Ebook Essentials of clinical geriatrics (7/E): Part 1

ESSENTIALS OF
CLINICAL GERIATRICS


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ESSENTIALS OF
CLINICAL GERIATRICS
SEVENTH EDITION

Robert L. Kane, MD
Professor and Minnesota Endowed Chair in Long-Term Care and Aging
School of Public Health
University of Minnesota

Minneapolis, Minnesota

Joseph G. Ouslander, MD
Professor and Senior Associate Dean for Geriatric Programs
Charles E. Schmidt College of Medicine
Professor (Courtesy), Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida

Itamar B. Abrass, MD
Professor Emeritus
Department of Medicine
Division of Gerontology and Geriatric Medicine
University of Washington
Harborview Medical Center
Seattle, Washington

Barbara Resnick, PhD, CRNP, FAAN, FAANP
Professor
University of Maryland School of Nursing
Sonya Gershowitz Chair in Gerontology  
Baltimore, Maryland

New York  Chicago  San Francisco  Lisbon  London  Madrid  Mexico City
Milan  New Delhi  San Juan  Seoul  Singapore  Sydney  Toronto


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Contents
List of Tables and Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

PART I

The Aging Patient and
Geriatric Assessment
  1. Clinical Implications of the Aging Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
  2. The Geriatric Patient: Demography, Epidemiology, and
Health Services Utilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
  3. Evaluating the Geriatric Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
  4. Chronic Disease Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Part II

Differential Diagnosis
and Management
  5. Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

  6. Delirium and Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
  7. Diagnosis and Management of Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
  8. Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
  9. Falls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
10. Immobility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

PART III

General Management
Strategies
11. Cardiovascular Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
12. Decreased Vitality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
13. Sensory Impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
14. Drug Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
15. Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
v


vi

Contents
16. Nursing Home Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
17. Ethical Issues in the Care of Older Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
18. Palliative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

APPENDIX  Selected Internet Resources on Geriatrics. . . . . . . . . . . . . . . . . . . . . . . . . . 481
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485


Tables and Figures

Chapter one
Table 1-1.

Pertinent Changes That Commonly Occur with Aging. . . . . . . . . . . . . . . . . 6

Table 1-2.

Major Theories on Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Table 1-3.

Web-Based Resources for Health Promotion. . . . . . . . . . . . . . . . . . . . . . . 16

Chapter Two
Table 2-1.

The Elderly Population of The United States: Trends 1900-2050. . . . . . . . 26

Table 2-2.Average Per Capita Health Spending for Medicare Beneficiaries
Age 65 and Over (Age-Adjusted) in 2003, Dollars by Functional
Status, 1992-2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Table 2-3.Changes in Commonest Causes of Death, 1900-2002,
All Ages and Those 65 Years and Older . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Table 2-4.Percentage of Older Adults Having Any Difficulty Performing
Selected Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Table 2-5.Hospital Discharge Diagnoses and Procedures for Persons Age
65 Years and Older, 2008. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Table 2-6.

Postacute Care Used Within 30 Days, 2006 and 2008,
for the Top Five Diagnostic Related Groups. . . . . . . . . . . . . . . . . . . . . . . 34

Table 2-7.

Percentage of Office Visits by Selected Medical Conditions, 2008 . . . . . . 34

Table 2-8.

Factors Affecting the Need for Nursing Home Admission. . . . . . . . . . . . . 37

Figure 2-1.Deaths Per 100,000 Men, Age 65 and Over (Age-Adjusted),
Selected Causes, 1981-2004. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Figure 2-2.Life Expectancy at Age 65 by Sex and Race/Ethnicity, 1950-2003. . . . . . 24
Figure 2-3.Living Arrangements by Age and Sex, 2006.. . . . . . . . . . . . . . . . . . . . . . 30
Figure 2-4.Percent of Persons Age 65 and Over (Age-Adjusted)
Reporting Selected Chronic Conditions by Sex, 2004-2005. . . . . . . . . . . . 31
Figure 2-5.Nursing Home Residents per 1000 Population by Age, Sex, and Race/
Ethnicity, 2004.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Chapter Three
Table 3-1.

Examples of Randomized Controlled Trials of Geriatric Assessment. . . . . 43

Table 3-2.

Potential Difficulties in Taking Geriatric Histories. . . . . . . . . . . . . . . . . . . . 45

Table 3-3.

Important Aspects of the Geriatric History . . . . . . . . . . . . . . . . . . . . . . . . 46

Table 3-4.Common Physical Findings and Their Potential Significance
in Geriatrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Table 3-5.

Laboratory Assessment of Geriatric Patients. . . . . . . . . . . . . . . . . . . . . . . 53
vii


viii

Tables and Figures
Table 3-6.

Important Concepts for Geriatric Functional Assessment. . . . . . . . . . . . . 55

Table 3-7.

Purposes and Objectives of Functional Status Measures. . . . . . . . . . . . . . 55

Table 3-8.

Examples of Measures of Physical Functioning. . . . . . . . . . . . . . . . . . . . . 56

Table 3-9.

Important Aspects of the History in Assessment of Pain . . . . . . . . . . . . . 59

Table 3-10.Important Aspects of the Physical Examination in
Assessment of Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Table 3-11.

Assessment of Body Composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Table 3-12.

Critical Questions in Assessing a Patient for Malnutrition. . . . . . . . . . . . . 61

Table 3-13.

Factors That Place Older Adults at Risk for Malnutrition. . . . . . . . . . . . . . 61

Table 3-14.

Mini Nutrition Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Table 3-15.Example of a Screening Tool to Identify Potentially
Remediable Geriatric Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Table 3-16.Questions on the Probability of Repeated Admissions Instrument
for Identifying Geriatric Patients at Risk for Health Service Use . . . . . . . . 65
Table 3-17.Suggested Format for Summarizing the Results of a
Comprehensive Geriatric Consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Table 3-18.

Key Factors in the Preoperative Evaluation of the Geriatric Patient . . . . . 66

Figure 3-1.

Components of Assessment of Older Patients.. . . . . . . . . . . . . . . . . . . . . 42

Figure 3-2.Samples of Two Pain Intensity Scales That Have Been Studied
in Older Persons.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Chapter four
Table 4-1.

Chronic Care Tenets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Table 4-2.

Rationale for Using Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Table 4-3.

Outcomes Measurement Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Table 4-4.

ACOVE Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Figure 4-1.

Paths to Chronic Disease Catastrophe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Figure 4-2.Narrowing of the Therapeutic Window. . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Figure 4-3.A Conceptual Model of the Difference Between Expected and
Actual Care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Figure 4-4.Clinical Glidepath Models... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Chapter five
Table 5-1.

Considerations in Assessing Prevention in Older Patients. . . . . . . . . . . . . 94

Table 5-2.

Preventive Strategies for Older Persons. . . . . . . . . . . . . . . . . . . . . . . . . . 95

Table 5-3.

Healthy People Report Card Items for Seniors . . . . . . . . . . . . . . . . . . . . . 95

Table 5-4.U.S. Preventive Services Task Force (USPSTF) Recommendations for
Screening Older Adults and Medicare Coverage. . . . . . . . . . . . . . . . . . . . 96


Tables and Figures
Table 5-5.Additional Preventive Services From U.S. Preventive Services
Task Force (USPSTF) (May Be Suitable for Older Adults)
and Medicare Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Table 5-6.

Types of Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Table 5-7.

Relative Effectiveness of Various Osteoporosis Treatments. . . . . . . . . . . 122

Table 5-8.

Common Iatrogenic Problems of Older Persons. . . . . . . . . . . . . . . . . . . 122

Table 5-9.

Frequency of Patient Risk Factors for Iatrogenic Hospital Events. . . . . . . 124

Table 5-10.

The Hazards of Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Table 5-11.

Patient Risk Factors for Iatrogenic Hospital Events . . . . . . . . . . . . . . . . . 125

Table 5-12.

Risk Factors for Functional Decline in Elderly Hospitalized Patients. . . . . 126

Table 5-13.

Potential Complications of Bed Rest in Older Persons. . . . . . . . . . . . . . . 126

Figure 5-1.Changes in Health Habits Among Persons 65 Years and Older.. . . . . . . 115
Figure 5-2.Narrowing of the Therapeutic Window. . . . . . . . . . . . . . . . . . . . . . . . . . 123

Chapter six
Table 6-1.

Key Aspects of Mental Status Examination. . . . . . . . . . . . . . . . . . . . . . . 134

Table 6-2.

Diagnostic Criteria for Delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Table 6-3.

Comparison of Presentation of Delirium and Dementia. . . . . . . . . . . . . 138

Table 6-4.

Common Causes of Delirium in Geriatric Patients. . . . . . . . . . . . . . . . . . 139

Table 6-5.

Drugs That Can Cause or Contribute to Delirium and Dementia. . . . . . . 140

Table 6-6.

Causes of Potentially Reversible Dementias. . . . . . . . . . . . . . . . . . . . . . 141

Table 6-7.

Causes of Nonreversible Dementias. . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Table 6-8.

Diagnostic Criteria for Alzheimer Dementia . . . . . . . . . . . . . . . . . . . . . . 143

Table 6-9.Alzheimer Disease Versus Multi-Infarct Dementia:
Comparison of Clinical Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Table 6-10.

Symptoms That May Indicate Dementia. . . . . . . . . . . . . . . . . . . . . . . . . 146

Table 6-11.

Evaluating Dementia: The History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Table 6-12.

Evaluating Dementia: Recommended Diagnostic Studies. . . . . . . . . . . . 148

Table 6-13.

Key Principles in the Management of Dementia . . . . . . . . . . . . . . . . . . 150

Figure 6-1.Primary Degenerative Dementia Versus Multi-Infarct Dementia:
Comparison of Time Courses.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Chapter Seven
Table 7-1.

Factors Associated with Suicide in the Geriatric Population . . . . . . . . . . 161

Table 7-2.

Factors Predisposing Older People to Depression. . . . . . . . . . . . . . . . . . 162

Table 7-3.

Examples of Physical Symptoms That Can Represent Depression. . . . . . 164

Table 7-4.

Key Factors in Evaluating the Complaint of Insomnia. . . . . . . . . . . . . . . 165

Table 7-5.

Medical Illnesses Associated with Depression . . . . . . . . . . . . . . . . . . . . 167

ix


x

Tables and Figures
Table 7-6.

Drugs That Can Cause Symptoms of Depression. . . . . . . . . . . . . . . . . . . 169

Table 7-7.Some Differences in the Presentation of Depression in the
Older Population, as Compared with the Younger Population. . . . . . . . . 170
Table 7-8.

Summary Criteria for Major Depressive Episode. . . . . . . . . . . . . . . . . . . 171

Table 7-9.

Major Depression Versus Other Forms of Depression. . . . . . . . . . . . . . . 172

Table 7-10.

Examples of Screening Tools for Depression. . . . . . . . . . . . . . . . . . . . . . 173

Table 7-11.Diagnostic Studies Helpful in Evaluating Depressed Geriatric
Patients with Somatic Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Table 7-12.

Evidence-Based Treatment Modalities for Depression. . . . . . . . . . . . . . . 175

Table 7-13.

Antidepressants for Geriatric Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Table 7-14.

Characteristics of Selected Antidepressants for Geriatric Patients. . . . . . 182

Chapter eight
Table 8-1.

Potential Adverse Effects of Urinary Incontinence. . . . . . . . . . . . . . . . . . 188

Table 8-2.

Requirements for Continence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

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

Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Table 8-4.

Medications That Can Cause or Contribute to Urinary Incontinence . . . . 195

Table 8-5.

Mnemonic for Potentially Reversible Conditions. . . . . . . . . . . . . . . . . . . 195

Table 8-6.

Basic Types and Causes of Persistent Urinary Incontinence . . . . . . . . . . 198

Table 8-7.Components of the Diagnostic Evaluation of Persistent Urinary
Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Table 8-8.

Key Aspects of an Incontinent Patient’s History. . . . . . . . . . . . . . . . . . . 201

Table 8-9.

Key Aspects of an Incontinent Patient’s Physical Examination. . . . . . . . 204

Table 8-10.Criteria for Considering Referral of Incontinent Patients for
Urological, Gynecological, or Urodynamic Evaluation . . . . . . . . . . . . . . . 207
Table 8-11.

Treatment Options for Geriatric Urinary Incontinence. . . . . . . . . . . . . . . 210

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

Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Table 8-13.

Examples of Behavioral Interventions for Urinary Incontinence . . . . . . . 212

Table 8-14.

Example of a Bladder Retraining Protocol. . . . . . . . . . . . . . . . . . . . . . . . 214

Table 8-15.

Example of a Prompted Voiding Protocol for a Nursing Home. . . . . . . . 215

Table 8-16.

Drug Treatment for Urinary Incontinence and Overactive Bladder . . . . . 217

Table 8-17.

Indications for Chronic Indwelling Catheter Use. . . . . . . . . . . . . . . . . . . 223

Table 8-18.

Key Principles of Chronic Indwelling Catheter Care. . . . . . . . . . . . . . . . . 223

Table 8-19.

Causes of Fecal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Table 8-20.

Causes of Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Table 8-21.

Drugs Used to Treat Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Figure 8-1.Prevalence of Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188


Tables and Figures
Figure 8-2.

Structural Components of Normal Micturition. . . . . . . . . . . . . . . . . . . . . 190

Figure 8-3.

Peripheral Nerves Involved in Micturition. . . . . . . . . . . . . . . . . . . . . . . . 191

Figure 8-4.Simplified Schematic of the Dynamic Function of the
Lower Urinary Tract During Bladder Filling (left) and Emptying (right).. . . . 192
Figure 8-5.

Basic Underlying Causes of Geriatric Urinary Incontinence.. . . . . . . . . . . 193

Figure 8-6.Simplified Schematic Depicting Age-Associated Changes in
Pelvic Floor Muscle, Bladder, and Urethra–Vesicle Position,
Predisposing to Stress Incontinence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Figure 8-7.

Basic Types of Persistent Geriatric Urinary Incontinence. . . . . . . . . . . . . 197

Figure 8-8.

Example of a Bladder Record for Ambulatory Care Settings.. . . . . . . . . . 202

Figure 8-9.Example of a Record to Monitor Bladder and Bowel Functions in
Institutional Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Figure 8-10. Example of a Simplified Grading System for Cystoceles.. . . . . . . . . . . . . 205
Figure 8-11. Algorithm Protocol for Evaluating Incontinence.. . . . . . . . . . . . . . . . . . . 209

Chapter nine
Table 9-1.

Complications of Falls in Elderly Patients . . . . . . . . . . . . . . . . . . . . . . . . 230

Table 9-2.

Age-Related Factors Contributing to Instability and Falls. . . . . . . . . . . . . 231

Table 9-3.

Causes of Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Table 9-4.

Common Environmental Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Table 9-5.

Factors Associated with Falls Among Older Nursing Home Residents. . . . . 234

Table 9-6.

Evaluating the Elderly Patient Who Falls: Key Points in the History. . . . 238

Table 9-7.Evaluating the Elderly Patient Who Falls: Key Aspects of the
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Table 9-8.Example of a Performance-Based Assessment of Gait and
Balance (Get Up and Go). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Table 9-9.Principles of Management for Elderly Patients with Complaints of
Instability and/or Falls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Table 9-10.Examples of Treatment for Underlying Causes of Falls. . . . . . . . . . . . . . 244
Figure 9-1.Multifactorial Causes and Potential Contributors to Falls
in Older Persons.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Chapter ten
Table 10-1.

Common Causes of Immobility in Older Adults. . . . . . . . . . . . . . . . . . . . 248

Table 10-2.

Complications of Immobility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

Table 10-3.

Assessment of Immobile Older Patients. . . . . . . . . . . . . . . . . . . . . . . . . 251

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

Older Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

xi


xii

Tables and Figures
Table 10-5.

Clinical Features of Osteoarthritis Versus Inflammatory Arthritis. . . . . . . 254

Table 10-6.

Drugs Used to Treat Parkinson Disease. . . . . . . . . . . . . . . . . . . . . . . . . . 258

Table 10-7.

Clinical Characteristics of Pressure Sores. . . . . . . . . . . . . . . . . . . . . . . . . 262

Table 10-8.

Principles of Skin Care in Immobile Older Patients. . . . . . . . . . . . . . . . . 263

Table 10-9.

Types of Pain, Examples, and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . 266

Table 10-10. Basic Principles of Rehabilitation in Older Patients. . . . . . . . . . . . . . . . . 268
Table 10-11.Physical Therapy in the Management of Immobile

Older Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Table 10-12.Occupational Therapy in the Management of Immobile
Older Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Figure 10-1. Characteristics of Different Types of Hip Fractures.. . . . . . . . . . . . . . . . . 256

Chapter Eleven
Table 11-1.Resting Cardiac Function in Persons Age 30 to 80 Years
Old Compared with That in Persons Age 30 Years Old. . . . . . . . . . . . . . 278
Table 11-2.Performance at Maximum Exercise in Sample Screened for
Coronary Artery Disease, Age 30 to 80 Years. . . . . . . . . . . . . . . . . . . . . 278
Table 11-3.

Initial Evaluation of Hypertension in Older Adults. . . . . . . . . . . . . . . . . . 279

Table 11-4.

Secondary Hypertension in Older Persons. . . . . . . . . . . . . . . . . . . . . . . 280

Table 11-5.

Thiazide Diuretics for Antihypertensive Therapy. . . . . . . . . . . . . . . . . . . 281

Table 11-6.

Antihypertensive Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

Table 11-7.

Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Table 11-8.

Outcome for Survivors of Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Table 11-9.

Modifiable Risk Factors for Ischemic Stroke . . . . . . . . . . . . . . . . . . . . . . 286

Table 11-10. Transient Ischemic Attack: Presenting Symptoms. . . . . . . . . . . . . . . . . . 287
Table 11-11. Factors in Prognosis for Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Table 11-12. Stroke Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Table 11-13. Presenting Symptoms of Myocardial Infarction. . . . . . . . . . . . . . . . . . . . 290
Table 11-14. Differentiation of Systolic Murmurs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Table 11-15. Manifestations of Sick Sinus Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . 295
Table 11-16. Calculation of the Ankle–Brachial Index . . . . . . . . . . . . . . . . . . . . . . . . . 297

Chapter Twelve
Table 12-1.

Step-Care Approach to the Treatment of Type 2 Diabetes . . . . . . . . . . . 306

Table 12-2.Hyperosmolar Nonketotic (HNK) Coma and
Diabetic Ketoacidosis (DKA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Table 12-3.

Thyroid Function in the Normal Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . 311

Table 12-4.

Laboratory Evaluation of Thyroid Disease in the Elderly. . . . . . . . . . . . . 312

Tables and Figures
Table 12-5.

Thyroid Function Tests in Nonthyroidal Illness. . . . . . . . . . . . . . . . . . . . . 312

Table 12-6.

Myxedema Coma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

Table 12-7.

Laboratory Findings in Metabolic Bone Disease. . . . . . . . . . . . . . . . . . . 317

Table 12-8.

Signs and Symptoms of Anemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Table 12-9.

Differential Tests in Hypochromic Anemia . . . . . . . . . . . . . . . . . . . . . . . 320

Table 12-10. Nutritional Requirements in Older Persons. . . . . . . . . . . . . . . . . . . . . . . 322
Table 12-11. Factors Predisposing to Infection in Older Adults . . . . . . . . . . . . . . . . . . 326
Table 12-12. Pathogens of Common Infections in Older Adults. . . . . . . . . . . . . . . . . . 328
Table 12-13. Clinical Presentation of Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Table 12-14. Clinical Presentation of Hyperthermia. . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Table 12-15. Complications of Heat Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Figure 12-1.Flow Diagram for Treatment of Hospitalized (Nonintensive Care Unit)

Patients with Type 2 Diabetes Mellitus.. . . . . . . . . . . . . . . . . . . . . . . . . 309
Figure 12-2.An Algorithm for the Management of Subclinical Hypothyroidism.. . . . . 314

Chapter Thirteen
Table 13-1.

Physiological and Functional Changes of the Eye. . . . . . . . . . . . . . . . . . 342

Table 13-2.

Ophthalmological Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

Table 13-3.

Restoring Vision After Cataract Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . 344

Table 13-4.Signs and Symptoms Associated with Common Visual
Problems in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Table 13-5.

Aids to Maximize Visual Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

Table 13-6.

Potential Adverse Effects of Ophthalmic Solutions. . . . . . . . . . . . . . . . . 349

Table 13-7.

Peripheral and Central Auditory Nervous System. . . . . . . . . . . . . . . . . . 350

Table 13-8.

Functional Components of the Auditory System. . . . . . . . . . . . . . . . . . . 351

Table 13-9.

Assessment of Hearing Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

Table 13-10. Effects of Aging on the Hearing Mechanism. . . . . . . . . . . . . . . . . . . . . . 352
Table 13-11. Hearing Performance in Older Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Table 13-12. Disorders of Hearing in Older Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Table 13-13. Factors in Evaluation for a Hearing Aid. . . . . . . . . . . . . . . . . . . . . . . . . . 355
Figure 13-1.Prevalence of Vision Problems in Older Persons, 1984.. . . . . . . . . . . . . . 343
Figure 13-2.Prevalence of Hearing Problems in Older Persons, 1984.. . . . . . . . . . . . 350
Figure 13-3.Diagnostic Approach to Polyneuropathy.. . . . . . . . . . . . . . . . . . . . . . . . . 357

Chapter Fourteen
Table 14-1.

Strategies to Improve Compliance in the Geriatric Population . . . . . . . . 364

Table 14-2.Examples of Common and Potentially Serious Adverse
Drug Reactions in the Geriatric Population. . . . . . . . . . . . . . . . . . . . . . . 366

xiii


xiv

Tables and Figures

Table 14-3.Examples of Potentially Clinically Important
Drug–Drug Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Table 14-4.Examples of Potentially Clinically Important
Drug–Patient Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Table 14-5.

Age-Related Changes Relevant to Drug Pharmacology. . . . . . . . . . . . . . 370

Table 14-6.

Renal Function in Relation to Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372

Table 14-7.

General Recommendations for Geriatric Prescribing. . . . . . . . . . . . . . . . 374

Table 14-8.

Examples of Antipsychotic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Table 14-9.Examples of Hypnotics Approved for Insomnia by the U.S.
Food and Drug Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Figure 14-1.Factors That Can Interfere with Successful Drug Therapy.. . . . . . . . . . . . 362
Figure 14-2.Example of a Basic Medication Record. . . . . . . . . . . . . . . . . . . . . . . . . . 363

Chapter Fifteen
Table 15-1.

Summary of Major Federal Programs for Elderly Patients. . . . . . . . . . . . 393

Table 15-2.Remaining Lifetime Use of Long-Term Supportive Services (LTSS)
by People Turning 65 in 2005. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Table 15-3.Comparison of Nursing Home Residents and the
Noninstitutionalized Population Age 65, 1995. . . . . . . . . . . . . . . . . . . . 405
Table 15-4.

RUG-IV Classification System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408

Table 15-5.

Home Care Provided Under Various Federal Programs. . . . . . . . . . . . . . 411

Table 15-6.

Examples Of Community Long-Term Care Programs. . . . . . . . . . . . . . . . 414

Table 15-7.

Variations in Case Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416

Figure 15-1.Theoretical Model of Observed Versus Expected Clinical Course. . . . . . . 382
Figure 15-2.Distribution of Personal Health-Care Expenditure, by Type of
Service: Selected Calendar Years 1980, 1990, 2000, and 2010.. . . . . . . 383
Figure 15-3.Percent Distribution of Medicare Program Payments,
by Type of Service: Calendar Years 1967 and 2010.. . . . . . . . . . . . . . . . . 385
Figure 15-4.Distribution of Medicaid Vendor Payments, by Type of Service:
Fiscal Years 1975 and 2008.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
Figure 15-5.Distribution of Place of Residence Among Older Persons with
Disabilities, 1999 and 2004.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Figure 15-6.Age-Adjusted Disability Rates Among the 65+ Population,

1984-2004.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Figure 15-7.Disability Prevalence and the Need for Assistance by Age: 2005.. . . . . 398
Figure 15-8.Projected Growth in Numbers of Older Persons
with Disabilities, 1996-2050. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Figure 15-9.Long-Term Care Spending, by Payer CY 2007... . . . . . . . . . . . . . . . . . . . 399
Figure 15-10.Change in the Rate of Nursing Home Use by Age Group, 1973-2004.. . . 402


Tables and Figures
Figure 15-11.Use of Different Types of Institutional Long-Term Care by
Age Group, 1985 and 2004.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Figure 15-12.Rate of Institutional Use Among Persons Age 65+ by
Level of ­Disability, 1984 and 2004.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Figure 15-13.Relative Likelihood of Using a Nursing Home as Function of
Potentially Changeable Lifestyle Disease.. . . . . . . . . . . . . . . . . . . . . . . . 405

Chapter Sixteen
Table 16-1.

Goals of Nursing Home Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420

Table 16-2.Factors That Distinguish Assessment and Treatment in the
Nursing Home Different From Assessment and Treatment
in Other Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Table 16-3.

Common Clinical Disorders in the Nursing Home Population. . . . . . . . . 423

Table 16-4.Important Aspects of Various Types of Assessment in the
Nursing Home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426

Table 16-5.SOAP Format for Medical Progress Notes on Nursing
Home Residents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Table 16-6.Screening, Health Maintenance, and Preventive Practices
in the Nursing Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Table 16-7.

Common Ethical Issues in the Nursing Home. . . . . . . . . . . . . . . . . . . . . 443

Figure 16-1.Basic Types of Nursing Home Patients.. . . . . . . . . . . . . . . . . . . . . . . . . . 420
Figure 16-2.Example of a Face Sheet for a Nursing Home Record.. . . . . . . . . . . . . . 432
Figure 16-3.Example of an INTERACT VERSION 3.0 Care Path for
Managing Acute Change in Condition in a Nursing Home.. . . . . . . . . . . 440

Chapter Seventeen
Table 17-1.

Major Ethical Principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448

Table 17-2.

Components of a Durable Power of Attorney for Health Care. . . . . . . . . 451

Table 17-3.Goals of Care and Symptoms Requiring Management at the
End of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457

Chapter eighteen
Table 18-1.

Hospice Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468

Table 18-2.A Five-Step Framework for Discussing Care Choices at the
End of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Table 18-3.

Signs and Symptoms of Frailty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471

Table 18-4.

Management of Symptoms Noted at End of Life. . . . . . . . . . . . . . . . . . 474

Table 18-5. Adjuvant Treatments for Pain Management. . . . . . . . . . . . . . . . . . . . . . 476

xv


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PREFACE
Since we wrote the original text almost 30 years ago, geriatrics has gone through a number
of transitions. The world has become increasingly aware of the centrality of chronic disease
and people have begun to recognize that the principles of geriatrics are eminently suited to
addressing this challenge. Sadly and ironically, just as the need for more and better primary
care and comprehensive care has grown, interest in primary care and geriatrics has waned. The
concepts and practices embodied in this book have never been more salient. If society fails to
embrace these ideas and to find ways to implement them, we will face a medical catastrophe.
There is growing appreciation that our medical care system is not structured to effectively
address complex chronic disease and multimorbidity, which are both common in the geriatric
population. Proposals for changes are endemic. At their heart is coordination and broader
accountability, principles embraced by geriatrics.

Stated simply, geriatrics stands at the intersection of three forces:
1.  Gerontology (both basic and applied)
2.  Chronic disease management, especially multimorbidities
3.  End-of-life care
Principles of gerontology can help to explain insights of geriatric care. For example, the
atypical presentation of disease in older persons occurs because a hallmark of aging is a
decreased ability to respond to stress, and the body’s stress response is what typically generates
the symptoms of an illness. Older people fail to respond as actively. Hence, they may not spike
fevers or show elevated white counts in the face of an infection. Heart disease may be silent.
Chronic disease management is difficult on its own. It is much more difficult when an
older patient suffers from multiple simultaneous diseases. Basic care guidelines may not work.
Indeed, they make pose a threat. Guidelines are disease specific, and application of guidelines
may result in recommendations for a plethora of nonpharmacological and pharmacological interventions that are unrealistic, unacceptable, expensive, and hazardous. Much of the
emphasis in geriatric care planning is directed at containing disease and maintaining function.
Moreover, geriatrics recognizes that medical issues can interact with other social and environmental issues, mandating comprehensive approaches to care.
Death is a part of old age. Geriatrics must deal with that reality and help patients and
families deal with end of life, helping them to make informed decisions that reflect their goals
and priorities. But geriatrics cannot focus exclusively on end-of life-care. One compromise has
been the evolution of palliative care (discussed in Chapter 18 of this edition).
To this list, one might also add appropriate attention to prevention. Healthy aging remains
a goal.
This seventh edition of Essentials of Clinical Geriatrics represents a timely tome that combines practical information to help clinicians and other practitioners from a variety of disciplines to more effectively address the challenges posed by the grey tsunami. But a thoughtful
reading will also reveal many tips for better chronic care practice in general.
It is organized to provide linear exposition on salient topics but also as a rapid reference
guide with many tables and figures that summarize and simplify complex areas. The goal of
the book remains to help people do a better job of caring for older patients.
As ever, we welcome ideas and suggestions about how we can make the book more useful.
xvii

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Pa r t I
P a rPatient
t X
The Aging
and
GeriatricPart
Assessment
Title


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3

Chapter 1

Geriatrics stands at the intersection of three forces:
1.Gerontology (both basic and applied)
2.Chronic disease management, especially multimorbidities
3.End-of-life care
Principles of gerontology can help to explain insights of geriatric care. For example,
the presentation of disease is often different in older persons because the response to
stress is different. A hallmark of aging is a decreased ability to respond to stress. The
body’s stress response is what typically generates the symptoms of an illness. Older
people fail to respond as actively. Hence, they may not have spiking fevers or elevated
white blood cell counts in the face of an infection. Heart disease may be silent.

Chronic disease management is difficult on its own. It is much more difficult when
an older patient suffers from multiple simultaneous diseases. Basic care guidelines
may not work. Indeed, they may pose a threat (Boyd et al., 2005).
Much of the emphasis in care planning is directed at containing disease and
maintaining function and improving quality of life. Death is a part of old age.
Geriatrics must deal with that reality and help patients and families deal with
end of life, helping them to make informed decisions that reflect their goals and
­priorities. But geriatrics cannot focus exclusively on end-of-life care. One compromise has been the evolution of palliative care (discussed in Chapter 18).
To this triad, some might also add a role for advocating reasonable preventive
actions (see Chapter 5).
The care of older patients differs from that of younger patients for a number of
reasons. While there continues to be a debate about the cause of these differences, it is
likely that they are a combination of biological changes that occur during the course of
aging, associated diseases, and attitudes and beliefs of older adults and their caregivers.
Aging is defined as the time-sequential deterioration that occurs in most living beings,
including weakness, increased susceptibility to disease and adverse environmental conditions, loss of mobility and agility, and age-related physiological changes (Goldsmith,
2006). At least in vitro, it is clear that the “aging clock” can be reset (reviewed in Rando
and Chang, 2012). Somatic cell nuclear transfer of the nucleus of a mature somatic cell
into an enucleated oocyte can give rise to mature, fertile animals.
It is important to distinguish life expectancy from life span. The former refers to
what proportion of the possible maximum age a person may live. The latter suggests a biological limit to how many years a species can expect to survive. In general,
geriatrics has the most to contribute to improving life expectancy, but new genetic

PART I

Clinical Implications of the
Aging Process


4

The Aging Patient and Geriatric Assessment

PART I

breakthroughs may ultimately affect life span as well. Another helpful distinction is
between chronological aging and gerontological aging. The latter is calculated on the
basis of the risk of dying, the so-called force of mortality. Thus, two people of the same
chronological age may have biologically very different ages depending on their health
state. Some of that propensity for death is malleable; some is simply predictable.
Perhaps one of the most intriguing challenges in medicine is to unravel the process of aging. From a medical perspective, the question continues to haunt us as to
whether aging is a feature of an organism’s design that has evolved over time and
is beneficial to the survival of species, or aging is a disease or defect that confers no
survival benefit. Even more important to medical management of aging is the question
of whether there are medically treatable factors that are common to the various manifestations of aging we see. Could aging treatments delay the signs and symptoms of
aging such as sensory changes, musculoskeletal problems, or skin-related changes?
Nonetheless, the distinction between so-called normal aging and pathologic
changes is critical to the care of older people. We wish to avoid both dismissing
treatable pathology as simply a concomitant of old age and treating natural aging
processes as though they were diseases. The latter is particularly dangerous because
older adults are so vulnerable to iatrogenic effects.
There is growing appreciation that everyone does not age in the same way or at the
same rate. The changing composition of today’s older adults compared with that of a
generation ago may actually reflect a bimodal shift wherein there are both more disabled
people and more healthy older people. We continue to learn more and more about
healthy or successful aging through hearing the stories of the growing number of centenarians. Generally the consensus is that moderation in all areas (eg, food intake, alcohol
intake), regular physical activity, and an engaging social life are critical to successful
aging. A recent large actuarial study (Gavrilova and Gavrilov, 2005) further suggested
that environmental factors may also be relevant. Social factors can also play a strong role
(Banks et al., 2006). The challenge is to recognize and appreciate aging changes while

using resources to prevent or halt further changes and overcome aging challenges.
CHANGES ASSOCIATED WITH “NORMAL” AGING

Clinicians often face a major challenge in attributing a finding to either the expected
course of aging or the result of pathologic changes. This distinction perplexes the
researcher as well. We currently lack precise knowledge of what constitutes normal
aging. Much of our information comes from cross-sectional studies, which compare
findings from a group of younger persons with those from a group of older individuals. Such data may reflect differences other than simply the effects of age, such as
those associated with lifestyle behaviors (physical activity, alcohol intake, smoking,
and diet), as well as prophylactic medication management. For example, older adults
in the coming century may present with less evidence of osteoporosis because of prophylactic lifelong intake of high calcium and vitamin D diets, regular physical ­activity,
and early interventions with biphosphanates and potentially future treatments for
osteoporosis. Statins can drastically affect the course of cardiovascular disease.


Clinical Implications of the Aging Process

PART I

Many of the changes associated with aging result from a gradual loss of homeostatic
mechanisms. (Jack Rowe termed this “homeostenosis.”) These losses may often begin
in early adulthood, but—thanks to the redundancy of most organ systems—the
decrement does not become functionally significant until the loss is fairly extensive.
The concept of aging, or at least what constitutes old age, has changed as life expectancy has increased, although the biology has not. Based on cross-sectional comparisons of groups at different ages, most organ systems seem to lose function at
about 1% a year beginning around age 30 years. Other data suggest that the changes
in people followed longitudinally are much less dramatic and certainly begin well
after age 70 years. In some organ systems, such as the kidney, a subgroup of persons
appears to experience gradually declining function over time, whereas others’ function remains constant. These findings suggest that the earlier theory of gradual loss
must be ­reassessed as reflecting disease rather than aging. Given a pattern of gradual
­deterioration—whether from aging or disease or both—we are best advised to think

in terms of thresholds.
The loss of function does not become significant until it crosses a given level. Thus, the
functional performance of an organ in an older person depends on two principal factors:
(1) the rate of deterioration and (2) the level of performance needed. It is not surprising then to learn that most older persons will have normal laboratory values. The
critical difference—in fact, the hallmark of aging—lies not in the resting level of performance but in how the organ (or organism) adapts to external stress. For example,
an older person may have a normal fasting blood sugar but be unable to handle a
glucose load within the normal parameters for younger subjects.
This failure to respond to stress explains the atypical presentation of many diseases
in older patients. Many of the signs and symptoms of disease are actually the body’s
response to those assaults. A depressed response will mean not having a high white
blood cell count with an infection or even pain with a heart attack. For example,
although currently not recommended for screening of asymptomatic patients, cardiac
magnetic resonance imaging reveals unrecognized myocardial infarctions in asymptomatic older adults that are associated with increased mortality (Schelbert et al., 2012).
The same pattern of decreased response to stress can be seen in the performance
of other endocrine systems or the cardiovascular system. An older individual may
have a normal resting pulse and cardiac output but be unable to achieve an adequate
increase in either with exercise.
Sometimes the changes of aging work together to produce apparently normal
resting values in other ways. For example, although both glomerular filtration and
renal blood flow decrease with age, many elderly persons have normal serum creatinine levels because of the concomitant decreases in lean muscle mass and creatinine
production. Thus serum creatinine is not as good an indicator of renal function in
older adults as in younger persons. Knowledge of kidney function is critical in drug
therapy. Therefore, it is important to get an accurate measure of kidney function.
A useful formula for estimating creatinine clearance on the basis of serum creatinine values in the elderly was developed (Cockcroft and Gault, 1976). (The actual
formula is provided in Chapter 14.) Table 1-1 (Schmidt, 1999) summarizes some

5


6

The Aging Patient and Geriatric Assessment
Table 1-1. Pertinent Changes That Commonly Occur with Aging

PART I

System

Common age changes

Implications of changes

Cardiovascular

Atrophy of muscle fibers that
line the endocardium
Atherosclerosis of vessels
Increased systolic blood pressure
Decreased compliance of the
left ventricle
Decreased number of
pacemaker cells
Decreased sensitivity of
baroreceptors
Decreased number of neurons
and increase in size and
number of neuroglial cells
Decline in nerves and nerve
fibers
Atrophy of the brain and

increase in cranial dead space
Thickened leptomeninges in
spinal cord

Increased blood pressure
Increased emphasis on atrial
contraction with an S4 heard
Increased arrhythmias
Increased risk of hypotension with
position change
Valsalva maneuver may cause a
drop in blood pressure
Decreased exercise tolerance

Neurological

Respiratory

Decreased lung tissue elasticity
Thoracic wall calcification
Cilia atrophy
Decreased respiratory muscle
strength
Decreased partial pressure of
arterial oxygen (Pao2)

Integumentary

Loss of dermal and epidermal
thickness

Flattening of papillae
Atrophy of sweat glands
Decreased vascularity
Collagen cross-linking
Elastin regression
Loss of subcutaneous fat
Decreased melanocytes
Decline in fibroblast proliferation

Increased risk for neurological
problems: cerebrovascular
accident
Parkinsonism
Slower conduction of fibers across
the synapses
Modest decline in short-term
memory
Alterations in gait pattern: wide
based, shorter stepped, and
flexed forward
Increased risk of hemorrhage
before symptoms are apparent
Decreased efficiency of ventilatory
exchange
Increased susceptibility to infection
and atelectasis
Increased risk of aspiration
Decreased ventilatory response to
hypoxia and hypercapnia
Increased sensitivity to narcotics

Thinning of skin and increased
susceptibility to tearing
Dryness and pruritus
Decreased sweating and ability to
regulate body heat
Increased wrinkling and laxity of
the skin
Loss of fatty pads protecting bone
and resulting in pain
Increased need for protection from
the sun
Increased time for healing of wounds
(continued )