Current Geriatrics Reports

Iron deficiency in heart failure has been associated with impaired functional capacity and quality of life. The purpose of this paper is to review mechanisms of iron homeostasis and current clinical data exploring mechanisms of iron repletion in heart failure. Multiple international societies now advise iron repletion for symptomatic heart failure patients with iron deficiency. Due to the chronic inflammation in heart failure, iron deficiency in heart failure is classically defined as ferritin < 100 µg/L or ferritin 100–300 µg/L and transferrin saturation < 20%. Multiple randomized clinical trials have demonstrated benefit from intravenous iron repletion, though studies have predominantly focused on functional capacity and quality of life. A recent study, AFFIRM-AHF, supports the treatment of iron deficiency identified during acute heart failure admissions, noting a reduction in future heart failure hospitalizations. Studies examining iron repletion in patients with heart failure with preserved ejection fraction are currently in process. Iron homeostasis is maintained predominantly through the regulation of iron absorption, keeping iron levels tightly controlled in the normal state regardless of iron intake. In chronic heart failure however, iron homeostasis becomes dysregulated with resulting iron deficiency in many patients, with and without associated anemia. Iron is a critical element not only for erythropoiesis and oxygen carrying, but also for energy production at the level of the mitochondria and in other cell processes. We thus propose a standardized approach be utilized to screen and treat heart failure patients with iron deficiency.

There is limited good-quality research focused on the prevention and management of pressure ulcers. Current available evidence reveals that the following approaches may help to prevent pressure ulcers: the use of support surfaces such as specialized foam and specialized sheepskin overlays, mattress overlays on operating tables, consultation with a dietician to ensure adequate general nutrition, but it is not known whether any specific supplementation is useful, and moisturizing dry sacral skin. For management of existing pressure ulcers, it is unknown whether any specific support surface or dressing is preferable to any others; whether routine nutritional supplementation is beneficial, or if adjunctive therapies improve healing compared with standard care. Current evidence shows that the presence of increasing pain may make infection of a chronic wound more likely. There may be individuals for whom pressure ulcers are unavoidable. Risk assessment tools may be useful for identifying individuals at high risk for developing pressure ulcers.

Affecting more than 5.1 million Americans in 2013, heart failure (HF) is a debilitating syndrome that causes dyspnea, reduced exercise tolerance, fatigue, and diminished quality of life. Most commonly diagnosed in individuals over 65 years of age, the prevalence of HF and its associated health care costs are expected to grow significantly. Aerobic exercise, resistance training, and inspiratory muscle training (IMT) are interventions that are currently used in the treatment of older adults with HF. A literature search was conducted for meta-analyses, systematic reviews, and large randomized control trials to evaluate the effect of aerobic exercise, resistance training, and IMT interventions on exercise tolerance and quality of life in individuals with HF. Overall, aerobic exercise, resistance training, and IMT appear to be safe and effective in appropriately selected individuals for improving exercise tolerance and quality of life in individuals with HF. The benefits of resistance training in isolation are not clear.

Colon cancer is one of the most common malignancies affecting older adults. Studies suggest that older adults are less likely to receive standard treatments, such as curative surgery or chemotherapy, compared to their younger counterparts, despite evidence suggesting that fit older adults derive equal benefit. The patient’s overall health, life expectancy from non-cancer conditions, and personal preferences are important considerations in decisions with regard to colon cancer screening and management of early-stage or metastatic disease. Geriatricians can help oncologists better understand an older adult’s overall health and life expectancy from a non-cancer point of view and can help elucidate patient goals of care, advocating for screening and chemotherapy in those who are healthy enough, and helping to prioritize goals of care when patients have other life-limiting illnesses that may preclude cancer treatment. This manuscript will attempt to provide practicing geriatricians with evidence-based data regarding the management of colon cancer in older adults.

Dementia detection in the community is challenging. The purpose of this paper is to review methods of dementia screening and provide a useable algorithm for screening for dementia a variety of clinical settings. In recent years, a number of brief performance and informant-based assessments have been developed and validated in research, clinical, and community samples. These assessments are now complemented by patient self-reports that afford the ability to detect subjective cognitive impairment. An optimal approach to dementia screening is to combine performance, informant, and self-reports, many of which can be completed in the waiting room or by non-physician staff prior to the start of the office visit. This diverse information may help inform the provider as to the presence or absence of a cognitive disorder, assist in staging the extent of the disorder, and help to develop a differential diagnosis and management plan.

Epigenetic mechanisms are essential in a host of biological processes and many different human diseases. Epigenetic modifications include DNA methylation, histone modification, non-coding RNA, and nucleosome positioning. In neuronal systems, extensive studies have revealed important regulatory roles of DNA methylation in brain function, from the embryonic stage through the process of aging. Here we review recent evidence that DNA methylation is involved in aging, learning and memory, and neurodegenerative diseases, including Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, and CGG repeat-induced neurodegenerative disorders. We also explore the dynamics of DNA methylation.

Approximately half of all patients with type 2 diabetes develop peripheral neuropathy, which contributes to functional decline and significantly reduces quality of life. Type 2 diabetes and consequent diabetic peripheral neuropathy share several pathogenic mechanisms and are both positively influenced by increased physical activity and exercise even prior to disease diagnosis. Successful exercise interventions in individuals with diabetic peripheral neuropathy have employed continuous endurance, resistance, balance and agility, and high-intensity interval training protocols and have been associated with improvement in stability, gait, sensory function, nerve regeneration rates, pain, mood, and quality of life. Recent evidence has shown no increased prevalence of foot trauma in those with diabetic peripheral neuropathy suggesting that weight-bearing exercise is safe in the absence of active ulceration. While exercise is often associated with improved glycemic control, several studies suggest improvement in neuropathy is independent of improved glycemic control or weight reduction, suggesting other metabolic effects, or exercise-related physiologic changes are important.

Major abdominal surgery in the elderly is challenging and complex. Frailty as a clinical entity in the elderly is increasingly recognized as a useful assessment tool to identify at-risk patients. We aim to review recent literature on frailty in surgical preoperative evaluation and postoperative recovery and determine its applications in emergency surgery. Frailty has been established as an independent predictor of morbidity and mortality in elderly surgical patients. Individualized treatment goals and tailor-made interventions to optimize clinical conditions in frail patients before and after surgery improve outcomes. Sarcopenia is increasingly recognized as a predictor of poor surgical outcome in elderly; its use in emergency surgery is promising. More research into this area is needed. Frailty is a useful tool to identify at-risk patients for optimization and targeted intervention before major surgery. To meet the complex needs of these patients, an integrated transdisciplinary approach is recommended.

Community-based exercise and fall prevention programs afford older adults the opportunity to engage in group-based activities that promote health and wellness, physical activity, and social interaction. This review will analyze eight programs, commonly offered to older adults, that utilize various instructional modes to target health promotion through exercise, falls efficacy, and education. All of the programs are supported by randomized control or quasi- experimental designs and have been found to reduce falls, reinforce falls efficacy, or improve some aspect of functional mobility. Program designs vary and include seminar-style instruction, exercise class activities, or a hybrid approach with interprofessional outreach. Physical performance benefits are based on a variety of outcomes. The Timed Up and Go (TUG) assessment was the most frequently administered outcome among programs, though the magnitude of improvement varied. Programs have become more accessible as outreach has extended to rural underserved areas and nontraditional settings such as faith-based organizations. Community-based programs offer older adults health promotion opportunities through exercise and education initiatives. Program designs vary and target different constructs of exercise and wellness to meet the needs of a wide variety of aging seniors. As a result of large-scale dissemination endeavors, programs are now extending to rural areas while maintaining operational fidelity.