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Disorders of Salt and Water
Loss of Vitality
Medication Problems (Polypharmacy)
Walking Problems, Immobility, and Falls
Abnormal cellular growths in the body are classified as either benign or malignant. An example of a benign growth is a wart. Malignant growths are called cancer, and incidence of these increases with age. Among people older than age 65 in the United States, cancer represents the second most common cause of death. (In Japan, cancer is the leading cause of death.) The prevention and early detection of cancer is critical in older people; if it is detected, then the effectiveness of cancer treatment and the older person's tolerance of cancer treatments need to be considered carefully.
The intricate mechanisms regulating the growth of cancerous cells have been partially unraveled by ongoing research. Growth factors activate the nuclei of cells and trigger them to grow and reproduce. This involves specific proteins called proto-oncogenes that help to regulate growth and repair normal tissues. In the normal situation, efficient mechanisms keep these proto-oncogenes under control. A failure of these controls can result in the unregulated growth of cells: neoplastic, or cancerous growth.
The discovery of some of the genes that are related to cancer has led to a multiple-step theory that helps to explain why the incidence of cancer increases with age. In older people, the effects of early exposure to various chemicals that promote cancer--i.e., carcinogens such as asbestos or uranium--have a longer period in which to act. Furthermore, when combined with the normal agerelated changes that occur in the nuclei of cells, these cells may become more vulnerable to subsequent exposures with multiple carcinogens.
The goals of cancer treatment--to prolong life and to relieve symptoms--may be influenced by age-associated changes in life expectancy, the aggressiveness of the cancer, and the effectiveness and complications of therapy. Some malignancies may have a milder course in older people, such as lung cancer and prostate cancer, while other malignancies, including Hodgkin's disease and acute leukemias, may actually be more aggressive. Furthermore, the number of tumors resistant to chemotherapy may increase in the older age group.
The main forms of cancer treatment are surgery, radiation therapy, chemotherapy, and hormonal therapies that modulate the body's response to tumor cells. Elective surgery is relatively well tolerated in people of advanced age, and rarely is age alone a reason for rejecting elective surgical treatment of cancer. Emergency surgery in older patients has a significantly increased death rate. Surgery is offered to remove a tumor and possibly cure the condition to prevent future problems (such as obstruction in colon cancer) or to clearly determine how far the disease has spread.
Radiation therapy uses energy produced by machines or naturally occurring elements such as cobalt or radium to penetrate body tissues to affect body cells. This radiation energy can be focused to the site of the cancer to provide greater radiation exposure to the malignancy and somewhat less to the normal tissues. Radiation therapy may be combined with surgery or may be used in some cases as a single treatment for some malignancies, such as lymphoma. (See Chapter 20 for more information on lymphoma.) A major role of radiation is to control spread of cancer and to manage pain. Bone pain may respond dramatically to radiation.
While surgery and radiation have been used for over a century, chemotherapy for cancer is a relatively new treatment. Chemotherapy uses chemicals derived from plants or developed in laboratories to kill cancer cells. Unfortunately, other body cells are also affected, such as in the bone marrow, intestinal tract, or hair follicles. Because of this, chemotherapy may cause problems with blood counts; induce nausea, vomiting, or diarrhea; and cause loss of hair. These effects can usually be controlled. Chemotherapy is given by mouth or by intravenous line and circulates throughout the body. This circulation allows the chemicals to reach cancer cells anywhere in the body except the brain. The brain has a natural protective chemical barrier.
Modulating the immune response is an especially appealing form of cancer treatment in older people whose immune defenses may be weak or less effective. Hormonal therapy for cancer is generally safe in older patients. For example, the anticancer medication tamoxifen has remarkably few side effects in older people.
Adjuvant treatments are treatments used to boost the primary forms of cancer treatment in controlling or eliminating the cancer. Both bone cancer and colon cancer are examples of conditions in which adjuvant chemotherapy prolongs survival. Considerable research is under way to develop therapeutic agents.
The sodium level in the blood reflects the relative amounts of sodium and water. A low sodium can mean either too much water or too little sodium. Older people are predisposed to develop low sodium in the blood for several reasons. Two of the most common are a decrease in kidney function and an increase in the levels of a hormone in the blood called antidiuretic hormone, or vasopressin. Several diseases that are especially prevalent in older people are associated with high levels of antidiuretic hormone, including cancer, lung disease, and nervous system disease. High levels of this hormone seem to keep the kidney from letting excess amounts of water in the body pass on to the bladder so that it can be excreted as urine. Thus, the extra water that cannot be eliminated dilutes the amount of sodium in the blood. This hormonal action can cause the urine to appear dark and concentrated. Furthermore, some drugs can cause low sodium in the blood, either by increasing the amount of antidiuretic hormone or by enhancing its action on the kidney.
Generally, the physician's approach to sorting out the causes of low sodium in the blood depend upon first confirming that the sodium is in fact low, and not just reduced because of very high blood sugar, fats, or proteins. The next step depends upon whether the person appears to be dehydrated, normally hydrated, or overhydrated. If the person is dehydrated, then the physician would look further for conditions that might cause loss of sodium and fluid from the gastrointestinal tract, skin, lungs, kidneys, or other sources. A person with a normal amount of fluid volume but a low sodium in the blood could have such conditions as kidney disease, severe loss of potassium, thyroid gland disease, adrenal gland disease, or be drinking too much water. People who have low sodium in the blood but who have an excess fluid volume usually have swelling in the skin, especially in the legs and feet. Conditions to consider in this situation include congestive heart failure, liver disease, and kidney disease.
The outlook for people with a low sodium depends upon many things, particularly the presence of any associated diseases, how rapidly the low sodium condition came about, and how low the level is. A low sodium level often reflects a serious problem because it occurs in advanced disease states. For example, people may develop a low sodium when they have significant heart, liver, or lung disease, or cancer that has spread widely. For people in the hospital, it means a poor outlook and a sevenfold increase in death.
Diuretic medications are one of the most common causes of a low sodium. Many people on diuretics become mildly dehydrated, with losses of potassium and magnesium. Apparently, the fluid loss caused by diuretics results in very high releases of antidiuretic hormone. This hormone and an increased sensation of thirst, which leads to drinking more and more water, combined with the inability to get rid of the extra water (because of the antidiuretic effects of the hormone on the kidney) causes the concentration of sodium to fall. Such a sequence of events frequently occurs in people who are hospitalized and given extra water by intravenous fluids.
The treatment of mild to moderate degrees of sodium loss involves restricting water to less than a liter per day, discontinuing any drugs that could aggravate the problem and treating underlying diseases. Severe symptoms include lethargy, seizures, coma, or other neurologic deficits, and require more aggressive treatment. Any treatment for sodium loss, particularly when a case is severe, should be given under the supervision of a physician because significant brain damage can occur if the sodium is corrected too rapidly.
An elevated sodium in the blood is usually caused by defects in the body's ability to conserve water. This can occur through illnesses, immobility, and a reduced capacity to feel thirst--all common problems in elderly people. A high blood sodium level is also a marker of serious illness and carries a high death rate. As with the low sodium in the blood, if the adjustment of the sodium level is made too rapidly, it can cause serious deterioration of the central nervous system. Treatment of this disorder should be done under a physician's supervision and usually requires intravenous fluids.
Approximately 15 percent of hospitalized men over the age of 70 have a high potassium level in the blood. In many cases this is due to decreased excretion of potassium through the urine. This decrease in secretion is partly due to changes in kidney hormones aggravated by long-standing kidney disease and partly by diseases or treatments that inhibit potassium excretion, for example, many nonsteroidal anti-inflammatory drugs (NSAIDs).
A low potassium level in the blood is commonly due to gastrointestinal disease or the use of diuretics (fluid pills). Low potassium can produce serious heartbeat irregularities, especially in people who have underlying heart problems. Sometimes a low potassium level is also associated with a low magnesium level in the blood. The low potassium cannot be corrected until the magnesium deficit has been resolved.
Diabetes mellitus (from the Greek and Latin, meaning "honey sweet siphon") refers to problems in regulating the blood sugar, and is usually identified by a high level of glucose in the blood.
The prevalence of diabetes mellitus increases with age. It is present in approximately 8 percent of people 65 and older and increases to 25 percent in those older than age 85. Usually, people in these older age groups have what is called Type 2 or non-insulin-dependent diabetes. This means that the problem is not due to the complete lack of insulin (Type 1 diabetes) but rather a relative unresponsiveness to normal or even high amounts of insulin.
Without a blood test, diabetes can be difficult to identify. People with diabetes mellitus usually have vague complaints of slowly resolving infections, weight loss, fatigue, weakness, loss of vitality, or neurologic changes such as numbness or tingling in their feet, acute confusion, or depression. In contrast to younger people, older people do not generally show increasing urination or fluid intake because both the kidney function and the thirst response tend to decline with age. In addition, glucose may not appear in the urine until the blood sugar reaches very high levels.
Older people with diabetes are subject to all of the complications of advanced diabetes: cardiovascular disease, eye problems, problems of the nervous system, and kidney disease. Older people may be at greater risk for certain complications such as blood vessel disease in the eye and neurological changes. These nervous system changes can cause impotence, difficulty with the muscles that control the eyes, painful nerves in the arms and legs, and problems with bowel function. Some studies suggest that poor control of diabetes can cause abnormalities of mental function in older people.
The degree to which blood sugar levels must be controlled in older people is still a matter of controversy. Obviously the treatment for diabetes is directed toward decreasing the symptoms and reducing the chance of infections, coma, and other disorders caused by having too high a blood sugar. It is also very important to avoid having too low a blood sugar (a condition called hypoglycemia) because older people tolerate low blood sugar levels very poorly. The strategy for treatment is aimed, moreover, at controlling other risk factors for blood vessel disease such as smoking and high blood pressure, each of which seems to accelerate the complications of diabetes. Some medications, such as diuretics and corticosteroids, can increase the blood sugar, making it more difficult to keep it at an appropriate level. Chronic conditions such as arthritis, decreased vision, and poor teeth may affect the person's ability to modify diet or exercise regimens.
As with younger people, the treatment for older people generally involves changing the diet. If the person is overweight, a loss of 10 to 15 pounds may improve the blood sugar control significantly. About half of the total calories in a diabetic person's diet should come from complex carbohydrates such as cereals, grains, pasta, and breads; less than 30 percent of the calories should come from fat (with an increase in polyunsaturated fats and a decrease in saturated fats), and the rest should come from protein. The diet should also be high in fiber. Despite its appeal, diet therapy is successful in only 10 to 20 percent of people. The next step in treating diabetes involves an exercise program tailored to the individual. Walking for about 20 to 30 minutes three times a week significantly improves the body's ability to utilize glucose.
If, after several weeks of conservative treatment the levels of fasting blood sugars continue to be high, oral medications are often recommended but their use is controversial. From what is known, these medications work by increasing the amount of insulin produced by the pancreas and by changing the body's receptors for insulin to make them more plentiful and more sensitive to stimulation. Medications that stay in the body for less than a day are preferred and reduce the chance of the blood sugar dropping too low. These oral medications do not appear to have an increased effect with increased dosage; thus, if an initial trial of treatment is not effective, the drug is unlikely to work.
The physician will most likely suggest insulin treatment if the levels of blood sugar remain high or are high initially, or if adequate control has not been achieved on oral medications. Usually the initial dose of insulin is low (about 15 units of an intermediate-acting insulin) as a once-a-day injection before breakfast. Older people often do not show early symptoms of a very low blood sugar. Because of this, blood sugar levels must be checked on an empty stomach, after eating, and at bedtime to be sure that no severe drops occur. Older people and care providers should learn how to use a simple machine to check blood glucose. The blood sugar should be checked every week even if the levels have stabilized.
Coma resulting from a very high blood sugar (hyperglycemic coma) is a complication of diabetes that is observed almost exclusively in older people. Blood sugar levels rise because of an agerelated reduction in kidney function (which limits the kidneys' ability to excrete glucose in the urine) and an inability to feel thirst, which causes a progressive dehydration. The rising glucose in the face of dehydration increases the thickness of the blood, making it more like molasses. About one-third of people suffering a hyperglycemic coma have no previous history of diabetes. The situation may be precipitated by a sudden illness, particularly an infection, or by certain medications. People who are susceptible to hyperglycemic coma often show signs of physical weakness, lethargy, agitation, a sudden change in their mental function, or coma. Changes in the nervous system can be pronounced and can even mimic a stroke. Significant dehydration and kidney failure are usually also present.
The goal of treatment for this sort of coma is to replace the fluids that have been lost, thereby restoring blood volume and reducing the blood viscosity. This is normally done over a period of two days. Very small amounts of insulin may also be given. A search for the underlying cause leading up to the coma such as pneumonia or a heart attack is conducted while treatment begins for the dehydration and increased blood sugar. The changes in body chemistry may improve in one to two days, but changes in mental function, including confusion and agitation, may persist for several weeks. People are usually discharged from the hospital without the need for ongoing insulin treatment, although they are at risk for a recurrence of hyperglycemia and need to be followed carefully.
Heat stroke is a medical emergency characterized by high fever, no sweating, and severe nervous system problems.
In elderly people, heat stroke occurs because normal body heat is not effectively dissipated. A person's perception of heat decreases with advancing age. Furthermore, the older person's thirst mechanism is less likely to sense and respond to fluid loss, increasing the chance of dehydration. Other factors that predispose people to heat stroke include cardiovascular diseases, neurologic disorders, medications, and extreme old age.
The older person with heat stroke has a change in mental function, high temperature, rapid heart rate, rapid breathing, and low blood pressure. The death rate is very high (around 10 percent) and emergency medical attention is required.
The treatment for heat stroke involves cooling the body as rapidly as possible using ice water or other appropriate measures and replacing fluids.
Older people taking psychotropic (neuroleptic) medicines may develop a very high body temperature (over 104°F), called the malignant neuroleptic syndrome. Fortunately this condition is uncommon and usually appears within the first month of therapy. In addition to the very high temperature, the person may have muscle rigidity, mental status changes, and extreme fluctuation in blood pressure and heart rate. Treatment requires stopping the neuroleptic drug and providing basic support. The death rate approaches 25 percent.
Hypothermia is a medical emergency in which body temperature decreases to below 95°F. As might be expected, hypothermia is more common during the winter months and in colder climates.
Older people are more likely to experience abnormal regulation of body temperature. The body's energy production is lower, as is heat produced by muscle activity, in part because of decreased muscle bulk. In addition, blood vessels in the skin of the older person are less able to constrict as a heat-conserving response. The perception of a drop in room temperature as well as body temperature becomes less acute with age, and the body's shivering response is blunted--these conditions reduce a person's awareness of a need to take self-protective measures.
Numerous other commonly occurring diseases also predispose older people to having a low body temperature. These conditions include thyroid disease, previous stroke, Parkinson's disease, diabetes mellitus, congestive heart failure, malnutrition, and septicemia and are discussed separately in other parts of this book. The use of alcohol and other drugs can diminish the body's ability to maintain a normal temperature. In people over the age of 75 the risk of death due to hypothermia is five times that of younger people.
The older person with hypothermia does not complain of being cold. One should suspect hypothermia when the older person wearing thin clothing does not appear to be cold especially if the temperature is low and other people feel cold. The skin is cold and the face is often pale and puffy. Mottled red and purple skin discoloration is often seen. Obviously, adding more clothing or blankets is appropriate. Rectal thermometers are used to measure core body temperature; a body temperature less than 95°F defines hypothermia.
Management of any underlying medical conditions is critical to recovery. Active rewarming with inhaled heated mist is safe and can easily be instituted in a hospital emergency room. This is an urgent situation and medical supervision is necessary.
While various age-related changes do compromise the body's ability to resist and control infectious organisms, there is disagreement among experts as to whether aging alone weakens the body's resistance. Other factors that increase the likelihood of infections in older as well as younger people include underlying diseases, hospitalization, stress, poor nutritional status, drug treatment, and complications of medical therapies. These factors are, however, more significant in older people.
The skin and mucous membranes are important barriers to infection. Microorganisms are always present on the skin and mucous membranes, but their activity varies according to the degree of dryness, the amount of acid on the surface, sweat gland secretions, and the presence of normal skin bacteria that help reduce the number of pathogens. Some of these barrier and antimicrobial properties of the skin may be impaired with age. In addition, certain skin conditions that predispose to infection, for example, pressure ulcers and blisters, are common in older people.
The mucous membrane surfaces that form the lining of the respiratory tract, gastrointestinal tract, and urinary system help prevent infection by trapping organisms in mucous secretions and removing them by transporting this mucous to a body opening where they are eliminated in sputum, urine, or vaginal discharge. Changes with aging may reduce the functioning of these barriers, thereby allowing increased numbers of potentially infectious bacteria to collect on the skin and mucous membranes. The mechanisms that keep bacteria from attaching to these surfaces may become less effective in older people due to changes in body hormones, such as decreased estrogen, and a decrease in the antibodies that attack the proteins used by bacteria to attach themselves to body surfaces.
Difficulty in swallowing, a common age-related change, predisposes older people to aspiration (see Chapter 21), which is a common cause of pneumonia. Aspiration together with the slowing of the mucous-transporting apparatus means that less material is cleared out of the lungs and airways. In addition, an older person may not be able to cough as vigorously as before. Changes in the breathing structures in the lungs, especially the collapse of small airways and the loss of lung elasticity, also increase the likelihood of infection.
Changes in the digestive system, such as reductions in the amount of gastric acid produced or reduced contractions throughout the bowel, alter the bacteria living in the gastrointestinal tract. Little pouches protruding from the wall of the lower intestine, called diverticula, can become inflamed when bacteria grow inside them. Changes in the urinary tract can produce any of the following: alterations in the composition of the urine; decreased prostatic fluid with reduced bacterial activity; a diminished flushing mechanism of the bladder; reflux of material from the bladder toward the kidney; and the potential for obstruction to urine flow by a prostate enlargement, displacement of urinary structures, narrowings of the urinary canals, or stones.
The age-related change in the immune system may explain some of the increased likelihood of infections, tumors, and blood vessel and immune diseases in older people. Older bodies are less able to produce the substances collectively called antibodies necessary to fight infection. Older people show less vigorous reactions to chemicals injected into the skin to check for previous infection (skin test reactions) suggesting that the response is impaired and that immunological memory of previous exposures may be affected.
Three basic principles help an older person or that person's caregiver to suspect and recognize infection in the older person. First, infection may cause an unexplained and rapid decline in ability to function or in a sense of well-being. Second, serious infections will generally produce a fever. Any elevated temperature in an older person requires very careful evaluation. Finally, up to 20 to 30 percent of older people can have serious infections such as pneumonia, urinary tract infections, an abscess in the abdomen, or tuberculosis without manifesting fever.
While any bacteria, given the right conditions, can cause an infection, different patterns of infection are seen in different settings. Recognition of these patterns can be helpful in identifying the probable source of the infection, especially in people with nonspecific symptoms.
In relatively healthy, functionally independent older people who live in the community, the most frequently seen infections are respiratory (influenza, bronchitis, and pneumonia), as well as urinary tract infections and intraabdominal infections (bladder infections, diverticulitis, appendicitis).
For people in the hospital, the major infections include urinary tract infection, which is often related to use of a catheter; pneumonia caused by aspiration; and skin and soft tissue infections such as infected pressure ulcers and postoperative wounds. Blood clots in the lungs and medications are also sources of fever in hospitalized older people.
When older people living in a nursing home are transferred to the hospital, it is usually because of fever or suspected infection. Pneumonia, urinary tract infection, and skin or soft tissue infection account for 70 to 80 percent of proven infections in this situation. Tuberculosis or infectious diarrhea should also be considered when an older person living in a nursing home appears to have an infection.
The greatest overall reduction in human suffering and death has resulted from the treatment of infectious diseases. Sulfonamides, sulfur-containing drugs, were introduced into medical practice in the 1930s, quickly followed by penicillin in the 1940s. Since then, hundreds of chemical compounds have become available to treat a wide variety of viral, bacterial, fungal, and parasitic infections. These compounds are called antibiotics (from the Greek, meaning "destructive of life"). Antibiotics work by inhibiting the growth of the infecting organism. Somewhat surprisingly, they generally do not seriously damage normal body cells despite significantly destroying invading microorganisms.
The severe loss of vitality in an older person represents a breakdown in overall biological and social function leading ultimately to institutionalization and death. Older people with this condition are typically frail and have difficulty in maintaining their independence. Clinically, loss of vitality shows itself as unintentional weight loss. The combination of severe weight loss along with various metabolic abnormalities on blood tests is sometimes called cachexia (from the Latin, "bad condition"). Both loss of vitality and cachexia impair body defenses and increase the susceptibility to the development of pressure ulcers.
Factors associated with increased mortality are low weight, diminished muscle mass, and physical weakness. Anemia and a low cholesterol in the blood are metabolic risk factors for death in elderly men living in nursing homes. Also well documented is the extreme decline in both physical function and the ability to conduct basic daily activities before death. The last activity to be lost is the ability to eat without assistance. People who require help with eating have an increased death rate. In addition, the loss of social interactions prior to death has been noted. Interestingly, there does not appear to be any precipitous decline in psychologic well-being immediately before death. As one might expect, loss of vitality frequently precedes institutionalization. The increase in risk factors that lead to institutionalization--decline in physical function, psychologic function, and social abilities--is significant but varies widely in individual circumstances.
Table 44. Causes of Loss of Vitality in Older People
In general, the diseases that lead to progressive weight loss, weakness, and, ultimately, loss of vitality are the same for people of all ages. These include cancer, heart failure, liver disease, and renal failure. Malignancies can lead to significant wasting of the body before they are discovered. Chronic infections can cause loss of vitality with very few other symptoms. The poor absorption of nutrients due to gastrointestinal disease can also reduce vitality.
Sensory conditions such as the loss of smell and problems with taste can lead to a loss of interest in foods. Loss of smell may be temporary if caused by an upper respiratory infection, and taste abnormalities are occasionally caused by reversible nutrient deficiencies such as zinc deficiency. Taste abnormalities can also be caused by medications including heart medicines and drugs used to treat psychiatric conditions. Adverse drug reactions are a common cause of loss of vitality in elderly people.
Difficulties in function can limit a person's ability to obtain food, cook it, or eat it. With advancing age, common conditions such as arthritis may affect both physical and social functions and are major sources of disability. Difficulties with hearing and vision can also produce progressive disability and social dysfunction. For example, they can limit the use of the telephone or automobile. All of these difficulties are compounded by social isolation and lack of community support. A major cause of loss of vitality is the increased disability due to simultaneous difficulties in many areas; for example, the combination of arthritis, hearing difficulty, and declining social support. Finally, even when food is available, problems with the teeth or dentures, a very dry mouth, or problems with swallowing can interfere with food intake.
Table 45. Treatment of Loss of Vitality in Older People
Psychologic problems such as dementing illness, depression, and prolonged grief reaction can be especially devastating in the elderly. Serious depression and other psychiatric problems can occur. In some cases, when an older person appears to give up, loss of vitality may be intentional.
A related problem that can result in loss of vitality is known as caregiver fatigue, which is caused by emotional and physical burnout. Poverty and isolation are other possibly reversible causes of loss of vitality.
A goal of effective care for older people consists of identifying and treating reversible causes of loss of vitality (see Tables 44 and 45). If they are not treated early, the condition can progress to such an extent that an irreversible loss of muscle mass occurs. As mentioned, this malnourished state is called cachexia. During the progression from loss of vitality to cachexia, people may demonstrate continued decline toward death. Elderly people in this situation are very vulnerable to acute events such as infections or falls. An acute event can then trigger further problems such as severe malnutrition or pressure ulcers, and these in turn can stimulate further declines in function propelling a vicious cycle that culminates in death. For an elderly person with the loss of vitality syndrome, a minor accident such as a fall can lead to death.
A key aspect of therapy is to have counseling on end-of-life decisions. Frank discussions between family members, your doctor, a religious counselor, and others can explore treatment preferences and alternatives. It is very important for as many caring people as possible to be clear about your wishes for care. (Chapter 11 contains more information on ethical issues and ways to make sure your decisions are respected if you can no longer participate in the decision-making process.)
Use of multiple medications, known as polypharmacy, places older people at increased risk of adverse drug reactions. (See Chapter 9 for additional information on adverse drug reactions.) The average older American uses 5 prescription medicines at any given time and fills from 12 to 17 prescriptions each year. Although comprising between 12 and 13 percent of the population, older Americans use over 25 percent of all prescription drugs. In addition, they use an average of 3½ over-the-counter medications. Frail older people tend to consume even more medicines. The average person in the nursing home takes more than 8 medications. In the nursing home setting, there is a particularly frequent use of medications that commonly lead to side effects, such as digitalis, diuretics, and drugs that affect the nervous system. The cost of prescription medications used by older people is well over $10 billion a year.
Older people are particularly vulnerable to adverse drug reactions because of the changes that occur with normal aging. Adverse drug reactions (ADRs) are defined as the development of unwanted symptoms, changes in blood or other tests taken, or death directly related to the use of a medication. The number of ADRs increases with the number of medications used and with the increasing age of the person (see Figure 46 and Table 46). Some studies suggest that there is no independent age effect on the rate of adverse reactions and that the risk of ADR may be increased in older people simply because of an increased prevalence of overall risk factors. In other words, adverse reactions probably occur more often in older people because they take more medicines, they have more illnesses, their illnesses are more severe, and there are changes in their bodies that affect the way medications are absorbed and eliminated.
Drugs that are used concurrently may interact with each other and these drug-on-drug interactions may have clinically significant consequences. One drug may either cause another to act more powerfully or may inhibit its action. Because of this, a sudden toxic reaction can develop when a seemingly safe medication is added to the medical regimen of a person who has been using another medication for a long time without any problems. For example, a person who has been taking stable doses of drug X may have a toxic reaction when given drug Y, if drug Y disrupts the metabolism of drug X. Even without changing the dosage level of a drug, drug-on-drug interactions can alter the effectiveness of a drug. For example, some antidepressant medications may inhibit the effect of certain drugs (like clonidine) given for high blood pressure.
Table 46. Number of Drugs Used and Relationship to Adverse Reactions
Older people are at increased risk for what might be called a drug-disease interaction. This occurs when medications that are useful in treating one illness exacerbate another illness. For example, an older person given eyedrops for glaucoma may faint because of a preexisting heart disease. This happens because the eyedrops are absorbed into the body and cause the already susceptible heart to beat slower. Similarly, an older man with an enlarged prostate who is given an antihistamine for an allergic reaction may have difficulty urinating. Antihistamines inhibit nerve response in this case, making it difficult to pass the urine through the prostatic obstruction.
Paradoxically, the increased prevalence of disease that makes the use of medications riskier in older people may also require that they use more medications. Because of this potentially vicious cycle, a concept of appropriateness of medication use has been developed among medical professionals. By the most commonly used clinical definition, the use of a medication is appropriate if its benefits significantly outweigh its potential risks. This means that medications may be correctly used, overused, underused, or misused. Medication is overused if it is prescribed without a good reason for doing so, underused if it is not prescribed when its use could be helpful, and misused if its use is appropriate but it is prescribed in an incorrect dose or for too short (or too long) a time, or in some other way that involves unnecessary risk.
By definition, inappropriate use of medications is associated with increased risk. An estimated 10 to 17 percent of hospital admissions for older people is directly attributable to inappropriate medication use. Older people break their hips twice as often while under the influence of some medications, such as long-acting benzodiazepines or drugs used to treat psychiatric conditions. One in 1,000 older people who are hospitalized dies because of the side effects of medications. As for underuse, it has been estimated that increasing the percentage of older people who are vaccinated against influenza to 50 percent would prevent more than 3,000 deaths each year. Clearly, inappropriate use of medication is a major health problem that could be avoided.
Compliance means that the patient follows the physician's instructions. Noncompliance with prescriptions is a problem in all age groups and does not appear to increase with age. Noncompliance increases with the number of medications a person uses and is a common problem in elderly people because they use more prescription medications. Sometimes there may be good reasons to not always follow a physician's advice, such as the appearance of a side effect or an error in prescribing.
Nearly one in five people fails to fill a prescription. In addition, between 30 and 60 percent of those who do fill a prescription use the medication differently from the way it was prescribed. As a result, about half of all prescriptions fail to produce the desired effect.
Some of the factors that affect compliance are shown in Table 47. People are more likely to comply with treatment if they believe that their condition is serious, that they might be susceptible to disease, or that the medication prescribed is effective in treating or preventing the disease. When noncompliance is a concern, the reasons need to be explored. For example, the person might have stopped taking the medication because of toxicity or adverse side effects. Methods of improving compliance include clarifying written and verbal instructions about the purpose and use of the medications, reducing the number of medications to be taken, simplifying the dosage schedules, and providing devices that make accurate self-administration more likely. On the other hand, long-term treatment, complex scheduling, increasing the number of medicines, and difficult-to-open containers, as well as the person's perception that the medication may cause side effects, reduce compliance.
Table 47. Factors Influencing Compliance
More than 60 percent of all visits to physicians conclude with the physician writing out a prescription. Half of all visits to an emergency room result in a prescription being given for at least one medicine. Moreover, by the time older people are discharged from the hospital, half of their medications have been replaced with new ones. Medications proved to be ineffective for some diseases, such as Alzheimer's disease, are still frequently prescribed.
Many physicians are reluctant to stop medications, especially if the medications have been used for a long period of time and the person is clinically stable. Even when physicians cannot determine whether the use of a medication was appropriate or whether the conditions that indicated its use continue to exist, they may fear that stopping the medication will precipitate problems.
Another way people end up taking too many medications is that they often see more than one physician. While some consulting physicians communicate directly with the referring physician, others typically prescribe for and advise patients directly. Furthermore, communication with the referring physicians is often imperfect, or people may seek consultations without informing their primary physician. People often fail to tell their primary physicians about medications that have been added to their regimen by other doctors. The discharge process from hospitals may also contribute to a person's taking too many medications since the medications that are routinely ordered in the hospital, such as sedatives, laxatives, and pain relievers are often continued unnecessarily when the patient is discharged. Discharged patients are sometimes not given adequate instructions about the adjustments they should follow in their medication regimen.
Finally, physicians are sometimes hampered by the inadequacy of their own records, because outpatient medical records may not contain accurate information on medication use. Even in the hospital and nursing home, where record keeping about current medications is usually accurate, a medical record is generally an unreliable source of information about medications a person may have used in the past or about a person's history of allergic and adverse reactions to drugs, or failure to recover from a disease treated with medications.
Clearly, physicians must keep accurate records of medication use as a basic medical responsibility. The medication listing must be updated at regular intervals so that medications prescribed by other physicians can be added to the list, ineffective medications can be stopped, and misunderstandings about how the medication should be taken can be detected and corrected. With medications used on a long-term basis it is important to review periodically whether they are still necessary, whether all medications currently being used are the safest and most effective ones available, and whether published evidence and expert medical opinion continues to support the use of each medicine. The older person's physician should not be complacent about continuing unnecessary medications since these may pose risks.
Any medication may cause side effects in older people, but certain drugs are more likely than others to cause problems. Examples of those that are best avoided are the long-lasting benzodiazepines and medications that powerfully affect the nervous system. If, for example, there is a need for these particular medications, safer alternatives are almost always available. A physician should prescribe other medications with extreme caution after taking note of any age-related body changes. (See Chapter 9 for more on age-related changes in the body's handling of medications.) Many physicians are not aware of these age-related changes.
Keeping up with all the newly released drugs can overwhelm even the most studious physician. Pharmacists can be very helpful on advising both physicians and patients on the advantages and disadvantages of specific preparations, dose adjustments, drug-on-drug and drug-disease interactions, and side effects. Pharmacy consultation and review is generally available for care in the hospital and mandated for care in the nursing homes. Pharmacists should package all medications in suitable containers that bear adequate instructions written in a type size that older people can read, and they should explain verbally how to take the medicine.
Some pharmacists provide written information to older people when prescriptions are filled. It is likely that these developments will increase with advances in computer technology.
Unrelieved pain is one of the most common complaints among older people. Between 25 and 50 percent of elderly people have significant pain. Among people living in nursing homes, the proportion may be between 45 and 80 percent. Pain causes depression, decreased socialization, sleep disturbances, impaired walking, increased usage of health services, and increased medical costs. Although less thoroughly explored, pain may also affect specific arthritis complaints, balance and gait disturbances, falls, lack of progress with rehabilitation, taking too many medications, cognitive dysfunction, and malnutrition. Moreover, pain and its management carry significant implications for quality of life, especially with regard to people with terminal illness and people who live in nursing homes.
The most common cause of pain appears to be arthritis and other muscle and bone conditions. Malignancy is also a common cause. One-third of people with active cancer and two-thirds with advanced cancer suffer significant pain. Shingles (herpes zoster), poor circulation, and inflammatory disease involving the blood vessels are some other specific pain syndromes that are known to affect older people in disproportionate numbers.
Theories that view pain as a simple sensation have long been abandoned, and pain is now recognized as a very complex sensory experience modified by a person's memory, expectations, and emotions. A number of anatomical and biochemical findings support what is known as the "gate control" theory of pain. This theory postulates that sensory information can be inhibited in the spinal cord. Although it seems to apply to pain in the body, the theory may not apply to pain that originates within the central nervous system. Two types of sensory information are relayed from the spinal cord to the brain. A fast track relays information directly to the brain about the location and quality of the pain, such as sharp, severe, and sudden. A slow track relating to the emotional qualities of pain is thought to produce such descriptors as "burning," "frightening," or "cruel." There is also a neural system to inhibit pain that influences pain transmission at the spinal cord level. This system, which descends from the midbrain to the spinal cord, appears to be very important in modulation of pain sensation.
The extremely complicated interaction of these systems may explain the diverse nature of pain perception and responses to various treatments such as opiates (narcotics), antidepressants, transcutaneous nerve stimulation therapy, acupuncture, and placebo effects.
Pain is usually characterized as acute or chronic. Acute pain, defined by its distinct onset and relatively short duration, usually occurs with some additional symptoms within the nervous system: fast heart rate, sweating, or a sudden elevation in blood pressure. Such symptoms imply the existence of an endangering injury. Chronic pain, which usually has a duration of more than three months, ordinarily does not occur with such neurologic symptoms and is often strong or intensely felt out of proportion to any indications of immediate danger. Chronic pain occurs with long-standing functional and psychological impairment.
Pain is such an individual experience that it usually requires a multidimensional approach to its assessment. To ensure an accurate assessment, physical, functional, and psychological evaluations should be combined, beginning with a thorough interview and physical exam. The interview generally establishes the presence of any medical conditions and provides a description of the experience of pain. Factors that worsen or relieve the pain are explored, including any physical or social limitations. For a person with chronic pain, sudden changes in the character of the pain may indicate deterioration in the condition or a new injury. These need careful evaluation. In addition, many different pain-producing conditions may coexist in any given person, especially in the context of malignancy. Each condition may require a different treatment approach.
Older people may underreport symptoms because they think the pain is caused by aging and progression of their disease. People who have cancer may not report pain because they are afraid of what the pain may mean or they may feel that it cannot be relieved. Elderly people often have multiple illnesses, and care must be taken to avoid attributing acute pain too quickly to some preexisting illness. What makes finding the cause even more challenging is that chronic pain is often variable, and that both the character and intensity of pain may fluctuate.
Functional impairment is an important guide for pain management in older people. Impairment in advanced activities of daily living such as psychosocial functions (social role, hobbies, recreation, etc.) may correlate with the presence and severity of pain. The information gained from the interview and physical examination can be useful in assessing the person's functional capacities.
A psychologic assessment is also conducted as part of the evaluation. Most people with chronic pain have significant symptoms of depression or anxiety and may benefit dramatically from psychologic or psychiatric intervention. Various pain assessment scales have been developed to help both doctors and researchers more accurately measure and document pain experiences (see Figure 47).
Records such as a pain diary provide the physician with a description of the person's individual pain experience and can be particularly useful in determining pain management. In people with cognitive impairment, body language such as facial grimaces and agitation may be important behavioral cues indicative of pain. Specific pain-rating scales such as numerical or verbal descriptor scales quantify the intensity of the person's pain and assess pain at a particular moment--for example, in response to therapy.
In the past 15 to 20 years, pain management has become very sophisticated, with specialized pain centers, multidisciplinary teams, and the development of high-technology pain management applications. Pain management may involve special problems for older people, but very few studies describe management techniques specifically for elderly individuals. For the most part, pain management strategies have been based upon studies of younger people and people with pain caused by malignancy.
Initially, the control of most acute pain relies on the treatment of the underlying disease and on short-term administration of pain relievers. Chronic pain, however, usually requires a multidimensional approach consisting of various behavioral and coping strategies as well as pain relievers and other drugs.
Drug treatment alone is usually not effective in chronic pain management. A combination of drug and nondrug techniques usually results in more effective pain control, with less reliance on medications that can produce major side effects in elderly people. The possible side effects of many pain-relieving drugs cannot be overstated. In general, people with pain caused by malignancy respond well to the constant administration of opiate (narcotic) pain relievers. The long-term use of these analgesics (pain relievers) remains controversial in the management of chronic pain not due to malignancy. Analgesics should be reserved for more severe pain that is unrelieved by other approaches. It should also be remembered that pain caused by nerve irritation, such as that resulting from shingles (herpes zoster), diabetes mellitus, and stroke, may respond to antidepressants or anticonvulsant medications.
Oral or injectable pain-relieving medicines, the most common treatments for pain, fall into two broad categories: nonsteroidal antiinflammatory drugs (NSAIDs) and narcotics. NSAIDs affect pain indirectly by blocking a class of compounds called prostaglandins that appear to be mediators in the pain process. They provide specific relief for inflammatory conditions that stimulate pain. These drugs have a pain-relieving effect that is characterized by a ceiling effect; that is, a level at which increasing the dose does not result in increased pain relief. Often working well individually or in combination with narcotic analgesics, NSAIDs may be especially helpful in managing cancer pain affecting the bone. They are not generally habit-forming. However, NSAIDs have been associated with a variety of adverse effects in older people, including stomach irritation, ulcer disease, kidney problems, and the tendency to cause bleeding. Although they are usually the safest form of pain relief for mild to moderate pain, experts have begun to question their overall safety among frail, older people.
Narcotic analgesic medications act on the nervous system to decrease the perception of pain. Some of these drugs--morphine, for example--may also have anesthetic properties and are used in providing anesthesia for surgery. With no absolute upper limit of dose, narcotics have been shown to relieve many types of pain, although they appear to be much less effective in managing chronic pain due to nerve irritation, compared with managing pain from other causes. Short-term studies of pain after surgery and for cancer have shown that compared with younger people, the elderly are more sensitive to the pain-relieving properties of these drugs.
Narcotics may produce such side effects as memory disturbances, constipation, and habitual use among elderly people. Suppression of breathing does not seem to occur if the drugs are carefully increased in dose until the pain is relieved. As with most psychoactive drugs, narcotics may produce inconsistent and variable effects. However, when they are administered appropriately, the effects of narcotics remain the best understood and the most predictable. Morphine remains the standard by which all other pain relievers are compared and is the drug of choice for severe pain. The reluctance of physicians to prescribe morphine has been overly influenced by recent political and social pressure generated by the reaction to illegal drug use. One study of over 12,000 medical records found only 4 cases of narcotic dependency produced medically. Psychologic dependence does not come from the use of morphine and other narcotics that are used to relieve pain. It appears that once the pain goes away, the narcotics are no longer desired.
Such side effects of narcotics as constipation and nausea do not wear off with time, and along with other symptoms may make the overall management of pain more difficult. Because of this, it is important to begin a bowel regimen at the same time the older person is started on these narcotics; such a regimen should include increasing fluids and the use of special lubricating agents and other medications.
Antidepressants, antiepileptics (drugs that are used to control seizures), and some sedatives are sometimes used to help control certain types of chronic pain. For example, the treatment of underlying depression or mood disorders with antidepressants may enhance other pain management strategies. In addition to reducing anxiety, stress, and tension, these drugs may also help the person have a good night's sleep. Chronic pain is an exhausting experience, and most people cope better if they have adequate sleep.
Although older people are more sensitive to the pain-relieving capacity of pain relievers (and their side effects), the doses and incremental increases remain the physician's decision. In the final analysis, the best advice is, "start low and go slow."
Patient-controlled analgesia (PCA) has proven to be an effective strategy in pain management. In this approach the person sets her own dose of medication; this often balances the person's pain tolerance and the side effects more effectively. Although PCA is often used with continuous intravenous infusions of pain relievers, the concept remains valid for other pain management strategies.
Advances in pain management strategies that do not include drugs have been strongly advocated for pain relief. These techniques include transcutaneous electrical nerve stimulation (TENS), physical therapy, biofeedback, hypnosis, and distractive techniques. In individual circumstances each of these techniques can be quite effective.
Transcutaneous electrical nerve stimulation has been used for a variety of older people's chronic pain conditions, such as painful nerves caused by diabetes, shoulder pain or bursitis, and for fractured ribs. Although the overall effectiveness of TENS is in doubt, some people who receive it experience relief of their symptoms. Its effectiveness often wears off after a few months, although some people have had years of pain relief. Care must be taken to avoid skin irritation and possible burns from the electrodes, especially when treating people with memory problems. (Chapter 8 has additional information about TENS units and other modalities.)
Physical methods such as heat, cold, and massage can be helpful in managing musculoskeletal pain. Many of these measures relax tense muscles and prove soothing for a variety of complaints. They can be managed by older people, thus giving them and their families a sense of control over the symptoms and the treatment. However, caution must be exercised with the prolonged use of heat or cold in older people, to avoid burns and other skin injury.
Biofeedback, relaxation, and hypnosis are some of the maneuvers that may be effective in controlling pain, although they are not as useful in people with cognitive impairment. These approaches require the skills of a trained psychologist or therapist.
Perception of pain may be decreased by a variety of distractions. Many people find comfort in music, meditation, or prayer. In general, as much involvement in activities, exercise, and recreation as the person can tolerate should be encouraged, since inactivity and immobility may contribute to depression and enhanced pain. Humor therapy also has a significant role in pain relief.
Disturbed sleep at night, sleepiness during the daytime, or both, are common complaints among older people. They are also important symptoms of the psychiatric disorders that may occur in late life, especially depression and dementing illness. Complaints of disturbed sleep are especially common among community-living elderly people who live alone, are unemployed, depressed, or bereaved. The use of sleeping medications increases steadily with advancing age, as does the likelihood of many types of sleep-related behavioral disturbances such as wandering at night, confusion, and agitated behavior. These disturbances may frustrate caregivers and may trigger a family's decision to institutionalize an older relative. Sedating medications are commonly prescribed for elderly people in the nursing home setting.
Sleeping states and sleep schedule change with age, which reflects both the aging process and the impact of any existing physical and psychiatric disorders. There are two very different states of sleep: nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. NREM sleep represents a quiescent brain whereas REM sleep represents an activated brain. During REM sleep, the heart rate, breathing rate, and blood pressure tend to increase compared to these values during NREM sleep. REM sleep is governed by activity in cells of one part of the brain; NREM sleep is influenced by activity in two other brain areas. The most important age-related changes in sleep include a decreased continuity of sleep with an increase in the number of arousals during sleep; a tendency for the major period of sleep to occur earlier in the night; a tendency for REM sleep also to occur earlier in the night; a decrease or a loss of the very deepest parts of NREM sleep; increased napping during the day; and a tendency to spend more time in bed. While this last tendency may be a response to poor sleep, it only seems to perpetuate the problem and make sleep quality worse. Other important age-associated changes in sleep include a decrease in the amount of growth hormone secreted and alterations in the sleep-associated secretion of other hormones.
Studies of sleep in healthy elderly people have also noted gender-related differences: Elderly men show poorer sleep maintenance than women. Paradoxically, older women are more likely than men to complain of sleep problems and to receive sleeping pills, possibly because they are more sensitive to sleep quality and sleep losses than older men. This may be especially true for the mood-disrupting effects of sleep loss.
Depression and dementing illness such as Alzheimer's disease produce characteristic changes in the way we sleep. The changes of sleep that occur with depression include a shortened time between the onset of sleep and REM sleep, various brain wave changes, and early morning awakening. Over half of people with depression experience some improvement in their symptoms after a night of sleep, but over 80 percent of these people relapse if they remain untreated after one night of sleep deprivation. Sleep in patients with Alzheimer's disease gets worse as the dementia progresses and is characterized by a more variable sleep-wake pattern, decreased eye movements in the REM stage, a normal or increased interval from the beginning of sleep to the development of REM sleep, and increased breathing problems occurring during sleep.
The body's internal clocks are called circadian rhythms, and they exert powerful effects on the regulation of sleep, particularly the temperature rhythm. The body temperature cycle is generally an accepted marker for the biological clock that seems to drive the daily cycles in REM sleep, alertness, and vigilance. Most likely, REM sleep is near the lowest level of daily temperature rhythm. Human temperature rhythms tend to flatten out and shorten with age, and this range reduction seems to result from an increase in the daily low point. These changes influence older people's preference for earlier bedtimes and wake-up times. Sleep disturbances such as insomnia show a blunting in the body's sleep temperature rhythm.
Lifestyle changes also contribute to sleep problems that occur in old age. For example, the fact that many older people spend increased time in bed may reflect a feeling that they have little reason to get up; their opportunities for social and physical activity may be diminished. Among institutionalized older people, environmental factors such as temperature, noise, and lighting undoubtedly provide important and perhaps deleterious changes in the time cues for the regulation of sleep and wakefulness.
As many as 30 percent of people over the age of 60 suffer from and complain of poor sleep quality on a regular basis. Interestingly, only about 1.6 percent of those over the age of 65 complain of getting too much sleep. Significant depression is much higher in people of any age who have sleeping difficulty (see Chapter 15 for more on depression). Between 20 and 25 percent of older people living in the community regularly use some form of sleeping pills. Older people frequently complain that their sleep is not refreshing and they have difficulty in maintaining sleep. Younger people are more likely to complain of difficulty in getting to sleep. As already noted, older people may also report trouble in maintaining alertness during the day, which may reflect the need for more sleep.
Sleep-related behavioral disturbances such as agitation at night, night-walking, shouting, and urinary incontinence are also important issues. The widespread prescriptions of sedative medications in nursing homes probably reflect, in part, the clinical importance of these sleep disturbances and behavioral problems. About 30 percent of the nursing home inhabitants receive medication for sleep on a regular basis.
Snoring has received the most attention among sleep behaviors. Habitual, severe snoring occurs in about 10 percent of men and about 3.5 percent of women ages 40 to 67. It seems more common in men with high blood pressure and in men with heart disease or stroke. Severe snoring is likely to reflect complete closing of the airway during sleep leading to a condition of impaired breathing called sleep apnea. Several studies have shown that sleep-disordered breathing increases with advancing age, but more commonly in men than in women. In one large community-based study, the prevalence of sleep-disordered breathing was about 25 percent. In addition, the prevalence rates were higher in men than in women, and were higher in nursing home residents and in hospitalized individuals than those who lived in the community.
Sleep disturbance is also a major debilitating reaction to bereavement and frequently persists following spousal bereavement. The importance of this sleep disturbance in late-life bereavement can be significant. It may lead not only to depression but also to self-medication with alcohol and sleeping pills.
The two major categories of sleep disorders are the insomnias--disorders in getting to sleep and maintaining sleep--and the hypersomnias--disorders of excessive daytime sleepiness. About 40 percent of people with persistent insomnia and about 50 percent of people with hypersomnia are related to psychiatric disease.
The key symptoms are complaints of insomnia, nonrefreshing sleep, excessive daytime sleepiness, a shift in the timing of the sleep period, frequent periods of sleep and wakefulness during the day, and changes in mood, performance, and alertness as a result of these sleep changes.
The person who is having sleeping problems should discuss with a physician how long these problems have been present and any likely contributing factors. Temporary disturbances lasting two to three weeks are usually determined by the specifics of the particular situation. More persistent problems, those lasting more than a month, indicate more serious, underlying medical or psychiatric conditions and require a more detailed evaluation. The person's sleep partner (if any) is usually eager to share information concerning the sleeping problem. Additionally, the person or the partner or other caregiver can keep a sleep log over a two-week period to determine the quality of sleep during the 24-hour day. The usefulness of the sleep log is improved if the information includes schedules of sleep and naps as well as social activities, information about meals, medications, and exercise. After reviewing this information a physician may recommend, among other things, an adjustment in drug use, both prescription and self-medications (alcohol and caffeine, for instance). Factors contributing to sleep disturbances in older people and possible additional problems are shown in Tables 48 and 49. Sometimes an evaluation in a sleep laboratory is recommended if the person has heavy snoring, excessive daytime sleepiness, severe muscle jerks at night, or restlessness of the legs during sleep. A sleep laboratory study can also be done if an initial attempt to treat the problem fails.
Most older people should realize that some sleep disturbance, particularly mild insomnia, may be an unavoidable consequence of aging. The reinforcement of a regular sleep-wake schedule, together with limiting the time in bed to no more than seven or eight hours nightly, is important to counteract the age-related tendency to replace a consolidated period of sleep with a more scattered sleep-wake cycle.
Practically speaking, the older person with insomnia should be encouraged to maintain control of the sleep schedule by going to bed only when sleepy, by getting up at the same time each morning, by reducing the time for naps to no more than 30 to 45 minutes a day, and by limiting the nightly time in bed to seven hours. In addition, the person should avoid using the bedroom for activities that are not conducive to sleep. This will serve to keep the bed as a powerful stimulus to sleep. When a person is encouraged to follow such suggestions he has an increased sense of control over the schedule and stimuli for sleep, which diminishes the need for sleeping pills. Other facets of the initial treatment approach involve reducing the amount of nicotine, alcohol, or caffeine; avoiding fluids just before bed (to lessen the need to urinate in the middle of the night); the timing of physical activity, meals, medications, and sleep periods (including naps); and removing depressant or stimulant drugs.
Table 48. Factors Contributing to Sleep Disturbances in Older People
Regular exercise, particularly if it leads to improved fitness, may improve the quality and depth of sleep in late life. Also, a behavioral technique called sleep restriction therapy may be particularly useful among older people with insomnia. In this treatment, the person is taught to spend less time in bed at night in order to create a modest sleep deficit, which then reduces sleep fragmentation.
Table 49. Causes of Sleep Disturbances in Older People
The cause of the sleep disorder must be determined if at all possible before an older person uses sleeping pills. Most experts on sleep disorders agree that there is a role for sleeping pills in a situation that is temporary or for persistent insomnia that is related to nonpsychotic psychiatric disorders. Before prescribing sleeping pills, a doctor should alert the patient to the effects the pills will have on thinking, breathing, alertness, and performance, among other factors.
Surprisingly few studies have provided information about the use of sleeping pills in very old people with dementia or related mental conditions. The normal classes of sleeping pills such as the benzodiazepines do not offer a useful long-term strategy for successful management of sleeping problems in older people. This is especially true for older people with dementing illness. For the nondemented person with severe insomnia who cannot function without sleep-promoting medication, the use of a lowdose sedating antidepressant may be a useful alternative. Antidepressants retain their sedating effects for a longer time than benzodiazepines but without incurring the development of tolerance, daytime symptoms, or withdrawal symptoms. These medications may have other effects, however, such as causing drops in blood pressure when a person is standing, and this must be taken into consideration. Frequently, people with sleep disorders have depressive symptoms that may benefit from the use of these antidepressant compounds. For people with major depressions, tricyclic antidepressants usually prolong the time between onset of sleep and REM sleep and suppress REM sleep to an appropriate 8 to 10 percent of total sleep. In short, some antidepressant medications seem to restore the sleep to a pattern closer to that seen in younger people.
Diphenhydramine, another medication, has long been used to promote sleep in older people, but its effectiveness is not as clear as that of other compounds and its usefulness in older people may be limited. If it is determined that muscle jerks at night (myoclonus) are a major cause of the person's insomnia, then a benzodiazepine may be helpful. Although the cause of nocturnal leg jerks is unknown, these medications seem to keep the person from waking up during the jerks, allowing normal sleep. Generally, in this condition it is important to use the benzodiazepines with the shortest elimination half-life.
The only reliable way to determine that the sleep disturbance is due to disordered breathing (sleep apnea) is for the person to participate in a sleep laboratory. There are many causes of this sleep apnea and an important element may be closing of the upper airway muscles leading to blockage and breathing difficulty. Whether this disorder requires treatment and what the treatment should be depends upon complex considerations. Interventions range from such behavioral changes as weight loss and reduction of alcohol consumption to significant surgical procedures involving the nasal passages, back of the mouth, and throat.
While physicians generally assume that sleep disturbance in late life tends to be chronic and intermittent, there is little information to guide them in this assumption. It seems reasonable to assume that a sleep disturbance will most likely occur in relation to medical and psychiatric conditions that then are seen as part of the cause of the complaint. One major aspect of sleep duration in late life is in its relationship to death. For example, men who report fewer than four hours of sleep per night have about three times higher the likelihood of dying within six years compared with those who sleep seven to eight hours per night.
Mobility refers to a person's ability to physically maneuver through the environment. Personal mobility depends upon being able to move from one surface to another and to propel oneself either by walking or by wheelchair. Immobility, therefore, is defined as having a problem in one or more of these areas. Falls are unintentional changes in position that result in hitting the ground. Generally, an event is not called a fall if a person faints or is overcome by a hazard, such as being hit by a car. Falls and immobility are related because immobility can lead to falls, which, in turn, may further reduce mobility. Because walking difficulties and falls often share the same causes and risk factors, let us consider them together.
Many older people have difficulty in walking and transferring from one place to another. (See Chapter 8 for more information.) If one defines a walking problem as significant slowing or an abnormal walking pattern, then gait disorders affect 15 to 20 percent of older people. About 20 percent of people who are over age 75 require help from someone to get out of a chair. Thirty percent of this group of people also have difficulty climbing stairs. In addition, 40 percent of people older than 75 are unable to walk for half a mile, and slightly less than 10 percent cannot walk across a room without the help of another person. Because the ability to move through the environment is essential for daily functioning, walking problems are partially responsible for the functional decline in activities of daily living that commonly occurs with aging. Severe immobility, defined as being unable to get out of a chair or a bed, can lead to other complications such as pressure ulcers, contractures of the joints, and urinary incontinence.
Each year, one-third of older people living in the community who are 75 and older fall. Of these one-half fall repeatedly. In nursing homes, the fall rate is estimated at one to two falls per person per year. The chance of falling increases with age.
In this country, the sixth leading cause of death in people over age 65 is accidents. The majority of these accidents are from falls. Broken bones and soft tissue injuries such as bruises and scrapes account for most of the nonfatal injuries related to falls. About 5 percent of falls in older people result in a fracture; 1 percent result in a hip fracture. In addition, 5 to 10 percent of falls cause restrictions in activity or result in a serious injury, such as a major bruise, joint dislocation, or sprain, requiring medical care. Although it is uncommon, a collection of blood between the brain and the skull, called a subdural hematoma, is a potentially devastating fall-related injury. Unfortunately, injuries other than hip fractures have not been studied thoroughly enough to provide accurate estimates of how often they occur, what lasting effects they cause, and what costs they incur.
Another disability caused by falls is the fear of falling again. This leads to self-imposed restriction of activity. Between 10 and 25 percent of people who have fallen admit to avoiding activities such as shopping or housekeeping because of their fears of falls or injury. Family members and other caregivers may also discourage activity. These physical and psychological consequences of falls and immobility contribute to the functional decline in many elderly people.
The causes and risk factors for falls and immobility can be understood by considering the various components that are necessary for us to remain stable while on our feet. Being stable requires the highly coordinated input and response of the several body systems: nervous, musculoskeletal, cardiovascular, respiratory, and others. Falls and immobility result either from a single disease that impairs a major component of stability or, more commonly, from the accumulated effect of multiple diseases superimposed on each other and on age-related changes. Some of the important age-related changes in balance include increased swaying from side to side and slowed responses to changes in position. The changes in walking that occur with age include a decreased step length, decreased walking speed, and increased time spent on both feet. These changes have very little significance until diseases and disorders become superimposed on them.
Various diseases can interfere with a person's balance, impair the gait, or promote falls and often affect the neurologic and musculoskeletal systems, including stroke, Parkinson's disease, severe arthritis in the neck, vitamin B12 deficiency, and problems with the lower back. Gait abnormalities are common and can involve difficulty in starting to walk, a stooped-over posture, variability in the steps, staggering, decreased height of the steps resulting in a shuffling kind of gait, and inability to walk in a straight line. People with these difficulties are usually able to keep from falling forward but may topple backward very easily.
Probably the most common cause of walking difficulty related to spinal cord disease in the older age group is cervical spondylosis, or degeneration of the cervical spine (the section of the spine located in the neck). Factors that predispose people to this condition include congenital narrowing of the spinal canal in the neck, trauma, bony growths that narrow the canal, and specific forms of arthritis such as rheumatoid arthritis. Numbness and tingling of the fingers and clumsiness with fine-motor tasks such as buttoning clothing are early symptoms. As the condition progresses, there may be mild weakness in the legs and difficulty in feeling vibration in the feet. The walking problems probably result from a combination of changes in muscle strength, coordination, and difficulty in telling one's position in space (the medical term for this is proprioception). While the degenerative changes of the cervical spine may be seen on X rays of the neck, additional studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be needed to demonstrate that the spinal cord is pinched in the neck.
There are other spinal canal conditions that cause walking difficulty. Narrowing of the spinal canal in the low back can occur with neck disease or it can occur independently. Most people with this condition (over 90 percent) feel a sense of pain, numbness, or weakness in the buttocks, thighs, or legs on standing or walking or sometimes with exercise. Usually these symptoms go away when the person sits down or lies down. The majority of people with this condition also have low back pain. A physical examination may show a change in neurologic reflexes in the ankle and knee and mild muscle weakness, particularly in the legs. Because serious diseases such as cancer can also produce neck and back problems, the older person with any change in walking ability should be evaluated carefully by a physician.
Sometimes blood vessel disease in the brain causes problems with walking. This is more common among people with high blood pressure; walking difficulty may result from changes in small blood vessels or even from small strokes.
Severe musculoskeletal problems can also result in instability, difficulty in walking, and falling. Severe arthritis of the hips or knees can compromise walking as a result of pain, muscle weakness, or loss of joint flexibility.
Falling can also be a sign of a sudden illness such as pneumonia, urinary tract infection, or congestive heart failure. About 5 percent of the time, falls are signals of these significant underlying diseases.
The majority of falls have several causes and result from the accumulated effect of multiple impairments of sensory, neurologic, and musculoskeletal components.
Diseases and disabilities in the eyes, ears, and balance control systems can increase the risk of falling and instability. Changes in the eyes that occur with age include slow adaptation to the dark and difficulty in accommodating to distances. Age-related diseases such as cataracts, macular degeneration, and glaucoma are also common. Visual orientation in space (and with movement) may be more relevant to falling than visual acuity--the ability to read letters along a line as in a standard vision test. Changes in the ear are common among older people and can create a sense of motion (vertigo), dizziness in response to head movements, and decreased stability in the dark. Factors that predispose to inner-ear disease include past exposure to certain antibiotics; present use of aspirin, tobacco, alcohol, and other drugs; head trauma; and previous ear infections or ear surgery. In addition, diseases that affect the balance system in the ear such as Ménière's disease are more common in older people.
The proprioceptive system orients people in space during changes in body position or when other senses are impaired. The system is made up of the joints in the neck, hips, knees, and feet, special receptors located in other joints, and other connections within the brain and nervous system. When an older person has difficulty maintaining balance as the body changes position, this is most likely due to malfunction of the nerve endings in the legs and feet. This condition is seen with diseases such as diabetes mellitus and vitamin B12 deficiency, both of which are more common in elderly people. As mentioned earlier, severe neck disease can also result in proprioceptive abnormalities. People with such abnormalities may complain of dizziness, a sense of motion, or unsteadiness when they turn their head. A common symptom is the inability to feel vibration in the legs and feet.
Because the central nervous system handles all of this sensory information, it is not surprising that central nervous system disorders including dementing illness, contribute to instability, immobility, and falling. Dementing illness increases the risk of falling even among people without a specific gait problem.
The movement aspect of the balance system involves the nervous system, muscles, joints, and bones. Disease or disabilities that affect any of these components such as arthritis, muscle weakness, or foot problems can result in an increased risk of imbalance and falling. Calluses, bunions, toe deformities, and deformed toenails, for example, may impair spatial orientation or cause limping or stumbling.
A sudden drop in blood pressure may act in concert with other conditions to cause falls and difficulty walking, but it is sometimes severe enough by itself to cause a person to fall. Medications, dehydration, and changes in the blood vessels and nervous system can all be culprits. People who feel dizzy, faint, or experience a fall within an hour after eating may have these symptoms because of a drop in blood pressure that occurs after meals.
Medications are significant as potential, and correctable, contributors to balance problems and falling. Any medication that affects the nervous system can increase the risk of falling and injury, such as sedatives, drugs given for anxiety, antidepressants, diuretics, heart medications, drugs for arthritis, and pain relievers. The greater the total number of medications a person receives, the greater the risk of falling.
Sedatives increase a person's chance of falling by 28 times. Dementing illness makes a person 5 times more likely to fall compared with people without dementing illness; leg problems make a person about 4 times more likely to fall. Among people living in nursing homes, weakness of the hip muscles, poor balance, and taking more than four medications are each independently predictive of falling during a year. All people who have three or more of these risk factors are highly likely to fall in the course of a year.
Over 75 percent of falls by elderly people occur at home. Tripping over objects or on stairs or steps is the most common cause. Environmental factors not only increase the chance of falling but they may also impair mobility. Low soft chairs, low toilet seats, a lack of things to hold on to, and poor access to light switches or dim lighting are just a few examples of environmental impediments.
Most falls occur during ordinary actions such as walking or changing position. Only about 5 to 10 percent of falls by people living in the community occur during clearly hazardous activities such as climbing a ladder or standing on a chair. The more active the person is the greater the risk of falling.
The ideal goal is to minimize the risk of falling while maximizing the person's mobility and independence. The best assessment and treatment plan will incorporate the preferences of the person, the family, the caregiver, and the physician.
Falling and immobility can be minimized in many ways; regular exercise is certainly a good strategy for reducing the likelihood of falling. However, once a fall or balance problem has occurred, it is important to review any previous falls and other risk factors and evaluate the person's balance and gait. Once any balance and gait problems have been identified, treatment solutions should include medical, rehabilitative, and environmental components. Medical and surgical interventions are aimed at eliminating or reducing the impairments; rehabilitative interventions are designed to help people compensate or adapt to impairments; and environmental interventions are directed at decreasing the impact of the impairments (see Chapter 8 for rehabilitation options).
The first step in evaluating ways to reduce falling is understanding its origin. A basic checklist that includes sensory, neurologic, musculoskeletal, and systemic diseases is useful (see Table 50). A careful review of medications is also an important part of this evaluation.
As indicated in Table 50, the results of the evaluation help determine the range of possible medical, rehabilitative, and environmental interventions. For example, people with impaired vision should see their opthalmologist for a change in their glasses, or if necessary, for evaluation of cataracts. They should also be advised to maximize the lighting inside their home to avoid falls due to poorly visualized obstacles.
Proprioceptive contributors to balance problems can often be detected by checking the range of movement in the neck. A physician can check for various disease states such as vitamin B12 deficiency. If a condition is uncovered, rehabilitative and environmental interventions include balance exercises, using appropriate walking aids, and wearing appropriate footwear. Firm shoes register a much better sensation of spatial relations to the feet than does walking barefoot or using slippers. Walking on thick carpets or uneven surfaces can also cause problems. People with proprioceptive difficulty should be careful in the dark because they tend to rely so much on their vision to maintain their balance.
Table 50. Possible Interventions for Fall Risk Factors
Musculoskeletal evaluation is an important part of the assessment. In individual circumstances, any of a number of interventions can be helpful. Examples of these include relief of pain, muscle strengthening, range-of-motion exercises, balance and gait training, back exercises, correct footwear, good foot care, and appropriate walking aids.
For people with a sudden drop in blood pressure on standing, the specific causes must be addressed. In addition to these, the therapy can involve eliminating or providing substitutions for any offending medications. Other useful steps include ensuring adequate intake of fluids, liberalizing salt intake, and flexing the ankles, wrists, and hands just before getting up. Elevating the head of the bed can also be useful. For people with a fall in blood pressure after meals, smaller meals and consuming judicious amounts of caffeine may sometimes help.
There are also several simple, practical, less expensive techniques to evaluate balance and gait. The simplest part of a physician's or caregiver's evaluation involves watching the person get up from a chair, walk a few steps, turn around, walk back to the chair, and sit down again. Difficulty or unsteadiness in any of these actions requires further evaluation. If stair climbing is a regular part of the person's daily activities, it, too, should be evaluated.
Assessment of the home is very important because most falls occur there. An environmental checklist that outlines the types of hazards to look for is shown in Table 51. To some extent, what actually constitutes an environmental hazard depends upon the person's problems. By helping to involve the person in the identification of hazards and developing a plan of care, home care can be improved significantly.
People who live in nursing homes are generally more frail than people who live in the community. More subtle hazards can affect them such as ill-fitting shoes, pants that are too long, or slippery floors. In certain circumstances, the objects used to improve safety may actually increase the risk of injury. For example, bed rails can be climbed over, walking aids can be tripped over, and restraints can be entangling.
Finally, in addition to identifying the predisposing factors, balance and gait problems, environmental hazards, and other factors, there should be a review of any previous falls. A knowledge of such things as newly prescribed medications, any new illness, recurring dizziness, or other symptoms may help to explain why a fall occurred and to prevent others. For example, if the fall occurred during a worsening of congestive heart failure, then closer observation and evaluation of the person would be warranted if the heart failure recurred or if the person had another fall.
The person's activity at the time of the fall should also be considered. If the person was not doing something considered hazardous, as is most often the case, the preventive emphasis should be on improving the safety and effectiveness of the activity, on balance and gait training, and on improving the safety of the environment in which the activity occurred.
Table 51. Strategies for Reducing Environmental Fall Hazards