Browse the corpus

Geriatric Medicine TABLE 58. Indices to Assess Basic and Instrumental Activities of Daily Living Index Assessed Functional Activity Scoring Comments Katz Index of Bathing Assign 1 point for each activity if it can be Simple to use and score; Independence in — performed independently (requiring no brief, takes only a few Activities of Daily resnleg supervision, direction, or personal minutes to complete Living Toileting assistance); scores are then added for Less discriminative at low a range of 0 to 6 (6 = fully functional; Transferring levels of disability 4= moderately impaired; 2 = severely Continence impaired) Feeding

Katz Index of Bathing Assign 1 point for each activity if it can be Simple to use and score; Independence in — performed independently (requiring no brief, takes only a few Activities of Daily resnleg supervision, direction, or personal minutes to complete Living Toileting assistance); scores are then added for Less discriminative at low a range of 0 to 6 (6 = fully functional; Transferring levels of disability 4= moderately impaired; 2 = severely Continence impaired) Feeding Lawton and Brody Ability to use telephone There are eight domains of function in this Simple to use; brief, takes Instrumental Activities scale, each with three or more described only a few minutes to Shopping of Daily Living (IADL) levels of activity. Each activity has a complete Scale Food preparation designated score of 0 or 1. Select the description that most closely resembles the | Housekeeping patient's highest functional level within the Laundry domain. The activity score for the highest functional level is assigned to the domain. Transportation Domain scores are added for a range of 0 Medication management to 8 (8 = independence; 0 = total dependence for IADLs) Ability to handle finances

Lawton and Brody Ability to use telephone There are eight domains of function in this Simple to use; brief, takes Instrumental Activities scale, each with three or more described only a few minutes to Shopping of Daily Living (IADL) levels of activity. Each activity has a complete Scale Food preparation designated score of 0 or 1. Select the description that most closely resembles the | Housekeeping patient's highest functional level within the Laundry domain. The activity score for the highest functional level is assigned to the domain. Transportation Domain scores are added for a range of 0 Medication management to 8 (8 = independence; 0 = total dependence for IADLs) Ability to handle finances Hearing cognitive function, and the need for institutionalization may Hearing loss is common in older adults, affecting more than all contribute to depression in this population. 80% of persons by age 80 years. Hearing loss is socially isolat- The USPSTF recommends screening for depression in all ing, perhaps more so than other sensory losses, and contrib- adults. The PHQ-2 has been validated as a screening instru- utes to decreased quality of life and increased morbidity. ment in older adults, with similar sensitivity and specificity to Because of the impaired communication abilities inherent to that in younger adults. Although sensitive, the PHQ-2 has a hearing loss, it may be misdiagnosed as cognitive dysfunction. lower specificity for depression than more comprehensive

utes to decreased quality of life and increased morbidity. ment in older adults, with similar sensitivity and specificity to Because of the impaired communication abilities inherent to that in younger adults. Although sensitive, the PHQ-2 has a hearing loss, it may be misdiagnosed as cognitive dysfunction. lower specificity for depression than more comprehensive Diagnostic tests that reliably screen for hearing loss screening instruments, and a positive screening result should include assessment of the patient’s ability to hear a whis- therefore prompt further assessment. The PHQ-9 and the pered voice, fingers rubbing together, or a watch ticking. Geriatric Depression Scale (https://integrationacademy.ahrq. These tests and single-question screening (i.e., asking “Do gov/sites/default/files/2020-07/Update_Geriatric_ you have difficulty hearing?”) perform as well as more com- Depression_Scale-15.pdf) have better sensitivity and specific- plex questionnaires or handheld audiometry in detecting ity in older adults. The Geriatric Depression Scale, with its hearing loss. yes-or-no answer format, may be easier to administer in There is no evidence that proactively identifying hearing patients with cognitive impairment. When depression is sus- loss translates to better hearing-related quality of life. As such, pected, a detailed medication review and inquiry about suici- routine screening for hearing loss in asymptomatic patients is dality should be completed. not recommended by the USPSTF. Patients with symptoms, Older adults with depression are most commonly treated however, should be referred to an otologist or audiologist for a with pharmacotherapy, and antidepressants protect against formal hearing test and evaluation to determine whether hear- suicide attempts in this population. Selective serotonin reup- ing aids would be beneficial. Hearing aids and cochlear take inhibitors are the most widely studied antidepressants implants improve speech recognition and may improve quality and are considered first-line therapy. Nonpharmacologic treat-

formal hearing test and evaluation to determine whether hear- suicide attempts in this population. Selective serotonin reup- ing aids would be beneficial. Hearing aids and cochlear take inhibitors are the most widely studied antidepressants implants improve speech recognition and may improve quality and are considered first-line therapy. Nonpharmacologic treat- of life in those with profound hearing loss. ment, including psychotherapy, exercise, and electroconvul- sive therapy, also have been shown to be effective. For the Depression treatment of mild to moderate depression, nonpharmacologic The prevalence of depression in adults older than 60 years is as options may be considered first in patients with medication high as 15%. Although diagnostic criteria for depression in intolerance or dementia. See Mental and Behavioral Health for older adults are no different from those in younger patients, more information on treatment options. some common symptoms, such as low energy and somatic symptoms, are often mistakenly attributed to aging or chronic Cognitive Function illness. Depression in older adults also may be confused with Cognitive impairment is defined as a progressive decline in at cognitive dysfunction and is itself a risk factor for cognitive least one cognitive domain (memory, attention, language, dysfunction. Chronic illness, grief associated with the loss of visual-spatial function, executive function) that negatively loved ones, social isolation due to decreased physical and affects patient functioning. The strongest risk factor for 90

Geriatric Medicine cognitive impairment is increasing age. In the absence of benefits and harms based on the circumstances of previous symptoms, routine screening is not recommended owing to a falls, presence of comorbid medical conditions, and the lack of evidence that it leads to effective intervention. However, patient’s values and preferences. The CDC has developed a because cognitive impairment is a risk factor for falls, loss of toolkit for patients and providers that includes the online independence, and poor control of chronic diseases, clinicians Check for Safety tool, a patient-administered home safety should have a low threshold for assessing for cognitive decline. checklist with practical suggestions for reducing fall risk The most widely studied instrument for evaluating cogni- (www.cdc.gov/steadi/pdf/check_for_safety_brochure-a.pdf). tive function is the Mini-Mental State Examination (MMSE). Formal home safety evaluation by an occupational therapist The proprietary nature of the MMSE and the time required to also has been associated with reducing fall risk. administer the test (approximately 7 minutes) may preclude its Specific interventions shown to reduce fall risk include use for routine outpatient case finding. The Montreal Cognitive exercises that emphasize gait/balance training and lower Assessment (MoCA) takes a similar amount of time to com- extremity strength, discontinuing or decreasing the dose of plete and is sensitive for detecting cognitive impairment; how- centrally acting medications, and assessing and modifying the ever, training and certification are required for its use. The home environment. The USPSTF recommends exercise to pre- Mini-Cog test has acceptable sensitivity and specificity in vent falls in community-dwelling adults aged 65 years or older identifying dementia and is available to clinicians without who are at increased risk for falls; exercise interventions charge, although it is copyright protected. It includes a three- include supervised individual and group classes as well as item recall test (similar to elements of the MMSE) followed by physical therapy. Exercise interventions targeting gait and bal- a clock-drawing test if one of the three recall items is missed. ance training and improving lower extremity strength are Evaluation and treatment of mild cognitive impairment generally recommended. (impaired cognition in the absence of impaired function) and Vitamin D supplementation should not be used to prevent dementia are further discussed in MKSAP 19 Neurology. falls in community-dwelling adults aged 65 years or older who are not known to have osteoporosis or vitamin D deficiency. Fall Prevention One in three adults older than 65 years and one in two adults Assessment of the Older Driver older than 80 years fall every year, making falls the leading Driving is one of the most valued IADLs for older adults, and cause of injury in older adults. Many health conditions, physi- cessation of driving in this population is associated with cal characteristics, and behaviors increase risk for falling, but negative health consequences, most notably decreased quality the greatest increases are associated with cognitive impair- of life and depression. However, drivers older than 65 years ment, psychoactive medications, gait/balance problems, and are responsible for more traffic fatalities than any other group decreased lower extremity strength. The presence of multiple of drivers other than those younger than 25 years. Motor vehi- risk factors has an additive effect on fall risk. Even fear of cle crashes are the second leading cause of injury in older falling in the absence of falls decreases self-rated health and adults. hastens functional decline. Decreased visual acuity, reduced cognitive abilities, use of Screening older adults for fall risk is recommended by the centrally acting medications, alcohol or marijuana use, condi- American Geriatrics Society (AGS) and is an element of the tions that increase the risk for loss of consciousness, and Medicare annual wellness visit. Despite these recommenda- mobility issues of the extremities or neck all increase the risk tions, only 25% of older adults report discussing falls with for motor vehicle crashes. Gradually accumulating deficits their physician. Patients should be asked about falls and may go unrecognized by the older adult driver until a crash unsteadiness with walking as well as fear of falling. Those who occurs. Fortunately, many older adults self-restrict driving, report falls or balance issues should be evaluated with the commonly discontinuing night driving and longer trips. Self- Timed Up and Go (TUG) test, in which the patient is asked to restricted driving, caregiver or family concern for driving rise from a chair with armrests, walk 10 feet (with their usual safety, history of traffic citations, and impulsive behaviors also assistive devices, if applicable), turn, return to the chair, and are associated with increased risk for crashes. sit down. A time of more than 12 seconds is considered abnor- The decision to advise an older driver to “retire from driv- mal. Patients with prolonged times on the TUG test may be ing” (the preferred terminology) is qualitative, complex, and referred for more comprehensive assessment or formal gait largely dependent on clinician judgment. The evaluation and balance assessment and therapy. An algorithm for fall risk should consider the known risk factors and underlying medi- assessment and prevention is presented in Figure 24. cal conditions. The AGS in partnership with the National The USPSTF recommends multifactorial interventions for Highway Transportation Safety Administration has developed fall prevention, which typically involves an initial assessment a guideline for multidisciplinary evaluation of the older driver of modifiable risk factors for falls and subsequent customized that includes screening instruments, resources for rehabilitat- interventions. The USPSTF acknowledges that the overall ben- ing those at risk for becoming unsafe to drive, and resources for efit of routinely offering multifactorial interventions to pre- patients who must retire from driving (www.nhtsa.gov/sites/ vent falls is small and should take into account the balance of nhtsa.dot.gov/files/812228_cliniciansguidetoolderdrivers.pdf).

cognitive impairment is increasing age. In the absence of benefits and harms based on the circumstances of previous symptoms, routine screening is not recommended owing to a falls, presence of comorbid medical conditions, and the lack of evidence that it leads to effective intervention. However, patient’s values and preferences. The CDC has developed a because cognitive impairment is a risk factor for falls, loss of toolkit for patients and providers that includes the online independence, and poor control of chronic diseases, clinicians Check for Safety tool, a patient-administered home safety should have a low threshold for assessing for cognitive decline. checklist with practical suggestions for reducing fall risk The most widely studied instrument for evaluating cogni- (www.cdc.gov/steadi/pdf/check_for_safety_brochure-a.pdf). tive function is the Mini-Mental State Examination (MMSE). Formal home safety evaluation by an occupational therapist The proprietary nature of the MMSE and the time required to also has been associated with reducing fall risk. administer the test (approximately 7 minutes) may preclude its Specific interventions shown to reduce fall risk include use for routine outpatient case finding. The Montreal Cognitive exercises that emphasize gait/balance training and lower Assessment (MoCA) takes a similar amount of time to com- extremity strength, discontinuing or decreasing the dose of plete and is sensitive for detecting cognitive impairment; how- centrally acting medications, and assessing and modifying the ever, training and certification are required for its use. The home environment. The USPSTF recommends exercise to pre- Mini-Cog test has acceptable sensitivity and specificity in vent falls in community-dwelling adults aged 65 years or older identifying dementia and is available to clinicians without who are at increased risk for falls; exercise interventions charge, although it is copyright protected. It includes a three- include supervised individual and group classes as well as item recall test (similar to elements of the MMSE) followed by physical therapy. Exercise interventions targeting gait and bal- a clock-drawing test if one of the three recall items is missed. ance training and improving lower extremity strength are Evaluation and treatment of mild cognitive impairment generally recommended. (impaired cognition in the absence of impaired function) and Vitamin D supplementation should not be used to prevent dementia are further discussed in MKSAP 19 Neurology. falls in community-dwelling adults aged 65 years or older who are not known to have osteoporosis or vitamin D deficiency. Fall Prevention One in three adults older than 65 years and one in two adults Assessment of the Older Driver older than 80 years fall every year, making falls the leading Driving is one of the most valued IADLs for older adults, and cause of injury in older adults. Many health conditions, physi- cessation of driving in this population is associated with cal characteristics, and behaviors increase risk for falling, but negative health consequences, most notably decreased quality the greatest increases are associated with cognitive impair- of life and depression. However, drivers older than 65 years ment, psychoactive medications, gait/balance problems, and are responsible for more traffic fatalities than any other group decreased lower extremity strength. The presence of multiple of drivers other than those younger than 25 years. Motor vehi- risk factors has an additive effect on fall risk. Even fear of cle crashes are the second leading cause of injury in older falling in the absence of falls decreases self-rated health and adults. hastens functional decline. Decreased visual acuity, reduced cognitive abilities, use of Screening older adults for fall risk is recommended by the centrally acting medications, alcohol or marijuana use, condi- American Geriatrics Society (AGS) and is an element of the tions that increase the risk for loss of consciousness, and Medicare annual wellness visit. Despite these recommenda- mobility issues of the extremities or neck all increase the risk tions, only 25% of older adults report discussing falls with for motor vehicle crashes. Gradually accumulating deficits their physician. Patients should be asked about falls and may go unrecognized by the older adult driver until a crash unsteadiness with walking as well as fear of falling. Those who occurs. Fortunately, many older adults self-restrict driving, report falls or balance issues should be evaluated with the commonly discontinuing night driving and longer trips. Self- Timed Up and Go (TUG) test, in which the patient is asked to restricted driving, caregiver or family concern for driving rise from a chair with armrests, walk 10 feet (with their usual safety, history of traffic citations, and impulsive behaviors also assistive devices, if applicable), turn, return to the chair, and are associated with increased risk for crashes. sit down. A time of more than 12 seconds is considered abnor- The decision to advise an older driver to “retire from driv- mal. Patients with prolonged times on the TUG test may be ing” (the preferred terminology) is qualitative, complex, and referred for more comprehensive assessment or formal gait largely dependent on clinician judgment. The evaluation and balance assessment and therapy. An algorithm for fall risk should consider the known risk factors and underlying medi- assessment and prevention is presented in Figure 24. cal conditions. The AGS in partnership with the National The USPSTF recommends multifactorial interventions for Highway Transportation Safety Administration has developed fall prevention, which typically involves an initial assessment a guideline for multidisciplinary evaluation of the older driver of modifiable risk factors for falls and subsequent customized that includes screening instruments, resources for rehabilitat- interventions. The USPSTF acknowledges that the overall ben- ing those at risk for becoming unsafe to drive, and resources for efit of routinely offering multifactorial interventions to pre- patients who must retire from driving (www.nhtsa.gov/sites/ vent falls is small and should take into account the balance of nhtsa.dot.gov/files/812228_cliniciansguidetoolderdrivers.pdf). 91

Geriatric Medicine Older patient encounters health care provider ! Obtain relevant medical history, Screen for fall(s) or risk for falling physical examination, and cognitive (see questions below) and functional assessment f Yes Determine multifactorial fall risk: ¢ History of falls Does the patient answer positively to y any of the screening questions? ¢ Medications * Gait, balance, and mobility ¢ Visual acuity

¢ History of falls Does the patient answer positively to y any of the screening questions? ¢ Medications * Gait, balance, and mobility ¢ Visual acuity ¢ Other neurologic impairments Does the patient report a single bisa Evaluate gait ¢ Muscle strength fall in the last 12 months? and balance ¢ Heart rate and rhythm | ¢ Postural hypotension Yes ¢ Feet and footwear Are abnormalities in gait or unsteadiness identified? © Environmental hazards ! Are there any indications for b+ £ additional intervention? | Yes Reassess periodically

! Are there any indications for b+ £ additional intervention? | Yes Reassess periodically Initiate multifactorial or multicomponent intervention to address identified risk(s) and prevent falls: ¢ Minimize medications e Provide individually tailored exercise program ° Treat visual impairment (including cataract) e Manage postural hypotension Screening for Fall(s) Questions ¢ Manage heart rate and rhythm abnormalities 1. Two or more falls in the prior 12 months? ¢ Manage footwear and foot problems 2. Presents with acute fall? © Modify the home environment 3. Difficulty with walking or balance? ¢ Provide education and information FIGURE 24. Prevention of falls in community-living older persons. Reproduced with permission from Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons.J Am Geriatr Soc. 2011;59:148-57. [PMID: 21226685] doi:10.1111/j.1532-5415.2010.03234.x ©2011, John Wiley & Sons, Inc.

Reproduced with permission from Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons.J Am Geriatr Soc. 2011;59:148-57. [PMID: 21226685] doi:10.1111/j.1532-5415.2010.03234.x ©2011, John Wiley & Sons, Inc. Physician advice to retire from driving is associated with might be expected to effectively reduce motor vehicle crashes, older drivers appropriately stopping driving; however, given although mandatory physician reporting of dementia to the risk for depression and social isolation associated with departments of motor vehicles has not been shown to reduce driving retirement, this advice should be coupled with sup- the percentage of crashes attributable to dementia. Effective port, suggestions for alternate forms of transportation, and strategies include requiring in-person application and vision follow-up assessment of mood and quality of life. When screening for license renewal. A recent guideline for determin- patients are resistant to retire from driving or when the ing appropriateness for retaining driving privileges in individu- appropriate decision is less clear, formal occupational ther- als with cognitive impairment, developed by a multidisciplinary apy driving assessment may be helpful. Addressing modifia- group in the United Kingdom, has been proposed as a resource ble risk factors (e.g., cataract removal), optimizing treatment for U.S. physicians and patients (https://research.ncl.ac.uk/ of arthritic conditions, and discontinuing risky medications driving-and-dementia/consensusguidelinesforclinicians/ are strategies that may permit continued safe driving. Final%20Guideline. pdf). The role of the individual clinician in preventing motor vehicle crashes caused by patients with cognitive impairment Screening for Mistreatment is unclear. Identifying cognitive impairment or dementia and Older adults are at increased risk for mistreatment, including subsequently targeting those patients for driving retirement abuse, neglect, and financial exploitation, because of decreased.

Physician advice to retire from driving is associated with might be expected to effectively reduce motor vehicle crashes, older drivers appropriately stopping driving; however, given although mandatory physician reporting of dementia to the risk for depression and social isolation associated with departments of motor vehicles has not been shown to reduce driving retirement, this advice should be coupled with sup- the percentage of crashes attributable to dementia. Effective port, suggestions for alternate forms of transportation, and strategies include requiring in-person application and vision follow-up assessment of mood and quality of life. When screening for license renewal. A recent guideline for determin- patients are resistant to retire from driving or when the ing appropriateness for retaining driving privileges in individu- appropriate decision is less clear, formal occupational ther- als with cognitive impairment, developed by a multidisciplinary apy driving assessment may be helpful. Addressing modifia- group in the United Kingdom, has been proposed as a resource ble risk factors (e.g., cataract removal), optimizing treatment for U.S. physicians and patients (https://research.ncl.ac.uk/ of arthritic conditions, and discontinuing risky medications driving-and-dementia/consensusguidelinesforclinicians/ are strategies that may permit continued safe driving. Final%20Guideline. pdf). The role of the individual clinician in preventing motor vehicle crashes caused by patients with cognitive impairment Screening for Mistreatment is unclear. Identifying cognitive impairment or dementia and Older adults are at increased risk for mistreatment, including subsequently targeting those patients for driving retirement abuse, neglect, and financial exploitation, because of decreased. 92

Geriatric Medicine functioning that leads to dependence on others. The prevalence Frailty Assessment of elder mistreatment is estimated to be roughly 10%. The most Frailty is a multifactorial geriatric syndrome that is usually commonly encountered form in the health care setting is neglect, characterized by five phenotypic elements: unintentional as either caregiver neglect (failure to meet the elderly person’s weight loss, low energy, low activity levels, weakness, and needs in terms of physical and mental well-being) or self-neglect slow walking speed. It has been linked to increased mortality, (by choice or because of dementia or mental health issues). falls, and risk for hospitalization, as well as reduced mobility Victims are high utilizers of emergency services, hospital care, and health-related quality of life. Frailty is predictive of mor- and nursing home care and have a higher mortality rate. bidity and mortality during or after many medical and surgical It is uncertain whether screening for elder mistreatment interventions, and its presence is associated with longer inpa- should be routine. The USPSTF recognizes elder abuse and tient lengths of stay, increased likelihood of discharge to a abuse of vulnerable adults as common and serious problems skilled nursing facility, and increased risk for inpatient delir- but has not identified reliable screening instruments for this ium. Notably, advanced age is not synonymous with frailty. patient population. Because of the potential negative health Frailty measurement is not currently recommended as effects of mistreatment, case finding should be considered in part of routine geriatric assessment; however, it is rapidly adults with vulnerability for or signs of abuse. Simple screen- being incorporated into preintervention assessment for many ing instruments, such as the Hwalek-Sengstock Elder Abuse Screening Test and the Vulnerability to Abuse Screening Scale, surgical, procedural, and medical treatments (see MKSAP 19

functioning that leads to dependence on others. The prevalence Frailty Assessment of elder mistreatment is estimated to be roughly 10%. The most Frailty is a multifactorial geriatric syndrome that is usually commonly encountered form in the health care setting is neglect, characterized by five phenotypic elements: unintentional as either caregiver neglect (failure to meet the elderly person’s weight loss, low energy, low activity levels, weakness, and needs in terms of physical and mental well-being) or self-neglect slow walking speed. It has been linked to increased mortality, (by choice or because of dementia or mental health issues). falls, and risk for hospitalization, as well as reduced mobility Victims are high utilizers of emergency services, hospital care, and health-related quality of life. Frailty is predictive of mor- and nursing home care and have a higher mortality rate. bidity and mortality during or after many medical and surgical It is uncertain whether screening for elder mistreatment interventions, and its presence is associated with longer inpa- should be routine. The USPSTF recognizes elder abuse and tient lengths of stay, increased likelihood of discharge to a abuse of vulnerable adults as common and serious problems skilled nursing facility, and increased risk for inpatient delir- but has not identified reliable screening instruments for this ium. Notably, advanced age is not synonymous with frailty. patient population. Because of the potential negative health Frailty measurement is not currently recommended as effects of mistreatment, case finding should be considered in part of routine geriatric assessment; however, it is rapidly adults with vulnerability for or signs of abuse. Simple screen- being incorporated into preintervention assessment for many ing instruments, such as the Hwalek-Sengstock Elder Abuse Screening Test and the Vulnerability to Abuse Screening Scale, surgical, procedural, and medical treatments (see MKSAP 19 are available but require self-reporting; this complicates General Internal Medicine 2). Applications include tailoring glycemic control and blood pressure targets; predicting assessment in persons with cognitive impairment who cannot provide information independently. Testing may not occur response to and tolerance of surgical and chemotherapeutic cancer treatment; and predicting postoperative outcomes because of unawareness of these instruments and how to use them, confusion regarding legal and reporting implications related to surgery.

are available but require self-reporting; this complicates General Internal Medicine 2). Applications include tailoring glycemic control and blood pressure targets; predicting assessment in persons with cognitive impairment who cannot provide information independently. Testing may not occur response to and tolerance of surgical and chemotherapeutic cancer treatment; and predicting postoperative outcomes because of unawareness of these instruments and how to use them, confusion regarding legal and reporting implications related to surgery. (which vary from state to state), and fear of potential harms to More than 70 standardized frailty indices are available, the patient and family members that result from false-positive and no one index is preferred. Although there is some con- and false-negative test results. sistency as to which outcomes are influenced by frailty, the Findings suggestive of abuse or neglect, whether thought degree to which an outcome is changed varies considerably to be intentional or unintentional, should prompt additional between instruments. The frailty index, a comprehensive investigation. Such investigation should ideally include a home assessment of chronic conditions and functioning, has been assessment, which can be most reliably conducted under the in use for a longer time than other indices; however, its

to be intentional or unintentional, should prompt additional between instruments. The frailty index, a comprehensive investigation. Such investigation should ideally include a home assessment of chronic conditions and functioning, has been assessment, which can be most reliably conducted under the in use for a longer time than other indices; however, its auspices of Adult Protective Services. length and complexity limit its usefulness in routine care. The five-item frailty phenotype was originally validated in the Cardiovascular Health Study of more than 5000 patients aged 65 years or older; it requires objective measurement of ¢ Comprehensive geriatric assessment is a multidiscipli- gait speed and grip strength (with a dynamometer), which nary diagnostic process to ascertain the physical, may not be feasible in primary care. The frailty index and the cognitive, psychological, environmental, and functional frailty phenotype are the most commonly used instruments capabilities of older persons, with the objective of in frailty research. developing a plan for preserving function and maxi- In addition to the more comprehensive assessments, mizing independence and quality of life. many indices have been developed for specific preinterven- e Although routine screening for hearing loss in asymp- tion screening. Most of these tools use self-reported meas- tomatic patients is not recommended, patients with ures, are simple to administer and score, and may be more symptoms of hearing loss should be referred to an otol- easily incorporated into a primary care practice. These rapid ogist or audiologist for formal testing and hearing aid screening tests are useful in the identification of patients placement, if appropriate. who might require more formal comprehensive geriatric e All older adults should be screened for depression. assessment or preintervention rehabilitation. Examples of ¢ Cognitive impairment is a risk factor for falls, loss of well-validated, brief, subjective instruments are presented in

auspices of Adult Protective Services. length and complexity limit its usefulness in routine care. The five-item frailty phenotype was originally validated in the Cardiovascular Health Study of more than 5000 patients aged 65 years or older; it requires objective measurement of ¢ Comprehensive geriatric assessment is a multidiscipli- gait speed and grip strength (with a dynamometer), which nary diagnostic process to ascertain the physical, may not be feasible in primary care. The frailty index and the cognitive, psychological, environmental, and functional frailty phenotype are the most commonly used instruments capabilities of older persons, with the objective of in frailty research. developing a plan for preserving function and maxi- In addition to the more comprehensive assessments, mizing independence and quality of life. many indices have been developed for specific preinterven- e Although routine screening for hearing loss in asymp- tion screening. Most of these tools use self-reported meas- tomatic patients is not recommended, patients with ures, are simple to administer and score, and may be more symptoms of hearing loss should be referred to an otol- easily incorporated into a primary care practice. These rapid ogist or audiologist for formal testing and hearing aid screening tests are useful in the identification of patients placement, if appropriate. who might require more formal comprehensive geriatric e All older adults should be screened for depression. assessment or preintervention rehabilitation. Examples of ¢ Cognitive impairment is a risk factor for falls, loss of well-validated, brief, subjective instruments are presented in independence, and poor control of chronic diseases; cli- Table 59. nicians should inquire about symptoms and perform Of note, interventions performed in the early stages of further evaluation when symptoms are present. frailty have the potential to reduce the associated risks. Strategies include muscle strengthening through exercise, HVC e Interventions shown to reduce fall risk include exercises that emphasize gait/balance training and lower extrem- protein and other nutritional supplementation, and address-

independence, and poor control of chronic diseases; cli- Table 59. nicians should inquire about symptoms and perform Of note, interventions performed in the early stages of further evaluation when symptoms are present. frailty have the potential to reduce the associated risks. Strategies include muscle strengthening through exercise, HVC e Interventions shown to reduce fall risk include exercises that emphasize gait/balance training and lower extrem- protein and other nutritional supplementation, and address- ity strength, discontinuing or decreasing the dose of ing mood disorders and polypharmacy. Response to these interventions may require weeks to months; therefore, screen- centrally acting medications, and assessing and modify- ing the home environment. ing for frailty well in advance of planned interventions should occur whenever possible. 93

Geriatric Medicine TABLE 59. Examples of Frailty Indices Instrument Description Scoring | FRAIL (Fatigue, Measures presence (1) or absence (0) of: Each item scored dichotomously as 0 for normal or | Resistance, Ambulation, 1 for abnormal Fatigue: Feeling fatigued most or all the time over | \IIness, and Loss of | weight) scale the past 4 weeks 1-2 = Prefrail Resistance: Difficulty walking up 10 steps alone 3-5 = Frail without resting or assistance | Ambulation: Difficulty walking several hundred yards without assistance | Illness: Presence of more than five illnesses Loss of weight: Weight loss >5% in the past year Osteoporotic Fractures Measures three items: Each item scored dichotomously as 0 for normal or Frailty Scale 1 for abnormal Ability to rise from an armless chair five times (inability= 1) 1 =Prefrail Response to the question “Do you feel full of 2-3 = Frail | energy?” (answer of “no”= 1) Weight loss >5% in the past year (presence of | weight loss = 1)

Response to the question “Do you feel full of 2-3 = Frail | energy?” (answer of “no”= 1) Weight loss >5% in the past year (presence of | weight loss = 1) are available: independent living, assisted living, and nursing homes. Independent living is suitable only for patients who e Frailty measurement is not recommended as part of can independently perform ADLs and IADLs and simply pro- routine geriatric assessment; however, it is rapidly being vides patients with the benefits of living in a community. incorporated into preintervention assessment for many Assisted living offers a home-like environment but provides surgical, procedural, and medical treatments. varying levels of assistance with medications, ADLs, house- keeping, and meals. For patients requiring additional help with ADLs or medical management, nursing homes provide Levels of Care 24-hour nursing care as well as rehabilitation services. As the population ages, medical complexity and care needs Residential care homes use a smaller, home-like environment also increase, necessitating a variety of care delivery models, in the care of patients with similar needs (e.g., patients with including home-based and facility-based options. chronic mental illness); however, services provided vary, and Resources for older adults who wish to remain in their the level of care provided may be similar to either assisted liv- homes but need assistance include home health agency care ing or nursing home care. Independent and assisted living are and custodial care services. Home health agencies offer assis- typically paid for with private funds, or “private pay.” Medicare tance with medication management, wound care, and physi- does not usually cover long-term nursing home or residential cal therapy. These services are provided on an intermittent home care. Medicaid may pay for long-term care depending basis (usually no more than two to three times per week) and on patient eligibility and state regulations. are covered by Medicare and Medicaid if the patient is home- Acute medical care is typically provided in a hospital set- bound with a documented skilled care need. Custodial care ting. Infrequently, serious acute illnesses may be treated in the services provide help with dressing, bathing, toileting, cook- patient’s living environment, although home hospital care ing, and other ADLs; these services are not covered by Medicare occurs only when significant home health resources are avail- but may be paid for by Medicaid. Visiting physicians can also able and avoidance of hospitalization has been established as a provide outpatient medical care. primary goal in care-planning discussions. When patients who are cared for by family members Posthospitalization care is available in multiple forms. require additional resources for gaps in care, adult day care Safe return to a patient’s previous living situation can be facili- can provide part-time assistance when the patient’s primary tated with outpatient physical, occupational, and speech ther- caregiver is unavailable. If supervision is needed for a longer apy in the home or clinic. If a patient requires functional time, respite care is available at many senior living communi- improvement before returning home, rehabilitation can be ties (assisted living facilities and nursing homes). Adult day performed in an acute rehabilitation program or skilled nurs- care and respite care are not typically covered by Medicare or ing facility (ie., subacute rehabilitation). Acute rehabilitation Medicaid. is provided in a freestanding rehabilitation hospital or a desig- When long-term daily care needs exceed those that can nated hospital unit, and it requires that the patient be able to be provided in a patient’s home, three different levels of care participate in 3 hours of therapy at least 5 days per week.

are available: independent living, assisted living, and nursing homes. Independent living is suitable only for patients who e Frailty measurement is not recommended as part of can independently perform ADLs and IADLs and simply pro- routine geriatric assessment; however, it is rapidly being vides patients with the benefits of living in a community. incorporated into preintervention assessment for many Assisted living offers a home-like environment but provides surgical, procedural, and medical treatments. varying levels of assistance with medications, ADLs, house- keeping, and meals. For patients requiring additional help with ADLs or medical management, nursing homes provide Levels of Care 24-hour nursing care as well as rehabilitation services. As the population ages, medical complexity and care needs Residential care homes use a smaller, home-like environment also increase, necessitating a variety of care delivery models, in the care of patients with similar needs (e.g., patients with including home-based and facility-based options. chronic mental illness); however, services provided vary, and Resources for older adults who wish to remain in their the level of care provided may be similar to either assisted liv- homes but need assistance include home health agency care ing or nursing home care. Independent and assisted living are and custodial care services. Home health agencies offer assis- typically paid for with private funds, or “private pay.” Medicare tance with medication management, wound care, and physi- does not usually cover long-term nursing home or residential cal therapy. These services are provided on an intermittent home care. Medicaid may pay for long-term care depending basis (usually no more than two to three times per week) and on patient eligibility and state regulations. are covered by Medicare and Medicaid if the patient is home- Acute medical care is typically provided in a hospital set- bound with a documented skilled care need. Custodial care ting. Infrequently, serious acute illnesses may be treated in the services provide help with dressing, bathing, toileting, cook- patient’s living environment, although home hospital care ing, and other ADLs; these services are not covered by Medicare occurs only when significant home health resources are avail- but may be paid for by Medicaid. Visiting physicians can also able and avoidance of hospitalization has been established as a provide outpatient medical care. primary goal in care-planning discussions. When patients who are cared for by family members Posthospitalization care is available in multiple forms. require additional resources for gaps in care, adult day care Safe return to a patient’s previous living situation can be facili- can provide part-time assistance when the patient’s primary tated with outpatient physical, occupational, and speech ther- caregiver is unavailable. If supervision is needed for a longer apy in the home or clinic. If a patient requires functional time, respite care is available at many senior living communi- improvement before returning home, rehabilitation can be ties (assisted living facilities and nursing homes). Adult day performed in an acute rehabilitation program or skilled nurs- care and respite care are not typically covered by Medicare or ing facility (ie., subacute rehabilitation). Acute rehabilitation Medicaid. is provided in a freestanding rehabilitation hospital or a desig- When long-term daily care needs exceed those that can nated hospital unit, and it requires that the patient be able to be provided in a patient’s home, three different levels of care participate in 3 hours of therapy at least 5 days per week. 94

Geriatric Medicine Subacute rehabilitation is appropriate for patients who cannot inappropriately withheld from patients with atrial fibrillation tolerate this level of therapy. Medicare covers the costs of both after an episode of gastrointestinal bleeding and from those at

Geriatric Medicine Subacute rehabilitation is appropriate for patients who cannot inappropriately withheld from patients with atrial fibrillation tolerate this level of therapy. Medicare covers the costs of both after an episode of gastrointestinal bleeding and from those at options for up to 100 days if the patient had an inpatient hos- risk for falls or who have fallen. pitalization of at least 3 days and continues to make progress with goals. Some patients require longer-term, high-intensity Polypharmacy medical care, including mechanical ventilation or multiple The percentage of patients aged 65 years or older who take parenteral therapies, and long-term acute care hospitals are an five or more prescription medications increased from 27% to appropriate option for these patients. 41% between 1999 and 2016. Nursing home patients take eight different medications on average, and medication errors occur in two thirds of such patients. Polypharmacy in Medication Management older patients is associated with increased health care Older patients are at significant risk for medication complica- utilization, cost, medication nonadherence, and functional tions, and a comprehensive medication management strategy decline. Patients transitioning between levels of care are is critical for prevention. Specific elements of a medication particularly vulnerable to inappropriate medication addi- management strategy include obtaining an accurate medica- tions, omissions, and dose changes; the risk for these mis- tion history, assessing medication adherence, recognizing the takes increases with the number of medications prescribed. effects of comorbidities and aging on drug metabolism, Hazards of polypharmacy include overtreatment or under- screening for drug-drug interactions, avoiding inappropriate treatment of disease, serious drug-drug interactions, drug- medications, and assessing for polypharmacy. disease interactions, and adverse reactions. Patients should be asked to bring all medications to the Although treatment of comorbid health conditions in visit for the purpose of medication reconciliation, especially older adults often necessitates the use of several medications, after transitions of care. Medication adherence can be assessed physicians can minimize the potential for adverse effects from with standardized questionnaires, pill counts, or review of polypharmacy. Frequent review of patient medications to pillboxes. Common alterations in drug metabolism in older confirm their necessity and proper dosing is paramount, patients, including decreased kidney and liver function, especially during care transitions. necessitate frequent assessment and adjustment of drug dos- ages. Medication lists should be reviewed regularly for drug- drug interactions, including at the time of care transitions. e Adverse effects from polypharmacy can be minimized During medication review, physicians should specifically tar- with frequent review of the patient’s current medica- get the reduction of medications that may be unsafe in older tions, discontinuation of drugs that are unnecessary or patients, such as first-generation antihistamines, tricyclic should be avoided, and adjustment of drug dosages as antidepressants, antipsychotics, and benzodiazepines. The appropriate.

options for up to 100 days if the patient had an inpatient hos- risk for falls or who have fallen. pitalization of at least 3 days and continues to make progress with goals. Some patients require longer-term, high-intensity Polypharmacy medical care, including mechanical ventilation or multiple The percentage of patients aged 65 years or older who take parenteral therapies, and long-term acute care hospitals are an five or more prescription medications increased from 27% to appropriate option for these patients. 41% between 1999 and 2016. Nursing home patients take eight different medications on average, and medication errors occur in two thirds of such patients. Polypharmacy in Medication Management older patients is associated with increased health care Older patients are at significant risk for medication complica- utilization, cost, medication nonadherence, and functional tions, and a comprehensive medication management strategy decline. Patients transitioning between levels of care are is critical for prevention. Specific elements of a medication particularly vulnerable to inappropriate medication addi- management strategy include obtaining an accurate medica- tions, omissions, and dose changes; the risk for these mis- tion history, assessing medication adherence, recognizing the takes increases with the number of medications prescribed. effects of comorbidities and aging on drug metabolism, Hazards of polypharmacy include overtreatment or under- screening for drug-drug interactions, avoiding inappropriate treatment of disease, serious drug-drug interactions, drug- medications, and assessing for polypharmacy. disease interactions, and adverse reactions. Patients should be asked to bring all medications to the Although treatment of comorbid health conditions in visit for the purpose of medication reconciliation, especially older adults often necessitates the use of several medications, after transitions of care. Medication adherence can be assessed physicians can minimize the potential for adverse effects from with standardized questionnaires, pill counts, or review of polypharmacy. Frequent review of patient medications to pillboxes. Common alterations in drug metabolism in older confirm their necessity and proper dosing is paramount, patients, including decreased kidney and liver function, especially during care transitions. necessitate frequent assessment and adjustment of drug dos- ages. Medication lists should be reviewed regularly for drug- drug interactions, including at the time of care transitions. e Adverse effects from polypharmacy can be minimized During medication review, physicians should specifically tar- with frequent review of the patient’s current medica- get the reduction of medications that may be unsafe in older tions, discontinuation of drugs that are unnecessary or patients, such as first-generation antihistamines, tricyclic should be avoided, and adjustment of drug dosages as antidepressants, antipsychotics, and benzodiazepines. The appropriate. 2019 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults lists medications that are problematic for elderly patients as well as recommendations Sleep regarding drug interactions to avoid. Aging patients experience physiologic changes to their sleep

2019 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults lists medications that are problematic for elderly patients as well as recommendations Sleep regarding drug interactions to avoid. Aging patients experience physiologic changes to their sleep Older patients are particularly susceptible to adverse drug cycle, including reductions in total sleep time, rapid eye move- events. Adverse drug events may be the result of adding a new ment (REM) latency, and sleep efficiency, as well as earlier drug, increasing the dose of a previously well-tolerated drug, morning awakening. Many older patients have concerns about or drug-drug interactions. Over-the-counter drugs or supple- insomnia, which is best managed with nonpharmacologic ments may also be responsible for an adverse drug event. The measures (e.g., cognitive behavioral therapy) because pharma- risk for adverse drug reactions can be reduced by stopping all cologic sleep aids must be used with caution in this population unnecessary drugs, seeking safer alternatives for essential (see Common Symptoms). Sleep disorders, such as REM sleep drugs, and considering nonpharmacologic alternatives to drug behavior disorder, may suggest other age-related diseases (e.g., therapy. For example, aspirin for the primary prevention of diffuse Lewy body dementia, Parkinson disease). cardiovascular disease may be discontinued in many individu- als not at increased risk. For some patients, topical NSAIDs may be appropriate and safer than oral NSAIDs in the treat- Urinary Incontinence ment of joint pain, and the need for proton pump inhibitor Epidemiology and Risk Factors therapy may be eliminated by implementing lifestyle The prevalence of urinary incontinence (UI) increases with modifications. age, with at least one third of community-dwelling adults Elderly patients also may be underprescribed drugs that older than 65 years and about two thirds of those in nursing may provide benefit. For example, statins are underprescribed homes experiencing UI. The incidence is higher in women in elderly patients, a group that may have the most to than in men. The true prevalence may be higher, however, gain when properly selected. Anticoagulants often are because many patients do not report symptoms owing to

Older patients are particularly susceptible to adverse drug cycle, including reductions in total sleep time, rapid eye move- events. Adverse drug events may be the result of adding a new ment (REM) latency, and sleep efficiency, as well as earlier drug, increasing the dose of a previously well-tolerated drug, morning awakening. Many older patients have concerns about or drug-drug interactions. Over-the-counter drugs or supple- insomnia, which is best managed with nonpharmacologic ments may also be responsible for an adverse drug event. The measures (e.g., cognitive behavioral therapy) because pharma- risk for adverse drug reactions can be reduced by stopping all cologic sleep aids must be used with caution in this population unnecessary drugs, seeking safer alternatives for essential (see Common Symptoms). Sleep disorders, such as REM sleep drugs, and considering nonpharmacologic alternatives to drug behavior disorder, may suggest other age-related diseases (e.g., therapy. For example, aspirin for the primary prevention of diffuse Lewy body dementia, Parkinson disease). cardiovascular disease may be discontinued in many individu- als not at increased risk. For some patients, topical NSAIDs may be appropriate and safer than oral NSAIDs in the treat- Urinary Incontinence ment of joint pain, and the need for proton pump inhibitor Epidemiology and Risk Factors therapy may be eliminated by implementing lifestyle The prevalence of urinary incontinence (UI) increases with modifications. age, with at least one third of community-dwelling adults Elderly patients also may be underprescribed drugs that older than 65 years and about two thirds of those in nursing may provide benefit. For example, statins are underprescribed homes experiencing UI. The incidence is higher in women in elderly patients, a group that may have the most to than in men. The true prevalence may be higher, however, gain when properly selected. Anticoagulants often are because many patients do not report symptoms owing to 95

Geriatric Medicine embarrassment. Older persons are often not assessed for UI medication history should be obtained, with special attention and, when treated, are less likely to be given evidence-based to the use of diuretics and medications with cholinergic or treatment than younger individuals. anticholinergic effects, including over-the-counter medica- Ulincreases risk for falls, depression, and social isolation; tions. In addition, all patients should be screened for chronic reduces health-related quality of life; and is a major factor conditions associated with increased risk for incontinence (see leading to loss of independence and nursing home placement. Table 60). Risk factors for UI include many common chronic medical The physical examination should include a genitourinary conditions (e.g., diabetes, heart failure, cerebrovascular dis- examination, with evaluation of the pelvis in women and the ease, Parkinson disease, osteoarthritis, and dementia) along prostate in men. Urinalysis is recommended because tran- with the medications used in their treatment. Other risk fac- sient incontinence may be explained by the presence of a tors are pelvic surgery, including hysterectomy and prostate urinary tract infection. Additional laboratory investigation or surgery; pelvic irradiation; pelvic trauma; and obesity. diagnostic testing is usually unnecessary. Postvoid bladder There are five main classifications of UI: stress, urge, over- residual volume assessment, which is performed with ultra- flow, functional, and mixed. UI classifications and disorders sonography after spontaneous voiding, may be considered in predisposing patients to specific types of incontinence are patients in whom overflow incontinence is suspected. presented in Table 60. Stress UI and urge UI are most com- Urodynamic studies are required only for complex cases in mon, although mixed presentations frequently occur. which neurologic disease is suspected and surgical interven- tion is being considered. Evaluation Geriatric patients should be asked about incontinence as part Treatment of their routine care, because patients may be hesitant to vol- Treatment strategies for UI are listed in Table 61. Nonpharma- unteer information owing to the psychological and social cologic therapy is the preferred treatment for all types of UI. implications. Questions about specific symptoms, precipitat- Lifestyle modification, including weight loss (if appropriate), ing events, duration, and frequency, as well as interference decreased consumption of alcohol and caffeine, treatment of with the patient’s quality of life, can be helpful in diagnosing constipation, and smoking cessation should be trialed for a the type of UI. Standardized questionnaires, such as the vali- minimum of 6 weeks. Behavioral therapy is more effective dated 3 Incontinence Questions (3IQ), are easy to administer than pharmacologic therapy and has fewer adverse effects; it in an office setting (Figure 25). A voiding diary may provide should be initiated, along with lifestyle modification, as first- additional helpful information. line therapy. Evaluation should incorporate a targeted history, includ- Pharmacologic therapy may be used as second-line ther- ing surgeries, instrumentations, and radiation. Female patients apy for some types of UI. Patients with continued symptoms should be questioned about pregnancies and gynecologic and reduced quality of life despite behavioral and pharmaco- procedures, and male patients should be asked about symp- logic therapies should be considered for third-line treatments, toms suggestive of prostate enlargement. A comprehensive including device therapy, injectable agents, and surgery. These

embarrassment. Older persons are often not assessed for UI medication history should be obtained, with special attention and, when treated, are less likely to be given evidence-based to the use of diuretics and medications with cholinergic or treatment than younger individuals. anticholinergic effects, including over-the-counter medica- Ulincreases risk for falls, depression, and social isolation; tions. In addition, all patients should be screened for chronic reduces health-related quality of life; and is a major factor conditions associated with increased risk for incontinence (see leading to loss of independence and nursing home placement. Table 60). Risk factors for UI include many common chronic medical The physical examination should include a genitourinary conditions (e.g., diabetes, heart failure, cerebrovascular dis- examination, with evaluation of the pelvis in women and the ease, Parkinson disease, osteoarthritis, and dementia) along prostate in men. Urinalysis is recommended because tran- with the medications used in their treatment. Other risk fac- sient incontinence may be explained by the presence of a tors are pelvic surgery, including hysterectomy and prostate urinary tract infection. Additional laboratory investigation or surgery; pelvic irradiation; pelvic trauma; and obesity. diagnostic testing is usually unnecessary. Postvoid bladder There are five main classifications of UI: stress, urge, over- residual volume assessment, which is performed with ultra- flow, functional, and mixed. UI classifications and disorders sonography after spontaneous voiding, may be considered in predisposing patients to specific types of incontinence are patients in whom overflow incontinence is suspected. presented in Table 60. Stress UI and urge UI are most com- Urodynamic studies are required only for complex cases in mon, although mixed presentations frequently occur. which neurologic disease is suspected and surgical interven- tion is being considered. Evaluation Geriatric patients should be asked about incontinence as part Treatment of their routine care, because patients may be hesitant to vol- Treatment strategies for UI are listed in Table 61. Nonpharma- unteer information owing to the psychological and social cologic therapy is the preferred treatment for all types of UI. implications. Questions about specific symptoms, precipitat- Lifestyle modification, including weight loss (if appropriate), ing events, duration, and frequency, as well as interference decreased consumption of alcohol and caffeine, treatment of with the patient’s quality of life, can be helpful in diagnosing constipation, and smoking cessation should be trialed for a the type of UI. Standardized questionnaires, such as the vali- minimum of 6 weeks. Behavioral therapy is more effective dated 3 Incontinence Questions (3IQ), are easy to administer than pharmacologic therapy and has fewer adverse effects; it in an office setting (Figure 25). A voiding diary may provide should be initiated, along with lifestyle modification, as first- additional helpful information. line therapy. Evaluation should incorporate a targeted history, includ- Pharmacologic therapy may be used as second-line ther- ing surgeries, instrumentations, and radiation. Female patients apy for some types of UI. Patients with continued symptoms should be questioned about pregnancies and gynecologic and reduced quality of life despite behavioral and pharmaco- procedures, and male patients should be asked about symp- logic therapies should be considered for third-line treatments, toms suggestive of prostate enlargement. A comprehensive including device therapy, injectable agents, and surgery. These TABLE 60. Types of Urinary Incontinence and Commonly Associated Conditions

embarrassment. Older persons are often not assessed for UI medication history should be obtained, with special attention and, when treated, are less likely to be given evidence-based to the use of diuretics and medications with cholinergic or treatment than younger individuals. anticholinergic effects, including over-the-counter medica- Ulincreases risk for falls, depression, and social isolation; tions. In addition, all patients should be screened for chronic reduces health-related quality of life; and is a major factor conditions associated with increased risk for incontinence (see leading to loss of independence and nursing home placement. Table 60). Risk factors for UI include many common chronic medical The physical examination should include a genitourinary conditions (e.g., diabetes, heart failure, cerebrovascular dis- examination, with evaluation of the pelvis in women and the ease, Parkinson disease, osteoarthritis, and dementia) along prostate in men. Urinalysis is recommended because tran- with the medications used in their treatment. Other risk fac- sient incontinence may be explained by the presence of a tors are pelvic surgery, including hysterectomy and prostate urinary tract infection. Additional laboratory investigation or surgery; pelvic irradiation; pelvic trauma; and obesity. diagnostic testing is usually unnecessary. Postvoid bladder There are five main classifications of UI: stress, urge, over- residual volume assessment, which is performed with ultra- flow, functional, and mixed. UI classifications and disorders sonography after spontaneous voiding, may be considered in predisposing patients to specific types of incontinence are patients in whom overflow incontinence is suspected. presented in Table 60. Stress UI and urge UI are most com- Urodynamic studies are required only for complex cases in mon, although mixed presentations frequently occur. which neurologic disease is suspected and surgical interven- tion is being considered. Evaluation Geriatric patients should be asked about incontinence as part Treatment of their routine care, because patients may be hesitant to vol- Treatment strategies for UI are listed in Table 61. Nonpharma- unteer information owing to the psychological and social cologic therapy is the preferred treatment for all types of UI. implications. Questions about specific symptoms, precipitat- Lifestyle modification, including weight loss (if appropriate), ing events, duration, and frequency, as well as interference decreased consumption of alcohol and caffeine, treatment of with the patient’s quality of life, can be helpful in diagnosing constipation, and smoking cessation should be trialed for a the type of UI. Standardized questionnaires, such as the vali- minimum of 6 weeks. Behavioral therapy is more effective dated 3 Incontinence Questions (3IQ), are easy to administer than pharmacologic therapy and has fewer adverse effects; it in an office setting (Figure 25). A voiding diary may provide should be initiated, along with lifestyle modification, as first- additional helpful information. line therapy. Evaluation should incorporate a targeted history, includ- Pharmacologic therapy may be used as second-line ther- ing surgeries, instrumentations, and radiation. Female patients apy for some types of UI. Patients with continued symptoms should be questioned about pregnancies and gynecologic and reduced quality of life despite behavioral and pharmaco- procedures, and male patients should be asked about symp- logic therapies should be considered for third-line treatments, toms suggestive of prostate enlargement. A comprehensive including device therapy, injectable agents, and surgery. These TABLE 60. Types of Urinary Incontinence and Commonly Associated Conditions Incontinence Type _— Definition Associated Conditions

embarrassment. Older persons are often not assessed for UI medication history should be obtained, with special attention and, when treated, are less likely to be given evidence-based to the use of diuretics and medications with cholinergic or treatment than younger individuals. anticholinergic effects, including over-the-counter medica- Ulincreases risk for falls, depression, and social isolation; tions. In addition, all patients should be screened for chronic reduces health-related quality of life; and is a major factor conditions associated with increased risk for incontinence (see leading to loss of independence and nursing home placement. Table 60). Risk factors for UI include many common chronic medical The physical examination should include a genitourinary conditions (e.g., diabetes, heart failure, cerebrovascular dis- examination, with evaluation of the pelvis in women and the ease, Parkinson disease, osteoarthritis, and dementia) along prostate in men. Urinalysis is recommended because tran- with the medications used in their treatment. Other risk fac- sient incontinence may be explained by the presence of a tors are pelvic surgery, including hysterectomy and prostate urinary tract infection. Additional laboratory investigation or surgery; pelvic irradiation; pelvic trauma; and obesity. diagnostic testing is usually unnecessary. Postvoid bladder There are five main classifications of UI: stress, urge, over- residual volume assessment, which is performed with ultra- flow, functional, and mixed. UI classifications and disorders sonography after spontaneous voiding, may be considered in predisposing patients to specific types of incontinence are patients in whom overflow incontinence is suspected. presented in Table 60. Stress UI and urge UI are most com- Urodynamic studies are required only for complex cases in mon, although mixed presentations frequently occur. which neurologic disease is suspected and surgical interven- tion is being considered. Evaluation Geriatric patients should be asked about incontinence as part Treatment of their routine care, because patients may be hesitant to vol- Treatment strategies for UI are listed in Table 61. Nonpharma- unteer information owing to the psychological and social cologic therapy is the preferred treatment for all types of UI. implications. Questions about specific symptoms, precipitat- Lifestyle modification, including weight loss (if appropriate), ing events, duration, and frequency, as well as interference decreased consumption of alcohol and caffeine, treatment of with the patient’s quality of life, can be helpful in diagnosing constipation, and smoking cessation should be trialed for a the type of UI. Standardized questionnaires, such as the vali- minimum of 6 weeks. Behavioral therapy is more effective dated 3 Incontinence Questions (3IQ), are easy to administer than pharmacologic therapy and has fewer adverse effects; it in an office setting (Figure 25). A voiding diary may provide should be initiated, along with lifestyle modification, as first- additional helpful information. line therapy. Evaluation should incorporate a targeted history, includ- Pharmacologic therapy may be used as second-line ther- ing surgeries, instrumentations, and radiation. Female patients apy for some types of UI. Patients with continued symptoms should be questioned about pregnancies and gynecologic and reduced quality of life despite behavioral and pharmaco- procedures, and male patients should be asked about symp- logic therapies should be considered for third-line treatments, toms suggestive of prostate enlargement. A comprehensive including device therapy, injectable agents, and surgery. These TABLE 60. Types of Urinary Incontinence and Commonly Associated Conditions Incontinence Type _— Definition Associated Conditions Stress Incontinence associated with increased intra-abdominal Multiparous pregnancy pressure, such as sneezing, laughing, or coughing Radical prostatectomy

Incontinence Type _— Definition Associated Conditions Stress Incontinence associated with increased intra-abdominal Multiparous pregnancy pressure, such as sneezing, laughing, or coughing Radical prostatectomy Urge (overactive Incontinence due to detrusor overactivity associated Often without clear cause bladder with with urge to void preceding or accompanied by leakage Spinal cord injury incontinence) of urine Overflow Incontinence due to incomplete bladder emptying, Chronic urinary retention leading to continuous urine leakage or dribbling, weak Bladder outlet obstruction urinary stream, urinary hesitancy, increased frequency, and nocturia Detrusor underactivity due to low estrogen or peripheral neuropathy Prostate hypertrophy with bladder outlet obstruction | Functional Incontinence due to physical inability to toilet in a timely Dementia manner Mobility issues (osteoarthritis, residual deficits from cerebrovascular disease, Parkinson disease) Mixed Incontinence due to a combination of increased intra- All conditions associated with stress and urge abdominal pressure and detrusor hyperactivity urinary incontinence

Geriatric Medicine 1. During the last 3 months, have you leaked urine (even a small amount)? QO Yes QO No Questionnaire completed. 2. During the last 3 months, did you leak urine: (Check all that apply.) Q a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise? Q b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough? Qc. Without physical activity and without a sense of urgency? 3. During the last 3 months, did you leak urine most often: (Check only one.) QO a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise? Q b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough? Qc. Without physical activity and without a sense of urgency? Q d. About equally as often with physical activity as with a sense of urgency? Definitions of type of urinary incontinence are based on responses to question 3: Response to Question 3 Type of Incontinence a. Most often with physical activity Stress only or stress predominant b. Most often with the urge to empty the bladder Urge only or urge predominant c. Without physical activity or sense of urgency Other cause only or other cause predominant d. About equally with physical activity and sense of urgency Mixed FIGURE 25. The 3 Incontinence Questions (310) for evaluation of urinary incontinence. Reproduced with permission from Brown JS, Bradley CS, Subak LL, et al; Diagnostic Aspects of Incontinence Study (DAISy) Research Group. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144:716. [PMID: 16702587] doi:10.7326/0003-4819-144-10-200605160-00005 ©2006, American College of Physicians.

Reproduced with permission from Brown JS, Bradley CS, Subak LL, et al; Diagnostic Aspects of Incontinence Study (DAISy) Research Group. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006;144:716. [PMID: 16702587] doi:10.7326/0003-4819-144-10-200605160-00005 ©2006, American College of Physicians. TABLE 61. Treatment Strategies for Urinary Incontinence Incontinence Behavioral Therapy Pharmacologic Therapy Other Therapies Type Stress Pelvic floor muscle training (Kegel Topical vaginal estrogen Pessaries, injectable bulking agents, exercises) with or without (postmenopausal women) sling cystourethropexy | biofeedback | Urge Bladder training/timed voiding Anticholinergic/antimuscarinics Spinal neuromodulators, botulinum (overactive (oxybutynin, darifenacin, solifenacin, toxin injections bladder with tolterodine, fesoterodine, trospium) incontinence) B-Adrenergics (mirabegron, vibegron) Topical vaginal estrogen (postmenopausal women)

| Urge Bladder training/timed voiding Anticholinergic/antimuscarinics Spinal neuromodulators, botulinum (overactive (oxybutynin, darifenacin, solifenacin, toxin injections bladder with tolterodine, fesoterodine, trospium) incontinence) B-Adrenergics (mirabegron, vibegron) Topical vaginal estrogen (postmenopausal women) Overflow Double voiding a-Blocker and 5a-reductase Transurethral prostatectomy can be inhibitors for BPH-related symptoms considered for BPH-related Triggered voiding symptoms Scheduled intermittent catheterization Functional Caregiver-prompted timed voiding No recommended pharmacologic None routinely recommended therapies

Scheduled intermittent catheterization Functional Caregiver-prompted timed voiding No recommended pharmacologic None routinely recommended therapies Mixed Pelvic floor muscle training with or Consider antimuscarinics or Consider therapies for stress or urge without biofeedback B-adrenergics incontinence depending on predominant symptoms Bladder training/timed voiding BPH = benign prostatic hyperplasia. 97

Geriatric Medicine patients should be referred to a urologist or urogynecologist. persons are especially susceptible to the central nervous sys- Indwelling urinary catheters are not recommended for any tem effects of anticholinergics, which may limit drug type of incontinence, owing to an unacceptably high risk for tolerability. infection associated with their use. Third-line therapy includes devices and procedural thera- pies. Refractory urge UI may be treated with repetitive botuli- Stress Urinary Incontinence num toxin injections into the detrusor muscle. Adverse effects After a trial of lifestyle modification, first-line behavioral ther- include urinary retention requiring self-catheterization. In apy for stress and mixed UI is pelvic floor muscle training rare cases, surgically implanted sacral nerve root neurostimu- (Kegel exercises). Patients should be instructed to contract the lation devices may be used in combination with behavioral pelvic floor as if attempting to avoid urination and sustain the therapy and pharmacotherapy for refractory urge UI. contraction for 10 seconds. Contractions should be performed in three or four sets of 10 each day. Patients should be coun- Overflow Urinary Incontinence seled that symptom improvement may not be noticeable until Behavioral therapy for overflow UI includes double voiding pelvic floor muscle training is consistently performed for sev- (remaining on the toilet for a few minutes after voiding and eral months. Some studies have demonstrated benefits when then attempting to void again) and triggered voiding (maneu- biofeedback therapy, in which a vaginal electromyography vers to stimulate voiding, including massaging the pubic bone probe is used to provide direct confirmation that the patient is and tugging on pubic hairs). Intermittent catheterization may contracting the pelvic floor muscles correctly, is included with be used to decrease the need for containment products, such these exercises. as pads or diapers. Vaginal estrogen formulations (tablets and ovules) Pharmacologic treatment of overflow UI associated with increase continence compared with placebo in patients with prostatic hyperplasia is discussed in MKSAP 19 General stress UI, but transdermal patches or implants are not helpful. Internal Medicine 2. Systemic estrogen should not be used for stress or mixed UI, especially in patients with breast cancer. Functional Urinary Incontinence Pessary devices are a low-risk, third-line treatment In patients with cognitive impairment-related functional UI,

patients should be referred to a urologist or urogynecologist. persons are especially susceptible to the central nervous sys- Indwelling urinary catheters are not recommended for any tem effects of anticholinergics, which may limit drug type of incontinence, owing to an unacceptably high risk for tolerability. infection associated with their use. Third-line therapy includes devices and procedural thera- pies. Refractory urge UI may be treated with repetitive botuli- Stress Urinary Incontinence num toxin injections into the detrusor muscle. Adverse effects After a trial of lifestyle modification, first-line behavioral ther- include urinary retention requiring self-catheterization. In apy for stress and mixed UI is pelvic floor muscle training rare cases, surgically implanted sacral nerve root neurostimu- (Kegel exercises). Patients should be instructed to contract the lation devices may be used in combination with behavioral pelvic floor as if attempting to avoid urination and sustain the therapy and pharmacotherapy for refractory urge UI. contraction for 10 seconds. Contractions should be performed in three or four sets of 10 each day. Patients should be coun- Overflow Urinary Incontinence seled that symptom improvement may not be noticeable until Behavioral therapy for overflow UI includes double voiding pelvic floor muscle training is consistently performed for sev- (remaining on the toilet for a few minutes after voiding and eral months. Some studies have demonstrated benefits when then attempting to void again) and triggered voiding (maneu- biofeedback therapy, in which a vaginal electromyography vers to stimulate voiding, including massaging the pubic bone probe is used to provide direct confirmation that the patient is and tugging on pubic hairs). Intermittent catheterization may contracting the pelvic floor muscles correctly, is included with be used to decrease the need for containment products, such these exercises. as pads or diapers. Vaginal estrogen formulations (tablets and ovules) Pharmacologic treatment of overflow UI associated with increase continence compared with placebo in patients with prostatic hyperplasia is discussed in MKSAP 19 General stress UI, but transdermal patches or implants are not helpful. Internal Medicine 2. Systemic estrogen should not be used for stress or mixed UI, especially in patients with breast cancer. Functional Urinary Incontinence Pessary devices are a low-risk, third-line treatment In patients with cognitive impairment-related functional UI, option for patients with stress UI. Limited high-quality evi- prompted voiding by the caregiver may be useful. Prompted

patients should be referred to a urologist or urogynecologist. persons are especially susceptible to the central nervous sys- Indwelling urinary catheters are not recommended for any tem effects of anticholinergics, which may limit drug type of incontinence, owing to an unacceptably high risk for tolerability. infection associated with their use. Third-line therapy includes devices and procedural thera- pies. Refractory urge UI may be treated with repetitive botuli- Stress Urinary Incontinence num toxin injections into the detrusor muscle. Adverse effects After a trial of lifestyle modification, first-line behavioral ther- include urinary retention requiring self-catheterization. In apy for stress and mixed UI is pelvic floor muscle training rare cases, surgically implanted sacral nerve root neurostimu- (Kegel exercises). Patients should be instructed to contract the lation devices may be used in combination with behavioral pelvic floor as if attempting to avoid urination and sustain the therapy and pharmacotherapy for refractory urge UI. contraction for 10 seconds. Contractions should be performed in three or four sets of 10 each day. Patients should be coun- Overflow Urinary Incontinence seled that symptom improvement may not be noticeable until Behavioral therapy for overflow UI includes double voiding pelvic floor muscle training is consistently performed for sev- (remaining on the toilet for a few minutes after voiding and eral months. Some studies have demonstrated benefits when then attempting to void again) and triggered voiding (maneu- biofeedback therapy, in which a vaginal electromyography vers to stimulate voiding, including massaging the pubic bone probe is used to provide direct confirmation that the patient is and tugging on pubic hairs). Intermittent catheterization may contracting the pelvic floor muscles correctly, is included with be used to decrease the need for containment products, such these exercises. as pads or diapers. Vaginal estrogen formulations (tablets and ovules) Pharmacologic treatment of overflow UI associated with increase continence compared with placebo in patients with prostatic hyperplasia is discussed in MKSAP 19 General stress UI, but transdermal patches or implants are not helpful. Internal Medicine 2. Systemic estrogen should not be used for stress or mixed UI, especially in patients with breast cancer. Functional Urinary Incontinence Pessary devices are a low-risk, third-line treatment In patients with cognitive impairment-related functional UI, option for patients with stress UI. Limited high-quality evi- prompted voiding by the caregiver may be useful. Prompted dence supports cystoscopically guided injection of bulking voiding involves regularly asking the patient to report on

patients should be referred to a urologist or urogynecologist. persons are especially susceptible to the central nervous sys- Indwelling urinary catheters are not recommended for any tem effects of anticholinergics, which may limit drug type of incontinence, owing to an unacceptably high risk for tolerability. infection associated with their use. Third-line therapy includes devices and procedural thera- pies. Refractory urge UI may be treated with repetitive botuli- Stress Urinary Incontinence num toxin injections into the detrusor muscle. Adverse effects After a trial of lifestyle modification, first-line behavioral ther- include urinary retention requiring self-catheterization. In apy for stress and mixed UI is pelvic floor muscle training rare cases, surgically implanted sacral nerve root neurostimu- (Kegel exercises). Patients should be instructed to contract the lation devices may be used in combination with behavioral pelvic floor as if attempting to avoid urination and sustain the therapy and pharmacotherapy for refractory urge UI. contraction for 10 seconds. Contractions should be performed in three or four sets of 10 each day. Patients should be coun- Overflow Urinary Incontinence seled that symptom improvement may not be noticeable until Behavioral therapy for overflow UI includes double voiding pelvic floor muscle training is consistently performed for sev- (remaining on the toilet for a few minutes after voiding and eral months. Some studies have demonstrated benefits when then attempting to void again) and triggered voiding (maneu- biofeedback therapy, in which a vaginal electromyography vers to stimulate voiding, including massaging the pubic bone probe is used to provide direct confirmation that the patient is and tugging on pubic hairs). Intermittent catheterization may contracting the pelvic floor muscles correctly, is included with be used to decrease the need for containment products, such these exercises. as pads or diapers. Vaginal estrogen formulations (tablets and ovules) Pharmacologic treatment of overflow UI associated with increase continence compared with placebo in patients with prostatic hyperplasia is discussed in MKSAP 19 General stress UI, but transdermal patches or implants are not helpful. Internal Medicine 2. Systemic estrogen should not be used for stress or mixed UI, especially in patients with breast cancer. Functional Urinary Incontinence Pessary devices are a low-risk, third-line treatment In patients with cognitive impairment-related functional UI, option for patients with stress UI. Limited high-quality evi- prompted voiding by the caregiver may be useful. Prompted dence supports cystoscopically guided injection of bulking voiding involves regularly asking the patient to report on agents into the urethral mucosa at the bladder neck. Injection incontinence, asking the patient if he or she needs to void and

option for patients with stress UI. Limited high-quality evi- prompted voiding by the caregiver may be useful. Prompted dence supports cystoscopically guided injection of bulking voiding involves regularly asking the patient to report on agents into the urethral mucosa at the bladder neck. Injection incontinence, asking the patient if he or she needs to void and therapy requires repeat administration in upwards of 70% of providing assistance, and praising the patient for continence. patients whose symptoms initially improve. Surgical treat- ment is reserved for stress UI that does not respond to other e Nonpharmacologic therapy, including lifestyle modifica- therapies and typically consists of sling cystourethropexy tion and behavioral therapy, is the preferred treatment for women or placement of an artificial urinary sphincter for all types of urinary incontinence. for men. e Urge and mixed urinary incontinence may be treated Urge Urinary Incontinence with pharmacologic therapy, including anticholinergic

patients whose symptoms initially improve. Surgical treat- ment is reserved for stress UI that does not respond to other e Nonpharmacologic therapy, including lifestyle modifica- therapies and typically consists of sling cystourethropexy tion and behavioral therapy, is the preferred treatment for women or placement of an artificial urinary sphincter for all types of urinary incontinence. for men. e Urge and mixed urinary incontinence may be treated Urge Urinary Incontinence with pharmacologic therapy, including anticholinergic Behavioral therapy for urge UI consists of bladder training and antimuscarinic agents, when symptoms persist with timed voiding. Bladder training comprises scheduled despite behavioral therapy. voiding attempts at intervals shorter than the usual time between incontinence episodes, regardless of the urge to void, with a gradual increase in the time between voids. If an epi- Pressure Injuries sode of urgency occurs before the designated voiding time, Pressure injuries (or pressure ulcers) represent damage to the patients are encouraged to use pelvic floor muscle contraction skin and underlying tissue caused by unrelieved pressure. until the urge passes and then proceed with voiding directly They may be classified by using a staging system (Table 62); afterward. advancing stages are characterized by increasing tissue loss, If behavioral therapy and lifestyle modification fail to cor- depth, and ulcer size. rect urge or mixed UI, several classes of pharmacologic agents The most important risk factors for pressure injury are are available as second-line therapy (see Table 61). The phar- immobility, malnutrition, sensory loss, and reduced skin per- macologic agents recommended for women with urge UI also fusion, which can occur with hypovolemia, hypotension, and are approved for use in men. Anticholinergic agents are con- systemic vasoconstriction. An estimated 2.5 to 3 million pres- traindicated in patients with angle-closure glaucoma and sure injuries are treated each year in acute care facilities in the severely impaired gastrointestinal motility and should be United States. The prevalence of pressure injuries ranges from avoided in patients with tachyarrhythmias. These agents 3% to 17% among hospitalized patients, but the rate is much should be used with caution in men with benign prostatic higher in some high-risk groups and approaches 50% in long- hyperplasia owing to the risk for urinary retention. Elderly term ICU patients. Patients who develop pressure injuries

Behavioral therapy for urge UI consists of bladder training and antimuscarinic agents, when symptoms persist with timed voiding. Bladder training comprises scheduled despite behavioral therapy. voiding attempts at intervals shorter than the usual time between incontinence episodes, regardless of the urge to void, with a gradual increase in the time between voids. If an epi- Pressure Injuries sode of urgency occurs before the designated voiding time, Pressure injuries (or pressure ulcers) represent damage to the patients are encouraged to use pelvic floor muscle contraction skin and underlying tissue caused by unrelieved pressure. until the urge passes and then proceed with voiding directly They may be classified by using a staging system (Table 62); afterward. advancing stages are characterized by increasing tissue loss, If behavioral therapy and lifestyle modification fail to cor- depth, and ulcer size. rect urge or mixed UI, several classes of pharmacologic agents The most important risk factors for pressure injury are are available as second-line therapy (see Table 61). The phar- immobility, malnutrition, sensory loss, and reduced skin per- macologic agents recommended for women with urge UI also fusion, which can occur with hypovolemia, hypotension, and are approved for use in men. Anticholinergic agents are con- systemic vasoconstriction. An estimated 2.5 to 3 million pres- traindicated in patients with angle-closure glaucoma and sure injuries are treated each year in acute care facilities in the severely impaired gastrointestinal motility and should be United States. The prevalence of pressure injuries ranges from avoided in patients with tachyarrhythmias. These agents 3% to 17% among hospitalized patients, but the rate is much should be used with caution in men with benign prostatic higher in some high-risk groups and approaches 50% in long- hyperplasia owing to the risk for urinary retention. Elderly term ICU patients. Patients who develop pressure injuries 98

Geriatric Medicine TABLE 62. Classification of Pressure Injuries injuries and may be accomplished with pressure-reducing equipment and proper patient positioning. Advanced static Description mattresses or overlays are effective for prevention in patients at 1 Nonblanchable erythema of intact skin increased risk. An advanced static mattress is made of special- 2 Partial-thickness skin loss with exposed ized sheepskin, foam, or gel and is immobile when a patient dermis. The wound bed is viable, pink or red, lies on it, whereas an advanced static overlay is a pad composed moist, and may also present as an intact or ruptured serum-filled blister of foam or gel that is secured to the top of a regular mattress.

TABLE 62. Classification of Pressure Injuries injuries and may be accomplished with pressure-reducing equipment and proper patient positioning. Advanced static Description mattresses or overlays are effective for prevention in patients at 1 Nonblanchable erythema of intact skin increased risk. An advanced static mattress is made of special- 2 Partial-thickness skin loss with exposed ized sheepskin, foam, or gel and is immobile when a patient dermis. The wound bed is viable, pink or red, lies on it, whereas an advanced static overlay is a pad composed moist, and may also present as an intact or ruptured serum-filled blister of foam or gel that is secured to the top of a regular mattress. 3 Full-thickness loss of skin, in which adipose Evidence of efficacy for repositioning, nutritional inter- (fat) is visible in the ulcer and granulation ventions, and local care (silicone foam dressings or creams) in tissue and epibole (rolled wound edges) are preventing pressure ulcers is limited. The role of alternating air often present. Slough and/or eschar may be visible. Undermining and tunneling may occur mattresses is unclear because data do not demonstrate a clear advantage compared with static mattresses. Alternating air 4 Full-thickness skin and tissue loss with | exposed or directly palpable fascia, muscle, mattresses also are associated with substantially higher costs. tendon, ligament, cartilage or bone in the Data are insufficient to recommend the routine use of dietary ulcer. Slough and/or eschar may be visible. supplements for pressure injury prevention. Epibole (rolled edges), undermining, and/or tunneling often occur Management Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer Successful treatment of established pressure injuries requires cannot be confirmed because itis obscured interdisciplinary management involving wound care, surgical by slough or eschar | debridement, surgical repair, vacuum-assisted closure (in some Deep tissue Intact or nonintact skin with localized area of cases), nutrition, and pressure-reducing surfaces. When necrotic injury persistent nonblanchable deep red, maroon, | _ or purple discoloration or epidermal tissue is present, it should be debrided. Hydrocolloid and foam separation revealing a dark wound bed or dressings are recommended treatments because they have been blood-filled blister shown to reduce ulcer size compared with gauze dressings in Information from Edsberg LE, Black JM, Goldberg M, et al. Revised National low-quality studies. There is moderate-quality evidence that Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43:585-97. [PMID: protein-containing supplements improve wound healing. 27749790] doi:10.1097/WON.0000000000000281 Although pressure redistribution measures should be instituted, the relative benefit of different support surfaces in the treatment of pressure injuries is unclear. Evidence is also insufficient to during an acute care stay are much more likely to be dis- support the use of platelet-derived growth factor dressings, charged to a long-term care facility. hydrotherapy, hyperbaric oxygen, or maggot therapy.

3 Full-thickness loss of skin, in which adipose Evidence of efficacy for repositioning, nutritional inter- (fat) is visible in the ulcer and granulation ventions, and local care (silicone foam dressings or creams) in tissue and epibole (rolled wound edges) are preventing pressure ulcers is limited. The role of alternating air often present. Slough and/or eschar may be visible. Undermining and tunneling may occur mattresses is unclear because data do not demonstrate a clear advantage compared with static mattresses. Alternating air 4 Full-thickness skin and tissue loss with | exposed or directly palpable fascia, muscle, mattresses also are associated with substantially higher costs. tendon, ligament, cartilage or bone in the Data are insufficient to recommend the routine use of dietary ulcer. Slough and/or eschar may be visible. supplements for pressure injury prevention. Epibole (rolled edges), undermining, and/or tunneling often occur Management Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer Successful treatment of established pressure injuries requires cannot be confirmed because itis obscured interdisciplinary management involving wound care, surgical by slough or eschar | debridement, surgical repair, vacuum-assisted closure (in some Deep tissue Intact or nonintact skin with localized area of cases), nutrition, and pressure-reducing surfaces. When necrotic injury persistent nonblanchable deep red, maroon, | _ or purple discoloration or epidermal tissue is present, it should be debrided. Hydrocolloid and foam separation revealing a dark wound bed or dressings are recommended treatments because they have been blood-filled blister shown to reduce ulcer size compared with gauze dressings in Information from Edsberg LE, Black JM, Goldberg M, et al. Revised National low-quality studies. There is moderate-quality evidence that Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43:585-97. [PMID: protein-containing supplements improve wound healing. 27749790] doi:10.1097/WON.0000000000000281 Although pressure redistribution measures should be instituted, the relative benefit of different support surfaces in the treatment of pressure injuries is unclear. Evidence is also insufficient to during an acute care stay are much more likely to be dis- support the use of platelet-derived growth factor dressings, charged to a long-term care facility. hydrotherapy, hyperbaric oxygen, or maggot therapy. Prevention Pressure injury prevention is a cost-effective intervention that e Pressure redistribution is of paramount importance in

3 Full-thickness loss of skin, in which adipose Evidence of efficacy for repositioning, nutritional inter- (fat) is visible in the ulcer and granulation ventions, and local care (silicone foam dressings or creams) in tissue and epibole (rolled wound edges) are preventing pressure ulcers is limited. The role of alternating air often present. Slough and/or eschar may be visible. Undermining and tunneling may occur mattresses is unclear because data do not demonstrate a clear advantage compared with static mattresses. Alternating air 4 Full-thickness skin and tissue loss with | exposed or directly palpable fascia, muscle, mattresses also are associated with substantially higher costs. tendon, ligament, cartilage or bone in the Data are insufficient to recommend the routine use of dietary ulcer. Slough and/or eschar may be visible. supplements for pressure injury prevention. Epibole (rolled edges), undermining, and/or tunneling often occur Management Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer Successful treatment of established pressure injuries requires cannot be confirmed because itis obscured interdisciplinary management involving wound care, surgical by slough or eschar | debridement, surgical repair, vacuum-assisted closure (in some Deep tissue Intact or nonintact skin with localized area of cases), nutrition, and pressure-reducing surfaces. When necrotic injury persistent nonblanchable deep red, maroon, | _ or purple discoloration or epidermal tissue is present, it should be debrided. Hydrocolloid and foam separation revealing a dark wound bed or dressings are recommended treatments because they have been blood-filled blister shown to reduce ulcer size compared with gauze dressings in Information from Edsberg LE, Black JM, Goldberg M, et al. Revised National low-quality studies. There is moderate-quality evidence that Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43:585-97. [PMID: protein-containing supplements improve wound healing. 27749790] doi:10.1097/WON.0000000000000281 Although pressure redistribution measures should be instituted, the relative benefit of different support surfaces in the treatment of pressure injuries is unclear. Evidence is also insufficient to during an acute care stay are much more likely to be dis- support the use of platelet-derived growth factor dressings, charged to a long-term care facility. hydrotherapy, hyperbaric oxygen, or maggot therapy. Prevention Pressure injury prevention is a cost-effective intervention that e Pressure redistribution is of paramount importance in can positively affect health status. Improved understanding of the prevention of pressure injuries and can be facili- ulcer pathogenesis and changes in reimbursement have tated by use of advanced static mattresses or overlays.

Prevention Pressure injury prevention is a cost-effective intervention that e Pressure redistribution is of paramount importance in can positively affect health status. Improved understanding of the prevention of pressure injuries and can be facili- ulcer pathogenesis and changes in reimbursement have tated by use of advanced static mattresses or overlays. increased the focus on identifying at-risk patients and allocat- e Protein-containing supplements and hydrocolloid or ing resources to prevention efforts. The Centers for Medicare & foam dressings are effective in the treatment of estab- Medicaid Services (CMS) has selected the development of a lished pressure injuries. severe pressure ulcer as a “never event” (adverse events that are unambiguous [clearly identifiable and measurable], usu- ally preventable, and serious [resulting in death or significant Dermatologic Conditions of Aging disability]) for health care facilities. Since 2008, CMS provides Dryness (xerosis cutis) is one of the most prevalent skin condi- no additional payment whena stage III or IV pressure ulcer is tions in aging adults. Although pilosebaceous glands become acquired after admission to a health care facility. larger with age, sebum production decreases by 50%. Xerosis The first step in pressure injury prevention is a structured occurs more often in the winter (low humidity) and on the risk assessment, including a history and physical examination, lower legs. It presents as dry, fissured patches with a scalelike to identify at-risk patients. Although standardized risk- appearance. Treatment of xerosis consists of avoidance of hot assessment tools are available (e.g., the Braden, Jackson/ baths; use of mild synthetic detergent soaps; and good skin Cubbin, Norton, and Waterlow scales), clinical validation stud- care measures, including frequent application of emollients to ies have found these instruments to have fairly low positive reduce dryness, especially immediately after bathing. predictive values (60%-70%). Bedside clinical assessment of Excessive xerosis can cause xerotic dermatitis, also called the skin remains an important part of risk evaluation. xerotic eczema, eczema craquelé, or asteatotic eczema (Figure 26). In patients identified as being at risk, pressure redistribu- When severe, lesions are erythematous with plate-like cracked tion is of paramount importance in the prevention of pressure scale, often resembling a dried-up creek bed (Figure 27).

increased the focus on identifying at-risk patients and allocat- e Protein-containing supplements and hydrocolloid or ing resources to prevention efforts. The Centers for Medicare & foam dressings are effective in the treatment of estab- Medicaid Services (CMS) has selected the development of a lished pressure injuries. severe pressure ulcer as a “never event” (adverse events that are unambiguous [clearly identifiable and measurable], usu- ally preventable, and serious [resulting in death or significant Dermatologic Conditions of Aging disability]) for health care facilities. Since 2008, CMS provides Dryness (xerosis cutis) is one of the most prevalent skin condi- no additional payment whena stage III or IV pressure ulcer is tions in aging adults. Although pilosebaceous glands become acquired after admission to a health care facility. larger with age, sebum production decreases by 50%. Xerosis The first step in pressure injury prevention is a structured occurs more often in the winter (low humidity) and on the risk assessment, including a history and physical examination, lower legs. It presents as dry, fissured patches with a scalelike to identify at-risk patients. Although standardized risk- appearance. Treatment of xerosis consists of avoidance of hot assessment tools are available (e.g., the Braden, Jackson/ baths; use of mild synthetic detergent soaps; and good skin Cubbin, Norton, and Waterlow scales), clinical validation stud- care measures, including frequent application of emollients to ies have found these instruments to have fairly low positive reduce dryness, especially immediately after bathing. predictive values (60%-70%). Bedside clinical assessment of Excessive xerosis can cause xerotic dermatitis, also called the skin remains an important part of risk evaluation. xerotic eczema, eczema craquelé, or asteatotic eczema (Figure 26). In patients identified as being at risk, pressure redistribu- When severe, lesions are erythematous with plate-like cracked tion is of paramount importance in the prevention of pressure scale, often resembling a dried-up creek bed (Figure 27). 99

Geriatric Medicine | FIGURE 26. Characteristic findings of xerotic eczema. Fine, porcelain-like cracks on eczematous skin are seen on the anterior leg. FIGURE 28. Purpuric ill-defined patches (actinic purpura) (white arrow) and ill-

Geriatric Medicine | FIGURE 26. Characteristic findings of xerotic eczema. Fine, porcelain-like cracks on eczematous skin are seen on the anterior leg. FIGURE 28. Purpuric ill-defined patches (actinic purpura) (white arrow) and ill- Although aging is the most common cause, hypothyroidism or defined tan macules (solar lentigines) (black arrow) on atrophic skin demonstrating signs of aging. such medications as diuretics may be implicated. Treatment includes a medium-potency topical glucocorticoid in an oint- Solar lentigines are tan or light brown, 1- to 3-cm well- ment base to be discontinued when the inflammation subsides, defined macules on sun-exposed areas of older adults, com- followed by liberal use of emollients to prevent recurrence. monly referred to as “liver spots” (Figure 29). They are a Actinic purpura appears as purpuric macules or patches, marker of sun damage. Ephelides or “freckles” are 2- to 5-mm most commonly on the forearms, due to minor trauma such as tan macules on sun-exposed areas that appear in childhood scratching (Figure 28). There may be associated stellate pseu- and darken with sun exposure. When solar lentigines or doscars, which are atrophic scars occurring after skin tears. ephelides are larger than 1 cm or irregular in shape, melanoma Actinic purpura is due to blood vessel fragility and dermal is in the clinical differential diagnosis and biopsy should be atrophy from aging. No additional testing needs to be per- considered (see MKSAP 19 Oncology). formed. There is no treatment for actinic purpura, but sun protection is recommended to prevent further damage. a

Although aging is the most common cause, hypothyroidism or defined tan macules (solar lentigines) (black arrow) on atrophic skin demonstrating signs of aging. such medications as diuretics may be implicated. Treatment includes a medium-potency topical glucocorticoid in an oint- Solar lentigines are tan or light brown, 1- to 3-cm well- ment base to be discontinued when the inflammation subsides, defined macules on sun-exposed areas of older adults, com- followed by liberal use of emollients to prevent recurrence. monly referred to as “liver spots” (Figure 29). They are a Actinic purpura appears as purpuric macules or patches, marker of sun damage. Ephelides or “freckles” are 2- to 5-mm most commonly on the forearms, due to minor trauma such as tan macules on sun-exposed areas that appear in childhood scratching (Figure 28). There may be associated stellate pseu- and darken with sun exposure. When solar lentigines or doscars, which are atrophic scars occurring after skin tears. ephelides are larger than 1 cm or irregular in shape, melanoma Actinic purpura is due to blood vessel fragility and dermal is in the clinical differential diagnosis and biopsy should be atrophy from aging. No additional testing needs to be per- considered (see MKSAP 19 Oncology). formed. There is no treatment for actinic purpura, but sun protection is recommended to prevent further damage. a Ye

Although aging is the most common cause, hypothyroidism or defined tan macules (solar lentigines) (black arrow) on atrophic skin demonstrating signs of aging. such medications as diuretics may be implicated. Treatment includes a medium-potency topical glucocorticoid in an oint- Solar lentigines are tan or light brown, 1- to 3-cm well- ment base to be discontinued when the inflammation subsides, defined macules on sun-exposed areas of older adults, com- followed by liberal use of emollients to prevent recurrence. monly referred to as “liver spots” (Figure 29). They are a Actinic purpura appears as purpuric macules or patches, marker of sun damage. Ephelides or “freckles” are 2- to 5-mm most commonly on the forearms, due to minor trauma such as tan macules on sun-exposed areas that appear in childhood scratching (Figure 28). There may be associated stellate pseu- and darken with sun exposure. When solar lentigines or doscars, which are atrophic scars occurring after skin tears. ephelides are larger than 1 cm or irregular in shape, melanoma Actinic purpura is due to blood vessel fragility and dermal is in the clinical differential diagnosis and biopsy should be atrophy from aging. No additional testing needs to be per- considered (see MKSAP 19 Oncology). formed. There is no treatment for actinic purpura, but sun protection is recommended to prevent further damage. a Ye FIGURE 29. Solar lentigines. These brown macules and patches occur in middle-aged to elderly fair-skinned persons in sun-damaged areas. Although FIGURE 27. Severe xerotic eczema, characterized by redness and a tile-like benign, they may occasionally be difficult to distinguish from melanoma. Useful pattern on dry skin (xerosis) with evidence of trauma from scratching. This typically discriminating characteristics include more homogeneous pigmentation and occurs during midwinter in northern climates. lighter color.

FIGURE 29. Solar lentigines. These brown macules and patches occur in middle-aged to elderly fair-skinned persons in sun-damaged areas. Although FIGURE 27. Severe xerotic eczema, characterized by redness and a tile-like benign, they may occasionally be difficult to distinguish from melanoma. Useful pattern on dry skin (xerosis) with evidence of trauma from scratching. This typically discriminating characteristics include more homogeneous pigmentation and occurs during midwinter in northern climates. lighter color. 100

Genetics, Genomics, and Precision Medicine to genetic counseling services; appropriate choices in genetic testing; and a collaborative discussion with patients, genetic HVC e Treatment of xerosis consists of avoidance of hot baths, counselors, and specialists in test interpretation. use of mild synthetic detergent soaps, and good skin Genetic testing has an established role in several areas of care measures. routine clinical practice, including oncologic disease; neuro- HVC e Actinic purpura is due to blood vessel fragility and der- logic disorders; and inherited cardiac, kidney, and gastrointes- mal atrophy from aging; no additional testing needs to tinal diseases. The CDC, for example, recognizes hereditary be done, and no treatment is required. breast and ovarian cancer, Lynch syndrome, and familial e¢ When solar lentigines or ephelides are larger than 1 cm hypercholesterolemia as Tier 1 conditions for which screening or irregular in shape, melanoma is in the clinical differ- in selected populations is recommended (www.cdc.gov/ ential diagnosis and biopsy should be considered. genomics/implementation/toolkit/tierl.htm). Although genetic testing is being used increasingly, it is not without limitations, including an absence of data on minority popula- tions and incomplete understanding of the clinical signifi- Genetics, Genomics, and cance of many genetic variants. In addition, limitations

to genetic counseling services; appropriate choices in genetic testing; and a collaborative discussion with patients, genetic HVC e Treatment of xerosis consists of avoidance of hot baths, counselors, and specialists in test interpretation. use of mild synthetic detergent soaps, and good skin Genetic testing has an established role in several areas of care measures. routine clinical practice, including oncologic disease; neuro- HVC e Actinic purpura is due to blood vessel fragility and der- logic disorders; and inherited cardiac, kidney, and gastrointes- mal atrophy from aging; no additional testing needs to tinal diseases. The CDC, for example, recognizes hereditary be done, and no treatment is required. breast and ovarian cancer, Lynch syndrome, and familial e¢ When solar lentigines or ephelides are larger than 1 cm hypercholesterolemia as Tier 1 conditions for which screening or irregular in shape, melanoma is in the clinical differ- in selected populations is recommended (www.cdc.gov/ ential diagnosis and biopsy should be considered. genomics/implementation/toolkit/tierl.htm). Although genetic testing is being used increasingly, it is not without limitations, including an absence of data on minority popula- tions and incomplete understanding of the clinical signifi- Genetics, Genomics, and cance of many genetic variants. In addition, limitations Precision Medicine inherent to specific testing methodologies and differences in approaches to interpretation can lead to differing results Introduction between testing laboratories. This section will provide an overview on taking a family his- Genetics is the study of single genes and their role in inherit- tory; identifying hereditary risk; and understanding genetic tests ance, whereas genomics is the study of all of an individual’s and testing strategies, including direct-to-consumer testing. genetic material (the genome). Interest in the clinical applica- tion of genetic information, and with it the field of precision medicine, has grown steadily since the human genome was sequenced in the Human Genome Project. Precision medicine Taking a Family History involves the application of individualized genetic information, Obtaining a family history is an important risk assessment along with environmental exposures and behavioral charac- strategy that can increase severalfold the proportion of patients teristics, to the treatment of patients, with a goal of improving identified as needing screening, genetic testing, or preventive clinical outcomes. In precision medicine, clinical decision treatment for some conditions. Features that suggest the pres- making includes identification of genetic risk factors; referral ence of a genetically inherited condition are listed in Table 63.

Precision Medicine inherent to specific testing methodologies and differences in approaches to interpretation can lead to differing results Introduction between testing laboratories. This section will provide an overview on taking a family his- Genetics is the study of single genes and their role in inherit- tory; identifying hereditary risk; and understanding genetic tests ance, whereas genomics is the study of all of an individual’s and testing strategies, including direct-to-consumer testing. genetic material (the genome). Interest in the clinical applica- tion of genetic information, and with it the field of precision medicine, has grown steadily since the human genome was sequenced in the Human Genome Project. Precision medicine Taking a Family History involves the application of individualized genetic information, Obtaining a family history is an important risk assessment along with environmental exposures and behavioral charac- strategy that can increase severalfold the proportion of patients teristics, to the treatment of patients, with a goal of improving identified as needing screening, genetic testing, or preventive clinical outcomes. In precision medicine, clinical decision treatment for some conditions. Features that suggest the pres- making includes identification of genetic risk factors; referral ence of a genetically inherited condition are listed in Table 63. TABLE 63. Red Flags Suggesting an Increased Genetic Risk in an Individual or Family

Precision Medicine inherent to specific testing methodologies and differences in approaches to interpretation can lead to differing results Introduction between testing laboratories. This section will provide an overview on taking a family his- Genetics is the study of single genes and their role in inherit- tory; identifying hereditary risk; and understanding genetic tests ance, whereas genomics is the study of all of an individual’s and testing strategies, including direct-to-consumer testing. genetic material (the genome). Interest in the clinical applica- tion of genetic information, and with it the field of precision medicine, has grown steadily since the human genome was sequenced in the Human Genome Project. Precision medicine Taking a Family History involves the application of individualized genetic information, Obtaining a family history is an important risk assessment along with environmental exposures and behavioral charac- strategy that can increase severalfold the proportion of patients teristics, to the treatment of patients, with a goal of improving identified as needing screening, genetic testing, or preventive clinical outcomes. In precision medicine, clinical decision treatment for some conditions. Features that suggest the pres- making includes identification of genetic risk factors; referral ence of a genetically inherited condition are listed in Table 63. TABLE 63. Red Flags Suggesting an Increased Genetic Risk in an Individual or Family Red Flag Description Example

Precision Medicine inherent to specific testing methodologies and differences in approaches to interpretation can lead to differing results Introduction between testing laboratories. This section will provide an overview on taking a family his- Genetics is the study of single genes and their role in inherit- tory; identifying hereditary risk; and understanding genetic tests ance, whereas genomics is the study of all of an individual’s and testing strategies, including direct-to-consumer testing. genetic material (the genome). Interest in the clinical applica- tion of genetic information, and with it the field of precision medicine, has grown steadily since the human genome was sequenced in the Human Genome Project. Precision medicine Taking a Family History involves the application of individualized genetic information, Obtaining a family history is an important risk assessment along with environmental exposures and behavioral charac- strategy that can increase severalfold the proportion of patients teristics, to the treatment of patients, with a goal of improving identified as needing screening, genetic testing, or preventive clinical outcomes. In precision medicine, clinical decision treatment for some conditions. Features that suggest the pres- making includes identification of genetic risk factors; referral ence of a genetically inherited condition are listed in Table 63. TABLE 63. Red Flags Suggesting an Increased Genetic Risk in an Individual or Family Red Flag Description Example Family history of multiple Such a pattern indicates increased risk, whether through Three family members in two affected family members with genetic or environmental risk factors or a combination of generations with cardiovascular the same or related disorders genes and environment disease

Family history of multiple Such a pattern indicates increased risk, whether through Three family members in two affected family members with genetic or environmental risk factors or a combination of generations with cardiovascular the same or related disorders genes and environment disease Earlier age of disease onset than Disorders that arise at a younger age than expected may Cardiovascular disease occurring expected occur because of a genetic predisposition that makes an in the fourth decade of life individual more susceptible to environmental exposures Condition in the less-often- A disorder may occur in the less common sex because of a Breast cancer in a male affected sex genetic predisposition that overrides other hormonal, developmental, and environmental factors that contribute to its occurrence Disease in the absence of known Genetic predisposition may lead to the occurrence of a Hyperlipidemia in an individual risk factors disorder in the absence of obvious environmental factors with an ideal diet and exercise regimen

Disease in the absence of known Genetic predisposition may lead to the occurrence of a Hyperlipidemia in an individual risk factors disorder in the absence of obvious environmental factors with an ideal diet and exercise regimen Ethnic predisposition to certain Some genetic disorders are more common in certain ethnic Among women with genetic disorders groups. Awareness of a patient's ethnicity or ancestral lymphangioleiomyomatosis, 87% background can aid in recommendation of genetic testing are White, 6% are of African descent, and evaluation of genetic conditions and 4% are of Asian descent Close biological relationship Consanguinity is a relationship by blood or a common Breast/ovarian cancer in between parents ancestor. Because relatives are more likely to share the same Ashkenazi Jewish women genes, children from a consanguineous couple related as first cousins or closer have an increased risk for an autosomal recessive condition Information from The Jackson Laboratory. Core principles in family history: interpretation. www.jax.org/education-and-learning/clinical-and-continuing-education/ccep-non-cancer- resources/core-principles-in-family-history/interpretation. Accessed February 8, 2021. 101