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Older Adults and Their Care

Nancy Evans, B.S.

Occupational therapy courses are accredited by AOTA and are accepted by the NBCOT Certification Renewal program. For information specific to this course, click here. Physical therapists—please click here for accreditation information. Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.

The graying of America has a lot of people worried. Not just seniors themselves, but public policy makers and health professionals. Caring for older people—those age 65 and older—can be complicated. Just as children are not small adults, older people are not just gray-haired 35-year-olds. They're different inside and out.

Old age is not for sissies. Bette Davis, actress

Age-related changes affect the function of every body system, even in the healthiest of people 65 and older. Heart output declines. Calcium migrates from bones and teeth into blood vessels. Cataracts dim vision. Hearing fades. Lung, liver, and kidney functions slow. Wear and tear on joints makes pain an unwelcome companion. However, these changes do not automatically equate with disability. Regular exercise, a healthy diet, and social and intellectual stimulation can help prevent or delay disease and disability.

Normal age-related changes may be accompanied by chronic health problems such as diabetes or heart disease. Combined, these factors increase the complexity of care. But early diagnosis and effective management of chronic conditions can enable older adults to enjoy their later years as functional, active, independent members of their community.

Management of most chronic conditions means that one or more medications is prescribed for use on a regular basis. Although medications may relieve symptoms, improve the quality of life, and in some cases increase the lifespan, they are not without risk. For example, research has shown that taking four or more prescription drugs is an independent risk factor for falls. And a fall can catapult an independent older adult into the ranks of the frail elderly.

Most health professionals who care for older adults are not geriatricians or geriatric nurse specialists but primary care providers. Some may never have had a formal course in geriatrics. In many cases, the care provider is much younger than the patient and may be from a different racial or ethnic background. This makes patient-provider communication challenging but it also offers an opportunity for mutual learning.

This course can serve as an introduction to essential information for providing competent, compassionate care to older people. It describes the demographics of aging in America, including health disparities, and focuses on common age-related changes in older people, medication use and misuse, and functional assessment. In addition, it discusses supporting family caregivers, preventing elder abuse, and planning end-of-life care.

DEMOGRAPHICS OF AGING

How old is old? What does it mean to be old?

As the first wave of the 77 million baby boomers move beyond their sixtieth birthday, they are seeking answers to those and many other questions about growing older in the twenty-first century. Public health professionals and policy makers are seeking ways to prepare for a society in which the number of people over 65 will nearly double in the next twenty years. By 2030, 1 in 5 Americans will be over 65 years of age. People in this age group today are the greatest consumers of healthcare services in the United States.

Today's Americans enjoy longer life than previous generations, although life expectancy at age 65 is lower than that of other industrialized countries (Federal Interagency Forum on Age-Related Statistics, 2008). The United States ranks 42nd in life expectancy among industrialized countries. The average life expectancy in the United States is 78.1 years, but there are gender and racial disparities. White women have the longest life expectancy at 81 years compared with black women at 76.9 years. The average life expectancy for white men is 76 years compared with black men at 70 years (CDC, 2008).

Many people in their sixties and seventies lead active, independent lives, enjoying sports, travel, and hobbies, sometimes in addition to full-time employment. However, some experts predict that the health of baby boomers is declining, based on the findings of the Health and Retirement Study (2007). This study of 20,000 Americans over age 50 found that boomers born between 1949 and 1954 reported having more pain, chronic health conditions, and alcohol and psychiatric problems than people who were the same age 12 years earlier. A major reason cited for this declining health is the continuing epidemic of obesity, which increases the risk of diabetes, heart disease, and arthritis.

According to the Agency for Healthcare Research and Quality (2008), three-quarters of Americans age 65 and older have two or more chronic conditions. Those who have access to healthcare, seek treatment for early symptoms of chronic conditions, and invest in "active control strategies" can often improve their health and prevent further decline and disability (Wrosch & Schulz, 2008).

HEALTH DISPARITIES IN AGING

The rich are different from you and me. They live longer. Yoshie, 2004

Disparities in health and life expectancy are related largely to socioeconomic inequities such as education, income, and environment, all of which affect health behaviors. People with more education tend to accumulate more wealth, enjoy better living and working conditions, and engage in more healthful behaviors. People with less than a high school education have lower incomes, more hazardous work and living environments, and are more likely to lack health insurance.

Communities of color are disproportionately affected by socioeconomic inequities: poorly funded schools, inadequate housing, high-crime neighborhoods, and low-paying jobs with lack of opportunity for advancement. As Steven Schroeder (2007) points out, "…better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans." He cites the example of smoking, which kills 435,000 Americans each year: "Smoking is increasingly concentrated in the lower socioeconomic classes and among those with mental illness or problems with substance abuse."

The American Psychological Association Resolution on Ageism (2001) notes the following:

Ageism—discrimination against older adults—is widespread in the United States…. Older adults are viewed stereotypically as (a) alike; (b) alone and lonely; (c) sick, frail and dependent; (d) depressed; (e) rigid and (f) unable to cope…. This pervasive view portrays all older adults in a negative light and ignores the incredible heterogeneity of aging and the strengths and positive attributes of older adults.

Growing older doesn't mean living in a nursing home. In fact, the number of nursing home residents has declined to less than 8 percent of Americans ages 75 and older. Today's seniors have a range of choices for housing and care, depending on their socioeconomic status and their health. These choices include aging in place (staying in their own homes by modifying them and arranging for home and healthcare services as needed) and moving to a retirement community or an assisted living or life care facility. In addition, some older people who can no longer live alone move in with their children.

Nursing home care is expensive and many Americans are financially unprepared for this type of care. The estimated average annual cost of nursing home care is between $67,000 and $100,000 (MetLife Market Survey, 2006). When savings run out, those who must have nursing home care must enroll in Medicaid, which can bankrupt individuals and might eventually bankrupt the healthcare system.

GOALS OF CARE

Care of the older adult should be individualized, based on life expectancy and the patient's values, goals, and preferences. Interventions appropriate for a healthy, active 65-year-old woman may be quite different than those for a frail woman of 85 who lives in a nursing home. For example, annual or biennial mammography screening should be recommended for the 65-year-old but may be inappropriate for the 85-year-old with congestive heart failure and diabetes whose life expectancy is less than 5 years.

Many health problems (eg, falls) common to people over 65 can be prevented, many (eg, hypertension) can be effectively treated, and many (eg, visual impairment, hearing loss, mobility problems) can be compensated for with assistive devices. Overarching goals of healthcare in people over 65 include:

• Maintaining self-care
• Preventing complications of aging or of existing conditions
• Delaying decline
• Achieving the highest possible quality of life

AGE-RELATED CHANGES IN HEALTH STATUS

Aging is both universal and individual. The physical changes of aging are universal, but the pace at which they occur is highly individual, depending on genes, age, sex, race, environment, and lifestyle. Some of us look and feel old at 60 or earlier, while others remain youthful in health, appearance, and outlook at 70 and beyond. The challenge for health professionals is to distinguish between normal age-related changes and symptoms of a disease or disorder that requires preventive or therapeutic action. For example, is forgetfulness in a particular patient just part of growing older or a sign of depression, or stress, or the beginning of dementia?

Structural Changes

MUSCULOSKELETAL CHANGES

Musculoskeletal changes significantly alter the posture and appearance of older adults, usually beginning in the fifth decade of life. Thinning of vertebral disks shortens the trunk of the body and diminishes height each year, making arms and legs appear longer by comparison. Calcium leaches from bones (resorption), resulting in osteoporosis, a condition much more common in women than in men, increasing the risk of fracture. At the same time, muscles and cartilage atrophy and weaken, leading to kyphosis, a curvature of the spine, which further decreases stature and requires a "chin-up" posture to make eye contact with others. Loss of muscle mass (sarcopenia) results primarily from disuse of skeletal muscle—in other words, inactivity. Disuse leads to disability.

Wear and tear on cartilage (ligaments, tendons, and joints) reduces flexibility and increases the risk of tears. The synovial fluid that lubricates joints decreases with age, resulting in slower and sometimes painful movement. However, regular exercise such as walking and resistance training as well as doing household chores such as vacuuming, sweeping, gardening, and washing the car help preserve flexibility and strength and delay or prevent musculoskeletal deterioration.

Resorption of bone also affects the jaw and therefore the fit of dentures, an issue for more than one-fourth of all older adults and nearly 40 percent of those with family income below the poverty line. Some older people do not wear their dentures because they are uncomfortable, which not only changes their appearance and self-image, but interferes with their speech and compromises their nutritional intake because they are unable to chew.

SUBCUTANEOUS TISSUE CHANGES

Subcutaneous tissue changes alter not only appearance but also the body's response to temperature changes. With aging, subcutaneous fat decreases, particularly around the eyes and in the forearms, accentuating the bony structures. Without that insulating layer of subcutaneous fat, the older person has a heightened sensitivity to cold. Therefore, a room temperature that feels comfortable to a younger family member may feel cold to an older person, particularly someone who is less active.

The gravest risk to the elderly person is exposure to cold. Poor housing, lack of heat, lack of [adequate] clothing … all are hazards for the elderly. Mary Opal Wolanin, 1981

Keeping older people warm is more than a comfort measure; it is essential to their health and well-being. Accidental or inadvertent hypothermia can lead to confusion and disorientation, amnesia, cardiac arrhythmias, loss of consciousness, irreversible coma, and death. Those people who cannot generate enough heat to maintain normal core body temperature (98.6°F [37°C]) through shivering are at greatest risk for developing hypothermia. Patients who are confined to bed or to a wheelchair are particularly vulnerable. According to CDC (2006),

Older persons with preexisting medical conditions such as congestive heart failure, diabetes, or gait disturbance are at increased risk of hypothermia because their bodies have a reduced ability to generate heat and because they are less likely to recognize symptoms of hypothermia and seek shelter from the cold.

Signs and symptoms of hypothermia include:

• Shivering
• Sensation of cold, exhaustion, and numbness
• Confusion and disorientation, slurred speech
• Amnesia
• Pallor or flushed skin
• Decreased hand coordination

Hypothermia can cause fatal arrhythmias in people with cardiovascular disease, renal disease, anemia, arthritis, and malnutrition. Immersion in water, wearing wet clothes, and exposure to wind also increase the risk of hypothermia. Alcohol and other mood- or cognition-altering drugs such as marijuana, phenothiazines, and sedatives impair judgment and are associated with death from hypothermia. Older adults undergoing surgery are also at risk for hypothermia related to medications such as muscle relaxants, narcotics, vasodilators, anesthetics, and room-temperature parenteral fluids.

Extreme heat also poses a threat to older people, although the risk is not related to subcutaneous fat loss but to age-related impairment and loss of sweat glands, the principal component of the body's normal evaporative cooling system. Even healthy older people are more prone to heat stress and heat stroke than younger people. Those with cardiovascular disease or hypertension are at the highest risk not only because of their disease but also because their medications impair the body's ability to regulate its temperature. Overweight people are at higher risk for heat-related illness because they retain more body heat.

In 2004 the CDC issued an Extreme Heat Sheet, which included the following information. "Heat stroke is the most serious heat-related illness, and can cause death or permanent disability if emergency treatment is not provided. Body temperatures can rise to 106°F within 10 or 15 minutes. Warning signs of heat stroke may include the following:

• Extremely high body temperature (above 103°F)
• Red, hot, and dry skin (no sweating)
• Rapid, strong pulse
• Throbbing headache
• Dizziness
• Nausea

Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fluids. Warning signs of heat exhaustion may include:

• Heavy sweating
• Paleness
• Muscle cramps
• Tiredness
• Weakness
• Headache
• Nausea or vomiting
• Fainting
• Skin: may be cool and moist
• Pulse rate: fast and weak
• Breathing: fast and shallow" (CDC, 2004)

Emergency measures for heat stress are focused on cooling the person as rapidly as possible. Methods may include immersing patients in a tub of cool water or putting them under a cool shower, spraying or sponging them with cool water, or, if the humidity is low, wrapping them in a cool, wet sheet and fanning them. Continue cooling efforts until the body temperature drops to between 101°F and 102°F.

Avoid giving any liquids with alcohol or large amounts of sugar and avoid very cold drinks because they can cause stomach cramps. Sports beverages can help replace the salt and minerals lost in sweating.

INTEGUMENTARY CHANGES

Aging changes the skin, hair and nails. These changes are some of the most dreaded in our youth-oriented society. Each year affluent Americans spend millions of dollars on plastic surgery to erase wrinkles and other evidence of aging. Ultra-violet (UV) light from the sun (and from tanning booths) is a major cause of wrinkles because it damages elastin, the fibers in the skin that make it resilient. Gravity also plays a role in wrinkles, causing skin to sag, as does cigarette smoking; with smoking, however, the aging mechanism is not fully understood.

As we age, skin becomes more delicate and more easily damaged. Skin cells take longer to renew themselves so wound healing takes longer than in younger people. Collagen levels and subcutaneous fat diminish, thinning the skin and increasing the risk of tears and bruising.

Dry skin is common among older people. Heating and air conditioning can make the problem worse because they remove moisture from the air. Heavy use of soaps, antiperspirants, deodorants, perfumes, or very hot baths or showers also can increase skin dryness as can sun exposure, dehydration, and stress. Moisturizers help relieve dryness but they must be applied often.

Skin cancer is the most common form of cancer in the United States. The two most common types of skin cancer—basal cell and squamous cell carcinomas—are highly curable if diagnosed and treated in their early stages. However, melanoma, the third most common skin cancer, is more dangerous (CDC, 2006).

An estimated 65 to 90 percent of melanomas are caused by exposure to UV light or sunlight. The U.S. Preventive Service Task Force advises clinicians to be aware that fair-skinned men and women age 65 or older and people with atypical moles or more than 50 moles, are at greater risk for developing melanoma. Clinicians need to look for skin abnormalities when conducting physical examination for other purposes (CDC, 2006). Skin cancers are seldom painful until they are very advanced so older patients may be unaware of lesions on their back or on other areas of the body not easily seen.

Hair changes in older adults vary according to race, sex and hormonal influences. Dark hair turns gray or even white and becomes thinner as melanin production in hair follicles diminishes and growth slows. The texture of hair may also change with age; fine, straight hair may become more coarse and somewhat curly. Hair loss is more noticeable in men and may begin well before age 40. Although women may lose hair, it occurs much later and more slowly. Body hair on both men and women is also thinner and more sparse.

Fingernails and toenails tend to harden and thicken with age and may develop vertical striations in the nail plate. Yellowish or dark nails may indicate a fungal infection.

BODY COMPOSITION CHANGES

Body composition changes over time. Weight and fat mass increase during middle age (the so-called middle age spread) and continue to about age 74 (Kyle et al., 2001). After age 74, seniors generally lose weight, stature, fat-free mass (FFM) and body cell mass. Decreased body cell mass results in decreased total body potassium (TBK) (McCance & Huether, 2002). Older adults also experience a decrease in total body water. As lean body mass declines, the proportion of body fat increases. This means that water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.

Functional Changes

CARDIOVASCULAR CHANGES

Cardiovascular changes include a slight decrease in the heart rate (the number of beats per minute) and in stroke volume (amount of blood pumped out of the heart with each beat). These two changes combine to decrease cardiac output, the total amount of blood pumped out of the heart each minute (Burbank & Riebe, 2002). Illness, excitement, activity, or stress may cause rapid heart rate (tachycardia), which in an older person takes longer than when younger to return to the baseline level.

Cardiovascular function helps determine the ability to live independently. A primary criterion in assessing cardiovascular function is VO₂max, the maximum amount of oxygen that can be consumed by the body per minute during physical activity. The minimum level of VO₂max for independent living is 17.7 ml/kg/min (milliliters per kilogram of body weight per minute) for men and 15.4 ml/kg/min for women (Paterson et al.,1999). Regular strength and endurance training can help inactive older adults increase their VO₂max as much as 10 to 20 percent, compensating for the loss of muscle mass and strength of normal aging.

As mentioned earlier, the migration of calcium from bone into blood vessels stiffens arteries, leading to atherosclerosis, some degree of which is present in most older adults. Stress testing may be necessary to distinguish between normal age-related changes and the presence of cardiovascular disease.

Atherosclerosis affects blood flow to the heart, liver, kidneys, and other organs. Vessel walls weaken and may swell under pressure, even in individuals without hypertension. Regular exercise and a low-fat diet help to delay or prevent the onset of cardiovascular disease in older adults.

RENAL AND UROLOGIC CHANGES

Renal and urologic changes associated with aging have major effects on the physical and psychosocial well-being of older adults. The kidneys are the major organs that regulate blood and fluid volume (balancing intake and output of fluids) throughout the body. In addition, the kidneys filter waste products from the blood, which are then excreted in the urine. At the same time, the kidneys conserve nutrients such as glucose, amino acids, and electrolytes for resorption into the bloodstream.

The kidneys' filtering process occurs within the nephrons, the functional units of the kidneys. In a young adult, each kidney contains more than a million nephrons, through which the body's entire blood supply circulates approximately 12 times an hour. However, the number of nephrons decreases with age and. by age 70, a person may have only one-third or one-half as many nephrons. In the absence of illness, this number is still sufficient to maintain appropriate fluid balance, which is why some people are able to lead a normal life with only one functioning kidney.

When blood circulates through the nephrons, the result is a fluid called glomerular filtrate produced at a rate of about 25 mL per minute. The volume-time ratio is called the glomerular filtration rate (GFR). Age-related vascular rigidity and decreased cardiac output reduce renal blood flow and the glomerular filtration rate (GFR),* lengthening the time required to excrete waste products such as nitrogen waste. Biologic half-life of medications is affected by kidney function. This can translate into slower elimination of certain medications such as streptomycin and result in toxic effects for older patients.

Aging also reduces the resorption of glucose, leading to increased levels of glucose in the urine (glycosuria). Decreased resorption of bicarbonate and sodium can upset the sodium-potassium ratio, resulting in hyperkalemia (elevated potassium levels). Signs and symptoms of hyperkalemia include muscle weakness or paralysis, tingling of the lips and fingers, restlessness, intestinal cramping, and diarrhea.

Sudden or large changes in fluid volume increase the risk of hypervolemia (abnormal amount of blood volume) or hypovolemia (abnormally low amount of blood). Acute losses of fluid or chronic fluid deficits can result in renal insufficiency in older adults.

Urologic changes are closely related to changes in the renal system. Age-related loss of muscle tone and decreased contractibility of the bladder can cause excessive urination at night (nocturia) and increased frequency of urination. These same factors may also cause urinary retention, thereby increasing the risk of bacterial growth and infection. Urinary tract infections (UTIs) are more common in women because of their shortened urethra and its proximity to the anus, which increases the risk of fecal contamination.

Some degree of age-related urinary incontinence is common in older people, particularly among the frail elderly. There are three principal types of incontinence: urge incontinence, stress incontinence, and overflow incontinence. Urge incontinence is generally caused by uninhibited bladder contractions (detrusor overactivity) that lead to leakage of urine. In men, this condition often is accompanied by urethral obstruction from benign hypertrophy of the prostate. Urethral obstruction is common in older men but rare in older women. Stress incontinence is urinary loss related to laughing, standing, coughing, or lifting heavy objects. Overflow incontinence (urinary frequency, nocturia, and frequent dribbling is related to detrusor underactivity, which may be caused by sacral lower motor nerve dysfunction ("neurogenic bladder").

Urinary incontinence also may be caused by factors unrelated to the renal and urologic system. These include delirium, excess fluid intake, medications, psychological factors, restricted mobility, and stool impaction and are discussed later under functional assessment of the older adult.

RESPIRATORY CHANGES

Respiratory changes in older adults are not completely understood but include loss of elasticity in the lungs and stiffening of the chest wall. Respiratory muscle strength and endurance also decrease as much as 20 percent by age 70 but can be increased with exercise (McCance & Huether, 2002). These changes reduce ventilatory reserves and decrease the older adult's exercise tolerance. Aging also increases immune dysregulation, asymptomatic low-grade inflammation, and the risk of infection. These changes elevate the risk of pneumonia. In addition, older people are at increased risk for respiratory depression from medications, particularly from opioid analgesics. This risk is highest among patients with COPD, liver or renal failure, and those with adrenal insufficiency.

ENDOCRINE CHANGES

The endocrine system undergoes many changes during aging, and these changes affect other body systems and processes. This discussion is limited to the thyroid gland and the gonadal (sex) hormones.

Age-related changes in the thyroid gland affect almost all body functions and include the following:

• Decreased secretion and plasma levels of triiodothyronine (T₃), especially in men
• Increasingly common hypothyroidism
• Decreased secretion of thyroid-stimulating hormone (TSH)
• Decreased responsiveness of plasma TSH concentration to thyrotropin-releasing hormone (TRH), especially in men

Hypothyroidism (deficiency in circulating thyroid hormone [TH]) is a common disorder, affecting about 5% of people over 60 (Fitzgerald, 2008). However, mild or early hypothyroidism may be underdiagnosed in older people because many of its clinical manifestations are also signs of aging: dry skin, low basal metabolic rate, cold intolerance, slightly lower body temperature, and constipation. Other characteristics of hypothyroidism may include lethargy, fatigue, muscle cramps, headache, anemia, hyponatremia (abnormally low levels of sodium in the circulating blood), and lack of mental alertness. Deficiency in TH increases production of TSH (Thyroid-stimulating hormone) and can lead to goiter. Correcting hypothyroidism in people over 60 requires a lower dose of replacement TH than in younger people. Replacement should be initiated slowly, particularly in those with coronary artery disease, to prevent angina and myocardial infarction.

Hyperthyroidism, or thyrotoxicosis (abnormally high levels of T₄ or T₃), may be caused by Graves' disease, an autoimmune disease, or by toxic multinodular goiter, thyroid adenomas, thyroid carcinoma, or by amiodarone. Hyperthyroidism is characterized by an accelerated metabolic rate, heat intolerance, sweating, protruding eyeballs, irritability, restlessness, anxiety, and tremors.

Androgen and estrogen secretions diminish with aging. Declining estrogen levels result in atrophy of the ovaries, uterus, and vaginal tissue in older women. Older men may develop firmer testes and hypertrophy of the prostate gland. These changes, together with other physical and psychosocial changes, may decrease sexual capacity. However, libido continues in both women and men. Although sexual activity may occur less often, it can still can remain satisfying.

One of the ageist stereotypes that exists among care providers and institutions is that older people are no longer sexual beings. Although serious illness, or physical or mental health problems, can take precedence over sexual needs, older people remain sexual beings and should be considered as such. While Medicaid stipulates that married couples have the right to be housed together, unmarried couples, including gay and lesbian couples, may find it more difficult to achieve such a living arrangement.

GASTROINTESTINAL CHANGES

Gastrointestinal changes begin in middle age and continue throughout life, affecting not only nutritional intake but also quality of life. Gastrointestinal function begins in the mouth—and aging takes its toll on teeth, gums, and salivary glands. Years of use wear down tooth enamel and dentin, increasing the risk of cavities. Periodontal (gum) disease leads to tooth loss and the need for dentures or dental implants. Dentures can limit the choice of food and ill-fitting dentures make eating painful. Aging as well as some medications decrease salivary secretions, which makes food more difficult to chew and swallow.

Gastric motility and volume decrease with age. Secretion of bicarbonate and gastric mucus decline, and the acidity of gastric juice diminishes, leading to insufficient hydrochloric acid and delayed gastric emptying. Nutrients such as proteins, fats, minerals, and carbohydrates (particularly lactose) are absorbed more slowly. The effects of these changes can be offset by small frequent meals rather than "three squares a day."

Constipation is often deemed an age-related problem. However, several factors may contribute to constipation in older adults. Other factors include long-established bowel habits, current diet, inadequate fluid intake, and inactivity or immobility.

The liver, pancreas, and gallbladder and bile ducts are also part of the gastrointestinal system. In healthy older adults, however, the altered function of these organs generally does not interfere with digestion. Even though the liver decreases in size and weight, liver function remains within normal range. Decreases in liver blood flow can have a negative effect on the oxidative metabolism of certain medications. Although pancreatic secretion decreases with age, there is generally no obvious dysfunction. Gallbladder and bile duct function remain largely unchanged except in the presence of gallstones, the incidence of which increases in older people.

The Federal Interagency Forum on Aging-Related Statistics (2008) reports:

Vision and hearing impairments and oral health problems are often thought of as natural signs of aging. Often, however, early detection and treatment can prevent, or at least postpone, some of the debilitating physical, social, and emotional effects these impairments can have on the lives of older people. Glasses, hearing aids, and regular dental care are not covered services under Medicare.

SENSORY CHANGES

Sensory changes in later life affect how we perceive and experience the world and can have enormous impact on independence, safety, and quality of life. All five—vision, hearing, taste, smell and touch—diminish in acuity as we age.

Vision changes generally begin in middle age and most adults need glasses or contact lenses for reading by age 50. Older adults also may experience increased sensitivity to glare, impaired night vision, and reduced color discrimination. In addition to these normal changes, people age 40 or older are also at risk of serious eye conditions that can lead to low vision or blindness if not diagnosed or treated early. The most common of these conditions are age-related macular degeneration (AMD), glaucoma, cataracts, and diabetic retinopathy. To prevent or delay serious eye disease, the American Academy of Ophthalmology recommends that people age 65 or older have an annual comprehensive eye examination.

Hearing changes related to aging can also have a major impact on independence, safety and quality of life. According to the National Institute on Deafness and Other Communication Disorders (NIDCD, 2008), age-related hearing impairment/loss (presbycusis) affects 1 in 3 people older than 60 and half of those older than 85. Hearing impairment is more prevalent in people with diabetes, according to a study based on CDC data, which found that diabetes appears to be an independent risk factor for hearing impairment (Bainbridge et al., 2008). In later life the eardrum thickens, decreasing its ability to transmit sounds. Age-related changes in the inner ear can also affect balance. These include a decline in number of hair cells in the inner ear and changes in the bony structures of the inner ear.

"Causes of hearing impairment are not clearly understood but it seems to run in families. Chronic exposure to loud noise can also cause hearing loss. Noise-induced hearing loss affects construction workers, farmers, musicians, airport workers, tree cutters, and people in military service. Too much loud noise can also cause a condition called tinnitus, which is a ringing, hissing, or roaring sound in the ears. Hearing loss can also be caused by a viral or bacterial infection, heart conditions or stroke, head injuries, tumors, and certain medications" (NIDCD, 2008).

Taste and smell changes related to aging can reduce the pleasure of eating as well as cancel an early warning system. For example, "Taste allows us to detect sour milk; smell alerts us to the smoke of a fire or a natural gas leak. Taste and smell are components of the chemical sensing system, along with something called the common chemical sense. Gustatory (taste) cells in the taste buds and other surfaces in the mouth and throat transmit signals through nerve fibers to the brain, which identifies specific tastes: sweet, sour, bitter, salty, and umami" (NIDCD, 2008).

"The common chemical sense consists of nerve endings on the moist surfaces of the eyes, nose, mouth, and throat that respond to sensations such as the sting of ammonia, the coolness of menthol or mint, or the irritation of chili peppers. Olfactory (smell) cells are located high up in the nose and connected directly to the brain" (NIDCD, 2008). These cells respond to odors, and together with gustatory cells and the common chemical sense produce a perception of flavor. With aging, the number of taste buds declines as does the sense of smell, diluting the intensity of flavors and possibly leading to loss of appetite.

Some medications can also alter both taste and smell. A reduced ability to taste is called hypogeusia. The rare inability to detect no tastes is called ageusia; perceived loss of taste usually reflects a loss of smell. Loss of taste may be due to upper respiratory infections, head injury, middle ear surgery, or radiation therapy for cancers of the head and neck.

Abnormalities with taste and smell may also indicate one of several health problems, including obesity, diabetes, hypertension, malnutrition, Parkinson's disease, Alzheimer's disease, and Korsakoff's psychosis.

Sleep alterations are common among older adults. According to the National Institute of Neurological Disorders and Stroke (2007), older people tend to sleep more lightly and for shorter time spans, but they generally need about the same amount of sleep as they did earlier (7 to 8 hours a night). Sleep needs are unique to the individual, however; some people need only 5 hours a night while others need twice that much. Many older people experience insomnia, which includes difficulty in falling asleep and/or staying asleep, periods of wakefulness during the night, waking very early in the morning, or combinations of any of the above.

Sleep is essential to survival, to good health and to mental alertness. Experimental research shows that sleep deprivation may impair immune function, memory, and physical performance. Extreme sleep deprivation can cause hallucinations and mood swings.

There are five phases of sleep: Stages 1, 2, 3, and 4 and REM (rapid eye movement) sleep, also called dream sleep and. Stages 3 and 4 are called delta sleep. Stage 4 is the deepest, most restful sleep and occurs during the first several hours after falling asleep. A normal sleep cycle includes four or five REM periods during the night, which together account for about one-fourth of the total night's sleep.

With age, the percentage of REM sleep remains about the same but there is a marked reduction in stage 3 and 4 sleep, plus an increase in wakeful periods. In addition to these age-related changes, other factors that can interfere with sleep in older people include nocturia, muscle cramps or other pain, anxiety, medications, caffeine, alcohol, smoking, and thyroid disorders. Medications prescribed to promote sleep (eg, benzodiazepines) increase sleep time and decrease the time needed to fall asleep and the periods of wakefulness.

When the medications are stopped, however, withdrawal occurs that includes nightmares. Antidepressants decrease REM sleep, which may improve symptoms of some depressions and worsen others. However, antidepressants increase the risks of falls. Therefore, interventions to relieve insomnia in older people should begin with nonpharmacologic measures such as regular exercise, exposure to bright light in the morning, and avoiding caffeinated beverages.

Touch changes during aging decrease an individual's awareness of vibrations, pain, pressure, and temperature. These changes are caused by both internal and external factors and can affect both physical and mental health.

• Internal factors include circulatory and neurological deterioration, confusion or dementia, and immobility. Chronic diseases such as diabetes increase the risk of peripheral neuropathy and loss of sensation, particularly in the feet. Coupled with vision impairment, peripheral neuropathy can prevent older people from noticing foot infections or discolorations. Peripheral neuropathies also lead to falls and gait disorders, which can be important factors in loss of autonomy and independence.
• External factors affecting touch include nutrition, medications, alcoholism, brain surgery, and personal losses. Dietary deficiencies, such as thiamin (Vitamin B1), may also contribute to these changes (Cohen, 2007). Thiamin is found in milk and other dairy products, yeast, pork, beef, liver, whole or enriched grains, and legumes (beans and peas). African Americans and Latinos are at highest risk for thiamin deficiency because the prevalence of lactose intolerance in these populations leads to avoidance of dairy products. However, lactose intolerance is common among older people of all racial and ethnic groups.

Older people who live alone and those with limited incomes may have more than one nutritional deficiency, either related to lack of appetite, mobility problems, or lack of financial resources. Excessive alcohol consumption also leads to deficiencies in thiamin and other nutrients.

The inability to interpret temperature sensation increases the risk of thermal injuries (burns, hypothermia, frostbite). Diminished pressure sensation can result in pressure ulcers in patients unable to change position frequently. Reduced hand sensitivity may result in dropping objects such as glassware or other breakable items, and cleaning up the result may lead to injury.

Although the sense of touch changes in later years, the human need for touch—for physical contact, for a sense of closeness with another human being—remains throughout life. The need for touch can increase during times of stress and illness. Many older people, especially those who are institutionalized, suffer from touch deprivation. They experience impersonal touch during procedures, but lack meaningful touch with others. As Phillips (1981) explains:

Touching in Western culture is reserved for close friends and significant others. As a person ages, more and more of the people who have provided touch input are lost through death. Older people tend not to replace the lost people in their lives. As a result, fewer people provide touch stimulation, and the very old person may be virtually untouched.

Attitudes about being touched are very individual, influenced by culture, education, and life experiences. Some people simply don't like to be touched. Therefore, care providers need to determine how best to offer appropriate touch to give reassurance, gain attention, and provide a greater sense of safety and security.

Psychosocial Changes

The physical changes of aging can have major effects on an individual's psychological and social well-being. Aging involves a succession of losses concluding with the ultimate loss—loss of self. Losses can include:

• Loss of physical strength and abilities
• Loss of mental abilities(confusion, dementia)
• Loss of relationships, when companions or friends die
• Loss of self-esteem
• Loss of body image
• Loss of independence
• Loss of control over life plans and lifestyle

Moving to a long-term care facility involves multiple losses: loss of independence, of self-esteem, of familiar surroundings and social networks, and loss of control over life plans and life styles. Many residents are at risk for what one author (Thomas, 2004) called the three plagues of living in a nursing home: loneliness, helplessness, and boredom. Experiencing multiple losses can also cause depression. Care providers and family caregivers need to be alert for signs of depression and the three plagues in older people so therapeutic measures can be implemented. (For more information on depression, see Functional Assessment of the Older Adult later in this course.)

MEDICATION USE AND MISUSE

About 1 in 3 older persons taking at least five medications will experience an adverse drug event each year, and about two-thirds of these patients will require medical attention. Approximately 95 percent of these reactions are predictable and about 28 percent are preventable. Cung Pham and Robert Dickman, 2008

Older people consume more prescription and over the counter (OTC) medications than any other age group. According to the Agency for Health Research and Quality (2000), seniors fill an average of 20 prescriptions annually. Although medications may improve the quality of life and health, they also hold the potential for misuse, overuse, and life-threatening complications.

Polypharmacy

Polypharmacy, the inappropriate use of multiple drugs, creates a significant risk for adverse drug events. A recent analysis of adverse drug events that led to emergency department (ED) visits showed that the three drugs most often implicated in these events were warfarin (Coumadin), insulin, and digoxin. Researchers found that the risk for ED visits for adverse events due to these three medications was 35 times greater than for medications generally considered to be potentially inappropriate for people over 65 (Budnitz et al., 2007).

Physician-prescribed drugs are only one component of medication use by older people. Self-prescribed OTC medications and/or vitamin and herbal supplements also play a part, and alcohol use can further complicate the situation.

Patients self-prescribe with OTC products and/or alcohol because they seek relief from symptoms that physician-prescribed medications do not offer—relief from chronic pain, stress, anxiety, depression, loneliness, or all of the above. The widely advertised promise of fast relief for these symptoms too often proves false—and can have devastating effects on seniors' health and well-being.

Patients who see several physicians for different ailments are at higher risk for adverse drug events related to drug interaction, as are those who use multiple pharmacies to fill their prescriptions or who order their prescriptions by mail. Ideally, each patient's complete medication profile would be monitored by a single health professional such as a clinical pharmacist. Electronic medical records (EMRs) in some HMOs now make that possible but the use of EMRs by private physicians in the United States is surprisingly limited.

Prescribing physicians need to consider the slowed metabolism and excretion of drugs in older patients—not only the choice of drugs but the dosage and timing of administration. Because older adults experience a decrease in total body water and a relative increase in body fat, water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.

Beers Criteria

Health professionals who are not geriatricians need to familiarize themselves with the Beers criteria, which identify potentially inappropriate medications for people age 65 and older (see box below). Nurses and other care providers should also be aware of the Beers criteria to monitor patients' medication use. They also need to consider the patient's (or family caregiver's) ability and resources to self-manage a complex drug regimen. All healthcare providers need to recognize that any senior taking four or more prescription drugs is at high risk for falling, which can lead to frailty and loss of independence.

The prevalence of chronic health conditions such as heart disease, hypertension, and diabetes among older people affects the number of drugs they are prescribed. For example, because diabetes increases the risk of heart disease, many people are being treated for both conditions. These same people may also take OTC non-steroidal anti-inflammatory drugs (NSAIDs) to relieve their arthritis pain, antacids for indigestion, and antihistamines for allergies. The potential for interaction among these various drugs is significant, and patients and their caregivers need to be aware of this risk.

Experts recommend periodic review of all medications that an older patient is taking, using the "brown-bag" approach. This means that the patient brings all medications—prescription and OTC—to the care provider's office and reviews with the physician or nurse the purpose of each drug, any side effects experienced, and whether it is necessary to continue taking each one. This type of review can sometimes mean dropping one or more medications from the regimen.

It is also an opportunity to evaluate how well the patient is managing the regimen and whether he or she understands the potential for interactions among drugs and between drugs and food and/or alcohol. For example, patients who are taking statins (Lipitor, Zocor, Mevacor, and others) to lower cholesterol, may not know to avoid grapefruit and grapefruit juice because it can raise circulating levels of the drug to potentially toxic levels. Patients taking warfarin need to know that food containing high levels of Vitamin K (broccoli, spinach, cabbage, and other green vegetables) can interfere with the blood-thinning effects of warfarin. Vitamin E and the popular herbal supplement gingko biloba also act to enhance the effects of warfarin.

ALCOHOL AND DRUGS

Alcohol use in older adults is highly variable, from those who enjoy an occasional glass of wine or beer to those who regularly use or abuse alcohol. Alcohol abuse is not always obvious, but health professionals should be aware that the problem exists and is often overlooked in older people. Patients should be cautioned to avoid alcohol when taking medications because it can interfere with drug metabolism and potentiate the effects of many drugs (eg, benzodiazapines). Some experts recommend that all older patients be screened for possible alcohol abuse. The CAGE screening test (see box below) is simple to use; two positive answers indicate the need for further assessment.

Signs of an alcohol or medication-related problem can include memory problems after having a drink or taking medicine, loss of coordination, changes in sleeping habits, unexplained bruises, irritability, sadness, depression, failing to bathe or wear clean clothes, difficulty concentrating, and unexplained chronic pain. Health professionals need to be alert to these signs in older patients (Substance Abuse and Mental Health Services Administration, 2008).

SENSORY AND MOTOR IMPAIRMENTS

Sensory and motor impairments can also affect an older person's ability to self-manage a complex drug regimen. Impaired vision increases the risk of errors in drug use or timing of administration or in noting expiration dates. Joint pain or weakness may make it difficult for patients to handle small tablets, open child-proof caps on medication containers, or administer eye drops. Large capsules or tablets can be difficult for older adults to swallow and may cause choking.

HEALTH LITERACY AND PATIENT TEACHING

The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care, partly because half of all patients leave their office visits without having understood what the physician said. Thomas Bodenheimer, MD, 2006

Health literacy is a critical element in self-management of medications for patients of all ages. According to AHRQ (2008), only 12 percent of adults in the United States have adequate health literacy to manage their own health. Only slightly more than half of those surveyed in one study could read instructions on a prescription label and determine the right time to take medication. These limitations are more prevalent among the poor, the old, and those with limited education, the same populations most likely to have one or more chronic conditions that require a high degree of self-management. Inadequate health literacy is an independent risk factor for all-cause mortality and cardiovascular death among older adults living in the community (Baker et al., 2007).

Research has shown that errors in the medication process cause the death of one person every day and injure more than a million people a year in the United States (IOM, 2000). "An individual's health literacy skills have a profound impact on his or her ability to manage a chronic illness, such as diabetes or high blood pressure. If an individual understands and can act upon medical instructions, unnecessary emergency department visits and hospitalizations can be reduced, which in turn lowers overall healthcare costs" (DeBuono, 2007).

Although there are a number of screening tests to measure health literacy, screening can be time-consuming for busy practitioners and embarrassing for patients. One physician uses an informal screening test when working in the clinic: She hands the patient an empty pill bottle and says "This is not your medication, but if it were, tell me how you would take it" (Marcus, 2007). Some authorities recommend that health professionals simply assume that all patients have a limited understanding of medical words and concepts, and focus on three key elements. A program called ASK ME 3 highlights three essential questions that patients should ask their provider at every visit:

• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?

Providers should be sure that their patients understand the answers to these questions (Partnership for Clear Health Communication, 2007).

COGNITIVE PROBLEMS

Cognitive problems such as Alzheimer's and other dementias also contribute to mismanagement of medication regimens. Responsibility for managing medications falls to family caregivers when the patient is at home. However, if the patient goes to adult daycare, the medication list and instructions must go along. Some medications, such as anticholinergics, are contraindicated in people with cognitive deficits because they can increase confusion and make memory problems worse.

When older patients are hospitalized, their list of current medications must accompany them to avoid exacerbating old problems such as cardiac arrhythmias. When they leave the hospital, the nurse needs to review the discharge medications with the patient, the family, or a care provider from the facility to which the patient is being transferred (Resnick, 2008).

There are various forms and other devices to help older patients and/or their caregivers manage their drug regimens. A sample form for keeping track of medications is shown in FDA, Medicines and You: A Guide for Older Adults (http://www.fda.gov/cder/consumerinfo/MedandYouEng.pdf). Day-of-the-week pill boxes can also be helpful if the regimen is not too complex. Electronic aids and services for self-management of medication by older adults include http://www.mypillbottle.org and http://www.medsfile.com; however, these require that either the patient or the caregiver have a computer and the skills required to use it.

COST OF MEDICATIONS

The soaring cost of medications among older patients with chronic health conditions is a major reason for nonadherence to prescription drug regimens, and affects at least one-quarter of Medicare recipients (Safran et al., 2005). Even with Medicare Part D reimbursement, the high cost-sharing expense makes medications unaffordable for some seniors.

To cope with high out-of-pocket costs for drugs, nearly 3 out of 4 seniors reported using such cost-cutting measures as choosing generic drugs rather than brand-name drugs, asking their providers for free samples, or ordering drugs over the Internet or from Canada (Soumera, et al., 2006). Others take less than the recommended dosage (eg, cutting pills in half) to make the medications last longer. Some are forced to choose between groceries and medications, a lose-lose solution.

Prescribing physicians should be aware of medication costs and design drug regimens that carry the lowest possible out-of-pocket costs without compromising treatment effectiveness. Social workers, nurses, and clinical pharmacists can often assist in designing these regimens to reduce the financial hardship on older patients who need medications.

STORAGE AND EXPIRATION OF MEDICATIONS

Proper storage of medications helps maintain their effectiveness. Patients need to know that medications should be stored in a cool, dry place away from bright light. They should be kept out of reach of children who may visit or live in the home. Medicines should not be refrigerated unless the doctor, pharmacist, or the label says to refrigerate.

Current medications should be kept separate from those not currently in use. For example, patients taking warfarin may need to stop taking it a few days prior to surgery. Expiration dates should be reviewed monthly and any expired medications should be discarded in the trash, not flushed down the toilet.

FUNCTIONAL ASSESSMENT OF THE OLDER ADULT

The goal of functional assessment is to determine how well older patients can care for themselves, manage their living environment, and move about in the world. Approximately 1 in 4 people over 65 have difficulties with activities of daily living (ADLs) or with instrumental activities of daily living (IADLs). ADLs include bathing, dressing, eating, transferring from bed to chair, continence, and toileting.

IADLs include driving or managing other transportation, shopping, cooking, using the telephone, managing finances, taking medications, doing housecleaning, and laundry. Half of people over 85 have difficulties with ADLs, indicating the need for long-term care either at home or in a residential care facility. Those who have problems with IADLs are more likely to have cognitive impairment than those who can still perform IADLs independently.

Once the assessment is completed, then a plan of care can be developed that specifies the type of support services and equipment that might be appropriate, including home care and/or modification of the home, or possible placement in assisted living or other long-term care facility. Those who need assistance only with IADLs may continue to live independently with the help of family caregivers, perhaps a financial/legal consultant (accountant, attorney, or family member with durable power of attorney), a cleaning service, and someone to drive, shop, and run errands.

The first step in assessment is to establish a trusting relationship. Make sure patients comfortable, and take time to get to know them  before launching into assessment questions. Be sure the room is well-lighted, quiet, and warm. If patients have brought a family member or friend, acknowledge that person but focus on the patient rather than the companion. Although the companion may assist communication during the assessment, it is important that the patient feel that the discussion is between the two of you and that you are not addressing the usually younger companion.

The following recommendations are essential for communicating effectively with older patients:

• Face patients directly so they can see your lips move when you speak; this is particularly important if the patient has a hearing problem.
• Speak in a clear, slow, lower pitch, and a slightly louder voice.
• Encourage questions from the patient and, if present, the companion.
• Ask only one question at a time and allow time for the responses. Even healthy older adults may take a little longer to process the question and frame a response.
• Tailor your communications to the individual's learning style and incorporate language the patient uses into your questions, avoiding complex medical terminology and abbreviations. (Curry et al., 2005)

During your initial conversation and history taking, assess patients' current knowledge and attitudes about healthcare and health behaviors. How do they rate their own health, for example? What do they do to maintain or improve their health? Do they think that feeling sick is just part of getting old? Or do they believe that their health problems can be treated successfully?

People often continue health habits and practices adopted years earlier that may no longer be effective or adequate to deal with age-related changes or chronic disease. Those without symptoms may tend to ignore recommendations for screenings such as mammography and colonoscopy.

Also assess the patient's ability to adapt to change. Remember that "Americans over 65 were born before television and computers were part of household furniture, before Playboy made sex a household word, before our society became geographically mobile and age-segregated" (Pipher, 1999). How are patients coping in today's world? For example, do they use a computer (or are they willing to learn) to access health information?

Some older people are inflexible in their attitudes and beliefs. Are patients open to changing their way of life to adapt to age-related problems they haven't recognized? For example, do the know that the dishes they just washed still have bits of food clinging to them? Do they see the dribbled food stains on their clothes? Do they realize that it's time to surrender their driver's license? When friends or family stop by to check on them, do they resent it?

Failure to admit problems such as these indicates an unwillingness and/or inability to make needed changes. This is where a trusted health professional can assist them in making changes, whereas a relative or friend might be considered a "meddler." Once trust is established, patients are more amenable to changes that will help ensure their safety and health.

Assess whether patients have the necessary resources to self-manage health. Can they afford the medications the doctor has prescribed or do they need financial assistance? Are they socially engaged with other seniors who can share health information? Are they sufficiently mobile to participate in an exercise class?

Assessing Physical Function

Assessment of physical function in the older adult includes some of the same elements of any assessment: weight, height, vital signs, and body mass index (BMI). In addition, functional assessment may include vision and hearing screening tests, balance and gait assessment, assessment of oral health, assessment of skin for bruises, wounds, and other signs of skin breakdown, and questions about nutrition and incontinence.

VISION

Adequate vision is essential to safety and quality of life. Visual impairment is an independent risk factor for falls. Age-related visual impairment is most often corrected by prescription eyeglasses or by contact lenses. Patients should be aware that eyeglasses need to be cleaned daily, rinsing with water or special eyeglass solution and wiping each lens with a soft cloth. Improved lighting (brighter but using frosted bulbs and lampshades to reduce glare) can also compensate for visual impairment. For example, a 70-year-old needs twice as much light to read or sew as a 35-year-old.

Serious vision impairment and even blindness can result from untreated eye conditions such as cataracts, glaucoma, or age-related macular degeneration (AMD). According to the National Eye Institute (2004), blindness or low vision affects 3.3 million Americans (1 in 28 people) and that figure is expected to reach 5.5 million by 2020. People 80 years old and older make up 8% of the population but more than two-thirds of those with blindness.

The incidence of serious eye diseases varies among racial groups. The leading cause of blindness among white Americans is AMD. Warning signs of AMD include:

• Lines or edges that appear wavy or distorted
• Blurry faces or difficulty seeing colors
• Dark or empty spaces that block the center of your vision
• Difficulty reading fine print or reading road signs from a moving vehicle
• Difficulty seeing at a distance or during twilight hours

Among African Americans, the leading causes of blindness are cataract and glaucoma. Among Hispanics, glaucoma is the most common cause of blindness. People with a family history of eye disease or who have diabetes and/or hypertension are at high risk of serious eye diseases. All people over 65 should have an annual examination by an ophthalmologist or optometrist to screen for these conditions and treat as necessary.

HEARING

Hearing impairment affects one-third of people over 65 and half of those over 85, and can limit social interaction, increase the risk of depression, and compromise safety. If the patient reports difficulty in hearing or understanding conversations, watching TV or watching movies, use of the whisper test can quickly confirm the need for referral to an audiologist for more precise testing and prescription of an amplification device (hearing aid). To perform the whisper test, stand 6 to 12 inches behind the patient and whisper several short sentences. If the patient cannot hear and understand you, an audiology referral is in order.

Some types of hearing loss can be corrected by hearing aids worn in or behind the ear. These devices amplify sounds but may prove annoying in crowded rooms or public places because it can be difficult to separate what you want to hear from other sounds. Research shows that hearing aids for both ears are advisable, and may not be covered under some health plans. If hearing loss cannot be corrected with conventional hearing aids, cochlear implants may help some people.

According to the National Institute of Deafness and Other Communication Disorders (NIDCD), before investing in a hearing aid, people with hearing problems should see an otolaryngologist, who may refer them to an audiologist for hearing assessment. Adults who do not see a physician before getting a hearing aid must sign a waiver.

Older adults with profound, uncorrectable hearing loss can benefit from a TTD/TTY line and other signaling devices that use flashing lights rather than sound (alarm clocks, smoke alarms, doorbells). These adaptations not only help people with hearing loss stay connected with family and friends but they are critical safety measures for those who live alone.

Other assistive devices include amplifiers for telephones and earphones for watching TV.

MOBILITY, STRENGTH AND GAIT

Assessing mobility, strength, and gait is essential in determining the older patient's risk for falling. Falls are one of the greatest threats to senior health and they can be life-threatening. Each year, one-third of people over 65 suffer a fall, and one-third of these falls cause injuries requiring medical treatment.

Muscle weakness and other subtle neurologic abnormalities (SNAs) also can be risk factors for cognitive and functional decline, cerebrovascular events, and mortality in older adults (noninstitutionalized) without overt neurologic diseases. A study by Italian researchers found that the presence of three or more SNAs detectable by a simple neurologic examination doubled the risk of mortality in a four-year period (Inzitari et al., 2008).

Fractures—of the hip, arm, leg, and ankle bones—are the most common injuries sustained in falls but some falls result from traumatic brain injury (TBI). In 2005 half of all unintentional fall deaths were caused by TBIs. A sudden bump or jolt to the head of an older person can easily tear cerebral blood vessels and lead to long-term cognitive, emotional, and/or functional impairments. Any older person taking blood-thinning medication (warfarin/Coumadin) should be seen immediately by a healthcare provider if they have a bump or blow to the head, even if they do not have any of the symptoms of TBI (CDC, 2008).

Patients and families need to know how to prevent falls. The CDC (2008) recommends the following four essentials:

• Encourage exercises that improve balance and coordination, such as Tai Chi.
• Make the home or other environment safer.
• Ask the healthcare provider to review all medications.
• Take the patient in for a vision check.

To make the home safer, remove tripping hazards such as throw rugs from stairs and floors, place often-used items within easy reach so that a step stool is not needed, install grab bars next to the toilet and in the tub or shower, place non-stick mats in the bathtub and on the shower floor, add brighter lighting and reduce glare by using lampshades and frosted bulbs, and add handrails and lights on all staircases.

Seniors should wear shoes that offer good support and have thin, non-slip soles. They should avoid wearing slippers and socks (without shoes) and going barefoot (CDC, 2008).

One simple means for assessing mobility, strength, and gait is the Timed Up and Go (TUG) test. Ask the patient to rise from a sitting position without the use of hands, walk 10 feet, turn around, walk back and sit down. Those who complete the TUG test in less than 10 seconds are probably normal. Anyone who is unable to do this in less than 14 seconds is at increased risk for falls.

The speed of walking, length of stride, and type of gait are also indicators of increased fall risk. Slower gait, smaller steps, and irregular gait can signal neurologic disorders that predispose the patient to falls. For example, slow gait may be caused by muscle weakness, inactivity, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), or angina. Short steps may be a sign of Parkinson's disease. Unsteady frontal gait may be a sign of cerebrovascular disease or normal pressure hydrocephalus.

[Note: The following five paragraphs are based on a 2003 journal article, Ambulatory Devices for Chronic Gait Disorders in the Elderly, that appeared in American Family Physician. See Van Hook et al. in the References for a complete citation.]

Although most gait disorders in older adults cannot be treated medically or surgically, they sometimes can be compensated by ambulatory assistive devices such as canes, crutches, and walkers. These devices improve the patient's balance and ability to bear weight. However, not all seniors are candidates for ambulatory assistive devices. For example, those with serious impairments in cognition, judgment, vision, or upper body strength may not be able to use one of these devices safely.

Patients who are candidates for canes, crutches, or walkers should be assessed to determine whether they need assistance for balance or weight-bearing while walking. Canes are used primarily by those who need support only on one side; a cane widens the base of support and thereby increases balance.

People needing bilateral upper-extremity support for walking need to have crutches or a walker. Crutches also offer full weight-bearing support. Two types of crutches are available: axillary crutches and forearm crutches. Axillary crutches are generally used by people who have experienced a fracture or other temporary condition restricting normal ambulation. Forearm crutches, also called Canadian or Lofstrand crutches, are used by those who need ongoing bilateral upper-extremity support with some weight-bearing. Forearm crutches allow freedom of hand movement without removing the crutches from the forearms.

Walkers improve balance by increasing the patient's base of support and lateral stability, and supporting the patient's weight. However, they can be difficult to maneuver through doorways and should not be used on stairs. Walkers also contribute to poor posture as the patient must bend forward while walking. Standard walkers are the most stable type of walker, having four legs with non-skid rubber tips.

Walkers are also available with front wheels only or with four wheels. Front-wheeled walkers are generally used by someone with a faster gait or who finds it difficult to lift a standard walker. Four-wheeled walkers provide a larger base of support but should not be used by someone who needs weight-bearing support, because full body weight could cause the walker to roll away and cause a fall.

All ambulatory assistive devices should be fitted to the individual patient, who will likely need training in using the device. Referral to a physical therapist can be helpful in the process of assessing each patient's needs and determining which assistive device would be most appropriate (Van Hook et al., 2003).

ASSESSING NUTRITIONAL STATUS

Functional assessment of nutrition in the older adult involves both physical and psychological factors as well as the type and quantity of food eaten. Is the patient able to bite, chew, and swallow properly? Edentulous patients may be greatly restricted in the types of food they can chew, either because they don't or won't wear their dentures or because the dentures do not fit properly, perhaps because of recent weight loss. Infected teeth or missing teeth also interfere with eating well, particularly with eating fresh fruits and vegetables.

Do patients have sufficient financial, educational, visual, and neurologic resources to shop and prepare nutritious, well-balanced meals? Have they lost interest in food because the food at the long-term care facility is not appealing? Have they lost or gained a significant amount of weight (5% or more in 30 days, 10% or more in 180 days) recently?

Malnutrition is not synonymous with thinness. Some obese persons are also malnourished: they consume more than enough calories but not enough of the nutrients essential to good health. The warning signs for poor nutrition can be remembered using the DETERMINE screen (see box below).

Older adults at greatest risk for nutritional deficiencies are those with less education, less income, or who live alone or in a long-term care facility. Chronic disease, including depression or dementia, use of three or more prescribed or OTC medications, and age over 80 years old further increase the risk of nutritional deficiencies.

Older people need more of certain nutrients such as protein, calcium, and vitamin D, than younger adults in order to maintain muscle strength and bone health. For example, research indicates that older adults should aim for a protein target (in grams) of half their body weight (in pounds) to protect muscle strength. In other words, someone weighing 140 pounds should have 70 grams of protein daily. Protein is particularly important for women, because it is more difficult for women than for men to replace age-related lost muscle mass as they age (Smith et al., 2008).

One study showed that seniors who consumed adequate or high levels of dietary protein and participated in resistance training not only strengthened skeletal muscles but also improved their oral glucose tolerance (Iglay et al., 2007). However, older adults tend to eat less protein because it's easier and cheaper to fix a meal with more carbohydrates (toast and jelly rather than a scrambled egg). Meat and fish, dairy and eggs, beans, tofu, and veggie burgers are all good sources of protein.

Calcium and vitamin D are essential for bone health and reducing the risk of falls. Many older adults don't get enough of either in their diets. All of us get vitamin D from the sun but in northern climates, especially in the winter, sun exposure is limited. Several studies have shown that daily vitamin D supplements (700–800 IU) in the diets of people in their seventies and eighties reduced the risk of falls and fractures (Bischoff-Ferrari et al., 2005; Broe et al., 2007). Food sources of vitamin D include Vitamin-D fortified milk or soy milk, fish such as salmon, mackerel and sardines, and some fortified cereals.

Calcium deficiency in older adults is not uncommon because many have lactose intolerance, and thus avoid milk and other dairy products. Experts recommend 1200 mg of calcium for both men and women age 50 and older. Sources of calcium other than dairy products include greens such as bok choy, broccoli, chinese/napa cabbage, kale, okra, turnip and collard greens, and fortified foods (tomato, orange, and other fruit juices, and certain cereals). However, calcium supplements probably are necessary to reach the recommended amount in the diet. Caffeine interferes with the absorption of calcium so calcium supplements should be taken at least two hours before or after consuming food (chocolate, for example) or caffeinated beverages (coffee, tea, soft drinks).

Vitamins B-6 and B-12 protect the nervous system, including memory and reasoning ability. They also decrease levels of homocysteine, which may reduce the risk of heart disease and Alzheimer's disease. Deficiency of these vitamins can result in unsteady gate, muscle weakness, slurred speech, and psychosis. Unfortunately, absorption of B-6 and B-12 is impaired in older people due to age-related changes in the digestive system; therefore, supplementation is necessary. The recommended daily allowance (RDA) of vitamin B-6 is 1.7 mg for older men and 1.5 mg for older women. The RDA of B-12 is 2.4 micrograms for women and men.

Malnourished older adults may also be deficient in folate, niacin (vitamin B-3) and zinc. Folate is essential to the synthesis of new cells and requires a healthy gastrointestinal tract to maintain fluid balance. Gastrointestinal problems in older adults such as irritable bowel syndrome may interfere with folate absorption. Alcoholics have a high risk of folate deficiency because alcohol damages the gastrointestinal tract. The RDA of folate for older adults is 400 micrograms daily. Food sources include green leafy vegetables, dried beans and peas, liver, and orange juice, as well as bread, cereals, and other grains that are fortified with folic acid.

Niacin (vitamin B-3) promotes nervous system function and acts as a coenzyme in energy metabolism. Deficiency in niacin can cause pellagra, characterized by dermatitis, diarrhea, and dementia; if untreated, it can result in death. The RDA for niacin is 14 mg. Too much niacin can result in liver damage, gastric ulcers, low blood pressure, nausea, and vomiting. Food sources for niacin include all protein foods and whole grains, enriched breads, and cereals.

Zinc is a trace metal that promotes tissue growth and wound healing, protects immune function, provides vitamin A transport, and supports the sense of taste. Zinc deficiency can cause hair loss, diarrhea, delayed wound healing, taste abnormalities, and mental lethargy. Too much zinc can cause anemia, elevated LDL cholesterol, lowered HDL cholesterol, diarrhea, vomiting, impaired calcium absorption, fever, renal failure, muscle pain, and dizziness. The RDA for zinc is 11 mg for older men and 8 mg for older women. Food sources for zinc include oysters, red meat, poultry, dried peas and beans, nuts, whole grains, fortified breakfast cereals, and dairy products.

Vitamin E includes a family of eight antioxidants, but alpha-tocopherol is the only form of vitamin E considered active in the body. The RDA for vitamin E is 15 mg for both men and women. The upper tolerable limit of vitamin E is 1000 mg per day. Studies of vitamin E's benefits have produced conflicting results. However, some studies have shown that vitamin E reduces the risk of heart attack and death from cardiovascular disease. Vitamin E may also have visual benefits, decreasing the risk of cataract formation and macular degeneration.

Other studies indicate that vitamin E may improve immune function. For example, a large trial in nursing home residents found that daily supplementation with 200 IU of synthetic alpha-tocopherol for one year significantly lowered the risk of contracting upper respiratory tract infections, especially the common cold, but did not affect lower respiratory tract (lung) infections (Meydani et al., 2004).

Vitamin E deficiency is linked with physical decline in older adults (Bartali et al., 2008), including impaired balance and coordination (ataxia), peripheral neuropathy, and muscle weakness. Older adults with these symptoms should be screened for Vitamin E deficiency. Food sources of vitamin E include vegetable oils (walnut, sunflower, cottonseed, safflower, canola) nuts, whole grains, and green leafy vegetables.

Obesity among older adults is a growing problem in America, affecting about one-third of people aged 65 to 74. Obesity increases the risk of type 2 diabetes and osteoarthritis, both of which diminish quality of life, and in the case of osteoarthritis, compromise mobility. Opinions vary on what constitutes the ideal body mass index (BMI) for older people.

Residents in long-term care are at particular risk for malnutrition, especially protein-calorie malnutrition. An estimated 12 to 50 percent of long-term care residents are malnourished, increasing the risk of digestive, lung, and heart problems as well as pneumonia and other serious infections. Malnutrition can also cause blood clots, pressure ulcers, and poor wound healing. In addition, malnutrition can worsen mental confusion and dementia.

Institutionalized elders may have cognitive, visual, or mobility impairments that make it impossible for them to feed themselves. Such instances call for assistance in feeding by mouth, not artificial nutrition and hydration (ANH). People with Alzheimer's disease or other dementias eventually forget how to feed themselves or even how to eat. These patients should be considered terminal and care providers need to help families understand that forgoing ANH is not "killing" or "starving" the patient.

The Ethics Advisory Panel of the Alzheimer's Association (2000) recommends assisted oral feeding coupled with hospice care when needed as the compassionate alternative to tube feeding. This recommendation is based on several studies which point out that tube feeding:

• Is associated with in creased diarrhea and related discomforts
• Results in increased use of physical restraints to prevent patients from pulling tubes out of their abdomens
• Does not usually improve nutritional status
• Does not lower the incidence of aspiration pneumonia or skin breakdown
• Does not improve longevity
• Denies the patient the gratification of tasting preferred foods.

ASSESSING SKIN

Skin assessment in older persons is focused on monitoring for dryness, pruritis, signs of skin breakdown such as pressure ulcers, lesions such as bruising that could indicate abuse or unreported falls, and possible skin cancers (squamous cell carcinomas or melanoma). Clinicians need to be vigilant in inspecting both hands and feet of older adults, particularly people who have diabetes or vision or mobility problems, including obesity, that may make them unable to trim their nails and properly care for their feet. These individuals need regular access to a podiatrist who can provide the necessary foot care and prevent or treat irritations and infections.

Very thin patients, those who are poorly nourished, and those who are confined to bed or a wheelchair are at greatest risk for developing pressure ulcers on bony prominences—shoulders, lower back, heels, hips, and buttocks should be carefully inspected. These patients should have a systematic skin inspection at least once a day. In male patients, the underside of the scrotum should be examined for pressure and irritation. Avoid massaging skin on bony prominences because it can increase the risk of pressure ulcers.

When assisting patients who bathe themselves, avoid hot water and offer a mild cleansing agent that minimizes irritation and dryness of the skin. Minimize the force and friction applied to the skin. The frequency of bathing should be individualized according to need and/or patient preference. Minimize environmental factors leading to skin drying, such as low humidity (less than 40%) and exposure to cold. Dry skin should be treated with moisturizers.

Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, provide underpads or briefs made of materials that absorb moisture and present a quick-drying surface to the skin. Topical agents that act as barriers to moisture can also be used.

INCONTINENCE

Incontinence is defined as any involuntary leakage of urine, and it affects approximately half of American women during their lifetimes (Melville et al., 2005.) Risk factors include white race, childbirth, cesarean delivery, obesity (BMI >30), medical co-morbidity, and hysterectomy. Incontinence becomes more prevalent among both men and women as they age. The precise incidence of incontinence is unknown because many patients often hesitate to talk with their physicians about it. Patients feel ashamed and embarrassed about incontinence and many physicians don't screen for it, either sensing the patient's embarrassment or because of limited time. However, most patients who have incontinence problems will admit it when a health professional asks the question "Do you have any problems with leakage of urine?"

Screening for incontinence is essential because therapeutic measures such as dietary modification (avoiding caffeinated food and beverages, weight loss in obese patients), pelvic-floor exercises (Kegel exercises), bladder retraining and regular voiding can reduce or eliminate incontinence in some patients, thereby preventing complications such as skin breakdown, urinary tract infections, and withdrawal from social activities, which can lead to isolation.

Incontinence can be transient (potentially reversible) or chronic. Age-related changes in the urinary tract are only one of several factors contributing to incontinence. Potentially reversible factors include those summarized in the mnemonic DIAPPERS:

• Delirium is the primary cause of incontinence in hospitalized patients. Those affected may not recognize the need to urinate or be unable to find a toilet or urinal. Once the delirium is resolved, so is the incontinence.
• Infection in the urinary tract that leads to urgency and incontinence
• Atrophic urethritis
• Pharmaceuticals (as well as alcohol and caffeine)
• Psychological factors (such as depression)
• Excess urinary output (caused by diabetes, use of diuretics, or excess fluid intake, especially of alcohol and caffeinated beverages)
• Restricted mobility can cause incontinence because the patient is unable to reach the toilet in time to avoid leakage. Restoring or improving mobility can resolve the incontinence. Otherwise a bedside commode or urinal should be provided.
• Stool impaction (can cause temporary confusion, leading to incontinence of both urine and stool). Removing the impaction generally restores continence.

People with diabetes are at high risk for incontinence due to neuropathy that affects pelvic nerves. Other high-risk groups include those with Parkinson's or stroke-related neurologic problems, women with relaxed pelvic muscles, and men who have had prostate surgery. By observing how long it takes from intake to urinary output, caregivers can intervene at the appropriate time for toileting. Controlling UTIs also helps prevent incontinence.

Stress incontinence is a particular problem for any older woman with a cough, either chronic or temporary. A productive cough is necessary to clear secretions from the chest, but the patient needs protection for her clothing to prevent the odor of stale urine. Wearing a panty liner or sanitary pad should be tried before selecting the more cumbersome incontinence garments. Frequent, careful cleaning of the genital area is also needed to prevent odor and skin breakdown. If the patient is unable to clean herself, the care provider must do so.

Preventing incontinence is based on keeping the bladder empty by frequent toileting, bladder retraining, and in some cases, catheterization. However, limiting fluid intake (except in the evening) can cause dehydration requiring other measures. Review of medications may identify one or more drugs that contribute to incontinence (see box below); if it is not feasible to discontinue the drug(s), substituting another drug may help reduce incontinence.

Research indicates that behavioral modification should be the first-line therapy for incontinence in older patients. Pelvic floor exercises are helpful for stress incontinence, while bladder training is helpful for urge incontinence. Both modalities are helpful when the patient has both types of incontinence (Teunissen, et al, 2004; Dumoulin & Hay-Smith, 2007). Drug treatment for stress incontinence is limited, although some experts recommend a trial of topical estrogen for women with symptomatic atrophic urethritis. Surgery is considered a last resort, particularly in very elderly women, although the success rate is 75% to 85% even in older women (Johnston et al., 2008).

When confusion and incontinence occur together, controlling the confusion may also help prevent incontinence. However, research suggests that patients who are taking medications for dementia (eg, cholinesterase inhibitors) should not also take medications for incontinence (eg, anticholinergic drugs) because the interaction of these two types of drugs can hasten functional decline (Sink et al., 2008). This finding has major public health implications because an estimated one-third of people with dementia also take a drug for incontinence.

Urge incontinence is caused by overactivity/contractions of the bladder's detrusor muscle and is the most common type of geriatric incontinence. These contractions cause an overwhelming urge to urinate and result in urine leakage. In older men, urge incontinence is often accompanied by urethral obstruction from benign prostate hyperplasia (BPH). Bladder stones or tumors can also cause bladder contractions and sudden-onset urge incontinence, especially if urination is painful or if there is blood in the urine (hematuria). Cystoscopic examination and urinalysis may be necessary to determine the cause.

Urethral obstruction is common in older men and causes dribbling incontinence after voiding, urge incontinence as described above, or overflow incontinence due to detrusor underactivity, which may be due to a condition called neurogenic bladder. Applying suprapubic pressure while voiding may help empty the bladder. If that proves ineffective, intermittent catheterization is indicated.

Assessing Psychosocial Function

Socially isolated older persons are difficult to find. Like other vulnerable older persons, they tend to be invisible. Michael K. Gusmano and Victor G. Rodwin, 2006

ISOLATION

Social isolation can be hazardous to health, particularly in older adults. One in three Americans live alone, and 1 in 4 of those are typically older women who live in poverty and report poor health. These women are at higher risk for institutionalization and loss of independence—as well as heart disease, memory problems, depression, and suicide—than someone living with a spouse or other companion.

Although living alone does not always mean being lonely or isolated, health professionals need to screen for social isolation and loneliness. People at risk for social isolation include those with low self-esteem, a history of abuse or homelessness, depression, chronic pain, incontinence, and mobility problems.

Research shows that having social networks and participating in social activities protects cognitive function and reduces dementia incidence, particularly among older women (Ertel et al., 2008); Crooks et al., 2008). Suggested measures to increase social engagement include referral to a support group, telephoning or emailing friends, or adopting a pet. Another strategy would be to contact a volunteer visitation organization such as Boston's Little Brothers Friends of the Elderly or New York's Dorot that matches older adults who live alone with volunteer visitors.

Institutionalized elders may also be socially isolated because of their health problems or because they have no family to visit. As mentioned earlier, loneliness is one of the three plagues of living in a nursing home. Volunteer visitation and pet therapy can also help reduce isolation among these elders.

DEPRESSION

Depressive disorder is not a normal part of aging. Emotional experiences of sadness, grief, response to loss, and temporary blue moods are normal. Persistent depression that interferes significantly with ability to function is not. National Institute of Mental Health, 2008

Depression is a widely under-recognized and undertreated medical illness in older adults. Estimates of major depression in older people living in the community range from 1 to 5 percent but the rate rises to more than 13 percent in those requiring home healthcare (Hybels & Blazer, 2003).

Depression can be immobilizing and can interfere with normal sleep, nutritional intake, thinking and concentration, and quality of life. Therefore, depression contributes indirectly to a decline in physical and mental health. In fact, a number of studies have shown that depression is an independent risk factor for falls.

Symptoms of depression include:

• Feeling sad, anxious, or "empty" most of the day, almost every day
• Lack of interest or pleasure in almost all activities, including sex
• Changes in appetite and/or weight
• Altered sleep patterns
• Changes in physical activity—ranging from slowing down to agitation or hyperactivity
• Feelings of worthlessness or excessive guilt
• Inability to concentrate or make decisions
• Recurrent thoughts of death or suicide, or suicide attempts

Recognizing the symptoms of depression in older people and referring them for appropriate treatment may greatly improve their quality of life. Treatment for depression may include psychotherapy as well as antidepressant medications. However, antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs), also increase the risk of falls (Kerse et al., 2008). If antidepressant medications are prescribed, care providers need to redouble efforts to prevent falls. Strategies include exercises to strengthen lower leg muscles and balance retraining, as well as home assessment and modification as needed.

SUICIDE

Depression is one of the conditions most commonly associated with suicide. According to the National Institute of Mental Health (2008), older Americans are disproportionately likely to die by suicide. Although people over 65 comprise only 12 percent of the U.S. population, they accounted for 16 percent of suicides in 2004 (CDC, 2005). The incidence of suicide is highest among non-Hispanic white men, and guns are the most frequently used method. Suicide is most common among older adults who are divorced or widowed.

Risk factors for suicide in people age 65 or older include:

• Male
• Chronic or terminal illness
• Social isolation
• Financial strain
• Bereavement
• Depression
• Alcohol or drug abuse
• History of other suicide attempts
• Family history of suicide
• Preoccupied with suicidal talk and plans

Preventing suicide depends on early recognition of suicidal intent and treating physical and psychiatric conditions, reducing social isolation, enhancing self-esteem, and helping people find meaning or satisfaction in life. Health professionals and family caregivers need to pay attention to statements such as "I'd be better off dead" or "I don't want to live." These suggest a need for counseling by a mental health professional.

Feeling helpless, hopeless, and worthless can lead to thoughts of suicide and, in some cases, committing suicide. From Hamilton (2008):

People who feel helpless need empowerment. People who feel worthless need to experience their own value to the folks who matter in their lives. People who feel hopeless need to see beyond today.

CONFUSION AND COGNITION

Confusion in the elderly is a symptom of environmental, social, sensory, and physiologic problems. Mary Opal Wolanin, 1981

Who among us has not been confused at one time or another? Losing our sense of direction when traveling in an unfamiliar city, waking up in the hospital after a serious car accident, becoming disoriented after hearing the news of a death in the family—all can cause confusion. When we are young, or even middle-aged, confusion is considered temporary and reversible.

In older adults, however, confusion is too often regarded as the first step on the road to dementia and "senility." As Wolanin (1981) wrote, "Diagnosis often becomes prognosis as health professionals use stereotypes for shaping their planning." Labeling confusion as cognitive impairment can have life-altering effects on patients and affect their treatment socially, legally, medically, and psychologically.

Health professionals need to assume that confusion may be reversible, particularly confusion of sudden onset, and seek the possible causes. Those causes of reversible confusion may include:

SYSTEMIC PROBLEMS

• Hypoxia
• Hypoglycemia
• Hyperglycemia
• Dehydration and fluid/electrolyte imbalance
• Hypercalcemia
• Hypocalcemia
• Hypothyroidism
• Hyperthyroidism
• Hypothermia
• Hyperthermia
• Hypotension
• Drug related intoxications
• Pernicious anemia
• Pellagra (niacin deficiency)
• Stress
• Fecal impaction

MECHANICAL PROBLEMS

• Obstruction to cerebral blood flow
• Increased intracranial pressure
• Brain cell death or loss

SENSORIPERCEPTUAL PROBLEMS

• Sensory deprivation related to vision or hearing impairment
• Sensory overload in noisy, crowded settings
• Lack of variety, lack of personal contacts, and lack of meaning, especially in institutional settings
• Relocation/transfer from familiar surroundings to unfamiliar surroundings

Some of the listed problems may also contribute to irreversible or chronic confusion and dementia, including Alzheimer's disease.

Gradual onset of confusion may also be reversible if it is related to a treatable or correctible condition such as nutritional deficiency, hypothyroidism, vision or hearing impairment, or depression. Careful assessment is needed to avoid misdiagnosis and thereby perpetuate the confusional state.

Delirium is an acute confusional state of rapid onset characterized by clouding of consciousness, disorientation, memory impairment, incoherent speech, and perceptual disturbance. Delirium can be caused by serious illness such as an infection, coronary ischemia, hypoxemia, toxic-metabolic conditions, medication interactions, intracranial lesions, trauma, sensory deprivation, or stress. Delirium is not unusual in older adult hospitalized patients, and it may progress to chronic confusion.

According to Johnston and colleagues (2008), about one-fourth of patients with delirium have dementia and about 40 percent of people with dementia experience delirium. Clearly it is important to screen for cognitive impairment and dementias. The Mini-Mental Status Examination (see below) is a quick evaluation tool used to assess people with cognitive impairment or memory loss. It measures an individual's reality orientation, registration abilities, attention and calculation skills, recall, language, and visuoconstruction (seeing and copying designs) abilities.

The highest possible score is 30 points. Those who score less than 24 need further evaluation for possible AD or other dementia, depression, delirium, or schizophrenia. Those who score 20 or less generally have one of these disorders.

THE MINI-MENTAL STATUS EXAM
Indications Cognitive Function Assessment Documentation of subsequent cognitive function decline
Questions (Total of 30 points)
Category	Points	Questions
1. Orientation	10	Year, season, date, day of week, and month State, county, town, or city Hospital or clinic, floor
2. Registration	3	Name three objects: apple, table, penny - Speak each one distinctly and with a brief pause - Patient repeats all three (one point for each) Repeat process until all three objects learned Record number of trials needed to learn all three
3. Attention and Calculation	5	Spell WORLD backwards: DLROW - Points given up to first misplaced letter - Example: DLORW scored as 2 points only
4. Recall	3	Recite the three objects memorized in number 2 (Registration)
5. Language	9	Patient names two objects when they are displayed - Example: pencil and watch (1 point each) Repeat a sentence: "No ifs, ands, or buts" Follow three-stage command: - Take a paper in your right hand - Fold it in half - Put it on the floor Read and obey the following: - Close your eyes - Write a sentence - Copy the design (picture of two overlapped pentagons

Mild Cognitive Impairment (MCI)

Mild cognitive impairment is a transitional state between the normal cognitive changes of aging and the development of Alzheimer's disease (AD) or other dementia. Two subtypes of MCI have been established: amnestic MCI, characterized by memory problems, and nonamnestic MCI, which affects cognitive functions other than memory, such as language, attention, critical thinking, reading, and writing. Experts estimate that MCI may affect more than 20 percent of the population over age 65. People diagnosed with MCI are at increased risk of developing AD or other dementia. Based on early research, the rate of progression from amnestic MCI to AD is estimated to be between 6 and 25 percent per year (Petersen et al., 2001).

In 2001 the American Academy of Neurology (AAN) established the following criteria for an MCI diagnosis:

• An individual's self-report of memory problems, preferably confirmed by another person
• Measurable, greater-than-normal memory impairment detected with standard memory assessment tests
• Normal general thinking and reasoning skills
• Ability to perform normal daily activities

Ongoing research on MCI suggests that earlier treatment with drugs approved for AD may slow its progression to AD. A three-year, placebo-controlled clinical trial of more than 750 patients with amnestic MCI showed that donepezil (Aricept) reduced the risk of developing AD during the first year (Petersen et al., 2005). However, by the end of the three-year study, the risk was the same as those in the placebo group. Nevertheless, delaying the progression to AD by a year represents a significant reprieve for both patients and caregivers in terms of maintaining function and quality of life as well as reducing healthcare costs.

Alzheimer's Disease and Other Irreversible Dementias

Alzheimer's disease is an age-related, irreversible brain disorder that gradually erases memory, thinking, understanding, and sense of self. Over time, as neurons die in widespread areas of the brain's cerebral cortex, mild sporadic memory loss evolves into severe cognitive dysfunction as well as behavior and personality changes and, eventually, loss of physical function. The course of AD and the rate of decline vary from person to person. On average, clients with AD live for 8 to 10 years after diagnosis but may live as long as 20 years.

Medial view of the human brain showing major landmarks. Courtesy of Alzheimer's Disease Education and Referral Center.

Although the risk of developing AD increases with age, AD and other dementia symptoms are not a part of normal aging but the result of diseases that affect the brain. In the absence of disease, the human brain can function well into the tenth decade of life.

Alzheimer's disease is one of a group of disorders called dementias, which are characterized by progressive cognitive and behavioral changes. Symptoms commonly appear after age 60, beginning with loss of recent memory, followed by faulty judgment and personality changes. People in the early stages of AD often think less clearly a