Teacher’s
Teacher’s
Manual
Manual
TEXAS Medical Clerkship Program
3rd year Medical Students
provided by:
TEXAS
Training Excellence in Aging
Studies
Division of Geriatric and Palliative
Medicine
The University of Texas Health
Science Center at Houston
School of Medicine
and funded by:
the Donald W. Reynolds
Foundation
Table of Contents
INTRODUCTION ................................................................................................................................................................... 3
HOW TO USE THIS MANUAL.............................................................................................................................................................3
FOCUS ........................................................................................................................................................................................3
JOURNAL PAGES ...........................................................................................................................................................................3
GEMS AND PEARLS........................................................................................................................................................................4
TEACHING TIPS .............................................................................................................................................................................4
DAY 1 – THE GERIATRIC SYNDROMES .................................................................................................................................. 5
SYNDROME #1 – DELIRIUM SYNDROME ............................................................................................................................................5
SYNDROME #2 – FALLS ..................................................................................................................................................................9
SYNDROME #3 – FRAILTY SYNDROME .............................................................................................................................................12
SYNDROME #4 – DEPRESSION ......................................................................................................................................................15
DAY 2 – ELDER ABUSE AND MISTREATMENT ..................................................................................................................... 20
DAY 3 – RX-POLYPHARMACY ............................................................................................................................................. 28
DAY 4 – ALZHEIMER’S DISEASE AND OTHER DEMENTIAS ................................................................................................... 34
ALZHEIMER’S DISEASE (AD) .........................................................................................................................................................34
VASCULAR DEMENTIA..................................................................................................................................................................36
DEMENTIA WITH LEWY BODIES......................................................................................................................................................37
FRONTO-TEMPORAL DEGENERATION ..............................................................................................................................................37
ASSESSMENT AND TREATMENT OF DEMENTIAS .................................................................................................................................38
DAY 5 – SOCIAL ISOLATION ................................................................................................................................................ 43
REFERENCES ...................................................................................................................................................................... 50
APPENDIX .......................................................................................................................................................................... 55
2
The TEXAS Medical Clerkship Program Teacher's Manual
The TEXAS Medical Guide Clerkship Program Teacher's Manual is written to help geriatric preceptors
enable medical students to practice effectively in a clinical setting. Medical students often have
difficulty in synthesizing multiple components of their education to formulate a patient's
comprehensive medical plan of care. Specifically, this manual will help to fill training gaps in caring
for older adult patients, many of which have complex medical problems influenced by social
situations that must be addressed differently than younger patients. The manual is based on the
Association of American Medical Colleges (AAMC) geriatric competencies, clinician experience and
evidence-based research.
How to use this manual
The manual has been designed to allow edits for your institution and needs. You do not need to
request permission to use the manual. Instead, you need to credit The University of Texas Health
Science Center at Houston School of Medicine (UTHealth School of Medicine) for the original
content and credit the Donald W. Reynolds Foundation for the original funding.
Focus
The TEXAS clerkship has been devised as a one-week clerkship; a clinical Geriatric Rotation of about
40 hours. The intent is to cover these principles.
The Geriatric Syndrome
Elder Mistreatment
rX - Polypharmacy
Alzheimer’s Disease
Social History
Journal Pages
We include for our students some
thought provoking journal topics,
one topic per day. A form is made
for each day in the Appendix.
Should you decide to use different
journal topics, you will find both a
lined and unlined blank journal
page also provided in the
Appendix.
3
The Gems and Pearls
You will find references to the Geriatric Gems and
Palliative Pearls in the text. The teacher’s manual text will
link you to the appendix where you will find the full text
for each Gem and Pearl.
**NOTE** We use spaced education through email to
deliver discrete content with defined learning principles on
Geriatric and Palliative topics to our UTHealth students.
Each email has a snippet of information on the topic, with a link to the full Gems and Pearls content
for that week. Each Gem and Pearl is only 1-3 pages in length. For you convenience, the full version
of each Gem and Pearl referred to in this manual is provided in the appendix.
**SUPPLEMENT ** There are other Gems and Pearls not used in this manual. You can access the
full list of Geriatric Gems and Palliative Pearls from The University of Texas Health Science Center at
Houston at: http://www.uth.tmc.edu/reynolds/soundbytes/executiveFunction.html
Teaching Tips
We have found that medical students have the most difficulty in integrating and applying the
multiple components of their education to formulate a comprehensive medical plan of care for a
given patient. This clerkship manual will assist you, the professor, to enable medical students to
practice effectively in a clinical setting. Case histories, simulated practice situations, pre and post
questions, frequently asked therapeutic questions and journaling provide a unique opportunity for
insight into the students’ learning experience. Our third year clerkship program draws from our
clinical experiences.
We hope this manual provides you the tools necessary to excite medical students about the field of
geriatric medicine.
4
TEXAS Medical Clerkship Program
T- The Geriatric Syndromes
E- Elder Mistreatment
rX -Polypharmacy
A -Alzheimer’s Disease
S –Social Isolation
Day 1 Medical Clerkship Program
Day 2 Medical Clerkship Program
Day 3 Medical Clerkship Program
Day 4 Medical Clerkship Program
Day 5 Medical Clerkship Program
Day 1 – The Geriatric Syndromes
We begin this clerkship with information on common geriatric syndromes.
Geriatric Syndromes are unique features of common health conditions that
occur more often in the elderly and can impact patient morbidity and mortality.
Geriatric syndromes do not fit into discrete disease categories, but generally
they are highly prevalent, multifactorial and impact the older adult's function
and quality of life. Common geriatric syndromes highlighted in this section
include delirium, falls, frailty and depression. Other identified syndromes are
incontinence, malnutrition, osteoporosis, sleep disorders, and geriatric failure
to thrive. This section is not intended to be an exhaustive review of geriatric
syndromes, but rather is an overview to introduce the student to these
common concepts.
By discussing information on common issues, incidence, risk factors and
scenarios, you will be better equipped as a physician to treat the elderly
patient, of which there is a growing percentage in the population.
Syndrome #1 - Delirium
Definition
Delirium is an acute change in cognition of an elderly patient. Delirium has unique characteristics
including: change in cognitive status with diminished attention; develops over a short period of time
(hours to days); presentation fluctuates throughout the day; and, there is evidence of a reversible
specific cause (adverse drug reaction, exacerbation of a medication condition, or acute infection).
5
Incidence and Demographics
Delirium is often seen in hospitalized older adults, especially those in intensive care units, emergency
departments, and long-term care. Patients who have undergone cardiovascular and orthopedic surgery
are also at high risk.
Risk Factors
1. Medications are one of the primary culprits of delirium. The following is a brief list of medications
known to contribute to delirium:
a. Analgesics – meperidine, opioids, non-steroidal anti-inflammatory drugs
b. Antibiotics and antivirals – acyclovir, aminoglycosides, cephalosporin, penicillin,
fluoroquinolone, macrolides, penicillin, rifampin, sulfonamides
c. Anticholinergics – atropine, benzatropine, diphenhydramine, scopolamine
d. Anticonvulsants – carbamazepine, phenytoin, valproate
e. Cardiovascular drugs – antiarrhythmic agents, beta blockers, clonidine, digoxin, diuretics
f. Corticosteroids
g. Dopamine agonist- amantadine, bromocriptine, levodopa, pergolide
h. Gastrointestinal agents: antiemetics, antispasmodics, histamine 2 receptor blocker
i. Hypoglycemic drugs
j. Hypnotics and sedatives – barbiturates, benzodiazepines
k. Muscle relaxants- baclofen, cyclobenzaprine
2. Infections: Central Nervous System infection, pneumonia, urinary tract
3. Metabolic disturbances: electrolyte imbalances, endocrine disturbances (thyroid, parathyroid,
pancreas, pituitary, adrenal), hyperglycemia, hypoglycemia, hypoxemia
4. Intracranial: brain tumor, head trauma, seizure
5. Cardiac: heart failure, myocardial infarction
6. Liver failure
7. Renal failure
Pathophysiology
This is poorly understood.
Assessment
1. Describe the history of the present illness (HPI): time frame of changing cognition, progression, and
periods of fluctuation.
2. Detailed review of systems (ROS) to rule out the multiple causes of delirium.
3. Complete Comprehensive Geriatric Assessment including the following:
 Confusion Assessment Method (CAM) http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf

Cognitive Assessment (SLUMS) http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
6

Depression Assessment – Geriatric Depression Scale – GDS Geriatric Depression Scale (GDS)
Short Form - http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF
Physical Exam
1. Comprehensive physical examination with a detailed neurological examination focusing on
assessment of level of consciousness, attention or inattention, visual fields, cranial nerves, and
assessing for focal neurological deficits.
2. Particular attention should be paid to the cardiac exam (heart sounds and rhythm); the pulmonary
exam (adventitious sounds; respiratory rate and depth); assessing for an acute infectious process
(urinary tract infection, wounds); assessing the urinary system (incontinence); and, assessing the
gastrointestinal system (fecal incontinence, diarrhea, and abdominal pain).
Diagnostics
1. Determined by the history and physical exam and suspected underlying etiology.
2. Complete blood count with differential, complete metabolic panel, thyroid function test, vitamin
B12 and Folate to identify reversible causes for cognitive impairment or delirium etiology.
3. The following should be considered based on your findings:
a. Chest X-ray if pneumonia is suspected;
b. Urinalysis if urinary tract infection is suspected;
c. Brain CT scan if space-occupying lesion or infarct suspected;
d. ECG if cardiopulmonary cause is suspected;
e. EEG if seizure is suspected;
f. Lumbar puncture is encephalopathy or meningitis is suspected; and,
g. Drug toxicity test (if available) if adverse drug reaction suspected.
Management
Goal: Identify etiology and treat it.
Non-pharmacologic
1. Medication Review – identify medications that may have contributed to delirium and discontinue
any unnecessary medications.
2. Provide environmental support – orientation, eyeglasses, hearing aids, noise reduction, and mobilize
the patient.
3. Maintain hydration, oxygenation and nutrition. Regulated bowel and bladder function – eliminate
fecal impaction.
4. Avoid restraints.
5. Consults – per etiology.
Pharmacologic
Depends on the etiology.
7
Geriatric Gems and Palliative Pearls
Delirium in the Hospitalized Elderly – see page 56
Resources
1. Article

Inouye, S.K., Zhange, Y., Jones, R.N., Kiely, D.K., Yange, F., & Marcantonio, E. R. (2007). Risk
factors for delirium at discharge: Development and validation of a predictive model. Archives of
Internal Medicine, 167 (13), 1406-1413.

Miller, M.O. (2008). Evaluation and management of delirium in hospitalized older patients.
American Family Practice, 78(11), 1265.

Pisani, M.A., Murphy, T.E., Van Ness, P.H., Araujo, K.L., & Inouye, S.K. (2007). Characteristics
associated with delirium in older patients in a medical intensive care unit. Archives of Internal
Medicine, 167(15), 1629-1634.

Wei, L.A., Fearing, M.A., Sternberg, E.J., & Inouye, S.K. (2008). The Confusion Assessment
Method: A systematic review of current usage. Journal of the American Geriatrics Society, 56(5),
823-830.
2. Instruments

Confusion Assessment Method (CAM) http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf1634.

Cognitive Assessment (SLUMS) http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf1634.

Depression Assessment – Geriatric Depression Scale – GDS Geriatric Depression Scale (GDS)
Short Form - http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF
3. Web-based

Medline Plus: Delirium http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm

Mayo Clinic: Delirium www.mayoclinic.com/health/delirium/DS01064

Medscape: Delirium http://emedicine.medscape.com/article/288890-overview

PubMed Health: Delirium http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001749/
8
Syndrome # 2 - Falls
Definition
Falls are defined as an unintentional lowering to rest from a higher to a lower position, not due to loss of
consciousness or violent impact.
Incidence and Demographics
1. The incidence varies with age. Persons aged 65 to 79 years living at home have a fall incidence of 30
to 40 percent. Older persons, aged 80 years and older, and living at home, have an increased falls
incidence of 50 percent.
2. If an older adult lives in a long-term care facility, their fall incidence rate is 50 percent.
3. Complications resulting from falls are the leading cause of death from injury in men and women
aged 65 and older.
4. More than 250,000 hip fractures occur in the United States annually due to falls.
Risk Factors
The causes of falls are related to complex interactions among factors intrinsic and extrinsic to the
older adult.
1. Intrinsic Risk Factors- There are many intrinsic reasons that increase an older adult's risk of falling:
a. Biological – age-related decline, advanced age, visual impairment, vestibular impairment,
balance impairment, gait disorder, muscle weakness, chronic disease, orthostatic hypotension,
vitamin D deficiencies, medications (benzodiazepines, diuretics).
b. Psychological – cognitive impairment.
c. Social – impaired activities of daily living and alcohol intake.
2. Extrinsic Risk Factors are related to environmental barriers, restraint use and improper footwear.
Pathophysiology
This is a multi-factorial syndrome. Falls are a red flag for a homeostasis imbalance. Often, older adults
have a superimposed risk factor, such as a urinary tract infection, or an adverse drug event which
exacerbates their already-impaired balance and gait disorder and contributes to the fall.
Assessment
When assessing an older adult who has fallen, ascertain the following information:
1. Was the fall witnessed or not?
2. What were the circumstances of the fall? What was the patient’s activity at the time; what was the
time of day; what were the clinical manifestations associated with the fall (lightheadedness,
imbalance, dizziness, syncope, weakness in legs, heart palpitations, etc.); was there loss of
consciousness; was the older adult able to get up on their own or did they need assistance; what
9
was the length of time they were down; did they injure their head, extremities, or chest; and, do
they have abrasions, lacerations or bruising?
3. Thorough evaluation of the past medical history (PMH), review of medications (over-the-counter
(OTC) drugs, supplements and prescriptions), history of previous falls, and review the risk factors
for falls.
Physical Exam
1. Conduct a thorough physical examination. Based on your history, pay particular attention to various
systems. Physical assessment should include:
a. Neurological examination - this should include cognitive function – see functional test below.
b. Musculoskeletal examination – see functional test below.
2. Comprehensive Geriatric Assessment should include:
a. SLUMS (St. Louis University Mental Status) – an 11-item questionnaire, which is free for clinical
use, to detect dementia or mild cognitive disorders. It measures aspects of cognition that
include orientation, short-term memory, calculations, naming of animals, clock drawing,
and recognition of geometric figures. Scores range from 0 to 30, with scores of 27-30
considered normal in a person with a high school education. Scores between 21 and 26 suggest
mild cognitive disorder, and scores below 20 indicate dementia. See instrument below in
resource section.
b. Get Up and Go Test – observe the patient stand up from a chair; instruct the patient not to
utilize the arms of the chair unless absolutely necessary; walk 10 feet; turn; come back to the
chair and sit down. This test assesses leg strength, balance, vestibular function and gait. See
instrument below in resource section.
c. Functional Reach Test – patient stands with fist extended alongside a wall and leans forward as
far as possible. The length of fist movement is measured (distances less than six inches indicate
increased fall risk).
Diagnostics
1. Determined by the history and physical exam and suspected underlying etiology.
2. Research has shown an indirect relationship between low vitamin D levels and risk of falls.
Recommend vitamin D-25 levels.
Management
Non-pharmacologic
1. Physical Therapy Consult for muscle strengthening and balance-retraining program.
2. Provide environmental support — orientation, eyeglasses, hearing aids, noise reduction, and
mobilize the patient. Have an interprofessional team consult for home evaluation (physical and
occupational therapy, social work and nursing).
10
3. Maintain hydration (prevent dehydration), oxygenation and nutrition.
Pharmacologic
1. Depends on etiology. Eliminate all unnecessary medications.
2. If vitamin D is deficient, supplement with vitamin D. There is currently a lack of consensus on
therapeutic levels for vitamin D in the older adult. The medical student is referred to the following
organizations for their guidelines on Vitamin D supplementation: The Institute of Medicine (IOM),
the American College of Rheumatology, and the American Family Physician websites. There you will
find a review of vitamin D literature and various recommendations based on their interpretations of
the current research literature. The range for therapeutic levels from these sources is 30 ng/mL to
75 ng/mL.
Geriatric Gems and Palliative Pearls
Fall Evaluation – see page 57
Resources
1. Article

Centers for Disease Control and Prevention. (2008). Self-reported falls and fall-related injuries
among persons aged > 65 years- United States, 2006. Morbidity and Mortality Weekly Report,
57. 225.

Ganz, D.A., Bao, Y., Shekelle, P.G., & Rubenstein, L.Z. (2007). Will my patient fall? Journal of the
American Medical Association, 297 (1), 77-86.

Oliver, D., Connelly, J.B., Victor, C.R., Shaw, F.E., Whitehead, A., Genc, Y., et al. (2007).
Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive
impairment; Systematic review and meta-analyses. British Medical Journal, 334 (7584), 82.

Rubenstein, L.Z., & Josephine, K.R. (2006). Falls and their prevention in elderly people: What
does the evidence show? Medical Clinics of North America, 90(5), 807-824.
2. Instruments

SLUMS - http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

Get Up and Go Test - http://www.healthcare.uiowa.edu/igec/tools/mobility/getupandgo.pdf
3. Web-based
Centers for Disease Control and Prevention. (2002). Hip fractures among older adults. Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Available at: http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html
11
Syndrome #3 – Frailty Syndrome
Definition
Frailty is age-related disability that is characterized by reduced physiologic reserves. Frailty is often
characterized by meeting at least three of the following characteristics:
1.
2.
3.
4.
5.
A five percent unintentional weight loss or greater in the last 12 months;
Decreased physical activity;
Slow walking speed;
Weakness as defined by diminished grip strength; and,
Self-reported exhaustion when engaging in activities.
Incidence and Demographics
1. Prevalence increases with age.
2. Up to thirty percent of older adults over the age of 90 meet criteria for frailty.
Risk Factors
1.
2.
3.
4.
5.
Multiple co-morbidities;
Physical inactivity;
Poor nutritional intake;
Physiological and psychological stress; and,
Advanced age.
Pathophysiology
This is a multi-factorial syndrome. The following list of items contributes to the syndrome.
1. The following diseases have been implicated in the cause of frailty:
a. Cancer;
b. Cardiac diseases, such as coronary artery disease and heart failure;
c. Pulmonary diseases, such as COPD and aspiration pneumonia;
d. Endocrine diseases, such as diabetes mellitus and hypothyroidism;
e. Renal disease;
f. Rheumatic diseases, such as rheumatoid arthritis and systemic lupus erythematous (SLE); and,
g. Psychiatric diseases, such as depression and psychosis.
2. Age-related physiological decline.
Assessment
When completing a frailty assessment on an older adult with reduced physiologic reserve, ascertain the
following in your PMH and review of system:
12

Past Medical History- history of fractures; prolonged or repeated hospitalizations; multiple
medical comorbidities; polypharmacy; and, prolonged or limited recovery after illness.

Review of Systems- recent fall(s); diminished activities of daily living; diminished level of
independence; diminished strength; a decrease in functional mobility; weight loss; decreased
energy; and, a general sense of decline observed by family members.
Physical Exam
Conduct a thorough physical exam. Based on your history, pay particular attention to the following:

General: Unintentional weight loss of five percent or more; dehydration (sunken eyes; furrowed,
dry tongue).

Skin: Poor skin turgor; pressure ulcers.

Head, Eyes, Ears, Nose and Throat (HEENT): Diminished visual acuity; lesions in mouth; dental
caries; goiter.

Lungs: Adventitious lungs sounds; diminished lung sounds.

Cardiovascular (CV): S3 or S4; irregular heartbeat; signs of heart failure.

Musculoskeletal (MSK): loss of muscle strength; signs of osteoarthritis; poor grip strength; slow
unsteady gait; muscle wasting.

Neuro: Prolonged reaction time; cognitive function.

Psychiatric: dementia; depression; anxiety.

Comprehensive Geriatric Assessment (CGA): Decreased scores in Activities of Daily Living (ADLs),
Instrumental Activities of Daily Living IADLs), Get Up and Go, and increased Geriatric Depression
Scale (GDS) score.
Diagnostics
Determined by the history, geriatric functional assessment scores, physical exam and suspected
underlying etiology.
Management
Non-pharmacologic
1. Physical Therapy consult for muscle strengthening and balance-retraining program.
2. Provide environmental support – orientation, eyeglasses, hearing aids, noise reduction, and mobilize
the patient.
3. Maintain hydration (prevent dehydration), oxygenation and nutrition.
13
Pharmacologic
Depends on etiology. Eliminate all unnecessary medications.
Geriatric Gems and Palliative Pearls
Frailty – see page 59
Resources
1. Article

Ahmed, N., Mandel, R., & Fain, M.J. (2007). Frailty: An emerging geriatric syndrome. The
American Journal of Medicine, 120(9), 748-753.

Cherniak, E. P., Florez, H.J., & Troen, B.R. (2007). Emerging therapies to treat frailty syndrome in
the elderly. Alternative Medicine Review, 12(3), 246-258.

Heuberger, R.A. (2011). The frailty syndrome: A comprehensive review. Journal of Nutrition in
Gerontology and Geriatrics, 30(4), 315-368.

Lang, P.O., Michel, J.P., & Zekry, D. (2009). Frailty syndrome: A translational state in a dynamic
process. Gerontology, 55(5), 539-549.
2. Instruments

Cognitive Assessment (SLUMS) http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

Geriatric Depression Scale (GDS) Short Form http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF

Katz Index of Independence in Activities of Daily Living (ADL)http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf

Instrumental Activities of Daily Living (IADL) http://www.abramsoncenter.org/pri/documents/iadl.pdf

Get Up and Go - http://www.healthcare.uiowa.edu/igec/tools/mobility/getupandgo.pdf

Checklist for Brown Bag Medication Checkup
http://www.ohiopatientsafety.org/meds/default.htm

Medication Review Form – Brown Bag Program
http://www.ohiopatientsafety.org/meds/default.htm
14
3. Web-based

Emerging Therapies to Treat Frailty Syndromes in the Elderly
http://www.ncbi.nlm.nih.gov/pubmed/18072820

Frailty, What is It, Exactly? http://www.healthandage.com/Frailty-What-Is-It-Exactly

Treating Frailty: A Practical Guide (2011) http://www.biomedcentral.com/1741-7015/9/83
Syndrome #4 - Depression
Definition
The DSM-IV-TR Criteria for depression are not specific for older adults. Depression is not a normal
part of aging. It is a disturbance in mood where an older adult has a loss of interest or pleasure in
the activities of daily living. Depression may be seen in patients with dementia.
Incidence and Demographics
1. Five to 20 percent of community dwelling older adults.
2. Twenty-five percent in hospitalized older adults.
3. Twenty-five to 40 percent in nursing home residents.
Risk Factors
1.
2.
3.
4.
5.
6.
Past medical history of a depressive episode or mood disorder;
Family history;
Alcohol and /or substance abuse history;
Stress (including caregiver stress);
Chronic co-morbid medical conditions;
Medications which cause depression symptoms:
a. Antihypertensive (calcium, channel blockers, beta blockers)
b. Analgesics
c. Anti-Parkinson disease drugs
d. Diuretics (thiazide)
e. Steroids
f. Alcohol
g. Hypnotics
h. Antipsychotics
i. Sedatives
j. Statins
k. Hormones (estrogen, progesterone)
l. Anticonvulsants
15
Pathophysiology
This is a brief synopsis of three intensive areas of research on the pathophysiology of depression.
There are entire books that elaborate more fully on this topic.
Genetics and Environmental Influences
Evidence exists that depression is partially inheritable. This research is based on the increased
incidence of mood disorders among patients’ relatives. Genetic research is a dynamic and growing
field with new discoveries occurring regularly. Chromosomal regions have been identified for
depression, and more than 19 candidates have been identified. Loci on Chromosome 18 and 22 are
of particular interest because of the association of depression, bipolar disorder and schizophrenia.
Depression symptomatology varies with each individual. This variation suggests that depression is a
multi-factorial disease with both genetic and environmental influences.
Neurochemical Dysregulation
Neurochemical dysregulation has been hypothesized to contribute to by: 1) alteration in
homeostatic regulation of brain neurochemicals; 2) circadian rhythm disruption; and, 3) inadequate
or overstimulation of specific neurotransmitters at synaptic sites. Neurotransmitter research is
focusing on: serotonin, norepinephrine, and dopamine.
Neuroendocrine Dysregulation
The hypothalamic-pituitary-adrenal (HPA axis) system plays a significant role in the body's stress
response (fight and flight response). Research is exploring the role of HPA, cytokines and hormonal
influences on mood modulation and behavior. Advancement in brain imaging studies and neuronal
cellular research is allowing neuroscientists to explore functional brain changes in depressed
patients. This research also seeks to clarify the multi-factorial influences that cause depression.
Assessment
History
1. Review the DSM-IV-TR criteria for Major Depressive Disorder (see reference).
2. In addition to the specific criteria mentioned above, assess for the following:
social isolation, poor self-hygiene, poor appearance, self-destructive behavior,
and non-specific somatic complaints.
Geriatric Comprehensive Assessment:
1.
2.
3.
4.
5.
SLUMS
GDS or PHQ-2
ADLs
IADLs
Ask patient if they have suicidal thoughts, feelings of hopelessness or helplessness.
Ascertain if patient has a history of prior suicide attempts.
 Geriatric Depression Scale (GDS) Short Form http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF
16
Physical Exam
A standard comprehensive physical exam should be completed to rule out potential medical
diseases that may contribute to depression or present with depression-like symptomatology.
Diagnostics
Attain the following:
1.
2.
3.
4.
5.
6.
7.
Thyroid stimulating hormone
B12 level
Calcium, liver and kidney function test
Electrolytes
Urinalysis
Complete blood count
Toxicology screen, if indicated
Diagnosis of Depression:
Five or more of the following symptoms have been present during the same two-week period
and represent a change from previous functioning; the DSM-IV-TR states at least one of the
symptoms is either a loss of interest/ pleasure or depressed mood:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood;
Loss of pleasure or interest;
Weight loss or gain;
Feeling worthless or inappropriate guilt;
Diminished ability to think or concentrate, or indecisive;
Insomnia or hypersomnia;
Fatigue or loss of energy;
Psychomotor agitation or retardation; and,
Recurrent thoughts of death, suicidal ideation, or suicide attempt.
Management
Non-pharmacologic
1.
2.
3.
4.
Cognitive behavioral therapy
Interpersonal therapy
Problem solving therapy
Somatic therapy (electroconvulsive therapy, transcranial magnetic stimulation, light
therapy)
5. Exercise
Pharmacologic
1. Individualized plan of care.
2. Medications include (not an exhaustive list):
a. SSRIs- First line. Examples include citalopram, escitalopram, fluoxetine, fluvoxamine,
paroxetine, sertraline
b. SNRIs- duloxetine, venlafaxine, desvenlafaxine
17
c. Other-bupropion, mirtazapine
3. If the patient appears to have a partial or no response to medication, consider a consult
with a psychiatrist for assistance with augmentation, or switch strategies for medication or
psychotherapy to achieve remission of depression and return to baseline functionality.
Geriatric Gems and Palliative Pearls
Geriatric Depression – see page 61
Resources
1. Article

American Psychiatric Association. (2010). Practice guidelines for the treatment of patients with
major depressive disorder, Third Edition.
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1667485

Gelenberg, A.J. (2010). Using assessment tools to screen for, diagnose and treat major
depressive disorder in clinical practice. Journal of Clinical Psychiatry, 71, (supplemental E1:e01).

Nutt, D.J., Davidson, J.R., Gelenberg, A.J., et al. (2010). International consensus statement on
major depressive disorder. Journal of Clinical Psychiatry, 71, (supplemental E1:e08).
2. Instruments

Geriatric Depression Scale (GDS) Short Form http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF

Patient Health Questionaire-2 (PHQ-2) - http://www.cqaimh.org/pdf/tool_phq2
3. Web-based


American Association for Geriatric Psychiatry – http://www.aagponline.org/
National Alliance for the Mentally Ill – http://www.nami.org

National Institute of Mental Health and Information Resources and Inquires—
http://nimh.nih.gov

Mental Health America – www.nmha.org

Geriatric Depression Scale - http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF
18
Day One Journal Entry
(Printout for day one journal entry is on page 71)
Many physicians have pre-conceived ideas about caring for older adults. Write a “surprise” or “a-ha
moment” that you did not expect from caring for an older adult.
Day One Case Study
Congratulations! You have completed your first day on the Geriatric and Palliative Service. In your
journal, please describe a patient you saw today who experienced one of the geriatric syndromes
described above. Please relate your comments to the description presented above. Did your patient fit
this profile? If yes, what correlated with the above description? If not, what was different? Be
prepared to discuss your comments with your professor.
19
TEXAS Medical Clerkship Program
T- The Geriatric Syndromes
E- Elder Mistreatment
rX -Polypharmacy
A -Alzheimer’s Disease
S –Social Isolation
Day 1 Medical Clerkship Program
Day 2 Medical Clerkship Program
Day 3 Medical Clerkship Program
Day 4 Medical Clerkship Program
Day 5 Medical Clerkship Program
Day 2 – Elder Abuse and Mistreatment
Every day, millions of older adults, aged 65 or older, are victims of physical and
psychological abuse, exploitation and abandonment, often by people that care
for them or that they trust. The National Center on Elder Abuse states that the
incidence of elder abuse and mistreatment is increasing at an alarming rate. As
a physician, it is your responsibility to assess and intervene in suspected elder
abuse and mistreatment cases. The actions you take today on behalf of an
elder mistreatment victim are life-saving in scope. Today’s information better
informs you about Elder Abuse and Mistreatment.
Definition
The National Center of Elder Abuse (NCEA) defines elder abuse as:
“Intentional or neglectful acts by a caregiver or ‘trusted’ individual that lead to, or may lead to, harm of
a vulnerable elder.”
The most common types of elder abuse are: physical abuse, neglect (including self-neglect), emotional
or psychological abuse, verbal abuse and treats, financial abuse and exploitation, sexual abuse and
abandonment. Further discussion regarding the various types of abuse is found below.
Incidence and Demographics
1. Millions of Americans aged 65 years or older have been injured, exploited, or otherwise mistreated
by a caregiver or someone they trust.
2. Elder abuse and mistreatment estimates range from two to 10 percent based on various sampling
and survey methods and case definitions.
3. Only one in 14 incidents of elder abuse in domestic settings, excluding self-neglect, are brought to
the attention of authorities.
4. Self-neglect is the most commonly reported form of elder abuse (mistreatment) and is increasing.
5. In older adults who self-neglect, African-American older adults had a higher mortality rate compared
to whites.
20
6. Mortality risk after one year remained significant for confirmed elder self-neglect.
7. The NCEA Survey of Adult Protective Services (APS) reported an increase in elder abuse of 20
percent from 2000 to 2004.
8. The 2004 NCEA Survey of APS also found:
a. Most victims are female (65.7%), and
b. The vast majority of elder abuse cases occurred in domestic settings (89%).
9. The mortality of older adults who are abused or neglected is about 30 percent higher in abused than
non-abused older adults (Lachs et al., 1998).
Risk Factors for Older Adult

Advancing age

The more functionally impaired and dependent a person becomes, the higher the risk of the older
adult being abused, neglected and exploited.

Personality disorder, mental illness and cognitive impairment of an older adult enhances their risk.

Isolation

Alcohol or drug abuse history

Poverty
Risk Factors for the Perpetrator

Caregiver cognitive impairment

Dependency of caregiver on older adult

Family history of abuse

Family history of alcohol and drug abuse

Family history of mental illness or mental retardation

Financial strain and stress
Types of Elder Mistreatment
Physical Abuse
Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment.
21
Physical abuse may include but is not limited to such acts of violence as:

Striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching or burning

Inappropriate use of drugs and physical restraints, force-feeding, and physical punishment of any
kind are also examples of physical abuse.

The ultimate form of physical abuse is homicide.
Sexual abuse
Sexual abuse is non-consensual, sexual contact of any kind with an older adult.
Sexual abuse includes, but is not limited to such acts as:

Unwanted touching;

All types of sexual assault or battery, such as rape, sodomy, coerced nudity and sexually explicit
photographing; and,

Any sexual contact with any person incapable of giving consent.
Neglect
Neglect is the failure to meet an older adult's basic needs either by refusal or failure to fulfill any part of
a person’s obligations or duties to an older adult.
Neglect includes, but is not limited to such acts as:

Failure of a person who has fiduciary responsibilities to provide care for an older adult;

Failure on the part of an in-home service provider to provide necessary care; and,

Refusal or failure to provide an older adult with such life necessities as food, water, clothing, shelter,
personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or
agreed-upon responsibility to an older adult.
Self-neglect
Self-neglect is a condition in which the older adult is no longer willing or able to provide basic care for
him or herself.
Self-neglect includes, but is not limited to such acts as:

An older adult’s inability, due to physical or mental impairment or diminished capacity, to perform
essential self-care tasks;

Inability to obtain essential food, clothing, shelter, and medical care;

Inability to obtain goods and services necessary to maintain physical health, mental health,
emotional well-being and general safety;

Inability to manage one’s own financial affairs; and,
22

A refusal to provide him/herself with adequate food, water, clothing, shelter, personal hygiene,
medication (when indicated), and safety precautions.
PLEASE NOTE: This excludes a situation in which a mentally competent older adult, who understands the
consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that
threaten his/her health or safety as a matter of personal choice.
Psychological or Emotional Abuse
Psychological or Emotional Abuse is defined as the infliction of anguish, pain, or distress through verbal
or nonverbal acts.
Psychological or Emotional Abuse includes, but is not limited to such acts as:

Verbal assaults, insults, threats, intimidation, humiliation, bullying, or harassment;

Treating an older adult like an infant;

Isolating an older adult from his or her family, friends or regular activities;

Giving an older adult the “silent treatment;” and,

Enforcing social isolation.
Abandonment
Abandonment is defined as the desertion of an older adult by an individual who has assumed
responsibility for providing care for an older adult, or by a person with physical custody of an
older adult.
Financial or Material Exploitation
Financial or material exploitation is defined as the illegal or improper use of an older adult's funds,
property or assets for monetary or personal benefit, profit or gain.
Financial or material exploitation includes, but is not limited to such acts as:

Cashing an older adult’s checks without authorization or permission;

Forging an older adult's signature;

Misusing or stealing an older adult's money or possessions;

Coercing or deceiving an older adult into signing any document; and,

Improper use of conservatorship, guardianship, or power of attorney.
Assessment
1. If elder abuse or mistreatment is suspected, the older adult and caregiver(s) should be
interviewed separately.
23
2. Depending on the type of elder abuse or mistreatment suspected, some suggested questions
could include:
a. Has anyone tried to hurt you or hit you?
b. Has anyone yelled at you or shouted at you?
c. Has anyone made you do things that you did not want to do?
d. Has anyone taken your things without your approval?
e. Are you afraid someone is going to hurt you?
Physical Exam
The following screening key indicators for Elder Abuse and Mistreatment were sourced from T. Fulmer
(2002) and the American Geriatrics Society – GNRS (2007).
General Exam: Clothing (inappropriate, soiled or in disrepair); hygiene (may be poor); nutritional status
(dehydration, malnutrition); skin integrity (bruising, lacerations, urine burns, pressure ulcers,
overgrown nails).
Suspected physical abuse: anxiety; nervousness especially towards the caregiver; bruising in various
healing stages (pay particular attention to the inner arms and inner thighs, and whether it is unilateral or
bilateral); fractures (look for various stages of healing); lacerations; check medical records (pay
particular attention to repeated hospital emergency department visits); repeated falls; signs of sexual
abuse; older adult makes statements about abuse by the caregiver.
Suspected neglect: contractures; dehydration; depression; diarrhea; failure to respond to warning of
obvious disease; fecal impaction; malnutrition; inappropriate use of medications (under or overuse),
poor hygiene; pressure ulcers; repeated falls; repeated hospital admissions; urine burns; older adult
makes statements about neglect by caregiver.
Exploitation: evidence of misuse of older adult's assets; inability of patient to account for money and
property or to pay for essential care; reports of demands for money or goods in exchange for caregiving
or other services needed by the older adult; unexplained loss of social security or pension checks; older
adult makes statement regarding exploitation.
Abandonment: evidence that the older adult is left alone in an unsafe manner; evidence of sudden
withdrawal by caregiver; older adult makes statement they have been abandoned.
Diagnostics
Diagnostic evaluation will be dependent on the type of elder abuse and mistreatment and findings from
your history and physical examination of the older adult.
Management
We believe that an interprofessional team approach is the best approach for the physician in
this situation.
24
Professionals (physicians, nurses, social workers, pharmacists, chaplains, and others) meet and share
information about the older adult, their family and their social situation. Decisions are made
collectively, and an intervention plan is designed. Professionals carry out aspects of the plan according
to their professional expertise and skill.
Geriatric Gems and Palliative Pearls
Elder Abuse and Mistreatment –see page 63
Resources
1. Article

American Geriatric Society. (2007). GNRS: A core curriculum in advanced practice geriatric
nursing, 2nd Ed. New York, NY. 80-83.

Brandle, B., Dyer, C.B., Heisler, C.J., Otto, J.M., Stiegel, L.A., & Thomas, R.W. (2007). Elder abuse
detection and intervention: A collaborative approach. New York: Springer Publishing Company.

Dyer, C.B., Hyman, D. J., Pavlik, V.N., Murphy, K.P., & Gleason, M.S. (1999). Elder neglect:
Collaboration between a geriatrics assessment team and adult protective services. Southern
Medical Journal, 92(2), 51-62.

Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. (2003). Washington,
DC: National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect.

Fulmer, R. (2002). Elder abuse and neglect assessment. Try This, 2(15), 2.

Lachs, M.S., Williams, C, O'Brien, S., Hurst, L., & Horwitz, R. (1997). Risk factors for reported
elder abuse and neglect: a nine-year observational cohort study. Gerontologist, 37, 469-474.

Lachs, M. A., Williams, C. S., O’Brien, S., Pillemer, K. A., & Charlson, M. E. (1998). Mortality of
elder mistreatment. Journal of the American Medical Association, 280(5), 428−432.

Lachs, M. S., & Pillemer, K.A. (2004). Elder Abuse. The Lancet, 364: 1192-1263.

Pavlik, V.N., Hyman, D., Festa, N., & Dyer, C.B. (2001). Quantifying the problem of abuse and
neglect in adults: Analysis of a statewide database. Journal of the American Geriatrics Society,
49, 45-48.

Pillemer, K.A., & Finkelhor, D. (1988). The prevalence of elder abuse: A random sample survey.
The Gerontologist, 28, 51-57.
2. Instruments
The NCEA serves as a national resource for older adult advocacy groups, adult protective services, law
enforcement and legal professionals, medical and mental health providers, public policy leaders,
educators, researchers, and concerned citizens. It is the mission of the NCEA to promote understanding,
knowledge sharing, and action on elder abuse, neglect, and exploitation.
25
You may contact the NCEA at the following address/phone number:
National Center of Elder Abuse
c/o University of California – Irvine
Program in Geriatric Medicine
101 The City Drive South
200 Building
Orange, CA 92868
1-855-500-3537 (ELDR) (Phone)
714-456-7933 (Fax)
ncea-info@aoa.hhs.gov (e-mail address)
At this time, there are no validated instruments to determine elder abuse and mistreatment. There are
several instruments currently being researched for instrument reliability and validity.
3. Web -based

Centers for Disease Control and Prevention. (2008). Understanding Elder Maltreatment: Fact
Sheet. Retrieved on February 28, 2012 at http://www.cdc.gov/violenceprevention/pdf/emfactsheet-a.pdf

National Academy of Elderly Law Attorneys – http://www.naela.org

National Center on Elder Abuse – http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx

National Committee for Prevention of Elder Abuse – http://www.preventelderabuse.org

National Senior Citizens Law Center – http://www.nsclc.org

Teaster, P.B. (2000). A response to the abuse of vulnerable adults: The 2000 survey of statue
adult protective services.
http://www.ncea.aoa.gov/main_site/pdf/research/apsreport030703.pdf

The National Center on Elder Abuse. (2005). Fact Sheet: Elder Abuse Prevalence and Incidence.
Retrieved on February 29, 2012 from
http://www.ncea.aoa.gov/main_site/pdf/publication/FinalStatistics050331.pdf

The National Center on Elder Abuse. (2012). Elder Abuse Definition. Retrieved on February 29,
2012 from http://www.ncea.aoa.gov/ncearoot/Main_Site/FAQ/Basics/Definition.aspx

The National Center on Elder Abuse (2012). Types of Elder Abuse. Retrieved on February 29,
2012 from http://www.ncea.aoa.gov/ncearoot/Main_Site/FAQ/Basics/Types_Of_Abuse.aspx
Day Two Journal Entry
(Printout for day two journal entry is on page 72)
Elder abuse, first described in 1975 as “granny battering,” affects two to 10 percent of the aging
population in the United States. According to the best available estimates, between one and two million
26
Americans aged 65 years and older have been injured, exploited or otherwise mistreated by someone
on whom they depended on for care and protection. Health care professionals in a variety of settings
are encountering increasing numbers of older victims and their perpetrators. Reports of elder abuse and
mistreatment to Adult Protective Services and law enforcement are rising.
1. In your journal today, please reflect on elder abuse and mistreatment and provide us your thoughts.
2. It has been recommended that management of elder abuse and mistreatment should be done
through an interprofessional team approach. How would you manage an elder self-neglect patient?
Day Two Case Study
Mrs. Jones was an 89-year-old female who died in her home. You have been consulted by the Police
Department regarding this case. The police are asking “next step” questions based on the following
information provided to you, the primary care physician.
At 3:00 am last night, 911 operators received a phone call from Mrs. Jones' son requesting an
ambulance after he found his mother unresponsive. Paramedics and police officers on the scene
reported the elderly woman was lying in her bed naked, disheveled with dried feces on her buttocks.
Paramedics reported that she appeared to be very thin, had elongated fingernails and toenails, two
large, Stage IV pressure ulcers located on her sacrum and one on her right hip.
When questioned, the son stated that the mother refused to come to the doctor's office or allow home
health providers to enter the home. The son lived with the mother. You last saw this patient one year
ago, and at that time, had given her a diagnosis of advanced dementia. Based on the information given,
which would be your next step:
A. Sign the death certificate.
B. Release the body to the mortuary and make an Adult Protective Services referral.
C. Request a medical examiner inquiry.
Expert Opinion:
The correct answer is C. This may be neglect and needs to be reported to the medical
examiner’s office or the county coroner. There needs to be a post-mortem evaluation
and autopsy.
27
TEXAS Medical Clerkship Program
T- The Geriatric Syndromes
E- Elder Mistreatment
rX -Polypharmacy
A -Alzheimer’s Disease
S –Social Isolation
Day 1 Medical Clerkship Program
Day 2 Medical Clerkship Program
Day 3 Medical Clerkship Program
Day 4 Medical Clerkship Program
Day 5 Medical Clerkship Program
Day 3 – rX - Polypharmacy
When multiple medications are used to treat a patient, there is a higher
probability of negative and adverse effects. As a physician, it is important to
know how medications interact, especially in cases where the patient is being
treated for several medical issues. It is also important to review whether the
patient understands how to take their medication, in the right combination,
and as prescribed. Day three fully explores polypharmacy.
Definition
Managing the use of medications in older adults is a complex process and requires an understanding of
normal pharmacodynamics and pharmacokinetic changes that occur with aging. Polypharmacy is
defined as "many medications" and is a problem that can occur when a patient is taking more
medication that may actually be necessary. In older adults, it has been estimated that this population,
which is approximately 13 percent of the U.S. population, accounts for at least 30 percent of all
prescribed medications.
Incidence and Demographics
Polypharmacy is often described as a patient taking greater than five prescribed medications.
The prevalence of polypharmacy is estimated to range from four to 42 percent in the global
older adult population.
Risk Factors
1. Risk factors associated with inappropriate prescribing, overprescribing, and under prescribing
include: having more than one prescriber; poor record keeping; renal insufficiency; and, the use of
more than one pharmacy.
2. Cardiovascular drugs, anticoagulants, diuretics, non-steroidal anti-inflammatory drugs,
hypoglycemics, and atypical antipsychotics are the drug classes most often associated with
preventable, adverse drug events.
28
3. Over-the-counter medications (vitamins, minerals, herbal supplements) can lead to drug-drug and
drug-age and/or drug-disease interactions.
Pathophysiology
1. Age-associated changes in body composition, metabolism, and pharmacodynamics make drug-drug
and drug-disease interactions a significant problem for older adults, leading to delirium, falls, and
other adverse outcomes.
2. Pharmacodynamic changes occur with aging, and it is often enhanced, rather than reduced, in
older adults.
3. Pharmacokinetic changes occur with aging, including the absorption, distribution, metabolism and
elimination of medications. Some general information to remember:
a. Transdermal absorption may be reduced because of diminished blood flow to the skin; in others
it may be enhanced because of aging skin atrophies and becomes thinner. Always consider
lower doses may be therapeutic.
b. Intramuscular and subcutaneous absorption rates are usually decreased. With age, there is
decreased muscle mass, decreased blood perfusion to the muscle, and a decrease in
subcutaneous tissues due to disease, i.e. cardiovascular disease. Remember-lower doses may
be therapeutic in older adults.
c. Fat soluble drugs (i.e. valium, valproic acid) have larger volume of distribution and often
prolonged elimination half-lives. Highly protein-bound drugs (i.e. dilantin, warfarin) have a
greater (active) concentration. As older adults age, there is an increase in fat:water ratio with
decreased plasma protein; these physiologic changes affect drug distribution.
d. As an older adult ages, there is a decrease in liver mass and liver blood flow which may decrease
drug metabolism. Lower doses may be therapeutic. There is a tendency for an increase in drugdrug interactions.
e. As an older adult ages, there is a decrease in the Glomeruli Filtration Rate (GFR) which
reduces renal elimination of drugs. Renal impairment and decreased muscle mass results
in less creatinine production. Serum creatinine is not a reliable measure of kidney function.
It is strongly recommended that you estimate the creatinine clearance with Cockcroft
Gault equation:
Cockcroft Gault equation:
CrCl = [(140-age)(IBW)/(72x serum creatinine)] x 0.85 for females, where age is in years,
ideal body weight (IBW) is in kilograms, and serum creatinine is in milligrams per deciliter.
Assessment
1. Older adults should be instructed to bring all of their medications (brown bag assessment), including
over-the-counter medications, to each appointment. Medication reviews should be conducted on
every visit.
29
2. When an older adult presents with new onset medical problems, the health care provider should
ALWAYS consider that it could be due to a medication side effect.
3. Assess and assist the older adult with medication adherence by asking the Morisky Self-reported
Measures of Medication Adherence:
a. Do you ever forget to take your medicine?
b. Are you careless at times about your medicine?
c. When you feel better, do you sometimes stop taking your medicine?
d. Sometimes if you feel worse when you take your medicine, do you stop taking it?
Physical Exam
A physical exam is not needed for a medication review. Refer to the Geriatric Skill Cards
BEERS Criteria.
Diagnostics
Therapeutic drug levels can be drawn on some medications. This will vary depending on the
patient's profile. Refer to the Geriatric Skill Cards BEERS Criteria.
Management
Non-pharmacologic
1. Patients should be instructed to “Brown Bag” their medications. The patient should bring all
medications, including over-the-counter medication, vitamins, and complementary medications
in a bag at each visit for the health care provider to review.
2. Provide written instructions with all medications.
3. Medication “day of the week boxes” should be used to reduce confusion.
Pharmacologic
1. Start low and go slow.
2. Appoint only one health care provider as main prescriber.
3. Encourage the use of one pharmacy for consistent record-keeping and a secondary
assessment of potential drug-to-drug interactions.
Geriatric Gems and Palliative Pearls
Geriatric Medication Review – see page 65
Preventing Polypharmacy – see page 70
30
Resources
1. Article

Delafuente, J.C. (2008). Pharmacokinetic and pharmacodynamic alterations in the geriatric
patient. Consultant Pharmacist 23 (4), 324-334.

Ham, R.J., Sloane, P.D, Warshaw, G.A., Bernard, M.A. & Flaherty, E. (2007). Primary care
geriatrics: A case-based approach (5th ed) . New York: Mosby Elsevier.

Hanlon, J.T., Aspinall, S. L., Semia, T. P., et al. (2009). Consensus guidelines for oral dosing of
primarily renally cleared medications in older adults. Journal of American Geriatrics Society,
57(2), 335-340.

Koda-Kimble, M.A., Young, L.Y., Alldredge, B.K., Corelli, R.L., Guglielmo, B.J., Kradjan, W.A., &
Williams, B.R. (2009). Applied therapeutics: The clinical use of drugs (9th Ed). Philadelphia:
Wolters Kluwer/Lippincott Williams & Wilkins.

Morisky, D.E., Green, L.W., Levine, D. M. (1986). Concurrent and predictive validity of a selfreported measure of medication adherence. Medical Care, 24(1), 67-74.

Qato, D.M., Alexander, G.C., Johnson, M., Schumm, P., & Lindau, S.T. (2008). Use of prescription
and over-the-counter medications and dietary supplements among older adults in the United
States. Journal of the American Medical Association, 300(24), 2867-2878.

Slabaugh, S.L., Maio, V., Templin, M., Abouzaid, S. (2010). Prevalence and risk of polypharmacy
among the elderly in an outpatient setting: A retrospective cohort study in the Emilia-Romagna
region, Italy. Drugs Aging, 27(12), 1019-1028.
2. Instruments


Checklist for Brown Bag Medication Checkup
http://www.ohiopatientsafety.org/meds/default.htm
Medication Review Form – Brown Bag Program
http://www.ohiopatientsafety.org/meds/default.htm
3. Web-based

Brown Bag Assessment Form:
http://www.ohiopatientsafety.org/meds/Brown%20Bag/BBMedicationReviewForm1.doc

Drug-drug interaction look up: http://medicine.iupui.edu/clinpharm/DDIs/table.aspx

American Society of Consultant Pharmacists: http://www.ascp.com
31
Day Three Journal Entry
(Printout for day three journal entry is on page 73)
1. Describe a patient you have worked with over the past three days who was on multiple medications,
perhaps experiencing polypharmacy. What did you learn?
2. The Pharmacist is an integral part of the interprofessional team. Share your thoughts on how the
Pharmacist could be instrumental in your practice and how he or she can help care for medically
complex older adults.
Day Three Case Study
Tomorrow in clinic, you are going to meet an 85-year-old Caucasian female who has been taking Aleve
for 20 years for bilateral osteoarthritis of the knees. She also has essential hypertension, for which she
has been taking HCTZ (hydrochlorothiazide) for 15 years. She has several other supplements she takes at
home. She is new to the clinic and did not know about the policy of bringing all medications to each visit.
She does remember that she takes Tylenol PM and Benadryl at night to help her sleep. You take her
blood pressure and it is 168/92. She states that it has been running at that rate for “some time.” She
also mentions feeling like her memory is “cloudy” in the morning. You get some preliminary blood work,
and it shows a BUN of 68 and a creatinine of 1.9.
In your journal, respond to the following questions:
1. You need to provide your attending with your initial assessment. What are you going to tell
the attending?
Expert Opinion:
The initial assessment would include: poorly controlled hypertension; renal insufficiency related
to longstanding hypertension, which may be exaggerated secondary to NSAID use; bilateral knee
osteoarthritis; insomnia; potential for drug safety issues with her age and Tylenol PM and
Benadryl; increased risk for falls; perhaps delirium due to medications.
2. Would you have ordered other tests? If so, which ones and why?
Expert Opinion:






Urinalysis – proteinuria and urinary sediment
Sodium levels – may be normal or hyponatremia
Potassium – may be elevated
Normochromic, Normocytic anemia
Liver function test (LFTs) – Tylenol administration
Functional assessment- SLUMs to determine mental status; Get Up and Go;
Fall Risk Assessment
3. Would you change any of the patient's medications?
32
Expert Opinion:
Yes. I would discuss with my attending the BEERs criteria and discuss the need to change the
following medications: HCTZ (furosemide is a more effective diuretic in patients with renal
insufficiency); Aleve-consider both non-pharmacologic (physical therapy, heat/cold treatment)
and pharmacologic treatment (topical analgesics or different pain medication based on your
assessment); and, Tylenol PM and Benadryl (assess the insomnia and determine both nonpharmacologic and pharmacologic strategies).
33
TEXAS Medical Clerkship Program
T- The Geriatric Syndromes
E- Elder Mistreatment
rX -Polypharmacy
A -Alzheimer’s Disease
S –Social Isolation
Day 1 Medical Clerkship Program
Day 2 Medical Clerkship Program
Day 3 Medical Clerkship Program
Day 4 Medical Clerkship Program
Day 5 Medical Clerkship Program
Day 4 – Alzheimer’s disease and other dementias
There are several forms of dementia that affect older adults aged 65 and older;
the most common of these is Alzheimer’s Disease. This disease affects millions
of older adults, but it influences both the older adult and their family/loved
ones. Knowing the signs of dementia and how to differentiate between the
types of dementia will allow you to better address symptoms and assist the
family in dealing with issues like possible loss of independence. Day 4 discusses
the progressive, fatal, devastating disease known as dementia.
Definition
The Alzheimer’s Association defines dementia as an umbrella term that describes a variety of
diseases and conditions. Dementia is NOT normal age-related cognitive changes in memory or
rate of information processing.
Types of Dementia
There are several types of dementia that will be described below:
Alzheimer’s Disease (AD)
Incidence and Demographics
1. Alzheimer’s Disease represents 60 to 80 percent of all dementia diagnoses.
2. An estimated 5.2 million Americans aged 65 and over had AD in 2012.
3. AD is the fifth leading cause of death.
Risk Factors
1. Advancing age
2. Family history (parent, brother or sister affected)
3. e4 form of the gene apolipoprotein
34
4. Possessing cardiovascular disease risk factors (physical inactivity, hypercholesterolemia, diabetes
mellitus, obesity)
5. Mentally and socially inactive
6. Past medical history of head trauma or traumatic brain injury
Pathophysiology
1. Multi-factorial causation.
2. Accumulation of protein beta-amyloid outside the neurons in the brain and accumulation of protein
tau inside the neuron.
3. Genetic mutations are seen in less than one percent of persons diagnosed with AD. The three
known genetic mutations are: (1) gene for amyloid precursor protein; (2) gene for the presenilin 1;
and, (3) gene for presenilin 2.
Clinical Manifestations
1.
2.
3.
4.
5.
6.
Progressive worsening of ability to remember new information.
Progressive memory loss that disrupts daily life.
Difficulty planning or solving problems, or completing familiar tasks at home, work or at leisure.
Confusion with time and place.
Change in behavior and personality, global cognitive dysfunction, and functional impairments.
Prominent loss of short-term memory early in the disease, with functional dependency as disease
process progresses.
Diagnosis
1. Diagnosis has been based on meeting DSM-IV criteria for dementia. The following are required.
Clinical manifestations must include a decline in memory and in at least one of the following
cognitive abilities:
a. Ability to generate coherent speech or understand spoken or written language.
b. Ability to recognize or identify objects assuming intact sensory.
c. Ability to execute motor activities, assuming motor abilities are intact, and sensory function and
comprehension of the required task.
d. Ability to think in the abstract, make sound judgments and plan and carry out complex tasks.
e. Decline in cognitive abilities must be severe enough to interfere with daily living.
2. Before a diagnosis of dementia is given, the physician must explore other potentially reversible
conditions that may cause cognitive clinical manifestations. These include:
a. delirium;
b. depression;
c. medication adverse effects;
d. thyroid dysfunction;
e. vitamin B12 and Folate deficiency;
f. Alcohol misuse or excessive use; and,
g. Illicit drug misuse or excessive use.
3. In 2012, the Alzheimer’s Association and National Institute for Aging proposed new AD criteria and
guidelines for the diagnosis of Alzheimer’s Disease. A brief description is provided here.
Stage I: Preclinical Alzheimer’s Disease
a. An individual has measurable changes in their brain.
35
b. Cerebrospinal fluid (CSF) and/or blood biomarkers (beta amyloid and tau protein levels) should
be attained.
c. Individuals in this stage have not yet developed the clinical manifestations of memory loss. This
is the earliest stage of the disease recognized by physiological brain changes and biomarkers.
Stage 2: Mild Cognitive Impairment (MCI) due to Alzheimer’s Disease
a. Mild measurable changes in thinking abilities that are noticeable to the person affected and to
family members, but these changes do not interfere with the person’s ability to carry out
everyday activities.
b. Comprehensive geriatric assessment, neuropsychological testing and above recommendations
are suggested.
Stage 3: Dementia due to Alzheimer’s Disease
a. Memory, thinking, and behavioral clinical manifestations impair the individual’s ability to carry
out activities of daily living.
b. Progressive decline in functional independence and cognitive abilities.
Vascular Dementia
Incidence and Demographics
1. Vascular dementia represents 10 to 20 percent of dementia cases.
2. This type of dementia is commonly seen in patients with a past history of a cerebrovascular accident
(CVA).
Pathophysiology
1. Patients with this type of dementia are found to have large artery infarctions (cortical or subcortical).
2. Patient may have subcortical small artery infarctions or lacunae, or chronic subcortical ischemia.
Clinical Manifestations
1. Dependent on cerebral artery involved in the ischemic event.
2. Abrupt or insidious, progressive onset.
3. Early disease manifestations include executive dysfunction and gait disturbance.
Diagnosis
1. Positive past medical history for cerebrovascular accident or vascular risk factors.
2. MRI will identify cortical or subcortical changes.
36
Dementia with Lewy Bodies
Incidence and Demographics
1. This dementia represents 10 to 20 percent of all dementia diagnoses.
2. Parkinson's Disease, dementia, and progressive supranuclear palsy are
all classified under this designation.
Pathophysiology
1. There is the presence of cortical Lewy Bodies.
2. It is common to see amyloid plaques and neurofibrillary tangles upon autopsy.
Clinical Manifestations
1. This type of dementia has a progressive cognitive decline.
2. In the early stages of the disease, the patient demonstrates fluctuating cognition.
3. Progressive cognitive decline with motor features of Parkinsonism. Prominent visual hallucinations
are present as part of the diagnosis.
Diagnosis
MRI demonstrates possible global atrophy.
Fronto-temporal Degeneration
Incidence and Demographics
1. This dementia is rarely seen in people older than 75 years of age.
2. This is usually seen in persons younger than 60 years of age.
3. This type of dementia represents 20 to 40 percent of all dementia cases.
Etiology
1. There may be an association with abnormalities in the protein tau that is present in the neurons.
2. There is focal atrophy of the frontal and temporal lobes of the brain.
Clinical Manifestations
1. Early in the disease, the patient demonstrates behavioral and personality changes with less memory
loss.
37
2. As the disease progresses, executive dysfunction, disinhibition, apathy and inappropriate social
behavior occurs more frequently.
3. Patient will have language deficits.
4. Potential for misdiagnosis as a personality or psychiatric disorder.
Diagnosis
1. Clinical diagnosis.
2. MRI will demonstrate atrophy of frontal and temporal lobes.
Assessment and Treatment of Dementias
Assessment of Dementia
1. History
a. Family history for dementia
b. HPI: time frame, type of progression, associated neurologic clinical manifestations
c. PMH: Hypertension, CAD, Hypercholesterolemia, CVA, head injuries, psychiatric illnesses
d. Medication review: See Day 3 Polypharmacy for more details. Review ALL medications (OTC,
supplements, home remedies, and prescriptions). Many medications can impair cognition –
analgesics, anticholinergics, psychotropic, and sedatives-hypnotics.
e. Social History: Marital status, occupation, present living condition, education level, use of
alcohol, tobacco and illicit drug use
f. Perform comprehensive geriatric assessment (CGA)
g. Cognitive testing — There are several validated, health care provider administered tools to
screen for cognitive impairment. These tests evaluate orientation, recall, attention, calculation,
language manipulation and constructional praxis. Examples include: the St. Louis University
Mental Status (SLUMS), the Montreal Cognitive Assessment, and shorter screeners, such as the
Mini-Cog test, which combines a three-item recall and the clock-draw test.
h. Functional testing— These tests serve as a baseline to determine functional independence in
activities of daily living and executive function activities. Examples include: the Katz
Independence in Activities of Daily Living (IADL), Functional Assessment Staging (FAST), and the
Activities of Daily Living (ADL).
i. Depression— Depression may affect memory and should be assessed. An example of a
depression scale is the Geriatric Depression Scale (GDS).
2. Physical Exam
a. A complete physical exam to rule out reversible causes of dementia must be done.
b. Particular attention should be given to the nervous system and cardiovascular exam.
3. Diagnostics
a. Laboratory testing should include a complete blood count; electrolytes; Folate; glucose; a liver
function test; renal; a thyroid function test; and, vitamin B12 levels. In addition, based on
history and the physical, consider urinalysis to rule out urinary tract infections and consider
screening for neurosyphilis if there is high clinical suspicion.
38
b. Radiology testing includes a non-contrast CT or MRI.
c. Neuropsychological testing is recommended.
d. Please see proposed changes to the Diagnosis of AD recommendations above – biomarkers are
now being proposed by the Alzheimer’s Association and the National Institute on Aging.
Dementia Treatment Management
Non-pharmacologic
1. Patient and family education on disease, treatment options and community resources available.
2. Interprofessional approach to care includes consults with social workers, home health care
providers, and chaplains.
3. Cognitive enhancements include reality orientation.
4. Individual and group therapy includes reminiscence, art and music therapy. Psychosocial therapy
for depression.
5. Caregiver support
6. Environmental modifications to address disease progression.
7. Safety and home evaluations include the prevention of wandering; registration with Safe Return;
and, a home evaluation to assess potential dangers in the home.
8. As the disease progresses, functional independence will diminish and level of care needs will
increase. Consider paid formal caregivers, palliative medicine services and hospice care as the
patient’s condition dictates.
Pharmacologic
1. Cholinesterase inhibitors – not disease modifying, treat symptoms and may improve agitated
behaviors. Examples: donepezil (Aricept), Rivastigmine (Exelon), Galantamine (Razadyne).
2. N-methyl-D-aspartate antagonist (NMDA) – used in combination with cholinesterase inhibitors,
used to slow disease progression, may have neuro protective effect. Example: Memantine
(Namenda).
3. Antipsychotics- atypical antipsychotics are used to treat clinical manifestations of paranoia,
delusions and hallucinations (not FDA approved for treatment of dementia-related psychosis).
Clinician must weigh risk versus benefit of using these types of drugs. Examples: olanzapine,
quetiapine, and risperidone.
4. Antidepressants – treatment of depressive symptoms such as appetite loss, fatigue, irritability
and agitation.
Geriatric Gems and Palliative Pearls
Dementia – see page 67
Dementia in the Hospitalized Elderly – see page 69
Resources1. Articles

Brayne, C., Fox, C., & Boustani, M. (2008). Dementia screening in primary care. Journal of the
American Medical Association, 298(20), 2409-2411.
39

Reuben, D.B., Herr, K.A., Pacala, J. T., Pollock, B.G., Potter, J.F., & Semla, T.P. (2010). Geriatrics
at your Fingertips (12th Ed.). New York, NY: American Geriatrics Society.

Rochon, P. A., Normand, S.L., Gomes, T., Gill, S.S., Anderson, G.M., Melo, M., et al. (2008).
Antipsychotic therapy and short-term serious events in older adults with dementia. Archives of
Internal Medicine, 168(10), 1090-1096.
2. Instruments
 Cognitive Assessment (SLUMS) http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

Geriatric Depression Scale (GDS) Short Form http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF

Katz Index of Independence in Activities of Daily Living (ADL)http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf

Instrumental Activities of Daily Living (IADL) http://www.abramsoncenter.org/pri/documents/iadl.pdf
3. Web-based

2012 Alzheimer’s Disease Facts and Figures- Proposed AD Staging and Diagnosis
http://www.alz.org/alzheimers_disease_facts_and_figures.asp

Alzheimer’s Association – http://www.alz.org

Alzheimer’s Disease Education and Referral Center – http://www.alzheimers.org

Saint Louis University Mental Status (SLUMS) Examination:
http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

Geriatric Depression Scale: http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF

Activities of Daily Living/Independent Activities of Daily Living:
http://son.uth.tmc.edu/coa/FDGN_1/RESOURCES/ADLandIADL.pdf
Day Four Journal Entry
(Printout for day four journal entry is on page 74)
1. Write about a patient you have seen this week with dementia. As a physician, what will be your
patient care challenges and how will you work with the family caregivers?
40
2. The Baby Boomer generation is growing older. Some call the aging of America a "health care
tsunami." As a physician, how will you manage large percentages of older adults in your practice?
Do you have any initial thoughts or strategies on how to effectively manage these complex medical
patients? Will you use an interprofessional team? How could advanced practice nurses or physician
assistants help you with the chronic management of these patients?
Day Four Case Studies
Case Study One
Mrs. Murphy is a 79-year-old Caucasian female, in the clinic to establish geriatric primary care on the
insistence of her two sons. Her sons state that she has been acting differently for the last two years. She
has a college education. She is a retired teacher (retired 12 years ago). She lives independently with her
husband in a home they own. Her Past Medical History is significant for well-controlled hypertension,
macular degeneration bilaterally, and osteoarthritis bilaterally of the knees. She no longer participates
in her social clubs or golf. Her son states that she becomes easily distracted and is “more sharp” with
her family than she has ever been. Mrs. Murphy states that she is fine and has no complaints. She
denies depression. Her physical exam was unremarkable. Her comprehensive geriatric assessment
scores were as follows:
SLUMS 29/30, GDS 2/15, ADL 6/6, IADL 8/8, Get Up and Go was normal.
As the physician, what is the appropriate next step?
1. Reassure Mrs. Murphy and her sons that her function is appropriate for her age.
2. Obtain neuro imaging.
3. Order formal neuropsychological testing.
4. Have the patient return in two weeks for repeat testing.
Expert Opinion:
The correct answer is 3. Order formal neuropsychological testing. Mrs. Murphy may be having
executive dysfunction. This can manifest as difficulty maintaining attention and focus; as a lack
of insight; or, changes in personality and poor judgment. The SLUMS assesses a number of
different cognitive functions (see above), and a score of 29 is very good. However, SLUMS
incompletely assesses executive function. Neuropsych testing will ascertain executive function
status. Given her sons' concerns and the potential for cognitive executive dysfunction, this
would be the most prudent way to proceed. The physician would not order neuro imaging first
because he or she has not ascertained the nature of the cognitive problem, or if there is a
cognitive problem.
Case Study Two
Mr. Garcia, age 76, comes to your office. His wife states his chief complaint is short-term memory loss
for several months. She states his memory loss is progressive. He has two years of college education.
His past medical history is significant for well-controlled hypertension. His physical exam is
unremarkable. There is no evidence of depression. His SLUMS score was 25/30. He was only able to
recall two of the five objects on recall, and he knew his name but not the date of the office visit. What is
your differential diagnosis?
41
1.
2.
3.
4.
Benign senescent forgetfulness
Mild cognitive impairment
Dementia
Depression
Expert Opinion:
The correct answer is 2. Mild cognitive impairment. Your initial thoughts should point you to
MCI. His wife has noticed a progressive memory loss with no other cognitive complaints. His
medical exam was unremarkable with no obvious medical problems. His SLUMS score has
abnormalities, especially with recall and orientation. He is not overtly depressed. You should
proceed with a diagnostic work up for reversible causes of cognitive impairment first.
Case Study Three
Mrs. Johnson is an 88-year-old Black female admitted to the ACE (Acute Care of the Elderly) Unit from
her nursing home. She has been diagnosed with pneumonia. Her Past Medical History is significant for
hypertension and right hemispheric stroke, which left hemiplegia. On admission, she was alert and
oriented x2. She follows commands and was pleasant to the hospital staff. On Day 2 of her admissions,
vital signs were stable, an IV antibiotic had been started for her pneumonia, and no problems were
reported by the night nursing staff. On rounds, Mrs. Johnson was found to be excessively sleepy, unable
to stay awake during the Attending Physicians questioning. Her breakfast tray had not been touched.
She complains of feeling extremely fatigued and does not want to talk to anyone. She becomes easily
distracted by the voice of the patient in the next bed. There have been no new medications except for
the antibiotic started yesterday.
What is your initial impression?
1.
2.
3.
4.
5.
Alzheimer’s Disease
Dementia with Lewy bodies
Delirium
Depression
New onset stroke
Expert Opinion:
The correct answer is 3. Delirium. Mrs. Johnson is demonstrating an acute change in her
cognition with inattention, lethargy, and fluctuation of her condition. It would be best for you,
as her physician, to utilize the Confusion Assessment Method (see Day 1) and ascertain if she is
having an acute change in mental status with a fluctuating course, inattention, and the presence
altered level of consciousness or thinking.
42
TEXAS Medical Clerkship Program
T- The Geriatric Syndromes
E- Elder Mistreatment
rX -Polypharmacy
A -Alzheimer’s Disease
S –Social Isolation
Day 1 Medical Clerkship Program
Day 2 Medical Clerkship Program
Day 3 Medical Clerkship Program
Day 4 Medical Clerkship Program
Day 5 Medical Clerkship Program
Day 5 – Social Isolation
Social isolation is an emerging issue that may occur in older adults, aged 55
and older, due to physical, psychological, emotional, social, or financial
problems. Social isolation may affect millions of older adults and their
family/loved ones. Social isolation may be secondary to many other conditions
that are assessed as a part of the comprehensive geriatric assessment. Chronic
illnesses, disabilities, depression, self-neglect, widowhood, and poverty (among
many other things) may be precursors to social isolation. Taking a thorough
social history and being alert to the signs and symptoms of social isolation may
assist the health care team and family in preventing social isolation, or
reversing it if it already exists. Day 5 includes information on identifying social
isolation in older adults and developing a treatment plan.
Definition
Social isolation is the lack of integration into society, and lack of participation in activities that enhance
productive aging and health. Social isolation usually infers a lack of connections between the older adult
and a social network, and/or a lack of family, friends or other community groups with people to turn to in
times of need or crisis. Three related concepts are included in any discussion of social isolation. Social
isolation is an objective concept that can be observed by watching the older adult's social interactions or
mapping the older adult's social network. Loneliness is sometimes thought of as the other side of the coin.
It is a subjective measure of the older adult's perceptions of relationships, activities and feelings about their
social involvement. External factors may also affect social isolation. Social exclusion is the term used by the
World Health Organization (2003) to refer to exclusion from social networks and social support because of
poverty, relative deprivation, racism, discrimination, stigmatization, hostility, and unemployment. Social
isolation, regardless of the underlying cause, can be socially and psychologically damaging and harmful to
mental and physical health.
43
Incidence and Demographics
A better understanding is needed of the incidence and prevalence of social isolation in older adults, its risk
factors, and the links between isolation and well-being. While the incidence and prevalence are unknown, it
occurs most often in older adults with the following demographic characteristics:
 Women
 Oldest elderly
 Poor
 Living alone
 Low socioeconomic status
 Deteriorated neighborhoods with high crime rates
 Widowed or never married
 Lack of transportation
 Relocation to another community
Risk Factors
1. Losses that increase the likelihood of living alone (i.e., death of spouse, family members, or
close friends or neighbors).
2. Chronic illnesses, especially those with associated disabilities that result in loss of mobility or
communication ability (i.e., stroke, Parkinson’s disease).
3. Conditions that cause mental impairment that interfere with the older adult's ability or
motivation to interact with others (i.e., chronic schizophrenia, depression, and dementia).
4. Loss of social networks resulting in a loss of social support (i.e., retirement, geographic
mobility of family and friends, relocation).
5. Conflicts in interpersonal relationships leading to a lack of social cohesion (trust, respect)
and causing the older adult to withdraw from social situations or feel excluded
(i.e., unresolved family disputes, dysfunctional families, substance abuse, elder abuse
and mistreatment).
6. Poverty resulting in lack of resources needed to maintain a social support system
(i.e., lack of money to participate in activities, lack of transportation, poor quality
housing, high crime neighborhoods).
Pathophysiology
The pathophysiology is unknown, but the World Health Organization (2003) reported that social isolation
and exclusion are associated with “increased rates of premature death, lower general well-being, more
depression, and a higher level of disability from chronic diseases.”
Assessment
Assessment includes a comprehensive examination with attention to the issues discussed in Days 1 through
4, including the geriatric syndromes, elder abuse and mistreatment, polypharmacy and dementias that may
be the precursors to loneliness and social isolation.
Observe the patient for signs of withdrawal; anxiety when others are present; dependency in ADLs; lack of
eye contact; and, unwillingness to engage in conversation.
44
The social history is an essential component of the comprehensive geriatric assessment and should be
performed in a sensitive manner with attention to establishing trust with the older adult. A complete social
history may help to identify risk factors for social isolation. The following areas should be covered in the
social history:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Marital status – married, widowed, separated, divorced (length of time)
Family involvement – adult children, grandchildren, siblings
Living arrangement – with spouse, with family, alone, in a residential setting
Social activities – hobbies, clubs, sports, games, church (solitary and group)
Social network – daily, weekly, monthly, yearly contact (is the person happy with the amount
and quality of the social network?)
Plan for emergencies
Spirituality – what gives meaning to life, relationship with a higher power, religious preference
Level of independence – cared for by others (family, paid, volunteer), caring for someone else
who is dependent on them
Financial status – do they have enough money to live comfortably; are they concerned about
paying household bills, buying groceries, buying medications, paying for medical care?
Use of chemicals – cigarettes/pipes/chewing tobacco, alcohol, recreational drugs
Legal documents – will, advanced directives, medical power of attorney
Safety – do they feel safe in their home and in the neighborhood?
Transportation – is transportation available (drive own car, dependent on family/friend), or do
they use public transportation (bus, train, taxi)?
The following are examples of questions that may help you to identify social isolation or loneliness in
your patient:
1. Tell me about an important relationship that you have. Are their challenges in the relationship?
Tell me about your relationship with other family members? With friends? What strategies have
you used to mend poor relationships?
2. How much contact do you have with other people during a week? Do you feel satisfied with
those contacts? Do you think that it is enough contact or would you like more?
3. How many people do you know that you feel like you could ask for help if you needed it?
4. What activities do you participate in? Are they enjoyable?
5. What interferes with your participation in social activities?
5. With whom do you share your emotional and social experiences?
6. Do you ever feel excluded from groups or activities that you would like to participate in?
Physical Exam
There is no physical examination specific for social isolation, but the physical exam would be based on risk
factors that are present and appear to be related to the loss of social networks, social support, social
cohesion, and social exclusion. Special attention should be directed to the most common causes of social
isolation and loneliness – chronic and disabling illnesses and/or pain, loss of mobility, loss of communication
ability due to problems with speech, vision, or hearing, dementia, depression, and elder abuse and
mistreatment, and/or substance abuse.
45
Diagnostics
No specific diagnostic procedures are used for social isolation. A few scales exist to measure loneliness. The
de Jong-Gierveld 6-item Loneliness Scale is short and easy to use in clinical practice, and has often been
used with older adult populations. It is included below:
Directions: Please indicate for each item, the extent to which they refer to your situation, how you feel
now. The answer options are: Yes, More or Less, No
1. I experience a general sense of emptiness.
2. I miss having people around.
3. I often feel rejected.
4. There are plenty of people I can rely on when I have problems.
5. There are many people I can trust completely.
6. There are enough people I feel close to.
Gierveld & Tilburg, 2006
Also do a network mapping exercise with the older adult.









On a blank piece of paper, draw a circle to represent the older adult and label it with their name.
Ask them to name people who they communicate with on a daily basis, a weekly basis, a monthly
basis, etc.
For each person they name, ask them how far this person is from them physically and emotionally.
Draw a circle to represent each person and label. Ask the older adult to help you determine how far
the person should be placed from them? Ask how strong the relationship is? Stronger relationships
will be connected to the older adult by bolder lines.
Ask them if they would be comfortable asking this person for help? Do they help this person? Is the
experience of helping mutual?
Draw arrows on the end of the lines based on which way the assistance goes.
When they have exhausted their list of names, ask about other potential people (i.e., postman,
police or fireman, clergy, church members, beautician/barber). Add any of these people to
the graph.
Then, looking at the graph, ask them to talk about how they could develop a social network that
includes these people.
Ask them to indicate specific tasks that they would be willing to ask these people to do.
Management
Non-pharmacologic
It is important to involve the interprofessional team in the treatment of older adults who are socially
isolated. The first step is to identify and treat conditions that may lead to social isolation, such as
sensory deficits, chronic illness or pain, and physical and/or mental disabilities.
If loneliness and social isolation are due to losses, referrals for bereavement counseling or grief groups
may be useful.
Social support has been shown to buffer the effects of stress and prevent social isolation. Social workers
can be helpful in determining the older adult's need for informal support. A family council meeting may
be necessary to explore ways that the older adult can be better supported in their home environment
46
by family members or by volunteers or church groups that provide friendly visitors and transportation to
senior centers or adult day care centers.
Nurses and therapists may also be involved in assessing the older adult's need for additional nursing and
therapy services after discharge. Older adults who are isolated due to multiple comorbidities may
benefit from home health services. Involvement of the family is important in recognizing and affirming
the need for formal health and social services, either in the home, or in facilitating entry into a formal
health care setting, such as an assisted living or skilled nursing facility.
Pharmacologic
Medications should be used to treat the factors that contribute to loneliness and social isolation. No
drugs are used specifically for social isolation.
Resources
1. Article

Gierveld, J.D.J, & Tilburg, T.V. (2006). A 6-item scale for overall, emotional, and social loneliness:
Confirmatory tests on survey data. Research on Aging, 28(5), 587-598. Retrieved from
http://roa.sagepub.com

Seeman, T. (2000) Health promoting effects of friends and family on health outcomes in older
adults. American Journal of Health Promotion, 14(6), 362-370.

Stewart, M., Craig, D., MacPherson, K., & Alexander, S. (2001). Promoting positive affect and
diminishing loneliness of widowed seniors through support intervention. Public Health Nursing,
18(1), 54-63.

Thompson & Krause. (1998). Living alone and neighborhood characteristics as predictors of
social support in late life. Journal of Gerontology: Social Sciences, 53B, 254-365.

Van Baarsen. (2002). Theories of coping with loss: The impact of social support and self-esteem
on adjustment to emotional and social loneliness following a partner’s death in later life. Journal
of Gerontology: Social Sciences, 57B(1), 33-42.

Victor, C., Scrambler, S., Bond, J., & Bowling, A. (2000). Being alone in later life: Loneliness,
social isolation and living alone. Reviews in Clinical Gerontology,10, 407-417.

World Health Organization. (2003). The social determinants of health: The solid facts-second
edition.
2. Instruments

De Jong Gierveld Loneliness Scale validation article
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921057/
47
3. Web-based

British Columbia Ministry of Health
http://www.health.gov.bc.ca/library/publications/year/2004/Social_Isolation_Among_Seniors.p
df

The Elderly and Social Isolation, Testimony to Committee on Aging, NYC Council, February 13,
2006. http://wagner.nyu.edu/faculty/testimony/rodwinNycCouncil021106.pdf

Gierveld, J.D.J. (2006). A 6-Item scale for overall, emotional, and social loneliness confirmatory
tests on survey data. Research on Aging, 28(5), 582-598.
Day Five Journal Entry
(Printout for day five journal entry is on page 75)
1. Describe a patient that you worked with during the last five days that you thought might be socially
isolated. What risk factors were present that make you suspicious of social isolation? How was it
addressed, or in retrospect, how do you wish you had addressed it?
2. How would you describe the patient’s social network and social cohesion? Was he/she experiencing
social exclusion and/or social isolation? Would a referral to another member of the
interprofessional team be appropriate?
Day Five Case Study
Mrs. Hattie is a 70-year-old African American woman you met when she was hospitalized with
uncontrolled diabetes and pneumonia. She has missed two clinic visits, and you are asked to make a
home visit to determine if she is following her discharge orders. Mrs. Hattie lives in an older part of
town with small bungalows. Her yard is closely cut and dry, and she has several pots and cans in
front of the house that are filled with blue, hot pink, and yellow, plastic flowers. She has a rusty
fence around her property. The front windows are covered with mangled plastic venetian blinds,
and some of the windows on the sides are boarded up. The only response to your knock on the door
is the barking of dogs.
In the mail slot at the side of the door, you yell, “Mrs. Hattie, are you home?” The door opens a
crack with the night chain still fastened, and she says, “Who are you?” After you introduce yourself
and the purpose of your visit, she reluctantly opens the door. The house is dimly lit and cluttered.
Food containers litter the floor, and empty pill bottles are on the table. There are two Chihuahua
dogs running loose. The table holds some pictures. When you ask about them, she responds,
“Those are my daughters, sister, and two brothers. I haven’t seen them in years. When they come,
we argue and they get mad and leave or whatever…. but I have my dogs to keep me company,” and
she reaches down to pet them. She has not been out of the house since she was discharged from
the hospital. She does not drive. The social worker arranged for her to get meals from Meals on
Wheels when she was discharged, and she still has them delivered at noon Monday through Friday.
What action would you take?
a. Teach her about the importance of her medications and clinic visits.
b. Arrange for transportation to the clinic next week.
48
c. Refer her to Adult Protective Services.
d. Call an ambulance and have her admitted to the hospital.
Expert Opinion:
The correct answer is c. Refer her to Adult Protective Services. Mrs. Hattie has the symptoms of
social isolation; poor social cohesion; lack of a functioning social network; and, social exclusion.
Her inability to care for herself, manage her medical conditions, or her environment, and her
apparent lack of concern or motivation to make changes, suggest that she may be experiencing
a common type of elder abuse or mistreatment- self-neglect. It would be appropriate to refer
her to Adult Protective Services, who can do a thorough assessment of the situation. They can
involve an interprofessional team to assess her executive function and mental capacity, and
bring in resources to clean up the environment, and arrange for transportation, home health
services, and medication, as well as continuing food deliveries.
49
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Ganz, D.A., Bao, Y., Shekelle, P.G., & Rubenstein, L.Z. (2007). Will my patient fall? Journal of the American
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Heuberger, R.A. (2011). The frailty syndrome: A comprehensive review. Journal of Nutrition in Gerontology
and Geriatrics, 30(4), 315-368.
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Pavlik, V.N., Hyman, D., Festa, N., & Dyer, C.B. (2001). Quantifying the problem of abuse and neglect in
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Activities of Daily Living/Independent Activities of Daily Living:
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53
Medline Plus: Delirium http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm
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Images
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Mokra at www.sxc.hu/photo/572286
Clarita at morguefile.com/archive/display/33743
54
Appendix
Geriatric Gems and Palliative Pearls






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
Delirium Screening by Susan Gorman, MSN, RN, GNP
Fall Evaluation by Kathleen Pace Murphy, PhD MS, GNP-BC; Jennifer Larson, MSE; and
Nasiya Ahmed, MD
Frailty by Kathleen Pace Murphy, PhD, MS, GNP-BC
Geriatric Depression by Jennifer Larson, MSE, and Nasiya Ahmed, MD
Elder Abuse and Mistreatment by Kathleen Pace Murphy, PhD, MS, GNP-BC
Geriatric Medication Review by Kathleen Pace Murphy, PhD, MS, GNP-BC
Dementia by Nasiya Ahmed, MD
Dementia in the Hospitalized Elderly by Nasiya Ahmed, MD
Preventing Polypharmacy, by Nasiya Ahmed, MD
Journal pages







Day 1 with topic
Day 2 with topic
Day 3 with topic
Day 4 with topic
Day 5 with topic
Blank, no lines, no topic
Blank, with lines, no topic
55
Learning Objectives:
Geriatric Gems and Palliative Pearls presents:
Delirium Screening
by Susan Gorman, MSN, RN, GNP
1.
2.
3.
4.
Define delirium.
Identify factors for delirium.
List diagnosing criteria.
Summarize the importance of
delirium screening
Risk Factors for Delirium Include:
Diagnosing Delirium:




Advanced Age
Functional Impairment
Medical Co-morbidities
Underlying Dementia
Delirium can be diagnosed using the Confusion Assessment Method (CAM).
The CAM has 4 Features:
 Feature 1: Acute Onset and Fluctuating Course: Is there evidence of an acute change in mental
status from patient’s baseline? This is usually best answered by someone close to the patient, such
as family, a care provider, or a nurse.
 Feature 2: Inattention: Did the patient have difficulty focusing? Were they easily distracted or could
they not stay awake?
 Feature 3: Disorganized Thinking: Was the patient’s thinking disorganized or incoherent?
 Feature 4: Altered Level of Consciousness: Overall, how would you rate this patient’s level of
consciousness? The answer should be anything other than alert (normal)
The Management of Delirium Includes:





Identify and remove or treat the underlying cause of delirium (i.e. infection, drugs, electrolyte
imbalance, anemia).
Reassure the patient by having well known family members or caregivers at the bedside.
Discern day from night surroundings (decreased stimulation at night to promote sleep, blinds open
during day with more activity).
Avoid bed rest if possible, using physical and/or occupational therapy, ambulation, range of motion,
and move patient out of bed to chair as tolerated.
Use corrective aids (glasses, hearing aids, dentures).
Management of Delirium with Acute Agitation or Aggression (Use Lowest Effective Dose):
 Haldol 0.25-2 mg po may be given Q4 hours PRN (peak effect 4 to 6 hours)
 Haldol 0.25-2 mg IM may be given Q1-2 hours PRN (peak effect 20 to 40
For the CAM to be positive for delirium, it requires the presence of both features 1 and 2, AND either 3
or 4. An Interactive training module on the CAM is available at http://icam.geriu.org.
References:



Beers, M., & Berkow, R. (Eds.). (2000). The Merck Manual of Geriatrics (3 ed.).
Merck Research Laboratories.
Inouye, S. (2006). Delirium in older persons. New England Journal of Medicine, 354(11),57-65.
Reuben, D.B., Herr, K.A., Pacala JT, et al. (2007). Geriatrics At Your Fingertips (9th Ed.)
New York: The American Geriatrics Society
56
Geriatric Gems and Palliative Pearls presents:
Fall Evaluation
by Kathleen Pace Murphy, PhD MS, GNP-BC; Jennifer
Larson, MSE; and Nasiya Ahmed, MD
Evaluating gait and balance is paramount to an
older adult’s health and independence. The
American Geriatrics Society recommends
conducting a fall risk assessment during routine
primary care visits. High risk groups should have a
more intensive assessment including the Timed Get
Up and Go screening.
The most important risk
factor for falling is a
history of falls, so ask
every time!
Learning Objectives:
1. Define falls.
2. Identify a screening tool
for high-risk groups
Fall Facts: Incidence and Demographics
1. Falls are defined as an unintentional lowering to rest from a higher to a lower position,
not due to loss of consciousness or violent impact.
2. Falls often go unrecognized by health care professionals because they are not
routinely evaluated while taking patient history during the physical examination, and
most patients do not admit to falls for fear of losing independence.
3. The incidence of falls varies with age. Persons aged 65 to 79 years living at home have
a fall incidence of 30 to 40 percent. Persons aged 80 years and older living
at home have an increased incidence of falls of 50 percent.
4. If an older adult lives in a long-term care facility, their fall incidence rate is 50 percent.
5. Complications resulting from falls are the leading cause of death from injury in men
and women aged 65 and older.
6. An estimated one in three adults aged 65 years or older falls each year (Abolhassani
et.al 2006).
Older adults are at greater risk of falling due to:





Decrease in balance
Shuffling gait
Medication side effects
Difficulty transferring
Difficulty maneuvering around environmental hazards
Common Causes of Falls in the Elderly:









Neurological disorders
Cardiovascular disorders
Gastrointestinal disorders
Metabolic disorders
Musculoskeletal disorders
Psychological disorders
Medications
Falls are a leading cause of hip fractures.
Falls often result in long-term functional impairment.
57
CATASTROPHE: a mnemonic for obtaining a functional history after a fall or near fall
C Caregiver and housing
A Alcohol (including withdrawal)
T Treatment (i.e. medications )
A Affect (depression or lack of initiative)
S Syncope (any episodes of fainting)
T Teetering (dizziness)
R Recent illness
O Ocular problems
P Pain with mobility
H Hearing (necessary to avoid hazards)
E Environmental hazards
(Sloan, 1997)
You can learn about your patient’s functional health just by observing their walking style.




How does the patient walk into the room?
How does the patient move to the examining table?
Are there changes in posture?
Are there involuntary movements?
To administer the Timed Get Up and Go, give the following instructions:






Rise from the chair.
Walk to the line on the floor (10 feet).
Turn
Metabolic disorders
Return to the chair.
Sit down again.
References:



Abolhassania, F., Moayyeria, A., Naghavib, M., Soltania, A., Larijania, B., & Shalmanib, H.T.
(2006). Incidence and characteristics of falls leading to hip fracture in Iranian population.
Bone, 39, 408–413
Fuller, G.F. (2000). Falls in the elderly. American Family Physician, 61(7), 2159-2168.
Sloan, J.P. (1997). Mobility failure. In J.P. Sloan (Ed.), Protocols in Primary Care Geriatrics, (3338). New York: Springer.
58
Geriatric Gems and Palliative Pearls presents:
Frailty
by Kathleen Pace Murphy, PhD, MS, GNP-BC
Older adults at risk for frailty
include advanced age, chronic
disease, physical inactivity, poor
nutritional status, and
physical/psychological stress.
Read on ...

Frailty is an age related alteration in physiology and pathology that leads to vulnerability, loss of
physiological reserve, and a range of poor medical and functional outcomes (Bergman, Ferrucci,
Gurainki, et al, 2007).

Frailty prevalence is uncertain. Lekan (2009) reported a 3-7% prevalence in older adults aged 65 to 75
years. Newman Gottdiener, McBurnie, et al (2001) reported in the Cardiovascular Health Study a
prevalence of 25% in older adults over the age of 85 years. Research studies are utilizing different
definitions, measurements and cohorts of older adults (community vs. institutionalized) leading to
this variability.
Etiology

Frailty etiology includes an array of diseases such as malignancy, heart failure, COPD, dementia, stroke,
Parkinson’s disease, diabetes mellitus, hypothyroidism, depression, and rheumatic diseases.

Other etiologies include inflammatory and immune responses with elevated proinflammatory
biomarkers and clotting cascade activation; serum cortisol elevations, diminished vitamin D levels,
growth and sex hormones have all been indicated.
Assessment

The frailty index is one measurement used to assess this syndrome in the older adult (Fried, Tangen,
Walston, et al, 2001). An older adult must have at least 3 of the 5 indices.
Scoring is 0= robust, 1-2= pre-frail, and 3=frail.

The frailty indices include:

Shrinking: Unintentional weight loss of 10 pounds or more in the past year

Exhaustion: Presence of fatigue and tiredness

Strength: Weakness of grip strength

Slowness: Unsteady/ unbalanced gait

Low physical activity: Inactivity

If frailty is suspected, health care providers are encouraged to conduct a comprehensive geriatric
assessment. Assess the following components:
1. Functional history (i.e. recent falls, Get Up and Go, ADL's and IADL's)
59
2. Medication review (i.e. polypharmacy)
3. Ascertain visual and hearing impairments
4. Nutritional status (i.e. recent weight loss, eating difficulties, dietary habits)
5. Geriatric depression
6. Cognitive impairment
7. Social resources

Physical examination should include orthostatic blood pressure checks (supine, sitting and standing),
musculoskeletal strength testing, assessment of postural balance, core truncal strength, quadriceps
strength, proprioception, and lower extremity sensory impairment.
Intervention







Frailty is a syndrome which requires an interprofessional team approach and a comprehensive plan
of care.
Physical and occupational therapy are instrumental in providing a plan of care to improve gait,
muscle strength, and improve functional independence (i.e. activities of daily living).
Dietician consult will provide a nutritional assessment and plan of care to address dehydration,
inadequate caloric intake, and dietary counseling for various co-morbidities (i.e. diabetes mellitus,
renal disease).
Speech therapy consult will evaluate swallowing problems which may contribute to diminishing
weight.
Dental consult will evaluate dental caries, poor fitting dentures and other dental disease which
prevents the older adult from adequately eating.
Social work consult provides a social assessment and plan of care as it relates to patient and family
support, referrals to community agencies and financial resources.
Frailty is a prognostic indicator for poor clinical outcome. Requesting a Palliative Care Team consult,
when indicated, will provide additional resources such as the Chaplain and home health nurses who
can provide quality of life and comfort support for the aging adult.
References:




Bergman, H., Ferrucci, L. Gurainki, J., et al. (2007). Frailty: An emerging research and clinical
paradigm-issues and controversies. Journals of Gerontology, 64A (7), 731-737.
Fried, LP, Tangen, CM, Walston, J., et al (2001). Frailty in older adults: Evidence for a
phenotype. Journal of Gerontology: A Biological Science, Medical Sciences, 56A, M146-M156.
Lekan, D (2009). Frailty and other emerging concepts in the care of the aged. Southern Online
Journal of Nursing Research, 9(3).
Newman, A.B., Gottdiener, J.S., McBurnie, M.A., et al (2001). Associations of subclinical
cardiovascular disease with frailty. Journal of Gerontology: Medical Sciences, 56A (3), M158-M166.
60
Geriatric Gems and Palliative Pearls presents:
Geriatric Depression
by Jennifer Larson, MSE, and Nasiya Ahmed, MD
Depression in older adults often goes
undiagnosed, yet is one of the most common
psychological disorders among older adults.
Health care providers may incorrectly believe that
depressive symptoms are a normal response to
older adult life experiences.
This Gem provides information on recognizing
and screening for geriatric depression.
Depression can and should be treated.
Depression:
 Amplifies disability/pain;
 Lessens quality of life and increases mortality;
 Results in increasing office and emergency department visits;
 Results in more prescription and over-the-counter medication use;
 Leads to increased alcohol and drug use; and,
 Increases the length of hospital stays.
Learning Objectives:
1. Recognize the existence of geriatric depression.
2. Identify a common screening tool for geriatric depression.
Depressive symptoms may present differently in older adults. It may be exemplified by:








Memory problems
Confusion
Aches or pains, headaches, digestive problems
Sleep disruptions
Changes in appetite
Irritability
Delusions and hallucinations
Social withdrawal
Symptoms are often described in terms of physical characteristics. Many older adults are
reluctant to discuss feelings of sadness, loss of interest or grief. According to a Mental Health
America survey, more than half of adults aged 65 and over have very little or no knowledge
about depression.
61
The Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold black indicate depression. Score one point for each bolded answer.
A score greater than five points is suggestive of depression. A score greater than or equal to 10 points
is almost always indicative of depression. A score greater than five points should warrant a follow-up
comprehensive assessment.
Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M.B., & Leirer, V.O. (1983). Development and validation of a
geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.
References:



Conwell, Y., & Brent, D. (1995). Suicide and aging. I: patterns of psychiatric diagnosis. International
Psychogeriatrics, 7(2), 149-164.
National Mental Health Association. (1996). American attitudes about clinical depression and its
treatment. Alexandria, VA.
Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M.B., & Leirer, V.O. (1983). Development
and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric
Research, 17, 37-49.
62
Geriatric Gems and Palliative Pearls presents:
Elder Abuse and Mistreatment
by Kathleen Pace Murphy, PhD MS, GNP-BC
Learning Objectives:
You may be the one person
who can help an older adult
who has been abused or
mistreated.
1. Identify three types of elder abuse or
mistreatment.
2. Identify risk factors for elder abuse or
mistreatment and neglect.
3. List three screening questions.
National Prevalence of Elder Abuse

Millions of Americans age 65 or older have been abused or injured, exploited, or otherwise
mistreated by a caregiver or someone they trust.
 Frequency of elder abuse estimates range from two to 10 percent based on various
sampling and survey methods and case definitions.
 Only one in 14 incidents of elder abuse and mistreatment in domestic settings, excluding
self-neglect, are brought to the attention of authorities.
 Most victims are female. (65.7 %)
 Many victims (42.8 %) are 80 years or older.
 The vast majority of elder abuse and mistreatment cases occurred in domestic settings
(89.3%).
 Self-neglect is the most commonly reported form of elder abuse or mistreatment and is
increasing.
 The mortality of older adults who are abused or neglected is about 30 percent higher in
abused than non-abused older adults, as demonstrated in a landmark study by Lachs and
colleagues in 1998.
 In older adults who self-neglect, African-American older adults had a higher mortality rate
compared to whites.
Often,
adults
are notcorrelation
forthcoming
with information
about abuse,
mistreatment
or neglect.
 older
There
is a strong
between
low social support
and previous
traumatic
events and
Frequently,
elder abuse and mistreatment is committed by someone close to the older adult; it could
abuse.
even be the individual that brought the older adult to the clinician. Since only a small percentage of
abuse and mistreatment cases are reported, the American Medical Association recommends that
patients in all clinical settings be screened for elder abuse and mistreatment. This includes a
confidential interview alone with the patient in most cases.
If a clinician suspects elder abuse, mistreatment, neglect, self-neglect or exploitation by caretakers,
he or she has a duty to report it to the authorities. Not reporting suspected abuse and mistreatment,
depending on state law, may result in charges being filed against the health care provider.
63
Types of Abuse:








Physical Abuse
Sexual Abuse
Self-Neglect
Caregiver Neglect
Psychological or Emotional Abuse
Abandonment
Financial or Material Exploitation
Undue Influence
Risk Factors:








Age
Dependency
Functional Decline
Personality Disorders
Isolation
Excessive Use of Drugs or Alcohol
Poverty
Cognitive Impairment
Screening is as simple as asking three questions:
1. Do you feel safe where you live?
2. Who prepares your food?
3. Who handles your money?
A vague response to any of these questions should prompt further investigation.
References:






Acierno, R., Hernandez, M.A., Amstadter, A.B., et al. (2010). Prevalence and correlates of
emotional, physical, sexual and financial abuse and potential neglect n the United States:
the National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292-297.
Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. (2003).
Washington, DC: National Research Council Panel to Review Risk and Prevalence of Elder
Abuse and Neglect.
Lachs, M. S., & Pillemer, K. (2004). Elder Abuse, The Lancet, 364, 1192-1263.
Lachs, M. S., Williams, C. S., O’Brien, S., Pillemer, K. A., & Charlson, M. E. (1998). Mortality of
elder mistreatment. Journal of the American Medical Association 280(5), 428−432.
Pillemer, Karl, & David Finkelhor. (1988). The prevalence of elder abuse: A random sample
survey, The Gerontologist, 28, 51-57.
Teaster, P.B. (2000). A response to the abuse of vulnerable adults: The 2000 survey of statue
adult protective services. Retrieved from
http://apsnetwork.org/Resources/docs/2002StateSurvey.pdf.
64
Geriatric Gems and Palliative Pearls presents:
Geriatric Medication Review
by Kathleen Pace Murphy, PhD MS, GNP-BC
Learning Objectives:
Medications affect older
adults differently due to
physiological changes.
1. Define polypharmacy.
2. Review Beer’s Criteria.
Polypharmacy—the inappropriate use of multiple Medications
It is not always easy to keep track of which drugs are treating what and which drugs are causing
which side effects. It is always important to be able to match prescribed medications to the patient's
correlating diseases. As older adults age, there are physiologic changes that can affect the
pharmacodynamics of medications. It is important to ascertain if prescribed medications are
beneficial, or at least are doing more good than harm.
Because of the impact associated with polypharmacy, it is critical to review medications during
every patient visit for optimal medication management. As a health care provider, it is your
responsibility to utilize your pharmacology knowledge to understand potential adverse drug effects.
Asking the right questions is always a good start.
Medication Review Questions to Ask
Questions to ask patients during history
1. Please tell me what prescribed medications you are on and for what problem?
2. Please tell me about medications that you buy for yourself from the grocery store, drug
store or your favorite discount store? Do you ever travel to a foreign country and buy
medications there? If so, which medications did you purchase?
3. Are you using eye drops, creams, lotions or other topical medications that I should know
about? Has your eye doctor or dentist prescribed any medications for you?
4. Lastly, I noticed that you also have the following medical problems but are not receiving any
medications for them - is that correct?
65
Questions clinicians must ask of themselves
The Hamdy Questions
1. Is the indication for which the medication was originally prescribed still present?
2. Are there duplications in drug therapy (i.e., same class)? Are simplifications possible?
3. Does the regimen include drugs prescribed for an adverse reaction? If so, can the original
drug be withdrawn?
4. Is the present dosage likely to be subtherapeutic or toxic because of the patient's age and
renal status?
5. Are any significant drug-drug or drug-illness interactions present?
Prescribing Principles and Older Adults
For Potentially Inappropriate Medications, Look to Beers Criteria





"Start Low and Go Slow"- give the lowest possible starting dose and titrate slowly upward.
Discontinue inappropriate therapy-Do not be reluctant to stop unnecessary medications.
Explore non-pharmacologic treatments– Try a trial before prescribing new medications.
Prescribe safe drugs-Identify potentially inappropriate medications using the Beers Criteria Index.
Assess renal function-estimate function with Cockcroft-Gault equation.
Optimize adherence—provide written and verbal patient education and consider how you prescribe
medications. Consider once-a-day dosing, medications around meal times (associated with an activity),
medications that have a dual purpose (i.e. mirtazepine—assists with anti-depression, but also helps with
sleep and stimulating appetite), and encourage the patient to utilize a weekly medication tray to prevent
errors in medication administration.
References:

Pham, C. B., & Dickman, R. L. (2007). Minimizing adverse drug events in older patients.
American Family Physician, 76(12), 1837-1844.
66
Geriatric Gems and Palliative Pearls presents:
Dementia
by Nasiya Ahmed, M.D..
Often, dementia is first discovered in the
hospital, when a patient is not able to
compensate for his/her memory loss in an
unfamiliar environment.
What happens when you don’t screen for
dementia . . . ?
Read on ...

Only 1/3 of patients with dementia have the diagnosis documented in their medical record

Dementia and its sequelae is the fourth leading cause of hospitalization.

1st screen for delirium using CAM before screening for dementia. Screen for dementia using the
Mini Mental Status Exam (adjust for age and education) or the Mini-Cog (but do not screen if you
suspect delirium) link
http://www.pogoe.org/AngelUploads/applications/Dementia/Content/mmse_va.html

Ask questions in a simple yes/no format

Do not routinely ask orientation questions, unless a change in mental status is suspected – this
may agitate the patient

Look for signs of non-verbal communication when examining the patient

Do not limit pain medications – these patients are not at increased risk for addiction, opioids
induced delirium, or somnolence, but are less likely to ask for pain meds
Delirium
Dementia
Onset
Acute
Chronic
Mood
Fluctuates
Stable
Course
May respond to treatment
Deterioration over time
Diagnosis
CAM
MMSE or Mini-Cog
Self-Awareness
May be aware of changes in
cognition; fluctuates
Likely to hide or be unaware of
cognitive deficits
67
Links:

Merck: Introduction to Delirium and Dementia
http://www.merckmanuals.com/professional/sec17/ch223/ch223a.html?qt=delirium%20and%2
0dementia&alt=sh
References:





Fields SD, MacKenzie CR, Charlson ME, et al. “Cognitive Impairment: Can it Predict the Course of
Hospitalized Patients?”. JAGS. August 1986; 34(8):579-85.
Folstein MF, Folstein SE, McHugh PR (1975). “Mini-mental state”. A practical method for grading
the cognitive state of patients for the clinician”. Journal of Psychiatric Research 12 (3): 189–98.
Crum RM, Anthony JC, Bassett SS, Folstein MF (May 1993). “Population-based norms for the
Mini-Mental State Examination by age and educational level”. JAMA 269 (18): 2386–91.
Morrison, R. Sean, Siu, Albert L. “Survival in End-Stage Dementia Following Acute Illness”. JAMA.
July 2000; 284(1).
Feldman, HH, Jacova, C, Robillard, A. “Diagnosis and Treatment of Dementia”. CMAJ. March
2009; 178(7):825-36
68
Geriatric Gems and Palliative Pearls presents:
Dementia in the Hospitalized Elderly
by Nasiya Ahmed, M.D..
Only 1/3 of patients with dementia
have the diagnosis documented in
their medical record; dementia is
often first diagnosed in the hospital,
when a patient is not able to
compensate for his memory loss in an
unfamiliar environment.
Read on ...

Screen for delirium before dementia . . . practice delirium prevention

Use the Mini Mental Status Exam (adjust for age and education) or the Mini-Cog to screen
for dementia

Establish a baseline - talk to the patient’s family, neighbors, physicians, or nursing home staff

Ask questions in a simple yes/no format and do not routinely ask orientation questions, unless a
change in mental status is suspected – this may agitate the patient

Look for signs of non-verbal communication when examining the patient

Do not limit pain medications – these patients are not at increased risk for addiction, opioidinduced delirium, or somnolence, but are less likely to ask for pain meds

Have a thorough discharge plan: provide a home safety evaluation to ensure a safe environment,
a KELS (Kohlman Evaluation of Living Skills) evaluation (done by OT) to determine ability to live
independently, and a detailed follow-up plan of care
If the patient has dementia, do not stop treatment. Ask for a geriatric consult!
References:


Lyketsos, Constantine G, Sheppard, Jeannie-Marie E, Rabins, Peter V. “Dementia in Elderly
Persons in a General Hospital”. Am J Psychiatry. 2000; 157:704-7
Bynum, Julie PW, Rabins, Peter V, Weller, Wendy, et al. “The Relationship Between a
69
Dementia Diagnosis, Chronic Illness, Medicare Expenditures, and Hospital Use”. JAGS.
February 2004; 52(2):187-194.
Geriatric Gems and Palliative Pearls presents:
Preventing Polypharmacy
by Susan Gorman, MSN, RN, GNP
30% of hospital admissions in elderly
can be linked to drug related effects,
and polypharmacy is the 5th leading
cause of death for hospitalized
elders. Underlying Dementia
Read on ...

Defined as >4 prescription medications or >3 new medications in a 24-hour period.

Always check medication regimen for drug-drug interactions.

Before initiating any treatment, make sure that the symptom requiring treatment is not a side
effect of another drug.

Use non-pharmacologic treatment first.

Check drug levels (remember, toxicity can occur at even normal therapeutic levels) and always
adjust for creatinine clearance.

When discharging a patient, provide a written medication list and if necessary, instructions
about medication changes (new medications, discontinued meds, meds that need monitoring).
Helpful Hints for Common Drug Classes
Antibiotics
Anti-Emetics
Anti-Histamines
Benzodiazepines
Coumadin
Diuretics
Iron
NSAIDS
Pain Medication
PPIs
Fluoroquinolones can cause some mental status changes, dose for
creatinine clearance
Zofran is preferred to the more sedating older anti-emetics
Can cause confusion, urinary retention, constipation, somnolence
Avoid if possible, but do NOT stop suddenly
To determine accurate starting doses try using www.warfarindosing.org
Beware of dehydration, hyponatremia, and hypotension
Dose only once a day and for no more than 6 months at a time, beware of
constipation
Increased risk of renal failure and GI bleed in elders
Stay away from using synthetic drugs such as Darvocet and Demerol
Decreased medication absorption and increased risk for clostridium–
make sure the patient really needs this medication
References:


Beers Criteria, 2003
Chutka, Darryl S. “Drug Prescribing in the Elderly”. Mayo Clinic Proceedings. July 1995:vol 70,
685-93
70
Highlight this text and just start typing to replace this with your journal entry.
Day 1
Many physicians have
preconceived ideas
about caring for older
adults. Write a
“surprise” or “ah ha
moment” that you did
not expect from caring
for an older adult.
71
Highlight this text and just start typing to replace this with your journal entry.
Day 2
Elder abuse, first
described in 1975 as
“granny battering,” affects
2- 10 percent of the aging
population in the United
States. According to the
best available estimates,
between one and two
million Americans aged 65
years and older have been
injured, exploited or
otherwise mistreated
by someone on whom
they depended on for care
and protection. Health
care professionals in a
variety of settings are
encountering increasing
numbers of older victims
and their perpetrators.
Reports of elder abuse
and mistreatment to
Adult Protective Services
and law enforcement
are rising.
1) In your journal today,
please reflect on
elder abuse and
mistreatment
and provide us
your thoughts.
2) It has been
recommended that
management of elder
abuse and
mistreatment should
be done through an
interprofessional team
approach. How would
72
you manage an elder
self-neglect patient?
Highlight this text and just start typing to replace this with your journal entry.
Day 3
1. Describe a patient you
have worked with over
the past three days who
was on multiple
medications, perhaps
experiencing
polypharmacy. What did
you learn?
2. The Pharmacist is an
integral part of the
interprofessional team.
Share your thoughts on
how the Pharmacist
could be instrumental in
your practice and how
he or she can help care
for medically complex
older adults
73
Highlight this text and just start typing to replace this with your journal entry.
Day 4
1. Write about a patient
you have seen this week
with dementia. As a
physician, what will be
your patient care
challenges and how
will you work with the
family caregivers?
2. The Baby Boomer
generation is growing
older. Some call the
aging of America a
"health care tsunami."
As a physician, how will
you manage large
percentages of older
adults in your practice?
Do you have any initial
thoughts or strategies on
how to effectively
manage these complex
medical patients? Will
you use an
interprofessional team?
How could advanced
practice nurses or
physician assistants
help you with the
chronic management of
these patients?
74
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Day 5
Describe a patient that
you worked with during
the last five days that you
thought might be socially
isolated. What risk
factors were present that
make you suspicious of
social isolation? How was
it addressed, or in
retrospect, how
do you wish you had
addressed it?
How would you describe
the patient’s social
network and social
cohesion? Was he/she
experiencing social
exclusion and/or social
isolation? Would a
referral to another
member of the
interprofessional team be
appropriate?
75
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76