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Geriatrics Ė Osteoporosis, Delirium, Polypharmacy, and Incontinence

Estrogen is now recommended, and you are almost never too old to start or continue to use estrogen. It was probably no more than ten years ago that I distinctly remember people saying that an 80-year-old with osteoporosis, thereís no reason to give them estrogen because theyíve already lost most of their bone mass. That is absolutely - well, itís true they have lost a significant amount of bone mass, but thereís plenty of reason to give people estrogen. In fact, bones are more responsive to estrogen the older the bones are. So there are significant beneficial effects on osteoporosis. In fact the benefits of osteoporosis are about equal to that of the bisphosphonates; etidronate and alendronate. They are also better than actually, maybe twice as potent, as calcitonin - estrogenís affects on bones. This is even in people with advanced osteoporosis. Beneficial effects on cardiovascular health, beneficial effects in cognition and mood, and, as Iíll mention next week, estrogen if given after the menopause and taken for years at the usual dose, gives people really significant prevention or prophylaxis against developing Alzheimerís disease. In fact, for people who take estrogen after the menopause and take it for years, they have a less that 50% risk of getting Alzheimerís disease.

Osteoporosis, in particular, primary prevention of osteoporosis really is calcium, 1500 mg a day, vitamin D, at least 400 IU a day, and hormone replacement therapy. Secondary prevention is all of the above, plus an additional antiresorptive agent. So this is for the older person who already has compression fractures or hip fracture. So all the above plus an additional antiresorptive agent such as alendronate or calcitonin. And donít forget etidronate. Etidronate, or Didronel, is still a

Osteoporotic compression fractures really ought to be treated with bed rest. Not physical therapy, but bed rest to take the gravitational pull off the spine. Another thing thatís very useful is calcitonin. Calcitonin is used as an analgesic. We used to use the injectable form of calcitonin and it really worked well as an acute analgesic through and endorphin-like mechanism in the brain. Now you can use the calcitonin nasal spray. This theoretically should work as well. I havenít

Mammograms can be stopped at the age of 85. This might seem a little counterintuitive because the risk of breast cancer increases with age, but there are

Pneumovax every six years, influenza vaccine every year for all elderly patients and healthcare workers, and I find healthcare workers the biggest offenders here

Headache. If you have an old person - at least giant cell arteritis ought to pop across your brain once or twice during the evaluation of an older person. And obtain an sed rate particularly if this is an older person who is not a headache-type person. One of the things to remember about giant cell arteritis or temporal arteritis is that there is no typical headache. So whether or not they have tender temporal arteries is really of no significance. When this has been studied there was

Hypercholesterolemia. It is absolutely not indicated for primary prevention in patients greater than 75 years of age. Thereís never been a study that shows that it

Hypertension. Treatment should be titrated to the standing blood pressure. Not the sitting blood pressure. All old people, when they come into the clinic - and the older you are the more this is true - should have sitting and standing blood pressures done. Not just sitting blood pressure. Itís very dangerous to continually

Congestive heart failure. Everybody with congestive heart failure deserves to have an echocardiogram because there is no good way of determining, on physical exam, the etiology of someoneís congestive heart failure. It is said that over 50% of people, old people with congestive heart failure, have normal systolic

Urinary tract infections. You should only treat symptomatic bacteruria in elderly people. Asymptomatic bacteruria, when studied, does not benefit from treatment with antibiotics and itís especially true for indwelling Foley catheters, particularly in nursing home patients. All of these indwelling Foley catheters

Delirium. Delirium is described as a syndrome of acute onset of global cognitive impairment, characterized by disturbances of attention, psychomotor disturbance, disorganized sleep-wake cycle, reduced levels of consciousness, fluctuations of mental status and - I think the best description of all of delirium - acute brain failure, in contrast to dementia which is chronic brain failure. Acute brain failure, sometimes called metabolic encephalopathy, toxic encephalopathy,

Lethargy sometimes alternates with hyper-alertness and vigilance. Thereís often psychomotor hyper-activity, but more commonly psychomotor hypoactivity. The most common situation is just simple lethargy and thatís why itís most often not diagnosed, or there is a delay in diagnosis because old people who are sitting

Other features to describe delirium is people are distractible. They are often disoriented, have memory problems. They have a disorganized thinking, lack of goal-directed behavior. Sometimes they donít know whatís wrong with them, they are just agitated. They are getting their clothes on, wanting to get out of here. They donít even know where they are going to go. They often have delusional thinking and itís typical paranoid delusional thinking. That the nursing staff is out to get them, or that theyíve been imprisoned, and of course when they are bolted down to the bed with vest restraints and wrist and ankle restraints, you can

How do you manage it? Well, you identify the cause. The first step is to try to round up the usual suspects and the second most important thing, Iíll tell you, is that the problem generally lies outside the brain. There are two ways of working up people with delirium. Thereís the geriatric primary care way of doing it and then

Polypharmacy. Twelve percent of the United States population are elderly. Yet, 30% of all prescription medications are written for elderly people. Therefore, some simple math will tell you that elderly people are on 2.5 times as many medicines as younger people. Then when you factor in the notion that elderly people

Community-dwelling elderly people and the medication profiles that they are on. And 25% of the community-dwelling elderly people that were surveyed were on at least one inappropriate medicine. By inappropriate medicine, that was defined as a medicine that either did not have an indication or a medicine that had a side effect profile that was unacceptable, or a medication that there is a much more user friendly alternative readily available.

On the top of the hit list was Elavil. The reason why Elavil is such a tough drug to handle in old people is because of how strongly anticholinergic it is and how long of a half life it has, and it has at least three active metabolites floating around with long half lives; 150 mg dose of Elavil is equal to 7 mg of atropine equivalents. Next is Darvon. (I donít necessarily agree with all of these. I just thought Iíd show then to you.) Next is Darvon and I donít think this is that big of a deal, but since it has no greater analgesic potency than aspirin or acetaminophen, thereís not a whole lot of reason to use it. It can make people a little bit off mentally.

Ser-Ap-Es. Itís still kind of popular. It dates you though, I tell you it dates you when you have a patient who is on Ser-Ap-Es because invariably that physician is really up in years that wrote this one. Itís very effective - itís a very effective antihypertensive agent- and itís cheap. Itís a combination of hydralazine, hydrochlorothiazide or some thiazide diuretic and reserpine. But reserpine does cause problems in old people. It causes parkinsonism and depression so you shouldnít use it. Aldomet has the same sort of problems. I donít see it as much as I see reserpine but you shouldnít use either one of them.

H2 blockers: I think are okay but we donít often enough consider dose reduction in the elderly, and maybe half the dose in the elderly would be appropriate. Especially the H2 blockers that are renally cleared. Antiemetics: these are problematic, especially with women. I say especially with women because women are the ones that are at such risk for tardive dyskinesia. If people take these for a long period of time - like Reglan - they can develop awful tardive dyskinesia that, as you know, is not easy to get rid of.

Antipsychotics: are along the same line. They are overused. They are overused in nursing homes, less so than they used to be. They really should be reserved for people with psychosis, not just people that are agitated, but people who have psychosis. If you use them in agitated people with psychosis they work very effectively and are the drugs of choice. By the way, the drug of choice, antipsychotic - I think in 2006 for old people - is olanzapine, Zyprexa. Itís not the older

Over-the-counter cold remedies often contain an antihistamine and a decongestant and therefore very sedating, anticholinergic. Cause people to fall, confusion, etc. Decongestants are safer if used for short periods of time. However, be careful of that elderly man who has a marginal ability to pee and he takes an

Dipyridamole, Persantine is pretty much a drug without any indications anymore, and I put nonsteroidal antiinflammatory drugs up here for effect just because these are very tough drugs for old people to tolerate. I think thereís going to be quite a market for old people in the new Cox 2 inhibitors that are going to come out next year that have a much cleaner side effect profile than do the current nonsteroidal antiinflammatory drugs.

So, in summary, if there is no indication get rid of the medication. Usually youíll be right. If you are wrong, restart it. Prescribe only when the overall therapy is likely to be beneficial because if you donít do this itís so easy to get an older person on a medication list thatís two pages long. It just happens so easily. Avoid those high risk medicines. Simplify medication schedules as much as possible. I almost always have to give written instructions on medications when Iím treating

Urinary incontinence is a very common condition in the elderly. Fifteen to 30% of community-dwelling elderly people have this. Thatís where the bulk of elderly people live anyway. Ninety-five percent of old people live in the community and if 25% of that 95% of old people have urinary incontinence, thatís a lot of urinary incontinence. These are also the people that you can do the most good with. Of course, if you have a patient with urinary incontinence who is immobile and has dementia you donít have a snowballís chance in you-know-where to make any progress with them, other than putting a diaper on them. Thatís what occurs in nursing home patients. About 50% of nursing home patients have incontinence. This is a group of patients that it is the most difficult to make significant

Transient incontinence. This is incontinence that, if you take care of the underlying cause, the incontinence goes away as opposed to fixed incontinence which is something that you need to deal with chronically. It can be remembered by the mnemonic DIAPERS - D for delirium, I for infection, typically urinary tract

Outlet obstruction. The outlet can either be too much, and this is usually in the setting of prostatism. That can be one of the causes of overflow incontinence. The other cause of overflow incontinence is backup. Here the hypoactive bladder, and then the exact opposite of outlet obstruction is an insufficient outlet which results in stress incontinence. These things can also be broken down by the post void residual urine volume, which is arbitrarily picked as 100 cc as the limit. Greater than 100 cc is consistent with bladder hypoactivity or outlet obstruction, and less than 100 cc is consistent with a hyperactive bladder or an insufficient outlet.

Evaluation of people with incontinence is pretty straightforward. You do a urinalysis and a culture, if thatís positive. A check of electrolytes, BUN and creatinine from people who have overflow symptoms, and you are concerned about hydronephrosis. A glucose is useful because getting control of a personís glucose can have an impact on their incontinence. Another thing, important for glucose, is that hyperglycemia is a common cause of neuropathy and people can easily have