
Let’s start with the 5 vital signs in the elderly—T, P, R, BP, and weight
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”)
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
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
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
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)
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
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
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?
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
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
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
Senescence and normal aging... • Peak at 24, 6 good years, gradual decline to baseline; FRC% Baseline function 1yr 30 75 yrs
Senescence and chronic disease... • More rapid decline with chronic disease (DM, COPD) FC% Baseline function 1yr 30 75 yrs
Senescence and gender differences... • Gender differences—the ovary (51.3 +/- 2.7) FC% Baseline function 1yr 30 75 yrs
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)
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?
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
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
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
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)
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
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
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
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…
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)
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
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)
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
“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
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
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
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)
“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”
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
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
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
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
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
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
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
Digression:When taking a history in the psych patient…the “if within 10 minutes” diagnosis… • If within 10 minutes you’re depressed…
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.)
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”
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.)
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…
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
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
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