Current Geriatrics Reports

Aging is a major risk factor for venous thromboembolism. Compared to the general population, the elderly have a much higher 1-year mortality from venous thromboembolism (VTE). Clinical presentation of VTE in the elderly tends to be different, with atypical symptoms being more common than in the general population. Diagnostic work-up starts with establishing a VTE pretest probability followed by D-dimer testing for patients with low pretest probability and confirmatory testing for patients with high pretest probability of VTE. The age-adjusted D-dimer cutoffs are associated with a higher specificity without compromising the test’s sensitivity. Anticoagulation is the cornerstone of VTE therapy. The use of novel oral anticoagulants is safe in elderly patients and is associated with a decreased risk of bleeding.

As the population ages and the number of patients with multimorbidity increases, geriatricians will benefit from having strong primary palliative care skills. To identify educational resources that show promise as potential tools for geriatricians wishing to improve upon their primary palliative care skills. The objective of this review was to determine the current resources and advances in primary palliative care education for geriatricians. The review encompassed literature written between 2018–2022 accessed via PubMed and Google Scholar. From the review process itself, we learned that there is no standard definition of primary palliative care (PPC) and that different domains of PPC are often taught and studied separately. While many aspects of palliative care are now incorporated into the geriatric medicine fellowship educational milestones, the PPC competencies for practicing geriatricians remains ill-defined. This suggests that creating a standardized definition of PPC will benefit future research and help better define the scope of both palliative care and geriatric medicine. Furthermore, the majority of PPC offerings are piecemeal in nature with significant variety in cost and educational content. PPC education is often marketed to a wide range of practitioners and there exists little geriatric-specific PPC education. PPC education designed specifically for practicing geriatricians who may not have had the benefit of a more recent fellowship experience remains an area primed for further opportunity and expansion.

Providing individualized care to older adults hinges on understanding their goals. The “Four M’s” - ?What matters most, medication, mentation and mobility - provides a framework for understanding an individual’s health care goals. “What matters most” is perhaps the anchor of the four and is often the most difficult to determine. Starting with understanding “what matters most” to an individuals helps those providing health care align diagnostic and treatment decisions with the patient’s health care preferences.

With no disease-modifying treatments for Alzheimer’s disease (AD) currently established, a priority for public health is prevention of cognitive decline and dementia. Treatment and prevention of cardiovascular disease (CVD) may provide such an opportunity. While the pathology of athero- and arteriolosclerotic cerebrovascular disease was once thought of as distinct from AD pathobiology, accumulating evidence suggests that there is more overlap in vascular and AD-related pathologies than previously recognized. CVD and its risk factors are associated with cognitive decline and dementia, in multiple studies. Given that CVD is prevalent among older adults, understanding the contributions of vascular disease to dementia is an important area of research. While the exact relationship remains to be defined, several mechanisms linking CVD to dementia have been proposed: [1] CVD and dementia have shared risk factors, which might alter clearance of brain toxins or otherwise increase neurodegeneration; [2] CVD might lead to clinical or subclinical strokes, leading to cognitive impairment; and [3] CVD might directly alter cerebral perfusion. Most prior work has focused on risk factors for CVD, but the relationship between end-organ CVD itself and dementia is of extreme importance in considering prevention. Earlier intervention might be the most beneficial since CVD risk appears to have strongest relationships with cognition when measured years before the onset of dementia. The practicing physician should see such evidence as an impetus to aggressively address both symptomatic CVD and CVD risk factors, not only in their elderly patients but importantly in those of middle age.

Infections and subsequent sepsis are an increasing cause of hospital admission and critical illness in the elderly population. The risk factors that predispose elderly patients to infections, such as comorbidities and frailty, also contribute to prolonged recovery times and subsequent mortality. Elderly patients may present with atypical symptoms such as delirium and remain afebrile thus delaying the diagnosis of infections. White blood cell count is not as useful in the diagnosis of infection as other biomarkers such as procalcitonin. Once an infection has begun, the elderly patient has less physiologic cardiac and respiratory reserve and develops end organ damage more rapidly. Frailty itself is strongly associated with high rates of first time sepsis. Mortality risk from sepsis clearly increases with age. Appropriate antibiotics and source control are necessary components of sepsis management as is early fluid resuscitation. Fluid resuscitation must be performed judiciously with appropriate endpoints utilizing bedside cardiac ultrasound and IVC collapsibility to avoid fluid overload. Acute kidney injury (AKI) occurs in 1/3–2/3 of elderly septic patients and increases mortality. AKI is potentially preventable with appropriate and timely fluid resuscitation and avoiding nephrotoxic medications including loading doses of vancomycin, limiting aminoglycoside exposure to < 3 days, and minimizing colistin use. Source control within 12 h when appropriate improves outcome. Specific infections, including Clostridium difficile, community-acquired pneumonia, and urinary tract infection, pose unique challenges in the elderly. Early goals-of-care discussions emphasizing potential complications and undesirable outcomes must be discussed when caring for critically ill elderly patients. Early recognition of sepsis via identification of atypical signs and symptoms in elderly patients is critical. This allows for timely and appropriate therapy to decrease the incidence of end organ damage and mortality in high-risk elderly patients.

Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs. We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record. Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip

COPD exacerbations are widely recognised as a significant cause of mortality and morbidity through their impact on respiratory function but their effect on skeletal muscle function and mass receives less attention. In this article, we review the association of this entity with COPD, the potential contributing factors, and the evidence behind the interventions available to manage this condition with a focus on the elderly population. In patients with COPD, there has been a paradigm shift from the focus on body weight and mass index to a more detailed assessment of the loss of muscle mass and function defined as sarcopaenia. Factors that can potentially lead to sarcopaenia has been the subject of multiple basic science and translational research studies. Interventions that have been proven to be associated with clinically significant outcomes in COPD patients include early mobilisation, inpatient exercise programmes, early pulmonary rehabilitation, and nutritional interventions. Prolonged courses of steroids following an acute exacerbation are non-beneficial and can lead to loss of muscle function. Multiple factors can potentially contribute to sarcopaenia among patients admitted with COPD exacerbations and should be identified early and treated in a multidisciplinary setting. Nutritional interventions, early mobilisation, and limitation of systemic steroid prescribing are simple and effective interventions that should be utilised.

Diffuse parenchymal lung diseases comprise a heterogeneous group of disorders with varying clinical, physiologic, radiographic and pathologic presentations. Age of onset varies considerably. Interstitial lung abnormalities, and in particular, idiopathic pulmonary fibrosis (IPF), occur much more commonly in older persons. In recent years, advances have been made in understanding IPF pathogenesis and changes have occurred in relation to how IPF is managed. The cause of IPF remains unclear. It is thought that a non-specific injury in susceptible individuals triggers a progressive fibrotic response. Genetic susceptibility is increasingly recognised. Multidisciplinary team input is essential for making a diagnosis. Although, originally thought to be an inflammatory process, it has been shown that anti-inflammatory therapies may, in fact, be harmful to the patient. Two anti-fibrotic therapies (pirfenidone and nintedanib) are now available. There is a better recognition of prognosis and improved symptom control and management of end of life issues. As life expectancy increases, further studies are necessary to assess the impact and natural history of interstitial lung diseases in the elderly.