Kevin C. Fleming

Delirium in Elderly Patients: Evaluation and Management

OBJECTIVE To review the evaluation and management of delirium in elderly patients for primary-care providers. DESIGN We summarize the clinical features, course, pathophysiologic aspects, predisposing factors, causes, and differential diagnosis of delirium and discuss approaches to affected patients and various management strategies. RESULTS Delirium, an altered mental state, occurs more frequently in elderly than in younger patients. The pathophysiologic changes associated with aging and the higher occurrence of multiple medical problems and need for medications contribute to the higher frequency of delirium in elderly patients. Evaluation should begin with a consideration of the most common causes, such as a change in or addition to prescribed medications, a withdrawal from alcohol or other sedative-hypnotic drugs, an infection, or a sudden change in neurologic, cardiac, pulmonary, or metabolic state. Finally, management of delirium is threefold: (1) identifying and treating underlying causes, (2) nonpharmacologic interventions, and (3) pharmacologic therapies to manage symptoms of delirium. CONCLUSION Elderly patients frequently experience delirium. Delirious symptoms can produce devastating consequences if they are not recognized and appropriately treated.

Drug Prescribing for Elderly Patients

Objective To describe the pharmacokinetic and pharmacodynamic changes that occur with aging and to discuss common problems noted with the use of medications often prescribed for elderly patients. Design We searched the medical literature, reviewed pertinent articles, and summarized drugrelated information applicable to geriatric patients. Results Use of medications is common in the elderly population; most elderly persons take two or more different medications each day. Aging is associated with anatomic and physiologic changes that can have an effect on how medications are handled. Such changes include alterations in various volumes of drug distribution and in drug absorption, metabolism, and clearance. Elderly patients may also have increased or decreased drug effects because of alteration in receptor response. These changes in pharmacokinetics and pharmacodynamics may result in a prolonged drug half-life, an increased potential for drug toxicity, and a greater likelihood for adverse drug reactions. Conclusion Medications for elderly patients should be prescribed only after the anatomic and physiologic changes of aging are understood and with increased surveillance for potential drug toxicity or adverse drug reactions.

Relation of colonic transit to functional Bowel disease in older people : A population-based study

OBJECTIVE: The pathophysiology underlying chronic constipation in older people is poorly understood. Our objective was to determine if functional bowel disease (particularly constipation) in this population is associated with risk factors (age, immobility, low dietary fiber intake, and medication use) or directly with slow colonic transit.

Constipation and fecal incontinence in the elderly population.

OBJECTIVE To describe the assessment and management of constipation and fecal incontinence in elderly patients. DESIGN We reviewed pertinent publications in the recent medical literature and outlined effective management strategies for constipation and fecal incontinence in the geriatric population. RESULTS Constipation can be classified into two syndromes--functional constipation and rectosigmoid outlet delay. Evaluation consists of elicitation of a detailed history, directed physical examination, and selected laboratory tests. Management involves nonpharmacologic (such as exercise and fiber) and pharmacologic measures. Fecal incontinence in elderly patients can be due to stool impaction, medications, dementia, or neuromuscular dysfunction. Management options include modification of contributing disorders, pharmacologic therapy, and behavioral techniques. CONCLUSION Constipation and fecal incontinence are common and often debilitating conditions in elderly patients. Management should be highly individualized and dependent on cause, coexisting morbidities, and cognitive status.

Pressure Ulcers: Prevention and Management

OBJECTIVE To describe important aspects of pressure ulcer prevention and management, especially in elderly patients. DESIGN We reviewed pertinent published material in the medical literature and summarized effective strategies in the overall management of the elderly population with pressure ulcers. RESULTS Pressure ulcers are commonly encountered in geriatric patients. The development of a pressure ulcer is associated with an increased risk of death. Certain well-recognized risk factors, such as immobility and incontinence, may predispose to the development of pressure ulcers; consequently, risk factor modification is an important aspect of prevention and treatment. For existing lesions, various innovative patient support surfaces and wound care products have been developed to alleviate pressure and to facilitate wound healing. The use of a particular product should be based on the clinical setting and the limited scientific evidence available. With treatment, most pressure ulcers eventually heal. CONCLUSION Pressure ulcers are often, but not always, preventable. The occurrence of such an ulcer signals the possible presence of chronic comorbid disease and should prompt a search for underlying risk factors in patients for whom ulcer treatment is considered appropriate.

Cardiovascular Disease in Elderly Patients

OBJECTIVE To provide an overview of the cardiovascular consequences of the normal aging process in humans and to review unique aspects of the diagnosis and management of heart disease in the elderly population. DESIGN We reviewed relevant published articles and summarized the diagnostic approaches and treatment recommendations for congestive heart failure, coronary artery disease, cardiac valvular disease, and arrhythmias in elderly patients. RESULTS The aging process is associated with predictable anatomic and physiologic alterations in the cardiovascular system. consequently, the manifestations of heart disease in the geriatric population differ from those found in younger patients. Additionally, outcomes of cardiac diseases and therapeutic options change with advancing age because of such factors as alterations in drug metabolism. CONCLUSION Age-related changes in the cardiovascular system result from intrinsic cardiac aspects of human senescence, primary cardiac disease, and influence of comorbid conditions on the heart. The natural history of heart disease is generally adversely affected by age. Although many treatment strategies with demonstrated efficacy in younger patients are relevant in the elderly age-group, careful attention to the influence of concomitant illness, the unique physiologic and pharmacologic changes, and the assessment of the potential effect of therapy on survival and quality of life is essential in treating elderly patients.

Management of Dementia-Related Behavioral Disturbances: A Nonpharmacologic Approach

OBJECTIVE To describe practical nonpharmacologic approaches to dementia-related behavioral problems for enhancement of the function and care of elderly patients with dementia. DESIGN We reviewed the pertinent medical literature and summarized strategies and available resources for management of geriatric patients with dementia and behavior problems. RESULTS For optimal care of older patients with dementia, key concepts of related behavior problems must be understood. Agitation and aggression, resisting help with care, wandering, incontinence, sleep disturbance, and emotional lability can become difficult management issues with such patients. In some patients, these disruptions can lead to overmedication and nursing home placement. Herein, practical nonpharmacologic measures for management of behavior problems that arise among community-dwelling and institutionalized elderly patients with dementia are discussed. Attention is directed to the medical, psychologic, environmental, and social factors that may contribute to unwanted behaviors. CONCLUSION Nonpharmacologic approaches can help ameliorate behavioral problems and assist in the overall care of elderly patients with dementia.

Medical Care of Nursing Home Residents

OBJECTIVE To present an overview of the special challenges of providing medical care for nursing home residents. DESIGN After researching the current medical literature, we summarized information on nursing home demographics, government regulations, and specific care issues for medical practice in nursing homes. RESULTS Almost 2 million Americans currently live in more than 20,000 nursing homes nationwide, and these nursing home residents are increasingly older and more frail than in the past. Most nursing home residents receive multiple prescription medications, and many are cognitively and functionally impaired. Nursing home-acquired infections are a frequent occurrence, as are falls and fall-related injuries. Recent federal laws have had a major effect on medical care in the nursing home and have made physicians more accountable for the care provided. The use of physical restraints and psychotropic drugs has been severely restricted. CONCLUSION The medical care of nursing home residents presents many challenges to primary-care physicians. Nevertheless, nursing home residents are among those patients in greatest need of competent, compassionate care. Despite numerous disincentives, provision of medical care for nursing home residents can be gratifying.

Common Rheumatologic Diseases in Elderly Patients

OBJECTIVE To review common rheumatologic disorders that affect elderly patients and emphasize the unique diagnostic and therapeutic challenges inherent in the management of rheumatologic diseases in this age-group. DESIGN We summarize our approach to treatment and management of specific rheumatologic problems in geriatric patients and discuss pertinent studies from the literature. RESULTS Among the spectrum of rheumatologic disorders frequently encountered in the elderly population are polymyalgia rheumatica, fibromyalgia, giant cell arteritis, crystalline arthropathies (gout and pseudogout), and degenerative joint disease. The initial manifestations of these rheumatologic diseases in elderly patients may differ from the typical findings in younger patients. Geriatric patients may have nonspecific complaints, a decline in physical function, or even confusion. Because of physiologic changes associated with aging and a decrease in functional reserves, elderly patients are susceptible to adverse effects of pharmacologic therapy (including nonsteroidal anti-inflammatory medications, corticosteroids, narcotic analgesics, allopurinol, and colchicine). Clinicians should be alert for such problems as hepatotoxicity and occult gastrointestinal blood loss. Comorbid conditions such as cardiovascular disease and cognitive impairment may complicate management strategies and may limit the goals of both surgical intervention and rehabilitation programs in elderly patients. CONCLUSION Rheumatologic disorders in geriatric patients pose special challenges to primary-care physicians. In the selection of optimal pharmacologic and nonpharmacologic therapeutic modalities, clinicians should focus on maintaining or improving the patients quality of life and level of independent function.

Dementia: Diagnosis and Evaluation

OBJECTIVE To describe an approach to the diagnosis of dementia based on effective assessment methods. DESIGN We reviewed the literature and summarized the available diagnostic and prognostic studies of dementia that may be useful to the primary-care physician. RESULTS Although controversy exists about certain aspects of the diagnostic workup, exclusion of potentially reversible causes of dementia is essential. Laboratory studies (for example, for detection of underlying metabolic abnormalities) and neuroimaging of the brain may be useful. The pattern of onset and the temporal course of the disease may suggest a cause and help direct the investigation. Functional losses can substantially impair the patients ability to live independently. CONCLUSION Dementia can be mistakenly considered as part of the normal aging process, and diagnosis necessitates a thorough, although not exhaustive, approach. Early identification of dementing illnesses improves the outcome for reversible disease and may also enhance the management of incurable dementias.