Chapter 41: Common Geriatric Problems

The syndromes of failure to thrive, pressure ulcers, and falls share features that make them particularly challenging. Their etiologies are multifactorial; they require an interdisciplinary approach to maximize care; and they often herald disability, institutionalization, and death. Interventions in multiple domains can improve outcomes. However, in patients with low functional reserve the physician should be prepared to transition from cure to palliative care. Open and frank communication is vital and should employ the skills needed to address life-changing diagnoses while continuing to supply hope and support. Eliciting patient’s goals, what they want and what they want to avoid, is fundamental to crafting an end-of-life framework that is consistent with their values and preferences. The physician can and should maintain a therapeutic relationship with the patient and the family beyond the time when medical therapies are effective. Home visits enhance this relationship and often reveal opportunity for interventions and support.

General Considerations

The National Institute on Aging defined failure to thrive (FTT) as “a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol.” The concepts, cachexia and sarcopenia, have enhanced our understanding of the pathophysiology of FTT and should be considered in the approach to the patient. Cachexia is the catabolic state seen in illnesses such as cancer, end-stage renal disease, lung disease, and heart failure. It is progressive and characterized by weight loss, anorexia, inflammation, and insulin resistance; nutrition therapy does not alter the course. Sarcopenia is loss of muscle mass that occurs with aging. It is associated with functional decline, disability, and falls; it is mitigated by exercise.

Clinical Findings

A. Symptoms and Signs

Weight loss is an essential feature. Functional decline contributes to falls, poor grooming, depression, and cognitive decline. As in infants, FTT can occur from organic and nonorganic causes, necessitating an approach that includes medical, psychological, functional, and social domains.

B. History and Physical Examination

The history provided by the patient and caregiver can help identify common acute triggers: change in medication, infection, constipation, pain, loss, or grief. Undiagnosed chronic diseases, such as endocrine disorders, tuberculosis, dementia, depression, substance abuse, and rarely, hypoactive delirium, may trigger FTT.

Assess, do not assume, medication compliance; have the patient demonstrate how he/she is taking all prescription and over-the-counter (OTC) medications. Drug effects and interactions should not be underestimated. Alendronate, antiarrhythmics, antihistamines (eg, H₂-blockers, α-antagonists, benzodiazepines, β-blockers, calcium antagonists, colchicine, and digoxin, even within therapeutic range), diuretics, iron or zinc, metformin, metronidazole, neuroleptics, nonsteroid anti-inflammatory drugs (NSAIDs), narcotics, steroids, SSRIs, tricyclic antidepressants, and xanthines have been associated with FTT. Levels are nonspecific; normal therapeutic levels can have adverse effects. Be aware of genetic and racial variation in drug metabolism.

A comprehensive physical examination should focus on the appropriate items noted in Table 41-1. Laboratory evaluations should include complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), erythrocyte sedimentation rate (ESR), total 25-OH vitamin D, and vitamin B₁₂ (if within 200–400 pmol/L, check a methylmalonic level or empirically replace). Additional workup could include fecal occult blood, purified protein derivative, and urinalysis.

Treatment

A. Assessment and Plan

Address modifiable medical conditions. Discuss risk/benefit of watchful waiting for conditions whose interventions carry high morbidity and mortality. Appetite stimulants are neither approved nor recommended and carry significant side effects. As medical interventions become more limited, palliative or hospice services should be initiated.

B. Team Approach

Simplify medications with help of a PharmD. Enlist the help of the Area Agency on Aging (AAA) [(800) 677–1116, “Elder Care Locater”]. Concerns about neglect or abuse should be discussed openly and nonjudgmentally; and should be reported. Home Health can supply short-term nursing, social worker, dietician, physical and occupational therapy, and aide services.

Pathogenesis

Extrinsic and intrinsic factors cause pressure ulcers. Extrinsic factors are prolonged pressure, moisture, friction, and shear. Intrinsic causes are the susceptibility of aged skin (less thickness and elasticity), loss of sensation, circulatory compromise, immobility, weight loss, dehydration, malnutrition, and cognitive impairment including sedation.

Prevention

When admitting a patient to acute or long-term care, document the condition of the occiput, spinous processes, scapulae, elbows, sacrum, ischia, greater trochanters, malleoli, and heels. Extra vigilance is needed in cognitively or sensorially impaired elders who wear support stockings, casts, or other orthopedic devices. These should be removed for inspection when possible. The admitting nurse will also do a complete skin assessment; the physician should review, verify, and document concurrence with the findings. Table 41-2 summarizes the AHRQ (Agency for Healthcare Research and Quality) guidelines for pressure ulcer prevention. Screening scales such as Braden and Norton help quantify risk and tailor treatment plans. The downside to these scales is the misconception that low- and moderate-risk patients are not as vulnerable; it takes them 2 hours to develop a stage I ulcer, the same as the high-risk patient. Although never studied, patient repositioning every 2 hours remains a mainstay in clinical practice.

Differential Diagnosis

Among the differential diagnoses for pressure ulcers are vascular ulcers, diabetic ulcers, and cellulitis. Venous ulcers are the result of prolonged venous hypertension and are usually located over the medial malleolus. Arterial ulcers are predominantly caused by atherosclerotic vessels, and may be located between toes, over phalangeal heads, or around the lateral malleolus. Diabetic ulcers are produced by a variety of factors: micro- and macrovascular injury, peripheral neuropathy, and mechanical changes in the bony architecture of the foot. These are usually located on the plantar aspect of the foot, metatarsal heads, or under the heel. Cellulitis is an acute inflammation of the dermis and subcutaneous tissue and thus blanches with palpation.

The National Pressure Ulcer Advisory Panel (NPUAP) Classification

A. Stage I

Stage I ulcers are characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones and may indicate “at risk” persons (a heralding sign of risk).

Preventive efforts should be intensified. Transparent films like Op-site or Tegaderm can be used; they provide barrier, prevent contamination, and reduce friction. The wound should be pressure-free. Donut cushions and bunny boots worsen ulcers. Use foam or gel overlay for beds or chairs, and inflatable heel elevators to protect feet. Compared with standard hospital mattresses, these devices decrease the incidence of ulcers. For a stage I, use group 1 support surfaces. (A good description of support surfaces can be found at www.wocn.org/pdfs/WOCN_Library/Fact_Sheets/medicare_part_b.pdf.)

B. Stage II

Stage II is characterized by partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister, or as a shiny or dry shallow ulcer without slough or bruising. (Bruising indicates suspected deep-tissue injury.) This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

1. Management

Cleansing around the wound with cleanser rather than normal saline has been shown to promote healing in stage II–IV ulcers, with stage II gaining the greatest benefit in healing time. Normal saline is fine if cleanser is not available. Do not use old favorites such as hydrogen peroxide, povidone-iodine (Betadine), liquid detergent, acetic acid, or hypochlorite solutions. Even when diluted, they are potentially toxic to both fibroblasts and white blood cells. Occlusive or semipermeable dressing that will maintain a moist wound environment should be used after cleansing. Hydrogel alone (Intrasite, Solosite) or hydrogel sheets (eg, NuGel) or hydrogel-impregnated gauze (eg, Normlgel) are appropriate. Wet/dry dressing should be avoided, as these ulcers need little debridement. If the wound is exudating, then use a dressing that will absorb the exudate such as alginate (Sorbsan or Aquacel) or NaCl-impregnated gauze (Mesalt.). If multiple stage II ulcers develop while patient is on a group 1 surface for ≥1 month, consider a group II device. Seventy-five percent of stage II ulcers will heal in 8 weeks.

C. Stage III

Stage III is characterized by full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. This stage may include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

1. Management

Use a sterile Q-tip while examining in order to document tunneling. Do not use this to culture the wound; it will not yield reliable results, as it is not a sterile culture. If necrotic tissue or slough is present, sharp debridement is the best management. Exceptions are heel ulcers, thrombocytopenia, or patient refusal. Other methods of debridement are pulse lavage, whirlpool, wet to dry dressings (NaCl-impregnated gauze several times daily), chemical debridement (Santyl), or autolytic debridement via an occlusive dressing (Duoderm). Occlusive dressings are good for eschar attached to intact skin; once separated, it is more easily debrided mechanically or chemically. Combinations are also effective: Santyl with pulse lavage is an example.

D. Stage IV

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. This stage often includes undermining and tunneling.

As in stage III, the depth of a stage IV pressure ulcer varies by anatomical location. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule), which could result in osteomyelitis. Exposed bone/tendon is visible or directly palpable.

These are bad wounds; only 62% ever heal, and only 52% heal within 1 year. They should be managed as in stage III. If after 14 days there is no sign of healing, consider infection; see appropriate management under the section on treatment, later.

Two other stages are grouped with stage IV because of their similar severity levels.

E. Unstageable

Ulcers characterized by full-thickness tissue loss, in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, cannot be staged.

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

F. Suspected Deep-Tissue Injury

A purple or maroon localized area of discolored intact skin or a blood-filled blister may indicate damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep-tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

Complications

The most common complications are cellulitis, osteomyelitis, and sepsis. If local erythema of ≥1 cm occurs around the wound, topical antibiotics such as mupirocin should be used. If the erythema is rapidly expanding, with heat, edema, or induration, the patient should be treated for cellulitis with systemic antibiotics. Use local susceptibility patterns to guide therapy. If the patient exhibits systemic symptoms, such as fever, rigors, delirium, or leukocytosis, draw blood cultures and obtain a sterile wound culture by needle aspiration or punch biopsy. We recommend consulting infectious disease specialists if any infection is suspected. Update tetanus immunity.

Osteomyelitis is another complication and should be suspected in painful and nonhealing ulcers and whenever bone is visible. The ^99mTc bone scan and magnetic resonance imaging (MRI) have equal sensitivity. CT has good specificity, poor sensitivity. Needle biopsy of bone is the most useful single test, with a sensitivity of 73% and a specificity of 96%.

Sepsis is a serious consequence of infected pressure ulcers and a frequent cause of death, with mortality rates as high as 48%.

Treatment

A. Management

We recommend a team approach once a stage 1 ulcer is identified. The wound should be checked daily and documentation of healing performed weekly. A tool to document healing has been developed by the NPUAP. The pressure ulcer status for healing (PUSH) tool measures three components—size, exudate amount, and tissue type. This tool has been validated, has good inter-rater reliability, and is sensitive to change over time.

Enlist the care of a wound team. A physical therapist will mobilize the patient. Unless contraindicated, no elder should be on bed rest. An occupational therapist can assist with positioning for safety and recommend devices to minimize pressure. A wound nurse will document and often photograph the wound, and will recommend appropriate dressings and support surfaces.

Nutrition is essential to healing. A dietician will assist with protein, calorie, and water recommendations as well as nutritional deficiencies. A BMI of <19, with >5% weight loss in 30 days or >10% loss in 180 days, and a serum albumin of <3.5 g/dL suggest malnutrition. Daily administration of 30–40 kcal/kg body weight, 1.2–1.5 g protein/kg body weight, and minimum fluid intake of 30 mL/kg body weight is recommended for at-risk patients. Those with ulcers are in a catabolic state and will require a more intensive and tailored approach by a clinical dietician. While supplements of vitamin C and zinc are commonly recommended, there is no evidence that they enhance wound healing unless the patient is deficient. Zinc at 100 mg daily can cause nausea and vomiting. A speech therapist and oral surgeon/dentist should be involved as needed.

Urinary and fecal incontinence must be managed on a case-by-case basis. The risk of Foley catheter urinary tract infection must be weighed against the projected benefit of a dry wound site. Fecal incontinence can cause skin breakdown and impair healing. Toilet ambulatory patients frequently, manage diarrhea, and use containment devices when necessary.

Attend to pain management: both physical and psychic. Patient dignity should be valued and respected. While use of sedation is associated with significantly increased risk of ulcers, pain from them must be addressed. This is especially important before dressing changes. Topical narcotics may be effective and have the added advantage of minimal systemic absorption, sedation, and constipation.

B. Alternative Therapies

As of 2013 no benefits have been established for a number of therapies in the frail elderly, including platelet-derived growth factors, therapeutic ultrasound, electromagnetic therapy, nutritional supplements, hyperbaric oxygen, infrared, UV, low energy, laser irradiation, and most recently, honey.

C. Cultural Considerations

Some studies have shown higher incidence and severity of pressure ulcers in the African American and Native American populations. Postulated contributing factors are dark skin color and economic factors.

D. Patient Education

Caring for a patient with pressure ulcers is demanding. It is likely that the patient who develops a pressure ulcer has significant comorbidities that necessitate palliative treatment and, in fact, may indicate imminent end of life. Direct caregivers to resources such as AAA, Home Health, and support groups.

For chronically or terminally ill patients with longstanding or recurrent ulceration, aggressive treatment may not be beneficial. Under these circumstances, maintaining patient comfort should be the primary goal rather than instituting major invasive procedures.

General Considerations

More than one-third of community-dwelling elders will fall each year. Overall, 20–30% will suffer moderate to severe injuries such as hip fractures and head trauma that reduce mobility and independence. Falls have psychological and social consequences such as fear of falling, anxiety, social isolation, and loss of self-confidence.

Pathogenesis

Understanding the following construct will guide your exam and interventions. Most falls in older people result from the interaction of multiple intrinsic (age-related physiologic changes, medications, gait or balance disturbance, risk taking) and extrinsic factors (environmental hazards, lighting, footwear). Assessment of an acute fall event or of patients at risk for falls warrants a multidimensional approach incorporating (1) postural stability, (2) medical comorbidities, (3) overall function, and (4) environment.

Postural stability is maintained in three phases: input, processing, and output. Input includes vision, vestibular apparatus, and proprioception. Processing requires an intact nervous system: both central processing and competent efferent command. Output requires a motor system characterized by strength, flexibility, absence of pain, and cardiovascular endurance. Impairment of any one phase increases the risk for falls, and the risk is cumulative. Conversely, interventions to modify any of these impairments will decrease the risk for falls.

Chronic diseases, and the medications that we use to treat them, constitute the second key area of assessment. Conditions and drugs that affect the components of postural stability are suspect, and there are usually more than one. Conditions to consider are autonomic dysfunction; arrhythmia; seizure; movement disorder; and central nervous system (CNS) pathology, including dementia, vertigo, or vision impairment. Any medication or combination can contribute to falls; the following are particularly notorious: psychotropics, narcotics, benzodiazepines, antihistamines, antiarrhythmics, the cumulative effect of antihypertensives, combination of more than any four drugs, and alcohol.

Finally, the concept of functional thresholds places the data into a framework that identifies the point at which a particular patient exceeds his/her compensatory abilities. A detailed history and focused physical and performance examination will provide key information on function. For those frail elders, who most commonly fall at home, a home assessment completes the evaluation.

Prevention

A systematic review of scientific studies has identified several strategies, targeting both intrinsic and environmental risk factors that are likely to be beneficial in preventing falls. The only evidence-based strategies shown to reduce fall risk are exercise programs targeting at least two areas: strength, balance, flexibility, and endurance; individually prescribed exercise programs at home; a 15-week tai chi group exercise program of other group exercise; home hazard modification for at-risk patients; withdrawl of psychotropic or sedating medications and decreasing number of medications; cardiac pacing for fallers with cardioinhibitory cardotid sinus hypersensitivity; cataract surgery; and vitamin D supplementation in deficient patients.

Risk reduction should also include advice on appropriate footwear (hard-soled, flat, closed-toed shoes); adequate lighting for all activities, and caution with any activity that requires balance. Seniors should not climb stairs without a hand on the railing, stairways should be well illuminated, and the stairs should be in good repair. Climbing ladders should be discouraged. Robust elders should be cautioned about activities that increase their risk for falls (skiing, skating, etc) and that would hence place them at higher risk for fractures. Patients identified as having balance difficulty or with a history of multiple falls will benefit from muscle strengthening and balance retraining. Assistive devices may prevent falls when used correctly within a targeted intervention. Hip protectors may be necessary to prevent serious injuries such as hip fractures. Environmental modification is of known benefit as part of an overall targeted intervention in the subgroup of older patients who are at known risk for falls.

Clinical Findings

A. Signs and Symptoms

The history should elicit the exact details and circumstances surrounding the fall as precisely as possible. The clinician should ask questions regarding when the fall or near-fall occurred (what time of the day, postprandial), where the patient was (indoors, outdoors), what the patient was doing (getting up from seated position, climbing stairs, turning, reaching, stooping, micturating), how the patient fell (tripped or stumbled, lost balance, lost consciousness), whether there was pain (severe arthritis) or other symptoms (chest pain, shortness of breath, dizziness/lightheadedness, vertigo, diaphoresis, numbness and weakness of extremities, loss of consciousness), what medications were taken (prescription or OTC), and whether the patient had ingested alcohol.

Pinpointing the patient’s subjective complaints is very helpful. Lightheadedness or a near-faint is consistent with cerebral ischemia and would suggest orthostasis, arrhythmias, and other cardiovascular conditions. Muscular weakness, the sense that their legs cannot hold them up, would be more consistent with deconditioning, or neuromuscular disease. Dysequilibrium or the sensation of failed coordination between the legs and the walking surface is suggestive of vestibulospinal tract, proprioception, somatosensory, and cerebellar lesions. Finally, the sensation of movement within the patient or of the room spinning is true vertigo. Clinical examination in itself can provide some useful information about the events surrounding a fall; for example, wrist fractures by a fall on an outstretched hand suggest that consciousness was preserved while falling, or bilaterally damaged patellas suggest drop attacks.

B. Physical Examination

Integrate both pathogenesis and the history to guide a targeted physical exam. Refer to Table 41-3 for details.

C. Performance Assessment

Gait speed is currently the best predictor of mobility problems and correlates with future disability and life expectancy. The timed “get up and go” test is a simple, well-validated office tool for assessing gait and balance disturbance in frail elders. The patient sits in a straight-backed chair, then rises and walks 10 feet, turns, walks back, and sits on the chair. The patient may use whatever assistive device she/he normally uses and should be allowed one trial before being timed. Completion of the test in <10 seconds represents no risk and can be expected from nonfrail elders. A score of 10–19 seconds represents minimal risk; 20–29 seconds, moderate risk; and >30 seconds, a definite risk for falling. Referral to physical therapy is warranted for patients scoring ≥20 seconds.

D. Laboratory Findings

While lacking evidence, the following are reasonable: complete blood count and serum electrolytes, including calcium, blood urea nitrogen, vitamin B₁₂, vitamin D, and thyroid function tests. Neuroimaging can be useful for a person with a head injury or a new neurologic deficit. Electroencephalography is rarely helpful but may be indicated if there is high suspicion of seizure. Persons with unexplained falls may benefit from ambulatory electrocardiography (Holter monitor), although this has been associated with high false positives and false negatives.

E. Environmental Assessment

A home assessment is warranted for frail elders and for anyone who has fallen at home. This may be done by the physician or occupational therapist and should include the environment itself as well as a replay of the circumstances of the fall. (See Table 41-4.)

Conclusion

In conclusion, falls, like other syndromes of the elderly, are multifactorial and require a multidisciplinary approach. Assessment that identifies intrinsic and extrinsic causes helps focus targeted interventions. A team approach that incorporates the patient, specialists (physiatrist, ophthalmologist, optometrist, podiatrist, orthopedist), and occupational and physical therapists will maximize outcomes.