Chapter 27: Care of the Older Adult

DEMENTIA, FEEDING TUBES

Population

• –Patients with advanced dementia.

Recommendations

American Geriatrics Society 2013

• –Percutaneous feeding tubes are not recommended for older adults with advanced dementia.

• –Careful hand-feeding should be offered.

Source

• –http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/

Comment

1. Careful hand-feedings and tube-feedings have identical outcomes of death, aspiration pneumonia, functional status, and patient comfort. In addition, tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.

DEMENTIA, ALZHEIMER DISEASE

Population

• –Adults.

Recommendations

NICE 2011

• –Donepezil, galantamine, and rivastigmine are recommended as options for mild-to-moderate Alzheimer disease.

• –Memantine is recommended as an option for managing moderate Alzheimer disease in patients who cannot tolerate acetylcholinesterase inhibitors.

Source

• –http://www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf

Comments

1. Common adverse effects of acetylcholinesterase inhibitors include diarrhea, nausea, vomiting, muscle cramps, bradycardia, and insomnia.

2. Common adverse effects of memantine are dizziness, headache, constipation, somnolence, and hypertension.

3. Reassess the efficacy of the pharmacological intervention. If the desired clinical effect (eg, stabilization of cognition) is not achieved, discontinue the medication (AGS, 2015).

DELIRIUM, POSTOPERATIVE

Population

• –Older adults at risk for or who have postoperative delirium.

Recommendations

AGS 2015

• –Institutions should enact multi-component intervention programs to manage delirium.

• –Consider regional anesthesia at the time of surgery to improve postoperative pain control.

• –Avoid inappropriate medications postoperatively in older adults.

• –Use antipsychotics at the lowest effective dose and for the shortest duration possible to treat severe agitated delirium.

• –Avoid benzodiazepines for postoperative delirium.

• –Avoid pharmacologic therapy for hypoactive delirium.

• –Avoid use of physical restraints.

Source

• –https://guidelines.gov/summaries/summary/49932

DEMENTIA

Population

• –Adults with dementia.

Recommendations

ACP 2008, AAFP 2008, AGS 2015

• –Recommend a trial of therapy with a cholinesterase inhibitor or memantine based on individual assessment of relative risks vs. benefits.

• –Reassess for clinically significant effect or adverse effects after 3-mo trial.

• –The choice of medication is based on tolerability, side-effect profile, ease of use, and medication cost.

• –The evidence is insufficient to compare the relative efficacy of different medications for dementia.

• –Evidence is insufficient to determine the optimal duration of therapy.

Source

• –http://www.annals.org/content/148/5/370.full.pdf

Comments

1. A beneficial effect of cholinesterase inhibitors or memantine is generally observed within 3 mo.

2. Good-quality data in mild-to-moderate Alzheimer disease and vascular dementia show that cholinesterase inhibitors provide a modest improvement in global assessment, but no clinically important cognitive improvement. Subsets ...