SAN FRANCISCO – Screening for the four common problems of old age that constitute geriatric syndrome–cognitive loss, falls, incontinence, and depression–offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.
These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).
“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”
A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one the following components at each visit:
▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive.
The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter). When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia–even mild dementia (Neurology 2004;62:556–62).
This test's flexibility means that it can be made culturally or intellectually appropriate for the patient. It may also provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.
Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said. Other strategies, such as antioxidant or anti-inflammatory approaches, and estrogen, vitamins, and statins, have not panned out. Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.
“I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”
▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.
In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.
Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” including factors such as dementia or age over 80 years, Dr. Hall said.
Even minimal strength training can reap benefits, and several exercises can be used that do not require expensive equipment or supervision.
▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it.
Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus, physicians must be proactive in looking for the problem, he said.
The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, Dr. Hall explained.
Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments such as biofeedback or electrical stimulation.
▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, the elderly are prone to subclinical depression that can almost be described as a “failure to thrive,” Dr. Hall said.
According to a Cochrane Collaboration review not yet published, effective screening for depression–even mild depression–can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”