Basics
Description
- The keys to successful aging for the elderly female patient involve:
- Continuation of physical activity
- Maintenance of chronic medical conditions
- Prevention of cognitive impairment
- Prevention of morbidity in the form of falls, fractures, and preventable infections
- This chapter will focus on the prevention and management of cognitive and functional decline in older women.
Epidemiology
- Women live an average of 6 years longer than men: Current life expectancy for women is 79.9 years.
- Older women spend more years and a larger percentage of their lives disabled.
- Nearly 80% of all older persons living alone are women.
- Studies have shown that among community dwelling adults aged ≥65, the prevalence of severe cognitive impairment in women was 4.7%.
Risk Factors
- Cognitive decline
- Family history of dementia
- Cerebrovascular disease
- Traumatic brain injury
- Poor nutritional status
- Poor social networks
- Functional decline
- Widowhood
- Fractures/osteoarthritis
- Comorbid illnesses
General Prevention
- Cognitive decline
- Maintenance of social networks
- Mental exercises
- Proper nutrition
- Physical exercise
- Diagnose and treat osteoporosis
- Pain management for osteoarthritis
- Evaluation and adjustment of environment (grab bars, raised toilet seats, removal of hazards)
Associated Conditions
- Cognitive decline
- Depression
- Hypothyroidism
- Vitamin B12 deficiency
- Folate deficiency
- Functional decline
- Osteoporosis
- Osteoarthritis
- Sarcopenia - the age-related loss of muscle mass and strength
- Coronary artery disease/congestive heart failure
Diagnosis
History
History taking for cognitive and functional decline should include the following:
- Assessment of cognition
- When did the problem begin?
- Has it progressed and, if so, over how long a period of time?
- Assessment of activities of daily living (ADLs) (bathing, toileting, transferring, dressing, grooming, feeding, walking inside the home, getting into/out of bed)
- Is the patient disheveled?
- Can the patient walk around the home?
- Can the patient transfer into/out of bed?
- Can the patient feed herself?
- Review medications for drug interactions from polypharmacy and potential drug toxicities.
- Assessment of instrumental ADLs (transportation, shopping, meal preparation, housework, finances, telephone use, medication management)
- Medication noncompliance
- Is the house disheveled?
- Do utilities (gas, electricity) get disconnected?
- Are the patient's finances in order?
- Is the patient missing appointments?
- Are there signs of abuse or neglect?
- Assessment of comorbid conditions
- Cognitive decline
- Problems with memory
- Depression
- Social isolation
- Functional decline
- Weight loss
- Decreased ambulation
- Difficulty performing ADLs as listed above
Physical Exam
The physical exam should be comprehensive, including a thorough neurological and musculoskeletal exam as well as a gait assessment for those with functional decline.
Tests
- For cognitive decline:
- The Mini Mental State Exam (MMSE)
- Under copyright and therefore permission required for use
- The Montreal Cognitive Assessment (MoCA)
- Clock drawing
- The executive interview (EXIT) for those with suspected executive dysfunction
- The Geriatric Depression Scale (GDS) to assess for depression
- Neuropsychological testing if further differentiation is required for functional decline
- The "timed get-up-and go"ť test
- Katz activities of daily living scale
- Lawton instrumental activities of daily living scale
- Direct observation during exam
Lab
- For cognitive decline:
- CBC to rule out megaloblastic anemia
- Electrolyte panel
- Hyponatremia
- Elevated glucose
- Elevated BUN/CR signifying dehydration, acute renal failure, or uremia
- Hypercalcemia
- Liver function tests, if indicated
- Thyroid function tests
- Vitamin B12/folate levels
- For functional decline:
- Albumin/ prealbumin to assess nutritional status
- VDRL or vitamin B12 level
- Thyroid function tests
Imaging
- For cognitive decline: CT scan of the brain, if focal deficit on neurological exam
- For functional decline:
- Plain film, if localized pain is causing decline in function (back, hip, knees, etc.)
- DEXA to diagnose osteoporosis and initiate appropriate therapies to reduce fracture risk
- Consider cancer work-up (mammogram, CT abdomen/pelvis, colonoscopy, etc.) if indicated
Surgery
For functional decline: Joint replacement/fixation if so indicated
Differential Diagnosis
- For cognitive decline:
- Alzheimer's dementia
- Vascular dementia
- Dementia of Lewy bodies
- Parkinson's disease
- Depression
- Hypothyroidism
- Pick's disease
- Normal pressure hydrocephalus
- For functional decline:
- Depression
- Malnutrition
- Osteoarthritis
- Stroke or other neurological condition
- Undiagnosed dementia
Treatment
Medication
Review current medications (including over-the-counter/alternative medications) that may contribute to cognitive or functional decline.
For cognitive decline:
- Cholinesterase inhibitors (for mild-to-moderate dementia) (1,2)[B]
- Donepezil (Aricept™):
- Start with 5 mg PO q.h.s.
- May increase to 10 mg PO q.h.s. in 4-6 weeks if tolerated
- Max dose of 23 mg may be used for moderate-to-severe disease.
- Rivastigmine (Exelon™):
- Start with 1.5 mg PO b.i.d. with food
- May increase to 3 mg PO b.i.d. in ~2 weeks (max dose 12 mg/day)
- Also comes in transdermal formulation (dose range 4.6-9.5 mg/24 hours)
- Galantamine (Razadyne™):
- Start with 4 mg PO b.i.d. with meals
- May increase to 8 mg PO b.i.d. after 4 weeks, then 12 mg PO b.i.d. after 4 weeks, if tolerated
- NMDA receptor antagonists (for moderate-to-severe dementia) (1)[B]
- Memantine (Namenda™):
- Has a titration schedule
- Increase by 5 mg/day at weekly intervals to a max dose of 20 mg/day
- Doses >5 mg/day should be divided b.i.d.
- Vitamin B12 and/or folate, if indicated
For functional decline:
- Osteoporosis treatment and prevention (3)[A]
- Bisphosphonates
- Must be taken as directed to avoid possible GI side effects (i.e., dyspepsia and esophagitis)
- Osteonecrosis of the jaw is a rare complication that should be discussed with patients.
- Alendronate (Fosamax™):
- Prevention: 35 mg PO weekly
- Treatment: 70 mg PO weekly
- Risedronate (Actonel™):
- Prevention/treatment: 35 mg PO weekly
- Ibandronate (Boniva™):
- Prevention/treatment: 150 mg PO qmonth (on same day of each month)
- Raloxifene (Evista™):
- Prevention/treatment: 60 mg PO daily
- Increased risk of venous thrombosis and exacerbation of hot flushes
- Calcitonin (Miacalcin™):
- Treatment: 200 units nasal spray per day; 100 unit SC/IM alternative is available
- Parathyroid hormone/teriparatide (Forteo™)
- Treatment: 20 ÎĽg daily SC injection
- Anabolic agent for postmenopausal women at high risk for fracture
- May cause leg cramps and dizziness
- Avoid in patients with increased risk of osteosarcoma
- Calcium: 1,200-1,500 mg/day
- Vitamin D: 400-800 units/day
- Multivitamins
Additional Treatment
Issues for Referral
- For assessment of cognitive decline:
- Geriatrician for comprehensive geriatric assessment
- Geriatric psychiatry
- Neurology/dementia specialists
- Neuropsychologist
- Driving safety assessment
- For assessment of functional decline:
- Physical therapy
- Occupational therapy
- Visiting nursing
- Social work
Additional Therapies
- For functional decline:
- Physical therapy
- Home safety evaluation
- Gait assessment
- Ambulatory aids
Ongoing Care
Follow-Up Recommendations
- An adjustment or change in environment may be beneficial.
- Home care companions or certified nursing assistants to assist in ADLs
- Involvement of family members in supervision of medications and physician visits
- Senior housing
- Adult day care
- Assisted living facilities
- Skilled nursing facilities for rehabilitation
- Hospitalization if acute changes in cognition or function raise concerns for delirium and an underlying acute medical condition.
Patient Monitoring
Outpatient assessment of cognitive and functional decline should include serial monitoring of each condition every 3 months.
Prognosis
The prognoses for cognitive and functional decline are variable depending on the reversibility of symptoms.
Complications
Complications for both conditions include:
- Higher risks of morbidity and mortality
- Nursing home placement
- Falls, fractures
- Accidents
References
1Qaseem A, Snow V, Cross T. Current pharmacologic treatment of dementia: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2008;148:370-378. [View Abstract]2Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006, Issue 1. Art. No. CD005593. [View Abstract]3Qaseem A, Snow V, Shekelle P. Pharmacological treatment of low bone density or osteoporosis to prevent fractures: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;149:404-415. [View Abstract]
Additional Reading
1Liu CK, Fielding RA. Exercise as an intervention for frailty. Clin Geriatric Med. 2011;27:101-110. [View Abstract]2 at http://www.aoa.gov [Accessed May 20, 2011].3 Available at http://www.aagponline.org [Accessed May 20, 2011].4 The state of aging and health in America, 2007. Available at http://www.cdc.gov/aging [Accessed May 20, 2011].5 The state of mental health and aging in America, 2008. Available at http://www.cdc.gov/aging/mentalhealth [Accessed May 20, 2011].
Codes
ICD9
- 290.0 Senile dementia, uncomplicated
- 715.90 Osteoarthrosis, unspecified whether generalized or localized, site unspecified
- 780.97 Altered mental status
- 311 Depressive disorder, not elsewhere classified
- 783.7 Adult failure to thrive
- 263.9 Unspecified protein-calorie malnutrition
ICD10
- F03.90 Unspecified dementia without behavioral disturbance
- G31.84 Mild cognitive impairment, so stated
- M19.90 Unspecified osteoarthritis, unspecified site
- M81.0 Age-related osteoporosis w/o current pathological fracture
- F32.9 Major depressive disorder, single episode, unspecified
- R62.7 Adult failure to thrive
- E46 Unspecified protein-calorie malnutrition
SNOMED
- 386806002 impaired cognition (finding)
- 52448006 dementia (disorder)
- 396275006 osteoarthritis (disorder)
- 64859006 osteoporosis (disorder)
- 35489007 depressive disorder (disorder)
- 129588001 adult failure to thrive syndrome (disorder)
- 2492009 nutritional disorder (disorder)
Clinical Pearls
- Successful aging includes maintenance of cognitive and functional abilities.
- Cognitive decline is common in older women and results in reduced quality of life and dependence.
- Functional decline is a common marker of many illnesses or conditions. It can also be a marker of an individual's prognosis and ability to recover from illness.