Introduction
We will all be geriatric individuals one day. As we age, we face many physical and emotional changes that can affect our level of function and well-being. Our baby-boomer population is aging, and people are living longer. We must maintain our functional independence in the elderly and address the needs of our older generation. Rehabilitation of geriatric patients is imperative for the patients' well-being and for society, so that we can thrive socially and economically.

Essential to geriatric rehabilitation is communication, specifically improving any sensory impairment, including those related to vision and hearing. The prevention of falls and osteoporosis can improve the patient's health and longevity. Addressing malnutrition can promote healing and vitalize the patient to participate in a formal rehabilitation program. Depression is common in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society.

Educating our peers and using these guidelines in our practice will enhance the quality of life of the geriatric patient.

For excellent patient education resources, visit eMedicine's Senior Health Center and Mental Health and Behavior Center.

Also, see eMedicine's patient education articles Hearing Loss, Macular Degeneration, Glaucoma Overview, Osteoporosis, and Understanding Osteoporosis Medications.

Also see Depression, Alzheimer Disease, and Dementia Overview.


Auditory And Visual Impairments
One of the greatest challenges in the geriatric population is their ability to communicate their problems, needs, and desires in a medical setting. Hearing and visual impairments can hamper a patient's ability to express himself or herself clearly or to understand questions or commands. This is an enormous burden on the patient, the caregiver, and the physiatrist as they work to achieve rehabilitation goals. Addressing these issues on the patient's initial visit can ameliorate problems and prevent frustration and further difficulties.



Auditory impairment
How many times have you had to shout at a patient? The likelihood that a patient over the age of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly.

Not all hearing impairments are reversible. Examples of impairments that are potentially reversible involve cerumen, cholesteatomas, or acoustic neuromas. These conditions should be recognized and the patient referred to an appropriate subspecialist, such as an ear, nose, and throat (ENT) specialist or a neurosurgeon. Initial otoscopic examination for cerumen or serous otitis is essential. Cerumen obstruction often contributes to hearing loss, and its removal can dramatically improve auditory acuity. This examination should be performed prior to any testing for hearing loss. Otosclerosis or noise-related cochlear damage can be surgically treated with bone removal or cochlear implants, respectively.

However, gradual decline in hearing acuity, or presbycusis, is due to degeneration of the organ of Corti, and it can simply be a result of aging. Most people acquire a conductive hearing loss with a narrow range of audibility, an inability to hear high-frequency sound, and difficulty in discriminating complex sounds. Hearing deficits are associated with paranoia, and they can also lead to depression, anxiety, and insecurity. Safety concerns are also an issue in the hearing impaired, and these issues need to be addressed as a part of aural rehabilitation.

Consequences of auditory impairment

Hearing loss has a major contribution to communication and quality-of-life issues. People who use hearing aids are more likely than others to report improvements in their physical, emotional, and social comfort. In a study by Keller et al, patients with intact hearing scored 2 points higher than did patients with hearing impairment. The investigators also found that patients with intact hearing also scored 6 points higher for instrumental ADLs (IADLs). IADLs include pertinent life tasks, such as writing checks and interacting with the public during financial transactions (ie, grocery shopping). These findings represent a significant difference in ADLs and IADLs and shows that hearing loss can affect a person's functional status.

This possibility for improved function emphasizes the need for hearing evaluations and treatment to help the patient make the maximal gains possible during rehabilitation. The individual's ADL functional level in the rehabilitation setting often determines his or her need for in-home supervision, assistance (eg, during bathing), and ancillary services (eg, those provided by social service organizations such as the Department on Aging and Meals on Wheels). Again, enhanced communication during therapy is important because entire functional independence measure (FIM) scores can be upgraded with this measure alone.

Hearing loss can result in withdrawal, poor self-concept, depression, frustration, irritability, cognitive impairment, isolation, loneliness, and compromised physical mobility. Solutions to hearing impairment positively affect one's daily functioning and psychosocial well-being. Improvement is noted in various areas: communicating the needs of daily living, telephone communication (social and emergency situations), psychosocial behavior, family relationships, enjoyment of leisure activities, and ability to live independently and safely. The financial costs of a simple hearing aid, approximately $500-$3000, is modest given the expected improvement in the quality of life and functional status of the person who uses it.

Screening for hearing loss is a valuable tool for early intervention. It is useful to ask patients and their family members about any changes in the patient's hearing, the onset and progression of impairments, and the sidedness of symptoms (ie, whether they are unilateral or bilateral). Further investigation can reveal a patient's difficulty in understanding women and children (because of the higher frequency of their voices), telephone conversations, television sounds, or voices when more than one person is speaking. Also, an avoidance of family functions, movies, and religious services because of changes in hearing is an important indicator of the severity of the disease. Such behavior indicates a significant functional loss.

Hearing acuity can be tested by using simple methods such as asking the patient to identify the presence of 2 fingers rubbing together by his or her ear. Difficulties with speech comprehension can be evaluated by using the whisper test, in which one whispers 10 words while standing 6 inches behind the patient. If the patient cannot repeat 50% of the words, he or she may have dysfunctional auditory processing. Unfortunately, the whisper test has only moderate repeatability.

When a hearing impairment is established, a formal consultation with an audiologist and the involvement of a speech and language pathologist are pertinent. Speech therapists can begin cognitive testing and provide continuous enhancement of a patient's communication skills during audiologic assessment and aural rehabilitation. There is a growing number of underserved individuals with a combination of multiple sensory, physical, and cognitive impairments, and all of these issues must be identified in the rehabilitation setting.

Management of auditory impairment

Audiologists perform quality control, physical fitting, and performance assessment of hearing aids to ensure that treatment goals have been met. Audiologists instruct patients and their families about proper use and care of hearing aids. Audiologists must also train allied health professionals and support staff who work in rehabilitation facilities regarding daily monitoring as part of a comprehensive hearing support program.

If the patient's vision is adequate, speech therapists often incorporate speech (lip) reading and the use of hand signs, gestures, writing boards, and/or magnetic boards to overcome communication barriers. A well-lit environment is effective for augmenting auditory input to a patient who also requires visual cues. It is important for the physician and staff to establish good visual contact while facing the patient, to reduce background noise, to rephrase misinterpreted words instead of simply repeating them, and to pause at the end of phrases or ideas. Standing 0.75-1 m from the patient and speaking slightly louder also facilitates communication.

Most patients achieve a substantial benefit with speech reading and audiovisual integration training; for example, recognition can be improved by as much as 26%, as Grant reported. The amount of visual influence is correlated with enhanced auditory recognition. Also, simple modifications, such as carpeting common areas to reduce reverberation and establishing quiet areas, can improve communication with the patient.

Assistive listening devices such as closed-captioned television and telephone amplifiers may help patients in performing their ADLs. Safety is also a focal rehabilitation issue because many warning signs (eg, cars on the road, ambulances, fire alarms) are auditory. Addressing safety issues is salient in ordinary and emergency situations, and adaptive devices that vibrate or that have flashing lights (eg, adapted fire alarms, telephones, doorbells) should be incorporated into the patient's home and rehabilitation setting.

In geriatric patients, the primary treatment for loss of auditory sensitivity caused by sensorineural hearing loss is the use of a hearing aid, as part of a total aural rehabilitation program. Modern hearing-aid technology has been advancing, and current aids can help in reducing the communication problems of individuals with hearing impairment. Hearing aids consist of the following components: a microphone (to pick up a signal), an amplifier (to make sounds louder), a receiver (to deliver sounds), a battery, and an ear mold with tubing. Different types of hearing aids include conventional analog; programmable; and digital types, which have the least amount of distortion.

Audiologists must conduct a thorough evaluation including impedance audiometry to assess the patient's middle-ear function and check the acoustic reflex to match the appropriate external and internal features of the hearing aid to the needs of the patient. Psychologically, patients are good candidates for the hearing aids if they are not concerned about the possible stigma attached to the cosmesis of hearing aids. For patients to benefit from a hearing aid, the degree and configuration of his or her hearing loss (eg, high-frequency loss no greater than a severe level). Socially, patients should have support networks, who can assist them with the insertion, removal, and adjustment of the hearing aid if needed.

In hearing-impaired patients, rehabilitation comprises the provision of a custom-fitted hearing aid and instruction on its use and maintenance. Progress during rehabilitation depends on patient and family education to help the patient adjust to the hearing loss and the use of hearing aids. Family training with a speech therapist is also crucial to teach them about auditory enhancement techniques and communication skills. Organizations such as the American Speech-Language-Hearing Association (ASHA) and the Hearing Loss Association of America (HLAA) can provide patients and their families with information about hearing loss and aural rehabilitation and also about support groups.

Improving the geriatric patient's ability to hear can lead to significant gains in terms of rehabilitation and the patient's overall quality of life. Physicians should evaluate their patient's hearing on a regular basis and consider the management of hearing deficits as they care for their patients.


Visual impairment
With aging, the gradual deterioration of sensory modalities, including vision, can interfere with one's daily activities. Nearly 7% of patients admitted to inpatient rehabilitation units have a severe visual impairment. A visual impairment is defined as visual acuity of 20/40 or worse, and legal blindness is defined as visual acuity of 20/200 or worse.

Testing for near vision is performed independently in each eye, with the aid of glasses (if worn). The patient holds the Rosenbaum card at a reading distance of 14 in. Or, if the Lighthouse near-acuity test is used instead, the card is held at 16 in. Far-vision testing can be accomplished with the Snellen wall chart at a distance of 20 ft. The patient's visual fields should also be checked for peripheral vision, hemianopsia, and other conditions. The extraocular muscles should be evaluated during the physical examination as well. An ophthalmoscopic evaluation for drusen, hemorrhages, and ischemia should be performed.

If any change in vision is noted or if the patient reports a functional deficit, follow up with an ophthalmologist is warranted to evaluate and issue the proper low-vision aids. Prevention is managed by performing biennial full-eye examinations in people older than 65 years, with annual evaluations in those with diabetes.

The most common visual change with increasing age is a gradual loss of the ability to focus on near objects (presbyopia). By the age of 75 years, 92% of individuals have presbyopia. Cataract formation (lens opacity) occurs to some degree in 95% of people older than 65 years.

Geriatric patients are also prone to further visual impairments such as glaucoma (intraocular pressure >21 mm Hg), which can be medically or surgically managed; age-related macular degeneration (ARMD), which involves atrophy of the central macular cells in the retinal pigment; and diabetic retinopathy (eg, microaneurysms, dot hemorrhages), which can be managed with glycemic control or laser surgery. The result of these various changes is a loss of visual acuity, decrease in peripheral vision, and a decline in dark adaptation ability. These visual impairments are related to a higher incidence of falls in the geriatric population, especially at night.

Correction and management of visual impairment

In the majority of the geriatric population, eyeglasses are sufficient to correct the visual impairments described above. However, for those who have become legally blind, the adjustment is difficult. Unlike individuals who were blind from an early age and who learned Braille as part of their developmental language, those who become legally blind in adulthood rarely master Braille for communication purposes. They focus primarily on tactile interpretation for face-to-face communication. Speech therapists are instrumental in improving the patient's communication skills in this situation.

Low-vision rehabilitation includes the use of adaptive optical devices that improve illumination and increase contrast and magnification. Transitional-lens eyeglasses reduce the symptoms of glare and photosensitivity and automatically adjust to the ambient light so that the patient does not need to have separate pairs of glasses for inside and outside use. Prism glasses can aid in expanding the patient's visual field. Binoculars or clip-on monocular telescopes are conventionally used to observe sporting events or for bird watching. Low-vision aids are an effective means of visual rehabilitation, helping almost 9 of 10 patients with an impaired ability to read.

Large-print material and devices (eg, telephone with large numbers) can facilitate the patient's daily activities. Similarly, talking clocks and watches are also useful. Handheld or standing magnifying glasses are inexpensive and effective for reading small print, such as that on price tags or financial statements.

Tactile feedback is important in patients with visual impairment; therefore, raised-dot dials on kitchen appliances are a preventive safety measure. Auditory assistance is also important. Books on audiotapes and closed-circuit televisions are available for the patient's leisure. In patients with ARMD, the presentation of 1 word at a time in the center of a display screen is easier than scrolling across the screen to read filtered text. Text filtering can help in enhancing images shown on digitally based viewing devices (eg, televisions, computers) and can be helpful in those with visual impairments; such text filtering should be tailored to the needs of the particular patient.

An occupational therapist, rehabilitation nurse for the blind, or teacher can instruct the patient about how to use labeling systems to identify their clothes and medication, among other items, and patient can learn to fold their money in various ways to indicate the denomination. Other environmental considerations include the use of floor lamps to reduce glare and the installation of motion sensors to turn on lights. Mobility aids include a long cane, a guide dog, or a friendly arm.

Consequences of visual impairment

Vision impairment exerts a more wide-ranging impact on functional status than does hearing impairment. Visual impairment is associated with increased physical disability, increased social isolation, low employment rates, reduced self-image, and depression. Physical disabilities include a decreased ability to perform ADLs and IADLs decreased physical endurance and mobility, and a lack of participation in activities.

Vision, proprioception, and vestibular function are the 3 main components of sensory feedback to maintain normal upright stance. Therefore, a loss of vision is associated with an increased risk of falling with a consequent increased risk of hip fractures. The patient's mental health can also deteriorate with vision loss, and the effects can include depressive episodes. Social isolation, in which the person feels left out and lonely, can lead to depression. Neuropsychologists may alert physicians about the patient's mood. The patient's primary physician should be aware of any vision impairment that might be improved with devices or environmental changes; these treatment approaches must not be overlooked in the rehabilitation setting.

Utilization of healthcare resources and assistance increases in the geriatric population with visual impairment because of their decreased level of function overall. The degree of visual impairment prevents most of these individuals from performing many ADLs and IADLs. Keller et al note an 18% visual impairment rate in a large cross-section of the geriatric population in one clinic. Mean functional status scores for patients with good visual acuity are higher than those with visual impairment; scores are 2 points higher on ADL assessment and 6 points higher on IADL assessment, which includes an evaluation of the person's ability to manage his or her finances, medication regimen, meal preparation, housekeeping, shopping, uses of a telephone, and transportation.

Low vision frequently coexists with other disabilities, including hearing loss, cognitive impairments, and mobility limitations. Dual sensory loss involving visual and hearing impairments is associated with a significant decrease in function, compared with the effect of a single sensory loss.

Data from the 1997 Survey of Income and Program Participation (SIPP) show that 12.1% of the geriatric population have difficulty seeing the words and letters in newspapers, even when wearing glasses or contact lenses. Of that group, 3.3% are unable to see the words and letters at all, while 8.8% had less-severe visual problems. These facts cause concern because 70-80% of the geriatric population still live in their own homes, many alone, and these individuals still need to perform IADLs, in many cases without assistance.

The geriatric population with dual visual and hearing impairments is 2 times more likely than those without such impairments to have difficulty with ambulation, transferring, meal preparation, and managing their medication regimen. According to the 1999 Surveillance for the Sensory Impaired study, older adults who report both vision and hearing loss were more likely than those without sensory impairment to have had the following: (1) a fall during the preceding year (37.4% vs 19.8%), (2) a hip fracture (7.6% vs 4.5%), (3) a higher reported prevalence of hypertension (53.4% vs 44.3%), and (4) a higher rate of heart disease (32.2% vs 20.6%). In addition, these older adults with dual impairments were twice as likely as the others to have a stroke (17.4% vs 7.3%).


Conclusion
Greater attention to sensory impairments by clinicians, public health advocates, and researchers, as well as patient and family education and compliance, are needed to enhance function and progressive rehabilitation in the geriatric population.


Falls
Falls and near-falls occur in more than 30% of people aged 65 years or older. Every year, 50% of people in the community older than 80 years have a fall, and approximately 60% of nursing home residents fall each year. The incidence of falls in the elderly is growing every year, reflecting the growth of the elderly population. By the year 2050, the projected proportion of people older than 65 years will be 23%. Women experience a greater proportion of falls because they make up the majority of the total population as they age, a difference mostly due to the earlier mortality of men.

Injuries occur in 10-20% of falls, and 3-5% of injuries result in fractures. About 10% of all falls have consequential injuries that are deemed serious; examples include fractures, joint dislocations, and severe head injuries. Approximately 90% of fractures in the hips, pelvis, and forearms result from falls. The mortality rate for a patient in the year after a fall resulting in a hip fracture is 14-36%. Of those experiencing hip fractures after a fall, 25-75% have lingering functional impairments. In 1994, approximately $10 billion in acute healthcare costs were spent on fall-related fractures.

Falls in the geriatric population can be associated with substantial morbidity. Falling is the most common cause of traumatic brain injury in those older than 65 years. About 14-50% of patients who fall are unable to rise after a fall. As a result, they may lie on the ground for a long time before they are found or before they can manage to contact help. This delay can result in catastrophic events, eg, the development of a pulmonary embolism or the onset of hypoglycemia in a diabetic patient. Falls are the primary etiology of accidental deaths in those older than 65 years, and falls are responsible for 70% of accidental deaths in people older than 75 years. However, the highest rate of death after a fall is in white men older than 85 years. These findings support an overwhelming need for fall prevention and education to optimize rehabilitation management in the geriatric population.

Risk factors for falling

Those most susceptible to falling are older white women with a low body mass index (BMI), greater height, lower bone mineral density (BMD), and history of a cerebrovascular accident (CVA). Alcohol-related falls are more common in men than in women. Surprisingly, 14% of elderly patients who go to the emergency department are alcohol dependent. Women fall on their hips or buttocks more often than men do. However, incidence of head injuries is substantially more in men than women.

Many intrinsic factors can contribute to falls in the elderly. The most predictive is a history of a previous fall. Individuals prone to falling are known to have increased hip flexion, decreased knee flexion in pre-swing, and decrease in knee power in pre-swing. Stride-to-stride variability increases the likelihood of falling by 5 times. Those who tend to fall are also noted to have a slow gait. Patients with more risk factors are more likely to fall.

Age-related physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP] <20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction.

The potential energy of a fall is determined by the height of the fall, the person's body mass, and the velocity with which the center of mass is displaced. Identifying the severity of injury after falls has been reviewed. Risk factors for minor injuries after a fall include a slow reaction time and decreased grip strength in the hands. Risk factors for major injuries after a fall include older age, female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension.

Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls. Results of recent studies suggest that the risk of falls and fractures in elderly patients taking selective serotonin reuptake inhibitors (SSRIs) is not different from that of patients taking tricyclic antidepressants. The use of 4 or more medications of any type also increases the risk of falls.

Fatigue induced by radiation therapy or chemotherapy also creates a risk of falls in an elderly patient with cancer. Environmental barriers include stairs, uneven footpaths, polished floors, thick mats or carpeting, and poor footwear choices (eg, wearing of high-heeled shoes).

Consequences of falls

Walking disability affects the older patient's autonomy and well-being. Sustaining a fall can damage self-esteem and threaten the independence of a geriatric patient because falls are associated with the placement of the patient in a long-term care facility. An elderly patient with a gait dysfunction has an increasing risk of falls; a fear of falling; and functional decline, with subsequent immobility, decreased activity, weakness, and isolation. Falls and the fear of falling share predictors, which include the following: those with perceived poor general health, older age, and the use of more than 4 medications. Older people who restrict their activity are physically deconditioned and have more depressive symptoms than those who have a fear of falling without these other conditions. Differences in patients' risk factors may help in refining the clinical intervention and preventive program for an individual patient.

Falls are associated with pain, a decline in function, and a loss of stamina. More than 40% of people with an injury from a fall report continued pain or restriction in activity 2 months after the fall. Documentation of the patient's level of pain (with the visual analogue scale) and of any nonpharmacologic treatments is important in determining the appropriate rehabilitation to help the patient regain full mobility and functional activity.

Rehabilitation after a fall

Rehabilitation physicians should develop a standard evaluation for targeted groups of patients to increase participation in rehabilitation programs after a fall. The patient's history should include information about the individual's history of falls, the circumstances of the falls, the associated symptoms, and the known comorbidities (eg, sensory impairment, depression, CVA, incontinence) that may lead to falls. Physical examination should include an assessment of the following: vital signs with orthostatic blood pressure measurements, visual and hearing impairments, arrhythmias, bruits, postural instability, joint limitations, podiatric problems, gait dysfunction, lower-extremity weakness, and changes in mental status. Any adaptive equipment and the patient's FIM score should be reviewed. The get-up-and-go test is a useful clinical tool for follow-up assessments of balance or gait dysfunction.

For geriatric patient at risk for falling, access to rehabilitation is important. Clinicians should aid their patients in finding opportunities for exercise (eg, swimming, yoga, tai chi) in their community, beyond formal physical and occupational therapy, and in overcoming barriers to obtaining needed services. Goals for the practitioner include educating patients and their caregivers and supportive family members about fall prevention and the risk factors for falls in older people. Patients with previous falls tend to accept the risk of falling; however, those with an active lifestyle tend to minimize their personal risk and the relevance of fall-prevention measures.

Strategies for successful rehabilitation include education about falls, modification of the environment, implementation of exercise programs, supplying and repairing aids, and reviewing drug regimens. A thorough approach to rehabilitation can improve the quality of life of a patient after a fall.

During rehabilitation, physical impairments should be addressed first. Interventions aimed at decreasing the incidence of falls should include an assessment of the patient's visual acuity and cataract status. If functional impairment is evident, the patient should be referred for treatment. Decreased visual acuity, visual-field defects, and cataracts are risk factors for hip fracture due to a fall. Good visual acuity facilitates head stabilization, which in turn aids dynamic balance. Ensuring that older people have access to regular eye examinations and timely treatment for eye diseases (eg, cataracts) may substantially reduce the incidence of falls and subsequent hip fractures. The identification of risk factors in patients with known vestibular dysfunction is also important because it affects their care.

Compared with the general geriatric population (>65 y), patients with bilateral vestibular loss have a greater incidence of falls. Patients may wear hip protectors, which help prevent hip injury caused by a direct fall from a standing position. If the etiology of the fall is postural, the following measures may be beneficial: use of ankle pumps and pressure stockings, elevating the head of the bed, sitting upright, ingesting caffeine, and modifying medications.

Periodic review of the patient's prescription and over-the-counter (OTC) medications is imperative. Medications should be minimized or discontinued is appropriate. Polypharmacy should be avoided if possible.

Falls are a major factor contributing to symptomatic fractures in postmenopausal women, which add to the risk attributable to age and osteoporosis. The prevention of osteoporosis with hormone replacement therapy (HRT) and calcium and vitamin D supplementation, as well as decreased caffeine intake, may decrease the risk of fracture after a low-velocity fall. A nutritional review and the supplementation of micronutrients, such as selenium, may also be warranted.

Prevention of falls

Clinical practice guidelines for general safety and fall prevention are important components of patient care in the acute medical, surgical and rehabilitation wards. The Fall Risk Assessment is a tool used by the nursing staff on a daily basis to monitor the change in the level of fall prevention necessary for each patient. This tool helps in determining the risk of falling and in identifying relevant interventions, for example, keeping the bathroom light on at all times, keeping the commode near the bed, keeping the patient in the lobby of the unit to provide constant supervision when one-to-one coverage is unavailable, using a wrap-around belt when the patient is seated in a wheelchair, using bed exit alarms, and keeping side rails of the bed up.

General safety standards should also be implemented, and examples of these include locking the breaks on the wheels of hospital bed, keeping the bed in a low position; keeping the patient's room and environment free from clutter; keeping the call light within the patient's reach; keeping at least 2 of 4 side rails up at all times; keeping wheelchairs locked during all transfers; and keeping the table, telephone, and bed controls within the patient's reach at all times.

The prevention of falls or a reduction in the number of falls can also reduce a patient's functional decline. The use of proper transfer techniques and moderate exercise (20-min sessions 5 d/wk) to maintain mobility are vital parts of a comprehensive rehabilitation program. The incorporation of resistance training 2-3 times per week into the patient's rehabilitation program increases his or her overall strength. Resistance can be increased when the patient is able to complete 10 repetitions of an exercise with full range of motion (ROM). Maintenance programs are important. A home-based program that targets the patient's underlying physical impairments can reduce the progression of functional decline.

One of the challenges that older people face is decreased postural stability, which also increases the risk of falls. Maintaining balance during dynamic activities is essential for preventing falls in older adults. Even head stabilization contributes to dynamic balance, especially during the functional task of walking.

Tai chi quan, or tai chi chuan, is a physical exercise that enhances balance and body awareness. In the rehabilitation community, the practice of tai chi is known to reduce falls. Over the last decade, interest has grown in the use of tai chi to improve postural balance and prevent falls in older people. This ancient Chinese art emphasizes low-velocity, low-impact exercise in harmony with deep breathing and concentration. Tai chi promotes strength, flexibility, balance, and postural stability (even in patients with simultaneous disturbances of vision and proprioception). Tai chi also benefits the cardiovascular system by reducing the patient's blood pressure, decreasing fat composition, and fear of falling.

Falls are further reduced with the addition of home-hazard management. Home visits by occupational therapists can help to preserve the patient's autonomy. Modifications to the patient's home environment may consist of smoothing out uneven surfaces, using ramps instead of stairs, applying non-skid and colored tape on the outer edges of steps, installing rails on stairs, eliminating throw rugs, removing thick carpet, repairing unstable furniture, and installing good lighting. A well-lit pathway to the bathroom that is clear of clutter must be emphasized. Large touch-lights or automatic sensory lights, which do not require dexterity, can be placed at the patient's bedside or in other areas to help decrease the risk of falls, especially at night. Motion-detector lights are helpful in providing illumination (eg, to the bathroom) at night.

Falls in the shower and bathtub are the third leading cause of accidental death, and more than half can be prevented with environmental modifications. Examples include the installation of tub mats, tub benches or seats, raised toilet seats, and grab bars in the shower and bathroom. Walkie-talkies, cell phones attached to waist clips, and lifelines are all excellent communication devices for the elderly, and these can be valuable in the event of a fall. Medical-alert bracelets can be useful to rescuers.

In addition to these environmental modifications, outpatient therapy can help the patient to learn how to address barriers that may be present in the community. For instance, the patient can practice on obstacle courses designed with low technology and simulated functional tasks that they may face in real life. One group notes that performance on such an obstacle course is not a predictor of future falls, but the findings can be used as short-term indicators of the patient's response to a rehabilitation program for balance and mobility (Means, 1996).

Conclusion

Overall, falls in the elderly are a tremendous concern because of the growing geriatric population. Today's practitioners should focus on the use of screening tools in the clinic, risk assessments, programs for fall prevention, and rehabilitation after a fall. The goal is to prevent falls in the geriatric population and thus decrease morbidity and mortality rates and improve the patient's mobility, outlook, and function in society.


Osteoporosis
Osteoporosis is extremely prevalent in the geriatric population, affecting one third of postmenopausal women and one half of the population older than 75 years. The prevention and treatment of osteoporosis deserves more attention than it has received because the consequences of osteoporosis significantly affect patients in the rehabilitation setting.

Osteoporosis is defined as the increased resorption and the defective formation of bone during remodeling. Remodeling occurs more rapidly in trabecular bone, such as the vertebral bodies, pelvis, proximal femur, and distal radius, than in other bone. Low BMD results in bone fragility and, consequently, an increased risk of fracture. The World Health Organization (WHO) defines osteoporosis as BMD >2.5 standard deviations (SDs) below the mean value in young adults; this measure is referred to as the T score.

Established osteoporosis is the occurrence of a minimal trauma with a fracture of any bone, usually the wrist, tibia, humerus, hip, or low thoracic or lumbar vertebrae. Approximately 25% of women older than 50 years have 1 or more vertebral compression fractures related to osteoporosis. The incidence increases to one third in those older than 65 years. Osteoporosis is responsible for at least half a million vertebral fractures, a quarter million hip fractures, and almost a quarter million wrist fractures annually in the United States.

According to a study of healthcare expenditures in California in 1998, Max et al found that osteoporosis accounts for more than $2.4 billion in direct healthcare costs and more than $4 million in lost productivity due to premature death. Nursing home care represents the largest cost among people with osteoporosis, accounting for 59% of the money spent to treat the disease. Their findings demonstrate the significant effect of osteoporosis on the care of the geriatric population and the importance of prevention with medication and rehabilitation.

Osteoporosis affects one half of the population older than the age of 75 years. Determinants of osteoporosis late in life are peak bone mass and the rate of bone loss. Bone mass peaks by the age of 35 years, and men have more bone mass than women. Men have a 20-30% rate of lifetime bone loss, whereas women have a 45-50% rate of lifetime bone loss. Bone loss begins earlier and progresses faster in women than in men. Of the estimated 10 million Americans with osteoporosis, 2 million are men. Only 4.5% of men are treated for osteoporosis after they are discharged from a hospital after an established fracture. Attention to the male, as well as the female, geriatric population is warranted in regard to the prevention and treatment of osteoporosis. Compared with women, men generally develop osteoporosis at an older age.

Types of osteoporosis

Different types of osteoporosis are described. Localized osteoporosis is seen in primary disorders, such as complex regional pain syndrome (CRPS) (type I formerly known as reflex sympathetic dystrophy and type II formerly known as causalgia) and transient regional osteoporosis. It is also seen as a secondary disease due to a primary condition, such as immobilization, inflammation, tumor, or necrosis.

Generalized osteoporosis includes involutional osteoporosis. This most common type of osteoporosis is divided into type I "high turnover" postmenopausal osteoporosis and type II "low turnover" age-associated (senile) osteoporosis. General osteoporosis can also be secondary to a disease process; in this case, it is considered type III osteoporosis.

CRPS type I or II radiographic changes occur in the first 3-6 months after onset, and images show patchy, periarticular demineralization of the affected area (Sudeck osteopenia). The triple-phase bone scan shows increased uptake in the involved extremity before radiographic changes occur. Treatment generally involves steroids. Tapering the dose is necessary to prevent further demineralization.

Transient regional osteoporosis is localized but migratory, and it predominantly involves the hip. This disease is usually self-limited, lasting 6-9 months. Transient regional osteoporosis is a rare cause of osteoporosis and is diagnosed with plain images, bone scans, and clinical suspicion.

Primary involutional type I postmenopausal osteoporosis affects only menopausal women. This disease is linked to estrogen deficiency. Estrogen inhibits secretion of IL-6, which recruits osteoclasts from the monocyte cell line. Type I affects women aged 50-65 years and lasts 15-20 years after menopause. Rapid bone loss occurs at a rate of approximately 3-5% per year. Type I is predominantly characterized with trabecular bone loss in the axial skeleton, thus consequential vertebral compression fractures increase. Other associated fracture sites caused by moderate trauma occur at the hip and wrist. Wrist fractures tend to occur 20-25 years earlier than hip fractures. In men with low testosterone levels, osteoporosis may be included in this category, which may be renamed hormonal-deficient osteoporosis; men with hormonal deficiency are often overlooked in the management of osteoporosis.

Primary involutional type II age-associated osteoporosis can affect men with normal gonad function or women older than 70 years. It results from increased parathyroid hormone (PTH) levels, decreased vitamin D levels, decreased levels of growth hormone and insulin-like growth factors, decreased dietary intake of calcium, and decreased osteoblast function. The annual bone loss is slower in type II than at type I at a rate of 0.5-3% per year. A proportional loss of trabecular and cortical bone occurs. Hip fractures characterize type II osteoporosis.

Type III osteoporosis is secondary to another disease process and usually reversible to some extent after treatment of the primary disease is established. The following conditions can contribute to secondary osteoporosis: bone marrow disorders; connective tissue disease; malnutrition; medication; cadmium poisoning; and endocrine, gastrointestinal, or lymphoproliferative disease.

To be complete, idiopathic juvenile osteoporosis affects children aged 8-14 years and is self-limited to a duration of 2-4 years. Idiopathic young-adult osteoporosis can be mild to severe, and it is self-limited to a period of 5-10 years from its onset. However, the resolution of these forms of osteoporosis does not exclude the patient from having osteoporosis later in life.

History taking, physical examination, and diagnostic workup for osteoporosis

An assessment of the patient's history is extremely important for the prevention and treatment of osteoporosis. The history should focus on risk factors. Screening and monitoring the geriatric population for osteoporosis is a certainty in the rehabilitation arena. At greatest risk are elderly white women.

Genetic risks include a family history of osteoporosis, early menopause (at <45 y), a small body frame, and white or Asian race. Medical conditions that predispose a patient to osteoporosis include Cushing disease, hyperthyroidism, hypogonadism, liver disease, multiple myeloma, primary hyperparathyroidism, malabsorption, lactose intolerance, and renal disease. Medications that can cause or exacerbate osteoporosis include steroids, high-dose inhaled corticosteroids, lithium, phenytoin, chronic high-dose heparin, and thyroxine. Lifestyle risks include low sun exposure, sedentary lifestyle, nulliparity, poor overall nutrition (including low calcium and vitamin D intake and high protein, sodium, and phosphate intake), smoking, and caffeine and alcohol consumption.

Other contributing factors in the geriatric population include dementia, poor general health, recurrent falls, impaired eyesight, weight less than 127 lb (as adipose tissue is the major source of extragonadal estrogen production after menopause), and bilateral oophorectomy.

Osteoporosis is diagnosed in patients with a BMD T score of more than 2.5 SDs below the mean. T scores are measured in comparison with values in young adults. A T score above –1.0 is correlated with normal bone mass. A T score of –1 to –2 is considered low bone mass less than 10-20% of the normal range, and thus is associated with doubling of the risk of fracture. A T-score below –2.0 (where bone mass is >20% below the normal value) quadruples the risk of fracture. Z scores, which are determined in comparison with values in persons of the patient's same age range, can also be measured.

Physical examination includes an evaluation of height, weight, strength, flexibility, and spinal deformities (eg, progressive dorsal kyphosis or Dowager hump). Observation of the patient's balance and gait for a fall-risk assessment should be a standard part of the physical examination. The patient's body habitus should be noted for signs of anorexia, Cushing disease, hypogonadism, goiter, gynecomastia, and barrel chest in chronic obstructive pulmonary disease (COPD). All of these medical conditions can contribute to changes in medical management.

Laboratory workup should include determinations of levels of the following: ionized calcium, 25-OH vitamin D, PTH, phosphorus, BUN, creatinine, albumin, total protein, thyroid-stimulating hormone (TSH)/T4, cortisol, alkaline phosphatase, and bioavailable testosterone in men and estrogen levels in women. In addition, liver function tests (LFTs) should be performed and CBC counts obtained. Further testing is specific for clinical picture. The erythrocyte sedimentation rate (ESR) can rule out exacerbating inflammatory processes. Urinalysis can be performed to look for proteinuria due to nephrotic syndrome. Erem and colleagues studied urine levels of cross-linked N -telopeptides of type I collagen (NTx), which are noted to be increased in patients who sustained osteoporotic hip fractures (Erem, 2002).

Plain images can indicate osteoporosis (25-30% loss of bone mass), but dual-energy x-ray absorptiometry (DEXA) is the criterion standard for measuring and monitoring true bone density. The National Osteoporosis Foundation recommends testing in these groups: all women older than 65 years, all postmenopausal women younger than 65 years if they have other risk factors, and postmenopausal women with fractures.

Quantitative CT can be used to measure true BMD; however, the radiation exposure and cost of quantitative CT are higher than those of DEXA. Ultrasonography is an inexpensive method of screening asymptomatic women for osteoporosis, but it has not been proven to be equivalent to DEXA as a diagnostic tool. DEXA examination costs approximately $200-$300, and it is covered by Medicare with guidelines for follow-up scans. DEXA BMD measurements can be used to monitor treatment response as well.

Prevention of osteoporosis

The prevention of osteoporosis includes medication, diet modification, and exercise. A formal nutrition evaluation is recommended. A dose of 1500 mg of calcium daily is recommended for adults, and 800 mg/d is recommended for children. A dose of 1000 mg of calcium daily is recommended if the patient is taking estrogen. An 8-oz glass of milk, an 8-oz cup of yogurt, and 1 oz of cheese each contain approximately 300 mg of calcium. Calcium citrate is the recommended supplement because it has a higher rate of absorption than calcium carbonate supplements.

A dose of 800 IU of vitamin D is recommended in combination with calcium for optimal absorption. This amount of vitamin D can also be supplemented with 2 multivitamins per day. Zinc and copper may also have a positive effect on osteoporosis when calcium supplementation is used because a subclinical deficiency and reduced dietary intake of these micronutrients may be concurrent conditions.

In a study of female nursing-home residents, McKercher and colleagues report that calcium and vitamin D reduce the rate of hip fractures by 30% (McKercher, 2000). Other prophylactic medications include estrogen, raloxifene (Evista), and bisphosphonates (eg, alendronate, risedronate).

Diet modifications include lower caffeine, lower phosphorus, lower sodium, and higher calcium and vitamin D intake. Smoking cessation and moderate alcohol intake are also lifestyle changes that should be implemented.

Weight-bearing exercise has a beneficial effect on BMD and helps to prevent osteoporosis. The Wolff law states that mechanical use results in increased cortical bone mass and strength along the line of force, whereas disuse leads to bone atrophy. An exercise regimen of 45 minutes 4 times per week is recommended. Walking and stair climbing offers sufficient bone loading. Studies from Sinaki demonstrate that spinal flexion exercises are not recommended for those with established osteoporosis because of the possibility of vertebral wedge fractures. Extension-based exercises are warranted and have a positive correlation on BMD of the spine. Aerobic, weight-bearing, and resistance exercises are all effective in improving the BMD of the spine. Walking is effective for promoting BMD of the spine and hip. Aerobic exercise is effective in increasing BMD of the wrist.

Of note, tai chi chuan (tai chi quan) increases neuromuscular coordination with consequent reduction in the number of falls and fall-related fractures (see the discussion about tai chi quan in the Falls section, above.) It can also help in preventing osteoporosis. In a recent study, Qin et al found that the practice of tai chi for 4 years significantly increases BMD of the spine, proximal femur, and distal tibia. This effect may be explained by an exercise-induced deceleration of bone loss. The benefits of tai chi are promising, and in the future, it may become a recommended mainstream exercise for the geriatric population.

Treatment of osteoporosis

Treatment recommendations from the National Osteoporosis Foundation include the initiation of treatment in all women with T scores less than –2.0, in all women with T scores less than –1.5 if they have other risk factors, and all women older than 70 years if they have multiple risk factors. In the elderly, calcium, vitamin D, regular exercise, postural stability, and fall prevention should be maintained in conjunction with other means of treatment for osteoporosis.

Women with hormonal deficiency can take 0.625 mg of estrogen daily for 3 of 4 weeks each month. If calcium is supplemented, 0.325 mg is sufficient. Controversy persists in regard to an increased risk for breast cancer with estrogen use and the extent of the cardiovascular profile of estrogen. However, Raloxifene 60 mg qd, a selective estrogen receptor modulator (SERM) that inhibits osteoclastic activity, increases BMD in the spine and femoral neck by 2%, according to Ettinger and colleagues. It decreases the levels of low-density lipoprotein (LDL), increases high-density lipoprotein (HDL), and decreases the incidence of breast cancer. Raloxifene has no negative effects on breast or endometrial tissue. Standardized regimens have not been studied in men with low testosterone levels, but they should be treated with supplementation and monitored on a regular basis.

Kannis in 1999 and Silverman in 2000 studied the efficacy of calcitonin for treatment of osteoporosis by decreasing new vertebral fractures by up to 54%. Calcitonin 100 IU administered subcutaneously every 3 days inhibits osteoclastic activity and increases BMD in the spine by 3%. This therapy is mainly used after a compression fracture of the spine has been documented. Salmon nasal spray in 1 nostril with a dose of 200 IU qd (alternating nostrils every other day) is also effective and has an analgesic affect with acute vertebral fractures.

Bisphosphonates, such as alendronate, etidronate, risedronate, and now once monthly ibandronate, may increase BMD in the spine and femoral neck by 5% or more. Alendronate increases BMD in the lumbar spine by 9% and BMD in the femoral neck by 6%, and it also reduces vertebral compression fractures. Orwoll and colleagues noted a 2.6% increase in BMD of the hip and 5.3% increase in BMD of the spine in a study of men taking alendronate (Orwoll, 2000). Alendronate therapy is relatively contraindicated in those with gastroesophageal reflux disease (GERD).

Patients with GERD may benefit from intravenous (IV) bisphosphonates. New research is showing effectiveness with once-yearly IV zoledronic acid in increasing BMD comparable to the other bisphosphonates. Renal function should be monitored in patients receiving zoledronic acid. A short course of IV pamidronate is effective in treating transient osteoporosis of the hip.

PTH stimulates bone formation when given intermittently in low doses. It can increase BMD in the spine, but not the femoral neck. Teriparatide is a biological PTH injectable (20 mcg qd) approved for men or women at high risk of fracture due to primary or hypogonadal osteoporosis or postmenopausal osteoporosis, respectively, taken for up to 24 months.

Growth factors may help in treating osteoporosis, but standard guidelines have not yet been established. Sodium fluoride 25 mg twice daily with calcium citrate promotes osteoblasts by increasing BMD in the lumbar spine by 8% and by increasing BMD in the proximal femur by 4%. However, the main adverse effect of gastrointestinal upset is seen in 30% of patients. The slow release form has fewer adverse gastrointestinal effects.

Biskobing and colleagues describes the use of tibolone, which is a tissue-specific steroid currently used in Europe for the prevention and treatment of osteoporosis (Biskobing, 2002). Tibolone may improve BMD, and it may be a future therapy in the United States.

Consequences of osteoporosis

In the past decade, the incidence of hip fracture has increased at a faster pace than can be explained by our aging population. About 1 in 3 women and 1 in 6 men will have a hip fracture by the age of 80 years. The primary risk factor in those older than 65 years is trabecular bone loss and diminished bone strength related to postmenopausal osteoporosis. Approximately 90% of osteoporotic hip fractures are intertrochanteric and femoral neck fractures.

Fall prevention encompassing increased physical activity and postural stability in this group of geriatric patients cannot be emphasized enough. In 1994, the combined cost of care for 2.3 million fractures due to osteoporosis in Europe and the United States totaled more than $23 billion, with most of the social and economic burden coming from hip fractures.

Surgical repair of hip fractures usually entails a hemiarthroplasty or open reduction internal fixation (ORIF), depending on extent of the fracture. Surgical repair may be delayed as long as 7 days for medical stabilization without an adverse effect on outcome. Postoperative rehabilitation addresses passive ROM (PROM) and active assistive ROM (AAROM). Isometric strengthening and the initiation of early ambulation with weight bearing depend on the components. Work simplification, energy conservation, joint protection, and hip precautions should be reinforced daily during rehabilitation.

The radiologic definition of a vertebral fracture is a 15-20% reduction of the total height of the bone in its anterior, posterior, or central aspect. Anteroposterior (AP) and lateral views plus bone scans can be used to determine the acuity or chronicity of the fracture. The initial pain of a vertebral compression fracture resolves in 4-6 weeks. For pain control, the following are appropriate measures: scheduled oral analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), brief rest or activity modification, and a trial with a transcutaneous electrical nerve stimulation (TENS) unit. In addition, moist heat can be applied for 20 minutes every 2 hours to relieve muscle spasm, and ice massage for 7-10 minutes at a time can be used intermittently.

Occasionally, patients need bracing to prevent further fractures. Braces can also be used to improve postural alignment and pain relief. Velcro-closure binders or corsets are used for lower lumbar spinal fractures, cruciform anterior sternal hyperextension (CASH) braces are used for lower thoracic fractures, and Jewett braces are used for thoracic fractures. Thoracic lumbar spinal orthosis (TLSO) braces are also used for multiple fracture sites. The duration for which braces are used is undetermined but approximately 6-8 weeks.

Compression fractures can lead to postural deformity, more commonly from T8 to L3 than elsewhere; this deformity appears as kyphosis. Fractures of vertebral bodies at the T4 level or higher are rare and may suggest malignancy. Respiratory impairment and pneumonia may ensue in a patient with kyphotic posture as a result of decreased space in the abdominal and thoracic cavity. Abdominal distention, early satiety, discomfort from ribs overlapping the iliac crests, sleep disturbances, and depression are also common sequelae.

Conclusion

Osteoporosis is an all-too-common disease in the elderly population, especially in women. A high rate of morbidity and mortality is related to osteoporosis. Physicians should offer medication and therapy to prevent osteoporosis in all of their elderly patients. Once osteoporosis is diagnosed, formal treatment should be initiated.


Malnutrition
In geriatric rehabilitation, malnutrition affects a patient's functional status and global medical condition. Malnutrition occurs when a deficiency of caloric, vitamin, mineral, protein, water, and/or nutrient uptake is present. Alternatively, malnutrition can be thought of as a BMI greater than 27. However, no exact definition of malnutrition has been established in the elderly.

Malnutrition can decrease one's resistance to infection and result in poor wound healing. Malnutrition can also lead to increased skin fragility, osteoporosis, anemia, diabetes, and cardiovascular disease. Again, although no exact definition exists, the following findings are associated with the diagnosis: involuntary weight loss (>15 lb over 6 mo, >12 lb in 3 mo, or > 9 lb in 1 mo), BMI less than 20 or more than 27, hypoalbuminemia ( <3.5 g/dL), hypocholesterolemia ( <160 mg/dL), and vitamin or micronutrient deficiency. Dietary intake of less than 75% at most meals can also be an indicator.

The Food and Nutrition Board of the United States has recommended daily allowances (RDAs) for those older than 51 years, but no formal guidelines have been established for the geriatric population older than 65 years.

Risk factors for malnutrition

Physiologic factors of aging may lead to malnutrition. These factors are reduced metabolic requirements, decreased total body protein level, decreased total body water, decreased BMD, decreased taste and smell sensation, diminished levels of neurotransmitters that increase appetite, and early satiety. Physical conditions include reduced physical activity; poor dentition; digestive disorders; and functional disability that interfere with activities such as grocery shopping, preparing meals, or going out to dine. A speech language pathologist can assess the patient for dysphagia and aspiration risk by evaluating the individual's oral motor swallowing skills with a clinical swallow study and/or a video fluoroscopic swallow study (VFSS).

Psychological factors that contribute to poor nutritional status in the elderly are depressive symptoms, bereavement, loneliness, and cognitive decline, all of which can affect appetite. Social barriers include financial limitations, living alone, or relying on others for meals. Other issues to assess when malnutrition is suspected are dietary restrictions, cultural rituals, and alcohol intake.

Assessment of malnutrition

The patient's dietary history should include information about the following: consistency of the diet, number of skipped meals, alcohol use, use of nutritional supplements, use of vitamin supplements, use of medications that affect appetite or nutrients, and food preferences to improve caloric intake. Nutritional screening by a dietitian should be emphasized in accordance with rehabilitation to promote and improve functional outcomes as well as wound healing. The rehabilitation nurse commonly records the Braden scale score, an assessment of the risk of skin breakdown, which is a result of poor nutrition. Cells become fragile as a result of an inability to sustain metabolism. Pressure points, especially bony prominences (eg, sacrum, ischial tuberosity), are prone to pressure sores in a state of malnutrition. The Braden scale score should be incorporated along with the patient's overall nutritional assessment.

Height and weight should be recorded at every outpatient visit, and they should be monitored closely while the patient is in the rehabilitation unit. This information is critical for the dietitian or nutritionist to know so that they can properly evaluate the degree of obesity or undernutrition. Caloric restriction, weight loss, and decreases in blood lipid levels with antihyperlipidemic agents can improve the patient's functional status and serve as preventive cardioprotection in the obese elderly patient. Decreasing height may also suggest osteoporosis and thus be an indication for treatment and fall prevention.

Physical features that can suggest malnutrition include thinning of enamel on teeth, thinning of the hair, ecchymoses, angular stomatitis, spoon nails, dermatitis, petechiae, pallor, edema, bleeding gums, and glossitis. Peripheral neuropathy and dementia can also be a sign of nutritional deficiency in the elderly.

Serum protein levels may decrease with trauma or infection, but good indicators of malnutrition are albumin levels (half-life, 18-20 d) and prealbumin levels (half-life of 48 h); these are used to monitor nutritional status. The elderly are at risk for marginal deficiencies of vitamins and trace elements. Many older adults consume small amounts of vitamins B-6, B-12, and D, as well as folate, calcium, magnesium, and zinc. A multivitamin with other necessary supplements can be helpful. Selenium can also be supplemented for wound healing in severely malnourished patients.

Hemoglobin (Hb) concentrations should be obtained to rule out anemia from pathologic processes such as iron deficiency anemia or anemia of chronic disease. The search for an underlying cause should begin when the Hb level is less than 13 g/dL in men and 11 g/dL in women. In both men and women older than 90 years, a level of 11 g/dL is adequate.

The mean corpuscular volume (MCV) should help in detecting vitamin B-12 and folate deficiency. Vitamin B-12 levels should be obtained if deficiency is clinically suspected. Vitamin D and ionized calcium levels can aid in determining if supplementation is needed to prevent osteoporosis. This determination is especially important in housebound elderly patients who are likely to have vitamin D deficiency. Vitamin D also influences the maturation and function of muscle cells, as shown in experimental studies. HbA1C levels should be obtained for diabetic monitoring. Serum cholesterol and lipid panels should be assessed to evaluate the cardiovascular risk. Vitamins A, C, and E can also increase cell-mediated immune function by increasing the absolute number of T cells.

Energy requirements of the elderly

Energy intake decreases with age, partly because of a lower metabolic rate associated with decreased physical activity. About 16% of the geriatric population eats less than 1000 kcal/d. For geriatric patients, the recommended daily intake is 25-35 kcal/kg.

Complex carbohydrates should make up 55-60% of the diet to help meet the patient's fiber, vitamin, and mineral needs. A daily fiber intake of 20-30 g is recommended for older adults to help prevent constipation, to lower cholesterol levels, and to decrease the risk of colon cancer. Protein should be increased to 15-20% of the diet in undernourished elderly patients, especially postoperative patients, patients with t