Pathy's Principles and Practice of Geriatric Medicine

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Группа авторов. Pathy's Principles and Practice of Geriatric Medicine

Table of Contents

List of Tables

List of Illustrations

Guide

Pages

Pathy’s Principles and Practice of Geriatric Medicine

About the Editors

About the Associate Editors

List of Contributors

Preface to the Fifth Edition

Preface to the Sixth Edition

Foreword

Introduction: Historical perspectives

Introduction

The earlier writers on old age

The birth of modern geriatric medicine

British developments

An overview of early geriatric medicine in the United Kingdom

The early pioneers in geriatric medicine

The second wave of geriatricians

Third wave of geriatricians

Geriatrics in the United States

Geriatrics in the rest of the world

Teaching geriatric medicine

Achievements of geriatric medicine. Gerontology: the science of the ageing process

Problem areas

Key points

References

CHAPTER 1 A biological perspective of ageing

Introduction

A populational perspective on ageing

The evolutionary roots of the phenomenon of ageing

The components of biological ageing

Genomic instability

Epigenetic changes

Mitochondrial dysfunction

Loss of proteostasis

Metabolic dysfunction

Cell senescence

Stem cell exhaustion

Immunosenescence

Challenges for the biology of ageing and geriatric medicine

Key points

References

CHAPTER 2 Physiology of ageing

The nervous system

Age‐related changes in the nervous system

The cardiovascular system

Age‐related changes in the cardiovascular system

The endocrine system

Thyroid

Growth hormone

Dehydroepiandrosterone (DHEA)

Oestrogen

Testosterone

Hypothalamic‐pituitary‐adrenal (HPA) axis

Arginine‐vasopressin (AVP)

The gastrointestinal system

Age‐related changes in the GI tract

Age‐related changes in GI organs and glands

The genitourinary tract

Age‐related changes in the kidneys

Age‐related changes in the lower urinary tract

Age‐related changes in genital organs

The immune system

Age‐related changes in the immune system

The musculoskeletal system

Age‐related changes in the skeleton

Age‐related changes in the muscles

The respiratory system

Age‐related changes in the respiratory system

The skin

Age‐related changes in the skin

Key points

References

CHAPTER 3 Psychological aspects of ageing

Introduction

Psychological development over the lifespan

Personality changes in older adulthood

Normal cognitive change with age

Abnormal cognitive ageing

Mental health and cognition in the elderly and associated medical issues

Psychological interventions in the elderly

Non‐pharmacologic interventions for cognitive decline

Implications for practice

Key points

References

CHAPTER 4 Social and community aspects of ageing

Introduction

Demography of ageing. Ageing population

The causes of population ageing

Old‐age dependency ratio

Gender imbalance

Geographic considerations: migration and immigration

Relationships, viewpoints, and ageing

Shifting attitudes

Marriage, cohabitation, and divorce

The changing family

Caregiver relationships

Religiousness and spirituality

Community and societal structures. Housing

Environment

Making a move

Incarcerated older adults

Employment and retirement

The internet and social media

Challenges of ageing

Ageism

Sensory impairments

Disability

Poverty

Social isolation and loneliness

Elder abuse

Scams and fraud

Natural disasters

Key points

References

CHAPTER 5 Sexuality and ageing

Introduction

Sexual health in older adults

Sexuality and the older woman

Menopause

Sexuality and the older man

Andropause

Sexuality and disease

Dementia

Sexually transmitted infections

Special considerations for LGBTQ older adults

Sexuality in the nursing home

Conclusion

Key points

References

CHAPTER 6 Ageing of the brain

Introduction

Structural age‐related brain changes

Atrophy

Small‐vessel disease

Altered proteins

Neurobiological hallmarks of brain ageing

Mitochondrial dysfunction

Oxidative damage

Loss of proteostasis

Dysregulation of calcium homeostasis

Impaired adaptive cellular stress responses

Inflammation

Aberrant neuronal network activity and altered synaptic plasticity

Impaired DNA repair

Impaired neurogenesis

Dysregulated energy metabolism

Changes in the neurological examination with ageing

Vision

Hearing

Taste and smell

Sensation

Reflexes

Posture, gait, and balance

Extrapyramidal signs

Cognitive changes with ageing

Key points

References

CHAPTER 7 Physical fitness and exercise

Introduction

What is physical activity or exercise?

Physical inactivity versus exercise

Inter‐individual variability in response to exercise (non‐responder phenomenon)

Does exercise increase life expectancy?

Physical function as a biomarker of healthy ageing and objective of exercise programmes

Preserving exercise capacity with age via an active lifestyle

Optimisation of body composition with ageing

Role of exercise and physical activity in bone health and fracture risk. Age‐related changes in bone

Physical activity and bone health

Exercise intervention trials in postmenopausal women and older men

Optimal exercise modality and intensity for bone health

Exercise in the treatment of osteoporotic fracture

Role of exercise and physical activity in adipose tissue accretion and distribution

Cross‐sectional studies of physical activity and fat mass

Experimental studies of the influence of physical activity on abdominal fat

Relationship between exercise intensity and changes in body fat

Relationship between exercise modality and changes in body fat

Role of exercise in preserving muscle mass with age

Exercise to maintain or increase muscle mass

Predictors of muscle hypertrophy after exercise

Muscle power training

Promotion of psychological well‐being

Exercise and cognitive function

Considerations regarding exercise for frail individuals with cognitive impairment

Effects of exercise interventions on mobility and frailty syndromes

Disease prevention through exercise

Evidence for the role of exercise in the treatment of disease. Mechanisms of benefit

Exercise in the treatment of type 2 diabetes

Evidence for exercise interventions in frail older adults with diabetes

Exercise to counteract iatrogenic disease

Exercise and the prevention and treatment of disability

Exercise for acute hospitalised older patients

Summary of exercise recommendations

Resistance training recommendations

Balance training recommendations

Aerobic and gait training

Multicomponent training

Conclusions:

Key points

References

CHAPTER 8 Health literacy and cultural sensitivity

Introduction

The importance of health literacy in health care

Factors that influence health literacy

The role of education in health literacy

Educational strategies to improve health literacy

Cultural sensitivity in geriatrics. The need for cultural sensitivity

When cultures clash

Barriers to cultural understanding

Common areas of conflict or misunderstanding in the clinical encounter

Prior experiences

Identifying the patient

Communication

Stereotyping

Age

Increasing cultural sensitivity in the clinical encounter. Increase self‐awareness

Improve communication

Explanation

Treatment

Healers

Negotiate

Intervention

Collaborate

Spirituality/seniors

Understand non‐verbal cues

Use professional translators when possible

Promote health

Resources

Cultural competence in health care

Health promotion programs

Key points

References

CHAPTER 9 Preventive geriatrics

Introduction

Background

The Health Maintenance Clinical Glidepath

Office visits

Blood pressure (BP), including orthostatic measurements

Weight

Height

Pain

Medication review including over‐the‐counter (OTC) and herbal medicines

Lifestyle education

Maintain awareness of elder abuse

Assess ADLs and IADLs

Visual acuity and auditory testing

Ask about urinary incontinence

Males: screen for erectile dysfunction (ED) and hypogonadism

Rapid Geriatric Assessment

Cognitive screening

Depression screening

Screening for gait and balance

Advance directives

Influenza vaccine

Pneumococcal vaccine

Tetanus

Zostavax and Shingrix

Hepatitis C

Breast cancer screening

Cervical cancer screening

Colon cancer screening

Prostate cancer screening

Lung cancer screening

Osteoporosis

Cholesterol screening

Thyroid‐stimulating hormone (TSH)

Diabetes mellitus

Sleep apnoea

Abdominal aortic aneurysm

Key points

References

CHAPTER 10 Polypharmacy and deprescribing in older adults

Introduction

Ageing physiology affects medication efficacy and tolerance

Tools for medication management

Principles of appropriate prescribing

Conclusion

Key points

References

CHAPTER 11 Patient safety

Introduction. History and evolution of the concept of patient safety

Definitions

Measurement – the scale of harm

Studies of errors

Why do adverse events occur?

Learning from other industries

Human error

System and organizational factors

What happens after an adverse event? Reporting and learning

Understanding why things go wrong

Caring for patients after an adverse event

Supporting staff

Patient safety and older people. The incidence of adverse events in older people in the hospital. Re‐analysis of international adverse event studies

Data from reporting systems

Types of adverse events experienced by older people in the hospital. The geriatric syndromes

Preventable functional decline as an adverse event

Adverse drug events in older people

Box 11.1 Adverse events in older people

Implications

Box 11.2 Common types of medication‐related problems in older people in the hospital

Why are older people more susceptible to healthcare‐associated harm than younger patients?

The effects of comorbidity and frailty

Decision‐making in the care of older people

Multidisciplinary teams and communication

Attitudes and ageism

Systems and processes of care for frail older people

Improving patient safety for older people

Education and skills for individual practitioners

Box 11.3 Some of the individual skills and behaviours that geriatricians use to maximize patient safety in older people

Design (human factors and ergonomics) and technology

Improving systems of care for older people

Interventions for the geriatric syndromes

Hospital‐acquired infections

Medication safety

Patient safety issues in community settings

Priorities for improving the safety and quality of care for older people. Patient safety for older people across the world

Improved definitions and measurement

Patient safety research in non‐hospital settings

Conclusion

Acknowledgement

Key points

References

CHAPTER 12 Nutrition and healthy ageing: Emphasis on brain, bone, and muscle

Introduction

Body weight and composition

Body mass index, weight loss, and ageing

Central adiposity and healthy ageing

Fluid status, dehydration, and healthy ageing

Bone loss, nutrition, and healthy ageing

Energy intake, macronutrients, and satiety in ageing

Determinants of dietary preference and intake among older adults

Dietary patterns and nutritional status associated with healthy ageing

Dietary patterns associated with healthy cognitive ageing

Nutritional status and healthy ageing

Micronutrients

Minerals

Macronutrients and omega‐3 fatty acids

Dietary guidelines and clinical applications

Key points

References

CHAPTER 13 The anorexia of aging

Introduction

‘Ideal’ body weight in older people

Weight loss in older people

Cachexia in older people

Causes of undernutrition in older people

Reduced food intake

Physical factors

Physiological changes

Loss of homeostasis

The ageing gut

Declining senses

Hormones and neurotransmitters: a selective review

Central neurotransmitters and hormones. Monoamines

Opioids

Neuropeptide Y

Galanin

Orexins (hypocretins)

Cocaine–amphetamine‐regulated transcript (CART)

‘Peripheral’ hormones, including gut peptides. Cholecystokinin (CCK)

Glucagon‐like peptide‐1 (GLP‐1)

Peptide YY (PYY)

Leptin

Ghrelin

Insulin

Testosterone and other androgens

Cytokines

Chronic disease and anorexia in older adults

Environment and social determinants of health

Iatrogenic impact

Conclusion

Key points

References

CHAPTER 14 Weight loss

Introduction

Weight loss and frailty

Weight loss and sarcopenia

The relationship of weight loss to mortality

Effect of weight loss on comorbid conditions

Weight loss, a hallmark of malnutrition

Starvation

Cachexia

Anorexia

The use of the Mini‐Nutritional Assessment (MNA) to explore weight loss

Interventions

Decreased food intake

The effect of exercise to improve body mass and function

Palliative treatment of anorexia

Conclusion

Key points

References

CHAPTER 15 Water and electrolyte balances in ageing

Introduction

Normal physiology

Water homeostasis in the elderly

Workup and treatment of hyponatremia

Workup and treatment of hypernatremia

Conclusions

Key points

References

CHAPTER 16 Vitamins and minerals

Introduction

Recommended intakes of vitamins and minerals

Medication influences on vitamin and mineral status

Vitamins and minerals – functions and characteristics

Micronutrients of special concern for older adults

Role of vitamin and mineral supplements in chronic disease: some reviews of the evidence

Bone health, fractures, vitamin D, and calcium

Prevention of fractures in high‐risk populations

Prevention of fractures in healthy populations

Summary

Mild cognitive impairment and dementia

Eye disorders – age‐related macular degeneration and age‐related cataracts

Prevention of AMD

Slowing the progression of AMD

Prevention and slowing of age‐related cataract (ARC) development

Cancer and cardiovascular diseases – selenium

Cancer and cardiovascular diseases – multiple vitamins and minerals

Practical implications

Nutrient intake and healing of pressure injury: focus on zinc

Summary

Key points

References

CHAPTER 17 Changes in gastrointestinal motor and sensory function associated with ageing

Introduction

Control of gastrointestinal motility and sensation

Pathophysiology of the ageing gut

Oesophagus

Changes in oesophageal motor function related to ageing

Clinical presentation of disordered oesophageal motility

Achalasia

Distal oesophageal spasm and ‘jackhammer’ oesophagus

Minor disorders of peristalsis

‘Pill esophagitis’

Non‐cardiac chest pain

Gastro‐oesophageal reflux disease

Stomach and duodenum

Changes in gastric motor function related to ageing

Small intestine

Changes in small‐intestinal motor function related to ageing

Postprandial hypotension

Systemic disorders associated with disturbance of gastrointestinal motility

Parkinson’s disease

Diabetes mellitus

Progressive systemic sclerosis

Functional disorders

Key points

Acknowledgements

References

CHAPTER 18 The liver and gallbladder in the geriatric population

Introduction

Acute viral hepatitis

Chronic hepatitis B and C

Fatty liver disease

Drug‐induced liver injury

Alcoholic liver disease

Primary biliary cholangitis

Hemochromatosis

Autoimmune hepatitis

Primary sclerosing cholangitis

Hepatocellular carcinoma

Biliary disease

Liver transplantation

Conclusion

Key points

References

CHAPTER 19 Faecal incontinence

Introduction

The physiology of defecation

Anatomy of the lower alimentary canal

Defecation

Changes relating to ageing

Epidemiology of faecal incontinence. Prevalence

Correlates and risk factors. Gastrointestinal disorders

Non‐GI risk factors

Neurological

Endocrine, diabetes, and metabolic

Geriatric syndromes

Medications and drugs

Sequelae of faecal incontinence

Assessment of faecal incontinence

Investigations

Management of faecal incontinence

Conservative Measures

Pelvic floor training and biofeedback

Surgical therapy

Sphincter repair

Neosphincter operations

Sacral neuromodulation

Faecal diversion

Containment

Conclusions

Key points

References

Note

CHAPTER 20 Constipation

Defining constipation

Epidemiology, pathophysiology, and impact

Aetiology of constipation

Clinical approach. History

Physical examination

Diagnostic tests

Treatment

Pharmacological management. Bulking agents

Stool softeners

Osmotic laxatives

Stimulant laxatives

Secretagogues (prosecretory agents)

Serotonin receptor agonists

Opioid antagonists

Enemas

Miscellaneous agents

Special categories of constipation

Conclusion

Key points

References

CHAPTER 21 Diseases of the pancreas

The ageing pancreas

Inflammatory diseases of the pancreas. Acute pancreatitis

Pathophysiology of acute pancreatitis

Presentation of acute pancreatitis

Diagnosis of acute pancreatitis

Assessment of the severity of acute pancreatitis

Management of acute pancreatitis

Chronic pancreatitis

Causes of chronic pancreatitis

Clinical presentation of chronic pancreatitis

Diagnosis of chronic pancreatitis

Imaging procedures

Complications of chronic pancreatitis

Management of chronic pancreatitis

Pancreatic cysts and tumours. Cystic lesions of the pancreas

Endocrine tumours of the pancreas

Pancreatic adenocarcinoma

Clinical features

Diagnosis of pancreatic cancer

Management of pancreatic cancer

Key points

References

CHAPTER 22 Anaemia in older people

Background

Epidemiology

Nutritional deficiencies. Iron deficiency anaemia

Vitamin B12 deficiency anaemia

Folate deficiency anaemia

Inflammatory anaemias. Anaemia of chronic disease

Anaemia of chronic kidney disease

Anaemia of clonal disorders

Conclusion

Key points

References

CHAPTER 23 Disseminated intravascular coagulation

Introduction

Pathophysiology

Diagnosis

Management

Chronic disseminated intravascular coagulation

Key points

References

CHAPTER 24 Disorders of haemostasis

Introduction

Disorders of platelet number

Decreased platelet production

Increased peripheral destruction

Increased pooling of platelets

Thrombocytopenia due to drugs

Functional platelet defects

Hereditary coagulation defects

Acquired coagulation defects

Vascular disorders

Thrombotic disorders

Thrombophilia

Lupus anticoagulant

Key points

References

CHAPTER 25 When to anticoagulate, and which anticoagulant?

Introduction

The elderly are more prone to thromboembolism

The elderly are more prone to haemorrhage

Anticoagulant response differs in the elderly

Anticoagulants are effective in the elderly

Optimizing the risk‐benefit equation in the elderly

Intensity of anticoagulation

Age‐related factors that predispose to bleeding. Tissue modifications

Falls

Concomitant use of antiplatelets

Duration of anticoagulant therapy

Start‐stop‐start anticoagulation. Starting anticoagulation in elderly patients

Situations that force interruption of anticoagulation. Intracranial bleeding (ICB)

Surgical interventions

Poor control of the INR

Definitive interruption of anticoagulation

Key points

References

CHAPTER 26 Myelodysplasia

Introduction

Epidemiology and clinical presentation

Elderly patients and risk assessment

Diagnosis. Blood and bone marrow examination

Complete blood count

Peripheral blood smear

Other useful parameters of peripheral blood

Bone marrow analysis

Differential diagnosis

Cytogenetics

Other genetic events

Diagnostic criteria

Classification

Uncertain conditions

Prognosis

Treatment

Treatment of lower‐risk MDS

Supportive measures for anaemia: erythroid‐stimulating agents

Transfusion support and iron overload

Alternative strategies to treat anaemia in MDS

Lenalidomide

Erythropoiesis maturating agents

Platelet growth factors

Pyridoxine, androgens, and vitamins

Disease‐modifying agents for high‐risk disease

Hypomethylating agents

Haematopoietic stem cell transplantation

Key points

References

CHAPTER 27 Management of myelodysplastic syndromes and acute myeloid leukaemias in the elderly

Introduction

Myelodysplastic syndromes. Pathophysiology

Epidemiology

Diagnosis

Prognostic factors

Treatment of lower‐risk MDS. Erythropoiesis stimulating agents (ESAs)

Red blood cell (RBC) transfusion

Iron chelation

Treatment of thrombocytopenia

Other treatments

Treatment of higher‐risk MDS. Hypomethylating agents

Allogeneic stem cell transplantation

Therapeutic decision

Acute myeloid leukaemias (AMLs) Pathophysiology

Epidemiology

Diagnosis

Prognostic factors

AML features in the elderly

Treatments of AML. Intensive chemotherapy

Low‐dose intensity regimens

Novel agents

Best supportive care

Treatment decision

Conclusion

Key points

Bibliography

CHAPTER 28 Epidemiology of heart disease

Introduction

Coronary heart disease

Box 28.1 Common heart diseases in older people

Risk factors and prevention

Age and sex

Ethnicity and race

Diet

Cholesterol

Exercise

Obesity

Smoking

Socioeconomic factors

Hypertension

Diabetes mellitus

Metabolic syndrome

Frailty and disability

Risk factors in the cognitively impaired

Reverse epidemiology

Heart failure

Box 28.2 Summary – CHD. Epidemiologic features

Clinical implications

Ethnic variations

Risk factors and prevention

Diastolic heart failure

Complexity and care for heart failure. Heart failure and cognition

Heart failure and geriatric conditions

Heart failure in care homes

Box 28.3 Summary – heart failure. Epidemiologic features

Clinical implications

Care needs for heart failure

Caregiver burden

Valvular heart disease

Degenerative valve disease

Infective valve disease

Box 28.4 Summary – valvular heart disease. Epidemiologic features

Clinical implications

Rhythm disorders

Atrial fibrillation

Sudden cardiac death

Box 28.5 Summary – rhythm disorders. Epidemiologic features

Clinical implications

Conclusion

Key points

References

CHAPTER 29 Arrhythmias

The normal cardiac conduction system

The ageing heart

Twelve‐lead and ambulatory ECG surveys

Incidental findings that may be normal in older people

Pathological findings in older people

Symptomatic bradycardias

Presentation

Assessment

Sinus node dysfunction (sick sinus syndrome)

Atrioventricular blocks. First‐degree heart block

Second‐degree heart block

Third‐degree heart block (complete heart block)

Choice of pacemaker

Single‐chamber atrial pacing

Dual‐chamber versus ventricular‐only pacing

Physiological pacing

Complications of pacemaker implantation

Atrial tachyarrhythmias. Atrial ectopic beats

Atrial tachycardia

Multifocal atrial tachycardia (MAT)

Atrial flutter

Atrial fibrillation

Classification

Epidemiology

Aetiology. Valvular AF

Non‐valvular AF

Lone AF

Consequences of AF

Atrial remodelling

Hemodynamic function

Thromboembolism

Clinical manifestations

History and examination

Confirmation of arrhythmia

Aetiology of arrhythmia

Effect of arrhythmia on the patient

Patient assessment for management options

Imaging

Other tests

Management

Rate control

Digoxin

Beta blockers

Non‐dihydropyridine calcium channel antagonists

Amiodarone

Combination of rate‐control agents

Non‐pharmacological rate control. Permanent pacemaker

Ablate and pace strategy

Rhythm control. Urgent DC cardioversion (DCC)

Elective DC cardioversion

Pharmacological cardioversion and rhythm control

Antiarrhythmic agents for preventing recurrence of AF

Amiodarone

Sotalol

Beta blockers

Flecainide

Dofetilide/ibutilide

Dronedarone

Recommendations for rhythm control

Non‐pharmacological rhythm control

Ablation procedures (surgical and catheter‐based)

Atrial pacing

Anticoagulation

Vitamin K antagonists

Direct thrombin inhibitors

Factor Xa inhibitors

When to anticoagulate in AF

Choice of anticoagulant agent

Underuse of anticoagulation in older patients

Anticoagulation issues in older patients. Risk of bleeding and warfarin dose

Practicalities of regular INR monitoring in older people

Pharmacokinetics of warfarin in older patients

Pharmacodynamics of warfarin older people

Risks associated with polypharmacy

Non‐pharmacological possibilities to prevent stroke

Other supraventricular arrhythmias

Ventricular premature beats (VPBs)

Ventricular arrhythmias

Prognosis

Pathogenesis

Management

Acute management

Drug therapy. Beta blockers

Class I antiarrhythmic agents

Class III antiarrhythmic agents

Role of implantable cardioverter defibrillators

Implantable cardioverter defibrillators in older people

Key points

References

CHAPTER 30 Ischaemic heart disease

Introduction

Cardiac changes with ageing

Pathogenesis

Epidemiology

Clinical presentation

Diagnosis

Management

Risk assessment

Prevention

Lifestyle

Risk factors

Treatment

Stable IHD

Acute ischaemic events

Cardiac rehabilitation

Prognosis

Considerations in old age

Future perspectives

Conclusion

Key points

References

CHAPTER 31 Lipid management

Introduction

Lipoprotein metabolism and ageing

Dyslipidaemia and prevention of ASCVD in the elderly

Secondary ASCVD prevention

Primary ASCVD prevention

Clinical approach to dyslipidaemic older subjects

Conclusions

Key points

References

Notes

CHAPTER 32 Hypotension

Introduction

Orthostatic hypotension. Definition and measurement

Epidemiology

Pathophysiology

Symptoms

Prevention and treatment

Non‐pharmacological interventions

Pharmacological interventions

Treatments to increase venous return/ intravascular volume

Pharmacological treatments to increase residual sympathetic nervous system tone

Short‐acting pressor agents

Postprandial hypotension. Definition and measurement

Prevalence

Pathophysiology

Symptoms

Prevention and treatment

Pharmacological treatments

Hypotension with carotid sinus syndrome (carotid sinus hypersensitivity) Definition and measurement

Prevalence

Pathophysiology

Symptoms

Prevention and non‐pharmacological treatment

Pharmacological interventions

Conclusion

Key points

References

CHAPTER 33 Hypertension in older people

Introduction

Age‐related vascular changes

Pathophysiology

Box 33.1 Age‐related vascular changes

Epidemiology

Definition and classification

Diagnosis

Types

Management

Recommended targets

Suggested targets

Lifestyle modification

Pharmacologic intervention

Considerations in old age

Systolic hypertension

Orthostatic Hypotension

Falls

Frailty

Dementia

Comorbidity and polypharmacy

Future perspectives

Conclusion

Key points

References

CHAPTER 34 Heart failure

Introduction

Pathophysiology. Pathogenesis

Cardiovascular ageing and HF

Epidemiology

Clinical features

Diagnosis

Aetiology and precipitating factors

Impact of comorbidities on HF. Cardiac comorbidities

Noncardiac comorbidities

Frailty and HF

Management of HF

Management of aetiological and precipitating factors

Nonpharmacological treatment

Exercise

Multidisciplinary care

Pharmacological management of HFrEF

ACE inhibitors

Beta blockers

Angiotensin II receptor blockers (ARBs)

Mineralocorticoid receptor antagonists

Hydralazine and isosorbide dinitrate

Diuretics

Digoxin

Ivabradine

Angiotensin receptor neprilysin inhibitor (ARNI)

Approach to treatment

Device therapy

Cardiac pacemakers

Implantable cardioverter defibrillators (ICDs)

Cardiac resynchronisation therapy (CRT)

Treatment of heart failure with a preserved ejection fraction

Palliative care in HF. Prognosis

Future perspectives

Summary

Key points

References

CHAPTER 35 Cardiac surgery and percutaneous interventions in the elderly

Introduction

Cardiac surgery and percutaneous intervention in the elderly

Mortality

Morbidity – neurological dysfunction

Assessment of the elderly patient for cardiac surgery or percutaneous intervention

Operative risk – estimated mortality for cardiac surgery or percutaneous intervention

Benefit of cardiac intervention – intended improved quality of life

Management of coronary artery disease

Coronary revascularisation – coronary artery bypass graft surgery or percutaneous coronary intervention/stent

Recurrent symptoms after revascularisation

CABG – use of the internal mammary artery as a conduit

CABG – off‐pump or on‐pump surgery

PCI – type of stent

Access site

Antithrombotic therapy after CABG surgery and PCI

Valve surgery – conventional or minimal‐access cardiac surgery or percutaneous catheter‐based valve intervention

Aortic valve disease in the elderly

Asymptomatic aortic stenosis

Surgical aortic valve replacement

Transcatheter aortic valve implantation

Mitral valve surgery in the elderly

Mitral valve replacement or repair

Conventional mitral valve surgery, minimal‐access surgery, or transcatheter approach

Choice of prosthetic valve: mechanical or biological in the elderly

Combined coronary artery bypass graft and valve surgery in the elderly

Anticoagulation management in the elderly

Anticoagulation for biological prosthetic valves or valve repairs. Aortic position

TAVI bioprosthesis

Mitral and tricuspid position

Anticoagulation for mechanical prosthetic valves

Anticoagulant management of patients with mechanical prosthetic valves undergoing noncardiac surgery

Anticoagulation for atrial fibrillation

Nonpharmacological curative therapy for atrial fibrillation

Heart failure

Cardiac resynchronisation therapy

Cardiac transplantation

Mechanical circulatory support

Thoracic aortic surgery

Ascending and aortic arch aneurysms

Descending and thoracoabdominal aneurysms

Conclusions

Key points

References

CHAPTER 36 Peripheral arterial disease

Introduction

Epidemiology

Risk factors for PAD

Consequences of PAD

Pathophysiology

Diagnosis

Anamnesis and physical assessment

Clinical presentation

Physical examination

Non‐invasive tests

Invasive tests

Treatment

Risk factor modification

Cigarette smoking

Diabetes mellitus

Hypertension

Hyperlipidaemia

Exercise rehabilitation

Foot care

Pharmacological therapy

Antiplatelet therapy

Cilostazol

Pentoxifylline

Naftidrofuryl

Revascularization

Conclusion

Acknowledgements

Key points

References

CHAPTER 37 Venous thromboembolism in the elderly

Introduction

Risk factors

Diagnosis. Clinical presentation

Clinical prediction rules

D‐dimer testing

Imaging for VTE

Treatment – anticoagulation

Prognosis and risk stratification

Bleeding and recurrent VTE

Conclusion

Key points

References

CHAPTER 38 Epidemiologic and pathophysiologic overview of respiratory infections

Introduction

Host factors. Alterations in immunity

Alterations in innate immunity

Alterations in acquired immunity

Anatomic alterations in the host

Altered airway protective mechanisms

Aspiration

Cough

Environmental factors. Overview

Travel and geographic factors

Family and close associate exposures. Influenza and influenza‐like illness

Tuberculosis

Institutional factors. Hospital‐acquired pneumonia

Nursing home and long‐term care–associated pneumonia

Environmental aerosol and dust exposure. Bacterial infection – Legionella

Nontuberculous mycobacterial infection

Endemic fungal infection

Non‐endemic fungal infection

Key points

References

CHAPTER 39 Pneumonia

Introduction

Causative agents

Clinical presentation of pneumonia in the elderly

Differential diagnosis of lower respiratory tract infection

Bronchitis

Exacerbation of chronic obstructive disease

Heart failure and pulmonary embolism

Cancer and other diseases of the lungs

Hospitalization and further investigations in elderly people with a suspected diagnosis of community‐acquired pneumonia

Referral to the hospital of an elderly person with suspected pneumonia

Are additional tests required?

Chest imaging

Biological tests

Therapy of pneumonia in the elderly. General measures

Box 39.1 Pneumonia related to emerging viruses in the elderly

Non‐infectious treatments for pneumonia

First‐line anti‐infective agents. Choice of antibiotics

Handling anti‐infective agents in the elderly

Follow‐up of patients. The 48‐hour assessment

Further follow‐up

Prevention of pneumonia in the elderly

Key points

Further reading

CHAPTER 40 Aspiration pneumonia

Introduction

Pathophysiology

Aspiration pneumonia

Aspiration pneumonitis

Risk factors for aspiration

Clinical presentation

Diagnosis

Management and prevention of aspiration

Chemical pneumonitis

Aspiration pneumonia

Prevention of recurrent aspiration

Acknowledgements

Key points

References

CHAPTER 41 The COVID‐19 pandemic in older people

Introduction

Coronaviruses

Transmission

Clinical impact

COVID‐19 in older people

Risk factors

Ageing

Comorbidities

Frailty

Dementia

Clinical presentation

Typical presentation

Atypical presentation

Diagnosis

Management

Symptomatic therapy

Drug therapy

Supportive care

Palliative care

Prevention

Ethical issues

Future perspectives

Conclusion

Key points

References

CHAPTER 42 Chronic obstructive pulmonary disease and asthma

Ageing mechanisms in the lungs

Generalities on lung function testing in the elderly

Inhalation techniques and adherence improvement issues

Polypathology and polypharmacy in elderly respiratory patients

Chronic obstructive pulmonary disease (COPD) Epidemiology

Diagnosis and clinical features

Investigations

Assessing COPD severity

Management of COPD – stable state

Pharmacological management of stable COPD

Long‐term oxygen therapy (LTOT)

Management of COPD exacerbations

Asthma. Epidemiology

Clinical features and diagnosis

Management

Key points

References

CHAPTER 43 Pulmonary rehabilitation

Introduction

Organization

Patient selection

Components of pulmonary rehabilitation. Exercise

Education

Psychosocial support

Outcomes

Maintenance following pulmonary rehabilitation

Summary

Key points

References

CHAPTER 44 Neurological signs of ageing

Introduction: interpreting ageing changes

Neurological signs of ageing

Cranial nerves, including special senses. Olfaction (olfactory nerve; cranial nerve I)

Visual system: neuro‐ophthalmology (optic, oculomotor, trochlear and abducens nerves; cranial nerves II, III, IV, VI)

Hearing and balance (vestibulocochlear nerve; cranial nerve VIII)

Sensorimotor function: motor systems. Appearance

Tone

Power

Coordination

Reflexes. Phasic muscle stretch reflexes (deep tendon reflexes)

Superficial or cutaneous reflexes

Primitive or developmental reflexes (frontal‐release signs)

Station and gait: postural responses

Sensorimotor function: sensory systems

Cognitive function

Conclusions

Key points

References

CHAPTER 45 Sleep apnoea and sleep disorders

Introduction

Basic sleep concepts. What is normal sleep?

How does sleep change in old age?

Main sleep alterations in seniors

Obstructive Sleep Apnoea

Restless legs syndrome (RLS) and periodic leg movement during sleep (PLMS)

REM sleep behaviour disorder

Circadian rhythm sleep disorders

Insomnia

Non‐pharmacological treatment

Pharmacological treatment

Benzodiazepine sedatives

Non‐benzodiazepine sedatives

Key points

References

CHAPTER 46 Normal pressure hydrocephalus

Introduction

Aetiology and pathophysiology

Clinical presentation

Differential diagnosis

Diagnostic modalities

CT/MRI

Brain morphology

CSF flow and CSF flow rate

Prognostic tests

Lumbar puncture

Lumbar drain trial or extended lumbar drainage protocol

Intracranial pressure measurement

ICP monitoring

Lumbar or CSF infusion test

Diagnostic performance of CSF‐based tests

Neuropsychological testing

Other tests

Diagnostic criteria of NPH

Treatment

Patient selection and decision‐making

Ventriculoperitoneal shunting

Ventriculoatrial shunting

Lumboperitoneal shunting

Endoscopic third ventriculostomy

Type of shunt valves

Drug therapy

Risks and complications

Outcome and prognosis

Long‐term care and follow‐up

Key points

References

CHAPTER 47 Acute stroke care and management of carotid artery stenosis

Introduction

Stroke aetiology

Stroke mimics

Prognosis of stroke

Clinical evaluation and stroke syndromes

Total middle cerebral artery (MCA) syndromes

Partial MCA syndromes

Lacunar syndromes

Posterior circulation syndromes

Thalamic syndromes

Prehospital care

Initial investigations and imaging

In‐hospital care

Airway

Breathing

Circulation

Blood sugar

Environment

Thrombolysis

Thrombectomy

Neuroprotective drugs

Neurosurgery for ischaemic stroke

Palliative care

Stroke units

Secondary prevention

Antiplatelet therapy

Blood pressure management

Cholesterol management

Diabetes management

Anticoagulation

Carotid artery stenosis

Atherosclerosis

Arterial dissection

Investigations

Carotid endarterectomy. The case for intervention

Symptomatic patients

Asymptomatic patients

Carotid artery stenting

Vertebral and intracranial arterial stenting

Intracranial and subarachnoid haemorrhage. Spontaneous intracerebral haemorrhage

Subarachnoid haemorrhage

Conclusion

Key points

References

CHAPTER 48 Stroke and stroke rehabilitation

Introduction

The neurological basis of recovery

Patterns of recovery

Objectives of rehabilitation

Process of rehabilitation

Assessment

Planning

Intervention

Early mobilization

Restoration of motor function

Neuromuscular stimulation

Motor imagery

Spatial neglect

Organised (stroke unit) care

Evaluation

Common problems in stroke rehabilitation

Dysphagia

Dysphasia

Perception

Tone and spasticity

The hemiplegic shoulder

Depression

Pain

Fatigue

Psychosocial aspects

Conclusion

Key points

References

CHAPTER 49 Communication disorders and dysphagia

Communication

Ageing and communication

Hearing

Vision

Cognition

Motor speech

Depression

Diagnosis and assessment of communication disorders

Dysphasia

Dyspraxia of speech

Dysarthria

Augmented and alternative communication

Swallowing. The normal swallow

Oral phase

Pharyngeal/oesophageal phases

Dysphagia

Box 49.1 Bedside swallow assessment

Key points

References

CHAPTER 50 Acute and chronic subdural hematoma

Introduction

Acute subdural hematoma

Epidemiology

Pathophysiology

Clinical presentation

Diagnosis

Prognosis

Management

Prevention

Chronic subdural hematoma

Epidemiology. Incidence

Predisposing risk factors

Pathophysiology

Clinical presentation

Differential diagnosis

Investigations. Imaging of the brain

Etiological diagnosis

Management. Conservative medical management

Surgical management

Endovascular treatment

Prevention of recurrence

Prognosis and outcome

Key points

References

CHAPTER 51 Epilepsy

Introduction

Epidemiology

Definition of epilepsy

Aetiology. Epileptic seizures

Epilepsy

Cerebrovascular disease

Epilepsy in Alzheimer’s disease (AD)

Head trauma

Brain tumours

Immune limbic encephalitis

Status epilepticus

Clinical manifestation

Seizure type

Epilepsy type

Epilepsy syndrome

Diagnosis

Differential diagnosis

Transient ischaemic attacks (TIAs)

Transient global amnesia (TGA)

Syncope

Delirium and confusional states

Psychogenic non‐epileptic seizures

Drop attacks

Parasomnias

Treatment. General recommendations

Polypharmacy

Indications

Comorbidities

Indications for adding a second AED

Side effects

Other new drugs and non‐pharmacologic treatments

Box 51.1 Proposed status epilepticus treatment algorithm

Driving regulations

Treatment of status epilepticus

Conclusion

Key points

References

CHAPTER 52 Syncope and non‐epileptic attacks

Introduction

Syncope

Mechanisms underlying syncope

Clinical manifestations of syncope

Motor manifestations

Other clinical features

Diagnosis and investigation of syncope

Management of syncope

Other non‐epileptic attack disorders. Panic attacks and hyperventilation attacks

Psychogenic non‐epileptic attacks

Sleep phenomena, hypoglycaemia, migraine, transient global amnesia, cataplexy, paroxysmal movement disorders, and paroxysmal symptoms in multiple sclerosis

Key points

References

CHAPTER 53 Parkinson’s disease

Introduction

Signs and symptoms of very late‐onset Parkinson’s disease

Differential diagnosis of Parkinson’s disease. Tremor

Extrapyramidal syndromes other than Parkinson’s disease

Box 53.1 Response to L‐dopa

Advanced Parkinson’s disease

Management of Parkinson’s disease in the elderly. Pharmacological treatment

Non‐pharmacological treatments. Functional neurosurgery

Rehabilitation and help with loss of independence

Psychological support and patient education

Key points

Further reading

CHAPTER 54 Non‐Parkinsonian movement disorders in the elderly

Introduction

Myoclonus. Clinical characteristics

Pathophysiology and classification

Diagnosis and treatment

Tremor. Clinical characteristics

Pathophysiology

Diagnosis and treatment

Dystonia. Clinical characteristics

Pathophysiology

Diagnosis and treatment

Tardive dyskinesia. Clinical characteristics

Pathophysiology

Diagnosis and treatment

Chorea. Clinical characteristics

Pathophysiology

Diagnosis and treatment

Functional movement disorders. Clinical characteristics

Pathophysiology

Diagnosis and treatment

Restless legs and periodic limb movements during sleep and while awake. Clinical characteristics

Pathophysiology

Diagnosis and treatment

Key points

References

CHAPTER 55 Diabetic neuropathy

Introduction

Epidemiology and risk factors

Pathogenesis

Box 55.1 Classifications of diabetic neuropathy

Classifications

Clinical presentation. Diabetic somatic neuropathy

Diabetic autonomic neuropathy

Diagnosis

Box 55.2 Clinical assessment of diabetic neuropathy

Box 55.3 Differential diagnosis of peripheral neuropathy

Management

Prevention

Treatment

Pathogenesis‐based therapy

Symptoms‐based therapy

Conclusion

Key points

References

CHAPTER 56 Disorders of the neuromuscular junction

Introduction

Myasthenia gravis. Clinical features

Symptoms and signs

Clinical classification of MG and associated diseases

Differential diagnosis

Diagnostic investigations

Acetylcholine receptor (AChR) antibodies

Anti‐MuSK antibodies

Striated muscle and other antibodies

Thyroid function

Neurophysiology: electromyography

Imaging

Edrophonium/Tensilon test

Ice pack test

Sleep test

Is MG different in the elderly?

Management

Anticholinesterase inhibitors

Steroids

Long‐term immunosuppressive agents

Plasma exchange

Intravenous immunoglobulin

Monoclonal antibodies

Thymectomy

Management in special circumstances

Prognosis

Lambert‐Eaton myasthenic syndrome

Peripheral nerve hyperexcitability

Acknowledgement

Key points

References

CHAPTER 57 Muscle disorders

Introduction

Clinical assessment

Laboratory investigations

Biochemical studies

Electrophysiology

Muscle biopsy

Molecular studies

Acquired myopathies

Idiopathic inflammatory myopathies

Dermatomyositis (DM) (see Chapter 110)

Polymyositis (PM)

Inclusion body myositis (IBM)

Toxic and drug‐induced myopathies

Alcohol‐related myopathies

Drug‐induced myopathies

Endocrine and metabolic myopathies

Hypothyroidism (see Chapter 83)

Hyperthyroidism (see Chapter 83)

Graves’ ophthalmopathy

Pituitary‐adrenal axis disorders (see Chapter 82)

Disorders of vitamin D metabolism

Osteomalacia

Primary hyperparathyroidism (see Chapter 81)

Paraneoplastic myopathies

Inherited myopathies. Muscular dystrophies

Dystrophinopathies

Limb‐girdle dystrophies

Facioscapulohumeral (FSH) muscular dystrophy

Oculopharyngeal muscular dystrophy

Myotonic dystrophy

Chronic progressive external ophthalmoplegia (CPEO)

Sarcopenia

Acknowledgements

Key points

References

CHAPTER 58 Motor neuron disease

Clinical presentation

Epidemiology

Genetic aspects

Diagnostic criteria

Heterogeneity and variants

Physiopathology

Treatments. Aetiologic treatments

Supportive treatments

Symptomatic treatments. Sialorrhea

Pseudobulbar affects

Spasticity

Depression/anxiety

Multidisciplinary team approach

End of life

Key points

References

CHAPTER 59 Chronic pain

Introduction

Pain and ageing. Prevalence of chronic pain

Age‐related changes in the nociceptive system

Pathophysiology

Special considerations in the management of pain in older people

Assessment

Pain

Comorbidities

Function

Psychosocial

Cognitive impairment

Management

Pharmacological therapies

Nonpharmacological therapies

Psychological therapies

Physical and complementary therapies

Procedural modalities

Conclusions

Acknowledgement

Key points

References

CHAPTER 60 Multiple sclerosis

Introduction

Pathophysiology, aetiology, and epidemiology

Diagnostic evaluation

Clinical spectrum

Visual, brainstem, and cerebellar dysfunction

Sensory manifestations

Pain

Muscle weakness and other motor manifestations

Gait and coordination disorders

Fatigue and sleep disorders

Neurogenic bowel

Neurogenic bladder

Sexual dysfunction

Other autonomic changes

Cognitive involvement

Mood and affective involvement

Seizures and other paroxysmal manifestations

Treatment: disease‐modifying drugs

Prognosis

Comorbidities

Complementary and alternative medicine (CAM)

Access to healthcare

Fostering healthy living and resilience

Key points

References

Pathy’s Principles and Practice of Geriatric Medicine

About the Editors

About the Associate Editors

List of Contributors

Preface to the Fifth Edition

Preface to the Sixth Edition

Foreword

CHAPTER 61 Delirium in older patients

Introduction

Rates of delirium

Consequences of delirium

Delirium phenotypes

Pathophysiology

Predisposing and precipitating factors

Delirium identification: screening versus diagnosing

Delirium screening

Delirium prevention

Pharmacologic prevention of delirium

Management of delirium

Non‐pharmacologic management

Pharmacologic management

Conclusion

Key points

References

CHAPTER 62 Memory clinics

Introduction

Developments around the world

Why the need?

Are they effective?

The memory clinic team

What happens in a memory clinic?

History and medical examination

Cognitive assessment

Laboratory tests

Neuroimaging

What interventions can be offered?

Diagnostic disclosure and meeting information needs

Memory aids

Memory training

Pharmacotherapy

Summary

Key points

References

CHAPTER 63 Alzheimer’s disease

Introduction

Epidemiology of Alzheimer’s disease

Risk factors of Alzheimer’s disease

Non‐modifiable risk factors

Modifiable risk factors

Neuropathology of Alzheimer’s disease

Amyloid pathology

Neurofibrillary pathology

What is the chronological relationship between amyloid deposits and neurofibrillary degeneration?

Definition of the stages of cognitive severity. Subjective cognitive decline

Mild cognitive impairment

Dementia stages

Process for the diagnosis of Alzheimer’s disease. Diagnosis context

Cognitive assessment

Functional and geriatric assessments

Behavioural assessment

Biomarkers of AD. Structural brain imaging

Cerebrospinal fluid biomarkers

Functional brain imaging

Blood biomarker development

AD diagnosis criteria

Treatment

Pharmacological treatment

Acetylcholinesterase inhibitors

Memantine

Approval of a new treatment for Alzheimer’s disease in China

Toward a new paradigm: the prevention of Alzheimer’s disease

Conclusion

Key points

References

CHAPTER 64 Mild cognitive impairment: an update

Core clinical criteria for the diagnosis of MCI

MCI research criteria incorporating biomarkers

Conclusion: clinical acceptance of MCI

Key points

References

CHAPTER 65 Vascular dementia

Historical perspective and definitions

Vascular cognitive impairment – current definitions

General epidemiological issues

Pathophysiology

Large single or multiple cortical infarcts

Subcortical vascular dementia

Single‐strategic infarct dementia

Genetically based vascular dementias

Clinical impact: cognitive and motor impairment

Preventive (risk‐factor control) and curative therapies

Conclusions

Key points

References

CHAPTER 66 Mental stimulation and dementia

Introduction

Cognitive (mental) interventions

Supporting evidence

Animal studies

Observational studies

Clinical trials

Mechanisms

Cognitive reserve

Vascular

Stress

Targets of intervention

Implementing interventions

Conclusions

Acknowledgements

Key points

References

CHAPTER 67 Exercise and dementia

Introduction

Physical activity and the prevention of dementia in clinical research

Physical activity and executive function

Frailty, physical activity, and cognitive reserve

Biological mechanisms of physical activity in preventing cognitive decline

Clinical practical applications: physical activity and prevention of AD

Intensity and frequency

Type of activity

Duration

Physical activity in AD populations

Practical clinical applications: physical activity for demented patients

Conclusion

Key points

References

CHAPTER 68 Drug development and Alzheimer’s disease

Introduction

Impact on cholinergic deficit

Anti‐amyloid therapies

Drugs to promote Aβ clearance

Active immunization

Passive immunization

Drugs to reduce Aβ production. α‐Secretase activators

β‐Secretase inhibitors

γ‐Secretase inhibitors and modulators

Anti‐aggregation and anti‐fibrillization agents

Drugs to target tau protein

Neuroprotective agents

Antioxidants

Anti‐inflammatory drugs

Glutamate‐mediated neurotoxicity

Neurorestorative approaches

Hormonal therapy

Drugs to target mitochondrial dysfunction

Statins

Receptor for advanced glycation end‐product inhibitors

Others

Non‐pharmaceutical therapies

Prevention and AD

Conclusion

Key points

References

CHAPTER 69 Other dementias

Introduction

Vascular cognitive impairment/vascular dementia

Lewy body disease

Dementia with Lewy bodies

Parkinson’s disease with dementia

Progressive supranuclear palsy

Corticobasal degeneration

Multiple system atrophy

Frontotemporal lobar degeneration

Behavioural‐variant frontotemporal dementia

Semantic dementia

Progressive non‐fluent aphasia

Treatment

Depression

Medications

Dementia with parkinsonism. General approach

Conclusion

Key points

References

CHAPTER 70 Management of neuropsychiatric symptoms in dementia

Introduction

Epidemiology

Outcomes of NPSs

Measurement of NFS

Aetiology of NPSs

Factors related to the person with dementia. Neurodegeneration associates with dementia

Acute medical issues

Unmet needs

Pre‐existing personality and psychiatric illnesses

Caregiver issues

Environmental issues

Management of NPSs

General principles

Non‐pharmacological management

Interventions targeting the person with dementia

Interventions targeting the caregiver

Interventions targeting the environment

Summary of non‐pharmacological treatments

Pharmacological treatment

Evidence base for psychotropic drugs in treating NPSs

Recommended pharmacological treatments for neuropsychiatric syndromes

Treatment of agitation in AD

Treatment of depression in AD

Treatment of psychosis in AD

Treatment of psychosis in dementia related to PD and LBD

Treatment of apathy in AD

Treatment of sleeping disturbances

Agents in clinical trials for treating NPSs

The DICE approach

Step 1: Describe

Step 2: Investigate

Step 3: Create

Step 4: Evaluate

Summary of treatments of NPSs in dementia

Perspectives and future directions

Key points

References

CHAPTER 71 Late‐life depression

Introduction

Definitions and concepts of depression

Classifying diagnosis of depression in old age

Clinical presentation of depression in older people

Psychomotor symptoms

Somatic symptoms

Age at onset

The ‘vascular depression’ hypothesis

Depression and neurodegenerative disorders

Diagnosis and risk factors

Suicidality

Instruments

Risk factors

Impact

Treatment

General aspects of treatment

Psychotherapy

Medication

Types of antidepressants

Other interventions

Conclusion

Key points

References

CHAPTER 72 Geriatric psychiatry

Introduction

Epidemiology

Challenges in geriatric psychiatry

The psychiatric interview of an older adult

Workup

Interdisciplinary approach and individualised care plan

Successful ageing

Depression

Bereavement

Severe mental illness

Bipolar affective disorder and late‐onset mania

Schizophrenia

Late‐life psychosis

Cognitive disorders

Dementias

Delirium

Mild cognitive impairment (MCI) and cognitive impairment no dementia (CIND)

Vascular dementia

Managing agitation and aggression in individuals with dementia

Substance use disorder (SUD)

Alcohol use disorder

Opioid use disorder (OUD)

Chronic benzodiazepine use

Chronic cannabis use

Anxiety disorders

Trauma‐related disorders

Personality disorders

Apathy syndrome

Suicide

Abuse and older people

Sleep disorder

Medication‐induced mental health problems

Special populations in geriatric psychiatry. LTC residents

Older adults visiting the emergency department (ED)

Older prisoners

Caregivers

Oldest old

Hospitalised older adults

End‐of‐life and palliative care

Rational deprescribing

Electroconvulsive therapy

Transcranial magnetic stimulation therapy (TMS)

Psychotherapy and other psychosocial interventions

ATMAN approach to managing chronic non‐cancer pain

Requests for physician‐assisted dying

Spirituality and mental health

Prevention in geriatric psychiatry

Best‐practice models for geriatric psychiatry services

Geriatric psychiatry in primary care offices

Geriatric emergency department and psychiatric emergencies

Key points

References

CHAPTER 73 Organisation of services in geriatric psychiatry

Introduction

The ageism saga continues

Developments in the UK 2000–2019. Moving on from the National Service Framework for Older People

A brief overview of more recent developments in the UK

Wider societal changes

Race – black and minority ethnic groups

Sexual orientation and gender reassignment – LGBT+ elders

Disability – older adults with intellectual disabilities

People with enduring mental illness

Alcohol and substance misuse

People with young‐onset dementia

Other marginalised groups

Services

Primary care

Secondary care

Bed‐based care, hospital‐based facilities, and acute in‐patient beds

Interface services

Patient and carer involvement

Key points

References

CHAPTER 74 The older patient with Down syndrome

Introduction

Genes and Down syndrome

The physician, and the patient with Down syndrome

Disorders associated with Down syndrome. Endocrinological

Otolaryngological conditions

Joint problems

Coeliac disease

Dermatological conditions

Cardiovascular disorders

Dental problems

Cancer

Foot problems

Gynaecological problems

Eye disorders

Alzheimer’s disease

Epilepsy

Behaviour disorders

Conclusion

Key points

References

CHAPTER 75 Disorders of the vestibular system

Introduction

Vestibular anatomy

Physiology and ageing of the vestibular apparatus

Clinical aspects and diagnostic strategy

History

Character of dizziness

Time course

Associated symptoms

Examination

Otological examination

Vestibulo‐ocular examination

Vestibulospinal assessment

Peripheral vestibular disorders. Vestibular neuritis (acute peripheral vestibulopathy)

Ramsay–Hunt syndrome (see Chapter 102)

Bacterial infection

Neoplasia

Vascular disorders

Trauma

Unilateral auditory and vestibular failure

Benign paroxysmal positional vertigo (BPPV)

Menière’s disease

Iatrogenic vestibular dysfunction

Central vestibular disorders. Cerebrovascular disease

Vertebrobasilar artery ischaemia

Completed strokes (see Chapter 47)

Cervical vertigo

Neoplasia

Infection

Neurological conditions

Management

Key points

References

CHAPTER 76 Smell and taste

Introduction

Olfaction. Terminology

Anatomy of the olfactory system

Age‐related changes in olfactory function

Olfactory dysfunction and mortality

Evaluating olfactory function in the clinical setting

Odour threshold tests

Odour identification tests

Prevalence of smell impairments

Causes of smell dysfunction in the elderly, and clinical diagnosis

Nasal/paranasal sinus disease

Prior upper respiratory infections

COVID‐19 infection

Head trauma

Neurodegenerative diseases

Other causes of olfactory loss

Taste

Terminology

Anatomy of the gustatory system

Age‐related changes in gustatory function

Clinical testing of gustatory function

Prevalence of taste dysfunction

Causes of taste dysfunction in the elderly

Evaluating and managing elderly patients with taste disorders

Treatment of gustatory dysfunction

Key points

References

CHAPTER 77 Osteoporosis: burden, diagnosis, and management

Introduction

Global epidemiology of fragility fractures and regional disparities

Burden of osteoporosis

The osteoporosis treatment gap

Intervention and assessment thresholds29,30

Management

Conclusion

Conflict of interest

Key points

References

CHAPTER 78 Gait, balance, and falls

Introduction

Balance

Gait

Age‐related changes

Falls. Epidemiology

Risk factors

Evaluation strategies

Prevention strategies

Key points

Appendix 78.1. Short Physical Performance Battery. 1. Repeated Chair Stands

2. Balance Testing

a. Semitandem Stand

b. Side‐by‐Side Stand

c. Tandem Stand

3. 8‐Foot Walk (2.44 meters)

Appendix 78.2. Tinetti Assessment Tool. Description

Tinetti Assessment Tool: Balance

Tinetti Assessment Tool: Gait

References

CHAPTER 79 Hip fracture and orthogeriatrics

Background

Diagnosis and classification

Preoperative care. Minimizing surgical delay

Analgesia

Preoperative traction

Electrolyte balance and blood transfusion

Thromboembolic prophylaxis

Prevention of pressure ulcers

Fracture repair and perioperative care. Surgical management

Conservative or operative treatment

Operative treatment

Undisplaced intracapsular fractures

Displaced intracapsular fractures

Trochanteric fractures

Subtrochanteric fractures

Type of anaesthesia

Antibiotic prophylaxis

Postoperative care. Postoperative wound drainage

Urinary tract catheterisation

Prevention of delirium

Prevention of constipation

Early mobilisation and weight‐bearing

Rehabilitation

Optimizing nutrition

Surgical complications. Wound healing complications

Internal fixation of intracapsular fractures

Sliding hip screw and intramedullary nail: fixation of extracapsular fractures

Arthroplasty complications

Secondary fracture prevention

Falls risk assessment and intervention

Hip protectors

Osteoporosis assessment and treatment

Fracture liaison service

Orthogeriatric collaboration and orthogeriatric models

Key points

References

CHAPTER 80 Foot problems

Introduction

Epidemiology of foot problems in older people. Prevalence

Risk factors

Impact of foot problems on individuals andthe healthcare system

Clinical assessment of foot problems. History taking

Physical examination

Management of foot problems in older people

Routine foot care and maintaining foot hygiene

Common foot disorders in older people and their management. Nail disorders

Keratotic disorders

Xerosis

Foot ulceration

Foot osteoarthritis

Hallux valgus

Lesser toe deformity

The role of footwear

Conclusion

Key points

References

CHAPTER 81 Endocrinology of ageing

Introduction

The modern field of endocrinology

Regulation of hormonal action

The principle of negative feedback

Hormonal rhythm and pulsatility

General changes in regulation and action of major hormones of metabolism, reproduction, and growth with age. General changes seen in the hypothalamus‐pituitary‐end organ axis with age

General changes in responsiveness to hormones with age

General changes in total circulating content hormones with age

Effects of ageing and related diseases on endocrine function

Effects of common endocrine diseases on ageing

Thyroid disease

Insulin resistance – obesity and metabolic syndrome

The hormonal fountain of youth

Oestrogen

Testosterone

Dehydroepiandrosterone (DHEA)

Pregnenolone

Growth hormone (GH) and insulin‐like growth factor 1 (IGF‐1)

Insulin growth factor‐1 (IGF‐1)

Ghrelin

Thyroid. Subclinical hypothyroidism

Vitamin D

Melatonin

Key points

References

CHAPTER 82 The pituitary gland

Introduction

Anatomy

Blood supply

Anterior pituitary disorders – clinical manifestations

Anterior pituitary disorders – treatment. Nonfunctioning pituitary tumours

Prolactinomas

Cushing’s disease

Acromegaly

Thyrotropin (TSH)‐secreting tumours

Gamma‐knife radiosurgery

Empty sella turcica

Anterior pituitary hormone secretion – functional changes with age

Gonadotropins (LH and FSH)

Prolactin (PRL)

Growth hormone

Posterior pituitary gland

Key points

References

CHAPTER 83 Thyroid disorders

Introduction

Age‐related modifications in thyroid function

Prevalence of thyroid disease in older populations

Hypothyroidism

Subclinical hypothyroidism

Hyperthyroidism

Subclinical hyperthyroidism

Nonthyroidal illness (NTI)

Thyroid nodules and nodular goitre

Conclusion

Key points

References

CHAPTER 84 Ovarian function and menopause

Introduction

The biological basis of menopause

Subclinical phase

Perimenopause/menopausal transition

Postmenopause

The Staging of Reproductive Aging Workshop (STRAW)

The impact of menopause

Menopausal symptoms. Vasomotor symptoms (hot flashes)

Genitourinary syndrome (GUS)

Insomnia

Sexuality

Musculoskeletal pain

Mood

Impact on body systems and risk for disease

Osteoporosis

Sarcopenia and dynapenia

Metabolic syndrome and cardiovascular disease

Cognition

Management of menopause

Hormone therapy

Health benefits of HT

Oestrogen and progestogens: compounds and combinations

Dose and route of administration

Other forms of hormonal treatment

Complementary and alternative medicine

Lifestyle

Key points

References

CHAPTER 85 Testicular function

Introduction

Decline in serum T with ageing

Decline in spermatogenesis with ageing

Diagnosis of hypogonadism in elderly men

Laboratory diagnosis

Treatment of late‐onset hypogonadism

Intramuscular injection

Subcutaneous injection

Transdermal systems

Oral and buccal agents

Subdermal implants

Intranasal T

Benefits of T replacement therapy

Effect of T therapy on symptoms

Improved body composition and strength

Effect on metabolic syndrome and cardiovascular risk factors

Improving anaemia

Bone mineral density

Risks of T therapy

The prostate and T therapy

Erythrocytosis

Other side effects of T therapy

Cardiovascular events and T therapy

Conclusion and recommendations

Key points

References

CHAPTER 86 Diabetes mellitus

Introduction

Epidemiology, pathogenesis, and modes of presentation

Modes of presentation

Impact of diabetes mellitus

Diabetic foot disease

Sexual function

Metabolic comas

Diabetes‐related disability, cognitive dysfunction, and depression

Cognitive dysfunction

Type 2 diabetes mellitus and depression

Importance of functional evaluation

Importance of detecting frailty

Treatment and care issues: learning from the literature

Glucose regulation

Blood pressure regulation and lipid lowering

Inpatient diabetes care

Hypoglycaemia

Box 86.1 Summary of benefits of BP control in older people with diabetes

Box 86.2 Summary of cardiovascular benefits of lipid‐lowering in older people with diabetes

Special features A: frailty and management in hospital inpatients with diabetes

Special features B: type 1 diabetes

Special features C: cardiovascular safety of glucose‐lowering agents

Special features D: deintensification of treatment

Special features E: care home diabetes

Prevalence of diabetes mellitus in care homes

Intervention studies in care homes

Rationale for early detection of diabetes mellitus in care homes

Diabetes care home provision – recommendation to improve safety and care

Prevention

Impact of Covid‐19 on residents with diabetes in care homes

Conclusion

Key points

Appendix 86.1: A scheme for treating older adults with type 2 diabetes using a three‐step approach

Note on insulin therapy in older adults

Appendix 86.2: Individualised metabolic targets according to major international guidelines

Appendix 86.3

Appendix 86.4: End‐of‐life diabetes care

References

CHAPTER 87 New therapies for diabetes mellitus

Introduction

‘Hyperglycaemia’, and when does T2DM start?

‘Defects in insulin secretion and action’

‘Long‐term damage, dysfunction and failure of various organs’

Microvascular complications

Macrovascular complications

Which should be the desired glycaemic target?

Lifestyle intervention

Currently approved antiglycaemic therapies

Metformin: life begins at 50

Sulfonylureas (SUs)

Meglitinides (glinides): faster is not always better

Thiazolidinediones (TZDs): the bloom is off the rose, and the pie is in the sky (rosiglitazone and pioglitazone) – downsizing expectations

Incretin therapies: the new kid on the block

GLP‐1 agonists

DPP4 inhibitors

SGLT2 inhibitors: now diabetics can eat that piece of cake without feeling guilty

α‐Glucosidase inhibitors (AGIs) – the drugs that get no respect

Insulin therapy

Basal insulin

Bolus insulin

Insulin analogues and new delivery approaches

Other drugs with antiglycaemic effect. Amylin analogues – pramlintide

Colesevelam: LDL and HA1C lowering – a match made in heaven

Bromocriptine: born again

Effects of antiglycaemic drugs on hypoglycaemia, weight, and CVD outcomes. Hypoglycaemia – the limiting factor

Weight gain

Cardioprotection

Renoprotection

Adjunctive therapy

Developing antiglycaemic classes and their characteristics

Dual and pan PPAR agonists: a fibrate, TZD, and exercise all in one pill

Glucokinase activators: targeting two organs – pancreas and liver – with one pill

Antiglycaemic therapies that evolved from G protein‐coupled receptor (GPCR) ‘orphans’

Oxyntomodulin analogues with dual GLP‐1 and glucagon activity

Sterol‐regulating element‐binding protein inhibitor – fatostatin

Anti‐obesity combos – it takes two to tango: pramlintide and metreleptin

Pramlintide/human insulin analogue co‐formulation

Gut microbiota: a new potential target for the treatment of type 2 diabetes

Conclusion

Key points

References

CHAPTER 88 Gynaecology and the older patient

Introduction

Effect of ageing on the genital tract. Vulva and vagina

Cervix and uterus

Ovaries and fallopian tubes

Pelvic floor

Urethra and bladder

Postmenopausal bleeding

Diagnosis

Investigation

Pelvic ultrasound scan

Treatment

Discharge per vagina

Uterovaginal prolapse

Symptoms

Classification

Assessment

Management

Conservative management

Surgical treatment

Urinary incontinence

Causes of urinary incontinence

Management

Surgical management of female urinary incontinence. Stress urinary incontinence (SUI)

Overactive bladder

Sexuality and ageing

Effect of chronic illness and surgery on sexuality

Management. General education

Medical management

Psychological therapy

Vulval disorders

Lichen sclerosus (LS)

Squamous cell hyperplasia

Other dermatoses

Vulvodynia (vulval pain)

Hormonal changes with ageing and menopause

Menopause

HRT in the geriatric population

Menopausal symptoms. Vasomotor symptoms

Nonhormonal treatment

Genitourinary syndrome of menopause (GSM)

Osteoporosis

Extended use of HRT after 65

Major risks of hormone therapy

Gynaecological cancer

Cervical cancer

Endometrial cancer

Ovarian cancer

Vulval cancer

HIV in old age

Conclusion

Key points

References

CHAPTER 89 Prostate diseases

Introduction

Benign prostatic hyperplasia

Epidemiology. Mortality

Prevalence

Pathogenesis and risk factors of BPH

Natural history

Diagnostics. Patient evaluation

Laboratory evaluation

Treatment30

Watchful waiting

Medical treatment

Minimally invasive treatment

Surgery

Prostate cancer. Epidemiology

Diagnosis and screening

Evaluation of health status of aged patients with prostate cancer

Management of localised prostate cancer

Low-risk patients

Intermediate-risk patients

High-risk patients

Treatment modalities for localised prostate cancer in the elderly. Total prostatectomy

Radiotherapy

Brachytherapy

Active monitoring

Minimally invasive therapies

Hormone therapy

Management of advanced and metastatic prostate cancer. Metastatic castration-sensitive prostate cancer

Castration-refractory prostate cancer

Side effects of androgen suppressive hormones59-61

Comprehensive care

Prostatitis. Definition

Acute prostatitis or male urinary tract infection

Microbiology

Clinical presentation

Diagnosis

Principles of treatment76

Chronic bacterial prostatitis

Clinical presentation

Diagnosis

Treatment

Chronic prostatitis/chronic pelvic pain syndrome

Definitions

Epidemiology

Aetiology

Diagnosis

Treatment

Key points

References

CHAPTER 90 The ageing bladder

Introduction

Anatomy of the ageing bladder

Bladder physiology and correlation to the anatomy of the ageing bladder

Special disease states

Parkinson’s disease

Cerebrovascular accidents (CVAs)

Nocturia

Dementias

Pharmacology as it relates to the ageing bladder

Receptors

Adrenergic stimulation/blockade

Antimuscarinics

5‐alpha reductase inhibitors

Surgical disease of the ageing bladder

Female stress urinary incontinence

Pelvic floor conditioning

Pharmacological management

Injection therapy

Operative therapy

Benign prostatic hyperplasia (BPH) in older males

Medical therapy

Minimally invasive therapy

Transurethral resection of the prostate gland (TURP)

Minimally invasive therapy for overactive bladder

Conclusion

Key points

References

CHAPTER 91 Geriatric nephrology

Introduction

Normal ageing: glomerular level. Decrease in glomerular filtration (senile glomerulosclerosis)

Estimating glomerular filtration

Consequences of senile hypofiltration

Diseases: at the glomerular level. Glomerulonephritis

Normal ageing: renovascular level. Senile renal vascular changes

Consequences of senile vascular changes

Diseases: reno‐vascular level. Renal vasculitis in older adults

Normal ageing: tubular‐interstitial level. Senile tubular‐interstitial changes

Consequences of tubular‐interstitial changes

Tubular dysfunction

Medulla hypotonicity: water handling

Tubular frailty

Diseases: tubular‐interstitial level. Interstitial nephritis

Urinary tract infection (pyelonephritis)

Obstructive uropathy

Acute kidney injury (AKI)

Chronic kidney disease (CKD)

Dialysis

Transplantation

Renal pharmacology

Key points

References

CHAPTER 92 Cancer and ageing

Introduction

Epidemiology and disparities

Ageing and tumour development

Cancer prevention

Cancer screening

Cancer treatment

Decision‐making

Surgery

Radiation

Systemic therapy

Conventional chemotherapy

Hormonal therapy

Biological agents

Targeted therapy

Supportive care

Multidisciplinary care models

Survivorship

Conclusion

Key points

References

CHAPTER 93 Oncological emergencies

Introduction

Haematological emergencies

Febrile neutropenia

Thrombocytopenia

Disseminated intravascular coagulation

Hyperviscosity syndrome

Metabolic emergencies

Hypercalcaemia

Hyponatraemia

Tumour lysis syndrome

Cardiovascular emergencies

Superior vena cava syndrome

Cardiac tamponade

Venous thromboembolic complications

Volume depletion

Neurological emergencies

Brain metastases and increased intracranial pressure

Spinal cord compression

Delirium

Structural emergencies

Airway obstruction

Bowel obstruction

Urinary obstruction

Pathological fractures

Acute pain emergencies

The role of geriatric evaluation in the prediction of oncological emergencies

Conclusion

Key points

References

CHAPTER 94 Breast cancer

The presentation

Stage of presentation

Variation in care and undertreatment in the elderly

Screening in the elderly

Risk factors in the elderly

Natural history of breast cancer in the elderly

Treatment of operable disease

Role of radiotherapy

Adjuvant endocrine therapy

Chemotherapy

Adjuvant bisphosphonates

Neoadjuvant therapy

Treatment of advanced disease

Prognostic factors in elderly breast cancer

Quality of life issues

Conclusion

Guidelines for therapy

Key points

References

CHAPTER 95 Maintaining functional status among older adult cancer patients and survivors

Introduction

A role for geriatricians in cancer care

Use structured methods to establish decisional capacity prior to treatment

Geriatric management during cancer treatment

Transitions of care and the older patient

Supportive management during cancer treatment is just good geriatric care

Follow AGS guidelines to treat pain in the elderly cancer patient

Treat fatigue in elderly cancer patients to limit functional decline

Anticipate anorexia, recognize cachexia, and support nutrition

Anticipate and prevent nausea and vomiting

Exercise. Exercise maintains function. How good is it for older cancer patients and survivors?

How cancer affects exercise tolerance

Choosing appropriate exercise along the trajectory of disease

Exercise and radiation toxicity

Exercise and chemotherapy toxicity

Breast and prostate cancer survivors experience accelerated ageing

Exercise and subjective quality of life

Conclusion

Key points

References

CHAPTER 96 Multidimensional geriatric assessment

Introduction

Definition

Rationale

Brief history of geriatric assessment

Components of geriatric assessment

Settings of geriatric assessment

Assessment in the office practice setting

Preventive home visits

Inpatient geriatric assessment

Hospital‐home assessment programmes

Geriatric assessment in the care of older cancer patients

Geriatric assessment in the care of nursing home patients

Effectiveness of geriatric assessment programmes. The pioneering studies of geriatric assessment

Evidence from controlled studies

Meta‐analytic data

Assessment in the office practice setting

Inpatient geriatric assessment programmes

Hospital‐home assessment programmes

Preventive home‐visitation programmes

Conclusion

Key points

References

CHAPTER 97 Frailty

Introduction

Pathophysiology of frailty

Disease

Decreased food intake

Sarcopenia

Conclusion

Key points

References

CHAPTER 98 Rehabilitation

Introduction

Terminology and classifications

Determinants of activity and participation restrictions

Psychological aspects of rehabilitation

Principles of rehabilitation

The rehabilitation process

Assessment

Assessment of activity and activity restriction

Assessment of participation and participation restriction

Goal setting

Therapy

Aids and adaptations

Education and secondary prevention

Psychosocial support

Discharge planning and follow‐up

Evaluation

The rehabilitation setting

Emerging technologies and rehabilitation

Development of devices

Rehabilitation at home

Specific rehabilitation problems. Cardiac rehabilitation

Pulmonary rehabilitation

Musculoskeletal disorders

The elderly amputee patient

Neurological rehabilitation

Future challenges

Key points

References

CHAPTER 99 Cachexia

Introduction

Consequences of cachexia

Pathophysiology of cachexia. Anorexia

Energy metabolism

Molecular mechanisms of muscle wasting in cachexia

Treatment of cachexia

Key points

References

CHAPTER 100 WHO Integrated Care for Older People (ICOPE)

Introduction

ICOPE steps

ICOPE implementation

Expected outcome moving forward

Key points

References

CHAPTER 101 Valvular heart disease and infective endocarditis

Introduction

Epidemiology and prevalence of valvular heart disease in the ageing population

Aetiology of valvular heart disease

Aortic stenosis

Aortic regurgitation

Mitral stenosis

History and physical exam

Investigations. Electrocardiogram (ECG)

Chest X‐ray

Echocardiography

Cardiac catheterisation

Cardiac magnetic resonance

Cardiac computed tomography

Aortic stenosis. Symptoms and signs

Investigations. The ECG and chest X‐ray

Echocardiography

Cardiac catheterisation

Indications for surgical or interventional treatment

Treatment

Aortic regurgitation. Symptoms and signs

Investigations. The ECG and chest X‐ray

Echocardiography

Cardiac catheterisation

Cardiovascular magnetic resonance

Prognosis and treatment

Mitral stenosis. Symptoms and signs

Investigations. The ECG and chest X‐ray

Echocardiography

Cardiac catheterisation

Prognosis and treatment

Mitral regurgitation. Aetiology

Symptoms and signs

Investigations. The ECG and chest X‐ray

Echocardiography

Cardiac catheterisation

Prognosis and treatment

Interventions

Tricuspid regurgitation. Aetiology

Symptoms and signs

Investigations. The ECG and chest X‐ray

Echocardiography

Cardiac catheterisation

Interventions

Tricuspid stenosis and pulmonic valve disease

Mixed valve disease

Aortic stenosis with mitral regurgitation

Aortic regurgitation with mitral regurgitation

Severe mitral or aortic disease with tricuspid regurgitation

Management of patients following valve interventions. Antithrombotic therapy

Prophylactic antibiotic use

Routine imaging of prosthetic valves

Prosthetic valve complications

Infective endocarditis

Epidemiology

Diagnosis

Treatment

Antibiotic prophylaxis for endocarditis

Conclusion

Key points

Key references

Further reading

CHAPTER 102 Infections of the central nervous system

Introduction

Meningitis. Community‐acquired meningitis

Viral meningitis. Epidemiology and aetiology

Clinical presentation

Diagnosis

Therapy

Bacterial meningitis. Epidemiology and aetiology

Clinical presentation

Diagnosis

Antimicrobial therapy

Adjunctive therapy

Healthcare‐associated ventriculitis and meningitis

Diagnosis of HCAVM

Management of HCAVM

Prognosis and prevention of HCAVM

Tuberculous meningitis. Epidemiology and aetiology

Clinical presentation

Diagnosis

Antimicrobial therapy

Adjunctive therapy

Spirochetal meningitis. Epidemiology and aetiology

Clinical presentation

Diagnosis

Antimicrobial therapy

Fungal meningitis. Epidemiology and aetiology

Clinical presentation

Diagnosis

Antimicrobial therapy

Adjunctive therapy

Focal central nervous system infections

Brain abscess. Epidemiology and aetiology

Clinical presentation

Diagnosis

Therapy

Subdural empyema. Epidemiology and aetiology

Clinical presentation

Diagnosis

Therapy

Epidural abscess. Epidemiology and aetiology

Clinical presentation

Diagnosis

Therapy

Encephalitis

Herpes simplex virus. Epidemiology and aetiology

Clinical presentation

Diagnosis

Antimicrobial therapy

Varicella zoster virus. Epidemiology and aetiology

Clinical presentation

Diagnosis

Antimicrobial therapy

West Nile virus. Epidemiology and aetiology

Clinical presentation

Diagnosis

Treatment

Postpolio syndrome. Epidemiology

Clinical presentation

Diagnosis

Therapy

Creutzfeldt‐Jakob disease. Epidemiology

Clinical presentation

Diagnosis

Therapy

Key points

References

CHAPTER 103 Good quality care: abuse

Ageism

Psychological control

Abuse

Good treatment

Laws and regulation

Ethics

Deontology

Prevention

Inclusive society

Conclusion

Key points

Bibliography

CHAPTER 104 Alcohol consumption and cognition

Evidence from studies

Prospective evidence

Alcohol consumption and Alzheimer’s disease

What is the cognitive and brain atrophy pattern in heavy drinkers?

Impact on cognitive performance

Impact on brain atrophy

Conclusion

Key points

References

CHAPTER 105 The use and abuse of prescribed medicines

Introduction

Use and harmful use

Pharmacology

Prevalence and correlates

Benzodiazepines

Prevalence of benzodiazepine use

Psychiatric morbidity

Gender and age

Illicit drug misuse

Aetiology

Polysubstance misuse

Detection

Detection of benzodiazepine use

Treatment

Initiating treatment

Psychological interventions

Prognosis

Conclusion

Key points

References

CHAPTER 106 Drug misuse and the older person: a contradiction in terms?

Introduction

Medications and the older people: geriatric specificities, adverse drug reactions, and drug misuse. Medications and the older people: geriatric specificities. Benefit–risk evaluation of medications in the older people

Age, polypharmacy, and adverse drug reactions

Disease–drug interactions and drug–drug interactions

Medications and the elderly: iatrogenic consequences

Medications and older people: drug misuse or suboptimal prescribing. Classification of the various types of suboptimal prescription

What is the quality of prescription in the older population when evaluated according to the different types of suboptimal prescription?

Medication and the older people: influence of suboptimal prescription in iatrogenic events

Prevention of iatrogenic incidents in practice: general rules for individual prescription

Starting treatment

Treatment follow‐up: adverse drug reaction alert

Treatment discontinuation

Prevention of iatrogenic incidents in practice: tools for collective evaluation. General considerations

Example of well‐known tools for evaluating prescription quality

Global evaluations tools

Key points

References

CHAPTER 107 Transportation, driving, and older adults

Introduction

Illness and transportation

What do we need to know to assess our older patients?

Taking a driving/transportation history

What factors are important in driving assessment?

What driving risks are associated with common diseases of later life?

What interventions can we make?

What is the physician’s responsibility with regard to driver licensing and insurance authorities?

Conclusion

References

CHAPTER 108 Smart Homes

Introduction

Definition of a Smart Home

Healthcare‐enabled Smart Homes

Ubiquitous Homes

The elderly as technology users

Example: healthcare‐enabled Smart Home for an aged resident

Challenges

Conclusions

Key points

References

CHAPTER 109 Modern use of biomarkers in geriatric medicine

Introduction

Comprehensive geriatric assessment

Dementia

Frailty

Biomarkers related to inflammatory response

Biomarkers related to metabolism

Biomarkers related to the endocrine system

Biomarkers related to the immune system

Other commonly measured biomarkers

Experimental biomarkers

Sarcopenia

Imaging markers for muscle mass

Circulating markers of muscle mass and strength

Growth factors

Markers of nutritional status

Genetic markers

Intrinsic capacity

Concluding remarks

Key points

References

Note

CHAPTER 110 Geriatric dermatology

Introduction

Inflammatory dermatoses. Asteatotic eczema

Seborrheic dermatitis

Stasis dermatitis

Bullous pemphigoid

Neurodermatitis

Infectious dermatoses. Bacterial. Impetigo

Erysipelas

Cellulitis

Fungal

Viral

Neoplastic dermatology. Benign

Malignant

Conclusion

Key points

References

CHAPTER 111 Pressure injuries: prevention and management

Clinical staging of pressure injuries

Measuring pressure injury healing

Risk factors

Risk assessment

Prevention of pressure injuries. Support surfaces

Nutrition

Moisturizing skin

Avoidability

Treatment of pressure injuries

Support surfaces

Nutrition

Local wound care

Adjunctive therapies

Diagnosing infection in chronic wounds. Accuracy of symptoms and signs for infection of chronic wounds

Non‐healable pressure injuries and skin failure

Key point

References

CHAPTER 112 Perioperative medical assessment of older adults

Shifting demographics create more need

Physiology of ageing and frailty

Age‐related changes in the cardiovascular system

Age‐related changes in the pulmonary system

Age‐related changes in the renal system

Age‐related changes in the neurological system

Essentials of preoperative assessment

How to screen

Framework for organizing complexities

Mobility

Medications

Mind

Multicomplexity

Cardiac risk

Pulmonary risk

What matters most

Postoperative management

Care after the hospital

Conclusion

Key points

References

CHAPTER 113 Anaesthesia

Introduction

Outcome of surgery and anaesthesia in the elderly

Cardiovascular morbidity associated with surgery and anaesthesia

Respiratory morbidity associated with surgery and anaesthesia

Central nervous system morbidity associated with surgery and anaesthesia

Postoperative confusion

Postoperative stroke

Renal morbidity associated with surgery and anaesthesia

Perioperative hypothermia

Preoperative assessment

Pain assessment and management in the elderly

Pain assessment

Pharmacological management of pain

The role of regional analgesia

The role of patient‐controlled analgesia (PCA) in the elderly

Ethical considerations for perioperative care of the elderly

Strategy to reduce postoperative morbidity and mortality in the elderly

Preoperative nutritional supplementation

Prevention of perioperative decubitus ulcers

The role of day case admissions

Safe sedation of older patients

Choice of surgical approach

Early access to critical care

Perioperative audit

Conclusion

Key points

References

CHAPTER 114 Health issues in the ageing woman

Cancer

Endometrial cancer

Aetiology and risk factors

Presentation

Diagnosis and management

Ovarian cancer

Aetiology and risk factors

Presentation

Diagnosis and management

Breast cancer

Aetiology and risk factors9

Presentation

Diagnosis and management

Cervical cancer

Aetiology and risk factors

Presentation

Diagnosis and management

Vulvar cancer

Presentation

Diagnosis and management

Vaginal cancer

Presentation

Diagnosis and management

Menopause

Diagnosis

Management

Genitourinary syndrome of menopause (GSM)

Postmenopausal vaginal bleeding

Presentation

Differential diagnosis

Management

Sexual dysfunction in menopausal women

Hormonal changes

Physical changes

Psychosocial changes

Acknowledgements

Key points

References

CHAPTER 115 Antiageing strategies

Introduction

The demographic revolution

What is antiageing medicine?

Can death be delayed?

Can the course of disability and functional dependence be reversed?

Can disability and functional dependence be delayed?

Mechanisms and evidence from biogerontological research

Caloric restriction (CR)

Intermittent fasting (IF)

CR mimetics

Epigenetics

Microbiota

Stem cells and ageing

Senolytics

Translation of results into humans

The hormonal fountain of youth

Preventive gerontology

Exercise

Diet

Antioxidants

Lifestyle

Ethical issues

Conclusion

Key points

References

CHAPTER 116 The ethics of geriatric care

Introduction

Ageism and geriatric care

Ethics and the geriatric patient

Longevity, healthspan, and health promotion

Conclusion

Notes

Key points

References

CHAPTER 117 Participation of older people in clinical trials

Introduction. The need for clinical trials involving older people

Why are older people excluded from clinical trials?

Consequences of the exclusion of older adults from clinical trials

Temporal trends in the inclusion of older people in clinical trials. Clinical trials reported in the literature

Clinical trials recorded in an online registry

Determinants of participation of older people in clinical trials

Patient factors. Patient factors associated with participation or non‐participation

Patient‐related motivators for participation

Patient‐related barriers to participation

Comment

Physician factors

Effect of patient characteristics

Barriers to the participation of older adults in clinical trials, according to physicians

Physician characteristics and knowledge

Environmental/logistical factors

Transportation and distance to the study centre

Incentives/cost

Trial characteristics

Communication

Facilitating the access of older people to clinical trials

Strategies tested in randomised controlled trials

Other proposed strategies

Conclusion

Key points

References

CHAPTER 118 Restraints and immobility

Introduction

Immobility

Physical restraints

Siderails

Risk factors and justification

Complications

Outcomes of restrictive device reduction

Approaches to reduce restrictive device usage

Promote mobility

Facilitate observation

Offer activities

Maintain continence

Promote comfort

Investigate mental status changes

Address fall risk

Reduce injury risk

Address treatment interference

Advanced practice nursing interventions

Staff education programmes

Conclusion

Key points

References

CHAPTER 119 Centenarians

Demography of centenarians: past, present, and forecasts

Sex differences and the paradox of centenarians

An optimistic view

Compression of morbidity versus disability

Heredity (nature) versus environment (nurture)

Omics technologies in centenarian studies

Conclusion

Key points

References

CHAPTER 120 End‐of‐life and palliative care

Introduction to palliative care

Hospice care

Communication

Prognostication

Symptom assessment and treatment

Pain

Dyspnoea and respiratory symptoms

Nausea and vomiting

Constipation

Bowel obstruction

Agitation and delirium

Fatigue

Psychosocial and spiritual domains

Cross‐cultural issues

Care transitions in end‐of‐life care

Key points

References

CHAPTER 121 End‐of‐life care: special issues

Introduction

The benefits of a palliative approach

When to involve SPCTs

Withholding and withdrawing treatment

Cardiopulmonary resuscitation (CPR)

Artificial nutrition and hydration

Care planning. Autonomy

Advance care planning

Planning for future care

End‐of‐life and terminal care

Terminal sedation

Assisted dying

Bereavement

Conclusion

Key points

References

CHAPTER 122 Improving quality of care

Introduction

The history of quality. The history of quality in business

The evolution of quality in healthcare

Organisations leading healthcare quality improvement

Quality improvement in geriatrics

Quality indicators

Geriatric medicine organisations focus on quality

Healthcare financing drives quality

Integrated care and population health

Healthcare accreditation

Quality in geriatrics hospital care

Quality in the community setting

Health outcomes research

Clinical practice guidelines

Healthcare audits as a QAPI process

Future initiatives in healthcare quality

Conclusion

Appendix 122.1: Healthcare quality organisations

Key points

References

CHAPTER 123 Clinical audit of healthcare

Introduction

History of clinical audits

Clinical audit versus quality improvement

Local versus national audit

Why do a clinical audit?

Designing and completing an audit

Planning

Determining audit criteria

Structure

Process

Outcomes

Determining standards

Defining terms

Sampling

Consent and confidentiality

Piloting

Data analysis

Identifying the cause of problems

Disseminating results and creating change

Re‐auditing and sustaining improvement

Audit as a driver for change

Big data

Patient and user input: codesign

Audits in relation to older people

Conclusion

Key points

References

CHAPTER 124 Caring for the caregiver

Impact of caregiving on the caregiver and the family

Distinctions between paid and unpaid caregivers

Aspects of caregiving. Mental health

Physical health

Financial well‐being

Social support

Spiritual well‐being

Assessments for caregivers

Strategies for coping and improved well‐being

Psychoeducation

Mindfulness

Support groups

Cultural diversity in caregiving

Topics to address with caregivers

Roles of healthcare providers in assisting caregivers

Discussion

Key points

References

CHAPTER 125 Nursing home care

Introduction

Societal role and governance of nursing homes

Spending

Regulation

Facility demographics

Medical care provided, providers, and care models

Resident demographics

Quality

Intersection between nursing homes and the law

End‐of‐life care in nursing homes

Challenges of research and cross‐country comparisons

Gaps, best practices, and innovations

Discussion – future directions

Key points

References

CHAPTER 126 Geriatric occupational therapy: achieving quality in daily living

Overview. Humans are occupational beings

Conceptual foundations of geriatric occupational therapy

Person‐Environment‐Occupation‐Performance/Participation model

Person (intrinsic factors)

Environment (extrinsic factors)

Occupation (activity)

Participation

Scope of occupational therapy services

Occupational therapy process. Assessment and intervention

Occupational profile

Occupational performance assessment

Intervention. Development of the intervention plan

Intervention implementation via client‐centred care

Use of occupation to enhance QOL health promotion

End of life

Community‐level instruction and patient/client education

Remediation strategies for functional decline

Physical environment adaptations

Technological aids and devices

Intervention review

Outcomes (engagement in activity to support participation)

Case examples. Case 1

Case 2

Case 3

Conclusion

Key points

References

CHAPTER 127 Geriatric medicine education in Europe and the United States

Introduction

Geriatric education in Europe

Undergraduate geriatric medicine education in Europe

Geriatric medicine teaching at the postgraduate level

Initiatives for improving undergraduate and postgraduate geriatric education in Europe

Geriatrics education in the United States of America

Undergraduate geriatrics education in the United States

Postgraduate geriatric education in US

Residency

Fellowship

Geriatrics education in other health professions education

Initiatives for geriatric education

Conclusion

Key points

References

CHAPTER 128 Systems of healthcare: the United States

Introduction

Overview of healthcare demographics

Development of geriatric medicine

Home healthcare

Post‐acute and long‐term care

Assisted living

Hospital care

Geriatric emergency departments (GEDs)

Acute care for the elderly (ACE) units

Stroke centres

Academic geriatrics

Conclusion

Key points

References

CHAPTER 129 Systems of healthcare: Australia

Overview of healthcare demographics

Healthcare services in Australia

Home healthcare

Nursing home care

Hospital care

Academic geriatric medicine

Conclusion

Key points

References

CHAPTER 130 Systems of healthcare: the UK

Introduction

Overview of healthcare demographics

Development of geriatric medicine

Home healthcare

Care homes

Hospital care

Academic geriatrics and geriatric training

Key points

References

Note

CHAPTER 131 Geriatric medicine in China

Introduction

Service provision

Training

Research

Conclusion

Key points

References

CHAPTER 132 Ageing in developing countries

Introduction

Demography

Heterogeneity in the ageing population in LAMICS

Socioeconomic differences in adult mortality and health status

Ageing and health

Evolution of life expectancy

Evolution of healthy life expectancy

Dementia and cognitive impairment

Multimorbidity

Frailty

Healthcare and geriatric medicine

Key points

References

Note

CHAPTER 133 Geriatric medicine in the European Union: towards unification of diversity

Introduction

Demography: an ageing society

Epidemiology: health and function

Organisation of the European Union

Healthcare systems in Europe

Geriatric medicine across Europe

Geriatric organisations in Europe

Recent developments in EU policy

Key points

References

CHAPTER 134 Research horizons for the twenty‐first century

Introduction

Ageing research models. Cell cultures

Animal models

Research in humans. Basic research

Clinical and epidemiological research

Cohort studies

Clinical trials

Setting priorities for research on ageing

Conclusions

Key points

References

Appendix. Function assessment scales

Components of the geriatric assessment

Activities of daily living (ADLs) and instrumental activities of daily living (IADLs)

Dental

Hallpike Manoeuvre

Osler Manoeuvre for pseudohypertension

Simplified Nutrition Assessment Questionnaire (SNAQ)

The Mini‐Nutritional Assessment (MNA) Scale

Saint Louis University social activities assessment

The Confusion Assessment Method (CAM) diagnostic algorithm

Index

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Отрывок из книги

To my wife, Caroline, and children and grandchildren, present and future, for their invaluable contributions to my work, my life, and my happiness!

.....

Katie Kompoliti Rush University Medical Center, Department of Neurology, Chicago, Illinois, USA

Thomas Krams Toulouse University Hospital and Centre of Geriatric Medicine, Toulouse, France

.....