Chronic Diseases in Geriatric Patients [1 ed.] 9781681082455, 9781681082462

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Recent Advances in Geriatric Medicine Volume 1 Chronic Diseases in Geriatric Patients Tuck Yean Yong Internal Medicine, Flinders Private Hospital Flinders Drive, Bedford Park South Australia 5042 Australia

Recent Advances in Geriatric Medicine Volume # 1 ISSN (Online): 2468-225X ISSN: Print: 2468-2241 Chronic Diseases in Geriatric Patients Editor: Tuck Yean Yong ISBN (eBook): 978-1-68108-245-5 ISBN (Print): 978-1-68108-246-2 © [2016}, Bentham eBooks imprint. Published by Bentham Science Publishers – Sharjah, UAE. All Rights Reserved. Reprints and Revisions: First published in 2016

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CONTENTS PREFACE .................................................................................................................................................................... i REFERENCES .................................................................................................................................................... iLL LIST OF CONTRIBUTORS

...................................................................................................................................... iv

CHAPTER 1 CONUNDRUMS IN THE CARE OF OLDER ADULTS WITH CORONARY ARTERY DISEASE ...................................................................................................................................................................... 3 OVERVIEW OF CORONARY ARTERY DISEASE IN THE ELDERLY .................................................. 3 CLINICAL PRESENTATION OF CORONARY ARTERY DISEASE IN THE ELDERLY ..................... 4 DIAGNOSTIC CONSIDERATION OF CAD IN THE ELDERLY .............................................................. 5 SPECIAL CONSIDERATIONS FOR MEDICAL THERAPY IN ELDERLY PATIENTS WITH CAD ......................................................................................................................................................................... 5 REVASCULARIZATION FOR OLDER PATIENTS WITH CAD .............................................................. 7 CARDIAC REHABILITATION FOR OLDER PEOPLE WITH CAD ........................................................ 9 ADDITIONAL CONSIDERATIONS FOR REVASCULARIZATION IN THE ELDERLY: BLEEDING RISKS AND ACUTE KIDNEY INJURY .................................................................................................. 9 CONCLUSION ................................................................................................................................................... 11 CONFLICT OF INTEREST ............................................................................................................................. 12 ACKNOWLEDGEMENTS ............................................................................................................................... 12 KEY POINTS ..................................................................................................................................................... 12 REFERENCES ................................................................................................................................................... 13 CHAPTER 2 TREATING THE “YOUNG AT HEART”: MANAGEMENT OF HEART FAILURE IN THE OLDER POPULATION ........................................................................................................................................... 17 INTRODUCTION .............................................................................................................................................. 17 CLINICAL FEATURES .................................................................................................................................... 18 EVALUATION OF HEART FAILURE IN OLDER PATIENTS ................................................................ 19 CARDIORENAL SYNDROME ....................................................................................................................... 20 HEART FAILURE AND GERIATRIC SYNDROMES ................................................................................ 20 NON-PHARMACOLOGICAL MANAGEMENT .......................................................................................... 21 PHARMACOTHERAPY FOR HEART FAILURE WITH REDUCED EJECTION FRACTION ......... 22 DEVICES IN HEART FAILURE WITH REDUCED EJECTION FRACTION ....................................... 24 PHARMACOTHERAPY FOR HEART FAILURE WITH PRESERVED EJECTION FRACTION ....................................................................................................................................................................... 25 GAPS IN EVIDENCE ........................................................................................................................................ 26 CONCLUSION ................................................................................................................................................... 26 CONFLICT OF INTEREST ............................................................................................................................. 26 ACKNOWLEDGEMENTS ............................................................................................................................... 26 KEY POINTS ..................................................................................................................................................... 26 REFERENCES ................................................................................................................................................... 27 CHAPTER 3 UPDATES ON TREATING HYPERTENSION IN OLDER PEOPLE ..................................... INTRODUCTION .............................................................................................................................................. PATHOPHYSIOLOGY ..................................................................................................................................... EVALUATION ................................................................................................................................................... BLOOD PRESSURE GOALS IN OLDER PEOPLE ..................................................................................... BENEFITS OF BLOOD PRESSURE CONTROL IN OLDER PEOPLE ................................................... MANAGEMENT – LIFESTYLE MODIFICATIONS ...................................................................................

34 35 35 35 36 37 39

MANAGEMENT – PHARMACOLOGICAL TREATMENT ...................................................................... MANAGEMENT OF RESISTANT HYPERTENSION ................................................................................ CHALLENGES OF HYPERTENSION MANAGEMENT IN OLDER PEOPLE ...................................... CONCLUSION ................................................................................................................................................... CONFLICT OF INTEREST ............................................................................................................................. ACKNOWLEDGEMENTS ............................................................................................................................... KEY POINTS ..................................................................................................................................................... REFERENCES ...................................................................................................................................................

40 41 43 44 44 45 45 45

CHAPTER 4 CROSSING NEW FRONTIERS IN THE CARE OF OLDER ADULTS WITH DIABETES MELLITUS ................................................................................................................................................................ 50 INTRODUCTION .............................................................................................................................................. 50 PATHOGENESIS .............................................................................................................................................. 51 SCREENING AND DIAGNOSIS ..................................................................................................................... 52 ASSESSMENT ................................................................................................................................................... 52 DIABETES CARE IN OLDER PEOPLE ........................................................................................................ 53 Non-Pharmacological Interventions ............................................................................................................. 54 Pharmacological Interventions for Glycaemic Control ................................................................................ 55 DIABETES AND GERIATRIC SYNDROMES ............................................................................................. 59 CHALLENGES IN TREATING OLDER PEOPLE WITH DIABETES .................................................... 61 CONCLUSION ................................................................................................................................................... 62 CONFLICT OF INTEREST ............................................................................................................................. 63 ACKNOWLEDGEMENTS ............................................................................................................................... 63 KEY POINTS ..................................................................................................................................................... 63 REFERENCES ................................................................................................................................................... 64 CHAPTER 5 HALTING THE DECLINE IN COGNITION: NEW INSIGHTS INTO ALZHEIMER’S DISEASE .................................................................................................................................................................... 73 INTRODUCTION .............................................................................................................................................. 74 EPIDEMIOLOGY ............................................................................................................................................. 74 RISK FACTORS ................................................................................................................................................ 74 PATHOGENESIS .............................................................................................................................................. 75 DIAGNOSIS ....................................................................................................................................................... 76 BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS ......................................................................... 77 NEUROIMAGING ............................................................................................................................................. 78 OTHER INVESTIGATIONS ............................................................................................................................ 79 NATURAL HISTORY ....................................................................................................................................... 79 MANAGEMENT – NON-PHARMACOLOGICAL THERAPY .................................................................. 79 MANAGEMENT – PHARMACOLOGICAL THERAPY ............................................................................ 80 MANAGEMENT – BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS ....................................... 81 PROPOSED TREATMENT ............................................................................................................................. 81 CAREGIVERS ................................................................................................................................................... 82 STRATEGIES TO PREVENT ALZHEIMER’S DISEASE .......................................................................... 83 GAPS IN CURRENT EVIDENCE AND FUTURE RESEARCH ................................................................. 83 CONCLUSION ................................................................................................................................................... 83 CONFLICT OF INTEREST ............................................................................................................................. 84 ACKNOWLEDGEMENTS ............................................................................................................................... 84 KEY POINTS ..................................................................................................................................................... 84 REFERENCES ................................................................................................................................................... 84

CHAPTER 6 NEW HORIZONS IN ISCHAEMIC STROKE AMONG OLDER PEOPLE ......................... 92 INTRODUCTION .............................................................................................................................................. 92 CLINICAL OUTCOMES AND EVALUATION ............................................................................................ 93 STROKE UNITS ................................................................................................................................................ 94 SECONDARY PREVENTION ......................................................................................................................... 94 Antiplatelet Therapy ..................................................................................................................................... 95 Anticoagulant Therapy and Atrial Fibrillation ............................................................................................. 95 Blood Pressure Control ................................................................................................................................ 98 Cholesterol-Lowering Treatment ................................................................................................................. 98 Carotid Artery Stenosis Treatment ............................................................................................................... 99 REHABILITATION .......................................................................................................................................... 99 CONCLUSION ................................................................................................................................................. 100 CONFLICT OF INTEREST ........................................................................................................................... 100 ACKNOWLEDGEMENTS ............................................................................................................................. 100 KEY POINTS ................................................................................................................................................... 100 REFERENCES ................................................................................................................................................. 101 CHAPTER 7 CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN OLDER PEOPLE: BREATHING DEEPER WITH AGE ............................................................................................................................................. 107 INTRODUCTION ............................................................................................................................................ 107 AGE-RELATED CHANGES IN RESPIRATORY SYSTEM ..................................................................... 108 EVALUATION ................................................................................................................................................. 109 COMMON COMORBIDITIES ...................................................................................................................... 110 MANAGEMENT OF COPD ........................................................................................................................... 112 Non-Pharmacological Interventions ........................................................................................................... 112 Smoking Cessation ............................................................................................................................. 112 Physical Activity ................................................................................................................................. 113 Nutrition ............................................................................................................................................. 113 Pulmonary Rehabilitation .................................................................................................................. 113 Pharmacological Interventions ................................................................................................................... 113 Bronchodilators .................................................................................................................................. 114 Inhaled Corticosteroids ...................................................................................................................... 115 Combination Therapies ...................................................................................................................... 115 Delivery Systems of Inhaled Medications ................................................................................................. 115 Immunizations ............................................................................................................................................ 116 Surgical Interventions ................................................................................................................................ 116 Other Therapies .......................................................................................................................................... 117 MANAGEMENT OF ACUTE EXACERBATIONS .................................................................................... 117 END-OF-LIFE MANAGEMENT ................................................................................................................... 119 CONCLUSION ................................................................................................................................................. 119 CONFLICT OF INTEREST ........................................................................................................................... 119 ACKNOWLEDGEMENTS ............................................................................................................................. 119 KEY POINTS ................................................................................................................................................... 120 REFERENCES ................................................................................................................................................. 120 CHAPTER 8 CANCER IN OLDER ADULTS: TO TREAT OR NOT TO TREAT? ................................... INTRODUCTION ............................................................................................................................................ CANCER IN DIFFERENT AGE GROUPS .................................................................................................. ASSESSMENT OF OLDER PEOPLE WITH CANCER ............................................................................ TREATMENT CONSIDERATIONS FOR OLDER PEOPLE WITH CANCER ..................................... CANCER SURVIVORSHIP IN OLDER ADULTS ..................................................................................... MODELS OF CARE ........................................................................................................................................

128 128 129 130 131 132 133

CHALLENGES IN CANCER CARE OF OLDER PEOPLE ..................................................................... CONCLUSION ................................................................................................................................................. CONFLICT OF INTEREST ........................................................................................................................... ACKNOWLEDGEMENTS ............................................................................................................................. KEY POINTS ................................................................................................................................................... REFERENCES .................................................................................................................................................

133 133 134 134 134 134

CHAPTER 9 OVERCOMING OSTEOARTHRITIS IN OLD AGE .............................................................. INTRODUCTION ............................................................................................................................................ DIAGNOSIS AND CLINICAL FEATURES ................................................................................................ NONPHARMACOLOGICAL INTERVENTIONS ...................................................................................... PHARMACOLOGICAL THERAPY ............................................................................................................ Oral Analgesics .......................................................................................................................................... Topical or Transdermal Agents .................................................................................................................. Intraarticular Agents ................................................................................................................................... COMPLEMENTARY AGENTS .................................................................................................................... JOINT REPLACEMENT SURGERY ........................................................................................................... FUTURE RESEARCH .................................................................................................................................... CONCLUSION ................................................................................................................................................. CONFLICT OF INTEREST ........................................................................................................................... ACKNOWLEDGEMENTS ............................................................................................................................. KEY POINTS ................................................................................................................................................... REFERENCES .................................................................................................................................................

138 138 139 139 140 140 143 143 144 145 146 146 147 147 147 147

CHAPTER 10 TOWARDS UNBREAKABLE OLD BONES: OSTEOPOROSIS IN OLDER ADULTS ... INTRODUCTION ............................................................................................................................................ CHANGES IN BONE AND GAIT STABILITY WITH AGING ................................................................ DIAGNOSIS ..................................................................................................................................................... STRATEGIES TO PREVENT FRAGILITY FRACTURES ...................................................................... Non-Pharmacological ................................................................................................................................. Falls Prevention ................................................................................................................................. Exercise Programs ............................................................................................................................. Hip Protectors .................................................................................................................................... Pharmacological ........................................................................................................................................ Calcium and Vitamin D Supplementation .......................................................................................... Oestrogen ........................................................................................................................................... Bisphosphonate ................................................................................................................................. Strontium Ranelate ............................................................................................................................. Selective Oestrogen Receptor Modulator .......................................................................................... Denosumab ......................................................................................................................................... Human Recombinant Parathyroid Hormone ..................................................................................... Other New Agents ............................................................................................................................... MANAGING OSTEOPOROSIS IN RESIDENTS OF AGED CARE FACILITIES ................................ OSTEOPOROSIS AND MULTIPLE COMORBIDITIES .......................................................................... GAPS IN CURRENT EVIDENCE AND FUTURE RESEARCH ............................................................... CONCLUSION ................................................................................................................................................. CONFLICT OF INTEREST ........................................................................................................................... ACKNOWLEDGEMENTS ............................................................................................................................. KEY POINTS ................................................................................................................................................... REFERENCES .................................................................................................................................................

155 156 156 157 158 158 158 158 158 159 159 160 160 162 163 163 164 164 165 165 166 166 167 167 167 167

CHAPTER 11 KEEP THE KIDNEYS FUNCTIONING TILL THE END: CHRONIC KIDNEY DISEASE IN THE OLDER POPULATION ................................................................................................................................ 174 INTRODUCTION ............................................................................................................................................ 175 CHANGES IN THE KIDNEYS WITH INCREASING AGE ..................................................................... 175 ASSESSING KIDNEY FUNCTION IN OLDER PEOPLE ......................................................................... 176 BURDEN OF CKD IN OLDER PEOPLE ..................................................................................................... 176 CKD AND GERIATRIC SYNDROMES ....................................................................................................... 177 MANAGEMENT OF CKD IN OLDER AGE ............................................................................................... 178 CKD PREVENTION ....................................................................................................................................... 179 SLOWING THE RATE OF CKD PROGRESSION .................................................................................... 180 MANAGEMENT OF CKD COMPLICATIONS .......................................................................................... 180 DIALYSIS ......................................................................................................................................................... 181 KIDNEY TRANSPLANTATION ................................................................................................................... 182 FUTURE RESEARCH .................................................................................................................................... 182 CONCLUSION ................................................................................................................................................. 183 CONFLICT OF INTEREST ........................................................................................................................... 183 ACKNOWLEDGEMENTS ............................................................................................................................. 183 KEY POINTS ................................................................................................................................................... 183 REFERENCES ................................................................................................................................................. 183 CHAPTER 12 END OF LIFE CARE IN OLDER PEOPLE ............................................................................ INTRODUCTION ............................................................................................................................................ RECOGNISING END-OF-LIFE .................................................................................................................... THE PUBLIC’S ATTITUDE TO END-OF-LIFE CARE DISCUSSIONS ................................................ ARE END-OF-LIFE CARE DISCUSSIONS BEING HELD? .................................................................... HEALTHCARE PROFESSIONALS’ ATTITUDE TO END-OF-LIFE CARE DISCUSSIONS ............ BARRIERS TO DISCUSSING END-OF-LIFE CARE ................................................................................ ADVANCE CARE PLANNING ..................................................................................................................... PALLIATIVE CARE FOR OLDER PEOPLE ............................................................................................. MEDICATION PRESCRIPTION IN THE END-OF-LIFE STAGE ......................................................... CONCLUSION ................................................................................................................................................. CONFLICT OF INTEREST ........................................................................................................................... ACKNOWLEDGEMENTS ............................................................................................................................. KEY POINTS ................................................................................................................................................... REFERENCES .................................................................................................................................................

189 189 190 191 191 192 192 193 193 194 195 195 195 195 196

CLOSING REMARKS: CHRONIC DISEASES IN GERIATRIC MEDICINE .............................................. 199 REFERENCES ................................................................................................................................................. 200 SUBJECT INDEX .................................................................................................................................................... 202

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PREFACE A rise in prevalence of chronic non-communicable diseases, including heart disease, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, diabetes mellitus, stroke, cancers and osteoarthritis, have been observed among older people in many countries [1, 2]. A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. To compound this burden on the older individual and society in general, effective intervention is complicated by ageism, complex multiple comorbidity and lack of access to age-appropriate care. The purpose of this book is to address some of the medical care needs that exist for eleven common chronic conditions in older people. An additional chapter on end-of-life care will address the needs of older people with chronic diseases as they approach the terminal phase of life. The chapter on coronary artery disease (CAD) in the elderly will look at the epidemiology, differences in clinical presentations and approach to evaluation and management that is appropriate for this age group. In particular issues on invasive assessment of the coronary artery and revascularisation procedures in older people with CAD will be addressed. Heart failure is common in the older population and is associated with a poor prognosis. Managing older people with heart failure is a challenge because presenting features can be different from younger patients and the risk of adverse effects from polypharmacy. The chapter on heart failure aims to address these issues. Hypertension is a common chronic condition in older people and an important risk factor for many vascular diseases. Therefore, the chapter on hypertension in older people will examine the evidence for controlling hypertension, target blood pressure and which antihypertensive agents to use in this age group. Diabetes mellitus, especially type 2 diabetes, is a condition that affects many older people, about 20% of those aged ≥65 years. Like younger people, diabetes in the older age group is associated with significant morbidity, reduction in quality of life and mortality. In the older population, diabetes is associated with an increased risk of geriatric syndromes such as cognitive impairment, urinary incontinence and falls, which require careful assessment and management. The chapter on diabetes mellitus will look at some of the chronic problems faced by older people living with this condition. Alzheimer’s disease has emerged as a major public health concern globally which has a significant impact on the patient, family, caregivers and health care system. Although it has been recognised for more than a century, its pathogenesis is still not understood and benefits

ii

from pharmacological treatment has been limited so far. The chapter on Alzheimer’s disease will provide updates on neuroimaging, nonpharmacological and pharmacological treatment. Ischaemic stroke is associated with one of the highest causes of disability in older people. Evidence suggest that older people with ischaemic stroke often receive less effective therapy and experience poorer outcomes compared with younger patients. The chapter on ischaemic stroke in this book will review the available evidence on secondary prevention and treatment of this condition in older people and reducing the disability burden among survivors after the acute event. Many older people have chronic obstructive pulmonary disease (COPD) as a result of smoking and age-related pulmonary changes. COPD is associated with increased morbidity and mortality for the older population. The chapter on COPD will look at the diagnostic and therapeutic aspects of this condition that are relevant to the older age group. Cancers are increasingly diagnosed among people aged ≥65 years and this age group makes up more than 50% of new diagnosis of malignancy. Cancer care in older people is complex and challenging which is further compounded by limited evidence on the risk-benefit of treatments. The chapter on cancers in the elderly will review the differences in approach to management and identify gaps in evidence related to care of this group of older patients. Osteoarthritis, especially in the hip or knee, is a common diagnosis in older people that causes significant pain leading to disability and decreased quality of life. Management of osteoarthritis in these joints among the elderly is challenging because they often have multiple chronic conditions that can compound pain and increased susceptibility to adverse effects of analgesics. The chapter on osteoarthritis will review evidence-based nonpharmacological, pharmacological and surgical approaches to management of this condition in the hips and knees of older people. Osteoporosis and fragility fractures are highly prevalent in older people, with the latter associated with significant disability, mortality and health care cost. Osteoporosis is still underdiagnosed and undertreated among older people. The chapter on osteoporosis will examine the efficacy of both nonpharmacological and pharmacological strategies in the management of this condition and prevention of associated fragility fractures among the older population. The prevalence of chronic kidney disease (CKD) in the older population is steadily increasing worldwide. Management of CKD in older people is complex because there are many competing factors that have to be taken into consideration. One of the chapters will attempt to untangle some of these complexities and provide an updated review on a holistic approach in management of older people with CKD.

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As most of the chronic diseases described in this book have no cure, it is inevitable that these diseases will affect older people at the end of life. Evidence indicates that technology-driven interventions at the end of life do not necessarily improve satisfaction with care or quality of life. As a result, the final chapter of this book will address the need for advanced care planning and provision of good quality end-of-life care that is in concordance with the older patients’ and their family’s or caregivers’ goals. In this book, the authors have sought to provide educational and updated reviews on common chronic diseases encountered in geriatric medicine. Although the chapters in this book are not an exhaustive list of all chronic diseases, they review conditions that are frequently managed as part of day-to-day clinical practice. Managing older people with chronic diseases require a holistic approach with comprehensive assessment, leading to well integrated continuing care and focusing foremost on patients’ goals in an effort to streamline care.

REFERENCES [1] Freedman VA, Martin LG, Pell JP. Contribution of chronic conditions to aggregate changes in old-age functioning. Am J Public Health 2000; 90(11): 1755-60. [PMID: PMC1446390] [2] Bhattacharya J, Choudhry K, Lakdawalla D. Chronic disease and severe disability among working-age populations. Med Care 2005; 46(1): 92-100. [PMID: 18162861]

Tuck Yean Yong Internal Medicine, Flinders Private Hospital Flinders Drive, Bedford Park South Australia 5042 Australia

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List of Contributors Danielle Wu

Department of Nephrology, Mackay Base Hospital, Mackay, Australia

Kareeann Sok Fun Khow

$JHGDQG([WHQGHG&DUH6HUYLFHV7KH4XHHQ(OL]DEHWK+RVSLWDODQG 'HSDUWPHQWRI0HGLFLQH8QLYHUVLW\RI$GHODLGH$GHODLGH6RXWK$XVWUDOLD $XVWUDOLD

Lei Gao

Department of Cardiology, General Hospital of People’s Liberation Army, Beijing 100853, People’s Republic of China

Tuck Yean Yong

Internal Medicine, Flinders Private Hospital, Flinders Drive, Bedford Park, Australia

Recent Advances in Geriatric Medicine, 2016, Vol. 1, 3-16

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CHAPTER 1

Conundrums in the Care of Older Adults with Coronary Artery Disease Lei Gao* Department of Cardiology, General Hospital of People’s Liberation Army, Beijing 100853, People’s Republic of China Abstract: Coronary artery disease (CAD) is one of the leading causes of death in both men and women aged > 65 years. However, older patients have been underrepresented in clinical trials resulting in limited data about the effectiveness of different treatment strategies in this population. Furthermore, the atypical clinical presentations of CAD in elderly patients, often make diagnosis challenging and can lead to suboptimal implementation of treatment and secondary preventive measures by health care professionals. This chapter reviews clinical presentations and diagnosis consideration of CAD in the elderly. This review will also address clinical challenges that often arise when considering medication therapy and percutaneous coronary intervention (PCI) in the elderly, as well as cardiac rehabilitation in this population. To optimize the benefits of therapy in the elderly, providers should consider complex interplay of variables such as comorbidities, functional and socioeconomic status, side effects associated with multiple drug administration, and individual biological variability.

Keywords: Acute coronary syndrome, Angina, Bleeding risk, Coronary artery disease, Medication therapy, Older adults, Percutaneous coronary intervention, Polypharmacy, Revascularization. OVERVIEW OF CORONARY ARTERY DISEASE IN THE ELDERLY The clinical manifestations of coronary artery disease (CAD) in older patients represent the effects of the disease superimposed on the physiological Correspondence author Lei Gao: Department of Cardiology, General Hospital of People’s Liberation Army, Beijing 100853, People’s Republic of China; Tel: +68 10 5549 9339; Fax: +68 10 5549 9339; E-mail: [email protected]. *

Tuck Yean Yong (Ed) All rights reserved-© 2016 Bentham Science Publishers

4 Recent Advances in Geriatric Medicine, Vol. 1

Lei Gao

effects of age. Mortality and morbidity from CAD is strongly associated with increasing age. The age–sex standardized mortality rate for age