Chapter 12: Special Population: Older Adults

DEMENTIA

Population

• –Adults.

Recommendations

ICSI 2014, USPSTF 2014

• –Insufficient evidence to recommend for or against routine screening for cognitive impairment or dementia.

CTFPHC 2016

• –Do not screen asymptomatic adults for cognitive impairment.

Sources

• –ICSI. Preventive Services for Adults. 20th ed. 2014.

• –CMAJ. 2016;188(1):37-46.

• –Ann Intern Med. 2014;160(11):791-797.

Comments

1. False-positive rate for screening is high, and treatment interventions do not show consistent benefits.

2. Early recognition of cognitive impairment allows clinicians to anticipate problems that patients may have in understanding and adhering to recommended therapy, and help patients and their caregivers anticipate and plan for future problems related to progressive cognitive decline.

FALLS IN THE ELDERLY

Population

• –All older persons.

Recommendation

NICE 2013, AAOS 2001, AGS 2010, British Geriatrics Society 2001

• –Ask at least yearly about falls.

Sources

• –NICE. Falls: Assessment and Prevention of Falls in Older People. London (UK): National Institute for Health and Care Excellence (NICE); 2013. 33 p. (Clinical guideline; no. 161)

• –2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons: http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf

Population

• –Community-dwelling older adults without known osteoporosis or vitamin D deficiency.

Recommendations

USPSTF 2018

• –Do not use vitamin D supplementation to prevent falls (Grade D).

• –Encourage exercise interventions to prevent falls in older adults at increased risk for falls (Grade B).

• –Selectively offer multifactorial interventions to prevent falls in older adults at increased risk for falls (Grade C).

Sources

• –JAMA. 2018:319(15):1592-1599.

• –JAMA. Published online April 17, 2018. doi:10.1001/jama.2017.21962.

Comments

1. Individuals are at increased risk if they report at least 2 falls in the previous year, or 1 fall with injury. Risk factors: Intrinsic: lower-extremity weakness, poor grip strength, balance disorders, functional and cognitive impairment, visual deficits. Extrinsic: polypharmacy (≥4 prescription medications), environment (poor lighting, loose carpets, lack of bathroom safety equipment).

2. A fall prevention clinic appears to reduce the number of falls among the elderly. (Am J Phys Med Rehabil. 2006;85:882)

3. Effective exercise interventions include supervised individual and group classes and physical therapy.

4. Multifactorial interventions include initial assessment of modifiable fall risk factors (balance, vision, postural blood pressure, gait, medication, environment, cognition, psychological health) and interventions (nurses, clinicians, physical/occupational therapy, dietitian/nutritionist, CBT, education, medication management, urinary incontinence management, environmental modification, social/community resources, referral to specialist “ophthalmologist, neurologist, etc.”).

5. All who report a single fall should be observed as they stand up from a chair without using their arms, walk several paces, and return (see Appendix II). Those ...