Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Elderly

Elderly - Key Features

1. In the elderly patient taking multiple medications, avoid polypharmacy by:
- monitoring side effects.
- periodically reviewing medication (e.g., is the medication still indicated, is the dosage appropriate).
- monitoring for interactions.

2. In the elderly patient, actively inquire about non-prescription medication use (e.g., herbal medicines, cough drops, over-the- counter drugs, vitamins).

n.b.: combined response to 1 & 2:

Assessment of inappropriate drug prescribing: use STOPP criteria (more sensitive than Revised BEERS criteria) which is a list of 65 drugs and when to avoid them (available online at http://www.biomedcentral.com/content/supplementary/1471-2318-9-5-S1.doc)

Assessing Care of Vulnerable Elders (ACOVE-3) recommendations:
- Maintain a list of Rx
- Include OTC Rx and herbals in that list
- Annually review medication
- Assess for duplication
- Assess for interactions (including drug-drug, or drug-disease)
- Assess for adherence & affordability
- Assess for specific classes of Rx assoc with common adverse events:

 warfarin

 analgesic esp. narcoids & NSAIDs  anti-HTN esp. ace and diuretics

 insulin and hypoglycemic agents  psychotropics

- Minimize/avoid anticholinergic use

STOPP Age Ageing 2008; 37:673.
J Am Geriatr Soc 2007; 55 Suppl 2:S373.

3. In the elderly patient, screen for modifiable risk factors (e.g., visual disturbance, impaired hearing) to promote safety and prolong independence.

General refs
J Am Geriatr Soc 2007; 55 Suppl 2:S417
J Am Geriatr Soc 2007; 55 Suppl 2:S359. Lancet 1999; 353:793.
N Engl J Med 2008; 358:1887
UpToDate: Geriatric Health Maintenance

Individual refs
Colon Ca: Can J Gastroenterol Vol 18 No 2 February 2004
Dementia: Alzhemiers & Dementia 2007 Oct;3(4), 262-65.
Dementia: CMAJ 2008;178(5):548-5
Depr: Journal of Affective Disorders 117 (2009) S1–S2
Falls: CMAJ 2009;181:815-20
Glaucoma: Can J Ophthalmol 2009;4(Suppl 1),S1-S93.
Hearing: PHAC. The Canadian Guide to Clinical Preventive Health Care. 1994. HTN: Can J Cardiol. 2011 Jul-Aug;27(4):415-433.e1-2
Imm: CDC. Tetanus--Kansas, 1993. MMWR Morb Mortal Wkly Rep 1994; 43:309. Nutrition: CTFPHC Technical Report #01-7. November, 2001. London, ON: Canadian Task Force. Osteoporosis: CMAJ 2010;182(17),1864-73 Pap: PHAC. Report No.: H39-616/1998E. Ottawa: Minister of Public Works and Government Services Canada; 2002
PrCa: Can Urol Assoc J. 2011 August; 5(4): 235–240
STOPP: BMC Geriatrics 2009, 9:5 Vision: Ann Intern Med. 2009;151:37-43, W10
Visual acuity: Can J Ophthalmol 2007;42(1),39-45 http://www.atlantic.aspc.gc.ca/publicat/clinic- clinique/index-eng.php

4. In the elderly patient, assess functional status to:
- anticipate and discuss the eventual need for changes in the living environment.
- ensure that social support is adequate.

COMPLETE FUNCTIONAL ASSESSMENT
- does living environment need to change?
- is social support adequate?
- hearing aid, denture, glasses, walker?

1. ADLs
- Mnemonic: DEAT2H

- Dressing

- eating and EtOH (CAGE)

- ambulating (falls?)

- toileting (non-judgemental questions)

- transferring

- hygiene/bathing

- Communication (Vision/ hearing)
- Caregiver
- Depression (ask!)
- Dementia (memory/MMSE/MOCA/clock)
- Social/living situation
- Don’t miss Abuse/neglect

2. IADLs - Mnemonic:SHAFT-TT

- Shopping

- Housework

- Accounting

- Food prep

- Telephone

- Transportation

- Taking Rx

- weight loss? dentures fitting?

3. Assessment for Alzheimer’s:
Mnemonic: CURE FROM IRAN
Ask patient about CURE = staging – modified from Brief Cognitive Rating Scale

C – Current Events (mild)

U – USA president (moderate)

R – Relatives – children / spouse names forgotten(severe)

E – Everything forgotten (severe)

Ask caregiver about FROM IRAN (Modified from Functional Assessment Staging Tool FAST)

F – Function

R – Repetitive Questioning

O – Onset (Acute vs. Slowly progressing) M – Memory

I – IADL impaired (mild)

R – Repetitive dressing (moderate)

A – ADLs impaired (severe)

N – Non-ambulatory, non-verbal (very severe)

5. In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (e.g., pneumonia, appendicitis, depression).

- Most commonly missed diagnoses are cancer, pulmonary embolus, coronary disease, aneurysms, appendicitis (J Am Board Fam Med 2012;25:87–97)
- Depression can present atypically with somatic complaints, cognitive, functional, or sleep problems as well as complaints of fatigue or low energy. However, serious organic pathology can present as depression; rule it out using a targeted history, physical examination, and investigations

Specific statements in the Priority Topics & Key Features:
Anemia Consider anemia in elderly on NSAIDs
Dementia do not attribute behavioural problems to dementia without assessing for other possible factors (e.g., medication side effects or interactions, treatable medical conditions such as sepsis or depression).
Dehydration is difficult to assess clinically; use reliable signs ie. vitals
Diarrhea: In elderly with unexplained diarrhea, pursue investigation sooner as they are more likely to have pathology
Fever: In elderly, there is no correlation between presence/absence of fever and presence/absence of serious pathology.
Fracture: if XR neg, may need bone scan / CT.
Depression can present atypically with somatic complaints, cognitive, functional, or sleep problems as well as complaints of fatigue or low energy. However, serious organic pathology can present as depression; rule it out using a targeted history, physical examination, and investigations
Infection: Look for infection as cause of ill- defined problems in elderly
Parkinsonism: Look for Parkinsonism in elderly with deterioration in functional status
Thyroid: Elderly are at higher risk
UTI: BPH is high-risk feature in elderly male. Suspect UTI in elderly with non-specific presentation (abdo pain, fever, delirium)

*Addendum FYI: Elderly patients are mentioned in a number of other topics in the Priority Topics and Key Features document, including:
Abdo pain: Include group-specific surgical causes of acute abdo pain in the elderly
Disability: Screen elderly patients for disability risks (e.g., falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis. In elderly, recommend primary prevention strategies (e.g., exercises, braces, counselling, work modification). See #3 above.
Grief: Recognize atypical reactions ie. behaviour change
Immunization and Pneumonia: Elderly, nursing home, hospitalized patients benefit from immunization ie. pneumococcus, flu, ribavirine. See #3 above.
Osteoporosis: Older men need osteoporosis counselling too.

Study Guide

Elderly

Resources

STOPP criteria
STOPP Age Ageing 2008; 37:673.
J Am Geriatr Soc 2007; 55 Suppl 2:S373.

General refs
J Am Geriatr Soc 2007; 55 Suppl 2:S417
J Am Geriatr Soc 2007; 55 Suppl 2:S359. Lancet 1999; 353:793.
N Engl J Med 2008; 358:1887
UpToDate: Geriatric Health Maintenance

Individual refs
Colon Ca: Can J Gastroenterol Vol 18 No 2 February 2004
Dementia: Alzhemiers & Dementia 2007 Oct;3(4), 262-65.
Dementia: CMAJ 2008;178(5):548-5
Depr: Journal of Affective Disorders 117 (2009) S1–S2
Falls: CMAJ 2009;181:815-20
Glaucoma: Can J Ophthalmol 2009;4(Suppl 1),S1-S93.
Hearing: PHAC. The Canadian Guide to Clinical Preventive Health Care. 1994.
HTN: Can J Cardiol. 2011 Jul-Aug;27(4):415-433.e1-2
Imm: CDC. Tetanus--Kansas, 1993. MMWR Morb Mortal Wkly Rep 1994; 43:309.
Nutrition: CTFPHC Technical Report #01-7. November, 2001. London, ON: Canadian Task Force.
Osteoporosis: CMAJ 2010;182(17),1864-73
Pap: PHAC. Report No.: H39-616/1998E. Ottawa: Minister of Public Works and Government Services Canada; 2002
PrCa: Can Urol Assoc J. 2011 August; 5(4): 235–240
STOPP: BMC Geriatrics 2009, 9:5 Vision: Ann Intern Med. 2009;151:37-43, W10
Visual acuity: Can J Ophthalmol 2007;42(1),39-45 http://www.atlantic.aspc.gc.ca/publicat/clinic- clinique/index-eng.php

Practice SAMP

Elderly SAMP