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ANSWERS TO CASE 18:
Geriatric Health Maintenance and End-of-Life Issues
Summary: A 75-year-old man presents with
Loss of speech discrimination
Complaint of difficulty understanding speech and conversation in noisy areas
Daily medications of aspirin and hydrochlorothiazide
No noticeable weakness or gait impairment
No cerumen impaction, normal tympanic membranes, and normal TSH and
blood pressure
Most likely diagnosis: Presbycusis.
Next step: Presbycusis is a diagnosis of exclusion. Hearing aids are underused in
presbycusis but are potentially beneficial for most types of hearing loss, including sensorineural hearing loss. Consequently, referral to an audiologist for testing and consideration of amplification with a hearing aid may be an important
next step.
ANALYSIS
Objectives
1. Be familiar with geriatric health maintenance. (EPA 1, 12)
2. Be aware of the importance of geriatric screening. (EPA 3, 11, 12)
Considerations
The patient described in the case is a 75-year-old man who has difficulty with
speech discrimination. His son reports that the patient has difficulty understanding speech and conversation in noisy areas. He most likely has presbycusis, which
is an age-related sensorineural hearing loss typically associated with both selective
high-frequency loss and difficulty with speech discrimination. Physical examination of the ears in patients with presbycusis is normal. Other conditions in the
differential diagnosis include cerumen impaction, otosclerosis, and central auditory
processing disorder (CAPD). Cerumen impaction and otosclerosis can be diagnosed by otoscopy. CAPD is diagnosed when the patient can hear sounds without
difficulty but has difficulty understanding spoken words.
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APPROACH TO:
Health Maintenance in the Elderly and End-of-Life Issues
DEFINITIONS
FUNCTIONAL ASSESSMENT: An evaluation process that gauges a patient’s
ability to manage tasks of self-care, household management, and mobility.
PRESBYCUSIS: An age-related sensorineural hearing loss typically associated
with both selective high-frequency loss and difficulty with speech discrimination.
CLINICAL APPROACH TO GERIATRIC HEALTH MAINTENANCE
By the year 2030, the number of people aged 65 years and older is expected to
double from what it was in 1999, increasing from 34 million to 69 million. Geriatric health maintenance provides screening and therapy with the goal of enhancing function and preserving health in the elderly. Screening is not indicated unless
early therapy for the screened condition is more effective than late therapy or no
therapy. Preventive services for the elderly include goals of the optimization of quality
of life, satisfaction with life, and maintenance of independence and productivity. Most
recommendations for patients older than age 65 years overlap recommendations
for the general adult population. Certain categories are unique to older patients,
including sensory perception and falling. The primary care provider can perform
effective health screening using simple and relatively easily administered assessment tools (Figure 18–1).
Functional Assessment
Functional assessment gauges a patient’s ability to manage tasks of self-care, household management, and mobility. Impairment in activities of daily living (ADL)
results in an increased risk of falls, hip fracture, depression, and institutionalization. An estimated 25% of patients older than age 65 years have impairments in their
instrumental activities of daily living (IADL) or ADL (Table 18–1). Persons who are
unable to perform IADL independently are far more likely to have dementia than
their independent counterparts.
Vision Screening
Visual impairment is an independent risk factor for falls, which has a significant
impact on quality of life. The majority of conditions leading to vision loss in the
elderly are presbyopia, macular degeneration, glaucoma, cataracts, and diabetic
retinopathy. Risk factors for cataracts and age-related macular degeneration
(AMD) in older patients include vision changes, smoking, diabetes, steroid use,
and family history. For these patients, visual acuity testing with the Snellen chart
would be of benefit for identifying visual impairment and is a reasonable initial
test to do in the primary care setting. However, the US Preventive Services Task
Force (USPSTF) has found insufficient evidence regarding beneficial functional
outcomes in the elderly who routinely undergo visual acuity testing. Visual acuity
testing does not accurately identify ocular diseases that affect the elderly, including
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Geriatric health maintenance
Assessment of
impairments
IADL
Functional
ADL
Vision
Hearing
Fall & gait
Cognitive
Incontinence
Depression
Figure 18–1. Approach to geriatric health maintenance. ADL, activities of daily living; DNAR, do not
attempt resuscitation; IADL, instrumental activities of daily living.
Preventive
measures
Nutrition
Hypertension
Cancer
Osteoporosis
Immunization
End of life
Advance
directives
Durable
power of
attorney
Stroke
DNAR
orders
cataracts, glaucoma, and AMD, so routine referrals for ophthalmologic examination should be considered.
Presbyopia and AMD. The incidence of presbyopia increases with age. Patients
have difficulty focusing on near objects while their distant vision remains intact.
AMD is the leading cause of severe vision loss in the elderly. AMD is characterized
Table 18–1 • INSTRUMENTAL ACTIVITIES OF DAILY LIVING IADL AND
ACTIVITIES OF DAILY LIVING ADL
IADL ADL
Transportation
Shopping
Cooking
Using the telephone
Managing money
Taking medications
Housecleaning
Laundry
Bathing
Dressing
Eating
Transferring (eg, from bed to chair)
Continence
Toileting
Grooming
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by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in the loss of central vision. Treatment options for exudative AMD
include laser photocoagulation and intravitreal injections of vascular endothelial
growth factor.
Glaucoma. Glaucoma is characterized by a group of optic neuropathies that can
occur in all ages. Although glaucoma is most often associated with elevated intraocular pressure, it is the optic neuropathy that defines the disease. For patients who
are asymptomatic, the USPSTF found insufficient evidence to routinely screen for
glaucoma. However, for elderly patients with risk factors, including increased intraocular pressure, family history, vision changes, or African American race, screening
is beneficial.
Cataracts. A cataract is any opacification of the lens. Age-related, or senile,
cataracts account for 90% of all cataracts. Cataract disease is the most common
cause of blindness worldwide. The definitive treatment for cataracts is surgery.
Diabetic retinopathy is the leading cause of blindness in working-age adults in
the United States. It is important to consider diabetic retinopathy in geriatric
vision screening.
Hearing Screening
More than one-third of persons older than age 65 years and half of those older
than age 85 years have some hearing loss. This deficit is correlated with social
isolation and depression. The whispered voice test has sensitivities and specificities ranging from 70% to 100%. The initial office screening for general hearing
loss can be reliably performed with a questionnaire such as the HHIE-S (Hearing Handicap Inventory for the Elderly Screening Version). Limited office-based
pure-tone audiometry is more accurate in identifying patients who would benefit
from a more formal audiometry.
The majority of patients with hearing impairment will present with complaints
unrelated to their sensory deficit. In a quiet examination room with face-to-face
conversation, patients can overcome significant hearing loss and avoid detection
from a health care provider. Family members are often more concerned about the
hearing loss than the patient. Common causes of geriatric hearing impairments
are presbycusis, noise-induced hearing loss, cerumen impaction, otosclerosis, and
CAPD.
Presbycusis. Presbycusis is age-related sensorineural hearing loss usually associated with both selective high-frequency loss and difficulty with speech discrimination. Presbycusis is the most common form of hearing loss in the elderly. Because
it often goes unrecognized, exact prevalence data are lacking. Presbycusis is a diagnosis of exclusion. Complete deafness is not an expected end result of presbycusis.
Noise-Induced Hearing Loss. Noise-induced hearing loss is essentially a wearand-tear phenomenon that can occur with either industrial or recreational noise
exposure. Patients will typically present with tinnitus, difficulty with speech discrimination, and problems hearing background noise.
Cerumen Impaction. Cerumen impaction in the external auditory canal is a common, frequently overlooked problem in the elderly that may produce a transient,
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mild conductive hearing loss. It is estimated that 25% to 35% of institutionalized
or hospitalized elderly are affected by impacted cerumen.
Otosclerosis. Otosclerosis is an autosomal dominant disorder of the bones in
the inner ear. It results in progressive conductive hearing loss, with onset most
commonly in the late 20s to the early 40s. Speech discrimination is typically preserved. Geriatric patients with hearing loss may have otosclerosis complicating
their presentation.
Central Auditory Processing Disorder. CAPD is the general term for conditions
involving hearing impairment that results from central nervous system dysfunction.
The patient with CAPD will have difficulty understanding spoken language but
may be able to hear sounds well.
Evidence for Screening. Just as with visual acuity testing, the USPSTF did not
find sufficient evidence to justify the use of routine screening tests for hearing
loss in the elderly. Since the last recommendation, evidence of routine screening
has become available that shows the widespread use of hearing aids after objective hearing loss was identified via in-office tests did not benefit those who did
not self-report hearing loss. In other words, only those who had subjective hearing
loss seemed to benefit from hearing aids. This raises the question of the benefit of
routine hearing loss screening in a population in which this problem is so prevalent
secondary to the natural process of aging. However, this recommendation does not
apply to elderly patients with symptoms of hearing loss, cognitive impairment, or
psychosocial complaints indicating other diagnoses.
Fall Assessment
Falls are the leading cause of nonfatal injuries in the elderly. The associated complications are the leading cause of death from injury in those older than age 65 years.
Hip fractures are common precursors to functional impairment and nursing home
placement. Approximately 30% of the noninstitutionalized elderly fall each year. The
annual incidence of falls approaches 50% in patients older than 80 years of age. Factors contributing to falls include age-related postural changes, alterations in visual
ability, certain medications, and diseases affecting muscle strength and coordination. Due to the far-reaching consequences that falls have on both the patient and
the health care system, the American Geriatric Society recommends clinicians ask
their elderly patients about history of falls and balance problems. Additionally, the
USPSTF recommends exercise interventions to prevent falls in community-dwelling
elders at increased risk (Grade B).
Cognitive Screening
The prevalence of dementia doubles every 5 years after age 60, so that by age
85 approximately 30% to 50% of individuals have some degree of impairment.
Patients with mild or early dementia frequently remain undiagnosed because
their social graces are retained. The combination of the “clock draw” and the “three-
item recall” is a rapid and fairly reliable office-based screening for dementia. When
patients fail either of these screening tests, further testing with the Folstein MiniMental State questionnaire should be performed (see Case 32 for more detailed
discussion).
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Incontinence Screening
Incontinence in the elderly is common. Incontinence is estimated to affect 11% to
34% of elderly men and 17% to 55% of elderly women. Continence problems are
frequently treatable and have major social and emotional consequences, but they
are often not raised by patients as a concern.
Depression Screening
Depressive symptoms are more common in the elderly despite major depressive
disorder being slightly lower in prevalence when compared with younger populations. Unlike dementia, depression is usually treatable. Depression significantly
increases morbidity and mortality, yet it is often overlooked by health care providers. A simple two-question screen (Have you felt down/depressed/hopeless in the last
2 weeks? and Have you felt little interest or pleasure in doing things?) shows high sensitivity. Positive responses can be followed up with the Geriatric Depression Scale,
a 30-question instrument that is sensitive, specific, and reliable for the diagnosis of
depression in the elderly.
Nutrition Screening
Approximately 15% of older outpatients and half of the hospitalized elderly are malnourished. A combination of serial weight measurements obtained in the office and
inquiry about changing appetite are likely the most useful methods of assessing nutritional status in the elderly. Adequate calcium intake for women is advised. Supple-
mentation with a multivitamin formulated at about 100% daily value can decrease
the prevalence of suboptimal vitamin status in older adults and improve their micronutrient status to levels associated with reduced risk for several chronic diseases.
Malnutrition is common in nursing homes, and protein undernutrition has a prevalence of 17% to 56% in this setting. Protein undernutrition is associated with an
increased risk of infections, anemia, orthostatic hypotension, and decubitus ulcers.
Hypertension Screening
Treatment of hypertension is of substantial benefit in the elderly. Heart disease
and cerebrovascular disease are leading causes of death in the elderly. Treatment
of hypertension has contributed to a reduction in mortality from both stroke and
coronary artery disease. Lifestyle modifications are recommended for all hypertensive patients. Thiazides are the drugs of choice unless a comorbid condition makes
another medication preferable.
Stroke Prevention
The incidence of stroke in older adults roughly doubles with each 10 years of age.
The greatest risk factor is hypertension, followed by atrial fibrillation. Anticoagulation with warfarin or newer agents, including dabigatran, rivaroxaban, and apixiban, reduces the risk of strokes in people with atrial fibrillation. However, many
elderly patients are not anticoagulated because of the fear of injuries from falls. In
most instances, the benefits of anticoagulation are likely to outweigh the increased
risk of fall-related bleeding, unless the patient has multiple falls, high-risk falls, or
a very low risk of stroke.
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Cancer Screening
Screening men over the age of 75 for prostate cancer is not routinely recommended
(Grade D), as it has not been definitively shown to prolong life and because of the
risk of incontinence or erectile dysfunction caused by the treatments. The decision
to screen men between the age of 50 and 75 for prostate cancer should be individualized (Grade C). An older woman should undergo annual mammography until her
life expectancy falls below 5 to 10 years; however, the USPSTF states that there
is insufficient evidence for or against screening in women over the age of 75. The
decision to screen for colon cancer in men and women between 65 and 75 years of
age should be individualized, with those who had not been screened before likely
to benefit most (Grade C). Screening for cervical cancer can be stopped in women
older than 65 who have had adequate prior screening and are not at high risk for
cervical cancer.
Osteoporosis Screening
The prevalence of low bone mineral density in the elderly is high, with osteopenia found in 37% of postmenopausal women. Primary prevention of osteoporosis
begins with identification of risk factors, which include older age, female gender,
white or Asian race, low calcium intake, smoking, excessive alcohol use, and chronic
glucocorticoid use. Calcium carbonate (500 mg three times daily) and vitamin D
(400-800 IU/d) reduce the risk of osteoporotic fractures in both men and women.
Bone mineral density testing, using dual-energy x-ray absorptiometry (DEXA), in
patients with multiple risk factors may uncover asymptomatic osteoporosis. The
USPSTF recommends osteoporosis screening for women 65 years and older and
those younger than 65 years of age with increased risks.
Immunizations
Everyone over the age of 6 months should receive an annual influenza vaccination.
Persons older than age 65 should receive one dose of the pneumococcal conjugate vaccine (PCV 13) and one dose of the pneumococcal polysaccharide vaccine
(PPSV23). They should also get a single booster dose of tetanus, diphtheria, and
pertussis vaccine. Vaccination for herpes zoster is recommended, with the preferred
regimen being two doses of the recombinant zoster vaccine (Shingrix) after the age
of 50. The less effective alternative is one dose of the live zoster vaccine (Zostavax)
after the age of 60.
CLINICAL APPROACH TO ENDOFLIFE ISSUES
Advance Directives
Well-informed, competent adults have a right to refuse medical intervention, even if
refusal is likely to result in death. To further patient autonomy, providers are obli-
gated to inform patients about the risks, benefits, alternatives, and expected outcomes of end-of-life medical interventions such as cardiopulmonary resuscitation
(CPR), intubation and mechanical ventilation, vasopressor medication, hospitalization and admission to the intensive care unit, and artificial nutrition and hydration. Advance directives are oral or written statements made by patients when they
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are competent; the directives are intended to guide care should they become incompetent. Advance directives allow patients to project their autonomy. Although oral
statements about these matters are ethically binding, they are not legally binding
in all states. Written advance directives are essential to give effect to the patient’s
wishes in these matters.
Durable Power of Attorney for Health Care
A durable power of attorney for health care allows the patient to designate a surrogate decision-maker. The responsibility of the surrogate is to provide “substituted judgment” to decide as the patient would, not as the surrogate wants. In the
absence of a designated surrogate, providers turn to family members or next of kin,
under the assumption that they know the patient’s wishes.
Do Not Attempt Resuscitation Orders
Clinicians should encourage patients to express their preferences for the use of
CPR. Despite the favorable portrayal of CPR in the media, only approximately 15%
of all patients who undergo CPR in the hospital survive to hospital discharge. DNAR
(“do not attempt resuscitation”) is the preferred term over DNR (“do not resuscitate”) to emphasize the low likelihood of successful resuscitation. In addition to
mortality statistics, patients deciding CPR preferences should also be informed
about the possible consequences of surviving a CPR attempt. CPR may result in
fractured ribs, lacerated internal organs, and neurologic disability. There is also a
high likelihood of requiring other aggressive interventions if CPR is successful. For
some patients at the end of life, decisions about CPR may not be about whether
they will live but about how they will die.
CASE CORRELATION
See also Case 32 (Dementia).
COMPREHENSION QUESTIONS
18.1 A third-year medical student is researching various recommendations for
the care of the geriatric patient. Which of the following statements is most
accurate?
A. The USPSTF recommends routine screening for colorectal cancer for
adult men starting at the age of 50 and for women starting at the age of 65.
B. The USPSTF recommends continuing screening for cervical cancer with
Papanicolaou (Pap) smear in all women until the age of 75.
C. The USPSTF recommends that all men should be screened for prostate
cancer with prostate-specific antigen (PSA) testing annually starting at
the age of 50.
D. Herpes zoster vaccination is recommended for all adults over the
age of 50.
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18.2 A 70-year-old man is having difficulty hearing his family members’ conversations. He is diagnosed with presbycusis. Which of the following statements
regarding his condition is most accurate?
A. Presbycusis does not respond to hearing aid use.
B. Presbycusis is usually caused by a conductive disorder.
C. Presbycusis usually results in loss of speech discrimination.
D. Presbycusis usually results in unilateral hearing loss.
E. Presbycusis usually results in low-frequency hearing loss.
18.3 Which one of the following recommendations is accurate regarding the
current USPSTF recommendation for osteoporosis screening in the elderly?
A. All women with strong risk factors, regardless of age, should be screened
for osteoporosis.
B. Only women above the age of 65 years should be screened for osteoporosis.
C. Men and women above the age of 65 years should be screened for
osteoporosis.
D. African American race is an independent risk factor for osteoporosis and
should warrant screening regardless of other risk factors.
ANSWERS
18.1 D. The recombinant zoster vaccine is recommended for all adults starting
at the age of 50. There is no recommendation for universal PSA testing
(answer C) for prostate cancer screening; the decision to screen men between
50 and 75 should be individualized. Pap smears (answer B) can be safely discontinued in women over the age of 65 who have had adequate prior screening. Colorectal cancer screening (answer A) is recommended to start at age 50
for both men and women.
18.2 C. Up to one-third of persons older than age 65 years suffer from hearing
loss. Presbycusis typically presents with symmetric high-frequency hearing
loss (not low frequency, as in answer E). There is loss of speech discrimination, so that patients complain of difficulty understanding rapid speech, foreign accents, and conversation in noisy areas. The mechanism is sensorineural
rather than a conductive problem (answer B). Presbycusis responds to hearing aid use (answer A) and generally affects both ears (not unilateral hearing
loss, as in answer D).
18.3 A. The USPSTF recommends screening for osteoporosis in all women
above 65 years of age AND women younger than 65 years of age with risk
factors (answer B). Therefore, considering age as a risk factor, essentially all
women with risk factors must be screened for osteoporosis with bone mineral density test or DEXA scan. The current recommendation applies only
to women (answer C), as there is insufficient evidence to support screening
in men, and the race most at risk is Caucasian (not African American race,
as in answer D).
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CLINICAL PEARLS
» Protein undernutrition is associated with an increased risk of infections,
anemia, orthostatic hypotension, and decubitus ulcers.
» Smoking is associated with osteoporosis.
» If “osteoporotic” fractures, such as vertebral compression fractures, occur
in conjunction with osteopenia on x-ray, the diagnosis of osteoporosis is
almost certain.
» Hearing loss and sensory impairments, in general, can be confused with
cognitive impairment or an affective disorder.
» Presbyopia, macular degeneration, glaucoma, cataracts, and diabetic
retinopathy account for the majority of conditions leading to vision loss
in the elderly.
» A durable power of attorney for health care allows the patient to desig-
nate a surrogate decision-maker.
» DNAR (“do not attempt resuscitation”) is the preferred term over DNR
(“do not resuscitate”).
REFERENCES
Centers for Disease Control. Recommended adult immunization schedule, United States—2019.
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.
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eds. Current Medical Diagnosis & Treatment 2019. New York, NY: McGraw Hill; 2019: Chap. 4.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449§ionid=194431416. Accessed
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Kudrimoti AM, Perman SE. Hearing & vision impairment in the elderly. In: South-Paul JE,
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Rosenfeld KE, Wenger NS, Kagawa-Singer M, et al. End-of-life decision making: a qualitative study of
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State-specific advance directives forms. https://www.nhpco.org/patients-and-caregivers/advance-care-
planning/advance-directives/downloading-your-states-advance-directive/ Accessed May 9, 2020.
Tatum PE, Talebreza S, Ross JS. Geriatric assessment: an office-based approach. Am Fam Physician.
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Tulsky JA, Fischer GS, Rose MR, et al. Opening the black box: how do physicians communicate about
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United States Preventive Services Task Force. Published guidelines. https://www.uspreventiveservices
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