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FRONTLINE - Geriatric Medicine

June 2010

Based on Sessions from the 30th Annual Meeting of the Canadian Geriatrics Society

Ottawa, Ontario / April 15-17, 2010

Introduction

The Growing Elderly Population: Societal Implications for the 21st Century

The Canadian Geriatrics Society (CGS) welcomed delegates to the 30th annual meeting held here in Ottawa recently. Serving as the moderator of the first clinical session, “The Geriatric Jungle: Survival Skills for the Family Physician,” Dr. Roger Wong, Clinical Associate Professor of Medicine, University of British Columbia shared the podium with Dr. Robert Lam, Assistant Professor of Family Medicine, University of Toronto, Ontario. Together they discussed the complexity of medical problems, administrative burden and communications barriers that are intrinsic to geriatric care which must all be dealt with to ensure the elderly receive adequate clinical care. “People 65 years of age and older account for half of all office-based visits today so family medicine is really geriatric medicine already,” Dr. Lam reminded delegates: by 2031, 25% of the population will be over the age of 65, he added (Figure 1).

Figure 1.

With only 211 currently certified internist geriatricians and 164 family physicians certified with care-of-theelderly additional training, “most of the geriatric care in Canada is and will continue to be provided by generalist family physicians,” Dr. Lam predicted: If they are to cope with the growing burden of elderly care, then they need to develop some “survival skills.”

Prioritization of medical issues is critical when caring for the elderly, as Dr. Lam suggested. When patients present during a regular office visit, physicians need to acknowledge that they cannot address what are likely to be multiple medical issues in a single visit but rather try and find a “common ground,” letting patients know that each topic eventually will be dealt with over time.

Patient-centred interviewing can help establish that common ground, Dr. Lam continued; with the patient’s help, prioritization of issues that are most pressing to them should improve patient satisfaction. So, too, can genuine communication. It can be difficult to establish a rapport with elderly patients, especially if they are cognitively impaired, acknowledged Dr. Lam.

On the other hand, the elderly can be very loyal to their physicians provided the physicians whom they trust can communicate well or have personalities that the elderly can relate to. In his own retrospective analysis of 104 consecutive elderly patients referred to his own Seniors Wellness Clinic, Dr. Lam determined after extensive analysis that physicians really need to pay more attention to the medical care process that the elderly really care about and less to the complexity of the medical issues they may be facing.

Patients are also more likely to need help for joint, neck and back pain, fibromyalgia, leg cramp pain, insomnia and diabetes than many other problems often featured in continuing medical education programs for family physicians. “Physicians also need to develop realistic goals that are in the best interest of a frail
tinued.

Table 1.

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Recruiting interdisciplinary teams and community care services can help meet many seniors’ needs, as Dr. Lam suggested. Physicians also need to work within the framework of their provincial billing codes and recognize that a 5- to 10-minute standard office visit is not enough time to address the multiple needs of the elderly. They also need to develop systems to monitor an elderly patient’s progressive disease over time and find ways to remind themselves that a patient requires specific interventions when the time is due.

“You can’t do it alone,” Dr. Lam acknowledged, “but if you develop the survival skills that are needed, it will make it easier to get through your day.”

Bracing for the Aging Baby Boomers

The public is acutely aware of the “silver tsunami” that is poised to explode over the next few decades as the first of the baby boomers turn 65 starting next year (Table 1). So, too, are the relatively few geriatric medicine specialists and family physicians with training in elder care who already have a full practice. In the view of Dr. William Dalziel, this year’s recipient of the Ronald Cape Distinguished Service Award for his invaluable contribution to the field of geriatric medicine, the wake-up call is not being heeded by those who are in a position to develop proactive systems across the spectrum of health care that are far more senior-friendly than they currently are.

“Everyone is talking about the aging population but they don’t seem to connect that to the need for specialist physicians and educated generalists and nurses who can provide better care for the elderly,” he indicated. Not that it has not been recognized, “it just hasn’t translated into the clinical field of geriatric medicine and many of us are concerned about the future of geriatrics in this country,” Dr. Dalziel observed. Abolishing the pay differential between geriatric medicine and other specialists in neurology or cardiology, for example (as is done in Great Britain, explained Dr. Dalziel), would remove a significant barrier to the more widespread appeal of geriatric medicine.

Greater exposure to geriatric medicine in medical school at a time when students are deciding whether or not to specialize and if so, in what specialty, may well increase interest in the specialty over time.

Dr. Dalziel concluded, “If you take the long view of things, I’m more optimistic but in terms of resources, we are doing it with one hand tied behind our back. “Ultimately, change has to happen at a national level and physicians will have to lead system change and argue with governments to make it happen.”

Transient Ischemic Attack: Carpe Diem

Physicians have a “stellar” opportunity to prevent stroke in patients who experience a transient ischemic attack (TIA), especially in the first few days following the TIA when the risk of stroke is highest.

“TIA is a warning symptom of stroke and it precedes at least 15% to 20% of strokes, so this is a great opportunity for preventative intervention,” stated Dr. Michael Sharma, Director, Champlain Regional Stroke Prevention Program, Ottawa, Ontario. Diagnosed clinically, TIAs are characterized by the sudden onset of a focal neurological deficit that is presumed to be on a vascular basis, he noted. Typically, a TIA lasts less than an hour; if symptoms last longer than one hour, it is a stroke, as Dr. Sharma confirmed. TIAs may also recur two to four times but not more, he added.

Immediate intervention is important, especially in patients at high risk for stroke. For example, if a 70% or greater stenosis is detected on carotid artery imaging, this is an immediate call for early referral for carotid endarterectomy; if the surgery is offered within two weeks of the TIA, the number needed to treat is 3 to prevent one stroke; if the surgery takes place much later, the number need to treat is considerably higher.

The early introduction of a statin has also been shown to reduce the risk of progression from TIA to stroke by at least 16% and probably more, Dr. Sharma reminded delegates. In contrast, the use of omega-3 supplements increase LDL-C and do not decrease the event rate so the use of these supplements should be discouraged in TIA patients.

“Hypertension is the single most important modifiable risk factor for stroke,” Dr. Sharma continued, contributing between 40% and 60% of all strokes. Any class of antihypertensive agent may be used to reduce stroke risk with the exception of beta blockers which do not have much impact on stroke, as Dr. Sharma noted, and they are not first-line agents for the elderly.

Antiplatelet agents should be introduced based on different risk categories determined by prediction scores such as the ABCD2 rule (Table 2). If the combination of ASA plus clopidogrel is indicated, it may be used for a short interlude following a TIA (maximum three months) but it is no
as it is associated with increased hemorrhagic risk.

Table 2.

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Patients also must to be encouraged to stop smoking as within days of smoking cessation, platelet adhesion and the risk of emboli decreases, lessening stroke risk.

Identify High-risk Patients

A number of different guidelines have been used to help identify TIA patients at high risk for stroke including the ABCD2 rule developed through a combined effort by American and British investigators. Based on studies in TIA cohorts, the ABCD2 rule indicates the following factors that distinguish patients at high risk for subsequent stroke:

“If a patient had 6 to 7 points [according to the ABCD2 rule], they were considered high risk with a sensitivity for stroke at 7 days of 83%,” noted Dr. Jeffrey Perry, Associate Professor of Medicine, University of Ottawa.

In their own prospective study, Dr. Perry and colleagues followed a cohort of patients presenting with symptoms suggestive of TIA to two tertiary-care emergency departments in the Ottawa area between January 2007 and April 2009.

Out of a total of 982 patients who had a 90-day follow-up, 32% were judged by the ABCD2 criteria to be at low risk for stroke, 49% were at moderate risk, and 19% were judged to be at high risk. Compared with the ABCD2 predicted stroke risk of 9.1
risk of stroke for all patients in the Ottawa cohort was only 3.2%, as Dr. Perry noted (Table 3).

Table 3.

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Importantly, only 6% of the cohort required admission to hospital and the subsequent risk of TIA, myocardial infarction and death by 90 days was 5.4%, 0.1% and 1.8%, respectively. “The high-risk ABCD2 score is not sensitive enough to be the sole guide for risk assessment of TIA patients,” Dr. Perry cautioned. “However, early referral based on the ABCD2 score plus clinical impression is still recommended to prevent subsequent stroke.”

Other mandatory interventions include an ECG to detect underlying atrial fibrillation if present and imaging studies to assess patients for the presence of critical stenosis or previous cerebral infarcts, all of which significantly increase the risk of stroke.

Advanced Dementia: Preparing Families/Proxies for End-of-Life Care

Advanced dementia is a terminal illness and families or caregiver proxies of affected patients must face the difficult task of preparing advanced directives that will determine which interventions are desired and, more importantly, which ones are not when patients develop complications.

Dr. Susan Mitchell, Associate Professor of Medicine, Harvard Medical School, Hebrew Rehabilitation Center, Roslindale, Massachusetts, noted that palliative care for patients with advanced dementia is suboptimal across multiple care settings because dementia is under-recognized as a terminal condition. Patients with advanced disease (global deterioration scale stage 7) are also more likely than cancer patients to receive aggressive interventions when they develop complications, even though they often die very shortly after receiving that intervention, she added.

Months before death, the same pattern and prevalence of dyspnea, pain, pressure ulcers, aspiration and agitation are seen in patients with advanced dementia as are seen in cancer patients. Determining the prognosis of patients with advanced dementia is difficult, Dr. Mitchell acknowledged, but it is important because not knowing a patient’s prognosis is the main barrier to patients with dementia receiving hospice care (only about 10% in the US do).

Attempts have been made to develop prognostic risk scores for advanced dementia but even when very rigorous techniques are applied, “we found that we can predict six-month mortality correctly only about 70% of the time and I’m now convinced that we really can’t predict when patients with advanced disease will die,” Dr. Mitchell told delegates, adding that she does not believe hospice care should in fact be tied to prognostic estimates.

Advanced Directives

In order to help families or their health care proxies formulate advanced directives for Alzheimer’s disease (AD) patients, Dr. Mitchell and colleagues first carried out a survey involving 570 nursing home residents to determine which of the most common complications patients with advanced dementia were likely to develop. Over 18 months of follo
t died (25% within six months), 93% of them died in the nursing home itself and virtually all of them from dementia, as Dr. Mitchell reported.

Figure 2.

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The most common complications identified in this cohort were pneumonia and eating problems; mortality rates were significantly higher among patients who developed either of these complications than those who did not.

Dr. Mitchell first emphasized how important it is for physicians to prepare the family or proxy caregivers for what they can expect in advanced dementia and help them formulate advanced directives before an intervention is needed. For example, studies suggest that over 30% of nursing home residents are tubefed, often the result of having been hospitalized for an acute event where parenteral th
145" />nd never terminated. Yet studies have consistently shown that tube-feeding has no impact on markers of malnutrition and it does not prolong survival, as it is purported to do (Table 4, 5).

Table 4.

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Table 5.

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According to Dr. Mitchell, tube-feeding inflicts only greater discomfort on patients, “so if your goal of care is comfort, hand-feeding is the way to go,” Dr. Mitchell affirmed.

There are enormous societal implications regarding inappropriate antibiotic use and the subsequent development of pathogen resistance to which inappropriate use of antibiotics in advanced dementia clearly contributes. Infectious complications are very common in advanced dementia. In her own nursing home study, Dr. Mitchell found that over 40% of nursing home residents received an antibiotic within the last 14 days of their life and they all died, despite the antibiotic. Again, if the family’s goals are comfort rather than prolongation of life, they should direct health care professionals not to give the patient any antibiotics if they develop an infection. Yet if they do choose to have the patient treated with antibiotics, families may prefer an oral formulation over an intraveous preparation because an oral tablet is less invasive. Patients who are not treated with an antibiotic do die sooner than those who are, as Dr. Mitchell observed, but they are also more comfortable than patients who receive an antibiotic.

The Driving and Dementia Toolkit

A quick 10-item, office-based dementia and driving checklist developed by a leader in the field of geriatric medicine should make the difficult task of assessing a patient’s fitness to drive slightly easier.

As checklist author Dr. William Dalziel, Chief, Regional Geriatric Program of Eastern Ontario, Ottawa, and Dr. Frank Molnar, Associate Professor of Medicine, University of Ottawa, discussed, it is not age per se that makes a driver dangerous but rather medical conditions, especially unstable ones, along with high and changing doses of medications that make a previously safe driver unsafe. As the gatekeepers of elder care, “it’s obvious that the medical community can prevent a lot of crashes,” Dr. Molnar indicated.

However, expert and consensus guidelines do not provide any guidance regarding how physicians are to apply recommended tests such as the Mini-Mental State Exam (MMSE), clock drawing, and the Trail Making B Test, or what cut-off scores to use to help them determine a patient’s fitness to drive. “When evidence is lacking, we must move to experiencebased approaches,” Dr. Molnar told delegates.

To that end, Ottawa-based geriatricians under the leadership of Dr. Dalziel developed a Driving and Dementia Toolkit based on their considerable experience in assessing senior’s fitness to drive.

The first item on the driving checklist seeks to determine what type of dementia the patient has. “The most unsafe types of dementia are the frontal temporal dementia or Lewy body dementia. If patients have either of these dementias, they are clearly unsafe to drive,” Dr. Dalziel declared.

Unfortunately, these dementias comprise but a small proportion of dementias overall and most of what physicians are seeing are AD, vascular dementia (VaD) and mixed AD and VaD. These latter dementias are considered “safer” dementias but much depends on the severity of the involvement; to determine severity, physicians need to assess functional losses rather than rely on MMSE scores. “Very mild” dementia generally involves only mild problems with activities of daily living (ADL) including shopping, housework, accounting or finances, food preparation and transportation (the SHAFT mnemonic). Because
of these activities, physicians should assess a male’s ability to operate small machinery and use of the telephone. “If patients have lost any personal ADL, they cannot drive, and if they have lost more than one instrumental ADL, they should not drive,” Dr. Dalziel emphasized.

Figure 3.

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Next, physicians need to make sure a family member has actually been in the car when the patient has been driving, as Dr. Dalziel explained. Physicians then need to ask the “granddaughter question,” namely: “would you feel it was safe if your 5-year-old daughter was in the car alone with the person driving?” This question often provokes a very definite “no.”

Visuospatial abilities can be assessed by giving patients tests such as drawing the numbers and time on a clock: if the tests are poorly done (incorrect placement of numbers on the clock), patients are likely unsafe to drive.

Physical reasons for not being able to drive a car are often better accepted than reasons of cognition, speakers here emphasized. If physical concerns such as musculoskeletal problems; weakness, inability to turn their neck or episodic “spells” can be singled out as a reason why driving will no longer be allowed, physicians should favour the physical over the cognitive reasons. Significant problems with visual acuity and field of vision also need to be determined.

If patients fail on any one of the six items, then the rest of the questionnaire does not need to be completed as they will already have qualified as unsafe to drive. If not, other items on the checklist include the possible hazard of using medications that cause drowsiness, slow reaction times or interfere with focus.

Trail Making A and B tests (available at http://giic. rgps.on.ca/driving-capacity) help determine if patients can problem-solve (Figure 3). If patients take more than 2 minutes or make more than 2 errors on the Trail Making A test, they are unsafe to drive, as they are if they take more than 3 minutes or make more than 3 errors on the Trail Making B test. If they require less than 2 minutes and make fewer than 2 errors on Trail Making B, they may be considered safe to drive. Patients who rank “unsure” on Trail Making B typically take 2 to 3 minutes or make two errors on the test, but physicians also need to consider how the test was performed, i.e. slowly, with hesitation, with poor focus or with multiple self-corrections—weighing unsure towards unsafe.

The “ruler drop” tests a patient’s reaction time. Here, the bottom end of a 12-inch ruler is placed between thumb and index finger; the physician asks repeatedly if the patient is “ready” to catch it and then lets it go: if the patient fails on two tries, the test should be considered abnormal.

Lastly, a simple test of a patient’s judgement may be ascertained by asking them what they would do if they were driving and saw a ball roll out on the street ahead of them (presumably, they would anticipate a child chasing after the ball and would slow down or stop the car).

Patients also should be asked: “With your diagnosis of dementia, do you think at some time you will need to stop driving?” Patients who are still deemed safe drivers based on checklist results should be reassessed every 6 to 12 months depending on the rate of cognitive decline, while those who are judged to be unsafe drivers need to be reported to the provincial registrar. Patients whose ability to drive is still uncertain should be referred to a specialized on-road assessment if only driving is an issue, and to a specialized dementia assessment service if issues other than driving also require assessment.

“The diagnosis of dementia does not automatically mean that a person cannot drive,” Dr. Molnar emphasized. “But if you have a patient with dementia, you have to ask if they are driving because lack of knowledge about driving status is no protection against legal pursuit.”

The Challenge of Alzheimer’s Disease Action Plans in Canada

Geriatricians and family physicians specially trained in the care of the elderly are in a powerful position to mobilize politicians to take an already existing Action Plan for Dementia seriously enough to implement its recommendations.

“When the ‘The Rising Tide’ came out in January, there was tremendous public support for the report and there was some modest response from Ottawa, but it has not turned into anything concrete,” said report author Scott Dudgeon, a health policy consultant and immediate past CEO of the Alzheimer Society of Canada. The report, official titled “The Rising Tide: The Impact of Dementia on Canadian Society: Towards a Brain Strategy for Canada,” was supported by an unrestricted grant from Pfizer Canada.

As Dudgeon told delegates here, “The Rising Tide” was carried out to estimate the health and economic burden of dementia in Canada over the next 30 years.

Dementia rates can be expected to increase to one quarter of a million new cases per year—2.5 times the current level of dementia incidence in 2008, as Dudgeon noted. Currently, the total economic burden associated with AD in Canada is approximately $15 billion a year (Table 6). Expressed in 2008 dollars, the cumulative economic bu
" /> substantially to $872 billion over the next 30 years. These include direct and indirect costs being estimated at $570 billion and “missed opportunity” costs— the cost of otherwise productive workers having to drop out of the workforce because they have to care for someone with AD—totalling about $300 billion (Figure 4).

Table 6.

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Figure 4.

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Dudgeon also estimated that approximately 75,000 patients with AD in Canada now are under the age of 65 and potentially at the peak of their earning power and their tax contributions, another significant missed opportunity cost.

Conversely, if there was a shift in physical activity levels by 50% for all people over the age of 65, “in only 10 years, we would s
in benefit,” Dudgeon noted. More billions in benefit within the same 10-year interval could be realized if onset of dementia could be delayed by two years ($24 billion in benefit); if a program to support caregivers were put into place (about $12 billion in benefit); and if system navigators could be recruited who would negotiate the needs of patients diagnosed with AD (about $24 billion in benefit) (Table 7).

Table 7.

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“We’ve given the governments across Canada the facts; we’ve given them potential solutions and we have invited them to talk to us about it,” Dudgeon told delegates. “Now, it’s Canadians who need to push them to the table and I think geriatricians are in a good position to help the public know what to ask for.”

Significant Improvements

Ontario has made some significant improvements in the care of people with dementia, but none of the comprehensive approaches being recommended will work unless there is considerably more investment than has been made to date.

Dr. Marie-France Rivard, Professor of Psychiatry, University of Ottawa, reviewed the initiatives taken by the province and their impact on strategic goals for the Ontario AD program. The program was the first comprehensive Alzheimer Strategy undertaken in Canada and was granted a total of $68.4 million over five years (1999 to 2004). The stated goals of the program included improvement in the quality of life of AD patients with and their caregivers; improvement in the treatment, care and environmental conditions of patients with AD; and increased public awareness of dementia and services available. “The goals were felt to be met,” Dr. Rivard noted.

However, integrating these goals into daily practice for care providers is an “ongoing challenge” she added, and there were not enough resources for some of the stated initiatives in the original program. Lessons learned from the initial program include a recognition that the needs of patients affected by dementia are complex and the province needs a multifaceted strategy in order to address those complexities.

Different departments including the Ministry of Health and Long Term Care need to collaborate because this fosters collaboration between agencies and other various interest groups. “Given the size of the problem we are facing, collaboration is very important for achieving what we want to do,” Dr. Rivard confirmed.

Other elements that contributed to the program’s success was a formal recognition of the mental health needs and behavioural complications associated with AD, something many organizations and individuals are reluctant to address because of the lingering stigma of mental health challenges, Dr. Rivard observed, adding: “Most of us will be affected by AD in our professional and personal lives and it’s important that we find ways to make things better for patients with dementia. We need to find solutions.”

Action Plan for Quebec

Dr. Howard Bergman, Vice President, Quebec Network for Research on Aging, Fonds de la recherche en santé du Québec, Montreal, in turn reviewed an expert Action Plan on AD and Related Disorders for the province of Quebec that he was instrumental in helping prepare. “The urgent need to act is now recognized internationally,” report authors noted, with France, the UK, Australia and New Zealand all having national AD action plans. The objectives of Quebec’s Priority Action 2 plan were to improve and simplify access for the assessment of cognitive function and diagnosis of dementia; to provide access to integrated case management as soon as the diagnosis is made; to innovate through effective, flexible co-ordination of the services required by people with AD and their families; and to adapt the proposed service structure and approach to local and regional circumstances.

As Dr. Bergman noted, the proposed action plan lays out seven priority actions, with 24 recommendations for their execution. “For me, probably the most important priority would be the second priority which is about access to assessment, diagnosis and treatment for patients with AD,” Dr. Bergman remarked. To achieve their objectives for this priority action in particular, the authors recommended adopting the chronic care management model where partnerships between physicians and nurse teams would be established as well as between AD patients and their families.

Nurses responsible for continuity of care would act as “care navigators” to ensure AD patients receive required services as needed but the partnerships would have to be able to count on fast, easy and flexible access to specialized resources as well. The initial care would be provided by family medicine groups and network clinics but in cooperation with regional health and social service agencies, which would be responsible for ensuring services are organized in order to take local and regional circumstances into account.

“The government is working on a five-year strategic plan for a health system in general in Quebec and the idea is to integrate this plan into primary and specialty care,” Dr. Bergman stated. “But I’m confident that it is being worked on and the more we see people coming into hospital with AD and staying longer and longer, at some point, people are going to wake up.”

A Review of the Literature

Delegates at this year’s CGS conference attended a review of 2009 literature. This was the last session of this year’s conference and it was delivered by Dr. Chris Brymer, Associate Professor of Geriatric Medicine, University of Western Ontario, London. Here are some of the highlights of his presentation entitled “Applying the Top Articles of Last Year in Your Practice.”

Hypertension and Congestive Heart Failure in Patients over 75 Years Old

• To reduce mortality, aim for BPs of 130/80 to 140/90 mm Hg.

• Amlodipine/felodipine, thiazide diuretics, ACE inhibitors reduce mortality.

• ARBs are less likely to cause cough than ACE inhibitors. • Treatment of all vascular risk factors (lipids, hypertension, smoking, diabetes and coronary artery disease) is highly associated with preservation of function and MMSE score over 2.5 years in patients with AD but no cerebrovascular disease at baseline.

• In case of myocardial infarction within 5 years or congestive heart failure with an ejection fraction of <45%, treat hypertension with a beta blocker to reduce mortality; the dose needed should only reduce the resting heart rate by about 10 bpm.

Diabetes

• Intensive glucose control refl ected by a hemoglobin A1c <7% increases the risk of severe hypoglycemia and possibly death and is inappropriate in this age group; recurrent episodes of hypoglycemia also increase the risk of developing dementia in a dose-dependent fashion.

• Frequent glucose self-monitoring has no measurable benefi t regarding outcomes, quality of life or patient satisfaction.

Alzheimer’s Disease and Dementia

• 10% of patients have dementia before their first stroke.

• 10% of patients develop dementia soon after their first stroke.

• 35% of patients will have dementia after a recurrent stroke.

• Primary and secondary stroke prevention could have a major impact on the risk of dementia.

• Add antipsychotics on top of citalopram/trazodone only when patients with dementia are a risk to themselves or others. Both typical and atypical antipsychotics are associated with an increased risk for sudden cardiac death in this patient group.

• In individuals between 75 and 95 years old, the association between plaques and dementia declines dramatically while the one between brain atrophy and dementia increases.

• Centrally active ACE inhibitors (i.e. perindopril) reduce dementia by 65% per year of exposure.

• Pathologic AD is less likely to be associated with dementia in 80- and 90-year-olds than in 60- to 70-year-olds.

• In one cohort of 7000 subjects over 65 years old in a four-year study, continued use of anticholinergic medications increased the risk of incident dementia by 65%.

• The SSRIs, especially citalopram, work better in depressed older patients (with or without dementia) than in depressed younger patients.

• Citalopram has been shown to especially reduce suicide risk in the elderly.

• Mediterranean diet and regular exercise each reduced the risk of AD by 35% over a 15-year follow-up in community dwelling seniors but these two factors together were no more effective than either alone.

Quality of Life

• Vitamin D prevents falls and fractures and 2000 IU/day is safe and recommended.

• Check patients’ vitamin D levels every two years. • The elderly should wear shoes whenever possible to improve balance.

• Elderly patients with acute medical conditions fare far better in acute geriatric units than general medical wards in terms of preserving function. Providing hospital care at home by well-trained nurses is one way for the elderly to avoid hospitalization and ER visits.

• The investigational oral growth hormone secretagogue capromorelin significantly improved tandem walking, stair climbing, weight and lean body mass in patients over 65 with mild functional limitation and had minimal side effects. Capromorelin may be a way to forestall the inevitable decline in function due to lack of growth hormone or growth hormone sensitivity as we age.