Hazzard's Geriatric Medicine and Gerontology

Cover
Copyright
Contents
Contributors
Foreword
Preface
Part I: Principles of Gerontology
Chapter 1: Biology of Aging and Longevity
What Is Aging?
Aging as a Coordinated, Malleable Process
Key Themes from Studies of Invertebrate Models
Molecular Leads for Further Study
Delayed Aging in Mice and Rats
Caloric Restriction
Methionine-Restricted Diets
Single-Gene Mutations That Extend Mouse Lifespan
Stress Resistance and Aging
Genetic Approaches to Analysis of Aging in Humans
Models of Accelerated Aging
Aging, Cellular Senescence, Telomeres, and Cancer
Aging Research and Preventive Medicine
Antiaging Research: Social Obstacles and Ethical Concerns
Acknowledgments
Further Reading
Chapter 2: Genetics of Age-Dependent Human Disease
The Biological Nature of Intrinsic Aging
Why Aging Occurs
Mechanisms of Aging
Oxidative Damage
DNA Damage and Repair
Telomeres
Mitochondria
Proteins
The Relationship Between Normal Aging and Disease
Genetic and Nongenetic Effects on Aging
Genetics of Human Longevity and the Implications for Age-Dependent Disease
Malleability of the Human Aging Process
Further Reading
Chapter 3: Immunology and Aging
General Aspects of Immunosenescence
Effect of Aging on Different Cell Types
Hematopoietic Stem Cells and Lymphoid Progenitor Cells
Hematopoiesis
Age-Related Changes of Hematopoiesis
Involution of the Thymus
Innate Immune System
Components and Functions of the Innate Immune System
Age-Related Changes of the Innate Immune System
Adaptive Immune System
Components and Principal Functions of the Adaptive Immune System
T Lymphocytes
Age-Related Changes in the T Cell Compartment
Age-Related Changes of T Cells on the Single Cell Level
Factors That Accelerate Age-Related Changes in the T Cell Pool
B Lymphocytes
Age-Related Changes of the B Cell Compartment
Age-Related Defects in Interactions Between T and B Cells
Cutaneous Immune System
Mucosal Immune System
Clinical Implications of Immunosenescence
Infectious Diseases
Immunosenescence and Cancer
Immunological Interventions
Vaccines
Recommendations for Vaccination
Improving Vaccination Efficacy
Caloric Restriction
Additional Measures to Improve Immune Function
Conclusion
Further Reading
Chapter 4: Inflammation and Aging
Inflammation in the Context of Aging and Adverse Health Outcomes
Molecular Biology of Inflammation
Inflammatory Signal
Inflammatory Message
Why Are Older Adults More Likely to Have Higher Levels of Inflammatory Cytokines?
Chronic Inflammation Contributes Directly to Pathophysiological Changes in Older Adults
Chronic Inflammation Contributes to Chronic Disease in Older Adults
Potential Clinical Utility of Inflammatory Markers and Anti-Inflammatory Interventions
Summary: Does Chronic Inflammation Contribute to an Altered Biological Platform for Late-Life Vulnerability?
Further Reading
Chapter 5: Demography and Epidemiology
Introduction
Demographics
Aging of the Population in the United States
Aging of the Population and Life Expectancy Around the World
Life Expectancy at Different Ages
Extreme Longevity
Demographic Characteristics of the Aging Population
Employment
Mortality
Leading Causes of Death
Mortality Rates
Disease Status
Prevalence of Common Diseases
Co-occurrence of Multiple Chronic Conditions
Health Care Utilization
Physician and Ambulatory Visits
Causes of Hospitalization
Cancer
Dementia
Disability
Measures of Function and Disability
Disability as an Indicator of Health Status and Prognosis
Prevalence of Disability
Risk Factors for Disability
Recovery from Disability
Types of Disability Progression
Physical Performance Measures
Trends in Disability
Aging of Individuals with Life-Long Disabilities
Behavioral Risk Factors
Acknowledgment
References
Chapter 6: International Gerontology
Implications of Global Population Aging for Health and Health Care
Overview
Demography of the Aging Global Population
Effect of Population Aging on Health and Health Care
International Comparisons
America: United States
Type of Health Care System
Overall Organization and Services Available for Older Adults
Peculiarities
Difficulties and Solutions for a Typical Geriatric Patient
America: Canada
Type of Health Care System
Overall Organization and Services Available for Older Adults
Pecularities
Difficulties/Solutions for a Typical Geriatric Patient
Europe: Iceland
Type of Health Care System
Overall Organization and Services Available for the Elderly
Peculiarities
Difficulties/Solutions for a Typical Geriatric Patient
Europe: Norway
Type of Health Care System
Overall Organization and Services Available for Older Persons
Hospital Services
Community Services
Peculiarities
Difficulties/Solutions for a Typical Geriatric Patient
Europe: United Kingdom
Type of Health Care System
Overall Organization and Services for Elderly Persons
General Medical Practices
Hospitals
Newer Models of NHS Provision
Private Providers
Local Government Authorities
Peculiarities
Difficulties/Solutions for a Typical Geriatric Patient
Europe: France
Type of Health Care System
Overall Organization and Services Available for Elderly Persons
Paying For Long-Term Care
Integrating Health and Social Care
Increasing Quantity and Quality of Services
Increasing Empowerment of Older Persons
Peculiarities
Difficulties/Solutions for a Typical Geriatric Patient
Europe: Italy
Type of Health Care System
Overall Organization and Services Available for Elderly Persons
Peculiarities
The Difficulties/Solutions for a Typical Geriatric Patient
Asia: Japan
Type of Health Care System
Overall Organization and Services Available for Elderly Persons
Peculiarities
Difficulties/Solutions for a Typical Geriatric Patient
Oceania: Australia
Type of Health Care System
Overall Organization and Services Available for Elderly Persons
Difficulties/Solutions for a Typical Geriatric Patient
Developing Countries: China
Type of Health Care System
Overall Organization and Services Available for Elderly Persons
Peculiarities
Difficulties/Solutions for a Typical Geriatric Patient
Need for Standard Assessment of Health Needs and Services Across Countries
InterRAI
Experiences with InterRAI
Ontario’s Experience
European Union Experience
Conclusion
Further Reading
Chapter 7: Psychosocial Aspects of Aging
Psychosocial Factors, Health, and Quality of Life
Social Relationships
Stress and Distress
Stressful Life Events
Biological Consequences of Stress
Personality, Affect, and Health
Psychosocial Aspects of Quality of Life and Valuation of Life
Conclusion
Further Reading
Chapter 8: General Principles of Pharmacology
Introduction
Pharmacokinetics
Bioavailability
Distribution
Clearance
Hepatic Drug Clearance
Renal Clearance
Glomerular Filtration
Tubular Secretion
Tubular Reabsorption
Nonhepatic, Nonrenal Clearance
Half-Life
Summary of Pharmacokinetic Changes with Aging
Pharmacodynamics
Mechanisms of Aging Pharmacodynamic Changes
Main Pharmacodynamic Changes with Aging
Cardiovascular System
Central Nervous System
Pharmacogenetics and Pharmacogenomics
Adverse Drug Reactions
Frailty and Pharmacology
Pharmacokinetics and Frailty
Pharmacodynamics and Frailty
Adverse Drug Events and Frailty
Drug Development and Regulation
Phase I Studies
Phase II Studies
Phase III Studies
Phase IV Studies
Pharmacoepidemiology
Advantages of Pharmacoepidemiologic Studies
Limitations of Pharmacoepidemiologic Studies
Pharmacoeconomics
Conclusion
Further Reading
Chapter 9: Preventive Gerontology: Strategies for Optimizing Health Across the Life Span
Introduction
Behaviors with Adverse Health Consequences
Tobacco Use
Substance Abuse
Alcohol
Illicit Drugs
Prescription Drug Misuse
Behaviors Increasing Risk of Injury
Head Trauma and Risk for Alzheimer’s Disease
Ultraviolet Light and Risk for Skin Cancers and Cataracts
Prevention of Age-Related Macular Degeneration
Excessive Noise and Risk for Hearing Loss
Sleep Deprivation and Motor Vehicle Crash Fatalities
Cell Phone Use While Driving and Motor Vehicle Crashes
Obesity
Taking a Proactive Approach to Personal Health and Well-Being
Nutrition
Physical Activity
Social Connections
Cognitive Activity
Napping
Health Care
Blood Pressure Evaluations
Lipid Evaluations
Glucose Monitoring
Cancer Screening
Depression Screening
Immunizations for Pneumococcal Pneumonia and Influenza
Aspirin for Primary Prevention of Myocardial Infarction
Low to Moderate Dose Aspirin for Reduction of All-Cause Mortality in Women
Conclusion
Further Reading
Part II: Principles of Geriatrics
Chapter 10: Evaluation, Management, and Decision Making with the Older Patient
Presentation
Evaluation
Reason for Performing a Test or Evaluation
Issues in Assessing and Interpreting Evaluation Results
Definition of Normal in Older Persons
Assessing Diagnostic Test Accuracy
Ability of Tests to Distinguish Patients Who Do and Do Not Have the Disease or Condition
Deciding Whether a Diagnostic Test Should Be Performed in a Specific Patient
History/Interview
Setting and Source of Information
Ascertainment of Goals and Preferences
Components of the History and Interview
Review of Symptoms and Syndromes
Assessment of Mood, Affect, and Cognition
Physical Examination
Functional Examination
Interpreting Examination Findings
Selecting Components of the Physical Examination to Perform
Laboratory and Ancillary Tests
Management
Further Reading
Section A: Assessment
Chapter 11: Principles of Geriatric Assessment
Geriatric Assessment by the Individual Clinician
Components of the Geriatric Assessment
Visual Impairment
Hearing Impairment
Malnutrition/Weight Loss
Urinary Incontinence
Balance and Gait Impairments and Falling
Polypharmacy
Cognitive Assessment
Affective Assessment
Assessment of Function
Assessment of Social Support
Economic Assessment
Environmental Assessment
Spirituality
Advance Directives
A Strategic Approach to Geriatric Assessment
Comprehensive Geriatric Assessment
Components of Comprehensive Geriatric Assessment
Data Gathering
Discussion among Team
Development of the Treatment Plan
Implementation of the Treatment Plan
Monitoring
Revising the Treatment Plan
Effectiveness of Comprehensive Geriatric Assessment
Geriatric Evaluation and Management Units
Inpatient Consultation
Posthospital Discharge Assessment and Management
Outpatient Consultation
In-Home Assessment
Lessons Learned from Geriatric Assessment
Further Reading
Chapter 12: Mental Status and Neurological Examination in Older Adults
The Neurology of Aging
What Is Normal Neurological Aging?
Age-Related Changes in the Neurological Examination
Cognitive Changes
Changes in Cranial Nerve Function
Changes in Motor Function
Changes in Sensory Function
Changes in Gait and Station
Changes in Deep Tendon Reflexes
The Neurological History
Neurological History from the Patient
Neurological History from an Informant
Mental Status Examination
Observational Assessment
Level of Consciousness
Appearance
Emotional State and Affect
Behavior
Movement
Speech and Communication
Cognitive Assessment
Attention
Memory
Language
Orientation
Abstraction
Judgment and Problem Solving Abilities
Visuospatial Skills
Calculation
Executive Function
Word List Generation
Informant Assessment
Neuropsychiatric Assessment
Thought Form
Thought Content
Insight
Behavior and Personality
Neurological Examination
Cranial Nerve Examination
Cranial Nerve I: Olfactory
Cranial Nerve II: Optic
Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens
Cranial Nerve V: Trigeminal
Cranial Nerve VII: Facial
Cranial Nerve VIII: Cochlear and Vestibular
Cranial Nerves IX and X: Glossopharyngeal and Vagus
Cranial Nerve XI: Accessory Nerve
Cranial Nerve XII: Hypoglossal
Motor System Examination
Muscle Bulk
Muscle Tone
Strength
Abnormal Movements
Sensory Examination
Light Touch
Pain and Temperature
Vibration
Position
Cerebellar Examination
Gait and Station
Muscle Stretch Reflexes
Pathologic and Primitive Reflexes
Higher Cortical Function
Neurovascular Assessment
Conclusion
Acknowledgments
References
Chapter 13: Assessment of Decisional Capacity and Competencies
Introduction
Definition of Decisional Capacity
Legal and Practical Aspects in Determining Decisional Capacity
Process of Determining Capacity
Traditional Mental Status Tools
Tests of Decisional Capacity
Capacity to Make Specific Decisions
Medical Decisions
Problems of Self-Care
Problems of Finances
Temporary Loss of Decisional Capacity
Consent Versus Assent
Informed Consent in Research
Further Reading
Chapter 14: Principles of Screening in Older Adults
General Framework for Making Informed Cancer Screening Decisions
Estimate Life Expectancy
Estimate Benefits of Cancer Screening
Estimate Harms of Cancer Screening
Integrate Patient Values and Preferences
Application of Screening Principles to Specific Cancers
Breast Cancer
Risk of Dying of Breast Cancer
Benefits of Breast Cancer Screening
Harms of Breast Cancer Screening
Recommendations
Colorectal Cancer
Risk of Dying of Colorectal Cancer
Benefits of Colorectal Cancer Screening
Harms of Colorectal Cancer Screening
Recommendations
Cervical Cancer
Risk of Dying of Cervical Cancer
Benefits of Cervical Cancer Screening
Harms of Cervical Cancer Screening
Recommendations
Other Cancers
Screening for Noncancerous Diseases
Further Reading
Section B: Organization of Care
Chapter 15: Health Care System
Introduction
The Elements of the System
Providers
Patients and Caregivers
Insurers
Public Health Insurance
Private Health Insurance
Medicare Advantage
Supplemental Health Insurance
Long-Term Health Insurance
Medicare Part D
Regulators
Care Management
Performance of the System
Role of Primary Care Clinicians
Improving the Health Care System
Chronic Care Model
Top–Down Organizational Change
Bottom–Up Change
Role of Academic Health Centers
Recent Quality Improvement Initiatives
Policy-Driven Initiatives
Provider-Driven Initiatives
Conclusion
Further Reading
Chapter 16: Transitions
Introduction
Transitions Traffic and Transitions Quality
Predictors of Problematic Transitions
Innovations in Transitional Care
Roles and Responsibilities
Strategies for Excelling at Transitional Care
Special Cases of Care Transitions
Educating Professionals in Care Transitions
Summary
Further Reading
Chapter 17: Acute Hospital Care
Hospital Admission
Reasons for Admission for Geriatric Patients
Admission Screening
Communication with Family and Primary Care Providers
Medication Reconciliation
Identify Frailty
Functional Screen
Dementia Screen
Hospital Stay
Common Problems in Hospitalized Elderly Patients
Delirium
Immobility and Falls
Nutrition
Preventing Nosocomial Infections
Hospital-Acquired Urinary Tract Infections
Hospital-Acquired Pneumonia
Clostridium difficile
Infection Control
Venous Thromboembolism Prophylaxis
Patient Safety
Palliative Care
Hospital Discharge and Care Transitions
Models of Hospital Care and the Elderly Patient
Hospitalist
Acute Care of the Elderly Units
Stroke Units
Further Reading
Chapter 18: Emergency Department Care
Epidemiology
Pathophysiology and Presentations
Evaluation
Management
Medication
Processes and Environment
Prevention
Accessing Vulnerable Populations
Prevention of Post-ED Decline
Special Issues
Emergency Medical Services
Geriatricians and the ED
The Emergency Department’s Relationship with Long-Term Care
Alternatives to Hospitalization
Disaster Planning
Conclusions
Further Reading
Chapter 19: Critical Care
Age-Related Changes in Physiology
Common Admitting Diagnoses
Associated Conditions That May Complicate ICU Care
Dementia and Delirium
Outcomes of Intensive Care
Caregiver Outcomes
Toward Improving Outcomes of Intensive Care in the Elderly
Further Reading
Chapter 20: Subacute Care
Definition of Subacute Care
Subacute Care Patients
Subacute Care Physicians
Role of Advanced Practice Clinicians
Subacute Care Regulations
Defining Quality in Subacute Care
Admitting a Subacute Patient: the Hospital Perspective
Admitting a Subacute Patient: the Facility Perspective
Case 1: Transition of Care Issues in the First 24 Hours
Patient/Family/Staff Interactions
Physician’s Role in Rehabilitation
Case 2: Importance of Communication in Subacute Care
Physician’s Role in Family Meetings
Medical Management in the Subacute Setting
Pain Management
Urinary Incontinence and Catheters
Swallowing Issues
Falls
Pressure Ulcers
Medication Issues
Case 3: Issues in How Medications Are Ordered
Dealing with Complications of the Acute Hospital
Acute Medical Problems in Subacute Care
Advance Directives and End-of-Life Issues
Discharge Planning in Subacute Care
Risk Management in Subacute Care
Subacute Facility Reimbursement
Reimbursement for Physicians
Subacute Care as a Safety Net
Further Reading
Chapter 21: Nursing Facility Care
Regulatory Issues
Resident Assessment Instrument
Nursing Facility Attending Physician
Nursing Facility Personnel
Practice Organization
Quality of Medical Care
Addressing Geriatric Syndromes
Health Maintenance
Behavioral Symptoms
Urinary Incontinence
Polypharmacy and Medication Errors
Falls
Altered Nutritional Status
Pressure Ulcers
Palliative Care
Managing the Acute Change of Condition
Acute Care/Nursing Facility Interface
Infections
Role of the Medical Director
Summary
Further Reading
Chapter 22: Community-Based Long-Term Care and Home Care
Semantic Challenges of CBLTC
Who Receives CBLTC?
Who Provides and Pays for CBLTC?
Is CBLTC Effective?
Innovations
Trends
Conclusion
Further Reading
Chapter 23: Rural Aging
Demography of Rural Aging
Health Status of Rural Elders
Ethnic and Minority Rural Aging
Rural Health Clinics
Rural Hospitals and Long-Term Care
Technology and Rural Aging
Summary
Further Reading
Section C: Special Management Issues
Chapter 24: Appropriate Approach to Prescribing
Epidemiology of Drug Therapy
Measuring the Quality of Drug Prescribing in Older Persons
Prescribing Cascades
Drug-Induced Parkinsonism
Acetylcholinesterase Inhibitors and Anticholinergic Therapy
Underuse of Beneficial Therapy
Example of Underuse of Beneficial Therapy: Hypertension
Example of Underuse of Beneficial Therapy: Beta-Blocker Therapy Postmyocardial Infarction
Example of Underuse of Beneficial Therapy: Osteoporosis
Example of Underuse of Beneficial Therapy: Opioid Analgesia and Cancer Pain
Example of Underuse of Beneficial Therapy: Warfarin in Atrial Fibrillation
Special Considerations Regarding Drug Therapy in the Long-Term Care Setting
Antipsychotic Therapy in the Long-Term Care Setting
Risk of Adverse Drug Events in the Long-term Care Setting
Deficiencies in Information About Drug Therapy in Older Adults
Inclusion of Older Persons in Clinical Trials
Using Alternative Study Designs to Study Drug-Related Risks and Benefits
Systematic Reviews to Guide Therapeutic Decision Making
Policy Issues Related to Drug Therapy in Older Adults
Cost-Related Adherence
Limited Manufacturing of Low-Dose Formulations of Recommended Drug Therapy
Medication Reconciliation
Practical Approach to Prescribing Medications to Older Persons
Review Current Drug Therapies
Discontinue Potentially Unnecessary Therapy
Consider Nonpharmacologic Approaches
Reduce the Dose
Summary
Further Reading
Chapter 25: Complementary and Alternative Medicine
Introduction
Current Use and Concerns with Cam Modalities
Use of Cam Modalities for Disorders of the Elderly Patient
Depression, Anxiety Disorders, and Insomnia
Osteoarthritis, Degenerative Disk Disease, and Chronic Pain
Dementia
Benign Prostatic Hyperplasia
Conclusion
Further Reading
Chapter 26: Team Care
Collaboration and the Importance of “Interdisciplinarity”
Principles of Successful Teamwork
Teams and Team Member Rules
The Well-Planned Meeting
Suggested Structure for Regular Health Care Team Meetings
Skills of Different Professionals on Teams
Effective Team Communication
Valuing Diversity
Team Conflict
Emphasizing Care Goals and Interdisciplinary Care Planning
Interdisciplinary Care Planning
Summary
Further Reading
Chapter 27: Social Work
Key Roles for Geriatric Social Workers
Direct Service Provision
Linkage Roles
Practice Issues with Populations Served
Cultural Diversity
The Poor
Immigrants and Refugees
Abused and Neglected
Mentally Ill
Cognitively Impaired
Older GLBT
Substance and Alcohol Abusers
HIV/AIDS Victims
Where Social Workers Practice
Nursing Homes
Community Mental Health Facilities
Hospitals and Health Care Facilities
Hospice
Home Care
Summary
Further Reading
Chapter 28: Self-Management of Health Behavior in Geriatric Medicine
Introduction
Defining Self-Management
Health Behaviors Embodied in Self-Management
Conceptual Framework for Self-Management
Commonsense Model of Self-Regulation
Conceptual Framework for Understanding the Complexities of Self-Management
Facilitating Factors in Self-Management
Inhibitory Factors in Self-Management
Operating on Automatic Pilot
Slips, Relapses, and Intergoal Conflict
Toxic Environments
Costs and the Problems of Distant Benefits
Knowledge, Skills, and Strategies
Lessons From the Literature on Self-Management
Partnerships in Self-Management: A Description and Conceptual Rationale
Traditional Versus Collaborative Patient Care
The Conceptual Importance of Partnerships in Health Care
Chronic Disease Self-Management Program
Other Programs from Stanford University
Individual Versus Group-Based Interventions
Challenges to Active Self-Management
Heterogeneity in Health Status and Health Goals
Need to Change Health Goals as Health Declines
Evidence of Effectiveness of Interventions that Facilitate Self-Management
Principles and Suggestions for Integrating Self-Management Into Geriatric Medicine
The Self-Management Partnership
Fostering Collaboration
Implementing a Framework for Effective Self-Management
Targets for Self-Management: General Practices
Targets for Self-Management: Assessing and Acting on Physical Disability
Further Reading
Chapter 29: Rehabilitation
Defining Rehabilitation
History of the Disability Framework
Evaluation
Goals of Evaluation
Disability-Oriented History and Physical Examination
Determining Rehabilitation Potential
Components of Rehabilitation
The Organization of Rehabilitation
Settings for Care
Rehabilitation Providers
Process of Care: Rehabilitation Interventions
Exercise/Physical Activity
General Principles of Exercise
Exercise to Increase Muscle Strength
Exercise to Increase Endurance
Exercise to Improve Balance
Flexibility Exercises
Task-Oriented Exercises to Improve Motor Control
Designing Exercise Prescriptions
Physical Modalities
Thermal Agents (Including Aquatic Therapy)
Electrotherapy
Phototherapy (MIRE)
Adaptive Aids
Mobility Aids
Bathroom and Self-care Aids
Electronic Devices (Environmental Control Units/Augmentative Communication Aids)
Orthotics and Prosthetics
Specific Conditions Treated with Rehabilitation
Pulmonary Rehabilitation
Cardiac Rehabilitation
Peripheral Arterial Disease
Amputation
Stroke Rehabilitation
Parkinsonism
Osteoarthritis and Total Joint Replacement
Falls
Hip Fracture
Sarcopenia and Deconditioning
Pain
Conclusion
Further Reading
Chapter 30: Pain Management
The Older Patient in Pain
How Aging Affects Pain Perception
Classification of Pain
Acute Versus Persistent Pain
Nociceptive Versus Neuropathic Pain
Clinical Evaluation of Pain
Pain History and Physical Examination
Pain Assessment Scales
Pain Assessment in Those with Cognitive Impairment
Management of Acute and Perioperative Pain
Management of Persistent Pain
Analgesic Medications
Acetaminophen
Nonsteroidal Anti-inflammatory Drugs
Opioid Analgesic Medications
Other Nonopioid Medications for Pain
Nondrug Strategies for Pain Management
Further Reading
Chapter 31: Palliative Care
The Experience of Serious Illness for Patients and Their Families
Palliative Care
Symptom Assessment and Treatment
Pain
Dyspnea
Gastrointestinal Symptoms
Depression, Delirium, and Anxiety
Fatigue
Last Hours of Life
Communication
Systems of Care for the Seriously Ill
Care Transitions
Special Issues
Dementia
Artificial Hydration and Nutrition
Grief and Bereavement
Conclusion
Further Reading
Chapter 32: Legal Issues
Overview of Health Care Regulation
Regulation of Health Professionals
Regulation of Health Care Facilities and Agencies
Standards of Care and Professional Liability in Geriatrics
Overview of Malpractice Liability
Developing and Disseminating Standards of Care
Informed Consent
Basics of Informed Consent
Decisional Capacity Issues
Advance Health Care Planning as Prospective Decision Making
Confidentiality
State Law
Federal Law
Particular Health Care Settings
Health Insurance Portability and Accountability Act
Summary
Further Reading
Chapter 33: Spirituality
Ways of Understanding Religion and Spirituality
A Categorical Approach to Spirituality
Historical/Contextual
Anthropological/Social Scientific
Theological/Normative
The Organization of Health-Related Spiritual Care
Future Directions: A Spirituality of Practice Within a Spirituality of Place
Further Reading
Chapter 34: Ethical Issues
Introduction
Deciding with Patients
Disclosing a Diagnosis of Alzheimer’s Disease
Advance Care Planning
Quality of Life
Refusing, Withdrawing, and Withholding Treatment
Euthanasia, Physician-Assisted Suicide, and Terminal Sedation
Deciding with Others: Surrogate Decision Making
Deciding Together: Living and Working in Health Care Systems
Conclusion
Further Reading
Section D: Surgical Management
Chapter 35: Perioperative Evaluation and Management
The Older Surgical Patient
How Age Increases Surgical Risk
Specific Considerations
Cardiac Complications
Pulmonary Complications
Renal Complications
Infectious Complications
Functional Capacity
Emergency Surgeries
Other Concerns
Period of Risk
Preoperative Management
History and Physical
Medications
Preoperative Assessment for Noncardiac Surgery
Other Cardiovascular Concerns
Hypertension
Valvular Disease
Perioperative Beta-Blockers
Other Preventive Measures
Do Not Resuscitate Orders
Postoperative Management
Pain Control
Early Mobilization
Catheters
Postoperative Delirium
Other Complications
Summary
Further Reading
Chapter 36: Anesthesia
Anesthesia and the Anesthesiologist
Preoperative Care of the Older Surgical Patient
Anesthetic Methods and the Older Adult
General Anesthesia
Intraoperative Anesthesia Care
Anesthetic Agents
Hemodynamic Stability During Anesthesia
Anesthesia and the Pulmonary System
Regional Anesthesia
Regional Versus General Anesthesia
Postoperative Analgesia
Patient-Controlled Analgesia
Peripheral Nerve Blocks
Perioperative Complications
Course of Recovery and Common Perioperative Complications in Older Patients
Models of Collaborative Care for the Surgical Patient
Conclusion
Further Reading
Chapter 37: Surgical Outcomes
Predictors of Operative Morbidity and Mortality
Age
Comorbidity
Functional Status and Cognitive Function
Frailty
Functional Outcomes
Functional Status Outcomes
Cognitive Outcomes
Discharge Disposition and Independent Living
Late Survival After Cancer Surgery
Summary
Further Reading
Section E: Nutrition
Chapter 38: Nutrition and Aging
Introduction
The Interrelationship Between Nutrition, Activity, and Disease
Nutrition–Activity Interrelationship
Nutrition–Disease Interrelationship
Age-Related Changes That Affect Nutrition
Changes in Body Composition
Changes in Appetite and Energy Intake Regulation
Loss of Taste, Smell, and Appetite with Advancing Age
Gastrointestinal Tract and Postabsorptive Effects on Appetite
Psychological, Socioeconomic, and Cultural Influences on Appetite
Nutrient Requirements to Maintain Health
Energy
Protein
Factors That Influence Protein Requirements
Fat and Cholesterol
Carbohydrates
Water
Fiber
Vitamins and Minerals
Recommended Intakes
Vitamin and Mineral Supplementation
Vitamin B-12 (Cobalamin)
Folate (Folic Acid)
Calcium, Vitamin D, and Bone Health
Specific Dietary Considerations for Optimal Health
Nutrients and Immunity
Vitamins and Cognition
Nutrition and Cardiovascular Disease
Micronutrients and Cancer
Nutrition and Age-Related Eye Diseases
Assessment of Nutritional Status
Initial Screening Assessment
Comprehensive Nutritional Assessment
Anthropometrics
Laboratory Assessment
Albumin
Transferrin
Prealbumin
Cholesterol
Assessment of Nutrient Intake
Community-Based Nutrition Programs for Older Adults
Further Reading
Chapter 39: Weight and Age: Paradoxes and Conundrums
Should the Health Practitioner Be Concerned About Weight in an Older Patient?
Predicting Weight in Older People: Nothing Special
Lifetime Weight History: Current Weight and Recent Weight Change Are Not Enough
Adiposity
Standards for Overweight and Obesity: Right for Older Patients?
Risks Associated with Underweight
Risks Associated with Overweight
Morbidity and Disability
Mortality Risks
Interventions and Recommendations
Body Composition
Overweight and Weight Reduction
Conclusions
References
Chapter 40: Malnutrition and Enteral/Parenteral Alimentation
Malnutrition
Definition
Epidemiology
Pathophysiology
Presentation and Evaluation
Assessment for Causes of Weight Loss
Management
General Considerations
Patient Preference
Enhancing Oral Intake
Nonpharmacological
Drugs
Maintaining Lean Body Mass and Functional Status
Anabolic Agents
Physical Activity
Nutritional Support
Enteral Nutrition
Efficacy
Tube Placement
Formula Selection
Administration Guidelines
Risks and Complications
Parenteral Nutrition
Efficacy
Administration Guidelines
Intravenous Access
Patient Monitoring and Complications
Special Issues
Comorbidity
Hip Fracture
Chronic Obstructive Pulmonary Disease
Nursing Home Care Setting
Dementia
Future Directions
Further Reading
Chapter 41: Disorders of Swallowing
Impact of Dysphagia
Swallowing Process
Normal Swallowing
Horizontal Subsystem
Vertical Subsystem
Neurophysiology of Oropharyngeal Swallowing
Senescent Swallowing
Age-Associated Changes in Swallowing
Neurophysiological Correlates of Senescent Swallowing
Differential Considerations for Dysphagia and Aspiration
Etiologies
Age-Related Conditions
Age-Related Disease
Symptoms
Screening Across a Continuum of Care Settings
Team Approach to Dysphagia
Focused Assessment of Swallowing
Noninstrumental Swallowing Assessment
Instrumental Examination
Oropharyngeal Videofluoroscopic Swallowing Evaluation
Fiberoptic Endoscopic Evaluation of Swallowing
Dysphagia Intervention
Compensatory Dysphagia Interventions
Postural Adjustments
Food and Liquid Rate and Amounts
Adaptive Equipment
Diet Modification
Knowing the Heimlich Maneuver
Rehabilitative Dysphagia Interventions
Optimizing Swallowing and Related Health Through Prevention
Medications
Oral Hygiene
TuBe or Not TuBe—Oral Versus Nonoral Intake
Further Reading
Chapter 42: Oral Cavity
Dentition
Periodontium
Salivary Glands
Sensory Function
Oral Mucosa
Motor Function
Summary
Further Reading
Section F: Sensory Function
Chapter 43: Assessment and Rehabilitation of Older Adults with Low Vision
Demographics
Aging and Loss of Vision
Normal Age-Related Changes in Vision
Prevalent Age-Related Causes of Visual Impairment
Age-Related Macular Degeneration
Diabetic Retinopathy
Cataract
Glaucoma
Traumatic Brain Injury
Role of the Geriatrician in Vision Rehabilitation
Adaptations of Clinical and Functional Evaluations for Older Adults
Case History Interview
Clinical Low-Vision Evaluation
Nursing Homes
Hospital Settings
Community Service Agency Settings
Private Home Settings
Functional Visual Assessment
Management of Low Vision
Developing a Vision Rehabilitation Plan
Instruction and Guided Practice Using Remaining Vision and Low-Vision Devices
Low-Vision Devices
Instruction in the Use of Low-Vision Devices
Reading and Writing with Low-Vision Devices
Environments for Older Persons
Improving the Lighting
Increasing Contrast
Using Color
Using Organizational Strategies
Alternative Strategies
Psychosocial Considerations
Adaptation to Vision Loss
Family and Social Support
Funding for Low-Vision Rehabilitation
Further Reading
Chapter 44: Age-Related Changes in the Auditory System
Introduction
Epidemiology of Age-Related Hearing Impairment
Risk Factors Modulating Age-Related Hearing Impairment
Genetics
Environmental Factors
Gender Differences and Hormonal Factors
Diabetes Mellitus
Cardiovascular Disease
Lifestyle
Psychology
Hearing Loss Basics: Frequencies and Sound Intensity
Anatomy of the Auditory Periphery
Functional Assessment of Hearing
Peripheral Pathology of Age-Related Hearing Impairment in Humans
Central Auditory Aspect of Age-Related Hearing Impairment
Animal Models of Peripheral Age-Related Hearing Impairment
Molecular Mechanisms of Age-Related Hearing Impairment in Animal Models
Genetic Contributions to Age-Related Hearing Impairment in Animal Models
Prevention of Age-Related Hearing Impairment
Management of Age-Related Hearing Impairment
Outlook
Acknowledgment
Further Reading
Section G: Gender and Sexuality
Chapter 45: Sex and Gender Across the Human Life Span
Definitions
History of the Sex Differential in Longevity
When Does the Sex Differential in Mortality Begin?
Mechanisms of the Biological Basis of the Sex Differential in Longevity
Basic Molecular Genetics of Sex Differences
Sex Differentials During Fetal, Childhood, and Adolescent Development
Sex May Affect Regulation of Redox State and Oxidative Stress
Sex Affects Neural Anatomy and Function
Sex Affects Immune Function
Sex Affects Sex Hormone Physiology Across the Adult Life Span
Sex Differential in Longevity
the Sex Differential in Atherosclerosis
Sex Differential in Cardiovascular Disease Risk Factors
Role of Sex Hormones in Mediating the Sex Differential in Coronary Heart Disease Risk
Sex Differential in Atherosclerotic Cardiovascular Disease
Female Hormone Replacement Therapy
Predicting the Future: The Sex Differential in Longevity Is Declining
Future of the Sex Differential in Longevity and Its Implications for Geriatric Medicine and Gerontology
Further Reading
Chapter 46: Menopause and Midlife Health Changes
Physiological Basis of Reproductive Aging
Disaggregating Menopause Symptoms and Chronological Aging
Menopause Symptoms and Clinical Features
Vasomotor Symptoms
Sleep Disturbances
Sexuality Dysfunction
Depressed Mood
Cognition and Memory
Cardiovascular Disease Risk
Diabetes Risk
Obesity and Body Composition
Bone Loss
Physical Function
Osteoarthritis
Skin and Collagen
Conclusions
Further Reading
Chapter 47: Sexuality, Sexual Function, and the Aging Woman
Introduction
Interactive Biopsychosocial Model
Sociodemographic Context of Older Women’s Sexuality
Sexuality in Long-Term Care Institutions
Sexual Activity, Behavior, and Problems
Sexual Partnership
Sexual Activity
Sexual Problems
Sexually Transmitted Infection
Sexual Trauma, Violence, and Abuse
Female Sexual Response Cycle
Female Sexual Physiology in Later Life
Endocrine System
Neurovascular System
Musculoskeletal System
Genitourinary System
Gastrointestinal System
Female Sexual Dysfunction
Diagnostic Classification of Female Sexual Dysfunction
Causes of Female Sexual Dysfunction
Sexual History—Talking and Communication about Sexual Problems
Clinical Management of Female Sexual Dysfunction
Dyspareunia
Vaginismus
Orgasmic Disorder
Persistent Sexual Arousal Disorder
Medical Therapy for Sexual Desire/Arousal Disorders and Dyspareunia
Conclusion
Further Reading
Chapter 48: Gynecological Disorders
Gynecological History
Physical Examination
Issues and Conditions by Anatomical Approach
Benign Breast Disease
Breast Lump
Breast Pain
Nipple Discharge
Breast Inflammation
Vulva
Examination of the Vulva
Benign Conditions of the Vulva
Inflammatory Dermatoses of the Vulva
Ulcerations and Infections of the Vulva
Cancer of the Vulva
Urethra
Vagina
Vaginal Atrophy
Vaginitis, Vaginosis, Vaginal Discharge
Cancer of the Vagina
Cervix
Examination of the Cervix
Cervical Cancer Screening
Cancer of the Cervix
Uterus
Benign Conditions of the Uterus
Cancer of the Uterus
Endometrial Neoplasia
Myometrial Neoplasia
Adnexa
Evaluation of the Adnexa
Adnexal Cysts
Cancer of the Ovary
Cancer of the Fallopian Tube
Common Clinical Issues
Gynecological Malignancies
Vaginal Bleeding
Initial Approach to Vaginal Bleeding
Endometrial Evaluation for Vaginal Bleeding
Genital Prolapse and Incontinence
Evaluation of Genital Prolapse
Management of Genital Prolapse
Pessaries for Genital Prolapse
Pessaries for Urinary Incontinence
Pelvic Pain and Dyspareunia
Abdominal and Myofascial Pain
Vulvar Pain, Vaginal Pain, and Dyspareunia
Pain Associated with Reproductive Organs
Interstitial Cystitis
Hormone Replacement Therapy
Summary
Further Reading
Chapter 49: Sexuality, Sexual Function, Androgen Therapy, and the Aging Male
Sexuality and Sexual Function in Older Men
Sexual Behaviors
Changes in Male Sexual Physiology with Age
The Aging Male Homosexual
Sex in Long-Term Care
Sex and Dementia
Sexual Dysfunction in the Aging Male
Categories of Male Sexual Dysfunction
Erectile Dysfunction
Physiology
Etiologies
Evaluation of Sexual Dysfunction
Treatments for Erectile Dysfunction
Testosterone and Male Sexual Dysfunction
Androgen Replacement Therapy in Older Men
Androgen Physiology and Changes with Aging
Defining Hypogonadism in Older Men
Testosterone Therapy Effects on Specific Target Organs
Bone
Body Composition and Strength
Mood
Cognition
Cardiovascular System
Adverse Effects of Testosterone
Testosterone Preparations for Replacement Therapy
Further Reading
Chapter 50: Benign Prostate Disorders
Definitions
Epidemiology and Natural History
Pathophysiology
Hyperplasia
Risk Factors
Nocturia
Evaluation
History
American Urological Association Symptom Index
Other Measures of LUTS and Quality of Life
Physical Examination
Laboratory Tests
Postvoiding Residual and Urine Flow Rate
Bladder Diaries (Frequency–Volume Charts)
Specialized Testing
Urodynamic Studies
Other Tests
Management
Making Treatment Decisions
Nonpharmacological Management
Watchful Waiting
Medications
Alpha-Adrenergic Blockers
5-α Reductase Inhibitors
Combination Therapy
Phytotherapy
Emerging Therapies
Surgery
Transurethral Resection of Prostate
Laser Prostatectomy
Open Prostatectomy
Minimally Invasive Procedures
Prostate Incision
Thermotherapy
Stents
Prevention
Further Reading
Part III: Geriatric Syndromes
Chapter 51: Aging and Homeostatic Regulation
Background
Homeostasis in a Historical Context
Homeostatic Regulation in Old Age
General Considerations
Systemic Patterns of Change
Alterations in Specific Homeostatic Mechanisms
Reconciling Different Views of Homeostatic Dysregulation
Specific Homeostatic Challenges
General Considerations
”Fight or Flight Response”
Lowered Ambient Temperature
Epidemiology
Pathophysiology
Clinical Presentation
Treatment
Emergency Care
General Support
Rewarming
Raised Ambient Temperature
Epidemiology
Pathophysiology
Clinical Presentation
Treatment
Orthostasis, Meals, and Hypovolemia
Hyperglycemia and Hypoglycemia
Fluid Challenge and Dehydration
Bladder Outlet Obstruction
Major Burns and Trauma
Altered Physical Activity
Anticholinergic Medications
Antidopaminergic Medications
Neuronal Degeneration
Acknowledgment
Further Reading
Chapter 52: Frailty
Frailty Is at the Core of Geriatric Medicine
What Is Frailty?
How Can Frailty Be Identifiedin Clinical Practice?
Standardized Approaches Developed to Ascertain Frailty
Potential Uses of an Operational Definition of Frailty
Evidence and Theory Regarding the Pathogenesis of Frailty and Implications for Treatment
Biomarkers of Frailty and Homeostatic Dysregulation
Treatment and Prevention of Frailty
Conclusion
Further Reading
Chapter 53: Delirium
Definition
Epidemiology
Etiology
Predisposing Factors
Precipitating Factors
Drug Use and Delirium
Relationship between Delirium and Dementia
Pathophysiology
Presentation
Cardinal Features
Tools for Evaluation of Delirium
Forms of Delirium
Prognosis
Evaluation
History and Physical Examination
Laboratory Tests and Imaging
Differential Diagnosis
Algorithm for the Evaluation of Altered Mental Status
Prevention
Management
Pharmacological Management
Neuroleptics
Other Pharmacological Approaches
Nonpharmacological Management
Nonpharmacological Sleep Protocol
Special Issues
Nursing Home Setting
Palliative Care Setting
Ethical Issues
Further Reading
Chapter 54: Falls
Definition
Incidence and Consequences of Falls
Incidence and Prevalence of Falling
Fall Injuries
Incidence of Fall Injuries
Hip Fractures
Death
Other Consequences of Falling
Etiology of Falls and Fall Injuries
Risk Factors for Falling
Age-Associated Changes and Chronic Diseases
Postural Control
Sensory Input
Central Processing
Musculoskeletal Impairments
Postural Hypotension
Medications
Acute Illness and Hospital Discharge
Challenges to Postural Control
Opportunity to Fall
Risk Factors for Fall Injury
Osteoporosis
Characteristics of the Fall
Fall Prevention in Community-Dwelling Older Persons
Trials of Interventions to Prevent Falls
Single Interventions
Multifactorial Interventions
Strategy for Decreasing Falls and Fall Injuries
Screen for Fall Risk
Multifactorial Assessment
Multidisciplinary Treatment
Falls in Skilled Nursing Facilities
Evaluation
Treatment
Multifactorial Approach
Alternatives to Restraints
Hip Protectors
Hospital Falls
Risk Factor Assessment
Preventive Measures
Evaluation of Falls and Revision of Care Plan
Areas for Future Research
Conclusion
Further Reading
Chapter 55: Sleep Disorders
Introduction
Changes in Sleep with Aging
Sleep-Disordered Breathing
Definition
Epidemiology
Pathophysiology
Presentation
Management
Positive Airway Pressure
Surgical Interventions
Oral Appliances
Diet and Lifestyle
Periodic Limb Movements in Sleep/Restless Legs Syndrome
Definition
Epidemiology
Pathophysiology
Presentation
Evaluation
Management
Circadian Rhythms Sleep Disorders
Definition
Epidemiology
Pathophysiology
Presentation
Evaluation
Management
Bright-Light Therapy
Rapid Eye Movement Sleep Behavior Disorder
Definition
Epidemiology
Pathophysiology
Presentation
Evaluation
Management
Pharmacological Interventions
Lifestyle
Insomnia
Definition
Epidemiology
Pathophysiology
Presentation
Evaluation
Management
Nonpharmacological Interventions
Sleep Hygiene
Stimulus-Control Therapy
Sleep-Restriction Therapy
Cognitive-Behavioral Therapy
Pharmacological Interventions
Special Issues
Sleep in Institutionalized Elderly Patients and Neurodegenerative Disorders
Summary
Acknowledgment
Further Reading
Chapter 56: Dizziness
Definition
Epidemiology
Pathophysiology
Presentation
Vertigo
Dysequilibrium
Presyncope
Other and Multifactorial
Etiology
Discrete Diseases Causing Dizziness
Vestibular Disorders
Ménière’s Disease
Benign Paroxysmal Positional Vertigo
Recurrent Vestibulopathy
Acoustic Neuroma
Central Nervous System Disorders
Psychiatric Disorders
Cervical Disorders
Systemic Causes
Orthostatic Hypotension
Postprandial Hypotension
Medications Contributing to Dizziness
Evaluation
History
Physical Examination
Provocative Tests
Laboratory Tests
Management
Pharmacological Therapy
Vestibular Rehabilitation
Surgery
Patient Education
Further Reading
Chapter 57: Syncope
Definition
Epidemiology
Pathophysiology
Multifactorial Etiology
Individual Causes of Syncope
Presentation
Evaluation
Orthostatic Hypotension
Pathophysiology
Aging
Hypertension
Medications
Other Conditions
Primary Autonomic Failure Syndromes
Secondary Autonomic Dysfunction
Presentation
Evaluation
Management
Carotid Sinus Syndrome and Carotid Sinus Hypersensitivity
Pathophysiology
Epidemiology
Presentation
Evaluation
Carotid Sinus Massage
Management
Vasovagal Syncope
Pathophysiology
Presentation
Evaluation
Management
Postprandial Hypotension
Summary
Further Reading
Chapter 58: Pressure Ulcers
Definition
Epidemiology
Morbidity Associated with Pressure Ulcers
Pathophysiology
Presentation
Assessment
Risk Assessment
Assessment of Pressure Ulcer Stage
Assessment of Pressure Ulcer Healing
Management
Local Treatment
Surgery
Drugs
Nutrition
Prevention
Special Issues
Summary
Further Reading
Chapter 59: Incontinence
Definition and Epidemiology
Pathophysiology and Classification
Basic Causes
Acute and Reversible Causes
Persistent Incontinence
Evaluation
Management
Behavioral Interventions
Drug Treatment
Surgical Approaches
Mechanical Devices, Undergarments, Catheters, and Other Supports
Fecal Incontinence
Further Reading
Chapter 60: Elder Mistreatment
Definitions
Epidemiology
Pathophysiology
Presentation
Management
Special Situations
Summary
Further Reading
Part IV: Organ Systems and Diseases
Section A: Human Brain
Chapter 61: Cellular and Neurochemical Aspects of the Aging Human Brain
Structural Changes in the Aging Brain
Cytoskeletal and Synaptic Changes
Vascular Changes
Amyloid Accumulation
Free Radicals and the Aging Brain
Lipid Peroxidation
Protein Oxidation
DNA Damage
Mechanisms that Promote Oxidative Stress in Aging and Neurodegenerative Disorders
Alterations in Energy Metabolism and Mitochondrial Function in the Aging Brain
Cerebral Metabolism
Mitochondrial Function
Neuronal Ion Homeostasis in the Aging Brain
Neurotransmitter Signaling in the Aging Brain
Cholinergic Systems
Dopaminergic Systems
Monoaminergic Systems
Amino Acid Transmitter Systems
Neuroendocrine Changes in the Aging Brain
Immunologic Factors in Brain Aging
Neurotrophic Factors in the Aging Brain
Neurotrophic Factors Counteract Age- and Disease-Related Neurodegeneration
”Use It or Lose It”
Genetic Factors in Brain Aging and Neurodegenerative Disorders
Longevity Genes
Disorder-Specific Genes
Dietary Factors in Brain Aging and Neurodegenerative Disorders
Calorie Intake
Folic Acid (Homocysteine)
Antioxidants
Stimulatory Phytochemicals
Conclusion
Further Reading
Chapter 62: Cognitive Changes Associated with Normal and Pathological Aging
The Effects of Normal Aging on Cognitive Function
General Intellectual Functioning
Attention
Executive Functions
Memory
Language
Language Comprehension
Language Production
Visuospatial Skills
Psychomotor Functions
Cognitive Effects of Common Age-Related Medical Conditions
Cardiovascular Disease
Hypertension
Nutritional Deficiency
Type 2 Diabetes Mellitus
Oxygen Deprivation
Chronic Obstructive Pulmonary Disease
Obstructive Sleep Apnea
Thyroid Dysfunction
Depression
Medications
Delirium
Neurodegenerative Disease
Alzheimer’s Disease
Patient History
Medical Examination
Neuropsychological Assessment
Memory
Attention and Executive Function
Language
Visuospatial Function
Motor Function
Behavioral Changes
Awareness of Deficits
Variant AD Presentations
Mild Cognitive Impairment
Vascular Dementia
Frontotemporal Dementia
Primary Progressive Aphasia
Lewy Body Disease
Parkinson Disease
Dementia with Lewy Bodies
Progressive Supranuclear Palsy
Alcohol-Related Dementia
Persistent Alcohol Dementia
Wernicke–Korsakoff Syndrome
Prion Diseases
Normal Pressure Hydrocephalus
Human Immunodeficiency Virus
Neurosyphilis
Conclusions
Further Reading
Chapter 63: Psychoactive Drug Therapy
Introduction
Antidepressants
Selective Serotonin Reuptake Inhibitors
Fluoxetine
Sertraline
Paroxetine
Citalopram and Escitalopram
Side Effects and Safety
Other Antidepressants
Bupropion
Duloxetine
Mirtazapine
Venlafaxine
Tricyclic Antidepressants and Monoamine Oxidase Inhibitors
Psychostimulants
Methylphenidate
Antipsychotics
Conventional Antipsychotics
Atypical Antipsychotics
Clozapine
Risperidone
Olanzapine
Quetiapine
Aripiprazole and Ziprasidone
Side Effects and Safety
Mood Stabalizers
Lithium
Anticonvulsants
Valproate
Carbamazepine
Gabapentin and Pregabalin
Lamotrigine
Anxiolytics
Benzodiazepines and Nonbenzodiazepine Hypnotics
Buspirone
Summary
Further Reading
Chapter 64: Cerebrovascular Disease
Ischemic Stroke or TIA Subtype
Pathophysiology and Clinical Presentation
Large Vessel, Atherothrombotic Stroke/TIA Subtype
Atherothrombotic Disease of the Anterior Cerebral Circulation (Origin of the Internal Carotid Artery, Its Major Branches, and the Common Carotid Artery)
Atherothrombotic Disease of the Posterior Cerebral Circulation: Vertebrobasilar and Posterior Cerebral Arteries and Their Branches
Lacunar Stroke/TIA Subtype (Small Vessel Disease)
Embolic Stroke/TIA Subtype
Patent Foramen Ovale and Embolic Stroke
Other Causes of Cerebral Infarction
Evaluation
Cardiac Evaluation
Therapeutic Strategies for Ischemic Stroke
Hyperacute/Acute
Subacute
Preventive
Preventive Strategies for Controlling Primary Risk Factors
Preventive Therapy Directed Toward the Specific Stroke/TIA Subtype
Treatment and Prevention of Complications of Stroke
Intracranial Hemorrhage
Intracerebral Hemorrhage
Deep Hemispheric Hemorrhage
Lobar Hemorrhage
Cerebral Amyloid Angiopathy
Lobar Hemorrhages Caused by Metastatic Disease
Vascular Malformations
Subarachnoid Hemorrhage
Further Reading
Chapter 65: Dementia Including Alzheimer’s Disease
Genetics of Alzheimer’s Disease
Neuropathology of Alzheimer’s Disease
Pathobiology of Alzheimer’s Disease
Amyloid Precursor Protein Processing and Generation of Aβ
Aβ: Pivotal Role in the Pathogenesis of Alzheimer’s Disease
Epidemiology and Risk Factors for Alzheimer’s Disease
Aging
APOE Genotype
Gender
Hypercholesterolemia and Vascular Risk Factors
Head Trauma
Depression
Education and Ethnicity
Clinical Presentations of Alzheimer’s Disease
Typical Clinical Presentation of AD
Atypical Clinical Presentations of Alzheimer’s Disease
Diagnosis of Alzheimer’s Disease
Future Diagnostic Tools
Managing Patients with Alzheimer’s Disease
Presenting the Diagnosis
Treatment of Cognitive Symptoms
Disease-Modifying Therapies
Preventive Strategies
Behavioral Management
Safety Management
Caregiver Support
End-of-Life Care
Summary
Further Reading
Chapter 66: Parkinson’s Disease and Related Disorders
Distinguishing Between Parkinson’s Disease and Parkinsonism
Pathology of Parkinson’s Disease and Parkinson-Plus Syndromes
Cause and Pathogenesis of Parkinson’s Disease and Parkinson-Plus Syndromes
Epidemiology and Clinical Features of Parkinson’s Disease
Principles of Therapy
Neuroprotective Therapy
Encourage Exercise to Keep the Patient Mobile
Individualize Therapy
Deep Brain Stimulation
Medical Therapy of Parkinson’s Disease
Motor Complications of Levodopa Therapy
Treatment of the “Wearing-off” Phenomenon
Treatment of Levodopa-Induced Dyskinesias
Treatment of Nonmotor Features
Surgical Therapy
Further Reading
Chapter 67: Other Neurodegenerative Disorders
Approach to the Evaluation of Cognitive and Behavioral Disorders in Adults
Disorders Associated with Alpha-Synuclein Deposition
Dementia with Lewy Bodies
Parkinson’s Disease Dementia
Multiple System Atrophy
Neurodegenerative Disorders Associated with Tau, Progranulin, or TDP-43 Pathology
Frontotemporal Lobar Degeneration Syndromes
Progressive Nonfluent Aphasia
Semantic Dementia
Frontal Variant Frontotemporal Dementia
Pick’s Disease
Other FTLD Neuropathologies
Treatment of FTLD
Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s Disease)
Corticobasal Degeneration
Progressive Supranuclear Palsy
Spinocerebellar Ataxia Syndromes
Concluding Remarks on Non-Alzheimer’s Disease Neurodegenerative Disorders
Further Reading
Chapter 68: Traumatic Brain Injury
Epidemiology
Etiology
Falls
Motor Vehicle Accident
Mortality
Types of Brain Injury
Severity of Injury
Outcomes
Global TBI Outcome and Age
Executive Dysfunction
Speed of Processing
Attention/Distractibility
Memory Dysfunction
Personality/Emotional Functioning
Self-Awareness
Neuropsychiatric Outcome
TBI and Subsequent Brain Atrophy and Cognitive Aging
Dementia and Trauma
Does Trauma Increase the Risk of AD?
Postacute Management of Geriatric Patients with TBI
Neuropsychological Assessment
Neuropsychiatric Disturbances
Pain
Further Reading
Chapter 69: Epilepsy
Definition of Epilepsy and Seizures
Incidence and Prevalence of Epilpesy and Use of AEDs
Incidence in Community-Dwelling Elderly
Prevalence in Community-Dwelling Elderly
Prevalence in Nursing Home Elderly
Prevalence at Time of Admission to Nursing Homes
Incidence After Admission to Nursing Homes
Causes
Diagnosis
History
CT and MRI Scans
Electroencephalogram
Treatment
Deciding to Treat
Clinical Pharmacology of AEDs in the Elderly
Variability of AED Levels in Nursing Homes
Clinical Trials of AEDs in the Elderly
Choosing an AED for the Elderly
Phenytoin
Carbamazepine
Valproate
Phenobarbital
Gabapentin
Lamotrigine
Levetiracetam
Pregabalin
Dosing of AEDs in the Elderly
Alternative Routes of Administration
Drug Interactions with Non-AEDs
Conclusions
Further Reading
Chapter 70: Late-Life Mood Disorders
Introduction
The Subtypes of Late-Life Mood Disorders
The Epidemiology of Late-Life Mood Disorders
The Outcome of Mood Disorders in Late Life
Origins of Late-Life Mood Disorders
Biological Origins
Psychological Origins
Social Origins
The Diagnostic Workup of Late-Life Mood Disorders
Treatment of Late-Life Mood Disorders
Biological Therapies
Psychological Therapies
Working with the Family of the Depressed Older Adult
Evaluating and Managing Suicidal Risk in the Depressed Older Adult
Further Reading
Chapter 71: Schizophrenia
Definition
Inclusion Criteria
Positive Symptoms
Negative Symptoms
Clinical Course
Exclusion Criteria
Associated Symptoms
Age of Onset
Early Onset
Late Onset
Differential Diagnoses
Mood Disorders
Schizoaffective Disorder
Dementia
Delirium
Delusional Disorder
Substance-Induced Psychotic Disorder
Schizophreniform Disorder and Brief Psychotic Disorder
Ictal Psychosis
Etiology
Genetic
Developmental
Treatment
Antipsychotics
Typical Antipsychotic
Atypical Antipsychotics
Psychosocial Treatments
Nonpsychotic Disorders That Can Be Confused with Schizophrenia
Charles Bonnet Syndrome
Delusional Parasitosis (Ekbom Syndrome)
Diogenes Syndrome
Hallucinations in Grief
Organic Delusional Disorder
Further Reading
Chapter 72: General Topics in Geriatric Psychiatry
Suicide
Factors Associated with Suicide
Evaluation and Assessment
Management and Treatment
Anxiety Disorders in the Elderly
Treatment Options for Anxiety
Posttraumatic Stress Disorder
Late-Life Psychotic Disorders
Clinical Presentation
Epidemiology and Terminology
Risk and Comorbidity
Psychosis in Dementia
Treatment Considerations
Alcohol and Substance Use in the Elderly
Geriatric Substance Abuse Prevalence
Diagnosis and Classification
Therapeutic Interventions
Clinical Approach and Management
Other Addictive Substances and Treatment
Personality Pathology in the Elderly
Personality Disorder Classification
Prevalence
Age-Associated Personality Changes
Treatment Strategies
Further Reading
Chapter 73: Management of Agitation in Dementia
Introduction
Pathophysiology
Assessment of the Agitated Patient
Clearly Define and Document the Problem
Assess the Impact on the Caregiver
Medical Workup: Rule Out Delirium
Rule Out Primary Psychiatric Disorders
Depression
Anxiety Disorders
Psychotic Symptoms
Management of Agitation
Identify Target Symptoms
Set Realistic Goals
Therapeutic Interventions
Nonpharmacological Interventions
Pharmacological Interventions
Antipsychotics
Efficacy
Mortality Risk and Antipsychotics
Cerebrovascular Adverse Events and Antipsychotics
Antipsychotics and Mortality in Patients with Dementia with Possible Lewy Body Pathology
Other Side Effects of Antipsychotics
Antidepressants
Anticonvulsants
Carbamazepine
Valproate
Gabapentin
Acetylcholinesterase Inhibitors
Antiadrenergic Approaches
Benzodiazepines
Gonadal Hormones
General Guidelines for the Selection of Pharmacological Interventions
Conclusion
Further Reading
Section B: Cardiology
Chapter 74: Effects of Aging on Cardiovascular Structure and Function
Principles of Aging Biology Pertinent to the Cardiovascular System
Aging of the Vasculature
Age Changes in Arterial Structure
Functional Changes of Aging Arteries
Aging and Atherosclerosis
Aging Changes in the Heart
Changes in Myocardial Composition
Myocite hypertrophy
Myocyte Degeneration
Connective Tissue
Senile Cardiac Amyloid
Adiposity
Changes in Cardiac Structure
Mass
Ventricular Wall Thickness
Chamber Size
Aorta
Valves
Pericardium
Atrial Septum
Coronary Arteries
Overall Appearance
Changes in Cardiac Function with Age at Rest
Heart Rate and Rhythm
Diastolic Function
Systolic Function
Possible Implications of the Age-Related Changes in Resting Cardiovascular Function
Effect of Age on the Cardiovascular Response During Exercise
Summary
Further Reading
Chapter 75: Aging and Atherosclerosis
Vascular Aging
Exposure
Accumulation
Attrition
Summary
Risk Factors for Vascular Pathology in Older Adults
Traditional Risk Factors
Hypertension
Dyslipidemia
Altered Glucose Metabolism
Smoking
Nontraditional Risk Factors
Chronic Renal Disease
Biomarkers Associated with Atherosclerosis
Depression and Social Isolation
Frailty
Obesity
Autoimmune Disease
Impact of Other Aging Organs
Volume-Regulating Hormones
Renal Aging
Iatrogenic Contributors
Medications
Radiation
Summary
Clinical Implications of Vascular Aging and Atherosclerosis
Isolated Systolic Hypertension
Heart Failure with Preserved Systolic Function
Coronary Artery Disease
Cerebrovascular Disease
Renovascular Disease
Aneurysms
Peripheral Arterial Disease
Reduced Exercise Capacity
Detection and Diagnosis
Stress Testing
Computed Tomography
Magnetic Resonance Imaging
Vascular Studies
Strategies to Prevent, Retard, and Regress Vascular Aging and Atherosclerosis
Novel Drug Targets
Pleiotropic Effects of Available Therapies
ACE-I/ARB
Statins
Exercise
Summary and Take Home Points
Further Reading
Chapter 76: Coronary Heart Disease
Prevalence
Effects of Aging on the Cardiovascular System
Presentation
Diagnostic Evaluation
Asymptomatic Elderly Patients
Chronic Stable Angina in the Elderly Patient
Acute Coronary Syndromes
Prognosis
Acute Coronary Syndrome Therapies
Fibrinolysis and Primary Angioplasty in Elderly Patients
Antiplatelet Therapy
Antithrombin Therapy
Beta-blockers
Secondary Prevention Strategies
Post-MI Testing
Coronary Revascularization
Special Considerations
Underrepresentation in Clinical Trials
Renal Function and Pharmacology
Patient Preferences
Social/Economic Issues
Summary
Further Reading
Chapter 77: Valvular Heart Disease
Aortic Stenosis
Etiology
Clinical Presentation and Diagnosis
Management
Asymptomatic Patients
Medical Management
Percutaneous Aortic Valvuloplasty
Surgical Management
Aortic Insufficiency
Etiology
Clinical Presentation and Diagnosis
Management
Medical Management
Surgical Management
Mitral Stenosis
Etiology
Clinical Presentation and Diagnosis
Management
Medical Management
Percutaneous Mitral Valvuloplasty
Surgical Management
Mitral Regurgitation
Etiology
Clinical Presentation and Diagnosis
Management
Medical Management
Surgical Management
General Considerations
Endocarditis Prophylaxis
Anticoagulation
Prosthetic Valve Choices
Mechanical Valves
Bioprosthetic Valves
Aortic Homografts
Pulmonary Valve Autotransplants (Ross Procedure)
Valve Repair
Chapter 78: Heart Failure
Epidemiology and Economic Impact
Pathophysiology
Etiology and Precipitating Factors
Precipitating Factors
Clinical Features
Symptoms
Signs
Systolic versus Diastolic Heart Failure
Diagnostic Evaluation
Systolic versus Diastolic Heart Failure
Management
Nonpharmacological Therapy
Physical Activity and Exercise
Exercise Prescription
Cessation of Exercise
Treatment of Systolic Heart Failure
ACE Inhibitors
Angiotensin II Receptor Blockers
Other Vasodilators
Beta-Blockers
Diuretics
Aldosterone Antagonists
Digoxin
Calcium Channel-Blockers
Antithrombotic Therapy
Statins
Treatment of Diastolic Heart Failure
Diuretics
Beta-Blockers
ACE Inhibitors
Angiotensin II Receptor Blockers
Aldosterone Antagonists
Calcium Channel-Blockers
Nitrates
Digoxin
Summary
Refractory Heart Failure
Prognosis
Ethical Issues and End-of-Life Decisions
Prevention
Summary
Further Studies
Chapter 79: Cardiac Arrhythmias
Overview of the Effect of Aging on Cardiac Electrophysiology and Evaluation of Arrhythmias
Electrophysiology and Arrhythmias in the Elderly
Clinical Testing
Bradyarrhythmia and Cardiac Pacemaker Therapy in the Elderly
Standard Indications
Acquired Advanced AV Block
AV Conduction Disease
Sinus Node Dysfunction
Pacemaker Therapy
Prospective Trials of Ventricular (VVI) and Physiological (AAI or DDD) Pacing
Syncope in the Elderly
Hypersensitive Carotid Sinus Syndrome
Neurocardiogenic (“Vasovagal”) Syncope
Elderly Patients with Syncope of Uncertain Cause
Tachyarrhythmias and Cardiac Implantable Defibrillator Therapy in the Elderly
Atrial Fibrillation
Stroke Prevention in Atrial Fibrillation
Pharmacologic Therapy for Atrial Fibrillation
Rate Control
Rhythm Control
Rate versus Rhythm Control
Nonpharmacologic Therapy for Atrial Fibrillation
Rate Control
Rhythm Control
Supraventricular Tachyarrhythmia
Ventricular Tachyarrhythmia
Secondary Prevention of Sudden Cardiac Death
Primary Prevention of Sudden Cardiac Death
Cardiac Resynchronization Therapy and Implantable Cardioverter Defibrillator
Aging and Drug-Induced Proarrhythmia
Changes in Pharmacokinetics Associated with Aging
Drug-Induced Arrhythmias
Novel, Emerging Therapies for Cardiac Arrhythmias
Biological Pacemakers for Bradyarrhythmias
Genetic and Cell Therapy for Tachyarrhythmias
Summary
Key Points
Further Reading
Chapter 80: Peripheral Vascular Disease
Definition
Epidemiology
Pathophysiology
Presentation
Evaluation
Pulse Palpation and San Diego Claudication Questionnaire
Noninvasive Vascular Tests
Treadmill Testing
Physical Function
Management
Risk Factor Modification
Smoking Cessation
Hypercholesterolemia
Hypertension
Diabetes
Antiplatelet and Anticoagulation Therapy
Vasodilators
Revascularization Therapy
Effects of Exercise Rehabilitation
Recommended Exercise Program for Treating Intermittent Claudication
Prevention
Summary
Further Reading
Chapter 81: Hypertension
Introduction
Epidemiology
Classification
Pathophysiological Characteristics
Diagnostic Evaluation
Measurement Considerations
Evaluation
Target Organ Damage and Risk Factor Assessment
Approach to Treatment
Treatment Effectiveness
Therapeutic Goals and Monitoring
Lifestyle Modifications
Pharmacological Therapies
Overview
Thiazide-type Diuretics
Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Antagonists
Calcium Channel Antagonists
Adrenergic Receptor Antagonists
Barriers to Improving Blood Pressure Control
Unanswered Questions and Future Research Directions
Summary
Further Reading
Section C: Respiratory System
Chapter 82: Aging of the Respiratory System
Introduction
Lung Volumes
Maximal Expiratory Flow
Spirometry
Respiratory Muscle Strength
Arterial Blood Gases
Diffusing Capacity
Differential Diagnosis of Asthma and COPD
Tests to Assess Response to Therapy for Asthma and COPD
Further Reading
Chapter 83: Chronic Obstructive Pulmonary Disease
Definitions
Epidemiology
Pathophysiology
Risk Factors
Pathogenesis and Pathology
Changes in Respiratory Physiology in COPD
Nonpulmonary Effects
Clinical Manifestations
Diagnosis
Spirometry
Other Tests
Severity of COPD
Natural History of COPD
Management
Goals of Management of Stable Disease
Smoking Cessation
Pharmacologic Management
Short- and Long-Acting Beta Agonist
Anticholinergic Agents
Methylxanthines
Corticosteroids
Inhalation Techniques
Mucolytic Agents
Phosphodiesterase (PDE)-4 Inhibitors
Adjunct Therapies
Nonpharmacologic Interventions
Oxygen Therapy
Pulmonary Rehabilitation
Weight Loss and Malnutrition
Noninvasive Positive Pressure Ventilation
Surgery for COPD
Acute Exacerbation of COPD
Diagnostic and Therapeutic Approaches
Summary
Further Reading
Chapter 84: Diffuse Parenchymal Lung Disease
Introduction
Epidemiology
Prognosis and Natural History
Pathogenesis
Diagnostic Approach
History
Physical Examination
Laboratory Tests
Chest Radiography
High-Resolution Computed Tomography
Pulmonary Function Tests
Bronchoscopic Studies
Lung Biopsy
Therapeutic Approach
Future Directions
Further Reading
Section D: Nephrology
Chapter 85: Changes in Kidney Function
Clinical Relevance
The Aging Process
Functional Changes
Renal Blood Flow
Glomerular Filtration Rate
Classification of Kidney Disease
Proteinuria
Tubular Function
Donor Organ Viability
Underlying Structural Changes
Gross Anatomy
Glomerulus
Age-Related Glomerulosclerosis
Tubule
Vasculature
Mechanisms Underlying the Decline in Kidney Function
Genetic Predisposition
Animal Models
Human Studies
Environmental Predisposing Factors
Diet
Free Radicals and Lipid Peroxides
Protein Restriction
Lipids
Hyperfiltration
Consequences of Impaired Kidney Function
Further Reading
Chapter 86: Renal Disease
Epidemiology
Acute Renal Failure
Definition
Clinical Presentation
Diagnosis
Treatment
Prognosis
Glomerular Diseases
Clinical Presentation
Acute Glomerulonephritis and Rapidly Progressive Glomerulonephritis
Nephrotic Syndrome
Definition
Pathophysiology
Clinical Manifestations
Histopathology Findings
Diagnosis
Treatment and Prognosis
Renovascular Disease
Definition
Clinical Features
Diagnostic Approach
Treatment
Tubulointerstitial Nephritis
Functional Defects
Acute Tubulointerstitial Nephritis
Acute Bacterial Pyelonephritis
Drug Hypersensitivity
Chronic Tubulointerstitial Nephritis
Analgesic Nephropathy
Neoplastic Diseases Associated with Interstitial Nephritis
Aging-Associated Interstitial Disease
Chronic Kidney Disease
Hemodialysis
Peritoneal Dialysis
Renal Transplantation
Further Reading
Chapter 87: End-Stage Renal Disease
Definition
Epidemiology
Acute Kidney Injury in the Elderly
Presentation
Etiology of End Stage Renal Disease in the Elderly Population
Referral of Patients to Nephrology
Chronic Kidney Disease and Management of Chronic Health Conditions
Indications for Initiation of Dialysis
Contraindications to Renal Replacement Therapy
Health-Related Quality of Life
Management
Choice of Renal Replacement Modality
Hemodialysis
Peritoneal Dialysis
Kidney Transplantation
Time-Limited Trial of Dialysis
Conservative Management
Management of End Stage Renal Disease on Dialysis
Anemia
Cardiovascular Disease
Calcium, Phosphorous, Hyperparathyroidism, and Bone Disorders
Metabolic Acidosis
Malnutrition
Pruritus
Special Issues
Prognosis and Survival
Withdrawal from Dialysis
Advance Directives
Summary
Further Reading
Chapter 88: Disorders of Fluid Balance
Effects of Normal Aging on Fluid Regulatory Systems
Body Composition
Thirst and Fluid Intake
Renal Changes of Normal Aging
Structural and Functional Changes
Water Regulatory Capacity
Renal Water Retention
Renal Water Loss
Sodium Regulatory Capacity
Renal Sodium Retention
Renal Sodium Loss
Vasopressin System in Normal Aging
Neurohypophyseal System
Basal Plasma Vasopressin Levels
Vasopressin Stimulation
Age-Related Changes in Atrial Natriuretic Hormone Secretion, Regulation, and Action
Renin–Angiotensin–Aldosterone
Disorders of Fluid Regulation
Hyponatremia
Dilutional versus Depletional Hyponatremia
Hyponatremia
Risk Factors
Syndrome of Inappropriate Antidiuretic Hormone Secretion
Diseases
Drugs
Cerebral Salt Wasting
Clinical Presentation
Management
Role of Aquaretics in the Treatment of Hyponatremia
Hypernatremia and Dehydration
Epidemiology
Risk Factors
Clinical Presentation
Management
Nocturnal Polyuria
Evaluation
Management
Water Balance in Alzheimer’s Disease
Summary
Further Reading
Section E: Gastroenterology
Chapter 89: Effect of Aging on Gastrointestinal Function
Oropharyngeal Function
Esophageal Function
Gastric Function
Small Intestinal Function
Colonic Function
Colonic Neoplasia
Hepatic and Biliary Function
Pancreatic Structure and Function
Gastrointestinal Immunity
Gastrointestinal Drug Metabolism
Summary
Further Reading
Chapter 90: Hepatic, Biliary, and Pancreatic Disease
Hepatic Disease
Introduction
Liver Morphology
Liver Function
Liver Diseases
Hepatitis A Virus
Hepatitis B Virus
Hepatitis C Virus
Drug-Induced Liver Damage
Primary Biliary Cirrhosis
Autoimmune Hepatitis
Hepatocellular Carcinoma
Transplantation
Biliary Disease
Cholelithiasis
Choledocholithiasis
Acute Cholecystitis
Chronic Cholecystitis
Investigations
Treatment
Carcinoma
Gallbladder Cancer
Cancer of the Extra-Hepatic Bile Ducts
Pancreatic Disease
Anatomy
Physiology
Aging and the Pancreas
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Cancer
Further Reading
Chapter 91: Upper Gastrointestinal Disorders
Gastroesophageal Reflux Disease in the Elderly
Definition
Pathophysiology
Symptomatology
Diagnosis
Treatment
Lifestyle and Dietary Modifications
Pharmacological Treatment: Short-Term Therapy
Long-Term Maintenance Therapy
Safety of Long-Term Antisecretory Treatment
The Role of Surgery
Peptic Ulcer Disease
Definition
Epidemiology
Pathophysiology
Helicobacter pylori-Associated Peptic Ulcer
NSAID/Aspirin-Associated Peptic Ulcer
Clinical Features
Diagnostic Tests
Testing for Helicobacter pylori Infection
Posttreatment Helicobacter pylori Evaluation
Other Noninvasive Tests
Treatment Options for Peptic Ulcer Disease
Eradication of Helicobacter pylori Infection
Treatment and Prevention of NSAID-Related Peptic Ulcer
Identify the High-Risk Patient
Reduce Dosage and Use Less Damaging NSAIDs
Use of Selective Inhibitors of Cyclo-Oxygenase-2 (Coxibs)
Cotreatment with Gastroprotective Drugs
Eradication of Helicobacter pylori Infection
Educational Programs
Non-NSAID, Non-Helicobacter pylori Ulcers
Bleeding Peptic Ulcer
Neoplasm of the Esophagus
Esophageal Cancer
Squamous Cell Carcinoma
Adenocarcinoma
Diagnosis
Treatment
Palliative Therapy
Benign Tumors
Gastric Cancer
Epidemiology
Etiology and Risk Factors
Clinical Features
Diagnosis
Treatment of Gastric Cancer
Surgery and Endoscopic Procedures
Chemotherapy
Palliative Therapy
Further Reading
Chapter 92: Common Large Intestinal Disorders
Diagnostic Testing
Endoscopic Procedures
Colonoscopy
Endoscopic Ultrasound
Radiology
Contrast Studies
CT Colonography
Diverticular Disease
Pathophysiology
Asymptomatic Diverticulosis
Painful Diverticular Disease
Diverticulitis
Diverticular Hemorrhage
Clostridium Difficile Colitis
Pathogenesis
Clinical Manifestations
Diagnostic Tests
Treatment
Microscopic Colitis
Pathology
Treatment
Inflammatory Bowel Disease
Crohn’s Disease
Symptoms and Signs
Management
Ulcerative Colitis
Symptoms and Signs
Management
Colon Cancer in IBD
Colon Ischemia
Pathophysiology
Clinical Features
Management
Colonic Obstruction
Acute Colonic Pseudo-obstruction
Pathophysiology
Clinical Features
Management
Lower Gastrointestinal Bleeding
Vascular Ectasias
Summary
Further Reading
Chapter 93: Constipation
Introduction
Definitions
Prevalence of Constipation and Constipation-Related Symptoms
Self-Reported Constipation
Infrequent Bowel Movements
Difficult Evacuation
Constipation Symptoms in the Long-Term Care Setting
Pathophysiology
Colonic Function
Intrinsic Mechanisms for Colonic Dysfunction in Older People with Constipation
Anorectal Function
Age-Related Changes in Anorectal Function
Anorectal Dysfunction in Older Persons
Risk Factors for Constipation in Older People
Reduced Mobility
Polypharmacy/Drug Side Effects
Dietary Factors
Fiber
Calories
Enteral Nutrition
Fluid Intake
Amount
Alcohol and Coffee
Parkinson Disease
Diabetes Mellitus
Dementia
Mood-Related Disorders
Stroke
Spinal Cord Injury/Disease
Metabolic Disorders
Colorectal Cancer
Rectocele
Presentation
Clinical Evaluation
Digital Rectal Examination
Pelvic Floor/Rectal Prolapse
General Assessment
Plain Abdominal X-Ray
Colonoscopy/Bowel Preparation
Anorectal Function Tests
Complications of Constipation in the Elderly
Fecal Incontinence
Fecal Impaction
Urinary Retention/Lower Urinary Tract Symptoms
Stercoral Perforation/Colon Ischemia
Sigmoid Volvulus
Colonic Pseudo-obstruction
Rectal Prolapse
Diverticular Disease
Psychological Impact/Quality of Life
Nonpharmacological Treatment
Education
Diet
Fluids
Physical Activity
Abdominal Massage
Pelvic Floor and Sphincter Strengthening Exercises
Toileting Habits
Toileting Access—Privacy and Dignity
Medication Review
Pharmacological Treatment
Laxative and Enema Use and Abuse in Older People
Evidence-Based Summary of Laxative, Suppository, and Enema Treatment in Older Persons
Stimulant Laxatives
Bulk Laxatives
Magnesium Salts
Hyperosmolar Laxatives
Fecal Softeners
Enemas
Suppositories
Enterokinetic Agents
Treatment Guidance
Further Research
Conclusions
Further Reading
Section F: Oncology
Chapter 94: Oncology and Aging: General Principles
Relationship of Aging and Neoplasia
Clinical Presentations and Disease Behavior
Screening in Asymptomatic Individuals
Breast Cancer
Cervical Cancer
Colon Cancer
Lung Cancer
Initial Presentation
Biological Behavior of Tumors in the Elderly Host
Management
Major Therapeutic Modalities
Surgery
Radiation Therapy
Chemotherapy and Hormonal Therapy
Supportive Care
Conclusion
Further Reading
Chapter 95: Breast Disease
Risk Factors and Biology
Diagnosis
Primary Prevention, Screening, and Diagnosis
Primary Prevention
Screening
Diagnosis
Staging
Treatment of Breast Cancer
Carcinoma In Situ
Management of Early Localized Lesions (Stage I and II)
Local Management
Management of the Breast
Breast Reconstruction
Radiation After Mastectomy
Axillary Assessment
Adjuvant Systemic Therapy
Follow-up for Women with Early Breast Cancer
Treatment of Metastatic Disease
Special Considerations
Endocrine Therapy as Initial Treatment
Male Breast Cancer
Conclusions
Further Reading
Chapter 96: Prostate Cancer
Epidemiology and Risk Factors
Prevention
Finasteride
Vitamin E and Selenium
Presentation
Evaluation
Management
Observation
Active Surveillance
Local Therapy: Surgery, Radiation, or Brachytherapy
Radical Prostatectomy
External Beam Radiation Therapy
Brachytherapy
Primary Androgen Deprivation
Adjuvant Therapy
Posttreatment Surveillance
Biochemical Recurrence
Salvage Local Therapy
Advanced Disease
Hormonal Therapy
First-Line Hormonal Therapy
Intermittent Androgen Deprivation
Second-Line Hormonal Therapy
Chemotherapy
Supportive Care
Bisphosphonates
Pain Control
Palliative Radiation and Systemic Radioisotopes
Further Reading
Chapter 97: Lung Cancer
Epidemiology
Etiology
Risk Factors
Tobacco Smoking
Other Risk Factors
Screening
Pathology
Clinical Presentation
Paraneoplastic Syndromes
Diagnosis
Staging
Metabolic Staging
Prognostic Factors
Treatment of Non–Small-Cell Lung Cancer
Stage I (T1N0, T2N0)
Stage II (T1N1, T2N1, T3N0)
Stage IIIA (T3N1, T1–3N2)
Stage IIIB (T4N0, any TN3)
Stage IV (any T, any N, M1)
Small-Cell Lung Cancer
Special Problems
Pancoast (Superior Sulcus) Tumors
Chest Wall Tumors
Superior Vena Cava Syndrome
Solitary Brain Metastases
Supportive Care
Further Reading
Chapter 98: Gastrointestinal Malignancies
Introduction
Colorectal Cancer
Risk Factors of Colorectal Cancer
Chemoprevention of Colorectal Cancer
Screening of Colorectal Cancer
Localized Colorectal Cancer
Surgery—Localized Colon Cancer
Surgery—Localized Rectal Cancer
Adjuvant Therapy—Localized Colon Cancer
Adjuvant Therapy—Localized Rectal Cancer
Postoperative Surveillance—Localized Colorectal Cancer
Advanced Colorectal Cancer
Surgery—Advanced Colorectal Cancer
Chemotherapy—Advanced Colorectal Cancer
5-Fluorouracil
Capecitabine
Irinotecan
Oxaliplatin
Bevacizumab
Cetuximab/Panitumumab
Pancreatic Cancer
Treatment—Localized Pancreas Cancer
Treatment—Advanced Pancreas Cancer
Gastric Cancer
Treatment—Localized Gastric Cancer
Treatment—Advanced Gastric Cancer
Primary Liver Cancer
Treatment—Primary Liver Cancer
Esophageal Cancer
Treatment—Localized Esophageal Cancer
Treatment—Advanced Esophageal Cancer
Gallbladder Cancer
Treatment—Gallbladder Cancer
Anal Cancer
Treatment—Anal Cancer
Clinical Trials
Further Reading
Chapter 99: Intracranial Neoplasms
Gliomas
Low-Grade Gliomas
Anaplastic Gliomas
Glioblastoma Multiforme
Background
Radiation Therapy
Chemotherapy
Primary Nervous System Lymphomas
Brain Metastases
Radiation Therapy
Surgery
Prognosis
Meningiomas
Neuromas
General Considerations
Clinical Presentation
Diagnostic Evaluation and Imaging
Non-Chemotherapy Medication Considerations
Conclusions
Further Reading
Chapter 100: Skin Cancer
Introduction
Etiology
Nonmelanoma Skin Cancer
Basal Cell Carcinoma
Squamous Cell Carcinoma
Treatment for BCC and SCC
Electrodessication and Curettage
Cryosurgery
Topical Chemotherapy
Radiotherapy
Surgical Excision
Mohs Micrographic Surgery
Melanoma
Staging and Prognosis
Microstaging
Treatment of Melanoma
Biopsy
Surgical Excision of the Primary Tumor
Regional Node Management
Sentinel Lymph Node Biopsy
Lymphadenectomy Indications
Treatment of Disseminated Melanoma (Stage IV)
Other Cutaneous Tumors
Further Reading
Section G: Hematology
Chapter 101: Aging of the Hematopoietic System
Introduction
Biology of Hematopoiesis
Murine Hematopoiesis
Effect of Age on CFU-S and LT-HSC
Effect of Aging on Bone Marrow Function
The Effect of Age on Hematopoiesis in Humans
Normal Hematopoiesis
Age-Related Changes in Lymphohematopoiesis
Myeloid Lineage
Hematopoietic Progenitors
Polymorphonuclear Neutrophils
Monocytes and Macrophages
Red Cells
Hematopoietic Growth Factors
Lymphoid Lineage
Hematopoietic Growth Factors in Elderly Persons
Summary
Further Reading
Chapter 102: Anemia
Definition of Anemia in Older Adults
Prevalence and Types of Anemia
Prevalence
Types of Anemia
Nutrient-deficiency Anemia
Anemia with Iron Deficiency
Anemia with Vitamin B-12 (Cobalamin) and/or Folate Deficiency
Anemia of CKD
Anemia of Chronic Inflammation
”Unclassified” or “Unexplained” Anemia
Outcomes Associated with Anemia
Mortality
Decline in Physical Function
Frailty Status
Cognitive Function
Other Selected Outcomes
Nature of Associations: Anemia as a Causal or Noncausal (Marker) Risk Factor?
Diagnostic Considerations
Therapeutic Considerations
Nutrient-deficiency Anemia
Anemia of CKD
Anemia of Chronic Inflammation
”Unclassified” or “Unexplained” Anemia
Impact of Anemia Correction with Recombinant Erythropoietin on Clinical Outcomes
Conclusion
Further Reading
Chapter 103: White Cell Disorders
Decreased White Blood Cells
Drug/Toxin Effects
Nutritional Deficiency
Infections
Bone Marrow Failure
Increased Destruction
Splenic Sequestration
Neoplastic Causes of Decreased WBC
Increased WBC
Benign Causes of Leukocytosis
Infection
Drug-Induced Leukocytosis
Other Reactive Leukocytosis
Malignant Disease of the Hematopoietic System
Myelodysplastic (Preleukemia) Syndromes
Acute Myelogenous Leukemia
Acute Lymphoblastic Leukemia
Chronic Lymphocytic Leukemia
B-cell CLL
B-Cell Prolymphocytic Leukemia
T-Cell PLL/CLL
Hairy Cell Leukemia
T-cell Large Granular Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Myeloproliferative Diseases
Cancers Metastatic to Bone Marrow
Further Reading
Chapter 104: Non-Hodgkin’s and Hodgkin’s Lymphomas and Myeloma
Non-Hodgkin’s Lymphoma
Epidemiology
Classification
Etiology
Evaluation and Staging
Clinical Features and Therapy
Diffuse Large B-Cell Lymphoma
Follicular Lymphoma
Small Lymphocytic Lymphoma/Chronic Lymphocytic Leukemia
Marginal Zone Lymphoma
Mantle Cell Lymphoma
Highly Aggressive Lymphomas
Hodgkin’s Lymphoma
Presentation
Histologies
Staging
Therapy
Response to Treatment and Survival
Multiple Myeloma and Related Plasma Cell Dyscrasias
Epidemiology
Etiology
Clinical Manifestations of Disease and Their Pathogenesis
Bone Pain
Infection
Renal Failure
Anemia and Bleeding
Hyperviscosity
Neurological Symptoms
Diagnosis and Staging
Monoclonal Gammopathy of Uncertain Significance
Smoldering Myeloma
Myeloma Staging
Therapy
Other Plasma Cell Dyscrasias Seen in Geriatric Populations
Waldenström’s Macroglobulinemia
Heavy-Chain Disease
Amyloidosis
Take Home Points for the Geriatrician
Further Reading
Chapter 105: Thrombosis
Epidemiology
Incidence of VTE
Risk Factors
Pathophysiology
Natural History
Acute Consequences of Venous Thromboembolism
Chronic Complications of Venous Thromboembolism
Diagnosis
Deep Vein Thrombosis
Clinical Features
Diagnostic Testing
Venography
Venous Ultrasonography
D-dimer Blood Testing
Recurrent Deep Vein Thrombosis
Pulmonary Embolism
Clinical Features
Diagnostic Tests
Chest Radiography and Electrocardiography
Pulmonary Angiography
Ventilation–Perfusion Lung Scanning
Computed Tomographic Pulmonary Angiography
D-dimer Blood Testing
Compression Ultrasonography
Uncommon Thromboembolic Disorders
Subclavian or Axillary Veins
Mesenteric Vein
Renal Vein Thrombosis
Treatment of Venous Thromboembolism
Management of Acute Venous Thromboembolism
Overview
Anticoagulant Therapy
Duration of Anticoagulant Therapy
Primary Prevention of Venous Thromboembolism
Overview
Therapies
Indications for Venous Thromboembolism Prophylaxis
General Surgery and Medicine
Major Orthopedic Surgery
Genitourinary Surgery, Neurosurgery, and Ocular Surgery
Complications of Antithrombotic Agents
Risks of Major Bleeding
Consequences of Bleeding in Elderly
Further Reading
Chapter 106: Hemorrhagic Disorders
Overview of Hemostasis
Age-Related Effects on the Hemostatic System
Clinical Approach to Bleeding in the Elderly Patient
Age of Onset of Symptoms
Bleeding Symptoms
Bruising, Purpura, Petechiae, and Ecchymoses
Oral Mucosal Bleeding
Menorrhagia
Gastrointestinal Bleeding, Hemoptysis, and Hematuria
Family History of Bleeding
Medications
Diet
Physical Examination
General Examination
Purpura
Importance of Correlation of Clinical and Laboratory Findings
Quantitative Disorders of Platelets
Isolated Thrombocytopenia
Pseudothrombocytopenia
Immune Thrombocytopenia
Posttransfusion Purpura
Drug-Induced Thrombocytopenias
Qualitative Disorders of Platelets
Antiplatelet Agents
Myeloproliferative Disorders
Uremia/Chronic Renal Failure
Coagulation Disorders
Congenital Coagulation Disorders in Elderly Patients
Acquired Coagulation Factor Inhibitors
Acquired Hemophilia (Inhibitors to Factor VIII (fVIII)
Acquired von Willebrand’s Syndrome
Anticoagulants
Combined Hemostatic Defects
Disseminated Intravascular Coagulation
Liver Disease
Vascular Purpura
Senile Purpura
Scurvy
Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome)
Conclusions
Further Reading
Section H: Endocrinology and Metabolism
Chapter 107: Aging of the Endocrine System and Selected Endocrine Disorders
Principles of Geriatric Endocrinology
Impaired Homeostatic Regulation
Altered Presentation of Endocrine Diseases
Changes in Diagnostic and Therapeutic Approach
Neuroendocrine Regulation
Neurotransmitters and Neuropeptides
Dopamine
Norepinephrine
Opioid Peptides
Melatonin
Hormonal Changes in Alzheimer’s Disease
Anterior Pituitary
Prolactin
Pituitary Adenomas
Hypopituitarism and the Empty Sella Syndrome
Posterior Pituitary
Hypothalamic–Pituitary–Adrenal Axis
Physiology
Laboratory Testing of HPA Axis Function
Hyperadrenocorticism
Glucocorticoid Therapy
Hypercortisolism
Diagnostic Testing
Treatment
Adrenal Insufficiency
Adrenal Androgens and Aging
Dehydroepiandrosterone Supplementation for Older Adults
Adrenal Neoplasms
Sympathoadrenal System
Physiology
Clinical
Hypertension
Metabolic Syndrome
Autonomic Insufficiency
Pheochromocytoma
Renin–Angiotensin–Aldosterone System
Growth Hormone Axis
Physiology
Age Effects
Growth Hormone Deficiency in Adults with Hypothalamic–Pituitary Disease
Growth Hormone Supplementation for Older People Without Hypothalamic–Pituitary Disease
The Hypothalamic–Pituitary–Testicular Axis
Age Effects
Laboratory Diagnosis of Hypogonadism
Further Reading
Chapter 108: Thyroid Diseases
The Aging Human Thyroid
Anatomy
Physiology
Screening for Thyroid Disease
Nonthyroidal Illness
Drugs and Thyroid Function
Hypothyroidism
Definition
Prevalence
Etiology and Pathogenesis
Clinical Manifestations
Diagnosis
Treatment
Subclinical Hypothyroidism
Myxedema Coma
Hyperthyroidism
Definition
Prevalence
Etiology and Pathogenesis
Clinical Manifestations
Diagnosis
Treatment
Subclinical Hyperthyroidism
Thyroid Nodules
Prevalence
Clinical Evaluation
Diagnostic Tests
Management
Thyroid Cancer
Papillary Thyroid Carcinoma
Follicular Thyroid Carcinoma
Medullary Thyroid Carcinoma
Anaplastic Thyroid Carcinoma
Thyroid Lymphoma
Further Reading
Chapter 109: Diabetes Mellitus
Definition and Classification
Type 1 Diabetes
Type 2 Diabetes
Other Specific Types of Diabetes
Gestational Diabetes Mellitus
Diagnostic Criteria
Diagnostic Testing for Older Adults
Epidemiology of Diabetes and Its Complications
Diabetes Mellitus and Prediabetes
Diabetes Complications
Pathophysiology of Diabetes and Its Complications
Effects of Aging
Insulin Resistance
Impaired Insulin Secretion
Interaction Between Impaired Insulin Secretion And Insulin Resistance
Genetics
Mechanisms for Diabetes Complications
Prevention
Presentation
Evaluation
Medical Evaluation
Other Evaluation Components
Diabetes Knowledge
Functional Status
Cognitive and Psychosocial Status
Overall Health Status
Diabetes Management
General Approach
Management of Cardiovascular Risk Factors
Prevention of Microvascular Complications
Other Diabetes Complications
Management of Hyperglycemia
Basic Care
Aggressive Care
Specific Interventions for Hyperglycemia
Diet
Caloric Intake
Diet Composition
Dietary Issues in Older People
Exercise
Noninsulin Agents
Sulfonylurea Drugs
α-Glucosidase Inhibitors
Biguanide
Thiazolidinediones
Meglitinide
D-Phenylalanine Derivative
Dipeptidyl Peptidase-4 (DPP-4) Inhibition
Glucagon-like Peptide-1 (GLP-1) Analog
Combination Therapy
Insulin Therapy
Advantages of Insulin
Disadvantages of Insulin
Insulin Regimens
Amylin Analog: Adjunct to Mealtime Insulin Therapy
Initiation of Insulin Therapy
Combination of Insulin and Oral Agents
Follow-up Care
Special Issues
Hypoglycemia
Hypoglycemia Counterregulation
Hypoglycemia in Elderly Patients
Hyperosmolar Coma and Diabetic Ketoacidosis
Diabetes in Long-Term Care
Further Reading
Chapter 110: Dyslipoproteinemia
Definition
Pathophysiology
Overview of Lipoprotein Subclasses and Lipoprotein Metabolism
Mechanisms Underlying the Age-Associated Changes in Lipids
Changes in Diet
Total and Visceral Adiposity
Physical Fitness
Lipoprotein Synthetic and Catabolic Rates
Epidemiology
Coronary Heart Disease
Age-Associated Changes in Lipids
Secular Changes in Lipoprotein Lipid Concentrations and Prescribing Patterns
Secular Changes in Lipoprotein Lipid Concentrations
Secular Changes in HMG-CoA Reductase Inhibitor (Statin) Prescription Patterns
Lipoproteins as Risk Factors for Coronary Heart Disease
Elevated Total and LDL-C Concentrations
Reduced Concentrations of HDL-C
Atherogenic LDL Pattern B Phenotype
Apolipoprotein 4 Allele
Elevated Lipoprotein (a)
Summary
Intervention Trials
Presentation
Evaluation
Management
Risk-Stratified Approach to Lipid Treatment
Therapeutic Lifestyle Intervention
Pharmacological Therapy
HMG-CoA Reductase Inhibitors (Statins)
Fibrates
Bile Acid Sequestrants
Nicotinic Acid (niacin)
Ezetimibe
Prevention
Special Issues
Secondary Dyslipidemias Caused By Medications
Diabetic Dyslipoproteinemia and Metabolic Syndrome
Hypocholesterolemia
Management of Dyslipidemia in the Nursing Home Setting
Further Reading
Chapter 111: Hyperparathyroidism and Paget’s Disease of Bone
Hyperparathyroidism
Background and Epidemiology
Etiology and Pathology
Signs and Symptoms
Diagnosis
Differential Diagnosis
Therapy
Paget’s Disease of Bone
Epidemiology
Etiology
Pathophysiology
Clinical Manifestations
Diagnosis
Therapy
Acknowledgments
Further Reading
Section I: Mobility and Musculoskeletal System
Chapter 112: Aging of the Muscles and Joints
Articular Cartilage
Normal Structure and Function
Regulation of Cartilage Matrix Turnover
Age-Related Changes in Cartilage
Changes in Cartilage Structure and Matrix Composition
Aging and Chondrocyte Function
Potential Role of Oxidative Stress in Cartilage Aging
Aging and the Development of Osteoarthritis
Aging as a Risk Factor for OA
Contribution of Aging to the Anabolic and Catabolic Imbalance in OA
Skeletal Muscle
Skeletal Muscle Structure and Function
Motor Unit
Events in Muscle Contraction and Relaxation: Skeletal Muscle Excitation–Contraction Coupling
Muscle Fiber Subtypes and Types of Contraction
Neural Control of Muscle Contraction
Mechanisms Underlying Skeletal Muscle Weakness in Old Age
Neurogenic Mechanisms of Skeletal Muscle Impairment with Aging
Myogenic Mechanisms of Skeletal Muscle Impairment with Aging
Combined Neurogenic–Muscular Mechanism
General Mechanisms of Aging that Involve Skeletal Muscle
Clinical and Experimental Interventions Aimed at Delaying or Preventing Age-Associated Changes in Skeletal Muscle Composition and Function
Tendons and Ligaments
Intervertebral Disks
Further Reading
Chapter 113: Biomechanics of Mobility
Prevalence of Mobility Problems Among Older Adults
Age and Gender Differences in Falls and Fall-Related Injury Rates
Fall-Related Injury Biomechanics
The Biomechanics of Hip Fractures
The Biomechanics of Wrist Fracture
Age Changes in Components of Biomechanical Capability
Myoelectric Latencies
Reaction Times
Age and Gender Group Differences in Latencies and Reaction Times
Biomechanical Effects of Age Differences in Latencies and Reaction Times Are Minor
Proprioception
Joint ROM
Muscle Strength and Power
Rapid Development of Joint Torque Strengths
Source of Age Differences in Rapid Strength Development
Age Differences in Performance of Simple Mobility Tasks
Assessment of Mobility Function
Ascribing Functional Decline Fully to Insufficient Motivation, Activity, or Training is Questionable
Gait
Rising From Chairs, Beds, and Floors
Turning in a Confined Space
Walking on Irregular Surfaces
Restoration of Standing Posture after Modest Disturbance
Cognitive and Other Psychological Factors
Age Differences in Performance of Time-Critical Mobility Tasks
Times Needed for Quick Responses to Maintain or Recover Balance
Studies of Time-Critical Obstacle Avoidance Tasks
Avoiding Obstacles by Stepping over Them
Avoiding Obstacles by Turning Away Before Reaching Them
Avoiding Obstacles by Stopping Before Reaching Them
Studies of Time-Critical Balance Recovery Tasks
Recovery from a Slip
Mechanisms Underlying Age and Gender Differencesin Performance of Time-Critical Tasks with High Strength Demands
Conclusions
Further Reading
Chapter 114: Exercise: Physiological and Functional Effects
Aging, Disuse, and Disease
Aging and Exercise
Endurance (Aerobic) Exercise Capacity
Aging-Associated Changes in Endurance Exercise Capacity
The Peripheral Components of Endurance Capacity
The Central (Cardiovascular) Component of Endurance Capacity
The Physiological Effects of Endurance Exercise Training
Effects on VO2max
Effects on Body Composition
Effects on Cardiac Function
Effects on Endothelial Function
Skeletal Muscle Strength and Power
Aging-Associated Changes in Muscle Strength and Power
Muscle Mass
Muscle Fibers
Motor Units
Muscle Quality
Disuse versus Aging
The Physiological Effects of Strength Training
Effect on Muscular Strength and Power
Physiological Mechanisms Explaining Gains in Strength with Exercise
Exercise, Physical Activity, and Functional Limitations
Evidence That Exercise Improves Functional Limitations
Nonlinear Relationship Between Physiological Impairment and Functional Limitation
Exercise and Common Geriatric Disorders
Insulin Resistance and Glucose Intolerance
Dyslipidemia
Hypertension
Atherosclerotic CVD and Overall Mortality
Arthritis
Osteoporosis
Cancer
Mood and Cognition
Other Chronic Medical Disorders
Risks Associated with Exercise
Recommendations
Further Reading
Chapter 115: Mobility
Introduction
Definitions and Methods of Classification
Defining Mobility
Classification Methods for Mobility
Epidemiology
Prevalence
Risk of Adverse Consequences Associated with Mobility Status
Pathophysiology
Epidemiological Perspective: Risk Factors
Biomechanical Perspective: Direct Assessment of the Body in Motion
Physiological Perspective: Using Organ System Impairment to Link Function and Disease
Gait Speed as an Integrator of Multiple Approaches
Evaluation
Strategy for the Clinical Encounter
Clinical Assessment of Mobility Performance
Differential Diagnosis Based on a Physiological Perspective
Psychosocial and Environmental Assessment
Management
Intervening Directly on Mobility
Treating Impairments
Attention to Factors that Modify Behavior and Environment
Care for the Immobile Person
Summary
Further Reading
Chapter 116: Osteoarthritis
Introduction
Epidemiology, Causes, and Predisposing Factors
Age and Gender
Joint Trauma and Nontraumatic Biomechanical Factors
Obesity
Muscle Strength
Classification and Pathophysiology
Classification
Pathophysiology
Presentation
Symptoms
Physical Abnormalities
Evaluation
Diagnostic Imaging
Magnetic Resonance Imaging
Laboratory Studies
Management
Patient Education
Nonmedicinal Interventions
Exercise
Electrical Stimulation
Ultrasound
Cryotherapy and Thermotherapy
Acupuncture
Massage
Orthoses
Braces and Splints
Assistive Devices
Symptom-Directed Medicinal Therapy
Topical Agents
Simple Analgesics
Non-steroidal anti-inflammatory Drugs
Cyclooxygenase-2 Inhibitors
Nutriceuticals
Narcotic Analgesics
Structure-Modifying Medicinal Agents
Intra-articular Therapies
Intra-articular Glucocorticoid Agents
Hyaluronic Acid Derivatives
Surgical Interventions
Arthroscopy with Debridement
Osteotomy
Arthroplasty
Unicompartment Arthroplasty
Patellofemoral Arthroplasty
Total Joint Arthroplasty
Bilateral Knee Arthroplasty
Hand Surgery
Restorative Tissue Interventions
Prevention
Special Issues
Pain and Incidental OA
Conditions Superimposed with OA
Functional Limitations
Falls
Comorbidities
Conclusions
Further Reading
Chapter 117: Osteoporosis
Definition of Osteoporosis
Epidemiology
Pathophysiology
Bone Cells
Genetics
Mechanical Factors
Local Factors
Systemic Hormones
Age-Related Bone Loss
Osteoporosis in Men
Presentation
Secondary Causes of Osteoporosis
Evaluation
Bone Density Measurement
Clinical Risk Factors
Biochemical Markers of Bone Turnover
Management
Nonpharmacological
Exercise
Nutrition
Pharmacological
Estrogen Replacement Therapy
Bisphosphonates
Calcitonin
Selective Estrogen Receptor Agonists
Parathyroid Hormone
Other Agents
Strontium Ranelate
Denosumab
Osteoporosis in Nursing Homes
Further Reading
Chapter 118: Hip Fractures
Introduction
What to Expect When Seeing Patients in Hospital
Medical Presentation and Fracture Characteristics
Cognitive Status
The Geriatrician’s Role in Caring for Patients with Hip Fracture on Entry into Acute Care and Recommendations Regarding Surgical Intervention
Postoperative Care in Hospital
The Geriatrician’s Role in Postoperative Care
Postfracture Changes in Physical and Psychosocial Function and Implications for Care
Physical Function
Psychological Status
Physiologic Changes Post Hip Fracture
Functional Recovery Post Hip Fracture
Postfracture Rehabilitation
Discharge Planning
Rehabilitation Services
The Role of the Geriatrician in the Rehabilitation Setting
What to Tell the Patient and Family to Expect in Terms of Function
The Geriatrician’s Role in Caring for Patients with Hip Fracture Following Rehabilitation
Conclusions
Acknowledgments
Further Reading
Chapter 119: Myopathy, Polymyalgia Rheumatica, and Temporal Arteritis
Skeletal Muscle, Aging, and Disease
Myopathies
Idiopathic Inflammatory Myopathies (IIM)
Polymyositis
Dermatomyositis
Inclusion Body Myositis
Treatment of Idiopathic Inflammatory Myopathies
Other Myopathies
Steroid-Induced Myopathy
Hypothyroidism-Related Myopathy
Hyperthyroidism-Related Myopathy
Statin-Induced Myopathy
Other Myopathies
Polymyalgia Rheumatica
Temporal Arteritis (Classic Cranial GCA)
Further Reading
Chapter 120: Rheumatoid Arthritis and Other Autoimmune Diseases
Rheumatoid Arthritis
Definition
Epidemiology
Pathophysiology
Aging Effects
Presentation
Evaluation
Management
Nonpharmacological Therapies
Pharmacological Therapies
Biological Response Modifiers
Safety and Other Issues with Biologics
Surgical Interventions
Prevention
Special Issues
Patient Preference and Comorbidity
Care Settings
Systemic Lupus Erythematosus
Diagnosis
Pathogenesis
Presentation
Management
Sjögren’s Syndrome
Definition
Epidemiology
Pathogenesis
Presentation and Clinical Features
Management
Drug-Induced Rheumatic Syndromes
Drug-Induced Lupus
Drug-Induced Myopathy/Myositis
Drug-Induced Vasculitis
Rheumatic Syndromes and Cancer
Musculoskeletal Symptoms Associated with Cancer
Rheumatic Diseases and Cancer
Risk of Cancer with Immunosuppression
Further Reading
Chapter 121: Back Pain and Spinal Stenosis
Epidemiology
Etiology of Back Pain
Tumor
Infection
Vertebral Compression Fractures
Osteoporotic Sacral Fractures
Sciatica
Lumbar Spinal Stenosis
Mechanical Low Back Pain
Diffuse Idiopathic Skeletal Hyperostosis
Evaluation
History
Physical Examination
Laboratory Tests and Imaging
Management
Vertebral Compression Fractures
Lumbar Spinal Stenosis
Mechanical Low Back Pain
Further Reading
Chapter 122: Primary Considerations in Managing the Older Patient with Foot Problems
Introduction
Etiological and Epidemiological Factors
Anatomy of the Foot and Changes Related to Age
Foot Changes with Age and Disease
Clinical Assessment and Medicare Considerations
Primary Management—Guidelines and Principles
Skin
Toenails
Pathomechanics and Biomechanics
Foot Orthopedics
Footwear and Orthoses
Therapeutic Shoes for Diabetics
Ulcerations
Diabetic and Peripheral Arterial Considerations
Conclusion
Further Reading
Chapter 123: Fibromyalgia and Myofascial Pain Syndromes
Fibromyalgia Syndrome
Definition and Epidemiology
Pathogenesis
Peripheral Tissue Abnormalities
Central and Peripheral Sensitization and Pain Amplification
Neuroendocrine Abnormalities
Biochemical Abnormalities
Functional Imaging of Pain
Genetics
Clinical Presentation
Patient History
Physical Examination
Treatment
Medications
Antidepressants
Antiepileptics
Analgesics
Hormonal Supplements and Other Agents
Nonpharmacological Therapies
Assessing Response to Treatment
Myofascial Pain Syndromes
Background and Epidemiology
Pathogenesis
Clinical Presentation and Evaluation
Cervicogenic Headaches
Piriformis Syndrome
Trapezius MP
Upper and Lower Back Pain
Pseudotrochanteric Bursitis
Postherpetic Pain
Other MP and Dysfunction Syndromes
Management
Treatment of Perpetuating Factors
Trigger Point Treatment
Conclusion
Further Reading
Section J: Infectious Diseases and Immunology
Chapter 124: Infection in the Elderly
Predisposition of the Elderly to Infection
Comorbidities
Waning Immunity
Nutrition
Social and Environmental Factors
Diagnosis and Management of Infections in the Elderly Patient
Presentation of Illness
Antibiotic Management
Clinical Syndromes in the Elderly
Infective Endocarditis
Bacteremia and Sepsis
Prosthetic Device Infections
Tuberculosis
Fever of Unknown Origin
Immunization of the Elderly
Pneumococcal Vaccine
Influenza
Zoster
Other Vaccines
Travel Recommendations for the Elderly Person
Further Reading
Chapter 125: General Principles of Antimicrobial Selection
Introduction
Identifying the Causative Pathogen
Clinical Features
Epidemiological Context
Determining Breadth of Coverage
Severity of Infection
Antimicrobial Resistance
Pharmacological Considerations
Pharmacokinetics
Toxicity and Polypharmacy
Final Considerations: Narrowing and Withholding Therapy
Specific Infectious Syndromes
Pneumonia and Other Respiratory Infections
Skin and Soft Tissue Infections
Gastrointestinal Infections
Infectious Diarrhea
C. difficile-Associated Diarrhea
Bone and Joint Infections
Osteomyelitis
Septic Arthritis
Prosthetic Joint Infection
Central Nervous System Infection
Meningitis
Encephalitis
Healthcare-Associated Infections
Healthcare-Associated Pneumonia
Skin and Soft Tissue Infections
Urinary Tract Infection
Bacteremia
Further Reading
Chapter 126: Pneumonia
Definitions
Epidemiology
Etiology
S. pneumoniae
Staphylococcus aureus
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Legionnaires’ Disease
Enterobacteriaceae
M. tuberculosis
Viruses
Respiratory Syncytial Virus
Human Metapneumovirus
Severe Acute Respiratory Syndrome
Other Coronaviruses
Hantavirus
Influenza A
Aspiration Pneumonia
Pathophysiology
Presentation
Evaluation
Site of Care
Transfer from a Nursing Home to Hospital
ICU Admission
Diagnostic and Therapeutic Evaluations
Diagnostic Evaluations
Therapeutic Evaluations
Discharge Decision
Management
Drugs
Antibiotics
When to Switch from Intravenous to Oral Antibiotics in the Treatment of CAP
Nonpharmacological Management
Ancillary Measures
Prevention
Pneumococcal Vaccine
Influenza Vaccine
Cessation of Tobacco Smoking
Prevention of Aspiration Pneumonia
Special Issues
Patient Preference
Patient Education
Quality of Care Measures
Conclusions
Further Reading
Chapter 127: Urinary Tract Infections
Presentations of Urinary Infection
Epidemiology
Asymptomatic Infection
Elderly in the Community
Institutionalized Older Adults
Symptomatic Urinary Infection
Elderly in the Community
Institutionalized Older Adults
Morbidity and Mortality
Asymptomatic Bacteriuria
Symptomatic Urinary Infection
Pathogenesis
Route and Site of Infection
Microbiology
Infecting Organisms
Antimicrobial Resistance
Host Factors
Elderly in the Community
Institutionalized Older Adults
Immune and Inflammatory Response
Clinical Presentation
Symptomatic Urinary Infection
Hematuria
Clinical Deterioration Without Localizing Genitourinary Symptoms
Laboratory Evaluation
Microbiological Diagnosis
Urine Specimen Collection
Interpretation of Urine Culture
Pyuria and Other Diagnostic Tests
Management
Asymptomatic Infection
Symptomatic Urinary Infection
Choice of Antimicrobial
Oral Therapy
Parenteral Therapy
Resistant Organisms
Duration of Therapy
Outcome Following Therapy
Controversies in UTI Management in Long-Term Care Facilities
Prevention
Asymptomatic Infection
Symptomatic Infection
Long-Term Indwelling Catheters
Epidemiology
Biofilm Formation
Clinical Presentations
Management of Symptomatic Infection
Prevention
Summary
Further Reading
Chapter 128: Human Immunodeficiency Virus Infection
Clinical Presentation
Diagnosis
Prognosis
Overlapping Complications, Comorbidities, and Toxicity
HIV and Related Conditions
Benefits and Harms of Antiretroviral Treatment
Substance Use and Abuse
Aging and Comorbid Medical and Psychiatric Disease
Management
Further Reading
Chapter 129: Herpes Zoster
Definition
Epidemiology
Varicella-Zoster Virus Transmission
Herpes Zoster Incidence and Risk Factors
Postherpetic Neuralgia Incidence, Prevalence, and Risk Factors
Clinical Features
Prodrome
Rash
Acute Herpetic Neuralgia
Complications
Diagnosis
Differential Diagnosis
Laboratory Tests
Management
Acute Herpes Zoster
Nonpharmacological Management
Antiviral Therapy
Analgesics
Corticosteroids
Adjuvant Agents
Postherpetic Neuralgia
Oral and Topical Pharmacotherapy
Topical Treatments
Gabapentin and Pregabalin
Tricyclic Antidepressants
Opioid and Opioid-Like Analgesics
Combination Pharmacotherapy
Other Treatments
Noninvasive Treatments
Invasive Treatments
Prevention
Varicella Vaccine
Zoster Vaccine
Further Reading
Chapter 130: Influenza and Respiratory Syncytial Virus
Influenza
Clinically Relevant Biological Characteristics of Influenza Virus
General Epidemiology of Influenza
Important Host Considerations in the Elderly
Clinical Presentation
Specific Diagnostic Tests
Infection Control Aspects
Immunization
Influenza and Long-term Care
Use of Antivirals to Prevent and Treat Influenza in Older Adults in the Community
Indirect Benefit of Immunization in Children to Protect Older Adults
Respiratory Syncytial Virus
Characteristics of Respiratory Syncytial Virus
General Epidemiology
Community-Dwelling Elderly and Respiratory Syncytial Virus
Epidemiology of Respiratory Syncytial Virus in Long-term Care Facilities
Clinical Features of Respiratory Syncytial Virus in the Elderly
Diagnosis
Therapy
Prevention
Further Reading
Index
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