Caring for the Geriatric Patient

Course #39101 - $18 -

Study Points

  1. Outline the clinical presentation and approach to treatment for age-related diseases such as osteoporosis, osteoarthritis, anemia, and geriatric failure to thrive.
  2. Identify signs of mild cognitive impairment and dementia, and differentiate between dementia and conditions that mimic dementia in the elderly patient.
  3. Define elder abuse and the different forms of elder abuse.
  4. Describe the approach to care near the end of life.

    1 . Which of the following statements regarding age-related physiologic changes is TRUE?
    A) With age, brain tissues atrophy due to normal cell degeneration.
    B) Vascular structure composition changes with age, predisposing older persons to hypertension.
    C) The health status of persons with vision and hearing loss is poorer compared with those without sensory loss.
    D) All of the above


    Biologic and physiologic changes are part of aging. The losses in the physical arena for the elderly can be numerous, which may then compound and/or have implications in social and psychologic 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 [1]. The health status of older persons with vision and hearing loss is poorer compared with those without vision or hearing loss [2]. In a study of more than 1,000 elders, 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 [2]. 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 [2].

    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. As a part of the aging process, the composition of vascular structures changes, affecting how peripheral arteries dilate and constrict [3]. The result is often hypertension, which affects 1.28 billion adults worldwide [4]. Epidemiologic studies have noted that 31.1% of adults worldwide have hypertension [3].

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    2 . Most skeletal difficulties in the adult female population are the result of
    A) falls.
    B) substance abuse.
    C) rheumatoid arthritis.
    D) postmenopausal osteoporosis.


    Postmenopausal osteoporosis causes most of the skeletal difficulties in the adult female population. Again, these molecular processes are not well understood. It is known that declining estrogen levels cause an increase in osteoclastic activity with a resulting imbalance between skeletal formation and resorption [8]. Estrogens act on nuclear receptors of both osteoblasts and osteoclasts. Deficiency of estrogen leads to, among other effects, the upregulation of osteoprotegerin ligand gene transcription and increased production of macrophage colony stimulating factor, both of which result in increased osteoclastic activity [9].

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    3 . Which of the following is NOT a chief characteristic of geriatric failure to thrive?
    A) Delirium
    B) Depression
    C) Malnutrition
    D) Impaired cognition


    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" [41]. 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 [43]. 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.

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    4 . All of the following are risk factors for suicide in the elderly, EXCEPT:
    A) Mental illness
    B) Loneliness and social isolation
    C) Physical illness or uncontrollable pain
    D) Continued employment into older age


    Although undiagnosed and/or untreated depression is the primary cause of suicide in the elderly, suicide completion is rarely preceded by only one factor. Risk factors for suicide in this population include a previous suicide attempt; mental illness; physical illness or uncontrollable pain; fear of a prolonged illness; major changes in social roles, such as retirement; loneliness and social isolation (especially in older men who have recently lost a loved one); and access to means, such as firearms in the home [71].

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    5 . Mild cognitive impairment is defined as
    A) any change in cognition from baseline.
    B) progressive and profound disruption in brain function and intellectual capacity.
    C) changes in mental function and ability that occur as the result of trauma or injury.
    D) a spectrum of mild but persistent memory loss that lies between normal age-related changes and diagnosed dementia.


    Through the process of aging and traumatic events, mild signs of neurologic dysfunction may begin to show. MCI is a spectrum of mild but persistent memory loss that lies between normal age-related memory loss and diagnosed dementia and Alzheimer disease. The memory deficits are beyond those expected for the person's age, and the individual persistently forgets meaningful information that he or she wants to remember. However, other cognitive functions may be normal, there is little loss of ability to work or function in typical daily activities, and there are no other clinical signs of dementia. MCI affects 15% to 20% of the aging population [74]. The presence of MCI may be the factor that influences the course of dementia toward Alzheimer disease. The signs of MCI go beyond those described as normal signs of aging. This level of impairment may last for a short time or for years.

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    6 . The primary signs of dementia are
    A) grandiose and persecutory delusions.
    B) changes in one's ability to see and hear.
    C) mood changes distinct from previous experiences.
    D) problems with memory, language, spatial-temporal reasoning, judgment, emotionality, thought disorder, and personality.


    Dementia is a progressive and profound disruption in brain function and intellectual capacity. The primary signs include problems with memory, language, spatial-temporal reasoning, judgment, emotionality, thought disorder, and personality. Dementia is a subtle progressive loss of cognitive functioning, with memory loss as its hallmark impairment, particularly loss of short-term memory. The ability to concentrate, make judgments, problem solve, and engage in abstract thought processes is also impaired. Personality and mood changes distinct from previous experiences are likely to develop, such as depression, apathy, elation, and anger. Impulse control becomes a major impairment with associated difficulties in social and physical relationships. Finally, grandiose and persecutory delusions are fairly common, especially in the more advanced stages of dementia [83]. It is possible for a young person to have dementia, but this is usually a result of a neurologic traumatic event or major illness with neurologic corollaries.

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    7 . Dementia with Lewy bodies is characterized by
    A) insidious onset secondary to multi-infarct events.
    B) early development of dementia and the presence of prions.
    C) visual hallucinations and an impairment in visuospatial/constructional functioning.
    D) onset following a traumatic impact to the frontal lobe, as in a motor vehicle accident.


    While 60% to 80% of cases of advancing dementia are categorized as the Alzheimer type, other disorders may fall within the broader classification of dementia [74]. These include but are not limited to [74,85]:

    • Vascular dementia: Rapid onset secondary to multi-infarct events

    • Huntington disease with dementia: Progressive inherited breakdown of the central nervous system in early adulthood affecting movement, cognition, and emotions

    • Human immunodeficiency virus (HIV) with dementia: Slow-onset dementia related to the progressive HIV infectious process affecting speed of motion, memory coordination, socialization, affect, and thought processes

    • Parkinson disease with dementia: Dementia beginning about one year after the diagnosis of Parkinson disease has been affirmed

    • Dementia with Lewy bodies: Characterized by visual hallucinations, an impairment of visuospatial/constructional functioning with a rapid onset and rapid decline, and often Parkinsonian motor dyscontrol and cognitive loss

    • Frontotemporal degeneration: Generally related to a traumatic impact to the frontal lobe, as in a motor vehicle accident, fall, or a career in boxing or similar sports with a repetitive cranial impact

    • Mixed dementia: Characterized by the hallmark abnormalities of more than one type of dementia—most commonly Alzheimer disease combined with vascular dementia

    • Creutzfeldt-Jakob disease: Degenerative neurologic disorder associated with early development of dementia and the presence of prions, a type of infectious protein

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    8 . All of the following may be causes of pseudodementias, EXCEPT:
    A) Infections
    B) Closed head trauma
    C) Reactions to medications
    D) Visual and hearing deficits


    There are also many reversible conditions that can mimic dementia [74]. For this reason, dementias should be fully assessed and diagnostically clarified [86]. Specific disorders known to cause pseudodementias include but are not limited to:

    • Reactions to medications

    • Metabolic disturbances

    • Vision and hearing deficits

    • Nutritional deficiencies

    • Endocrine abnormalities

    • Infections

    • Subdural hematoma

    • Brain tumors and hydrocephalus

    • Atherosclerosis

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    9 . Among patients in institutionalized settings, which of the following is the most common type of elder abuse?
    A) Sexual abuse
    B) Physical abuse
    C) Financial abuse
    D) Psychological abuse


    Abused and neglected elders, who may be mistreated by their spouses, partners, children, or other relatives, are among the most isolated of all victims of family violence. In a meta-analysis conducted in 2017, 11.6% of participants (community dwelling adults 60 years of age or older) were victims of emotional abuse in the past year, 2.6% physical abuse, 0.9% sexual abuse, 4.2% potential neglect, and 6.8% current financial abuse by a family member [24].. The estimated annual incidence of all elder abuse types is 2% to 10%, but it is believed to be severely under-measured. According to one study, only 1 in 25 cases of elder abuse are reported to the authorities [24,25].

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    10 . Which of the following is a domain of the National Consensus Project for Quality Palliative Care's clinical practice guidelines?
    A) Physical aspects of care
    B) Cultural aspects of care
    C) Spiritual, religious, and existential aspects of care
    D) All of the above


    The priorities set by patients and healthcare professionals were considered carefully in the structuring of clinical practice guidelines for high-quality palliative care developed by the National Consensus Project for Quality Palliative Care. These guidelines are organized according to eight domains [26]:

    • Structure and process of care

    • Physical aspects

    • Psychologic and psychiatric aspects

    • Social aspects

    • Spiritual, religious, and existential aspects

    • Cultural aspects

    • Care of the patient nearing the end of life

    • Ethical and legal aspects

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