Nutrition, Hearing and Vision, Falls

00:00 What about nutrition in older adults? In general, appetite and body weight decline with age and there is this reduction in lean mass and it’s replaced by fat mass.

00:11 That process continues during middle age through older adulthood until about age 65 to 70 years when it tends to stabilize.

00:20 Unintentional weight loss is a pretty common condition among older adults and it is associated with a higher risk for morbidity and mortality.

00:29 So, why do older adults lose weight? Of course, the big worry is cancer.

00:34 So, we have to think about the concept of an undiagnosed tumor in promoting weight loss.

00:40 I think much more commonly, it's due to psychiatric effects, depression and cognitive effects, early dementia.

00:50 And those are the reasons we might see some weight loss.

00:53 Don't forget about medications cause, many of which promote nausea or may cause constipation.

01:02 That can reduce appetite.

01:04 And then social isolation and changes in their social environment.

01:08 I always find that losing a special loved one, especially if they lived with that individual, is a high risk for weight loss.

01:17 And so, I've definitely seen that multiple times.

01:20 And that's where you want your social worker to be involved and/or a counselor, mental health professional.

01:27 But that said, in nearly 30% of cases, and depending on what study you’re looking at, the cause of the weight loss is unexplained.

01:37 So, standard workup for these patients with unexplained weight-loss, CBC, comprehensive metabolic panel, a TSH, a sed rate, lactate dehydrogenase level which is – can be a sign of tumor breakdown, and urinalysis.

01:52 So, one thing to consider would be an abdominal ultrasound for these patients looking for a tumor, but it’s a also good chance – again, if they have – particularly, if they have a good five-year life expectancy, maybe it's time to go and readdress.

02:06 You know, you never did get that second round of colorectal cancer screening.

02:10 We should order today.

02:11 Or breast cancer or whatever cancer has been left unscreened.

02:14 Maybe this is a good impetus to do it.

02:17 Let’s talk about hearing and vision among older adults.

02:19 Presbycusis is a very common condition.

02:23 It almost seems to be universal among older adults, and so that's usually associated with a high frequency hearing loss.

02:31 Yet, the Preventive Service Task Force recommends asking seniors about their hearing, but no objective testing is necessary on a broad basis.

02:39 For patients who failed – come in, I can’t hear as well, you put them through audiometry, usually it's a high-frequency hearing loss.

02:49 They should be referred to otolaryngology for anything like a failed hearing test if they have chronic otitis media or they have – certainly, if they have sudden hearing loss, but the treatment is usually going to be hearing aids for presbycusis.

03:03 And then also watch out for conditions such as macular degeneration for your exam.

03:07 It’s very important, macular degeneration versus a cataract, which is the central visual loss.

03:15 But the Preventive Service Task Force recommends against routine ophthalmoscopy, looking for evidence of any of these conditions.

03:24 Now, falls are an important cause of morbidity and mortality among older adults.

03:31 In 2014, it’s estimated that 27,000 seniors died related to falls.

03:37 And nearly a third of US seniors experienced a fall in 2014 and a third of those cases required medical attention.

03:46 So, they’re pretty serious.

03:48 So, one thing I really like is the Tinetti balance and gait evaluation.

03:53 The get up and go test is another term for this.

03:56 It's sitting in a chair, then getting up, walking 10 feet in front of you, turning around, walking back and sitting down.

04:04 So, if the timing on that is under 16 seconds, that's normal.

04:09 There are actually some nomograms that give patients a little bit more time based on their age.

04:15 So if they’re 94, they may not be able to the Tinetti test in the same time the 68-year-old does it.

04:22 But a good general rule on my practice is, if it's 15 seconds or less, they’re okay.

04:29 What does that mean they’re okay? It means that their risk of falling is lower.

04:33 They shouldn’t have a high risk of falls based on this evaluation.

04:37 That test has demonstrated good sensitivity for fall risk.

04:41 What should we be doing to prevent falls? For those patients with a positive Tinetti test and/or who have a history of fall, that's the best predictor as a history of previous fall.

04:51 Think about physical therapy and activity with targeted training.

04:55 So, a lot of times, they will have to – it's not just about doing just general exercise.

04:59 Try to do some targeted training and that’s where the physical therapies comes in.

05:04 Vitamin D isn't just healthy for bones.

05:06 It can actually help prevent falls.

05:08 So, these patients should be taking vitamin – all older adults should be taking a vitamin D and getting enough vitamin D in their diet.

05:16 And then securing the household environment.

05:17 This is something that a home visit can be really helpful to do.

05:22 So, avoiding clutter, avoiding loose rugs, those things that make people suffer mechanical falls.

05:27 And then thinking about assistive devices as well as equipment in the home such as a bedside commode, shower chair and grab bars that can prevent falls at the most frequent sites of serious falling.

05:41 Let’s talk about smart prescribing among older adults.

05:45 So, over a third of adults at age 60 or more take five or more prescriptions per day.

05:50 About half also take over-the-counter drugs at the same time.

05:55 There is a significant risk of drug-drug interactions.

05:59 About 1 in 20 – if you just take a bunch of random adults and pluck out their medications, about 1 in 20 has a risk of a serious drug-drug interaction.

06:09 And it's thought that 30% of admissions due to delirium and falls and also unnecessary hospital admissions are due to inappropriate drug interactions and/or side effects.