Communication with older patients

Real-world executive functions and comprehension do not typically decline with age. Abilities that do decline include speed of information processing, learning and recall of new information, finding words, and reaction time. Distractions impair attention more readily. Learning “nonsense” words, such as medical terms, is enhanced by connecting new information to something familiar. Physicians should speak slowly and clearly, eliminate interruptions, repeat information, relate new information to old, write down medical terms and instructions, and confirm what the patient understands. Rate of speech and providing context for the information are particularly important.

Patients often mask dementia well, conversing easily with no gaps or sentence fragments. Critically considering cognition early in a visit can avoid taking an unreliable history or giving fruitless instructions. Answers that lack specificity signal a possible impairment. Numerous screening tools have been validated; 3 are listed in Table 2 . The Mini-Cog is affected little by language, educational, and cultural differences. The Six-Item Screener and Naming Test are easily remembered.

Frailty

Frailty is an emerging concept with wide health implications. Early recognition offers a chance to intervene, improving vigor and prolonging independence. Frailty is a state of progressive decline and dysregulation of molecular, cellular, and physiologic systems. When a critical number of impairments develops in mobility, strength, balance, motor processing, cognition, nutrition, endurance, and/or physical activity, a person becomes “frail.” She is more vulnerable to disability, dependency, falls, and death. Definitions vary, but having 3 of 5 conditions–muscle weakness, poor endurance, low physical activity, slow gait speed, and significant weight loss–should prompt consideration of referral.

Examination

Observe the patient to assess strength, mobility, and the ability to follow instructions. Rising from a chair without using arms (arms crossed over chest, hands on shoulders) shows leg strength and balance, and gives insight into physical fitness or frailty. Much information is gained from observing the patient get onto the examination table without assistance.

Pelvic examination

The utility of a pelvic examination (without Papanicolaou [pap] smear) in older women is unknown. Dangerous pathology is rarely detected in the cognitively intact, healthy, asymptomatic person. Nonetheless, a symptom or concern is commonly revealed only during the pelvic examination. Examination may be even more important in cognitively impaired women. Position carefully for hip and knee problems, usually with foot supports maximally extended lengthwise. The assistant should bring extra pillows if the patient has dorsal kyphosis; one is rarely adequate. Topical lidocaine applied to the vestibule for tenderness or anxiety is usually nonirritating and facilitates examination. To determine the full extent of pelvic organ prolapse (POP) a standing examination is usually required, especially in the frail and cognitively impaired.

Osteoporosis

The annual cost of caring for fragility fractures in the United States exceeds that of treating cardiovascular disease. The impact of vertebral or hip fractures on a woman’s quality and even quantity of life can hardly be overstated. Only half of women who experience a hip fracture ever regain their prefracture function. Preventive care in older women must address issues of bone mineral density (BMD), vitamin D, fracture risks, and fall risks.

Multiple expert groups recommend screening women for osteoporosis with bone densitometry beginning at age 65 years. Low BMD is not required to diagnose osteoporosis in postmenopausal women who sustain a low trauma fracture or have significant kyphosis with multiple risk factors. If BMD is low, medications that accelerate bone loss should be carefully reconsidered. Secondary causes of osteoporosis should be ruled out, notably in the elderly hypercalciuria, hyperparathyroidism, and malabsorption. Aerobic exercise, resistance exercise, and walking slow the loss of spinal BMD. The benefits of pharmacologic treatment for osteoporosis usually outweigh potential risks even in frail elderly if life expectancy is ≥2 years. Screening for vitamin D deficiency in community-dwelling women age >65 years is becoming a standard of care. For a serum 25-hydroxy vitamin D level of <20 ng/mL, typical repletion regimens use 50,000 IU of cholecalciferol (vitamin D3) once or twice weekly for 6-12 weeks, then ongoing monitoring.

More than half of hip fractures occur in women who do not have osteoporosis by bone densitometry; >90% occur with falling. Advanced age, previous fragility fracture, and low BMD are the strongest independent predictors of fracture; age is even more important than BMD. Additional validated risk factors are long-term glucocorticoid use, low body weight, family history of fracture, cigarette smoking, and excessive alcohol use. The online FRAX World Health Organization Fracture Risk Assessment Tool incorporates age, BMD, and other factors into an individualized 10-year fracture probability calculation ( http://www.shef.ac.uk/FRAX/ ). Previous falls; strength, gait, and balance impairments; and medications are the strongest fall risk factors. Additional ones include the use of assistive devices; arthritis; impairment in basic activities of daily living, vision, or cognition; fear of falling; depression; and age >80 years. Drugs most associated with falling are psychotropics, anticonvulsants, and antihypertensives. Referral to a fall risk reduction program, physical therapist, or geriatrics specialist is a consideration for fall or fracture risk factors. Adequate vitamin D intake and physical therapy for progressive balance and strength training are advisable for virtually all those at risk. In vitamin D deficiency central processing of sensory information is impaired; supplementation likely reduces falls. Physical therapy regimens that combine balance training with other components (strength, gait, endurance, and/or tai chi) can reduce falls 20-45%.

Benign breast disease

Mastalgia can be the presenting symptom for medical conditions or disease in nonlactational structures, such as vasculature, connective tissue, lymphatics, and nerves. The most urgent extramammary etiology to consider is angina. Others are cholecystitis, hiatal hernia, gastroesophageal reflux disease, herpes zoster, postherpetic neuralgia, intercostal neuralgia, cervical radiculopathy, costochondritis (Tietze syndrome), and venous thrombophlebitis (Mondor disease). Breast lesions could be manifestations of metastatic lung cancer, Wegener granulomatosis, sarcoidosis, other skin diseases, tuberculosis, or even syphilis.

Lower abdominal pain

“Lower abdominal pain–rule out gyn pathology” is a fairly common referral. While reproductive organs uncommonly cause pain in the elderly, myofascial pain is common and often overlooked. Also called “chronic abdominal wall pain,” the diagnosis and treatment of this problem are simple and inexpensive. Proper diagnosis can eliminate repeated imaging as well as fear. Diverticulitis, constipation, functional bowel disease, neuropathy, herpes zoster, nephrolithiasis, abdominal wall hernia, and pelvic tuberculosis are considerations. Fecal impaction should always be ruled out.

Postmenopausal bleeding

The differential diagnosis of postmenopausal bleeding in older women includes neglected pessary, cervical or rectal polyp, urethral prolapse, vulvovaginal cancer, and a number of other nonuterine conditions that require care. Thus, even women in long-term care facilities merit evaluation. The risk of cancer is higher in women age >70 years. Endometrial cancer incidence peaks between age 70 and 80 years, with a relative increase in the more aggressive type II cancers in older ages. Office endometrial biopsy and transvaginal sonography are both about 98-99% sensitive for neoplasia. Particularly the type II cancers, which arise in an atrophic endometrium, can be missed by sonography.

If the cervix is too stenotic for an office biopsy and the endometrial stripe is ≤4 mm, it is reasonable to assume a benign cause rather than have the patient undergo a surgical procedure, while not losing the patient to follow-up. Further evaluation as needed may be an interval ultrasound, repeated attempt at office biopsy, or hysteroscopy with endometrial sampling. Vaginal or oral misoprostol 100-200 μg can be given safely to older patients not taking other prostaglandin agonists, but probably does not facilitate cervical dilation in postmenopausal women. Hammoud et al reported a creative approach to endometrial sampling using ultrasound-guided transvaginal, transmural aspiration.

Vulvovaginitis

Both aging and long-term estrogen deficiency increase vulvar susceptibility to trauma and decrease vulvar immune function. The most common symptomatic vulvar and vaginal conditions in the elderly are typical postmenopausal ones such as atrophy, lichen sclerosus, and candidiasis. In older ages, multiple contributing factors are common and should be sought, for example, atrophy plus irritation from pads and prolonged sitting, or lichen sclerosis with candidiasis and a secondary bacterial infection in a diabetic.

If a patient referred for “atrophic vaginitis refractory to estrogen” is not sexually active, the problem is probably a vulvar dermatosis. Vulvar architecture gives important clues. Absence of distinct labia minora can be found in advanced atrophy, but is more often due to a dermatosis or condition with chronic inflammation. Biopsy specimen for diagnosis is preferred, but a trial of therapy based on clinical impression is appropriate. Other than topical estrogen, treatment is usually moderate-to-high potency topical glucocorticoids. Following symptom resolution, daily application of a barrier ointment such as solid vegetable or mineral oil will minimize further trauma, reduce symptoms, and delay recurrence.

The incidence of vulvar cancer rises exponentially after age 65 years. Invasive vulvar cancer is also on the rise in all age groups for unclear reasons. The extent to which lichen sclerosus is precancerous is debated, but this condition warrants examination at least annually even when asymptomatic. Indications for biopsy are the same as in younger women: asymmetry, border irregularity, color variation, rapid change, bleeding, nonhealing ulceration, persistence, and lack of a firm diagnosis.

Chronic vaginal discharge that has not responded to the usual creams and antibiotics may indicate inflammatory vaginitis. Purulent vaginal discharge is uncommonly due to chronic endometritis caused by cervical stenosis or from an enterovaginal fistula, particularly if she has had diverticulitis. In both cases the discharge is malodorous.

Urinary tract infection

Urinary tract infection (UTI) is the most frequent bacterial infection in the elderly. Management is complicated by diagnostic uncertainty, polypharmacy concerns, more resistant organisms, and host factors that reduce treatment efficacy. A short 3-day course of antibiotics is less likely to be curative than in younger women, although this does usually treat uncomplicated cystitis. Trimethoprim-sulfa and fluoroquinolones are acceptable agents. Nitrofurantoin is not contraindicated but is avoided when possible because renal insufficiency is common in aging. Medication interactions should be reviewed. For instance, sulfonamides displace warfarin from plasma proteins. For recurrent UTIs, postvoid residual urine volume (PVR) measurement, topical estrogen, and urine cultures and sensitivities prior to initiating treatment are indicated.

A test of cure culture following treatment is contraindicated if symptoms have resolved, because treatment of asymptomatic bacteriuria (ASB) is contraindicated in older women. However, in frail elderly the “symptom” might be lethargy, irritability, vague discomfort, or a fall, making this determination difficult. Urinary incontinence may be symptomatic of infection or completely unrelated. If incontinence worsened recently, a positive urine culture favors UTI (should be treated) over ASB (should not be treated), but since incontinence waxes and wanes ASB is still possible. If a trial of antibiotics is undertaken, ask the patient or family to report the impact on symptoms immediately rather than rely on memory weeks later.

Urinary incontinence–evaluation

Urinary incontinence in older women usually has several contributing factors, and successful treatment addresses as many as possible. Typical lower urinary tract age-related changes include more detrusor overactivity and underactivity, decreased bladder sensation, and lower urethral closure pressure. Comprehensive evaluation and management of this complex condition in older women can be found in a number of excellent reviews and chapters. A few points are noted here.

Geriatric incontinence evaluation begins with understanding its impact on that patient’s quality of life and daily function. With increasing age, comorbidities, and duration of incontinence, successful treatment may be amelioration of only the most distressing symptom(s). Evaluation includes medication review; examination for neurologic conditions; determination of mobility and dexterity issues; and assessment of medical conditions such as peripheral edema, diabetes, and hypercalciuria. Initial or concurrent management with a primary care provider may be needed. Fecal impaction should be ruled out, and fecal incontinence (FI) queried. A bladder diary should always be obtained if possible, even if a patient’s ability to complete one is unclear. Clues about cognition, literacy, and/or motivation usually emerge.

Opinion is divided about the utility of measuring PVR. PVR increases with age, and no specific volume predicts pathology or requires treatment. Anecdotally, once-daily self-catheterization reduces the PVR over time, thereby improving incontinence. In the absence of continence surgery, an elevated PVR usually indicates impaired detrusor contraction rather than outlet obstruction. Causes include idiopathic detrusor underactivity, diabetes, vitamin B12 deficiency, and central nervous system lesions. Since outlet obstruction is not usually a factor, even with anterior vaginal wall prolapse, the upper urinary tract is rarely at risk of damage from high voiding pressures. Stage III-IV POP can, however, cause obstruction at the ureterovesical junction, which is more likely with older age and uterus in situ. Although screening for hydroureter/hydronephrosis is not considered standard of care, it is appropriate for prolapse beyond the hymen, especially for stage IV.

Nocturia impairs quality of life and increases fracture risk. Etiology can be generally categorized as a bladder, fluid, or sleep problem. The latter 2 should be investigated prior to medicating the bladder. Nocturnal polyuria has multiple interacting physiologic and medical causes in the elderly. Nocturnal urine output fails to diminish as it does in the nonelderly, which compounds any polyuria caused by medical conditions. Patients may strictly limit evening fluid intake without perceptible improvement. A bladder diary will clarify total daily, diurnal, and nocturnal urine output. Sleep problems can usually be assessed with history alone, such as, “When was the last time you considered yourself to be a good sleeper?” A bladder diary will show some of the nocturnal voided volumes to be smaller than her diurnal capacity. Bladder relaxants are only indicated in patients with overactive bladder symptoms unresponsive to behavioral management, since all have anticholinergic effects. Tricyclic antidepressants (imipramine) should be avoided in the elderly. Regardless of nocturia etiology, a bedside commode may improve quality of life and reduce risks.

Urinary incontinence–treatment

Differentiation of urge and stress incontinence can be difficult in elderly women, due to multiple contributing factors and an increased prevalence of mixed incontinence. Fortunately, establishing an exact mechanism is not necessary for initial treatment. Behavioral therapy benefits stress, mixed, and urge urinary incontinence. Pelvic floor muscle training (PFMT) can effect significant improvement even if the patient’s contraction is weak. Far from being a sign of futility, a weak “Kegel” suggests a good chance for improvement with modest strength increase. The important determination is whether she can or cannot contract her pelvic floor at all, and a weak contraction is often missed. Detection is enhanced using a rectal examination, coaching the patient to relax, then having her contract her muscle to avoid passing gas. Reexamining her contraction at subsequent visits best reinforces the importance of PFMT.

Bladder relaxants are effective in older women, but anticholinergic medications may impair cognition and function. Low doses and periodic review are critical. No one bladder relaxant is invariably preferable in the elderly. Although some newer medications have shown less cognitive impact than oxybutynin, the few randomized trials contain methodological flaws, primarily high oxybutynin doses that would never be used in geriatric practice. Once daily (oral) or twice weekly (transdermal) administration improves adherence, but very long half-lives carry a risk of drug accumulation. Immediate-release medications are useful in treating incontinence that is episodically problematic. For instance, oxybutynin 2.5 mg or tolterodine 1 mg before church or a bus ride may achieve the necessary control.

Fecal incontinence

Few medical symptoms are as distressing and socially isolating for older people as FI. FI is rarely volunteered and providers fail to inquire, leading to a downward spiral of distress, dependency, and poor health. A common self-care strategy is reducing activity or exercise, markedly counterproductive for healthy aging. Rectal urgency is particularly associated with incontinence. FI is a risk factor for nursing home placement, but the fundamental problem is the person’s inability to manage the incontinence herself due to cognitive or physical impairment.

Even when known, FI is often poorly assessed and passively managed in older women. In frail women fecal impaction is a common etiology. After impaction is ruled out, PFMT and skin care can be recommended pending further evaluation. A thorough evaluation entails an appraisal of predisposing factors, medications, and medical conditions, and a comprehensive physical examination. FI treatments are marginally better than placebo in many controlled studies. However, in one study combined PFMT, behavioral strategies, diet, and pharmacotherapy resulted in 50% improvement in over half of participants, mean age 59 years. Biofeedback using 3 different modalities effected modest improvement in symptoms and quality of life in 70% of studied patients, mean age 62 years.

Pessaries for POP

Older women motivated to avoid surgery are excellent pessary candidates. Pessary fitting and management remains an art. Specific measurements such as the pelvic organ prolapse quantification (POP-Q) do not adequately inform pessary choice. Size of the genital hiatus, vaginal length, hysterectomy, pelvic reconstructive surgery, parity, and specific organ descent have been variably associated with successful or unsuccessful pessary fitting. Continuation is associated with older age and treatment of prolapse rather than incontinence; discontinuation is associated with previous hysterectomy or prolapse repair and a large posterior vaginal wall prolapse. However, no constellation of characteristics adequately describes the successful user; any woman of any age is a potential candidate.

Most older women can learn to change (remove, cleanse, reinsert) their own pessary, even through their ninth decade. Dental floss can be tied through the pessary to aid in removal; a perforation can be safely created in most pessaries. The patient unable to remove her own pessary should be seen a short time after placement (1-3 days). Continuing to change her pessary at least monthly would be ideal, but intervals may be as long as 3 months before excessive leukorrhea and odor occur. Estrogen-releasing vaginal rings are useful. Cube pessaries are particularly prone to vaginal wall erosion, even after pretreatment with estrogen, and good follow-up is essential.

Immediate potential complications include pain, bleeding, urinary retention, defecatory dysfunction, and urethral mucosal prolapse. The rare major complications occur mainly in elderly women due to a neglected or forgotten pessary. Factors include prolonged use (years to decades), vaginal atrophy, advanced age, cognitive impairment, change in health care provider, and residence transition. Erosion into or through the vaginal wall causes most major complications, such as pessary incarceration, vesicovaginal fistula, rectovaginal fistula, intraperitoneal bowel complications (rupture, obstruction), uremia, pyelonephritis, septicemia, cervical incarceration, small bowel prolapse and incarceration, and myiasis. Pressure can cause hydronephrosis, ureteral obstruction, and uremia. Chronic inflammatory reaction has been implicated in vaginal cancers. Removal of an impacted pessary is facilitated by vaginal estrogenization, and bone cutters have been useful.

Few long-term care facilities have personnel who change pessaries, although this is within the scope of nursing practice after appropriate training. Some facilities work with a knowledgeable nurse practitioner. Occasionally, a family member can accomplish this. Unfortunately, pessary changes usually require an office visit. Patients with dementia typically do well, but may incur distress. Topical lidocaine applied at the introitus and/or intravaginally alleviates fear and confusion. If anxiety persists, surgery may be a better alternative.

With long-term pessary use pelvic support may improve. A pessary placed for a large prolapse may require downsizing after some months due to a smaller genital hiatus. A prolapse reduced for years may not recur for months or years after pessary removal, although most recur soon. If a pessary is used prior to a vaginal obliterative procedure such as colpocleisis, reevaluation of the prolapse prior to the date of surgery is wise, in case the planned procedure is no longer feasible.