Geriatric Rehabilitation

As we age, we face many physical and emotional changes that can affect our level of function and well-being. Our baby-boomer population is aging, and people are living longer. We must maintain functional independence in the elderly and address the needs of our older generation. Rehabilitation of geriatric patients is imperative for the patients' well-being and for society, so that we can thrive socially and economically. ^[1]

Essential to geriatric rehabilitation is communication, specifically improving any sensory impairment, including those related to vision and hearing. The prevention of falls and osteoporosis can protect the patient's health and improve longevity. Addressing malnutrition can promote healing and vitalize the patient to participate in a formal rehabilitation program. Depression is common in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. ^[2] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below.

Educating our peers and using these guidelines in our practice will enhance the quality of life of the geriatric patient.

In a meta-analysis of randomized controlled trials (N=10,315) in 6 countries, comprehensive geriatric assessment (CGA) was compared with usual care. The results determined that CGA, especially if given in designated wards, increased a patient's chance of being alive and living in his or her own home after an emergency hospital admission. A cost reduction was also realized compared with general medical care. ^[3]

Lifestyle factors such as not smoking and engaging in physical activity are associated with longer survival, even after age 75. ^[4]

Overview

One of the greatest challenges in the geriatric population is their ability to communicate their problems, needs, and desires in a medical setting. Hearing and visual impairments can hamper a patient's ability to express himself or herself clearly or to understand questions or commands. This is an enormous burden on the patient, the caregiver, and the physiatrist as they work to achieve rehabilitation goals. Addressing these issues on the patient's initial visit can ameliorate problems and prevent frustration and further difficulties.

Auditory Impairment

How many times have you had to shout at a patient? The likelihood that a patient over the age of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly.

Not all hearing impairments are reversible. Examples of impairments that are potentially reversible involve cerumen, cholesteatomas, or acoustic neuromas. These conditions should be recognized and the patient referred to an appropriate subspecialist, such as an ear, nose, and throat (ENT) specialist or a neurosurgeon. Initial otoscopic examination for cerumen or serous otitis is essential. Cerumen obstruction often contributes to hearing loss, and its removal can dramatically improve auditory acuity. This examination should be performed prior to any testing for hearing loss. Otosclerosis or noise-related cochlear damage can be surgically treated with bone removal or cochlear implants, respectively.

However, gradual decline in hearing acuity, or presbycusis, is due to degeneration of the organ of Corti, and it can simply be a result of aging. Most people acquire a conductive hearing loss with a narrow range of audibility, an inability to hear high-frequency sound, and difficulty in discriminating complex sounds. Hearing deficits are associated with paranoia, and they can also lead to depression, anxiety, and insecurity. Safety concerns are also an issue in the hearing impaired, and these issues need to be addressed as a part of aural rehabilitation.

Consequences of auditory impairment

Hearing loss has a major contribution to communication and quality-of-life issues. People who use hearing aids are more likely than others to report improvements in their physical, emotional, and social comfort. In a study by Keller et al, patients with intact hearing scored 2 points higher than did patients with hearing impairment. The investigators also found that patients with intact hearing also scored 6 points higher for instrumental ADLs (IADLs). IADLs include pertinent life tasks, such as writing checks and interacting with the public during financial transactions (ie, grocery shopping). These findings represent a significant difference in ADLs and IADLs and shows that hearing loss can affect a person's functional status.

This possibility for improved function emphasizes the need for hearing evaluations and treatment to help the patient make the maximal gains possible during rehabilitation. The individual's ADL functional level in the rehabilitation setting often determines his or her need for in-home supervision, assistance (eg, during bathing), and ancillary services (eg, those provided by social service organizations such as the Department on Aging and Meals on Wheels). Again, enhanced communication during therapy is important because entire functional independence measure (FIM) scores can be upgraded with this measure alone.

Hearing loss can result in withdrawal, poor self-concept, depression, frustration, irritability, cognitive impairment, isolation, loneliness, and compromised physical mobility. Solutions to hearing impairment positively affect one's daily functioning and psychosocial well-being. Improvement is noted in various areas: communicating the needs of daily living, telephone communication (social and emergency situations), psychosocial behavior, family relationships, enjoyment of leisure activities, and ability to live independently and safely. The financial costs of a simple hearing aid, approximately $500-$3000, are modest given the expected improvement in the quality of life and functional status of the person who uses it.

Screening for hearing loss is a valuable tool for early intervention. It is useful to ask patients and their family members about any changes in the patient's hearing, the onset and progression of impairments, and the sidedness of symptoms (ie, whether they are unilateral or bilateral). Further investigation can reveal a patient's difficulty in understanding women and children (because of the higher frequency of their voices), telephone conversations, television sounds, or voices when more than 1 person is speaking. Also, an avoidance of family functions, movies, and religious services because of changes in hearing is an important indicator of the severity of the disease. Such behavior indicates a significant functional loss.

Hearing acuity can be tested by using simple methods such as asking the patient to identify the presence of 2 fingers rubbing together by his or her ear. Difficulties with speech comprehension can be evaluated by using the whisper test, in which one whispers 10 words while standing 6 inches behind the patient. If the patient cannot repeat 50% of the words, he or she may have dysfunctional auditory processing. Unfortunately, the whisper test has only moderate repeatability.

When a hearing impairment is established, a formal consultation with an audiologist and the involvement of a speech and language pathologist are pertinent. Speech therapists can begin cognitive testing and provide continuous enhancement of a patient's communication skills during audiologic assessment and aural rehabilitation. There are a growing number of underserved individuals with a combination of multiple sensory, physical, and cognitive impairments, and all of these issues must be identified in the rehabilitation setting.

Management of auditory impairment

Audiologists perform quality control, physical fitting, and performance assessment of hearing aids to ensure that treatment goals have been met. Audiologists instruct patients and their families about proper use and care of hearing aids. Audiologists must also train allied health professionals and support staff who work in rehabilitation facilities regarding daily monitoring as part of a comprehensive hearing support program.

If the patient's vision is adequate, speech therapists often incorporate speech (lip) reading and the use of hand signs, gestures, writing boards, and/or magnetic boards to overcome communication barriers. A well-lit environment is effective for augmenting auditory input to a patient who also requires visual cues. It is important for the physician and staff to establish good visual contact while facing the patient, to reduce background noise, to rephrase misinterpreted words instead of simply repeating them, and to pause at the end of phrases or ideas. Standing 0.75-1 m from the patient and speaking slightly louder also facilitates communication.

Most patients achieve a substantial benefit with speech reading and audiovisual integration training; for example, recognition can be improved by as much as 26%, as Grant reported. The amount of visual influence is correlated with enhanced auditory recognition. Also, simple modifications, such as carpeting common areas to reduce reverberation and establishing quiet areas, can improve communication with the patient.

Assistive listening devices such as closed-captioned television and telephone amplifiers may help patients in performing their ADLs. Safety is also a focal rehabilitation issue because many warning signs (eg, cars on the road, ambulances, fire alarms) are auditory. Addressing safety issues is salient in ordinary and emergency situations, and adaptive devices that vibrate or that have flashing lights (eg, adapted fire alarms, telephones, doorbells) should be incorporated into the patient's home and rehabilitation setting.

In geriatric patients, the primary treatment for loss of auditory sensitivity caused by sensorineural hearing loss is the use of a hearing aid, as part of a total aural rehabilitation program. Modern hearing-aid technology has been advancing, and current aids can help in reducing the communication problems of individuals with hearing impairment. Hearing aids consist of the following components: a microphone (to pick up a signal), an amplifier (to make sounds louder), a receiver (to deliver sounds), a battery, and an ear mold with tubing. Different types of hearing aids include conventional analog; programmable; and digital types, which have the least amount of distortion.

Audiologists must conduct a thorough evaluation, including impedance audiometry to assess the patient's middle-ear function and a check of the acoustic reflex to match the appropriate external and internal features of the hearing aid to the needs of the patient. Psychologically, patients are good candidates for hearing aids if they are not concerned about the possible stigma attached to the cosmesis of hearing aids. Socially, patients should have support networks, which can assist them with the insertion, removal, and adjustment of the hearing aid if needed.

In hearing-impaired patients, rehabilitation comprises the provision of a custom-fitted hearing aid and instruction on its use and maintenance. Progress during rehabilitation depends on patient and family education to help the patient adjust to the hearing loss and the use of hearing aids. Family training with a speech therapist is also crucial to teach them about auditory enhancement techniques and communication skills. Organizations such as the American Speech-Language-Hearing Association (ASHA) and the Hearing Loss Association of America (HLAA) can provide patients and their families with information about hearing loss and aural rehabilitation and also about support groups.

Improving the geriatric patient's ability to hear can lead to significant gains in terms of rehabilitation and the patient's overall quality of life. Physicians should evaluate their patient's hearing on a regular basis and consider the management of hearing deficits as they care for their patients.

Visual Impairment

With aging, the gradual deterioration of sensory modalities, including vision, can interfere with one's daily activities. Nearly 7% of patients admitted to inpatient rehabilitation units have a severe visual impairment. A visual impairment is defined as visual acuity of 20/40 or worse, and legal blindness is defined as visual acuity of 20/200 or worse.

Testing for near vision is performed independently in each eye, with the aid of glasses (if worn). The patient holds the Rosenbaum card at a reading distance of 14 in. Or, if the Lighthouse near-acuity test is used instead, the card is held at 16 in. Far-vision testing can be accomplished with the Snellen wall chart at a distance of 20 ft. The patient's visual fields should also be checked for peripheral vision, hemianopsia, and other conditions. The extraocular muscles should be evaluated during the physical examination as well. An ophthalmoscopic evaluation for drusen, hemorrhages, and ischemia should be performed.

If any change in vision is noted or if the patient reports a functional deficit, follow up with an ophthalmologist is warranted to evaluate and issue the proper low-vision aids. Prevention is managed by performing biennial full-eye examinations in people older than 65 years, with annual evaluations in those with diabetes.

The most common visual change with increasing age is a gradual loss of the ability to focus on near objects (presbyopia). By the age of 75 years, 92% of individuals have presbyopia. Cataract formation (lens opacity) occurs to some degree in 95% of people older than 65 years. ^[5]

Geriatric patients are also prone to further visual impairments such as glaucoma (intraocular pressure >21 mm Hg), which can be medically or surgically managed; age-related macular degeneration (ARMD), which involves atrophy of the central macular cells in the retinal pigment; and diabetic retinopathy (eg, microaneurysms, dot hemorrhages), which can be managed with glycemic control or laser surgery. The result of these various changes is a loss of visual acuity, decrease in peripheral vision, and a decline in dark adaptation ability. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night.

Correction and management of visual impairment

In the majority of the geriatric population, eyeglasses are sufficient to correct the visual impairments described above. However, for those who have become legally blind, the adjustment is difficult. Unlike individuals who were blind from an early age and who learned Braille as part of their developmental language, those who become legally blind in adulthood rarely master Braille for communication purposes. They focus primarily on tactile interpretation for face-to-face communication. Speech therapists are instrumental in improving the patient's communication skills in this situation.

Low-vision rehabilitation includes the use of adaptive optical devices that improve illumination and increase contrast and magnification. Transitional-lens eyeglasses reduce the symptoms of glare and photosensitivity and automatically adjust to the ambient light so that the patient does not need to have separate pairs of glasses for inside and outside use. Prism glasses can aid in expanding the patient's visual field. Binoculars or clip-on monocular telescopes are conventionally used to observe sporting events or for bird watching. Low-vision aids are an effective means of visual rehabilitation, helping almost 9 of 10 patients with an impaired ability to read.

Large-print material and devices (eg, telephone with large numbers) can facilitate the patient's daily activities. Similarly, talking clocks and watches are also useful. Handheld or standing magnifying glasses are inexpensive and effective for reading small print, such as that on price tags or financial statements.

Tactile feedback is important in patients with visual impairment; therefore, raised-dot dials on kitchen appliances are a preventive safety measure. Auditory assistance is also important. Books on audiotapes and closed-circuit televisions are available for the patient's leisure. In patients with ARMD, the presentation of 1 word at a time in the center of a display screen is easier than scrolling across the screen to read filtered text. Text filtering can help in enhancing images shown on digitally based viewing devices (eg, televisions, computers) and can be helpful in those with visual impairments; such text filtering should be tailored to the needs of the particular patient.

An occupational therapist, rehabilitation nurse for the blind, or teacher can instruct the patient about how to use labeling systems to identify their clothes and medication, among other items, and patient can learn to fold their money in various ways to indicate the denomination. Other environmental considerations include the use of floor lamps to reduce glare and the installation of motion sensors to turn on lights. Mobility aids include a long cane, a guide dog, or a friendly arm.

Consequences of visual impairment

Vision impairment exerts a more wide-ranging impact on functional status than does hearing impairment. Visual impairment is associated with increased physical disability, increased social isolation, low employment rates, reduced self-image, and depression. Physical disabilities include a decreased ability to perform ADLs and IADLs decreased physical endurance and mobility, and a lack of participation in activities.

Vision, proprioception, and vestibular function are the 3 main components of sensory feedback to maintain normal upright stance. Therefore, a loss of vision is associated with an increased risk of falling with a consequent increased risk of hip fractures. The patient's mental health can also deteriorate with vision loss, and the effects can include depressive episodes. Social isolation, in which the person feels left out and lonely, can lead to depression. Neuropsychologists may alert physicians about the patient's mood. The patient's primary physician should be aware of any vision impairment that might be improved with devices or environmental changes; these treatment approaches must not be overlooked in the rehabilitation setting.

Utilization of healthcare resources and assistance increases in the geriatric population with visual impairment because of their decreased level of function overall. The degree of visual impairment prevents most of these individuals from performing many ADLs and IADLs. Keller et al note an 18% visual impairment rate in a large cross-section of the geriatric population in one clinic. ^[6] Mean functional status scores for patients with good visual acuity are higher than those with visual impairment; scores are 2 points higher on ADL assessment and 6 points higher on IADL assessment, which includes an evaluation of the person's ability to manage his or her finances, medication regimen, meal preparation, housekeeping, shopping, uses of a telephone, and transportation.

Low vision frequently coexists with other disabilities, including hearing loss, cognitive impairments, and mobility limitations. Dual sensory loss involving visual and hearing impairments is associated with a significant decrease in function, compared with the effect of a single sensory loss.

Data from the 1997 Survey of Income and Program Participation (SIPP) show that 12.1% of the geriatric population have difficulty seeing the words and letters in newspapers, even when wearing glasses or contact lenses. Of that group, 3.3% are unable to see the words and letters at all, while 8.8% had less-severe visual problems. These facts cause concern because 70-80% of the geriatric population still live in their own homes, many alone, and these individuals still need to perform IADLs, in many cases without assistance.

The geriatric population with dual visual and hearing impairments is 2 times more likely than those without such impairments to have difficulty with ambulation, transferring, meal preparation, and managing their medication regimen. According to the 1999 Surveillance for the Sensory Impaired study, older adults who reported vision and hearing loss were more likely than those without sensory impairment to have had the following: (1) a fall during the preceding year (37.4% vs 19.8%), (2) a hip fracture (7.6% vs 4.5%), (3) a higher reported prevalence of hypertension (53.4% vs 44.3%), and (4) a higher rate of heart disease (32.2% vs 20.6%). In addition, these older adults with dual impairments were twice as likely as the others to have a stroke (17.4% vs 7.3%).

Conclusion

Greater attention to sensory impairments by clinicians, public health advocates, and researchers, as well as patient and family education and compliance, are needed to enhance function and progressive rehabilitation in the geriatric population.

Falls and near-falls occur in more than 30% of people aged 65 years or older. Every year, 50% of people in the community older than 80 years have a fall, and approximately 60% of nursing home residents fall each year. The incidence of falls in the elderly is growing every year, reflecting the growth of the elderly population. By the year 2050, the projected proportion of people older than 65 years will be 23%. Women experience a greater proportion of falls because they make up the majority of the total population as they age, a difference mostly due to the earlier mortality of men.

Injuries occur in 10-20% of falls, and 3-5% of injuries result in fractures. About 10% of all falls have consequential injuries that are deemed serious; examples include fractures, joint dislocations, and severe head injuries. Approximately 90% of fractures in the hips, pelvis, and forearms result from falls. The mortality rate for a patient in the year after a fall resulting in a hip fracture is 14-36%. Of those experiencing hip fractures after a fall, 25-75% have lingering functional impairments. According to a study by Florence et al, in 2015 an estimated $50.0 billion in medical costs could be attributed to fatal and nonfatal falls in US adults aged 65 years or older. ^[7]

Falls in the geriatric population can be associated with substantial morbidity. Falling is the most common cause of traumatic brain injury in those older than 65 years. About 14-50% of patients who fall are unable to rise after a fall. As a result, they may lie on the ground for a long time before they are found or before they can manage to contact help. This delay can result in catastrophic events, eg, the development of a pulmonary embolism or the onset of hypoglycemia in a diabetic patient. Falls are the primary etiology of accidental deaths in those older than 65 years, and falls are responsible for 70% of accidental deaths in people older than 75 years. However, the highest rate of death after a fall is in white men older than 85 years. These findings support an overwhelming need for fall prevention and education to optimize rehabilitation management in the geriatric population.

Risk factors for falling

Those most susceptible to falling are older white women with a low body mass index (BMI), greater height, lower bone mineral density (BMD), and history of a cerebrovascular accident (CVA). Alcohol-related falls are more common in men than in women. Surprisingly, 14% of elderly patients who go to the emergency department are alcohol dependent. Women fall on their hips or buttocks more often than men do. However, incidence of head injuries is substantially more in men than women.

Many intrinsic factors can contribute to falls in the elderly. The most predictive is a history of a previous fall. Individuals prone to falling are known to have increased hip flexion, decreased knee flexion in pre-swing, and decrease in knee power in pre-swing. Stride-to-stride variability increases the likelihood of falling by 5 times. Those who tend to fall are also noted to have a slow gait. Patients with more risk factors are more likely to fall.

Age-related physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP] < 20 mm Hg), balance disorders, and vasovagal syncope.

A study by Renner et al of older males (aged 64-100 years) indicated that fatigue is an independent risk factor for falls in this population. Over a 3-year follow-up period, fall risk was 25% higher in men with greater fatigue, with the odds of recurrent falls being 50% higher in the first year. ^[8]

Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory, and processing speed, suggesting that a thorough cognitive assessment is warranted in individuals with mobility difficulties. ^[9]

In a study of inhospital falls in patients aged 65 years or older, Jørgensen et al found that the risk of fall-related major injury was significantly greater in patients with dementia, osteoporosis, stroke, depression, chronic obstructive pulmonary disease, or Parkinson disease. The study involved 4754 patients who suffered an inhospital, fall-related fracture or head injury requiring surgery or intensive observation, with femur fracture being the most common injury (61.6%). ^[10]

The potential energy of a fall is determined by the height of the fall, the person's body mass, and the velocity with which the center of mass is displaced. Identifying the severity of injury after falls has been reviewed. Risk factors for minor injuries after a fall include a slow reaction time and decreased grip strength in the hands. Risk factors for major injuries after a fall include older age, female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension.

Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls. Results of studies suggest that the risk of falls and fractures in elderly patients taking selective serotonin reuptake inhibitors (SSRIs) is not different from that of patients taking tricyclic antidepressants. The use of 4 or more medications of any type also increases the risk of falls.

Fatigue induced by radiation therapy or chemotherapy also creates a risk of falls in an elderly patient with cancer. Environmental barriers include stairs, uneven footpaths, polished floors, thick mats or carpeting, and poor footwear choices (eg, wearing of high-heeled shoes).

In a population-based 12-month study, an increased chance of multiple, not single, falls were found to be associated with poorer gait for individuals aged 60-86 years. Step length and double-support phase were linearly associated with an increased risk of multiple falls, and nonlinear associations were with gait speed, cadence, and step time variability. ^[11]

Consequences of falls

Walking disability affects the older patient's autonomy and well-being. Sustaining a fall can damage self-esteem and threaten the independence of a geriatric patient because falls are associated with the placement of the patient in a long-term care facility. An elderly patient with a gait dysfunction has an increasing risk of falls; a fear of falling; and functional decline, with subsequent immobility, decreased activity, weakness, and isolation. Falls and the fear of falling share predictors, which include the following: those with perceived poor general health, older age, and the use of more than 4 medications. Older people who restrict their activity are physically deconditioned and have more depressive symptoms than those who have a fear of falling without these other conditions. Differences in patients' risk factors may help in refining the clinical intervention and preventive program for an individual patient.

Falls are associated with pain, a decline in function, and a loss of stamina. More than 40% of people with an injury from a fall report continued pain or restriction in activity 2 months after the fall. Documentation of the patient's level of pain (with the visual analogue scale) and of any nonpharmacologic treatments is important in determining the appropriate rehabilitation to help the patient regain full mobility and functional activity.

Rehabilitation after a fall

Rehabilitation physicians should develop a standard evaluation for targeted groups of patients to increase participation in rehabilitation programs after a fall. The patient's history should include information about the individual's history of falls, the circumstances of the falls, the associated symptoms, and the known comorbidities (eg, sensory impairment, depression, CVA, incontinence) that may lead to falls. Physical examination should include an assessment of the following: vital signs with orthostatic blood pressure measurements, visual and hearing impairments, arrhythmias, bruits, postural instability, ^[12] joint limitations, podiatric problems, gait dysfunction, lower-extremity weakness, and changes in mental status. Any adaptive equipment and the patient's FIM score should be reviewed. The get-up-and-go test is a useful clinical tool for follow-up assessments of balance or gait dysfunction.

For geriatric patient at risk for falling, access to rehabilitation is important. Clinicians should aid their patients in finding opportunities for exercise (eg, swimming, yoga, tai chi) in their community, beyond formal physical and occupational therapy, and in overcoming barriers to obtaining needed services. Goals for the practitioner include educating patients and their caregivers and supportive family members about fall prevention and the risk factors for falls in older people. Patients with previous falls tend to accept the risk of falling; however, those with an active lifestyle tend to minimize their personal risk and the relevance of fall-prevention measures.

Strategies for successful rehabilitation include education about falls, modification of the environment, implementation of exercise programs, supplying and repairing aids, and reviewing drug regimens. A thorough approach to rehabilitation can improve the quality of life of a patient after a fall.

During rehabilitation, physical impairments should be addressed first. Interventions aimed at decreasing the incidence of falls should include an assessment of the patient's visual acuity and cataract status. If functional impairment is evident, the patient should be referred for treatment. Decreased visual acuity, visual-field defects, and cataracts are risk factors for hip fracture due to a fall. Good visual acuity facilitates head stabilization, which in turn aids dynamic balance. Ensuring that older people have access to regular eye examinations and timely treatment for eye diseases (eg, cataracts) may substantially reduce the incidence of falls and subsequent hip fractures. The identification of risk factors in patients with known vestibular dysfunction is also important because it affects their care.

Compared with the general geriatric population (>65 y), patients with bilateral vestibular loss have a greater incidence of falls. Patients may wear hip protectors, which help prevent hip injury caused by a direct fall from a standing position. If the etiology of the fall is postural, the following measures may be beneficial: use of ankle pumps and pressure stockings, elevating the head of the bed, sitting upright, ingesting caffeine, and modifying medications.

Periodic review of the patient's prescription and over-the-counter (OTC) medications is imperative. Medications should be minimized or discontinued is appropriate. Polypharmacy should be avoided if possible.

Falls are a major factor contributing to symptomatic fractures in postmenopausal women, which add to the risk attributable to age and osteoporosis. The prevention of osteoporosis with hormone replacement therapy (HRT) and calcium and vitamin D supplementation, as well as decreased caffeine intake, may decrease the risk of fracture after a low-velocity fall. A nutritional review and the supplementation of micronutrients, such as selenium, may also be warranted.

Prevention of falls

Clinical practice guidelines for general safety and fall prevention are important components of patient care in the acute medical, surgical and rehabilitation wards. The Fall Risk Assessment is a tool used by the nursing staff on a daily basis to monitor the change in the level of fall prevention necessary for each patient. ^[13] This tool helps in determining the risk of falling and in identifying relevant interventions, for example, keeping the bathroom light on at all times, keeping the commode near the bed, keeping the patient in the lobby of the unit to provide constant supervision when one-to-one coverage is unavailable, using a wrap-around belt when the patient is seated in a wheelchair, using bed exit alarms, and keeping side rails of the bed up.

General safety standards should also be implemented, and examples of these include locking the breaks on the wheels of hospital bed, keeping the bed in a low position; keeping the patient's room and environment free from clutter; keeping the call light within the patient's reach; keeping at least 2 of 4 side rails up at all times; keeping wheelchairs locked during all transfers; and keeping the table, telephone, and bed controls within the patient's reach at all times.

The prevention of falls or a reduction in the number of falls can also reduce a patient's functional decline. The use of proper transfer techniques and moderate exercise (20-min sessions 5 d/wk) to maintain mobility are vital parts of a comprehensive rehabilitation program. The incorporation of resistance training 2-3 times per week into the patient's rehabilitation program increases his or her overall strength. Resistance can be increased when the patient is able to complete 10 repetitions of an exercise with full range of motion (ROM). Maintenance programs are important. A home-based program that targets the patient's underlying physical impairments can reduce the progression of functional decline.

In a 2012 study, the balance improvements and fall-risk reductions seen in older adults following a 12-week home-based exercise program were partially to totally lost 12 weeks after completion of the program, suggesting the need for sustained regular exercise to reduce the risk of falls. ^[14]

One of the challenges that older people face is decreased postural stability, which also increases the risk of falls. Maintaining balance during dynamic activities is essential for preventing falls in older adults. Even head stabilization contributes to dynamic balance, especially during the functional task of walking.

Tai chi quan, or tai chi chuan, is a physical exercise that enhances balance and body awareness. In the rehabilitation community, the practice of tai chi is known to reduce falls. ^[15] Over the last decade, interest has grown in the use of tai chi to improve postural balance and prevent falls in older people. This ancient Chinese art emphasizes low-velocity, low-impact exercise in harmony with deep breathing and concentration. Tai chi promotes strength, flexibility, balance, and postural stability (even in patients with simultaneous disturbances of vision and proprioception). Tai chi also benefits the cardiovascular system by reducing the patient's blood pressure, decreasing fat composition, and fear of falling. In a study by Rand et al, on exercise and balance in adults older than 60 years without a neurological condition, tai chi interventions were found to be most helpful in increasing the balance confidence of geriatric patients. ^{[16, 17]}

Falls are further reduced with the addition of home-hazard management. Home visits by occupational therapists can help to preserve the patient's autonomy. Modifications to the patient's home environment may consist of smoothing out uneven surfaces, using ramps instead of stairs, applying non-skid and colored tape on the outer edges of steps, installing rails on stairs, eliminating throw rugs, removing thick carpet, repairing unstable furniture, and installing good lighting. A well-lit pathway to the bathroom that is clear of clutter must be emphasized. Large touch-lights or automatic sensory lights, which do not require dexterity, can be placed at the patient's bedside or in other areas to help decrease the risk of falls, especially at night. Motion-detector lights are helpful in providing illumination (eg, to the bathroom) at night.

Falls in the shower and bathtub are the third leading cause of accidental death, and more than half can be prevented with environmental modifications. Examples include the installation of tub mats, tub benches or seats, raised toilet seats, and grab bars in the shower and bathroom. Walkie-talkies, cell phones attached to waist clips, and lifelines are all excellent communication devices for the elderly, and these can be valuable in the event of a fall. Medical-alert bracelets can be useful to rescuers.

In addition to these environmental modifications, outpatient therapy can help the patient to learn how to address barriers that may be present in the community. For instance, the patient can practice on obstacle courses designed with low technology and simulated functional tasks that they may face in real life. One group notes that performance on such an obstacle course is not a predictor of future falls, but the findings can be used as short-term indicators of the patient's response to a rehabilitation program for balance and mobility. ^[18]

In 2013, Britain’s National Institute for Health and Care Excellence (NICE) updated its guidelines for the assessment and prevention of falls in the elderly, including recommendations for the prevention of falls during hospital stays. The newer guidelines for preventing falls in older inpatients included the following ^[19] :

• Ensure that aspects of the inpatient environment (including flooring, lighting, furniture, and fittings [such as handholds]) that could affect patients' risk of falling are systematically identified and addressed

• For patients at risk of falling in the hospital, consider a multifactorial assessment and a multifactorial intervention

• Ensure that any multifactorial intervention takes into account whether the risk factors for falling in the hospital can be treated, improved, or managed during the patient's expected stay

• Do not offer fall prevention interventions that are not tailored to address the patient's individual risk factors for falling

Bischoff-Ferrari et al conducted a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of supplemental (cholecalciferol or ergocalciferol) and active forms of vitamin D (1-hydroxycalciferol or 1,25-dihydroxycholecalciferol) in fall prevention among elderly persons. ^[20] Upon systematic review of the literature, 8 RCTs of supplemental vitamin D and 2 RCTs of active vitamin D met inclusion criteria. Pooled analysis demonstrated that falls were significantly reduced by 19-23% among patients who received high-dose supplemental vitamin D but not among patients who received low-dose supplemental vitamin D. Active forms of vitamin D also significantly reduced fall risk, by 22%.

In the Health, Aging, and Body Composition Study, older adults with low vitamin D concentrations had poorer physical performance, but low vitamin D concentrations were not associated with accelerated decline in physical performance or strength over 4 years of follow-up. ^[21]

Conclusion

Overall, falls in the elderly are a tremendous concern because of the growing geriatric population. Today's practitioners should focus on the use of screening tools in the clinic, risk assessments, programs for fall prevention, and rehabilitation after a fall. The goal is to prevent falls in the geriatric population and thus decrease morbidity and mortality rates and improve the patient's mobility, outlook, and function in society.

Osteoporosis is extremely prevalent in the geriatric population, affecting one third of postmenopausal women and one half of the population older than 75 years. The prevention and treatment of osteoporosis deserves more attention than it has received because the consequences of osteoporosis significantly affect patients in the rehabilitation setting.

Osteoporosis is defined as the increased resorption and the defective formation of bone during remodeling. Remodeling occurs more rapidly in trabecular bone, such as the vertebral bodies, pelvis, proximal femur, and distal radius, than in other bone. Low BMD results in bone fragility and, consequently, an increased risk of fracture. The World Health Organization (WHO) defines osteoporosis as BMD >2.5 standard deviations (SDs) below the mean value in young adults; this measure is referred to as the T score.

In established osteoporosis, a fracture of any bone, usually the wrist, tibia, humerus, or hip or a low thoracic or lumbar vertebra, can occur with minimal trauma. Approximately 25% of women older than 50 years have 1 or more vertebral compression fractures related to osteoporosis. The incidence increases to one third in those older than 65 years. Osteoporosis is responsible for at least half a million vertebral fractures, a quarter million hip fractures, and almost a quarter million wrist fractures annually in the United States.

In a study of the economic burden of incident osteoporosis-related fractures in the United States, Burge et al predicted that between 2016 and 2025, the cumulative cost of such fractures would be $228 billion. ^[22]

Osteoporosis affects one half of the population older than the age of 75 years. Determinants of osteoporosis late in life are peak bone mass and the rate of bone loss. Bone mass peaks by the age of 35 years, and men have more bone mass than women. Men have a 20-30% rate of lifetime bone loss, whereas women have a 45-50% rate of lifetime bone loss. Bone loss begins earlier and progresses faster in women than in men. Of the estimated 10 million Americans with osteoporosis, 2 million are men. Only 4.5% of men are treated for osteoporosis after they are discharged from a hospital after an established fracture. Attention to the male, as well as the female, geriatric population is warranted in regard to the prevention and treatment of osteoporosis. Compared with women, men generally develop osteoporosis at an older age.

Types of osteoporosis

Different types of osteoporosis are described. Localized osteoporosis is seen in primary disorders, such as complex regional pain syndrome (CRPS) (type I formerly known as reflex sympathetic dystrophy and type II formerly known as causalgia) and transient regional osteoporosis. It is also seen as a secondary disease due to a primary condition, such as immobilization, inflammation, tumor, or necrosis.

Generalized osteoporosis includes involutional osteoporosis. This most common type of osteoporosis is divided into type I "high turnover" postmenopausal osteoporosis and type II "low turnover" age-associated (senile) osteoporosis. General osteoporosis can also be secondary to a disease process; in this case, it is considered type III osteoporosis.

CRPS type I or II radiographic changes occur in the first 3-6 months after onset, and images show patchy, periarticular demineralization of the affected area (Sudeck osteopenia). The triple-phase bone scan shows increased uptake in the involved extremity before radiographic changes occur. Treatment generally involves steroids. Tapering the dose is necessary to prevent further demineralization.

Transient regional osteoporosis is localized but migratory, and it predominantly involves the hip. This disease is usually self-limited, lasting 6-9 months. Transient regional osteoporosis is a rare cause of osteoporosis and is diagnosed with plain images, bone scans, and clinical suspicion.

Primary involutional type I postmenopausal osteoporosis affects only menopausal women. This disease is linked to estrogen deficiency. Estrogen inhibits secretion of IL-6, which recruits osteoclasts from the monocyte cell line. Type I affects women aged 50-65 years and lasts 15-20 years after menopause. Rapid bone loss occurs at a rate of approximately 3-5% per year. Type I is predominantly characterized with trabecular bone loss in the axial skeleton, thus consequential vertebral compression fractures increase. Other associated fracture sites caused by moderate trauma occur at the hip and wrist. Wrist fractures tend to occur 20-25 years earlier than hip fractures. In men with low testosterone levels, osteoporosis may be included in this category, which may be renamed hormonal-deficient osteoporosis; men with hormonal deficiency are often overlooked in the management of osteoporosis.

Primary involutional type II age-associated osteoporosis can affect men with normal gonad function or women older than 70 years. It results from increased parathyroid hormone (PTH) levels, decreased vitamin D levels, decreased levels of growth hormone and insulin-like growth factors, decreased dietary intake of calcium, and decreased osteoblast function. The annual bone loss is slower in type II than at type I at a rate of 0.5-3% per year. A proportional loss of trabecular and cortical bone occurs. Hip fractures characterize type II osteoporosis.

Type III osteoporosis is secondary to another disease process and usually reversible to some extent after treatment of the primary disease is established. The following conditions can contribute to secondary osteoporosis: bone marrow disorders; connective tissue disease; malnutrition; medication; cadmium poisoning; and endocrine, gastrointestinal, or lymphoproliferative disease.

To be complete, idiopathic juvenile osteoporosis affects children aged 8-14 years and is self-limited to a duration of 2-4 years. Idiopathic young-adult osteoporosis can be mild to severe, and it is self-limited to a period of 5-10 years from its onset. However, the resolution of these forms of osteoporosis does not exclude the patient from having osteoporosis later in life.

History taking, physical examination, and diagnostic workup for osteoporosis

An assessment of the patient's history is extremely important for the prevention and treatment of osteoporosis. The history should focus on risk factors. Screening and monitoring the geriatric population for osteoporosis is a certainty in the rehabilitation arena. At greatest risk are elderly white women.

Genetic risks include a family history of osteoporosis, early menopause (at < 45 y), a small body frame, and white or Asian race. Medical conditions that predispose a patient to osteoporosis include Cushing disease, hyperthyroidism, hypogonadism, liver disease, multiple myeloma, primary hyperparathyroidism, malabsorption, lactose intolerance, and renal disease. Medications that can cause or exacerbate osteoporosis include steroids, high-dose inhaled corticosteroids, lithium, phenytoin, chronic high-dose heparin, and thyroxine. Lifestyle risks include low sun exposure, sedentary lifestyle, nulliparity, poor overall nutrition (including low calcium and vitamin D intake and high protein, sodium, and phosphate intake), smoking, and caffeine and alcohol consumption.

Other contributing factors in the geriatric population include dementia, poor general health, recurrent falls, impaired eyesight, weight less than 127 lb (as adipose tissue is the major source of extragonadal estrogen production after menopause), and bilateral oophorectomy.

Osteoporosis is diagnosed in patients with a BMD T score of more than 2.5 SDs below the mean. T scores are measured in comparison with values in young adults. A T score above –1.0 is correlated with normal bone mass. A T score of –1 to –2 is considered low bone mass less than 10-20% of the normal range, and thus is associated with doubling of the risk of fracture. A T-score below –2.0 (where bone mass is >20% below the normal value) quadruples the risk of fracture. Z scores, which are determined in comparison with values in persons of the patient's same age range, can also be measured.

Physical examination includes an evaluation of height, weight, strength, flexibility, and spinal deformities (eg, progressive dorsal kyphosis or Dowager hump). Observation of the patient's balance and gait for a fall-risk assessment should be a standard part of the physical examination. The patient's body habitus should be noted for signs of anorexia, Cushing disease, hypogonadism, goiter, gynecomastia, and barrel chest in chronic obstructive pulmonary disease (COPD). All of these medical conditions can contribute to changes in medical management.

Laboratory workup should include determinations of levels of the following: ionized calcium, 25-OH vitamin D, PTH, phosphorus, BUN, creatinine, albumin, total protein, thyroid-stimulating hormone (TSH)/T4, cortisol, alkaline phosphatase, and bioavailable testosterone in men and estrogen levels in women. In addition, liver function tests (LFTs) should be performed and CBC counts obtained. Further testing is specific for clinical picture. The erythrocyte sedimentation rate (ESR) can rule out exacerbating inflammatory processes. Urinalysis can be performed to look for proteinuria due to nephrotic syndrome. Erem and colleagues studied urine levels of cross-linked N -telopeptides of type I collagen (NTx), which are noted to be increased in patients who sustained osteoporotic hip fractures. ^[23]

Plain images can indicate osteoporosis (25-30% loss of bone mass), but dual-energy radiographic absorptiometry (DRA) is the criterion standard for measuring and monitoring true bone density. The National Osteoporosis Foundation recommends testing in these groups: all women older than 65 years, all postmenopausal women younger than 65 years if they have other risk factors, and postmenopausal women with fractures. See the images below.

Quantitative CT can be used to measure true BMD; however, the radiation exposure and cost of quantitative CT are higher than those of DRA. Ultrasonography is an inexpensive method of screening asymptomatic women for osteoporosis, but it has not been proven to be equivalent to DRA as a diagnostic tool. DRA examination costs approximately $200-$300, and it is covered by Medicare with guidelines for follow-up scans. DRA BMD measurements can be used to monitor treatment response as well.

Prevention of osteoporosis

The prevention of osteoporosis includes medication, diet modification, and exercise. A formal nutrition evaluation is recommended. A dose of 1500 mg of calcium daily is recommended for adults, and 800 mg/d is recommended for children. A dose of 1000 mg of calcium daily is recommended if the patient is taking estrogen. An 8-oz glass of milk, an 8-oz cup of yogurt, and 1 oz of cheese each contain approximately 300 mg of calcium. Calcium citrate is the recommended supplement because it has a higher rate of absorption than calcium carbonate supplements.

A dose of 800 IU of vitamin D is recommended in combination with calcium for optimal absorption. This amount of vitamin D can also be supplemented with 2 multivitamins per day. Zinc and copper may also have a positive effect on osteoporosis when calcium supplementation is used because a subclinical deficiency and reduced dietary intake of these micronutrients may be concurrent conditions.

In a study of female nursing-home residents, McKercher and colleagues report that calcium and vitamin D reduce the rate of hip fractures by 30%. ^[24] Other prophylactic medications include estrogen, raloxifene (Evista), and bisphosphonates (eg, alendronate, risedronate).

Diet modifications include lower caffeine, lower phosphorus, lower sodium, and higher calcium and vitamin D intake. Smoking cessation and moderate alcohol intake are also lifestyle changes that should be implemented.

Weight-bearing exercise has a beneficial effect on BMD and helps to prevent osteoporosis. The Wolff law states that mechanical use results in increased cortical bone mass and strength along the line of force, whereas disuse leads to bone atrophy. An exercise regimen of 45 minutes 4 times per week is recommended. Walking and stair climbing offers sufficient bone loading. Studies from Sinaki demonstrate that spinal flexion exercises are not recommended for those with established osteoporosis because of the possibility of vertebral wedge fractures. Extension-based exercises are warranted and have a positive correlation on BMD of the spine. Aerobic, weight-bearing, and resistance exercises are all effective in improving the BMD of the spine. Walking is effective for promoting BMD of the spine and hip. Aerobic exercise is effective in increasing BMD of the wrist.

A study by Pasqualini et al involving 33 postmenopausal women with low bone mass found that after a 3-month program of weight-bearing and resistance exercise, the subjects demonstrated a significant increase in procollagen type 1 N-terminal peptide (a bone turnover marker) and the number of circulating osteogenic cells. Improvements in pain, physical and mental function, and general quality of life were also found. ^[25]

Of note, tai chi chuan (tai chi quan) increases neuromuscular coordination with consequent reduction in the number of falls and fall-related fractures (see the discussion about tai chi quan, under Falls). It can also help in preventing osteoporosis. A study by Qin et al found that the practice of tai chi for 4 years significantly increases BMD of the spine, proximal femur, and distal tibia. This effect may be explained by an exercise-induced deceleration of bone loss. The benefits of tai chi are promising, and in the future, it may become a recommended mainstream exercise for the geriatric population. See the image below.

Treatment of osteoporosis

Treatment recommendations from the National Osteoporosis Foundation include the initiation of treatment in all women with T scores less than –2.0, in all women with T scores less than –1.5 if they have other risk factors, and in all women older than 70 years if they have multiple risk factors. In the elderly, calcium, vitamin D, regular exercise, postural stability, and fall prevention should be maintained in conjunction with other means of treatment for osteoporosis.

Women with hormonal deficiency can take 0.625 mg of estrogen daily for 3 of 4 weeks each month. If calcium is supplemented, 0.325 mg is sufficient. Controversy persists in regard to an increased risk for breast cancer with estrogen use and the extent of the cardiovascular profile of estrogen. However, Raloxifene 60 mg qd, a selective estrogen receptor modulator (SERM) that inhibits osteoclastic activity, increases BMD in the spine and femoral neck by 2%, according to Ettinger and colleagues. It decreases the levels of low-density lipoprotein (LDL), increases high-density lipoprotein (HDL), and decreases the incidence of breast cancer. Raloxifene has no negative effects on breast or endometrial tissue. Standardized regimens have not been studied in men with low testosterone levels, but they should be treated with supplementation and monitored on a regular basis.

Kannis in 1999 and Silverman in 2000 studied the efficacy of calcitonin for treatment of osteoporosis by decreasing new vertebral fractures by up to 54%. Calcitonin 100 IU administered subcutaneously every 3 days inhibits osteoclastic activity and increases BMD in the spine by 3%. This therapy is mainly used after a compression fracture of the spine has been documented. Salmon nasal spray in 1 nostril with a dose of 200 IU qd (alternating nostrils every other day) is also effective and has an analgesic affect with acute vertebral fractures.

Bisphosphonates, such as alendronate, etidronate, risedronate, and now once monthly ibandronate, may increase BMD in the spine and femoral neck by 5% or more. Alendronate increases BMD in the lumbar spine by 9% and BMD in the femoral neck by 6%, and it also reduces vertebral compression fractures. Orwoll and colleagues noted a 2.6% increase in BMD of the hip and 5.3% increase in BMD of the spine in a study of men taking alendronate. ^[26] Alendronate therapy is relatively contraindicated in those with gastroesophageal reflux disease (GERD).

Patients with GERD may benefit from intravenous (IV) bisphosphonates. New research is showing effectiveness with once-yearly IV zoledronic acid in increasing BMD comparable to the other bisphosphonates. Renal function should be monitored in patients receiving zoledronic acid. A short course of IV pamidronate is effective in treating transient osteoporosis of the hip.

PTH stimulates bone formation when given intermittently in low doses. It can increase BMD in the spine, but not the femoral neck. Teriparatide is a biological PTH injectable (20 mcg qd) approved for men or women at high risk of fracture due to primary or hypogonadal osteoporosis or postmenopausal osteoporosis, respectively, taken for up to 24 months.

Growth factors may help in treating osteoporosis, but standard guidelines have not yet been established. Sodium fluoride 25 mg twice daily with calcium citrate promotes osteoblasts by increasing BMD in the lumbar spine by 8% and by increasing BMD in the proximal femur by 4%. However, the main adverse effect of gastrointestinal upset is seen in 30% of patients. The slow release form has fewer adverse gastrointestinal effects.

Biskobing and colleagues describes the use of tibolone, which is a tissue-specific steroid currently used in Europe for the prevention and treatment of osteoporosis. ^[27] Tibolone may improve BMD, and it may be a future therapy in the United States.

Consequences of osteoporosis

In the past decade, the incidence of hip fracture has increased at a faster pace than can be explained by our aging population. About 1 in 3 women and 1 in 6 men will have a hip fracture by the age of 80 years. The primary risk factor in those older than 65 years is trabecular bone loss and diminished bone strength related to postmenopausal osteoporosis. Approximately 90% of osteoporotic hip fractures are intertrochanteric and femoral neck fractures.

Fall prevention encompassing increased physical activity and postural stability in this group of geriatric patients cannot be emphasized enough. In 1994, the combined cost of care for 2.3 million fractures due to osteoporosis in Europe and the United States totaled more than $23 billion, with most of the social and economic burden coming from hip fractures.

Surgical repair of hip fractures usually entails a hemiarthroplasty or open reduction internal fixation (ORIF), depending on extent of the fracture. Surgical repair may be delayed as long as 7 days for medical stabilization without an adverse effect on outcome. Postoperative rehabilitation addresses passive ROM (PROM) and active assistive ROM (AAROM). Isometric strengthening and the initiation of early ambulation with weight bearing depend on the components. Work simplification, energy conservation, joint protection, and hip precautions should be reinforced daily during rehabilitation. ^[28]

The radiologic definition of a vertebral fracture is a 15-20% reduction of the total height of the bone in its anterior, posterior, or central aspect. Anteroposterior (AP) and lateral views plus bone scans can be used to determine the acuity or chronicity of the fracture. The initial pain of a vertebral compression fracture resolves in 4-6 weeks. For pain control, the following are appropriate measures: scheduled oral analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), brief rest or activity modification, and a trial with a transcutaneous electrical nerve stimulation (TENS) unit. In addition, moist heat can be applied for 20 minutes every 2 hours to relieve muscle spasm, and ice massage for 7-10 minutes at a time can be used intermittently.

Occasionally, patients need bracing to prevent further fractures. Braces can also be used to improve postural alignment and pain relief. Velcro-closure binders or corsets are used for lower lumbar spinal fractures, cruciform anterior sternal hyperextension (CASH) braces are used for lower thoracic fractures, and Jewett braces are used for thoracic fractures. Thoracic lumbar spinal orthosis (TLSO) braces are also used for multiple fracture sites. The duration for which braces are used is undetermined but approximately 6-8 weeks.

Compression fractures can lead to postural deformity, more commonly from T8 to L3 than elsewhere; this deformity appears as kyphosis. Fractures of vertebral bodies at the T4 level or higher are rare and may suggest malignancy. Respiratory impairment and pneumonia may ensue in a patient with kyphotic posture as a result of decreased space in the abdominal and thoracic cavity. Abdominal distention, early satiety, discomfort from ribs overlapping the iliac crests, sleep disturbances, and depression are also common sequelae.

Conclusion

Osteoporosis is an all-too-common disease in the elderly population, especially in women. A high rate of morbidity and mortality is related to osteoporosis. Physicians should offer medication and therapy to prevent osteoporosis in all of their elderly patients. Once osteoporosis is diagnosed, formal treatment should be initiated.

In geriatric rehabilitation, malnutrition affects a patient's functional status and global medical condition. Malnutrition occurs when a deficiency of caloric, vitamin, mineral, protein, water, and/or nutrient uptake is present. Alternatively, malnutrition can be thought of as a BMI greater than 27. However, no exact definition of malnutrition has been established in the elderly.

Malnutrition can decrease one's resistance to infection and result in poor wound healing. Malnutrition can also lead to increased skin fragility, osteoporosis, anemia, diabetes, and cardiovascular disease. Again, although no exact definition exists, the following findings are associated with the diagnosis: involuntary weight loss (>15 lb over 6 mo, >12 lb in 3 mo, or > 9 lb in 1 mo), BMI less than 20 or more than 27, hypoalbuminemia (< 3.5 g/dL), hypocholesterolemia (< 160 mg/dL), and vitamin or micronutrient deficiency. Dietary intake of less than 75% at most meals can also be an indicator.

The Food and Nutrition Board of the United States has recommended daily allowances (RDAs) for those older than 51 years, but no formal guidelines have been established for the geriatric population older than 65 years.

Risk factors for malnutrition

Physiologic factors of aging may lead to malnutrition. These factors are reduced metabolic requirements, decreased total body protein level, decreased total body water, decreased BMD, decreased taste and smell sensation, diminished levels of neurotransmitters that increase appetite, and early satiety. Physical conditions include reduced physical activity; poor dentition; digestive disorders; and functional disability that interfere with activities such as grocery shopping, preparing meals, or going out to dine. ^[29] A speech language pathologist can assess the patient for dysphagia and aspiration risk by evaluating the individual's oral motor swallowing skills with a clinical swallow study and/or a video fluoroscopic swallow study (VFSS).

In a study of malnutrition risk factors in older patients (noncritically ill, aged 65 years or older) in emergency departments, Burks et al determined that patient characteristics linked to malnutrition included absence of a college degree, admission to the hospital, and residence in an assisted living facility. Risk factors also included poor oral health, food insecurity, and lack of transportation, with the population attributable risk proportions for these being 54%, 14%, and 12%, respectively. ^[30]

Psychological factors that contribute to poor nutritional status in the elderly are depressive symptoms, bereavement, loneliness, and cognitive decline, all of which can affect appetite. Social barriers include financial limitations, living alone, or relying on others for meals. Other issues to assess when malnutrition is suspected are dietary restrictions, cultural rituals, and alcohol intake.

Assessment of malnutrition

The patient's dietary history should include information about the following: consistency of the diet, number of skipped meals, alcohol use, use of nutritional supplements, use of vitamin supplements, use of medications that affect appetite or nutrients, and food preferences to improve caloric intake. Nutritional screening by a dietitian should be emphasized in accordance with rehabilitation to promote and improve functional outcomes as well as wound healing. The rehabilitation nurse commonly records the Braden scale score, an assessment of the risk of skin breakdown, which is a result of poor nutrition. Cells become fragile as a result of an inability to sustain metabolism. Pressure points, especially bony prominences (eg, sacrum, ischial tuberosity), are prone to pressure sores in a state of malnutrition. The Braden scale score should be incorporated along with the patient's overall nutritional assessment.

Height and weight should be recorded at every outpatient visit, and they should be monitored closely while the patient is in the rehabilitation unit. This information is critical for the dietitian or nutritionist to know so that they can properly evaluate the degree of obesity or undernutrition. Caloric restriction, weight loss, and decreases in blood lipid levels with antihyperlipidemic agents can improve the patient's functional status and serve as preventive cardioprotection in the obese elderly patient. Decreasing height may also suggest osteoporosis and thus be an indication for treatment and fall prevention.

Physical features that can suggest malnutrition include thinning of enamel on teeth, thinning of the hair, ecchymoses, angular stomatitis, spoon nails, dermatitis, petechiae, pallor, edema, bleeding gums, and glossitis. Peripheral neuropathy and dementia can also be a sign of nutritional deficiency in the elderly.

Serum protein levels may decrease with trauma or infection, but good indicators of malnutrition are albumin levels (half-life, 18-20 d) and prealbumin levels (half-life of 48 h); these are used to monitor nutritional status. The elderly are at risk for marginal deficiencies of vitamins and trace elements. Many older adults consume small amounts of vitamins B-6, B-12, and D, as well as folate, calcium, magnesium, and zinc. A multivitamin with other necessary supplements can be helpful. Selenium can also be supplemented for wound healing in severely malnourished patients.

Hemoglobin (Hb) concentrations should be obtained to rule out anemia from pathologic processes such as iron deficiency anemia or anemia of chronic disease. The search for an underlying cause should begin when the Hb level is less than 13 g/dL in men and 11 g/dL in women. In men and women older than 90 years, a level of 11 g/dL is adequate.

The mean corpuscular volume (MCV) should help in detecting vitamin B-12 and folate deficiency. Vitamin B-12 levels should be obtained if deficiency is clinically suspected. Vitamin D and ionized calcium levels can aid in determining if supplementation is needed to prevent osteoporosis. This determination is especially important in housebound elderly patients who are likely to have vitamin D deficiency. Vitamin D also influences the maturation and function of muscle cells, as shown in experimental studies. HbA1C levels should be obtained for diabetic monitoring. Serum cholesterol and lipid panels should be assessed to evaluate the cardiovascular risk. Vitamins A, C, and E can also increase cell-mediated immune function by increasing the absolute number of T cells.

A survey by Everink et al of geriatric rehabilitation facilities across Europe found that 73% of respondents said that all of their patients were screened for (risk of) malnutrition, while 24% said that only selected patients were, and 3% acknowledged that no patients were screened. The lowest rate of respondents stating that all patients were screened was in Eastern Europe, at 29%, while the rates in Northern, Central, and Southern Europe were 77%, 77%, and 76%, respectively. ^[31]

Energy requirements of the elderly

Energy intake decreases with age, partly because of a lower metabolic rate associated with decreased physical activity. About 16% of the geriatric population eats less than 1000 kcal/d. For geriatric patients, the recommended daily intake is 25-35 kcal/kg.

Complex carbohydrates should make up 55-60% of the diet to help meet the patient's fiber, vitamin, and mineral needs. A daily fiber intake of 20-30 g is recommended for older adults to help prevent constipation, to lower cholesterol levels, and to decrease the risk of colon cancer. Protein should be increased to 15-20% of the diet in undernourished elderly patients, especially postoperative patients, patients with trauma, patients with pressure sores, and those with active infections. Fat calories should account for 10-30% of the daily caloric intake; however, fat requirements are not standardized for the elderly. The rehabilitation dietitian should monitor the daily calorie count in malnourished patients, taking all these factors into account.

Treatment of malnutrition

Lactose-free oral and enteral products have excellent nutritional value and are usually well tolerated by the geriatric population. The most common problem is diarrhea. The following products provide high protein levels, water, electrolytes, and calorie supplementation: oral low-residue formulas (eg, Boost, Ensure), oral clear liquids (eg, Resource), diabetic formulas (eg, Choice DM, Glucerna), enteral low residue formulas (eg, Osmolite, Nutren), and enteral high-fiber formulas (eg, Jevity).

Approximately 5-30% of those receiving tube feedings experience diarrhea. This effect may be due to the lactose content of the formula, the osmolality of the formula, the rate of delivery, or impaired absorption. To prevent aspiration, the head of the patient's bed should be maintained at 30° elevation during and for 2 hours after tube feedings. Total parenteral nutrition (TPN) is a more temporary method for achieving adequate nutrition in malnourished patients.

The most common cause of fluid and electrolyte disturbances in the geriatric population is dehydration. Physiologic reasons for decreased fluid intake and increased fluid loss include the following: a decreased ability to concentrate urine after fluid deprivation, an altered thirst sensation, decreased renin activity, decreased aldosterone secretion, and increased renal resistance to vasopressin.

Isotonic dehydration is attributed to the loss of water and sodium, most commonly due to fasting, vomiting, or diarrhea. Hypertonic dehydration occurs when water depletion exceeds sodium depletion (serum sodium level >145 mmol/L and serum osmolality >300 mmol/kg); this type of dehydration is exemplified by fever with the loss of water through the lungs and skin and a decrease in oral fluid intake. Hypotonic dehydration occurs when sodium depletion exceeds water depletion (serum sodium level < 135 mmol/L and serum osmolality < 280 mmol/kg); this occurs with excessive use of diuretics.

Significant consequences of dehydration are changes in mental status, functional status, orthostatic hypotension, and medication sensitivity. These changes affect the rehabilitation process and can also predispose the patient to falls. Beside fluid replacement, treatment involves the use of fans, air conditioning, oral fluid intake of 1500-2500 mL/d) for those without cardiac or renal disease, daily monitoring of the patient's weight, monitoring of orthostatic blood pressures, and a review of the patient's current medications. Fluid requirements also increase with the use of air-mattress systems.

In a depressed patient, SSRIs may play an important role. A positive effect of paroxetine (Paxil) is increased appetite, which is beneficial for depressed elderly patients who are undernourished. The use of other appetite stimulants, such as megestrol, melanocortins, and cannabis, is controversial in geriatric patients in a malnourished state. However, these adjuncts are frequently used in cancer patients. Sherry alcohol is used effectively in England, and it is on the British National Formulary.

The social worker has an important role in helping the geriatric patient achieve a better nutritional state. Economic and food assistance programs, such as Meals on Wheels, can greatly aid a geriatric patient in increasing his or her food intake. The social worker can help the patients arrange transportation for grocery shopping or obtain services from local programs, such as those of the various state departments on aging, which provide the grocery shopping services and food delivery to the home. Also, the social worker can help to devise plans with family members for meal preparation.

Conclusion

The prevention and early recognition of malnutrition are essential in the process of rehabilitation because good nutrition is a component of positive outcomes in the rehabilitation setting. Nutritional support is a team effort. With an understanding and awareness of the factors contributing to malnutrition in the geriatric population, rehabilitation goals are more easily attainable.

Depression is the most common mood disorder in the geriatric population. Some symptoms of depression, such as weight loss, sleep disturbance, and fatigue, may be associated with other concurrent medical conditions. These medical issues must be ruled out prior to establishing a diagnosis of depression. Cognitive disorders may also interfere with the diagnosis of geriatric depression. Depression significantly contributes to an individual's disability, functional decline, and quality of life. The early diagnosis and management of depression can help to decrease further disability, restore function, and reduce the risk of suicide in the geriatric population.

The prevalence of depression in the elderly is 17-37%, with 11-30% of that population having major depression. The prevalence is higher in the presence of significant medical illness. The elderly, most commonly those older than 75 years, often contemplate suicide. In older white men, the risk of suicide is 5 times higher than that of any other age group. Depression and significant comorbidity are principal reasons why elderly persons consider suicide.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines major depressive disorder as the occurrence of five or more of the following during the same 2-week period (with one of the symptoms being depressed mood or diminished interest/pleasure): depressed mood, diminished interest or pleasure, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished energy to concentrate, and suicidal ideation.

However, depression in the general population and depression in the geriatric population may differ in some ways. Elderly people with depression are more likely than others to have somatic complaints, to minimize their depressed mood to others (masked depression), and to hide their feelings of guilt. Hypochondriasis occurs in 65% of the elderly population with depression. Sociologic and demographic factors are not significantly associated with major depression in the elderly.

Screening for depression

A brief screening instrument, the Geriatric Depression Scale (GDS), is beneficial in the rehabilitation setting. ^[32] The GDS is simple to repeat screenings on multiple occasions to assess any improvement of the patient's depression. The short-form scale consists of the 15 questions below. Patients are asked to reply "Yes" or "No," and the answers in parentheses are counted as 1 point.

• Are you basically satisfied with your life? (No)

• Have you dropped many of your activities and interests? (Yes)

• Do you feel that your life is empty? (Yes)

• Do you often get bored? (Yes)

• Are you in good spirits most of the time? (No)

• Are you afraid that something bad is going to happen to you? (Yes)

• Do you feel happy most of the time? (No)

• Do you often feel helpless? (Yes)

• Do you prefer to stay at home, rather than going out and doing new things? (Yes)

• Do you feel you have more problems with memory than most? (Yes)

• Do you think it is wonderful to be alive now? (No)

• Do you feel worthless the way you are now? (Yes)

• Do you feel full of energy? (No)

• Do you feel that your situation is helpless? (Yes)

• Do you think that most people are better off than you are? (Yes)

A score of 0-5 points is normal, 6-10 indicates mild depression, and 11-15 indicates severe depression. This screening tool can be helpful as a guide to rehabilitation management in the inpatient and outpatient settings.

Risk factors for depression

Other risk factors of depression that can be screened in the geriatric patient include poor self-rated health, poor cognitive function, impaired ADLs, 2 or more medical clinic visits in the past month, frequent falls, and a slow walking speed. Passive suicide is also a risk. Caregivers should be aware of poor nutritional intake, noncompliance with medication, excessive alcohol intake, and taking physical risks because these can be attempts at passive suicide. However, the most common presentation of depression in the elderly involves new medical complaints or an exacerbation of preexisting ones.

The geriatric patient may have a preoccupation with their poor health or physical limitations. The patient may express fatigue, poor concentration, and diminished interest in pleasurable activities. Anxiety, psychomotor retardation, and weight loss in the context of major depression is highly associated with disability.

Consequences of depression

The consequences of depression in the geriatric patient are disability, an increased burden on caregivers, poor compliance with medical treatment, increased medical morbidity, higher mortality rates, and higher suicide rates. In the elderly, depression has been noted to decrease the following: standing balance, walking speed, the ability to rise from a chair, and function in ADLs and IADLs. Those with depression may have prolonged recovery and overall increased morbidity after surgery. Lower levels of physical performance are strongly predictive of institutionalization; further subsequent disability; and, possibly, death.

Many factors contribute to depression in the geriatric patient. Medical conditions that may lead to depression include malnutrition, Cushing disease, hyperparathyroidism, hypothyroidism, systemic lupus erythematosus, hepatitis, HIV infection, cancer, stroke, Alzheimer disease (AD), Parkinson disease, and Huntington disease. ^[32] Arthritis, circulatory problems, speech disorders, or skin problems are related to more significant depression. About 50% of patients with Parkinson disease and 20-25% of patients with stroke have depression, especially those with cortical and lacunar infarcts. Cerebrovascular lesions in the frontal lobe may promote depression because the frontal lobe integrates sensory, emotional, and neuroendocrine functions that are often impaired in depression.

Gillen and colleagues noted that patients with stroke have more depressive symptoms and that they progressed slowly in regaining basic functional capacities such as mobility, dressing, and feeding. ^[33] The success of rehabilitation in stroke patients is often measured in terms of physical functioning. However, the patient may be discouraged if significant emphasis placed on physical disability if he or she is not progressing quickly. Addressing the emotions and depressive symptoms that affect the older patient after a stroke is important in helping the patient to reach his or her functional goals.

Medications may also lead to depression. Some common medications that can lead to depression include benzodiazepines, chemotherapy agents, corticosteroids, psychostimulants, cimetidine, clonidine, digitalis, estrogen, hydralazine, progesterone, alpha-methyldopa, propoxyphene, propranolol, reserpine, and tamoxifen.

Depression can also stem from elder abuse because of the dependency of the geriatric patient on a caregiver with poor coping skills. Also, if the caregiver or spouse is depressed, the patient may experience similar depressive symptoms. In addition, many patients receiving home healthcare are not treated for depression because the medical liaison may not recognize the significance of the patient's depressed mood. In the case of physical decline, the home healthcare worker contacts the primary physician, but the reason for the patient's decline may remain undiscovered.

Treatment of depression

Depression is not a normal part of aging. Depression is a treatable source of disability and suffering in the geriatric population. One of the most effective and important mechanisms to combat depression is to emphasize rehabilitation after illness and injury. Often, older people become depressed as a result of injury or illness, and therefore, they need rehabilitation. Depression has been shown to be a barrier to rehabilitation, so addressing the illness and injury as well as the depression is important to prevent further debility in the elderly.

The earlier treatment begins, the more effective and the greater the likelihood of preventing serious recurrences. Treatment of depressive symptoms may be one of the most effective interventions to reduce physical decline and to increase the number of years during which older people are free of disability. Medications, electroconvulsive therapy (ECT), and behavioral psychotherapy have all been successfully used to treat depression in elderly patients. Medications used for depression include tricyclic antidepressants, SSRIs, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants.

Tricyclic antidepressants and SSRIs may increase the risk of falls and should be used cautiously. SSRIs have a class adverse effect of extrapyramidal symptoms (EPSs) and hyponatremia. Paroxetine, an SSRI, is helpful with concomitant anxiety, and it may also improve a patient's appetite. MAOIs can lead to hypotension; therefore, the patient's blood pressure should be monitored closely when therapy is initiated. Most atypical antidepressants, such as bupropion, nefazodone, trazodone, and venlafaxine, do not interfere with other medications, and these may be used in adjunct with other classes of antidepressants. Methylphenidate may be used as a short-term adjunct, especially with apathy. Mirtazapine can be sedating and increase appetite; it may be a good choice for those with concurrent insomnia and/or malnutrition.

In the elderly, an adequate antidepressant trial is 7-9 weeks. Testosterone may also be a good adjunct in a depressed elderly man with low testosterone levels. Although trials have not proven the effectiveness of St John's wort in the treatment of moderately severe depression, many patients are trying alternative medicine, with anecdotal success. More research must be conducted before the medicinal use of these natural supplements can be supported.

ECT can be a life-saving intervention for severely depressed and suicidal patients. It is also indicated for those who are resistant to drug therapy and in those who are unable to tolerate antidepressant medications. ECT also improves depression, tremors, rigidity, and bradykinesia in those with Parkinson disease. The neuropsychologist is imperative in the team treating the depressed geriatric patient. Behavioral psychotherapy, including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), may be effective in treating depression. CBT helps the patient recognize and change negative thinking patterns that contribute to depression. IPT focuses on improving relationships with other people, which can reduce depressive symptoms.

Group therapy, which focuses on coping skills, information exchange, and mutual support, is also a positive approach in the depressed elderly patient. This counseling technique can reduce the patient's feelings of hopelessness and despair. Approximately 80% of older adults with depression improve with psychotherapy in conjunction with antidepressant medication.

Meeting a patient's physiologic needs for adequate nutrition, regular exercise, and uninterrupted sleep can help decrease his or her depression. Depressed people are often sedentary and have no motivation to increase their physical activity. Exercise activates serotonin and norepinephrine, which can lead to a feeling of euphoria and, ultimately, enhanced mental health. Exercise can also increase physical endurance and functioning, which can improve the patient's quality of life.

Light therapy may be an effective treatment for major and minor depression that has a seasonal pattern. The optimal duration for light therapy is 45-60 minutes daily. Longer light exposure is associated with a better outcome.

Music therapy is often used to treat depression in the geriatric population. It can provide motivation to increase physical activity. The patient plays a musical instrument, which can increase his or her ROM and develop muscle strength and endurance. Music therapy facilitates relaxation, thereby promoting sleep and decreasing pain, depression, and anxiety. It also promotes social awareness and interaction. Pet therapy, gardening, spiritual practices, reentry into the community, participation in social groups, and recreation can also improve the patient's mental health.

Conclusion

Because depression is prevalent in the geriatric population after injury or illness, screening patients for depressed mood is essential for early therapeutic intervention. The management of depression with medication, psychotherapy, exercise, and other adjuncts can improve the patient's compliance with the rehabilitation program and improve his or her functional outcomes.

Overview

Delirium and dementia are common in the geriatric population. Subsequent impairment of executive functioning impacts the patient's mobility, ADLs, and IADLs. The effects of delirium and dementia can be detrimental to the patient's functional recovery in the rehabilitation setting and in everyday situations.

Delirium

Delirium is a disorder of attention. The DSM-IV defines delirium as a fluctuating level of consciousness and pervasive impairment in mental, behavioral, and emotional functioning. It is usually of acute onset and temporary. Delirium is frequently caused by physical disease or drug effects.

Hypoactive and hyperactive subtypes of delirium are described. The hypoactive variant, in which decreased psychomotor activity is present, is more common. Strong stimuli are often needed for arousal, which is incomplete and transient. However, patients with hyperactive symptoms, such as agitation, are more likely to be identified than patients with the hypoactive variant.

Hallucinations occur in 40% of patients with delirium and can accompany both subtypes. Visual hallucinations are more common than auditory hallucinations. Delirium can be worse at night and is often referred to as sundowning in the geriatric population. Symptoms of delirium may persist for hours to weeks. The differential diagnosis of delirium includes psychotic disorders, dementia, and epilepsy.

Causes of and risk factors for delirium

Delirium often occurs as a direct physiologic consequence of a general medical condition. Common examples are anemia, uremia, hypoxia, hypoglycemia, infection, inflammatory conditions, stroke, heart failure, liver failure, pulmonary emboli, and cancer. Other conditions associated with delirium include sleep deprivation, sensory impairment, incontinence, fecal impaction, and dehydration. Impairment of the vascular system is associated with the most diffuse profile of declined neuropsychological performance in hospitalized geriatric patients, according to Patrick and colleagues. ^[34]

Delirium commonly occurs as a result of substance intoxication or medication use. Drugs that are commonly associated with delirium are anticholinergics, sedative-hypnotics, narcotics, histamine-receptor blockers, and agents used to treat Parkinson disease. Other associated agents include tricyclic antidepressants, lithium, neuroleptics, and gastrointestinal and cardiac medications. Delirium also can occur when the substance is withdrawn. Delirium due to multiple etiologies is defined as the presence of more than 1 general medical condition or the presence of a general medical condition plus substance intoxication or a drug adverse effect.

Delirium is detected in only 30-50% of affected patients. The risk of delirium is higher in severely ill patients with comorbid medical problems, in patients older than 80 years old, and in those with impaired physical function. Other risk factors include preexisting cognitive impairment, electrolyte abnormalities, hypoalbuminemia, polypharmacy, sensory deprivation, and a history of trauma.

The hospital environment is often a cause of heightened delirium. Hospital mortality rates have been reported to be 2-20 times higher in patients with delirium. Also, prolonged hospitalization, impaired physical function, and increased rates of nursing home placement are correlated with delirium. Other consequences of delirium in the geriatric population are deconditioning, immobility, decline in ADL and IADL functioning, social isolation, dehydration, malnutrition, aspiration pneumonia, and pressure sores. Prolonged cognitive dysfunction may also leave permanent memory problems. Delirious patients also have a significant risk of suicide. The risk for overall mortality following an episode of delirium remains high, even after 2 years after the acute episode.

Screening for delirium

Because postoperative delirium is common in the geriatric population, geriatric patients should be screened during the preoperative visit. Factors that increase the risk of delirium in the surgical population include existing dementia, low cardiac output, perioperative hypotension, postoperative hypoxia, and use of anticholinergic drugs. Predictors of postoperative delirium may include advanced age; poor cognitive function at baseline; poor physical function; self-reported alcohol abuse; abnormal serum sodium, potassium, or glucose levels; aortic aneurysm surgery; and noncardiac thoracic surgery.

Rates of delirium have been reported to be as high as 15% after general surgery and as high as 61% after orthopedic surgery. Acute confusional states have also been reported in patients undergoing open-heart surgery. The intraoperative use of meperidine has been shown to increase the risk of postoperative delirium. Postoperatively, hypoxia and hypercapnia have been shown to contribute to a state of delirium; therefore, oxygen saturations must be monitored closely. With a preoperative geriatric assessment and the management of medical conditions and medications, rates of postoperative delirium can be decreased from 61.3% to 47.6%.

Preventive interventions in the hospital or outpatient rehabilitation setting are available to identify risk factors for delirium in the elderly patient. Cognitively stimulating activities (eg, discussing current events) and reorienting the patient to his or her surroundings several times a day can decrease the risk of cognitive impairment. Active exercise programs can also help in preventing immobility, which can be an associated factor. Relaxing music, massage, and noise reduction at bedtime may help to decrease sleep deprivation. Visual and hearing aids can improve sensory impairments. Volume repletion can decrease the incidence of dehydration if no fluid restrictions exist. The use of a beverage cart on the ward or a pitcher at bedside on the inpatient setting has been suggested.

Evaluation for delirium

Thorough history taking and physical examination are necessary in the acute stage of delirium. The history must include data regarding new functional impairments, incontinence, impaction, hallucinations, and alcohol use. A nutritional assessment to rule out malnutrition or dehydration is important. Prescription and OTC medications must be reviewed. The FIM and IADL scores should be documented on a daily basis to detect any functional changes. The physical examination should focus on vital signs (especially in patients with fever or hypothermia) and oxygen saturation. Checking for skin breakdown and screening for sensory deficits are also important.

The Mini-Mental Status Examination (MMSE) is helpful in determining delirium. MMSE scores less than 24 are considered abnormal with the attention, concentration, and recall subscales being the most sensitive for detecting delirium. Screening with 3-item recall and reciting the days of the week backward are especially sensitive.

The Confusion Assessment Method (CAM) also can be used to clinically diagnose delirium. An acute onset, a fluctuating course of delirium during the day, and inattention must be present. The patient must also have either disorganized thinking (rambling, illogical flow of ideas) or an altered level of consciousness (hyperalertness, lethargy, stupor, coma). The neuropsychologist can be helpful in assessing baseline cognitive function; he or she can use cognitive testing to monitor any changes. The etiology, however, must be further explored.

Infection and other medical causes (metabolic, cardiovascular, or neurologic conditions) must be identified and treated if present. Laboratory tests based on history and physical findings may include LFTs and a determination of the CBC count and vitamin B-12, thiamine, folate, heavy metal, drugs (eg, narcotics, alcohol), TSH/T4, and albumin levels. A basic metabolic panel (BMP), HIV testing, urinalysis, culture and sensitivity testing, chest radiography, and electrocardiography may also be helpful.

Immediate management starts by discontinuing unnecessary medications. Acute symptomatic control may require risperidone, carbamazepine, trazodone, or a benzodiazepine. If these medications are the cause of the delirium, they must be discontinued slowly. If the delirium is secondary to alcohol use, administer thiamine in the acute stage. Direct wording, simple questions, simple instructions, and a calm approach are ideal for good communication with the patient experiencing delirium. Avoiding excessive noise because stimulation can decrease agitation.

Education of the nursing staff and family are important because they can help to monitor the frequency and duration of changes in the patient's mental status and function during the day. Caregivers and family members should visit or call the patient often. Close supervision by a nighttime sitter or assigning the patient to a room near the nursing station in a hospital may be of assistance.

Continuously orienting the patient throughout the day should be a part of rehabilitation. A clock with large numbers, a calendar, and a fixed daily activity schedule should be visible to the patient in his or her room. The environment should be modified if the patient has any sensory deficits; for example, the bathroom light can be left on at night. Photos and a personalized environment should also surround the patient's room.

Patients should have ready access to news and radio stations with current events. The patient should leave his or her room and be involved in physical activities at least once daily. At night, interruptions should be minimized so that the patient has normal sleep-wake cycles to decrease confusion and disorientation. Physical restraints are used only as a last resort to maintain patient safety because serious injury and death have been reported in their use in delirious patients.

Delirium is a relatively common disorder in the geriatric patient during acute hospitalization. A workup should be performed to find the likely cause for delirium in each patient. Many times, correcting the instigating factors can help clear the patient's thought process. Delirium should be considered in the differential diagnosis of dementia.

Dementia

Dementia is a problem with decline in memory and at least 1 other cognitive function (eg, aphasia, apraxia, agnosia, executive function). The World Health Organization defines dementia as memory decline, especially in the learning of new information, lasting longer than 6 months. Dementia is not a normal part of aging. Dementia disrupts one's daily activities and leads to a decline in memory and previous functioning, and it can also lead to social impairment.

The diagnosis is based on the gradual onset of cognitive impairment and continuing decline. The diagnosis is made when all other possible causes of cognitive impairment are ruled out. These other causes include medical, neurologic, and psychiatric problems. Dementia must be differentiated from delirium. If diagnosed early, the patient has the opportunity to be involved in his or her own medical-care decisions.

AD is the most common cause of dementia. AD is the etiology of 60-70% of the geriatric population with dementia. The prevalence of AD doubles every 5 years after the age of 60 years; therefore, by the age of 85 years, 30% of the population has AD.

Vascular dementia, or multi-infarct dementia (MID), is the etiology in 15-25% of cases of dementia in the elderly. Compared with AD, MID has a more abrupt onset and is associated with hypertension. Patients tend to be younger at onset, and the predominance is slightly higher in males than in females. Often, insight is preserved, but personality can be labile, and the gait usually is abnormal. Transient focal neurologic signs, such as dysphagia or seizure activity, may also be observed. MID is also associated with a higher 3-year mortality rate and a higher rate of institutionalization than those seen in AD. Potentially reversible dementia affects 2-5% of the elderly with dementia; such dementia may be the result of drug toxicity, metabolic disturbances, subdural hematoma, hydrocephalus, syphilis, hyperthyroidism or hypothyroidism, vitamin B-12 or niacin deficiency, or hypocalcemia. However, the degree of reversibility may be limited if permanent neurologic damage persists.

Noncognitive symptoms are also associated with dementia. Psychotic symptoms occur in approximately one third of patients with AD. Delusions are usually accusatory or paranoid. Hallucinations are usually visual. Depressive symptoms occur in as many as 40% of patients with AD, and it may be a cause of accelerated decline. However, depression is not associated with reversible dementia in the patient with minimal dementia. Depressive symptoms can potentially decrease in these patients, even if their cognitive function continues to decline.

With progressing dementia, emotional control, motivation, and social behavior also decrease. Agitation or aggression occurs in as many as 80% of those affected by AD. Patients may have a catastrophic reaction, which is an emotional reaction precipitated by task failure. Patients with AD may be able to express their frustration in only an irritable, combative manner, which may lead to resistance in achieving physical rehabilitation goals. Providing reassurance that the situation can improve and maintaining a scheduled routine is necessary. Agitation is a leading cause for institutionalization because it can increase the stress on caregivers. Almost 75% of patients with dementia are admitted to a long-term care facility. Costs of medical, long-term, and home care and the costs of lost productivity due to dementia approach $10 billion annually. Patients with dementia live an average of 8-10 years after the initial symptoms begin.

Risk factors for AD

Definite risk factors of AD include advanced age and a family history. Familial AD, which has associated genetic mutations on chromosomes 1, 14, and 21, may begin prior to the age of 60 years. Down syndrome and the apolipoprotein allele-4 (APOE-4) have also been shown to be significant risk factors. Other possible risk factors are head trauma, clinical depression, and a low educational level. Small head circumference and small brain size have been associated with an early onset of AD. Women are at greater risk than men, even after the longer life expectancy of women is eliminated. ^[35]

Patients in high-risk groups should undergo neuropsychological testing with a focus on a mental-status evaluation. Protective factors may be an APOE-2 genotype, NSAID use, estrogen therapy, and antioxidant use. Higher levels of education are associated with a delay in the onset of AD. In a study by St John and Montgomery, patients with subjective memory loss had a higher risk of having dementia 5 years later, and this memory loss was associated with a higher mortality rate. ^[36] However, the authors noted that subjective memory loss is not a strong predictor of dementia.

Evaluation for AD

The evaluation of possible dementia includes good history taking (which may involve talking with the patient's family or friends), physical examination, and a formal MMSE. In one study by Puchinskas and colleagues, preliminary results suggest that the patient's ability to draw and copy a clock face can be predictive of a patient's level of physical function and the potential benefits of rehabilitation. One should consider adding this test to the standard examination. An assessment of the patient's functional status, which includes an evaluation of his or her mobility and ability to accomplish ADLs and IADLs, should also be performed.

In the workup of dementia, laboratory tests that are typically ordered include LFTs; serologic tests for syphilis; urinalysis for heavy metals; and determinations of CBC count, BMP, TSH/T4, vitamin B-12, folate, and calcium levels. If vascular dementia is suspected, MRI should be performed. Nonenhanced CT can be helpful in ruling out a space-occupying lesion or hydrocephalus. Positron emission tomography (PET) or single photon emission CT (SPECT) might provide possible evidence of AD. With these neuroimaging studies, decreased glucose metabolism and low blood flow in the temporal and parietal regions are associated with AD.

Stages of AD

Four stages of AD that are well recognized in the literature.

The first stage is preclinical and defined as mild cognitive impairment. The patient with preclinical AD has delayed recall but no other cognitive or functional impairments. The MMSE score is 26-30.

The second stage consists of a slightly higher degree of cognitive impairment and usually occurs 1-3 years after the onset of symptoms. The patient has difficulty with recent recall, anomia, orientation to date, visuospatial activities, problem solving, and insight. Problems with some IADLs, including managing finances and medications, are noticeable. Also observed are mood changes, including irritability; these can lead to social isolation. The MMSE score is 22-28 in this stage.

The third stage is moderate impairment, and this is usually recognized 2-8 years after the onset of symptoms. The patient has a decreased ability to learn new information; their retention can be as short as a few minutes. They may also have difficulty calculating numbers, comprehending simple questions, and orienting themselves to date and place. Functional impairment is more significant in this stage, and the patient experiences difficulty with basic ADLs, primarily dressing and grooming. The patient also has difficulty with a wider range of IADLs, particularly using a telephone, cooking, planning meals, shopping, and banking. Impaired judgment, delusions, agitation, aggression, and wandering (including getting lost while driving) may be prominent in this stage. The MMSE score is 10-21.

The fourth stage occurs when the patient is severely impaired, and it usually occurs 6-12 years after the initial symptoms appear. The patient has impaired remote memory and an inability to write or copy figures. He or she may also be unintelligible when communicating. The patient is often incontinent at this stage and completely dependent on others to help with ADLs and IADLs. The MMSE score is 0-9.

Treatment of dementia

The treatment of dementia revolves around improving the patient's quality of life and maximizing his or her functional performance by focusing on cognition, mood, and behavior. Identifying any underlying medical cause or contribution to dementia is the first step. The environment should be stable, and a change of residence should not be considered to maintain familiarity in the person's surroundings.

Behavioral techniques (eg, distraction), environmental modification (eg, increasing the level of stimulation), music therapy, and massage therapy are important in the care of a patient with dementia and behavioral problems. Increased sunlight exposure may be beneficial in increasing the sleep-wake cycle and positively affecting the patient's behavior. Sleep hygiene also includes restriction of naps, fluid intake at night, and use of stimulants (eg, caffeine, which has been noted to increase risk of accidents and wandering). Moderate exercise early in the day, supervision, use of a bedside commode, and keeping the room cool and quiet may also help.

Education of the family or caregiver is pivotal to the patient's care. The patient's cognitive and functional strengths and weaknesses must be presented so that the caregiver is aware of any changes, which may mark a decline. Reasonable therapy goals and expectations should be discussed. The caregiver must also monitor the patient's behavior (alertness, initiative, aggression, agitation), and he or she should be taught how to handle potential problems. Behavioral decompensation may also indicate infection, injury, or fecal impaction; this must be formally evaluated.

It is helpful for the patient to maintain a daily routine that provides structure to his or her life. The patient should continue performing ADLs and IADLs every day. Occupational therapy can help with techniques to correct individual disabilities and teach caregivers the essential needs of the patient's self-care activity. Greater physical activity has been associated with lower risk of cognitive impairment and dementia of any type. Physical therapy should also be incorporated into the patient's daily life; for instance, frequent walks should be included. Physical therapy can also help in improving the patient's balance and the safety of his or her transfers; these are generally affected in patients with dementia. Procedural learning (learning by performing the activity) should continue, even if declarative learning (learning by verbal instruction) is impaired.

Wolfs et al looked at the cost of diagnosing and managing dementia in ambulatory geriatric patients in an integrated, multidisciplinary diagnostic facility, comparing it with the cost of the usual care strategies for dementia. ^[37] The study found that patients who received care in the diagnostic facility had a mean increase of 0.05 quality-adjusted life years over study patients in the usual-care group, with the cost of this increase coming to 65 euros (approximately $90). According to the investigators, the results indicated that integrated, multidisciplinary diagnostic facilities are a cost-effective resource for diagnosing and managing dementia in ambulatory patients.

Caregiver burnout is common among those caring for patients with dementia, and this should be prevented. Helping the caregiver may delay institutionalization of the patient and may prevent elder abuse. Local support groups and educational materials from national organizations can help the caregiver to discuss and understand their feelings of depression, anger, frustration, and guilt. Miyamoto and colleagues report that caregivers who take care of mobile patients may perceive a burden greater than that of caregivers of nonmobile patients. ^[38] The reason is the increased likelihood of wandering activity, which requires more constant supervision. Wandering can result in serious or fatal injury. Good interventions to prevent wandering consist of having an alarm system, covering locks on doors, and placing a stop sign on the door. Medical alert bracelets may be advised in patients who wander.

Indicators of psychological distress among caregivers are physical illness, isolation, and anxiety. The patient's physician must be aware of caregiver stress because clinical depression is seen in 50% of those caring for patients with dementia. The increased degree of dependence in ADLs in the later stages of dementia may be predictive of caregiver distress. In their report, Thompsell and Lovestone remind the medical community that high levels of emotional stress are still prevalent in family members that are not the primary caregivers to the patient. ^[39] Access to educational information about dementia is also important for family members who are not located near the patient but still interested in their family member's care and well-being.

Social workers can offer community resources, including respite and daycare programs to alleviate stress that caregivers may face. One study demonstrated that daycare programs help in maintaining stability in the cognitive function of patients with mild-to-moderate dementia, although the programs do not decrease agitation. Social workers can also offer the patient community social activities to help increase stimulation and help to decrease social isolation, especially in the early stages in which the patient is not fully dependent. Social workers can also help in making arrangements regarding legal issues, which may include financial planning and the establishment of advanced directives.

A neuropsychologist should follow up the patient's MMSE results with serial visits, especially if changes are noted in the caregiver's report. Physiatric FIM scores and IADL scores should also be recorded to prescribe the appropriate rehabilitation at each stage.

Medications are also important in the management of dementia. Cholinesterase inhibitors are being used in the mild-to-moderate stages of dementia to try to slow the patient's cognitive decline, which may delay his or her placement in a nursing home. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors that are showing promising effects. In 2 randomized 26-week trials, rivastigmine improved scores on neuropsychological testing and on measures of behavior and function in 25-30% of patients with dementia. Neuroprotective agents, such as vitamin E (up to 2000 IU/d) and selegiline have retarded the progress of AD and reduced losses in the ability to perform ADLs.

For treatment of intermittent agitation, short-acting benzodiazepines (lorazepam, oxazepam) are useful on an as-needed basis. However, even low doses can increase the risk of falling. Tegretol and valproate are also used, but with these drugs, CBC counts should be monitored for agranulocytosis and thrombocytopenia. Antipsychotics, such as risperidone and quetiapine are good for the agitated patient and can aid with sleep. These medications are particularly good in patients with agitation and psychosis. SSRIs are recommended if the patient's agitation occurs in conjunction with depression. It is important to not confront a patient about his or her delusions or hallucinations; instead, the patient might be distracted or redirected.

Trazodone or buspirone is useful in the geriatric patient with anxiety or mild-to-moderate irritability, although watching for orthostatic hypotension is imperative. In men, sexual aggression or impulse-control problems can be treated with estrogen or medroxyprogesterone.

Conclusion

Delirium and dementia are of immense concern in the geriatric population. Awareness of any cognitive and behavioral changes in the elderly patient is crucial when focusing on rehabilitation. These changes significantly affect the quality of life of the patient and of his or her caregivers and family members.

Overview It is a little known fact that rehabilitation specialists can evaluate a patient's driving knowledge and ability. Kinesiotherapists, who work mainly in the Veteran's Administration Hospital system, and occupational therapists may be trained to evaluate an individual's ability to drive safely. For this evaluation, they may use written, visual, and road tests. Few clinicians routinely focus on a patient's driving capabilities during history taking or physical examination.

In the United States, the number of licensed drivers older than 65 years is projected to be 53 million in the year 2020. Because of the growing population of elderly drivers awareness about driver evaluations should increase among those in the medical community, especially physicians who manage the continuity of care in geriatric patients. Such physicians include geriatricians, internists, family practitioners, and physiatrists, among others.

Beside teenagers, the elderly have the highest accident rate per mile driven. A failure to yield the right-of-way and not abiding by signs or signals are major contributors to motor vehicle accidents in the elderly population. They also have a higher rate of collisions when making left turns. Although the elderly represent only 9% of all licensed drivers, they account for 13% of all traffic fatalities. Because of statistics like these, clinicians should be more aware of the services available to elderly drivers and of driver's evaluations, driving safety, and related rehabilitation issues.

Factors Affecting Driving Ability

Factors affecting driving ability include physiologic factors, vision and hearing, cognition, distractions while driving, psychomotor functioning, and medical conditions.

Physiology

Physiologic factors and the additional effect of medical conditions increase the risk of unsafe driving in the geriatric population. Age-related physiologic changes that can affect driving include sensory, cognitive, and psychomotor functioning.

Vision and hearing

Visual function is the most important sensory change in predicting driving impairment. Static and dynamic visual acuity, contrast sensitivity, peripheral vision, night vision, glare, visual perception, and useful field of view (UFOV) can decrease with age and adversely affect one's driving skills. UFOV has a high sensitivity and specificity in predicting crashes. There are significant changes with aging with visual localization and the ability to detect moving or stationary objects in the outer regions of the visual field. The elderly also have slower saccadic eye movements to track horizontally moving targets and have difficulty with estimating the speed of vehicles around them.

Glaucoma can reduce the visual field and contrast sensitivity. Cataracts can reduce contrast sensitivity and glare resistance. Glare vision and glare recovery progressively decline after the age of 40 years.

Ophthalmologists can help to detect and correct specific visual problems. Physiatrists and therapists can continue to train patients with visual impairments. There are lower fatal crash rates among older drivers in states that mandate vision and road testing at license renewal.

Elderly people with a hearing impairment report more adverse driving events. Most elderly people, however, do not stop driving, and they do not make adaptations to driving despite their hearing loss. If a patient requires a hearing aid, audiologists can program the device while the patient is in the car to make specific modifications.

Cognition

Cognitive changes can also impair driving ability in the elderly population. In a study by Carr and colleagues, 60% of elderly drivers had some degree of cognitive impairment. ^[40] Speech language pathologists and neuropsychologists can assess and monitor the patient's cognitive abilities. Emphasis should be placed on reaction times and attention, as these are well-documented, age-associated problems related to driving. See the images below.

Three forms of attention are described: selective, divided, and sustained. Selective attention involves shifting one's attention between stimuli. This type of attention involves use of the UFOV to direct a person's attention to significant events while driving. This attention is reduced when the driver is distracted from the central task. UFOV narrows with age, and this change is related to the accident risk in older drivers. Training a person to increase his or her UFOV has been successful in decreasing their likelihood of performing dangerous maneuvers. Divided attention is when a person monitors 2 sources of stimuli at the same time. Results of studies on divided attention are less conclusive. Sustained attention is the maintenance of one's attention to a single task. This type of attention seems to not be age related.

Patients with dementia are at increased risk of unsafe driving because of memory loss, visuospatial disturbances, and impaired judgment. A 1994 study group in the US Department of Transportation reported that 33% of people with dementia who were still driving had motor vehicle accidents or moving violations in the 6 months preceding the study. In the first year after dementia is diagnosed, patients have an accident rate similar to that of registered drivers of all ages. However, the risk can increase 3-fold in the following years. This observation is important because patients with AD often drive for an average of 2.5 years after receiving their diagnosis. Many individuals with dementia report that not driving is one of the most difficult aspects of the disease. Decisions regarding driving are also one of the most difficult issues for family members to address.

Distractions

Because telephonic technology is advancing, it is important to be aware of the relationship between driving and cell phone use. The cognitive requirements of simultaneously driving and conversing may exceed a person's ability to do both well. Phone use while driving will likely become more prevalent in the geriatric population as younger generations who already are accustomed to the technology age. In 1999, Noy and colleagues found that cell phone use had no effect on a driver's ability to maintain their car in a lateral position under normal traffic conditions; this was true of drivers of all ages. However, night and poor weather conditions may impair this ability.

Intuitively, the use of hands-free systems would seem to eliminate most of the manual dexterity tasks required to operate a phone and thus away from additive safety-related cognitive issues, specifically that of attention. In 2001, a Canadian group reviewed the effect of using a hands-free phone on driving performance in people of all ages. This study illustrated that the use of such systems had a positive net effect in terms of conservative or anticipatory behavior in response to changes in traffic signals. This benefit was observed in drivers of all ages. However, when conversation factors were equally controlled, subjects aged 45-70 years reaction times longer than those of younger subjects; this finding is consistent with the expected effects of aging.

Psychomotor functioning

Psychomotor slowing due to the loss of fast-twitch muscle fibers is evident with age. Thus, the motor component of one's reaction time generally becomes slower with age. Even the movements needed to fix one's eyes on objects of interest are slower. Because of these changes, and because of decreased ROM in the cervical spine due to arthritic conditions, many elderly drivers have a static head, which leads to peripheral vision decline and which contributes to accidents. Their ability to judge safe gaps in which they may enter or cross moving traffic may be affected by visual and motor difficulties, including spatial deficits. Geriatric patients must be able to maintain their motor strength and good balance to retain good driving skills. In the older population, a history of falls within a period of 1-2 years may be predictive of adverse driving events.

Medical conditions

Medical conditions that affect the geriatric population can also affect their driving skills. Medical conditions that are most consistently related to unsafe driving are the following: cardiac diseases, diabetes mellitus, and neurologic diseases (mainly stroke, dementia, seizures, and Parkinson disease). Diabetes can increase the risk of unsafe driving because of related retinopathy, peripheral neuropathy, or hypoglycemic episodes. The risk of collisions resulting in injury is substantially increased among older diabetic drivers who are taking insulin or oral agents, among those who have had diabetes for more than 5 years, and among those with coexisting cardiac disease.

Depression, sleep apnea, and foot disorders can also contribute to driving impairment. Limitations in cervical ROM due to arthritic changes can adversely affect a person's driving by decreasing his or her ability to check blind spots when changing lanes, for example. Impaired cervical motion has been associated with accidents and moving violations.

Medications, such as narcotics, muscles relaxants, benzodiazepines, tricyclic antidepressants, and hypnotics may also be factors in driving impairment. Alcohol has been implicated in fatal accidents among those older than 70 years; however, the effect of alcohol remains more important in the younger population.

Confronting Patients About a Driving Evaluation

It is not an easy task for physicians to confront their patients regarding a driving evaluation because of the possible consequences. Preserving the patient's autonomy is difficult if the evaluation results in the patient's license being rescinded. If no alternative transportation is available for the person to complete their necessary errands (eg, grocery shopping, going to the bank, and visiting their doctor), problems may arise because physicians need to protect society against unsafe drivers. Thus, mandatory reporting requirements may have a negative impact on the physician-patient relationship. As a consequence of such reporting, the patient may lose faith in their physician and not accept his or her help in seeking alternatives.

Patients are generally unaware of their deficits, especially those regarding judgment, and they may refuse to surrender their driver's license. Some patients believe that driving cessation is an indication of incompetence. It implies social disability and threatens the patient's independence. A referral to a kinesiotherapist or an occupational therapist for an evaluation of driving performance may or may not convince the patient of his or her impairments. Family members may have to take possession of the patient's car keys or even the car if the patient refuses a formal evaluation. The family should be involved in the decision-making process to help ensure that the recommendations are followed. In addition, physicians can inform patients and family that insurance companies may refuse to pay for damages incurred in accidents that occur after a physician recommends that the patient should not drive.

Self-evaluation

Use of a previsit questionnaire can aid in identifying physiologic, medical, and social issues mentioned above. The questionnaire can also be used to determine whether the patient is still driving, the frequency of such driving, the length of the trips, the types of roadways used, and any self-imposed restrictions. The driving history should include information about the following: night driving, use of a navigator, transporting other passengers, accidents and near-misses, tickets, getting lost while driving.

It is essential to determine the patient's need to drive. Questions alluding to alternatives available to the patient in the case of driving cessation should be incorporated in the questionnaire; examples of such alternatives include family members who can provide transportation, shopping services, and public transportation, among others.

Family or friends may add to the comments by answering questions regarding their perception of the patient's driving skills. Reports of adaptation to driving (eg, asking passenger to look both ways or not driving during rush hour) may be a signal of impending driving impairment.

Physical examination

The physical examination should include an assessment of medical conditions, vision, hearing, mental status, muscle strength, joint ROM (cervical, upper and lower extremities), gait, sitting and standing balance, mobility, and overall function. An independent predictor of adverse driving events is the MMSE, specifically the component of copying a pentagon. This simple visuospatial task should become standard in the evaluation of the geriatric patient because it seems to aid in determining the levels of dementia and driving impairment among the elderly.

Many of the elderly have jobs that require driving, such as driving school buses or company vehicles, and as a result, these individuals may be required to undergo an annual health examination. Anecdotally, patients with careers as taxi or truck drivers who drive an enormous number of miles per year have better reaction times and maintain a higher driving ability when compared with their counterparts in the same age range. However, driving is not always a main focus on annual health examinations for all elderly patients.

The physician's assessment can be supplemented by formal testing. Kinesiotherapists or occupational therapists can perform a variety of tests of skill and function to identify drivers who are at increased risk for accidents.

Rehabilitation

Treatment for any medical conditions and age-associated physiologic changes is the first step in helping the geriatric driver. Balance, strength, mobility, and cognitive issues should then be treated with appropriate therapies.

During a driving assessment, kinesiotherapists and occupational therapists can test a patient's visual, cognitive, and motor skills before performing a road test. Therapists often evaluate patients with progressive diseases (eg, multiple sclerosis) or other cognitive deficits on a yearly basis. In patients with dementia, the severity of disease and the appropriateness of continued driving should be formally reassessed at intervals of every 6 months to 1 year. Road testing has been advocated as the preferred method for assessing driving competency and for retraining.

Specialists trained in driver's rehabilitation incorporate good history taking and physical examination into their entire evaluation. Salients are evaluations of the following: information processing, memory, cognition, sensation, proprioception, coordination, endurance, sitting and standing balance, extremity strength and ROM, transfers in and out of the vehicle, and adaptive equipment (eg, braces, splints). Therapists often review the use of corrective lenses and then test the following: visual acuity, UFOV, lateral field of vision, saccadic eye movement, tracking, night vision, glare vision, glare recovery, color appreciation, depth perception, and spatial awareness.

Braking and steering reaction times and anticipatory skills are tested by using a simulator. Simulators and road testing are used to evaluate the patient's ability to perform basic maneuvers in residential, rural, urban, and freeway environments. The main objectives are to evaluate the driver's speed, following distance, ability to drive safely with changing traffic situations, and functional operation of the controls of the motor vehicle. Education regarding seat belt use, transfers in and out of the vehicle, defensive driving, and vehicle modifications complements the driver's training. An adjunct to the rehabilitation education is the 55 Alive/Mature Driving Program of AARP, which provides education for older drivers.

The therapist may also recommend modifications to the patient's vehicle to assist with driving safely. Adaptive equipment includes spinner knobs on the steering wheel or extensions on turn signals for stroke patients, left-foot acceleration pedals for patients with right-foot deformities or amputation, and hand controls for paraplegics. Each state's Department of Motor Vehicles (DMV) reviews and mechanically tests the available adaptive equipment and administers restrictions to ensure the appropriateness of the modifications. Therapists train the patient until he or she has adequate knowledge of the adaptations and can pass the road test while using the adaptive equipment.

Legal Issues

Physicians should be aware of and follow state guidelines regarding the reporting of potentially unsafe drivers. Regulations vary from state to state. State-mandated tests of visual acuity are associated with lower rates of fatal accidents. Although physicians and therapists evaluate patients by documenting and reporting physiologic changes, medical conditions, and formal test results, the state ultimately confers licenses to operate a motor vehicle. State DMVs, however, take the results of these evaluations into strong consideration.

In 1996, the California DMV implemented a requirement that physicians must report patients who have moderate-to-severe AD, and the DMV revokes the patient's license without additional testing. Patients with mild dementia are required to undergo repeat examination to demonstrate their driving ability. If physicians fail to comply with this regulation, they may lose their medical license and also incur legal liability should their patient be involved in a collision. In a study by Cable and colleagues, 30% of geriatricians in states other than California do not know how to report patients with dementia who are potentially dangerous drivers. ^[41] All states should develop protocols for the evaluation of patients with cognitive impairments.

In Florida, drivers aged 70 years or older may renew their license by mail for 2 renewal periods (8 y total) with only vision testing at the third renewal.

In New Hampshire and Illinois, drivers aged 75 years or older undergo vision and road testing to renew their license. In 2001, 942 licensed drivers in Illinois were aged 95 years or older.

In Oregon, the Older Driver Advisory Committee recommended reducing the driver's license renewal cycle from 8 to 4 years for drivers aged 65 years or older. The recommended screening tests assess visual (including UFOV), cognitive, and functional abilities.

In Minnesota and Iowa, the law does not require physicians to report patients who should not drive; however, it protects physicians from any liability if they do so.

Cessation of Driving

When confronted with the diseases of aging, some elderly drivers stop driving on their own accord. The most common factors associated with driving cessation are increasing age, female sex, functional impairment, neurologic disease (eg, dementia, Parkinson disease, CVA), and visual impairment. Some individuals may just limit their driving. For example, an older person may choose to drive only during daylight or off-peak hours (eg, 9 am to 4 pm), to drive only on surface streets instead of freeways or highways, or to restrict their driving by relying on public transportation for trips more than a certain distance (eg, 75 miles). Those who stop driving are at risk for social isolation, depression, and functional impairment.

Social workers can assist a patient by providing them with resources to help the person maintain mobility in the community and to prevent social isolation. One option is using a senior van, which transports elderly people to and from their doctor's office, senior center, and grocery store, for example. Psychologists can help the patient cope with the loss of driving privileges, as this often leads to depression, a loss of identity, and a loss of self-esteem. Physiatrists can determine if the person has a need to improve his or her functional skills.

Conclusion

Overall, the driver's evaluation by rehabilitation specialists is an underutilized service. To keep our roads safe for our patients and for society, it is imperative that we manage emerging problems that can affect the driving ability of our geriatric patients.