Managing Age Related Disorders

The most common disorders of the elderly are dementia, cardiovascular disease, osteoporosis, and incontinence. It is not unusual for elderly patients to suffer from all these disorders simultaneously.

DEMENTIA Nearly half of all elderly patients suffer from various degrees of dementia. Two-thirds are caused by Alzheimer's disease (AD), which is currently irreversible. Reversible dementias are caused by strokes, neoplasms, or toxins such as alcohol, or those produced by infections. Although a complete cure for most dementias is not possible, optimal management can improve the ability of these patients to cope with basic tasks. In many cases, dementia is the result of one or more small strokes caused by hypertension. Thus the first step in managing dementia is aggressive treatment for high blood pressure. This is followed with pharmacological agents that enhance cognition and function, and treat associated problems such as depression, paranoia, delusions, agitation, and even psychoses.

Where AD is suspected, the patient may be treated with cholinesterase inhibitors to maximize the half-life of brain neurotransmitters. There are three such drugs available: donepezil, rivastigmine, and galantamine. Clinical trials have shown that these drugs can improve cognitive function. However, side effects, including nausea, vomiting, and diarrhea, can lead to serious complications. Other drugs, such as estrogen (for women), vitamin E, ginkgo biloba, and nonsteroidal anti-inflammatory agents, are also used but their effectiveness is in doubt. However, while these agents may be ineffective as a treatment for advanced dementia, they may be useful in treating milder cases.

CARDIOVASCULAR DISEASE Cardiac output and the response of the heart to exercise decreases with age. Ventricular contractions become weaker with each decade, a problem that is compounded by the age-related reduction in blood vessel elasticity. Hardening of the arteries is the prime cause of hypertension in the elderly, but it is not an unavoidable consequence of aging. The first stage in managing hypertension and cardiovascular disease is a change in lifestyle. Clinical trials have shown that even the very old can benefit by this approach, which involves maintaining an ideal body weight, no smoking, regular aerobic exercises, and a diet consisting of fruits, vegetables, and low-fat dairy products (all of which are rich in essential potassium, calcium, and magnesium). If these procedures fail to reduce blood pressure, drugs such as thiazide, beta-blockers, or calcium channel blockers may be used, but the diet and exercise regimen should be maintained.

OSTEOPOROSIS Diminished bone mass can be determined most conveniently with special X-ray machines (dual energy X-ray absorptiometry) or with ultrasound densitometry. Both procedures determine the density as g/cm2, which is compared to normal values from a younger population and is used to estimate the likelihood of fracture. The first attempts to manage this disease involve a diet rich in calcium and vitamin D, along with regular weight-bearing exercises. Hormone replacement therapy has also been recommended, for men and women, but as discussed in a previous chapter, this approach can lead to dangerous side effects. An alternative drug therapy involves the use of bisphosphonates, antiresorptive drugs that are known to increase bone mass. The bisphosphonate, alendronate, was shown to decrease the incidence of vertebral and nonvertebral fractures by more than 50 percent in postmenopausal women. The major side effects are gastrointestinal, and the drug must be taken on an empty stomach in an upright position.

INCONTINENCE Incontinence, or the involuntary loss of urine or stool, is very common in the geriatric population. About 33 percent of elderly women and 20 percent of elderly men suffer from this disorder. The prevalence may be as high as 80 percent in nursing homes or long-term-care institutions. Incontinence may develop because of neurological damage sustained after a stroke or it may be traced to age-related changes in the urinary system, in particular, the integrity of the urethra and the holding volume of the bladder, which decreases with age. Delirium and exposure to a new environment, such as recent admission to hospital or nursing home, can also lead to incontinence in the elderly. Simply modifying the patient's fluid intake and eliminating diuretics such as coffee or tea can often treat transient incontinence.

Persistent or acute incontinence is managed initially by ensuring that the patient can reach a toilet quickly. It may also be necessary to provide the patient with incontinence undergarments and pads. Often with special care and training, the problem can be resolved. In other cases, it may be necessary to resort to drug therapy. A commonly used drug is a bladder relaxant, tolterodine, which is available in long-acting preparations. In severe cases, surgery may be required to repair damaged sphincters that normally regulated urine flow through the urethra.

It may also be necessary to fit the patient with a catheter that continually drains the bladder into a plastic bag. However, chronic indwelling catherization is not advised, as it is associated with a high risk of developing urinary system infections.

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