Special Considerations in Managing Geriatric Patients

CHAPTER 16 Special Considerations in Managing Geriatric Patients



Meena Seshamani, Matthew L. Kashima



Key Points



• The population is aging, as people are living longer.

• The geriatric population is made up of a significant proportion of otolaryngologic practice.

• Presentation in older adults may be different than in the younger population, and the spectrum of disease may be different.

• Diagnosis, prognosis, and goal of therapy need to be discussed with patient and family.

• Sensory disorders affecting hearing, speech, taste, smell, and balance are common and may significantly affect the quality of life of the geriatric patient.

• Awareness of how otolaryngologic processes affect the geriatric population will allow for better satisfaction for the patients, their families, and the otolaryngologists involved in caring for this population.

The social and economic significance of the graying of America has received a great deal of attention. Numerous articles and editorials document the projected rate of growth of the geriatric population and how it will affect the practice of medicine. Together, geriatricians and other specialists in geriatric medicine and surgery are developing a system of care that keeps older adults healthier, more functional, and more independent at older ages than was previously possible. Otolaryngologists have taken up the challenge of describing and treating problems involving the senescent ear, nose, and throat. Otolaryngologists play a role as communication specialists and are a key resource for helping older adults avoid isolation. The American Society of Geriatric Otolaryngology was formed in 2007 to help the specialty present a unified position in treating geriatric patients with otolaryngologic conditions.



Magnitude


The term geriatrics was coined by I. L. Nascher in 1909.1 Since then, industrialized countries have experienced an exponential increase in life expectancy, from 50 years in 1900 to 78 years in 2005, with a prediction of 85 years by 2050.2 Coupled with this increased longevity is a historic bump in birth rate during the 2 decades after World War II (i.e., the “baby boom”) and a current decline in fertility, leading to an increasing proportion of the population in the older age groups. In 1980, 11.3% of the U.S. population was 65 years of age or older, compared with 12.4% in 20053 and a projected 19.6% in 2030.4 Within the geriatric population, persons 85 years of age and older make up the fastest growing segment, more than doubling from 2 million (1.0% of the population) in 1980 to 5 million (1.7% of the population) in 2005.3


The aging of the population in turn affects systems of social support, in that the number of people who work and generate income declines relative to those who do not work. This concept underlies the “old age dependency ratio,” which is the number of people aged 65 and older per 100 working people (between 15 and 64 years of age). Currently there are just more than five supporting individuals for every elderly person. By 2050, this number is expected to drop to two.5


Disability and disease are more prevalent in older populations. One study of the National Health and Nutritional Examination Survey found that 74.6% of women and 67.4% of men aged 65 and older suffer from chronic diseases such as arthritis, diabetes, coronary artery disease, cerebrovascular accidents, or chronic lower respiratory tract disease.6 Moreover, older adults are more likely to experience limitations in activities of daily living, with 53% of people aged 85 years and older reporting functional limitations.7 In turn, chronic disease and functional limitations translate to increased health care utilization and cost. Nearly half of lifetime-per-capita health expenditures occur after age 64 years.8 From 1980 to 2005, nursing home and home health care expenditures increased 8-fold from $21 billion to $169 billion.9 The expected growth of the geriatric population therefore portends a significant impact on society’s social, economic, medical, and ethical needs and obligations.



Basic Principles of Geriatric Medicine


Irvine defined six basic principles that are useful in the care of older patients.10 Clinical decisions in this patient group tend to be complex. The fundamentals are:


1. Coexistence of multiple diseases: The unitary disease hypothesis usually does not apply. As people age, they accumulate medical diagnoses, both major and minor. These comorbidities can have an impact on the presentation and response to therapy in older adults. Signs and symptoms are more likely to be the result of several medical problems.

2. Unique spectrum of illness: In addition to many of the diseases seen in their younger counterparts, older adults tend to suffer certain diseases that occur only in old age. This includes a wide range of degenerative disorders and certain cancers.

3. Unusual presentation of illness: Typical symptoms, such as fever and pain, are often absent, and nonspecific symptoms, such as anorexia or falling, may herald a serious underlying disorder.

4. Proper role of the aging process: Differentiating treatable disease from the natural aging process may be difficult, particularly in the area of degenerative diseases. Most geriatric specialists believe that patients and families have a tendency to overrate the role of aging. As a result, they experience unnecessary suffering and dysfunction. Specific disease processes should be sought and treated whenever possible.

5. Underreporting of health problems: Patients and families often fail to report symptoms commonly relegated to old age.

6. Function-based treatment goals: Improving a patient’s quality of life may shift therapeutic goals toward maximizing function and independence, possibly at the expense of potential for cure.

Medical care provided to older adults serves several purposes. Treatment can be directed at specific acute disease processes, and the goal of this therapy can be curative or palliative. Health care can also be directed toward chronic conditions related to the aging process, such as presbycusis. Here treatment can be directed toward reversing these conditions, preventing further disability, or educating patients about their condition. Prevention is also an important function for health care, and otolaryngologists should take advantage of opportunities to educate patients about lifestyle implications on future health.



Access to Medical Care


Consideration of barriers to medical care in older adults can help physicians play a central and effective role in the advocacy of their older patients. For example, a decreased level of strength and confidence may limit the ability of the older adult to visit a physician’s office or the hospital, especially in the absence of strong family or community support. Social support systems often function better for acute and more serious problems, leading to the potential neglect of wellness and prevention initiatives. The high cost of modern health care may also create a barrier; the typical older couple has to save $300,000 to pay for health care costs not covered by traditional Medicare plans.11


An additional barrier to care is difficulty in obtaining accurate data from this population. Older adults have a relatively high incidence of memory impairment and cognitive dysfunction, which can significantly affect the ability of the practitioner to obtain an accurate history.12 Even the presence of involved caregivers (e.g., adult children) may not be enough to provide complete historical data.



Diagnostic Testing


Because of the general principles mentioned previously, diagnosis may be the most challenging aspect of medical care in older patients; the focus should be on identifying treatable diseases and symptoms. A good deal of judgment is required to separate specific illness from the adverse (but natural) effects of aging, and it is usually not appropriate to attribute symptoms to aging unless other causes have been ruled out first.


Invasive diagnostic procedures are relatively contraindicated when functional reserve is poor. Fortunately, modern diagnostic techniques, especially in imaging, have limited the need for invasive procedures.



Treatment



Medical Therapy


The proper use of medications is particularly important in the older patient. Indeed, one study showed that the adverse effects of medication were the most common cause of symptoms mistaken for senile dementia.13 According to Avon and Gurwitz, any symptom in an older patient may be a drug side effect until proven otherwise.14 It is well known that sensitivity to drugs increases with advancing age, but the reasons for this are not completely clear. There is some evidence that drug metabolism by the liver and clearance by the kidney both decline as one ages, but this does not explain the entire phenomenon. Drug receptors at the cellular level also seem to increase in sensitivity. Drug interactions can be prevented by carefully evaluating existing drug therapy before starting any new medicines; this is especially important in the geriatric population, because most older patients are taking several drugs (both over-the-counter and prescription) at any given time.


Finally, the use of some medications by older adults should be completely avoided because of the known high incidence of side effects. A good example is sympathomimetic decongestants in older men, which frequently cause urinary retention.



Surgical Therapy


The decision to operate is never made lightly, and this is particularly true for older patients. Given the higher rate of chronic disease, preoperative cardiac, renal, and pulmonary clearance is important. Moreover, the physiologic changes that occur with aging affect the body’s ability to respond to insults. Aging is associated with globally decreased functional reserve, which may be well-compensated under normal conditions, but not during times of physiologic stress. For example, reduced fibroplasia and decreased ability to remodel collagen can lead wounds in the older adult to heal slower. Up to 60% of older patients hospitalized for major surgical procedures suffer acute delirium or confusion.7 Data from the Department of Veterans Affairs demonstrates a 6% 30-day mortality for patients aged 70 years and older, and 20% are likely to have at least one complication during their hospital stay. The 30-day mortality rate increases by 10% for every year after age 70. Complications and mortality are also associated with preoperative American Society of Anesthesiologists status, and may be more common after emergency procedures.15



End-of-Life Care


An important consideration with the treatment of older patients is the goal of therapy. Whether palliative or curative, the goal must be explicitly discussed with patients and their families to ensure that everyone is in agreement regarding the patient’s global state of health.7 Difficulties can arise when there is a difference in goals between a patient and his or her adult children, or when the patient’s or family’s expectations are unrealistic.


Issues of end-of-life care are particularly relevant in the current environment of rising health care costs. Even though costs are concentrated in the older age groups, studies have shown that they are particularly concentrated at the end of life, with costs in the last year skyrocketing six times higher than costs in prior years.16 Indeed, economic studies have shown that inpatient expenditures are related more with proximity to death than with age, whereas long-term care expenditures are more closely related to patient age.17 As the population ages, decisions on end-of-life care can have far-reaching socioeconomic ramifications.



The Aging Ear


The normal process of aging affects all parts of the ear, but the greatest clinical impact is on cochlear and vestibular function. Presbycusis, which is the loss of hearing that is associated with aging, is the most common type of auditory dysfunction and is thought to be due to a series of insults over time, including age-related degeneration, noise exposure, and diseases of the ear. It is greatly affected by genetic background, diet, and systemic disease. Vestibular symptoms are present in more than half of older adults. Because balance depends on input from the ears, eyes, and peripheral sensory systems, all of which degenerate over time, impaired function in any of these systems contributes to vestibular complaints.


The pinna is commonly involved in actinic disorders, especially basal and squamous cell carcinoma. Sun protection and frequent inspection are important. The external auditory canal suffers a decrease in cerumen production due to degeneration of cerumen glands and a reduction in the total number of glands. This may lead to a drier cerumen that is less protective of the underlying skin and may result in a higher incidence of impaction and infection. Ceruminosis can be exacerbated by an increase in hair at the external auditory meatus. The skin also undergoes atrophy, which results in itching, fragility, and subsequent self-induced lacerations. The use of topical emollients has been recommended for difficult cases.



Presbycusis


Presbycusis, which is the auditory dysfunction associated with the aging process, is a generic term used to include several forms of hearing degeneration. It has been estimated that of the 27 million Americans with hearing loss (13% of the population), only 10% to 20% are due to noise exposure and most of the remainder is age-related.18 Presbycusis may have a devastating effect on older individuals by reducing their ability to communicate, thereby jeopardizing autonomy and limiting opportunities of being an active member of society. An impaired ability to communicate can also have wide-ranging health effects, because ineffective communication between a patient and his or her health care provider can lead to missed diagnoses.7 With the growth of the aged population, presbycusis has become a great challenge to the otologist.


Gacek and Schuknecht initially defined four histopathologic types of presbycusis: (1) sensory, which is characterized by hair cell loss; (2) neural, which is associated with the loss of spiral ganglion cells and axons; (3) metabolic, which is characterized by strial atrophy; and (4) mechanical or conductive.19 Subsequently, two more categories were added: mixed and indeterminate. The indeterminate category alone may account for 25% of cases.20 Recent studies indicate that a mixture of pathologic changes may be present most of the time.21



Sensory Presbycusis


The audiometric findings in this type of presbycusis include an abrupt, steep, and high-frequency sensorineural loss with slow, symmetric bilateral progression, usually beginning during middle age. Pathologic lesions are limited to the first few millimeters of the basal turn of the cochlea. There is flattening and atrophy of the organ of Corti due to the loss of hair cells and supporting cells. There is also an accumulation of lipofuscin, which is the aging pigment.



Neural Presbycusis


Audiometric findings include gradual hearing loss with a moderate slope toward the high frequencies; however, there is a disproportionately severe decrease in speech discrimination. This difficulty with speech discrimination makes hearing loss refractory to amplification in many cases. Atrophy of the spiral ganglion and nerves of the osseous spiral lamina occur mainly in the basal turn of the cochlea. The organ of Corti is largely intact, as opposed to what is found in sensory presbycusis.



Strial Presbycusis (Metabolic Presbycusis)


The hearing loss associated with strial presbycusis is flat sensory loss beginning during the third through sixth decades and progressing slowly. Speech discrimination is generally good, and no recruitment is present. This condition is often familial, and patients do well with amplification. The characteristic pathologic findings are that atrophy of the stria vascularis is either patchy in the basal and apical turns or diffuse. The organ of Corti and spiral ganglion cells are usually unaffected.



Inner Ear Conductive Presbycusis


Both inner ear conductive presbycusis and atrophy of the spiral ligament cause bilateral symmetric sensorineural loss, with an upward slope toward the high frequency and preserved speech discrimination. No anatomic correlates with conductive sensorineural hearing loss are known, but it is hypothesized that the functional loss is due to stiffness of the basilar membrane, which correlates with its anatomic shape. The histopathologic pattern of atrophy of the spiral ligament includes different degrees of pathologic changes that are progressive through the patient’s life; it is most noticeable in the apical turn and least in the basal turn. Cystic degeneration may cause detachment of the organ of Corti from the lateral cochlear wall, thereby resulting in hearing loss.



Proposed Etiologies


The specific causes of presbycusis are speculative at this time, but they are likely a combination of the effects of years of function, of exposure to harmful environmental factors such as noise and chemicals, and of genetically programmed biologic degeneration.



Morphology


It is clear that morphologic changes in human beings (as well as animal models) regularly demonstrate the age-related loss of inner and outer hair cells and supporting cells, primarily from the basal turns of the cochlea. Outer hair cells decrease more than inner hair cells. Age-related loss of eighth nerve fibers has been reported to be as high as 20% in old rats.22 Age-related changes may occur as high as the superior olivary complex in the brainstem.


Nixon23 and previously Glorig and Davis24 showed high-frequency conductive hearing losses attributed to stiffness and laxity of the joints in the aging middle ear. They also proposed the concept of an inner ear conductive hearing loss due to stiffness of the cochlear partition.



Vascular


Circulatory disorders have long been proposed as the cause of hearing loss in aging persons. In the Framingham cohort, coronary artery disease, stroke, intermittent claudication, and hypertension were linked to hearing loss.25 However, there is insufficient histopathologic evidence of this etiology for confirmation. The relationship between high-frequency sensorineural hearing loss and the degree of cerebral atherosclerosis has been used to support this theory; unfortunately, both may be independent but age-related. Atherosclerotic disease of renal vessels and inner-ear vessels has also been related to age. In 1959, Johnson and Hawkins demonstrated the progressive involution of the human cochlear vasculature from the fetus and newborn through the aged. They noted that, during the first decade of life, the radiating arterioles and outer spiral vessels in the basal coil attain adult size. Devascularization of capillaries and arterioles was subsequently found in the spiral ligament that is associated with aging.26 They found a similarity between the degeneration of inner ear vessels with analogous changes in the retina due to microangiopathy, and they demonstrated that the plugging of vascular canals by bony tissue is a generalized phenomenon that is related to aging. They believed that the plugging of vascular canals was one of the major causes of presbycusis.27



Metabolic


Much like arteriosclerosis, diabetic angiopathy may contribute to presbycusis. In this disorder, disseminated proliferation and hypertrophy of the intimal endothelium of arterials, capillaries, and venules causes significant narrowing of the lumen; there is also the precipitation of lipids and other substances in the vascular wall. In addition, arteriolosclerosis is more common and more extensive in patients with diabetes. Even though recent epidemiologic studies demonstrate a higher incidence of sensorineural hearing loss among diabetic patients than age-matched controls, this effect is mitigated in populations older than 60 years. Additionally, hemoglobin A1C levels did not correlate with hearing loss.28,29


Serum cholesterol may also play a role in presbycusis. In Rosen’s studies of Finnish patients on long-term controlled diets,30 the reduction of saturated fat resulted in a significant lowering of serum cholesterol and an improvement in auditory threshold testing. However, the link between serum lipids and hearing loss is not definitive.25,31



Noise


Noise is thought to be a common cause of presbycusis. It is clear that a direct correlation exists between noise-induced inner ear damage and the frequency, intensity, and duration of noise exposure. However, some may effectively argue that noise exposure causes hearing loss at any age and is not true presbycusis. Indeed, recent studies on the interaction of noise-induced hearing loss and age-related hearing loss are contradictory and variable, likely secondary to the underlying influence of other intrinsic and environmental variables on both mechanisms.32–35


Noise-induced hearing loss may arise from mechanical damage, metabolic exhaustion, or vascular changes. Mechanical damage is seen in the cochlea that has been exposed to high-intensity or impulse noise of short duration. There may be detachment of the organ of Corti from the basal membrane. Metabolic exhaustion is characterized by changes of intracellular ultrastructure, thereby indicating the depletion of enzymes and metabolites in overstimulated sensory cells. Noise has clearly been shown to cause ischemic changes of the inner ear. Capillaries below the basilar membrane have been noted histologically to undergo spasmodic changes. In addition, edema of endothelial cells impairs blood flow to the spiral ligament and stria vascularis. Sludging and aggregation of erythrocytes with increased blood viscosity secondary to decreased capillary flow also occurs.



Genetic Considerations


Presbycusis has been found to cluster in families, and in fact approximately half of the variability in presbycusis may be attributed to genes.36,37 The effect of genes is more pronounced for the strial atrophy pattern of hearing loss (flat audiogram) than the sensory phenotype (high-frequency loss).25 Genes that may play a role include those that protect against oxidative stress, in that this stress plays a significant role in presbycusis. Proposed genes in recent studies include those that code for glutathione peroxidase and superoxide dismutase, two antioxidant enzymes that are active in the cochlea.38,39 Genes responsible for monogenic deafness may also play a role.



Hearing and Dementias


Recent studies of the cochlea in temporal bones from patients with confirmed Alzheimer’s disease showed a lack of degeneration in the cochlea, which is typical of Alzheimer’s patients. This finding is distinguished from findings in the peripheral olfactory and visual systems, which show the typical neurofibrillary tangles and neuritic plaques.40


Conversely, a possible relationship between central auditory dysfunction was found in the Framingham follow-up study of 1662 subjects. However, that study is weakened by the absence of objective testing in competing message tests.40



Treatment


Amplification remains the mainstay of treatment for presbycusis. The correction of other health factors that may impact age-related hearing loss, such as smoking, hypertension, and cholesterol levels, may play a role. Although dietary measures over the long term may be effective in reducing the progression of hearing loss in certain aging patients, further data are necessary before this treatment modality is clinically accepted.


Cochlear implantation may play a role in treating older adults with severe to profound sensorineural deafness. Such a degree of hearing loss is most often due to an underlying pathologic process such as Meniere’s disease or otosclerosis in combination with presbycusis; the latter does not produce this degree of hearing impairment on its own. A recent study of 749 adolescent and adult cochlear implant recipients found that age was a clinically insignificant predictor of audiologic outcome from cochlear implantation, compared with duration of profound deafness and residual speech recognition.41 Quality-of-life scores between elderly and nonelderly cochlear implant recipients are also similar.42 As discussed previously, comorbid chronic health conditions seen more commonly in older populations will play a role in surgical planning and perioperative management.



Presbystasis


Presbystasis, which is the dysequilibrium of aging, is a group of disorders that affect the mobility of a large number of older persons. Due to the degeneration of the vestibular, proprioceptive, and visual senses, the ability to walk and drive can be reduced to the point of incapacitation; lessening spatial-orientation abilities contribute to this as well. Loss of balance is the most common manifestation of vestibular dysfunction in older adults.


Although attempts have been made to categorize the dysequilibrium of aging as a single specific entity, a large number of vestibular disorders are seen in older patients. These include vascular disease, Meniere’s disease, benign positional vertigo, and adaptation deficits. Input from the vestibular, visual, proprioceptive, and other systems can be thought of as providing input into a common central processor that, in turn, controls posture and eye movement. This adaptive control system alters afferent signals from the various receptors at both visual-vestibular interfaces as well as proprioceptive-vestibular interfaces. Control circuits can be affected by disturbances in the general condition of the patient, the availability of the neurotransmitter, and in pathologic disorders.43 Other feedback loops help control visual tracking and postural adjustment in response to motion. Cognitive controls also exist and contribute primarily in the areas of spatial orientation, the hallucination of motion, and the development of athletic skills.


Disorders of these sensory organ systems have traditionally been treated by otolaryngologists, neurologists, and ophthalmologists, depending on the organ system causing the most obvious dysfunction. However, development of the unifying discipline of neuro-otology has led to an integrated approach to, evaluation of, and care for older persons with dysequilibrium. Otolaryngologists must be aware of other causes of dysequilibrium or dizziness, because a variety of organ systems may contribute to these difficulties, including vestibular, ocular, proprioceptive, musculoskeletal, central processing, cardiovascular, and neuromotor. For example, side effects of psychotropic medications, abnormalities in blood pressure, leg muscle weakness, neuromotor disorders such as Parkinson’s disease, and generalized loss of coordination can contribute to feelings of dysequilibrium and dizziness. The failure of one organ system can be overcome with compensation, but with multisystem failure, increasingly severe deficits occur.7


Falls are one of the most common concerns relating to imbalance in older adults. Approximately one-third of adults older than age 65 in the community and one-half of adults older than age 80 in institutionalized settings fall each year. One-third of these falls result in injuries that require medical attention or the restriction of activities for at least 1 day, and 10% to 15% of these falls result in fracture. As a result, the medical costs of fall-related injuries totaled $19 billion in 2000, with nearly $9 billion for hip fractures alone.44 Moreover, falls lead to functional decline, anxiety, depression, and social withdrawal. In particular, one-half of older adults hospitalized for a hip fracture do not return to prior levels of function.45



Vestibular Pathology


Age-related degeneration has been noted in hair cells, neurons, and supporting structures of the peripheral vestibular system, as well as more centrally in the vestibular nuclei and cerebellum. Hair cell loss has been found in the semicircular canals, the utricle, and the saccule. This degeneration is most noted in the central area of the cristae, whereas macular degeneration is more diffuse. Degeneration of the saccule may be greater than that of the macula. A decrease in the total number of peripheral vestibular neurons, as well as a decrease in the size of myelinated nerve fibers, has been described in patients who are older than 65 years old. Degenerative changes also occur in otoconia of the human maculae, deformities of the vestibular end organs, and degeneration of the synaptic structures of afferent dendrites.46

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Jun 5, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Special Considerations in Managing Geriatric Patients

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