Senior moments: A simple change could have a big impact on your patient's health
■ One misstep can trigger an older patient's rapid decline. Geriatricians offer advice about attending to the warning signs and tips to prevent a doom spiral.
By Kathleen Phalen Tomaselli amednews correspondent — Posted Jan. 3, 2005
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Other than passing birthdays, an unwary reflection in a store window or an ever-mounting cache of pills, aging sometimes seems to progress relatively unnoticed. Unnoticed, that is, until something happens -- the onset of a chronic condition, an illness, a fall -- that makes the struggle to maintain health more difficult and requires the patient's system to work harder to compensate.
The challenge of anticipating such occurrences is a critical element to providing preventive care for older populations. In this manner, treating elderly patients requires vigilance, because something as simple as the wrong pair of shoes or a new kind of cold medicine can undermine a patient's delicate equilibrium.
"It's an uneasy balance, and any additional insult can throw the whole thing off," said Joanne G. Schwartzberg, MD, director of aging and community health for the American Medical Association.
By 2030, one in five people will be older than 65. Couple burgeoning numbers with dramatically increased longevity, and there aren't enough geriatricians to take care of aging patients. As a result, primary care doctors will continue to play an important role for this patient population, said Mary Jo Cleveland, MD, a geriatrician and director of the Suma Health Center for Senior Health in Akron, Ohio.
"Primary care physicians can look for correctable or reversible problems," agreed Barney Spivak, MD, director of medical services and geriatric medicine at Waveny Care Center in New Canaan, Conn.
Thus, there are certain warning signs. What follows are the red flags, as well as tips and strategies offered by geriatricians to aid primary care physicians in making their moments with seniors more valuable.
Seniors account for more than 30% of all prescriptions written, many taking eight or 10 different medications each day. These multiple meds -- often from several doctors -- make elderly patients vulnerable to a host of problems. And a seemingly benign act, such as taking an over-the-counter cold remedy, can spark trouble.
"They could be going along fine, but the cold remedy now interacts with one of the drugs," Dr. Schwartzberg said. "Maybe they get dizzy and fall, starting a whole cascade of things."
Medication problems come from many sources: interactions with other drugs, foods or alternative therapies; poor eyesight and other sensory problems; finances; cognitive issues; and a lack of understanding how or when the drug should be taken.
According to a study at the University of Massachusetts Medical School, published in the March 5, 2004 Journal of the American Medical Association, about 50 out of 1,000 seniors had some sort of adverse drug event; 38% were categorized as serious, life-threatening or fatal; and 27.6% were considered preventable. With these figures in mind, it is clear there is always a need to ask about all medications the patient is taking and how they take them, including herbs, vitamins and drugs from outside the United States.
"Don't assume because you prescribed something, they are taking it. They pick the one that takes away symptoms; often something for pain or sleep," said Juan Cobo, MD, an internist and geriatrician at Chicago's Access Community Health Network. "The chronic conditions like blood pressure and diabetes don't hurt so much, but not taking these medications could actually kill them."
Also, it is important to remember that older patients often try to solve medication problems on their own. They may share pills with family or friends, self-medicate, choose less costly over-the-counter alternatives, spread out the prescribed dose by skipping days or halving pills, or choose one prescription over another because of limited finances.
Dr. Cobo's strategy is to list medications on a piece of paper, in large print and in the patient's language, during the office visit and ask patients to bring the list and all the medications for every return appointment. That way, he said, "I am able to see if they are taking something from another doctor, if they're not taking a medication, if it's outdated, or from another country."
Bracing the fall
Each year, one out of three people older than 65 falls, accounting for at least 95% of hip fractures, the majority of traumatic brain injuries and injury-related deaths.
"Many older adults don't ever regain the ability to walk like before," Dr. Spivak said. "But for the most part, falls are preventable."
Who's most at risk? White females and patients with lower body weakness, gait or balance problems, visual problems, more than one chronic disease, history of stroke, Parkinson's disease, neuromuscular disease, urinary incontinence, postural hypotension or cognitive impairment.
The American Geriatrics Society recommends that doctors always ask about falls. Older adults who have fallen previously or who stumble frequently are two to three times more likely to fall.
Shoes are a factor to which attention should be paid. Seniors often lose sensation in the bottom of their feet, making it difficult to feel the ground. Thick, crepe-soled shoes complicate the issue, according to a study published in the September 2004 Journal of the American Geriatrics Society.
Researchers at Harborview Injury Prevention and Research Center and Group Health Cooperative of Puget Sound in Seattle found that awareness of footwear could play an important role in fall prevention. "Those wearing canvas sneakers were at the lowest risk of falling; those wearing no shoes were at highest risk," Dr. Spivak said of the study's findings.
Another time for caution is with a patient who is taking four or more medications or any psychoactive drugs. This amount of medication increases fall risk, according to Centers for Disease Control data. Benzodiazepines, Benadryl and narcotics can result in a fall if the dose is inappropriate or it makes the patient sleepy or confused. Diuretics, Dr. Cobo said, can lead to falls because patients are getting up in the night to go to the bathroom.
There are preventive steps a doctor can recommend. For starters, a home health occupational therapist can go into the home to evaluate safety. Simple things such as removing throw rugs, securing wires and improving lighting can reduce falls. But evidence indicates that education and awareness are necessary, too.
Prescribing an exercise regimen that emphasizes increasing lower body strength and improving balance also can make a difference in reducing risk and severity of fall-related injuries. Physical therapists can help patients get started on a strengthening routine.
Surrendering the keys
As people age, certain physiological changes -- decreasing response time, declining vision, hearing and motor response, as well as multiple medications -- can impair ability and make driving dangerous.
Consider these National Highway Safety Traffic Administration statistics. In 2000, older people made up 9% of the resident population but accounted for 13% of all traffic fatalities, and people 70 and older have more motor vehicle deaths per 100,000 than any other demographic except those younger than 25.
Still, one of the most devastating blows to seniors is relinquishing the right to drive. "It is a major catastrophe giving up the car, giving up the independence," said Dr. Schwartzberg, adding that the AMA has focused on issues of older driving. Determining when a patient is no longer fit to drive is a tricky proposition, but there are signals physicians and family members can watch out for and ways to make the determination.
For starters, physicians can ask about prior vehicular mishaps.
"Then there are a myriad of other tip-offs, such as family members complaining that they are not safe, about cognitive impairment, visual and hearing impairments, neuromuscular or arthritic disorders," said Adele L. Towers, MD, MPH, vice chair of quality improvement and patient safety at the University of Pennsylvania division of geriatric medicine. "The problem is that we as physicians do not think to discuss these issues in the context of driving with either the patient or the family."
Dr. Cleveland uses a simple screening test. She asks elderly patients to draw a clock with 12 numbers and place the hands at 2:35. The result she looks for is a closed circle with 12 well-spaced numbers and two correctly placed hands. "Their ability to draw a well-organized clock correlates to driving ability."
When a problem is detected, doctors can soften the blow by being honest with both the family and the patient and explaining how he or she is required to proceed. Maybe even more important is the message that the end of driving does not have to be the end of the patient's social life.
Family members can be included in the discussion about other possible transportation options. This conversation can start with questions such as, "When your car is in the shop, how do you get around?" and "Have you ever thought about how you would get around if you didn't drive?"
Depression in older adults is underrecognized and undertreated, even though more than 5 million seniors have some sort of depressive symptoms. Many older patients think their difficulties are a normal part of aging, attributing their feelings to the loss of friends, family, jobs or independence, and leading them to be mum when seeing their doctors. In addition, family can mistake symptoms for dementia.
Still, these at-risk older patients do have regular contact with the health care system. According to the National Alliance for the Mentally Ill, 20% of older people who committed suicide had seen a doctor that day; 40% had seen a physician during the week leading up to the act; and 70% in the preceding month. "It seems they are turning to their primary care doctor for help," said Brian Carpenter, PhD, assistant professor of psychology at Washington University in St. Louis.
The problem, Dr. Carpenter said, looks different in seniors. He recommends asking all the usual questions -- does the patient feel nervous or empty, guilty or worthless, or very tired and slowed down? Are they able to enjoy things the way they used to or do they feel restless and irritable, like no one cares? Other tip-offs include diet -- are they eating more or less than usual -- and persistent headaches, stomachaches or chronic pain.
"Sometimes if you ask about mood, they say they are fine," Dr. Carpenter said. "But if you ask about hobbies, they might reveal that they've lost interest."
In the cases of patients who seem to be depressed, physicians can help by being aware of community resources. For instance, at the University of Pennsylvania, nurse practitioners follow depressed elderly patients. Another area of caution is how to prescribe antidepressants once the problem has been identified. Older adults have a sensitivity to these medications, and experts recommend referral to a geriatric psychiatrist or other geriatric specialist.