492. Geriatrics Diagnosis & Treatment

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492. Geriatrics Diagnosis & Treatment



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Authors xiii
Preface xxv
Section I. Principles of Geriatric Care
1. Transforming the Care of Older Adults:
Knowledge, Skills, & System Change 1
Anna Chang, MD & Brie A. Williams, MD, MS
Guiding Principles 1
2. Consideration of Function
& Functional Decline 3
Susan E. Hardy, MD, PhD
Geriatric Principles 3
Epidemiology of Functional Limitations 3
Assessment of Functional Status 4
Risk Factors for Functional Decline 5
Prevention of Functional Decline 6
Rehabilitation: The Treatment
of Functional Decline 7
3. Goals of Care & Consideration
of Prognosis 9
Eric W. Widera, MD &
Alexander K. Smith, MD, MS, MPH
Goals of Care Discussions 9
A Practical Guide to Goals of
Care Discussions 9
Importance of Surrogate Decision Makers 10
Prognostication 10
Prognosis Related to Specifi c Diseases 12
Communicating Prognosis to Patient
or Surrogate 13
4. The Social Context of Older Adults 15
Helen Chen, MD
Financial Issues in the Third Age 15
Food Insecurity and Older Adults 16
Medicare 16
Housing and Long-Term Care 16
Caregiving 18
Recommendations for Clinicians 18

5. The Interprofessional Team 19
Josette A. Rivera, MD,
Scott Reeves, PhD,
& Louise Aronson, MD, MFA
Key Defi nitions and Concepts 19
Interprofessional Team Innovations
in Geriatrics 20
Evidence of Interprofessional Teams
in the Care of Older Adults 21
Resources and Tools for Teamwork 21
Barriers to the Advancement
of Teamwork 22
Future Steps 22
6. Geriatric Assessment 24
Bree Johnston, MD, MPH
& David B. Reuben, MD
Teams and Clinical Sites of Care 24
Prognosis 24
Patient Goals 25
Functional Assessment 25
Preventive Services 25
Falls and Gait Impairment 26
Vision Impairment 26
Hearing Impairment 26
Dementia 26
Incontinence 26
Depression 27
Nutrition 27
Medication Use 27
Caregiver Support 27
Financial, Environmental
and Social Resources 27
Abuse 27
Geriatric Assessment in
Primary Care 28
7. Atypical Presentations
of Illness in Older Adults 30
Carla M. Perissinotto, MD, MHS
& Christine Ritchie, MD, MSPH
Defi ning Atypical Presentations 30
Identifying Patients at Risk 30

8. Prevention & Health Promotion 35
Dandan Liu, MD
& Louise C. Walter, MD
Screening Issues for the Geriatric
Population 35
Geriatric Syndromes 35
Health-Related Behaviors 39
Immunizations 40
Endocrine Disorders 41
Cardiovascular Disease 42
Cancer 43
9. Principles of Prescribing for
Older Adults 46
Michael A. Steinman, MD
& Holly M. Holmes, MD
Geriatric Principles 46
Drug Metabolism and Physiologic
Effects in Older Adults 46
Geriatric Therapeutics 47
Prescribing for Older Adults 53
Adherence 55
Managing Complexity 56
Prescribing Across the Care Continuum 57
10. Addressing Multimorbidity
in Older Adults 59
Cynthia M. Boyd, MD, MPH
& Christine Ritchie, MD, MSPH
Background and Defi nitions 59
Multimorbidity and Health Outcomes 59
Clinician Challenges in the Care of
Older Adults with Multimorbidity 59
General Considerations in the Care
of Multimorbid Older Adults 60
11. Geriatrics & Palliative Care 63
John G. Cagle, PhD, MSW
& Eric W. Widera, MD
Overview of Palliative Care 63
Psychological, Spiritual, and Social Issues 63
Communication, Decision Making,
and Advance Care Planning 63
Challenges to Providing Palliative Care
in Long-Term Care Settings 64
Caring for Family Members:
Grief and Bereavement 67

12. Ethics & Informed Decision Making 69
Alexander K. Smith, MD, MS, MPH
& Bernard Lo, MD
Ethical Issues in the Care of Older Adults 69
Decision-Making Capacity and Informed
Decision Making 69
Advance Care Planning and
Advance Directives 71
Surrogate Decision Making 71
Balancing Promotion of Independence
and Patient Safety 72
Section II. Care Settings
13. Transitions and Continuity of Care 75
Lynn A. Flint, MD
General Principles in Older Adults 75
Defi nitions 75
Background 75
Adverse Events During Transitions 76
Barriers to Successful Care Transitions 76
Overcoming the Barriers: Best Practices 77
Evidence-Based Interventions 77
Innovations 78
Conclusion 78
14. Ambulatory Care & the
Patient-Centered Medical Home 80
Helen Kao, MD
General Principles in Older Adults 80
Personal Physician 80
Physician Directed Medical Practice 81
Whole-Person Orientation 81
Care Coordination and Integration 81
Quality and Safety 81
Enhanced Access 82
15. Providing Quality Care to Older
Adults in the Emergency Department 83
Gallane D. Abraham, MD
& Corita R. Grudzen, MD, MSHS, FACEP
General Principles 83
Models of Emergency Care 83
Structural Enhancements 84
Financing 84
Clinical Care 84
Future of Emergency Care 85

16. Hospital Care 87
Kathryn J. Eubank, MD, Edgar Pierluissi, MD,
& C. Seth Landefeld, MD
General Principles in Older Adults:
Hazards of Hospitalization 87
Successful Models of Care 88
Approach to the Hospitalized Older Adult 89
Therapy 91
Prevention 92
Transitioning from Hospital to Home 93
17. Perioperative Care in Older
Surgical Patients 95
Lawrence Oresanya, MD
& Emily Finlayson, MD, MS
General Principles in Older Adults 95
Surgical Risk in the Older Adult 95
Clinical Care 96
Models of Surgical Care 98
18. Long-Term Care, Nursing Home,
& Rehabilitation 99
Theresa A. Allison, MD, PhD
General Principles in Older Adults 99
Long-Term Care in the Community 99
Institutional Long-Term Care 100
Hospice and End-of-Life Care 102
19. Home-Based Care 104
Jessica L. Colburn, MD,
Jennifer L. Hayashi, MD,
& Bruce Leff, MD
Preventive Home Care/
Geriatric Assessment 104
Medical House Calls 104
Posthospitalization Case Management
& Transitional Care Models 104
Home Rehabilitation 104
Hospital at Home 104
Eligibility Requirements 105
Payment Denials 106
Innovations in Care Delivery 106
Medicaid 107
Area Agencies on Aging 107
Postacute Hospitalization &
Home Rehabilitation Care 107
Home Care & Assessments 107
House Calls & Home-Based Primary Care 107

20. The Aging Traveler 109
Gerald Charles, MD
General Principles in Older Adults 109
Overview of Travel Problems 109
Risk of Venous Thromboembolism
Due to Travel 109
Resources About Travel Risks 110
Ship Travel 110
Air Travel 111
Section III. Common Conditions
in Geriatrics
21. Delirium 115
Tammy Ting Hshieh, MD
& Sharon K. Inouye, MD, MPH
22. Cognitive Impairment & Dementia 123
Kaycee M. Sink, MD, MAS & Kristine Yaffe, MD
23. Cerebrovascular Disease 135
Daniel Antoniello, MD
24. Parkinson Disease & Essential Tremor 141
Nicholas B. Galifianakis, MD, MPH
& A. Ghazinouri, MD
Parkinson Disease 141
Essential Tremor 148
25. Falls & Mobility Disorders 150
Deborah M. Kado, MD, MS
& Daniel Slater, MD, FAAFP
26. Osteoarthritis 159
C. Kent Kwoh, MD & Yong Gil Hwang, MD
27. Osteoporosis & Hip Fractures 169
Rubina A. Malik, MD, MSc
28. Coronary Disease 178
Sanket Dhruva, MD & Melvin Cheitlin, MD
Acute Coronary Syndrome 180
Chronic Coronary Heart Disease 185

29. Heart Failure & Heart
Rhythm Disorders 190
Susan M. Joseph, MD, Jane Chen, MD,
& Michael W. Rich, MD
Heart Failure 190
Bradyarrhythmias 195
Tachyarrhythmias—Atrial Fibrillation
& Atrial Flutter 196
Ventricular Arrhythmias 199
30. Hypertension 202
Quratulain Syed, MD
& Barbara Messinger-Rapport, MD, PhD
31. Valvular Disease 213
Margarita M. Sotelo, MD,
Michael W. Rich, MD,
& G. Michael Harper, MD
Aortic Stenosis 213
Aortic Insuffi ciency 216
Mitral Stenosis 217
Mitral Regurgitation 218
32. Peripheral Arterial Disease
& Venous Thromboembolism 222
Teresa L. Carman, MD
& Sik Kim Ang, MB, BCh, BAO
Peripheral Arterial Disease 222
Venous Thromboembolism 226
33. Chronic Venous Insufficiency
& Lymphedema 230
Teresa L. Carman, MD
& Sik Kim Ang, MB, BCh, BAO
Chronic Venous Insuffi ciency 230
Lymphedema 233
34. Chronic Obstructive
Pulmonary Disease 236
Brooke Salzman, MD
& Danielle Snyderman, MD
35. Gastrointestinal &
Abdominal Complaints 244
Karen E. Hall, MD, PhD
Gastroesophageal Refl ux Disease 244
Dysphagia 246
Motility Disorders 247

Peptic Ulcer Disease 248
Dyspepsia 248
Diarrhea 249
Diverticular Disease 251
Infl ammatory Bowel Disease 251
Fecal Incontinence 252
Colonic Ischemia 253
Abdominal Pain 254
36. Constipation 256
Alayne Markland, DO, MSc
37. Fluid & Electrolyte Abnormalities 261
Mariko Koya Wong, MD
& Kellie Hunter Campbell, MD, MA
Hyponatremia 261
Hypernatremia 263
Potassium Disorders 264
Hypokalemia 264
Hyperkalemia 265
Nocturnal Polyuria 267
38. Chronic Kidney Disease 269
C. Barrett Bowling, MD, MSPH
& Katrina Booth, MD
39. Urinary Incontinence 275
Julie K. Gammack, MD
40. Benign Prostatic Hyperplasia
& Prostate Cancer 284
Serena Chao, MD, MSc
& Ryan Chippendale, MD
Benign Prostatic Hyperplasia 284
Prostate Cancer 287
41. Thyroid, Parathyroid, & Adrenal
Gland Disorders 291
Steven R. Gambert, MD, Ravi Kant, MD,
& Myron Miller, MD
Subclinical Hypothyroidism 291
Subclinical Hyperthyroidism 292
Hypothyroidism 292
Myxedema Coma 293
Hyperthyroidism 294
Nodular Thyroid Disease & Neoplasia 297
Acute Adrenal Insuffi ciency 300
Cushing Syndrome 301
Hyperparathyroidism 302

42. Diabetes 305
Josette A. Rivera, MD,
Jessamyn Conell-Price, MS,
& Sei Lee, MD, MAS
43. Anemia 314
Gary J. Vanasse, MD
44. Common Cancers 321
Joanne E. Mortimer, MD, FACP
& Janet E. McElhaney, MD
Breast Cancer 321
Lung Cancer 323
Colorectal Cancer 324
Pancreatic Cancer 324
Ovarian Cancer 325
Leukemia 325
Lymphoma 325
45. Depression & Other Mental
Health Issues 328
David Liu, MD, MS,
Mary A. Norman, MD,
Bobby Singh, MD,
& Kewchang Lee, MD
Depression 328
Suicide 333
Bipolar Disorder 333
Anxiety & Stress Disorders 334
Schizophrenia & Psychotic Disorders 337
46. Sexual Health & Dysfunction 340
Angela Gentili, MD
& Michael Godschalk, MD
47. Common Infections 347
Lona Mody, MD, MSc,
James Riddell IV, MD,
Keith S. Kaye, MD, MPH,
& Teena Chopra, MD, MPH
Urinary Tract Infections 348
Respiratory Tract Infections 352
Gastrointestinal Infections 353
Skin and Soft-Tissue Infections 354
Prosthetic Joint Infections
and Osteomyelitis 355

48. Pressure Ulcers 359
David R. Thomas, MD, FACP, AGSF, GSAF
49. Common Skin Disorders 367
Christine O. Urman, MD
& Daniel S. Loo, MD
Seborrheic Keratosis 367
Epidermal Inclusion Cyst 367
Warts (Verruca Vulgaris
& Verruca Plantaris) 368
Onychomycosis 369
Dry Skin, Pruritus, & Asteatotic
Dermatitis 370
Seborrheic Dermatitis 372
Stasis Dermatitis 372
Psoriasis 373
Rosacea 374
Contact Dermatitis 375
Drug Eruption (Morbilliform) 376
Herpes Zoster 376
Scabies 378
Bullous Pemphigoid 379
Actinic Keratosis 380
Basal Cell Carcinoma 381
Squamous Cell Carcinoma 382
Melanoma 382
50. Sleep Disorders 384
Diana V. Jao, MD & Cathy A. Alessi, MD
Insomnia 384
Sleep Apnea 388
Periodic Limb Movement During Sleep
& Restless Legs Syndrome 388
Narcolepsy 389
Circadian Rhythm Sleep Disorders 390
REM Behavior Disorder 390
Sleep Problems in Special Populations 390
51. Oral Diseases & Disorders 392
Dick Gregory, DDS, FASGD,
Bonnie Lederman, DDS, BSDH,
& Susan Hyde, DDS, MPH, PhD, FACD
Section IV. Common Clinical
Scenarios in Geriatrics
52. Evaluating Confusion in Older Adults 399
Caroline Stephens, PhD, MSN

53. Addressing Polypharmacy &
Improving Medication Adherence
in Older Adults 404
David Sengstock, MD, MS
& Jonathan Zimmerman, MD, MBA, FACP
Problems Caused by Polypharmacy 404
Unprescribing: Intervening
to Reduce Polypharmacy 405
Adherence 407
54. Managing Persistent Pain
in Older Adults 410
Vyjeyanthi S. Periyakoil, MD
55. Considering Anticoagulation
in Older Adults 417
Anita Rajasekhar, MD, MS
& Rebecca J. Beyth, MD, MSc
Available Classes of Anticoagulant
Therapy 417
Management of Bleeding in Older
Patients on Anticoagulants 423
56. Assessing Antiaging Therapies
for Older Adults 425
Milta O. Little, DO & John E. Morley, MB, BCh
Antiaging Therapies 425
Ethical and Legal Issues with
Antiaging Therapies 425
57. Considering Complementary &
Alternative Medicines for Older Adults 430
Milta O. Little, DO & John E. Morley, MB, BCh
Massage and Chiropractic Therapy 430
Herbs & Supplements 431
Other Forms of Alternative or
Complementary Medicine 434
58. Managing Misuse of Alcohol
& Psychoactive Prescription
Medications in Older Adults 436
Frederic C. Blow, PhD & Kristen L. Barry, PhD
Health Risks Associated with Hazardous
and Harmful Use in Older Adults 436
Psychoactive Medications 437
Defi nitions to Guide Screening
and Interventions 437
Brief Interventions 441

59. Assessing Older Adults for
Syncope Following a Fall 443
Natalie A. Sanders, DO, FACP
& Mark A. Supiano, MD
General Approach to the Patient
with Falls or Syncope 443
How Falls and Syncope Overlap 444
When to Consider Syncope
as a Cause of Falls 444
Common Diagnostic Categories
to Consider 445
60. Treating Headaches in Older Adults 447
Katherine Anderson, MD & Jana Wold, MD
61. Managing Vision Impairment
in Older Adults 451
Meredith Whiteside, OD
Normal Changes in the Aging Eye 451
Cataracts 452
Age-Related Macular Degeneration 453
Diabetic Retinopathy 454
Glaucoma 455
Systemic Medications and Glaucoma 458
Visual Symptoms Indicating
Need for Urgent Referral to
an Eye-Care Specialist 458
62. Managing Hearing Impairment
in Older Adults 460
Dane J. Genther, MD & Frank R. Lin, MD, PhD
63. Addressing Chest Pain in Older Adults 468
Christina Paruthi, MD
& Miguel Paniagua, MD, FACP
64. Addressing Dyspnea in Older Adults 472
Leslie Kernisan, MD, MPH
65. Managing Joint Pain in Older Adults 478
Lisa Strano-Paul, MD
Gout 478
Calcium Pyrophosphate Crystal Disease 479
Polymyalgia Rheumatica 480
66. Managing Back Pain in Older Adults 482
Una E. Makris, MD & Leo M. Cooney Jr, MD

67. Determining the Appropriate Use
of Exercise for Older Adults 487
Sara J. Francois, PT, DPT, MS,
Jennifer S. Brach, PhD, PT,
& Stephanie Studenski, MD, MPH
68. Defining Adequate Nutrition
for Older Adults 494
Michi Yukawa, MD, MPH
69. Helping Older Adults with
Low Health Literacy 502
Anna H. Chodos, MD, MPH
& Rebecca L. Sudore, MD
Unique Health Literacy Considerations
in Older Adults 502
Screening 504
Clear Health Communication Strategies 504
Systems Approaches 506
70. Understanding the Effects of
Homelessness and Housing
Instability on Older Adults 507
Rebecca Brown, MD, MPH & Margot Kushel, MD
Pathways to Homelessness
Among Older Adults 507
Strategies to Prevent Homelessness
Among Older Adults 508
Health Status of Older Homeless Adults 509
Interaction Between Health Status
and Environment 509
Conclusions & Next Steps 511
71. Understanding the Effects of Criminal
Justice Involvement on Older Adults 513
Lisa C. Barry, PhD, MPH
& Brie A. Williams, MD, MS
Epidemiology 513
The Clinical Encounter 514
72. Detecting, Assessing, & Responding
to Elder Mistreatment 517
Tessa del Carmen, MD
& Mark S. Lachs, MD, MPH

73. Meeting the Unique Needs
of LGBT Older Adults 524
Mark Simone, MD
& Manuel Eskildsen, MD, MPH
Defi nitions 524
Health Issues for LGBT Older Adults 525
Biopsychosocial Aspects of Care 527
Conclusion 528
Section V. Broadening Clinical Practice
74. Applying Evidence-Based
Medicine to Older Patients 529
Kenneth E. Covinsky, MD, MPH
The Challenges with Current Evidence 529
Applying the Evidence to
Your Older Patients 530
75. International Perspectives
in Geriatric Care 532
Sandra Y. Moody, MD, BSN, AGSF
& Miwako Honda, MD
Jochanan Stessman, MD
& Jeremy M. Jacobs, MBBS
Shuang Wang, MD & Joseph H. Flaherty, MD
Gunnar Akner, MD, PhD
Challenges for the Future of China’s
Aging Population 537
76. Public Policy Intersecting with
an Aging Society 543
Gretchen E. Alkema, PhD
& Bruce Allen Chernof, MD, FACP
Three Spheres of Aging with Dignity
and Independence 543
Key Programs and Services for
Older Adults 543
Opportunities in the Patient Protection
and Affordable Care Act 546
Where Do We Go from Here? 547
Index 551



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