1. Geriatric Gems

2. Let’s start with the 5 vital signs in the elderly—T, P, R, BP, and weight

3. Temperature patterns in the elderly • Loss of diurnal variation • Contributes to sleep problems—diurnal variation and melatonin secretion • May not rise as rapidly with infections or as high • A rise of greater than 1.3° C (2.4° F) within 2 hours—consider sepsis • Patients on neuroleptic drugs (central dopamine blockers) such as haloperidal and/or the atypical antipsychotics, tend to have lower basal temperatures (always complaining of “feeling cold”)

4. Temperature patterns in the elderly • Loss of subcutaneous fat (actually you don’t LOSE the fat, you just move it to the internal visceral organs) with age--difficulty maintaining internal temperatures with extremes of ambient temperature* • Hypothermia/hyperthermia • “You’re not dead until you’re warm and dead.” • Always check the thyroid gland—myxedema coma + cold ambient temperature

5. Why is type 2 diabetes more common in older adults? 1) Weight itself may NOT be an issue in the elderly patient--↑visceral fat distribution = insulin resistance 2) Reduced physical activity; decreased exercise = decreased insulin sensitivity and increased insulin resistance 3) An old pancreas finally gives out

6. Aging and type 2 diabetes • 50% of all type 2 diabetics are over 60; • 18% are 65-75; • 40% of people over 80 have diabetes

7. Pulse/heart rate • Bradycardia—hypothyroidism, dig, beta blockers decrease HR by 10-15% (even topical beta blocker eyedrops {Timoptic, Betoptic, etc.) can cause bradycardia*, calcium channel blockers such as verapamil and diltiazem, and cholinergic drugs for Alzheimer’s disease and other dementing processes--galantamine (Razadyne), rivastigmine (Exelon), donepezil (Aricept); OTC cimetidine (Tagamet) with beta blockers • *and anhedonia (by crossing the BBB and blocking norepinephrine in the energy center of the brain)

8. Pulse/heart rate • Palpitations with CHF, hyperthyroidism, AF, menopause • Unexplained tachycardia (60 to 80 is the normal resting heart rate)—consider hyperthyroidism, atrial fibrillation (which can also be caused by hyperthyroidism) • Levothyroxine RX can also cause atrial fib if the dose is too high; levothyroxine doses DECREASE with aging; some patients only need 0.5 mcg/kg/day vs. younger adults with 1.7 mcg/kg/day (Prescriber’s Letter July 2011) • Diabetics with tachycardia (loss of vagus nerve due to autonomic neuropathy) and silent ischemia in diabetics

9. Respirations • Tagamet (cimetidine) and morphine—increased bioavailability of morphine with a possible reduction in respiratory rate to 4-6 per minute; NO TAGAMET (cimetidine) in older patients—ZERO TOLERANCE 1st dose delirium; highly anticholinergic

10. Respirations • Fever and tachypnea in the older adult—consider an acute pulmonary syndrome— • Pulmonary embolism (over 85? 700 PE/100,000) • Pneumonia—confusion, tachypnea, fever and shoulder pain—referred pain due to a big “wet” lung* • How much embryology did you get in Nursing school?

11. Referred pain…Let’s go back about 80 years…to the embryo. • Embryologic development and the diaphragm—C3, C4 • Shared sensory afferents with somatic structures— • Diaphragm and the shoulder • Other structures/causes of referred pain to the shoulder

12. Weight as a vital sign in the elderly • Unexplained weight loss--causes are numerous but always LOOK for a cause—no money for food? Transportation issues? Cancer? Cardiorespiratory? TB? • Drugs and weight loss (dig, metformin, chemo, cholinesterase inhibitors for dementia) • Drugs and weight gain-- insulin, sulfonylureas, SSRIs (paroxetine/Paxil; fluoxetine/Prozac), corticosteroids, atypical antipsychotics—clozapine/Clozaril and olanzepine/Zyprexa, mirtazepine/Remeron (good drug for depressed frail elderly) • Heart failure and weight gain due to fluid retention

13. What is senescence?? • The rate of deterioration of the structure and function of body parts • The 1%rule • Functional reserve capacity of tissues is 4-10 x greater than baseline (the amount needed just to function on a day-to-day basis) • Peak functional capacity at 24 • 6 good years • Party’s over • Reach baseline between 72-77

14. Senescence and normal aging... • Peak at 24, 6 good years, gradual decline to baseline; FRC% Baseline function 1yr 30 75 yrs

15. Senescence and chronic disease... • More rapid decline with chronic disease (DM, COPD) FC% Baseline function 1yr 30 75 yrs

16. Senescence and gender differences... • Gender differences—the ovary (51.3 +/- 2.7) FC% Baseline function 1yr 30 75 yrs

17. Livin’ on the edge…renal function • Glomerular filtration rate (GFR)—120-125 ml/min at age 30; decreases by ~1% per year; • 75-year-old = 1.2 mL/min x 45 years = 53 mL/min; 120-53 = GFR of 67 mL/min in a HEALTHY 75-year-old (not taking into account weight, ethnicity, or gender) • BUT, a GFR of 60-89 mL/min is considered mild renal insufficiency or stage 2 CKD • a GFR of less than 60 mL/min/1.73 m2 represents a loss of more than half of normal kidney function (Stage 3 CKD)

18. Throw in some nephrotoxic drugs and the elderly and they may go over baseline • Antibiotics (aminoglycosides)—once a day dosing decreases risk of nephrotoxicity (the ears and the kidneys) • Radiocontrast dyes for procedures • NSAIDs block prostaglandin production—prostaglandins are important renovasodilators in the elderly; block? Renovasoconstriction with a decreased GFR; may increase SBP by 5-8 mmHg, fluid retention with peripheral edema • ACE inhibitors (“prils”) are especially dangerous if renal blood flow is compromised—renal artery atherosclerosis (stenosis) and/or NSAIDS • WHY?

19. Normal function: Angiotensin II helps maintain glomerular filtration pressure in the nephron • Afferent arteriole (vasodilated via (prostaglandins) • Blood entering glomerulus • Glomerulus→filter • Efferent arteriole (vasoconstricted via (angiotensinII) • Blood exiting glomerulus Prostaglandins filter Angiotensin II Toilet

20. ACE inhibitors and NSAIDS… • Prostaglandins are inhibited by NSAIDS causing vaso- constriction—CLOSE the front door • ACE inhibitors inhibit angiotensin resulting in vasodilation OPEN the BACK DOOR SHUT DOWN filtration PG filter AT2 Toilet

21. In addition to causing renal failure… • Vasoconstriction of the afferent arteriole by NSAIDs results in sodium, potassium, and water retention, and you could have a deadly rise in potassium, resulting in a fatal cardiac arrhythmia; increased BP • NSAIDs should NOT be used in patients with heart failure – can significantly exacerbate symptoms • And the “prils” increase potassium too, as does spironolactone (Aldactone) • Potentially fatal potassium—keep checking levels

22. Water loss and aging • Decrease in total body water stores • Decreased volume of distribution • Increased drug toxicity with water-soluble drugs—dig for example • Encourage fluid intake (loss of response to thirst receptors)

23. Decreased water, collagen*, elastic tissue • FYI, estrogen maintains the health of collagen in the skin • (Wolff EF, et al. Long-term effects of hormone therapy on skin rigidity and wrinkles. Fertility Sterility 2005 Aug; 84:285-8.) • Wrinkles and Premarin Vaginal Cream

24. How do you test for dehydration in the elderly? • Shrunken eyeballs? NO • Poor skin turgor? Not the usual test • Where do you check skin turgor in the elderly? pinch skin over the sternum or the forehead

25. 1% rule—but instead of the usual decrease in function, an INCREASE by 1% per year of clotting factors • Increased risk of clotting in the elderly • DVTs most common in elderly; increased risk for PE • Acute coronary syndromes • Wake up with a “stroke in progress” • Window for tPA for ischemic strokes • Atrial fibrillation is common in the elderly • Warfarin (Coumadin) and the newer anticoagulants (rivaroxaban/Xarelto, epixaban/Eliquis, dabigatran/Pradaxa) are a VERY popular drug in the over 70 group • The newer anticoagulants for AF are better at preventing strokes; 25% higher risk of GI bleed

26. 1% rule—an increase in body fat • Retention of lipid-soluble drugs • Half-life (T1/2) of diazepam (Valium) is the patient’s “age, in hours” 25-year old = 25 hours 75-year old = 75 hours Shorter-acting benzodiazepines should be used in the elderly (Restoril (temazepam), Serax (oxazepam), Ativan (lorazepam), Xanax (aprazolam) Halcion (triazolam) Start low and go slow…

27. Neurology of aging… • 5% loss of cerebral weight in females by 70 • 10% loss in men (men start out with a bigger brain, however) • By 80, 17-20% loss • Selected areas are the frontal lobes and the medial temporal lobes (hippocampus)

28. Loss of hippocampal cell function • Loss of recent memory • This is the first neurologic function to go with the aging process • Benign forgetfulness • Mild cognitive impairment

29. What is mild cognitive impairment? (MCI) • Borderline state—individuals are not demented, but they perform worse than their peers • They sense that they are forgetful, and somebody close to them has probably noticed it, too; (repetition of questions and comments; misplacing things—relying more on notes and calendars, forgetting meds, familiar persons; word finding difficulties; • Demanding task – new technology may prove challenging; 10-15% per year evolve to clinical Alzheimer’s disease vs. normal elderly who do so at a rate of 1-2% per year • Montreal Cognitive Assessment (www.mocatest.org)

30. Reduction in prefrontal lobe function with the aging brain… • Personality changes • Decreased ability to concentrate on the task at hand • Anti-social, regressive behavior (the loss of tact) • Hostile behavior

31. “MOTHER” is responsible for your behavior…your prefrontal lobe is your “mom” • What’s the only word a mother needs to know? • NO, Stop, Don’t, Negative…she is inhibitory • Socialization, judgment, insight • You learn through inhibitory influences

32. With a dementing process… • Mom is no longer responsible for “sociable behavior” (bilateral frontal lobes) • Sexual indiscretions • The world becomes the bathroom • Clothing is optional

33. Diagnostic features of dementia… • Hallmark is memory impairment • Apraxia—inability to carry out a motor function in the absence of paralysis • Auditory and/or visual agnosias • Impaired executive functioning—planning, organizing, abstracting (judgment/problem solving) • Abstraction—cow, horse, pig: car, boat, airplane? • Significant impairment in occupational functioning • Lots of causes—need a complete workup including CT scan for normal pressure hydrocephalus • Reversible vs. non-reversible causes

34. Important causes of dementia—don’t overlook • Nutritional dementia (B12 deficiency)--(B12 --lower limits 200 pg/mL but patients with dementia and levels less than 300 pg/mL should be given a trial of B12); reversible; a methyl malonic acid test (MMA) is more accurate for a B12 deficiency • Hypothyroidism (treatable) • Primary brain tumor or metastatic cancer (+/- treatable) • Neurosyphilis—Argyll-Robertson pupil; accommodates but doesn’t react to light (treatable) • Huntington’s disease (not treatable)

35. “Assume that the onset of delirium in the old person is due to infection.”—Clifton Meador, M.D. • Pneumonia—decreased oxygenation to brain • Listen to the base of the lungs • A few basilar crackles can be normal in the very old patient • “hairy backs”

36. Urinary tract infections (UTI) • The leading nosocomial (hospital-acquired, facility acquired) infection is the UTI—generally related to an indwelling catheter • The prevalence of bacteriuria in elderly men is 10%; elderly women—20% • In residents of LTCF, bacteruria is more common and the frequencies in women and men become similar • Asymptomatic bacteriuria is defined as the presence of a positive urine culture in the absence of new signs and symptoms of UTI

37. Symptomatic UTIs in elderly • “Assume that the onset of delirium in the old person is due to infection.”—Clifton Meador, M.D. • 1/3 are caused by E. coli; 1/3 caused by Proteus spp. • Klebsiella and pseudomonas common in LTCF • 25% of cases in LTCF are polymicrobial • Lots of common risk factors for UTIs—diabetes, dehydration, kidney stones, relaxation of pelvic floor muscles and inefficient bladder emptying, prostatic hypertrophy, chronic prostatitis, incontinence, poor hygiene

38. Word to the wise • UTIs and TMP/SFX (Bactrim or Septra) • Antibiotic increases K+ levels • Watch levels if they are also on an ACE inhibitor (drug with last name “pril”)/and spironolactone/Aldactone • TMP/SMX can also increase the INR if the patient is on warfarin • Clarithromycin and Digoxin—Clarithromycin can increase the potential for dig toxicity • Zithromax can prolong the QT interval

39. Polypharmacy and delirium… • The blood brain barrier in the elderly is more permeable to drugs • Narcotics • Benzodiazepines • Any drugs with “anti” as their first name…Anticholinergics, anti-histamines, antihypertensives, antipsychoticcs, antiparkinsonism, antianxiety, antidepressants • And more… • Tagamet, steroids, acetaminophen, diuretics, meperidine, amantidine • Sudden withdrawal of drugs

40. Other causes of delirium…check lab tests for… • Low sodium • High or low potassium • High calcium (cause in elderly?) • Hypoglycemia (insulin, sulfonylureas—not metformin alone); hyperglycemia • TSH —hyper/hypo • LFTs • BUN, Creatinine • Hypoxia, hypercarbia • MI, Stroke with aphasia • Check hearing and vision

41. Other considerations… • ETOH withdrawal—3rd to 5th day after last drink—due to dopamine rebound • Fecal impaction • Urinary retention • Transfer to unfamiliar surroundings—ICU, hospital, nursing home • Sundowning –sensory deprivation in unfamiliar surroundings

42. Depression… • More common than dementia • Often co-exists with dementia • May appear withdrawn, uncooperative or intermittently agitated • Functionally or cognitively impaired • May prolong recovery from illness due to lack of cooperation

43. Digression:When taking a history in the psych patient…the “if within 10 minutes” diagnosis… • If within 10 minutes you’re depressed…

44. In the elderly? • The SALSA signs of depression are unreliable in the elderly… • S—sleep disturbances, A – appetite changes, LS—low self esteem, A – anhedonia • Usual aging brings changes in sleep patterns and reduced energy expenditure therefore sleep disturbances, appetite changes, decreased energy are not as significant in the elderly • AND, there is NO significant illness or medical condition in late life that does NOT impinge upon sleep, appetite, energy or sense of vitality • The neurovegetative signs of depression overlap entirely with the constitutional symptoms of chronic or significant medical illness • (Grossman H. Misplacing empathy and misdiagnosing depression. Geriatrics 2004;59(4):39-41.)

45. In the elderly—the Ps Pervasive, Perplexing, and Pessimistic. • The pervasive depressed patient just “can’t shake it”…and is unable to get distracted from their depression • The perplexed depressed patient just doesn’t understand why she feels that way • The pessimistic depressed patient thinks “it will NEVER get better”

46. In the elderly—the D’s Doomed, Dead, and Deserving. • The doomed depressed patient “can’t imagine that things will EVER improve.” • The dead, depressed patient wouldn’t be a concern any longer, but this is not what is meant by “dead” in this context. The “dead” in the diagnosis of depression is a “wish for death, a plan for death, or a comment about wishing to commit suicide.” • The deserving depressed patient feels that his or her misery is a fit punishment for their life circumstances. • (Grossman H. Misplacing empathy and misdiagnosing depression. Geriatrics 2004;59(4):39-41.)

47. Some caveats to know in diagnosing depression in the elderly • Crying is not necessarily depression—however, a change in the propensity for crying is most likely depression • Don’t assume that every patient with cancer (18-39%), diabetes (5-11%), or a stroke (22-50%)** is depressed—those who have been resilient all of their lives will likely remain so • Acute coronary syndromes in women--high risk for depression; depression increases risk for MI; • Parkinson’s disease—high risk of depression • Don’t forget to check the thyroid…

48. Peripheral neuropathy--stocking glove distribution—dermatone distribution • 3 major causes in the elderly? • DM, B12 deficiency, B1 (thiamine deficiency) • 50% of elderly patients have lost their Achilles reflex • Weaker in the lower body than the upper body—maintenance of upper body strength is common, the legs give out

49. The aging heart… • 1% rule--maximal O2 consumption and cardiac output decrease by 1% per year; • Heart rate does not decrease with age by 1% per year  • Decreased heart rate reserve and maximum attainable heart rate; decreased contractile reserve—increased risk of CHF

50. The aging heart and vascular system • Decline in sinus node function—increased risk for sick sinus syndrome; increased risk for atrial fibrillation and atrial flutter; impaired chronotropic responsiveness—increased need for pacemaker • Endothelial dysfunction—increased risk for atherosclerosis; increased risk of CHD • The number one cause of heart failure in the elderly is DIABETES