CDP20 • Renewal Course ONLY for Certified Dementia Practitioner Certification

Table of Contents

CDP20 • Renewal Course ONLY for Certified Dementia Practitioner Certification

How to Receive Credit

NetCE 2 Hour Course #96102 • Frontotemporal Dementia

96102 • Frontotemporal Dementia

1. INTRODUCTION

2. EPIDEMIOLOGY OF FTD

3. PATHOGENESIS AND PATHOPHYSIOLOGY OF FTD

4. CLINICAL PRESENTATION

5. GENETICS AND FTD

6. MANAGEMENT OF FTD

7. PROGRESSION OF FTD

8. RESEARCH RELATED TO FTD

9. CASE STUDY

10. CONCLUSION

11. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 3 Hour Course #99354 • Aging and Long-Term Care

99354 • Aging and Long-Term Care

1. INTRODUCTION

2. AN OVERVIEW OF OLDER ADULTS IN THE UNITED STATES

3. BIOLOGIC PROCESSES AND PHYSICAL WELL-BEING IN OLDER ADULTS

4. CHALLENGES AND ADJUSTMENTS ASSOCIATED WITH AGING

5. SPECIAL POPULATIONS

6. LONG-TERM CARE

7. ASSESSMENT TOOLS FOR OLDER ADULTS

8. GENERAL GUIDELINES FOR INTERVENTIONS

9. ETHICAL PRACTICE WITH OLDER ADULTS

10. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 5 Hour Course #99204 • Geriatric Failure to Thrive: A Multidimensional Problem

99204 • Geriatric Failure to Thrive: A Multidimensional Problem

1. INTRODUCTION

2. DEFINITIONS

3. REGULATORY AND LEGAL ISSUES

4. ASSESSING FOR GERIATRIC FAILURE TO THRIVE

5. DEVELOPING A TREATMENT PLAN

6. MONITORING AND FOLLOW-UP

7. HOSPICE

8. CASE STUDIES

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

CDP20 • Renewal Course ONLY for Certified Dementia Practitioner Certification

Lauren E. Evans, MSW

Ellen Steinbart, RN, MA

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

CDP20 • Renewal Course ONLY for Certified Dementia Practitioner Certification

Expiration Date: 10/31/2024

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

96102 • Frontotemporal Dementia

Lauren E. Evans, MSW

Ellen Steinbart, RN, MA

www.netce.com

Copyright © 2021 NetCE, All rights reserved.

Frontotemporal dementia (FTD) is a group of degenerative brain disorders causing progressive deterioration in behavior, language, and/or movement. There are presently approximately 60,000 people with FTD in the United States. Onset generally occurs between 50 and 70 years of age, making FTD one of the most common presenile dementias. FTD affects the frontal and temporal lobes of the brain, which control emotions, judgment, personality, memory and language. The clinical diagnosis of FTD can be challenging, as some symptoms overlap with Alzheimer disease and other forms of dementia. FTD can be categorized based on its primary symptoms into three basic types: behavioral variant FTD, primary progressive aphasia, and progressive motor decline. Although most FTD does not appear to be inherited, genetics does play a role in a significant minority of cases. There is no effective treatment or cure for FTD, but there are strategies for management of symptoms. This course will discuss the possible causes and pathophysiology, diagnosis, and management strategies for FTD.

Table of Contents

96102 • Frontotemporal Dementia

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. EPIDEMIOLOGY OF FTD

3. PATHOGENESIS AND PATHOPHYSIOLOGY OF FTD

4. CLINICAL PRESENTATION

BEHAVIORAL PRESENTATION

LANGUAGE PRESENTATION

FTD OVERLAP WITH MOVEMENT DISORDERS

CLINICAL DIAGNOSIS OF FTD

5. GENETICS AND FTD

6. MANAGEMENT OF FTD

CAREGIVER SUPPORT

7. PROGRESSION OF FTD

8. RESEARCH RELATED TO FTD

9. CASE STUDY

10. CONCLUSION

11. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

96102 • Frontotemporal Dementia

Education Category. Psychiatric / Mental Health

Release Date. 11/01/2021

Expiration Date. 10/31/2024

Course Overview

Frontotemporal dementia (FTD) is a group of degenerative brain disorders causing progressive deterioration in behavior, language, and/or movement. There are presently approximately 60,000 people with FTD in the United States. Onset generally occurs between 50 and 70 years of age, making FTD one of the most common presenile dementias. FTD affects the frontal and temporal lobes of the brain, which control emotions, judgment, personality, memory and language. The clinical diagnosis of FTD can be challenging, as some symptoms overlap with Alzheimer disease and other forms of dementia. FTD can be categorized based on its primary symptoms into three basic types: behavioral variant FTD, primary progressive aphasia, and progressive motor decline. Although most FTD does not appear to be inherited, genetics does play a role in a significant minority of cases. There is no effective treatment or cure for FTD, but there are strategies for management of symptoms. This course will discuss the possible causes and pathophysiology, diagnosis, and management strategies for FTD.

Audience

This course is designed for physicians, nurses, and allied health and mental health professionals who may intervene to support patients with frontotemporal dementia and their families.

Accreditations & Approvals

In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is approved by the California Nursing Home Administrator Program as a provider of continuing education. Provider number 1622. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 2 ANCC contact hour(s). NetCE designates this continuing education activity for 1 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 2.4 hours for Alabama nurses. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. This home study course is approved by the Florida Board of Nursing Home Administrators for 2 credit hour(s). This course is approved by the California Nursing Home Administrator Program for 2 hour(s) of continuing education credit - NHAP#1622002-9389/P. California NHAs may only obtain a maximum of 10 hours per course. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program. AACN Synergy CERP Category A.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through July 29,2025); Alabama, Provider #ABNP0353, (valid through July 29, 2025); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2025; South Carolina, Provider #50-2405; South Carolina, Provider #50-2405. West Virginia RN and APRN, Provider #50-2405.

Special Approvals

This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to provide healthcare professionals with current information on frontotemporal dementia (FTD). Understanding the epidemiology, pathology, clinical features, diagnostic process, genetics, symptom treatment/management, role of brain autopsy, and current research provides a foundation for the care of patients with FTD and support for their families.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe the epidemiology of frontotemporal dementia (FTD) in the United States.

2. Explain the brain changes of FTD and their general clinical manifestations.

3. Identify the three general presentations of FTD.

4. Review how a clinical diagnosis of FTD is made, including differentiation from Alzheimer disease.

5. Summarize the role of genetics in FTD.

6. Discuss strategies for managing symptoms of FTD and providing support to family caregivers.

7. Identify goals of current research on FTD.

Faculty

Ellen Steinbart, RN, MA, received a Bachelor of Arts from Macalester College in 1972, a Bachelor of Science in Nursing from Cornell University-New York Hospital School of Nursing in 1974, and a Master of Arts from the University of Washington School of Nursing in 1979. She worked as a hospital medical-surgical nurse and an intensive-care burn unit nurse, and she taught medical-surgical nursing at the University of Washington School of Nursing. For 25 years, she was a research nurse at the University of Washington, coordinating research projects on the role of genetics in dementia, including frontotemporal degeneration. She is now retired.

Lauren E. Evans, MSW, received her Master’s degree in Social Work from California State University, Sacramento, in 2008. Her focus was on political and community social work. She has also been a Registered International Instructor of Therapeutic Horseback Riding through the Professional Association of Therapeutic Horsemanship International (PATH Intl.) since 2006. She currently works as a mental health practitioner with the homeless population.

Faculty Disclosure

Contributing faculty, Ellen Steinbart, RN, MA, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Contributing faculty, Lauren E. Evans, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Jane C. Norman, RN, MSN, CNE, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Frontotemporal dementia (FTD) is a group of degenerative brain disorders characterized by behavior and language problems and also overlapping with some motor/movement diseases. FTD causes progressive deterioration in a person's ability to function as the result of damage to the frontal and temporal lobes of the brain. FTD is also referred to as frontotemporal degeneration, frontotemporal lobar degeneration, and Pick disease.

Dr. Arnold Pick, a Czech neurologist, psychiatrist, and neuropathologist, first described frontal and temporal lobe atrophy causing dementia and progressive aphasia in 1892 [1]. The clinical syndrome subsequently became known as "Pick disease." FTD is the third leading cause of dementia across all age groups, after Alzheimer disease (AD) and Lewy body dementia [2]. It is one of the most common causes of early-onset dementia, with onset typically between 45 and 64 years of age [2,3].

The clinical presentation of FTD can be complex, and obtaining an accurate diagnosis can be challenging. The unique clinical symptoms of FTD, neuropsychologic assessment, and brain imaging can help distinguish it from AD and other dementias. There is presently no effective treatment for FTD, and symptom management can be challenging for healthcare providers and family caregivers. Research is in progress to better understand FTD, hopefully leading to effective treatment, cure, and prevention of this devastating disease.

2. EPIDEMIOLOGY OF FTD

It is estimated that FTD affects approximately 60,000 people in the United States [3]. As noted, the age of onset for FTD is typically 45 to 64 years, with a mean of 58.5 years and a reported range between 21 and 80 years of age [2,3,4,5]. In the United States, the prevalence in people 45 to 64 years of age is estimated at 15 to 22 per 100,000 population; the incidence in this group is 2.7 to 4.1 per 100,000 [5]. It is estimated that 60% of those with FTD have onset between 45 and 64 years of age; 10% have onset before 45 years of age, and 30% have onset after 64 years of age [5]. FTD is now considered by some to be the most common form of pre-senile dementia in patients younger than age 60, even more common than AD in this group [6,7,8].

FTD affects both men and women. However, it is unclear if men and women are affected equally, or if some subtypes of FTD may be more common in one gender or the other [9]. Significant time (average: 3.6 years) often passes between symptom onset and actual clinical diagnosis [5].

The disease duration for FTD can range from 2 to 20 years from symptom onset to death, with a mean duration of 6 to 13 years [3,5]. Pneumonia is the most common cause of death [3].

3. PATHOGENESIS AND PATHOPHYSIOLOGY OF FTD

Patients with FTD experience a progressive loss of neurons in the frontal and anterior temporal lobes, resulting in atrophy in these areas of the brain. They may also develop gliosis in the frontal and temporal lobes where neurons have been lost or damaged.

In FTD, affected neurons have an abnormal accumulation of protein within the cell, called inclusions. Three types of intra-neuronal inclusions have been identified, based on the protein involved. In some cases, the inclusions are composed of an abnormal form of the protein tau. In other patients, the inclusions are composed of the transactive response DNA-binding protein 43 (TDP-43). In a smaller number of FTD cases, the inclusions are composed of fused in sarcoma (FUS) protein [10].

The frontal and anterior temporal lobes of the brain control executive functions (e.g., planning, organizing, abstract thinking, judgment, decision making), personality, social behavior, and language. The changes associated with FTD causes impairments in executive function, personality, behavior, and/or language. The location of the neurodegeneration correlates fairly well with the clinical presentation [10]. Changes in other areas of the brain may cause overlapping movement problems. While the cause of most cases of FTD is not known, some cases are now known to be caused by genetic mutations.

4. CLINICAL PRESENTATION

FTD causes a gradual, progressive decline in behavior and/or language; movement disorders may also be involved. Behavior or language problems are typically the first and most prominent symptoms of FTD, whereas memory problems are the first symptoms of AD [5]. Subtypes of FTD have been identified based on clinical presentation (Table 1). Behavioral variant FTD (bvFTD) is the most common form and involves changes in behavior, personality, and emotions. Language presentations are referred to as primary progressive aphasia (PPA) and can take one of three forms: nonfluent/agrammatic variant PPA (nfvPPA), semantic variant PPA (svPPA), or logopenic variant PPA (lvPPA) [11]. Nonfluent/agrammatic PPA begins with problems in speech production, while svPPA involves impaired word comprehension and object recognition and lvPPA involves word-finding problems. A movement presentation may appear as progressive supranuclear palsy (PSP), corticobasal syndrome (CBS), or motor neuron disease (MND). Some patients may present with symptoms that overlap the different subtypes of FTD or may develop symptoms of other subtypes of FTD as the disease evolves. As more is learned about FTD, the terminology and classification of the subtypes may be revised.

Table 1: FORMS OF FRONTOTEMPORAL DEGENERATION

Behavioral presentation

- Behavioral variant FTD (bvFTD)

Language presentation, variants of primary progressive aphasia (PPA)

- Nonfluent/agrammatic PPA (nfvPPA), previously called progressive non-fluent aphasia (PNFA)

- Semantic variant PPA (svPPA), previously called semantic dementia (SD)

- Logopenic variant PPA (lvPPA) (often found to have Alzheimer disease pathology at autopsy)

Associated movement disorders (not classified as FTD, but have shared symptoms)

- Corticobasal syndrome (CBS)

- Progressive supranuclear palsy (PSP)

- Motor neuron disease, also called amyotrophic lateral sclerosis (FTD/MND or FTD/ALS)

Source: Compiled by Author

BEHAVIORAL PRESENTATION

Behavioral Variant FTD

As noted, bvFTD is the most common type of FTD, estimated to account for more than half of all cases [12]. The prominent features include disinhibition, apathy/inertia, loss of empathy, compulsive behaviors, hyper-orality, and impaired executive function (Table 2) [13]. People with FTD may become socially withdrawn, inflexible, and impulsive. They may have a shortened attention span and a tendency to be easily distracted. Behavior may become socially inappropriate. People with bvFTD are usually unaware of the changes in their personality and behavior and the impact these changes have on others. Memory and visual-spatial functioning are initially relatively spared in bvFTD. Some individuals with bvFTD may develop symptoms similar to Parkinson disease, such as bradykinesia, rigidity, postural instability, and masked face.

Table 2: BEHAVIORAL VARIANT FTD

Major Clinical Features

Examples

Disinhibition

Making inappropriate comments, taking food off someone else's table at a restaurant, telling sexual jokes, shoplifting, hitting

Apathy

Less involved in old hobbies or activities, deterioration in personal hygiene

Loss of empathy

Indifferent when a family member is hurt

Compulsive behaviors

Repeating the same phrase, clapping hands in the same pattern repeatedly, checking the time repeatedly

Hyper-oral behaviors

Overeating, eating one certain type of food, eating excessive sweets

Impaired executive function

Poor performance at work, poor financial decisions, difficulty planning and preparing a meal

Source: Compiled by Author

LANGUAGE PRESENTATION

Nonfluent/Agrammatic Variant PPA

Nonfluent/agrammatic variant PPA, also referred to as progressive non-fluent aphasia (PNFA), accounts for about 25% of all FTD cases and involves problems with language expression [12]. People with nfvPPA have difficulty producing speech but retain the meaning of words and know what they want to say. As a result, speech may become hesitant, slow, and labored. Speech patterns may be "agrammatic" or "telegraphic," meaning that only the most important content words are used, without connecting words. For example, a patient might say "Tuesday…hospital…sister." Patients with nfvPPA have difficulty talking on the telephone and tend to talk progressively less. Eventually, some may become mute. While in the early stages, these patients continue to understand the speech of others, but this comprehension is eventually lost also. Reading and writing skills are better preserved than speech, although these abilities are also eventually lost. As the disease progresses, patients may develop behavioral symptoms. Some individuals with nfvPPA may develop extrapyramidal symptoms of rigidity and tremors, as seen in CBS and PSP.

Semantic Variant PPA

Semantic variant PPA, also referred to as semantic dementia, represents about 20% of FTD cases [12]. Semantic variant PPA involves the loss of understanding of the meaning of words and objects. Speech is still fluent and grammatically correct, but people with svPPA have a declining ability to comprehend the meaning of words (especially nouns) or to recognize familiar objects or faces. For example, a person with svPPA who is very familiar with vegetables might read a menu and ask: "What is broccoli?" If shown a picture of a carrot, the patient may not be able to name it and may not recognize the word when told. There are progressive word-finding problems, reading and spelling skills decline, and retrieving names becomes difficult. Later in the disease, people with svPPA may develop behavioral changes similar to those seen in patients with bvFTD.

Logopenic Variant PPA

Logopenic variant PPA is characterized by difficulty retrieving words, resulting in slow speech with frequent pauses. These patients may also have trouble repeating long phrases and understanding complex sentences. Eventually, people with lvPPA may become mute. Reading and writing skills are initially preserved, but these decline as the disease progresses. People with lvPPA have word-finding problems similar to people with AD and are often found to have AD pathology at autopsy [8].

For all patients with suspected language presentations of FTD, it is important to consider the role of culture and preferred language.

FTD OVERLAP WITH MOVEMENT DISORDERS

Progressive Supranuclear Palsy

PSP is a neurodegenerative condition characterized by problems with gait and balance, causing postural instability, falls, and difficulty with eye movement coordination. The pathophysiology of PSP shows a loss of cells in the basal ganglia, substantia nigra, subthalamus, and brainstem, and affected neurons have inclusions composed of abnormal tau protein. There are similarities between PSP and Parkinson disease, including bradykinesia, rigidity, masked face, dysarthria, dysphagia, apathy, and depression. Some people with PSP develop behavioral problems, but these are often milder than those seen in other types of FTD. Some people with PSP may develop progressive memory and language problems, and there may be a decline in executive function.

Corticobasal Syndrome

CBS is a neurodegenerative condition that may initially present with movement problems, dementia, or both. In CBS, there is atrophy in multiple areas of the brain, including the frontoparietal regions, basal ganglia, and cerebral peduncles. Neuronal inclusions are usually composed of abnormal tau protein. Signs of CBS typically begin with decreased movement on one side of the body, muscle rigidity, and tremor. A hand, arm, or leg on the affected side may demonstrate apraxia (i.e., inability to make the limb follow commands). Patients may describe the affected limb as not feeling like a part of their body, a sensation referred to as "alien limb syndrome." Symptoms may become bilateral as the disease progresses. People with CBS may also experience personality changes, executive dysfunction, and language problems as the disease progresses.

FTD with Motor Neuron Disease

Approximately 15% of people with FTD also develop problems with motor neurons that control voluntary movement [10]. This is referred to as FTD with motor neuron disease (FTD/MND) or FTD with amyotrophic lateral sclerosis (FTD/ALS). Pathologically, in addition to frontal and temporal lobe atrophy, there is also atrophy in the motor regions of the cortex and loss of motor neurons in the brain stem and spinal cord. In FTD/MND, damaged neurons usually have abnormal inclusions composed of the protein TDP-43. Patients may present with behavior or language problems, but then additionally develop muscle problems, including weakness, stiffness, twitches, cramps, and/or atrophy. Muscle problems can affect arms, legs, face, mouth, and tongue, causing patients to experience clumsiness, dysphagia, dysarthria, and hyper-reflexia. An estimated 15% of patients with MND or ALS go on to develop behavioral and executive dysfunction symptoms of FTD as their disease progresses [10].

CLINICAL DIAGNOSIS OF FTD

The diagnosis of FTD can be challenging because of the wide range of symptoms, the relatively early age of onset, and the slow progression. There is no single test to diagnose FTD, and it may be initially misdiagnosed as a psychiatric disorder (e.g., depression, schizophrenia), AD, Parkinson disease, or vascular dementia. Accurate diagnosis of FTD is important because some of the medications used to treat these other diseases may be detrimental to patients with FTD. Patients with suspected FTD are often referred to neurologists or neuropsychologists with special expertise in FTD and related neurodegenerative disorders for a comprehensive evaluation.

The clinical diagnosis of FTD is based on the clinical history, family history, neurologic examination, neuropsychologic evaluation, and neuroimaging. Other tests may also be performed for differential diagnosis. The diagnostic process may take time, and the diagnosis may change as more tests are done or as new symptoms appear.

The clinical history is obtained from the patient and his/her family or friends. It is important that family or friends provide information regarding symptoms, as patients are often unaware of their behavior changes.

The family history should focus on whether any other relatives have had a neurodegenerative disease. Any cases of dementia, language problems, or movement disorders should be noted, along with specific information about symptoms, diagnosis, age of onset, course of disease, age at death, and autopsy findings. Such background information may be valuable for both diagnosis and understanding genetic risk.

The neurologic examination typically includes assessment of the patient's general appearance and speech, mental status, cranial nerves, motor system, sensation, reflexes, and cerebellar function (coordination and balance). Consulting a neurologist who has knowledge and experience in FTD can be valuable when reaching a definitive diagnosis.

The neuropsychologic examination assesses brain function and may identify areas of the brain that have been damaged. It typically involves an interview and the administration of written tests. These tests may focus on attention and concentration, memory, orientation, language, visual-spatial abilities, and/or executive functions (e.g., reasoning, planning, organizing, problem solving). Patients with FTD may show deterioration in the areas of attention and concentration, language, and executive function, but may do relatively well on memory and visual-spatial tests.

The Neuropsychiatric Inventory (NPI) may be administered to caregivers of patients with suspected FTD. This survey helps assess behavior and psychopathology by inquiring about the patient's delusions, hallucinations, agitation/aggression, dysphoria, anxiety, euphoria, apathy, disinhibition, irritability, unusual motor activity, nighttime behavioral problems, and eating abnormalities.

Brain scans are important tools in the diagnosis of FTD. Computed tomography (CT) may be done to determine if there is a tumor, hemorrhage, or other brain injury that could account for the symptoms. Magnetic resonance imaging (MRI) provides better visualization of the brain than CT and is often done to evaluate brain atrophy when FTD is suspected. Patients with FTD have progressive frontal and anterior temporal atrophy apparent on MRI. Typically, in bvFTD, there is atrophy of the frontal lobe (involved in personality, judgment, and executive function) and the anterior temporal lobe. In nfvPPA, there is left frontal lobe atrophy (involved in speech production). In svPPA, the atrophy is focused in the anterior temporal lobe (involved in language and face recognition). In specialty or research centers, positron emission tomography (PET), single photon emission computed tomography (SPECT), or functional MRI (fMRI) brain scans may be done to further evaluate brain functioning.

While there is no laboratory test that can diagnose FTD, some tests may be ordered to rule out other diseases with symptoms similar to those of FTD. Blood work may be ordered to identify dehydration, thyroid disease, vitamin B12 deficiency, or infections affecting the brain. An electroencephalogram (EEG) may be done if there is concern that seizures might be causing the patient's symptoms. In the early stages of FTD, EEG findings are usually normal or have non-specific findings. Lumbar puncture may be done to evaluate cerebral spinal fluid and rule out rare brain infections or cancer. Electromyography may be used to identify muscle weakness or myoclonus if MND (or ALS) is being considered as a possible diagnosis. In addition, language evaluation by a speech pathologist can be an important tool in diagnosing patients with nonfluent/agrammatic, semantic, or logopenic variant PPA.

It may be challenging to clinically differentiate FTD from early AD (Table 3). The only way to establish an unquestionable diagnosis of FTD is through a brain autopsy after a patient has died. Examination of the brain tissue will show the precise location and severity of the brain atrophy, and microscopic studies can determine the protein composition of the inclusions in affected neurons.

Table 3: EARLY SIGNS AND SYMPTOMS OF FTD VERSUS ALZHEIMER DISEASE

Clinical Features

FTD

Alzheimer Disease

Hallmark

Decline in behavior, language, and/or movement; memory is retained initially

Decline in memory; socially appropriate behavior is retained initially

Initial language problems

May involve speech production, understanding words and recognizing familiar objects, or retrieving words

Word-finding or name recall

Age at onset

Usually 45 to 64 years of age

Usually 65 years of age or older

Movement problems

May have early movement disorder, with gait and balance problems, rigidity, apraxia, or muscle weakness

Usually no movement problems early in disease

Source: [3,8,14]

For families, brain autopsy can confirm the diagnosis (or identify a different cause of the dementia) and bring a measure of closure. Accurate diagnosis may be especially important if there is concern about genetic risk to other family members.

Discussion about brain autopsy should be handled delicately and with compassion at a time that is appropriate for the family; the subject may be emotionally difficult for some families. Introducing the topic ahead of time allows families to consider their feelings about brain autopsy aside from the emotional crisis of the death of a loved one and the immediate time pressure of funeral arrangements. Families may then discuss the topic among themselves and come to a consensus.

Should a family wish to have a brain autopsy done when the patient dies, the physician can help identify a pathology service experienced in neurologic disorders and preliminary logistical planning can be done ahead of time. Arrangements may be coordinated with a research center that specializes in brain autopsy for FTD. The autopsy is done as soon as possible after death, often within 6 to 24 hours. The procedure is not disfiguring, so open-casket funerals may be planned if the family so chooses.

In addition to answering families' questions regarding diagnosis, brain autopsy can also aid researchers in better understanding the correlation between the clinical signs of FTD and the pathologic changes in the brain. This may benefit future generations by improving diagnosis and advancing research on therapies for FTD.

5. GENETICS AND FTD

Understanding of the role of genetics in FTD is still evolving. Presently, it appears that most cases of FTD (approximately 60%) are sporadic, meaning one person in a family has the disease, there is no family history of any relative with the disease, and the disease does not appear to be inherited.

However, approximately 40% of those with FTD report a family history of one or more relatives with a neurodegenerative disease [6,9,10]. This is referred to as familial FTD. In some cases of familial FTD, no specific genetic mutation can be identified as the cause. The risk to family members of a person with familial FTD without an identified genetic mutation is increased over the general population, but the specific increased risk is unclear.

An estimated 10% to 20% of all FTD cases are caused by an inherited genetic mutation [6,8]. Patients with a strong family history of multiple relatives with FTD and/or MND are more likely to have an inherited form of FTD caused by a genetic mutation. Genetic mutations causing FTD are inherited in an autosomal dominant inheritance pattern, meaning each child of an affected parent is born with a 50% chance of inheriting the genetic mutation.

Several specific genetic mutations have been identified as being implicated in inherited FTD. In 1998, the first gene associated with hereditary FTD—the microtubule-associated protein tau (MAPT) gene on chromosome 17—was discovered [15,16]. Mutations in this gene cause an abnormal accumulation of tau protein in affected neurons. MAPT mutations are thought to account for 2% to 11% of familial FTD cases [17]. These mutations most commonly cause bvFTD but may also cause svPPA, PSP, and/or CBS. FTD symptoms may vary widely, even within families.

In 2006, mutations in the progranulin (GRN) gene on chromosome 17 were discovered to cause FTD [18,19]. Mutations in the GRN gene cause abnormal accumulations of TDP-43 protein in affected neurons. GRN mutations are thought to represent about 5% to 10% of all inherited FTD cases [17]. They most commonly cause bvFTD, but are also associated with nfvPPA and CBS. GRN mutations appear to have decreased penetrance, meaning that, for unknown reasons, some people with the mutation may not develop symptoms of the disease.

In 2011, the genetic mutation C9orf72 was discovered on chromosome 9 [20,21]. Mutations in C9orf72 cause an abnormal accumulation of TDP-43 in affected neurons. To date, C9orf72 mutations are the most common genetic cause of FTD, found in about 25% of familial FTD and 6% of sporadic cases [22]. C9orf72 mutations appear to cause FTD (usually bvFTD or language presentation), MND, and a combination of FTD and MND.

Other very rare genetic mutations have also been associated with FTD. Mutations in the gene valosin-containing protein (VCP) on chromosome 9, charged multivesicular body protein 2B (CHMP2B) on chromosome 3, TAR DNA-binding protein (TARDBP), FUS, TBK1, EXT2, and SQSTM1 have been associated with FTD [29].

Clinical genetic testing is available for the MAPT, GRN, and C9orf72 genetic mutations causing hereditary FTD, as well as some of the other very rare genetic mutations. Genetic testing may be ordered after informed consent and clear discussion of the implications with the patient and his/her family. For patients with FTD, identification of a genetic mutation confirms the diagnosis of FTD and provides information about risk to other family members. Each of the patient's siblings and each of the patient's children would be at 50/50 risk for having inherited the genetic mutation causing FTD. If a genetic mutation causing FTD is identified, other at-risk family members may be tested.

If a genetic mutation causing FTD is identified in a patient with FTD, unaffected at-risk family members could choose to have pre-symptomatic (predictive) genetic testing done to determine if they have inherited the genetic mutation that would someday cause FTD. Individuals considering pre-symptomatic genetic testing are referred for formal professional genetic counseling to help them make the best decision regarding whether or not to learn their FTD genetic status.

6. MANAGEMENT OF FTD

There is presently no treatment to slow the progression of or cure FTD. No medication has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of FTD; however, medications used to treat other disorders may be prescribed off-label for the management of FTD symptoms. Their use may be limited by the potential adverse effects. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), may be prescribed for behavioral symptoms of FTD, and low-dose trazodone has been used for agitation and aggression [9]. While the anticholinesterase inhibitors donepezil, galantamine, and rivastigmine are beneficial for some patients with AD, they generally have not been helpful for patients with FTD [9]. The glutamate NMDA receptor antagonist memantine, used for moderate-to-severe AD, has been used for patients with FTD as well, but a 2013 study showed that it provided no benefit to patients with FTD and that it may be harmful to cognition [23]. Antipsychotics are occasionally used to treat significant agitation and behavioral symptoms, but only with caution, as antipsychotics can have serious adverse effects such as extrapyramidal adverse effects (parkinsonism), depression, sedation, falls, incontinence, and disinhibition, and patients with FTD may have an increased susceptibility to the these effects [9]. Elderly patients with dementia who take antipsychotics have a 1.6- to 1.7-fold increase in mortality secondary to cardiac problems or infection, prompting the FDA to issue a warning about their use in older patients with behavioral disturbances [9]. L-DOPA has shown a minimal response for parkinsonism in patients with PSP and CBD [28]. Research is being done to further evaluate the use of available medications for the management of FTD and to find new, more effective treatments.

Evidence Based Practice Recommendation

According to the Royal Australian and New Zealand College of Psychiatrists, general principles of dementia care apply for the management of frontotemporal dementia, but specific issues relate to the early onset of the illness in middle life and that affected persons may lack insight into their deficits leading to occupational and social problems.

https://journals.sagepub.com/doi/abs/10.1177/1039856215582276

Last Accessed: October 15, 2021

Strength of Recommendation/Level of Evidence: Expert Opinion/Consensus Statement

Management of FTD includes providing care to patients with FTD and support to their families. Caring for a person with FTD involves managing the symptoms, keeping the patient safe, and providing help in activities of daily living.

Apathy is a common symptom in patients with bvFTD, often resulting in neglect of their personal hygiene and grooming. Supervision, encouragement, and help with bathing, dressing, and grooming may be needed. For behavioral problems, simple interventions like distraction (e.g., introducing a new activity) may help interrupt the troublesome behavior. For some patients, modification of the environment or behavior may help minimize the potential for harm. For example, if the patient is pacing, creating a safe route for him or her to walk can be helpful. Physical therapists may be able to help develop an exercise program to maintain mobility. Exercise has also been shown to improve mood and cognition and may improve behavior management in patients with dementia [24]. If behaviors such as agitation or aggression become severe, a medication may be prescribed off-label to control difficult or dangerous behaviors. Supervision may be necessary to ensure patients take medications as prescribed.

Some individuals with FTD have eating problems, such as overeating, eating just one type of food, or craving sweets. For these patients, it may be necessary to monitor weight and provide help with meal preparation to provide a balanced, nutritious diet. Access to additional foods, drinks, or sweets should be limited.

Speech pathologists or therapists may be helpful in diagnosing the specific language problems exhibited by patients with FTD, including nonfluent/agrammatic, semantic, or logopenic variant PPA. Speech therapy may also help patients to find new communication strategies, such as sign language, carrying cards with specific messages, or using a computer with pre-programmed words or phrases [25]. Such techniques may help those with language problems communicate with family and friends. Speech therapists may also be able to evaluate and address swallowing problems, if these arise.

Caring for a patient with FTD includes maintaining a safe environment for the patient and for those around him/her. A structured environment and keeping the daily routine the same is often helpful. In addition, persons with FTD should no longer drive, and safety measures should be taken at home, especially in the kitchen and bathroom. If a patient with FTD shows aggression, disinhibition, or poor judgment, close supervision is necessary when he/she is around others, especially children or the frail elderly, to prevent them from being inadvertently harmed.

It also may be necessary to monitor the patient's behavior in public places. If an individual displays inappropriate behavior, tense situations may be diffused by explaining that he or she has FTD and cannot control his/her behavior. Simple cards with this brief explanation can be made, carried, and shared with people who might be disturbed by a patient's inappropriate behavior.

If a patient with FTD has gait and balance problems, measures should be taken to prevent falls. This may include keeping the home environment free of obstacles and loose rugs and installing shower bars and a raised toilet seat. Mobility aids may be helpful. Occupational therapists should provide intervention to help patients with FTD complete activities of daily living as the disease progresses.

CAREGIVER SUPPORT

FTD places enormous burdens on the family. Most dementia care is provided at home by family caregivers, often spouses. Caregivers for those with FTD face physical, emotional, and financial challenges. FTD caregiver burden, stress, and depression are greater even than that seen with AD [26,27].

The first challenge that families of those with FTD may face is obtaining an accurate diagnosis. The process can involve years of uncertainty and stress before the correct clinical diagnosis of FTD is made. Even during the diagnosis process, support for families begins with information and education about FTD. Accurate information can lead to understanding and a greater sense of control over the stressful situation. It is important for families and caregivers to understand that the behavior changes they observe are the result of the disease. Their loved one may display behaviors that are embarrassing, offensive, self-centered, uncaring, and aggressive, with complete lack of insight about how the behavior affects others. The caregiver may feel like he/she is suddenly living with a stranger.

The aggression, disinhibition, and poor judgment associated with FTD can put family members at risk of harm. Because FTD affects people at a relatively young age, there may still be children in the home. Families should recognize the risk to others in the home and seek help creating strategies to keep themselves and other family members safe.

Language may be impaired in people with FTD, making communication difficult. This can interfere not only with communication between the patient and the caregiver, but it can also limit participation in larger social activities. Speech therapy can provide new approaches to communication, helping not only the patient but also the caregiver.

Because FTD usually begins at a relatively young age, it can cause a significant financial burden for families. There may be loss of income, and retirement benefits may be affected because the patient is unable to continue working. Financial and legal issues that should be addressed include insurance, social security disability, financial planning for the future (when additional care will be needed), power-of-attorney arrangements, and a living will. Social workers, financial advisors, and attorneys are resources available to families to help address these issues.

The demands on caregivers increase as FTD progresses. Caregivers will be required to provide more supervision and increasing assistance for activities of daily living. While providing care for an individual with FTD, the caregiver may also be grieving the loss of his or her previously healthy loved one. Family caregivers can become physically and emotionally exhausted, and they may feel isolated in their role as caregiver. Interventions to help reduce caregiver stress include an individualized patient management plan, environmental changes to promote safety and facilitate care, and strengthening caregiver coping strategies and skills. Family caregivers should be encouraged to ask for and accept help in caring for their loved one with FTD, allowing them to take time for themselves and address their own health needs. Connection with community resources may also be helpful. Community resources for FTD caregivers include national organizations such as the Association for Frontotemporal Degeneration, attorneys and financial planners, social service programs, adult day care programs, respite care, support groups, and individual or family counseling.

Family caregivers should look ahead and consider how they wish care to be provided to their loved one as FTD progresses. Patients with FTD will become more dependent and more difficult to safely manage at home by a family caregiver as the disease progresses. Social workers can be a good resource to caregivers as they consider options such as extra in-home nursing care, care communities, and long-term care facilities. Locating an appropriate care facility that accepts patients with FTD can be challenging. These patients are often younger, stronger, and more active than the typical residents of care facilities. Facility staff may need education and support to understand the unique features of FTD and to learn how to provide care to these patients while maintaining a safe environment for all residents in the facility.

Nurses play an important role in caring for those with FTD and providing support to their families. Nurses interact with patients with FTD and their families in the outpatient clinic setting, in-home care setting, and long-term care facility and may be involved in monitoring symptoms, developing and implementing individualized patient care plans, and providing direct patient care. It is important for all healthcare providers to coordinate care for the patient with FTD. All members of the interdisciplinary healthcare team can support families by listening to them, providing ongoing information and education about FTD, offering guidance to improve caregiving skills, and helping families connect to appropriate resources.

7. PROGRESSION OF FTD

The prognosis for people with FTD is poor. FTD worsens progressively, usually over several years, and patients require increasing behavioral supervision and personal care. Eventually, people with advanced FTD become mute and bedbound and require full care at home or in a care facility. As patients with FTD become more debilitated, they are vulnerable to complications such as infections and falls. The most common cause of death in people with FTD is infection (e.g., pneumonia) [3,8]. The average duration of the disease is 6 to 13 years, but it can range from 2 to 20 years [3,5].

8. RESEARCH RELATED TO FTD

The goals for research on FTD include gaining a better understanding of the pathology; identifying causes and risk factors (genetic and environmental); improving the diagnosis of FTD through enhanced neuroimaging, biomarkers, and characterization of clinical features; developing therapies to treat, cure, or prevent FTD; and exploring new ways to support family caregivers. However, research on FTD is challenging. It is an uncommon disease, so awareness is low, there are fewer potential subjects available for research studies, and there is a relatively small market for medications. FTD is a complicated disease with a wide variety of presentations (behavior, language, and movement problems) and underlying causes (sporadic and genetic). Pathologically, microscopic brain inclusions may consist of different abnormal proteins (e.g., tau, TDP-43, FUS), but there are no good biomarkers to diagnose FTD or to monitor the progression of the disease. Drug development faces the challenge of creating a medication to treat FTD that can cross the blood/brain barrier.

Despite these challenges, the pace of research on FTD has accelerated rapidly. There are an increasing number of studies and a better awareness of the varied symptoms of FTD. In the past few decades, there have been discoveries of the genetic mutations underlying some causes of FTD and a growing understanding of the changes that occur in the brain of those with FTD. Presently, there are clinical trials underway for potential medications to treat FTD. Information on clinical research studies, including participation in studies, can be found at the National Institutes of Health website https://clinicaltrials.gov.

9. CASE STUDY

Patient A was a high school homecoming queen who completed two years of college, worked in an office, then married and had three children. She was an energetic homemaker and an active community volunteer, serving as school parent-teacher association president for several years, and was fastidious about her appearance.

Patient A's mother, three maternal uncles, a maternal grandfather, and great-grandmother died with dementia; her brother and maternal aunt are living with the disease. The mean age of onset of dementia in the family is 51 years, and the mean age at death is 67 years.

When Patient A is 52 years of age, her husband notices changes in her behavior. She often appears distracted, and her impeccable grooming declines. She is less affectionate toward him and she stops participating in community activities. She has difficulty making arrangements for a planned vacation. Her previously gourmet meals become simple, functional meals. She becomes obsessed with repeatedly raking the lawn, eventually killing all the grass in the yard. When her grandchildren visit, Patient A alternates between ignoring them and playing too rough. Patient A begins to impulsively leave the house for fast-paced walks, but she always returns home and never gets lost. She frequently visits a local shopping mall, getting down on her hands and knees looking for dropped change near the cash registers. She is once stopped by mall security for shoplifting. When shopping with her husband, she approaches strangers, stands inappropriately close to them, and announces "We don't know you."

Patient A's husband brings her to a dementia clinic for evaluation. A neurologic examination and neuropsychologic testing are completed. Memory and visual-spatial performance are in the normal range, but personality, judgment, and executive function show significant decline. A brain MRI shows frontal and anterior temporal lobe atrophy, and the diagnosis of familial bvFTD is made. Clinical genetic testing identifies a mutation in the MAPT gene on chromosome 17, the believed cause of the dementia.

Patient A's husband stops working in order to care for her at home. As her disease progresses, Patient A requires increasing care and supervision. She spends much of her day watching television, writing numbers in a notebook, and pacing. She develops a craving for sweets and often rummages through kitchen cabinets looking for candy. At mealtime, Patient A stuffs her mouth with food before chewing and swallowing properly, precipitating episodes of choking. She also develops a pattern of hand-clapping that she repeats every few minutes, along with the phrase "We haven't had any phone calls lately."

Patient A's husband is encouraged to accept help from others (such as their adult children), consider local adult day care programs, and utilize respite care at a nearby nursing home. He is in monthly phone contact with nursing staff to review symptoms and develop strategies for managing symptoms. At different times during her illness, Patient A is prescribed an antidepressant and an antipsychotic medication (off label) to treat difficult behavioral symptoms, but both were eventually discontinued. The family faces financial difficulties as a result of the husband's loss of income, diminished retirement benefits, and the later cost of nursing home care. Social work support helps the family address issues such as insurance, social security benefits, adult day care programs, and selecting a nursing facility for eventual long-term care.

When Patient A is 60 years of age, her husband is no longer able to care for her at home and she is admitted to a skilled nursing facility. She is incontinent and requires full care for all activities of daily living. Her husband visits twice daily, and she always appears to recognize him. That same year, Patient A dies unexpectedly of a myocardial infarction. A brain autopsy is done and confirms the diagnosis of FTD.

Patient A's husband shares the results of her genetic testing and autopsy with their three adult children. Each of Patient A's three children is at a 50% risk for having inherited the MAPT genetic mutation. Two of the children request pre-symptomatic genetic testing. The two children who request pre-symptomatic genetic testing are referred to professional genetic counselors. After genetic counseling, they both choose to have pre-symptomatic genetic testing done. One defers getting the results for two years, underscoring the very difficult personal decision it can be to choose pre-symptomatic genetic testing.

Patient A demonstrated the typical symptoms of bvFTD and her evaluation was done at a dementia center by specialists with expertise in FTD, so her initial diagnosis was strong. The neurologic evaluation, blood tests, neuropsychologic testing, and neuroimaging together led to the clinical diagnosis of bvFTD. Patient A's family history showed a pattern of autosomal dominant inheritance. The genetic cause of her FTD was confirmed by clinical genetic testing, which documented a mutation in the MAPT gene.

10. CONCLUSION

FTD is now recognized as one of the most common causes of dementia in persons younger than 65 years of age. This course has provided an overview of FTD epidemiology, pathophysiology, clinical presentation, diagnosis, management, prognosis, and current research. Understanding FTD can help healthcare professionals provide better care to patients with FTD and support to their families.

11. RESOURCES

Association for Frontotemporal Degeneration

2700 Horizon Drive, Suite 120

King of Prussia, PA 19406

(866) 507-7222

https://www.theaftd.org

National Institute on Aging

Building 31, Room 5C27

31 Center Drive, MSC 2292

Bethesda, MD 20892-2292

(800) 222-2225

https://www.nia.nih.gov

National Institute of Neurological Disorders and Stroke

P.O. Box 5801

Bethesda, MD 20824

(800) 352-9424

https://www.ninds.nih.gov

Works Cited

1. Pick A. Ueber die Beziehungen der senile Hirnatrophie zur Aphasie. Prager Medicinische Wochenschrift. 1892;17(16):165-167.

2. Arvanitakis Z. Update on frontotemporal dementia. Neurologist. 2010;16(1):16-22.

3. Association for Frontotemporal Degeneration. Disease Overview. Available at https://www.theaftd.org/what-is-ftd/disease-overview. Last accessed September 22, 2021.

4. Hodges JR, Davies R, Xuereb J, Kril J, Halliday G. Survival in frontotemporal dementia. Neurology. 2003;61(3): 349-354.

5. Knopman DS, Roberts RO. Estimating the number of persons with frontotemporal lobar degeneration in the U.S. population.J Mol Neurosci. 2011;45(3):330-335.

6. Ghosh S, Lippa CF. Clinical subtypes of frontotemporal dementia. Am J Alzhiemers Dis Other Demen. 2015;30(7):653-661.

7. Wang X, Shen Y, Chen W. Progress in frontotemporal dementia research. Am J Alzheimers Dis Other Demen. 2013;28(1):15-23.

8. UCSF Memory and Aging Center. Frontotemporal Dementia. Available at https://memory.ucsf.edu/dementia/ftd. Last accessed September 22, 2021.

9. Seltman RE, Matthews BR. Frontotemporal lobar degeneration. CNS Drugs. 2012;26(10):841-870.

10. Sieben A, VanLangenhove T, Engelborghs S, et al. The genetics and neuropathology of frontotemporal lobar degeneration. Acta Neuropathol. 2012;124:353-372.

11. Gorno-Tempini ML, Hillis AE, Weintraub S, et al. Classification of primary progressive aphasia and its variants. Neurology. 2011;76:1006-1014.

12. Johnson JK, Diehl J, Mendez MF, et al. Frontotemporal lobar degeneration: demographic characteristics of 353 patients. Arch Neurol. 2005;62(6):925-930.

13. Rascovsky k, Hodges JR, Knopman D, et al. Sensitivity of revised diagnostic criteria for the behavioral variant of frontotemporal dementia. Brain. 2011;134(Pt 9):2456-2477.

14. Alzheimer's Association. Frontotemporal Dementia (FTD). Available at https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/frontotemporal-dementia. Last accessed September 22, 2021.

15. Hutton M, Lendon CL, Rizzu P, et al. Association of missense and 5'-splice-site mutations in tau with the inherited dementia FTDP-17. Nature. 1998;393(6686):702-705.

16. Poorkaj P, Bird TD, Wijsman E, et al. Tau is a candidate gene for chromosome 17 frontotemporal dementia. Ann Neurol. 1998;43(6):815-825.

17. Rohrer JD, Warren JD. Phenotypic signatures of genetic frontotemporal dementia. Curr Opin Neurol. 2011;24:542-549.

18. Baker M, Mackenzie IR, Pickering-Brown SM, et al. Mutations in progranulin cause tau-negative frontotemporal dementia linked to chromosome 17. Nature. 2006;442(7105):916-919.

19. Cruts M, Gijselinck I, van der Zee J, et al. Null mutations in progranulin cause ubiquitin-positive frontotemporal dementia linked to chromosome 17q21. Nature. 2006;442(7105):920-924.

20. DeJesus-Hernandez M, Mackinzie IR, Boeve BF, et al. Expanded GGGGCC hexanucleotide repeat in noncoding region of C9ORF72 causes chromosome 9p-linked FTD and ALS. Neuron. 2011;72:245-256.

21. Renton AE, Majounie E, Waite A, et al. A hexanucleotide repeat expansion in C9ORF72 is the cause of chromosome 9p21-linked ALS-FTD. Neuron. 2011;72:257-268.

22. Majounie E, Renton AE, Mok K, et al. Frequency of the C9orf72 hexanucleotide repeat expansion in patients with amyotrophic lateral sclerosis and frontotemporal dementia: a cross-sectional study. Lancet Neurol. 2012;11:323-330.

23. Boxer AL, Knopman DS, Kaufer DI, et al. Memantine in patients with frontotemporal lobar degeneration: a multicentre, randomized, double-blind, placebo-controlled trial. Lancet Neurol. 2013;12(2):149-156.

24. Ahlskog JE, Geda YE, Graff-Radford NR, et al. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876-884.

25. Mesulam M. Primary progressive aphasia: a dementia of the language network. Dement Neuropsychol. 2013;7(1):2-9.

26. Wong C, Merrilees J, Ketelle R. The experience of caregiving: differences between behavioral variant of frontotemporal dementia and Alzheimer disease. Am J Geriatr Psychiatry. 2012;20(8):724-728.

27. Mioshi E, Bristow M, Cook R, Hodges JR. Factors underlying caregiver stress in frontotemporal dementia and Alzheimer's disease. Dement Geriatr Cogn Disord. 2009;27(1):76-81.

28. Association for Frontotemporal Degeneration. Treating FTD. Available at https://www.theaftd.org/for-health-professionals/treating-ftd. Last accessed September 22, 2021.

29. Olney NT, Spina S, Miller BL. Frontotemporal dementia. Neuro Clin. 2017;35(2):339-374.

Evidence-Based Practice Recommendations Citations

1. Mocellin R, Scholes A, Walterfang M, Looi JCL, Velakoulis D. Clinical update on frontotemporal dementia: diagnosis and treatment. Australas Psychiatry. 2015;23(5):481-487. Available at https://journals.sagepub.com/doi/abs/10.1177/1039856215582276. Last accessed October 15, 2021.

99354 • Aging and Long-Term Care

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

In 2022, persons 65 years of age and older comprised 16.8% of the U.S. population. In order to ensure appropriate care for the aging population, this course will review biopsychosocial dimensions of aging, with both its challenges and adjustments. It will also provide an overview of unique social problems that remain hidden in this population. Assessments, interventions, and ethical issues that emerge when working with older adults will be reviewed.

Table of Contents

99354 • Aging and Long-Term Care

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

DEFINITION OF AGING

2. AN OVERVIEW OF OLDER ADULTS IN THE UNITED STATES

CURRENT TRENDS AND PROJECTIONS

COMMON MYTHS OF AGING

3. BIOLOGIC PROCESSES AND PHYSICAL WELL-BEING IN OLDER ADULTS

HIV/AIDS

4. CHALLENGES AND ADJUSTMENTS ASSOCIATED WITH AGING

PSYCHOLOGICAL THEORETICAL FRAMEWORKS

DEPRESSION AND SUICIDE

GRIEF, MOURNING, AND BEREAVEMENT

ALCOHOL AND SUBSTANCE ABUSE

ELDER ABUSE

5. SPECIAL POPULATIONS

GRANDPARENTS PARENTING

OLDER ADULT ETHNIC MINORITIES

OLDER ADULT WOMEN

GAY AND LESBIAN OLDER ADULTS

6. LONG-TERM CARE

7. ASSESSMENT TOOLS FOR OLDER ADULTS

SCREENING TOOLS FOR DEPRESSION

SCREENING TOOLS FOR COGNITIVE IMPAIRMENT

ASSESSMENT TOOLS FOR SUICIDALITY

SCREENING TOOLS FOR ALCOHOL ABUSE

SCREENING FOR ELDER ABUSE

8. GENERAL GUIDELINES FOR INTERVENTIONS

ENGAGEMENT

AUTONOMY AND EMPOWERMENT

INTERPROFESSIONAL COLLABORATION AND PRACTICE FOR OLDER ADULTS

9. ETHICAL PRACTICE WITH OLDER ADULTS

PROMOTING AUTONOMY AND SELF-DETERMINATION

CAPACITY

CONFIDENTIALITY

10. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

99354 • Aging and Long-Term Care

Education Category. Geriatrics

Release Date. 06/01/2023

Expiration Date. 05/31/2026

Course Overview

In 2022, persons 65 years of age and older comprised 16.8% of the U.S. population. In order to ensure appropriate care for the aging population, this course will review biopsychosocial dimensions of aging, with both its challenges and adjustments. It will also provide an overview of unique social problems that remain hidden in this population. Assessments, interventions, and ethical issues that emerge when working with older adults will be reviewed.

Audience

This course is designed for nurses, social workers, counselors, mental health professionals, and allied health professionals involved in the care of older adults.

Accreditations & Approvals

In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. NetCE is approved by the California Nursing Home Administrator Program as a provider of continuing education. Provider number 1622. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. This course, Aging and Long-Term Care, Approval #07012022-41, provided by NetCE is approved for continuing education by the New Jersey Social Work Continuing Education Approval Collaborative, which is administered by NASW-NJ. CE Approval Collaborative Approval Period: Friday, July 15, 2022 through August 31, 2024. New Jersey social workers will receive 3 Clinical and Social & Cultural Competence CE credits for participating in this course. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is approved as a provider of online continuing education for certified nursing assistants through the California Department of Public Health Licensing and Certification Division. Nurse Aide Certification (NAC) Provider #7005. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 3 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this continuing education activity for 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. NetCE designates this continuing education activity for 3 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 3 Clinical continuing education clock hours. This home study course is approved by the Florida Board of Nursing Home Administrators for 3 credit hour(s). This course is approved by the California Nursing Home Administrator Program for 3 hour(s) of continuing education credit - NHAP#1622003‐8950/P. California NHAs may only obtain a maximum of 10 hours per course. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program. AACN Synergy CERP Category A.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through July 29,2025); Alabama, Provider #ABNP0353, (valid through July 29, 2025); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2025; South Carolina, Provider #50-2405; South Carolina, Provider #50-2405. West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Course Objective

The purpose of this course is to provide the tools necessary for social workers, counselors, mental health professionals, and allied health professionals to successfully assess and care for older adults, an increasingly large portion of the U.S. population.

Learning Objectives

Upon completion of this course, you should be able to:

1. Review the demographic profile and associated myths of older adults in the United States.

2. Discuss age-related biologic and physiologic changes experienced by older adults.

3. Identify psychological and social challenges and adjustments commonly encountered in the older adult population, with particular attention to older adult subpopulations, including custodial grandparents, racial/ethnic minority older adults, gay and lesbian older adults, and older adult women.

4. Outline the impact of long-term care on older adults and their care providers.

5. Describe assessments for depression, suicide, substance abuse, and elder abuse that specifically target older adults.

6. Discuss interventions that are sensitive to the biopsychosocial needs of older adults and are appropriate ethically and legally.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margo A. Halm, RN, PhD, NEA-BC, FAAN

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Western society holds many myths about aging and older adults. These myths can be positive or negative and stem from ageism. Ageism is defined as societal stereotypes, prejudice, and/or discrimination toward an outgroup that is associated with their chronologic age. More often than not, these myths can have negative consequences on individual, family, workplace, and/or societal levels [188]. Generally, Americans tend to attribute more problems to advanced age than are actually reported, such as being dependent on others for financial support, transportation, and medical care. There is an image of older adults as being highly dependent or living in nursing homes [50]. In the workforce, older workers are often believed to be untrainable [52]. Yet, simultaneously, these years are often viewed as the "golden years," when one retires, travels, and has a certain amount of leisure time. It is difficult for the public, and healthcare professionals, to reconcile these seemingly opposing views of aging.

When 41 female nurses were asked about their fears of aging, and specifically of growing old as a woman, they used terms like: "dependency," "ill health," "loneliness," "loss of dignity," and "looking old" [1]. Cross-culturally, these myths are remarkably similar. For example, college students in Taiwan reported believing that older adults (e.g., older teachers) are resistant to change, not motivated to learn new things, and not willing to listen to new ideas [4]. Okoye and Obikeze conducted focus groups with 800 Nigerian youths, and the participants described older adults as dependent, sickly, child-like, conservative, and suspicious [33]. In a study of adults in Colombia, individuals with negative stereotypes about older adults were also more concerned about aging [53]. This gives some insight into societal perceptions about older persons and aging. Qualms and fears toward aging often stem from negative cultural images and stereotypes of aging [1].

DEFINITION OF AGING

There is no one agreed upon definition of aging. One approach defines aging according to four key dimensions [86]:

- Aging is universal. All species experience the phenomenon of aging.

- Aging is intrinsic. External factors are not the primary cause of origin.

- Aging is progressive. It occurs progressively throughout the life cycle.

- Aging is deleterious. There will be negative physical ramifications.

Researchers have compiled a list of definitions that have been used in the literature [8]. This list included [8]:

- "Inevitable progressive deterioration of physiological function with increasing age…"

- "A decline or loss of adaptation with increasing age…"

- "…inevitable and "irreversible age-related process of loss of viability and increase in vulnerability"

These definitions touch on chronologic, physiologic, or biological aging. Kyriazis argues that while these definitions are valid, they are not practically meaningful for practitioners working with older adults [8]. Instead, he advocates for the use of the term "time-related dysfunction," reflecting a functional perspective. With the passage of time, older adults experience damage that cannot be easily repaired, resulting in a failure of normal functioning. Therefore, when a practitioner assesses an older patient, the practitioner takes into context the patient's personalized environment and their ability to complete certain tasks [8].

It is important to distinguish chronologic aging from physiologic aging. All persons, without exception, grow old chronologically. However, physiologic aging is unique process and varies from person to person. It involves changes in how an individual responds to internal and external stressors as well as inalterable variables, such as genetic predisposition [7]. In addition, studies are now focusing on aging as a process and underscoring the concept of successful aging [89].

Several subtly different terms are commonly employed when exploring aging. Successful aging refers to the physical and biologic advantages of remaining engaged throughout life. Active aging describes being active and engaged and maximizing opportunities to promote a good quality of life. Productive aging emphasizes integrating older adults into society and recognizing their unique contributions [189]. The World Health Organization uses the term healthy aging to describe the process of maintaining one's functional abilities throughout life [190]. These terms imply multidimensional dimensions of aging, and they are dynamic versus static [20]. The more "traditional" definitions of aging are static and homogenous, while terms like active, successful, and healthy aging connote a diverse and dynamic element to aging.

2. AN OVERVIEW OF OLDER ADULTS IN THE UNITED STATES

CURRENT TRENDS AND PROJECTIONS

The age at which one is considered "older" or "senior" is always evolving and is influenced by culture and societal life expectancy. In England in 1875, old age was defined as 50 years or older, as stated in the Friendly Societies Act [88]. Today, most developed countries in the world use the chronologic marker of 65 years as a definition of old age; in some cases, the age of 62 years is used as a chronologic marker because, in the United States, one could receive social security benefits starting at this age [87]. However, Mohanty notes that using the criterion of age at retirement or when one becomes eligible to receive retirement benefits is not universal, given the fact that there are so many in the world who live in areas in which there are no formal definitions of retirement [88]. Using these chronologic markers to define old age is arbitrary, but they can be useful when studying the group as a whole [2]. Older adults can be further divided into various segments: the young-old, defined as 65 to 74 years of age; middle-old, defined as 75 to 84 years of age; and the oldest-old, defined as those who are 85 years of age and older [3]. In 2021, 32.5 million Americans were 65 to 74 years of age, 16.5 million were 75 to 84 years of age, and 6.7 million were 85 years of age and older [31]. In 2010, there were 53,364 persons 100 years of age and older in the United States [94]. By 2020, there were 92,000 U.S. centenarians [32]. Worldwide, in 2015, there were more than 500,000 centenarians, and it is estimated by 2050, there will be 3.7 million, with the greatest growth in China [90]. In the United States, it is projected that there will be 9.7 centenarians per 10,000 people by 2050 [90].

According to the U.S. Census, there were 55.9 million Americans 65 years of age or older in 2022, which translates to 16.8% of the U.S. population [41]. In 2020, Maine, Florida, West Virginia, and Vermont had the highest percentage of population comprised of adults older than 65 years of age [31]. By 2060, it is estimated that nearly 94.7 million Americans will be 65 years of age or older [42]. This is due to the aging of the "baby boomer" generation (i.e., those born between 1946 and 1964).

For many years, the average life expectancy has continued to increase, and this trend is projected to continue. In 2017, the average life expectancy in the United States was 79.7 years of age. However, life expectancy decreased from 78.8 years in 2019 to 77 years in 2020, largely due to excess mortality during the COVID-19 pandemic [31]. In 2021, the life expectancy was 76.4 years, a further decline from 2020 [44].

COMMON MYTHS OF AGING

As mentioned, society holds several myths about older adults. Many of these myths may be easily disputed based on data from the U.S. Census and other studies.

- Myth: Most older adults do not have enough money and end up becoming destitute.
Fact: As of 2020, 5 million Americans 65 years of age and older lived below the federal poverty level [31]. This population is also more likely to have health insurance coverage than the general population. As of 2020, 94% were insured by Medicare [31].

- Myth: Most older adults live alone and are isolated.
Fact: In 2021, 60% of adults 65 years and older were married. An estimated 27% lived alone [31]. In 2016, an estimated 20% of the U.S. population lived in a household comprised of two adult generations or a grandparent or at least one other generation, compared with 12% in 1980 [43,93]. This multigenerational household trend particularly affects those 65 years and older, with 21% of these individuals living in multigenerational households in 2016. This group was second only to individuals 25 to 29 years of age (33%) [43]. Several factors have contributed to this trend, including growing racial and ethnic diversity and adults getting married later [43,93].

- Myth: Many older Americans end up living in nursing homes.
Fact: In 2019, only 1.2 million of adults 65 years of age and older lived in nursing homes. Proportionately, 1% of adults 65 to 74 years of age and 2% of adults 75 to 84 years of age are in nursing homes [31].

- Myth: Most older adults engage in very minimal productive activity.
Fact: In 2021, 10.6 million persons 65 years and older were employed or actively looking for work [31]. Older adults are more engaged in self-employed activities than younger persons. In 2016, 16.4% of those 65 years of age and older were self-employed, compared with an average of 5.5% of those 16 years to 64 years of age [103].

- Myth: Life satisfaction is low among the elderly.
Fact: Field examined data from the Berkeley Older Generation Study and found that many elders are quite satisfied with their life [9]. More than one-third (36%) of persons older than 59 years of age and 15% of those older than 79 years of age stated they were currently experiencing the best time in their lives. A 2022 survey study conducted by the American Association of Retired Persons (AARP) found that older adults were the happiest age cohort compared with younger adults [49]. Most of the factors that predict happiness for the young, such as good health and financial stability, also apply to the elderly. Older adults tend to report higher levels of well-being in part due to the quality of their social relationships [191].

- Myth: Old people feel old.
Fact: According to a 2009 telephone survey, only 21% of individuals 65 to 74 years of age stated they felt old, and only 35% of those 75 years of age and older reported feeling old. Another study in 2018 showed that individuals 50 years of age report feeling 10 years younger, and also found that as age increased individuals felt approximately 20% younger than their actual age [110]. As much as any other age group, older adults are working hard to live a healthy and active lifestyle. They walk, eat well, exercise, and do strength training [49].

3. BIOLOGIC PROCESSES AND PHYSICAL WELL-BEING IN OLDER ADULTS

Biologic and physiologic changes are part of aging. Although it is not known why these changes occur, biologic theories of physiologic aging include [3,7,86,95,121,140,143,91,105]:

- Wear and tear: Aging is genetically determined, and as a result, the tissues and muscles eventually deteriorate. However, one of the critiques of this theory is that cells repair themselves, and it is possible to get stronger as one ages.

- Cross-linkage: The body's proteins attach to other structural substances, thus decreasing elasticity in the skin and causing other physical changes in the organs and slowing of physiologic processes. This is an example of an error theory, which focuses on aging as a series of "accidents" rather than something that is programmed to occur.

- Autoimmune: As the body ages, it is unable to recognize the difference between healthy and diseased cells, causing it to react against itself.

- Cellular aging: The replication of cells slows as a result of aging.

- Apoptosis theory: Aging is due to inevitable pre-programmed cell death in our bodies. Apoptosis is a normal process in the body, but it is speculated that if dysregulated apoptosis could lead to Alzheimer disease, Parkinson disease, or cancer.

- Free radical: This is another example of an error theory. As free radical exposure increases in older organisms, the antioxidant system is not able to counteract the free radicals that have been generated and accumulated during the life of the cell, resulting in cellular death. Experimental findings have not conclusively supported this theory.

- Evolutionary: Humans' developmental life cycles are affected by mutation and selection. In other words, all biologic dimensions are affected by mutation, and there will be variations among human beings. This will lead to a natural selection of those who are more fit to survive in an environment. Aging leads to vulnerability.

The losses in the physical arena for older adults can be numerous, which may then compound and/or have implications in social and psychological arenas. Studies have shown that brain tissues atrophy due to natural cell degeneration, with the volume of the brain decreasing by 15% or more between adolescence and old age [122]. Crews notes that the health status of older persons with vision and hearing loss is poorer compared with those without vision or hearing loss [10].

Subjective aging, defined as one's view of their own aging, is related to vision and hearing loss. In a longitudinal study with 2,499 older adults, more positive attitudes toward one's aging were related to less reported hearing loss [144]. Nine years later, along with increased age, favorable attitudes toward one's own aging remained correlated to less reports of hearing loss, but not vision loss. Subjective perceptions of aging are an important variable to take into account when caring for older adults [144].

Rates of heart disease, hypertension, hip fractures, and stroke are higher among those with sensory loss [10]. In a study of more than 1,000 older adults, 53.7% of those with impaired vision also had hypertension, compared with 43.1% of those without impaired vision. Of those with impaired hearing, 27.6% experienced heart disease, compared with 18.6% of those without a hearing loss [10]. Interestingly, the rates double when persons have both hearing and vision impairment. Almost one-fifth (19.9%) of persons with both impairments had experienced a stroke, while only 8% with no sensory loss had experienced a stroke [10].

Mobility is affected by muscle atrophy associated with advanced age. Muscle strength, for example, can decline 30% to 40% between 30 and 80 years of age [11]. This is one of the reasons for practitioners to advocate for increased physical activity. Lower levels of physical activity among older adults increase the risk of limited mobility regardless of demographic and clinical factors [220]. This can lead to falls, which are common among older adults. It is estimated that half of Americans 75 years of age and older experience some form of functional disability that affects their mobility [192]. Women tend to experience more disabilities throughout the life span than men [192]. Thirty percent of those 65 years of age and older have fallen within the last 12 months, and 50% of persons older than 80 years of age have experienced a fall in the last 12 months [11]. The causes of these falls vary and include environmental factors, sensory losses, medical factors, and psychiatric conditions, such as depression or cognitive impairments [11,12]. Most falls among older adults occur in the morning. This is not surprising given that the majority of activity and movement occur during this time [146]. Loss of ambulatory mobility is also common after hospitalization among older adults. This phenomenon, known as hospital-associated disability, is present in previously independent and ambulatory adults who have impaired mobility upon hospital discharge. It occurs among 16% to 65% of adults 65 years and older [123]. Infrequent ambulation and bed rest are the most commonly cited causes [123].

With the increase in life expectancy, there is also an increase in the incidence of acute and chronic illnesses, such as cardiovascular diseases and hypertension. Between 2015 and 2018, more than one-quarter of individuals 60 to 79 years of age in the United States had cardiovascular disease [221]. As a part of the aging process, the composition of vascular structures changes, affecting how peripheral arteries dilate and constrict [13]. The result is often hypertension, which affects 1 billion individuals worldwide [14]. Epidemiologic studies have noted that 12% to 14% of adults 65 years of age and older have hypertension [13]. However, it is important not to use age as the only criterion to determine the type of treatment for hypertension among older adults. Frail older adults should be assessed and have treatment tailored for their specific needs [163].

Arthritis is also a leading cause of disability among older adults, accounting for 29% of chronic disease diagnoses in the United States [5,193]. One in 10 Americans have limited activities because of arthritis [222]. Arthritis may refer to rheumatoid arthritis or osteoarthritis. Rheumatoid arthritis is a systemic autoimmune disorder that attacks the joints, causing inflammation in the hands, feet, and other parts of the body [15]. Osteoarthritis breaks down the cartilage of joints, such as the shoulder, knee, hip, and ankle, causing pain and limitation of movement [15]. Osteoarthritis is one of the most common pain disorders in the United States and is the leading cause of disability among older adults [124]. The knee is most commonly affected area, and experts predict that 3.5 million total knee replacements will be done annually by 2030 [124]. Because chronic arthritis pain and depressive symptoms are often comorbid, it is important for practitioners to assess these patients' mood and mental state. In a four-year longitudinal study with 299 older adults living in a retirement community, strong social support and intact cognitive functioning were protective against chronic pain-related depression [164].

Sleep problems are also more common among older adults, primarily stemming from changes in the sleep cycle that occur with age (e.g., decreased time spent in slow-wave sleep) [125,194]. Sleep difficulties, such as insomnia, are correlated with impaired physical and psychological well-being, cardiovascular disease, diabetes, obesity, and quality and length of life [96,223]. Among older adults with diabetes, hypertension, and/or a history of heart disease, 30% reported they got less than seven hours of sleep per day [224]. In a longitudinal study with older adult individuals in the United Kingdom, 44.7% complained of sleep dysfunction. Those who had greater restrictions of activities of daily living, greater numbers of reported physical illnesses, poor social support, higher levels of depression, and were widowed, divorced, or separated were more likely to report sleep complaints. One year later, of those who reported no sleep problems at baseline, an additional 21.4% reported increased impairment in obtaining adequate rest or sleep [96]. Depression was the strongest predictor of sleep problems. Ultimately, insomnia can increase the risk for other medical and psychological complications in addition to adversely affecting a patient's quality of life [125,194]. Older adult women are more likely than men to have sleep problems after adjusting for age [223]. Practitioners might suggest increasing activities such as walking, running, resistance exercise, and tai chi, as some studies have shown that the sleep quality of older adults can improve when these activities are included in daily life [165].

HIV/AIDS

In industrialized countries, it is estimated that 10% to 15% of human immunodeficiency virus (HIV) infections occur in adults 50 years of age and older, and approximately one of every nine new HIV diagnoses in the United States occur in those 50 years of age or older [17,18,126]. In 2019, there were 3,100 new cases of HIV among adults 55 years of age and older [225]. Between 2015 and 2019, the rate of new HIV diagnoses remained stable among those 55 years of age and older [226]. This prevalence may be higher in developing countries [18]. In 2016, there were an estimated 6,812 newly diagnosed cases of HIV among adults 50 years of age and older, accounting for 17% of total diagnoses in the United States. Of these, 841 diagnoses occurred in persons 65 years of age and older. In 2015, approximately 47% of all individuals with living with HIV were 50 years of age and older, and 2,749 people 55 years of age and older died from HIV disease [97]. However, older adults are not generally considered an at-risk group. This has led to a lack of targeted education and screening among older adults. For example, only 32% of state departments of public health websites contained information about HIV/AIDS in older adults [167].

Older adults living with HIV experience a variety of other medical conditions that place them at even further risk for frailty and other diseases of aging. Among older persons with HIV, more than half are considered pre-frail and experience challenges with instrumental activities of daily living (e.g., cooking, cleaning, managing finances, doing laundry) [195].

Because the symptoms of HIV infection (i.e., fatigue, weight loss, memory loss) are similar to those of other age-related illnesses, such as dementia, and because many older adults harbor the misconception that they are not at risk, this population frequently goes untested for the virus [17]. When these individuals do seek medical help, symptoms are often attributed to other disorders, such as Alzheimer disease or a respiratory disorder [17]. It has been argued that women 50 years of age and older are more vulnerable to HIV infection during heterosexual encounters than men or younger women for several reasons [19]. Older women often do not insist on condom use because there is no longer the risk of pregnancy. Furthermore, male-to-female transmission of HIV is higher than female-to-male transmission [19]. Due to divorce or being widowed, increasing numbers of older people are becoming sexually active with multiple partners. This increase in sexual activity can also be partially attributed to older men more commonly using medication in order to maintain erections [21]. Vaginal drying and thinning associated with menopause and aging can result in small tears or cuts during sexual activity, which also raises women's risk for infection with HIV [22]. Lusti-Narasimhan and Beard note that older women are generally more vulnerable to sexually transmitted infections because menopause affects the lining of the vagina, making it less protective to infection [127]. Furthermore, as one ages, the immune system also declines.

Ultimately, practitioners should be vigilant when working with older adults with HIV due to age-related comorbidities. Perhaps due in part to the misconception that older adults are not sexual beings, practitioners often do not have conversations with their older adult clients about HIV/AIDS and other sexually transmitted infections [168]. In addition, polypharmacy is common in the older population, and drug interaction with HIV medications should be considered [128]. Generally, older adults metabolize antiretroviral medications slower, which could place them at risk for higher levels of toxicity [126]. Older adults who are diagnosed with HIV/AIDS are also at greater risks for being diagnosed with cancers [126].

4. CHALLENGES AND ADJUSTMENTS ASSOCIATED WITH AGING

PSYCHOLOGICAL THEORETICAL FRAMEWORKS

Disengagement Theory

Disengagement theory, originally proposed by Cumming and Henry, maintains that successful aging involves whole or partial disengagement [23,196]. In other words, as individuals age, they must accept a decline in status and forfeit some of their social and leadership roles [23]. The goal is to help older individuals disengage so they can die more peacefully [169]. Furthermore, disengagement allows younger adults to assume roles previously held by older adults [227]. This is a structural functional theory, because disengagement contributes to the overall functioning of society [227]. However, this theory is controversial, particularly in Western society, where work is central in defining one's identity. Furthermore, other theorists argue that it is not disengagement or alienation from society that defines successful aging; rather, some assert that new activities may be assumed for those roles that are given up [24]. According to this theory, for older persons to successfully journey through the aging process they must remain active [24].

Gerotranscendence Theory

The gerotranscendence theory was developed by Lars Tornstam in reaction to the tenets of disengagement theory. Tornstam posited that older people do not retreat into themselves and withdraw socially. Instead, aging can be viewed from a positive perspective, as older adults become less occupied with themselves, material things, and achievement. They redefine themselves in terms of the world and their relationships with others [129]. This theory assumes that gerotranscendence is a natural developmental process that yields greater life satisfaction. As part of this process, a person's values and worldviews evolve to become more spiritual [197].

This theory is not a revised version of disengagement theory, which focuses on pursuits of external things [169]. Instead, this theory emphasizes inner-development. For example, an older adult may appear to be disengaging and withdrawing by not participating as many social activities, and a practitioner might even speculate a diagnosis of depression. However, according to gerotranscendence theory, it is possible that the older person is simply becoming more deliberate and reflective [170]. In an interview study of 14 older adults between 80 and 96 years of age, themes that emerged were consistent with this theory [130]. The study participants discussed reconnecting with the past and past generations, focusing less on themselves, and worrying less about money and material possessions.

In another qualitative study on active living and gerotranscendence with 39 community dwelling older adults, three themes surfaced. First, participants reported they were continually growing and changing through self-awareness, charity, and ego-integrity; this was referred to as self-transcendence. Second, participants experienced social transcendence, defined as a change in views about personal and social relationships (e.g., becoming comfortable with solitude). Finally, the individuals reported experiencing cosmic transcendence, which included a change in perceptions of time, space, and happiness. This included being content and rejoicing in small events and accepting death [228].

Erikson's Stages of Development

Erik Erikson, a prominent developmental theorist, had a more optimistic view of aging, focusing on the positive ways of overcoming the various crises one encounters throughout life [25,26]. Erikson postulated eight stages of psychosocial development. Each stage provides the individual with a choice of two alternatives to consider and accept; one is an opportunity for growth, while the other results in unhappiness. In late adulthood, individuals confront the challenge of integrity versus despair. During this stage, individuals reflect on their lives, and determine if they have lived a life of purpose. If so, the individual will feel contentment, having attained integrity [26].

Attainment of integrity is defined as the ability to examine all of one's life experiences and find a sense of peace and accomplishment. However, despair will be experienced by those who have not lived a meaningful life. In these cases, death is either viewed as welcome, a means to end a miserable life, or is feared because one can no longer compensate for past failures [27]. This theory, as in other stage theories, recognizes that psychological and social growth continue throughout an individual's life [171]. In one study of women who graduated from college in 1964, generativity and ego integrity appeared to increase starting at 43 years of age, continuing past 72 years of age, without any decline [198]. Ego-integrity is also integrally related to other psychosocial aspects of life. In a study of 394 older adults, life satisfaction, general self-efficacy, and meaningfulness were positively related to ego-integrity [229]. Those who scored lower in ego integrity had higher depression scores.

Peck's Developmental Tasks of Aging

Peck's Developmental Tasks of Aging is another theoretical framework to understanding aging, maintaining that older adults must complete three development tasks to achieve happiness [28]. First, shifting from a work-role preoccupation to self-differentiation is necessary. As many older persons retire, a new identity and social role must be created. New interests should be explored, and ultimately, individuals should realize that their identities are worthwhile regardless of their occupation [28].

The second task involves shifting from body preoccupation to body transcendence [28]. Those who transcend preoccupations with health issues, physical changes, and youth-based beauty ideals will be more satisfied with life.

Finally, the third task is the shift from self-preoccupation to self-transcendence. As death becomes more of a reality, persons may become depressed. However, others accept it with a healthy and positive attitude; this improves the quality of life [28].

Activity Theory

Activity theory asserts that older adults must remain embedded in social activities and relationships in order to accomplish their goals [169]. Starting from middle age and progressing into the later developmental years, being intrinsically linked with others, activities, and tasks that are viewed as meaningful are believed to produce physically, psychologically, and emotionally good health [98; 230]. In other words, sedentariness does not promote wellness for older adults [169]. This theory has been criticized for being overly simple, as it does not take into account the social environment [199]. In addition, it does not acknowledge the potential for healthy individuals who prefer to retreat and live a more quiet and solitary life [230].

Socioemotional Selectivity Theory

Socioemotional selectivity theory focuses on older adults' changed mentality, worldviews, and social networks. As individuals age, their goals may change from being knowledge-oriented to being more emotion-related [171]. According to this theory, the older adult become more purposeful with whom they interact, looking for and prioritizing emotionally rewarding relationships as time is perceived as being more limited [200; 231]. Conflicts tend to be avoided, knowing that their remaining time is short [171]. In addition, older adults tend to retain positive information and events [231].

Age Stratification Theory

The historical context of an elder's life forms the basis for the age stratification theory. Individuals and their generational cohort may respond, behave, and adhere to certain worldviews due to the historical, social, and cultural events that occurred during their lifetimes. These experiences then shape how individuals view social roles, cope with stressors, and respond to various events [98].

DEPRESSION AND SUICIDE

Findings are mixed regarding the scope of depression among older adults. In one study, it was reported that 7% of the older adult population worldwide experiences depression [201]. However, in a meta-analysis of 48 studies involving 72,878 older adults, the reported global prevalence rate of depression was much higher, at 28.4% [232]. Depression can affect the older person and is more prevalent among those who have experienced the loss of friends and family members [29]. The death of a spouse is a stressful event that may precipitate depression and may predict the onset of illness and earlier death [3]. Older women tend to experience greater depression and, once depressed, tend to stay depressed for longer periods of time compared with their male counterparts [131]. Older women with long, stable marriages were more likely to experience depression compared with women who had been married for a short period of time or whose marital quality was not as good [131]. In one study, older adults who are socially isolated are more likely to experience depression, fatigue, and sleep disturbances [202]. Psychosocial stressors (e.g., financial concerns) are also risk factors [233].

Depression is a concern among older adults because it can place them at greater risk for developing medical illnesses. The converse is also true; those who have medical illnesses or disability are also at risk for depression [30; 203; 233]. For example, older adults with high blood pressure and depression are three times more likely to experience a stroke compared with older hypertensive individuals who are not depressed [29]. It is interesting to note that older persons with rheumatoid arthritis or osteoarthritis experience higher levels of depressive symptoms [30]. As individuals age, it is more likely they will experience some form of chronic pain. Adults between 45 and 64 years of age are more likely to report that they experience physical suffering lasting more than 24 hours [172].

The highest rates of depression in older adults occur in those who have had strokes, coronary artery disease, cancer, Parkinson disease, and Alzheimer disease [84]. Recurrence rates are also very high. Although it is a misconception that older persons are more depressed than the general public, they may still be at risk. It is important to assess each person individually.

It is also crucial to remember that older person may not necessarily display dysphoria and feelings of sadness. Instead, depressive symptoms may be manifested somatically. Older adults who experience sadness or loss of pleasure in the things they normally enjoy are more likely to attribute these symptoms to aging rather than depression [203].

Suicide is also a concern, as individuals 65 years of age and older account for 19% of all suicides in the United States [173]. Death by suicide is 6.2 times higher among older male adults compared with their female counterparts [99]. The male-to-female suicide ratio is 3:1 in Western countries. However, women are more likely than men to attempt suicide [233]. In a 2021 study, functional disability and frailty were predictors of suicide ideation among older adults, regardless of severity of depressive symptoms [234].

Practitioners should be mindful that older adults are less likely to express emotional pain compared with their younger counterparts and are also less likely to endorse suicidal ideations [132]. It is important to account for risk factors more common in an older population, such as chronic illness, pain, loneliness, and social isolation, some of which may not be part of suicide risk assessments [132].

GRIEF, MOURNING, AND BEREAVEMENT

Although the terms "grief," "mourning," and "bereavement" are often used interchangeably, they have specific and unique meanings. Grief is a normal reaction to a loss, while mourning is the expression of grief and the process by which individuals adjust to the loss. Bereavement is the period of time during which grief and mourning occur [35,133]. Psychosocial support is essential for individuals who have lost loved ones and can help to decrease the risks of morbidity, substance abuse, and mortality commonly found among widows/widowers and other persons who have lost a loved one [36].

Grief

Grief comprises a range of feelings, thoughts, and behaviors in the realm of the physical, emotional, and social domains [35]. Individuals may have trouble sleeping, changes in appetite, or other physical symptoms or illness. Studies have shown that widowers may be at risk of poor nutrition and inadequate caloric intake, and widows who were financially dependent on their spouse are vulnerable to falling into a state of poverty [174]. Emotions can include sadness, anxiety, guilt, and anger. A return to work, activities with friends, and taking care of family are beneficial behaviors in the social domain. Social support is a buffer to grief reactions (e.g., depression) for bereaving older adults [235]. The issue of grief becomes more prevalent among older adults as they inevitably face the death of family members and friends. In a qualitative study with older adults 62 to 88 years of age, the participants described experiences that were laced with emotional distress [134]. They also talked about how their grief was unique and did not meet traditional expectations in terms of intensity and severity.

In cases of terminal illness, grief counseling should begin before death occurs, with a focus on life meaning and contributions [37]. Awareness and understanding of the mediators of grief responses can assist in recognizing individuals who may be at increased risk for adapting poorly to the loss. These mediators are [38]:

- Nature of attachment (how close and/or dependent the individual was with regard to the deceased)

- Mode of death (the suddenness of the death)

- Historical antecedents (how the individual has handled loss in the past)

- Personality variables (factors related to age, gender, ability to express feelings)

- Social factors (availability of social support; involvement in ethnic and religious groups)

- Changes and concurrent stressors (number of other stressors in the individual's life, as well as coping styles)

Mourning

Satisfactory adaptation to loss is dependent on tasks of mourning [38]. In the past, "stages" of mourning were discussed; however, the stages were not clear-cut and were not always followed in the same order. The tasks associated with mourning include [38]:

- Accepting the reality of the loss

- Experiencing the pain of the loss

- Adjusting to the environment in which the deceased is missing (external, internal, and spiritual adjustments)

- Finding a way to remember the deceased while moving forward with life

After an individual's death, the family should be encouraged to talk about the deceased, as this promotes acceptance of the death. A wide range of emotions is normal during the mourning process. Explaining the process can help family members understand that experiencing these emotions is a necessary aspect of grieving. Frequent contact with family members after the loved one's death can ensure that the family is adjusting to the loss. Referrals for psychosocial and spiritual interventions should be made as early as possible to optimize their efficacy.

Older adults who lose a spouse will not only mourn the loss but also be confronted with their own mortality. They also have to cope with assuming new roles and potentially learning new tasks. Those who had been married a long time may feel they have lost a part of themselves [133].

Bereavement

Bereavement can trigger a host of physical and psychological issues because of its highly stressful nature [100]. An estimated 10% to 15% of individuals who have experienced a loss of a loved one will experience depression, prolonged grief disorder, and bereavement-related post-traumatic stress disorder [204]. In one study of persons 50 years of age and older who lost a parent, there was a 83% likelihood of body mass index (BMI) loss compared with counterparts who had not lost a parent [175]. Loss of a spouse resulted in a 37% increased risk of BMI loss compared with those who had not lost a spouse.

How bereavement services are provided vary. Programs usually involve contacting the family at regular intervals to provide resources on grieving, coping strategies, professional services, and support groups [36,37,39]. Notes or cards are especially beneficial at the time of the first holidays without the deceased, significant days for the family (deceased's birthday, spouse's birthday), and the anniversary of the death. Bereavement services should extend for at least one year, but a longer period may be necessary [36,39].

Bereavement services should also be culturally relevant. Certain groups, like gender and sexual minority (or LGBT+) older adults, may feel isolated because of stigma and, in some cases, outright discrimination and prejudice. In a qualitative study, older adult LGB women who had lost their spouse or partner talked about how they needed support and a community of other women who understood their experiences because they "speak a different language" [236]. Participants in this study related that providers often may have meant well but lacked the skills and knowledge to provide sensitive, compassionate care given their unique experiences and needs.

ALCOHOL AND SUBSTANCE ABUSE

Alcohol and substance abuse/dependence in the older adult population are generally hidden problems. However, between 2002 and 2006, substance use rates almost doubled among those 50 to 54 years of age. It is estimated that slightly more than 10% of the older adult population abuse prescription drugs, with up to 5 million older individuals projected to have drug use disorders and 4.4 million requiring substance abuse treatment by 2030 [101,135,176]. It is estimated that more than 80% of patients 57 to 85 years of age are taking at least one prescription medication daily. In addition, more than 50% are taking more than five medications daily [177]. Among adults 65 years of age and older, there was an increase in past-month cannabis use and binge drinking between 2015 and 2019 [237]. The opioid use disorder hospitalization rate increased 120% from 46 per one million population in 2007 to 101 per one million population in 2014 [238]. Several factors contribute to the invisibility of these disorders. First, many older individuals do not disclose alcohol or substance abuse because they are ashamed. This is compounded by healthcare professionals' reluctance to ask older adults about substance abuse, mostly due to the prevalent images of young people misusing substances [40]. Polypharmacy is also a concern, as many older adults are taking prescribed medications for medical comorbidities and/or chronic pain [239]. Additionally, the symptoms of alcohol and substance abuse can mimic or resemble conditions and chronic illnesses associated with aging, thereby masking an underlying drinking or substance disorder [40; 239]. Finally, some older adults may be isolated, with minimal social contacts or networks to intervene in cases in which alcohol or substance use has become a problem [239].

A study comparing the 12-month prevalence of alcohol use, high-risk drinking, and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV alcohol use disorder from 2001–2002 to 2012–2013 showed significant increases in the number of individuals 65 years of age that met those criteria. Alcohol use among older adults increased from 45.1% to 55.2% (a 22.4% increase), high-risk drinking increased from 2.3% to 3.8% (a 65.2% increase), and alcohol use disorder according to the DSM-IV criteria rose from 1.5% to 3.1% (a 106.7% increase) [120]. Approximately 11% of older adults reported binge drinking in 2022, which appears to defy stereotypes of older adults [239].

Late-onset alcoholism is common in older adults, and several risk factors may contribute to the development of alcohol use disorders in older age. Some may use alcohol to self-medicate to mitigate physical symptoms, such as difficulty sleeping or chronic pain. Chronic illnesses and depression are also risk factors [205]. Mourning a loved one, loss of social supports, and loneliness can also instigate alcoholism later in life [102]. In general, late-onset alcoholism is more common among older women than older adult men [136]. It is also more prevalent among older adults in higher socioeconomic brackets. Compared with early-onset alcoholism, individuals with late-onset alcoholism tend to experience less psychosocial and legal consequences as a result of the substance abuse [136].

Rigler argues that the DSM criteria for alcohol use disorder may be difficult to apply to older adults [45]. For example, age-related physiologic changes may change the individual's response to alcohol, increasing their sensitivity and levels of tolerance. Because of this, they may not spend a lot of time or expend a great amount of energy in activities related to alcohol or substance consumption [46]. Thus, these persons would not meet the DSM criteria for alcohol use disorder as they require smaller amounts of alcohol to become intoxicated. In addition, the DSM criterion of giving up activities or responsibilities as a result of substance use may not be appropriate for older adults because they may have fewer regular activities resulting from diminished vocational or social responsibilities [46]. Unfortunately, there are few evidence-based substance use disorder treatment approaches that are targeted for older adults. Practitioners tend to simply adapt treatments created for younger populations for older adults [135].

ELDER ABUSE

The 2015 White House Conference on Aging identified elder abuse as a top priority in public health [178]. Elder abuse refers to "any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to an older adult" [47]. There are three general categories of elder abuse, which appeared for the first time in the 1987 Amendments to the Older Americans Act [48]. These three categories of elder abuse are: domestic elder abuse, institutional abuse, and self-neglect or self-abuse [48].

Definitions of elder abuse vary based upon state statutes. However, the National Center on Elder Abuse has identified seven types of behavior associated with elder abuse [47,206]:

- Physical abuse: Use of physical force that results in injury, pain, and impairment, such as slapping, punching, kicking, or restraining

- Sexual abuse: Nonconsensual contact of any form

- Emotional abuse: Infliction of distress, anguish, and/or pain through verbal or nonverbal acts

- Financial/material exploitation: Illegal or improper use of an older adult's resources, property, funds, and/or assets without the consent of the elder

- Caregiver abandonment/neglect: Refusal or failure to provide goods or services to an older adult, including denying food or medical-related services

- Abandonment: Desertion of an older person by the individual who has physical custody or who is the primary caretaker

- Self-neglect: Behaviors of older persons that jeopardize their own safety and/or physical health

Epidemiologic studies of the prevalence of elder abuse indicate a prevalence of between 2% and 10%, with 1.7% experiencing more than one type of abuse [48,137,207]. In a survey study with 3,005 adults between 57 and 85 years of age, 0.2% disclosed to physical abuse in the last year, 9% reported verbal abuse, and 3.5% indicated financial abuse [138]. In a national study of older Americans with a mean age 75.5 years, 40% of women and 22% of men reported at least one form of mistreatment [240]. These prevalence rates may be lower than the actual rate given the amount of under-reporting due to fear of reprisals, embarrassment/shame, and hopelessness [179]. A study of 441 Michigan individuals living in nursing homes found that 21% of family members reported some type of elder neglect in the last year [139]. More recent data show similar rates. A 2022 meta-analysis study found that the neglect rate was 64% in home care and verbal abuse was 21% in nursing homes [241]. The factor most predictive of neglect was limited ability to engage in activities of daily living. Cognitive impairment also appears to be predictive of elder abuse [179].

5. SPECIAL POPULATIONS

GRANDPARENTS PARENTING

Typically, older adults do not think about parenting at their particular life stage; however, there has been an increase in grandparents parenting in the last decade. The U.S. Census approximated that, in 2019, 4% of children younger than 18 years of age did not reside with a parent; 53.2% (2.5 million children) lived with a grandparent [242,243]. The reasons for grandparents taking over parenting responsibilities of their grandchildren are numerous, ranging from parents' substance abuse, divorce, health and mental health concerns, reported child abuse, and death of a parental figure [180,208]. In a 2019 study, one of the main reasons Native American and White grandparents raised grandchildren was parental drugs and alcohol abuse [244]. Many grandparents assume these roles so their grandchildren do not enter the foster care system.

Often, grandparents are placed in these new roles without much preparation, making the task more difficult. Some older adults may feel uncomfortable addressing issues such as drugs, sexually transmitted infections, gangs, and school violence [54]. Some studies indicate that these new parenting roles, particularly if the grandchildren have physical or mental health problems, trigger anxiety and negative well-being for grandparents [55]. In one study, Ross studied 50 African American grandparents raising grandchildren, and a majority (94%) reported increased stress [56]. Those grandparents who were involved in counseling and special school programs reported less stress. In a separate study of African American custodial grandparents, sleep disorders were common, with most linking the lack of sleep or poor sleep quality on the stresses of parenting their grandchildren [16]. A separate survey of custodial grandparents showed that 95% of respondents had one or more concerns regarding finances, legal issues, and/or physical health. Respondents also indicated that they had limited social supports and community resources, compounding the stress experienced [145].

Stress also results from the financial constraints associated with raising grandchildren. It is estimated that 21% of grandparents who raise their grandchildren live in poverty [245]. The unanticipated costs of raising children in retirement years may severely impact financial independence, as these individuals may already be living on a tight budget. With additional medical costs and, at times, costs associated with other therapies, many grandparents may experience caregiving burden [57]. Inadequate or inappropriate housing for children may also be an issue [209]. Custodial grandparents who are unable to work may have difficulty applying for Temporary Assistance for Needy Families (TANF) [34]. The TANF family grant offers financial support based on the income of the entire family, but it also has a work requirement for the grandparent [34].

The additional stress in assuming primary care of grandchildren may also be a contributing factor to the poorer physical health of custodial grandparents. Grandparents who are caring for their grandchildren report worse self-reported health symptoms, such as more body pain and general health perception, compared with their counterparts not providing care to their grandchildren [51]. However, the evidence is not conclusive. In a 2020 study, biomarkers (e.g., cholesterol levels) were compared in custodial and non-custodial grandparents [246]. Custodial grandparents did not necessarily have worse biomarkers, but they self-reported less healthy compared with their counterparts. The researchers speculated that custodial grandparents rate energy levels lower and stress levels higher than non-custodial grandparents, which contributed to the higher rates of self-reported poor health. Although there are negative effects, there are also positive outcomes for custodial grandparents. Some view it as a second chance to rectify mistakes they feel they made as parents [141]. In a study of custodial grandmothers, some reported enjoying parenting the second time because they felt they had more experience, had learned from past mistakes, and could now offer wisdom. In many respects, this created a sense of freedom, relaxation, and confidence [142]. Some grandmothers felt they had more time and attention to give to their grandchildren compared with raising their own children, when they had additional demands such as work [142]. Some custodial grandparents took on the role because they wanted to be useful in a time of need for their children [210]. In a mixed-methods study, grandparents related having peace of mind knowing that their grandchildren's basic needs were met. Aside from the knowing that their grandchildren will be secure, they also described how they enjoyed the simple pleasures of partaking in activities with them [210].

OLDER ADULT ETHNIC MINORITIES

The older adult population in the United States is far from homogeneous in terms of race and ethnicity. In 2020, 24% of older adults 65 years of age and older in the United States were from a racial/ethnic minority group. Aside from Hispanic/Latino, the largest group was Black/African Americans, at 9% [31]. Between 2018 and 2060, it is projected that the proportion of older adults who identify as non-Hispanic White will drop from 77% to 55% [247]. Given the discrimination and oppression that racial and ethnic minority older persons may have experienced over the years, they may be reluctant to seek mainstream health and mental health services. In addition, some may be limited in English proficiency, which is often another barrier to help-seeking and compliance with health and mental health services. Practitioners should be aware of the dynamics that stem from the result of cultural differences in values, belief systems, health beliefs, attributions of causation to illness and problems, and communication styles [104]. Not understanding cultural differences can lead practitioners to take on a deficit or pathology perspective when viewing their clients.

OLDER ADULT WOMEN

In examining historical trends, there are gender differences in longevity rates; women tend to live longer than men [5,92]. For example, women who reach 65 years of age are expected to have a life expectancy of an additional 20.6 years; men who reach 65 years of age have an average life expectancy of 18.1 years [92]. As such, there are significantly more older women (30.8 million) than men (24.8 million) [31]. This longer lifespan has social and economic ramifications. In general, older adult women are more likely to be widowed, living alone, and experience greater poverty than their male counterparts. For example, the poverty rate for women 80 years of age and older was 14.7% in 2021 [248]. In 2021, 10.1 million U.S. women 65 years of age and older lived alone, compared with 5.2 million men [31]. Despite some of these negative social trends, a qualitative study of 15 urban elderly women related stories of survival, strength, and resilience [106]. The themes that emerged in these narratives were that of being able to rebound from adversity and tapping into social network systems that stemmed from their churches, community, and family.

GAY AND LESBIAN OLDER ADULTS

There are an estimated 2.4 million lesbian, gay, bisexual, and transgender (LGBT) individuals 50 years of age and older, a number that is expected to double by 2030 [183]. In 2018, only 0.7% and 0.2% of older adults in the U.S. self-identified as gay/lesbian or bisexual, respectively [31]. The overall predominant attitude about sexuality is that it is a private matter, and the general myth is that older individuals are sexless [107]. Therefore, the unique needs of gay, lesbian, and transgendered/transsexual older adults are often ignored or unacknowledged. Furthermore, in a heteronormative society, older adults may have experienced (and continue to experience) discrimination [184]. Older adult homosexuals experience intersecting oppression stemming from ageism as well as homophobia. Older gay men, for example, are stereotyped as "dirty," "lecherous," and "oversexed" [108]. These stereotypes lead to discrimination, marginalization, and oppression and affect health, mental health, and social services. In a survey with 613 adults 60 years of age and older, ageism and stigma related to sexuality predicted psychological distress and mental health [249]. The interaction of ageism and concerns of sexuality acceptance by others are important dimensions for practitioners to consider when caring for patients.

Chronic minority stress results in health disparities among older LGBT older individuals, including greater risk of cardiovascular disease, depression, and premature cognitive decline [211]. One of the major fears associated with aging in the gay community is decline in health status and not being able to access services that accommodate to gays' and lesbians' needs and concerns [107]. Lesbians tend to express concern about lack of recognition of same-sex partners and lack of services that are sensitive and relative to gays and lesbians. Gay men tend to fear being alone in later life. Discriminatory housing policies in assisted living facilities are also a concern [212]. It has been hypothesized that, due to the discriminatory policies affecting gay and lesbian individuals' access to different types of services, older gay and lesbian women are more vulnerable to needing long-term care than their same-age heterosexual counterparts [147,212]. After controlling for race, age, and education, researchers found that women living with female partners were more likely to need help with bathing or dressing compared with women living with or married to male partners. Similarly, men living with male partners were more likely than men living with or married to female partners to need help with errands.

It is important to use the lifespan perspective to understand the experiences of older gay and lesbian adults [148]. Their reality is shaped by a culture that has historically criminalized, medicalized, and pathologized same-sex relationships. Therefore, they have historically been socially isolated and ostracized by their families and friends [109]. In addition, access to care and social services have been adversely impacted, which then has led to health disparities [148].

6. LONG-TERM CARE

In the United States, there were 1.2 million adults residing in nursing homes at the end of 2019 [31]. As age increases, the percentage of those residing in nursing home also increases. Only 16.5% of residents are younger than 65 years of age, 18.2% are 65 to 74 years of age, 26.7% are 75 to 84 years of age, and 38.6% are 85 years of age and older. Women are highly represented among nursing home residents, comprising 64.6% of this population. In addition, the majority (75.1%) are non-Hispanic White, followed by Black (14.3%), and Hispanic (5.4%) [149]. Among residents in nursing homes, the majority require assistance with activities of daily living, including bathing (96.7%), dressing (92.7%), walking or locomotion (92%), toileting (89.3%), transferring in or out of bed (86.8%), and eating (59.9%) [149]. In addition, it is estimated that the number of older adults with significant physical or cognitive disabilities will increase from 6.3 million in 2015 to 15.7 million in 2065 [149].

In 2018 in the United States, 56% of those 65 years and older required long-term services [213]. Institutions providing long-term care to older individuals often provide a variety of services, including personal, social, and medical services. Key factors that predict older adults entering a nursing home include [111]:

- Non-Hispanic White race

- Lower income bracket

- Restricted activities of daily living

- Cognitive impairments or a history of falls

- Chronic diseases (e.g., diabetes, cardiac conditions, stroke)

- Limited social supports (e.g., widowed, divorced, few or no children)

Although nursing homes remain an integral factor in long-term care, there have been concerted efforts to move away from institutionalized care and to home- or community-based options [80]. This may be in part due to most individuals' wishes to remain in their own homes for as long as possible, receiving more patient-centered and responsive care. It is important to note that family members provide the majority of care to older individuals. In 2015, 34.2 million people in the United States provided unpaid care to an adult 50 years of age or older [81]. Six years later, it was calculated that 38 million family caregivers provided about 18 hours of care a week, all of which were unpaid. This would translate into approximately $600 billion [250].

Providing long-term care is complicated, as integrated psychosocial and medical care is often required. Specialized assessment tools, including the Resident Assessment Instrument, are available in order to assist in the development of care plans for residents in long-term care facilities [82].

Ten ethical issues have been identified has having significance in geriatrics and long-term care [79]:

- Beneficence: The main concern should be for the well-being of the client or patient.

- Non-maleficence: Harm should be avoided

- Futility of treatment: Interventions should be consistent with the individual's goals.

- Confidentiality: All laws should be conformed to in regards to confidentiality.

- Autonomy and informed consent: All patients have the right to self-determination, including the right to refuse treatment. Persons should also be encouraged to complete a healthcare directive and to name a proxy in the event that they are incapacitated.

- Clinician-patient relationship: All clinicians should strive to create a therapeutic alliance with the patient.

- Truth telling: Communication should be honest and thorough, and medical terminology should not be used to obscure the truth.

- Justice: An objective decision-making process should be used.

- Non-abandonment: Clinicians have the responsibility of ensuring that patients are provided with adequate therapy. If a therapeutic relationship must be terminated, it may not end until time has been given for the patient or his or her proxy to make other arrangements.

- Limited resources: Make decisions and allocate limited healthcare resources in a nondiscriminatory and objective manner.

For older adults and their family members who believe their rights have been violated or who have complaints about their long-term care services, all states have an Ombudsman Program under the Title VII Older Americans Act that is overseen by the Administration on Aging [112]. Volunteers from this program work with older adults and families to advocate on their behalf to provide information about long-term care, to investigate complaints, and to promote changes in institutions in order to improve the quality of life for long-term care residents.

7. ASSESSMENT TOOLS FOR OLDER ADULTS

This section will touch on key assessment tools in the areas of depression, suicidality, substance and alcohol abuse, and elder abuse. Older adult patients should be routinely screened for these conditions, in spite of some practitioners' discomfort with asking questions about sensitive topics. These population-appropriate assessments may be included in other health screening tools [58].

SCREENING TOOLS FOR DEPRESSION

Evidence Based Practice Recommendation

The Institute for Clinical Systems Improvement asserts that clinicians should routinely screen all adults for depression using a standardized instrument.

https://www.icsi.org/wp-content/uploads/2019/01/Depr.pdf

Last Accessed: May 22, 2023

Strength of Recommendation/Level of Evidence: Strong recommendation/low-quality evidence (The work group feels that the evidence consistently indicates the benefit of this action outweighs the harms. This recommendation might change when higher quality evidence becomes available.)

Structured instruments like the Center for Epidemiologic Studies Depression-Revised scale (CESD-R) and the Beck Depression Inventory are brief self-reports that measure signs and symptoms of depression [59,60,166]. These practical tools are easily accessed and administered by practitioners. However, they are self-reports and can be unreliable, particularly for those with impaired memory. The CESD-R is a 20-item instrument consisting of closed-ended questions; the Beck Depression Inventory is a 21-item rating inventory. These assessment tools were not developed specifically for older adults.

In addition to these tools, a specific assessment measure for older adults, the Geriatric Depression Scale (GDS), has been developed [85]. Available in both a short and long form, this scale consists of 15 to 30 closed-ended questions. The GDS is recommended when screening older adults who are functioning well cognitively or are only slightly cognitively impaired for depressive symptoms [84,203].

If a practitioner finds that an older individual scores positively for depression, the patient should be further evaluated in a clinical interview to determine whether the symptoms are of sufficient intensity, number, and duration to meet the criteria for major depression or dysthymia.

SCREENING TOOLS FOR COGNITIVE IMPAIRMENT

Older adults are more likely to experience cognitive decline, and presence of the early signs of impairment should prompt immediate intervention [83]. Patients who display symptoms of changes in psychological status may be evaluated for dementia or cognitive impairment using the Mini Mental State Examination (MMSE). The MMSE consists of 11 items that assess five areas of cognitive function: orientation, registration, attention and calculation, recall, and language. A maximum score is 30, and any score less than 24 indicates cognitive impairment [83]. Because the MMSE takes little time to administer, it may be integrated into practice relatively easily.

The Mini-Cog is also another quick screening tool used to assess for cognitive impairment. It involves a three-item recall and a clock drawing test and takes about three to five minutes to administer. The patient is given three unrelated words to remember, then is asked to draw the face of a clock, with the time of 10 minutes after 11 o'clock. After drawing the clock, the patient is asked to repeat the original three words. He or she receives one point for each recalled word [150]. A score of 0 indicates likelihood of cognitive impairment, and a score of 3 indicates no concern of cognitive impairment. If the score is 1 or 2, the results of the clock drawing test are taken into account; an abnormal drawing is suggestive of cognitive impairment. This test has a sensitivity rate of 99% and classified a group of subjects correctly 96% of the time [150]. In a study of older adult veterans, researchers found that the majority of participants with no documented diagnoses of dementia failed the Mini-Cog [151]. The authors concluded that this simple screening tool can easily be incorporated into standard assessments.

The Montreal Cognitive Assessment (MoCA) assesses for memory, orientation, language, abstraction, executive functioning (i.e., ability to remember instructions, focus, and handle and execute multiple tasks), and constructional praxis (i.e., skill to join parts to make a whole). Some prefer this assessment because it detects milder forms of cognitive impairment compared with the MMSE [214]. It consists of 30 items and takes approximately 10 minutes to administer. More information on the MoCA is available at https://mocacognition.com.

In addition, the Alzheimer's Association has published a cognitive assessment toolkit intended to allow practitioners to detect cognitive impairment quickly and efficiently during the Medicare annual wellness visits. The toolkit is available online at https://www.alz.org/media/documents/cognitive-assessment-toolkit.pdf.

ASSESSMENT TOOLS FOR SUICIDALITY

Asking questions about thoughts and/or intent to harm oneself is often uncomfortable for practitioners [61]. However, it can be done in a non-confrontational manner that conveys caring and respect. It is also recommended that cultural sensitivity be at the forefront of practitioners' minds when assessing for risk of suicide. Individuals from certain cultural backgrounds may view suicide as sinful [61,152]. Taking this into consideration, questions include: With this much stress, have you thought of hurting yourself? Do you think life is worth living? Have you ever thought of killing yourself? How would you do it? Do you have the tools to carry out your plan? What would stop you or what has stopped you from carrying out your plan?

When suicidal ideation is known or suspected, a more direct approach, using forced choice questioning, may be helpful [62]. Shea recommends inquiring about specific symptoms with an emphasis on overestimation in order to prevent individuals from underestimating the symptoms [62]. For example, a clinician might ask: "Do you think about hurting yourself 20 hours a day?"

The Geriatric Suicide Ideation Scale (GSIS) is targeted to older adults to specifically measure for suicidal ideations. It consists of 31 items in four subscales: suicidal ideation, death ideation, loss of personal and social worth, and perceived meaning of life [215].

The Depression and Suicide Screen (DSS) may also be useful. It consists of five items, is simple to administer, and can be used in health and mental health settings. The DSS requires patients to answer yes or no to following questions [113]:

- Is your life pretty full? If no, score 1 point.

- Do you still enjoy doing the things you used to do? If no, score 1 point.

- Do you think it is too much trouble to do the things you used to do? If yes, score 1 point.

- Do you feel that you are a useful person who is needed by others? If no, score 1 point.

- Do you feel tired without any specific reason? If yes, score 1 point.

A score of 2 or greater is considered sensitive for depression and/or suicidality.

SCREENING TOOLS FOR ALCOHOL ABUSE

There are several screening tools available for assessing older adults with problem drinking. The Drug Abuse Screening Test (DAST) is a 28-item questionnaire consisting of yes or no responses. The Short Michigan Alcohol Screening Test (SMAST) is a 13-item questionnaire with a similar response format. These instruments are commonly used but may not be appropriate for the older adult population. However, a longer version of the SMAST, the Michigan Alcohol Screening Test-Geriatric (MAST-G) was specifically developed in order to accurately assess alcohol abuse and dependence in older adults [46]. The MAST-G consists of 24 items, which may limit its incorporation into regular screening procedures. As opposed to the standard MAST, this version focuses more on drinking in response to grief and changes in drinking patterns over time.

The CAGE Questionnaire for Alcohol Abuse is a brief, easy-to-administer screening device that is easily incorporated into a medical or psychosocial assessment; it is the most widely used instrument in clinical practice (Table 1) [63]. The CAGE Questionnaire consists of four closed-ended items that assess an individual's perception of their drinking habits. Affirmative responses to any one item indicate a potential problem with alcohol abuse [64]. However, this tool does not identify those who may be in the early stages of alcohol abuse [63].

Table 1: CAGE QUESTIONNAIRE

Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Source: [64]

In general, patients will be willing to answer questions if they perceive that the practitioner is caring and nonthreatening. Responses to the screening questions will be most accurate when patients believe their responses will be kept confidential and will help with their health diagnosis [136].

SCREENING FOR ELDER ABUSE

There is no one single tool that is considered the criterion standard to assess and measure elder abuse [179]. One tool, the Indicators of Abuse form, is available for practitioners to use when observing and interviewing the client and family members for elder abuse [65]. This tool is not dependent upon self-reporting but is based on observation and assessment. Researchers have been able to isolate caregiver characteristics that are strongly related to elder abuse [65]. These characteristics include the caregiver's personal and emotional problems, financial dependence of a caregiver on the older adult, and the caregiver's general lack of knowledge about the older adult health and psychological concerns. Furthermore, elder abuse was also correlated with family conflict, the older adult's lack of social support, and history of past abuse (though not by the caregiver) [65]. Using these findings, the Indicators of Abuse form was developed. Based on observations and lengthy interviews with both the elder and family members, it asks practitioners to estimate how large the problem is in two areas: dimensions related to the caregiver (e.g., behavior problems, financial status, alcohol/substance problem, or marital/family conflict) and dimensions related to the older adult (e.g., social isolation, unrealistic expectations, suspicious falls/injuries, or behavior problems) [65].

Another good assessment instrument is the Elder Abuse Suspicion Index (EASI). It is a five-item tool that provides practitioners a very quick sense whether there is suspicion about the potential presence of elder abuse [114]. It was originally developed for physicians, but it may be used by practitioners in diverse disciplines. The screening questions are:

- Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

- Has anyone prevented you from having food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with?

- Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

- Has anyone tried to force you to sign papers or use your money against your will?

- Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

The Brief Abuse Screen for the Elderly (BASE) is another instrument, consisting of only five questions, that takes less than one minute to complete [153]. This tool is designed for the practitioner to complete to determine level of suspicion—the patient is not questioned directly. It is ideally suited for practitioners to use in conjunction with a patient screening tool [153].

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults.

https://jamanetwork.com/journals/jama/fullarticle/2708121

Last Accessed: May 22, 2023

Strength of Recommendation: I (Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.)

There is no shortage of elder abuse assessment tools. A systematic review of elder abuse assessment tools published since 2015 found a total of seven new tools [251]. It is beyond the scope of this curriculum to conduct a comprehensive review of all the various elder abuse assessment tool, but the National Center on Elder Abuse (NCEA) has compiled 46 assessment tools housed in their Tools Inventory. This inventory is available here online at https://ncea.acl.gov/Resources/Tools-Inventory.aspx.

Assessing for elder abuse does not only involve asking questions to the older adult client. It is also about asking oneself difficult self-evaluative questions, such as: "Do I hold ageist attitudes? How are these attitudes translated when I conduct an assessment? Do I believe that older adults can be abused, even sexually abused?" Pervasive ageist attitudes held by practitioners can result in a failure to acknowledge that elder abuse (particularly sexual abuse) can occur [154]. This can impact whether certain assessment questions are even asked.

8. GENERAL GUIDELINES FOR INTERVENTIONS

Wellness and purpose have become important emphases when working with older adults [66]. In the past, aging was associated with disability, loss, decline, and a separation from occupational productivity. Although client growth and positive change and development are values that practitioners embrace, the unconscious acceptance of societal myths and stereotypes of aging may prevent practitioners from promoting these values in elderly individuals [115]. These values are consistent with a strengths perspective. The practitioner helps patients identify various types of strengths and instances of resilience in their lives. Potential obstacles are also identified. Practitioners are encouraged to urge the patient to use their own words to make the process real and concrete [252]. In a study of 200 older adults residing in assisted living facilities, participants scored low on levels of depression and high for successful aging, despite having a variety of chronic health conditions [155]. Researchers also found few differences between the young-old and the old-old subgroups in terms of their ratings of successful aging. More than half of the residents exercised regularly, which had both physiologic and social benefits. It is important not to assume that older adults will automatically decline, and it is important to give these patients a sense of purpose and activities that promote successful aging. In a qualitative study conducted by Griffith, Caron, Desrosiers, and Thibeault, older adults defined meaningful occupational roles in a variety of ways [67]. For some, meaningful occupations involved using a skill they are good at; for others, meaningful occupations help to express an identity they value. According to Penick, there is no empirical evidence that older adults do not desire purposeful activities and goals, although their goals may be different from those in other stages of the developmental life cycle [68]. A study conducted by Greenfield and Marks found that elders who were not engaged in activities that promoted a sense of identity were more likely to experience negative psychological well-being and less sense of a purpose in life [69]. However, those who were engaged in meaningful activities, like formal volunteering, were more likely to experience positive psychological well-being. Consequently, caring for older adults necessitates a focus on wellness, goals, and purpose, which requires practitioners to shed stereotypical views of aging. Environments that provide older adults with opportunities to explore and formulate new goals are vital [68]. In assessments of older individuals, practitioners should encourage older adults to talk about what gives meaning to their lives and to identify goals based on their social interests [68]. Furthermore, Koenig and Spano argue that the concept of hope may have to be redefined given the context of the lives of elders [115]. For example, if hope is defined as achievement and control, this may be problematic for elders. However, if hope is reconceptualized to mean strengthening existing coping skills and capabilities to transcend challenges, then elders can be empowered to focus on their strengths versus their deficits.

Reminiscence interventions may also be beneficial for older adults. As a therapeutic intervention, reminiscing allows older adults to recall and relive past events in order to integrate their experiences [156,253]. However, this approach consists of more than simply recalling past memories; these interventions emphasize the importance of the reflective process in assisting individuals to define and redefine themselves [185]. Some counselors use photographs, videos, autobiographies, or other materials to help trigger memories. These concepts are reflected in nursing homes and other long-term care facilities that encourage residents to display family photos or create memory books [186]. This type of intervention can improve self-esteem, mood, cognition, and behavioral functioning. In reminiscence groups with caregiver participation, caregivers reported learning more about the patients and appreciating their lives and experiences [156]. A comprehensive literature review found that reminiscence interventions were beneficial for older, community-dwelling adults without dementia [253]. These types of interventions helped to improve well-being, life satisfaction, social engagement, anxiety, memory, and depression. One study evaluated a spiritual reminiscence group consisting of patients with mild-to-moderate dementia in Taiwan over six weeks [185]. Those who participated in the intervention showed increases in hope, life satisfaction, and spiritual well-being compared with the control group. Another study found that older adults who participated in a reminiscence intervention experienced greater levels of problem solving and social support seeking and were less likely to use avoidance coping compared with the control group [216]. A meta-analysis and systematic review conducted in 2021 to determine the effectiveness of life reviews for older adults experiencing depression identified 15 relevant studies [254]. Those in the life review group experienced a moderate reduction in depression level compared with those in the control group. At a later follow-up, there continued to be a reduction in depression in the life review group, albeit smaller than at immediate post-intervention [254].

ENGAGEMENT

Coping with loneliness can involve increasing the number of social contacts or intensifying certain specified relationships and lowering individuals' expectations about relationships [157]. Loneliness and social isolation impact older adults' mental and physical well-being. For example, living alone, loneliness, and social isolation are correlated with falls among older adults [219].

Increasing or intensifying social networks can involve various approaches. Cattan and White identified three key aspects of interventions for older adults that support active engagement: group activities that provide support (e.g., support for bereavement), interventions targeted to a specific subgroup (e.g., widowers), and activities or interventions emphasizing older adults' control [70]. Several interventions for older adults that focus on decreasing social isolation have been identified and may be classified into four general categories [71]. The first type of intervention to address isolation is one-on-one telephone support services, whereby a counselor checks in with older adults periodically. Second, teleconferencing, whereby a group of older individuals are brought together via a phone conference, has been found to be a cost-effective and useful intervention. Third, face-to-face support groups were found to be beneficial in reducing social isolation, particular groups that last for at least five months [71]. Lastly, with increasing Internet accessibility, e-mails and Internet support groups can also be beneficial for older individuals. Older adults who have access to and use computers have more social support and are less likely to experience loneliness [217]. A study exploring the use of videoconferencing with frail older adults in Australia found that the patients preferred videoconferencing with a pain specialist over a face-to-face consultation [116]. A systematic review found that social connectedness and support were increased in older adults who used Internet technologies, although the effects were short term [187]. As discussed, loneliness is often intertwined with other variables, such as shyness or limited resources. Therefore, interventions should not simply focus on providing venues for older adults to meet; interventions and programs that focus on people's expectations about friendships and relationships are equally important [157].

When discussing engagement, practitioners should take into account the subjective quality of engagement. Engagement is not merely about the quantity of activities or the number of hours placed into an activity. Rather, it is more about the amount of physical and cognitive investment one is engaged in the particular activity that might reinforce the individual's sense of role identity and purpose [255]. Practitioners can spend time exploring with older adults what they perceive their roles are and how these roles promote health and wellness [255]. It is important to help these individuals reflect on how they can reconnect to their past accomplishments. Reminiscence techniques can help older adults recall and honor these past activities and memories [255].

AUTONOMY AND EMPOWERMENT

Autonomy is a quality valued by all, but it may be even more important for persons whose movements are restricted by physical limitations, which is often the case with older individuals. Autonomy refers to the freedom and ability to act on one's own behalf [72]. It is described as having two attributes: independence and control. Independence entails the physical ability to act as one wishes; control is defined as perception of one's ability to exert power [72]. Control also refers to self-determination, or the ability to choose for oneself or formulating and executing a plan for oneself [117]. When older adults perceive they are losing their sense of autonomy, they are more vulnerable to becoming apathetic, depressed, powerless, and indecisive [158]. Family members become more involved as well [181]. For those living in nursing home facilities, it is crucial to provide them with choices and to empower them to make those choices, even simple decisions such as which foods to eat, activities to engage in, and clothes to wear [158].

Autonomy is central in promoting a sense of empowerment. Empowerment is the process by which individuals or groups perceive they can make positive changes or impact within their own lives related to interpersonal relationships and an array of social, political, and economic arenas [73]. In one small study of older adult women, the participants expressed the importance of relationships in the feeling of empowerment, including the significance of mutuality, problem solving based on collectivism, and mutual support and action [73]. Cox and Parsons recommend small group interventions, particularly for older women, that emphasize self- and mutual-help, meaningful relationships, and problem-solving skills [73].

With these overall themes in mind, Silverstone offers several practice guidelines when caring for older individuals [74]:

- Assessment and diagnosis of an older adult's needs should take place within the context of the individual, family, and environment.

- Differential features of practice with older adults should be listed. These features may include health, mental health, loss, control, spirituality, and adaptive behaviors. Listing these different areas should help practitioners consider the array of domains to be covered in psychosocial assessments. It also assists practitioners to identify areas in which they may need to seek additional education and/or information.

- Collaboration with members from multidisciplinary teams is vital in order to address areas of importance to older adults.

- Practitioners should seek evidence-based literature to inform their practice.

INTERPROFESSIONAL COLLABORATION AND PRACTICE FOR OLDER ADULTS

Interprofessional collaboration and practice (ICP) is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for patients and their families to improve health, mental health, social, and/or family outcomes [256]. ICP traverses professional boundaries, allowing teams to harness the skills and knowledge of diverse professionals in order to achieve a common goal [257]. Studies on the benefits of implementing ICP have demonstrated that health outcomes improve for patients; errors and mortality decrease; patients and families express higher levels of satisfaction; and measures of quality of life increases [258,259,260].

Because many older adults have complicated, chronic, and multiple conditions, they may be managed by several providers and be prescribed multiple medications. Unfortunately, practitioners often do not discuss prescribed treatments and medications with each other. ICP can help to minimize polypharmacy [261]. For frail older adults who may be at risk for falls, practitioners from different disciplines who have expertise and knowledge in gait and balance assessments, orthostatic blood pressure, nutrient deficiency, environmental evaluations to promote safety, and occupation/physical therapy and exercise (e.g., tai chi) can collaborate to improve patient outcomes [262]. In the case of financial elder abuse, attorneys and forensic accountants, may be included in the care team [263]. Well-coordinated, collaborative, and comprehensive intervention(s) should be communicated among the involved providers.

9. ETHICAL PRACTICE WITH OLDER ADULTS

General societal misconceptions regarding older adults can influence practitioners' ethical decision-making capabilities when working with older adults [75]. The first misconception is that older adults are helpless victims and must be rescued [75]. Another misconception is that older adults cannot change at this stage in their lives. Some may also believe that because this life stage is characterized by decline, older individuals are not able to better themselves or heal [75]. If practitioners are influenced, consciously or unconsciously, by this bias, it can then affect or motivate their decision-making processes.

PROMOTING AUTONOMY AND SELF-DETERMINATION

The ethical principle of beneficence mandates the duty of practitioners to do good and avoid harm [76]. The balance of good and harm is continuously evaluated. All persons have the right to self-determination, and it should be assumed that all adults (with some exceptions) have the capability to make decisions. Practitioners are responsible for encouraging (but not pressuring) the client to be autonomous [77]. This includes respecting the older adult's views/beliefs and right to make choices and decisions without manipulation by family members or providers [264].

Family members and practitioners may pressure older adults to use certain devices (e.g., electronic pill dispensers, data-gathering devices, robotic pets) because they appear to be beneficial and life-improving [218]. However, if an individual does not want to use the device, it is important consider if the pressure compromises his or her autonomy. A four-step process to assist practitioners to promote beneficence and client autonomy has been developed [76]:

- Discuss each client's values and preferences.

- Evaluate care plans related to physical safety, independence, and each client's values and preferences.

- Protect the client's autonomy by considering the client's values and preferences and weighing them with potential negative consequences of implementing any care regimen.

- Support each client's values and preferences, even if they conflict with the practitioner's own value system.

The violation of clients' autonomy and self-determination can be very subtle. Practitioners should consider the role of power dynamics between the two parties and how the practitioner's expert status inadvertently reinforces a hierarchical relationship [118]. In a study of 21 older adults receiving in-home nursing care, one of the main themes that emerged was older adults need to be treated as people—as unique individuals and not cases [159]. The participants reported wanting to be treated with respect and dignity and wanting to make decisions about their care. Furthermore, older adults with chronic conditions eventually learn to live with and have established competencies and routines to manage it. They are still active in their decision making and want to continue to be [160; 264].

Informed consent is the direct expression of the principle of autonomy. The three criteria for informed consent are competence, voluntariness, and being informed [182]. Practitioners should evaluate older adults' capacity to consent, and the consent process should be an ongoing process rather than a one-time event [265].

CAPACITY

Decision-making capacity refers to an individual's ability to understand, appreciate, reason, and ultimately express choices. There are different categories of decision-making capacity, such as personal, medical, and financial [119]. It is important for practitioners not to assume that older adults cannot make their own decisions, as this would be based on the ageist assumption that with age comes a lack of mental capacity. However, practitioners should remember that some losses may be associated with the normal process of aging. Loss of hearing, for example, can lead to miscommunication and a sense of isolation, anxiety, or paranoia. Therefore, effective communication, regardless of client disabilities, is key in helping older adults make informed choices [78]. It is also important to remember that assessing an older adult's level of capacity should be continuous [161].

The issues of an older adult's mental capacity and self-determination come into play with informed consent, particularly if cognitive impairments are present. Informed consent involves three dimensions: the communication of the information, the opportunity to ask questions, and the process of making a decision [162]. As stated, an older adult's self-determination should be promoted. It must involve not only the communication of the information but also giving older adults the opportunity to ask questions about their care, the intervention, and/or services provided to them and empowering them to make the decision. However, there may be times when an older adult cannot give informed consent. One way to assess if the older adult understands the intervention is to have him/her reiterate what the intervention entails [6]. However, there are a few options when an older adult's capacity is compromised. First, a surrogate caregiver could provide consent. Second, double informed consent could occur, whereby the surrogate caregiver gives informed consent and the older adult gives assent. Finally, it is possible to obtain early informed consent from the older person via legally binding documentation of wishes prior to any cognitive impairment [6]. Practitioners may consider the following questions when assessing capacity [266]:

- Is the patient able to provide consent for the treatment or intervention?

- Is the patient capable of refusing treatment?

- Is it safe for the patient to live alone?

- Is the patient at risk of abuse?

- Can the patient continue to drive safely?

Several tools are available to assess capacity, including [161]:

- Aid to Capacity Evaluation

- MacArthur Competence Assessment Tool for Treatment

- The Assessment of Capacity for Everyday Decision-Making

- Semi-Structured Clinical Interview for Financial Capacity

These tools evaluate different dimensions of capacity, highlighting the lack of consensus on the criteria to determine capacity.

CONFIDENTIALITY

The ethical principle of confidentiality is defined as the preservation of client privacy. Older adults have the right to confidentiality regardless of how family members may feel. In some case, family members may attempt to pressure practitioners to disclose information about the health or well-being of the patient, but patients who have capacity to make informed decisions have the right to confidentiality [267].

When older individuals are at risk of harming themselves or being harmed by others, as in the case of elder abuse or cognitive impairment, the issue of confidentiality becomes a challenge [267]. Practitioners should assess patients' risk and safety, and if safety is compromised, confidentiality may need to be breached [267]. Surveillance devices offer the benefit of monitoring the whereabouts of an older adult with dementia at the cost of reduced privacy. The decision of whether or not to use these devices should consider the extent of the older person's cognitive deficits and his/her ability to make decisions [218]. In the case of elder abuse, the ethical intervention is dependent upon state and national laws. Therefore, practitioners should be well-versed in their state's laws regarding elder abuse, advance directives, and other relevant issues. In addition, practitioners should clearly present the limitations of confidentiality to the client [267].

10. CONCLUSION

Age-sensitive practice is crucial and will continue to grow more important as the nation's demographic shifts and life expectancy increases. The older segment of the population is extremely diverse in terms of the span of developmental, social, and psychological needs. Resilience and potentiality rather than decline and deficits should be emphasized throughout all assessments and interventions. Practitioners should explore their beliefs and values to determine if any normative ageist assumptions about older adults are present. Instead of viewing older adults as a group with many problems, diseases, and pathologies, a strength perspective that emphasizes their rich and diverse life experiences should be infused into clinical practice. In order to facilitate the best care for older adults, the promotion of knowledge and skills in these areas is vital.

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Evidence-Based Practice Recommendations Citations

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99204 • Geriatric Failure to Thrive: A Multidimensional Problem

Susan Waterbury, MSN, FNP-BC, ACHPN

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

As the number of elderly patients increases, nurses and other healthcare providers must become knowledgeable about the special healthcare needs of the geriatric population. Undesired weight loss and malnutrition in the elderly are significant problems, leading to increased morbidity and mortality. Residents of skilled nursing facilities are at special risk. Geriatric failure to thrive is a diagnosis commonly used in geriatrics, and the four chief characteristics are impaired physical function, malnutrition, depression, and cognitive impairment. Participants who complete this course will learn about the identification, evaluation, and assessment of geriatric failure to thrive, including use of the Mini Nutritional Assessment, the Mini Mental Status Evaluation, and the Geriatric Depression Scale. Diagnostic/laboratory and physical assessment skills will be reviewed with a focus on weight-loss assessment. Creation of a multidisciplinary treatment plan with review of pharmaceutical options will be explored. This will give the healthcare professional the knowledge and tools necessary to identify this syndrome early. This activity will help promote better health outcomes for the geriatric population by education of the care providers and with the promotion of evidence-based practice.

Table of Contents

99204 • Geriatric Failure to Thrive: A Multidimensional Problem

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. DEFINITIONS

FAILURE TO THRIVE

SARCOPENIA

CACHEXIA

ANOREXIA OF AGING

3. REGULATORY AND LEGAL ISSUES

ADVANCE DIRECTIVES

GASTRIC FEEDING TUBES

4. ASSESSING FOR GERIATRIC FAILURE TO THRIVE

WEIGHT LOSS

DYSPHAGIA

CANCER EVALUATION

PHYSICAL ASSESSMENT

ASSESSMENT OF PHYSICAL FUNCTION

POLYPHARMACY

LABORATORY EVALUATION

MENTAL HEALTH AND COGNITIVE EVALUATIONS

ELDER ABUSE

5. DEVELOPING A TREATMENT PLAN

THE FAMILY CONFERENCE

NUTRITIONAL THERAPY

GERIATRIC PSYCHIATRY REFERRAL

PHARMACOLOGIC THERAPY

6. MONITORING AND FOLLOW-UP

IMPAIRED PHYSICAL FUNCTION

MALNUTRITION

DEPRESSION

COGNITIVE IMPAIRMENT

7. HOSPICE

8. CASE STUDIES

CASE STUDY 1

CASE STUDY 2

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

99204 • Geriatric Failure to Thrive: A Multidimensional Problem

Education Category. Geriatrics

Release Date. 04/01/2024

Expiration Date. 03/31/2027

Course Overview

As the number of elderly patients increases, nurses and other healthcare providers must become knowledgeable about the special healthcare needs of the geriatric population. Undesired weight loss and malnutrition in the elderly are significant problems, leading to increased morbidity and mortality. Residents of skilled nursing facilities are at special risk. Geriatric failure to thrive is a diagnosis commonly used in geriatrics, and the four chief characteristics are impaired physical function, malnutrition, depression, and cognitive impairment. Participants who complete this course will learn about the identification, evaluation, and assessment of geriatric failure to thrive, including use of the Mini Nutritional Assessment, the Mini Mental Status Evaluation, and the Geriatric Depression Scale. Diagnostic/laboratory and physical assessment skills will be reviewed with a focus on weight-loss assessment. Creation of a multidisciplinary treatment plan with review of pharmaceutical options will be explored. This will give the healthcare professional the knowledge and tools necessary to identify this syndrome early. This activity will help promote better health outcomes for the geriatric population by education of the care providers and with the promotion of evidence-based practice.

Audience

This course is designed for nurses, nurse practitioners, and behavioral health professionals who work in or are interested in learning more about geriatrics. Other disciplines that may benefit from this training include dieticians, therapists, and psychologists.

Accreditations & Approvals

In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is approved by the California Nursing Home Administrator Program as a provider of continuing education. Provider number 1622. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. This course, Geriatric Failure to Thrive: A Multidimensional Problem, Approval #07012022-40, provided by NetCE is approved for continuing education by the New Jersey Social Work Continuing Education Approval Collaborative, which is administered by NASW-NJ. CE Approval Collaborative Approval Period: Friday, July 15, 2022 through August 31, 2024. New Jersey social workers will receive 5 General & Social and Cultural Competence CE credits for participating in this course. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is approved as a provider of online continuing education for certified nursing assistants through the California Department of Public Health Licensing and Certification Division. Nurse Aide Certification (NAC) Provider #7005.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 5 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 1 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours. This home study course is approved by the Florida Board of Nursing Home Administrators for 5 credit hour(s). This course is approved by the California Nursing Home Administrator Program for 5 hour(s) of continuing education credit - NHAP#1622005‐8961/P. California NHAs may only obtain a maximum of 10 hours per course. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program. NetCE designates this continuing education activity for 5 credit(s).

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through July 29,2025); Alabama, Provider #ABNP0353, (valid through July 29, 2025); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2025; South Carolina, Provider #50-2405; South Carolina, Provider #50-2405. West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Course Objective

The purpose of this course is to educate nurses, social workers, and other healthcare providers regarding geriatric failure to thrive and to promote evidence-based clinical practice when caring for patients with this condition.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define the various conditions responsible for unintended weight loss in geriatric patients, including geriatric failure to thrive.

2. Analyze various ethical and legal issues that can arise when treating geriatric failure to thrive patients and the role of advance directives in ameliorating some of these issues.

3. Outline necessary components of the physical assessment and differential diagnosis of geriatric failure to thrive.

4. Evaluate the role of polypharmacy in unintended weight loss in elderly patients.

5. Describe the role of mental health screening in geriatric failure to thrive patients.

6. Create a treatment plan for a geriatric failure to thrive patients, including possible pharmacotherapy approaches and areas for monitoring and follow-up.

7. Identify geriatric failure to thrive patients for whom hospice referral should be considered.

Faculty

Susan Waterbury, MSN, FNP-BC, ACHPN, entered the medical field in 1985 as a certified medical assistant and basic x-ray operator. She achieved her RN in 1990 and practiced in a variety of settings, including hospital, home health care, and hospice. Ms. Waterbury achieved her BSN in 1996 and her MSN as a Family Nurse Practitioner in 1999. She was board-certified as an FNP-BC in 2000 and has practiced in family practice, geriatrics, corporate leadership, hospice, and palliative care settings. She holds RN and NP licenses in Florida and Arizona.

In addition to her clinical roles, Ms. Waterbury continues to play an active role in educating and mentoring nurses and healthcare professionals. She has been a faculty member of the University of Phoenix since 2015, teaching in the nurse practitioner and MSN programs. She develops and presents educational programs for a variety of healthcare organizations and community groups.

Faculty Disclosure

Contributing faculty, Susan Waterbury, MSN, FNP-BC, ACHPN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Mary Franks, MSN, APRN, FNP-C

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Undesired weight loss in the elderly causes a reduced quality of life and contributes to serious illness. Elderly residents of nursing facilities who lose 5% of their body weight in one month are 4.6 times more likely to die within a year[1]. Poor prognosis is also associated with low prealbumin and cholesterol levels. Malnutrition in the elderly can result in pressure sores, functional decline, longer rehabilitation, and multiple medical complications.

The "baby boomers" will continue to account for a substantial increase in the elderly population (Figure 1). By 2060, persons older than 65 years of age are projected to make up 24.4% of the population [2]. The number of the "oldest old," those 85 years of age and older, is expected to increase from 6.7 million in 2020 to 14.4 million in 2040 [3]. More elderly persons will be dependent on others for their survival, with increasing numbers living in skilled nursing and assisted living facilities. Healthcare providers should become prepared for the projected growth of the elderly population and be prepared to treat the various conditions unique to this group.

Figure 1: NUMBER OF PERSONS IN THE UNITED STATES 65 YEARS OF AGE OR OLDER, 1900–2060

Source: [3]

2. DEFINITIONS

FAILURE TO THRIVE

The term "failure to thrive" was originally used to identify abnormal growth and development patterns in children. The term was borrowed from pediatrics in the 1970s to describe a similar syndrome that affected geriatric patients. Failure to thrive is a common diagnosis in geriatrics. As of October 2014, the Centers for Medicare and Medicaid Services (CMS) no longer accepts adult failure to thrive as a principal diagnosis for hospice claims, but it has been noted that access to hospice is not impeded by this fact because the principal diagnosis may instead be, for example, one of or a combination of cachexia, malnutrition, dysphagia, or muscle weakness, with an additional diagnosis of adult failure to thrive [4,5].

Failure to thrive is defined by the Institute of Medicine as "weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol" [6]. It is not a single disease or medical condition. Rather, it is a multidimensional problem that requires a multidisciplinary approach for its treatment. The four chief characteristics of geriatric failure to thrive are impaired physical function, malnutrition, depression, and cognitive impairment [7]. Failure to thrive is commonly used as a nonspecific diagnosis when a patient loses weight due to an unknown cause. After the diagnosis is made, it stimulates further assessment and interventions. Each of the domains of geriatric failure to thrive should be evaluated to determine areas in which the elder is having difficulty.

Geriatric practitioners often order extensive diagnostic work-ups for these patients, which do not always reveal a reversible cause. It is a challenge to differentiate disease states common for older patients versus "normal aging." Furthermore, large amounts of Medicare dollars are paid to hospitals at the very end of the patient's life [8]. This raises the ethical dilemma of providing "futile care" that is cost intensive and yields few benefits.

Despite costly, time-intensive medical evaluations, 25% to 35% of patients with geriatric failure to thrive have no obvious medical cause for this weight loss [1,9]. If weight loss is attributed to the normal aging process, this can prevent early interventions from being employed.

SARCOPENIA

Sarcopenia can be defined as an age-related loss of skeletal muscle mass and strength that usually occurs after 60 years of age [10]. Decreased strength leads to decreased function, and this functional decline can result in multiple complications, including falls, fractures, cognitive impairment, depression, and loss of independence. Nursing home residents are at special risk, as inactivity and immobility lead to muscle wasting [11,12,13]. This wasting is accelerated when nutritional deficits are present, and studies report that 18% to 60% of residents of nursing facilities are undernourished [14,15].

CACHEXIA

Cachexia is a physical wasting with weight and muscle mass loss, usually secondary to chronic progressive diseases such as cancer, acquired immune deficiency syndrome (AIDS), and chronic obstructive pulmonary disease (COPD). An estimated 10% of nursing home residents in the United States have cachexia [16]. Cachexia is a hypermetabolic state in which loss of body mass cannot be reversed nutritionally. The mechanisms that cause cachexia are poorly understood, but inflammatory cytokines and metabolic imbalances probably play a role [17,18]. Cachectic patients often have a poor prognosis due to multiple medical comorbidities. Cachexia is seen in the late stages of almost every major chronic illness, affecting an estimated 16% to 42% of people with heart failure, 30% of those with COPD, and up to 60% of people with kidney disease [18].

ANOREXIA OF AGING

Anorexia of aging, also known as age-related wasting, is a complex problem with physical, psychologic, and sociologic causes [19]:

- Physical causes: Medical illness, comor- bidities, functional decline, sensory loss, reduced smell and taste, water and sodium imbalance, reduced thirst and ability to concentrate urine, medication side effects, and early satiety

- Psychologic causes: Cognitive impairment, delirium, depression, and/or psychiatric illness

- Sociologic causes: Poverty, lack of family support, isolation, dependency, substandard living conditions, and elder abuse

In addition, there is usually a component of sarcopenia and/or cachexia present. When undesired weight loss and/or malnutrition occur in the elderly patient, it becomes a complex problem requiring a multidisciplinary approach. Unless this syndrome is identified early and interventions begun, the prognosis can be quite poor. An age- or illness-related weight loss or physical decline can quickly progress to a terminal hospice diagnosis.

3. REGULATORY AND LEGAL ISSUES

Weight loss is a serious issue in nursing facilities, and state and federal regulatory agencies monitor undesired weight loss as a quality indicator. It is also an area of focus for plaintiff attorneys, and advertisements may encourage loved ones to sue facilities/care providers for weight loss, accusing neglect. Furthermore, inadequate treatment and monitoring of the patient with dysphagia has become a malpractice litigation issue. Plaintiffs may accuse the nursing home or staff members of inadequate screening, evaluation, and/or treatment of the patient with dysphagia [20]. Plaintiff attorneys may assert that adequate treatment and supervision could have prevented aspiration and death.

Undesired weight loss can usually be attributed to medical illness, terminal condition, food refusal, cognitive impairment, psychologic illness, or hypermetabolic state; however, one in four older adults experiencing weight loss have no discernible medical cause [21]. Careful communication with the patient and healthcare proxy, with adequate documentation of options for treatment, provides a basis for defense. Nursing facilities can protect themselves by responding quickly and appropriately, using established protocols for dysphagia management.

ADVANCE DIRECTIVES

Advance healthcare directives allow the patient and family to determine what medical care is desired. State regulations vary regarding how and when advance directives can be used. It is important for healthcare providers to be familiar with laws governing the use of advance directives in the state in which they practice [22]. While it is desirable for a patient to have an advance directive, it may never be a condition of admission or continuance of their stay in a nursing facility.

When caring for any patient with failure to thrive, it should first be determined if advance directives exist, and copies of any documents should be obtained. If no advance directives exist, it should be determined if the patient is capable of making his or her own healthcare decisions. This is called a determination of capacity and usually requires the signatures of two physicians. If the patient is deemed incapable of making medical decisions, the healthcare proxy will assume the role of medical decision maker. A healthcare proxy is a person that is chosen by the patient/family to make healthcare decisions for the patient. If there is not a surrogate designated, a close family member or personal friend may be appointed the proxy.

There are many types of medical care that a living will can address [22]. A do not resuscitate (DNR) order is a pre-hospital determination stating that the patient does not want cardiopulmonary resuscitation (CPR), ventilatory support, or other heroic lifesaving measures. It is important to note that this does not prevent other life-sustaining treatments (e.g., artificial nutrition, hydration) and will not compromise the level of care given [22].

The concept of living wills grew from the limitations of DNR orders. These legal documents predetermine the medical care that will be accepted and refused. It may also designate a healthcare proxy or organ donation. If lifesaving or life-prolonging treatment is warranted and the patient is unable to communicate his or her preferences, the living will is activated. The living will should be as detailed as possible, and a physician should review the contents with the patient, if possible, to ensure understanding. A nutrition/hydration directive may be created in order to ensure that a patient's/proxy's wishes regarding nutrition and hydration care are followed. This clarifies whether a feeding tube may be inserted or IV fluids administered. In some cases, patients may refuse a gastric feeding tube but allow IV hydration or blood transfusion [22].

If a patient/proxy and healthcare provider determine that further hospitalizations would not be beneficial, a do not hospitalize (DNH) order may be made. A DNH allows care to be provided in a nursing facility or home. These orders are often made when further hospitalizations would most likely cause further pain, suffering, or complications, and the patient would rather be cared for by familiar caregivers. If a patient's/proxy's wishes are contrary to a healthcare professional's recommendations, he or she may be required to sign a refusal of treatment. This document indicates that the patient or responsible party has received informed consent regarding treatments, procedures, specialty referrals, diagnostics, and recommendations and has declined the recommendation. In addition, a waiver of responsibility may be necessary. This form is designed to relieve responsibility of the nursing facility when a patient does not follow recommendations. It is most commonly used when the patient/proxy refuses fluid restrictions, dietary modification, or thickened liquids. Many facilities do not allow waivers, as they may not adequately protect from litigation.

At times, advance directives may be difficult to implement due to pressure from family or the facility. When a patient has a living will and has clearly communicated end-stage desires and wishes to family, problems following a directive should be minimal. In other cases, there may be no advance directive and family members must make these difficult, and often divisive, decisions without knowing the patient's last wishes. Family members who may or may not have a close relationship with the patient can revoke living wills, DNRs, and other directives; they may be in denial of the patient's declining condition or have a personal agenda. Social workers are instrumental in the process of determining advance directives and communicating with families.

Medically futile care consists of medical diagnostics, treatments, or procedures that most likely will not provide a meaningful benefit to the patient. This is a difficult issue, particularly when the physician recommends withdrawing or withholding treatments and the family wants everything possible done. Ethics committees are useful resources when there is conflict that cannot be resolved.

It can take several hospitalizations or trips to the emergency room before family members or patients will be ready to sign DNR or DNH directives. In addition to debilitating illness, patients may be physically restrained at the hospital, usually to prevent them from falling or pulling out IVs or tubes. Physical or chemical restraint causes a forced immobility, potentially leading to pressure sores and muscle wasting.

Long-term care facilities have regulations and practices regarding physical restraints and have protocols to be followed when a restraint is required; some pride themselves on being a restraint-free environment. These facilities can utilize creative means to keep patients from harming themselves, including bed and chair alarms, activity programs, and low beds with mats on either side to prevent injury should the patient get up unassisted and fall. Physical and occupational therapists can be instrumental in initiating programs to promote patient safety and prevent falls. The least restrictive method of physical restraint is the most desirable for patients and facilities.

GASTRIC FEEDING TUBES

Gastric feeding tubes are commonly seen in nursing facilities, and they can be used for years to provide medications, hydration, and nutrition. Feeding tubes are routinely used for progressive neurologic diseases (e.g., Parkinson disease), stroke, and radiation therapy of the head or neck. However, gastric feeding tubes are not recommended for patients with advanced dementia, and there is no evidence that placement of a feeding tube improves the quality of life or survival in these patients [23,24]. Complications that can occur with a feeding tube include aspiration, infection, and tube dysfunction. In some cases, gastric feeding tubes prolong pain and suffering at the end of life. The impact of these potential complications should be considered before a gastric feeding tube is prescribed. Evidence-based information about feeding tube placement should be given to patients and family members to assist them to make informed decisions.

4. ASSESSING FOR GERIATRIC FAILURE TO THRIVE

WEIGHT LOSS

Evidence Based Practice Recommendation

According to the American Academy of Family Physicians, unintentional weight loss of 5% or greater within 6 to 12 months is associated with increased morbidity and mortality in older adults and should prompt evaluation.

https://www.aafp.org/pubs/afp/issues/2021/0700/p34.html

Last Accessed: March 22, 2024

Level of Evidence: B (Consistent findings from multiple prospective cohort studies with good follow-up)

Most nursing facilities have protocols to be followed when a resident has a 5% weight loss in one month or a 10% weight loss in six months. Physician notification, dietician consults, and speech therapy evaluations are usually the first interventions.

Dieticians perform nutritional assessments, recommend liquid supplements, discontinue restrictive diets, obtain calorie counts, determine food preferences, recommend protein supplements, and add nutritious snacks. Dieticians or dietary technicians should evaluate a patient's nutritional status regularly: upon admission to a nursing facility, quarterly, and in case of significant change in weight.

The Mini Nutritional Assessment (MNA) is a validated tool often used to evaluate the nutritional status of elderly persons [25,26,27]. The MNA is inexpensive, quick, and easy to administer. The short-form version consists of a six-item checklist that assesses the patient's food intake, mobility, weight loss, psychologic stresses and problems, and body mass index (BMI). Calf circumference can be substituted if BMI cannot be obtained. The MNA can quickly identify elderly at risk of malnutrition and guide nutritional intervention. A copy of the MNA may be accessed online at https://www.mna-elderly.com.

DYSPHAGIA

Assessment and interventions for causes of dysphagia are often necessary in patients with geriatric failure to thrive. A speech therapist will evaluate the patient's swallowing ability and can test for sensory deficits. Dysphagia assessments may include bedside assessment of swallow, the videofluoroscopic swallowing study (VFSS), and the fiberoptic endoscopic evaluation of swallowing (FEES) [28,29]. Both the VFSS and the FEES can detect laryngeal penetration, tracheal aspiration, and pharyngeal residue. The VFSS is more commonly known as the modified barium swallow study, which is usually performed at acute care or diagnostic facilities [28].

During the assessment period, the speech therapist will try different food and fluid consistencies. Thickening of liquids is one of the most common treatments for dysphagia, and thickened liquids are routinely tried during modified barium swallow studies, especially if a patient demonstrates difficulty with thin liquids. The degrees of thickness or viscosity are generally categorized as regular or unthickened (nothing added); nectar-like or nectar-thick; honey-like or honey-thick; or pudding-like or pudding-thick [30]. After assessment and testing, the speech therapist will determine the consistency of food and fluids most appropriate for the patient.

Patients often are at risk for aspiration secondary to dysphagia, and this complication is considered life-threatening. Therefore, patients with a diagnosis of dysphagia should be carefully monitored for signs of choking and/or pneumonia. Signs of dysphagia or aspiration include [31]:

- Coughing or choking associated with eating

- Excessive swallowing

- Throat clearing

- Gargling sound while eating

- Wet voice

- Sensation that something is stuck in throat

- Food or liquid spilling from the mouth

- Sneezing

- Food pocketing in mouth

- Recurrent pneumonia

- Chest or lung congestion

- Desaturation while eating

After a thorough assessment of a patient's swallowing and speaking ability is complete, a program to restore nutrition and intake by mouth will be established. The restorative dining program consists of intensive education, assistance, and supervision with meals to restore swallowing ability. The speech therapist may also work with patients with gastric feeding tubes in order to restore oral feedings.

The use of neuromuscular electrical stimulation (NMES) to provide assistance in swallowing rehabilitation has been extensively studied. This involves the application of electrodes to the neck that provide small electric currents to strengthen and retrain the muscles involved in swallowing. Patients who are unable to regain their swallowing function after a stroke or other debilitating illness may be good candidates for this type of therapy, especially when other techniques have failed. Most experts agree that NMES is a promising technique for swallowing rehabilitation; however, they also state that additional research is needed to provide evidence of its efficacy [32,33,34,35,36].

In cases of irreversible dysphagia, a gastric feeding tube may be the only option to maintain nutrition. Either the patient or the healthcare proxy may decline a feeding tube and elect to have oral feedings despite the risk of aspiration and choking. This is an instance in which obtaining a waiver of responsibility may be appropriate. Some facilities may be uncomfortable allowing a patient to eat a regular diet or drink thin liquids when tests have proven the patient to be at high risk for aspiration. It is important to note that a waiver may not provide adequate legal protection against litigation.

CANCER EVALUATION

It is important to evaluate patients for metabolic or treatable causes of weight loss, including cancer. The incidence of cancer increases with age, and screening for cancer and evaluation of risk factors are essential parts of the assessment of geriatric failure to thrive, with special focus on screening for the most common types of cancer (Figure 2).

Figure 2: MOST COMMON SITES OF NEW CANCER DIAGNOSES AND CANCER DEATHS, 2024: MALE AND FEMALE, UNITED STATES—ALL RACES

Source: [37]

Each patient should be carefully evaluated on an individual basis, taking into consideration patient age, advance directive, and functional and mental status. Clear communication with the patient and/or healthcare proxy along with clarification of any and all advance directives is necessary. Patients or patient representatives should feel empowered to accept or decline diagnostic procedures or treatments.

Digital rectal exam (in men), fecal occult blood test, prostate-specific antigen test (PSA), breast exam or mammogram (in women), and a chest x-ray are vital aspects of a comprehensive cancer screening when cancer is suspected; routine screening of older individuals with limited life expectancy is generally not recommended. Diagnostic and laboratory tests may be completed, even when surgery or treatment is not advised, in order to guide the treatment of geriatric failure to thrive.

PHYSICAL ASSESSMENT

A thorough baseline evaluation is necessary for all patients with unexplained weight loss. History taking and a complete and accurate physical assessment lay the foundation for further treatment, monitoring, and follow-up. A patient's baseline physical function and health should be determined before assessing for abnormalities. Changes associated with normal aging may include loss of subcutaneous fat from face and periphery (re-deposited to the abdomen and hips), shorter stature, shrinkage of muscle mass, kyphosis, and senile ptosis or ectropion. Many geriatric patients have chronic medical conditions, and seemingly abnormal exam findings may actually reflect these long-term illnesses (Table 1) [7]. Common findings in the geriatric patient may include heart murmurs and cardiac arrhythmias, chronic skin lesions such as seborrheic keratoses, orthostatic hypotension, sensory deficit (e.g. visual, hearing), and arthritic deformities. Good history taking with input from family members and staff will help differentiate problems that require intervention from normal findings for that patient. In addition to standard physical assessment, special attention should be paid to cancer detection, as discussed, and gastrointestinal tract disorders.

Table 1: COMMON MEDICAL CONDITIONS ASSOCIATED WITH GERIATRIC FAILURE TO THRIVE

Medical Condition

Cause of Failure to Thrive

Cancer

Metastases, malnutrition, cancer cachexia

Chronic lung disease

Respiratory failure

Chronic renal insufficiency

Renal failure

Chronic steroid use

Steroid myopathy, diabetes, osteoporosis, vision loss

Cirrhosis, history of hepatitis

Hepatic failure

Depression, other psychiatric disorder

Major depression, psychosis, poor functional status, cognitive loss

Diabetes

Malabsorption, poor glucose homeostasis, end-organ damage

Hip, other large-bone fracture

Functional impairment

Inflammatory bowel disease

Malabsorption, malnutrition

Myocardial infarction, congestive heart failure

Cardiac failure

Previous gastrointestinal surgery

Malabsorption, malnutrition

Recurrent urinary infections or pneumonia

Chronic infection, functional impairment

Rheumatologic disease (e.g., temporal arteritis, rheumatoid arthritis, lupus erythematosus)

Chronic inflammation

Stroke

Dysphagia, depression, cognitive loss, functional impairment

Tuberculosis, other systemic infection

Chronic infection

Source: Reprinted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med. 1997;13(4):769-778.

The initial physical assessment includes baseline measures of BMI, height, weight, triceps skinfold measurement, calf measurement, full vital signs, and oxygen saturation. To calculate the BMI it is necessary to have an accurate height and weight. BMI calculators and charts are readily available for easy calculation. If either height or weight is unavailable, calf circumference may be used. Patients with a BMI of less than 22 are considered at risk (Table 2).

Table 2: BMI WEIGHT STATUS CATEGORIES

BMI

Weight Status

Less than 18.5

Underweight

Less than 22

Hospice criteria

18.5 to 24.9

Normal

25 to 29.9

Overweight

30 and greater

Obese

Source: Compiled by Author

Oral examination findings in patients with geriatric failure to thrive may include candidiasis, dental problems, oral lesions, xerostomia, and post-nasal drainage. Monitoring oxygen saturation while having the patient swallow fluids can detect risk of aspiration. Choking or coughing while drinking fluids may or may not indicate aspiration; coughing may actually be a defense mechanism preventing aspiration. If a patient's oxygen saturation drops while eating or drinking, further evaluation and referral to speech therapy is necessary.

Xerostomia, or dry mouth, is a common complaint in geriatric patients [9]. It can be a side effect of a medication or of radiation to the head or neck. Poor dentition is a contributing factor. Over-the-counter sprays, mouthwashes, hard candies, or ice chips can provide some relief. Medications with anticholinergic effects are not generally recommended for elderly patients due to potential adverse effects, such as dry mouth, dysgeusia, constipation, and changes in mental status [7]. If the use of an agent with anticholinergic effects is necessary, the lowest effective dose should be utilized.

Referral to a dentist for management of any dental problems or concerns is crucial. Dental problems lead to decreased oral intake and weight loss. Caries and broken teeth should be restored, and the fit of dental prosthesis should be verified.

Post-nasal drainage and vasomotor rhinitis can contribute to decreased nutritional intake. In these cases, treatment of allergic conditions can help improve oral intake.

Auscultation of the heart and lungs is also necessary in order to evaluate chronic diseases and detect new problems [7]. Normal age-related changes to physiology and parameters should be noted. The chest often increases in anteroposterior diameter with aging. Occasional ectopic beats are common and do not necessarily indicate underlying heart disease. Systolic blood pressure commonly increases with age; diastolic blood pressure usually stays constant. For patients with abnormal cardiovascular findings, additional diagnostics include chest x-ray, electrocardiogram, echocardiogram, and 24-hour Holter monitoring.

Disorders of the gastrointestinal tract can cause weight loss. The aging abdomen often has increased deposits of subcutaneous fat and thinner musculature. Peristalsis may be visible, in the absence of obesity. Osteoporotic kyphosis causes a protuberant appearance of the abdomen. Medications may cause gastrointestinal side effects, such as nausea, heartburn, and constipation.

Examination of the abdomen may reveal hepatomegaly, masses, constipation, distention, hernias, ascites, and tenderness. Bowel and bladder patterns and function should be assessed, using the patient's normal patterns as a baseline. Conditions such as atrophic gastritis, gastric or peptic ulcer, constipation, lactose intolerance, diverticulosis, colitis, and diabetic gastroparesis may be the cause of significant weight loss. Diagnostic approaches for abnormal exam findings may include abdominal or pelvic ultrasounds, fecal occult blood test, and kidneys, ureters, and bladder x-ray. Referral to a gastroenterologist can be crucial for patients' treatment and outcome.

Thyroid function should also be assessed, as both hypothyroidism and hyperthyroidism may result in impaired absorption of nutrients and weight fluctuations. Some patients with hypothyroidism may develop decreased peristalsis, leading to chronic constipation and impaired absorption of nutrients. With hyperthyroidism, patients may display increased appetite secondary to increased peristalsis, diarrhea, and weight loss. If there is accompanying vomiting with abdominal pain, this can lead to malnutrition and a negative nitrogen balance. Screening for thyroid dysfunction, and treating when present, may improve weight loss in some elderly patients.

The neurologic assessment should include sensory evaluation, cranial nerves, focal deficits, strength against resistance, and ambulation/gait evaluation. Documentation of baseline functional status is necessary, noting any assistive devices the patient uses for ambulation, including any splints or braces. If a patient is non-ambulatory and requires assistance for activities of daily living, this should be documented. Elderly patients may have slower responses, benign tremors, and a slower and more deliberate gait. Deep tendon reflexes are less brisk. Assessment of cognitive and mental status is an important aspect of the neurologic evaluation and will be thoroughly explored later in this course.

Baseline physical assessment lays the foundation for the ultimate plan of care. It also facilitates diagnosis of comorbid medical conditions. Documentation of serial measures of BMI, weight, and triceps skinfold thickness will help to track progress or decline. Depending on the patient's progress, the treatment plan can be revised or continued.

ASSESSMENT OF PHYSICAL FUNCTION

Impaired physical function is one of the four domains of geriatric failure to thrive, and evaluation of physical functioning is an integral part of the geriatric evaluation [7]. It is important to determine any changes in mobility and evaluate for signs of a functional decline. This decline may be rapid, in cases of hospitalization and severe illness, or gradual, with the patient experiencing decreased mobility and independence over a period of time. Occupational therapists can provide a complete assessment of a patient's mobility and ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADL). The Katz ADL scale assesses six activities: bathing, dressing, toileting, transferring, continence, and eating [38,39]. The Lawton IADL scale assesses a patient's ability to use the telephone, shop, take transportation, manage a budget, adhere to medication regimens, cook, and perform housekeeping and laundry chores [40]. Approximately 34% of adults 65 years of age or older reported having some type of disability (i.e., difficulty in hearing, vision, cognition, ambulation, self-care, or independent living), and 49% of adults 75 years of age and older reported having difficulty in physical functioning. This ranged from 5% reporting it was very difficult (or impossible) to sit for two hours, to 33% reporting it was very difficult (or impossible) to stand for two hours [3]. For patients with failure to thrive, assessment of eating and ability to feed oneself is particularly important. Recommendations regarding contracture management and prevention, need for splints, positioning in wheelchairs or specialty chairs, and the need for assistive devices to help with eating may be made. A rehabilitation plan to assist the patient to regain independence in daily activities can be helpful.

The patient's current strength, mobility, balance, and safety awareness should all be evaluated. Based on this assessment, assistive devices, such as walkers, canes, wheelchairs, and splints, may be prescribed. For a patient who has declined in function, a physical therapist may create a plan of rehabilitation to return the patient to his or her prior level of function. Rehabilitation may include therapeutic exercises, resistance exercise training, pain management modalities, and gait and ambulation training [41,42].

POLYPHARMACY

Polypharmacy has been described as the use of more than 5 medications, and excessive polypharmacy is defined as the use of more than 10 medications [43]. Known hazards of polypharmacy include lack of adherence, overtreatment, adverse drug reactions (including unexplained weight loss), and incorrect dose and administration regimen. In addition to these factors, physiologic changes of aging cause differences in the absorption, distribution, metabolism, and excretion of medications [44].

Elderly patients commonly take medications for many chronic conditions, including diabetes, hypertension, arthritis, and cardiovascular disease, making them at increased risk for the adverse effects of polypharmacy. Geriatric illnesses are often more complex and require referral to medical specialists. Each specialist may order diagnostic testing and medications without a complete knowledge of the patient's comorbidities and other treatments [44]. The primary care provider should perform a risk and benefit analysis to evaluate the need for multiple medications or tests. The primary care provider may then accept or refuse the specialist's recommendation, but should justify any refusal.

Assessment of each patient's medication regimen is crucial and should identify medications that may be causing problems. In each evaluation of a geriatric patient, medication side effects should be an initial consideration, including evaluation of over-the-counter medications, vitamins, and herbal remedies and supplements [44].

As an elderly patient begins to decline or lose weight, some previously prescribed medications may no longer be necessary. For example, lipid-lowering medications may not be necessary in patients who have lost weight or declined. Diuretic doses should be adjusted as necessary, as overdosing can cause azotemia. Insulin dosages should be titrated to reflect weight loss or poor food intake. Collaboration with multiple specialists may be beneficial to determine the necessity of certain medications. For example, a cardiologist may be consulted before stopping or changing doses of beta-blockers or angiotensin-converting enzyme inhibitors.

The risks of certain medications may outweigh the potential benefits in many cases. For instance, a patient 85 years of age with a longstanding history of treatment for atrial fibrillation may no longer be a candidate for anticoagulants. If the patient is at risk for falls, gastrointestinal bleeding, or hemorrhagic stroke, the risks of anticoagulation outweigh the potential benefit and the medication should be stopped. Another important consideration is the patient's adherence to prescribed medications and necessary monitoring. Patients who cannot or will not undergo regular blood test monitoring should not be on a warfarin regimen.

Patients with dysphagia may require changes to their medication routes to accommodate the condition. In some cases, medications may be crushed; if this method is chosen, controlled-release medications should be changed to a formulation that allows this administration. A nurse or family member can provide information regarding whether the patient requires crushed or liquid medications and whether the patient refuses any medications. Consultation with a pharmacist may help to identify any medications that can be reduced or stopped. The consultant pharmacist usually reviews the records monthly and makes recommendations according to state regulations.

The Beers list is a collection of medications potentially inappropriate for the elderly patient for a variety of reasons [45,46]. This list identifies medications not recommended for patients 65 years of age or older and identifies potentially harmful prescribing practices. Certain medications may be detrimental to elderly patients due to extended half-lives, interactions, or side effects. For example, benzodiazepines are associated with risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in the elderly, and before prescribing these medications, it should be clear that the potential benefits outweigh the risks [46]. Common medications on the Beers list include alprazolam, digoxin, cimetidine, diphenhydramine, lorazepam, and naproxen [45,46].

Many patients take over-the-counter allergy, cold, or cough medications as sleeping aids, some of which contain acetaminophen/diphenhydramine. Elderly patients should be advised to avoid such use, as diphenhydramine is associated with falls in this population; another sleep aid can be prescribed [46,47]. Medications that patients have taken for years may require re-evaluation if changes in health status occur.

LABORATORY EVALUATION

There are a variety of laboratory and diagnostic tests available to evaluate elderly patients whose health is failing, but it is important to refrain from ordering unnecessary tests that will not benefit the patient. Initial laboratory tests to evaluate unintentional weight loss include complete blood count, chemistry profile, thyroid, carcinoembryonic antigen in patients with cancer, urinalysis with culture (if indicated), and fecal occult blood test. Further laboratory and diagnostic tests should be guided by the results of these tests and by history, physical exam, and patient wishes. More extensive testing can include a chest x-ray, PSA, tumor markers, nutritional markers (e.g. vitamin D, vitamin B complex), anemia work-up, drug levels (e.g., phenytoin, digoxin), prealbumin, and albumin.

MENTAL HEALTH AND COGNITIVE EVALUATIONS

Cognitive impairment is another domain of geriatric failure to thrive. To fully evaluate geriatric failure to thrive, it is necessary to also assess psychologic and sociologic functioning. The Mini-Mental State Examination (MMSE) or Folstein test may be used as an objective assessment of cognition, either to establish a baseline measurement of mental status or to track progress or decline [48]. It is a 30-item exam that takes approximately 10 to 15 minutes to complete. A correct answer for each item is awarded 1 point, and a score of 25 or more is considered normal. Lesser scores can indicate severe (≤9 points), moderate (10–20 points), or mild (21–24 points) cognitive impairment. It is helpful to document serial scores in the medical record.

Another screening test for dementia is the clock drawing test [49,50]. There are variations in how this test is administered, but it generally consists of asking the patient to draw a picture of an analog clock, complete with numbers, set to a certain time. In some cases, the circle will be predrawn for the patient. Just as there are variations in the test, scoring methods also vary. One system is based on a score of five points as follows: 1 point for the clock circle, 1 point for all the numbers being in the correct order, 1 point for the numbers being in the proper place on the clock face, 1 point for the two hands of the clock, and 1 point for the correct time. Scores of 4 or 5 are considered normal. Studies are mixed on whether the complicated scoring, which is used to determine the severity or stage of dementia, is more effective than a simple pass/fail, but the consensus among experts is that the test is useful for determining whether further testing is required, regardless of the scoring method used [51,52].

This clock becomes part of the medical record and can clearly identify moderate-to-advanced cognitive impairment, although it is not sensitive for mild cognitive impairment or early Alzheimer disease. The clock drawing test is cost-effective and can be performed by trained assistants. Serial clock drawings incorporated into the medical record can document the onset and progression of dementia for geriatric clients [53].

Geriatric Depression Evaluation

Depression is a major cause of weight loss in the elderly, and geriatric depression is a significant health risk, affecting function and quality of life. Assessment for depression is crucial in the patient who has had an unintentional weight loss. Delay in diagnosis may accelerate the decline associated with failure to thrive and may increase morbidity and mortality [7]. Geriatric patients have often experienced multiple losses, including the death of a spouse, peers, or children; loss of independence; loss of health or mobility; and loss of physical or financial independence. Each of these events can induce depression.

The stigma of psychiatric illness may prevent elderly patients from seeking help for depression. They are more likely to complain of physical problems than to mention conventional depressive symptoms (e.g., mood changes) [7]. Therefore, screening should be incorporated into each clinical contact with a geriatric patient. Depression in the elderly may present with confusion, forgetfulness, apathy, slowing of thinking and movement, lack of interest in personal hygiene, and unexplained physical symptoms, including weight loss; however, these signs are often misdiagnosed as dementia in the elderly, making accurate assessment essential [7]. Disruption in sleep, changes in appetite, and psychomotor changes may prompt a patient to seek medical care. When a patient has multiple vague physical symptoms, depression should be included in the differential diagnosis. Suicidal ideation or attempt should be considered a medical emergency.

The Geriatric Depression Scale (GDS) is a self-report measure of depression that may be utilized to screen for depression in elderly patients (Figure 3) [7,54,55]. The shortened version (GDS-S) consists of 15 questions (taken from the long form) that assess mood and hopelessness. The GDS-S can be completed in five to seven minutes, which makes it ideal for patients who are easily fatigued or limited in their ability to concentrate for longer periods of time [55]. A score of 5 or greater on this test is considered positive. If a test is positive, referral to a psychiatrist specializing in geriatric patients should be made, as these patients do respond to depression treatment (e.g., psychotherapy, pharmacotherapy).

Figure 3: GERIATRIC DEPRESSION SCALE (SHORT FORM)

Source: [56]

ELDER ABUSE

Older patients who present with dehydration, malnutrition, and/or failure to thrive may be exhibiting signs of neglect or abuse. In a systematic review that represented 28 different countries, the overall prevalence rate of elder abuse was assessed at 15.7%; 11.6% had experienced psychologic abuse [57]. It is estimated that approximately 1 in 10 Americans older than 60 years of age has been the victim of abuse, including physical abuse, psychologic or verbal abuse, sexual abuse, financial exploitation, and neglect [58,59,60]. Denying food has been explicitly identified as a form of neglect.

Persons being assessed for geriatric failure to thrive should be evaluated for abuse. Certain situations may make some elders more vulnerable to elder abuse [61]. Any elder, for example, who is incapable of taking care of his/her own daily needs and is dependent on another person is automatically in an at-risk situation. The Elder Abuse Suspicion Index (EASI) is a five-item tool that provides practitioners with a very quick sense of whether there is potential presence of elder abuse [62]. It is validated to screen for abuse in patients who are cognitively intact [63]. The EASI has been recommended by the U.S. Preventive Services Task Force and was originally developed for use by physicians, but it can be used by practitioners in diverse disciplines [64]. The following items comprise the index [62]:

- Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

- Has anyone prevented you from food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with?

- Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

- Has anyone tried to force you to sign papers or use your money against your will?

- Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

5. DEVELOPING A TREATMENT PLAN

When developing a treatment plan, it is important to take a holistic and interdisciplinary approach in order to address all of the domains of geriatric failure to thrive [7]. Input from medical specialists, nursing staff, social workers, and physical, speech, and occupational therapists should be considered. Treatment efforts addressing only the physical effects of geriatric failure to thrive will most likely not achieve the desired results. For patients with both acute and chronic illnesses, acute infections and conditions should be resolved before a longer term plan is implemented.

During periods of acute illness, an elderly patient can experience a decline in function, and resolution of the acute condition may return the patient to his or her baseline. Common acute illnesses that cause physical and cognitive function deficits in older adults include urinary tract infection, pneumonia, dehydration, and exacerbation of congestive heart failure or COPD. Extended periods of bed rest also prove detrimental and can cause severe debility. Delirium can develop, requiring the use of physical or chemical restraints. Acute medical conditions also increase nutritional requirements at a time when nutritional intake is often reduced secondary to poor eating. After the acute issue is resolved, medical treatment may be provided for any other conditions present. Optimization of treatment of chronic illnesses is crucial in the care of patients with failure to thrive.

THE FAMILY CONFERENCE

Family meetings may be difficult but are often productive interactions. These conferences provide an opportunity to present the results of the specialty consults and the tests and assessments that have been performed and for the patient and family to ask questions or request additional information. If further medical care and treatments would be futile or serve to prolong the dying process, this should be conveyed to the patient and family. Advance directives should be reviewed and updated. Any concerns expressed by the patient or family should be fully addressed. The healthcare provider, family members, and patient should leave the meeting with an agreement regarding the plan of care and treatment desired. When patients and family members have a good understanding of the options available, including potential benefits and risks, they are in a position to provide informed consent, and this can help to prevent misunderstandings later.

NUTRITIONAL THERAPY

Correction of vitamin and nutritional deficits is necessary to reverse malnutrition. As such, collaboration with a dietician and a speech therapist is essential when caring for patients with failure to thrive. The speech therapist can determine the consistency of food best suited for the patient's needs and can recommend modifications to the established diet. The patient may require thickened liquids, puréed diet, mechanical soft diet, or other variation. Some patients will benefit from a restorative dining program, as supervision, encouragement, and socialization may increase food intake.

Discontinuation of restricted diets is an appropriate step for the patient with malnourishment. Therapeutic and restrictive diets do not promote adequate energy intake and should be thoroughly reviewed for each patient [65]. For example, the American Dietetic Association recommends a liberalized diet approach for nursing home residents [66]. A dietician should assess patients' food preferences and determine if oral nutritional supplements would be appropriate and accepted by the patient. The most common approach is to provide liquid nutritional supplements, shakes, and puddings between meals, with the goal of increasing calorie consumption. Geriatric patients may eat most of their calories at breakfast, which should be accommodated. It is important to provide high-calorie, fortified foods when the patient's appetite is greatest [7].

The first line of treatment for most patients living in nursing facilities is administration of oral liquid nutritional supplements. These are added to the plan of care and generally administered by nursing staff and dietary assistants. Compliance with the treatment plan can be an issue, and it is essential to evaluate whether the supplements are offered and taken as prescribed.

Fortified foods are prepared with extra protein and calories to provide a more calorie-dense food. The addition of one-third cup of instant, nonfat dry milk adds 80 calories, 8 g protein, and 12 g carbohydrates. The addition of butter, milk, and cream boosts calorie intake as well, and oral protein supplements are available to help reverse protein malnutrition. Making the supplements appealing to the patient is an ongoing challenge.

Families can play a large role in reversing malnutrition in a nursing facility. When the family is present for a meal or brings in the patient's favorite food, intake is improved [7]. Patients may complain that they do not like the food that is served, and family members are better equipped to cater to any ethnic preferences. Family members can often coax their loved one to eat their meal and take liquid nutritional supplements. Dedicated staff members and caregivers can promote positive outcomes by making sure supplements are offered and taken.

Vitamin Deficiencies

A number of common vitamin and mineral deficiencies may occur in patients with failure to thrive. Deficiencies may occur from not consuming enough fresh, nutrient-rich foods and/or from malabsorption disorders of the gastrointestinal tract. Common nutrient deficiencies include vitamin B12, vitamin D, iron, and zinc. In most cases, deficiencies will resolve with the administration of vitamins and supplements.

Vitamin D

The consequences of vitamin D deficiency include muscle weakness, body sway, osteomalacia, and a tendency for falls and fractures [67]. Many elderly persons are not exposed to enough sunlight each day for adequate vitamin D synthesis. Supplementation with 800 IU of vitamin D daily is recommended and has been shown to reduce falls [68,69].

Vitamin B12

Vitamin B12 deficiency occurs due to inadequate dietary intake or impaired absorption. It may be associated with neurologic symptoms such as tingling of extremities, fatigue, irritability, depression, weakened concentration, and impaired memory [70]. It is fairly common in the elderly population due to decreased or absent intrinsic factor secondary to atrophic gastritis, achlorhydria, or previous gastric surgery. Deficiency may also be caused by medication side effects, such as those associated with the prolonged use of proton pump inhibitors. Vitamin B12 deficiency is traditionally treated by injectable cobalamin but is also effectively addressed with an oral supplement 1–2 grams daily.

Eldertonic is a vitamin B complex elixir with zinc, manganese, and magnesium in an alcohol base. The usual dose is 15 cc given three times daily, just before meals [70]. It is similar to a before meal alcoholic drink with a sherry base. Although some patients may find it distasteful and refuse to take it, no significant side effects have been noted [71]. It is associated with a mild anecdotal appetite improvement, which may be the result of correcting zinc and vitamin deficiencies.

Zinc

Zinc deficiency is common in the institutionalized and homebound elderly patient. Zinc is needed for protein synthesis and is important in wound healing and skin repair and renewal. Zinc deficiency is caused by inadequate intake, gastrointestinal malabsorption, or increased zinc losses from the body (e.g., with diarrhea) and is associated with increased inflammation in older patients [72]. A diet lacking in zinc can lead to frequent infections, delayed wound healing, reduced appetite, decreased taste and smell, poor skin condition, and white flecks on the nails. A replacement dose of 50 mg elemental zinc per day is recommended.

Iron

Iron deficiency leading to anemia is a common finding in the elderly patient, affecting an estimated 3 million elderly Americans [73]. The most common causes include iron deficiency (with or without blood loss), chronic disease/inflammation, and chronic kidney disease [73,74]. Serum ferritin levels less than 45 mcg/L are suspicious for iron deficiency in the elderly [75]. Iron replacement therapy should be undertaken cautiously, as high iron stores can also be detrimental.

It is important to identify the cause of anemia and to treat accordingly. This often includes a gastroenterology evaluation [73]. Ferrous sulfate 200 mg three times a day is usually sufficient to replenish iron stores. It is important to consider ordering stool softeners at the same time, as constipation and fecal impaction are side effects. Supplementation should continue for three months past correction of the deficiency.

GERIATRIC PSYCHIATRY REFERRAL

In addition to multiple medical comorbidities and psychiatric disorders associated with aging (e.g., dementia), the geriatric patient may have longstanding psychiatric illness, such as bipolar disorder or psychosis, requiring multiple medications [76]. This makes treating the geriatric psychiatric patient quite complex.

There are multiple long-term complications associated with typical and atypical antipsychotic medications, including pharmacokinetic and pharmacodynamic changes, limitations, and cardiovascular and other adverse effects (e.g., gastrointestinal, liver) [76]. A patient may develop a Parkinsonian syndrome secondary to long-term antipsychotic use, resulting in dysphagia, tremors, difficulty performing activities of daily living, and difficulty feeding, all of which can result in unintentional weight loss [76]. Prior to changing longstanding medication regimens, a geriatric psychiatrist should be consulted in order to help prevent exacerbation of the underlying psychiatric illness.

Psychiatric symptoms associated with dementia, such as anxiety or agitation, may cause an increased energy demand. Psychiatric symptoms such as pacing, hyperactivity, repetitive behaviors, insomnia, and mania all can lead to weight loss. These symptoms should be effectively managed. Referral to a psychiatrist or psychologist is recommended in cases of continued weight loss, treatment failures, and additional behavioral problems.

PHARMACOLOGIC THERAPY

Evidence Based Practice Recommendation

The American Geriatrics Society recommends avoiding the use of prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, they recommend optimizing social supports, discontinuing medications that may interfere with eating, providing appealing food and feeding assistance, and clarifying patient goals and expectations.

https://www.americangeriatrics.org/sites/default/files/inline-files/AGS%20Choosing%20Wisely%20Poster.pdf

Last Accessed: March 22, 2024

Level of Evidence: Expert Opinion/Consensus Statement

Potential underlying causes of unintentional weight loss should be fully assessed and treated prior to initiating pharmacotherapy for geriatric failure to thrive. Each patient should be evaluated on an individual basis prior to prescribing an appetite stimulant. The medications commonly used and discussed in the following section are not approved by the U.S. Food and Drug Administration (FDA) for appetite stimulation in patients with failure to thrive.

Mirtazapine

Mirtazapine is an atypical antidepressant with noradrenergic and specific serotonergic effects. It is indicated for major depressive disorder in the elderly; the starting geriatric dose is 7.5 mg at bedtime [47]. This can be increased to a maximum of 45 mg, if necessary. Mirtazapine's antihistamine-like effects are more pronounced at the 15 mg daily dosage. Mirtazapine has been studied for treatment of depression, anxiety, and anorexia nervosa with depression, with weight gain as a secondary endpoint. The weight gain usually occurs early in therapy. It has not been shown to be effective for weight gain in nondepressed individuals. Its sedating effects can be useful for patients with sleep disturbances or anxiety.

Dronabinol

Dronabinol is a schedule III drug that contains delta-9-tetrahydrocannabinol (THC), the major active component of cannabis. It is FDA-approved to treat AIDS-related anorexia and refractory nausea and vomiting secondary to chemotherapy [47]. Dronabinol may also improve disturbed behavior in patients with Alzheimer disease [83]. Dronabinol is available in doses of 2.5 mg, 5 mg, and 10 mg in a gel cap that cannot be crushed and as an oral solution with a calibrated oral dosing syringe [47]. When used for geriatric failure to thrive, it is usually given one hour before meals (lunch and dinner). It has also been used as a single dose at bedtime due to central nervous system (CNS) side effects.

More research is needed regarding the use of dronabinol in the elderly population. Precautions should be used if this drug is prescribed to patients with liver disorders or seizure disorders [47]. There may be significant CNS side effects, including somnolence, emotional lability, and euphoria.

Megestrol Acetate

Megestrol acetate is a synthetic progestin and antineoplastic agent product, originally used for patients with cancer. Its use for weight loss in geriatric patients without cancer or AIDS is considered off label [47]. In small studies, megestrol has been effective at increasing appetite in certain geriatric patients at higher doses, although the actual impact on weight gain appears slight and side effects are common [77,78,79,80]. It has the potential to increase hypercoagulability, leading to thromboembolism. In addition, megestrol has glucocorticoid-like activity, which can potentially cause adrenal insufficiency and worsening of diabetes. New-onset diabetes and exacerbation of pre-existing diabetes have been reported with long-term use [47]. A case report associated megestrol acetate to two cases of osteoporosis; higher dosages of megestrol are associated with decreased bone density and may be associated with bone loss and fractures [82].

While megestrol has had some positive results for weight gain in the past, the potential drawbacks limit its use in practice. Patients with a history of thromboembolism should not receive megestrol. The Beers list includes megestrol acetate as a potentially harmful drug in the elderly, and its use should generally be avoided [81].

Anabolic Steroids

Anabolic steroids have been used in elderly patients with unintended weight loss with varying results. However, the side effects may prohibit their use in the geriatric population. Adverse reactions may include hyperglycemia, aggression, agitation, psychosis, and osteoporosis [84]. Anabolic steroids are possibly best well known as the substance that athletes use to increase muscle volume and strength. The Anabolic Steroids Control Act classifies steroids as a controlled substance [85,86]. It is a criminal offense for providers to prescribe an anabolic steroid unless it is used to treat a disease or medical condition.

The anabolic steroid nandrolone decanoate was the subject of a study of hip fracture recovery in elderly women [87]. In this study, a small dose was administered to determine if it could preserve lean body mass. The authors suggest that nandrolone decanoate with vitamin D and calcium supplementation improved body composition, bone mineral density, and clinical function. However, a systematic review found insufficient evidence to support the use of anabolic steroids for rehabilitation after hip fracture in the elderly and recommended that future research focus on a combined intervention of anabolic steroids and nutritional supplements [88].

Other Drugs

Administration of testosterone, growth hormone, and essential amino acids are other approaches to geriatric sarcopenia and cachexia that have had variable results [89,90]. Growth hormone was found to increase lean body mass and decrease fat mass. The side effects may prohibit its use, however, except for in controlled trials [89]. Growth hormone was found to cause insulin resistance, diabetes, and carpal tunnel syndrome. More clinical research is necessary before the use of anabolic steroids, amino acids, or growth hormones can be recommended for geriatric weight loss.

6. MONITORING AND FOLLOW-UP

Close monitoring of the geriatric patient with failure to thrive is essential, with special attention to each applicable domain. In addition, referral to a specialist to better address each domain's unique challenges may be necessary.

IMPAIRED PHYSICAL FUNCTION

Patients being treated for geriatric failure to thrive will undergo regular physical and occupational therapy; the progress reports for this therapy should be reviewed with the patient and family, at which point one can discuss any medical concerns that may be interfering with rehabilitation, including dizziness, medication side effects, uncontrolled pain, unresolved infections, and balance problems. Recommendations for adaptive or assistive devices based on these reports may be made. Referral to neurology, rheumatology, or orthopedics may be considered if physical function is drastically impaired [7].

MALNUTRITION

Patients should be weighed and have a BMI calculated weekly; this can decrease to monthly as the patient stabilizes. A speech therapist will continue assessing for dysphagia. It is important to monitor intake, particularly of liquid oral supplements and vitamin, mineral, and protein replacement. This requires ongoing dietician assessment and monitoring of nutritional status and consideration of a gastric feeding tube, when appropriate. Some patients will require referral to gastroenterology for treatment of underlying medical conditions leading to poor intake (e.g., gastroesophageal reflux contributing to dysphagia, esophageal stricture requiring dilation). Patients should also be assessed for oral pathology, ill-fitting dentures, speech or swallowing difficulties, medication use that might cause anorexia or dysgeusia, and financial or social problems [7].

DEPRESSION

Depression is the most common psychiatric condition in older persons [7]. Geriatric patients with failure to thrive should continue to be evaluated for signs and symptoms of depression and suicidal ideation. If prescribed, the efficacy of antidepressant therapy should be monitored, including adverse drug reactions and necessary adjustments in the medication regimen. Referral to a social worker, psychiatrist, and/or psychologist is strongly advised.

COGNITIVE IMPAIRMENT

Evaluation of psychosocial function should include an assessment of the patient's cognitive status, mood, and social setting [7]. Any behavior problems should be reviewed with the patient, family, and staff. Results of cognitive assessments, such as the MMSE and the clock drawing test, should be evaluated on a regular basis. The role of medical conditions or medication side effects should be considered. If dementia treatment has been attempted, efficacy of the prescribed regimen will be assessed. If necessary, the patient may be referred to neurology, psychiatry, or social work.

7. HOSPICE

Despite adequate evaluation and treatment, certain patients with failure to thrive will not respond to interventions. These patients will continue to lose weight and decline. If the BMI is less than 22 and significant physical impairment is causing disability, the patient qualifies for hospice care [91]. When the patient has declined parenteral feeding or has not responded to nutritional support despite adequate caloric intake, a referral to hospice should be considered. As noted, geriatric failure to thrive is no longer an acceptable diagnosis for hospice according to CMS [4]. Instead, the underlying condition most contributory to the patient's terminal prognosis should be noted (e.g., malnutrition).

The first step in initiating hospice is to obtain terminal evaluations by two physicians along with an evaluation of competency. After the patient has been certified as terminal, the next step is to have a meeting with the patient and healthcare proxy. Options for hospice care should be thoroughly discussed. When hospice services are recommended as an option, the patient and proxy may be shocked by the seriousness of the patient's condition. If the patient and healthcare proxy desire a conservative and comfort approach to care, then a referral to hospice is initiated. For a patient in a nursing facility, the hospice services will be rendered in the facility; others may use a home hospice service. The patient and family members should be supported through the dying process.

8. CASE STUDIES

CASE STUDY 1

Patient E is a woman, 82 years of age, recently hospitalized for pneumonia. Her medical history is positive for hypertension, diabetes, coronary artery disease, and heart failure. She is admitted to the rehabilitation center with functional decline, unsteady gait, weight loss, and difficulty swallowing; the rehabilitation will be short term.

During the initial medical evaluation, the patient appears frail, alert, and cooperative. She is able to answer questions appropriately. Patient E has been living alone in a senior independent living apartment for the last seven years. She has a daughter who lives nearby who is very involved in her care. The daughter states that Patient E has been slowly losing weight over the last six months. The patient states she has never been a big eater but admits her appetite is not what it used to be. The daughter has noticed the patient coughing and clearing her throat frequently while eating. Since the pneumonia, Patient E has had poor activity tolerance and requires frequent rest periods.

Patient E has both a healthcare proxy and a DNR on record. Her chief complaints are fatigue, poor appetite, leg weakness, and nonproductive cough. Her weight is 107 pounds and height is 5 feet 4 inches, with a BMI of 18.4, which is slightly underweight. She appears frail, though alert and cooperative. She is in no apparent pain or distress sitting up in a wheelchair. Upon initial physical examination, her blood pressure is 104/60 mm Hg, apical pulse 86 beats per minute, regular rate and rhythm with systolic ejection murmur (grade 2/6). Her respirations are 22 breaths per minute, with an oxygen saturation of 92% (on room air). Respirations are even and unlabored at rest, and crackles are noted in the right base. Patient E's abdomen is soft and nontender with active bowel sounds. Trace ankle edema are present bilaterally, and muscle atrophy and kyphosis are noted. The patient displays no focal deficit, and cranial nerves are normal.

Several assessment tests are administered, and the scores of each are noted:

- MMSE: 24 (mild cognitive impairment)

- Clock-drawing test: 4 (normal)

- GDS: 6 (suspicious for depression)

- MNA: 7 (malnourished)

In addition, several laboratory/diagnostic tests are ordered. The results are as follows:

- Hemoglobin: 10.4 g/dL

- Hematocrit: 31%

- Platelet: 132 platelets/L

- Comprehensive metabolic panel

- Glucose: 124 mg/dL

- Blood urea nitrogen (BUN): 35 mg/dL

- Creatinine: 1.4 mg/dL

- CO_2: 30 mmol/L

- Albumin: 2.9 g/dL

- Estimated glomerular filtration rate: 36 mL/min

- Thyroid stimulating hormone: 2.05 mIU/L, urinalysis-negative

- Vitamin B12: 318 pg/mL

- Vitamin D hydroxyl: 18 ng/mL

- Zinc: 55 mmol/L

A chest x-ray shows right lower lobe infiltrate and cardiomegaly. Finally, the modified barium swallow test indicates aspiration on thin liquids.

The patient is referred to several specialists for evaluation of potential causes of weight loss and continued failure to thrive. After two weeks, the results of the consultations are available. The physical therapist indicates muscle disuse atrophy of both lower extremities, poor endurance, and dizziness upon standing; however, the patient is able to walk 10 feet with assistance and walker. Occupational therapy indicates that Patient E requires assistance with bathing, dressing, and eating. The speech therapist recommends that the patient be placed on a mechanical soft diet with thickened liquids. Finally, the dietician finds that the patient's appetite is fair to poor, as she eats only 25% to 50% of meals. Patient E is resistant to modified diet and supplements; therefore, the dietician recommends liberalization of diet to regular with fortified foods.

Based on abnormal exam and laboratory findings, Patient E is diagnosed with anemia, chronic kidney disease, pneumonia (still on treatment), and functional decline, particularly a decline in mobility and nutritional status. She also displays evidence of vitamin and mineral deficiencies, with low vitamin D, protein, and zinc levels. Her vitamin B12 level is also borderline low. The blood pressure is below normal and may be responsible for the patient's dizziness. She is malnourished, with a low BMI, and symptoms of depression are present.

Patient E is taking several daily medications, all of which are assessed for necessity and potential interactions. Her current regimen includes:

- Coated aspirin: 81 mg/day

- Metoprolol: 50 mg twice per day

- Furosemide: 40 mg/day

- Potassium chloride: 20 mEq/day

- Metformin: 500 mg twice per day

- Levofloxacin: 500 mg daily for five more days

- Ipratropium/albuterol: Unit dose per nebulizer every four hours as needed

Evaluation of the medication regimen indicates that the patient's dizziness or weakness upon standing may be due to medication side effects. Furthermore, metoprolol is associated with fatigue in the elderly. Patient E's diuretic dose may need to be decreased due to her elevated BUN level. Metformin is not recommended in patients older than 80 years of age or with creatinine levels 1.4 mg/dL or greater. As a result of this information, the physician orders that the patient's prescriptions for furosemide and potassium chloride be halved to 20 mg/day and 10 mEq/day, respectively. The metoprolol dose is tapered gradually and held if the systolic blood pressure is less than 110 mm Hg.

In addition to adjustments to the patient's existing medication regimen, it was determined that Patient E could benefit from the addition of a medication to address the signs of osteoporosis and a vitamin and mineral supplement. The physician prescribes calcium carbonate with vitamin D 500 mg/200 mg twice daily as well as a daily multivitamin. To treat the patient's depressive symptoms, 7.5 mg of mirtazapine is prescribed to be taken at bedtime.

Supplementary diagnostic tests are ordered, including anemia profile, ferritin level, stool for presence of occult blood, and folate level. Patient E is instructed to return in one week for a follow-up appointment, at which time another blood test and metabolic profile will be completed.

When Patient E returns for her one-week follow-up appointment, her lungs are clearer and she appears to be more alert. Although she continues to complain of fatigue and poor endurance, she is experiencing less dizziness. She has completed the antibiotic therapy for her pneumonia and has been participating in skilled therapy, increasing her assisted walk distance to 25 to 50 feet.

Her vital signs are normal, indicating a blood pressure of 112/64 mm Hg, pulse 88 beats per minute, and respirations 18 breaths per minute.

The patient intake has also improved, as she is reportedly consuming 50% of most meals and accepts one to two cans of liquid supplement daily. She has gained three pounds, to a weight of 110 pounds and a BMI of 18.9, which is considered healthy. Her completed blood test and metabolic panel indicate the following values:

- Occult blood test: Negative

- Hemoglobin: 10.5 g/dL

- Hematocrit: 31.8%

- Ferritin: 245 mcg/L

- Folate: 18 mcg/L

- Serum iron: 54 mcg/dL

- Blood glucose: less than 150 mg/dL

- BUN: 29 mg/dL

- Creatinine: 1.4 mg/dL

The physician instructs Patient E and her family to continue on the current plan of care. She is scheduled for a follow-up chest x-ray to confirm the absence of pneumonia, and she is instructed to return to the physician in one month to evaluate the continued effectiveness of the treatment plan.

At her one-month follow-up appointment, Patient E has continued to have daily rehabilitation and her weight has stabilized. She is lucky to have the support of her daughter, who encourages her through the process. Her medical conditions have stabilized, which required adjustments to her medication regimen. The patient has progressed well and is discharged home to her apartment. Future considerations for health maintenance include a dual-energy x-ray absorptiometry scan to evaluate osteoporosis treatment, a mammogram, and a colonoscopy.

CASE STUDY 2

Patient S is a man, 70 years of age, who was admitted to the hospital with altered mental status, exhibiting symptoms of delirium, agitation, and confusion. He was found to have a urinary tract infection and obstructive uropathy leading to acute renal failure. His condition is stabilized, and he is admitted to the rehabilitation facility. The physician completed the initial assessment shortly after his admission to the rehabilitation center. Findings from medical record review indicate a positive history for hypertension and hyperlipidemia. The patient has no advance directives on record, and medical care prior to hospitalization was sporadic. Patient S has lived in a studio apartment for 12 years and does not have any close family members. His support system consists of friends and neighbors. He smokes one-half pack of cigarettes per day and usually drinks two to three beers each day. Prior to hospitalization, he was found by a neighbor; he was delirious, with poor hygiene and incontinent of urine and stool.

Patient S is examined while sitting bedside. His chief complaint is pain in his right knee with walking, though no injury is noted. He also complains of stomach discomfort, gas, and constipation. The patient appears to be suspicious of the physician and makes it clear that he is not staying long. He requests discharge as soon as possible. The patient has gaps in his memory as to what happened prior to hospitalization. He indicates that he eats regularly and does not know why he has lost weight. When dinner is provided, he requests that a beer be provided as well. The Foley catheter is maintained pending further urologic evaluations and treatments.

The initial physical examination indicates that Patient S's height is 5 feet 8 inches, weight 140 pounds, and BMI 21.3; however, the patient's usual weight is 158 pounds. His blood pressure is 134/82 mm Hg, apical pulse 82 beats per minute, and respirations 20 breaths per minute. He has poor dentition, but the mouth is otherwise healthy. The lungs are essentially clear, with slightly diminished breath sounds in the bases. His abdomen is soft and nontender, with active bowel sounds, and the Foley catheter is draining clear, yellow urine. The right knee is mildly edematous and warm to touch. Slight resting tremor is noted of the right hand, but there is no focal deficit. A complete blood test, metabolic panel, and knee x-ray are ordered, as are physical therapy, occupational therapy, speech therapy, and dietician evaluations.

Assessments of function, nutrition, and depression are administered and indicate:

- MMSE: 18 (moderate cognitive impairment)

- GDS: 10 (moderate depression)

- MNA: 9 (at risk of malnutrition)

The laboratory tests return the following results:

- Hemoglobin: 12.8 g/dL

- Hematocrit: 38%

- BUN: 22 mg/dL

- Creatinine: 1.0 mg/dL

- Thyroid-stimulating hormone: 3.86 mIU/L, urinalysis-negative

- Vitamin B12: 585 pg/mL

- Vitamin D hydroxyl: 22 ng/mL

- Zinc: 88 mmol/L

The knee x-ray displays evidence of mild degenerative joint disease. The physical therapist's report indicates that Patient S has weakness of the lower extremities with unsteady gait. The patient's right knee pain is causing limited range of motion and mobility. In spite of these limitations, the occupational therapist finds that the patient requires minimal assistance with activities of daily living and hygiene. The speech therapist finds that the patient has poor short-term memory and retention, but no difficulty swallowing. Finally, the dietician notes that Patient S eats about 50% of most meals, refuses liquid supplements, and refuses to go to the dining room because "it is depressing looking at all those sick people."

Because the patient has no advance directives on file, he is referred to a social worker for assistance in planning his care. The patient declines DNR and names a neighbor as his healthcare proxy. The social worker notes that it is questionable if the patient will be able to live alone after rehabilitation is completed due to the lack of regular caregiver and the presence of cognitive deficits.

Finally, the patient's medication regimen is assessed. Patient S is currently prescribed the following medications:

- Coated aspirin: 325 mg/day

- Amlodipine: 5 mg/day

- Simvastatin: 20 mg/day at bedtime

- Trimethoprim/sulfamethoxazole: One double-strength tablet twice daily for three more days

- Dutasteride: 0.5 mg/day

Based on the laboratory and examination findings, Patient S is diagnosed with moderate cognitive impairment/dementia and has symptoms of depression. The degenerative nature of the patient's joint impairment indicates osteoarthritis of the right knee. Alcohol dependence is suspected, though the patient refuses assistance with smoking or alcohol cessation. The patient is dyspeptic and constipated. He has developed obstructive uropathy due to undercare of urology.

Assessment of Patient S's medication regimen shows several undertreated conditions, including no medication prescribed for depression, dementia, or vitamin/mineral deficiencies (resulting from weight loss). It is also noted that the aspirin may be causing adverse gastric effects and that side effects related to antibiotic use may be contributing to the decrease in appetite and food intake.

Patient S is started on a regular diet with fortified foods and high-calorie snacks, with the addition of a daily multivitamin. However, the physician advises the patient to decrease alcohol intake to one beer daily (preferably a low-alcohol type). To address the constipation, daily prune juice and milk of magnesia (30 cc as needed) are recommended. Omeprazole 20 mg taken 30 minutes before a meal is prescribed for the patient's continued dyspepsia. Finally, acetaminophen (1 g three times per day) is added to Patient S's regimen to treat his arthritic knee pain. If the patient experiences side effects of the oral acetaminophen, a topical nonsteroidal anti-inflammatory drug may be substituted. The patient is also instructed on physical therapy modalities to manage his pain, including heat, use of a brace, and massage. He continues physical, speech, and occupational therapy for therapeutic exercises, strengthening, endurance, gait training, and cognitive/memory training.

In addition, Patient S is referred to a urologist, psychiatrist, and social worker for continued care planning. It is important that the patient consider options for long-term care, assisted living, and financial assistance, as returning to living alone in his apartment will likely not be a possibility. He is instructed to return in one week for a follow-up appointment.

At Patient S's one-week follow-up appointment, the patient states that his right knee is still sore but slightly improved and his stomach discomfort is relieved, with improvement in constipation. The patient appears mildly confused but is able to answer questions appropriately. He does have multiple complaints regarding food, staff, and policies of the skilled nursing facility where he has been living. He feels he is making good progress with his therapy and is eager for discharge. The patient also expresses a hope that his catheter will be removed soon. He continues to decline assistance with smoking cessation.

At this visit, Patient S's blood pressure is 130/80 mm Hg, pulse 74 beats per minute, respirations 16 breaths per minute, weight 141 pounds, and BMI 21.4. The report from the urologist indicates the ongoing need for the Foley catheter due to obstructive uropathy. The patient has been scheduled for cystoscopy and ultrasound of the bladder and kidneys. Occupational and speech therapies are to be discontinued this week, but continued physical therapy is necessary for gait training, therapeutic exercises, mobility, and balance with a cane.

The psychiatrist reports an MMSE result of 19 and has diagnosed Patient S with depression and vascular dementia. She recommends computed tomography (CT) scan of the brain with contrast. The patient has been prescribed citalopram 20 mg/day, and the future consideration of cholinesterase inhibitors for dementia treatment is noted. His physician instructs Patient S to continue with the current treatment plan, including following up with psychiatry and urology as necessary.

Although Patient S's weight stabilizes, he never regains the weight loss of 18 pounds. The CT of his brain shows microvascular ischemic changes consistent with vascular dementia, possibly a result of the combined risk factors of alcohol and tobacco use, hyperlipidemia, and hypertension. The potential for self-neglect and inadequate medical care is high, and Patient S is not able to return to his apartment to live independently. The lack of family or caregiver is a contributing factor.

After many discussions and care meetings and the intervention of a social worker, the patient moves into an assisted living facility that is subsidized by the government. He continues to be treated by his urologist and psychiatrist. His appetite improves, but he never returns to his pre-illness status.

9. CONCLUSION

Geriatric failure to thrive is a challenging condition for healthcare providers. It is vital to remember that undesired weight loss in the elderly is generally not a normal part of aging. However, in up to 35% of patients there is no obvious cause for the weight loss.

The four domains of geriatric failure to thrive are impaired physical function, malnutrition, depression, and cognitive impairment. The patient should be evaluated and treated for each area. The MMSE, MNA, and GDS are useful tools for evaluating cognition, nutrition, and depression in these patients. Serial measurements may be used to track progress or decline. A complete physical assessment is also necessary, noting any changes that are the result of normal aging.

Polypharmacy is a significant problem in this population due to side effects, interactions, noncompliance, and use errors. Evaluating patients for adverse drug reactions is crucial. The Beers list of potentially inappropriate medications in the elderly can be used as a guide for prescribing medications. If it is necessary to prescribe a potentially inappropriate medication, the lowest effective dose should be used.

Advance directives are important in determining the care plan. Conferences with the patient and family are crucial for clarifying the goals of care. Taking a multidisciplinary approach is helpful. Referrals to a dietician and/or physical, occupational, and speech therapy are made as indicated. Medical specialists are consulted, as needed, depending on patient needs.

There should be adequate follow-up and monitoring of any interventions taken, with revision of the plan of care when necessary. For patients who do not respond to treatments, geriatric failure to thrive may progress to a terminal condition with poor prognosis. A hospice referral may be appropriate for end-stage care.

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Evidence-Based Practice Recommendations Citations

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