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Part 2 book “Current diagnosis & treatment - Family medicine” has contents: Common geriatric problems, hospice & palliative medicine, movement disorders, tickborne disease, anxiety disorders, personality disorders, interpersonal violence, tobacco cessation,… and other contents.
Section IV Geriatrics ▲ Healthy Aging & Geriatric Assessment Lora Cox-Vance, MD CHARACTERISITICS OF AGING The population of the United States, similar to that of other industrialized nations, is aging The US population of adults aged ≥65 years increased at a faster rate (15.1%) between 2000 and 2010 than did the total US population (9.7%) Between the years 2010 and 2050, the number of Americans aged ≥65 years is projected to have doubled In the rapidly changing arena of healthcare financing and delivery, services that promote or improve functional abilities, prevent or delay disease progression, and improve the overall health status of this aging population are essential This chapter defines successful and healthy aging, highlights recommendations for health promotion and disease prevention, and describes key elements in geriatric assessment Aging is a physiologic process, and the term healthy aging does not imply an absence of limitations, but rather an adaptation to the changes associated with the aging process that is acceptable to the individual Successful or healthy aging appears to include three factors: (1) low probability of disease and disability, (2) higher cognitive and physical functioning, and (3) an active engagement with life (Table 40-1) Healthcare providers can promote healthy aging by assisting the older adult in developing competence in directing and managing future roles, thereby maintaining autonomy and a sense of self-worth While there are common physiologic changes associated with aging, the geriatric population is a highly heterogeneous group with varying degrees of chronic disease, and physical and cognitive disability within individuals A number of chronic conditions commonly affect this population (Table 40-2) The overall health status and well-being of older adults is highly complex and results from many interacting processes, including risk factor exposure (tobacco, alcohol, drugs, diet, sedentary lifestyle), biological agerelated changes, and the development and consequences of functional impairments Many of the conditions previously South Paul-Ch40_433-445.indd 433 433 40 considered “normal aging” are now known to be modifiable or even preventable with appropriate disease prevention and health promotion strategies Bryant LL, et al In their own words: a model of healthy aging Soc Sci Med 2001; 53:927 [PMID: 11522138] Fried LP: Epidemiology of aging Epidemiol Rev 2000; 22:95 [PMID: 10939013] Kyle L A concept analysis of healthy aging Nurs Forum 2005; 40:45 Peel N, et al Behavioral determinants of healthy ging Am J Prevent Med 2005; 28:298 United States Census Bureau 2010 Census Briefs; The Older Population: 201; issued 2011 ( available at http://www.census gov/prod/cen2010/briefs/c2010br-09.pdf; accessed March 22, 2013) United States Census Bureau The Next Four Decades The Older Population in the United States: 2010 to 2050; issued May 2010 (available at http://www.aoa.gov/AoARoot/Aging Statistics/ future_growth/DOCS/p25-1138.pdf; accessed March 22, 2013) PREVENTION & HEALTH PROMOTION Prevention in geriatrics attempts to delay morbidity and disability and should be a primary goal of any medical practice caring for older individuals The primary strategy for prevention lies in the alteration of lifestyle and environmental factors that contribute to the development or progression of chronic disease A prospective cohort study of older adults with an average baseline age of 68 years found that participants with fewer lifestyle risk factors experienced lower disability and mortality with the benefits persisting through the ninth decade of life Frailty is a complex geriatric syndrome associated with several chronic conditions, many of which may be preventable (Table 40-3) Important evidence of frailty includes slow walking speed, low physical activity, weight loss, and cognitive impairment Preventive services for older adults should be implemented with a goal of preventing frailty, preserving function, and optimizing quality of life 1/9/15 2:52 PM 434 ▲ Chapter 40 Table 40-1. Factors associated with healthy aging “Going and doing” is worthwhile and desirable to the individual Social activities Reading Travel Housework Fishing Creative outlets: eg, music, arts, dance, needlework Sufficient abilities to accomplish valued activities Mobility Vision Cognitive functioning Coping Independence Having appropriate resources to support the activity Valued relationships: friends and family Healthcare and health information Optimistic attitude Self-esteem, self-efficacy, self-confidence Data from Bryant LL, et al In their own words: a model of healthy aging Soc Sci Med 2001; 53:927 [PMID: 11522138] Health promotion is a broad term that encompasses the objective of improving or enhancing the individual’s current health status The purpose of health promotion, especially as applied to the elderly, is the prevention of avoidable decline, frailty, and dependence, thereby promoting healthy aging For health promotion to be effective with older adults, it must be individualized, factoring in age, functional status, comorbid conditions, life expectancy, patient goals and preferences, and culture Culture is important in understanding the older adult’s health belief system Without this Table 40-3. Conditions associated with frailty Advanced age, usually ≥85 years Functional decline Falls and associated injuries (hip fracture) Polypharmacy Chronic disease Dementia and depression Social dependence Institutionalization or hospitalization Nutritional impairment Data from Hammerman D Toward an understanding of frailty Ann Intern Med 1999; 130:945 understanding, a healthcare provider may be unable to negotiate a health promotion and prevention strategy that is acceptable to the patient and the provider Ahmed N, et al Frailty: an emerging geriatric syndrome Am J Med 2007;120:748-753 [PMID: 17765039] Chakravarty EF, et al Lifestyle risk factors predict disability and death in healthy aging adults Am J Med 2012; 125(2):190-197 [PMID: 22269623] Rothman MD, et al: Prognostic significance of potential frailty criteria J Am Geriatr Soc 2008; 56:2211-2216 [PMID: 19093920] HEALTH PROMOTION & SCREENING Many of the leading causes of death in the geriatric population (Table 40-4) are amenable to both primary and secondary preventive strategies, especially if targeted early in life The major targets of prevention should therefore be focused at the major causes of death—including coronary heart Table 40-4. Leading causes of death age ≥65 years, United States, 2010 Table 40-2. Most common conditions associated with aging Arthritis Hypertension Heart disease Hearing loss Influenza Injuries Orthopedic impairments Cataracts Chronic sinusitis Depression Cancer Diabetes mellitus Visual impairments Urinary incontinence Varicose veins South Paul-Ch40_433-445.indd 434 Cause of Death Number Cardiovascular disease 477,338 Cancer 396,670 Lung disease 160,877 Stroke 109,990 Alzheimer’s disease 82,616 Diabetes mellitus 49,191 Nephritis Unintentional injury 41,994 41,300 Data from National Center for Health Statistics Leading Causes of Death Reports (available at http://webappa.cdc.gov/sasweb/ncipc/ leadcaus10_us.html; accessed March 29, 2013) 1/9/15 2:52 PM Healthy Aging & Geriatric Assessment disease, cancer, lung disease, and stroke—with the goals of reducing premature mortality caused by acute and chronic illness, maintaining function, enhancing quality of life, and extending active life expectancy A priority in screening should be given to preventive services that are both easy to deliver and associated with beneficial outcomes Primary, secondary and tertiary preventive efforts should be considered in older adults as enthusiastically as they are employed in younger adults In developing screening and preventive strategies for individual patients, a number of factors must be considered, including major causes of death and related risk factors, the burden of comorbidity, functional ability, cognitive status, life expectancy, and patients’ goal and preferences These considerations should guide the patient-provider discussion and decision making A review of the literature reveals controversy and variation in some specific recommendations across sponsoring medical specialties This is largely related to a lack of randomized clinical trials in patients aged >75 years As the number of quality clinical trials including older adults, these recommendations will further evolve The US Preventive Services Task Force (USPSTF) has set the standard for providing recommendations for clinical practice on preventive interventions, including screening tests, counseling interventions, immunizations, and chemoprophylactic regimens These standards are established by a review of the scientific evidence for the clinical effectiveness of each preventive service A detailed discussion of health promotion and preventive screening strategies relevant to the geriatric population, including recommendations from the USPSTF, can be found in Chapter 15, on health maintenance for adults The Agency for Healthcare Research and Quality provides an electronic resource, the Electronic Preventive Services Selector, to assist providers in identifying age-appropriate preventive and screening measures (This tool is available online at http://epss.ahrq.gov/PDA/ index.jsp or for download on most smartphones.) Albert RH, Clark MM Cancer screening in the older patient Am Fam Physician 2008; 78:1369 PHYSICAL ACTIVITY & EXERCISE IN OLDER ADULTS Exercise and physical activity as a form of primary prevention have many benefits, even for sedentary older adults Even leisure activities can serve as a form of primary prevention and have many benefits in older adults The Leisure World Cohort Study of activities and mortality in the elderly suggests that as little as 15 minutes of leisure physical activity per day decreases mortality risk, with the greatest reduction noted at 45 minutes of physical activity per day A specific aim of the US Government Healthy People 2020 Initiative is to increase the proportion of older adults with reduced South Paul-Ch40_433-445.indd 435 ▲ 435 physical or cognitive function who engage in leisure-time physical activities by 10% A meta-analysis of physical activity and well-being in advanced age concluded that the maximum benefit of physical activity was in the area of self-efficacy, and that improvements in cardiovascular status, strength, and functional capacity also improved well-being Engaging in leisurely physical activities has been shown to increase levels of exercise in sedentary populations The American Heart Association (AHA) and American College of Sports Medicine (ACSM) recommend the following exercise goals for older adults: (1) moderate aerobic activity for 30 minutes on days per week, (2) 10 repetitions of 8–10 strength training exercises at least days per week, and (3) balance exercises for community-dwelling adults at risk for falls When engaging in moderate aerobic exercise, the older adult should be advised to work hard enough to sweat but below the point at which increased breathing efforts make conversation difficult The AHA recommends a pre-participation history and physical exam (Table 40-5) for sedentary older adults planning to begin an exercise program The ACSM recommends exercise stress testing for older adults before engaging in a vigorous exercise program such as strenuous cycling or running (Table 40-6) Conditions that are absolute and relative contraindications to exercise stress testing or embarking on an exercise program should be evaluated (Table 40-7) Recommendations for exercise should be provided to older patients in writing and include the frequency, intensity, type, and duration of exercise It is important for older adults to gradually increase their physical activity levels over Table 40-5. Contents of a physical activity preparticipation evaluation for older adults History, to include Patient’s lifelong pattern of activities and interests Activity level in past 2–3 months to determine a current baseline Concerns and perceived barriers regarding exercise and physical activity: Lack of time Unsafe environment Cardiovascular risks Limitations of existing chronic diseases Level of interest and motivation for exercise Social preferences regarding exercise Physical examination, with emphasis on Cardiopulmonary systems Musculoskeletal, and sensory impairments Reproduced with permission from Fletcher GF, et al AHA scientific statement: exercise standards for testing and training; a statement for healthcare professionals from the American Heart Association Circulation 2001; 104:1694 1/9/15 2:52 PM 436 ▲ Chapter 40 Table 40-6. Graded exercise test (GXT) recommendations according to coronary heart disease (CHD) risk factorsa and exercise stratification Risk Moderate Intensity Exercise Vigorous Intensity Exercise Walking at 3–4 mph Cycling for pleasure 10 mph Swimming, fast tread or crawl Singles tennis or racquetball GXT not necessary GXT not necessary GXT not necessary GXT recommended Moderate Men aged ≥54 and women ≥55 years or those with ≥2 CHD risk factors GXT not necessary GXT recommended High Individuals with symptoms of disease or known metabolic, cardiovascular, or pulmonary disease GXT recommended GXT recommended Low Men aged 10% in months An older adult with a basal metabolic index (BMI) of