II. Epidemiology: Incidence

  1. Community adults: >5%
  2. Nursing Home: >25%
  3. Hosptalized: >50%

III. Pathophysiology: Contributing Factors

  1. Physical function decline: Weakness, falls, ADL decline
  2. Malnutrition: Weight loss, anorexia, decreased immunity
  3. Depression
  4. Cognitive Impairment (Delirium, Dementia)

IV. Causes

  1. Medications
    1. See Medications to Avoid in Older Adults
    2. See Polypharmacy
    3. Most common medication culprits
      1. Psychotropic medications
      2. Anticholinergic Medications
      3. Recently added medications
    4. Consider non-prescription drug use, Herbals
    5. Missed dose and non-compliance
    6. Medication Overdosage (or with Renal Insufficiency)
  2. Acute
    1. Infection: Pneumonia, UTI, Cellulitis
    2. CHF exacerbation
    3. COPD exacerbation
    4. Diabetes Mellitus
    5. Elecrolyte disrders
    6. Acute gastrointestinal bleeeing
    7. See Medications above
  3. Subacute
    1. Anemia
    2. Cirrhosis
    3. Chronic Kidney Disease
    4. Infection
    5. Diabetes Mellitus
    6. See Medications above
  4. Acute
    1. Cancer
    2. Dementia
    3. Endocrine conditions (Thyroid, Parathyroid disease)
    4. Tuberculosis
    5. HIV Infection
    6. Chronic Obstructive Pulmonary Disease
    7. Cardiomyopathy
    8. Valvular heart disease
    9. Chronic Kidney Disease
    10. Chronic Liver Disease
    11. Polymyalgia Rheumatica

V. Labs

  1. Complete Blood Count
  2. Chemistry panel including Renal Functions, electrolytes
  3. Serum Glucose
  4. Thyroid Stimulating Hormone
  5. Urinalysis (consider chronic colonization vs UTI)
  6. Liver Function Tests
  7. Erythrocte sedimentation rate or C-Reactive Protein
  8. Malnutrition Labs
    1. See Lab Markers of Malnutrition
    2. Albumin
    3. Total Cholesterol

VI. Imaging

  1. Chest XRay
  2. Consider Echocardiogram
  3. Consider anatomic imaging (CT, MRI)
  4. Consider Pulmonary Function Tests

VII. Evaluation

  1. Consider causes above
  2. Focus on medications
    1. What medications can be stopped?
    2. Are medications dosed correctly?
      1. Interpret doses in light of Renal Function
    3. Are medication side effects resulting in failure?
    4. Consider Drug Interactions

VIII. Management: General

  1. Treat acute illness
  2. Optimize chronic disease management
  3. Manage medications as above (stop those not needed)
  4. Address Advanced Directives
  5. See Depression in the Elderly

IX. Management: Physical Impairment

  1. Avoid bed rest
  2. Up in chair for all meals
  3. Walk twice daily in hallway if able
  4. Physical Therapy
  5. Avoid restraints including Foley Catheter
  6. Bathroom use (up with assistance)

X. Management: Malnourishment

  1. Use oral nutrition supplements
  2. Sample protocol
    1. Split one can supplement into four doses
    2. Take interspersed as snacks
    3. Take with medications
    4. Make more palatable by mixing with ice cream

XI. Prognosis

  1. Nearly 16% mortality rate

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