Preface to the Fifth Edition
Preface to the Fourth Edition
Preface to the Third Edition
Preface to the Second Edition
Preface to the First Edition
Contents
About the Editors
Contributors
Part I: What´s Different About Geriatric Medicine
1 The Geriatrics Approach to Care
Introduction
The 5Ms
What Matters
Medications
Mobility
Mentation
Multimorbidity
Case Study
Conclusion/Summary
Learning Objectives
References
2 Collaborative Decision-Making
Introduction
Success and Challenges of Chronic Illness Care for Older Adults
Elderhood Today
Epidemiology of Multiple Morbidity
Understanding Multimorbidity Through Mrs. Jones
Disease-Oriented Approach to Medical Decision-Making
How Clinicians Make Treatment Decisions
How Practice Guidelines Are Translated into Health Outcomes in Usual Care
Challenges of the Single-Disease Approach in the Care of Older Adults
Costs Outweigh Benefits of Single-Disease Guidelines for Older Adults with Multimorbidity
Understanding the Relevant Outcome Goals for Older Adults with Multimorbidity
Burdensome Treatments and Care as a Meaningful Variable in Clinical Decision-Making
Need for Trade-Offs in Multimorbidity Care
Satisfactory Trade-Offs Require a Process of Collaborative Decision-Making
Patients´ Perspectives on What Is High-Quality Healthcare
Collaborative Decision-Making to Address Clinical Equipoise
Model of Collaborative Decision-Making for Older Adults with Multiple Morbidities
Key Concepts Related to Collaborative Decision-Making
When to Use the Model for Collaborative Decision-Making
An Overview of the Model for Collaborative Decision-Making
A Pathway for Identifying Health Outcome Goals
Describing What Matters Most: Health Values
An Empirically Grounded Set of Health Value Dimensions Among Older, Multimorbid Adults
Placing Broad Values Within the Context and Realities of Patients´ Health and Lives
Arriving at Collaborative Health Outcome Goals
The Pathway for Aligning Care with Health Outcome Goals
Identifying Care Options that May Facilitate Goal Attainment
Patients´ Care Preferences Modify Selection of Care Options
Revisit Care Options Based on Goal Attainment
What Most Matters: Building an Evidence-Base for Collaborative Decision-Making
The Patient Priorities Care Approach
Patient´s Health Priorities Are What Matters to Older Adults
Overview of the Patient Priorities Care Approach
Identifying Health Priorities Core Component of PPC
Aligning Care with Health Priorities Core Component of PPC
Examples and Evidence of Patient Priorities Care in Action
Patient Priorities Care Case Study
Benefit of Aligning Health Care with Health Priorities
Evidence Supporting the Effectiveness of Patient Priorities Care
Lessons Learned
Summary
References
3 Caring for Patients in an Evidence-Limited World
Introduction
Internal Validity
Clinically Meaningful Results
Applicability
Treatment Studies: Applying Results to Older Adults
Patient-Disease Interactions
Disease Differences
Patient Differences
Treatment Differences
Patient-Treatment Interactions
Diagnosis Studies - Diagnostic Tests, Differential Diagnosis, Screening, and Clinical Prediction Rules: Applying Results to Ol...
Prognosis Studies: Applying Results to Older Adults
Clinical Trials and Older Adults
Case Study
Conclusion/Summary
References
4 Geriatric Prescribing Principles and Interprofessional Healthcare Team Leadership
Introduction
Systemic Changes in Normal Aging
Pharmacokinetic and Pharmacodynamic Changes with Aging
Pharmacodynamics
Pharmacokinetics
Drug Absorption
Drug Distribution
Protein Binding
Metabolism
Excretion
Failure to Thrive
Protein Malnutrition
Role of Prealbumin in Tube Feeding Decisions
Wound Healing
Herbal Supplements
Adverse Drug Reactions in the Elderly
Polypharmacy and the Prescribing Cascade
Deprescribing
Special Considerations for Persons Over 80 Years Old
Deprescribing During Common Chronic Disease States
Case Presentation
Case Follow-Up
Rationale for the Recommendations
Advantages of Interdisciplinary Teams in Geriatric Patients´ Decision-Making
Leadership Model for Healthcare Teams
Common Goals and Benefits of an Interprofessional Care Team
Challenges of Interprofessional Care Teams
Emotional Intelligence Discussion
Summary
References
5 Social Determinants of Health
Introduction
Social Determinants of Health in Older Persons
Social Isolation and Loneliness
Screening for Loneliness and Social Isolation
Interventions for Loneliness and Social Isolation
Cultural Determinants of Loneliness
Food Insecurity in Older Adults
Screening for Food Insecurity
Health Consequences of Food Insecurity
Interventions for Food Insecurity
Access to Transportation Among Older Adults
Driving and Older Adults
Community Transportation Resources
Financial Insecurity in Older Adults
Screening for Financial Insecurity
Housing Insecurity in Older Adults
Ageism in Older Adults
Conclusion/Summary
References
6 Legal Aspects of Geriatric Medicine
Introduction
Informed Consent
Implied Consent
Decision-Making Capacity (DMC)
Sexuality and Dementia: Balancing Patient Rights with Patient Safety
Surrogate Decision Making
Power of Attorney
Guardian
Conservator
Resident´s Representative
Advance Directives
Do Not Resuscitate (DNR) Orders
Medical Orders for Life-Sustaining Treatment (MOLST) and Physician Orders for Life-Sustaining Treatment (POLST)
Off-Label Prescribing and Antipsychotics
Advance Care Planning
Home Care and Hospice
End of Life Options Acts (EOLOA)
Effective Pain Management Versus Elder Abuse
Medical Marijuana and Geriatric Medicine
Collateral Legal Actions
Legal Theories of Liability
Negligence
Malpractice
Medical Malpractice
Res Ipsa Loquitor
Stark Law
Anti-kickback Statute (AKS)
Medical Errors and Extreme Honesty
Documentation
Conclusion
Dedication
References
7 Ethical Issues in the Care of Older Adults
Introduction
Learning Objectives
General Principles of Bioethics
What Is Different About Geriatric Ethics?
New Challenges Facing Geriatric Bioethics
Justice and Access to Healthcare for Health Disparity Populations
The Growing Threat of Social Isolation and Loneliness
Case Studies
Case 1: Dignity and Moral Distress
Case 2: Withholding Medically Effective Treatment
Case 3: Withholding Medically Futile Interventions
Conclusion
References
8 Policy Issues in the Care of Older Adults
Introduction
Policy Issues in the Care of Older Adults
Case Study #1: CA AB 749
Policy Pearls
Key Policy Issues
Future Trends
Conclusions and Recommendations
References
9 Age-Friendly Health Systems in an Ecosystem Perspective
Age-Friendly Health Systems
Evidence for the 4Ms
Geriatric Care Models
Acute Care for Elders Unit
Geriatric Emergency Department Collaborative
Hospital-at-Home
Hospital Elder Life Program
Interventions to Reduce Acute Care Transfers
Nurses Improving Care for Healthsystem Elders
Palliative Care
Program of All-Inclusive Care for the Elderly
Transitional Care Model (TCM)
UCLA Alzheimer´s and Dementia Care
Age-Friendly Ecosystem
Age-Friendly Cities and Communities
Age-Friendly Public Health Systems
Age-Friendly Universities
Measuring an Age-Friendly Ecosystem
Disease Prevention and Health Promotion: Continuity of Care with a 4Ms Framework and Ecosystem Approach
Case Study
The Cambridge Health Alliance, Cambridge, Massachusetts
Conclusion
References
10 WHO Approach to Healthy Aging
The Concept of Healthy Aging
The World Report on Aging and Health and the Concept of Intrinsic Capacity
The Five Domains of Intrinsic Capacity
The Predictive Value of Intrinsic Capacity
Differences Between Intrinsic Capacity and Other Constructs
The Expected Impact on the Healthcare Systems
Toward the Integration of Care
Generic Care Pathway for Older People by ICOPE
The Care Pathway for Each Domain of Intrinsic Capacity
Cognition
Locomotion
Psychological
Sensory
Vitality
The Impact of Polypharmacy on Intrinsic Capacity
The Impact of Social Care and Caregivers on Intrinsic Capacity
Accessibility of Healthcare Services
Planning to Integrate the ICOPE Approach into Health and Long-Term Care Systems
Innovation and Technologies
Conclusions
References
11 Ethnogeriatrics
Important Concepts and Definitions
Learning Objectives
Introduction
Healthy Aging
Comprehensive Geriatric Assessment
The ADDRESSING Model
Health Literacy
Verbal and Nonverbal Communication
Selecting Interpreters
The Physical Exam
Family and Caregiver Involvement
Advance Care Planning and Decision-Making
Race, Ethnicity, and Culture: Clinical Considerations
Mental Health
Elder Abuse
Settings of Care
Outpatient Clinical Care
Inpatient Clinical Care
Long-Term Care (Alf, Nursing Home, and SNF)
Serious Illness and End-of-Life Care
Serious Illness and Religion
Hospice and Palliative Care (at Home)
Cognitive Evaluation and Cognitive Impairment
Cognitive Evaluation Tools
Ethnogeriatrics Research
Conclusion/Summary
References
12 Caregiving (in the Twenty-First Century)
Introduction
Changing Landscape of Aging
Caregiving Epidemiology
The Care-Recipient
The Caregiver
Caregiving Tasks: What Do Caregivers Do?
Tasks
Duration of Care
Impact of Caregiving on Health of Recipient and Caregiver
Care-Recipient Outcomes
Caregiver Outcomes
Caregiving and Elder Abuse
Role of the Interdisciplinary Team
Care-Recipient Assessment
Caregiver Assessment
Interdisciplinary Management
Caregiver-Specific Education and Support Resources
Advance Care Planning as Part of Caregiving
Goals of Caregiving: The Ideal
Gaps in Knowledge and Research
Joy in Caregiving
Case Study
Conclusion
Clinical Pearls
References
13 Comprehensive Geriatric Assessment
Introduction
Medical Assessment
Falls/Gait Disorder
Vision Impairment
Hearing Impairment
Malnutrition
Urinary Incontinence
Polypharmacy
Cognitive Assessment
Psychologic Assessment
Functional Assessment
Driving Assessment
Social Assessment
Patient´s Goals and Preferences
Welcome to Medicare Visit
Annual Wellness Visit
Conclusion
References
14 Determination of Decision-Making Capacity
Introduction
Definitions of Capacity
Differentiating Capacity from Competence
Components of Valid Informed Consent and Making a Decision
Capacity to Make Medical Decisions
Capacity to Consent or Refuse Psychiatric Treatment
Capacity to Choose Where to Live
Capacity to Refuse Assistance
Contractual Capacity
Testamentary Capacity
Capacity to Marry
Capacity to Consent to Sexual Relations
Financial Capacity
Capacity to Consent for Research
Special Considerations
Evolution Within Gillick´s Stratification Model (Robust, Frail, Moderately Demented, and End of Life)
Delirium and Fluctuating Capacity
End-of-Life Decision-Making
Aphasia
Undue Influence
Tools to Aid Determining Capacity
International Considerations
Case Example
References
15 Physical Exercise
Introduction
Exercise for Independent Living and Health Aging
Preserving Exercise Capacity with Age Via an Active Lifestyle
Physical Function as a Real Biomarker of Healthy Aging and Objective of Exercise Programs
Interindividual Variability in Response to Exercise (Nonresponder Phenomenon)
Exercise for Frail Individuals with Cognitive Impairment
Effects of Exercise Interventions on Muscle Strength, Incidence of Falls, and Gait Ability
Exercise for Acute Hospitalized Older Patients
Multicomponent Tailored-Exercise Program Vivifrail
Conclusion/Summary
Key Points
References
16 Nutrition in Older Adults
Introduction
Learning Objectives
Gastrointestinal Tract (GI) Changes with Aging
Nutrient Requirements and Intake
Calorie Requirements
Protein Requirements
Malnutrition in Older People
Nutrition Screening and Assessment in Older People
Nutritional Intervention
Enteral Nutrition
Parenteral Nutrition
Reimbursement and Home Nutrition Support
Conclusion
References
17 Health Maintenance and Prevention
Introduction
Person-Centered Health Maintenance
Considerations in Person-Centered Health Maintenance in Older Adults
Limited Evidence
Lag Time to Benefit
Life Expectancy and Prognosis
Functional Status
Cognitive Impairment
Sources for Health Maintenance Recommendations in Older Adults
Clinical Glidepaths Based on Gillick´s Stratification Model
ACOVE
The US Preventive Services Task Force
Health Counselling Recommendations
Nutrition
Physical Activity
Smoking Cessation
Unhealthy Alcohol Use
Cancer Screening
Colorectal Cancer
Breast Cancer
Prostate Cancer
Lung Cancer
Cervical Cancer
Immunizations
Disease Prevention Recommendations
Hypertension
Abdominal Aortic Aneurysm
Dyslipidemia
Diabetes
Osteoporosis
Geriatric Syndromes
Baseline Function Assessment
Cognitive Impairment and Dementia
Falls
Urinary Incontinence
Depression
Hearing and Vision Screening
Medication Management
Advance Care Planning
Case Studies
Conclusions
References
18 Frailty
Introduction
Frailty: What Is It?
The Operationalization of Frailty
The Frailty Phenotype
The Frailty Index
Other Models and Instruments
The Physical Frailty and Sarcopenia (PF&S Model)
Interventions Against Frailty
Comprehensive Geriatric Assessment
Other Interventions
Nutritional Intervention
Physical Activity and Physical Exercise Interventions
Pharmacological Agents
Conclusion
References
Part II: Medical Care
19 Management of Cardiovascular Disease in the Elderly
Cardiac Arrhythmias
Introduction
Supraventricular Tachycardia
Atrial Fibrillation
Atrial Flutter
AV Reentrant (Accessory Pathway), AV Node Reentrant, and Atrial Tachycardia
Bradyarrhythmia
Ventricular Arrhythmias and Sudden Cardiac Death
Stable Ischemic Heart Disease and Acute Coronary Syndromes
Introduction
Pathophysiology of Myocardial Ischemia
Established Risk Factors for Atherosclerotic CAD
Clinical Presentation and Diagnosis
Spectrum of Coronary Artery Disease
Stable Ischemic Heart Disease and Subclinical Atherosclerosis in Older Adults
Acute Coronary Syndrome in Older Adult Patients
Diagnosis
Risk Stratification
Treatment Strategies
Medications
Coronary Revascularization Strategies in Older Adults
Dyslipidemia
Introduction
Pathophysiology
Dyslipidemia Interventions in Elderly Adults
Lifestyle Modification
Statin Therapy
Statin Therapy Studies
Statin in Primary Prevention
Evaluation and Risk Assessment
Statins in Secondary Prevention
High-Risk Group
Side Effects Associated with Statin
Other Lipid-Lowering Agents (Nonstatin Drugs)
Lipid-Lowering Therapy and Frailty
Clinical Management Consideration/Implication
Heart Failure with Preserved Ejection Fraction
Introduction
Definition and Diagnosis
HFpEF and Multimorbidity
Treatment
Pharmacological Treatment for Symptomatic HFpEF (See Update)
Treatment of Underlying Comorbidities
HFpEF Management Based on Clinical Phenotypes
Intervention
Aortic Stenosis
Introduction
Pathology and Epidemiology
Clinical Manifestations
Diagnostic Modalities
Treatment Indications and Aortic Stenosis Therapy
Venous Thromboembolism in the Elderly
Introduction
Epidemiology
Etiology and Risk Factors
Immobilization
Malignancy
Comorbidities
Hormone Replacement Therapy (HRT)
Genetic Risk Factors
Age-Specific Risk Factors
Frailty
Sarcopenia
Endothelial Dysfunction
Venous Insufficiency
Nursing Home Residence
Prevention and Prophylaxis of Venous Thromboembolism
Risk Stratification
Pharmacological Thromboprophylaxis
Mechanical Thromboprophylaxis
Diagnosis
Clinical Prediction Rules
Electrocardiogram
Laboratory Tests
Radiological Workup
Treatment
Conclusion
References
20 Hypertension
Introduction
Diagnosis
Evaluation
Evidence for Treatment
Goals of Treatment
Considerations for Determining Individual Goals
Quality of Life in Hypertension Management
Treatment
Nonpharmacologic Approaches
Pharmacologic Treatment
Combination Therapy
Monitoring of Treatment and for Side Effects
When to Consider Discontinuation/Deprescribing
Resistant Hypertension
Severe Asymptomatic Hypertension and Hypertensive Emergency
Therapies to Be Used with Caution
High-Value Care
Patient and Family Education
Social Determinants of Health
Case Studies
Conclusion
References
21 Orthostatic (Postural) and Postprandial Hypotension in Older Adults
Introduction
Epidemiology
Pathophysiology
Diagnosis
Etiology
Orthostatic Hypotension
Postprandial Hypotension
Symptoms
Orthostatic hypotension
Postprandial Hypotension
Evaluation and Assessment
Orthostatic Hypotension
Postprandial Hypotension
Management
Nonpharmacologic Treatment of Orthostatic Hypotension
Pharmacologic Treatment of Orthostatic Hypotension
Nonpharmacological Treatment of Postpradial Hypotension
Pharmacologic Management of PPH
Prognosis
Conclusions
References
22 Syncope
Introduction
Pathophysiology of Syncope
Syncope Etiology
Neurally Mediated or Reflex Syncope
Vasovagal Syncope
Carotid Sinus Syncope
Orthostatic Syncope
Cardiac Syncope
Diagnosing Syncope in the Older Patient
Initial Evaluation
Carotid Sinus Massage
Additional Tests
Tilt Testing
Blood Pressure Monitoring
Autonomic Function Tests
Electrocardiographic Monitoring
Treatment
Treating Reflex Syncope
Treating Orthostatic Syncope
Special Population
Syncope and Falls in the Older Patient
Syncope and Dementia
Case Study
Male, 86 Years Old
Proximate Medical History
Conclusion/Summary
References
23 Peripheral Arterial Disease
Key Points
Epidemiology, Anatomy, and Pathophysiology
Epidemiology
Pathogenesis
Anatomy
Risk Factors
Demographics
Diabetes, Hypertension, and Dyslipidemia
Tobacco Use
Socioeconomic Status, Race, and Ethnicity
Brief Overview of Uncommon Risk Factors
Clinical Presentation and Diagnosis
History
Physical Exam
Ankle Brachial Index
Toe Brachial Index
Other Measures of Perfusion
Diagnostic Imaging
Person-Centered Focus on Approach to Diagnosis, Treatment, and Management
General Principles
Asymptomatic PAD
Intermittent Claudication
Patient History
Neurogenic Claudication
Chronic Limb Threatening Ischemia
Treatment and Medical Management
Medical Management
Risk Factor Modification
Glucose Control
Antiplatelet Therapy
Cilostazol
Exercise Therapy
Revascularization
Femoral-Popliteal Disease
Operative Techniques
Person-Centered Approach
Multidisciplinary Approach
Patient and Family Education (Health Literacy)
Emergencies
Quality and Safety Alerts
Social Determinants of Health
Ethical Dilemmas
Cost Implications
Conclusion Summary
References
24 Diabetes
Introduction
Evaluation and Care of Older Adults with Diabetes
Pathogenesis
Clinical Features and Recognition
Diagnosis
Factors that Affect A1C and Pitfalls in Its Interpretation
Clinical Burden of Diabetes
Challenges of Managing Diabetes
Optimal Care for Older Adults with Type 1 Diabetes
Assessment of Patients
Person-Centered Approach
Treatment Goals for Glycemia in Older Adults
Management
Control of Cardiovascular Risk
Hyperglycemia Management: A Case-Based Approach
Case Study
Case Discussion
Case Discussion with Concurrent CKD Stage 4
Diabetes Management in the COVID-19 Pandemic
Reducing Hypoglycemia
Hospital Care
Improving Care Transitions: Appropriate Information Sharing and Integrated Communication
Care of Patients with Diabetes at the End of Life
The Interprofessional Team and Key Supportive Services
Diabetes Technology in Older Adults
Clinical Pearls
Conclusion
References
25 Thyroid Disorders in Older Adults
Introduction
Learning Objectives
Etiology, Anatomy, and Pathophysiology of Thyroid Disorders
Epidemiology and Risk Factors
Evaluation of Thyroid Function
Medications that Interfere with Laboratory Tests of Thyroid Function in Euthyroid Individuals
Hypothyroidism
Definitions
Signs and Symptoms of Hypothyroidism in Older Adults
Secondary Hypothyroidism
Diagnosis of Hypothyroidism
Management of Hypothyroidism
Subclinical Hypothyroidism
Definition
Diagnosis
Signs and Symptoms
Clinical Impact
Management of Subclinical Hypothyroidism
Hyperthyroidism
Definitions
Signs and Symptoms of Hyperthyroidism in Older Adults
Subclinical Hyperthyroidism
Diagnosis of Hyperthyroidism
Management of Hyperthyroidism
Thyroid Nodules and Thyroid Cancer
Diagnostic Approach to Thyroid Nodules
Ultrasound Features of Malignancy
Thyroid Biopsy
Evaluation and Management of Thyroid Nodules
Thyroid Cancer Treatment
The Safety of Thyroid Surgery in Older Adults
Follow-Up of Patients with a History of Thyroid Cancer
Clinical Pearls
Case Study
Management
Conclusion/Summary
References
Epidemiology
Drugs and Thyroid Hormone Action
Thyroid Nodules and Thyroid Cancer
Thyroid Surgery
26 Infectious Diseases in Older Persons
Introduction
Aging and Host Defenses
Clinical Features of Infection in Older Persons
Pneumonia
Introduction
Pathogenesis
Etiology
Diagnosis
Management
Prevention
Urinary Tract Infection
Introduction
Pathogenesis/Risk Factors for UTI
Etiology
Diagnosis
Management
Prevention
Summary
Clostridioides difficile
Introduction
Diagnosis
Management
Coronavirus Disease 2019 (COVID-19)
References
27 Hematologic Disorders
Introduction
Anemias
Definition of Anemia in an Older Adult
Epidemiology of Anemia in an Older Adult
Diagnosis of Anemia in an Older Adult
Consequences of Anemia in an Older Adult
Anemia of Inflammation
Laboratory Findings Associated with Anemia of Inflammation
Approach to Treatment of Anemia of Inflammation
Use of Erythropoiesis-Stimulating Agents to Treat Anemia of Inflammation
Use of Iron in Patients with Anemia of Inflammation
Anemia due to Vitamin B12 Deficiency
Clinical Presentation
Laboratory Testing
Management of Vitamin B12 Deficiency Anemia and Pernicious Anemia
Assessing and Monitoring Response to Treatment
Iron-Deficiency Anemia and the Older Adult
Diagnosis of Iron-Deficiency Anemia
Management of Iron-Deficiency Anemia
Hematological Malignancies
Myelodysplastic Syndromes
Clinical Manifestations and Diagnosis of MDS
Classification
Management of MDS
Myeloproliferative Neoplasms
Chronic Myelogenous Leukemia
Clinical and Diagnostic Features of CML
Management of CML for Older Adults
Polycythemia Vera
Management of PV
Essential Thrombocythemia
Management of ET
Primary Myelofibrosis
Management of PMF
Multiple Myeloma
The Role of Geriatric Assessments and Frailty Scales in Multiple Myeloma
Developing a Personalized Approach for the Management of Adults with Multiple Myeloma
Conclusion/Summary
References
28 Gastrointestinal Disorders in Older Patients
Introduction
Disorders of Swallowing and the Esophagus
Overview of Common Conditions Associated with Dysphagia
Diagnostic Testing to Consider in Geriatric Patients with Dysphagia
Treatment Options
Gastroesophageal Reflux Disease
Overview
Diagnostic Testing to Consider in Geriatric Patients with GERD
Treatment
Disorders of the Stomach
Overview of Common Gastric Conditions
Peptic Ulcer Disease
Overview
Diagnosis
Treatment
Gastrointestinal Bleeding
Clinical Approach to GI Bleeding
Presentation
Evaluation
Endoscopy
Imaging
Medical Therapy
Surgical Intervention
Common Causes of Gastrointestinal Bleeding in the Older Population
Peptic Ulcer Disease
Diverticular Bleeding
Ischemic Bowel Disease
Vascular Ectasias
Radiation Proctitis
Small Intestine Diseases
Overview
Celiac Disease
Mesenteric Ischemia
Small Bowel Bleeding
Small Intestinal Bacterial Overgrowth (SIBO)
Disorders of the Colon
Constipation
Irritable Bowel Syndrome
Diverticulosis and Diverticulitis
Inflammatory Bowel Disease
Pseudomembranous colitis
Liver Disorders
Drug-Induced Liver Injury
Autoimmune Liver Disease
Cirrhosis in the Older Population
Gallstone Disorders
Pancreatic Disorders
Pancreatic Cancer
Treatment Approaches to Pancreatic Cancer
Conclusions
References
29 Pulmonary Disease
Introduction
Learning Objectives
The Aging Lung
Asthma in the Elderly
Definition and Epidemiology
Pathophysiology
Clinical Presentation and Diagnosis
Management
Pharmacologic Therapies
Non-pharmacologic Therapies
Additional Therapies
COPD in the Elderly
Definition and Epidemiology
Pathophysiology
Clinical Presentation and Diagnosis
Management
Pharmacologic Therapies
Non-pharmacologic Therapies
Acute Exacerbations of COPD
Advanced Therapies
Idiopathic Pulmonary Fibrosis
Definition and Epidemiology
Pathophysiology
Clinical Presentation and Diagnosis
Management
Other Pulmonary Conditions
Obstructive Sleep Apnea
Lung Cancer
Neuromuscular Disease
Conclusion
Clinical Cases
Case 1
History
Discussion
Case 2
History
Discussion
Case 3
History
Discussion
References
30 Kidney Disorders
Introduction
Epidemiology of Chronic Kidney Disease
Kidney Anatomy, Physiology, and Senescence
Assessing Kidney Function
Chronic Kidney Disease Management Considerations
Specialist Referral
Glomerular Syndromes
Immunosuppression Considerations
Membranous Nephropathy
Minimal Change Disease
Kidney in Systemic Disease
Infection-Associated Glomerulonephritis
ANCA-Associated Glomerulonephritis
Paraproteinemia
Hypertensive Nephrosclerosis
Cardiorenal Syndrome
Diabetic Kidney Disease
Analgesic Nephropathy
Obstructive Uropathy
Acute Kidney Injury
Acute Interstitial Nephritis
Disorders of Sodium and Fluid Balance
Hyponatremia
Hypernatremia
Kidney Toxicity and Drug Dosing
Drug Dosing
Conclusion
References
31 End-Stage Kidney Disease in the Elderly Population
Case Study
Introduction and Epidemiology
Severe Acute Kidney Injury in Critically Ill Elderly Patients
End-Stage Kidney Disease in the Elderly
Life Expectancy
Approach to Decision-Making: Kidney Replacement Therapy Versus Conservative Management
Optimal Timing of Dialysis Initiation
Comparison of Hemodialysis Versus Peritoneal Dialysis
Hemodialysis in the Elderly
Is Incremental HD a Good Choice in the Elderly?
Home Hemodialysis in the Elderly
Optimal Vascular Access
Peritoneal Dialysis in the Elderly
Transplantation in the Elderly Population
Conservative Management in ESKD/Hospice and Palliative Care
Case Study Follow-Up
Conclusion
References
32 Dermatologic and Mucocutaneous Disorders
Introduction
The Hair and Scalp
Aging of the Hair
Common Geriatric Conditions of the Hair and Scalp
Non-Scarring Alopecias
Scarring Alopecias
Acquired Hair Shaft Disorder
Other Treatments
The Nail Apparatus
Aging of the Nails
Common Geriatric Diseases of the Nails
Infections of the Nail
Onychodystrophy
Tumors and Pigmented Lesions of the Nail
Nails and Systemic Disease
The Skin
Aging of the Skin
Common Geriatric Conditions of the Skin
Decubitus Ulcers
Fungal Infections of the Skin
Bacterial Infections of the Skin
Viral Infections of the Skin
Parasitic Infections of the Skin
Benign Neoplastic Conditions of the Skin
Malignant Neoplastic Conditions of the Skin
Cutaneous Drug Eruptions
Elder Abuse
Physical Abuse
Sexual Abuse
Neglect
Management of Elder Abuse
Conclusion
References
33 Changes and Diseases of the Aging Eye
Basic Parts of an Eye Examination
Refractive Error
Dry Eye Syndrome and Ocular Surface Disease [7]
Pathophysiology
Evaporative Dry Eye
Aqueous Deficient Dry Eye
Eyelid Malposition and Dry Eye
Blepharitis
Management
Cataract [8, 9]
Pathophysiology
Management
Nonsurgical Management
Surgical Management
Preoperative Evaluation
Surgical Phase
Post-surgical Phase
Glaucoma [10-13]
Pathophysiology
Diagnostic Tools
Management
Age-Related Macular Degeneration [14-19]
Pathophysiology
Diagnostic Tools
Management
Diabetic Retinopathy [20, 21]
Pathophysiology
Diagnostic Tools
Management
Summary
References
34 Otologic Changes and Disorders
Introduction
Presbycusis (Age-Related Hearing Loss)
Anatomy and Pathophysiology
Definitions
Sensory Presbycusis (Outer Hair Cell Loss)
Metabolic Presbycusis (Strial Atrophy)
Neural Presbycusis (Ganglion Cell Loss)
Pathogenesis of Presbycusis
Clinical Presentation
Risk Factors
Cochlear Age
Genetic Predisposition
Noise Exposure and Environment
Comorbidities
Hearing Loss and Cognition
Clinical Evaluation of Hearing Loss
History and Risk Factor Assessment
The Physical Examination
Screening Tests and Audiometry
Imaging Studies
Management
Prevention
Rehabilitation
Communication Courtesy
Speech Reading
Auditory Training
Information Counseling and Support
Amplification
Assisted Listening Devices
Conventional Hearing Aids
Middle Ear Implants and Bone Conduction Implants
Cochlear Implantation
Presbystasis
Pathophysiology, Risk Factors, and Etiology
Clinical Evaluation of Imbalance
History and Risk Factor Assessment
The Physical Examination and Work-Up
Management
Vestibular Rehabilitation
Fall Prevention
Future Directions and Conclusions
References
35 Aging and the Oral Cavity
Introduction
Learning Objectives
Why Does the Oral Health of Older People Matter?
Which Are the Most Frequent Oral Conditions Among the Older People?
Dental Decay (Caries)
Periodontal Diseases (Gingivitis and Periodontitis)
Tooth Loss
Decay-Tooth Loss
Root Remnants
Periodontitis-Tooth Loss
Dry Mouth
Mucosal Disorders
Dental Prostheses
Which Are the Consequences of These Oral Conditions?
Nonverbal Communication
Verbal Communication
Eating
Pain
Which Are the Implications of Older peoples Oral Conditions?
Social Functioning
Diet
Physiology and Biology
Conclusion
References
36 Bone and Joint Disorders
Introduction
Osteoporosis
Epidemiology
Pathophysiology
Person-Centered Approach in Older Adults
To Treat or Not to Treat
Individualized Fracture Risk Assessment Tools
Shared Decision-Making
Diagnosis
Diagnostic Criteria
Differential Diagnosis and Work-Up for Secondary Causes
Screening and Case Finding
Treatment
Non-pharmacological Measures
Calcium and Vitamin D
Physiology
Recommended Calcium Intake and Vitamin D Levels
Calcium Supplements: Pharmacology
Pharmacology of Vitamin D Supplements
Role of Calcium and Vitamin D Supplements in Osteoporosis
Safety of Calcium and Vitamin D Supplements
Osteoporosis Drugs and Treatment Algorithms
Estrogen Replacement Therapy and SERMs
Bisphosphonates
Denosumab
Medication-Related Osteonecrosis of the Jaw (MRONJ) and Atypical Femoral Fractures
Bone Anabolic Drugs
Follow-Up
Osteoarthritis
Epidemiology and Pathophysiology
Diagnosis
Person-Centered Approach in Older Adults
Treatment
Treating Pain and Inflammatory Flares
Physical and Occupational Therapy
Disease-Modifying OA Drugs
Joint Prosthesis Surgery
Follow-Up
Gout
Epidemiology
Pathophysiology
Person-Centered Approach in Older Adults
Diagnosis
Treatment
Patient Education and Lifestyle Measures
Treatment for Gout Flares
Urate-Lowering Therapies
Indications and Treatment Target
Allopurinol
Febuxostat
Uricosuric Drugs
Pegloticase
Prophylactic Therapy to Prevent Flares During Initiation of Urate-Lowering Therapy
Treatment for CPPD
Follow-Up
Polymyalgia Rheumatica and Giant Cell Arteritis
Epidemiology
Pathophysiology
Person-Centered Approach in Older Adults
Diagnosis
Symptoms and Signs
Laboratory Tests
Imaging
Temporal Artery Biopsy
Treatment
Patient Education and Lifestyle Measures
Glucocorticoids
Glucocorticoid-Sparing Drugs
Follow-Up
References
37 COVID-19 in Older Adults
Introduction
Learning Objectives
Overview and Epidemiology
Diagnosis
Treatment
Vaccines
Continuum of Care Challenges
Acute Care Setting
Long-Term Care Facilities
Outpatient
Home Setting
Clinical Pearls
Social Determinants of Health
Case Studies
Case Study 1
Case Study 2
Case Study 3
Conclusion
References
Part III: Cancer in Older Adults: An Overview
38 Cancer and Older Adults: The Introduction
Introduction
Epidemiology
Global Aging, Global Geriatric Oncology, and Global Effort
Disparity in Cancer Outcomes Based on Age
Frailty
Assessing Frailty
Frailty and Cancer Outcomes
Benefits of Frailty Assessment
Interventions Following Frailty Assessment
The Role of Geriatricians and Geriatric Care Providers in Geriatric Oncology
Quality Versus Quantity of Life
Digital Health Technologies and Geriatric Oncology
Electronic Patient Reported Solutions
Handheld and Wearable Technologies
A Case of an Older Patient with Colon Cancer
Conclusion
References
39 Cancer Screening in the Older Adult
Introduction
Historical Perspective on Cancer
Emergence of Screening and Prevention
Considerations for Screening: Balance Between Benefits and Risks
Consideration in Older Adults- Individualized Decision-Making
Cancer Screening Guidelines for Older Adults
Breast Cancer
Risk Factors
Nonmodifiable
Modifiable
Primary Prevention
Screening
Lung Cancer
Risk Factors
Nonmodifiable
Modifiable Risk Factors
Primary Prevention
Screening
Colorectal Cancer
Risk Factors
Nonmodifiable
Modifiable Risk Factors
Primary Prevention
Screening
Cervical Cancer
Risk Factors
Primary Prevention
Screening
Uterine Cancer
Risk Factors
Primary Prevention
Screening
Ovarian Cancer
Risk Factors
Genetic Factors
Nongenetic Factors
Screening
Vulvar and Vaginal Cancers
Prostate Cancer
Risk Factors
Nonmodifiable Risk Factors
Modifiable Risk Factors
Primary Prevention
Screening
Risks Associated with Prostate Cancer Tests and Treatments
Bladder Cancer
Risk Factors
Nonmodifiable Risk Factors
Modifiable Risk Factors
Primary Prevention
Screening
Skin Cancer
Risk Factors
Nonmodifiable
Modifiable
Primary Prevention
Screening
Conclusion
References
40 Breast Cancer
Introduction
The Female Breast
Aging and the Breast
Epidemiology of Breast Cancer in Older Adults
Breast Cancer Subtypes in Older Adults
Person-Centered Focus on Approach to Diagnosis, Treatment, and Management
Breast Cancer Screening in Older Adults
Approach to Palpable Breast Masses in Older Adults
Breast Cancer Staging and Workup
Therapeutic Approach to Breast Cancer in Older Women
Surgery
Radiotherapy
Systemic Treatment
Neoadjuvant/Adjuvant Cytotoxic Chemotherapy
Neoadjuvant/Adjuvant Endocrine Therapy
Neoadjuvant/Adjuvant Targeted Therapy
Treatment Considerations in Older Women with Metastatic Disease
Primary Endocrine Therapy
Novel Therapeutic Options
Patient and Family Education
Emergencies
Clinical Pearls
Social Determinants of Health
Cost Implications
Case Study Vignette
Conclusions
References
41 Colorectal Cancer in Older Adults
Epidemiology
Transitioning from Age to Frailty
Assessing Frailty
Borrowing From Frailty to Create Predictive Models for Outcomes of Older Adults with Cancer
Frailty Management
What Geriatricians Need to Know About Colorectal Cancer Treatment
References
42 Lung Cancer in Elderly: Patient-Centered Approach for Optimal Delivery of Care
Introduction
Overview of Lung Cancer in Geriatric Patients
Significance of Geriatric Focus
Risk Factors
Screening Guidelines for Older Adults
Treatment Approaches in Older Adults with Lung Cancer
Management of Early-Stage Lung Cancer
Surgical Resection
Non-Surgical Local Treatment
NSCLC
Small Cell Lung Cancer (SCLC)
Adjuvant Treatment After Surgery
Locally Advanced Lung Cancer: Role of Chemoradiation Therapy
Management of Metastatic Lung Cancer
Emerging Trends for Treatment
Geriatric Consideration
Frailty
Clinical Vignettes
Palliative Care and Symptom Management for Elderly Patients
Conclusion
References
43 Prostate Cancer
Demographics of Prostate Cancer in the Elder Population
Risk Factors for Prostate Cancer Development
Germline Mutations
Black Race
Screening and Diagnosis
Prostate-Specific Antigen
Prostate Cancer Diagnosis (Prostate Biopsy)
ISUP Grade Group
Prostate Cancer Risk Categories and Stage Classification
Age-Related Considerations, Frailty, and Treatment Evaluation
Therapeutic Options
Treatment Decision-Making in Older Men
Interprofessional Team
Localized Prostate Cancer
Active Surveillance and Watchful Waiting
Radical Prostatectomy
Radiation Therapy
Androgen Deprivation Therapy
Focal Therapies
Follow-Up
Advanced Prostate Cancer
Non-metastatic Castration-Resistant Prostate cancer, Metastatic Hormone-Sensitive Prostate Cancer, and Metastatic Castration-R...
Docetaxel
Abiraterone Plus Prednisone
Enzalutamide
Apalutamide
Darolutamide
Sipuleucel T
Radium 223 Dichloride
Cabazitaxel
Poly(adenosine diphosphate ribose) Polymerase Inhibitors
Metastasis-Directed Therapy
Emergency situations
Acute Urinary Retention
Imminent Fractures/Spinal Cord Compression
Radiation Cystitis
Conclusions
References
44 Gynecologic Oncology
Introduction
Overview of Gynecologic Malignancies
Symptoms at Presentation
Screening
Treatment
Disparities in Care of Older Adults with Gynecologic Malignancies
Individualized Care for Older Adults
Conclusions
References
45 Hematologic Malignancies
Introduction
Learning Objectives
Benign and Malignant Hematological Diseases
Incidence, Etiology, and Risk Factors
Common Hematological Malignancies of Older Adults
Geriatric Assessment in Hematologic Malignancies
Risk-Adapted Approaches to Management
Patient Education, Communication, and Prognosis
Integrated Care Delivery, Quality and Safety, Cost Implications
Case Study
Case 1
Case 1 Discussion
Case 2
Case 2 Discussion
Case 3
Case 3 Discussion
Conclusion/Summary
References
Part IV: Sexuality and the Genitourinary System
46 Gynecologic and Urologic Problems in Older Women
Introduction
Learning Objectives
Urogenital Changes in the Older Woman
Effects of Aging on Female Urogenital Tract
Gynecologic Evaluation
General Principle of Gynecologic Examination
System-Based Gynecologic Examination
External Genitalia
Clitoris
Vagina
Cervix
Uterus
Ovaries/Adnexa
Urethra
Bartholin´s Glands
Common Urogynecologic Problems of the Older Woman
Genitourinary Syndrome of Menopause
General Definition
Manifestations of Genitourinary Syndrome of Menopause (GSM)
Epidemiology
Pathophysiology
Clinical Evaluation
Differential Diagnosis
Laboratory Evaluation
Treatment
First-Line Treatment
Vulvovaginal Care
Nonhormonal Products
Second-Line Treatment
Opposed Progestin in Vaginal Estrogen Therapy
Special Considerations
Cancer Risks
Estrogen Exposure to Male Partner
Other Available Treatment Options for GSM
Dehydroepiandrosterone (DHEA)
Ospemifene
Testosterone
Probiotics
Energy-Based Therapies
Pelvic Floor Therapy: Dilators
Vulvar Disorders
Lichen Simplex Chronicum
Lichen Sclerosus
Medical Management
Lichen Planus
Urethra
Urethral Caruncle
Urethral Prolapse
Other Gynecologic Problems in Older Women
Postmenopausal Bleeding
Pelvic Floor Disorders
Pelvic Organ Prolapse
Management of Pelvic Organ Prolapse
Evaluation
Prolapse Classification Systems
Prolapse Examination
Treatment
Nonsurgical Treatment Approaches
Pelvic Floor Muscle Exercises
Pessaries
Surgical Management
Reconstructive Versus Obliterative Procedures
Common Co-existing Pelvic Floor Disorders
Urinary Incontinence
Fecal Incontinence
Case Study
Conclusion/Summary
References
47 Sexuality and Aging
Learning Objectives
Introduction
Sexuality and Aging
Sexual Dysfunction in Older Men
Sexual Dysfunction in Older Women
Menopause
Sexually Transmitted Infections and Older Adults
Impact of Chronic Disease on Sexual Function
Urinary Incontinence
Sexuality in Long-Term Care Settings
Sexuality in Persons with Dementia
LGBTQ-Identifying Older Adults
Intimacy at the End of Life
Conclusion/Summary
References
48 BPH and Male Lower Urinary Tract Symptoms
Introduction
Etiology, Anatomy, and Pathophysiology
Epidemiology
Risk Factors
Person-Centered Focus on Approach to Diagnosis, Treatment, and Management
Management
Clinical Pearls
Conclusion/Summary
References
49 Voiding Problems and Urinary Incontinence in the Geriatric Patient
Introduction
Understanding Incontinence Means Understanding Continence
It´s Not Just the Aging Bladder and Sphincter
Incontinence Does Not Occur in Isolation
Why Is This Patient Incontinent?
Bladder Diaries
Postvoid Residual Volume
Cough Stress Test
Laboratory and Radiographic Testing
Office Cystometry
Urodynamics
Managing Urinary Incontinence
Patient Centered Approach to Urinary Incontinence
Highly Functional Older Adults
Older Adults with Physical or Cognitive Impairments
End of Life
Conservative Management
Lifestyle Modification
Behavioral Management
Bladder Training
Some Bladder Control Strategies Include
Prompted Voiding
Timed Voiding
Habit Training
Pharmacotherapy
Anticholinergics
Beta 3-adrenoceptor Agonist
Incontinence Due to an Impaired Urinary Sphincter
Alternative Treatments
Social Determinants of Health
Appendix A
Appendix B
Appendix C: Office Cystometry Procedure and Interpretation
Procedure
Interpretation
References
Part V: Disorders of the Brain
50 Alzheimer´s Disease and Other Dementias
Introduction
Alzheimer´s Disease and Other Dementias
Epidemiology
Etiology and Pathophysiology
Alzheimer´s Disease Risk Factors and Genetics
Diagnosis
Screening Visit
Diagnostic Assessment
Treatment
Pharmacologic Therapies
Nonpharmacologic Therapies
Management of Behavioral and Psychological Symptoms of Dementia
Case Study (Evidence-Based Practice Case Studies or Vignette Which Highlights the Concept of Person-Centered Care in Order to ...
Case 1: Alzheimer´s Disease Genetics
Case 2: Alzheimer´s Diagnosis
Conclusion/Summary
Cross-References
References
51 Cerebrovascular Disease and Stroke
Introduction
Ischemic Stroke
Cardioembolic Stroke
Large Artery Atherosclerosis
Small Vessel Occlusive Disease
Embolic Stroke of Undetermined Source
Diagnosis and Acute Treatment
Intravenous Thrombolytic Therapy
Endovascular Intervention
Antiplatelet Therapy
Neuroprotection
Acute Stroke Units
Stroke Prevention
Stroke Risk Factors
Hypertension
Dyslipidemia
Other Factors
Conditions Requiring Treatment
Atrial Fibrillation
Carotid Stenosis
Post-Stroke Depression
Hemorrhagic Stroke
Subarachnoid Hemorrhage
Diagnosis of SAH
Treatment
Intracerebral Hemorrhage
Epidemiology
Pathophysiology
Clinical Features
Diagnostic Investigations
Management
Management of Blood Pressure
Ventricular Blood and Hydrocephalus
Surgical Evacuation
Seizures and Epilepsy
Cerebral Amyloid Angiopathy
Conclusion
References
52 Parkinson´s Disease and Other Movement Disorders
Introduction
Learning Objectives
Parkinson´s Disease
Pathophysiology
Risk Factors
Diagnosis
Prognosis/Progression
Symptoms and Management
Motor Symptoms: Tremor, Rigidity, and Bradykinesia
Gait
Nonmotor Symptoms
Inpatient Management
Atypical, Neurodegenerative, Parkinsonism
Pathophysiology
Diagnosis
Prognosis
Management
Secondary Parkinsonism
Drug-Induced Parkinsonism
Vascular Parkinsonism
Head Trauma
Other Causes of Secondary Parkinsonism
Essential Tremor
Diagnosis
Treatment
Drug-Induced and Enhanced Physiologic Tremor
Diagnosis
Treatment
Dystonia
Epidemiology and Risk Factors
Diagnosis
Management
Secondary Dystonia and Acute Dystonic Reaction
Other Hyperkinetic Movement Disorders
Chorea
Tardive Syndromes: Dyskinesia, Dystonia, and Akathisia
Myoclonus
Other Notable Movement Disorders in Older Adults
Ataxia
Restless Leg Syndrome
Conclusion/Summary
Cross-References
References
53 Schizophrenia and Other Late-Life Psychoses
Introduction
Aetiology and Risk Factors of Schizophrenia
Pathophysiology of Schizophrenia
Clinical Presentation of Schizophrenia
Psychotic Symptoms in Older Adults Emerging in the Context of Pathological Conditions Different from Schizophrenia
Diagnosis of Schizophrenia and Differential Diagnosis of Psychotic Symptoms in Older Adults
Treatment and Management of Schizophrenia
Pharmacological Treatment of Schizophrenia
Safety Alerts
Non-pharmacological Treatment of Schizophrenia
Treatment of Psychoses in Late Life
Conclusions
Cross-References
References
Part VI: Diagnosis and Management of Geriatric Syndromes
54 Depression, Anxiety, and Other Mood Disorders
Introduction
Depression
Anxiety
Comorbidity of Anxiety Disorders and Late-Life Depression
Comorbidity of Anxiety Disorder and Substance Use
Comorbidity of Anxiety Disorders and Medical Illness
Anxiety Disorders and Neurocognitive Impairment
Other Mood Disorders
Case Study
Conclusion/Summary
References
55 Delirium
Introduction
Main Text (Disease and Syndrome Related Chapters)
Delirium: A Typical Syndrome of Older Adults
Epidemiology and Outcomes of Delirium
Causes of Delirium
Pathophysiology of Delirium
Delirium and Frailty: A Complex Relationship
Diagnosis of Delirium
The Diagnosis of Delirium Superimposed on Dementia (DSD): A Clinical Challenge
Prevention of Delirium
Treatment of Delirium
Case Study (Evidence-Based Practice Case Studies or Vignette Which Highlights the Concept of Person-Centered Care in Order to ...
Conclusion/Summary
References
56 Pain Management in the Older Adult
Introduction
The Under Recognition of Pain in Older Adults
Effects of Chronic Pain in Older Adults
Commonly Occurring Disease States in Older Adults
Familiar Challenges in Pain Management When Treating Older Adults
Pain Assessment
Assessment Scales
Pain Assessment in the Setting of Dementia
Pharmacological Management
Age-Related Changes to Drug Metabolism
Nonopioid Analgesics
Nonsteroidal Anti-Inflammatory Drugs (NSAID)
Antidepressants
Gabapentinoids
Muscle Relaxants
Opioid Analgesics
Full Agonists
Partial Agonists
Adverse Events Related to Opioids
Nonpharmacological Strategies to Treat Pain
Physical Therapy
Behavioral Therapy
Acupuncture
Interventional Pain Medicine
Conclusion
Patient Case
Analgesics
What Analgesic Options May Be Appropriate?
References
57 Pressure Injury and Chronic Wounds
Introduction
Aging Skin
Wound Healing Overview
Psychosocial Aspects of Chronic Wounds
Nutritional Aspects of Wound Care
Infectious Aspects of Chronic Wounds
Osteomyelitis
Necrotizing Soft Tissue Infections
Cutaneous Candidiasis
Pressure Injuries
Lower Extremity Wounds
Venous Ulcers
Arterial Ulcers
Diabetic Ulcers
Leg Ulcers from Sickle Cell Disease
Pyoderma Gangrenosum
Martorell´s Hypertensive Ischemic Ulcer
Calciphylaxis
Wounds Related to Vasculitis
Lymphedema
Nonhealing Surgical Wounds
Traumatic Wounds
Lacerations
Skin Tears
Burns
Factitious (Self-inflicted) Wounds
Wounds Related to Malignancy
Moisture Associated Skin Damage (MASD)
Principles of Chronic Wound Management
Palliative Care for Chronic Wounds
Conclusions/Summary
References
58 Sarcopenia
Introduction
Diagnosis
The European Working Group on Sarcopenia in Older People
The Foundation for the National Institutes of Health (FNIH) Sarcopenia Project
The European Working Group on Sarcopenia in Older People 2
Physical Frailty and Sarcopenia, According to SPRINTT Consortium
Pathophysiology
Risk Factors
Outcomes
Muscle Mass Assessment
Body Imaging Techniques
Magnetic Resonance Imaging
Computed Tomography
Dual Energy X-ray Absorptiometry
Bioelectric Impedance Analysis (BIA)
Muscle Ultrasonography
Anthropometric Measures
Calf Circumference
Mid-Arm Muscle Circumference
Biochemical Markers for Muscle Mass Estimation
Total or Partial Body Potassium
Circulating Creatinine and Deuterated Creatine (D3-Creatine) Dilution Method
Assessment of Muscle Strength and Muscle Function
Handgrip Strength
The Chair Stand Test
Knee Flexion/Extension
Short Physical Performance Battery
Timed Get-Up-and-Go Test
400-m Walk Test
Treatment
Non-pharmacological Approaches
Pharmacological Approaches
Conclusion/Summary
References
59 Falls in Older Adults
Introduction
Falls in Older Adults: Pathophysiology, Screening, and Prevention
Treatments for Falls Prevention
Social Determinants of Health
Case Study
Conclusion/Summary
References
60 Sleep and Sleep Disorders
Introduction
Sleep and Aging
Physiologic Changes
Sleep Architecture
Circadian Rhythms
Sleep and Comorbidities in Older Adults
Sleep Among Older Adults in Special Settings
Long-Term Care
Acute Hospitalization
Sleep Disorders
Insomnia
Behavioral Treatment of Insomnia
Pharmacologic Options
Sleep-Related Breathing Disorders
Epidemiology of Sleep Apnea Syndromes
Obstructive Sleep Apnea
Central Sleep Apnea
Consequences of Sleep Apnea
Diagnosis of Sleep Apnea
Treatment of Sleep Apnea and Common Barriers to Success
Sleep-Related Movement Disorders
Periodic Limb Movement Disorder
Restless Legs Syndrome
Parasomnias
REM Sleep Behavior Disorder
Other Parasomnias
Conclusions/Summary
References
61 Elder Mistreatment and Abuse
Introduction
Definitions
Epidemiological Trends and Clinical Consequences
Screening and Diagnosis
Clinical and Ethical Challenges
Conclusions
References
Part VII: Care Delivery and Systems Approaches to Geriatric Care
62 Primary Care
Introduction
Primary Care Defined
Focus on Function
Focus on Purpose
Focus on Managing Chronic Disease(s) and Developing Chronic Care Treatment Models
Identify and Manage Psychological and Social Aspects of Care
Respect a Person´s Dignity and Autonomy
Respect Cultural and Spiritual Beliefs
Be Sensitive to the Person´s Financial Condition
Promote Wellness
Listen and Communicate Effectively
Person-Centered Approach to Care
Realistically Promote Optimism and Hope
Team Approach to Care
Primary Care Models
Patient-Centered Medical Home (PCMH)
Guided Care
Comprehensive Primary Care Plus (CPC+)
Primary Care First
Geriatrics Models in Primary Care
Program of All-Inclusive Care of the Elderly (PACE)
Geriatric Resources for Assessment and Care of Elders (GRACE)
The Independence at Home Demonstration
Patient-Aligned Care Teams (PACT)
Aging Brain Care (ABC) Program
Conclusion/Summary
References
63 Emergency Medicine and the Person-Centered Approach to the Older Adult
The 4M Framework
Geriatric Emergency Department Accreditation
A Person-Centered Approach in the ED
Triage
Geriatric-Specific Triage and Screening
Special Considerations in Triage
Delirium
Falls
Waiting Room
The Patient Encounter
The Emergency Department (ED) Experience
Emergency Department Referral
The Geriatric Emergency Department
Atypical Presentations and Multicomplexity
Approaches to ED Care
Person-Centered Care
Caregivers
Nursing Interventions
Pain Assessment and Treatment
Polypharmacy
Iatrogenic Harm
Critical Care
Palliative Care and End of Life
Social Complexity
Common Geriatric Presentations in the ED
Infections
Chest Pain
Abdominal Pain
Frailty and Functional Decline
Cognitive Dysfunction and Delirium
Trauma
Disposition of the Older Emergency Department Patient
Admission
Why Admission Is Not Always the Best Answer
Disposition Decision-Making
ED Teamwork
Case Managers (CMs)
Social Workers (SWs)
Geriatric Nurse Specialists
Alternatives to Admission
Skilled Nursing Facilities (SNFs)
Long-Term Acute Care Hospital (LTACH)
Inpatient Rehabilitation Facility (IRF)
Assisted Living Facilities (ALFs)
Home Health (HH) Services
ED Observation
Palliative Care/Hospice
Safe Discharge Home
Discharge Stability
Discharge Planning (CWs, SWs, and GNs Can Often Help with the Following)
ED Discharge Instructions
Future Steps
References
64 Approach to Acute Hospital Care
Introduction
Admission to Hospital
Why, When, and Where of Hospitalization
Why Is the Patient in the Hospital?
When Is the Patient Ready for Transition?
Where Will the Patient Go from Hospital?
Vulnerability of Older Adults to Adverse Outcomes of Hospitalization
The 4Ms Framework in the Care of Older Adults
General Considerations to Promote Person-Centered Care Consistent with the 4Ms Framework (What Matters´´)
Consider Social Supports and Living Arrangements (What Matters´´)
Bedside Patient Evaluation: Interdisciplinary Team-Based Care
Person-Centered Evaluation
Medical Decision-Making (What Matters´´)
Polypharmacy and Adverse Events (Medications´´)
Medications and Mentation
Assessing Risk of Functional Decline (Mobility´´)
The Functional Trajectory
Tools to Predict Risk of Functional Decline
Identify and Prevent Geriatric Syndromes
Management of Geriatric Syndromes
Delirium
Immobility and Falls (Mobility, Mentation, Medications´´)
Urinary Incontinence
Pressure Injury
Transitions of Care
Hospital Models of Care: Paradigms of the 4Ms
Inpatient Models
Care Transitions Models
Case Study: The 3Ws in Action
Take Home Message: Acute Care for Elders is Age-Friendly
Conclusion
References
65 Surgical Care
Introduction
Surgical Care: A Person-Centered Approach
Preoperative Assessment and Perioperative Care
Procedure Risk
Preoperative Assessment Framed by the 4Ms
Mentation
Mobility
Medication Management
What Matters
Preoperative Testing
Assessment of Cardiac Risk
Assessment of Pulmonary Risk
Preoperative Testing
Perioperative Care
Intraoperative Management (See section ``Anesthesia´´)
Postoperative Care
Mentation
Delirium
Postoperative Cognitive Dysfunction (POCD)
Depression
Mobility and Function
Mobility
Medication Management
Pain Management
What Matters Most
Other Common Postoperative Complications
Discharge Planning and Transitional Care
Anesthesia and Intraoperative Care
Anesthesia
Preoperative Fasting
Multimodal Analgesia
Postoperative Nausea and Vomiting (PONV)
Patient Safety
Positioning
Minimizing Pulmonary Complications
Hypothermia
Fluid Management
Hip and Knee Replacement
Medical Aspects of Hip Fracture Management
Orthogeriatric Comanagement Programs
Case Study (Evidence-Based Practice Case Studies or Vignette Which Highlights the Concept of Person-Centered Care in Order to ...
Perioperative Geriatric Comanagement Case Study
Conclusion/Summary
References
66 Care in the Community
Learning Objectives
Today´s Healthcare for the Elderly
Other Developments Targeting the High-Needs Population
Urgent Care at Home
Acute Hospital-Level Care at Home
Targeted Geriatric Evaluation Tools
A Closer Look at Our Community
Federal Level
State Level
Local Charitable Organizations
Disease-Focused Organizations
References
67 Nursing Home Care in the USA
Introduction
Demographics
Regulations
Long-Term Care Versus Short Stay and Subacute Rehab
Staffing
Nurses
Medical Providers
Medical Care Issues
The Interface of Acute and Long-Term Care
Medical Direction
Quality Improvement
References
68 Palliative Care
Introduction
Palliative Care and Geriatrics
Team Approach
Clinical Approach
Palliative Care Settings
Inpatient
Outpatient Clinic
Home-Based Programs
Long-Term Care
Prognostication
Communication of Prognosis
End of Life Care
Palliative Care for Specific Conditions
Dementia
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease (COPD)
Case Study
Conclusion/Summary
Cross-References
References
69 Geriatric Rehabilitation
Introduction
Geriatric Syndromes: Influence on Functioning
Post-acute Care Needs (and Predictive Factors for Outcomes in Geriatric Rehabilitation)
Goal Setting
Approach to Goal Setting
Interdisciplinary Team and Therapy
Outcome Measures
Integrated Care Pathways
Informal Caregivers
Conclusion/Summary
Cross-References
References
70 Antibiotic Stewardship
Learning Objectives
Introduction: The Need to Optimize Antibiotic Prescribing
Principles of Antibiotic Stewardship
Antibiotic Stewardship in Ambulatory Care Settings
Antibiotic Stewardship in the Hospital
Antibiotic Stewardship in Post-Acute and Long-Term Care
Case Study
Conclusion/Summary
References
71 Population Health for Older Adults
Demand and Supply
Population Health Core Focus: Who CARES ME
Wellness
Caregiver Support and Coordinated Care
Preventable Admissions and Readmissions
Case Example
Acute Care Management
Medication Management
End of Life Care
Social Determinants of Health
Behavioral Health Needs
Population Health Delivery Models
The Program of All-Inclusive Care for the Elderly
Special Needs Plans
Managed Care Plans
CMMI Pilots
Health Systems
Grounded on the Fee for Service Dock
In a Shaky Value-Based Boat
Straddling the Two Worlds of FFS and Value-Based Care
Falling in the Water
References
72 Mechanisms of Paying for Health Care
Introduction
Medicare Part A
Medicare Part B
Medigap
Medicare Part C/Medicare Advantage
Special Needs Plans
Dual-Eligible SNP (D-SNP)
Chronic Condition SNP (C-SNP)
Institutional SNP (I-SNP)
PACE/Program for All-Inclusive Care for the Elderly
Social/Health Maintenance Organization
Mechanism for Care Delivery Through Application of Managed Care Principles
Medicaid and the Dually Eligible (Medicare and Medicaid)
Medicare Part D
Shift to Value-Based Care
Complex Mechanism for Paying and Delivering Care Made Simple
Conclusion
References
73 Interdisciplinary Care and Care Coordination
Learning Objectives
Introduction
Background
The Shift Toward Interprofessional Practice
Health Education Reform
Team-Based Care and Health System Reform
Competencies
IPEC Core Competencies
Team-Based Care
Why Is Team-Based Care Important?
What Makes a Good Team?
Integrating Team-Based Care into Practice
Roles and Responsibilities
Role of the Geriatrician
Team Lead
Geriatrics Medical Expert (Consult)
Care Coordination
Coordinating with Physicians from Other Disciplines
Geriatrician as Primary Care Provider
Geriatrician as Consultant
Non-geriatrician Teams
The Role of Advanced Practice Providers
Licensed Nurses
Social Workers
Medical Assistants, Nursing Assistants, and Home Health Aides
Team Differences in Settings
Nursing Homes
Assisted Living or Residential Care
Hospice and Palliative Care
Home Health
Care Coordination
Communication
Values and Ethics
Teams and Teamwork
Patient and Family as Team Members
Summary
References
74 Improving Quality and Safety in the Care of Older Adults
Learning Objectives
Introduction
Background and Significance
Patient Safety and Quality Improvement Definitions
Two Landmark Reports
The Triple Aim to the Quintuple Aim
Quality and Safety Competencies
Quality and Safety Agencies
Implications for Geriatricians and Other Geriatrics-Trained Health Professionals
Approach to Patient Safety and Quality Improvement
Avedis Donabedian MD, the Father of Healthcare Quality
Understanding Errors and Adverse Events
Patient Safety Essentials
Reducing Harm
Root Cause Analysis
The Human Component of Patient Safety
The Swiss Cheese Model
Patient Safety Metrics
Safety Culture: Just Culture
Integrating Patient Safety in Practice
Key Aspects of Patient Safety in Primary Care
Patient Safety Case
Essentials in Quality Improvement
QI Models
The IHI Model for Improvement
The Lean and Six Sigma Approaches
The QI Process
Identifying an Area(s) for Improvement
Putting Together a Team
Goal Setting
Understanding the Current Process and Root Cause Analysis
Developing an Intervention
Determine Measures
Developing an Implementation Strategy
Implementing the Plan: The PDSA Cycle
Quality Improvement Metrics
Pilot Testing
Conclusion
References
Part VIII: The Science of Aging
75 The Demography and Biodemography of Aging
Introduction
Causes and Consequences of Population Aging
Individual Aging
Conclusion
References
76 Molecular and Biological Factors in Aging
Introduction
Aging: Perspectives and Potential Mechanisms
Normal Aging Versus Disease
Evolutionary Perspective
Disposable Soma Hypothesis
Weak Link Mechanisms
Immune System
Neuroendocrine
Loose Cannon Mechanisms
Oxidative Stress
Glycation
Dietary Restriction (DR) Increases Life Span and Delays Age-Related Diseases
Discovery in the 1930s
Extension to Many Different Species
Different Modalities of Restriction
Extension to Diseases
Cancer
Neurodegenerative Diseases
Immune Cell Function
Mechanisms Implicated in Protective Effects of DR
Macronutrients
Metabolic Rate
Temperature
Hormesis
Glucose Metabolism
Role of the Insulin-Like Pathway in Regulating Life Span and Age-Related Diseases
Dietary Restriction, Insulin-Like Signaling, and mTOR: Final Common Pathways
Other Interventions
Hormone Replacement Therapy
DR-Mimetics
Rapamycin
Metformin, Resveratrol
Senolytics
Drugs That Increase Life Span in C. elegans
Drugs That Delay Impairments in a C. elegans Model of Alzheimer´s Disease
The Brain and Aging
Normal Versus Disease
Cognition
Sensory
Motor
Neuroendocrine
Endocrine Systems and Aging
Menopause
Andropause or Functional Hypogonadism (Also Referred to as Late-Onset, Age Related, or Adult-Onset Hypogonadism or Functional ...
Pathophysiology of Testosterone Decline in Aging
DHEA
GH
HPA
Thyroid
References
77 Physiology of Aging
Introduction
Conclusion
References
Bibliography
78 Immunology of Ageing
Introduction
Basic Principles and Constraints on Studies of Age-Associated Changes to Immunity in Humans
What Is Immunosenescence?
Hematopoiesis in Older Adults
Age-Associated Changes to Innate Immunity
Phagocytic Cells
Natural Killer Cells
Dendritic Cells
Age-Associated Changes to Adaptive Immunity
B and T Lymphocyte Development and Antigen Recognition Repertoire
B-cells
T-cells
T-cell Immune Function
Conclusions: Immune Correlates of Successful Vaccination and With Mortality
References
Index