Common Geriatric Syndromes in Older Adults Nursing CE Course for APRNs

Best-practice and evidence-based geriatric protocols have been developed and utilized in hospitals, rehabilitation centers, long-term care (LTC) facilities, home-care agencies, and community clinics. Management of geriatric syndromes requires HCPs to work collaboratively with an interdisciplinary team to ensure optimal patient outcomes through continued maintenance of function, dignity, and self-determination. A comprehensive geriatric assessment (CGA) is critical to identifying and managing conditions to prevent complications. A CGA is a multidisciplinary diagnostic and treatment process that identifies psychosocial, medical, and functional limitations to implement a coordinated care plan (Ghimire & Dahal, 2023; Magnuson et al., 2019; Ward & Reuben, 2022). The most common areas of concern in a CGA include:

• functional status
• physical health
  • vision and hearing impairment
  • fall prevention
  • urinary incontinence
  • nutritional status
  • osteoporosis and arthritis
  • urinary incontinence
• polypharmacy and medication reconciliation
• cognitive assessment
  • sleep and insomnia
  • mood disorder
  • dementia (Ghimire & Dahal, 2023)

For more information, please see the NursingCE course on Comprehensive Geriatric Assessments. While numerous geriatric syndromes exist, this course will highlight some of the most common: pressure injuries, incontinence, falls, functional decline or frailty, delirium, malnutrition, insomnia, self-neglect, depression, and hearing loss.

Pressure Injuries

The National Pressure Injury Advisory Panel (NPIAP) recommends the term pressure injury instead of the outdated term pressure ulcer. Pressure-induced injuries are among the most common conditions encountered in LTC and acutely hospitalized patients. Roughly 2.5 million pressure-induced injuries are treated in acute care hospitals in the US each year. These wounds develop when external forces are applied to the skin at a sufficient magnitude and duration to cause tissue injury; they range from non-blanchable erythema of intact skin to deep ulcers extending to the bone. High-stage injuries begin as deep tissue damage adjacent to the bone-muscle interface and do not progress from Stages 1 through 4. Pressure injuries can be chronic and lead to bacteremia, sinus tracts that connect with the bowel or bladder, heterotrophic calcification, systemic amyloidosis, and squamous cell carcinoma. A patient’s tissue morphology and capacity for repair affect their tissue’s resiliency. Shearing forces (gravity’s effect on friction) may also contribute to injury and result in more severe tissue damage. Pressure above the arteriolar pressure (32 mm Hg) limits or prevents blood supply—and thus oxygen and nutrients—to tissues. Studies utilizing animal models indicate irreversible tissue damage from pressure over 70 mm Hg for two or more hours. Muscle tissue is the most susceptible to damage, followed by subcutaneous fat, while the dermis is the most resilient. Pressure is highest over bony prominences, which bear the patient’s weight. Moisture increases the coefficient of friction, tissue deformation, and shear forces, making deep tissue injury more likely (Berlowitz, 2022a, 2022b, 2023; Mervis & Phillips, 2023).

Risk Factors and Prediction

The primary independent risk factors for pressure-induced injury are immobility, malnutrition, reduced tissue (skin) perfusion, and sensory loss, often occurring in older adults. Immobility may be prolonged or temporary. Reduced perfusion may be related to hypovolemia, hypotension, vasomotor failure, peripheral artery disease (PAD), or vasoconstriction, as associated with certain medications, cardiovascular shock, and heart failure. The loss of sensation may be due to neurological injury (e.g., stroke, spinal cord injury, peripheral neuropathy), dementia, or delirium (Berlowitz, 2022a; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

Risk prediction for pressure injury is often complicated, with over 100 risk factors identified in the literature. Global measures of disease severity and overall comorbidities such as the Comprehensive Severity Index (CSI), the Acute Physiology and Chronic Health Evaluation (APACHE), and the Laboratory-Based Acute Physiology Score, version 2 (LAPS2) have all been associated with increased risk of pressure injury in certain patient populations (skilled nursing facilities [SNFs], intensive care units [ICUs], and hospitalized patients, respectively). The published guidelines from NPIAP and their European counterpart suggest the use of a prediction tool, such as the Norton or Braden scales, despite little evidence that the use of these validated tools results in fewer pressure injuries as compared to a comprehensive nursing assessment, including the patient history and physical examination with regular (daily) skin inspections. The Norton scale includes five subscales (physical condition, mental condition, activity, mobility, and incontinence), each given a score between 1 and 4 and then added for a final score ranging from 5 to 20. A score at or below 14 is considered at-risk (see Table 2 for the Norton Scale categories and scoring). The Braden scale includes six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction/shear). Most categories are scored between 1 and 4, except for friction/shear, which has a maximum score of 3. Total scores range between 6 and 23; a score below 19 is considered at-risk (see Table 3 for Braden Scale categories and scoring). Unfortunately, these scales have a relatively low rate of interobserver reliability unless performed by trained staff, leading to a sensitivity ranging from 0.70-0.90 and specificity ranging from 0.60-0.80. Two studies indicated that the activity and mobility subscores of the Norton scale are sufficient to predict risk, and including the remaining three characteristics may reduce the scale’s predictive performance. Research has identified that the Braden scale is less useful in ICU and surgical patients due to the high rate of immobility in these populations (Berlowitz, 2022a; European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2019).

Table 2

Norton Scale and Scoring

                                                                                                             (AHRQ, 2014)

Table 3

Braden Scale 

                                                                                   (AHRQ, 2014; Hovan, 2021)

Outside of a formal tool, a retrospective study identified low serum albumin, fecal incontinence, and a recent fracture as predictors among immobile (chair- or bed-bound) hospitalized patients. Given the medical preference for prospective rather than retrospective data, several studies have attempted to identify risk factors in various healthcare settings. One such study of over 300 hospital admissions found that pressure injuries correlated with immobility as well as recent stroke and impaired nutrition. A larger study (n=1192) found an increased risk in older patients admitted to the hospital for an acute medical condition with non-blanching erythema or skin trauma at the time of admission, DM, and low hemoglobin. A nationwide survey monitoring over 1,500 LTC facility residents found an increased risk among patients with a recent history of pressure injury, higher initial severity of illness (i.e., as measured by the CSI), significant weight loss or eating problems, and those with documented use of catheters or positioning devices. A study including more than 3,200 patients found an increased risk of pressure injury during the first two days of hospitalization in certain patient populations. They found a higher risk in older male patients residing in an LTC facility prior to admission with poor nutrition, dry skin over a bony prominence, incontinence, difficulty with bed mobility (turning independently), or a recent hospitalization in the last six months. A 40-week study of 12,650 outpatients over the age of 60 found an increased risk of pressure injuries in older male patients admitted to an LTC facility with a history of previous pressure injury, DM, falls, cataracts, renal insufficiency, and PAD (Berlowitz, 2022a).

Prevention

Numerous modalities can be utilized to prevent pressure injuries. Pressure redistribution can be performed through the use of support surfaces and devices. Reactive support surfaces can change their weight distribution when a load is applied and may be powered or nonpowered. In contrast, an active support surface is powered and designed to change its distribution regardless of the applied load. An overlay is made to be placed on top of an existing surface. A mattress is a support surface used with an existing bed frame, and integrated bed systems combine a support surface with a bed frame. Regardless of components, a support system should incorporate features shown to prevent pressure injuries, such as air fluidization (i.e., a fluid-like medium achieved by forcing air through beads), alternating pressure (i.e., cyclic changes in pressure redistribution), lateral rotation (i.e., rotation on a longitudinal axis), low air loss (i.e., airflow designed to manage the heat and humidity of the skin), and multiple zones (i.e., areas of the system with unique pressure redistribution characteristics). Other factors that should be considered include cost and ease of use. A Cochrane review of support surfaces found that postoperative injuries were reduced using a pressure-relieving overlay, especially a micropulse overlay, on the operating room table. Foam overlays may cause adverse skin changes, and a meta-analysis combining three randomized clinical trials (RCTs) found that Australian Medical Sheepskin may relieve pressure when used on top of a hospital mattress. Research indicates with moderate certainty that pressure injury risk is reduced by using a powered active air surface versus a standard hospital mattress and that dynamic support surfaces may be cost-effective for high-risk patient cohorts. Alternative high-specification foam mattresses may provide a singular alternative to standard foam mattresses without needing an additional purchase. In chair-bound patients, research supports using full-seat cushions over donut-shaped cushions. Cushions composed of air, viscous fluid and foam, or gel and foam are superior to standard segmented foam cushions (Berlowitz, 2022b; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

Patient positioning and repositioning are crucial for injury prevention, although most recommendations are based on theoretical rationale, as the available data are relatively low quality. Pillows or foam (e.g., wedges) may prevent knee and ankle skin breakdown in patients with lower extremity immobility. Heel protectors can prevent breakdown at the heels, or pillows should be placed under the lower legs to “float” the heels. The head of the bed should be kept at or below 30 degrees to avoid pressure on the greater trochanter when side-lying and to prevent injury due to sliding or friction when supine. Patients should be repositioned gently to maintain microcirculation and decrease interface pressure. Chair-bound patients should be repositioned hourly using seat tilting, wheelchair pushups, or monitoring devices as a reminder if needed. Bed-bound patients can typically be repositioned in 2-hour intervals, with adjustments based on the mattress quality/construction, use of a support surface, the patient’s activity level, ability to reposition themselves, presence of existing tissue damage/injury, and other risk factors. The patient should be repositioned repeatedly from their back (supine) to their side and then to the other side; an assistive device should be utilized to reduce friction and shear as needed. The evidence supporting mechanized beds designed for continuous rotation along a longitudinal axis is insufficient to recommend their use (Berlowitz, 2022b; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

Supportive patient interventions also prevent pressure injury development. The most important interventions are improving the patient’s mobility using an early mobilization (EM) program, physical therapy (PT), pharmacological treatment for severe spasticity, and limiting sedatives or other medications contributing to immobility. Skin perfusion can be optimized by increasing cardiac contractility and avoiding hypotension, hypovolemia, and the use of vasoconstrictive agents. Patients with severe PAD should be evaluated by a vascular surgeon for consideration of revascularization. Skin assessments should be thorough (e.g., an inspection of skin color and palpation for skin temperature, turgor, moisture status, and integrity), well-documented, and occur daily. The skin should be cleaned with a pH-balanced cleanser and warm (not hot) water to avoid irritation, then dried. Vigorous massage over bony prominences should be avoided. Moisturizers containing fatty acids should be used to prevent excessive dryness and scaling, protect against friction and pressure, and reduce hyperproliferative skin growth, especially over the sacrum. Excess heat increases the likelihood of injury by transferring the heat to deeper tissues, while excess moisture increases friction, thereby contributing to shear forces on deeper tissues. Incontinence can be managed using absorbent pads or loosened adult briefs to allow air circulation along with consistent cleansing in patients with intact skin integrity. However, catheterization may be needed while treating an acute wound. Multilayer silicone foam dressings applied over a bony prominence may help prevent pressure injury formation. Nutritional assessments should be performed to ensure adequate nutrition, especially regarding caloric and protein intake. Unless contraindicated, patients should maintain a daily protein intake of 1.2-1.5 g/kg, and any nutritional deficiencies should be addressed. Continuous pressure mapping may have limited benefit, as evidence for its effectiveness outside of an ICU setting is lacking (Berlowitz, 2022b; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

Diagnosis and Staging

Superficial moisture-induced injuries, skin tears, tape burns, perineal dermatitis, or excoriation injuries should not be diagnosed or labeled as pressure injuries. Wounds should be assessed for size (e.g., depth, width, and length), the presence of sinus tracts, necrotic tissue, or exudate. All findings should be documented vigilantly, including granulation, which indicates wound healing. Photographs are often helpful for staging. Infection delays wound healing and may be indicated by local signs (e.g., erythema, warmth, tenderness, purulent drainage, odor) or systemic indications (e.g., fever, leukocytosis). Wound infections may contain resistant pathogens, necessitating culture and sensitivity testing to ensure appropriate treatment (Berlowitz, 2023; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

The NPIAP classification system for wound staging was last revised in 2016 and remains the most commonly used option in the US. This system can be used to describe a pressure injury during the initial assessment. However, it should not be applied to traumatic injuries, moisture-related injuries, incontinence injuries, adhesive injuries, or dermatitis. Reverse staging, or adjusting the staging as the injury heals, is not recommended by the NPIAP. Prior to Stage 1, an area of injury may develop altered sensation, temperature, or firmness (Berlowitz, 2023; Mervis & Phillips, 2023). The NPIAP stages include the following (see Figure 1; Berlowitz, 2023; Edsberg et al., 2016):

• Stage 1 wounds contain intact skin with an area of non-blanchable erythema.
• Stage 2 wounds demonstrate exposed dermis due to partial-thickness loss of skin. The wound bed is pink or red and may contain a serum-filled blister. No adipose or deeper tissues are visible, and no eschar, slough, or granulation tissue is present.
• Stage 3 wounds involve full-thickness loss of skin, exposing the underlying adipose tissue but not fascia, muscle, tendon/ligament, or bone. Granulation tissue and epibole (i.e., rolled or curled under closed wound edges) may be evident, along with eschar or slough. These wounds should be assessed for undermining and tunneling.
• Stage 4 wounds result from full-thickness skin and tissue loss, exposing the underlying fascia, muscle, tendon/ligament, cartilage, or bone. Epibole, undermining (i.e., separation of wound edges from surrounding healthy tissue), and tunneling (i.e., tunnel or channel that extends deeper into the tissue) are common, and slough or eschar may be present.
• Unstageable wounds are full-thickness wounds (Stage 3 or 4) that are obscured by eschar or slough, making the depth of the injury indeterminant.

Figure 1

NPIAP Wound Stages

The NPIAP system also allows for diagnosing a deep tissue pressure injury, characterized by a discolored (deep red or purple) area of intact or broken skin that is preceded by temperature changes and discomfort. The skin may appear firm, spongy, or boggy compared to the surrounding tissue. This injury indicates underlying deep tissue damage secondary to intense or prolonged pressure and typically evolves rapidly, revealing a full-thickness pressure injury. Deep tissue pressure injuries can be especially difficult to detect in patients of darker skin tones. Pressure injuries should be categorized based on their deepest point. The amount of subcutaneous adipose tissue can drastically affect the depth of wounds in different body areas (Berlowitz, 2023; Edsberg et al., 2016).

Management

The first step in managing pressure injuries is eliminating additional pressure through enhanced prevention techniques such as pressure redistribution and support surfaces. Patient positioning should avoid or minimize pressure on an existing wound. Patients who smoke should be encouraged to quit, with assistance offered and rationale provided regarding the deleterious effect of tobacco smoking on wound healing. Wound care may necessitate debridement (if necrotic tissue develops) or adjunctive therapies such as negative pressure wound therapy (NPWT or wound vac placement). The patient’s pain level should be assessed and aggressively managed, and psychosocial support should be provided. Pain may be intermittent (e.g., during dressing changes or debridement), continuous, or cyclic, and opioid analgesics may be required for moderate to severe pain. Topical local anesthetics may offer limited benefit but can be trialed, along with topical opioids and nonsteroidal anti-inflammatory drug (NSAID)-releasing dressings. The patient’s progress should be assessed regularly and meticulously documented, including electronic images. Healing scales may be used for documentation purposes, such as the Pressure Ulcer Scale for Healing (PUSH) tool, the Pressure Sore Status Tool (PSST), the Sessing Scale, or the Wound Healing Scale. Documentation should also include the status of the dressing, the area surrounding the wound, pain, pain control adequacy, and possible complications. Any clinically evident infection within a pressure injury should be cultured and treated based on sensitivity assays. The healthcare team should include a dietitian to optimize nutrition and promote sufficient caloric and protein intake. Supplementation may be necessary if oral intake is insufficient, but data do not support its use in patients without nutritional deficiencies. Supplemental vitamin C and zinc are commonly used despite a lack of evidence regarding their efficacy (Berlowitz, 2023; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

              Stage 1 injuries are typically managed by covering them with a transparent dressing for protection and intensifying the prevention techniques discussed previously. Uninfected Stage 2 injuries require little to no debridement (except for a ruptured blister), but a moist wound bed must be maintained. Therefore, wet-to-dry dressings are avoided in exchange for semi-occlusive (e.g., transparent film) or occlusive (e.g., hydrocolloids or hydrogels) dressings to encourage the digestion of necrotic tissue by the enzymes naturally found within the wound bed. Dressings are both protective against contamination and helpful in establishing the optimal level of moisture. Excessive moisture in a wound bed leads to maceration and inhibits cell proliferation, while desiccation slows epithelial cell migration. Absorptive dressings include foams and alginates. Dry wounds are best treated using transparent films, hydrocolloids, and hydrogels (Armstrong & Meyr, 2022; Berlowitz, 2023; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

Stage 3 or 4 injuries and unstageable wounds typically require debridement of necrotic tissue. Necrotic tissue promotes bacterial growth and impairs wound healing. Stable eschar (dry, adherent, and without fluctuance or erythema) on the heel or an ischemic limb should not be softened or debrided due to proximity to the bone. Stage 3 or 4 wounds with granulation tissue should not be debrided. Debridement can be done enzymatically, mechanically, or surgically. Surgical debridement is preferred for areas with extensive necrosis or thick eschar, while minor tissue slough is amenable to mechanical, enzymatic, or biological debridement. Once healthy granulation tissue is present and necrotic tissue has been removed, debridement should be discontinued. In certain circumstances, surgical management of pressure injuries using a skin graft, skin flap, or myocutaneous flap may be indicated, particularly for patients with relatively low surgical risk and whose QOL may improve significantly with rapid wound closure. This decision should be based on patient preference, risk of recurrence, and treatment goals. Before surgical closure, the wound must be fully debrided of devitalized tissue and free of infection; the patient’s nutrition should be optimized. Despite this, complications are common, including wound infection, dehiscence, postoperative anemia necessitating blood transfusion, sepsis, UTI, and pneumonia. In wounds contaminated regularly by fecal material, a colostomy may be considered, although this has questionable efficacy and is associated with a high rate of complications (Armstrong & Meyr, 2022; Berlowitz, 2022b; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

Adjunctive therapies include NPWT, electrical stimulation, therapeutic ultrasound, hyperbaric and topical oxygen, and topical growth factors. NPWT increases blood flow and granulation tissue, decreases edema, improves patient comfort, and decreases the labor intensity of wound care. Several small studies indicate enhanced healing with electrical stimulation during which a direct current is applied to the wound bed once or twice daily via a wound overlay. This applied current promotes the proliferation and migration of fibroblasts. Therapeutic ultrasound evidence is limited, but two RCTs using high-frequency (1 MHz) ultrasound demonstrated a significant reduction in wound surface area versus controls. Hyperbaric oxygen therapy is often advocated despite insufficient evidence of sustained benefit for pressure injuries and risk of adverse effects, including pneumothorax and seizures. Becaplermin gel (Regranex) is a platelet-derived growth factor applied topically to enhance wound healing that appears cost-effective. Platelet-rich plasma (PRP) may also improve wound healing. Electromagnetic therapy and pulsed radiofrequency energy therapy have shown limited or no evidence of benefit for wound healing (Armstrong & Meyr, 2022; Berlowitz, 2023; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

The treatment plan for all pressure injuries should start with establishing appropriate patient-specific treatment goals and consider treatment preferences, QOL, discharge potential, and prognosis. The healthcare team should select the most appropriate wound dressing based on self-care abilities and clinical assessment, including:

• shape, diameter, and depth of the wound
• need to address the bacterial bioburden
• ability to keep the wound bed moist
• volume and nature of wound exudate
• condition of the wound bed tissue and peri-wound skin
• presence of undermining or tunneling (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2019)

The healthcare team should also consider the cost-effectiveness of wound dressing options to prevent financial burden to the patient or facility. The prognosis of early-stage pressure injuries is favorable when timely, appropriate treatment occurs. Typically, after six months of treatment, most stage 2 pressure injuries heal, whereas only half of stage 3 and some of stage 4 resolve in this time frame. If the care of the injury and management of concurrent disorders are not improved, long-term outcomes are usually poor. Non- or slow-healing wounds should be evaluated for infection or reversible ischemia causes (DM, vascular insufficiency). As mentioned earlier, the PUSH tool is a validated and easy-to-use healing metric that aligns with the NPIAP system (Armstrong & Meyr, 2022; Berlowitz, 2023; Mervis & Phillips, 2023; Mondragon & Zito, 2022).

For additional information regarding the assessment, diagnosis, and treatment of pressure injuries, please refer to the NursingCE course on Pressure Injuries.

Incontinence

Urinary incontinence is defined as the involuntary leakage of urine. While up to 50% of adult females experience urinary incontinence (38% of females over the age of 60), only 25% to 61% of symptomatic community-dwelling females seek care. In comparison, 21% of males over 65 experience incontinence symptoms, and only 1 in 5 of these seek medical care for the condition. This may be due to embarrassment, lack of knowledge regarding treatment options, and fear of surgery. Although incontinence does not impact mortality, it does affect QOL. Incontinence is associated with depression, anxiety, work impairment, social isolation, sexual dysfunction, perineal infections, falls, fractures, and increased caregiver burden. Evidence suggests these effects may be even greater for male patients. For example, males are more likely than females to decrease participation in activities (i.e., work, socialization) and have higher rates of depression. Outside of age, other risk factors for incontinence include obesity, parity and mode of delivery, family history, ethnicity/race, smoking, caffeine intake, DM, stroke, depression, vaginal atrophy, fecal incontinence, hormone replacement therapy, genitourinary surgery, and radiation. Recent evidence suggests that the urogenital microbiome differs between women with incontinence compared to women who are continent, particularly for urge urinary continence. The prevalence of incontinence in cognitively impaired adults is 10% to 38% (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

Types of Urinary Incontinence

Stress incontinence is defined as the leakage of urine from increased intraabdominal pressure (e.g., exertion, sneezing, coughing, laughing) without an urge to void. Stress incontinence is the second most common type of incontinence in women. The risk of stress incontinence increases with high-impact activities, such as running and jumping, and the urine volume varies (small to moderate). It often affects younger women and is caused by urethral hypermobility or intrinsic sphincteric deficiency (ISD). Urethral hypermobility involves insufficient support of the pelvic floor and vaginal connective tissue to the urethra/bladder neck; this may be caused by high-impact activity or trauma related to vaginal delivery. ISD is the loss of mucosal and muscular tone to keep the urethra closed secondary to neuromuscular damage. This damage may be related to multiple pelvic or incontinence surgeries and can result in severe leakage with minimal abdominal pressure increase. ISD is more difficult to treat and tends to have less favorable surgical outcomes. While the condition is less common in men, stress incontinence may develop after mechanical damage to the urethral sphincter during prostate surgery or medications that impair sphincter function (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

Urge incontinence involves the involuntary leakage of urine immediately after or during an urge to void. It is also referred to as overactive bladder (OAB) if accompanied by nocturia and urinary frequency. The risk of urge incontinence rises with impaired functional status, recurrent urinary tract infections (UTIs), and bladder symptoms in childhood (e.g., enuresis). It is more common in men and older women. Leakage can range in amount and is likely related to detrusor overactivity (i.e., uninhibited contractions during bladder filling), although this has been detected in as many as 21% of healthy, continent older adults. Detrusor overactivity may be related to neurological injury, bladder abnormalities, or an increased or altered bladder microbiome, but it is often idiopathic. Urge incontinence in men may also be related to bladder outlet obstruction (BOO) as a component of lower urinary tract symptoms (LUTS) secondary to BPH. BOO can also be caused by neurologic conditions affecting the brain (i.e., normal pressure hydrocephalus, stroke) and medications that increase bladder contractility or exacerbate obstructive effects. Men with urge incontinence may describe hesitancy, straining, and an intermittent or slow stream. Patients with symptoms of both stress and urge incontinence have mixed incontinence, which is rare in men but more common in women (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

Overflow incontinence is a sequela of incomplete bladder emptying leading to continuous urinary leakage or dribbling. It is associated with a weak or inconsistent urinary stream, hesitancy, frequency, and nocturia. If the bladder becomes too full, symptoms of either stress or overflow urinary incontinence emerge. Overflow incontinence is typically related to detrusor underactivity or BOO. While detrusor contractility and efficiency diminish with age, severe underactivity occurs in only 5% to 10% of older adults. The detrusor muscle contractility can become significantly impaired in patients with severe acute sustained overdistention of the bladder, Fowler’s syndrome, fibrosis, reduced estrogen levels, peripheral neuropathy, or spinal cord damage affecting the spinal detrusor efferent nerves. These patients will typically have no warning or trigger with urine loss, and leakage may occur with activity or position changes. In women, BOO typically occurs due to urethral compression, which may be secondary to fibroids, pelvic organ prolapse, or overcorrection of the urethra following pelvic floor surgery. It may also result from urethral stricture, an external mass or tumor, or uterine incarceration of a retroverted uterus. Patients often describe stress or urge incontinence symptoms with an intermittent or slow stream, hesitancy, incomplete emptying, and straining. A small subset of women with overflow incontinence can develop the condition due to detrusor hyperactivity with impaired contractility (DHIC), a combination of detrusor hyperactivity (similar to above in urge incontinence) with impaired contractility of the bladder, causing incomplete emptying. In men, BOO is often related to prostate hypertrophy, as described above, as well as urethral stricture disease, neurologic disorders, or some medications (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

Other underlying etiologies for incontinence in female patients include genitourinary syndrome of menopause or vaginal atrophy due to low estrogen levels, leading to a diminished mucosal seal, urethritis, loss of compliance, and irritation. Chronic or acute UTIs can contribute to incontinence during and immediately after the resolution of the infection. Less common urological or gynecologic causes for urinary incontinence in women include urogenital fistulas, urethral diverticula, and ectopic ureters. Men may describe post-void dribbling (PVD), which is the leakage of a small amount of urine retained in the urethra immediately after voiding. It is often but not always described in men with other LUTS (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

Systemic causes of incontinence include spinal cord dysfunction, stroke, Parkinson’s disease, and normal pressure hydrocephalus. Diabetic neuropathy can contribute to overflow incontinence. Bladder cancer and invasive cervical cancer may present with urinary incontinence. Functional incontinence involves an intact genitourinary system with storage and emptying capabilities. However, these patients have a limited ability to toilet themselves due to mobility issues, manual dexterity limitations, or cognitive impairment. Among patients with known cognitive impairment, incontinence is caused or exacerbated by comorbid conditions and medications. Environmental and reversible factors that may aggravate incontinence include alcohol intake (decreases contractility), caffeine intake (increases contractility), constipation or stool impaction, and certain medications (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023). The list of medications that may contribute to incontinence is lengthy and includes the following:

• antihistamines (first-generation H1 antagonists such as chlorpheniramine [Chlor-Trimeton], hydroxyzine [Vistaril], and diphenhydramine [Benadryl]) decrease contractility via anticholinergic effects
• decongestants such as pseudoephedrine (Sudafed) and phenylephrine (Sudafed PE) increase urethral sphincter tone
• benzodiazepines impair micturition via muscle relaxation
• opioids reduce the sensation of bladder fullness and increase urethral sphincter tone
• antimuscarinics designed to treat OAB (oxybutynin [Ditropan], solifenacin [Vesicare], tolterodine [Detrol], trospium [Sanctura], fesoterodine[Toviaz], and others) decrease contractility via anticholinergic effects
• spasmolytics such as dicyclomine (Bentyl), hyoscyamine (Levsin), glycopyrrolate (Robinul), and others decrease contractility via anticholinergic effects
• antiparkinson medications such as benztropine (Cogentin) and trihexyphenidyl (Artane) decrease contractility via anticholinergic effects
• angiotensin-converting enzyme (ACE) inhibitors decrease the contractility of the bladder and cause a chronic cough
• alpha-agonists such as midodrine (Orvaten, ProAmatine) and various vasopressors increase urethral sphincter tone
• alpha-1 blockers such as doxazosin (Cardura), tamsulosin (Flomax), and terazosin (Hytrin) decrease urethral sphincter tone
• antiarrhythmics disopyramide (Norpace) and flecainide (Tambocor) decrease bladder contractility via local anesthetic or anticholinergic effects
• diuretics increase urine production, bladder contractility, or rate of emptying
• antidepressants such as serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine (Cymbalta) increase urethral sphincter tone, while tricyclic antidepressants (TCAs) such as amitriptyline (Elavil) and clomipramine (Anafranil) decrease contractility via anticholinergic effects
• antipsychotics such as chlorpromazine (Thorazine), fluphenazine (Prolixin), clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal) decrease contractility via anticholinergic effects, stimulate alpha-1 receptors, and have central dopaminergic effects
• skeletal muscle relaxants such as orphenadrine (Norgesic, Norflex) and tizanidine (Zanaflex) decrease contractility via anticholinergic effects
• oral estrogen therapy increases urinary incontinence
• beta-3 agonist mirabegron (Myrbetriq) decreases contractility (Lukacz, 2023a)

The American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (known as the Beers Criteria, or BC) was last updated in 2023. The list includes close to 100 medications or classes of medications. In addition to many of the listed medication warnings, the 2023 BC explicitly warns against combining loop diuretics with alpha-1 blockers for older patients due to an increased risk of incontinence (AGS Beers Criteria Update Expert Panel, 2023).

Evaluation and Assessment of Urinary Incontinence

A thorough history and physical examination should be completed first, evaluating the patient for potentially reversible causes of incontinence and underlying conditions and medications that may be contributing. Patients at high risk for incontinence should be screened regularly as opposed to waiting for the patient to bring up the subject. Symptoms should be characterized, including the severity, duration, frequency, and volume of the incontinence. The patient should be asked about any associated hesitancy, precipitating factors, nocturia, intermittent or slow stream, incomplete emptying, continuous leakage, and straining. The 3 Incontinence Questionnaire (3IQ) is a short, standardized form that can distinguish between stress, urge, and mixed incontinence with a sensitivity of 0.75 and a specificity of 0.77. Evaluating a patient’s post-void residual (PVR, or the remaining volume of urine in the bladder after voiding) may help distinguish between overflow incontinence due to detrusor muscle underactivity and mixed urinary incontinence in female patients. A history of systemic symptoms such as fevers, pelvic or flank pain, dysuria, and hematuria may indicate a UTI. Intake of caffeine and alcohol should be assessed, and patients who ingest either or both may want to consider reducing or eliminating them to observe for an associated improvement in their incontinence symptoms. Patients should be asked to consider and then identify the aspects or symptoms that are most bothersome in order to prioritize care based on patient concerns. A voiding diary may help identify patterns related to urinary frequency, volume, and large amounts of fluid intake. Free versions can be found online, or clinics can construct their own based on desired information. Most are completed over 72 hours and include a column for cataloging the time of day, any fluid intake with the amount, and the volume of voids with an assessment of associated urgency or leaks. Many specialty clinics will request that referred patients complete this diary before their initial appointment for efficiency. This process allows the data to be readily reviewed during the patient’s clinic assessment. However, it presupposes that (a) clinic staff can give the patient a copy of the instructions and form electronically, (b) the patient can print the form at home, and (c) the patient has access to a drugstore where they can purchase a plastic disposable “hat” or jug with which to measure their urine output (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

During the examination, female patients should be asked to consent to a pelvic exam if their symptoms do not immediately indicate stress versus urge incontinence, if there is suspicion of urinary retention, if they present with systemic symptoms, or if there is evidence of pelvic pathology. A neurological exam may be indicated for any patient who presents with sudden-onset incontinence, especially urge incontinence, or associated neurological symptoms. The exam typically includes an evaluation of bilateral lower extremity strength, reflexes (with long-track signs), and sensation, including perineal sensation. Poor strength with hyperreflexia may indicate an upper motor neuron lesion (i.e., brain or spinal cord), while reduced strength, areas of numbness or paresthesia, and diminished reflexes suggest a lower motor neuron lesion (i.e., exerting pressure on the spinal nerves, not the cord). A urinalysis should be performed on all patients, with a follow-up urine culture indicated for symptomatic patients or those with abnormal urinalysis results. Renal function is not routinely evaluated unless there is concern for severe urinary retention resulting in hydronephrosis. Male patients should be asked to consent to a rectal exam to assess the size and consistency of their prostate. After reviewing the risks and benefits, the decision to include prostate-specific antigen (PSA) testing should be made via shared decision-making. All patients should undergo a brief abdominal exam evaluating for an overextended bladder or an abdominal mass causing interference or pressure on the bladder (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

Additional testing may be indicated. A bladder stress test is an option for female patients with symptoms of stress incontinence. With a comfortably full bladder, the patient is asked to stand and cough or complete a Valsalva maneuver while the examiner observes the urethra opening (in women, by separating the labia) for leaking caused by the increased pressure. In patients with mobility impairment or cognitive dysfunction, this test may be easier to perform in the dorsal lithotomy position (laying on the back with feet elevated and abducted out). A positive test (leaking with stress) has a high predictive value for stress incontinence, while a negative result may be related to low urine volume or voluntary inhibition of leakage (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023).

If there is clinical concern for urinary retention or overflow incontinence, an uncertain diagnosis, or no significant resolution of incontinence symptoms with initial treatment, PVR assessment may be indicated. Patients with neurological disease, recurrent UTIs, DM with associated peripheral neuropathy, severe constipation, or pelvic organ prolapse may benefit from PVR assessment. If the residual volume of urine is under 50 mL or below one-third of the voided volume, the value is typically considered within normal limits. A residual volume greater than 150-200 mL warrants additional testing. While PVR can easily be assessed using catheterization, an ultrasound bladder scan is less invasive and more comfortable for the patient. Urodynamic testing with cystometry may be beneficial for a small subset of patients, but for the vast majority of patients with incontinence, this testing is invasive, costly, and likely unnecessary. It has not been proven to improve outcomes in patients with uncomplicated stress incontinence. This testing may be beneficial for patients with overflow incontinence secondary to neurologic conditions or DM, complicated stress incontinence, or mixed incontinence. This test assesses bladder function by objectively indicating the pressure and volume of fluid present during bladder filling, storage, and voiding. In rare circumstances, patients may require a referral to a subspecialist for a urethral mobility evaluation (Clemens, 2022; Lukacz, 2023a; Shenot, 2023; Tran & Puckett, 2023). Other indications that a patient may benefit from a specialist referral include:

• associated abdominal or pelvic pain in the absence of a UTI
• recurrent UTIs (three in a year or two in 6 months)
• hematuria in the absence of a UTI, prostate nodule/induration/asymmetry, or elevated PSA with risk factors for malignancy
• lifelong or severe (multiple heavy pads/briefs daily) incontinence
• suspected vesicovaginal fistula
• urethral diverticula, pelvic mass, or severe prolapse (beyond the hymen) on exam
• new neurologic symptoms with incontinence
• history of pelvic reconstructive surgery or pelvic/prostate irradiation
• persistently elevated PVR volume (> 300 mL), despite successful treatment of underlying causes
• overflow incontinence due to an underlying neurological condition or DM
• chronic catheterization or difficulty inserting a catheter (Clemens, 2022; Lukacz, 2023a)

Management of Urinary Incontinence

Once diagnosed and correctly characterized, the first step in managing incontinence is establishing treatment priorities based on the patient’s care goals and managing expectations. The goals should include improving QOL by focusing on the patient’s most bothersome symptoms, but rarely is full continence achieved. Tools to assist the assessment of symptom impact may help focus treatment goals and track efficacy, such as the International Consultation on Incontinence Questionnaire, the King’s Health Questionnaire, the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the OAB Questionnaire, and the Patient Global Impression of Improvement (PGII) or Severity (PGIS). Regardless of the cause or type, most patients with incontinence utilize disposable undergarments or incontinence pads. In the US, these products are easily accessible but may be expensive over time and do not address the underlying cause of incontinence. These products can also lead to contact dermatitis or skin breakdown if they are not changed frequently enough. Men may also utilize an external condom catheter if able, as many find this option preferable to pads/briefs. These patients should undergo urodynamic testing to assess bladder storage pressures and avoid consequent renal damage. Indwelling or intermittent bladder catheterization is associated with a high risk for infection. As a result, it is reserved for limited instances with few alternatives (Clemens, 2022; Lukacz, 2023b).

Treatment should begin with conservative therapies prior to more invasive or aggressive options. External contributing factors should be addressed first, such as medical conditions or medications that are exacerbating the patient’s incontinence. This should include assessment and treatment for constipation if present (Lukacz, 2023b). Older patients typically experience decreased gastric motility, which may predispose them to constipation and require the use of a bulk-forming laxative such as psyllium (Metamucil; Nguyen et al., 2020). Lifestyle modifications that may be beneficial for those with incontinence include weight loss for patients with an elevated BMI; smoking cessation; avoidance of alcoholic, caffeinated, and carbonated beverages; and maintaining a fluid intake of no more than 64 ounces/day. Patients with nocturia symptoms should avoid drinking within several hours of their bedtime. Pelvic floor (Kegel) exercises can be especially helpful for male and female patients with stress, urge, or mixed incontinence. Exercises should be completed in sets of 8-12 contractions, held for 8-10 seconds each, and repeated three times per day. Supervised pelvic floor PT may be helpful for patients who struggle with technique (properly isolating pelvic floor muscles), as they can incorporate biofeedback, electrical stimulation, pulsed magnetic stimulation, or vaginal weights to increase strength. Patients with urge incontinence or those who experience stress incontinence at higher volumes may benefit from bladder training. A bladder diary should be used to identify the patient’s shortest voiding interval, which serves as the initial point for training. Patients should be instructed to void based on the clock at that interval (e.g., every hour). Distraction, mental relaxation, and quick flicks (i.e., rapid-fire pelvic floor contractions) should be used if urgency develops between intervals. Once the patient can successfully avoid leaking for a full day, the interval is increased by 15 minutes, with an end goal of voiding every 3-4 hours while awake without urgency or incontinence episodes. This process may take weeks to accomplish. Hypnotherapy and acupuncture are both relatively safe complementary therapies that may be beneficial, although the research regarding their effectiveness for treating incontinence is minimal (Lukacz, 2023b, 2023c; Shenot, 2023).

Stress Incontinence Management

Treatment for stress incontinence varies depending on the underlying pathology. Conservative management can include controlling fluid intake, prompted voiding, constipation management, Kegel exercises, and bladder training. Weight loss can help lessen incontinence for patients who are obese. Female patients with urethral hypermobility require additional support for the urethra. In contrast, patients with ISD may benefit from increased blood flow and urethral coaptation achieved with pelvic floor exercises and/or surgery. Women with vaginal atrophy due to genitourinary syndrome of menopause (GSM) may benefit from topical vaginal estrogen. Risks associated with topical vaginal estrogen are low as systemic absorption is minimal. These are available as creams, rings, gelcaps, or tablets, typically dosed twice weekly; the ring is dosed every three months. Patients may not see results for up to three months, and some may need higher doses. Oral (systemic) therapy with estrogen may worsen incontinence and is not recommended. Estrogen therapy may be especially effective for patients with stress incontinence related to ISD secondary to increased blood flow (Lukacz, 2023b; Shenot, 2023). Dosing of vaginal estrogen includes (Lukacz, 2023b):

• Vaginal ring (Estring): Strength is 7.5 mcg estradiol daily. The ring is inserted into the vagina by the patient or clinician and replaced every 90 days.
• Vaginal insert (Imvexxy): Strength is 4 mcg estradiol per insert. Insert one tablet intravaginally daily for two weeks, followed by twice weekly. The dose may be increased to the 10 mcg insert if needed.
• Vaginal insert (Vagifem, Yuvafem): Strength is 10 mcg estradiol per insert. Insert one tablet intravaginally daily for two weeks, followed by twice weekly.
• Vaginal cream (Premarin): Strength is 0.625 mg conjugated estrogens per g of cream. Use 0.5 g of cream intravaginally daily for two weeks, then twice weekly. Dosing may range from 0.5-2 g based on response.
• Vaginal cream (Estrace): Strength is 100 mcg estradiol per g of cream. Use 0.5 g of cream intravaginally daily for two weeks, then twice weekly. Depending on the response, dosing may range from 0.5-4 g initially and 0.5-1g maintenance.

Estrogen should be used with caution in patients with a history of estrogen-receptor-positive breast cancer, as use is controversial. Nonhormonal methods should be the first-line treatment for urogenital symptoms (i.e., silicone-, polycarbophil-, or water-based lubricants, polyacrylic acid, hyaluronic acid, and vitamin D and E vaginal suppositories). The decision to use low-dose vaginal estrogen preparations should be made in coordination with the patient’s oncologist (The American College of Obstetricians and Gynecologists, 2021).

Continence pessaries (Figure 2) are common support devices that a urologic continence specialist or gynecologist traditionally fits, although a disposable over-the-counter option (Impressa) has recently become available. These devices are especially helpful for patients who experience stress incontinence during specific activities (e.g., exercise). Although many have been evaluated, the US Food and Drug Administration (FDA) has not approved pharmacological treatment options for stress incontinence. Duloxetine (Cymbalta) is an antidepressant that may improve stress incontinence by increasing urethral sphincter tone but with a high rate of associated adverse events. While not approved for this indication in the US, it is used in many European countries. Duloxetine (Cymbalta) functions by stimulating pudendal motor neuron receptors, and some studies have shown it may be effective in men with stress incontinence. Alpha-adrenergic agonists (phenylpropanolamine [Phenyldrine]) have been used previously to treat stress incontinence but are no longer recommended because of the high rate of adverse effects. Imipramine (Tofranil) is a tricyclic antidepressant with insufficient evidence to support its use in patients with stress or mixed incontinence. Some men with stress incontinence, in combination with normal bladder capacity and storage function, can utilize a penile clamp. Penile clamps should only be used for ambulatory men who can place and remove the clamp themselves and have good bladder storage function. These can cause discomfort with consistent use and are specifically implemented when needed, such as attending an event or eating at a restaurant. Men with sensory abnormalities should not use a penile clamp due to the risk of tissue damage (Clemens, 2022; Lukacz, 2023a, 2023b; Shenot, 2023).

Figure 2

Continence Pessaries

A mid-urethral sling is a minimally invasive surgical treatment option with a high curative rate for female patients with stress incontinence. It may also be beneficial in patients with persistent mixed incontinence. The surgical risks of this treatment should be considered and fully explained to the patient. A similar surgical approach, referred to as a perineal sling, has also been adapted to treat stress incontinence in men. They compress and mobilize the urethra using a synthetic mesh placed transversely through the obturator foramen. Artificial urinary sphincters are the most effective long-term corrective option for men with stress incontinence. The silicone cuff, balloon reservoir, and pump are implanted surgically, with success rates ranging from 59% to 90%. Unfortunately, surgical revision may be necessary due to urethral erosion, infection, or device malfunction. Erosion is more likely to occur following catheterization, so this should be kept to a minimum. If catheterization is necessary, the smallest possible catheter should be utilized, and the sphincter should be deactivated prior to catheterization. The choice between the perineal sling and the artificial urinary sphincter is based on patient preference, and most patients prefer the perineal sling (Clemens, 2022; Lukacz, 2023b).

Transurethral radiofrequency collagen denaturation is a minimally invasive device-based option that has been proposed but has insufficient evidence to establish its effectiveness. A urethral bulking agent (UBA) may be an option for women with persistent incontinence related to ISD who fail to improve or cannot tolerate surgery and men with mild stress incontinence or who are not surgical candidates. These periurethral injections may be associated with urinary retention and an increased risk of UTI, as well as pain at the injection site. Injections typically need to be repeated to maintain efficacy. UBAs have become popular as a primary treatment because they are less invasive and have a rapid recovery. Transurethral bulking agents are a reasonable option for men who are not good candidates for invasive surgery. This approach is less effective in men than women and often requires multiple injections (up to four) to achieve results. There is some evidence that electroacupuncture therapy over six weeks may reduce incontinence frequency and volume, but the limited availability of this procedure in the US is challenging (Clemens, 2022; Lukacz, 2023b).

Urge Incontinence Management

Pharmacotherapy for the management of urge incontinence/OAB or urge-predominant mixed incontinence consists of two classes: antimuscarinics and beta-3 adrenergic medications (e.g., mirabegron [Myrbetriq], vibegron [Gemtesa]). This approach includes treating non-neurogenic OAB in men unrelated to obstruction, thereby reducing acetylcholine-related bladder contractions. Antimuscarinics are less expensive, as they are available in a generic form and are often attempted first for this reason. They function by increasing bladder capacity and decreasing urgency by blocking acetylcholine’s stimulation of the muscarinic receptors. Several options are available in the US at varying strengths, including darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan, Oxytrol), solifenacin (Vesicare), tolterodine (Detrol), and trospium (Sanctura). Dosing should begin as low as possible and be titrated up every 2 to 3 weeks based on patient response and side effects. Extended-release (ER) formulas may improve adherence and minimize side effects. Anticholinergic side effects are most common with antimuscarinics, including urinary retention, dry mouth, constipation, dizziness, blurred vision, tachycardia, drowsiness, and impaired cognition. Darifenacin (Enablex) and solifenacin (Vesicare) are the more selective antimuscarinics, which may decrease side effects. Those at high risk or with retention symptoms should have a baseline PVR and occasional repeat testing to assess for urinary retention. If the baseline PVR is elevated, antimuscarinics are not the ideal primary therapeutic choice and should be trialed cautiously. Antimuscarinics are contraindicated in patients with uncontrolled tachyarrhythmias, gastric retention, narrow angle-closure glaucoma, and myasthenia gravis. Antimuscarinics may not be suitable for older patients with dementia due to their anticholinergic effects; however, trospium (Sanctura) does not cross the blood-brain barrier and may not impact cognition substantially. Symptom improvement may take 4 weeks, and the full effect may not appear for 12 weeks. Adherence should be assessed before changing therapies or adjusting medications (Lukacz, 2023c; McVary, 2023; McVary & Saini, 2023). See Table 4 for antimuscarinic medications and dosing.

Table 4

Antimuscarinic Medications, Dosing, and Characteristics for Urge Incontinence and OAB

(Lukacz, 2023c)

Mirabegron (Myrbetriq) or vibegron (Gemtesa) may be used as a secondary option for patients with OAB who cannot take an antimuscarinic or did not get the desired effect. They may also be used in combination with an antimuscarinic in some cases. Due to their favorable side effect profile, they can be a primary treatment for some with OAB, especially for patients with elevated PVRs or who are concurrently taking a cholinesterase inhibitor (to avoid increasing the anticholinergic effects). They activate the bladder’s beta-3 adrenergic receptors, causing relaxation of the detrusor and increasing bladder capacity. Mirabegron (Myrbetriq) should be dosed at 25 mg, increasing to 50 mg after 2-6 weeks if the response is inadequate. Mirabegron (Myrbetriq) is an ER tablet and cannot be crushed, divided, or chewed. Vibegron (Gemtesa) is available only as a 75 mg tablet dosed once daily. Some monitoring with PVRs to assess for urinary retention may be necessary, although beta-3 adrenergic receptor agonists are not associated with retention as frequently or severely as antimuscarinics. Mirabegron (Myrbetriq) is contraindicated in patients with uncontrolled or severe hypertension (HTN), and blood pressure (BP) should be monitored after starting the medication to assess for HTN. It can also elevate heart rate and may have minimal QT interval prolongation. Vibegron (Gemtesa) does not elevate BP or prolong QT interval and can be crushed, divided, or chewed. Both medications should be avoided in patients with severe renal (eGFR < 15 mL/minute) or hepatic impairment (Child-Pugh class C), as they have not been tested in this subset of patients (Lukacz, 2023c; McVary, 2023; McVary & Saini, 2023).

Management of persistent urge incontinence/OAB should be referred to a subspecialist. More aggressive treatment options include onabotulinumtoxinA (Botox) injections into the detrusor muscle. This option is associated with a higher risk of urinary retention, which should be monitored carefully. The onset of action is approximately 2 weeks, and the duration of effect is between 3 to 12 months. Injections must be repeated every 6-9 months to maintain effectiveness. OnabotulinumtoxinA (Botox) injections are typically avoided for patients with a history of retention or recurrent UTIs for this reason. Some women with detrusor muscle overactivity may benefit from percutaneous tibial nerve stimulation. Weekly 30-minute sessions over 12 weeks are followed by monthly maintenance sessions, conferring a low risk for side effects. However, this therapy has minimal evidence regarding long-term efficacy. Sacral neuromodulation is an OAB management technique that surgically places a neuromodulator at the S3 foramen to deliver electrical stimulation to the sacral nerve roots after a test phase. Although minimally invasive, surgical complications and device malfunction or failure can occur. Additional surgical treatment options for urge incontinence/OAB that do not respond to other treatments include augmentation cystoplasty (bladder augmentation or enlargement), urinary diversion, or placement of a suprapubic catheter. When approaching the treatment of urge incontinence or OAB in older adults, nonpharmacologic approaches should be considered first. For individuals over 65 and those with cognitive impairment, beta-3 adrenergic agonists are preferred over antimuscarinics due to the anticholinergic effects and possible risk of dementia. If antimuscarinic medications are used, darifenacin (Enablex) and tropium (Sanctura) are recommended due to their reduced impact on the central nervous system (CNS; Lukacz, 2023c; McVary & Saini, 2023; Shenot, 2023).

              Urge incontinence in males related to BOO secondary to BPH is common, as previously mentioned. If symptoms are mild to moderate, pharmacological treatment is typically initiated using an alpha-blocker, 5-alpha reductase inhibitor, or a combination. Approved alpha adrenergic-receptor antagonists include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo). These agents relax the smooth muscles at the prostate and along the bladder neck. Terazosin (Hytrin) and doxazosin (Cardura) may not be ideal for older males, as they are associated with an increased likelihood of dizziness and hypotension due to less specific targeting in their pharmacotherapeutics. The medication doses should be titrated carefully to avoid these effects. If the incontinence is directly related to BPH, a 5-alpha reductase inhibitor may be considered. Before starting pharmacologic treatment, this should be confirmed via rectal exam, PSA (> 1.5 ng/mL), or transrectal ultrasound. In the US, the approved options in this class include finasteride (Proscar, Propecia) and dutasteride (Avodart). These medications convert testosterone to dihydrotestosterone. The full therapeutic effect can take 6-12 months, and the agent should be continued indefinitely if effective. Most patients experience a reduction in PSA by roughly half. A baseline PSA level should be checked before starting therapy and can be used to monitor treatment efficacy. These medications may reduce the risk of prostate cancer but also make detection more difficult, thus increasing the risk of high-grade prostate cancer developing without detection. These medications may cause sexual dysfunction. They can contribute to abnormal fetal development and should be avoided in pregnant patients. For some patients with severe BPH, combination therapy with doxazosin (Cardura) and finasteride (Proscar, Propecia) or tamsulosin (Flomax) with dutasteride (Avodart) has been more effective than monotherapy with either drug. In men with a combination of BPH and erectile dysfunction, phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil [Viagra], tadalafil [Cialis]) may relieve symptoms of both conditions simultaneously. Common side effects include headaches, flushing, heartburn, nasal congestion/sinusitis, and myalgias, especially back pain. These drugs are typically not combined with alpha-blockers due to the compound risk of hypotension. For BPH treatment, tadalafil (Cialis, Adcirca, Alyq) should be dosed at 5 mg daily (McVary, 2023; McVary & Saini, 2023).

Men with treatment-resistant urge incontinence related to BPH should be referred to a surgical specialist for further discussions regarding more aggressive treatment options. Minimally invasive options exist, including microwaves or radiofrequency ablation to decrease the size of the prostate gland. Laser vaporization, transurethral resection, and open prostatectomy are additional surgical options used commonly in the US, the details of which are beyond the scope of this activity (McVary & Saini, 2023).

Fecal Incontinence

Fecal or anal incontinence is the involuntary loss of solid/liquid feces or flatus. It impacts the patient’s QOL and ability to live independently, leading to financial implications related to increased assistance required for ADLs and the potential for a forced change in the patient’s living arrangements or setting. Fecal incontinence can also have profound professional and, consequently, financial implications for younger patients who are unable to continue working due to their condition. This leakage may be associated with a perceived urge to defecate (urge incontinence) or a lack of awareness (passive incontinence). Many factors affect bowel function, including anal sphincter pressure, rectal compliance, anorectal sensation, colonic transit time, and stool consistency and volume. Adequate cognitive function and access to a bathroom are also necessary for continence. The internal anal sphincter is mostly responsible for maintaining continence at rest and contributes to approximately 70% to 80% of resting sphincter tone. This barrier is reinforced by the voluntary squeeze of the external anal sphincter, the anal mucosal folds, and the endovascular cushions. Continence requires a complex interaction of signals of the smooth muscle of the colon, rectum, puborectalis, and anal sphincters. The rectum distends as colonic contents are presented to the rectum, leading to a sensation transmitted along the S2, S3, and S4 parasympathetic nerves. These signals result in the relaxation of the internal sphincter and contraction of the external sphincter (Ferzandi, 2023a; O’Donnell, 2020; Robson & Lembo, 2022).

The exact prevalence of fecal incontinence is difficult to determine because many patients are reluctant to disclose their symptoms. The reported prevalence in the general population is 2% to 3%. It is estimated that approximately 13% to 25% of women who are 3 to 6 months post-partum following a vaginal or cesarean section report fecal incontinence. The financial costs associated with fecal incontinence can be significant due to the costs of continence undergarments, estimated at $400 million annually. Fecal incontinence is the second leading cause of admission to LTC facilities. Beyond older age, additional risk factors include diarrhea, fecal urgency, urinary incontinence, DM, and hormone replacement therapy. Fecal incontinence may result from anal sphincter weakness related to neurologic disorders (e.g., DM or spinal cord dysfunction), infiltrative disorders (e.g., systemic sclerosis), and anal trauma (e.g., post-childbirth, postoperative). It may also be due to rectal compliance issues (e.g., related to ulcerative or radiation proctitis, proctectomy), decreased rectal sensation (e.g., related to neurologic dysfunction secondary to DM, Parkinson’s disease, spinal cord injury), altered stool consistency (e.g., stool impaction), or a combination of these etiologies. It may also be idiopathic, which occurs most commonly in middle-aged and older women. Certain medical conditions, such as thyroid dysfunction, can alter the frequency or number of bowel movements. Smoking can affect colonic transit, highlighting another reason to facilitate smoking cessation (Ansari, 2023; Ferzandi, 2023a; O’Donnell, 2020; Robson & Lembo, 2022).

Patients should be explicitly asked about any changes in bowel and bladder habits for screening, as most will not voluntarily disclose incontinence issues unless directly asked. The HCP should determine if fecal incontinence is present by differentiating it from frequency and urgency. Subjective questions should focus on the onset, duration, frequency, amount, type of leakage, nocturnal episodes, and precipitating events (i.e., medication use or occurring in the setting of diarrhea). The HCP should ask about urinary incontinence, lower back pain, perineal pain, and motor or sensory symptoms in the lower extremities. A history of DM, pelvic irradiation, neurologic conditions, and anorectal surgery are also important. An obstetric history should be obtained, including prolonged labor, use of forceps, perineal laceration, and the number of vaginal deliveries. When evaluating a patient with fecal incontinence, the history and physical examination should include an inspection of the perianal area, a digital rectal exam, and an assessment of the patient’s anocutaneous reflex (anal wink sign). This reflex is tested by stroking the perianal area towards the anus with a cotton swab to observe a reflexive contraction of the external anal sphincter. The HCP should inspect for a fistula, hemorrhoids, rectal prolapse, or contact dermatitis suggesting chronic incontinence (Ansari, 2023; Ferzandi, 2023a; O’Donnell, 2020; Robson & Lembo, 2022).

Stool studies should be performed in patients with diarrhea to evaluate for any underlying pathology (e.g., C. difficile infection). Basic laboratory studies should be considered to rule out DM, thyroid disease, and celiac disease. Endoscopy exams should be considered to assess for malignancy in those presenting with persistent diarrhea, bleeding, obstruction, or other risk factors (e.g., family history). While a flexible sigmoidoscopy is acceptable for patients under 40 at average risk for colon malignancy, a colonoscopy should be performed for all patients over 40 or those at increased risk for malignancy or inflammatory bowel disease. Although less supported by evidence on sensitivity and specificity, a fecal immunochemical test may be used as a screening test for malignancy in low-risk patients without the inconvenience of dietary restrictions and bowel preparation. Providers should consider anorectal manography and/or endorectal ultrasound or magnetic resonance imaging (MRI) for patients who do not respond to initial treatment to assess for functional sphincter weakness, abnormal rectal sensation, or structural anomalies (e.g., sphincter damage, muscle atrophy). Anal manometry assesses resting and squeezing pressures of the anal sphincter, rectal sensation, and capacity. Barium defecography may be needed, especially for patients considering surgical intervention, to assess for enterocele, rectocele, rectal prolapse, anal sphincter length, anorectal angle, and pelvic descent. This test visualizes the pelvic floor during relaxation and contraction using barium and psyllium fiber that is injected into the rectum (Ansari, 2023; Ferzandi, 2023c; O’Donnell, 2020; Robson & Lembo, 2022).

Management of Fecal Incontinence

The American Society of Colon and Rectal Surgeons clinical practice guidelines for managing fecal incontinence were recently updated in 2023 (Bordeianou et al., 2023). Initial management should consist of basic supportive care, including perianal skin care. The skin should be kept clean and dry with premoistened wipes, avoiding astringent cleaners and excessive wiping; a barrier cream should also be applied. Incontinence pads may be used, and certain patients may benefit from a regular defecation program (e.g., patients with cognitive impairment or functional limitations). Foods that exacerbate symptoms should be avoided, such as incompletely digested sugars (e.g., fructose, lactose, sugar substitutes) and caffeine. A food and stool diary should be completed over 2 to 3 months to help patients identify personal triggers. Smoking cessation should be encouraged. Medications should also be reviewed to identify drugs that may be contributing to fecal incontinence: metformin (Glucophage) and proton pump inhibitors (PPIs) typically loosen stool consistency, while calcium channel blockers (CCBs) and nitrates reduce sphincter tone (Bordeianou et al., 2023; Ferzandi, 2023b; Lembo & Spivak, 2023; O’Donnell, 2020).

Medical therapy aims to reduce stool frequency and optimize stool consistency. Any underlying conditions present should be treated. Patients with fecal impaction should be disimpacted. Adding a bulking agent (e.g., psyllium [Metamucil], methylcellulose [Citrucel]) to the diet is beneficial for patients with loose stools at lower volumes. Loperamide (Imodium) or diphenoxylate/atropine (Lomotil) can alleviate the symptoms of liquid stools by slowing intestinal motility and improving sphincter tone. The dosing regimen for loperamide (Imodium) is usually 2 to 4 mg twice or three times daily with a maximum daily dose of 16 mg. Loperamide (Imodium) is preferred over diphenoxylate/atropine (Lomotil) since this medication can cause dependence and is a Schedule V medication under the Controlled Substance Act. Bismuth subsalicylate (Pepto Bismol) and cholestyramine (Questran) bind bile acids, which may be especially helpful for patients with a history of cholecystectomy or ileocolonic resection. Amitriptyline (Elavil), a TCA, inhibits sphincter relaxation and gastric motility but is typically not used for older adults due to its anticholinergic side effects. The use of suppositories or enemas to evacuate the rectum on a schedule reduces incontinence episodes, especially in patients with neurogenic bowel related to spinal cord injury. The role of phenylephrine gel (Preparation H) applied to an intact anal sphincter to improve resting tone is unclear and may be associated with dermatitis, a burning sensation, and headaches. For patients with passive fecal incontinence, injectable anal bulking agents (e.g., dextranomer in hyaluronic acid [Deflux, Solesta]) may improve anal resting pressure and promote continence (Ansari, 2023; Ferzandi, 2023b; Lembo & Spivak, 2023; O’Donnell, 2020).

Many nonpharmacological management options are available for fecal incontinence. Anal plugs to reduce incontinence episodes have limited efficacy and are poorly tolerated by most patients. If anorectal manometry indicates external anal sphincter weakness or decreased rectal sensation, biofeedback may be a beneficial treatment that is painless, non-invasive, low-risk, and inexpensive. Unfortunately, it requires a significant time commitment from the patient over several months to obtain results. Biofeedback attempts to retrain the muscles of the pelvic floor and abdominal wall to increase strength, endurance, and sensation. It has not been shown to help patients with isolated internal sphincter weakness, behavioral or psychiatric disorders, neurogenic bowel, decreased rectal storage, or major structural damage to continence mechanisms. Radiofrequency ablation attempts to create thermal lesions at the anorectal junction under local anesthesia, with limited evidence regarding its efficacy. Posterior tibial nerve stimulation appears to be less effective for patients with fecal incontinence. If confirmed on anorectal ultrasound/MRI, anatomic external sphincter injury (e.g., after vaginal delivery) can be surgically repaired in some cases with anal sphincteroplasty. Unfortunately, functional gains tend to dissipate with time after sphincteroplasty. Sacral nerve electrical stimulation may be considered for patients with structurally intact yet defective anal sphincters if biofeedback and sphincteroplasty are either unavailable or ineffective. Just as sacral neuromodulation was described above for urinary incontinence, stimulation benefits those with neurologic dysfunction or status-post lower anterior resection. Some studies approach an 80% success rate (Bordeianou et al., 2023; Ferzandi, 2023b; Lembo & Spivak, 2023; O’Donnell, 2020).

Finally, for refractory symptoms, colostomy, dynamic graciloplasty, or an artificial anal sphincter are currently the most aggressive surgical management options. Colostomy procedures permanently reroute or divert the fecal stream. Dynamic graciloplasty is associated with considerable morbidity, and the implantable pulse generator that stimulates the transposed gracilis muscle around the anal canal is not currently available in the US. An artificial sphincter—the Neosphincter by Acticon—consists of an implanted cuff, a pressure-regulating balloon, and a control pump implanted in the labium or scrotum that the patient squeezes to permit defecation. These are often effective but are associated with a high rate of complications such as infection, device erosion, or malfunction. Other implantable devices (e.g., a balloon that senses and alerts the patient about an imminent bowel movement, a silastic inflatable cuff, and a magnetic anal sphincter) are less commonly utilized (Bordeianou et al., 2023; Ferzandi, 2023b; Lembo & Spivak, 2023; O’Donnell, 2020).

Falls

A fall is an event when an individual inadvertently drops to the ground, typically caused by acute disorders (i.e., seizure, stroke) or environmental hazards (i.e., tripping or being struck by a moving object). Falls are the leading cause of injury-related deaths in adults over 65. Each year, over 14 million (one in four) older adults (over 65) report falling, with 37% of those falls resulting in an injury that requires medical treatment. The CDC reports that approximately 3 million older adults are seen in emergency departments (EDs) each year, resulting in 800,000 hospitalizations, most related to head injuries and hip fractures. Falls can cost approximately $50 billion annually in medical costs. In addition, falls can threaten the independence of older adults, and many will not report a fall for fear of being placed in an LTC facility. HCPs must be diligent about screening for falls because the history of a fall doubles the risk of a future fall (CDC, 2023a; Ward & Reuben, 2022).

Most falls are multifactorial in etiology, with a complex interaction of intrinsic (i.e., age-related, functional decline, adverse medication reactions), extrinsic (i.e., environmental hazards), and situational factors (i.e., hurrying to the bathroom or being distracted) contributing to the risk. Intrinsic factors include instability, unsteady gait, visual disturbances (acuity, depth perception), sensory loss, and muscle weakness. Since many people wrongly assume that falls are an inevitable component of aging, falls frequently go unreported if the patient is not asked directly and if there is no significant associated injury. Often, HCPs who care for a patient following a fall focus solely on addressing the related injuries rather than the underlying causes of the fall. Therefore, instead of discussing the management of injuries suffered during a fall, which consists of a straightforward utilization of orthopedic injury management guidelines, we will discuss the evaluation process for falls, fall prevention in community-dwelling adults, and fall complication prevention. When a complete assessment of fall risk is needed, HCPs should focus on identifying intrinsic, extrinsic, and situational factors. HCPs should explore the details of any recent falls, including when and where the fall occurred and what they were doing at the time. Patients should be asked about symptoms before the fall (e.g., shortness of breath, chest pain, vertigo, or palpitations). HCPs should explore past and present medical problems and the use of alcohol, illicit substances, or OTC and prescription medications. Physical examination should include heart rate and rhythm, blood pressure (orthostatic), temperature, visual acuity, cardiovascular exam, neurological exam, mental status examination, and range of motion and strength testing. The "Timed Get Up and Go (TUG) Test" can be used to assess mobility and other key components of a neurologic exam. The patient is asked to rise (without using their arms) from a seated position, walk 10 feet, turn, walk back to the chair, turn again, and sit. The normal time to complete this test is 7 to 10 seconds, with those requiring more than 10 seconds at higher risk of falls. There is no standard diagnostic laboratory testing for a patient being evaluated for a fall; however, a complete blood count (CBC), blood glucose, and basic metabolic profile (BMP) may be indicated based on identified factors. An electrocardiogram (ECG) should be considered if a cardiac arrhythmia is suspected (Agarwal, 2023a; Ali, 2020a; Kiel, 2023a; Stafanacci & Wilkinson, 2023).

Multiple interventions have been identified to reduce the risk of falls based on systematic reviews of hundreds of RCTs involving tens of thousands of patients. These interventions include educational and interventional programs to improve strength or balance, modifications of the external environment, and optimization of medications. Studies indicate that fall prevention programs should be individualized based on the relevant risk factors identified during the assessment and multifactorial (i.e., encompassing multiple factors and interventions collectively). Exercise is the most consistent intervention that reduces the rate and risk of falls in older patients by as much as 23%. Activities should specifically focus on increasing strength and improving balance. Tai chi is especially beneficial due to its ability to integrate balance, strength, and movement. Exercise regimens that are progressive and incorporate resistance training have also been found to reduce the risk of falls. These regimens include gait and balance training, strength training, movement (e.g., dance), and aerobic exercises. Exercise programs should be tailored to patient preference, and a PT consultation may provide helpful insight for a patient with little experience exercising. Exercise may be less beneficial (but not harmful) for sedentary female patients over 70 with physical performance impairment, but current research is limited (Kiel, 2023b; Stafanacci & Wilkinson, 2023).

Deprescribing high-risk medications (e.g., psychotropic medications such as benzodiazepines, sedatives, and antipsychotics) has proven effective in reducing the rate of falls (Kiel, 2023b; Stafanacci & Wilkinson, 2023). The 2023 BC includes the following medications that should be avoided in older patients at risk for falls: SNRIs, selective serotonin reuptake inhibitors (SSRIs), TCAs, antiepileptic drugs (AEDs), antipsychotics, benzodiazepines, nonbenzodiazepine receptor agonists (non-BZRAs or Z-drugs, such as zolpidem [Ambien], zaleplon [Sonata], and eszopiclone [Lunesta]), and opioids, specifically mu-opioid receptor agonists (AGS Beers Criteria Update Expert Panel, 2023). Some studies indicate that while universal vitamin D supplementation does not help prevent falls, supplementation (about 1,000 international units [IU] daily) in high-risk older adults (i.e., those with limited sun exposure, malabsorption, obesity, slow gait speed, or impaired balance) may be beneficial. A home safety assessment with an occupational therapist (OT) is useful for reducing the rate and risk of falls. These assessments should be followed by safety recommendations, such as installing handrails on stairs and grab bars in bathrooms, ensuring clear and adequate lighting, optimizing slip-resistant surfaces, removing throw rugs and other trip hazards, and adding nonslip mats in bathrooms. Nonslip shoes worn during winter may help reduce the rate of outdoor falls. Some patients may benefit from single-lens eyewear (versus multifocal) while walking outdoors. Interventions that do not appear to reduce the risk of falls include ophthalmology assessments to improve vision, mobility training, and using an assistive device (e.g., a walker or cane). Education regarding falls as a stand-alone intervention was also ineffective (Kiel, 2023b; Stafanacci & Wilkinson, 2023).

The CDC (2023c) developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool kit in 2019 with recommendations for HCPs to develop a multifactorial and individualized plan to reduce fall risk in older patients. The tool offers resources for patients/caregivers, providers, and pharmacists to work collectively to reduce fall risk for patients over 65. The algorithm provides succinct guidance regarding the 3-step process to screen patients for fall risk, assess for modifiable risk factors, and intervene to address the risk factors identified. Patients should be screened yearly for fall risk or more frequently if the patient presents after a fall. There are various screening tools available, including the 12-question stay independent tool. Scores ≥ 4 indicate a risk for falls. Another option recommended in the STEADI algorithm is asking three screening questions:

• Do you feel unsteady when walking or standing?
• Do you worry about falling?
• Have you fallen in the past year (CDC, 2023c)?

If the patient answers yes to any of these questions, then they are determined to be at risk of falls. For patients who are screened not at risk for falls, prevention strategies should include (CDC, 2023c):

• educate the patient on fall prevention
• assess vitamin D intake and recommend supplementation if deficient
• refer to community exercise programs
• reassess yearly or if the patient presents after a fall

HCPs should assess for modifiable risk factors discussed above for patients screened at risk. An individualized and multifactorial plan should be developed with interventions to address risk factors. Finally, for patients with individualized plans, the STEADI algorithm recommends follow-up with patients in 30-90 days (CDC, 2023c). A small study (n=36) based on the CDC algorithm utilized exercise, home safety visits, and an individualized medication plan to identify and limit polypharmacy. While the results did not find a statistically significant reduction in falls in the intervention group compared to their baseline before the intervention, they did confirm a statistically significant reduction in falls in the intervention group compared to the control group over 12 months (Frith et al., 2019).

Interventions designed to treat comorbidities also decrease the risk of falls related to those conditions. For example, patients with syncope related to carotid sinus hypersensitivity have a reduced fall rate when a cardiac pacemaker is implanted. For patients with cataracts, surgical correction of at least one eye can lower the risk of falls and hip fractures. For older adults with a body mass index (BMI) under 20 kg/m² who had been recently hospitalized, oral nutritional supplementation for three months reduced the number of falls and the number of individuals reporting a fall. Treatment for postural hypotension (e.g., reduced antihypertensive medications, increased fluids, compression stockings, corticosteroid fludrocortisone [Florinef], or alpha-agonist midodrine [Amatine]) has been effective in reducing fall risk. For those with disabling foot pain, podiatry care that is comprehensive and multifaceted (e.g., consultation, orthotics, footwear subsidy, exercises, fall education) led to a 36% reduction in falls. Even osteoporosis treatment via denosumab (Prolia, Xgeva) was linked to a 21% reduction in falls in a meta-analysis of RCTs (Kiel, 2023b).

Some interventions have effectively prevented the complications of falls when they do happen. Osteoporosis screening using an assessment of known risk factors followed by appropriate treatment decreases the incidence of hip fractures. After a fall, prolonged time on the floor (i.e., an inability to get up after falling) is associated with a serious injury, hospital admission, and transition to an LTC facility. While call alarm systems designed to summon assistance after falls or emergencies (e.g., LifeAlert) are promoted to prevent long periods on the floor, their efficacy is unproven, as the vast majority are not used after a fall. Hip protectors have not been proven effective, likely related to poor patient compliance with these devices and significant variations in device thickness, stiffness, and geometry (Kiel, 2023b). For more information on the epidemiology, risk factors, and individual fall risk assessment in older patients, please see the corresponding section in our Comprehensive Geriatric Assessment course.

Syncope

Syncope is the transient loss of consciousness due to inadequate cerebral flow, most often due to a diminished blood flow causing an abrupt drop in systemic BP. The hypotensive event is self-limited and brief (8 to 10 seconds). Typically, the entire syncope event lasts 1 to 2 minutes, and recovery is complete unless a secondary injury occurs (e.g., head injury). Near-syncope is light-headedness and a sense of impending syncope without loss of consciousness. Syncope is a common disorder, with as many as 50% of the population experiencing an event in their lifetime. It is estimated that 1-2% of ED visits and 6% of hospital admissions each year in the US are related to syncope. While 10% of syncope cases are idiopathic, most can be categorized as:

• reflex (neural-mediated, e.g., vasovagal, carotid sinus, or micturition, defecation, swallowing, or coughing-triggered syncope)
• orthostatic
• related to cardiac arrhythmia (e.g., atrioventricular [AV] block, sinus node pause, ventricular tachycardia [VT], bigeminy, or supraventricular tachycardia[SVT])
• related to structural cardiopulmonary disease (e.g., aortic stenosis, cardiomyopathy, atrial myxoma, pulmonary embolism [PE], or stenosis).

Reflex syncope accounts for most of the cases of syncope in younger individuals, and approximately one-half of syncope cases in older patients are considered reflex syncope, in which HR and BP are inappropriately modified. Older age increases the risk of orthostatic and cardiac causes of syncope. Atherosclerotic disease of the cerebral arteries is rarely the cause of true syncope. Conditions that mimic syncope should be ruled out first, such as seizures, sleep disturbances, intoxication, and some psychiatric conversion reactions (Benditt, 2022b; Morag, 2017; Thompson & Shea, 2022).

The initial evaluation of a patient with a syncope episode enables HCPs to determine if the episode was a true syncope or another type of event, determine risk stratification (admission versus outpatient treatment), and assess for potential causes. To effectively evaluate a patient with syncope, the history (including the number, frequency, duration, provocative factors, and associated symptoms of episodes) and a physical examination should be completed, including a careful carotid sinus massage and a 12-lead ECG. Patients with vasovagal syncope typically describe a prodromal sensation of lightheadedness, feeling warm or cold, sweating, palpitations, pallor, nausea, blurry vision, and auditory changes. Past medical history should include reviewing conditions that increase the risk of syncope, including structural heart disease (i.e., valvular or congenital disease, cardiomyopathies), neurological conditions (i.e., migraines, Parkinson's), and DM. For older adults, syncope often has more than one cause, such as taking blood pressure medications and being exposed to hot, humid weather (Benditt, 2022a; Morag, 2017; Shen et al., 2017; Thompson & Shea, 2022).

Vital signs should be obtained when the patient is supine, seated, and standing to assess for orthostatic hypotension (evidenced by a decrease in SBP of at least 20 mm Hg over 5 minutes or at least 30 mm Hg in a patient with HTN). An audible heart murmur may indicate aortic stenosis, hypertrophic cardiomyopathy, or myxoma, while tachycardia, in combination with tachypnea, may indicate a PE. Arrhythmias are rarely identified on the ECG and may require longer monitoring (e.g., Holter). If structural cardiopulmonary disease is suspected, it should be confirmed with a transthoracic echocardiogram (TTE). Focal neurological symptoms (hemiparesis, dysarthria, diplopia, vertigo) should warrant a full neurological workup to assess for a potential neurological cause of the patient’s loss of consciousness. A finger stick blood glucose should be checked to rule out hypoglycemia as a cause of syncope. A stool guaiac examination may also be recommended for patients with syncope to rule out bleeding. When clinically indicated, laboratory testing should be ordered to evaluate for anemia, electrolyte imbalances, and kidney function (Benditt, 2022a; Morag, 2017; Shen et al., 2017; Thompson & Shea, 2022).

Medications causing or contributing to syncopal episodes should be eliminated, replaced, reduced, or adjusted in schedule or timing. Antihypertensives should be reviewed for dose reduction or elimination in these patients, especially those with carotid sinus hypersensitivity. Patients with orthostatic hypotension related to hypovolemia or electrolyte disturbances (e.g., hypokalemia) should avoid diuretics. Orthostatic hypotension may be due to medications (e.g., vasodilators or negative chronotropics) that should be eliminated, replaced, or reduced. Anti-arrhythmic agents, anti-infective agents (e.g., azole antifungals, macrolides, fluoroquinolones), antidepressants, and antipsychotic medications can cause polymorphic VT with associated QT interval prolongation, increasing the risk of syncope. The 2023 BC indicates that acetylcholinesterase inhibitors should be avoided based on high-quality evidence due to the risk of bradycardia, which could lead to syncope. Nonselective peripheral alpha-1 blockers (doxazosin [Cardura], prazosin [Minipress], and terazosin [Hytrin]) should be avoided due to their increased risk of orthostatic hypotension. Tertiary TCAs and certain antipsychotics (chlorpromazine [Thorazine], thioridazine [Mellaril], and olanzapine [Zyprexa]) should be avoided due to the risk of bradycardia or orthostatic hypotension based on high-quality evidence (AGS Beers Criteria Update Expert Panel, 2023; Benditt, 2022a, 2022c; Thompson & Shea, 2022).

Caregivers should be educated regarding safety measures they can take when they witness a syncopal episode. These safety measures include gently and safely lowering the patient to the ground, placing them supine and elevating their legs, assessing their vital signs, and calling for assistance if required. Patients with vasovagal syncope should be educated regarding the benign nature of the diagnosis, avoidance of individual triggers (e.g., prolonged standing, straining), and the identification of warning signs. Otherwise, management should include physical isometric counterpressure maneuvers that the patient starts when the prodromal symptoms begin. The most common maneuvers include lower extremity muscle tensing, crossing of the legs, maximal handgrip, or arm tensing. These may also help patients with orthostatic hypotension. Patients with carotid sinus hypersensitivity should also avoid accidental mechanical stimulation of the carotid sinuses. Patients with orthostatic hypotension related to hypovolemia should be counseled on the importance of remaining adequately hydrated. Patients with arrhythmias may be candidates for medication, procedural (e.g., ablation), or device therapy (e.g., cardiac pacemaker or implantable cardioverter-defibrillator [ICD]) under the supervision of a cardiologist. Aortic valve replacement may be required for patients with severe aortic stenosis and associated persistent syncopal episodes. In some cases of recurrent syncope, driving restrictions should be instituted (Benditt, 2022c; Thompson & Shea, 2022).

Vertigo

Dizziness is a term that can be used to describe sensations of light-headedness, unsteadiness, spinning sensation, faintness, or a swimmy head feeling. Vertigo is a symptom, not a diagnosis; it is most commonly experienced as transient spinning dizziness, an illusion of movement. More specifically, it is the sensation of movement of the self or environment when there is no actual movement. Vertigo can be perceived as a spinning or rotating sensation or being pulled to one side. Dizziness and vertigo are often used interchangeably, even though vertigo is a delineated subset of dizziness. Dizziness accounts for 5-6% of visits to an HCP and becomes more common with older age. Vertigo is typically caused by damage or dysfunction of the labyrinth, vestibular nerve, or central vestibular structures in the brainstem, leading to asymmetry in the vestibular system. This sensation may be associated with nausea, vomiting (unless mild and brief), and postural or gait instability. Vestibular dysfunction may also cause a tilt illusion, drop attacks (a sudden feeling of being pushed or pulled to the ground), spatial disorientation, oscillopsia (i.e., a visual illusion of environmental motion and blurred vision with head movement), and poor balance. Vertigo related to vestibular dysfunction is typically not permanent and continuous but episodic and diminished as the vestibular system adapts. Benign paroxysmal positional vertigo (BPPV) typically presents with discrete but recurrent episodes lasting under 1 minute, and a history of head trauma is common. A patient with vertigo related to a migraine or transient ischemia of the labyrinth or brainstem will present with a single vertigo episode lasting minutes to hours. Patients with migraines will typically describe concurrent photophobia, headaches, and hyperacusis (sound sensitivity; Branch & Barton, 2022; Furman & Barton, 2022a; Kaylie, 2022).

Meniere disease and recurrent vestibulopathy both cause recurrent vertiginous episodes lasting minutes to hours, often accompanied by tinnitus and loss of hearing secondary to a peripheral lesion of the inner ear. Vestibular neuritis, multiple sclerosis, or infarction of the brainstem or cerebellum causes severe, prolonged vertigo episodes that can continue for days. A patient who has suffered a vertebrobasilar stroke will typically present with other indications of ischemia—such as dysarthria, diplopia (double vision), dysphagia (difficulty swallowing), or weakness—and often has risk factors for stroke such as HTN, tobacco use, DM, and vascular disease. Certain head movements will provoke or worsen vertigo symptoms. Episodes of BPPV are often triggered by a specific motion, such as extending the neck or rolling over in bed. Vertigo that worsens with coughing or sneezing may indicate a perilymphatic fistula or a superior canal fistula. A family history of vertigo can point to a rare familial channelopathy (Branch & Barton, 2022; Furman & Barton, 2022a; Kaylie, 2022).

The history and physical examination should help the HCP distinguish vertigo from other types of dizziness. Causes of vertigo are often organized into peripheral or central disorders (see Table 5). The time course of symptoms is one of the best clues to differentiate the pathophysiology of vertigo. The HCP should explore aggravating and provoking factors. Head movement almost always worsens vertigo, and the absence of this aggravating factor can indicate that the dizziness is not vertigo. Visual vertigo is more likely when dizziness is provoked by static visual stimuli (i.e., patterns on carpets or scrolling on a computer) (Furman & Barton, 2022a; Kaylie, 2022).

Table 5

Causes and Clinical Features of Central versus Peripheral Vertigo

(Furman & Barton, 2022a; Kaylie, 2022)

Nystagmus—repetitive, involuntary, rapid eye movements—is the physical manifestation of a patient’s report of vertigo. Nystagmus on physical exam suggests vertigo associated with a vestibular lesion, while pronounced nystagmus in combination with mild vertigo indicates a potential brainstem lesion. Specific features of nystagmus can often specify the location and underlying cause of vertigo. A neurological exam should be done to assess balance, gait, cranial nerve function, and hearing. An abnormal hearing test supports the diagnosis of Meniere disease. The Dix-Hallpike maneuver may be performed to confirm vertigo and nystagmus in those with BPPV related to canalithiasis of the posterior semicircular canal (dysfunction in the posterior canal of the lower ear). In this maneuver, the neck is extended while the patient sits upright on a bed. The neck is turned 45 degrees to the side, and the patient is reclined quickly into the supine position with the head hanging off the edge of the bed. This position is held for 30 seconds while noting any nystagmus. The patient should then be returned to the seated position and observed for nystagmus for another 30 seconds. The maneuver should then be repeated on the alternate side. A peripheral vestibular lesion (inner ear or vestibular nerve) is typically confirmed with a head impulse test or head thrust test. In this assessment, the patient sits with their head turned slightly (10 degrees or so) and their gaze fixed on a distant target. The examiner turns the patient’s head approximately 15 degrees quickly and without warning. A healthy patient will maintain their gaze on the target during and after the head turn. In contrast, a deficient vestibulo-ocular reflex on the side of the head turn will result in the gaze chasing the head turn, followed by a saccade back to the target. This test may help separate vestibular dysfunction from nonvestibular dizziness or central vertigo (e.g., cerebellar infarct). Alternative tests may include assessing the patient’s nystagmus for direction changes or a test of skew, which looks for the vertical misalignment of both eyes. Advanced imaging (MRI, MR angiography [MRA], or computed tomography [CT]) should be performed to rule out a lesion or vascular event in patients with suspected central vertigo. Laboratory tests are not usually helpful in evaluating vertigo but could be considered based on suspected etiology. A finger stick blood glucose and a pregnancy test should be completed. HCPs should also consider an ECG and possibly a Holter monitor to evaluate for arrhythmia (Furman & Barton, 2022a; Kaylie, 2022).

Vertigo should be managed by addressing the underlying pathology when possible. Medications to suppress vestibular symptoms are best used for vertigo episodes that last a few hours or days. Acute symptomatic treatment should be used for no more than 48 hours, as these options may affect the patient’s ability to compensate and recover long-term. Such treatments involve various drug classes (Furman & Barton, 2022b; Kaylie, 2022):

• first-generation antihistamines (dimenhydrinate [Dramamine], diphenhydramine [Benadryl], or meclizine [Antivert])
• antiemetics (e.g., ondansetron [Zofran], promethazine [Phenergan], metoclopramide [Reglan], or prochlorperazine [Compazine])
• benzodiazepines (e.g., alprazolam [Xanax], clonazepam [Klonopin], diazepam [Valium], or lorazepam [Ativan])

The response to these medications is often dose-related. Antihistamines are usually the medication of choice since benzodiazepines and some antiemetics promethazine [Phenergan] and prochlorperazine [Compazine]) are sedating and have an increased risk of side effects. Meclizine [Antivert] is often prescribed at 25 to 50 mg three times a day. As previously mentioned, many of these medications are potentially inappropriate and should be used with extreme caution in older patients. Patients with peripheral vestibular disorders (e.g., BPPV, vestibular neuritis, Meniere disease) and even some with central vestibular disorders (e.g., vestibular migraine, infarction or ischemia of the cerebellum or brainstem, multiple sclerosis), should be referred to a PT specializing in vestibular therapy. This therapy is likely more effective when initiated early, as it supports the CNS’s ability to compensate. The main tenets of vestibular rehabilitation are that activity promotes adaptation and facilitates strategic substitution, while inactivity leads to secondary physical and psychological effects. Exercises are typically tailored to address the specific condition (e.g., acute versus chronic peripheral vertigo, bilateral injury, central vertigo) as indicated (Furman & Barton, 2022b; Kaylie, 2022).

Functional Decline, Frailty, and Failure to Thrive

Functional capacity refers to a patient’s ability to perform basic, instrumental, and advanced ADLs. These ADLs include toileting, grooming, eating, cooking, driving, and managing finances. As a patient loses the ability to perform these various tasks, they are described as experiencing a functional decline. Frailty in older adults is defined by weight loss, malnutrition, and inactivity. Older adults with frailty experience physiological decline that places them at an increased risk of adverse outcomes, an increased symptoms burden such as fatigue and weakness, medical complexity, and reduced tolerance to medical and surgical interventions. Frailty prevalence estimates vary between 4% and 16% of community-dwelling adults over 65 and up to 43% for older adults with cancer. Pre-frailty is estimated at 28% to 44% in adults over 65. Although older age is a risk factor for frailty, it does not define frailty. Risk factors for frailty in the US patient population include lower educational level, smoking, hormone replacement therapy, African American or Hispanic American ethnicity, unmarried status, depression, antidepressant use, and intellectual disability. Female patients and those with lower incomes, more comorbidities, and poorer overall health are also at increased risk. Frailty is a significant predictor of hip fractures, disability, and hospitalization and also a precursor to many other geriatric syndromes, including falls, delirium, and incontinence (Agarwal, 2023a; Poursalehi et al., 2023; Voelker, 2018; Walston, 2023; Ward & Reuben, 2022).

Frailty exists on a spectrum, with the end stage of frailty on the continuum often considered to be failure to thrive (FTT). FTT in older patients is a syndrome of global decline characterized by weight loss (more than 5%), anorexia (decreased appetite), poor nutrition, and inactivity that is often accompanied by dehydration, symptoms of depression, impaired immunity, and decreased cholesterol. FTT may be considered to result from three components: physical frailty, disability (difficulty or dependency in completing ADLs), and impaired neuropsychiatric function (delirium, depression, and dementia). The prevalence of FTT in community-dwelling adults is 5% to 35% and 25% to 40% in adults living in an SNF. Many factors increase the risk of FTT. The mnemonic 11 D's of "The Dwindles" outlines many of the precipitators of FTT: disease (medical illness); dementia; delirium; drinking alcohol or other substance misuse; drugs; dysphagia; deafness, blindness, or other sensory deficits; depression; desertion by family, friends (social isolation); destitution (poverty); despair (giving up; Agarwal, 2023a; Ali, 2020a; Walston, 2023).

Compared to the FTT syndrome seen in pediatric patients who cannot achieve an expected functional level, older adults with the same constellation of symptoms cannot maintain their previously acquired functional status. These terms may function interchangeably or be used to describe points along a continuum between the independence and virility of middle age and the full dependence and decline experienced at the end of life. Others consider physical frailty to be a required component of an FTT diagnosis, typically accompanied by psychical disability and neuropsychiatric impairment; however, these elements are not necessary to establish a diagnosis. FTT and frailty are often related to adverse effects of medication(s) or medical comorbidities and are compounded by psychosocial factors. Before establishing a treatment plan for a patient with frailty or FTT, the patient and their caregiver(s) should engage in an extensive conversation to clarify their goals of care. The treatment plan should be based on the patient’s priorities. In this context, a thorough CGA can efficiently and effectively guide an older adult's care via shared decision-making and clear goals. For example, pain management may be a key focus in the care plan for many patients diagnosed with frailty or FTT (Agarwal, 2023a; Ali, 2020a; Walston, 2023). Please see the NursingCE course, The Comprehensive Geriatric Assessment, for more details on this process.

Evaluation

A thorough history is essential to diagnose the underlying cause(s) of FFT in an older adult, including a review of systems, nutrition, medications, social history, functional status, and cognitive function. The Simplified Nutrition Assessment Questionnaires (SNAQ) is a set of three easy tools for use in a hospital, SNF, and community setting to screen older adults for malnutrition and anorexia and predict future weight loss. In addition, a complete physical examination should be performed, including a hearing and vision examination. The TUG Test can be used to assess mobility and other key components of a neurologic exam. The history and physical examination should guide laboratory testing to screen for potential causes of FTT, including infection, organ failure, or malignancy. HCPs may consider ordering a CBC, BMP, liver function studies, calcium, phosphate, thyroid function studies, urinalysis, vitamin B12 and folate levels, albumin, and total cholesterol. An ECG may be considered to detect an arrhythmia (Agarwal, 2023a; Ali, 2020a).

All patients with FTT should undergo a thorough medication review to assess for and address polypharmacy. If a medication with the potential for adverse effects is identified, the situation should be discussed with the patient, including the risks and benefits of continuing the medication, alternatives for replacing the medication, or the process of deprescribing the medication. This risk is more common with medications that cause drowsiness or lethargy and those considered inappropriate by the AGS Beers Criteria (e.g., anticholinergics). If a medication is replaced or deprescribed, the patient should be monitored closely for signs or symptoms of withdrawal in the short term, as well as improvement in FTT symptoms after the medication has been stopped. Medications commonly associated with FTT include antiepileptics, benzodiazepines, beta-blockers, central alpha agonists, diuretics, glucocorticoids, neuroleptics, opioids, SSRIs, and taking more than four prescription medications. Please see the NursingCE course Polypharmacy and Prescribing for additional details regarding prescribing and deprescribing medications safely for older adult patients (Agarwal, 2023a, 2023b, Ali, 2020a).

The most important aspect of managing older adults with FTT is to fully and correctly identify all underlying and contributing conditions, such as malignancy, depression, and thyroid dysfunction. Please see the NursingCE course, The Comprehensive Geriatric Assessment, for additional details regarding the assessment and diagnosis of these conditions. Next, the management plan should include optimization and adequate treatment of the diagnosed condition(s). For these patients, FTT should be considered a symptom that will resolve when the underlying condition is adequately addressed. For example, a patient diagnosed with depression who initiates structured psychotherapy plus an antidepressant medication may experience an improvement in their FTT symptoms. Based on their side effect profiles, mirtazapine (Remeron), citalopram (Celexa), and venlafaxine (Effexor) are less likely to contribute to anorexia and weight loss, while TCAs, bupropion (Wellbutrin), fluoxetine (Prozac), and sertraline (Zoloft) should be avoided for these patients. For those with severe depression, electroconvulsive therapy (ECT) has also been effective (Agarwal, 2023a, 2023b; Ali, 2020b). Please see the forthcoming section on Depression for additional information about the management of social isolation and mood disorders in older adults.

There are instances of FTT in older patients already receiving optimal care for their existing medical condition(s), or no underlying etiologies are identified. In these cases, FTT is managed symptomatically according to the patient’s care goals in collaboration with a multidisciplinary team. This team may consist of a clinician, nurse, PT, OT, speech-language pathologist (SLP), licensed social worker (LSW), dietitian, and dentist where appropriate. Findings from a comprehensive history and physical examination help identify complications of inactivity, malnutrition, and FTT (e.g., pressure injuries, venous thromboembolism [VTE], and chronic subcutaneous infections). These should be addressed according to the evidence-based guidelines associated with each condition (Agarwal, 2023a, 2023b; Ali, 2020b). The next section will focus on the symptomatic management of older adults diagnosed with frailty and FTT.

A consultation with various specialists will contribute to a comprehensive treatment plan for a patient diagnosed with FTT or frailty and ensure the underlying contributing factors are correctly identified and addressed. This plan should include a referral to an SLP and dietitian for patients with unintentional weight loss or malnutrition to distinguish between difficulty with chewing, swallowing issues, or potential aspiration. The SLP may recommend incorporating certain food textures, swallowing exercises and techniques, and body positioning to optimize function while eating. A dietitian may plan meals based on the individual’s caloric needs in light of their activity level, comorbid conditions, and nutritional status. A referral to PT and OT may be most beneficial for patients with inactivity, apraxia, cognitive decline, or a limited ability to perform ADLs independently. These providers can recommend and facilitate the delivery and proper utilization of assistive devices, grab bars, and other safety equipment, along with a treatment plan that addresses the patient’s most significant deficits. Patients with global deficits may be recommended for enrollment in a comprehensive rehabilitation program. An LSW can address social isolation, patient and family education, advanced care planning, and referrals to community or mental health resources (Agarwal, 2023a, 2023b).

Management

FTT symptoms should be addressed, particularly weight loss, physical frailty, and neuropsychological impairment. Interventions for weight loss should address any impediments to intake (e.g., mechanical, social, financial, dietary). A dental consultation to manage oral pain or adjust dentures should be included. A dietitian consultation should consist of suggested meal plans with adequate caloric and protein intake using creative alternatives when necessary for patients who report taste alterations, food intolerances, or other special circumstances. An SLP should be consulted to address any dysphagia, chewing issues, or texture modifications. An OT can assist with food preparation, transportation details to obtain groceries, and exercises to address upper extremity limitations related to weakness or tremors. Assistance with shopping or feeding may be required for some patients, and strategies should be explored with the patient and caregiver. Social interaction during mealtimes is beneficial, along with frequent small meals. The patient should be encouraged to eat whenever they are hungry and avoid limiting their diet based on previous education; for example, low-salt or low-fat modifications can be discontinued. The nutrient density of foods can be optimized by adding whey or milk powder, egg whites, or tofu to increase the protein content or by adding olive oil or avocado to increase fat content (Agarwal, 2023b; Ali, 2020b; Ritchie & Yukawa, 2023).

The decision to use caloric supplements should only be considered after the removal of dietary restrictions and other causes of dysphagia or anorexia have been addressed. Caloric supplements have not been proven to improve QOL, mood, or functional status despite evidence that they provide a 2% increase in weight and a small reduction in mortality in older adults with FTT. The decision to use caloric supplements should be based on the patient's care goals. The AGS's "Choosing Wisely" initiative advises avoiding high-calorie supplements. In addition, the AGS does not recommend the appetite stimulant megestrol acetate (Megace) and the antihistamine cyproheptadine (Periactin) due to a lack of evidence that these medications improve QOL or reduce mortality in older adults with FTT, in addition to their unfavorable associated risks (VTE events, fluid retention, increased mortality; Agarwal, 2023b; Ali, 2020b; Ritchie & Yukawa, 2023). Additional information regarding the diagnosis and management of malnutrition can be found in the corresponding section of this course.

A 2018 meta-analysis and systematic review by Kojima and colleagues reviewed the effect of the Mediterranean diet, specifically on older adults and frailty. They looked at four studies comprising 5,789 community-dwelling adults with a mean age of over 60. When scored on dietary adherence, participants’ enhanced adherence to the Mediterranean diet was associated with a significantly lower incident frailty risk without significant heterogeneity (Kojima et al., 2018). In another systematic review, Poursalehi and colleagues (2023) found that adherence to a Mediterranean diet was inversely associated with the risk of frailty and pre-frailty in older adults. The researchers determined that the certainty of evidence in the included studies was high. The Mediterranean diet contains a significant source of plant foods (e.g., fruits, vegetables, legumes, whole grains, seeds, olives, and tree nuts). It includes moderate fish intake as the primary source of protein while limiting or avoiding red or processed meats. Olive oil is the primary source of fat, along with avocados and other “healthy” fats. Dairy products are somewhat limited, but small amounts of wine with meals are encouraged. The diet is generally anti-inflammatory, which may explain its effectiveness. The fish content in the diet supplies vitamin B12, and other antioxidants (e.g., vitamins A, C, B6, D, and folate) are provided in abundance. The Mediterranean diet is also associated with cultural and lifestyle elements, encourages the social and community aspects of food, and emphasizes the health benefits of 30 minutes of moderate physical activity daily (Voelker, 2018).

In addition to the dietary approaches discussed above, interventions to address physical frailty include strength and aerobic exercise plus vitamin D supplementation. Exercise improves function, mobility, and gait and prevents disability and falls. Exercise can also improve bone mineral density and increase a patient’s overall well-being. An exercise plan should be made through a PT referral for those with any physical limitations or disability and according to the patient’s wishes if they are terminally ill. The method with the most robust evidence of effectiveness is progressive resistance training, which increases muscle mass, gait speed, and exercise tolerance. Vitamin D supplementation may help those with sarcopenia (age-related loss of lean muscle mass) and a serum 25-hydroxyvitamin D level below 20 ng/mL. Supplementation may still provide a low-risk intervention with a modest benefit for patients with sarcopenia and a normal vitamin D level. As mentioned above, vitamin D supplementation may reduce the risk of falls, promote the maintenance of muscle strength, and enhance balance. The daily vitamin D intake should be at least 800-1000 IU in older adults. Anabolic agents (testosterone replacement), growth hormone, growth hormone stimulants (e.g., ghrelin), and dehydroepiandrosterone sulfate supplementation are not recommended due to significant known risks and a current lack of evidence for efficacy. In a French study, a multidimensional program incorporating cognitive training, education on physical activity, and nutritional counseling decreased the risk of developing or persisting comorbidities in over 1,600 community-dwelling older adults. Along with exercise and nutritional supplementation, cognitive training effectively ameliorated multiple frailty components according to a systematic review of 21 RCTs regarding frailty prevention. An outpatient program by Medicare entitled the Program of All-inclusive Care for the Elderly (PACE) aims to overcome environmental challenges to improve function and keep patients living at home. The interdisciplinary PACE team comprises geriatric practitioners, nurses, PTs, OTs, and LSWs. The customized program can include home visits, therapy sessions, transportation assistance, self-care aides, or adult daycare (Agarwal, 2023b; Ali, 2020b; Walston, 2023).

Patients with frailty or FTT related to dementia tend to respond positively to environments with increased support and supervision, as well as increased social interaction. Advanced dementia typically renders the patient unable to feed themselves, chew, or swallow. Feeding may be provided with assistance for comfort, but a discussion with the family regarding the risks of aspiration is warranted. Advance care planning in the early stages of dementia should guide shared decision-making with advanced dementia patients regarding the use of supplemental tube feeding (Agarwal, 2023b).

Frail older adults who are hospitalized have an increased risk of institutionalization and report a decreased QOL. However, certain acute geriatric care units are attempting to improve this experience. Geriatric Evaluation and Management Units (GEMUs, in US Department of Veterans Affairs [VA] hospitals) or those based on the Acute Care of the Elderly model (ACE, found in private hospitals) are typically staffed by clinicians who assume primary care of the patient, thereby streamlining the implementation of recommendations. These models place a skilled team of professionals (e.g., nurses, PT, OT, SLP, LSW) who tailor care to the older adult population, enhancing therapy consistency. This care model is designed to prevent the prolonged functional decline typically seen after acute hospitalizations in frail older adults (Walston, 2023; Ward & Reuben, 2022).

For older adults with FTT nearing the end of their life, the focus of care should shift from improving outcomes to comfort and palliation. Screening and intervention should be less aggressive and no longer target non-life-threatening conditions. FTT is no longer recognized by the Centers for Medicare and Medicaid Services (CMS) as a qualifying diagnosis for hospice care. Instead, hospices are instructed to bill for the underlying primary disease state. However, clinical decline worsens the prognosis of any underlying condition. It typically includes clinical features such as weight loss not related to reversible causes, inadequate oral intake due to intractable dysphagia, and progressive decline in Karnofsky Performance Scale status, among other factors. Additionally, progressive inanition (exhaustion related to malnutrition) is a criterion that may indicate a life expectancy at or below six months. Consultation with a palliative care or hospice provider is recommended for this subset of patients (Agarwal, 2023b; Walston, 2023).

Malnutrition

Changes associated with aging increase the risk of malnutrition in older adults. Malnutrition and undernutrition are often used synonymously; however, malnutrition is a broader concept that also includes overweight and obese conditions. Malnutrition affects older adults more often compared to younger adults and also exerts a greater impact on their health outcomes. It can interfere with function, increase healthcare utilization, and lengthen postoperative hospital stays for surgical patients. Data suggests that the prevalence of malnutrition among older adults varies by setting—6% of outpatients, 17.5% of SNF patients, 22% of hospitalized patients, 28.7% of LTC patients, and 29% of rehabilitation/sub-acute care patients. It is estimated that 71% of older adults acutely hospitalized are at risk or have malnutrition. Malnutrition in an older adult patient may initiate a cycle of frailty, as it leads to a decrease in lean muscle mass, which reduces strength, aerobic capacity, gait speed, and activity level, resulting in functional decline and progressive frailty. Risk factors for malnutrition in older adults include anorexia, acute delirium, a higher BMI, the presence of a pre-existing infection or cancer, and the need for assistance while eating. Weight loss may be due to inadequate intake or anorexia, sarcopenia (loss of lean muscle mass and strength), or the inflammatory effects of a disease (e.g., cachexia). Inadequate intake in older adults can result from social isolation, financial limitations, and medical or psychological conditions. Age-related physiologic changes (e.g., decreased sensitivity to smells and taste, delayed gastric emptying, and early satiety due to adjustments in digestive hormones) contribute to an expected reduced appetite with age. Illness, medications, and chronic conditions (e.g., dementia, depression) also contribute to anorexia. Polypharmacy in older adults can also prompt or worsen malnutrition, as it has been associated with a decreased intake of fiber, minerals, and fat-soluble and B vitamins and an increase in cholesterol, glucose, and sodium intake (Agarwal, 2023a; Bhupathiraju & Hu, 2023; Ritchie & Yukawa, 2023; Saljoughian, 2019).

The mnemonic MEALS ON WHEELS summarizes some of the common causes of malnutrition and unintentional weight loss in adults, which include the following:

• medications (e.g., AEDs, digoxin [Lanoxin], anticholinergics, angiotensin-converting enzyme [ACE] inhibitors, antibiotics, chemotherapeutic agents)
• emotional problems (e.g., mood disorders such as depression or anxiety)
• anorexia
• late-life paranoia or alcoholism
• swallowing disorders (e.g., odynophagia [painful swallowing], dysphagia)
• oral factors (e.g., dental carries/abscess, ill-fitting dentures, xerostomia)
• no money (financial limitations, e.g., economic hardship, food deserts, lack of transportation to obtain food)
• wandering (by dementia patients)
• hyperthyroidism or hyperparathyroidism
• entry problems or malabsorption
• eating problems (e.g., upper extremity or jaw weakness due to stroke or tremor)
• low-salt or low-cholesterol diet
• shopping and food preparation problems (e.g., food deserts, lack of transportation to obtain food; Agarwal, 2023a; Ritchie & Yukawa, 2023)

Various medical conditions can also contribute to weight loss, such as malignancy (most commonly), gastrointestinal conditions (e.g., peptic ulcer disease, chronic pancreatitis, inflammatory bowel disease), cardiac conditions (e.g., heart failure, coronary artery disease), pulmonary conditions (e.g., chronic obstructive pulmonary disease [COPD], interstitial lung disease), infectious conditions (e.g., tuberculosis [TB], bacterial endocarditis), neurologic conditions (e.g., stroke, dementia, Parkinson’s disease), endocrine disorders (e.g., DM, thyroid dysfunction), renal conditions (e.g., uremia, nephrotic syndrome), psychiatric conditions (e.g., depression, alcohol use disorder), or rheumatic conditions (e.g., polymyalgia rheumatica). Malnutrition and weight loss may also be related to a deficiency in thiamine, vitamin B12, vitamin C, or zinc (Agarwal, 2023a; Ritchie & Yukawa, 2023).

Diagnosis

Malnutrition diagnostic criteria were proposed in a 2012 joint statement from the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN). The list includes six criteria, two or more of which must be present to establish a diagnosis of malnutrition:

• insufficient energy (caloric) intake
• weight loss
• loss of lean muscle mass
• loss of subcutaneous adipose tissue
• fluid accumulation, either generalized or localized, that may conceal weight loss
• decreased strength, as evidenced by handgrip strength testing (Kesari & Noel, 2023; Ritchie & Yukawa, 2023)

The Global Leadership Initiative on Malnutrition (GLIM) introduced updated criteria in 2018 to develop a global consensus on the identification and diagnostic criteria for malnutrition to facilitate the collection of prevalence, treatment, and outcome data. This diagnosis requires the presence of at least one phenotypic criterion (non-volitional weight loss, low BMI, or reduced muscle mass) and one etiologic criterion (reduced food intake or absorption or underlying inflammation due to chronic or acute disease or injury). These new criteria eliminated the diagnostic criteria related to subcutaneous adipose tissue, fluid accumulation, and decreased strength (Kesari & Noel, 2023; Ritchie & Yukawa, 2023).

Current and recent weight loss should be evaluated as the first step in screening for malnutrition. Weight loss of 2% or more in a month, 5% or more over three months, or 10% over six months is considered clinically significant. The LTC Minimum Data Set (MDS) defines clinically significant weight loss similarly as 5% of body weight over a month or 10% over six months. Numerous screening tools are available to assist in identifying older adults with malnutrition. The Malnutrition Screening Tool (MST) and the Mini Nutritional Assessment - Short Form (MNA-SF) are two of the most sensitive and specific tools. The MST was developed for hospitalized adults but is also validated for use in cancer patients. It is a brief, straightforward tool that asks about unintentional weight loss and whether the patient has been eating poorly due to decreased appetite. In hospitalized adults, the MST's sensitivity ranges from 74%-100% with a specificity of 76%-93% (Kesari & Noel, 2023; Ritchie & Yukawa, 2023).

The MNA-SF was adapted from the original MNA, which was designed by the Nestle Nutrition Institute for older adults in various settings. The full MNA comprised 18 questions targeting diet, a series of body measurements, a global assessment, and a subjective perception of health. The MNA-SF version was condensed to 6 questions. It asks the patient about a decrease in intake, weight loss in the last three months, mobility, psychological stress or acute illness in the previous three months, neuropsychological conditions, and the patient’s BMI. If BMI is unknown, the patient’s calf circumference can be substituted. A total score of at least 12 points is considered normal nutritional status, 8-11 is considered at risk of malnutrition, and 7 or below indicates malnutrition. Alternatives for hospitalized patients include the Nutritional Risk Screening (NRS) 2002 and the Malnutrition Universal Screening Tool (MUST). The SNAQ has been tested in community-dwelling and LTC patients. The Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II) was designed for community-dwelling older adults but contains 17 questions, making it lengthier than other tools. An abbreviated version of the SCREEN II with eight questions is also available (Kesari & Noel, 2023; Nestle Nutrition Institute, n.d.; Ritchie & Yukawa, 2023).

Aside from weight loss over time, body fat and lean muscle mass can be estimated using bioelectrical impedance or anthropometric measures. Bioelectrical impedance can vary with hydration, so a patient’s hydration status should be considered and remain consistent between serial measurements if possible. These devices are also available for bedbound and patients who use wheelchairs. The patient’s mean upper arm or mid-arm circumference is measured at the mid-point between the olecranon process and the acromion on the left arm. A measurement below 22 cm in women or 23 cm in men suggests chronic energy deficiency. A complete history should also include the patient’s appetite report, dietary patterns (number, timing, contents, and size of meals and snacks in an average day), satiety, and recent changes or patterns in any of these factors. This history may be completed through a dietitian consult (Kesari & Noel, 2023; Ritchie & Yukawa, 2023).

Laboratory screening may help identify any metabolic or inflammatory conditions. Basic labs typically include a CBC, a BMP, TSH, and c-reactive protein (CRP). Vitamin B12 and 25-hydroxyvitamin D levels may be required if a deficiency is suspected based on the presence of risk factors (patients with a history of H. pylori infection, those who are institutionalized, homebound, obese, or those with limited sun exposure). Imaging studies, including x-rays of the patient’s chest and abdomen, and advanced imaging studies, such as CT of the patient’s chest, abdomen, and pelvis, are not universally recommended but may be indicated if the patient’s history and physical exam suggest an underlying condition that has not been conclusively identified. While upper endoscopy studies may be indicated for patients with early satiety not otherwise explained, colonoscopy is typically not useful, as colon cancer does not generally present with initial weight loss except in cases of obstruction or extensive metastases (Kesari & Noel, 2023; Ritchie & Yukawa, 2023).

Management

If malnutrition is related to a reversible cause, this condition should be addressed first or alongside any nutritional support. For example, a patient with a vitamin B12 deficiency (or an older adult with low-normal levels) should be encouraged to take a daily B12 supplement and ensure 10-15 mcg of dietary B12 daily. The potential benefits of vitamin D supplementation regarding bone fracture risk reduction and frailty are known. Daily caloric requirements should be determined by consulting a dietitian or applying the estimated energy requirement (EER) formula. This formula uses the patient’s age, height, weight, sex, and physical activity coefficient (PAC) to calculate caloric intake. The PAC is 1.0 for sedentary patients, 1.12 for low-activity individuals, 1.27 for active individuals, and 1.45 for very active patients. Regarding energy expenditure, low activity is equivalent to walking 2 miles/day at a pace of 3-4 miles/hour, while active is defined as 7 miles/day, and very active is equivalent to 17 miles/day (Kesari & Noel, 2023; Ritchie & Yukawa, 2023). Based on these components, the EER formula is as follows:

For females: 354.1 - (6.91 x age in years) + PAC x ([9.36 x weight in kg] + [726 x height in m])

For males: 661.8 - (9.53 x age in years) + PAC x ([15.91 x weight in kg] + [539.6 x height in m])

The National Academy of Medicine, which makes recommendations for the daily intake of macronutrients, suggests 0.80 g/kg of body weight in daily protein intake for adults over 50. Studies indicate that a protein intake higher than this may preserve lean muscle mass and strength and decrease the risk of disability. Like older adults diagnosed with frailty, malnourished older adults should not adhere to dietary restrictions (e.g., low-salt or low-fat), as this may impede intake. This includes a short-term reprieve from carb counting and sugar restrictions for older adults with DM who are nutritionally at risk. Shopping or feeding assistance should be provided if needed. Dietary advice should be tailored to the patient’s taste to encourage intake, including ethnic and cultural preferences. As noted with frail older adults, liquid nutritional supplements provide only a modest (approximately 2%) increase in weight gain across research studies involving older adults, with no improvement in mortality (in community-dwelling adults) or function (across multiple settings). Nutritional supplementation may facilitate some improvement in mortality risk for hospitalized undernourished patients over 75 (Agarwal, 2023; Ritchie & Yukawa, 2023).

One randomized trial of 41 sarcopenic older adults found improvements across multiple outcomes (e.g., lean body mass, grip strength, albumin, MNA score) when given an amino acid supplement. However, this data should be confirmed on a larger scale before being adopted in clinical practice. Vitamin D supplementation with 600-800 IU daily of cholecalciferol (vitamin D3) is recommended for those with a serum 25-hydroxyvitamin D level of 20-30 ng/mL, while higher doses may be required for those with levels under 20 ng/mL. As calcium absorption decreases significantly with age (decreasing by as much as one-third between the ages of 70 and 90), the recommended dietary allowance (RDA) of calcium intake for those over age 50 is 1,200 mg/day. Mineral and vitamin supplementation (i.e., a daily multivitamin with minerals) may aid in managing malnutrition until an underlying cause can be identified. Long-term, using a multivitamin/multimineral supplement may benefit certain high-risk older adults (e.g., those in LTC settings) who are not meeting their micronutrient needs due to poor intake if intake cannot be increased or improved via other means. The patient’s dietary intake should be monitored to avoid exceeding the tolerable upper intake level of these nutrients (Agarwal, 2023; Ritchie & Yukawa, 2023).

Pharmacologic appetite stimulants should be prescribed cautiously to malnourished older patients. Megestrol acetate (Megace) has only been shown to increase weight in patients with anorexia or cachexia related to cancer or AIDS. These patients should be monitored closely for adverse effects, such as edema, worsening congestive heart failure, VTE, adrenal dysfunction, and weakness. Studies indicate an elevated mortality risk among older SNF residents. Dronabinol (Marinol) is a cannabinoid that appears to improve appetite in AIDS patients with cachexia but is less effective than megestrol acetate (Megace) for cancer patients. It has not been well-studied in older adults and may cause significant side effects to the CNS. For patients with coexisting or underlying depression, SSRIs should be avoided, but mirtazapine (Remeron) is an antidepressant that may lead to more weight gain. Ghrelin mimetics are endogenous growth hormone secretagogues that can help stimulate appetite and increase muscle mass in healthy older adults with weight loss and no other underlying conditions. However, additional safety and efficacy studies are needed (Ritchie & Yukawa, 2023).

Regarding overnutrition in older adults, the risks associated with being overweight or obese appear to diminish with older age. Most studies indicate that being overweight does not increase the risk of mortality. Factors such as cardiorespiratory fitness, strength, and abdominal circumference may be more important risk indicators in this age group than BMI alone. Older adults who are obese with sarcopenia have increased risks of mortality, falls, and cognitive impairment. Weight loss may provide other benefits for older adults who are obese, such as reduced disability and improved physical function, improved cholesterol and blood glucose, and enhanced QOL. It can also improve symptoms of pain related to arthritis or fatigue due to obstructive sleep apnea (OSA). If appropriate, weight loss in older adults should be slow, cautious, and achieved through regular exercise and a balanced diet consisting of whole foods—especially fruits and vegetables—instead of caloric restrictions. Supplementation with calcium and vitamin D may also limit the loss of muscle mass and bone mineral density seen in older adults with significant weight loss, even when such weight loss is intentional. A high-protein diet may preserve muscle mass and be especially important for older obese adults with concomitant sarcopenia (Ritchie & Yukawa, 2023).

Delirium

The prevalence of cognitive impairment increases with age, especially after 85. Cognitive impairment in older adults can be difficult to differentiate between dementia and delirium. Most patients with dementia exhibit a steady cognitive decline over months with intact attention and remote memory despite impaired short-term memory, judgment, confusion, and disorientation. In addition, patients with dementia may experience paranoia and hallucinations, although these episodes are rare. By contrast, cognitive impairment associated with attention deficit that develops over hours or days may indicate delirium. Delirium is an acute confusional state characterized by an altered level of consciousness with a reduced ability to focus, sustain, or shift attention, resulting in cognitive and perceptual disturbances not associated with pre-existing dementia. A key feature that defines delirium is the high likelihood that the acute cognitive change is related to a medical condition, medication, substance use, or withdrawal. It typically persists for days but may last for months (termed persistent) if the underlying cause is not correctly identified and treated quickly; symptoms often worsen throughout the day, peaking in the evening. For older patients who are acutely ill, cognitive and behavioral changes may be the only obvious symptom of their underlying illness. Psychomotor disturbances (e.g., hypoactivity or hyperactivity), sleep disturbances, emotional disturbances, hallucinations, and delusions often accompany delirium (Francis, 2019; Francis & Young, 2022).

Delirium can occur at any age but is most common after 70. An estimated 10% of older adults are admitted to the hospital with delirium, and an additional 15% to 50% will experience delirium at some point during hospitalization. Delirium is a common postoperative complication among older adults. Research estimates that 10% to 20% of older adults undergoing major elective surgery and 50% undergoing high-risk procedures will experience delirium postoperatively due to various factors, including anesthesia and pain medications. Postoperative delirium can increase a patient's hospital length of stay (LOS) by 2 to 3 days and is associated with a 7% to 10% increase in 30-day mortality. Since delirium can occur during any illness or surgery, it can be challenging for HCPs to recognize and manage it effectively, leading to complications and poor outcomes. Healthcare costs attributable to delirium are estimated to be $164 billion annually. The clinical presentation of delirium can vary significantly, with three identified subclasses: hyperactive, hypoactive, and mixed motor. Patients with hyperactive delirium will have more spontaneous movements that are purposeless, uncontrollable, and inefficient. These patients may appear agitated, restless, and anxious and are more likely to exhibit psychotic features (i.e., hallucinations) that interfere with the delivery of care, including attempting to remove external devices (e.g., drains, intravenous [IV] lines, face masks). In contrast, patients with hypoactive delirium will have slowed mentation, withdrawn attitude, lethargy, and decreased movements. The mixed motor subtype of delirium is characterized by fluctuations between hypoactive and hyperactive states (Ali & Cascella, 2022; Huang, 2023).

Delirium is a clinical manifestation of stress that impacts the CNS function in a vulnerable patient. There are numerous potential pathophysiological causes of delirium, with each patient likely experiencing one or more interconnected and complex processes. Risk factors for developing delirium can be categorized into predisposing factors (i.e., present before admission to the hospital) and precipitating factors (i.e., acquired in the hospital related to the environment or treatment). Those with underlying brain disorders (e.g., dementia, Parkinson’s disease, or stroke) have an increased risk of delirium. Other predisposing risk factors include male gender, vision and hearing impairment, frailty, terminal illness, alcohol and substance use disorder (SUD), current tobacco use, and multimorbidity (e.g., cardiac disease, HTN, respiratory disease). Precipitating factors can include infection, malnutrition, injury, surgery, and other treatments. Medications can be a significant precipitating factor, and older adults are particularly vulnerable to the effects of these medications and the risk of delirium (Ali & Cascella, 2022; Francis, 2019; Francis & Young, 2022; Huang, 2023). Medications that are more likely to cause delirium include:

• new medications or three or more medications
• recent or prolonged exposure to anesthesia
• anticholinergics (e.g., diphenhydramine [Benadryl], benztropine [Cogentin], scopolamine [Maldemar], atropine)
• opioids
• NSAIDs
• benzodiazepines (e.g., midazolam [Versed], lorazepam [Ativan])
• non-BZRA or Z-drugs (e.g., zolpidem [Ambien], zaleplon [Sonata], and eszopiclone [Lunesta])
• neuromuscular blockades
• dopamine agonists (e.g., amantadine [Symmetrel], levodopa, pramipexole [Mirapex])
• hypoglycemics
• skeletal muscle relaxants (e.g., cyclobenzaprine [Flexeril], baclofen [Lioresal])
• gastrointestinal agents (e.g., antiemetics, antispasmodics, histamine 2 receptor blockers, loperamide [Imodium])
• antihistamines (promethazine [Phenergan])
• antibiotics (e.g., aminoglycosides, cephalosporins, fluoroquinolones, linezolid [Zyvox], macrolides, penicillins, sulfonamides, cycloserine [Seromycin], isoniazid [Nydrazid], metronidazole [Flagyl], rifampin [Rifadin])
• antivirals (e.g., acyclovir [Zovirax])
• AEDs (e.g., carbamazepine [Tegretol], levetiracetam [Keppra], phenytoin [Dilantin], valproate [Depakote], vigabatrin [Vigadrone])
• antidepressants (e.g., mirtazapine [Remeron], SSRIs, TCAs)
• antipsychotics
• cardiovascular and hypertensive drugs (e.g., antiarrhythmics, beta-blockers, clonidine [Catapres], digoxin [Lanoxin], diuretics, methyldopa [Aldomet])
• corticosteroids (Ali & Cascella, 2022; Francis, 2019; Francis & Young, 2022; Huang, 2023)

Delirium symptoms may persist for up to a year, especially in those with underlying dementia. Early recognition of delirium is critical because early resolution of symptoms is associated with favorable outcomes. The mortality rate among patients with delirium is roughly twice that of patients without delirium in the 6 to 12 months following their illness. In a long-term study, only one-third of patients with delirium lived independently two years after their diagnosis (Ali & Cascella, 2022; Francis, 2019; Francis & Young, 2022; Huang, 2023).

Diagnosis

Brief screening tools have been developed to help identify potential cases of delirium with high sensitivity and specificity, such as the Confusion Assessment Method (CAM), the 3-Minute Diagnostic Assessment (3D-CAM), the 4 As Test, and the Family CAM. The CAM or the CAM-ICU can assist in identifying delirium in about 5 minutes. The CAM tool has been used widely across medical and surgical settings and is reliable and valid, with a sensitivity of 94% to 100% and a specificity of 90% to 95%. The CAM-ICU was adapted from the CAM assessment and has been validated, with a sensitivity of 47% to 100% and a specificity of 81% to 100%. The CAM-ICU tool allows HCPs to consider observed behaviors and nonverbal responses to simple questions, as well as auditory and visual recognition tasks for mechanically ventilated patients. Table 6 depicts the CAM-ICU diagnosis tool with the features of delirium and associated assessment. Confirmation of a delirium diagnosis requires the presence of features 1 and 2, plus either feature 3 or 4 (Francis & Young, 2022; Ramirez Echeverria et al., 2022).

Table 6

CAM-ICU Diagnosis Tool for Delirium

(Francis & Young, 2022; Ramirez Echeverria et al., 2022)

The ICDSC is another delirium screening tool frequently used in the ICU. Researchers have found that the CAM-ICU and the ICDSC have high agreement rates. The ICDSC can be administered in 2 to 5 minutes and has a sensitivity of 64% to 99% and a specificity of 61% to 88%. Like the CAM-ICU, the ICDSC has two steps. HCPs must first assess a patient's level of consciousness based on a 5-point scale, ranging from A (unresponsive) to E (exaggerated response). No further delirium assessment should be performed for patients who score an A or B. Further assessment is recommended for patients who score C to E. The HCP should evaluate if seven identified symptoms were present in the last 24 hours, leading to a score of 0 to 8. A score of 4 to 8 is considered diagnostic of delirium. Table 7 depicts the ICDSC criteria for delirium screening (Ali & Cascella, 2022; Poulsen et al., 2021).

Table 7

The Intensive Care Delirium Screening Checklist

(Ali & Cascella, 2022; Girard et al., 2008)

The 3D-CAM contains three orientation items, four attention items, three symptom probes, and ten observational items with a sensitivity of 95% and a specificity of 94%. The 4 As Test is brief, but its sensitivity and specificity are lower (84% to 89%) than the other tests described. If not already included in the above screening, the patient’s attention can be assessed with the mini-mental state exam (MMSE), serial 7s (repeatedly adding by a factor of 7), the backward spelling of the word “world,” digit span (asking a patient to repeat a series of random digits from memory), or the vigilance “a” test (reading a list of random letters, asking the patient to indicate every time they hear the letter “a” listed). They may also be asked to recite the months of the year or the days of the week backward. Routine use of the modified Richmond Agitation and Sedation Scale (mRASS) for screening purposes in patients with suspected delirium outside of the postoperative recovery room and ICU is not recommended (Francis & Young, 2022; Huang, 2023).

The Diagnostic and Statistical Manual of Mental Disorders 5^th edition Text Revision (DSM-5-TR) criteria are considered the gold standard for diagnosing delirium (APA, 2022). These criteria include the following:

1. a severe change in mental abilities, leading to a lack of focus and situational recognition of their environment
2. these symptoms are radically different from the patient's healthy state and occur quickly (hours or days) with a waxing and waning of symptoms over the day
3. additional mental alterations are also present, including:
   1. confusion regarding where they are or why, the time/day/year
   2. inability to understand the spatial relationship between objects
   3. speech deficits
   4. inability to interpret information
   5. forgetfulness
4. the changes described above cannot be attributed to another neurological disorder and are not associated with a decreased level of consciousness
5. clinical evidence indicates that the changes are due to substance use or cessation of prolonged use, a medical condition, a toxin, or a combination of these (APA, 2022)

The assessment should account for the patient’s baseline level of functioning if known. Caregivers and family members can help establish this baseline if prior cognitive testing results are not immediately available. A recent history of illness, a new medication, or SUD should be established. A physical exam, including a neurological exam, should be performed to determine the underlying condition. The most common conditions that contribute to delirium include metabolic encephalopathy related to fluid and electrolyte disturbances, infection, organ failure, hypoglycemia, drug toxicity (which may occur even with “therapeutic” levels of drugs such as digoxin [Lanoxin] or lithium [Lithobid]), or withdrawal from alcohol or sedatives. Targeted laboratory testing will facilitate the identification of any underlying conditions, which may include a BMP, CBC, urinalysis/urine culture, toxicology screen, drug levels of narrow therapeutic range medications (e.g., digoxin [Lanoxin], lithium [Lithobid]), arterial blood gas panel, liver function testing, thyroid-stimulating hormone (TSH), and a vitamin B12 level. If an obvious cause is still not identified, advanced brain imaging may be indicated via CT or electroencephalogram (EEG). Differential diagnoses to consider for a patient with suspected delirium include dementia with sundowning, stroke, traumatic brain injury (TBI), Wernicke aphasia, bitemporal dysfunction, Anton syndrome of cortical blindness and confabulation, bifrontal brain lesion (e.g., due to tumor or trauma), nonconvulsive status epilepticus, and primary psychiatric illnesses such as depression, bipolar depression with mania, or schizophrenia. Older patients who contract meningitis may present with delirium, as opposed to the classic triad of fever, headache, and meningismus (a state of meningeal irritation causing neck stiffness or hypersensitivity to light), requiring a lumbar puncture for confirmation. Differentials that should be ruled out or considered include other mental health conditions (e.g., psychotic disorders or mood disorders with psychotic features), acute stress disorder, malingering and factitious disorder, and dementia or a similar neurocognitive disorder (APA, 2022; Francis, 2019; Francis & Young, 2022).

Prevention

The 2023 BC recommends avoiding certain high-risk medications for older patients based on moderate-quality evidence regarding delirium risk. These medications are listed above, and HCPs should thoroughly review the medications a patient takes, considering the type and number of medications being taken (AGS Beers Criteria Update Expert Panel, 2023). Orientation protocols, which provide access to outside windows, clocks, calendars, and as-needed verbal reorientation, may help prevent delirium in institutionalized older adults, especially immediately after transitions between settings and unfamiliar locations. Cognitive stimulation may help, especially for patients with underlying dementia, but sensory overstimulation should be avoided. Cognitive stimulation can be achieved through simple reminiscence or engaging conversation. Uninterrupted sleep during nighttime is crucial, ideally in a quiet, dark environment, to facilitate restorative sleep. Acutely ill patients appear to benefit from early mobilization with PT and OT consultation for safety. Patients with hearing or vision impairment should receive aids or devices to facilitate accurate sensation and processing. Pain, dehydration, hypoxemia, and infection are common contributors to delirium and should be avoided or managed appropriately in older adults. Combining three or more of the above interventions into a multi-component program is most effective in preventing delirium, especially for non-ICU hospitalized patients. Unfortunately, these programs may be less effective for patients in LTC facilities and those with cancer or terminal illness. The evidence does not support the routine use of pharmacological agents to prevent delirium. Cholinesterase inhibitors (e.g., rivastigmine [Exelon], donepezil [Aricept]) have been proposed as a means to prevent delirium in high-risk patients (i.e., older adults with or without dementia, postoperative patients, or poststroke patients; Francis, 2019).

Management

Once identified, any underlying medical condition should be appropriately treated. In cases of sedative or alcohol withdrawal, benzodiazepines such as lorazepam (Ativan) can be dosed at 0.5-1 mg as needed and tapered over several days to avoid severe withdrawal, delirium tremens, and seizures. Otherwise, medical care for older adults with delirium should be interdisciplinary and focus on sustaining hydration, optimizing nutrition, and maintaining mobility and range of motion (Francis, 2019).

The prevention measures listed above to promote reorientation, sleep, cognitive stimulation, and vision or hearing deficit correction should also be instituted as nonpharmacological treatment. Any incontinence or pain should be managed as in other older patients, with care to avoid opioids if possible and meperidine [Demerol] especially. Nonopioid medications such as acetaminophen (Tylenol) are preferred, and pre-emptive pain management may be beneficial. A nerve block is an example of a pain-management technique frequently used postoperatively; it may reduce the incidence of delirium and help manage pain effectively in patients immediately following surgery. Long-acting opioids such as methadone (Dolophine) may also provide some benefit versus shorter-acting agents. The risk of skin breakdown and pressure injuries or aspiration pneumonitis should be assessed and minimized. This care may need to continue for months and extend beyond the acute hospital environment. Patients with delirium with disruptive or agitated behavior may respond to frequent reassurance, verbal orientation, and physical touch, especially when provided by family members or familiar persons. If present, delusions and hallucinations should not be confirmed but also not denied. Physical restraints should be a last resort for these patients, as they increase agitation and delirium duration, reduce mobility, and increase the risk of pressure injuries and aspiration. Vigilant supervision may be more effective if available (Francis, 2019).

Healthy sleep patterns should be encouraged, as described above, and melatonin supplementation or adding 8 mg of oral ramelteon (Rozerem) at bedtime if needed. Ramelteon (Rozerem) works as a melatonin receptor agonist, activating melatonin receptors in the brain. Additional sleep hygiene strategies can be found in the forthcoming Insomnia section of this course. Ethically, the healthcare team must provide care with implied consent in life-threatening situations only. In all other instances, the patient’s ability to make decisions and consent to medical care should be consistently and carefully documented. If a patient cannot consent to care, informed consent should be obtained from a surrogate decision-maker (Francis, 2019; Neubauer, 2023).

Scales to assess the severity of delirium have been developed with some success, such as the CAM-Severity score (CAM-S), the Delirium Rating Scale ­– Revised-98 (DRS-R-98), or the Memorial Delirium Assessment Scale. These scales can help establish prognosis, stratify risk, and assess response to treatment. For severe cases of agitation with a threat of self-harm, antipsychotics may be used off-label, as they are not indicated for the management of delirium. Haloperidol (Haldol) may be given in 0.5-1 mg doses as needed (oral, intramuscular, or intravenous [IV]), up to a maximum of 5 mg daily. It should not be dosed continuously or prophylactically but only in the short term. Less substantial evidence and experience support the use of newer antipsychotics, such as quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon), and olanzapine (Zyprexa). However, these agents have fewer side effects when studied in other settings and have shown similar efficacy in small studies. Doses should be kept low to avoid extrapyramidal symptoms, especially with haloperidol (Haldol). These medications may increase a patient’s mortality and stroke risk, and intravenous (IV) haloperidol (Haldol) is also associated with QT prolongation, which should be closely monitored (Alagiakrishnan, 2019; Francis, 2019). A 2016 systematic review conducted by Neufeld and colleagues evaluated the use of antipsychotics across 19 studies. Researchers concluded that the evidence does not currently support antipsychotic use for preventing or treating delirium in hospitalized older adults due to a lack of significant impact on delirium incidence, duration, or severity. However, they found no association with mortality (Neufeld et al., 2016). Oh and colleagues (2019) conducted a similar systematic review and found that the research does not support the use of antipsychotics for preventing delirium. However, they did conclude that there is limited evidence to support second-generation antipsychotics in reducing the incidence of delirium in postoperative patients. More research is still needed on this topic. In most cases, the management of delirium with benzodiazepines is not recommended. An older adult with severe delirium near the end of their life (often termed terminal or preterminal delirium) may benefit from palliative sedation with a short-acting benzodiazepine that can be titrated to effect, such as midazolam (Nayzilam). The use of methadone (Dolophine) for those with refractory pain and terminal delirium may be effective (Alagiakrishnan, 2019; Francis, 2019).

Insomnia

Insomnia is the repeated difficulty with sleep initiation, maintenance, consolidation, or quality that occurs despite adequate opportunity and time for sleep, resulting in daytime impairment. The diagnostic criteria for insomnia include taking longer than 30 minutes to fall asleep (i.e., sleep latency), staying asleep for less than 6 hours, waking more than three times a night, or experiencing poor-quality sleep. Insomnia results from an interaction of physical, biological, psychological, and environmental factors. Transient insomnia can occur in anyone, but chronic insomnia only develops in a subset of people, usually those with an underlying predisposition. Insomnia affects between one-third and two-thirds of American adults, with 10%-15% indicating their insomnia is chronic and associated with daytime consequences. Although insomnia has a high prevalence, only about 5% of patients with chronic insomnia discuss their concerns with a provider. Insomnia can contribute to impaired daytime performance, increase the risk of comorbidities, and decrease QOL. It is more common among women (peri- and post-menopausal) and older adults and persists longer in these individuals. It is estimated that the prevalence of chronic insomnia increases from 25% in adults to 50% in older adults. Other environmental risk factors include unemployment, being single due to divorce/separation or the death of a spouse, and lower socioeconomic status. Having a pre-existing psychiatric disorder also increases a patient’s risk, as approximately one-half of patients with chronic insomnia have a mood disorder, SUD, or posttraumatic stress disorder (PTSD). Other sleep disorders—including OSA, restless leg syndrome (RLS), and circadian sleep-wake rhythm disorders—often co-occur with insomnia. Medical conditions such as pulmonary disease, HTN, DM, cancer, chronic pain, and heart failure are also associated with insomnia. Insomnia frequently accompanies neurodegenerative conditions such as Parkinson’s disease and dementia. Certain medications can contribute to insomnia, especially stimulants, hypnotics or other sedatives (i.e., benzodiazepines), antimetabolite chemotherapy, AEDs, respiratory stimulants (i.e., theophylline [Elixophyllin]), appetite stimulants, antidepressants, beta-blockers, and corticosteroids. OTC medications such as cold medicine and nasal decongestants can also cause insomnia. The use of alcohol or tobacco or the ingestion of caffeine also correlates with insomnia in adults (Bonnet & Arand, 2023a, 2023b; Chawla, 2022b; Shwab, 2022).

Diagnosis

Given insomnia’s prevalence, screening by HCPs should be integral to the patient’s preventative care and wellness plan. Patients with chronic insomnia seldom present with sleep difficulty as their primary concern. Screening can occur easily and informally with a straightforward inquiry regarding the patient's recent sleep habits. Short-term insomnia occurs for less than 3 months and is typically associated with a particular medical or psychosocial stressor. Treatment for short-term insomnia is usually not necessary, as symptoms typically resolve when the stressor is eliminated. Chronic insomnia lasts longer than 3 months and occurs at least three times a week. These patients report difficulty falling (sleep-onset insomnia) or staying asleep (sleep-maintenance insomnia) despite adequate opportunity and circumstances for sleep; the sleeplessness must also be associated with daytime functional impairment, including fatigue, inattentiveness, mood disturbances, lack of motivation, increased rate of errors, behavioral disturbances, and increased worry regarding sleep. The patient's anxiety regarding the consequences of lost sleep tends to increase as bedtime approaches. This anxiety lengthens the period of attempting to fall asleep, creating a cycle of worry and poor sleep. Symptoms usually wax and wane, with reports of a good night followed by a couple of bad nights of sleep. Patients with chronic insomnia typically report taking longer than 30 minutes to fall asleep at night (a healthy average is 10-20 minutes for an adult) and spending more than 30 minutes awake during the night. Early morning awakening in chronic insomnia is defined as waking up more than 30 minutes before the desired time (Bonnet & Arand, 2023a; Chawla, 2023a; Reynolds & Cone, 2018).

Chronic insomnia should be differentiated from delayed sleep-wake phase disorder (DSWPD), which is a significant circadian sleep-wake rhythm disorder that is most prominent in adolescence. These patients similarly report difficulty falling asleep at traditional times and struggle to wake in the morning at an appointed time. In contrast, patients with DSWPD find that they can sleep well when they are on vacation or allowed to sleep based on their desired timeline (e.g., going to bed late on the weekends). Older adults are prone to advanced sleep-wake phase disorder (ASWPD), in which their circadian rhythm is shifted earlier. They tend to fall asleep early (1900) and wake early (0300). Similarly, ASWPD can be differentiated from chronic insomnia by asking the patient about their ability to fall asleep if they go to bed when they are tired (e.g., in the early evening). Those with ASWPD typically report no difficulty falling asleep at an earlier time. In contrast to patients with DSWPD and ASWPD, chronic insomnia patients report difficulty sleeping regardless of timing. Chronic insomnia should also be carefully distinguished from short sleep duration, which is a genetic predisposition to a decreased sleep requirement for adequate functioning, and chronic sleep insufficiency, which is a volitional sleep restriction or lack of ample opportunity to sleep (Bonnet & Arand, 2023a).

The diagnosis of insomnia is made clinically based on the patient's report of symptoms and history. The history should include a sleep, medical, psychiatric, and medication history. The 2008 American Academy of Sleep Medicine (AASM) guidelines state that, at a minimum, patients should complete a general medical and psychiatric questionnaire to detect co-morbid conditions, a sleepiness assessment (Epworth Sleepiness Scale), and a 2-week sleep log to define sleep-wake patterns and variability (Schutte-Rodin et al., 2008). The sleep history should entail how long the problem has persisted, how often symptoms occur, the number of awakenings, the length of awakening, the bedtime, duration until sleep onset, awakening time, nap times and length, sleep environment, and any associated daytime symptoms. A validated questionnaire such as the Pittsburgh Sleep Quality Index or the Sleep Problems Questionnaire may be the most reliable method for obtaining this history, as these provide a score that can indicate significant sleep disturbance. The Epworth Sleepiness Scale can also be used to assess the severity of sleepiness. Most patients with chronic insomnia will exaggerate the amount of time it takes them to fall asleep and underestimate their total sleep time when compared to objective measures such as polysomnography (PSG) or actigraphy (Bonnet & Arand, 2023a; Chawla, 2022a; Reynolds & Cone, 2018). Despite this phenomenon, the patient’s perception of their sleep disturbance is the primary diagnostic indicator used in clinical practice. A sleep diary may help track symptoms with greater accuracy, as events are reported in real-time and are less prone to reporting errors from the patient. A sleep diary may be especially helpful for patients with highly variable sleep patterns or those who cannot give an accurate history. Sleep diaries may also aid in tracking symptom changes to assess treatment plan effectiveness. The Consensus Sleep Diary is a 21-item validated sleep log that should be completed within an hour of awakening (items 1-10) and right before bed (items 11-15). Substances (e.g., caffeine, alcohol), medications, and medical conditions that may be contributing to the patient’s sleep dysfunction should be identified via a complete history and physical and optimized if needed. Contributing factors may include:

• psychiatric conditions (e.g., depression/anxiety, PTSD, SUD)
• pulmonary conditions (e.g., COPD, asthma)
• rheumatologic conditions (e.g., arthritis, fibromyalgia/chronic fatigue syndrome, chronic pain)
• cardiovascular conditions (e.g., heart failure, ischemic heart disease, nocturnal angina, HTN)
• neurological conditions (e.g., Alzheimer’s disease, dementia, Parkinson’s disease, peripheral neuropathy, stroke, brain tumor, TBI, headache syndromes, narcolepsy, and fatal familial insomnia)
• other sleep disorders (e.g., RLS, periodic limb movement disorder, OSA, DSWPD, ASWPD, jet lag, shift work disorder, non-24-hour sleep-wake rhythm disorder, irregular sleep-wake rhythm disorder)
• other medical conditions (e.g., hyperthyroidism, nocturia, gastroesophageal reflux, DM, cancer, pregnancy, menopause, Lyme disease, HIV infection, pruritis)
• medications known to cause sleep disturbance (e.g., stimulants, CNS depressants, bronchodilators, antidepressants, beta-antagonists, diuretics, corticosteroids; Bonnet & Arand, 2023a)

A set of diagnostic criteria for chronic insomnia called the International Classification of Sleep Disorders – Third Edition (ICSD-3-TR) was last revised in 2023 and is summarized in Table 8 (AASM, 2023; Bonnet & Arand, 2023a).

Table 8

ICSD-3-TR Diagnostic Criteria for Chronic Insomnia Disorder*

*A through F are required for this diagnosis

(AASM, 2023; Bonnet & Arand, 2023a, Table 1)

Similarly, the DSM-5-TR lists the following diagnostic criteria for insomnia disorder:

• a consistent report of poor sleep, either related to reduced quality or an inadequate amount, occurring three or more nights each week for 12 or more weeks
• this is accompanied by reports of difficulty falling or staying asleep (which may include waking up in the middle of the night or trouble going back to sleep) or waking too early
• in pediatric patients, this may present as requiring assistance from a caregiver
• the symptoms must cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise
• the symptoms are not directly related to the use of a substance, medication, or pre-existing medical diagnosis or health concern
• this lack of sleep is not related to a lack of sufficient time allotted for sleep
• the symptoms are not due to a more appropriate sleep-wake disorder, such as parasomnia, sleep apnea, circadian rhythm disorder, or narcolepsy
• a concurrent psychiatric or medical diagnosis does not sufficiently account for the symptoms
• the disorder may be specified as episodic (consistent symptoms for a month), persistent (consistent symptoms for at least three months), or recurrent (more than a single episode within 12 months)
• the disorder may be specified as occurring with a mental disorder, medical condition, or another sleep disorder (APA, 2022)

Patients with symptoms lasting for less than the required three months described above but satisfying all other listed characteristics may be given the diagnosis of other specified insomnia disorder, acute and short-term (APA, 2022). Due to a high correlation with anxiety and depression, patients with insomnia may benefit from screening for these conditions using a validated tool such as the Patient Health Questionnaire – 2 (PHQ-2), PHQ-9, the generalized anxiety disorder 7-item scale (GAD-7), or the State-Trait Anxiety Inventory. The only laboratory or diagnostic testing necessary for patients being evaluated for insomnia is confirmation of any contributing medical condition(s). Patients with persistent treatment-resistant insomnia or signs and symptoms of other sleep or neurological disorders, such as severe daytime sleepiness indicative of narcolepsy or circadian rhythm sleep-wake disorders, should be referred to a sleep medicine specialist for additional evaluation. A PSG is only indicated clinically for patients with other suspected sleep disorders, such as OSA. The multiple sleep latency test (MSLT) is indicated for suspected narcolepsy, as evidenced by extreme daytime sleepiness, which is not common in chronic insomnia. Actigraphy is only indicated for those with a suspected sleep-wake rhythm disorder; it uses a noninvasive wristwatch-style accelerometer to track sleep and motor activity over several days. The ability to track treatment effectiveness is crucial for chronic insomnia, and this may be done using a sleep diary or a validated tool such as the Insomnia Severity Index (ISI) score (Bonnet & Arand, 2023a; Chawla, 2023c).

Management

All contributing conditions and medications should be addressed in order to manage chronic insomnia successfully. For episodic insomnia, patient education and reassurance are typically adequate. Basic sleep hygiene principles should be explained to all patients with insomnia, such as establishing a consistent bedtime routine, avoiding substances (e.g., caffeine after lunch or alcohol and nicotine before bed) or activities (e.g., vigorous exercise within 2 to 3 hours of sleep) that interfere with sleep, avoiding daytime sleeping (e.g., no naps, especially longer than 1 hour and later in the day), and optimizing the sleep environment (e.g., temperature, darkness, limitation of ambient noise). A stable bedtime and wake time should be followed throughout the week, with little to no variation on weekends and weekdays. The sleep environment should be kept quiet, dark, and cool. A white noise machine or earplugs can reduce ambient noise, while blackout curtains or an eye mask can minimize ambient light overnight. Using technological devices (tablets, smartphones, TV) before bed may impact circadian rhythms and shift sleep timing later. Checking the time repeatedly while trying to fall asleep is counterproductive, increasing cognitive arousal and prolonging wakefulness, and should be avoided. Some patients remove their bedside alarm clocks for this reason. Large meals or rich, heavy foods should be avoided right before bed, but an evening meal should be eaten to prevent hunger. Regular physical activity can facilitate sleep, especially if performed 4-6 hours before bedtime (Reynolds & Cone, 2018; Winkelman, 2023). A recent RCT involving 320 older adults found a statistically significant improvement in sleep efficiency, wake time after sleep onset, and the number of awakenings in both the traditional exercise (brisk walking combined with strengthening exercises) and tai chi treatment arms of the study compared to the control group. Both intervention groups completed three hour-long exercise or tai chi sessions per week throughout the 12-week study. These improvements were maintained through the study’s 24-month follow-up (Siu et al., 2021).

For older adults with chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I) is considered the first-line treatment prior to pharmacological interventions. This multi-component approach targets common behaviors and thoughts that interfere with sleep and can be easily taught to patients by nonpsychiatric clinicians familiar with the components. Alternatively, CBT-I may be delivered face-to-face in individual or group settings over 4-8 sessions. In addition to the sleep hygiene principles described above, sleep restriction is another common component of CBT-I, in which the time spent in bed is limited to the approximate time of desired sleep (e.g., 8 hours in bed). This time should be individualized based on the patient’s 2-week sleep diary. The time spent asleep should be added to half of the time spent awake in bed, yielding the new prescribed sleep restriction. This time should never be below 5 hours. Once the patient sleeps for at least 80% of the prescribed time for 7 consecutive days, the prescription should be increased by 20 minutes for the following week. An example of this calculation is as follows:

A patient reports sleeping 3 hours a night on average over the last 2 weeks in their sleep diary. They report an average rest (awake) time in bed of 7 hours.

Their prescribed sleep restriction time would be 3 + (7 x ½) = 6.5 hours.

CBT-I also includes avoiding other activities in bed (e.g., reading, watching TV) other than sleeping and sex. Patients are encouraged to go to bed when they feel most sleepy and to get out of bed if they start feeling anxious while lying awake. If anxious and unable to sleep, the patient should leave the room for approximately 10-15 minutes and return to bed when they feel sleepy again. A scheduled wake time should be adhered to consistently, regardless of the amount of sleep achieved. This concept, called stimulus control, is designed to repair the cognitive association between the patient’s bed, bedtime, and sleep. The cognitive components of CBT-I typically focus on anxious thoughts associated with sleep quality and quantity, realistic sleep quantity expectations, accurate attribution of daytime dysfunction and symptoms, and relaxation techniques (e.g., progressive muscle relaxation, diaphragmatic breathing, meditation). The relaxation techniques decrease sympathetic stimulation and physical arousal at bedtime and strive to facilitate calmness and awareness by reconnecting the mind and body. Common misconceptions that should be addressed for patients with chronic insomnia include the belief that (a) sleep must occur for 8 hours uninterrupted to be sufficient, (b) sleep initiation should occur within 10 minutes, and (c) initial tiredness upon awakening indicates poor sleep quality. This cognitive retraining typically takes the most time and may require a referral to a psychiatric provider or sleep center (Reynolds & Cone, 2018; Winkelman, 2023). A recent study by McCurry and colleagues found that CBT-I delivered via telephone was effective. This RCT was completed in Washington State and involved 282 participants 60 years of age and above with chronic osteoarthritis pain. The researchers found that over half (56%) of the study participants remained in remission (as evidenced by an ISI score of < 8) at 1 year (McCurry et al., 2021). For most patients, nonpharmacological treatments should be given for 6 weeks to improve insomnia symptoms before escalating treatment to include a pharmacologic component (Reynolds & Cone, 2018).

Many OTC sleep aids are available in the US. OTC antihistamines, which are often used by younger adults for short-term insomnia and even occasionally for chronic symptoms, typically have significant anticholinergic effects, leading to confusion, constipation, urinary retention, sedation, blurry vision, and other side effects in older adults. Dietary supplements like exogenous melatonin are not regulated in the US, making the use of these products less reliable. Melatonin is available as immediate- or extended-release pills, dissolvable tablets, transdermal patches, and liquids and should be dosed a few hours before bedtime for the appropriate effect. It functions as an agonist at melatonin receptor sites, decreasing evening arousal of the suprachiasmatic nucleus, and is typically dosed at 1-5 mg. The most commonly reported side effects include vivid dreams or nightmares, dizziness, daytime sleepiness, headaches, stomach cramps, and mood symptoms (depressed or irritable mood), but it is generally considered safe. Evidence for melatonin’s effectiveness in treating sleep-onset insomnia (extended sleep latency or difficulty falling asleep, with or without nighttime or early awakenings) is weak. A 2020 systematic review indicated a small but statistically significant improvement in sleep latency and total sleep time with melatonin use. The study was inconclusive regarding whether these effects were clinically significant. There is no evidence that melatonin is effective in maintaining sleep later in the night or early morning (Reynolds & Cone, 2018; Neubauer, 2023). Research indicates that the production of melatonin typically decreases with age, which may account for the increased prevalence of insomnia in older adults. For this reason alone, some primary care practices (and the American Academy of Family Physicians [AAFP]) recommend a trial of melatonin or a melatonin agonist, which will be discussed later (Matheson & Hainer, 2017). The AASM does not recommend diphenhydramine (Benadryl) and melatonin for the treatment of chronic insomnia in adults based on weak evidence. Valerian and L-tryptophan—other OTC products that are often marketed for sleep—are also not recommended by the AASM for the treatment of chronic insomnia in adults based on weak evidence. Specifically, all four products have shown no efficacy in reaching clinical significance. While most of these options appear to carry roughly equivalent harms and benefits, the potential harms of L-tryptophan outweighed the benefits (Sateia et al., 2017).

For those with severe distress and dysfunction related to their insomnia, the short-term use of medication may be indicated alongside CBT-I (Winkelman, 2023). The AASM published a clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults in 2017. Eszopiclone (Lunesta), zolpidem (Ambien), and temazepam (Restoril) are recommended by the AASM for the treatment of insomnia in adults with both sleep-onset and maintenance symptoms. They recommended zaleplon (Sonata) and triazolam (Halcion) for the treatment of insomnia in adults with sleep-onset symptoms (Sateia et al., 2017). Unfortunately, most sleep-inducing medications exacerbate existing age-related impairments (e.g., gait instability, urinary dysfunction, sedation, cognitive dysfunction) and may be inappropriate for older adults. Additionally, older adults may have altered drug metabolism, increasing serum concentrations of these medications during the day (Winkelman, 2023). Older adults have an increased risk of experiencing adverse drug reactions such as delirium and falls due to sleep medications. Benzodiazepines (e.g., estazolam [ProSom], flurazepam [Dalmane], temazepam [Restoril], triazolam [Halcion], and quazepam [Doral]) and the newer non-BZRAs (e.g., eszopiclone [Lunesta], zaleplon [Sonata], and zolpidem [Ambien]) are all considered potentially inappropriate and included in the most recent and prior versions of the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. This is due to the risk of impaired cognition, delirium, falls, or motor vehicle accidents. Non-BZRAs may be used with extreme caution in carefully selected older adults, and dosing should be based on the prescribing information for older adults (typically the lowest available dose). Zolpidem (Ambien) also specifies in its prescribing info that it should be tapered at a rate of 25% every 1-2 weeks when discontinued to avoid withdrawal symptoms (Neubauer, 2023). A 2016 review of the efficacy and safety of medications used for sleep in older adults concluded that using non-BZRAs should be limited based on the current evidence. Non-BZRAs can cause cognitive deficits and serious injury (e.g., fracture) despite their improved side effect profile when compared to traditional benzodiazepines (Schroeck et al., 2016). Antidepressants that are used off-label for insomnia in younger adults (e.g., trazodone [Desyrel]) may have unintended hypotensive effects in older adults and should be considered with extreme caution (Neubauer, 2023). In addition, trazodone (Desyrel) is not recommended by the AASM for the treatment of chronic insomnia in adults based on weak evidence (Sateia et al., 2017).

Dual orexin receptor antagonists (DORAs; e.g., lemborexant [DayVigo] and suvorexant [Belsomra]) reduce the wake drive to facilitate sleep and are categorized as schedule IV controlled substances (very low abuse potential). Both drugs are contraindicated in patients with narcolepsy. They have been tested for older adults with cognitive impairment, and suvorexant (Belsomra) has been approved for patients with mild to moderate Alzheimer’s disease. These medications are typically considered first-line treatment for older adults with persistent chronic insomnia despite CBT-I or are used short-term while CBT-I is being initiated. The patient should have at least 7 hours available for sleep after taking a DORA. Lemborexant [DayVigo] should be dosed at 5 mg immediately before bed, while suvorexant (Belsomra) should be dosed at 10-15 mg within 30 minutes of bedtime for older adults. A recent meal may delay their onset of action. They typically display similar potency to non-BZRAs, especially for patients with sleep-maintenance symptoms. Their use should also be avoided in patients with severe hepatic impairment or those taking moderate or strong inhibitors of CYP3A4 (e.g., clarithromycin [Biaxin], ketoconazole [Nizoral], voriconazole [Vfend], indinavir [Crixivan], darunavir [Prezista]). The primary side effect of concern is next-day sleepiness due to a longer half-life, and higher costs may be a limitation for many patients (Neubauer, 2023). Suvorexant (Belsomra) is recommended by the AASM to treat sleep-maintenance insomnia in adults (Sateia et al., 2017). Rosenberg and colleagues (2019) recently published their double-bind RCT involving more than 1,000 adults over the age of 55 with insomnia. They compared 5 or 10 mg of lemborexant (DayVigo) to 6.25 mg of zolpidem extended-release (Ambien XR) or placebo for a month. Their study results indicated a significant improvement in sleep latency, efficiency, and wake time after sleep onset when lemborexant (DayVigo) was compared to placebo, as well as a decreased wake time after sleep onset in the second half of the night when lemborexant (DayVigo) was compared to zolpidem extended-release (Ambien XR; Rosenberg et al., 2019).

Also, 8 mg of ramelteon (Rozerem), a melatonin receptor agonist, within 30 minutes of bedtime may be used as a first-line treatment for those who describe isolated sleep-onset symptoms. It functions as a melatonin receptor agonist and has no abuse potential. Ramelteon (Rozerem) typically has a less potent effect (increased sleep time of < 10 minutes) but is also considered a safer option than DORAs for those with mildly delayed circadian rhythms. Patients should avoid eating a high-fat meal with or before taking ramelteon (Rozerem). Aside from somnolence, the most commonly reported side effects include dizziness, nausea, and worsening insomnia. Ramelteon (Rozerem) should be avoided in those taking fluvoxamine (Luvox) and those with severe hepatic impairment (Neubauer, 2023). Ramelteon (Rozerem) is recommended by the AASM for treating sleep-onset insomnia in adults (Sateia et al., 2017). Melatonin receptor agonists are especially helpful for shift workers and others with circadian rhythm disturbances. Tasimelteon (Hetlioz) is approved for patients with underlying non-24-hour sleep-wake rhythm disorder due to blindness or sleep disturbance related to Smith-Magenis syndrome (a genetic developmental disability syndrome; Reynolds & Cone, 2018). Of note, Ramelteon (Rozerem) is also recommended by the AAFP for sleep-onset insomnia in adults, although they note that it is “only modestly effective” (Matheson & Hainer, 2017).

For older adults who describe difficulty with sleep maintenance or mixed symptoms (i.e., both sleep-onset and sleep-maintenance difficulty), a low dose (3-6 mg QHS) of doxepin (Silenor) may also be considered a first-line treatment option. This TCA antagonizes the histamine receptors centrally, with high selectivity for the postsynaptic receptor, creating a sedating effect. It has no abuse potential and is not a controlled substance. Doxepin (Silenor) should be initiated at 3 mg within 30 minutes of bedtime and not within 3 hours of a meal. It should not be used concurrently with a monoamine oxidase inhibitor (MAOI). Other side effects include nausea and other anticholinergic effects besides the intended somnolence. Little improvement was noted across several RCTs between the 3 mg and 6 mg doses (an increase in 30 versus 38 minutes of sleep/night), and those with hepatic impairment should be maintained at 3 mg (Matheson & Hainer, 2017; Neubauer, 2023). The AASM and AAFP recommend doxepin (Silenor) to treat sleep-maintenance insomnia in adults due to improved sleep outcomes and a lack of significant adverse effects (Matheson & Hainer, 2017; Sateia et al., 2017). Of note, the AGS states that doxepin (Silenor) may worsen/cause orthostatic hypotension and strong anticholinergic effects in older adults if dosed > 6 mg/day (AGS Beers Criteria Update Expert Panel, 2023).

Regardless of the medication used, the lowest effective dose should be prescribed, and refills should not be given unless tolerability and required need have been established. These medications should not be combined with alcohol, opioids, or other CNS depressants or sedatives. Irrespective of treatment, patients with insomnia should be scheduled for follow-up every 4-8 weeks, depending on their symptom severity, until symptoms stabilize. Sleep hygiene practices and some learned components of CBT-I can be continued indefinitely as long as the patient perceives them as beneficial. Rarely, patients may require pharmacological treatment for their insomnia long-term, and these patients should be seen to assess medication utilization, need, and effectiveness every 6 months. Patients with persistent symptoms despite treatment or those with symptoms requiring pharmacological treatment beyond 6 months should be referred to a specialist (Neubauer, 2023; Reynolds & Cone, 2018).

Self-Neglect

Self-neglect among older adults is defined as the “refusal or failure to provide oneself with care and protection in areas of food, water, clothing, hygiene, medication, living environments, and safety precautions” (Dong, 2017, p. 1). Self-neglect can compromise an older adult's well-being, and in the US, self-neglect is determined to be the underlying cause for roughly 40% of neglect cases reported to Adult Protective Services. Prevalence is difficult to estimate due to a paucity of research on the topic and variable operational definitions and measurement methods. The Chicago Health and Aging Project (CHAP) found a self-neglect prevalence of 21% among Black participants and only 5.3% among White participants across 5,519 total study participants. While the 2010 Elder Justice Act (EJA) defines self-neglect as “the inability, due to physical or mental impairment or diminished capacity, to perform essential self-care,” numerous conceptual definitions have been developed since that time, and no universal operational definition exists. Risk factors are equally difficult to define but generally include cognitive impairment (e.g., diminished executive or global functioning), physical disability (i.e., the presence of multiple chronic conditions, SUD), and psychological distress (e.g., depressed mood). Self-neglect also appears to occur more commonly among older adults with limited family or social support and engagement. Self-neglect not only impacts well-being but also increases healthcare resource utilization and mortality risk. It typically leads to poor adherence to the medical care plan and nutritional deficiencies (Dong, 2017; Kaplan, 2023).

Screening and Assessment

The American Medical Association (AMA) and the American Academy of Neurology both recommend screening individuals over 65 for potential abuse. A screening tool may help HCPs identify vulnerable older adults. Screening can be difficult to perform clinically, as most scales contain an in-home assessment portion. HCPs must be aware that in most states, reporting suspected abuse of adults over 65, including self-neglect, is mandatory for medical providers. HCPs should know their state's and locality's specific regulations regarding the expectations of reporting suspected abuse of adults over 65. Reporting can typically be done confidentially and does not require the patient's permission. Currently, two available screening tools for self-neglect have been tested psychometrically: The Chicago Self-Neglect Scale (CANS) and the Texas Self-Neglect Scale (TSNS). The CANS assesses for self-neglect across five domains: hoarding, personal hygiene, a house in need of repair, unsanitary conditions, and inadequate utilities. The TSNS uses five categories: living condition, financial status, physical/medical status, mental status, and social interaction/support. The Elder Self-Neglect Assessment (ESNA) evaluates a patient’s living conditions, as well as their physical and mental health, social network, and financial concerns. The Self-neglect Severity Scale (SSS) also incorporates the patient’s hygiene, function, and living environment. If suspicion exists, a full history and physical exam (e.g., CGA) should be completed, focusing on functional and cognitive ability. Direct observation should be prioritized over a patient’s response to questioning. Warning signs of physical injuries include skin tears, pressure injuries, fractures, and wounds that are not properly cleaned or dressed. The HCP should also note evidence of malnutrition or dehydration, such as rapid weight loss, hypernatremia, elevated blood urea nitrogen (BUN), low cholesterol, decreased lymphocyte count, and elevated hemoglobin. HCPs should also assess whether patients are taking their medications as prescribed (Baruth & Lapid, 2017; Dong, 2017; Halphen, 2023; Kaplan, 2023).

An older adult’s lack of awareness regarding self-neglect behaviors may indicate a diminishing capacity for decision-making. The capacity to make decisions requires understanding the current situation or problem, grasping the proposed solution(s) and their associated risks and benefits, and communicating that understanding to those around them. This ability may falter during the decision-making process or in the execution. In general, an HCP should assume older adults have decision-making capacity until indicated otherwise, even when their decision may not align with the HCP’s expectations. Brief screening tools to assess decision-making capacity include the Aid to Capacity Evaluation, the Hopkins Competency Assessment Test, and Understanding Treatment and Disclosure. The results of a CGA, as mentioned above, will also aid the HCP in assessing a patient's decision-making ability without infringing on their autonomy. The patient’s prior decision-making history should also be considered to help determine whether recent decisions align or deviate from previous patterns. Neuropsychological testing may be required if the patient’s decision-making capacity remains in question, and the legal system is ultimately responsible for determining a person’s capacity for self-care and self-protection (Baruth & Lapid, 2017; Dong, 2017; Halphen, 2023).

If an older adult is no longer capable of making decisions, the HCP should advocate for the maximum preservation of the patient’s rights and decision-making based on the patient’s best interests. This balance between the medical concepts of beneficence (acting in the patient’s best interest), nonmaleficence (doing no harm), and the patient’s right to self-determination and autonomy is difficult to navigate for even the most experienced and conscientious HCPs. If a patient is determined to be incapable of decision-making, a surrogate decision-maker should be appointed immediately based on the patient’s advance directives, if available (Baruth & Lapid, 2017; Dong, 2017). While legal provisions vary by state for adult guardianship, the following conceptual model describes six key domains:

• the presence of a medical condition that may lead to disability
• cognitive impairment (e.g., memory, communication, attention, or executive function)
• difficulty with everyday functioning (e.g., the provision of food, shelter, and protection)
• consideration for the patient’s preferences and values
• the risk of harm present and the level of supervision required
• consideration of the feasibility of a less-restrictive option besides guardianship (Halphen, 2023)

Prevention and Management

Unfortunately, RCTs regarding the best methods to prevent and manage self-neglect are lacking. Most prevention programs focus on training HCPs to recognize the signs of neglect and encouraging a more positive attitude toward older adults within a community or culture. Training should include all HCPs, not just those specifically caring for older adults, as most HCPs interact with older adults in some capacity and can intervene on their behalf. This training should also encompass reporting suspected abuse, including local statutes and common barriers to reporting (e.g., lack of recognition regarding when and why to report, lack of knowledge about how and where to report suspected cases, and awareness of the legal protections for those who report suspected cases of neglect in good faith). Public education campaigns often target community members who interact with older adults daily (e.g., grocery store clerks, police officers, mail carriers) with similar information, such as risk factors, warning signs, and the process of filing a report. Just like the assessment process, self-neglect management should involve a multidisciplinary team with solid communication patterns, collaboration, and shared decision-making. This team should include HCPs, a licensed social worker, community educational programs, and financial service agencies. Any underlying conditions identified during the evaluation, such as depression or delirium, should be managed appropriately based on evidence-based guidelines. Through discussions regarding goals of care and shared decision-making, the HCP should find commonality whenever possible to encourage teamwork; the patient and the healthcare team should then collaborate on achieving these goals first. Safety interventions should focus on areas with the greatest possible harm reduction (Baruth & Lapid, 2017; Dong, 2017).

Depression and Loneliness

Depression often affects older adults (with a prevalence of 2% to 10% in community-dwelling older adults) but is not a normal part of aging. Sadness, stress, and grief are expected reactions to some of the common life events that occur after the age of 65, such as experiencing the departure of grown children; selling a home to downsize; retiring; losing family members and loved ones; declining social, cognitive, or physical functioning due to age or illness; and decreasing independence due to disability. The prevalence of depression increases with comorbid medical conditions and within healthcare settings, climbing as high as 50% in SNF residents. Risk factors for late-life depression include female sex, social isolation, previously married status (i.e., separated, divorced, or widowed), lower socioeconomic status, comorbid medical conditions, chronic pain, insomnia, functional impairment, and cognitive impairment. Depressed mood amplifies a patient’s disabilities, decreases their QOL, increases their consumption of healthcare resources, and increases their risk of SUD. Although adults over age 65 account for roughly 13% of the US population, they comprise nearly 24% of completed suicides. The suicide rate is highest among older men, especially over the age of 85. Acute indications of suicide risk include hopelessness, insomnia, agitation, restlessness, poor concentration, psychotic symptoms, SUD, and untreated pain (Espinoza & Unutzer, 2023; Halverson, 2023a).

For additional information regarding the assessment and prevention of suicide, please refer to the NursingCE course entitled Suicide.

Assessment and Diagnosis

Depression may be harder to diagnose in older adults, as their symptoms may vary. Older adults often exhibit fatigue, sleep disturbances, irritability, confusion, or inattention. Chronic medical conditions (e.g., Alzheimer’s disease, Parkinson’s disease, heart disease, stroke, and cancer) can increase the risk of depression or cause depressive symptoms. This is especially true of vascular depression, which is more common in older adults with other vascular conditions, such as cardiovascular or cerebrovascular disease. Certain medications can also provoke symptoms of depression. Older adults with depression may present with no response to standard medical treatment for an unrelated condition, poor motivation to participate in their medical care, somatic symptoms that are more severe than expected, or decreased engagement with the healthcare team. For those older than 85, dysphoric mood is a less reliable indicator of depression (Coryell, 2023; Espinoza & Unutzer, 2023).

A validated assessment tool, such as the Two-Question Screener/PHQ-2, should be used for depression screening. This tool asks about feeling down, depressed, or hopeless and lacking interest or pleasure in doing previously enjoyable things (anhedonia). If positive, the remaining seven questions that make up the PHQ-9 can be used to improve the specificity of the screen. See Table 9 for the PHQ-9 screening components. Ranges of depression scores include 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 or greater (severe; Espinoza & Unutzer, 2023; Ward & Reuben, 2022).

Table 9 

PHQ-9 Depression Questionnaire

(Espinoza & Unutzer, 2023, Table 5)

The Geriatric Depression Scale is specifically designed for use in older adults. This 5-item self-report instrument has been studied in several different settings. Two out of five depressive responses ("no" to question 1 or "yes" to questions 2 to 5) suggest a depression diagnosis. The questions include (Espinoza & Unutzer, 2023; Ward & Reuben, 2022):

• Are you basically satisfied with life?
• Do you often get bored?
• Do you often feel helpless?
• Do you prefer staying at home rather than going out and doing new things?
• Do you feel pretty worthless the way you are now?

Major Depressive Disorder (MDD) is defined by the presence of at least one Major Depressive Episode (MDE) in an individual with no history of mania or hypomania. Based on high-quality evidence, the APA (2022) strongly recommends that clinicians use the DSM-5-TR criteria to determine a diagnosis of MDD, MDE, and other specified or unspecified depressive disorders. The DSM-5-TR outlines the required diagnostic criteria for a diagnosis of MDD, as summarized in Table 10. Of note, criteria A through C represent an MDE. These symptoms must be new for the individual or worsening of an existing symptom and must be present over 2 weeks. A diagnosis requires a thorough interview, as individuals often circumvent direct questioning when discussing their mood. For other patients, symptoms of MDD can present as a physical manifestation (e.g., pain). Other patients may report feelings of agitation or anger instead of sadness. This pattern is common in adolescents and children who may present as irritable or cranky instead of sad or dejected. A diagnosis can be complicated if the individual has a concurrent disease that can produce similar symptoms (e.g., cancer, diabetes, or pregnancy; APA, 2022).

Table 10

DSM-5-TR Diagnostic Criteria for Major Depressive Disorder*

(APA, 2022)

*This is an interpretive representation of the diagnostic criteria detailed in the DSM-5-TR; the provider should reference the diagnostic guidelines listed in the DSM-5-TR to make an actual diagnosis.

Grief, which is also common among older adults, can be difficult to distinguish from MDD or MDE. Feelings of emptiness and loss characterize grief, and dysphoria occurs in varying intensity (associated with reminders of the departed) but typically decreases over time. These “waves” or “pangs” of grief are interspersed by periods of humor or positive emotions. Thoughts tend to focus on the deceased and joining them, but suicidal ideations are uncommon. While guilt is common regarding actions or lack of actions regarding the deceased, self-esteem is preserved. By contrast, dysphoria in MDE is consistent, and thoughts are largely self-critical and pessimistic. Feelings of worthlessness and thoughts of suicide are common (APA, 2022).

For additional information regarding the assessment and diagnosis of depression, please refer to the NursingCE courses on Depression and The Comprehensive Geriatric Assessment.

Management

The undertreatment of depression can have devastating effects. In a systematic review and meta-analysis of older adults with depression living in the community or being managed through a primary care office, only 4% to 37% of patients received some treatment. At the 2-year follow-up, only 33% of patients were well, while 33% reported persistent depression, and 21% were deceased (Kok & Reynolds, 2017). Physical exercise offers many benefits for adults over 60 with depression, especially cardiovascular activities such as walking or swimming. Although high-quality RCTs are lacking and the benefits seem modest, systematic reviews are positive. Bright light therapy, using pale blue 2,500 to 10,000 lux, appears to be well-tolerated and may be beneficial for some adults with depression. Light therapy should be initiated in the morning at a distance of 30 to 60 cm. The patient should sit in front of the light for 30 to 60 minutes daily. If available, home-based interventions may help those with limited mobility and mild depression. The involvement of family members in the education and care of patients with depression can improve outcomes, as they not only assist in reinforcing and encouraging treatment adherence but also provide valuable observational insight to the healthcare team (Coryell, 2023; Espinoza & Unutzer, 2023; Halverson, 2023b; Kok & Reynolds, 2017).

Yoga is a mind and body practice founded in ancient Indian philosophy. It centers on achieving a relaxation response through spirituality and meditation. Meditation is especially beneficial for reducing stress and depressive symptoms. Studies have shown that yoga and meditation have positive benefits for people with depression and various mental health conditions (National Alliance on Mental Illness, n.d.; National Center for Complementary and Integrative Health, 2023). Sharma and colleagues (2017) evaluated the feasibility, efficacy, and tolerability of Sudarshan Kriya yoga (SKY) as an adjunctive intervention for patients with MDD. SKY is a breathing-based meditative technique that focuses on slow, medium, or fast rhythmic breathing cycles. It has been reported to decrease cortisol, increase prolactin, and improve antioxidant status in practitioners. The researchers’ findings demonstrated that SKY helped alleviate severe depression in people who did not fully respond to antidepressant treatments (Sharma et al., 2017).

Both psychotherapy and somatic treatments (e.g., antidepressant medication) are considered first-line and equally efficacious for older adults with depression of any severity. The choice between options (or a combination) should depend on various factors, such as contraindications, availability, cost, patient preference, and condition characteristics (severity, type, and chronicity). Pharmacotherapy is recommended for those with moderate to severe disease, while a combination of pharmacotherapy and psychotherapy appears to be most effective for those with chronic symptoms. A collaborative care model can produce improved outcomes, using patient education and care managers or non-physician mental health professionals to integrate the psychiatric and primary care components of care. These programs improve not only depression but also general medical outcomes and reduce mortality. Depression-specific case management can reduce depressive symptoms and mortality (Coryell, 2023; Espinoza & Unutzer, 2023; Halverson, 2023b).

Psychotherapy is effective yet underutilized; it can be difficult to access (at times) depending on location and often not/poorly covered by medical insurance. It can be done individually, in groups, or as a couple or a family. It can be performed in a private office, in a senior center, or within outpatient or day treatment programs. Multiple RCTs and meta-analyses have demonstrated a significant, clinically moderate to large effect. Options for psychotherapy include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy. They are typically delivered over a 2- to 4-month period. While CBT is the most widely studied, research indicates that IPT is equally efficacious, and problem-solving therapy can be beneficial. Psychotherapy may be adequate for the treatment of depression that is mild to moderate (i.e., with a PHQ-9 score of below 10; Coryell, 2023; Espinoza & Unutzer, 2023; Halverson, 2023b; Kok & Reynolds, 2017).

CBT 

CBT is a type of psychotherapy with strong clinical evidence supporting its use as an effective treatment for depression. There is evidence that CBT is effective across all ages but is particularly valuable for older adults who are prone to problems or side effects with medications. CBT helps patients assess and restructure negative thinking patterns associated with depression. The patient can recognize negative thoughts and learn positive and effective coping strategies through CBT. CBT is time-limited and typically consists of 8 to 16 sessions. Patients track their thoughts and activities to identify the affective and behavioral consequences. They subsequently learn techniques to change their way of thinking and activities to improve their mood. CBT has demonstrated efficacy across diverse populations, including civilians, veterans, active service members, and family members suffering from depression. CBT can also be administered via computer programs, a process referred to as computer-based CBT (CCBT). An RCT of older adults with an anxiety disorder also found that CBT in a primary care setting effectively decreased worry and moderately improved depressive symptoms (CDC, 2022; Espinoza & Unutzer, 2023; Halverson, 2023b; Stein & Norman, 2023).

Mindfulness-Based Cognitive Therapy (MBCT) 

MBCT is designed to reduce relapse among individuals who have been successfully treated for an episode of recurrent MDD. MBCT integrates CBT interventions with mindfulness-based skills to help patients attend to the present moment in a non-judgmental, accepting manner. Unlike CBT, MBCT does not seek to modify or eliminate dysfunctional thoughts. Instead, it helps patients become more detached and objectively observe their thoughts without attempting to change them. MBCT employs meditation, imagery, experiential exercises, and relaxation techniques. Mindfulness is not appropriate as first-line therapy for severe depression but rather as an adjunct or complementary therapy or an alternative for mild symptoms in motivated patients. MBCT is structured to include eight weekly, 2-hour group sessions. Patients are assigned daily homework, which includes awareness exercises to focus on bodily sensations, thoughts, and feelings (Halverson, 2023b).

IPT 

IPT focuses on improving problems within personal relationships as a core component of depression. While an event or a relationship may not always cause depression, depression affects relationships and can create interpersonal problems. IPT is a short-term treatment (typically 16 sessions) that teaches patients to evaluate their interactions to understand and improve how they relate to others. IPT is derived from attachment theory, and it treats depression by focusing on improving interpersonal functioning and exploring relationship-based difficulties. IPT specifically targets four primary areas: interpersonal loss, role conflict, role change, and interpersonal skills. The initial phase (sessions 1-4) builds a working alliance and identifies one of the four areas to focus on. During the middle phases (sessions 5-12), specific interventions are used to address the area of focus, including providing validation and support, improving communication skills, and working to solve interpersonal problems. The final phase (sessions 13-16) focuses on the termination of therapy, including developing relapse prevention strategies and addressing emotions that come with the end of treatment (CDC, 2022; Halverson, 2023b).

Pharmacotherapy 

Antidepressant medications are the pharmacological treatment of choice for depression. While mild-to-moderate depression can often be treated with therapy alone, moderate-to-severe cases of depression often require the addition of medication (PHQ-9 score of 10 or above). Medication therapy aims to help reduce or control the symptoms of depression. The bulk of medications that the US FDA currently approves for treating depression target the three neurotransmitters historically associated with depression: serotonin, norepinephrine, and dopamine. Most agents need to be initiated at low doses, tapered up slowly when starting, and tapered down before discontinuing. Antidepressants should not be abruptly stopped due to the risk of withdrawal and the subsequent return of depressive symptoms. If they are stopped abruptly, withdrawal-like symptoms can include dizziness, headaches, flu-like syndrome (tiredness, chills, muscle aches), agitation, irritability, insomnia, nightmares, diarrhea, and nausea. Regardless of the medication prescribed, patients must be counseled that antidepressants may take 4-6 weeks to have an effect and 12-16 weeks to achieve their full benefits. Older adults should be treated with monotherapy when possible to avoid drug-drug interactions and polypharmacy. While the initial dosing should be adjusted (typically by cutting the initial adult dosage in half), most older adults should be maintained within the same therapeutic dosage range as younger adults (Espinoza & Unutzer, 2023; Kok & Reynolds, 2017; NAMI, 2017; National Institute of Mental Health [NIMH], 2022; US Department of Veterans Affairs [VA], 2022).

All of the major medication classes commonly prescribed for depression are included in the 2023 BC list, including SNRIs, SSRIs, and TCAs. TCAs can exert anticholinergic effects, such as sedation, leading to orthostatic hypotension and falls. SSRIs are included on the list, and SNRIs were recently added, but only for older patients with a history of falls. SSRIs and SNRIs both increase the risk of patient falls, hyponatremia, and syndrome of inappropriate antidiuretic hormone secretion. The BC list cites a study that showed a 48% increase in fall risk for older adults taking an antidepressant. They also caution against combining three or more CNS-active medications (e.g., antidepressants, antipsychotics, AEDs, and benzodiazepines). The AGS encourages HCPs to avoid antidepressants unless safer alternatives are unavailable, specifying that the evidence does not appear to support the safety of one particular antidepressant over others (AGS Beers Criteria Update Expert Panel, 2023).

In 2004, the FDA required a warning to be printed on the labels of all antidepressant medications regarding the increased risk of suicidality among children and adolescents taking these medications. The warning was expanded in 2007 to include all young adults, especially those under the age of 25, stating that these individuals may experience an increase in suicidal thoughts or behaviors during the first few weeks of taking an antidepressant. Before starting the medication, the individual may have been too paralyzed by depression to make a suicide plan. As a result, the risk of suicide rises while the depressive symptoms start to improve (Espinoza & Unutzer, 2023). Researchers found evidence that individuals taking antidepressant medication may have an even higher risk of suicide than individuals whose depression is improving for other reasons (Fornaro et al., 2019). The FDA also requires manufacturers to provide a Patient Medication Guide (MedGuide), which is given to individuals receiving these medications to advise them of the risks and precautions that can reduce the risk of suicide. Furthermore, clinicians are advised to ask patients about suicidal thoughts prior to prescribing antidepressants to young persons (FDA, 2018). Studies have shown a similar trend in older adults, with a mild increase in the suicide rate among men over age 65 during the first month of treatment with SSRIs (Espinoza & Unutzer, 2023).

SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox CR), paroxetine (Paxil), and sertraline (Zoloft). Compared to TCAs, these drugs have fewer adverse cardiac effects, typically require only one or two dose increases to reach their targeted dose, and have a reduced risk of fatal overdose. Unfortunately, they involve more drug-drug interactions than TCAs, which is a concern among older adults, who are more prone to polypharmacy. Research indicates that the improved side effect profile of SSRIs is clinically significant, leading to a higher rate of voluntary patient withdrawal when patients are given TCAs versus SSRIs. For this reason, in combination with the anticholinergic effects of TCAs, SSRIs are typically the first-choice antidepressant for older adults. This is not related to an increased efficacy of SSRIs. In older adults, SSRIs can also cause parkinsonism, restlessness (akathisia), anorexia, sinus bradycardia, and hyponatremia. SSRIs increase serotonin levels in the body, posing a risk of serotonin syndrome, which is characterized by agitation, anxiety, confusion, high fevers, sweating, tremors, a lack of coordination, dangerous fluctuations in blood pressure, and rapid heart rate. Serotonin syndrome is a potentially life-threatening condition for which patients must seek immediate medical attention (Espinoza & Unutzer, 2023; Kok & Reynolds, 2017; NAMI, 2017).

A dose-related increase in the risk for fragility fractures has been reported with SSRI use. Sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro) are generally well-tolerated (i.e., non-sedating with a low risk of insomnia) and may be good first choices for older adults with depression. Escitalopram (Lexapro) should be initiated at 5 mg daily, with a goal of 5-20 mg/day. Citalopram (Celexa) should be initiated at 10 mg daily, with a goal of 10-20 mg/day. Due to an increased risk for QT interval prolongation and arrhythmias, citalopram (Celexa) should not be dosed for older adults above 20 mg/day. Sertraline (Zoloft) should be initiated at 12.5-25 mg every morning, with a goal of 25-200 mg/day; it has been reported to cause diarrhea more often than other SSRIs. Fluoxetine (Prozac) should be initiated at 5-10 mg every morning, with a goal of 5-60 mg/day. It may have an activating effect, which may benefit patients with fatigue. It also has a longer half-life, which may lengthen the period to reach a steady state but typically involves a lower need to taper when discontinuing. All other SSRIs should be tapered when discontinuing to avoid withdrawal symptoms. Paroxetine (Paxil) should be initiated at 10 mg every evening, with a goal of 10-40 mg/evening. Paroxetine (Paxil) has been found to increase the risk of weight gain. Fluvoxamine (Luvox) should be initiated at 25 mg every evening, with a goal of 25-200 mg/evening. Paroxetine (Paxil) and fluvoxamine (Luvox) may be good choices for those with insomnia, although fluvoxamine (Luvox) and fluoxetine (Prozac) have more significant drug interactions (Espinoza & Unutzer, 2023, Table 6). A longitudinal study involving over 2,300 adults (average age 55) found an association between SSRI use and weight gain, especially for those who ate a Western diet, had a sedentary lifestyle, and smoked (Shi et al., 2017).

SNRIs include duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima). Like SSRIs, SNRIs can cause serotonin syndrome. SNRIs are typically a second choice for those who do not respond to or tolerate treatment with an SSRI. They may be especially beneficial for those with chronic pain. Few studies directly compare SSRIs and SNRIs, although one study indicates that frail patients may not tolerate venlafaxine (Effexor) as well as sertraline (Zoloft). Both venlafaxine (Effexor) and duloxetine (Cymbalta) may cause diastolic HTN at higher doses, and extended-release formulas of venlafaxine (Effexor) appear to cause fewer gastrointestinal symptoms and agitation. Venlafaxine (Effexor) and desvenlafaxine (Pristiq) may have an activating effect, which may benefit those with fatigue. Venlafaxine (Effexor) should be initiated at 37.5 mg daily, with a goal of 75-225 mg/day for ER formulas and 18.75-37.5 as an initial dose daily or twice daily and 75-150 mg twice daily for immediate-release formulas. Desvenlafaxine (Pristiq) should be initiated at 50 mg every morning and maintained at this dosage. It should be dosed at 50 mg every other day for those with a creatine clearance (CrCl) below 30 mL/min. Duloxetine (Cymbalta) should be initiated at 10-20 mg daily, with a goal of 20-60 mg/day. It is mildly sedating and poses a reduced risk of insomnia but more significant drug interactions (Espinoza & Unutzer, 2023; NAMI, 2017).

Tricyclic and tetracyclic antidepressants are an older class of medications consisting of amitriptyline (Elavil), nortriptyline (Pamelor), clomipramine (Anafranil), imipramine (Tofranil), and desipramine (Norpramin). They also inhibit norepinephrine and serotonin reuptake but carry significantly more adverse effects than SSRIs or SNRIs. TCAs may be fatal in overdose, have significant drug-drug interactions, and are potentially cardiotoxic. Anticholinergic side effects include dry mouth, constipation, urinary retention, blurry vision, and orthostatic hypotension. Due to these effects, they are contraindicated in men with prostatic disease or patients with narrow-angle glaucoma. They are also no longer considered first- or second-line treatment options for depression. They may be effective for those with melancholic or delusional depression, and they may prevent relapse after ECT. Nortriptyline (Pamelor) should be started at 10 mg every evening, increasing to a maximum of 100 mg daily in one dose or two divided doses. The established serum concentration is 50-150 ng/mL. Nortriptyline (Pamelor) tends to be mildly sedating, making it more useful for anxious patients with insomnia when taken at bedtime. Desipramine (Norpramin) should be started at 10 mg every morning, increasing to a maximum of 150 mg daily in one dose or two divided doses. The established serum concentration is 125-300 ng/mL. It tends to have a mild stimulant effect, which may benefit patients with low energy. Mirtazapine (Remeron) is a tetracyclic antidepressant that is occasionally used to treat depression in older adults, especially those who have anorexia or insomnia related to their mood disorder, as it tends to be sedating and leads to weight gain. It can also cause dry mouth and constipation. Mirtazapine (Remeron) should be initiated at 7.5 mg every evening with a dosing goal of 15-60 mg per evening. It can also be beneficial for those with essential tremors or parkinsonism and nausea related to chemotherapy but may cause delirium, as previously stated (Espinoza & Unutzer, 2023; NAMI, 2017).

MAOIs were the first type of antidepressant medications developed. They impair serotonin’s metabolism and block monoamine oxidase, an enzyme that breaks down excess tyramine in the body. Tyramine is an amino acid that occurs naturally in the body (and certain foods) to help regulate blood pressure. MAOIs include tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan), and a transdermal skin patch (selegiline [Emsam]). They may be effective for reverse neurovegetative depression, mixed anxiety-depressive states, and panic disorders. Due to the risk of serious adverse effects, the use of MAOIs for the treatment of depression should be reserved for patients who have failed all other treatment options or those who have previously been started on and tolerated them. MAOIs have dangerous drug and food interactions that can lead to serotonin syndrome and hyperadrenergic crisis. In particular, HCPs must warn patients to avoid foods containing high levels of tyramine, such as aged cheese (aged cheddar, swiss, parmesan, and blue); cured, smoked, or processed meats (pepperoni, salami, hotdogs, bologna, bacon, corned beef, smoked fish); pickled or fermented foods (sauerkraut, kimchi); sauces (soy sauce, miso, teriyaki); soybean products; and alcoholic beverages (beer, red wine, liquors). Drug interactions with other medications that increase serotonin levels, such as triptans to treat migraines, can cause serotonin syndrome (Espinoza & Unutzer, 2023; NAMI, 2017; NIMH, 2022). The most common adverse effects of antidepressants are displayed in Table 11.

Table 11

Common Side Effects of Antidepressants by Medication Class

 (Espinoza & Unutzer, 2023; NAMI, 2017; NIMH, 2022)

There are also a few uncategorized atypical antidepressants. Bupropion (Wellbutrin) blocks the reuptake of norepinephrine and dopamine and can be used for depression, seasonal affective disorder, and smoking cessation. Bupropion (Wellbutrin) affects mostly dopamine in the brain and does not confer a risk of serotonin syndrome. It should be initially dosed at 75 mg in the morning and increased to twice daily (midafternoon) toward a goal of 150 mg twice daily. Bupropion (Wellbutrin) should be avoided by those with a seizure history or bulimia nervosa and should not be used concurrently with CNS depressants (e.g., benzodiazepines). It tends to have a stimulating effect, which may benefit patients with lethargy or fatigue but should be avoided for those with agitation or anxiety. Its dopaminergic activity may also be beneficial for those with a diagnosis of Parkinson’s disease. It can also cause diastolic HTN at higher doses in older adults. Bupropion (Wellbutrin) was found to be among the most likely antidepressants contributing to weight loss and should be avoided in those with anorexia or malnutrition (Espinoza & Unutzer, 2023; NAMI, 2017; NIMH, 2022).

Trazodone (Oleptro) antagonizes serotonin and alpha-1 adrenergic receptors and blocks serotonin reuptake. It should initially be dosed at 12.5-25 mg about 30-60 minutes before bedtime, with a goal of increasing the dose to 25-100 mg daily before bed. It tends to be highly sedating, making it beneficial in lower dosages as an adjunctive treatment for depressed patients reporting insomnia. It can also cause orthostatic hypotension, nausea, cognitive impairment, residual daytime fatigue, and priapism. Similarly, nefazodone (Serzone) antagonizes serotonin receptors and blocks the reuptake of norepinephrine and serotonin. It has been removed from markets around the world due to hepatotoxicity concerns. It may cause sedation or drowsiness, making it useful for certain depressed patients who report insomnia, anxiety, or agitation. Significant drug-drug interactions may occur with macrolide antibiotics, antiarrhythmics, and certain psychotropics. Both trazodone (Oleptro) and nefazodone (Serzone) have been associated with hyponatremia. Vilazodone (Viibryd) is an SSRI and a partial serotonin receptor agonist. It should initially be dosed at 10 mg daily with food, with a goal of increasing the dose to 20-40 mg daily with food. It may cause side effects such as diarrhea, nausea, vomiting, dizziness, or insomnia but has a lower incidence of sexual dysfunction and weight gain. Vortioxetine (Trintellix) is a newer medication for depression that inhibits serotonin reuptake and acts as a mixed antagonist/agonist of specific serotonin receptors (Espinoza & Unutzer, 2023; NAMI, 2017; NIMH, 2022).

Once a medication has been started, patients should be contacted within two weeks and seen in the office in 2 to 4 weeks to discuss tolerance, side effects, efficacy, complications, and dose adjustments if appropriate. The usual course of treatment for an initial MDE or episode of MDD is 6-12 months once remission is achieved. This treatment period may need to be extended to prevent relapse, which occurs at a higher rate in older adults compared to younger adults. Those with persistent depressive disorder or multiple relapses may require long-term treatment. Most research findings support treatment lasting for a year before discontinuation is considered. Multiple relapses likely indicate the need for a longer treatment course to reduce the risk of relapse, lasting up to 24 months in those with two episodes of depression and up to 36 months in those with three or more episodes of depression (Espinoza & Unutzer, 2023; Kok & Reynolds, 2017).

As previously stated, older adults with depression and unintended weight loss should be treated with structured psychotherapy and antidepressant medication to reverse their weight loss and improve mood and QOL. Certain SSRIs should be avoided for older adults with depression who are malnourished, as they may contribute to weight loss. Mirtazapine (Remeron), amitriptyline (Elavil), citalopram (Celexa), paroxetine (Paxil), and venlafaxine (Effexor) are less likely to contribute to anorexia and weight loss. At the same time, TCAs, bupropion (Wellbutrin), and certain SSRIs—especially fluoxetine (Prozac) and sertraline (Zoloft)—should be avoided by these patients. Research has shown that weight gain is more likely to occur with citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), sertraline (Zoloft), duloxetine (Cymbalta), mirtazapine (Remeron), and venlafaxine (Effexor). Psychostimulants, at low doses, may be beneficial for some older adults with severe depression and associated apathy. Methylphenidate (Ritalin, Concerta) may be initiated cautiously for this group at a dose of 2.5 mg in the morning and titrated up if needed to a maximum of 5-40 mg daily. Caution should be used regarding dosing, as methylphenidate (Ritalin, Concerta) leads to weight loss when administered in doses of 20 mg daily or higher. When combined with an SSRI, methylphenidate may improve outcomes and lead to a faster improvement in mood versus either treatment alone. Aripiprazole (Abilify), a dopamine and serotonin receptor partial agonist and serotonin receptor antagonist that is typically used as an antipsychotic, may be combined with an SNRI for those with treatment-resistant depression. Side effects of aripiprazole (Abilify) include weight gain, akathisia, and parkinsonism. While quetiapine (Seroquel) is effective in treating MDD, the side effects are substantial and extensive, making this treatment option unattractive. Typical side effects include sedation, dry mouth, weight gain, and extrapyramidal symptoms. Lithium (Lithobid) has also been used as adjunctive therapy for severe treatment-resistant depression with some success in older adults, with an overall response rate of 42% (Agarwal, 2023b; Espinoza & Unutzer, 2019; Kok & Reynolds, 2017; Ritchie & Yukawa, 2023).

Brain Stimulation

For patients with severe depression, ECT is also effective. ECT is a brain stimulation technique that may be appropriate for those with severe depression (i.e., causing significant functional impairment or life-threatening) who have not responded to pharmacologic treatments. Other brain stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS), are used for the treatment of medication-resistant depression. However, no RCTs are available to show a significant benefit for older adults (Agarwal, 2023b; Espinoza & Unutzer, 2023).

ECT involves transmitting short electrical impulses into the brain. These controlled electric currents provoke a brief period of seizure-like activity. ECT is typically performed in a series of 4-6 treatments before an improvement can be expected, with a total of 6-12 treatments administered over 2-6 weeks; monthly maintenance treatments are sometimes required. The patient is placed under general anesthesia for each treatment and can resume normal activity about an hour following the procedure. ECT can have significant adverse effects, such as headaches, muscle pain, nausea, confusion, and memory loss. It is only utilized for severe depression, depression with psychosis, or bipolar disorder that has not responded to medication and psychotherapy with more conventional methods. For patients with uncomplicated severe depression, ECT can lead to improved mood in 80% of cases. Patients need to understand the potential risks and benefits of ECT before beginning treatment. ECT effectiveness ranges from 60%-80% for older adults with MDD and is especially beneficial in cases of severe depression or for patients with psychotic features, severe malnutrition, or treatment nonadherence (Espinoza & Unutzer, 2023; Kok & Reynolds, 2017; NIMH, 2023).

Hearing Loss

Hearing loss may be either conductive or sensorineural. Conductive hearing loss involves external or middle ear dysfunction, affecting the ability to transmit vibrations mechanically from the environment to the inner ear. This dysfunction may be due to cerumen impaction, infection, foreign body occlusion, squamous cell carcinoma, congenital microtia, otosclerosis, cholesteatoma, or trauma to the tympanic membrane or temporal bone. Sensorineural hearing loss is typically related to an inner ear disorder, disrupting the transduction of sound information into usable neural signals. It is rarely related to the vestibulocochlear nerve, despite the term nerve deafness. The condition may be hereditary or due to labyrinthitis, Meniere disease, viral cochleitis, vascular insult, autoimmune disorder, excessive noise or ototoxin exposure, vestibular schwannoma (acoustic neuroma), or trauma to the inner ear (Blevins, 2022; Wahid et al., 2021).

Presbycusis, or age-related hearing loss, typically affects higher frequencies (i.e., above 2 kHz) and is quite common with increasing age. The prevalence of presbycusis is approximately 43% in individuals over the age of 65, over 50% in adults over 75, and more common in men than women. There is a genetic component to age-related hearing loss, and dietary factors (e.g., a high-fat diet) may be associated (Blevins, 2022; Saadi, 2023). Other risk factors include:

• White race
• low socioeconomic status
• previous exposure to loud noise or ototoxins (e.g., aminoglycosides, heavy metals, certain chemotherapeutic agents)
• history of otologic infection(s)
• smoking
• HTN
• DM
• vascular disease
• immunologic disorders
• hormonal factors (Blevins, 2022)

Presbycusis often consists of sensorineural hearing loss due to dysfunction of the cochlear hair cells and, to a lesser degree, the spiral ganglion cells in the vestibulocochlear nerve. Presbycusis may be categorized histopathologically as sensory (a loss of high-frequency sounds due to loss of hair cells), metabolic (a loss of low-frequency sounds due to loss of stria vascularis), or neural (variable hearing loss due to loss of ganglion cells). Many researchers have proposed that this classification system is overly simplistic and thus invalid, although it continues to be used regularly, as presbycusis varies clinically. Anatomical studies indicate that patients with presbycusis often exhibit degeneration of the hair cells (predominantly the outer hair cells), the stria vascularis, and the spiral ganglion cells, combining the three histopathological categories detailed above. The resulting hearing loss typically presents bilaterally and gradually over the years. It can be associated with tinnitus and vertigo and may contribute to falls. Over time, the middle and lower frequencies (0.5 to 2 kHz) may be affected, including those associated with human speech, which typically occurs at frequencies between 500 Hz and 4 kHz at a volume of about 50 dB. Consonants, which convey much of the meaning of speech, tend to involve higher frequencies and softer decibels, while vowels tend to be at lower frequencies and louder volumes. Due to the insidious nature of presbycusis (and the negative stigma), a patient will often wait for years before presenting with hearing loss in order to obtain evaluation and assistance at the insistence of family members. If untreated, presbycusis can lead to social isolation, depression, and interpersonal or family stress (Blevins, 20222; Saadi, 2023).

Patients with presbycusis often can hear when someone is speaking, as the lower and middle frequencies carry the majority of the energy of the sound wave. However, the higher frequencies carry the consonant sounds and most speech information. For this reason, patients often describe being unable to understand the speech. These difficulties are exacerbated in the presence of background noise and make it more difficult for patients to hear women’s (higher-pitched) voices than men's. A paradoxical report of hypersensitivity to loud noises can also be common in older adults with presbycusis due to “recruitment,” causing a narrowing of the patient’s dynamic range. This compensation makes adjusting hearing aids and other devices difficult, as the upper output limit must be carefully considered to avoid discomfort. This recruitment is also why shouting at a patient with presbycusis is often counterproductive, as it only augments the low vowel frequencies and creates discomfort (Blevins, 2022; Saadi, 2023).

Patients with presbycusis commonly report tinnitus, often described as steady and bilateral ringing, static, rushing, or musical bells/chirping. A report of pulsing may indicate a vascular disorder and asymmetrical symptoms suggest the need for further testing by an audiologist or otolaryngologist. Patients with vestibular end-organ dysfunction or presbyastasis may experience vertigo and falls. This loss of vestibular function may be amplified by pre-existing peripheral neuropathy, arthritis, peripheral vascular disease, or reduced visual acuity. These conditions make compensation nearly impossible (Blevins, 2022; Saadi, 2023).

Assessment and Diagnosis

The American Speech-Language-Hearing Association recommends audiometric testing for all adults over the age of 50 every 3 years. However, this screening requires extensive resources and time. The United States Preventive Services Task Force (USPSTF) has maintained that they cannot recommend for or against the routine screening of asymptomatic adults over 50 for hearing loss. However, a patient's report of progressive hearing loss (or reports from a spouse or caregiver) should prompt an assessment. Other historical information includes concurrent symptoms, exposure to ototoxins (including medications), occupational exposure to loud noises, and family history. Unilateral or asymmetrical symptoms may indicate otitis media, trauma, a tumor, or asymmetrical exposure to higher decibels (e.g., firearms or power tools are often utilized consistently on a person’s dominant side). A sudden or rapid hearing loss should also elicit a more in-depth evaluation, as this does not indicate presbycusis. The gradual onset of unilateral sensorineural hearing loss may indicate Meniere disease or vestibular schwannoma. A screening tool, such as the Hearing Handicap Inventory for the Elderly ­­– Screening (HHIE-S), may also be used to collect this information. A brief physical examination, including otoscopy, should be done to rule out excessive or impacted cerumen or another foreign body occlusion. A tone-emitting otoscope can be used for screening. A whisper test and a 512 Hz tuning fork can differentiate sensorineural from conductive hearing loss. Then, audiogram testing should be performed to confirm presbycusis, assess its severity, and clarify management (Blevins, 2022; Weber, 2023).

Any occlusion or infection in the external canal, including cerumen impaction, should be ruled out before performing the whisper or Rinne tests, as detailed below. The eardrum and middle ear should be examined to confirm they are intact (not perforated) and free from inflammation or infection. Additional laboratory testing may be indicated to rule out metabolic abnormalities associated with hearing loss. A blood glucose test may indicate DM, while a CBC would help the examiner rule out anemia. A TSH would indicate the presence of thyroid dysfunction, and a syphilis test may be required if this sexually transmitted infection (STI) is suspected based on other historical or examination findings. Rheumatologic or autoimmune serology tests (rheumatoid factor and antinuclear antibody) may also be needed to rule out Sjogren’s syndrome for patients reporting dry eyes or mouth (Kong & Fowler, 2023; Weber, 2023).

Whisper, Weber, and Rinne Tests

The whispered voice test is a simple assessment that can be performed in an office setting. One systematic review showed it offered a sensitivity of 90%-100% and a specificity of 70%-87%. The examiner should stand behind the patient (to prevent lip reading) and occlude the right ear canal while simultaneously rubbing the tragus on the same side to further prevent hearing in the right ear. The examiner whispers a short sequence of letters or numbers and asks the patient to repeat them. The exam is then repeated while occluding the left ear (Weber, 2023).

The Weber and Rinne tests attempt to differentiate between a patient’s hearing ability via air and bone conduction. They are not screening tests for hearing loss but can further characterize this condition. An individual with normal hearing will report symmetrical hearing (Weber) and enhanced air conduction via the tympanic membrane, which is louder than bone conduction via the skull and cochlea (Rinne). The Weber test involves striking a tuning fork (the examiner grasps the handle/stem between the index finger and thumb and strikes the tines against their knee or elbow at one-third of the distance from the end of the tines/prongs) and pressing the handle on the patient’s nose, forehead, or top of the head to assess for symmetry (see Figure 3). For patients describing unilateral hearing loss, the examiner should note which side they report loss of hearing prior to the test. Patients should be asked if they hear the tuning fork more on the left, on the right, or equally in both ears. Patients who report hearing the tuning fork equally in both ears have symmetrical and intact hearing. For those with unilateral sensorineural hearing loss, the sound will be heard louder on the contralateral or “good” side. As previously mentioned, unilateral sensorineural hearing loss may indicate Meniere disease or vestibular schwannoma. Patients with unilateral conductive hearing loss will report hearing the tuning fork vibration louder in their affected or “bad” ear. Those with bilateral conductive hearing loss typically report no lateralization (Wahid et al., 2021; Weber, 2023).

Figure 3

Weber Test

During a Rinne test, the patient covers their contralateral ear canal while the handle of a struck (vibrating) tuning fork is placed against the mastoid bone behind the ear. The patient indicates when the sound is no longer audible. The bifurcated end of the tuning fork is then placed perpendicularly at 3-4 cm from the external auditory canal (see Figure 4). If the patient reports they can hear the sound again for a time (typically twice as long), the test is normal (as air conduction = bone conduction x2) or positive. If the patient reports that bone conduction extends beyond air conduction (i.e., when the vibrating tuning fork is moved in front of the external auditory canal, the patient denies hearing it again), this is an abnormal or negative test result. The latter case typically indicates a conductive hearing loss on that side. This condition is most often due to external or middle ear pathology. A patient with profound or total sensorineural one-sided hearing loss may present with a false-negative test result due to sound waves from the tuning fork on the affected side being transmitted through the skull to the unaffected side. Any abnormal findings on the whisper, Weber, or Rinne tests should be followed up with audiometry testing for confirmation prior to diagnosis (Kong & Fowler, 2023; Weber, 2023).

Figure 4

The Rinne Test

Audiometry

An audiogram indicates a patient’s ability to hear tones and understand words. In this test, the patient is presented with tones of varying frequencies (250 Hz to 8 kHz) through headphones while sitting in a soundproof booth. An individual with intact hearing should be able to perceive tones below 25 dB. A pure-tone air conduction average is calculated using the patient’s average decibel scores at 500, 1000, and 2000 Hz. A patient with presbycusis typically has a “downward slope” to their tone threshold, requiring tones at higher frequencies to be transmitted at higher decibels to be audible. Older patients with high-frequency thresholds above 40 dB should be referred for an amplification trial with an audiologist. Tone testing may be repeated with a bone oscillator held against the mastoid to assess bone conduction. A significant gap between air and bone conduction indicates conductive hearing loss (Blevins, 2022; Weber, 2023).

Speech audiometry has two components: the speech reception threshold (SRT) and the word discrimination score. The SRT is the softest level at which the patient can correctly repeat half (50%) of the prompted words. These words are two syllables (e.g., airplane, armchair, or pancake) in which both syllables are stressed. The SRT can confirm the air conduction tone testing above, as it typically equals the patient’s pure tone average ± 6 dB. The word recognition or discrimination score is based on the patient’s ability to understand a standardized list of words at a given volume (usually 40 dB above the patient’s SRT established above) and repeat them. A 90% or above score indicates normal hearing, while a low score indicates advanced neural degeneration. Higher scores also predict a favorable response to amplification. Word discrimination testing can help audiologists locate the specific location of a lesion (Blevins, 2022; Weber, 2023).

Additional testing may include pneumoscopy, which is performed to assess the tympanic membrane’s mobility in response to applied air pressure. Tympanometry objectively measures any changes in the acoustic impedance of the middle ear due to air pressure changes, so it can be considered a “hard copy” of pneumoscopy. This test may indicate fluid behind the tympanic membrane, a retracted tympanic membrane, stiffness due to myringosclerosis or otosclerosis, or an overly compliant tympanic membrane indicating ossicular chain discontinuity. Stapedial reflex testing and auditory brainstem response testing are available but rarely performed for adults with hearing loss except in specific circumstances. Advanced imaging studies, such as an MRI or CT, are rarely needed for patients with diagnosed presbycusis. These measures should only be considered to rule out space-occupying lesions or other central pathologies for patients who present with asymmetrical/unilateral tinnitus, vertigo, cranial nerve deficits, or significant asymmetry in their hearing loss. A CT scan of the temporal bone is most appropriate for a patient with conductive hearing loss due to an unknown etiology, while an MRI with gadolinium may help identify the underlying cause of unilateral/asymmetrical or fluctuating sensorineural hearing loss (Blevins, 2022; Weber, 2023).

Management

Despite its prevalence, there is no direct treatment for presbycusis. Effective communication with older adults with hearing impairment requires using a lower-pitched voice, facing the patient so that they can read the speaker’s lips, and speaking slowly and clearly. Engaging the patient in active conversation or asking them to paraphrase what was said may help ensure understanding. Once the diagnosis of hearing loss has been made, treatment options to help the patient manage their symptoms and optimize their function include hearing aids, assistive listening devices, auditory rehabilitation, and cochlear implants for those with refractory hearing loss (Blevins, 2022; Lustig, 2022).

The use of appropriately fit hearing aids reduces withdrawal, depression, and the emotional impact of presbycusis and improves patients’ QOL. Concerns include patients who are uncomfortable with the cosmetic and social implications of wearing hearing aids, their high cost, high levels of static or noise, and an improper fit within the meatus. Patients may also produce too much cerumen, clogging the device. As a result, patients should be evaluated by an experienced audiologist in order to be matched with the most appropriate device for their needs and anatomy. Most options can be trialed prior to purchase. Many patients with tinnitus related to presbycusis report a reduction in this bothersome symptom with well-fitting hearing aids. Follow-up visits and referrals to rehabilitation services may enhance the patient’s chance of success and maximize the benefit of their hearing aids (Blevins, 2022; Lustig, 2022).

Auditory rehabilitation incorporates and integrates sensory management, patient education/instruction, perceptual training, and counseling to improve the function and QOL of those with presbycusis. It may involve active listening training to augment the patient’s conversational listening skills from a cognitive standpoint. Auditory rehabilitation may also include speech reading (i.e., lip-reading) and other communication-enhancement skills. Patients can learn to assess a speaker’s facial expressions, lip contours, and body language. They are typically counseled to enhance environmental factors whenever possible by phasing out competing sound sources and optimizing the lighting to enhance visualization skills. Patients are encouraged to select restaurants and other venues based on acoustics and to position themselves to hear others better by sitting on the side with superior hearing (if their hearing loss is unilateral or asymmetrical). Most importantly, and yet sometimes most difficult, rehabilitation programs reinforce to patients that they must consistently inform their companions of their hearing loss. This disclosure allows others to optimize their communication patterns and facilitates communication. Despite observational reports, there is little evidence that auditory rehabilitation significantly improves communication for those with hearing loss (Blevins, 2022).

Those with presbycusis often utilize assistive auditory devices to enhance hearing and improve QOL or convenience. Options include flashing lights that correspond with doorbells or phone chimes to alert an individual with hearing loss when someone is at their door or their phone is ringing. Telecoils transmit sounds directly from a phone to an individual’s hearing aid. High-fidelity frequency-modulation systems are often useful in theaters or large lecture halls with troublesome acoustics. Closed captioning for television or movies is another example of an assistive listening technique. Cochlear implantation may be considered for patients who do not report significant improvement with hearing aids and have been diagnosed with severe bilateral presbycusis. This procedure involves the surgical placement of an electrode array in the inner ear to stimulate the remaining cochlear neurons, bypassing the damaged cochlea (Blevins, 2022).

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