Nutrition

Optimal nutrition in the elderly has important relevance to stabilize the added demands of comorbid diseases and functional impairment. Research indicates that the traditional Mediterranean diet that is high in vegetables, fruits, fish, whole grains, and monounsaturated oil can be protective against cognitive decline and dementia.[3] Diet also influences development of cardiovascular disorders, endocrine diseases including type 2 diabetes and some types of cancer. Health-care teams must recognize factors influencing nutrition, review dietary intake, identify dietary deficiencies and establish nutritional balance (Figure 46-2).[4] Determinants of nutrition are multifactorial including food access, physical and mental health status, habits affecting nutrition, and socioeconomic status.[4] Physical limits may include gastrointestinal disorders affecting swallowing and absorption. Poor dentition also contributes to the ability of chew food. Osteoarthritis can impact the ability to prepare food. Depressed mood and cognitive function may affect appetite and routine patterns of meals. Older patients who are not able to adequately care for themselves and who live in isolated housing are particularly at risk of poor nutrition. Smoking, alcohol, and illicit drug use also affect nutrition. Nutritional deficiencies can be both the cause and result in the cycle of elder care challenges. Poor nutrition can result in opposite extremes of malnutrition or obesity.

Figure 46-2

Nutritional balance.

Cachexia is a metabolic disorder associated with underlying chronic medical conditions such as cancer and HIV/AIDS; it is characterized by loss of muscle and fat mass.[5] Malnourishment can be unrecognized by health-care practitioners. One method of evaluation is the mini nutrition assessment tool; its short form can be easily used as an initial screen for malnutrition.[6] Malnutrition has many consequences including longer hospitalization, increased fall risk, decreased physical function, poor quality of life, and increased morbidity and mortality.[5] Interventions to correct undernourishment include multidisciplinary support, nutritional education, counseling with individualized diet plans prepared by registered dieticians, and follow-up home visits.[5]

Obesity is associated with a number of medical disorders including hypertension, diabetes, and hyperlipidemia. From 1980 to 2008, obesity has doubled in adults.[7] In patients over 60, 31% are obese.[8] (See Chapter 39 for additional discussion on obesity.) Older patients who are obese are also more likely to report chronic joint pain, back pain, indigestion, depressed mood, anxiety, fatigue, and insomnia.[9] Weight loss strategies in older adults should be implemented gradually with a combination of calorie restriction and individualized resistance exercise regimen. It is important to maintain adequate protein and vitamin requirements including calcium, vitamin D, and B12 throughout the weight loss process.[10] The role of bariatric surgery in severe or morbidly obese patients over 65 is unclear. In general, lifestyle modifications that can be maintained are the best initial strategies for weight control.

Exercise

Physiologic changes related to exercise can counter morbidity related to health disorders. These overall effects may be found in many organ systems seen in Table 46-1.[11] The Centers for Disease Control and Prevention (CDC) offers guidelines for older adults who are generally fit with no limiting health conditions (see Figure 46-3).[12] Exercise regimens must be adapted and closely supervised for individuals with health disorders.

Figure 46-3

CDC guidelines on exercise: If you’re 65 years of age or older, are generally fit, and have no limiting health conditions, you can follow the guidelines listed.

Immunizations

All health-care providers should review immunization history and establish recommendations for vaccines based on the patient’s need. The following list is a summary of the CDC-recommended vaccines that should be considered for geriatric office patients:[13]

Adults aged 65 and older can be given the standard-dose IIV or, alternatively, high-dose IIV. Patients who are severely immunocompromised should receive the IIV rather than the LAIV. The dosage should be given every year in the fall or winter as soon as the vaccine is available.

This vaccine is recommended for people aged 65 and older. Patient should receive one dose if unvaccinated or if the vaccination history is unknown. If the first dose was given before age 65 and five years have elapsed, a second dose should be administered.

Patients who are born before 1957 are considered to be immune, but assessment of immunity through serology or documentation should be obtained by health-care professionals.

All patients without evidence of immunity should be vaccinated. The vaccine should be given in two doses, four to eight weeks apart.

This is recommended for all adults who desire protection even without risk factors. For those patients older than 40 and within a two-week exposure to the virus, immune globulin is preferred over the vaccine. Other work, travel, and medical criteria may be considered for vaccine administration. The vaccine is given in two does, 6–18 month apart.

This is recommended for all adults who desire protection even without risk factors. Geriatric patients with HBs-Ag positive household contacts and sexual partners, other high-risk sexual behavior, health-care professionals, and people with chronic liver disease should receive the vaccine. The vaccine is given in three doses at zero, one, and six months.

The vaccine is recommended only in those geriatric patients with a high risk for haemophilus infection such as asplenic patients and recipients of hematopoietic stem cell transplant (HSCT).

This vaccine should be given to geriatric patients with anatomic or functional asplenia or persistent complement component deficiency. Booster doses are given to these patients every five years.

This vaccine is recommended for patients who lack documentation of previous immunization. A Td booster is repeated every 10 years.

This vaccine is recommended in patients 60 years and older. Patients are given a one-time dose if unvaccinated or even if they had a previous history of herpes zoster or chickenpox.

Visual acuity

The prevalence of visual acuity impairment is approximately 9% among older adults and can lead to significant risk for falls and a reduction in life quality. The most common reasons for visual impairment are refractive error, cataracts, and age-related macular degeneration. Risk factors for most forms of visual impairment are age. Other risk factors for cataracts include smoking, corticosteroid use, alcohol use, diabetes, exposure to ultraviolet light, and African-American race. Smoking, family history, and Caucasian race are associated risk factors for age-related macular degeneration.

Screening for visual acuity impairment with a validated visual test is a method that can be performed in the primary care office. The American Congress of Obstetrics and Gynecology (ACOG) recommends evaluation and counseling about visual acuity screening for all women aged 65 and older.[14]

Hearing acuity

The most common cause of hearing loss is aging. Prevalence rates of up to 30% are found in the age group 65–74, and up to 45% in adults 75 years and older.[15, 16] Hearing loss can be due to a variety of reasons including congenital and various acquired reasons such as infection, loud noise, ototoxic medications, and head injury. Tinnitus or problems understanding speech are early signs. In the geriatric patient, presbycusis usually happens slowly over time and in both ears.

Screening tests can be utilized in the office. Visual inspection looking for anatomical abnormalities and signs of infection should be the first step. Additional assessment of the patient’s hearing can be accomplished with physical diagnostic tests such as the whispered voice and finger rub near the ears. Screening questionnaires such as the Self-assessment of Communication (SAC) or the Hearing Handicap Inventory for the Elderly Screening Version (HHIE-S) may be used.[17] Screening should occur every three years.

Dental health

Geriatric patients are at risk for chronic oral conditions such as dental caries, periodontitis, benign mucosal lesions, and oral cancer. Increasing evidence exists that poor oral health can be associated with diabetes, cardiovascular disease, pneumonia, rheumatologic diseases, and wound healing.[18] Dental visits should be encouraged during gynecologic office visits.

Preventative screening for early detection of oral cancer may identify individuals with pre-cancerous lesions such as leukoplakia. Screening can be targeted to high-risk populations including individuals with a history of tobacco and alcohol usage. The most common screening method is visual inspection. There is no evidence that the use of adjunctive technologies such as toluidine blue, brush biopsy, or fluorescence imaging are useful to reduce oral cancer mortality.[19] The Cochrane review concluded some evidence exists that visual inspection might reduce the death rate in this high-risk population.[20]

Cardiovascular health

Cardiovascular disease is the leading cause of mortality and accounts for 42% of all deaths in people over 65. Preventive strategies to avoid development and complications of cardiovascular disease, including management of hypertension and lipid disorders, are most effective in prolonging the lifespan of the elderly.

Mental health and cognition

After age 75 formal functional and cognitive status screening should be assessed, and a team approach should be utilized to make age appropriate decisions regarding care.[26] There is some cognitive decline in all patients as they age. Memory changes are the most commonly reported cognitive complaint in elderly patients; however, remote memory is relatively preserved. Older patients report less ability to learn or retain new information compared to younger individuals. History taking should be slow paced and follow-up instructions should be written for geriatric patients.

Many forms of dementia exist. Alzheimer’s disease is the most prevalent of the primary neurodegenerative disorders. It is characterized by progressive memory decline in the absence of other medical or psychiatric causes. Confirmation of Alzheimer’s disease is proven by neuropsychological testing with significant deficiency in two or more areas of cognition.[27] In addition to Alzheimer’s disease, other medical conditions may impact cognitive function, including hypertension, diabetes, nutritional deficiencies, delirium, and medical problems resulting in oxygen deprivation including chronic obstructive pulmonary disease and obstructive sleep apnea. Depression is common in the elderly and can affect mental function. Medications including opiates, benzodiazepines, anticonvulsants, and antidepressants may also affect cognitive status. Mini cognition tests, six item screener test, and naming test have all been proposed as initial assessment tools in geriatric gynecology.[28] Reversible causes should be identified and treated, and medical conditions should be optimized.

Bone health

Avoiding bad habits, risk reduction strategies

Avoiding behavior with adverse health consequences is also important during the aging process. In the Nurses Health Study, middle-aged women who were normal weight, with a healthy diet and exercise routine, who did not smoke and consumed only moderate amounts of alcohol, had a significant reduction in their risk of coronary events compared to their counterparts.[31, 32]

Smoking cessation is discussed in Chapter 40. Moderate alcohol consumption, not exceeding two 8-ounce drinks per day, may have some survival benefit in relation to cardiovascular disorder. Excessive consumption can be associated with organ system dysfunction, including gastrointestinal effects (GI bleeding, esophageal and liver disorders), cardiovascular compromise (cardiomyopathy), and neurologic impairment (seizures, cerebellar degeneration, peripheral neuropathy, and cognitive disorders).[32]

Polypharmacy or the use of multiple medications in which some are redundant or not clinically indicated is a common problem in elderly populations. Recognition of this problem and coordinated care across medical disciplines can help avoid harmful drug interaction or overtreatment of medical conditions.

Avoidance of other risky behaviors should also be advised. Exposure to ultraviolet light may increase risk of cataracts and skin cancer. Sleep deprivation, cell phone use while driving, impaired reaction time, and lack of seat belt use may contribute to injury in motor vehicle accidents.