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Tables and Figu..
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Chapter One

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Table 1-1. Pertinent Changes That Commonly Occur With Aging

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Table 1-2. Nine Hallmarks of Aging

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Table 1-3. Web-Based Resources for Health Promotion and Aging

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Chapter Two

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Figure 2-1. Change in the relationship of older persons and workers

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Figure 2-2. Age-adjusted death rates for selected leading causes of death: United States, 1958–2013

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Figure 2-3. Medicare spending by function and chronic disease

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Table 2-1. Changes in Most Common Causes of Death, All Ages and Those 65 Years and Older

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Figure 2-4. Life expectancy at age 65 by sex and race/ethnicity

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Table 2-2. Percentage of Medicare Beneficiaries Reporting Difficulty With Common Activities, by Age Group: 2012

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Figure 2-5. Living arrangements by age and sex, 2015

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Figure 2-6. Percentage of Medicare FFS beneficiaries by number of chronic conditions and age: 2010

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Figure 2-7. 30-day readmission rates for five diseases

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Table 2-3. Hospital Discharge Diagnoses and Procedures for Persons Aged 65 Years and Older, 2010

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Table 2-4. Postacute Care Used Within 30 Days in 2008, for the Top Five Diagnostic-Related Groups

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Table 2-5. Percentage of Office Visits by Selected Medical Conditions, 2012

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Table 2-6. Factors Affecting the Need for Nursing Home Admission

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Chapter Three

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Figure 3-1. The Kaiser Pyramid

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Figure 3-2. Components of assessment of older patients

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Table 3-1. Examples of Randomized Controlled Trials of Geriatric Assessment

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Table 3-2. Potential Difficulties in Taking Geriatric Histories

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Table 3-3. Important Aspects of the Geriatric History

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Table 3-4. Geriatric Screening Questions and Recommendations for Further Assessment

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Table 3-5. Essential Elements of Person-Centered Care

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Table 3-6. Common Physical Findings and Their Potential Significance in Geriatrics

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Table 3-7. Laboratory Assessment of Geriatric Patients

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Table 3-8. Important Concepts for Geriatric Functional Assessment

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Table 3-9. Purposes and Objectives of Functional Status Measures

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Table 3-10. Examples of Measures of Physical Functioning

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Table 3-11. Important Aspects of the History in Assessment of Pain

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Table 3-12. Important Aspects of the Physical Examination in Assessment of Pain

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Figure 3-3. Samples of two pain intensity scales that have been studied in older persons. Directions: Patients should view the figure without numbers. After the patient indicates the best representation of his or her pain, the appropriate numerical value can be assigned to facilitate clinical documentation and follow-up

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Table 3-13. Assessment of Body Composition

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Table 3-14. Critical Questions in Assessing a Patient for Malnutrition

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Table 3-15. Factors That Place Older Adults at Risk for Malnutrition

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Table 3-16. Medicare Initial Preventive Physical Examination

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Table 3-17. Medicare Annual Wellness Visit

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Table 3-18. Example of a Screening Tool to Identify Potentially Remediable Geriatric Problems

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Table 3-19. Questions on the Probability of Repeated Admissions Instrument for Identifying Geriatric Patients at Risk for Health Service Use

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Table 3-20. Suggested Format for Summarizing the Results of a Comprehensive Geriatric Consultation

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Table 3-21. Preoperative Assessment Checklist

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Table 3-22. Potential Manifestations of Caregiver Stress

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Chapter Four

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Figure 4-1. Paths to chronic disease catastrophe

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Table 4-1. Chronic Care Tenets

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Figure 4-2. Narrowing of the therapeutic window. This diagram portrays in a conceptual manner how the space between a therapeutic dose and a toxic dose narrows with age

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Figure 4-3. A conceptual model of the difference between expected and actual care. The heavier line represents what is usually observed in clinical chronic care. Despite good care, the patient’s course deteriorates. The true benefit, represented by the area between the dark line and the dotted line, is invisible unless some means is found to display the expected course in the absence of good care. Such data could be developed based on clinical prognosis, or they could be derived from accumulated data once such a system is in place.

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Figure 4-4. Clinical glidepath models. (A) In this model, the expected course (solid line) calls for gradual decline. The confidence intervals are shown as dotted lines. Actual measures that are within or better than the glidepath are shown as o’s. When the patient’s course is worse than expected, the o changes to an x. The design shown uses confidence intervals with upper and lower bounds, but actually only the lower bound is pertinent. Any performance above the upper confidence interval boundary is very acceptable. (B) The design of the glidepath can also take another form. It may be preferable to think in terms of reaching a threshold level within a given time window (eg, in recuperating from an illness) and then maintaining that level

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Table 4-2. Team Models

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Table 4-3. Team Composition

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Table 4-4. The Two-Step Discharge Decision-Making Process

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Table 4-5. Rationale for Using Outcomes

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Table 4-6. Outcomes Measurement Issues

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Table 4-7. Geriatric Outcome Categories

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Table 4-8. Choosing Wisely Recommendations

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Table 4-9. ACOVE Recommendations

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Chapter Five

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Table 5-1. Considerations in Assessing Prevention in Older Patients

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Table 5-2. Preventive Strategies for Older Persons

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Table 5-3. Healthy People 2020 Report Card Items Most Relevant for Older Adults

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Table 5-4. U.S. Preventive Services Task Force (USPSTF) Recommendations for Screening Older Adults

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Table 5-5. Additional Preventive Services From U.S. Preventive Services Task Force (USPSTF) (May Be Suitable for Older Adults)

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Table 5-6. Requirements for the Welcome to Medicare Visit and Annual Wellness Visit

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Table 5-7. Measurement of Psychosocial Factors Among Older Adults

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Table 5-8. Types of Exercises

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Figure 5-1. MyPlate for older adults

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Table 5-9. Efficacy of Common Biphosphonates for the Prevention of Fractures

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Table 5-10. Common Iatrogenic Problems of Older Persons

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Figure 5-2. Narrowing of the therapeutic window. This diagram portrays in a conceptual manner how the space between a therapeutic dose and a toxic dose narrows with age

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Table 5-11. Potential Complications of Bed Rest in Older Adults

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Chapter Six

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Table 6-1. Key Aspects of Mental Status Examination

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Table 6-2. NIA–AA Core Clinical Diagnostic Criteria for Mild Cognitive Impairment

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Table 6-3. Diagnostic Criteria for Delirium

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Table 6-4. Predisposing and Precipitating Factors for Delirium From Validated Predictive Models

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Table 6-5. The Confusion Assessment Method Diagnostic Algorithm

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Table 6-6. Differentiating Delirium, Dementia, Depression, and Acute Psychosis

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Table 6-7. Common Causes of Delirium in Geriatric Patients

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Table 6-8. Drugs That Can Cause or Contribute to Delirium and Dementia

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Table 6-9. Interventions for Risk Factors for Delirium

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Table 6-10. NIA-AA Core Clinical Diagnostic Criteria for All-Cause Dementia and Dementia Due to Alzheimer Disease

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Table 6-11. Potentially Reversible Conditions That Can Contribute to Cognitive Impairment and Dementia

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Table 6-12. Causes of Dementia

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Table 6-13. Clinical Features of Common Dementias

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Figure 6-1. Primary degenerative dementia versus multi-infarct dementia: comparison of time courses. (1) Recognized by patient, but detectable only on detailed testing. (2) Deficits recognized by family and friends. (3) See text for explanation. (4) Exact time courses are variable; see text

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Table 6-14. Symptoms That May Indicate Dementia

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Table 6-15. Evaluating Dementia: The History

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Table 6-16. Evaluating Dementia: Recommended Diagnostic Studies

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Table 6-17. Key Principles in the Management of Dementia

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Chapter Seven

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Table 7-1. Factors Associated With Suicide in the Geriatric Population

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Table 7-2. Factors Predisposing Older People to Depression

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Table 7-3. Examples of Physical Symptoms That Can Represent Depression

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Table 7-4. Key Factors in Evaluating the Complaint of Insomnia

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Table 7-5. Medical Illnesses Associated With Depression

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Table 7-6. Drugs That Can Cause Symptoms of Depression

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Table 7-7. Some Differences in the Presentation of Depression in the Older Population, as Compared With the Younger Population

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Table 7-8. Summary Criteria for Major Depressive Episode

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Table 7-9. Major Depression Versus Other Forms of Depression

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Table 7-10. Examples of Screening Tools for Depression

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Table 7-11. Diagnostic Studies Helpful in Evaluating Depressed Geriatric Patients With Somatic Symptoms

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Table 7-12. Evidence-Based Treatment Modalities for Depression

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Table 7-13. Antidepressants for Geriatric Patients

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Table 7-14. General Treatment Approaches for Use of Antidepressants

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Table 7-15. Characteristics of Selected Antidepressants for Geriatric Patients

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Chapter Eight

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Figure 8-1. Prevalence of urinary incontinence (UI) in the geriatric population. “Regular UI” is more often than weekly and/or the use of a pad. (Percentages range in various studies; those shown reflect approximate averages from multiple sources.)

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Table 8-1. Potential Adverse Effects of Urinary Incontinence

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Table 8-2. Requirements for Continence

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Figure 8-2. Structural components of normal micturition

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Figure 8-3. Peripheral nerves involved in micturition

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Figure 8-4. Simplified schematic of the dynamic function of the lower urinary tract during bladder filling (left) and emptying (right). As the bladder fills, true detrusor pressure (thick line at bottom) remains low (<15 cm H2O) and does not exceed urethral resistance pressure (thin line at bottom). As the bladder fills to capacity (generally 300–600 mL), pelvic floor and sphincter activity increase as measured by electromyography (EMG). Involuntary detrusor contractions (illustrated by dashed lines) occur commonly among incontinent geriatric patients (see text). They may be accompanied by increased EMG activity in attempts to prevent leakage (dashed lines at top). If detrusor pressure exceeds urethral pressure during an involuntary contraction, as shown, urine will flow. During bladder emptying, detrusor pressure rises, urethral pressure falls, and EMG activity ceases in order for normal urine flow to occur (right side of figure)

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Figure 8-5. Simplified schematic depicting age-associated changes in pelvic floor muscle, bladder, and urethra–vesicle position, predisposing to stress incontinence. Normally (left), the bladder and outlet remain anatomically inside the intra-abdominal cavity, and rises in pressure contribute to bladder outlet closure. Age-associated changes (eg, estrogen deficiency, surgeries, childbirth) can weaken the structures maintaining bladder position (right); in this situation, increases in intra-abdominal pressure can cause urine loss (stress incontinence)

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Table 8-3. Reversible Conditions That Cause or Contribute to Geriatric Urinary Incontinence

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Table 8-4. Medications That Can Cause or Contribute to Urinary Incontinence

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Table 8-5. Mnemonic for Potentially Reversible Conditions

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Table 8-6. Basic Types and Causes of Persistent Urinary Incontinence

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Table 8-7. Components of the Diagnostic Evaluation of Persistent Urinary Incontinence

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Table 8-8. Key Aspects of an Incontinent Patient’s History

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Figure 8-6. Example of a bladder record for ambulatory care settings

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Figure 8-7. Example of a record to monitor bladder and bowel functions in institutional settings. This type of record is especially useful for implementing and following the results of various training procedures and other treatment protocols

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Table 8-9. Key Aspects of an Incontinent Patient’s Physical Examination

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Figure 8-8. Example of a simplified grading system for cystoceles

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Table 8-10. Criteria for Considering Referral of Incontinent Patients for Urological, Gynecological, or Urodynamic Evaluation

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Figure 8-9. Algorithm protocol for evaluating incontinence

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Table 8-11. Treatment Options for Geriatric Urinary Incontinence

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Table 8-12. Primary Treatments for Different Types of Geriatric Urinary Incontinence

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Table 8-13. Examples of Behavioral Interventions for Urinary Incontinence

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Table 8-14. Example of a Bladder Retraining Protocol

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Table 8-15. Example of a Prompted Voiding Protocol for a Nursing Home

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Table 8-16. Drug Treatment for Urinary Incontinence and Overactive Bladder

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Table 8-17. Indications for Chronic Indwelling Catheter Use

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Table 8-18. Key Principles of Chronic Indwelling Catheter Care

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Table 8-19. Causes of Fecal Incontinence

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Table 8-20. Causes of Constipation

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Table 8-21. Drugs Used to Treat Constipation

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Chapter Nine

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Table 9-1. Complications of Falls in Older Patients

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Figure 9-1. Multifactorial causes and potential contributors to falls in older persons

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Table 9-2. Age-Related Factors Contributing to Instability and Falls

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Table 9-3. Causes of Falls

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Table 9-4. Common Environmental Hazards

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Table 9-5. Factors Associated With Falls Among Older Nursing Home Residents

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Table 9-6. Evaluating the Older Patient Who Falls: Key Points in the History

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Table 9-7. Evaluating the Older Patient Who Falls: Key Aspects of the Physical Examination

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Table 9-8. Example of a Performance-Based Assessment of Gait and Balance (Get Up and Go)

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Table 9-9. Principles of Management for Older Patients With Complaints of Instability and/or Falls

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Table 9-10. Examples of Treatment for Underlying Causes of Falls

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Chapter Ten

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Table 10-1. Factors That Influence Immobility

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Table 10-2. Complications of Immobility

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Table 10-3. Assessment of Immobile Older Patients

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Table 10-4. Example of How to Grade Muscle Strength in Immobile Older Patients

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Table 10-5. Clinical Features of Osteoarthritis Versus Inflammatory Arthritis

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Figure 10-1. Characteristics of different types of hip fractures

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Table 10-6. Recommended Treatment Options for Venous Thromboembolism Prophylaxis in Immobility

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Table 10-7. Drugs Used to Treat Parkinson Disease

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Table 10-8. Clinical Characteristics of Pressure Sores

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Table 10-9. Principles of Skin Care in Immobile Older Patients

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Table 10-10. Pain Categories and Management Options

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Table 10-11. Examples of Drug Groups and Associated Drugs Commonly Used to Treat Pain

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Table 10-12. CDC Recommendations for Determining When to Initiate or Continue Opioids for Chronic Pain

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Table 10-13. Basic Principles of Rehabilitation in Older Patients

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Table 10-14. Physical Therapy in the Management of Immobile Older Patients

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Table 10-15. Occupational Therapy in the Management of Immobile Older Patients

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Chapter Eleven

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Table 11-1. Resting Cardiac Function in Persons Aged 30 to 80 Years Old Compared With That in Persons Aged 30 Years Old

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Table 11-2. Performance at Maximum Exercise in Sample Screened for Coronary Artery Disease Aged 30 to 80 Years

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Table 11-3. Initial Evaluation of Hypertension in Older Adults

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Table 11-4. Secondary Hypertension in Older Persons

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Table 11-5. Thiazide Diuretics for Antihypertensive Therapy

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Table 11-6. Antihypertensive Medications

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Table 11-7. Stroke

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Table 11-8. Outcome for Survivors of Stroke

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Table 11-9. Modifiable Risk Factors for Ischemic Stroke

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Table 11-10. Transient Ischemic Attack: Presenting Symptoms

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Table 11-11. Factors in Prognosis for Rehabilitation

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Table 11-12. Stroke Rehabilitation

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Table 11-13. Presenting Symptoms of Myocardial Infarction

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Table 11-14. Differentiation of Systolic Murmurs

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Table 11-15. Manifestations of Sick Sinus Syndrome

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Table 11-16. Calculation of the Ankle–Brachial Index

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Chapter Twelve

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Table 12-1. Common Noninsulin Medications for Diabetes Mellitus in Older Adults

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Table 12-2. Common Clinical Conditions to Consider in the Care of Older Individuals With Diabetes Mellitus

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Figure 12-1. Flow diagram for treatment of hospitalized (nonintensive care unit) patients with type 2 diabetes mellitus. CHF, congestive heart failure; NPH, neutral protamine Hagedorn (insulin); NPO, nothing by mouth; PO, by mouth; TPN, total parenteral nutrition

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Table 12-3. Thyroid Function in Normal Older Adults

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Table 12-4. Laboratory Evaluation of Thyroid Disease in Older Persons

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Table 12-5. Thyroid Function Tests in Nonthyroidal Illness

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Figure 12-2. An algorithm for the management of subclinical hypothyroidism. LDL, low-density lipoprotein

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Table 12-6. Myxedema Coma

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Table 12-7. Laboratory Findings in Metabolic Bone Disease

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Table 12-8. Signs and Symptoms of Anemia

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Table 12-9. Differential Tests in Hypochromic Anemia

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Table 12-10. Nutritional Requirements in Older Persons

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Table 12-11. Factors Predisposing to Infection in Older Adults

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Table 12-12. Pathogens of Common Infections in Older Adults

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Table 12-13. Clinical Presentation of Hypothermia

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Table 12-14. Clinical Presentation of Hyperthermia

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Table 12-15. Complications of Heat Stroke

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Chapter Thirteen

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Table 13-1. Physiological and Functional Changes of the Eye With Advancing Age

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Table 13-2. Ophthalmological Screening Covered by Medicare Fee-for-Service

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Table 13-3. Restoring Vision After Cataract Surgery—Intraocular Lenses

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Table 13-4. Signs and Symptoms Associated With Common Visual Problems in Older Adults

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Table 13-5. Potential Adverse Effects of Ophthalmic Solutions

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Table 13-6. Aids to Maximize Visual Function

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Table 13-7. Functional Components of the Auditory System

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Table 13-8. Assessment of Hearing

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Table 13-9. Initial Evaluation of an Older Patient With Acute or Subacute Hearing Loss

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Table 13-10. Effects of Aging on the Hearing Mechanism and Hearing Performance in Older Adults

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Table 13-11. Health Implications of Hearing Loss in Older Adults

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Table 13-12. Medical Conditions That Present With Hearing Loss in Older Adults

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Table 13-13. Factors to Consider in Evaluation of an Older Adult for a Hearing Aid

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Table 13-14. Some Advantages and Disadvantages of Various Styles of Hearing Aids

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Table 13-15. Essential Points That a Health Professional Should Know About Over-the-Counter Wearable Hearing Devices

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Table 13-16. Strategies to Improve a Health Professional’s Communication With an Older Patient Who Has a Hearing Impairment

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Table 13-17. Essential Points That a Health Professional Should Know About Cochlear Implants

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Chapter Fourteen

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Figure 14-1. Factors that can interfere with successful drug therapy

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Figure 14-2. Example of a basic medication record recommended by the U.S. Food and Drug Administration

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Table 14-1. Strategies to Improve Adherence With Drug Therapy in the Geriatric Population

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Table 14-2. Examples of Common and Potentially Serious Adverse Drug Reactions in the Geriatric Population

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Table 14-3. Examples of Potentially Clinically Important Drug–Drug Interactions

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Table 14-4. Examples of Potentially Clinically Important Drug–Patient Interactions

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Table 14-5. Age-Related Changes Relevant to Drug Pharmacology

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Table 14-6. Renal Function in Relation to Age

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Table 14-7. General Recommendations for Geriatric Prescribing

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Table 14-8. Examples of Antipsychotic Drugs

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Table 14-9. Examples of Sedative–Hypnotics Approved for Insomnia by the U.S. Food and Drug Administration

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Chapter Fifteen

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Figure 15-1. Measuring the effects of good chronic care. Both trajectories show decline, but the slope of expected care is steeper. The yellow area between the lines represents the effects of good care

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Figure 15-2. Medicare fee-for-service expenditures and percentage distribution, by Medicare program and type of service: calendar years 1995–2014

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Table 15-1. Summary of Major Federal Programs for Older Patients

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Figure 15-3. Living arrangements of older people with disabilities by age group, 2012

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Table 15-2. Essential Elements of Person-Centered Care

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Figure 15-4. Disability prevalence and the need for assistance by age: 2010

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Figure 15-5. Change in ADLs and IADLs from 1992 to 2013

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Figure 15-6. Long-term care spending by payer, 2013

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Table 15-3. Potential Symptoms of Caregiver Stress

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Figure 15-7. Change in the rate of nursing home use by age group, 1973–2004

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Figure 15-8. Use of different types of institutional long-term care by age group, 1985 and 2004

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Figure 15-9. ADLs limitations by living situation. Estimates based on CMS National Health Expenditure Accounts data for 2013

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Figure 15-10. Institutional use by disability

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Table 15-4. Remaining Lifetime Use of Long-Term Supportive Services (LTSS) by People Turning 65 in 2005

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Table 15-5. RUG-IV Classification System

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Table 15-6. Home Care Provided Under Various Federal Programs

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Figure 15-11. Core components of long-term care

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Figure 15-12A. Personal care pyramid

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Figure 15-12B. Medical needs pyramid

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Table 15-7. Examples of Community Long-Term Care Programs

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Table 15-8. Variations in Case Management

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Chapter Sixteen

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Table 16-1. Goals of Nursing Home Care

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Figure 16-1. Categories of individuals in nursing homes. In this chapter, short-stayers are generally referred to as “patients” and long-stayers as “residents” due to the different nature of their conditions and goals for care

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Table 16-2. Factors That Distinguish Assessment and Treatment in the Nursing Home From Assessment and Treatment in Other Settings

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Table 16-3. Common Clinical Disorders in the Nursing Home Population

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Table 16-4. Important Aspects of Various Types of Assessment in the Nursing Home

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Figure 16-2. Example of a face sheet for a nursing home record

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Table 16-5. SOAP Format for Medical Progress Notes on Nursing Home Residents

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Table 16-6. Screening, Health Maintenance, and Preventive Practices in the Nursing Home

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Figure 16-3. Example of an INTERACT VERSION 4.0 care path for managing acute change in condition in a nursing home

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Table 16-7. Common Ethical Issues in the Nursing Home

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Chapter Seventeen

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Table 17-1. Major Ethical Principles

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Table 17-2. Components of a Durable Power of Attorney for Health Care

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Table 17-3. Step Approach to Discussions With Patients Around EOL Care

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Table 17-4. Details and Goals of Care and Symptom Management at the End of Life

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Table 17-5. The Older Americans Reauthorization Act of 2016 (S. 192)

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Table 17-6. Evidence of Abuse or Neglect

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Chapter Eighteen

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Table 18-1. Hospice Services

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Table 18-2. A Five-Step Framework for Discussing Care Choices at the End of Life

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Table 18-3. Signs and Symptoms of Frailty

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Table 18-4. Principles for End-of-Life Decision Making in Frail Older Adults

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Table 18-5. Assess ABCDE to Determine Level of Cultural Influence in EOL Decisions

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Table 18-6. Management of Symptoms Noted at End of Life

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Table 18-7. Adjuvant Pharmacologic Treatments for Pain Management

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