hypotension Nausea

Nausea Somnolence

Syncope Nausea Somnolence

trihexyphenidyl (Artane, Tremin)

and helps to restore balance between cholinergic and dopaminergic systems

Dry mouth Constipation Urinary retention Blurred vision Exacerbation of glaucoma Tachycardia

Confusion Behavioral changes

Balance difficulties Anorexia

Vomiting Weight loss Depressive symptoms

* Top number represents carbidopa; bottom number, levodopa.

† Eliminated by kidney; dosages should be adjusted when renal function is diminished.

‡ Several other anticholinergic agents are available.

MAO-B, monoamine oxidase type B.

considered in the treatment of PD Rotigotine transdermal patch (Neupro), which

is a nonergolinic dopamine agonist, is being used in Europe in combination with levodopa The ease of administration and maintenance of blood levels may have some benefit over other modes of administration In addition, there is evidence to support the use of cholinesterase inhibitors in patients with PD-associated dementia, with a positive impact on global assessment (Rolinski et al., 2012) Several pre-liminary studies have demonstrated that coenzyme Q10 can protect the nigrostriatal dopaminergic system among patients with PD, although further research is needed (Liu et al., 2011) Given the variability noted in response to drug therapy, there is

an increased interest in pharmacogenetics with regard to management of PD More individualized approaches to medication management are anticipated in the future (Kalinderi et al., 2011)

Surgical options are also gaining more attention and are a viable choice for a select group of individuals, including thalamotomy, pallidotomy, and deep brain stimula-tion interventions (Murdoch, 2010) Although less common, intraputamenal fetal mesencephalic allografts have also been used to treat patients with PD

Despite the many challenges to engaging older adults in exercise activities and to demonstrating outcomes, there is some evidence to support the benefits of exercise among patients with PD (Goodwin et al., 2011) Specifically, combinations of aero-bic, strengthening, balance, and stretching exercise programs can improve balance among those with PD

■Stroke

To prevent the progression of immobility moving toward disability and subsequent complications, patients with completed strokes should receive prompt and inten-sive rehabilitative therapy (Stroke is also discussed in Chapter 11.) In many elderly patients, coexisting medical conditions (eg, cardiovascular disease) limit the intensity

of rehabilitation treatment that can be tolerated in order to qualify for Medicare coverage in an acute inpatient or skilled nursing facility However, all patients should

be evaluated and managed as actively as possible during the first several weeks after

a stroke Although all stroke patients deserve an assessment and consideration for intensive rehabilitation, the cost-effectiveness of various approaches to stroke reha-bilitation is controversial, and there is no evidence to support or guide the amount of time spent in therapy sessions Whether the rehabilitative efforts occur in the acute care hospital, special rehabilitation unit, nursing home, or at home, these efforts should involve a multidisciplinary rehabilitation team, and the basic principles remain the same (see Rehabilitation later in this chapter)

Despite the lack of data from controlled trials, even some of the most severely affected stroke patients can achieve meaningful improvements in functional status by early reha-bilitative efforts Although complete functional recovery occurs in less than half of stroke patients, immobility and its attendant complications can almost always be prevented or minimized Treadmill training, for example, has repeatedly shown significant benefits

in gait and balance among stroke survivors There is interest in using brain–computer interfaces to facilitate rehabilitation after stroke Innovative interventions with motor

■Pressure Ulcers

A pressure ulcer is defined as damage caused to the skin and underlying soft tissue

by unrelieved pressure when the tissue is compressed between a bony prominence and external surface over a period of time Three main factors contribute to the development of pressure sores: pressure, shearing forces, and friction The amount

of pressure necessary to occlude blood supply to the skin (and thus predispose to irreversible tissue damage) depends on the quality of the tissue, blood flow to the area, and the amount of pressure applied For example, in a patient with peripheral artery disease, heel pressure over a relatively short period of time may cause an ulceration to occur

Shearing forces (such as those created when the head of a bed is elevated and the torso slides down and transmits pressure to the sacral area) contribute to the stretch-ing and angulation of subcutaneous tissues Friction, caused by the repeated move-ment of skin across surfaces such as bed sheets or clothing, increases the shearing force This can eventually lead to thrombosis of small blood vessels, thus undermin-ing and then destroying skin Shearing forces and friction are worsened by loose, folded skin, which is common in the elderly because of loss of subcutaneous tissue and/or dehydration Moisture from bathing, sweat, urine, and feces compounds the damage In light of the many risk factors and their variable influence, numerous scales have been developed to quantify a person’s risk of developing pressure ulcers The two most commonly used scales are the Braden scale (http://www.bradenscale.com/) and the Norton scale (http://www.orthotecmedical.com/pdfs/Norton.pdf) Pressure ulcers can be classified into four stages, depending on their clinical appear-ance and extent (Table 10-7) (Reed, 2012) The area of damage below the pressure ulcer can be much larger than the ulcer itself This is caused by the manner in which pressure and shearing forces are transmitted to subcutaneous tissues More than 90%

of pressure ulcers occur in the lower body—mainly in the sacral and coccygeal areas,

at the ischial tuberosities, and in the greater trochanter area

The cornerstone of management of the skin in immobile patients is prevention of pressure ulcers (Table 10-8) (European Pressure Ulcer Advisory Panel, 2010) Once

a stage I or II pressure ulcer develops, all preventive measures listed in Table 10-8 should be used to avoid progression of the ulcer, and intensive local skin care must

be instituted Many techniques have been advocated for local skin care; none is more successful than the others The most important factor in all these techniques is the attention that the skin gets, including relief from pressure Almost any technique that involves removing pressure from the area and regularly cleansing and drying the skin will work Alternating pressure mattresses and alternating pressure overlays

TAblE 10-7 Clinical Characteristics of Pressure Sores

Stage I

Acute inflammatory response limited to

epidermis

Presents as irregular area of erythema,

induration, edema; may be firm or

Redness with pressure persists after

30 min; in dark skin the color may be red, blue, or a purple hue

Often over a bony prominence

Skin is unbroken

Stage II

Extension of acute inflammatory

response through dermis to the junction

of subcutaneous fat

Appears as a blister, abrasion, or

shallow ulcer with more distinct edges

May look like an abrasion or a blister

Early fibrosis and pigment changes occur

Stage III

Full-thickness skin ulcer extending

through subcutaneous fat This may

extend down to but not through the

underlying fascia

The skin may have undermining

Base of ulcer infected, often with

necrotic, foul-smelling tissue

This presents like a crater and may have undermining of the adjacent tissue

Stage IV

Extension of ulcer through deep fascia,

so that bone is visible at base of ulcer

Undermining is even more common and there may be sinus tracts

Osteomyelitis and septic arthritis can be

present

or biological dressings in the treatment of pressure ulcers There is some clinical evidence to support the use of platelet-derived growth factor, although the evidence

is not sufficient to recommend that this be used routinely

The management of stage III and IV pressure ulcers is more complicated Debridement of necrotic tissue and frequent irrigation (two to three times daily), cleansing (with saline or peroxide), and dressing of the wound are essential Eschars should be undermined and removed if they are suspected of hiding large amounts of necrotic and infected tissue Chemical debriding agents can be helpful The role of

TAblE 10-8 Principles of Skin Care in Immobile Older Patients

Preventive

Identify patients at risk

Decrease pressure, friction, and skin folding

Keep skin clean and dry

Avoid excessive bed rest: optimize and encourage function

Avoid oversedation

Provide adequate nutrition and hydration (30-35 kcal/kg) overall, protein (1-1.5 g/kg), and fluid (1 mL/kcal)

Stages I and II pressure sores

Clean wounds with warm, normal saline or water

Avoid pressure and moisture

Cover open wounds with an occlusive dressing: determined based on ulcer condition (eg, presence of granulation, necrotic tissue), type and amount of drainage,

surrounding tissue, and evidence of infection

Prevent further injury and infection: use antibiotics very judiciously

Provide intensive local skin care *

Manage associated pain

Stage III pressure sores

Debride necrotic tissue: autolytic, chemical, mechanical, sharp, or surgical options

Cleanse and dress wound as above*

Culture wound: treat only in cases of confirmed bacteremia, sepsis, osteomyelitis,

and cellulitis †

Manage associated pain

Stage IV pressure sores

Take tissue biopsy for culture

Use systemic antimicrobials as noted in stage III

Cleanse and dress wound as above

Have surgical consultation to consider surgical repair

Manage associated pain

* Many techniques are effective (see text).

† Cultures and topical antimicrobials should not be used routinely (see text).

gram-negative organisms, and Staphylococcus aureus In selected instances,

consider-ation of plastic surgery for stage IV lesions is warranted

Documentation of pressure sores is critical and should include the ing components: (1) the type of ulcer, how long it has been present, and in what setting it occurred; (2) the size measured as length × width × depth in centi-meters (area of the wound bed that is deepest, without a tract); (3) the color as percentage, with red indicating amount of granulation tissue, yellow indicat-ing the amount of slough present, and black being necrotic tissue or eschar; (4) exudate as serous, serosanguinous, sanguinous, or purulent; (5) the presence or absence

follow-of odor in the wound (this should be determined after the wound is thoroughly cleaned); (6) description of the periwound tissues (eg, viable, macerated, inflamed, or hyper-keratotic); and (7) evidence of undermining (undermining is a separation of the tissues between the surface and the subcutaneous tissues)

PAIN MANAGEMENT

Pain is a major cause of immobility in older adults Immobility, in turn, can erbate painful conditions and create a vicious cycle of pain, decreased mobility, and increased pain The American Geriatrics Society has published recommendations of

exac-an expert pexac-anel for the mexac-anagement of persistent pain in older adults, exac-and readers are referred to this publication for more details (American Geriatrics Society, 2009) (Pain is also discussed in Chapter 3.) Pain assessment and management tools are available at the Sigma Theta Tau Geriatric Pain website (http://www.geriatricpain.org/Pages/home.aspx)

Pain in older persons is commonly underdiagnosed and undertreated despite the availability of many assessment tools and effective therapeutic interventions Pain

is now viewed as a “fifth vital sign,” and health professionals are encouraged to routinely inquire about pain When pain is identified, it should be carefully char-acterized In addition to the standard questions about location, timing, aggravating factors, and the like, a simple standardized pain scale can be helpful in rating the severity of pain Several such scales are available, as noted earlier, with some scales being more appropriate for those with cognitive impairment who may be less able

to discuss pain management options with older adults and to assess pain on an ing basis to determine if it has been resolved, if treatment is tolerable (ie, drug side effects), or if there is a need to alter the pain management regimen.

ongo-It is useful to differentiate between nociceptive pain and neuropathic pain The former, includes somatic pain arising from the skin, bone, joint, muscle, or con-nective tissue and is often described as throbbing; visceral pain, which arises from internal organs such as the large intestine or pancreas The latter is pain sustained by abnormal processing of sensory input by the peripheral or central nervous system Neuropathic pain is generally described as burning, tingling, shock-like, or shoot-ing Differentiating pain helps to guide management strategies and assures more efficient pain relief Pain management should consider nonpharmacological and pharmacological approaches Nonpharmacological approaches include cold therapy, breathing exercises and guided imagery, distraction, heat, massage, music, position-ing, acupuncture, relaxation, and physical activity, particularly exercises that focus

on strengthening muscles around the joint

The mainstay of pain management is drug therapy (American Geriatrics Society, 2009) Table 10-9 lists drugs that can be helpful in managing pain in older adults For persistent pain, most experts recommend initiating treatment with acetamino-phen and the use of topical treatments such as capsaicin or ketamine gel or com-bination gels, lidocaine patches, or local intra-articular corticosteroid injections Nonselective NSAIDs and cyclooxygenase-2 (COX-2) selective inhibitors should

be avoided and only considered rarely, with caution, in highly selected individuals

If pain management is not controlled with nonpharmacological interventions and acetaminophen, consideration should be given to adding an opioid when pain is impacting function and quality of life (see Table 10-9) The side effects of opioids are well known and include respiratory depression, sedation, constipation, nausea, vom-iting, and delirium Side effects should be anticipated and a plan of care is initiated

as prevention (http://www.geriatricpain.org/Content/Management/Interventions/Documents/Side%20Effects.pdf)

Nonopioid medications to treat persistent pain include a group of treatment options referred to as adjuvant therapy and include antidepressants such as the selective serotonin reuptake inhibitors (SSRIs) and tricyclics and anticonvulsants Tricyclic antidepressants were the first drugs used in this way, but due to their sig-nificant anticholinergic side effects including dry mouth, urinary retention, consti-pation, delirium, tachycardia, and blurred vision, they are contraindicated in older adults SSRIs and mixed serotonin and norepinephrine reuptake inhibitors (SNRIs)

Differential

TAblE 10-9. Types of Pain, Examples, and Treatment

type of pain and examples Source of pain typical description

effective drug classes and treatment

Nociceptive: somatic

Arthritis, acute postoperative,

fracture, bone metastases

Tissue injury, eg, bones, soft tissue, joints, muscles

Well localized, constant; aching, stabbing, gnawing, throbbing

Nonopioids, NSAIDs, opioids Physical and cognitive-behavioral therapies

Nociceptive: visceral

sites, intermittent, paroxysmal; dull, colicky, squeezing, deep, cramping; often accompanied

by nausea, vomiting, diaphoresis

Treatment of underlying cause, APAP, opioids

Physical and cognitive-behavioral therapies

Prolonged, usually constant, but can be paroxysmal; sharp, burning, pricking, tingling, squeezing; associated with other sensory disturbances, eg, paresthesias and dysesthesias; allodynia, hyperalgesia, impaired motor function, atrophy, or abnormal deep tendon reflexes

Tricyclic antidepressants, anticonvulsants, opioids, topical anesthetics

Physical and cognitive-behavioral therapies

Undetermined

Myofascial pain syndrome,

somatoform pain disorders

out of proportion to identifiable organic pathology; widespread musculoskeletal pain, stiffness, and weakness

Antidepressants, antianxiety agents Physical, cognitive-behavioral, and psychological therapies

Reprinted with permission from Reuben DB, Herr KA, Pacala JT, et al Geriatrics at Your Fingertips: 2012, 14th ed New York, NY: The American Geriatrics Society; 2012.

A few drugs should be avoided when managing pain in older adults, unless no other alternative is effective Muscle relaxant drugs such as cyclobenzaprine, cari-soprodol, and chlorzoxazone, among others, have not been shown to be effective for muscle spasm and pain and should be avoided because of the associated fall risk when they are used Likewise benzodiazepines are not likely to be effective for pain management unless used on a trial basis to treat muscle spasm Meperidine is metab-olized to normeperidine, a substance that has no analgesic properties but may impair kidney function and cause tremulousness, myoclonus, and seizures Tramadol, a drug that combines opioid-receptor binding and norepinephrine and serotonin reuptake inhibition, lowers the seizure threshold and should not be given when the individual

is taking other medications with serotonergic properties

EXERCISE

Exercise is a critical intervention for preventing immobility and its complications and is also discussed in Chapter 5 Meta-analytic reviews have provided strong evi-dence that participation in either nonspecific physical activity or specific aerobic or resistive exercise is associated with decreased progression of DJD, which is critical for maintaining mobility

The specific amount of exercise needed to achieve the desired benefit varies based on individual goals and capabilities Combining recommendations from the American College of Sports Medicine, the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH), health-care providers should recom-

mend that older adults engage in 30 minutes of physical activity daily, and this

activity should incorporate aerobic activity (walking, dancing, swimming, biking), resistance training, and flexibility Exercises can be done individually or in group settings depending on the individual’s preference, cognitive ability, and motivational level

In light of the many benefits of physical activity and the relatively low risk of serious adverse events associated with low- and moderate-intensity physical activity, current guidelines from a consensus group from the American Heart Association and the American College of Cardiology (U.S Preventive Services Task Force, 2004) no longer recommend routine stress testing for those initiating a physical activity For sedentary older people who are asymptomatic, low-intensity physical activity can be safely initiated regardless of whether an older adult has had a recent medical evalu-ation Moreover, sedentary behavior may create more of a risk than moderate-level physical activity Resources are readily available for older adults interested in getting more information about the type and amount of exercise to do For example, the

TAblE 10-10 Basic Principles of Rehabilitation in Older Patients

Optimize the treatment of underlying diseases, nutrition and hydration, and

Prevent secondary disabilities and complications of immobility

Treat primary disabilities

Set realistic, individualized goals

Emphasize functional independence

Set measurable goals related to functional performance

Enhance residual functional capacities

Provide adaptive tools to maximize function

Adapt the environment to the patient’s functional disabilities when feasible

Attend to motivation and other psychological factors of both patients and caregivers Use a team approach

National Institute of Aging provides free exercise booklets that cover a basic exercise program including resistive, stretching, balance, and aerobic activities, and Go4Life DVD, video, and printed materials are likewise available at no cost (http://www.nia.nih.gov/health/publication/go4life-dvd-everyday-exercises-national-institute-aging)

REHAbIlITATION

The goal of rehabilitation is to restore function and prevent further disability The goal of restorative care is to continue to focus on the restoration and/or mainte-nance of physical function by compensating for functional impairments so that the individual maintains his or her highest level of function and increases time spent

in physical activity Maintaining a restorative philosophy of care is therefore a core element of geriatric practice, especially for immobile elderly patients Implementing this philosophy of care necessitates a team effort Physiatrists and physical and/or occupational therapists can be very helpful in developing appropriate and optimal rehabilitative and restorative plans for older adults across the care continuum It is beyond the scope of this text to provide a detailed discussion of rehabilitation in the older adult Table 10-10 outlines some of the key principles Careful assessment of a patient’s function and underlying capability, the setting of realistic goals, prevention

of secondary disabilities and complications of immobility, evaluation of the ment, and adapting the environment to the patients’ abilities (and vice versa) are all essential elements of the rehabilitation process Moreover, ongoing motivation

environ-of the older individual as well as the caregivers is critical to successful rehabilitation and restoration of function (Resnick, 2011) The expertise of an interdisciplinary team, specifically physical and occupational therapists, can be extremely valuable in