Geriatrics Guide

Notable Contributors: Melanie Zuo, M.D. | Nasiya Ahmed, M.D.

Key Points:

ACE Units are general medical units specifically for older adults. These units typically have the following components:

• An inter-professional team: physician, advance practice nurse, physician assistant, physical therapist, occupational therapist, speech therapist, nutritionist, social worker, pharmacist and nurses.
• Focus on functional ability: daily PT/OT starting on the day of admission.
• Discharge planning: Starts on admission day with goal of returning to the community.
• A thorough pharmaceutical review: usually in conjunction with a pharmacist to check dosages, therapeutic levels, side effects, and drug interactions.
• A prepared environment designed to facilitate physical and cognitive function: large clocks and calendars, handrails, raised toilet seats, and other environmental modification to assist the older patient.

Additional ACE Unit Facts:

• First started in 1989 at the University Hospitals of Cleveland
• Clinical and cost-effective benefits include:
• Fewer medications at discharge
• Reduced prevalence and duration of delirium
• Decreased length of stay
• Decreased re-admission rate
• Decreased nursing home placement
• Better functional capacity including improved ambulation and ability to perform instruments of daily living
• Better pain satisfaction scores
• Cost savings are realized by increased discharges to home versus long-term care, decreased length of stay, and decreased readmissions.

Supplemental Files:

Acute Care for the Elderly Handout

Complications of Hospitalization Video

Understanding Restraints and Restraint Alternatives Video

References:

Ahmed, N.N. & Pearce, S. E. (2010). Acute Care for the Elderly: A Literature Review. Population Health Management:13 (4): 219-225.

Ahmed, N., Taylor, K., McDaniel, Y., Dyer, C.B. (2012). The role of an acute care for the elderly unit in achieving hospital quality indicators while caring for frail hospitalized elders. Population Health Management: 15(4): 236-240.

Flood, K., MacLennan, P., McGrew, D. , et al.(2013). Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions. Journal of the American Medical Association, 173(11):981-987.

Fox, M,T., Sidani, S., Persaud, M., Tregunno, D., Maimets, I., Brooks, D., & O'Brien, K. (2013). Acute Care for Elders Components of Acute Geriatric Unit Care: Systematic Descriptive Review. Journal of the American Geriatrics Society: 61(6): 939–946.

Landefeld, C.S., Palmer, R.M., Kresevic, D.M., Fortnsky, R.H., & Kowal, J. (1995). A Randomized Trial of Care in a Hospital Medical Unit Especially Designed to Improve the Functional Outcomes of Acutely Ill Older Patients. New England Journal of Medicine; 332:1338-1344.

Key Points:

Patients have the right to manage their own health care decisions, to accept or refuse medical treatment, and ultimately make advance directives. The Agency for Healthcare Research and Quality, in a 2011 report, noted that less than 33% of older adults have completed advance directives and often these advance directives are not part of the electronic medical record. Learn more about advance directives and tips on how to have discussions with older adults about these documents.

Supplemental Files:

Advance Care Planning Handout

References:

Agency for Healthcare Research and Quality (2011). Elders' preferences for end-of-life care are not captured by documentation in their medical records. Research Activities. https://archive.ahrq.gov/news/newsletters/research-activities/jun11/0611RA25.html

Crosby, J.T. (2015). Advance Care Planning Discussions: A step-by-step guide with verbal options. Annals of Long-Term Care (September): 28-32.

House, T. & Lach, H.W. (2014). Advance directives in hospitalized patients: A retrospective cohort study. The Journal for Nurse Practitioners 10 (7): 465-471.

Tulsky, J. (2015). Beydon advance directives, importance of communication skills at the end of life. Journal of American Medical Association 294(3):359-366.

Key Points:

Persons with Intellectual Development Disabilities (IDD) are aging at a rapid rate. Adults with intellectual disabilities have intellectual functional limitations that occur prior to the age of 18 years. Adults with developmental disabilities have functional limitations in 3 or more areas of life activity (self-care, language, mobility, self-direction, capacity for independent living). Constipation is a major medical conditions that commonly is seen among persons with IDD and may lead to serious complications.

Supplemental Files:

Aging Persons with Intellectual Developmental Disorders (IDD): Constipation Handout

Aging Persons with Intellectual Developmental Disorders (IDD) Powerpoint Presentation

References:

Health Guidelines for Adults with an Intellectual Disability. Available at: http://www.intellectualdisability.info/how-to../health-guidelines-for-adults-with-an-intellectual-disability#constipation

Lewis SJ, Heaton KW (1997). Stool Form Scale as a Useful Guide to Intestinal Transit Time. Scand. J. Gastroenterol. 32 (9): 920–4. doi:10.3109/00365529709011203.PMID 9299672

Office of Training and Professional Development (2011, October 15). The Fatal Four: Constipation: A Major Challenge that Impacts People with Developmental Disabilities. Division of Developmental Disabilities Services 4(9), pp 1-2.

Schalock, RL, Borthw9ck-Duff, SA, Bradley VJ, et al. (2010). Intellectual Disability: Definition, Classification and Systems of Supports. (11th ed). Washington DC: American Association on Intellectual and Developmental Disabilities.

Smith, MA, & Escude, CL (2015). Intellectual and Developmental Disabilities. The Clinical Advisor, February:49-58.

Key Points:

Comprehensive Geriatric Assessment (CGA) is a mainstay in the assessment, evaluation and development of a plan of care in older adults. Aging adults have several unique features including multi-comorbidities, diminishing physiologic reserves, aging organ systems which may influence functional independence and changing social-economic status. The comprehensive geriatric assessment is an overall biopsychosocial approach to meet the holistic needs of older adults.

Supplemental Files:

Comprehensive Geriatric Assessment Handout

References:

Borenstein, JE, Aronow HU, Bolton LB, Dimalanta MI, Chan, E, Palmer K, Zhang, X, Rosen B, & Braunstein, GD. (2015). Identification and team-based interprofessional management of hospitalized vulnerable older adults. Nursing Outlook, on-line, 1-9. http://dx.doi.org/10.1016/j.outlook.2015.11.014.

Dyer, C.B., & Ostwald, S. (2011). Ageing and health: Managing co-morbidities and functional disability in older people. In E. Stuart-Hamilton (Ed.), An introduction to gerontology (pp. 87-125). Cambridge, UK: Cambridge University Press.

Flood, KL, MacLennan, PA, McGrew, D, Green, D, Dodd, C, & Brown, CJ (2013). Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Internal Medicine, 173(11), 981-987.

Interprofessional Education Collaborative (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

Ward, K.T., & Reuben, D.B. (2012). Up To Date. Comprehensive Geriatric Assessment. Retrieved from http://www.uptodate.com/contents/comprehensive-geriatric-assessment.

World Health Organization (WHO). (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health Organization. Retrieved September 17, 2013 from https://www.who.int/publications/i/item/framework-for-action-on-interprofessional-education-collaborative-practice.

Key Points:

Conditions of the Cervical Spine

Supplemental Files:

Conditions of the Cervical Spine Handout

References:

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Key Points:

Considerations in Aging with Disabilities

Supplemental Files:

Considerations in Aging with Disabilities

References:

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Key Points:

Delirium

Supplemental Files:

Delirium Handout

Delirium in Older Adults Powerpoint Presentation

References:

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Key Points:

Depression in the Elderly

Supplemental Files:

Depression in the Elderly Handout

Delirium in Older Adults Powerpoint Presentation

Delirium in Older Adults Powerpoint Presentation

References:

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Key Points:

Hypothyroidism in Older Adults

Supplemental Files:

Hypothyroidism in Older Adults Handout

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Illicit Substance Use Disorder Among Older Adults

Supplemental Files:

Illicit Substance Use Disorder Among Older Adults Handout

References:

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Intimacy and Sexuality Through the Aging Process

Supplemental Files:

Intimacy and Sexuality Through the Aging Process Powerpoint Presentation

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Key Points:

Older Adult Hearing Loss and Screening

Supplemental Files:

Older Adult Hearing Loss and Screening

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Key Points:

Osteoporosis

Supplemental Files:

Osteoporosis Handout

Age Related Bone Loss and Osteoporosis PowerPoint

References:

Blume, S.W., & Curtis, J.R. (2011). Medical costs of osteoporosis in the elderly Medicare population. Osteoporosis International, 22, 1835-1844.

Cauley, J. (2013). Public Health Impact of Osteoporosis. Journal of Gerontology: Medical Sciences. Doi: 10.1093/Gerona/glt093. E-pub ahead of print.

Carey, J.J. (2005). What is a 'failure' of bisphosphonate therapy for osteoporosis? Cleveland Clinic Journal of Medicine; 72:1033-1039.

Chodzko-Zajko, W.J., Proctor, D.N., Singh, M.A., Minson, C.T., Nigg, C.R., Salem, G.J., and Skinner, J.S. (2009). Exercise and physical activity for older adults. American College of Sports Medicine Science Exercise, 4, 1510-1530.

Holick, M. (2006). High Prevalence of Vitamin D Inadequacy and Implications for Health. Mayo Clinic Procedures; 81:353-373.

National Osteoporosis Foundation. (2011). Clinician's Guide to Prevention and Treatment of Osteoporosis. Retrieved from http://www.nof.org/professionals/clinical-guidelines

National Institutes of Health (2000). Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement 17(1):1e36. Retrieved from http://consensus.nih.gov/2000/2000Osteoporosis111

The National Osteoporosis Foundation (2012). Fast Facts. Retrieved from www.nof.org

Sweet, M.G., Sweet, J.M., Jeremiah, M.P., and Galazka, S.S. (2009). Diagnosis and Treatment of Osteoporosis. Journal of American Family Physician, 79,193-200.

Key Points:

Pain Management

Supplemental Files:

Pain Management Handout

Assessing Pain in Older Adults Powerpoint

References:

Bosilkovska, M., Walder, B., Besson, M., Daali, Y., & Desmeules, J. (2012). Analgesics in Patients with Hepatic Impairment. Drugs, 72(12), 1645-1669.

Delgado-Guay, M., & Bruera, E. (2008). Management of pain in the older person with cancer: Part 1: Pathophysiology, Pharmacokinetics, and Assessment. Oncology, 22, 56-61.

Fallon, M., Cherny, N., & Hanks, G. (2011). Opioid analgesic therapy. In G. Hanks, N. I. Cherny, N. A. Christakis, M. Fallon, S. Kaasa, & R. K. Portenoy, Oxford Textbook of Palliative Medicine (pp. 661-698). New York: Oxford University Press.

International Association for the Study of Pain. (2006). Pain: Clinical Updates; Older People's Pain.

Johnson, S. J. (2007, November 30). Opioid Safety in Patients with Renal or Hepatic Dysfunction. Retrieved from Pain Treatment Topics: www.Pain-Topics.org

Mercadante, S., & Arcuri, E. (2007). Pharmacological Management of Cancer Pain in the Elderly. Drugs Aging, 24, 761-776.

Pergolizzi, J., Boger, R., Budd, K., Dahan, A., Erdine, S., Hans, G., . . . Sacerdote, P. (2008). Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids. Pain Practice, 8(4), 287-313.

Portenoy, R. (2012, February). Pain. Retrieved from The Merck Manual Online: http://www.merckmanuals.com/professional/neurologic_disorders/pain/overview_of_pain

Rastogi, R., & Meek, B. (2013). Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control. Clinical Interventions in Aging, 8, 37-48.

Schmader, K. E., Baron, R., Haanpaa, M. L., Mayer, J., O'Connor, A. B., Rice, A., & Stacey, B. (2010). Treatment Considerations for Elderly and Frail Patients with Neuropathic Pain. Mayo Clin Proc, 85(3), S26-S32.

Yennurajalingam, S., Braiteh, F., & Bruera, E. (2005). Pain and Terminal Delirium Research in the Elderly. Clinics in Geriatric Medicine, 21, 93-119.

Zeppetella, G. (2011). Breakthrough Pain. In G. Hanks, N. I. Cherny, N. A. Christakis, M. Fallon, S. Kaasa, & R. K. Portenoy, Oxford Textbook of Palliative Medicine (p. 655). New York: Oxford University Press.

Key Points:

Prescription Drug Misuse among Older Adults

Supplemental Files:

Prescription Drug Misuse Handout

References:

Culberson, J.W., Ticker, R.L., Burnett, J., Marcus, M.T, Pickens, S.L., & Dyer, C. B. (2011). Prescription medication use among self-neglecting elderly. Journal of Addictions Nursing, 221), 63-68.

Culberson, J.W., & Ziska, M. (2008). Prescription drug misuse/abuse in the elderly. Geriatrics, 63(9), 22-31.

Grohol, J. M.A. (2010). Top 25 Psychiatric Prescriptions for 2009. Retrieved September 26, 2013, from http://psychcentral.com/lib/top-25-psychiatric-prescriptions-for-2009/0003170

Institute of Medicine. (2012a). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? In J. Eden, K. Maslow, M. Le & D. Blazer (Eds.), Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services. Washington, DC: Institute of Medicine, The National Academies Press.

Institute of Medicine. (2012b). The mental health and substance use workforce for older adults In whose hands? Washington, DC: National Academy of Sciences.

Kalapatapu, Raj K., & Sullivan, Maria A. (2010). Prescription Use Disorders in Older Adults. American Journal on Addictions, 19(6), 515-522. doi: 10.1111/j.1521-0391.2010.00080.x

Kan, C. C., Hilberink, S. R., & Breteler, M. H. (2004). Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Comprehensive psychiatry, 45(2), 88-94.

Laqueille, X., Dervaux, A., El Omari, F., Kanit, M., & Bayle, F.J. (2005). Methylphenidate effective in treating amphetamine abusers with no other psychiatric disorder. European Psychiatry, 20(5-6), 456-457.

Manchikanti, L. (2006). Prescription Drug Abuse: What is Being Done to Address This New Drug Epidemic? Testimony Before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9, 287-321A.

Maxwell, Jane Carlisle. (2011). The prescription drug epidemic in the United States: A perfect storm. Drug and alcohol review, 30(3), 264-270. doi: 10.1111/j.1465-3362.2011.00291.x

National Institute on Aging. (2013). Alcohol use in older people. Retrieved from http://www.nia.nih.gov/health/publication/alcohol-use-older-people

Simoni-Wastila, L., & Yang, H. K. (2006). Psychoactive drug abuse in older adults. American Journal of Geriatric Pharmacotherapy, 4, 380-394.

Wu, Li-Tzy, & Blazer, Dan G. (2011). Illicit and Nonmedical Drug Use Among Older Adults: A Review. Journal of Aging and Health, 23(3), 481-504.

Key Points:

Primary hyperparathyroidism (PHPT) is characterized by elevated plasma levels of parathyroid hormone (PTH) and calcium with reduced plasma phosphate. PHPT is the third most frequently diagnosed endocrine disorder. It is a silent health problem in the elderly until it becomes apparent with cognitive and physical consequences, for example, mental status change, severe constipation, and fracture.

Supplemental Files:

Primary Hyperparathyroidism Handout

References:

Adami, S., Marcocci, C., & Gatti, D.. Epidemiology of primary hyperparathyroidism in Europe. Journal of Bone and Mineral Research 2002;Suppl 2:N18-23.

Bilezikian, J., Khan, A., Potts, T. Jr, (2009). Third International Workshop Asymptomatic Primary Hyperthyroidism. Guidelines for the management of asymptomatic primary hyperparathyroidism: Summary statement. Journal of Clinical Endocrinology & Metabolism; 94:335-339.

Kim, L., Whittier Krause, M., & Kantorovich. (2012). Primary Hyperparathyroidism. Medscape Reference Drugs, Diseases & Procedures. Retrieved from http://emedicine.medscape.com/article/127351-overview#aw2aab6b4

Key Points:

• Model of care which utilizes inter-professional teams and adult daycare center to promote older adults “aging in place” within their communities.
• Utilizes Medicare and Medicaid funding
• Capitated program which is fully responsible for meeting the healthcare needs of its enrollees.
• There are four basic requirements for enrollment:
• Aged 55 years and older
• Certified by the state of residence as requiring nursing home level of care
• Live in a safe home environment
• Live in an area that is serviceable by a PACE Program
• Enrollees must:
• Agree to an inter-professional plan of care
• Change their primary care provider to a PACE physician
• Benefits include:
• Lower hospitalization rates in PACE enrollees
• Lower readmission frequency
• Lower emergency room visits
• Better health management outcomes and less hospital use
• Inter-professional Team Based Approach at the PACE Programs:
• Team of physicians, nurse practitioners, nurses, social workers, physical and occupational therapists, dieticians, recreational therapists and others
• Work together to develop and individualized comprehensive plan of care for each enrollee
• The team focuses on preventive, primary, acute, rehabilitation and long-term care needs of each enrollee
• Adult Daycare Center Approach at the PACE Programs:
• Enrollees are expected to attend the center at least once per month for a clinical examination and check-up
• Enrollees are encouraged to come more often and participate in socializing with other enrollees, recreational activities, meals and clinical care
• Transportation is provided to and from the program
• Electronic Resources:
• Medicaid Government website with a comprehensive overview, applications and instructions for starting a PACE Program:
• https://www.medicaid.gov/medicaid/ltss/pace
• Medicare Government website with a comprehensive overview on PACE Programs:
• https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/pace
• National PACE Association for older adults and/or their loved ones who are interested in PACE programs around the country and in your state of residence
• http://www.npaonline.org/pace-you

Supplemental Files:

PACE Program Handout

References:

Casiano A. A Model of Care for Individuals with Multiple Chronic Conditions. Annals of Long Term Care. 2015:41-45.

Hirth V, Baskins J, Dever-Bumba M. Program of all0inclusive care (PACE): past, present and future. Journal of American Medical Director Association. 2009; 10(3): 155-160.

Meret-Hanke L. Effects of the Program of All-Inclusive Care for the Elderly on hospital use. Gerontologist. 2011; 51(6):774-785.

Segelman M, Szydlowski J, Kinosian B, et al. Hospitalizations in the Program of All-Inclusive Care for the Elderly. Journal of the American Geriatric Society. 2014; 62(2):320-324.

Key Points:

Age-related changes in sleep physiology, multi-morbidity and sedentary lifestyles make older adults vulnerable to sleep disturbances. As older adults age, there are changes to total sleep time, time spent in deep sleep and altered sleep patterns. Sleep physiology changes with increased nocturnal awakenings and daytime napping. Research has shown older adults spend more time in bed without good sleep efficacy. Late life insomnia often occurs due to secondary causes such as medical conditions, medications, neuropsychiatric illnesses.

Supplemental Files:

Sleep Disturbance in Older Adults Handout

References:

Flaherty, J. (2008). Insomnia among Hospitalized Older Patients. Clinics in Geriatrics Medicine:24:51-67.

Kamel, N.S., & Gammack, J.K. (2006). Insomnia in the elderly: Cause, Approach and Treatment. The American Journal of Medicine 119, 463-469.

Martin, J.L., Alam, T., & Alessi, C.A. (2007). Sleep Disorders. In R. J. Ham, P.D. Sloan, G.A. Warshaw, M.A Bernard & E. Flaherty (Eds). Primary Care Geriatrics: A Case-Based Approach (5th Ed). New York: Mosby Elsevier: pp. 391-400.

Subramanian, S. & Surani, S. (2007). Sleep disorders in the elderly. Geriatrics, 62(12):10-32.

Key Points:

This current generation of older adults in the United States has the highest smoking rate of any generation. Smoking is the most preventable cause of disease and death in the United States. Smoking is a strong risk factor for premature mortality in older age and smoking cessation is beneficial at any age. Smoking can interfere with the effectiveness of many medications. Older adults who smoke have been shown to be more successful at quitting than younger smokers.

Supplemental Files:

Smoking and Older Adults Handout

References:

Boyd, N. R. (1996). Smoking cessation: A four-step plan to help older patients quit. Geriatrics, 51(11), 52-57.

Centers for Medicare & Medicaid Services. (2012). Tobacco Use Cessation Counseling Services. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/smoking.pdf

Gellert, C., Schöttker, B., & Brenner, H. (2012). Smoking and all-cause mortality in older people: Systematic review and meta-analysis. Archives of Internal Medicine, 172(11), 837-844. Retrieved from SCOPUS database.

Jones, S.J., Gardner, C.L., Cleveland, K.K. (2014). Development of a smoking cessation algorithm for primary care providers. The Journal for Nurse Practitioner,10 (2):120-127.

Nicita-Mauro, V., Maltese, G., Nicita-Mauro, C., Lasco, A., & Basile, G. (2010). Nonsmoking for successful aging: Therapeutic perspectives. Current Pharmaceutical Design, 16(7), 775-782. Retrieved from SCOPUS database.

The American Lung Association, (2010). Smoking and older adults. Retrieved from: http://www.lung.org/stop-smoking/about-smoking/facts-figures/smoking-and-older-adults.html

Zoorob, R. J., Kihlberg, C. J., & Taylor, S. E. (2011). Aging and disease prevention. Clinics in Geriatric Medicine, 27(4), 523-539. Retrieved from SCOPUS database.

Key Points:

Syncope is one of the most common causes of emergency visits by an older adult. Thirty-five percent of older adults 65 years or older experiences syncope every year and the number increases to 45% for those 85 years or older. Syncope can be defined as an abrupt and transient loss of consciousness associated with absence of postural tone, followed by complete and usually rapid spontaneous recovery. It is often benign and self-limited; however, it may also indicate multiple underlying disease process.

Supplemental Files:

Syncope in Older Adults Handout

References:

Kenny, RA, O’Shea, D, Walker, HF. (2002). Impact of a dedicated syncope and falls facility for older adults on emergency beds. Age and Ageing, 31: 272-275.

Olshansky, B, Ganze, LE, Yeon, SB, Hockberger, RS. (2014). Evaluation of syncope in adults.UpToDate. http://www.uptodate.com

Cheitlin, MD. (2003). Cardiovascular physiology-changes with aging. American Journal of Geriatric Cardiology, 12(1): 9-13.