I WOMEN 65 YEARS AND OLDER
Currently, 13.3% of the U.S. population is 65 years of age or older. It is projected that this number will double to 88.5 million people by 2050, more than double original estimates.
This increase in the older population is due in large part to the “baby boomers,” who began to turn age 65 years in 2011. This aging process is frequently associated with the development of chronic medical conditions and disabilities, which can be exhibited as behavioral, emotional, and functional changes that may affect independence, self-sufficiency, and autonomy. Limited and fixed incomes compound these issues for individuals if their available funds are inadequate to purchase services and medication. Obstetrician-gynecologists and other health care providers should aim to ensure that this segment of the population remains as healthy as possible and to provide appropriate health care. Clinicians can begin to meet these goals during the routine annual visit by providing age-appropriate screening (see also “Well-Woman Care: Assessments & Recommendations” at www.acog.org/wellwoman) and addressing the special needs of this population of patients.Communication Issues
Communication with elderly patients can present special challenges. Visual and hearing deficits are more common in these patients and can detract from effective communication. It is important to be alert to inattention, inappropriate questions, and lack of response. Ask early in the visit whether there is an issue with hearing or vision, and assess mental status. Appropriate adjustments can then be made that will make the visit more effective and reduce frustration and stress on all parties involved.
In the elderly, memory for short, logically associated material usually is good; however, this may not be true for more complex material.
Comprehension can be improved by the following:
• Reducing and screening out distractions
• Alerting the patient to changes of subject
• Stating clearly the important information to be learned
• Keeping new information brief and relevant
• Providing written instructions (in large print size)
• Reviewing and repeating salient points several times
• Utilizing a teach-back method of counseling
Functional Assessment
There is wide variation in the mental, social, and physical status of older women.
In addition, medical problems may be made more complex by the physiologic changes that accompany aging; for example, changes in height, weight, and posture may cause pain and the need for pain-relief medications, which can then affect cognition. Other changes, such as altered regulation of homeostasis, can contribute to more serious medical problems, to altered metabolism of drugs with increased sensitivity to medications, and to increased susceptibility to infection, all of which can contribute to slower, more complicated recovery from illnesses and surgical procedures.Loss of independence and inability to perform daily living activities are realistic fears of older people. For many, a time comes in which a decision must be made about independent living and the need for assistance with daily life activities. Although remaining in their homes is a preference for many older people at this life stage, personal safety must be considered when addressing these issues. It is important for the elderly to maintain their dignity, independence, and ability to make major life decisions as long as possible while remaining in a safe environment. An assessment of the woman’s ability to function in the home setting is critical. Identification, prevention, and minimization of disorders associated with decreased mobility are good initial steps to ensure patient safety. Evaluation of functional assessment findings, coupled with appropriate management, referrals, or both can assist the elderly woman to live independently and maintain her health. A functional assessment also should be carried out before any medical intervention or surgery.
The following functions should be evaluated:
• Cognitive and affective mental function
• Vision
• Hearing
• Motor function
• Gait and balance
• Bowel and bladder function
• Environmental risks and support systems
Numerous screening and assessment tools for functional assessment have been developed and tested (see Resources).
Cognitive Function
Cognitive changes in aging women are subject to significant variation. Some changes may be age related, whereas others may be related to underlying (often unidentified) illnesses, medications, depression, or a combination of these factors. An important first step in caring for aging women and others who may have impaired cognitive function is to assess the patient’s ability to make health care decisions. At times this is not clear. A woman’s capacity to make a decision depends on her ability to understand information and appreciate the implications of that information, and assessing her capacity may require the assistance of professionals with expertise in making such determinations. Surrogate decision makers should be identified for patients who are incapable of making health care decisions or who have been found legally incompetent (see also the “End-of-Life Considerations” section later in Part 3).
Some deterioration of mental status commonly occurs with aging. Marked changes in mental status usually are associated with dementia. Depression may be preexisting in a patient, but it also can be initiated, exacerbated, or both in old age by social and family isolation, inactivity, inability to mobilize, elder abuse, and neglect. Delirium, although often confused with dementia, usually is transient and frequently is associated with a treatable medical condition or with drug toxicity, drug interaction, or both.
There are several etiologies of cortical dementias. The most common are as follows:
• Alzheimer disease
• Dementia associated with cerebrovascular disease
• Previous head trauma
Alzheimer disease is the most common form of dementia, with an estimated 11% of the U.S. population 65 years and older believed to have the disease. The lifetime risk of developing Alzheimer disease for women older than 65 years without signs of dementia is one in five. Alzheimer disease is associated with aging: 38% of affected individuals are 85 years or older, whereas only 4% are younger than 65 years.
There also are a number of causes of noncortical dementias, related to the following:• Drug toxicity
• Drug interaction
• Alcohol and other substance abuse
• Systemic infections
• Renal failure
• Heart failure
• Metabolic diseases
— Malnutrition
— Iron deficiency
— Hypothyroidism
— Vitamin B12 and folate deficiencies
Delirium is characterized by an acute and fluctuating course and is an impairment of cognition that is not attributable to prior or progressive dementia. Any disturbance in consciousness or environment can be a risk factor for development of delirium, including the following: recent anesthesia or surgery; use of sleep medications; an idiosyncratic response to medication; a change in living arrangements; or an underlying untreated, poorly treated, or inadequately treated medical condition.
Hearing and Vision
Early identification and management of hearing and visual difficulties can improve emotional and physical morbidity. Hearing disorders afflict more than one third of women older than 65 years. Hearing difficulties may appear as tinnitus, high-frequency hearing loss (difficulty understanding women and children), difficulty locating the source of sounds, and vertigo. Visual problems occur in just under one fifth of women of this age, even when eyeglasses or contacts are used. The primary signs and symptoms are night blindness, reading difficulty, eye pain, blurred central vision, and diminished awareness of peripheral objects.
Bladder and Bowel Function
Depending on the definition used and the population queried, urinary incontinence affects 10-70% of women living in a community setting and up to 50% of nursing home residents. The prevalence of incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in the elderly. In addition to causes intrinsic to the lower urinary tract, the following factors may be involved: delirium, infection, atrophic urethritis or vaginitis, medications, depression, excessive urine output (eg, that is due to hyperglycemia or medications to treat congestive heart failure), restricted mobility, and stool impaction.
Asymptomatic bacteriuria is a common incidental finding and does not require treatment.Approximately 20% of elderly people report problems with bowel function. Normal bowel habits include formed stools every 1-3 days. Constipation can be related to a low-fiber diet, medications, low fluid intake, colorectal dysmotility, irritable bowel syndrome, obstruction, hypothyroidism, sedentary lifestyle, or inadequate toilet facilities. Diarrhea may result from infection, medications, laxative abuse, irritable bowel syndrome, or interventions to alleviate bowel impaction.
Common Medical Conditions
There are a number of medical conditions that are seen more frequently in the elderly. These include cardiovascular disease, fractures, cancer, and infections. In addition, nutritional deficiencies may occur.
Cardiovascular Disease
Cardiovascular disease is the leading cause of death among women, with an overall increase in heart attacks occurring about 10 years after menopause, according to the American Heart Association. Changes in women’s physiology after menopause—including increases in blood pressure, triglyceride, and low-density lipoprotein cholesterol levels; decreases in high- density lipoprotein cholesterol; and declining estrogen levels—contribute to an increased risk of cardiovascular disease. Gender differences in the presenting signs and symptoms of cardiovascular disease also exist. Often, the indicators of cardiovascular disease are more subtle in women than in men and require a high index of suspicion to diagnose. Delay in evaluation and diagnosis of symptoms is a major contributor to women’s increased morbidity and mortality from the disease. Late onset of hypertension, especially isolated systolic hypertension, increases the incidence of stroke and myocardial infarction; therefore, early detection and treatment are important (see also the “Cardiovascular Disorders” section earlier in Part 3).
Fractures
Fracture is a major health hazard in women 65 years and older.
Morbidity and loss of function can occur with all fractures and consequently present a significant burden to the patient, the family, and society. Vertebral and hip fractures are common and are associated with morbidity and mortality. These fractures lead to immobility, surgical procedures, prolonged rehabilitation, and, potentially, placement in a long-term care facility. Morbidity and mortality are especially high with hip fractures. Of women older than 80 years who have had a hip fracture, only 56% could walk independently after 1 year. Approximately 3-6% of women die of complications while hospitalized for hip fracture, an outcome often correlated with comorbidity and age. In addition, patient immobility following hip fracture surgery can lead to complications, such as phlebitis and pulmonary emboli, and can be exacerbated by other age-related visual or auditory impairments. Full mobility may not be realized and the individual may need to use a walker, acquire an unstable gait, and be at risk of another fall. Osteoporosis increases the risk of fractures; for more information, see also the “Osteoporosis” section earlier in Part 3.Cancer
Cancer is the second leading cause of death in women 65 years or older. Appropriate screening and preventive counseling should take place (see also the “Cancer Screening and Prevention” section earlier in Part 3). Increasingly, however, screening is no longer recommended in older women for types of cancer that are slow to develop because limited life expectancy may minimize patients’ ability to benefit from screening. For example, cervical cancer screening should be discontinued at age 65 years for women at average risk who have a history of adequate recent screening and no history of advanced cervical abnormalities. Screening for breast cancer has been particularly controversial. There is no consensus as to whether there is an age at which the risks of mammography outweigh the benefits. Medical comorbidity and life expectancy should be considered in a breast cancer screening program for women aged 75 years or older because the benefit of screening mammography decreases compared with the harms of overtreatment with advancing age. Women aged 75 years or older should, in consultation with their physicians, decide whether or not to continue mammographic screening.
Infections
Infections account for mortality in approximately one third of older women. The most common ones are urinary tract infections, pneumonia, influenza, herpes zoster infections, and tuberculosis, especially in institutionalized women. Appropriate immunizations should be recommended and administered (see also the “Immunizations” section earlier in Part 3). Women who are 65 years or older who are vaccinated against the flu can receive either the standard-dose or high-dose inactivated influenza vaccine.
A stronger immune response occurs with the high-dose vaccine than with the standard-dose vaccine, but it is not known whether the improved immune response leads to greater protection against influenza.
Nutritional Deficiencies
Nutritional requirements and metabolism change with aging. Illness and chronic medical conditions can lead to nutritional deficiencies. A simple and easily implemented solution to this problem is to increase intake of foods that naturally contain large amounts of vitamins and minerals, such as complex carbohydrates (eg, grains, legumes, potatoes, and fruit). A diet rich in complex carbohydrates (55-60%) will increase nutrient intake.
Fewer calories are needed to maintain good health as women age. Women should be encouraged to maintain their weight in the normal range by adjusting their diet accordingly and to follow a regular exercise program for weight regulation, bone health, and for other health benefits (see also the “Fitness” section earlier in Part 3). Serial measures of weight, a dietary history, or both may reveal potential problems and warrant additional diagnostic testing. When all laboratory values have been received, medical conditions that have been uncovered should be treated. Management should include nutrition counseling and an evaluation of the individual’s support system, including any financial issues, with social service referrals as necessary.
Common Psychosocial Concerns
In addition to variations in cognitive function, many older women are at increased risk of psychosocial problems. Depression is very common in elderly women and often is unrecognized and untreated. Women should be screened for suicide risk factors, symptoms of depression, abnormal bereavement, and changes in cognitive function and be offered treatment as indicated. Sleep disorders in aging women are associated with menopausal symptoms, dementia, depression, sleep apnea, daytime medication use, and pain syndromes.
Alcoholism, sexual dysfunction, and complications that arise from multiple medication use increase and often are undiagnosed in this age group.
Health care providers should be aware of signs and symptoms of physical or emotional abuse and of neglect. The woman’s social support system is critical for her health, recovery, and functioning. Patients should be asked about family and other support systems, as well as whether they have formal or informal help at home.
Medication Use
Older women experience adverse events that relate to drug therapy more frequently and in more unexpected ways than younger women. Polypharmacy, or the administration of many drugs from many sources, is not uncommon. Over-the-counter medications, including complementary and alternative supplements, often are not included by women in their recall of medications. To verify what drugs and other agents are being used, have the patient or a family member bring all medications, including vitamins and over-the- counter medications, to the office visit. Health care providers should obtain information on the medications that each patient currently is taking, either at scheduled times or on an as-needed basis. This should include information about allergies or drug sensitivities. As part of its National Patient Safety Goals, The Joint Commission recommends that this information be compared with the new medications ordered for the patient in the hospital or outpatient setting to identify and resolve discrepancies. This process of comparing a patient’s new medication orders with all of the medications the patient currently is taking is called medication reconciliation. The Joint Commission also recommends that patients be provided with written information on the medications they should be taking when they are discharged from the hospital or at the end of the outpatient visit.
Often, older women have poor medication adherence because of multiple medications, misunderstanding of instructions, diminished hearing, impaired vision, or poor short-term memory. Difficulties also may result from a lack of access to a pharmacy, inability to pay for medications, or difficulty opening medications (eg, childproof bottles). In addition, borrowed medication can make up a substantial percentage of medication taken by older women.
The physiologic changes that accompany aging result in alterations in the processes of drug absorption, distribution, metabolism, and elimination (pharmacokinetics), and can alter drug bioavailability. In addition, the biochemical and physiologic effects of the drugs themselves and their mechanisms of action (pharmacodynamics) appear to change in aging women. The elderly often are more sensitive or responsive to the effects of a drug and require smaller doses. This altered responsiveness ranges from increased therapeutic effects to serious adverse drug reactions. Adverse effects in the elderly may present atypically as subtle changes in mental status or an acute decline in functional status. Serious drug reactions in the elderly most commonly are caused by psychotropic drugs, diuretics, and cardiovascular agents.
A reduction in the number of drugs prescribed may minimize adverse drug reactions and interactions. Medical conditions should be managed without medications whenever appropriate. It is critical to monitor for multiple medications prescribed by different physicians and to develop a coordinated medication plan for elderly patients. The cornerstone of a medication plan is an accurate list of everything the patient is taking, including over-the-counter and borrowed medications. This list requires review, updating, and evaluation of adherence and drug-taking patterns at every visit. Many new drugs have not been evaluated thoroughly in elderly women and may need to be used with caution.
A variety of techniques may improve a patient’s adherence to medication regimens. They include actively involving the patient in the decision to use a medication, simplifying the dosing regimen as much as possible, eliminating unnecessary medications, evaluating the woman’s functional ability to take the medications, using assistance devices such as easy-to- open bottles and prefilled medication boxes, and encouraging the woman to report any adverse reactions immediately.
The American Geriatric Society publishes the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults as a means to inform clinical decision making concerning the prescribing of medication for older adults in order to improve safety and quality of care. It recommends against the use of systemic estrogen, with or without progestins, in patients 65 years and older, because of evidence of carcinogenic potential (breast and endometrium) and lack of cardioprotective effect and cognitive protection in older women. Because some women aged 65 years and older may continue to need systemic hormone therapy for the management of vasomotor symptoms, the American College of Obstetricians and Gynecologists recommends against routine discontinuation of systemic estrogen at age 65 years. As with younger women, use of combined hormone therapy or estrogen therapy should be individualized based on each woman’s risk-benefit ratio and clinical presentation. Vaginal estrogen may be an option for women whose chief concern is vaginal atrophy (see also the “Menopause” section earlier in Part 3).
Bibliography
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Resources
Alzheimer’s Association. Provider tools for identifying and managing cognitive impairment. Available at: http://www.alz.org/documents/mndak/toolkitsin- glemarch13.pdf. Retrieved July 31, 2013.
American College of Obstetricians and Gynecologists. Healthy eating. Patient Education Pamphlet AP130. Washington, DC: American College of Obstetricians and Gynecologists; 2013.
American Geriatrics Society, British Geriatrics Society. Prevention of falls in older persons. AGS/BGS clinical practice guideline. New York (NY): AGS; London: BGS; 2010. Available at: http://www.medcats.com/FALLS/frameset.htm. Retrieved September 16, 2013.
American Geriatrics Society. A guide to dementia diagnosis and treatment. Available at: http://dementia.americangeriatrics.org/documents/AGS_PC_Dementia_Sheet_ 2010v2.pdf. Retrieved July 30, 2013.
California Workgroup on Guidelines for Alzheimer’s Disease Management. Guideline for Alzheimer’s disease management: final report. Sacramento (CA): State of California, Department of Public Health; 2008. Available at: http://www.cdph. ca.gov/programs/alzheimers/Documents/professional_GuidelineFullReport.pdf.
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North American Menopause Society. Available at: http://www.menopause.org. Retrieved July 31, 2013.
Pharmacological management of persistent pain in older persons. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. J Am Geriatr Soc 2009;57:1331-46. [PubMed]