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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 4. Care oftheElderly Patient
T . (continued)
Assessment
Target
Urinary
incontinence
procedure
Ask: “do you
ever lose your
urine and get
wet?”
Nutrition Weigh the
patient.
Measure
height
Mental
status
Instruct: “I am
going to name
three objects
(pencil, truck,
book). I will
ask you to
repeat their
names now
and then
again in a few
minutes from
now”
Abnormal
result
Suggested
intervention
Yes Ascertain
frequency and
amount. Search
for remediable
causes including
local infections,
polyuric states,
and medications.
Consider urologic
referral
Weight
below
Do appropriate
medical evaluation
acceptable
range for
height
Inability
to recall
all three
objects
after 1min
Administer
Folstein MMSE.If
score is <24,
search for causes
of cognitive
impairment.
Ascertain onset,
duration, and
fluctuation of overt
symptoms. Review
medications. Assess
consciousness
and affect. Do
appropriate
laboratory tests
93
(continued)
94
V. M. LoFaso
T . (continued)
Assessment
Target
Depression Ask: “do
ADL-IADL Ask: “can you
procedure
you often
feel sad or
depressed?”
get out of bed
yourself?”
“Can
you dress
yourself?”
“Can you
make your
own meals?”
“Can you
do your own
shopping?”
Abnormal
result
Yes Administer
No to any
question
Suggested
intervention
geriatrics
depression
scale. If positive
(normal score,
0–10), check for
antihypertensive,
psychotropic, or
other pertinent
medications.
Consider
appropriate
pharmaceutical
or psychiatric
treatment
Corroborate
responses
with patients’
appearance;
question family
members if
accuracy uncertain.
Determine reasons
for inability
(motivation
compared with
physical limitation).
Institute
appropriate
medical, social,
and environmental
interventions
Chapter 4. Care oftheElderly Patient
T . (continued)
Assessment
Target
Home
environment
Social
support
Lachs etal. [3]
procedure
Ask: “Do
you have
trouble with
stairs inside
or outside
your home?”
Ask about
potential
hazards inside
the home with
bathtubs, rugs,
or lighting
Ask: “Who
would be able
to help you
in the case
of illness or
emergency?”
Abnormal
result
Yes Evaluate home
Suggested
intervention
safety and institute
appropriate
countermeasures
List identified
persons in the
medical record.
Become familiar
with available
resources for the
elderly in the
community
95
96
V. M. LoFaso
• Allows for monitoring response to interventions and
medications
• Predicts mortality and morbidity [4, 5].
• Prognosticates likely outcomes from surgery or
chemotherapy
• Identifies new diagnoses
• Determines proper level of assistance in the home and
proper housing options
Health Promotion andDisease Prevention
Health promotion and disease prevention strategies should
always consider the individual’s health beliefs and goals and
life expectancy. The risk and benefit of each intervention
should be carefully weighed before subjecting patients to
unnecessary or potentially harmful interventions.
Vaccines forIndividuals over 65Years ofAge [6]
Influenza: High-dose IIV (Fluzone High-Dose) vaccine is
recommended yearly given throughout the flu season [6].
Pneumococcal: Vaccination with PPSV23 is recommended
for all individuals >65years of age. Prevnar 13 is no longer
routinely recommended unless the patient is immunocompromised, has asplenia, cerebrospinal leak, or cochlear
implants or hx of invasive pneumococcal disease. The use of
Prevnar 13 vaccine in those with chronic medical conditions
(cardiac, pulmonary, diabetes, smokers, etc.) can be decided
on an individual basis.
Tdap: One booster dose if never vaccinated. Tdap should
be give regardless of when last Td or tetanus was received.
Repeat Tdap every 10years [7].
Herpes zoster: RZV (Shingrix) vaccine is recommended
for most immunocompetent individuals >50years of age. Two
doses given at 0 and 2−6 months. Caution should be used in
patents with history of Guillain-Barre, autoimmune disorders, and transplant recipients [8].
Chapter 4. Care oftheElderly Patient
97
Primary andSecondary Disease Prevention
The US Preventive Services Task Force is an excellent reference for age-appropriate screening procedures. See www.
uspreventiveservicestaskforce.org [9].
Calculating life expectancy can be a helpful guide when
considering which interventions to institute for an older
adult. See www.eprognosis.org [10].
Lifestyle andBehaviors
• Exercise: Physical activity in older adults should focus on
moderate-intensity aerobic activity, muscle-strengthening
activity, having an active lifestyle, and risk management. A
goal of 150-min moderate aerobic exercise/week including
2days per week of muscle-strengthening activity and balance exercises (e.g., Tai Chi) [11].
• Alcohol-NIH recommends no more than seven alcoholic
beverages per week and no more than three alcoholic beverages on any given day for older adults.
• Smoking cessation should be encouraged, and use of nicotine replacement therapy as needed.
• Social supports: Data show that individuals with robust
social networks who remain engaged in activities and have
purpose have better health outcomes [12].
Geriatric Syndromes
Geriatric syndromes are clinical syndromes commonly
encountered in older adults.
Urinary Incontinence (See Table4.2)
98
V. M. LoFaso
Antimuscarinic
Bladder regimen
Day and
night
(N>D)
Sudden need
to void
Pessary
Day Kegel exercises
Leakage with
coughing or
sneezing or
exercise
Antimuscarinic
Kegel exercises
Day and
night
with exercise,
coughing-
sense of
urgency
stroke; local bladder
abnormalities
Lesions in the
inhibitory nerve
pathways
T . Types of urinary incontinence
Type Gender Amount Risk factor Complaint Timing Treatment
Urge M=F Large Idiopathic; post-
Stress F>M Small Multiple or large
births; postmenopausal
estrogen loss; pelvic
floor weakening;
obesity; sphincter
failure (men)
F>M Variable See above Leakage
Mixed
(stress+urge)
Environmental
modification;
assistive devices
Day and
night
Can’t make
it to the
bathroom
Chapter 4. Care oftheElderly Patient
Beta3-adrenergic
agonist
(Mirabegron)
Alpha-blockers,
type II 5-alpha-
reductase
inhibitors, TURP
Day and
night
emptying.
Day and
Elevated post
void residual
Dribbling;
night
(D>N)
hesitancy;
weak stream
Elevated PVR
99
mobility disorder
Functional M=F Variable Functional impairment;
DHIC M=F Variable Overactive detrusor Incomplete
Overflow M>F Dribbling Outlet obstruction-
prostate enlargement;
cystocele
DHIC detrusor hyperactivity with impaired contractility
100
V. M. LoFaso
Dementia (See Chapter onCognitive Impairment)
Dementia is a progressive neurocognitive disorder manifested by decline in mental function that results in significant
functional impairment usually affecting individuals after age
65. Approximately 5.1 million people over the age of 65 have
Alzheimer’s disease and dementia [13]. Caring for the needs
of patients with dementia, which is fulfilled mostly by family
and friends, often results in financial, psychological, and
physical stress. It is crucial when evaluating a patient with
dementia to consider the caregivers and support them
throughout the course of this difficult disease. Social work
consultation is often needed and appreciated by families.
Referral to dementia support groups, elder lawyers, and geriatric care managers is a useful intervention for caregivers.
• www.alz.org/caregiversupport
• www.dementiasociety.org
Delirium
Although delirium is more often encountered in the inpatient
setting during acute illness, it can still be encountered in the
outpatient setting and must always be distinguished from
dementia and depression. For the diagnosis of delirium, the
CAM (Confusion Assessment Method) method can be
utilized.
Confusion Assessment Method (CAM): Short version [14]
1. Acute onset and uctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
Diagnosis of delirium must have #1 and #2 and either #3 or #4.
Chapter 4. Care oftheElderly Patient
101
Delirium can manifest as either quiet delirium or active
delirium. In the former patients may seem sedate, disengaged,
sleepy, and withdrawn, and this presentation can be easily
overlooked and ascribed to the patient being fatigued or
depressed. In reality quiet delirium can be a life-threatening
condition resulting from sepsis, stroke, hypercarbia, or dehydration among other considerations. Active delirium, which
can manifest with agitation, hallucinations, and even violent
behavior, is much less likely to be overlooked as the caregiver
can easily see the patient is distressed and is therefore more
likely to intervene.
Delirium Evaluation
• Assess vital signs: fever, tachycardia, orthostatic changes.
• Complete examination: especially neurological and cardiac exams, signs of urinary retention or fecal impaction.
• Check pulse oximetry and blood gas if indicated: hypoxia,
hypercarbia.
• Check glucose and electrolyte measurements: hypoglycemia, hypernatremia, hyponatremia, hypercalcemia.
• EKG: MI, arrhythmia.
• Review of medications.
• Consider drug or alcohol ingestion or withdrawal.
• Ascertain any history of psychiatric illness.
• Imaging of the brain: CVA, tumor, hemorrhage.
• Environmental factors: lack of sleep, light deprivation,
sensory impairments.
• Assess for untreated pain.
Management of delirium is targeted at treating the under-
lying condition.
Behavioral and environmental modifications can help
reorient the delirious patient. Controlling pain, ensuring
adequate sleep, treating dehydration, and improving oral
intake can all help to reorient the patient. Establishing a
sleep-wake cycle, having family and friends at bedside, and
avoiding unnecessary interruptions by staff throughout the
night can all be helpful interventions. Lastly, ensuring den-
102
V. M. LoFaso
tures, glasses, hearing aids, and home assistive devices are
present can all give patients a sense of normalcy and increase
their engagement with their environment.
The use of antipsychotic medications is reserved for situa-
tions where the patient is a danger to self or others. Olanzapine
(2.5–5 mg), risperidone (0.5 mg), haloperidol (0.5 mg), and
quetiapine (12.5–25 mg) are available as needed. EKGs
should be done periodically to monitor QTc while on antipsychotic medications.
The prognosis for delirium is generally recovery within a
few days of treating the underlying condition; however, cases
of protracted delirium do occur and can last weeks to months.
Pharmacologic interventions should be evaluated daily and
discontinued as soon as possible.
Depression
Although depression is commonly seen in older adults, it
should not be considered a normal part of aging. Untreated
depression can lead to adverse health outcomes and significant impairment in the quality of life. Late-onset depression
is more likely to be of vascular etiology rather than genetic
origin and may even be a harbinger of early dementia [15].
Medication Management
Dosing should start low and be titrated up slowly. Older
patients will usually need the full dose to achieve therapeutic
effects. The full therapeutic effect on mood may not be seen for
4–6weeks after initiating treatment. Therapy should continue
for approximately 6–12 months after the therapeutic effects
have been reached for the first-time episode of depression.
1. SSRIs are the rst-line treatment
Sertraline or citalopram. Side effects: GI upset, hypona-
tremia, upper GI bleeding, decrease bone mineral density.