Geriatrics & Death & Dying

Clinical problems in aging

• In younger adults individual diseases tend to have a more distinct pathophysiology with well-defined risk factors

• Diseases in older persons may have a less distinct pathophysiology and are often the result of failed homeostatic mechanisms

• Population aging emerged as a worldwide phenomenon for the first time in history within the past century

• Governments and societies—as well as families and communities— now face new social and economic challenges that affect health care

• While the number of children has remained relatively stable, explosive growth has occurred among older populations (especially among the oldest)

• The number of persons aged 80–89 years more than tripled between
  1960 and 2010

Top two deaths in the US

Heart disease

Cancer

How do people die?

• Sudden Death

  • not for ~70% of people in Global North, most have conditions that let them plan for death

• Significant Illness (best case scenario)

  • long life of high functioning and then decompensate and die

• Organ failure (slow decline w/ interment episodes)

  • ex. organ failure

  • recovery happens bc of significant interventions, not spontaneous

• Frailty and Dementia

  • slow dwindling of fxn

Which are the norms / most common ways of dying today

Organ failure (slow decline w/ interment episodes)

Frailty and Dementia

Active Dying is measured in

Days

Terminal illness is measured in

Weeks to months

Are vital signs a predictor of death?

• No, they can actually remain quite stable until really close to death

• Heart rate is variable (systolic and diastolic declines) as heart rate increases

  • only variable VS

• RR maintained until time of death

  • but pattern changes

• Temperature goes up at time of death then declines after death

What are the clinical signs of active death?

Seen in 1-3 days in life

• Pattern of breathing changes (apneic breathing)

  • apnea has to be >30 seconds

• Chenyes Stokes breathing (apnea and hyper apnea)

  • caused by change in pH

  • hyperventilation relieves acidic state

• ** both breathing patterns are types brainstem breathing, not sign of physical distress

• Death rattle

  • caused by dysphagia and build-up of secretions

  • seen later

• Dysphagia (loss of swallow reflex)

  • seen earlier

• Decreased LOC

  • seen earlier

• Peripheral cyanosis

  • mottling of skin = late sign of death

• Loss of radial pulse

  • seen later

• Respirations with mandibular movement

  • seen later

• Urinary output declines

How to prevent or stop the death rattle?

• Anticholernergic agents (scopolomine)

• Position change

What are clinical signs of decreased cardiovascular?

• Decrease in cardiac output (despite tachycardia)

• Decrease in blood pressure

• Shunting of blood to core

• Decreased peripheral perfusion

• Peripheral & central cyanosis

• Skin mottling

• Loss of peripheral pulses

What does the palliative performance scale measure?

• 30% or above is bad

  • a positive finding

• at 30%

  • completely physically reliant

  • still consuming food and water

  • full, drowsy, or confusion LOC

• Activity

• Ambulation

• Intake

• Consciousness

What is to common coma pathway in death?

Sleepy → Lethargic → Obtunded (very difficult to arose) → Semicomatose → Comatose → Death

What is to not common coma pathway in death?

Restless → Confused → Tremulous → Hallucination → Delirium → (maybe: Myoclonic jerks → Seizures) → Semicomatose → Comatose → Death

• “difficult path”

• interventions

  • antianxiety meds for restlessness/confusion

  • dopamine

  • recognizing person is close to death so stop invasive and uncomfortable tx

What are drugs or palliative drugs used to help with confusion and restless during death?

Dopamine

Why does withdrawing liquids and food help in death?

Reduce discomfort, continuing liquids + food does not prolong life

What are neurological signs of impending death

• Seen in the last one to four days

• Decreased response to verbal

• Decreased to visual

• Drooling of nasolabial folds

• Hyperextension of the neck

• Non reactive pupils

• Inability to close eyelid (closer to death)

• Grunting of vocal cords (closer to death)

Major issues with aging

• Increasing disability (difficulty with ADLs)

• Cognitive impairment

• Increased use of healthcare resources/ increased health expenditures

• Expenditures increase with age, degree of disability, and are highest in the last year of life

What are ADLs (activities of daily living)

basic self-care activities

• personal hygiene

• dressing / undressing

• eating

• transferring from bed to chair & back

• voluntarily controlling urinary & fecal d/c

• using the toilet

• moving around (vs. being bedridden)

What are IADLs (instrumental activities of daily living)

tasks that are not necessary for fundamental functioning but permit an individual to live independently in a community

• according to Erickson’s stage of life, this is “ego integrity vs despair”

• doing light housework

• preparing meals

• taking medications

• shopping for essential items (e.g. groceries, clothing)

• using the telephone

• managing money

• using technology (new!)

When do you spend more one care?

The last year of your life

What is the Erikson Stage for aging adults?

Ego integrity vs Despair

What are geriatric syndromes

common conditions found in older adults that tend to be multifactorial & do not fall under discrete disease categories, including:

• delirium

• gait d/o's / falls

• chronic pain

• urinary incontinence

• anorexia / malnutrition

• cognitive impairment

• chronic pain

• disability

• disease susceptibility / comorbidity

• decubitus ulcers

• sleep d/o's

4 domains (systemic effects) of aging

• body composition

  • lean body mass declines (muscle and visceral organ tissue) → body fat increases

• balance between energy availability & energy demand

  • becomes imbalanced with age → fatigue

• decline of signaling networks (e.g. endocrine & nervous systems) that maintain homeostasis

• neurodegeneration

Domain: body composition

• This might be the most evident & and inescapable effect of aging

• Caused by disruptions in links b/t synthesis, degradation, & and repair that normally serve to remodel tissues

• Influenced by aging, illness, lifestyle factors (e.g. physical activity, diet)

Assessment: body composition

• PE → muscle strength testing (isometric, isokinetic), anthropometrics (weight, height, BMI, waist circumference, arm & leg circumferences, skin folds)

• labs → biomarkers (24-hr creatinuria OR 3-methyl-histidine)

• imaging → CT & MRI, DEXA

• other → hydrostatic weighing

Manifestations: body composition

• body weight ↑ through childhood, puberty, & adulthood until late middle age

• body weight begins to ↓ in

  • male-bodied people 65 - 70 y/o

  • female-bodied people somewhat later

• fat mass ↑ in middle age then ↓ in late life

  • so may be slightly overweight may better to enter last stage of life

• lean body mass (predominantly muscle + visceral organs) ↓ steadily after 3rd decade

  • faster in fast-twitch (used in long runs)

• waist circumference continues to ↑ through lifespan

  • suggests that visceral fat continues to accumulate

• muscle strength ↓ with age → ↑ weakness

  • strong independent predictor of mortality

• bone strength ↓ with age from progressive demineralization / architectural modification → ↑ risk for fractures

true or false: Muscle strength is a strong independent predictor of mortality.

• true

• prevention:

  • low-impact strength training has been shown to ↓ muscle atrophy & weakening of bones

  • body awareness-strengthening activities (e.g. yoga, Tai Chi) shown to ↓ falls

In skeletal muscle, atrophy that occurs as we age is greater in _____-twitch than in _____-twitch fibers.

fast, slow

true or false: Male-bodied people tend to lose bone mass at a younger age & more quickly than female-bodied people.

false

Rationale: Female-bodied people tend to lose bone mass at a younger age & more quickly than male-bodied people (i.e. reach threshold of low bone strength that ↑ fracture risk sooner).

What kind of fat is responsible for most of the pathologic consequences of obesity?

visceral

What constitutes "energy demand" for the body?

the energy required to complete tasks of daily life PLUS compensate for any kind of chronic condition that requires energy expenditure to maintain homeostasis

Assessment: balance between energy availability & energy demand

• self-reported questionnaires re: physical activity, sense of fatigue, exercise tolerance (including sexual activity)

• PE → performance-based tests of physical function

• imaging → magnetic resonance spectroscopy

• other → resting metabolic rate, treadmill testing (of O2 consumption during walking), objective measures of physical activity (e.g. accelerometers, double-labeled water)

Manifestations: balance between energy availability & energy demand

• fitness ↓ → ↓ activity tolerance

• energy production / consumption (measured by VO2) ↓ progressively & rate of ↓ is accelerated in persons who are sedentary / those affected by chronic illness

• BMR ↓

  • only partially explained by ↓ in metabolically active lean body mass

• individuals with chronic illness expend more energy in resting state → higher RMR, weight loss observed with illness

• old age + chronic illness + physical impairment all ↑ energetic cost of motor activities

What is fitness?

• max possible energy production over an extended period of time

• This declines with age

How are energy production & consumption measured?

indirectly via oxygen consumption (VO2)

Why do sick, older individuals often consume all of their available energy performing their most basic ADLs?

because of the ↑ energetic cost of motor activities (i.e. despite available energy levels being lower, chronically ill people require more energy both at rest AND during all physical activity)

*why these individuals are often fatigued, mostly sedentary

Domain: decline of signaling networks that maintain homeostasis

• reflexes & homeostatic mechanisms start to fail including

  • hormonal signaling via endocrine system

  • electrical signaling via nervous system

  • signaling that involves cytokine release and immune function

• changes develop in parallel and affect one another

Assessment: decline of signaling networks that maintain homeostasis

• labs → nutritional biomarkers (e.g. vitamins, antioxidants), baseline levels of biomarkers & hormone levels, inflammatory markers (e.g. ESR, CRP, IL-6, TNF-ɑ)

• other → stress response, response to provocative tests (e.g. OGTT, Dexamethasone test)

Manifestations: decline of signaling networks that maintain homeostasis

• Changes in body composition cause (& are, in turn, worsened by) changes in hormonal & cytokine / adipokine regulation of energy balance

  • example: ↑ fat mass (esp. visceral) → metabolic syndrome → ↓ testosterone, ↑ inflammation

• ↑ fat mass → insulin resistance

• Altered leptin / adiponectin → neurodegeneration

• - ↓ testosterone, ↑ inflammation, ↓ IGF-1 (associated with aging) → ↓ in muscle mass / strength

• Changes in hypothalamic & autonomic functioning affect nearly all homeostatic maintenance systems

Domain: neurodegeneration

• changes in structure & function of nervous system that are thought to be compensatory (attempt by NS to reorganize & compensate for aging) why significant ↓ in function is not always seen in older individuals

• early detection of pathological decline requires careful screening / testing!

Assessment: neurodegeneration

• PE → objective assessment of gait, balance, reaction time, coordination; standard neurologic exam, including assessment of global cognition

• imaging → MRI, fMRI, PET, other dynamic imaging techniques

• other → evoked potentials, electroneurography, electromyograph

Manifestations: neurodegeneration

• brain atrophy occurs after 60 y/o, proceeding at varying rates in different parts of brain

• less coordination b/t brain regions

• less localization of cortical activity during tasks requiring executive function

• spinal cord changes occur after 60 y/o → ↓ motor neurons, myelin damage

• ANS changes → changes in CV & splanchnic function

In older individuals with mild cognitive impairment, atrophy has been found mostly in what 2 regions of the brain?

prefrontal cortex & hippocampus (most important regions for executive function)

true or false: Brain pathology typically associated with specific neurodegenerative diseases has been found upon autopsy in individuals who had normal cognition (as assessed by extensive testing in year prior to death).

true

Rationale: Not all individuals whose brains undergo neurodegenerative histological changes (e.g. amyloid plaques & neurofibrillary tangles typical of Alzheimer’s disease) will experience associated cognitive changes. Research show that learning things and engaging can cause this phenomenon

As the number of motor neurons in the spinal cord decreases with age, the motor neurons that survive compensate via __________ & service to larger / smaller (select one) motor units.

• ↑ branching, larger

• as motor units become larger, they ↓ in # at rate of ~1%/yr (starting after 3rd decade)

• contributes to ↓ in fine motor control & manual dexterity

What is frailty?

• physiologic syndrome characterized by

  • ↓ reserve & diminished resistance to stressors that results from cumulative decline across multiple physiologic systems

  • that causes vulnerability to adverse outcomes, disability & a high risk of death

  • state in which a person has extremely low resistance to stress (i.e. exhibits severe weakness)

  • altered response to tx

• a person who is "frail" is “one step away" from acute decline → sign someone is nearing / in their last stage of life

• makes someone susceptible to geriatric syndromes

• extreme presentation of phenotype of aging

Why wont aging patients show symptoms outside of decreased level of consciousness?

Immune system is suppressed

What is aging phenotype

• outward physical manifestations of aging, including:

  • presence of multiple coexisting conditions & polypharmacy

  • impaired stress response, including ↑ susceptibility to disease & limited ability to heal or recover after an acute illness

  • disability

  • emergence of geriatric syndromes

5 signs of frailty

included in “Frailty Index”, which has been shown to be reliable predictor of (1) survival in a community dwelling older people & (2) survival, length of stay, & d/c location in acute care settings

1. weight loss

2. fatigue

3. impaired grip strength

4. diminished physical activity

5. slow gait

What is the relationship between frailty & chronic or acute stress?

• pre-existing chronic diseases (e.g. DM, CHF) may trigger onset of frailty in an aging person → worsening condition / quality of life → death

• frailty can mean that any acute injury, disease, or impairment may trigger a rapid decline in health precipitating significant disability or death

  • ex: older frail adults who fracture bone as a result of falling are at ↑ risk of mortality within 6 months of injury

4 main clinical consequences of Frailty

1. Ineffective or incomplete homeostatic response to stress

   • reduced ability to cope with challenges such as acute diseases

   • ex. being in a hospital → loss of muscle that they can never recover

   • infx more likely to become septic

2. Multiple coexisting diseases (multi- or comorbidity) and polypharmacy

3. Physical disability

4. Geriatric syndrome

How does the presence of multiple comorbidities & polypharmacy complicate the diagnosis & treatment of older individuals?

• drug tx more complex because comorbid diseases may affect absorption, volume of distribution, protein binding, & elimination of many drugs → fluctuation in therapeutic levels & ↑ risk of under- or overdosing

• pt’s with many diseases usually have multiple rx’s from various HCPs who don’t communicate

• risk of adverse drug rxn’s, drug-drug interactions, & poor compliance ↑ dramatically with # of rx’s & severity of frailty

measures to minimize adverse effects of polypharmacy

• always ask pt’s to bring in ALL medications, including rx drugs, OTC products, vitamin / mineral supplements, herbals (the “brown bag test”)

• screen for unnecessary drugs → d/c those without clear indication for use

• simplify drug regimens in terms of # of agents & schedules (avoid frequent changes in medications, use single daily dose regimens whenever possible)

• avoid drugs that are $$$ and/or not covered by insurance whenever possible

• minimize # of drugs to those that are absolutely essential & always check for possible drug-drug interactions

• ensure pt or available caregiver understand prescribed regimen

• provide legible instructions in the pt's primary language

• schedule periodic medication reviews (MTM!)

Why should infections be prevented, anticipated, & assertively treated in older adults?

• they're more likely to become septic & resolve more slowly than in younger individuals

• should be considered when choosing tx & assessing prognosis (e.g. tx plans may need to be modified to enhance tolerance)

• hospitalization & bedrest should be avoided

What 3 biomedical measures do physical & cognitive function in older persons predict more accurately than any others?

1. healthcare utilization

2. institutionalization

3. mortality

Disability occurs early / late (select one) in the frailty process

late (after reserve & compensation have been exhausted)

*if not already frail, headed towards frailty

Interventions aimed at preventing & reducing disability in older adults should have a dual focus on both the ___________ & systems needed for __________.

• precipitating cause, compensation

• example: fall prevention in older adults should ALSO include balance & strength training (both needed for recovery from fall, if it occurs)

Why do older individuals experience decreased food intake?

• ↓ energy demand (from ↓ physical activity, lean body mass, & rate of protein turnover)

• loss of taste sensation

• ↑ circulating levels of CCK

• ↓ stomach compliance

• ↓ testosterone levels associated with ↑ leptin (males)

• when present, diet should be liberalized & dietary restrictions should be lifted as much as possible

• nutritional supplements should be given b/t meals to avoid interference with food intake at mealtime

true or false: Decreased food intake is more marked in older female-bodied people than their male-bodied counterparts.

false

Rationale: Decreased food intake is more marked in male-bodied older adults.

What are causes of weight loss in older adults?

• anorexia

  • not the same as anorexia nervosa

• cachexia* (body wasting)

• sarcopenia*

• malabsorption*

• hypermetabolism*

• dehydration*

• recent move to long-term care setting

• acute illness (often with inflammation)

• hospitalization with bedrest for as little as 1 - 2 days

• depression

• drugs that cause anorexia and/or N/V (e.g. Digoxin, abx)

• swallowing problems

• poverty with reduced access to food

• isolation

*most common and in some combo

What is cachexia?

weakness & wasting of the body due to severe chronic illness

What is sarcopenia?

loss of muscle mass, strength, & function that come with aging

Why should older adult patients' weight be regularly monitored?

• because weight loss can be insidious!

• should be done both at home & by HCP & maintained in medical record

true or false: There is little evidence that intentional weight loss in overweight older people prolongs life.

true

Rationale: Weight loss after 70 y/o should be limited to persons with extreme obesity & should always be medically supervised.

What are risk factors for gait disorders & falls?

• poor muscle strength

• neural damage in basal ganglia & cerebellum

• DM

• peripheral neuropathy

Interventions to prevent & reduce instability & falls in older adults usually require a mix of medical, rehab, & environmental modification approaches, & often include...

• medication adjustment

• PT

• home modifications

• vit D supplementation (800 IU daily)

What are risk factors for urinary incontinence?

• female-bodied

• caucasian

• hx of childbirth

• obesity

• comorbidities

3 types of urinary incontinence

1. stress incontinence

2. urge incontinence

3. overflow incontinence

stress incontinence

• failure of the sphincteric mechanism to remain closed when there is sudden ↑ in intra-abdominal pressure (e.g. coughing, sneezing)

• causes:

  • in female-bodied people often d/t insufficient strength of pelvic floor muscles

  • in male-bodied people almost exclusively 2° to prostate surgery

urge incontinence

• sudden sensation of the need to urinate & the inability to control it accompanied by loss of urine

• cause: detrusor (bladder) muscle overactivity (i.e. lack of inhibition) d/t loss of neurologic control or local irritation

overflow incontinence

• urinary dribbling, either constantly or for some period after urination, d/t overfilling of the bladder

• causes:

  • impaired detrusor contractility d/t denervation (e.g. in DM)

  • bladder outlet obstruction (e.g. prostate hypertrophy in male-bodied people, cystocele in female-bodied people)

Older female-bodied people are most likely to have what kind of urinary incontinence?

mixed (urge + stress)

What is the first-line treatment for urinary incontinence in older adults?

bladder training associated with pelvic muscle exercises (e.g. Kegel exercises)

What medications associated with urinary incontinence

• diuretics

• antidepressants

• sedative hypnotics

• adrenergic agonists / blockers

• anticholinergics

• CCBs

• *whenever possible, d/c these meds in older adults!

What is delirium?

• an acutely disturbed state of mind that occurs in fever, intoxication, & other d/o's & is characterized by restlessness, illusions, & incoherence of thought & speech

• normal consequence of surgery, chronic disease, or infections in older pt’s

Delirium affects _____ to _____% of hospitalized older adult patients.

15 to 55%

What are risk factors for delirium

• dementia

• any other condition associated with chronic or transient neurologic dysfunction (e.g. neurologic diseases, dehydration, ETOH use, psychoactive drugs)

• sensory (hearing & visual) deprivation

Delirium is an independent risk factor for...

• morbidity

• prolonged hospitalization

• death

frequent features of delirium in older adults

• rapid ↓ in LOC with difficulty focusing, shifting, or sustaining attention

• cognitive change (e.g. rumbling incoherent speech, memory gaps, disorientation, hallucinations) NOT explained by dementia

• PMH suggestive of pre-existing cognitive impairment, frailty, or comorbidity

Tx for acute vs chronic delirium

• acute: dementia eval

• chronic: cognitive assessment and delirium eval

  • delirium confirmed → identify and address cause + supportive care + prevent complications + management of s/sx

  • delirium r/o → r/o depression, mania, and psychosis

What is the most common cause of chronic pain reported by older adults?

• MSK d/o’s

• neuropathic & ischemic pain also common

Chronic pain in older adults can lead to...

Most common symptom reported by older adults

• restricted activity

• depression

• sleep d/o’s

• social isolation

• ↑ risk for adverse effects of medications

• regular analgesic schedules are appropriate & should be combined with non-pharmacologic approaches (e.g. splints, exercise, heat)

According to the CDC, what were the 2 leading causes of death in the USA & Great Britain in 2010?

USA

1. heart disease (24.2%)

2. malignant neoplasms (cancer) (23.3%)

Great Britain

1. malignant neoplasms (28.5%)

2. heart disease (28.3%)

trajectory 1 of death

sudden death (e.g. acute MI, trauma)

trajectory 2 of death

short period of evident decline (e.g. cancer)

trajectory 3 of death

long-term limitations with intermittent serious episodes of illness (e.g. organ failure)

trajectory 4 of death

prolonged dwindling (e.g. frailty, dementia)

*more likely to experience this kind of death with increasing age

What trajectory(ies) to death is/are most common in industrialized countries?

trajectories 3 & 4

For most people, death is a __________, not an event.

process

*as timeline to death gets more abbreviated, there are transitions of care & appropriate changes in location & goal of that care

A person with months to weeks to live is considered to have a __________, while someone with days to live is considered to be __________.

terminal illness ("end of life"), actively dying

Why are vital signs not very helpful with respect to signaling onset of death?

they're highly variable & can remain quite stable until just before the moment of death

*HR is only sign that tends to significantly ↑ (relative to other VS)

What are clinical signs typically seen in last 1 - 3 days of life

- periods of apnea

- Cheyne-Stokes respirations

- respiration with mandibular movement

- death rattle

- dysphagia of liquids

- ↓ LOC

- ↓ performance status

- peripheral cyanosis

- pulselessness of radial artery

- cessation of urine output

What is apneic breathing

prolonged pauses between each breath; also called “brainstem breathing” (compensatory mechanism to relieve acidosis)

criteria for (+): < 30 sec; 30 - 60 sec; > 60 sec

Apneic breathing is a sign of impending death that, on average, has been found to begin roughly how many days before the actual time of death?

1.5 days

What is Cheyne-Stokes respiration?

alternating periods of apnea & hyperapnea with a crescendo-decrescendo pattern

criteria for (+): present

Cheyne-Stokes respiration is a sign of impending death that, on average, has been found to begin roughly how many days before the actual time of death?

2 days

What is the death rattle

gurgling sound produced on inspiration and/or expiration R/T airway secretions that accumulate d/t increasing coma & loss of gag reflex / ability to swallow

criteria for (+): audible if very close; audible at the end of bed; audible > 6 m from door of room

*loved ones may perceive that the pt is choking

*can be improved with enhanced positioning & anticholinergic agents (e.g. Scopolamine)

Scopolamine

anticholinergic agent, antiemetic

SE:

- tachycardia

- dissociation (may be an advantage or disadvantage, depending on the pt)

Death rattle is a sign of impending death that, on average, has been found to begin roughly how many days before the actual time of death?

1.5 days

What 2 common breathing patterns are observed leading up to the time of death?

1. apneic breathing

2. Cheyne-Stokes respirations