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Chapter One

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

Table 1-2. Nine Hallmarks of Aging

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

 

Chapter Two

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Chapter Three

Figure 3-1. The Kaiser Pyramid

Figure 3-2. Components of assessment of older patients

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

Table 3-2. Potential Difficulties in Taking Geriatric Histories

Table 3-3. Important Aspects of the Geriatric History

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

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

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

Table 3-7. Laboratory Assessment of Geriatric Patients

Table 3-8. Important Concepts for Geriatric Functional Assessment

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

Table 3-10. Examples of Measures of Physical Functioning

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

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

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

Table 3-13. Assessment of Body Composition

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

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

Table 3-16. Medicare Initial Preventive Physical Examination

Table 3-17. Medicare Annual Wellness Visit

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

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

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

Table 3-21. Preoperative Assessment Checklist

Table 3-22. Potential Manifestations of Caregiver Stress

 

Chapter Four

Figure 4-1. Paths to chronic disease catastrophe

Table 4-1. Chronic Care Tenets

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

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.

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

Table 4-2. Team Models

Table 4-3. Team Composition

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

Table 4-5. Rationale for Using Outcomes

Table 4-6. Outcomes Measurement Issues

Table 4-7. Geriatric Outcome Categories

Table 4-8. Choosing Wisely Recommendations

Table 4-9. ACOVE Recommendations

 

Chapter Five

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

Table 5-2. Preventive Strategies for Older Persons

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

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

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

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

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

Table 5-8. Types of Exercises

Figure 5-1. MyPlate for older adults

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

Table 5-10. Common Iatrogenic Problems of Older Persons

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

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

 

Chapter Six

Table 6-1. Key Aspects of Mental Status Examination

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

Table 6-3. Diagnostic Criteria for Delirium

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

Table 6-5. The Confusion Assessment Method Diagnostic Algorithm

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

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

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

Table 6-9. Interventions for Risk Factors for Delirium

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

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

Table 6-12. Causes of Dementia

Table 6-13. Clinical Features of Common Dementias

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

Table 6-14. Symptoms That May Indicate Dementia

Table 6-15. Evaluating Dementia: The History

Table 6-16. Evaluating Dementia: Recommended Diagnostic Studies

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

 

Chapter Seven

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

Table 7-2. Factors Predisposing Older People to Depression

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

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

Table 7-5. Medical Illnesses Associated With Depression

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

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

Table 7-8. Summary Criteria for Major Depressive Episode

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

Table 7-10. Examples of Screening Tools for Depression

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

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

Table 7-13. Antidepressants for Geriatric Patients

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

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

 

Chapter Eight

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.)

Table 8-1. Potential Adverse Effects of Urinary Incontinence

Table 8-2. Requirements for Continence

Figure 8-2. Structural components of normal micturition

Figure 8-3. Peripheral nerves involved in micturition

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)

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)

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

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

Table 8-5. Mnemonic for Potentially Reversible Conditions

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

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

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

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

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

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

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

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

Figure 8-9. Algorithm protocol for evaluating incontinence

Table 8-11. Treatment Options for Geriatric Urinary Incontinence

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

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

Table 8-14. Example of a Bladder Retraining Protocol

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

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

Table 8-17. Indications for Chronic Indwelling Catheter Use

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

Table 8-19. Causes of Fecal Incontinence

Table 8-20. Causes of Constipation

Table 8-21. Drugs Used to Treat Constipation

 

Chapter Nine

Table 9-1. Complications of Falls in Older Patients

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

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

Table 9-3. Causes of Falls

Table 9-4. Common Environmental Hazards

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

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

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

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

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

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

 

Chapter Ten

Table 10-1. Factors That Influence Immobility

Table 10-2. Complications of Immobility

Table 10-3. Assessment of Immobile Older Patients

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

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

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

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

Table 10-7. Drugs Used to Treat Parkinson Disease

Table 10-8. Clinical Characteristics of Pressure Sores

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

Table 10-10. Pain Categories and Management Options

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

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

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

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

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

 

Chapter Eleven

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

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

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

Table 11-4. Secondary Hypertension in Older Persons

Table 11-5. Thiazide Diuretics for Antihypertensive Therapy

Table 11-6. Antihypertensive Medications

Table 11-7. Stroke

Table 11-8. Outcome for Survivors of Stroke

Table 11-9. Modifiable Risk Factors for Ischemic Stroke

Table 11-10. Transient Ischemic Attack: Presenting Symptoms

Table 11-11. Factors in Prognosis for Rehabilitation

Table 11-12. Stroke Rehabilitation

Table 11-13. Presenting Symptoms of Myocardial Infarction

Table 11-14. Differentiation of Systolic Murmurs

Table 11-15. Manifestations of Sick Sinus Syndrome

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

 

Chapter Twelve

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

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

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

Table 12-3. Thyroid Function in Normal Older Adults

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

Table 12-5. Thyroid Function Tests in Nonthyroidal Illness

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

Table 12-6. Myxedema Coma

Table 12-7. Laboratory Findings in Metabolic Bone Disease

Table 12-8. Signs and Symptoms of Anemia

Table 12-9. Differential Tests in Hypochromic Anemia

Table 12-10. Nutritional Requirements in Older Persons

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

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

Table 12-13. Clinical Presentation of Hypothermia

Table 12-14. Clinical Presentation of Hyperthermia

Table 12-15. Complications of Heat Stroke

 

Chapter Thirteen

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

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

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

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

Table 13-5. Potential Adverse Effects of Ophthalmic Solutions

Table 13-6. Aids to Maximize Visual Function

Table 13-7. Functional Components of the Auditory System

Table 13-8. Assessment of Hearing

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

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

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

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

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

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

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

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

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

 

Chapter Fourteen

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

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

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

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

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

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

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

Table 14-6. Renal Function in Relation to Age

Table 14-7. General Recommendations for Geriatric Prescribing

Table 14-8. Examples of Antipsychotic Drugs

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

 

Chapter Fifteen

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

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

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

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

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

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

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

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

Table 15-3. Potential Symptoms of Caregiver Stress

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

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

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

Figure 15-10. Institutional use by disability

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

Table 15-5. RUG-IV Classification System

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

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

Figure 15-12A. Personal care pyramid

Figure 15-12B. Medical needs pyramid

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

Table 15-8. Variations in Case Management

 

Chapter Sixteen

Table 16-1. Goals of Nursing Home Care

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

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

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

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

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

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

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

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

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

 

Chapter Seventeen

Table 17-1. Major Ethical Principles

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

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

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

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

Table 17-6. Evidence of Abuse or Neglect

 

Chapter Eighteen

Table 18-1. Hospice Services

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

Table 18-3. Signs and Symptoms of Frailty

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

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

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

Table 18-7. Adjuvant Pharmacologic Treatments for Pain Management

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