Clinicopathologic Correlations

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Many organ system problems are seen in the geriatric age group. This section covers several disorders and functional states that are especially common among older individuals and are not discussed in other chapters of this book.

Senile macular degeneration occurs in nearly 10% of the geriatric population, affecting more women than men. It represents the most common cause of legal blindness in the United States. There is painless and progressive loss of central vision. The patient frequently complains of difficulty reading. Because only the macula is involved, peripheral vision is spared, and complete blindness does not result. See Figures 10-121 to 10-123.

Temporal arteritis and polymyalgia rheumatica are unique to the geriatric age group and probably are manifestations of a condition known as giant cell arteritis. Polymyalgia rheumatica is estimated to occur in 40% to 50% of patients with temporal arteritis. Both of these conditions are threefold to fourfold more frequent among women than among men.

The symptoms of temporal arteritis include headache, which is frequently associated with scalp tenderness; the temporal artery may also be tender. There are several generalized symptoms as well, such as fever, weight loss, anorexia, and fatigue. Visual disturbances include loss of vision, blurred vision, diplopia, and amaurosis fugax. Sometimes patients may also complain of pain on chewing food. The diagnosis is made from temporal artery biopsy, which has a sensitivity of 90% and a specificity of 100%.

Many patients with polymyalgia rheumatica complain of symmetric pain, especially in the morning, and stiffness of the neck, shoulders, lower back, and pelvic girdle. They often find it difficult to brush their hair. The proximal muscle groups of the upper extremities and pelvic girdle are commonly affected.

Pressure sores, or decubitus ulcers, are serious problems that can lead to pain, a longer hospital stay, and a slower recovery. They are caused by unrelieved pressure that results in damage to underlying tissue. They affect up to 3 million individuals yearly. The annual health-care expenditures for these lesions are in excess of $5 billion. It has been estimated that the cost to heal one decubitus ulcer ranges from $5,000 to $50,000. In long-term health-care facilities, the prevalence of decubitus ulcers is 15% to 25%, whereas the prevalence in the community is 5% to 15%. There are thousands of legal cases each year as a result of the development of pressure sores and the related morbidity and mortality. Bacteremia is common, and osteomyelitis occurs in more than 25% of all patients with nonhealing decubitus ulcers.

Decubitus ulcers result from prolonged pressure over bony prominences. A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony prominences (bones close to the skin) such as the elbows, heels, hips, ankles, shoulders, back, sacrum, and back of the head. It is thought that this pressure causes a decrease in perfusion to the area, leading to the accumulation of toxic products, with subsequent necrosis of skin, muscle, subcutaneous tissue, and bone. Moisture, caused by fecal or urinary incontinence or by perspiration, is also implicated because it causes maceration of the epidermis and allows tissue necrosis to occur. Shearing force is also a factor. Shear is generated when the head of a bed is elevated, causing the torso to slide down and transmit pressure to the sacrum. Poor nutritional status and delayed wound healing are other widespread contributing factors.

Pressure ulcers are staged to classify the degree of damage observed. The four clinical stages of decubitus ulcers are as follows:

Stage I: Nonblanching erythema of intact skin;the heralding lesion of skin ulceration Stage II: Partial-thickness skin loss involving epidermis or dermis;ulcer extending up to subcutaneous fat

Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue without involving muscle or bone

Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to underlying muscle, bone, or supporting structures

Ulcers covered by superficial necrosis must undergo debridement before they can be staged. The patient in Figure 25-5 presented with a stage I pressure sore, and 1 week later, when this photograph was taken, the sore had rapidly advanced to a stage IV lesion. The patient died of sepsis 4 days after the photograph was taken.

Prevention of decubitus ulcers is extremely important in the care of bedridden or chair-bound patients. Repositioning or rotating the patient at least every 2 hours, minimizing moisture, practicing basic skin care, and improving the nutritional state are important. Skin should be cleansed at the time of soiling and at routine intervals. Care should be used to minimize the force and friction applied to the skin.

Urinary incontinence is an important problem in the geriatric age group. It occurs in 15% to 30% of community-dwelling individuals 65 years of age and older. Among institutionalized patients, the prevalence is 40% to 60%. About 12 million adults in the United States have urinary incontinence. It is most common in women older than 50 years. In 2000, the total cost of health care for urinary incontinence was more than $15 billion.

There are many causes of urinary incontinence, including decreased bladder capacity, increased residual volume, medications, diabetes, and pelvic relaxation. In women, thinning and drying of the skin in the vagina or urethra may cause urinary incontinence; in men, an enlarged prostate gland or prostate surgery can cause urinary incontinence. The major transient causes of urinary incontinence can be remembered by the mnemonic ''DIAPPERS'':

D: Delirium or dementia I: Infections (urinary)

A: Atrophic vaginitis or urethritis;atonic bladder P: Psychologic causes such as depression;prostatitis

P: Pharmacologic agents such as anticholinergics, psychotropics, alcohol, diuretics, opiates, and alpha-adrenergic agents E: Endocrine abnormalities such as diabetes and hypercalcemia R: Restricted mobility S: Stool impaction

There are four types of urinary incontinence: stress, urge, overflow, and functional. In stress incontinence, urine leaks because of sudden pressure on the lower abdominal muscles, as during coughing, laughing, or lifting a heavy object. It is very common in women. Urge incontinence occurs when the need to urinate comes on too fast—before the patient can get to a toilet. Urge incontinence is most common in elderly persons and may be a sign of an infection in the kidneys or bladder. Overflow incontinence is a constant dripping of urine caused by an overfilled bladder. This type of urinary incontinence often occurs in men and can be caused by an enlarged prostate gland or tumor. Diabetes or certain medicines may also cause this problem. Functional incontinence occurs when the patient has normal urine control but has trouble getting to the bathroom in time because of arthritis or other conditions that make it hard to ambulate.

Dementia, according to criteria contained in the American Psychiatric Association's (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision), is characterized by an acquired and persistent impairment in short- and long-term memory and other disturbances, such as impairment in language (e.g., reading, writing, fluency, naming, repetition), concentration ability, visuospatial function (e.g., drawing, copying), emotions, and personality, despite a state of clear consciousness. A diagnosis of dementia requires evidence of decline from previous levels of functioning and impairment in multiple cognitive domains. The prevalence of dementia in the general population 65 years of age is estimated to be 5% to 10%, and the incidence doubles with every additional 5 years. In chronic care facilities, the prevalence is higher than 50% of all hospitalized patients. Despite its prevalence, dementia is often unrecognized in its early stages.

The most common causes of dementia are strokes and Alzheimer's disease. The onset and course of the symptoms often provide clues to the cause of dementia. A sudden onset is almost always related to a cerebrovascular accident. A subacute, insidious course may be related to tumor, Jakob-Creutzfeldt disease, or Alzheimer's disease. Dementia with rigidity and brady-kinesia is strongly suggestive of Parkinson's disease. Dementia in association with urinary incontinence and a spastic, magnetic gait is seen in hydrocephalus. The development of dementia after a fall should raise suspicion of a subdural hematoma.

Some of the symptoms that may be indicative of dementia are difficulty in the following areas:

Learning and retention of new information

• Handling of complex tasks Reasoning ability Spatial ability and orientation Language Behavior

Falls are a common problem in the geriatric age group. More than 30% of adults 65 years of age and older fall each year. Of those who fall, two thirds fall again within 6 months. Falls are the leading cause of injury-related deaths among people aged 65 years or older and are the most common cause of nonfatal injuries and hospital admissions for trauma. In 2004, the most recent year statistics are available, almost 15,000 people in this age group died from falls, and about 1.9 million were treated for injuries in emergency rooms. The elderly account for 75% of deaths from falls. More than half of all fatal falls involve people aged 75 years or older—only 4% of the total population. Among people aged 65 to 69 years, 1 of every 200 falls results in a hip fracture, and among those aged 85 years or older, 1 fall per 10 results in a hip fracture. One fourth of those who fracture a hip die within 6 months of the injury.

The most profound effect of falling is the loss of independent functioning. Of persons who fracture a hip, 25% require life-long nursing care, and approximately 50% of the elderly who sustain a fall-related injury are discharged to a nursing home instead of returning home.

In 2001, more than 1.6 million older adults were treated in emergency departments for all fall-related injuries, nearly 388,000 were hospitalized, and 11,600 people 65 years of age and older died from fall-related injuries. Falls are the result of a decline in vision, balance, sensory perception, strength, and coordination and are often precipitated by medication ingestion. Most falls are sustained by patients who have taken long-acting sedative-hypnotic agents, antidepressants, or major tranquilizers. Whenever possible, try to reduce the number of medications that a patient is taking.

Several modifiable risk factors have been identified with falling. These include lower body weakness, problems with walking and balance, and taking four or more medications or any psychoactive medications. The health-care provider should try to encourage elderly patients to improve lower body strength and balance through regular physical activity. Tai chi is one exercise program that has been shown to be very effective. In one study, tai chi reduced the number of falls by 47%. All health-care providers must also review carefully all of a given patient's medications to reduce side effects and interactions. Eye examinations to check vision are needed at least once a year.

Approximately half to two thirds of all falls occur in and around the home. Therefore, it makes sense to reduce potential home hazards. To make living areas safer, elderly persons should (1) remove tripping hazards such as throw rugs, (2) use nonslip mats in the bathtub, (3) have grab rails installed next to the toilet and in tub, (4) have handrails installed on both sides of stairways, and (5) improve lighting throughout the home.

Review the DVD-ROM included with this book, which demonstrates how to perform a screening mental status examination on a geriatric patient.

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