UNDERNUTRITION & FRAILTY

General Considerations

Undernutrition affects substantial numbers of elderly. The degree of unintended weight loss that deserves evaluation is not agreed upon, although a reasonable threshold is loss of 5% of body weight in 1 month or 10% of body weight in 6 months.

“Frailty” is a term that may be clinically useful for describing a subgroup of patients—almost always elders—who have delicate health, are not robust, and have decreased functional reserve. Although clinicians generally agree on most of the clinical characteristics that define the frailty syndrome, there is not yet a consensus definition of frailty. Frailty may be accompanied by physiologic changes in inflammatory and neuroendocrine systems. The label of “failure to thrive” is typically applied when some triggering event—loss of social support, a bout of depression or pneumonia, the addition of a new medication—pulls a struggling elderly person below the threshold of successful independent living.

Clinical Findings

Useful laboratory and radiologic studies for the patient with weight loss include complete blood count, serum chemistries (including glucose, TSH, creatinine, calcium), urinalysis, and chest radiograph. These studies are intended to uncover an occult metabolic or neoplastic cause but are not exhaustive. Exploring the patient’s social situation, cognition, mood, and dental health are at least as important as looking for a purely medical cause of weight loss.

There is not yet a standard assessment tool for frailty. However, the most widely recognized definition of frailty requires that the patient exhibit at least three of the five following clinical criteria: (1) slow gait speed; (2) low hand grip strength; (3) exhaustion; (4) weight loss; and (5) low energy expenditure. Few physicians screen for the syndrome, since an evidence-based treatment for frailty does not yet exist. Patients who meet criteria for the frailty syndrome are at increased risk for poor clinical outcomes.

Treatment

Oral nutritional supplements of 200–1000 kcal/d can increase weight and improve outcomes in malnourished hospitalized elders. Megestrol acetate as an appetite stimulant has not been shown to increase body mass or lengthen life in the elderly population. For those who have lost the ability to feed themselves, assiduous hand feeding may allow maintenance of weight. Although artificial nutrition and hydration (“tube feeding”) may seem a more convenient alternative, it deprives the patient of the taste and texture of food as well as the social milieu typically associated with mealtime; before this option is chosen, the patient or his or her surrogate should be offered the opportunity to review the benefits and burdens of the treatment in light of overall goals of care. If the patient makes repeated attempts to pull out the tube during a trial of artificial nutrition, the treatment burden becomes substantial, and the utility of tube feeding should be reconsidered. Although commonly used, there is no evidence that tube feeding prolongs life in patients with end-stage dementia.

The ideal strategies for preventing the frailty syndrome are unknown. At present, treatment is largely supportive, multifactorial, and individualized based on patient goals, life expectancy, and comorbidities. Sometimes, transitioning a patient to a palliative approach or a hospice program is the most appropriate clinical intervention when efforts to prevent functional decline fail. 

URINARY INCONTINENCE

ESSENTIAL DAIGNOSIS

Involuntary loss of urine.
Stress incontinence: leakage of urine upon coughing, sneezing, or standing.
Urge incontinence: urgency and inability to delay urination.
Overflow incontinence: may have variable presentation.

General Considerations

Incontinence in older adults is common, and interventions can improve most patients. Many patients fail to tell their providers about it. A simple question about involuntary leakage of urine is a reasonable screen: “Do you have a problem with urine leaks or accidents?"

Classification

Because continence requires adequate mobility, mentation, motivation, and manual dexterity, problems outside the bladder often result in incontinence. In general, the authors of this chapter find it useful to differentiate between “transient” or “potentially reversible” causes of incontinence and more “established” causes.

A. Transient Causes

Use of the mnemonic “DIAPPERS” may be helpful in remembering the categories of transient incontinence.

1. Delirium—A clouded sensorium impedes recognition of both the need to void and the location of the nearest toilet. Delirium is the most common cause of incontinence in hospitalized patients; once it clears, incontinence usually resolves.

2. Infection—Symptomatic urinary tract infection commonly causes or contributes to urgency and incontinence. Asymptomatic bacteriuria does not.

3. Atrophic urethritis or vaginitis—Atrophic urethritis can usually be diagnosed presumptively by the presence of vaginal mucosal telangiectasia, petechiae, erosions, erythema, or friability. Urethral inflammation, if symptomatic, may contribute to incontinence in some women. Some experts suggest a trial of topical estrogen in these cases.

4. Pharmaceuticals—Drugs are one of the most common causes of transient incontinence. Typical offending agents include potent diuretics, anticholinergics, psychotropics, opioid analgesics, a-blockers (in women), a-agonists (in men), and calcium channel blockers. 

5. Psychological factors—Severe depression with psychomotor retardation may impede the ability or motivation to reach a toilet.

6. Excess urinary output—Excess urinary output may overwhelm the ability of an older person to reach a toilet in time. In addition to diuretics, common causes include excess fluid intake; metabolic abnormalities (eg, hyperglycemia, hypercalcemia, diabetes insipidus); and disorders associated with peripheral edema, with its associated heavy nocturia when previously dependent legs assume a horizontal position in bed.

7. Restricted mobility—(See Immobility section, above.) If mobility cannot be improved, access to a urinal or commode (eg, at the bedside) may improve continence.

8. Stool impaction—This is a common cause of urinary incontinence in hospitalized or immobile patients. Although the mechanism is still unknown, a clinical clue to its presence is the onset of both urinary and fecal incontinence. Disimpaction usually restores urinary continence.

B. Established Causes

Causes of established incontinence should be addressed after the transient causes have been uncovered and managed appropriately. Risk factors for incontinence include older age, female sex, increased body mass index, and limited physical activity.

1. Detrusor overactivity (urge incontinence)—Detrusor overactivity refers to uninhibited bladder contractions that cause leakage. It is the most common cause of established geriatric incontinence, accounting for two-thirds of cases, and is usually idiopathic. Women will complain of urinary leakage after the onset of an intense urge to urinate that cannot be forestalled. In men, the symptoms are similar, but detrusor overactivity commonly coexists with urethral obstruction from benign prostatic hyperplasia. Because detrusor overactivity also may be due to bladder stones or tumor, the abrupt onset of otherwise unexplained urge incontinence—especially if accompanied by perineal or suprapubic discomfort or sterile hematuria—should be investigated by cystoscopy and cytologic examination of a urine specimen.

2. Urethral incompetence (stress incontinence)— Urethral incompetence is the second most common cause of established urinary incontinence in older women. Stress incontinence is most commonly seen in men after radical prostatectomy. Stress incontinence is characterized by instantaneous leakage of urine in response to a stress maneuver. It commonly coexists with detrusor overactivity. Typically, urinary loss occurs with laughing, coughing, or lifting heavy objects. Leakage is worse or occurs only during the day, unless another abnormality (eg, detrusor overactivity) is also present. To test for stress incontinence, have the patient relax her perineum and cough vigorously (a single cough) while standing with a full bladder. Instantaneous leakage indicates stress incontinence if urinary retention has been excluded by postvoiding residual determination using ultrasound. A delay of several seconds or persistent leakage suggests that the problem is instead caused by an uninhibited bladder contraction induced by coughing.

3. Urethral obstruction—Urethral obstruction (due to prostatic enlargement, urethral stricture, bladder neck contracture, or prostatic cancer) is a common cause of established incontinence in older men but is rare in older women. 68 CMDT 2013 Chapter 4 It can present as dribbling incontinence after voiding, urge incontinence due to detrusor overactivity (which coexists in two-thirds of cases), or overflow incontinence due to urinary retention. Renal ultrasound is required to exclude hydronephrosis in men whose postvoiding residual urine exceeds 150 mL.

4. Detrusor underactivity (overflow incontinence)— Detrusor underactivity is the least common cause of incontinence. It may be idiopathic or due to sacral lower motor nerve dysfunction. When it causes incontinence, detrusor underactivity is associated with urinary frequency, nocturia, and frequent leakage of small amounts. The elevated postvoiding residual urine (generally over 450 mL) distinguishes it from detrusor overactivity and stress incontinence, but only urodynamic testing differentiates it from urethral obstruction in men. Such testing usually is not required in women, in whom obstruction is rarely present.

Treatment

A. Transient Causes

Each identified transient cause should be treated regardless of whether an established cause coexists. For patients with urinary retention induced by an anticholinergic agent, discontinuation of the drug should first be considered. If this is not feasible, substituting a less anticholinergic agent may be useful.

B. Established Causes

1. Detrusor overactivity—The cornerstone of treatment is bladder training. Patients start by voiding on a schedule based on the shortest interval recorded on a bladder record. They then gradually lengthen the interval between voids by 30 minutes each week using relaxation techniques to postpone
the urge to void. Lifestyle modifications, including weight loss and caffeine reduction, may also improve incontinence symptoms. For cognitively impaired patients and nursing home residents who are unable to manage on their own, timed and prompted voiding initiated by caregivers is effective.

Pelvic floor muscle (“Kegel”) exercises, with or without biofeedback, can reduce the frequency of incontinence episodes when performed correctly and sustained. If behavioral approaches prove insufficient, drug therapy with antimuscarinic agents may provide additional benefit. The two oral drugs for which there is the most experience are tolterodine and oxybutynin. Available regimens of these drugs follow: short-acting tolterodine, 1–2 mg twice a day; long-acting tolterodine, 2–4 mg daily; short-acting oxybutynin, 2.5–5 mg twice or three times a day; long-acting oxybutynin, 5–15 mg daily; and oxybutynin transdermal patch, 3.9 mg per day applied twice weekly. All of these agents can produce delirium, dry mouth, or urinary retention; long-acting preparations may be better tolerated. Agents such as fesoterodine (4–8 mg orally once daily), trospium chloride (20 mg orally once or twice daily), darifenacin (7.5–15 mg orally daily), and solifenacin (5–10 mg orally daily) appear to have similar efficacy and have not been clearly demonstrated to be better tolerated than the older agents in long-acting form.

The combination of behavioral therapy and antimuscarinics appears to be more effective than either alone although one study in a group of younger women showed that adding behavioral therapy to individually titrated doses of extended-release oxybutynin was no better than drug treatment alone.

In men with both benign prostatic hyperplasia and detrusor overactivity and who have postvoid residual volumes of 150 mL or less, an antimuscarinic agent added to an a-blocker may provide additional relief of lower urinary tract symptoms.

2. Urethral incompetence (stress incontinence)—Lifestyle modifications, including limiting caffeine intake and timed voiding, may be helpful for some women, particularly women with mixed stress/urge incontinence. Pelvic floor muscle exercises are effective for women with mild to moderate stress incontinence; the exercises can be combined, if necessary, with biofeedback, electrical stimulation, or vaginal cones. Instruct the patient to pull in the pelvic floor muscles and hold for 6–10 seconds and to perform three sets of 8–12 contractions daily. Benefits may not be seen for 6 weeks. Pessaries or vaginal cones may be helpful in some women but should be prescribed by providers who are experienced with using these modalities.

Although a last resort, surgery is the most effective treatment for stress incontinence, resulting in a cure rate as high as 96% even in older women. Drug therapy is limited. Clinical trials have shown that duloxetine, a serotonin and norepinephrine reuptake inhibitor, reduces stress incontinence episodes in women but efficacy in older women remains unknown. It is approved for use for this indication in some countries but not the United States. Side effects, including nausea, are common.

3. Urethral obstruction—Surgical decompression is the most effective treatment for obstruction, especially in the setting of urinary retention due to benign prostatic hyperplasia. A variety of less invasive techniques make decompression feasible even for frail men. For the nonoperative candidate with urinary retention, intermittent or indwelling catheterization is used. For a man with prostatic obstruction who does not require or desire immediate surgery, treatment with a-blocking agents (eg, terazosin, 1–10 mg daily; prazosin, 1–5 mg orally twice daily; tamsulosin, 0.4–0.8 mg daily) can improve symptoms and delay obstruction. Finasteride, 5 mg daily, can provide additional benefit to an a-blocking agent in men with an enlarged prostate.

4. Detrusor underactivity—For the patient with a poorly contractile bladder, augmented voiding techniques (eg, double voiding, suprapubic pressure) often prove effective. If further emptying is needed, intermittent or indwelling catheterization is the only option. Antibiotics should be used only for symptomatic upper urinary tract infection or as prophylaxis against recurrent symptomatic infections in  patient using intermittent catheterization; they should not be used as prophylaxis with an indwelling catheter.

When to Refer

• Men with urinary obstruction who do not respond to medical therapy should be referred to a urologist.
• Women who do not respond to medical and behavioral therapy should be referred to a urogynecologist or urologist.

Falls & Gait Disorders

About one-third of people over age 65 fall each year, and the frequency of falls increases markedly with advancing age. About 10% of falls result in serious injuries such as fractures, soft tissue injuries, and traumatic brain injuries. Complications from falls are the leading cause of death from injury in persons over age 65. Hip fractures are common precursors to functional impairment, nursing home placement, and death. Furthermore, fear of falling may lead some elders to restrict their activities.

Every older person should be asked about falls; many will not volunteer such information. Assessment of patients who fall should include postural blood pressure and pulse, thorough cardiac examination, evaluations of strength, range of motion, cognition, and proprioception, and examination of feet and footwear. A thorough gait assessment should be performed in all older people. Gait and balance can be readily assessed by the “Up and Go Test,” in which the patient is asked to stand up from a sitting position without use of hands, walk 10 feet, turn around, walk back, and sit down. Patients who take < 10 seconds are usually normal, patients who take longer than 30 seconds tend to need assistance with many mobility tasks, and those in between tend to vary widely with respect to gait, balance, and function. The ability to recognize common patterns of gait disorders
is an extremely useful clinical skill to develop. Examples of gait abnormalities and their causes are listed in Table 4–3.

Causes of Falls

Balance and ambulation require a complex interplay of cognitive, neuromuscular, and cardiovascular function. With age, balance mechanisms can become compromised and postural sway increases. These changes predispose the older person to a fall when challenged by an additional insult to any of these systems.

A fall may be the clinical manifestation of an occult problem, such as pneumonia or myocardial infarction, but much more commonly falls are due to the interaction between an impaired patient and an environmental risk factor. Falls in older people are rarely due to a single cause, and effective intervention entails a comprehensive assessment of the patient’s intrinsic deficits (usually diseases and medications), the activity engaged in at the time of the fall, and environmental obstacles.

Intrinsic deficits are those that impair sensory input, judgment, blood pressure regulation, reaction time, and balance and gait. Dizziness may be closely related to the deficits associated with falls and gait abnormalities. While it may be impossible to isolate a sole “cause” or a “cure” for falls, gait abnormalities, or dizziness, it is often possible to identify and ameliorate some of the underlying contributory conditions and improve the patient’s overall function.

As for most geriatric conditions, medication use is one of the most common, significant, and reversible causes of falling. A meta-analysis found that sedative/hypnotics, antidepressants, and benzodiazepines were the classes of drugs most likely to be associated with falling. The use of multiple medications simultaneously has also been associated with an increased fall risk. Other often overlooked but treatable contributors include postural hypotension (including postprandial, which peaks 30–60 minutes after a meal), insomnia, use of multifocal lenses, and urinary urgency.

Since most falls occur in or around the home, a visit by a visiting nurse, physical therapist, or health care provider reaps substantial benefits in identifying environmental obstacles and is generally reimbursed by third-party payers, including Medicare.

Complications of Falls

wrist, hip, and vertebrae. There is a high mortality rate (approximately 20% in 1 year) in elderly women with hip fractures, particularly if they were debilitated prior to the time of the fracture.

Fear of falling again is a common, serious, but treatable factor in the elderly person’s loss of confidence and independence. Referral to a physical therapist for gait training with special devices is often all that is required.

Chronic subdural hematoma is an easily overlooked complication of falls that must be considered in any elderly patient presenting with new neurologic symptoms or signs. Headache or known history of trauma may both be absent.

Patients who are unable to get up from a fall are at risk for dehydration, electrolyte imbalance, pressure sores, rhabdomyolysis, and hypothermia.

Prevention & Management

The risk of falling and consequent injury, disability, and potential institutionalization can be reduced by modifying those factors outlined in Table 4–4. Emphasis is placed on treating all contributory medical conditions (eg, cataracts), minimizing environmental hazards, and eliminating medications
where the harms may outweigh the benefits particularly those that induce orthostasis and parkinsonism (eg, a-blockers, nitrates, antipsychotics). Also important are strength, balance, and gait training as well as screening and treatment for osteoporosis, if present. Falls and fractures may be prevented by prescribing vitamin D at a dose of 800 international units daily or higher.

Assistive devices, such as canes and walkers, are useful for many older adults but are often used incorrectly. Canes should be used on the “good” side. The height of walkers and canes should generally be about the level of the wrist. Physical therapists are invaluable in assessing the need for an assistive device, selecting the best device, and training a patient in its correct use.

Early surgery for patients with cataracts may reduce falls, but eyeglasses, particularly bifocal or graduated lenses, may actually increase the risk of falls, particularly in the early weeks of use. Patients should be counseled about the need to take extra care when new eyeglasses are being used (eg, to look down to use the lens above the bifocal when going up or down stairs).

Patients with repeated falls are often reassured by the availability of phones at floor level, a portable phone, or a lightweight radio call system. Their therapy should also include training in techniques for arising after a fall. The clinical utility of anatomically designed external hip protectors in reducing fractures is currently uncertain.

When to Refer

Patients with a recent history of falls should be referred for physical therapy, eye examination, and home safety evaluation.

When to Admit

If the patient has new falls that are unexplained, particularly in combination with a change in the physical examination, hospitalization should be considered.

IMMOBILITY

Although common in older people, reduced mobility is never normal and is often treatable if its causes are identified. Bed rest is an important cause of hospital-induced functional decline. Among hospitalized medical patients over 70, about 10% experience a decline in function, much of which results from preventable reductions in mobility.

The hazards of bed rest in older adults are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate. More striking changes occur in skeletal muscle, with loss of contractile velocity and strength. Pressure sores, deep venous thrombosis, and pulmonary embolism are additional serious risks. Within days after being confined to bed, the risk of postural hypotension, falls, and skin breakdown rises rapidly in the older patient. Moreover, recovery from these changes usually takes weeks to months.

Prevention & Treatment

When immobilization cannot be avoided, several measures can be used to minimize its consequences. Skin, particularly areas over pressure points, should be inspected at least daily. If the patient is unable to shift position, staff should do so every 2 hours. To minimize cardiovascular deconditioning, patients should be positioned as close to the upright position as possible, several times daily. To reduce the risks of contracture and weakness, range of motion and strengthening exercises should be started immediately and continued as long as the patient is in bed. Whenever possible, patients should assist with their own positioning, transferring, and self-care. As long as the patient remains immobilized, antithrombotic measures should be used if that is consistent with the patient’s goals of care.

Avoiding restraints and discontinuing invasive devices (intravenous lines, urinary catheters) may increase an elderly patient’s prospects for early mobility. Graduated ambulation should begin as soon as it is feasible. Advice from a physical therapist is often helpful both before and after discharge. Prior to discharge, physical therapists can recommend appropriate exercises and assistive devices; after discharge, they can recommend safety modifications and maintenance exercises.

Delirium

ESSENTIAL DIAGNOSIS

Rapid onset and fluctuating course.
Primary deficit in attention rather than memory.
May be hypoactive or hyperactive.
Dementia frequently coexists.

General Considerations

Delirium is an acute, fluctuating disturbance of consciousness, associated with a change in cognition or the development of perceptual disturbances (see also Chapter 25). It is the pathophysiologic consequence of an underlying general medical condition such as infection, coronary ischemia, hypoxemia, or metabolic derangement. Delirium persists in up to 25% of patients and is associated with worse clinical outcomes (higher in-hospital and postdischarge mortality, longer lengths of stay, greater probability of placement in a nursing facility).

Although the acutely agitated elderly patient often comes to mind when considering delirium, many episodes are more subtle. Such quiet, or hypoactive, delirium may only be suspected if one notices new cognitive slowing or inattention.

Cognitive impairment is an important risk factor for delirium. Approximately 25% of delirious patients are demented, and 40% of demented hospitalized patients are delirious. Other risk factors are male sex, severe illness, hip fracture, fever or hypothermia, hypotension,malnutrition, polypharmacy and use of psychoactive medications, sensory impairment, use of restraints, use of intravenous lines or urinary catheters, metabolic disorders, depression, and alcoholism.

Clinical Findings

A number of bedside instruments for the assessment of delirium are available. The confusion assessment method (CAM), which requires (1) acute onset and fluctuating course and (2) inattention and either (3) disorganized thinking or (4) altered level of consciousness, is easy toadminister and performs well.

A key component of a delirium work-up is review of medications because a large number of drugs, the addition of a new drug, or the discontinuation of a medicationknown to cause withdrawal symptoms are all associated with the development of delirium. Medications that are particularly likely to increase the risk of delirium include opioids, benzodiazepines, dihydropyridines, and antihistamines.

Laboratory evaluation of most patients should include a complete blood count, electrolytes, blood urea nitrogen (BUN) and serum creatinine, glucose, calcium, albumin, liver function studies, urinalysis, and electrocardiography. In selected cases, serum magnesium, serum drug levels, arterial blood gas measurements, blood cultures, chest radiography, urinary toxin screen, head CT scan, and lumbar puncture may be helpful.

Prevention

Prevention is the best approach in the management of delirium. Measures include improving cognition (frequent reorientation, activities, socialization with family and friends, when possible), sleep (massage, noise reduction, minimizing interruptions at night), mobility, vision (visual aids and
adaptive equipment), hearing (portable amplifiers, cerumen disimpaction), and hydration status (volume repletion). No medications have been consistently shown to prevent delirium or reduce its duration or severity.

Treatment

Management of established episodes of delirium is largely supportive and includes reassurance and  reorientation, treatment of underlying causes, eliminating unnecessary medications, and avoidance of indwelling catheters and restraints. Antipsychotic agents (such as haloperidol, 0.5–1 mg, or quetiapine, 25 mg, at bedtime or twice daily) are considered the medication of choice when drug treatment of delirium is necessary. Other medications (eg, trazodone, acetylcholinesterase inhibitors, and mood stabilizers) have also been used, but evidence in support of these approaches is weak. In ventilated patients in the intensive care unit setting, dexmedetomidine or propofol (or both) may also be useful alternatives or adjuncts to antipsychotic therapy in patients with delirium.

Most episodes of delirium clear in a matter of days after correction of the precipitant, but some patients suffer episodes of longer duration, and a few never return to their former baseline level of functioning. These individuals merit closer follow-up for the development of dementia if not already diagnosed. 

When to Refer

If an initial evaluation does not reveal the cause of deliriumr if entities other than delirium are in the differential diagnosis, referral to a neuropsychologist, neurologist, or geropsychiatrist should be considered.

When to Admit

Patients with delirium of unknown cause should be admitted for an expedited work-up if consistent with the patient’s goals of care.

DEPRESSION

ESSENTIAL DIAGNOSIS

Depressed elders may not admit to depressed mood.
Depression screening in elders should include a question about anhedonia

General Considerations 

Depressive symptoms—often related to loss, disease, andlife changes—may be present in more than 25% of elders; however, the prevalence of major depression is similar in younger and older populations. Depression is particularly common in hospitalized and institutionalized elders. Older single men have the highest suicide rate of any demographic group. Geriatric patients with depression are more likely to have somatic complaints, less likely to report depressed mood, and more likely to experience delusions than younger patients. In addition, depression may be an early symptom of a neurodegenerative condition such as dementia. Depressed patients who have other comorbidities, such as congestive heart failure or diabetes, have worse outcomes than their non-depressed counterparts.

Clinical Findings 

A simple two-question screen—which consists of asking “During the past 2 weeks, have you felt down, depressed, or hopeless?” and “During the past 2 weeks, have you felt little interest or pleasure in doing things?”—is highly sensitive for detecting major depression in persons over age 65. Positive responses can be followed up with more comprehensive, structured interviews, such as the Geriatric Depression Scale (http://www.stanford.edu/~yesavage/GDS.html) or the PHQ-9 (http://www.depression-primarycare.org).

Elderly patients with depressive symptoms should be questioned about medication use, since many drugs 

DEMENTIA

ESSENTIAL DIAGNOSIS

Progressive decline of intellectual function.
Loss of short-term memory and at least one other cognitive deficit.
Deficit severe enough to cause impairment of function.
Not delirious.

General Considerations

Dementia is an acquired persistent and progressive impairment in intellectual function, with compromise of memory and at least one other cognitive domain, most commonly aphasia (typically, word finding difficulty), apraxia (inability o perform motor tasks, such as cutting a loaf of bread,  despite intact motor function), agnosia (inability to recognize objects), and impaired executive function (poor abstraction, mental flexibility, planning, and judgment). The diagnosis of dementia requires a significant decline in function that is severe enough to interfere with work or social life.

Dementia has a prevalence that doubles every 5 years in the older population, reaching 30–50% at age 85. Women suffer disproportionately, both as patients and as caregivers. Alzheimer disease accounts for roughly two-thirds of dementia cases in the United States, with vascular dementia (either alone or combined with Alzheimer disease) and dementia with Lewy bodies accounting for much of the rest. Some of the risk factors for Alzheimer disease are older age, family history, lower education level, and female sex. Education, cognitive “exercises,” and social support may be protective. Risk factors for vascular dementia are those for stroke, ie, older age, hypertension, cigarette use, atrial fibrillation, diabetes mellitus, and hyperlipidemia.

Depression and delirium are also common in elders, may coexist with dementia, and may also present with cognitive impairment. Depression is a common concomitant of early dementia. A patient with depression and cognitive impairment whose intellectual function improves with treatment of the mood disorder has an almost fivefold greater risk of suffering irreversible dementia later in life. Delirium, characterized by acute confusion, occurs much more commonly in patients with underlying
dementia.

Clinical Findings

A. Screening

1. Cognitive impairment—Although there is no consensus at present on whether older patients should be screened for dementia, the benefits of early detection include identification of potentially reversible causes, planning for the future (including discussing values and completing advance care directives), and providing support and counseling for the caregiver.

The combination of a clock drawing task with a threeitem word recall (also known as the “mini-cog”) is a simple screening test that is fairly quick to administer. While different methods for administering and scoring the clock draw test have been described, the authors of this chapter favor the approach of pre-drawing a four inch circle on a sheet of paper and instructing the patient to “draw a clock” with the time set at 10 minutes after 11. Scores are classified as normal, almost normal, or abnormal. When a patient is able to draw a clock normally and can remember all 3 objects, dementia is unlikely. When a patient fails this simple screen, further cognitive evaluation with a standardized instrument is warranted. The Montreal Cognitive Assessment (MoCA ©) is a 30-point test that takes about 10 minutes to administer and examines several areas of cognitive function. A score below 26 is considered abnormal. Free downloadable versions in multiple languages are available at http://www
.mocatest.org.

2. Decision-making capacity—Cognitively impaired elders commonly face serious medical decisions, and the clinicians involved in their care must ascertain whether the capacity exists to make the choice. While no single test of capacity exists, the following five elements should be considered in a thorough assessment: (1) ability to express a choice; (2) understanding relevant information about the risks and benefits of planned therapy and the alternatives, in the context of one’s values, including no treatment; (3) comprehension of the problem and its consequences; (4) ability to reason; and (5) consistency. A patient’s choice should follow from an understanding of the consequences.

Sensitivity must be used in applying these five components to people of various cultural backgrounds. Decisionmaking capacity varies over time: A delirious patient may regain his capacity after an infection is treated, and so reassessments are often appropriate. Furthermore, the capacity to make a decision is a function of the decision in question. A woman with mild dementia may lack the capacity to consent to coronary artery bypass grafting yet retain the capacity to designate a surrogate decision maker. 

 B. Symptoms and Signs

The clinician can gather important information about the type of dementia that may be present by asking about: (1) the rate of progression of the deficits as well as their nature (including any personality or behavioral change); (2) the presence of other neurologic symptoms, particularly motor problems; (3) risk factors for HIV; (4) family history of dementia; and (5) medications, with particular attention to recent changes.

Work-up is directed at identifying any potentially reversible causes of dementia. However, such cases are indeed rare. For a detailed description of the symptoms and signs of different forms of dementia, see Chapter 24.

C. Physical Examination

The neurologic examination emphasizes assessment of mental status but should also include evaluation for sensory deficits, possible previous strokes, parkinsonism, or peripheral neuropathy. The remainder of the physical examination should focus on identifying comorbid conditions that may aggravate the individual’s disability. For a detailed description of the neuropsychological assessment,
see Chapter 24.

D. Laboratory Findings

Laboratory studies should include a complete blood count, electrolytes, calcium, creatinine, glucose, thyroid-stimulating hormone (TSH), and vitamin B12 levels. While hypothyroidism or vitamin B12 deficiency may contribute to the cognitive impairment, treating these conditions typically does not completely reverse the dementia. HIV testing, RPR (rapid plasma reagin) test, heavy metal screen, and liver biochemical tests may be informative in selected patients but should not be considered part of routine testing. For a detailed description of laboratory findings, see Chapter 24.

E. Imaging

Most patients should receive neuroimaging as part of the diagnostic work-up to rule out subdural hematoma, tumor, previous stroke, and hydrocephalus (usually normal pressure). Those who are younger and those who have focal neurologic symptoms or signs, seizures, gait abnormalities, and an acute or subacute onset are most likely to yield positive findings and most likely to benefit from MRI scanning. n older patients with a more classic picture oflzheimer disease in whom neuroimaging is desired, a noncontrast  CT scan is sufficient. For a detailed description of imaging, see Chapter 24.

Differential Diagnosis

Older individuals experience occasional difficulty retrieving items from memory (usually manifested as wordfinding complaints) and experience a slowing in their rate of information processing. Mild cognitive impairment is an increasingly recognized condition in which a patient complains of memory problems, demonstrates mild deficits (most commonly in short-term memory) on formal testing, but does not meet criteria for dementia. Dementia will develop in more than half of people with mild cognitive impairment within 5 years. Acetylcholinesterase inhibitors have not consistently demonstrated a delay in the progression of mild cognitive impairment to Alzheimer disease. An elderly patient with intact cognition but with severe impairments in vision or hearing commonly becomes confused in an unfamiliar medical setting and consequently may be falsely labeled as demented. Cognitive testing is best performed after optimal correction of the sensory deficits.

Delirium can be distinguished from dementia by its acute onset, fluctuating course, and deficits in attention rather than memory. Because delirium and dementia often coexist, it may not be possible to determine how much impairment is attributable to each condition until the patient is fully recovered and back in their usual setting. Many medications have been associated with delirium and other types of cognitive impairment in older patients. Anticholinergic agents, hypnotics, neuroleptics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines (including H1 and H2-antagonists), and corticosteroids are just some of the medications that have been associated with cognitive impairment in elders.

Treatment

Patients and families should be made aware of the Alzheimer’s Association (http://www.alz.org) as well as the wealth of helpful community and online resources and publications available. Caregiver support, education, and counseling can prevent or delay nursing home placement. Education should include the manifestations and natural history of dementia as well as the availability of local support services such as respite care. Even under the best of circumstances, caregiver stress can be substantial. Collaborative care models and disease management programs appear to improve the quality of care for patients with dementia.

Cognitive Impairment

Because demented patients have greatly diminished cognitive reserve, they are at high risk for experiencing acute cognitive or functional decline in the setting of new medical illness. Consequently, fragile cognitive status may be best maintained by ensuring that comorbid diseases such as congestive heart failure and infections are detected and treated.

1. Acetylcholinesterase inhibitors—Many experts recommendconsidering a trial of acetylcholinesterase inhibitors (eg, donepezil, galantamine, rivastigmine) in most patients with mild to moderate Alzheimer disease. These medications produce a modest improvement in cognitive function that is not likely to be detected in routine clinical encounters. Acetylcholinesterase inhibitors may also have similarly modest cognitive benefits in patients with vascular dementia or dementia with Lewy bodies. However, acetylcholinesterase inhibitors have not convincingly been shown to delay institutionalization or functional decline.

Starting doses, respectively, of donepezil, galantamine, and rivastigmine, are 5 mg orally once daily (maximum 10 mg once daily), 4 mg orally twice daily (maximum 12 mg twice daily), and 1.5 mg orally twice daily (maximum 6 mg twice daily). The doses are increased gradually as tolerated. The most bothersome side effects include diarrhea, nausea, anorexia, weight loss, and syncope. In those patients who have had no apparent benefit, experience side effects, or for whom the financial outlay is a burden, the drug should be discontinued.

2. Memantine—In clinical trials, patients with more advanced disease have been shown to have statistical benefit from the use of memantine, an N-methyl-d-aspartate (NMDA) antagonist, with or without concomitant use of an acetylcholinesterase inhibitor. Long-term and meaningful functional outcomes have yet to be demonstrated.

B. Behavioral Problems

1. Nonpharmacologic approaches—Behavioral problems in demented patients are often best managed with a nonpharmacologic approach. Initially, it should be established that the problem is not unrecognized delirium, pain, urinary obstruction, or fecal impaction. It also helps to inquire whether the caregiver or institutional staff can tolerate the behavior, as it is often easier to find ways to accommodate to the behavior than to modify it. If not, the caregiver should keep a brief log in which the behavior is described along with antecedent events and consequences. Recurring precipitants of the behavior are often found to be present or it may be that the behavior is rewarded—for example, by increased attention. Caregivers are taught to use simple language when communicating with the patient, to break down activities into simple component tasks, and to use a “distract, not confront” approach when the patient seems disturbed by a troublesome issue. Additional steps to address behavioral problems include providing structure and routine, discontinuing all medications except those considered absolutely necessary, and correcting, if possible, sensory deficits.

2. Pharmacologic approaches—There is no clear consensus about pharmacologic approaches to treatment of behavioral problems in patients who have not benefited from nonpharmacologic therapies. The target symptoms— depression, anxiety, psychosis, mood lability, or pain—may suggest which class of medications might be most helpful in a given patient. Patients with depressive symptoms may show improvement with antidepressant therapy. Patients with dementia with Lewy bodies have shown clinically significant improvement in behavioral symptoms when treated with rivastigmine (3–6 mg orally twice daily). 

For those with Alzheimer disease and agitation, no agents have demonstrated consistent efficacy. Despite the lack of strong evidence, antipsychotic medications have remained a mainstay for the treatment of behavioral disturbances, largely because of the lack of alternatives. The newer atypical antipsychotic agents (risperidone, olanzapine, quetiapine, aripiprazole, clozapine, ziprasidone) are reported to be better tolerated than older agents but should be avoided in patients with vascular risk factors due to an increased risk  of stroke; they can cause weight gain and are also associated with hyperglycemia in diabetic patients and are considerably more expensive. Both typical and atypical antipsychotics n several short-term trials and one long-term trial have  been demonstrated to increase mortality compared with placebo when used to treat elderly demented patients with behavioral disturbances. When the choice is made to use these agents, patients and caregivers should be carefully warned of the risks. Starting and target dosages should be much lower than those used in schizophrenia (eg, haloperidol, 0.5–2 mg orally; risperidone, 0.25–2 mg orally). Federal regulations require that if antipsychotic agents are used in treatment of a nursing home patient, drug reduction efforts must be made at least every 6 months.

C. Driving 

A common yet vexing problem that providers are regularly asked to assess is whether a patient with dementia is able to continue driving. The consequences of a decision to either stop or continue driving can be far-reaching for both the patient and the general public and therefore every case requires careful consideration. Although drivers with dementia are at an increased risk for motor vehicle accidents, many patients continue to drive safely well beyond the time of diagnosis, making the timing of when to recommend that a patient stop driving particularly challenging.

There is no clear-cut evidence to suggest a single best approach to determining an individual patient’s risk, and there is no accepted “gold standard” test. The result is that clinicians must consider several factors upon which to base their judgment. For example, determining the severity of dementia can be useful. Patients with very mild or mild dementia according to the Clinical Dementia Rating Scale were able to pass formal road tests at rates of 88% and 69%, respectively. Experts agree that patients with moderately severe or more advanced dementia should be counseled to stop driving. Although not well studied, clinicians should also consider the effects of comorbid conditions and medications and the role each may play in contributing to the risk of driving by a patient with dementia. Assessment of the ability to carry out IADLs may also add to the determination of risk. Caregivers of patients with at least a 30% decline in their IADL score were more likely to rate them as unable to drive safely than other, less impaired patients. Finally, in some cases of mild dementia, referral may be needed to a driver rehabilitation specialist for evaluation. Although not standardized, this evaluation often consists of both off- and on-road testing. The cost for this assessment can be substantial, and it is typically not covered by health insurance. Experts recommend such an evaluation for patients with mild dementia, for those with dementia for whom new impairment in driving skills is observed, and for those with significant deficits in cognitive domains such as attention, executive function, and visuospatial skills. At present, there is no convincing evidence to support the use of interventions to improve driving skills and driver safety.

Clinicians must also be aware of the reporting requirements in their individual jurisdictions. Some states have Starting doses, respectively, of donepezil, galantamine, and rivastigmine, are 5 mg orally once daily (maximum 10 mg once daily), 4 mg orally twice daily (maximum 12 mg twice daily), and 1.5 mg orally twice daily (maximum 6 mg twice daily). The doses are increased gradually as  tolerated. The most bothersome side effects include diarrhea, nausea, anorexia, weight loss, and syncope. In those patients who have had no apparent benefit, experience side effects, or for whom the financial outlay is a burden, the drug should be discontinued.

2. Memantine—In clinical trials, patients with more advanced disease have been shown to have statistical benefit from the use of memantine, an N-methyl-d-aspartate (NMDA) antagonist, with or without concomitant use of an acetylcholinesterase inhibitor. Long-term and meaningful functional outcomes have yet to be demonstrated. 

B. Behavioral Problems

1. Nonpharmacologic approaches—Behavioral problems in demented patients are often best managed with a nonpharmacologic approach. Initially, it should be established that the problem is not unrecognized delirium, pain, urinary obstruction, or fecal impaction. It also helps to inquire whether the caregiver or institutional staff can tolerate the behavior, as it is often easier to find ways to accommodate to the behavior than to modify it. If not, the caregiver should keep a brief log in which the behavior is described along with antecedent events and consequences. Recurring precipitants of the behavior are often found to be present or it may be that the behavior is rewarded—for example, by increased attention. Caregivers are taught to use simple language when communicating with the patient, to break down activities into simple component tasks, and to use a “distract, not confront” approach when the patient seems disturbed by a troublesome issue. Additional steps to address behavioral problems include providing structure and routine, discontinuing all medications except those considered absolutely necessary, and correcting, if possible, sensory deficits.

2. Pharmacologic approaches—There is no clear consensus about pharmacologic approaches to treatment of behavioral problems in patients who have not benefitedfrom nonpharmacologic therapies. The target symptoms— depression, anxiety, psychosis, mood lability, or pain—may suggest which class of medications might be most helpful in a given patient. Patients with depressive symptoms may show improvement with antidepressant therapy. Patients with dementia with Lewy bodies have shown clinically significant improvement in behavioral symptoms whentreated with rivastigmine (3–6 mg orally twice daily).

For those with Alzheimer disease and agitation, no agents have demonstrated consistent efficacy. Despite the lack of strong evidence, antipsychotic medications have remained a mainstay for the treatment of behavioral disturbances, largely because of the lack of alternatives. The newer atypical antipsychotic agents (risperidone, olanzapine, quetiapine, aripiprazole, clozapine, ziprasidone) are reported to be better tolerated than older agents but should be avoided in patients with vascular risk factors due to an increased risk of stroke; they can cause weight gain and are also associated with hyperglycemia in diabetic patients and are considerably more expensive. Both typical and atypical antipsychotics n several short-term trials and one long-term trial have  been demonstrated to increase mortality compared with placebo when used to treat elderly demented patients with behavioral disturbances. When the choice is made to use these agents, patients and caregivers should be carefully warned of the risks. Starting and target dosages should be much lower than those used in schizophrenia (eg, haloperidol, 0.5–2 mg orally; risperidone, 0.25–2 mg orally). Federal regulations require that if antipsychotic agents are used in treatment of a nursing home patient, drug reduction efforts must be made at least every 6 months.

C. Driving

A common yet vexing problem that providers are regularly asked to assess is whether a patient with dementia is able to continue driving. The consequences of a decision to either stop or continue driving can be far-reaching for both the patient and the general public and therefore every case requires careful consideration. Although drivers with dementia are at an increased risk for motor vehicle accidents, many patients continue to drive safely well beyond the time of diagnosis, making the timing of when to recommend that a patient stop driving particularly challenging.

There is no clear-cut evidence to suggest a single bestapproach to determining an individual patient’s risk, and there is no accepted “gold standard” test. The result is that clinicians must consider several factors upon which to base their judgment. For example, determining the severity of dementia can be useful. Patients with very mild or mild dementia according to the Clinical Dementia Rating Scale were able to pass formal road tests at rates of 88% and 69%, respectively. Experts agree that patients with moderately severe or more advanced dementia should be counseled to stop driving. Although not well studied, clinicians should also consider the effects of comorbid conditions and medications and the role each may play in contributing to the risk of driving by a patient with dementia.  Assessment of the ability to carry out IADLs may also add to the determination of risk. Caregivers of patients with at least a 30% ecline in their IADL score were more likely to rate them as unable to drive safely than other, less impaired patients. Finally, in some cases of mild dementia, referral may be needed to a driver rehabilitation specialist for evaluation. Although not standardized, this evaluation often consists of both off- and on-road testing. The cost for this assessment can be substantial, and it is typically not covered by health insurance. Experts recommend such an evaluation for patients with mild dementia, for those with dementiafor whom new impairment in driving skills is observed, and for those with significant deficits in cognitive domains such as attention, executive function, and visuospatial skills. At present, there is no convincing evidence to support the use of interventions to improve driving skills and driver safety.

Clinicians must also be aware of the reporting requirements in their individual jurisdictions. Some states have mandatory reporting laws for clinicians, but in other states, the decision to report an unsafe driver with dementia is voluntary. When a clinician has made the decision to report an unsafe driver to the Department of Motor Vehicles, he or she must consider the impact as a potential breach in confidentiality and must weigh and address, in advance when possible, the consequences from the loss of driving independence.

D. Advance Financial Planning

Difficulty in managing financial affairs often develops early in the course of dementia. The patient’s caregiver may seek advice from the patient’s primary care clinician. Although expertise is not expected, clinicians should have some proficiency to address financial concerns. Just as clinicians counsel patients and families about advance care planning, the same should be done to educate about
the need for advance financial planning and to recommend that patients complete a durable power of attorney for finance matters (DPOAF) when the capacity to do sostill exists. In most states the DPOAF can be executed with or without the aid of an attorney. Other options to assist in managing and monitoring finances include online banking, automatic bill payments, direct deposits andjoint bank accounts. A potential risk of the joint account is that the joint account holder has no obligation to act in the best interest of the patient.

No gold standard test is available to identify when a patient with dementia no longer has financial capacity. However, the clinician should be on the lookout for signs  that a patient is either at risk for or actually experiencing financial incapacity. Because financial impairment can occur when dementia is mild, making that diagnosis should alone be enough to warrant further investigation. Questioning patients and caregivers about late, missed or repeated bill payments, unusual or uncharacteristic purchases or gifts, overdrawn bank accounts and reports of missing funds can provide evidence of suspected financial impairment. Patients with dementia are also at increased risk for becoming victims of financial abuse and some answers to these same questions might also be signs of potential financial abuse. When financial abuse is suspected, clinicians should be aware of the reporting requirements in their local jurisdictions.

Prognosis

Life expectancy after a diagnosis of Alzheimer disease is typically3–15 years; it may be shorter than previously reported. Other neurodegenerative dementias, such as dementia with Lewy bodies, show more rapid decline. Hospice is often appropriate for patients with end-stage dementia.

When to Refer

Referral for neuropsychological testing may be helpful in the following circumstances: to distinguish dementia from depression, to diagnose dementia in persons of very poor education or very high premorbid intellect, and to aid diagnosis when impairment is mild.