Table Of Content1600 John F. Kennedy Blvd.
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Primary Care Geriatrics: A Case–Based Approach ISBN-13: 978-0-323-03930-7
ISBN-10: 0-323-03930-8
Copyright © 2007, 2002, 1997, 1992 by Mosby, Inc., an affiliate of Elsevier, Inc.
1st edition, 1983, Published simultaneously by John Wright & PSG, Inc.
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In memory of my parents, John and Eileen Ham, and of Lawrence J Frankel, who died in 2004 at 100 years of
age, pioneer of exercise in old age as the means to “be alive as long as you live”.
RJH
To my parents, Walter and Grace Heddesheimer, and my in-laws, Aaron and Janice Itkin,
who have taught me much about what matters as one ages.
PDS
To my wife, Martha Capps Warshaw
GAW
To my children, Lisa Therese Jenkins and Michael Lee Jenkins
MAB
To my grandmothers, Gertrude Campbell Hain and Mary Mullane Flaherty.
EF
http://avaxho.me/blogs/ChrisRedfield
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My thoughts on old age...
A gift for old age is to be able to delight in comfort.
Bed, bath, food, drink. To enjoy the simple and immediate.
Acknowledge one’s disabilities—then try to forget them.
For our children we must be brave, happy–looking, and interesting.
They will never see you as you are but
as you were. It is only to old friends that one can speak
frankly.
Nothing works properly – our bodies are unreliable.
I just hope I die before I lose my independence.
If there is life after death, I shall be most interested.
I don’t know what, if not. Well, I shall be happy to just finish.
Think of us sometimes (the best bits).
Think of us on our birthdays and play for me, Richard.
Eileen Ham (1920-2001), in a notebook found after her death
And death shall have no dominion.
Dead men naked they shall be one
With the man in the wind and the west moon;
When their bones are picked clean and the clean bones gone,
They shall have stars at elbow and foot;
Though they go mad they shall be sane,
Though they sink through the sea they shall rise again;
Though lovers be lost love shall not;
And death shall have no dominion.
Dylan Thomas (1914-1953), from And Death Shall Have No Dominion
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C O N T R I B U T O R S
Tarannum Alam Kyle R. Allen, DO
Multicampus Program in Geriatric Medicine and Associate Professor of Internal Medicine
Gerontology and Veterans Administration Greater and Clinical Family Medicine
Los Angeles Healthcare System Northeastern Ohio Universities College of Medicine
Geriatric Research, Education, and Clinical Center Rootstown, Ohio
University of California, Los Angeles School of Chief, Division of Geriatric Medicine
Medicine Medical Director, Post Acute/Senior Service Line
Los Angeles, California Summa Health System
VA Sepulveda Ambulatory Care Center Akron, Ohio
Geriatric Research, Education and Clinical
Center (11E)
Kristin M. Alline, M.D.
North Hills, California
Geriatrician
Quality Geriatric Care
Cathy A. Alessi Rutherford, North Carolina
Multicampus Program in Geriatric Medicine and
Gerontology and Veterans Administration Greater
Michael J. Anderson, Pharm.D.
Los Angeles Healthcare System
Director of Clinical Programs and Education
Geriatric Research, Education, and Clinical Center
Ovations Pharmacy Solutions
University of California, Los Angeles School of
Minnetonka, Minnesota
Medicine
Los Angeles, California
VA Sepulveda Ambulatory Care Center
Lodovico Balducci, M.D.
Geriatric Research, Education and Clinical
Professor of Oncology and Medicine
Center
Interdisciplinary Oncology Program
North Hills, California
University of South Florida
Tampa, Florida
Neil B. Alexander, M.D.
Mobility Research Center
Karlene K. Ball, Ph.D.
Professor
Department of Psychology
Division of Geriatric Medicine
University of Alabama at Birmingham
Department of Internal Medicine
Birmingham, Alabama
Institute of Gerontology
University of Michigan
Ann Arbor VA Health Care System Steve Bartz, M.D., FAAFP, R.Ph.
Director Family Medicine Residency Program
Geriatric Research Education and Clinical Center Mercy Health System
Ann Arbor, Michigan Janesville, Wisconsin
vii
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viii Contributors
Douglas B. Berkey, DMD, MPH, MS Charles A. Cefalu, M.D., MS
Professor, Department of Applied Dentistry Professor and Chief, Section of Geriatric Medicine
University of Colorado at Denver and Health Department of Family Medicine
Sciences Center LSU Health Science Center
School of Dentistry New Orleans, Louisiana
Aurora, Colorado
Heather B. Congdon, Pharm.D, CACP, CDE
Jeremy Boal, M.D. Assistant Professor of Clinical Pharmacy
Associate Professor of Medicine and Geriatrics West Virginia University Health Sciences Center
The Mount Sinai School of Medicine Martinsburg, West Virginia
New York, New York
David V. Espino, M.D.
Lucy Bonnington, PAC Professor and Deputy Chairman
Department of Dermatology Family and Community Medicine
Norristown Dermatology University of Texas Health Science Center
Plymouth Meeting, Pennsylvania San Antonio, Texas
Malaz A. Boustani, M.D., MPH Laura Esslinger
Assistant Professor of Medicine and Scientist Senior Director of Development
Indiana University Center for Aging Research and Government Affairs
Regenstrief Institute, Inc. Evercare
Indianapolis, Indiana Maitland, Florida
Sally L Brooks, M.D. Maria Fedor, M.D.
National Medical Director Broward General Medical Center
Ovations Pharmacy Solutions Department of Emergency Medicine
West Chester, Ohio North Broward Hospital District
Ft. Lauderdale, Florida
Kenneth Brummel-Smith, M.D.
Charlotte Edwards Maguire Professor and Chair Karen Funderburg, MS, RD/LD
Department of Geriatrics Assistant Professor
Florida State University College of Medicine Chairman, Department of Nutritional Sciences
Tallahassee, Florida The University of Oklahoma Health Sciences Center
College of Allied Health
Amna Buttar, M.D. Oklahoma City, Oklahoma
Clinical Assistant Professor of Medicine
Indiana University Center for Aging Research Allon Goldberg, PT, Ph.D.
Indianapolis, Indiana Assistant Professor
Department of Health Care Sciences
James W. Campbell, M.D., MS, AGSF Program in Physical Therapy
Professor of Family Medicine Wayne State University
CASE School of Medicine Detroit, Michigan
Chair, Department of Family Medicine and Geriatrics
The MetroHealth System Nathan E. Goldstein, M.D.
Cleveland, Ohio Hertzberg Palliative Care Institute and
The Brookdale Department of Geriatrics and Adult
Alvah R. Cass, M.D., S.M. Development
Associate Professor The Mount Sinai School of Medicine
Vice Chair and Director of Research New York, New York
Department of Family Medicine The Bronx-New York Harbor Geriatric Research,
The University of Texas Medical Branch Education, and Clinical Center
Galveston, Texas Bronx, New York
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Contributors ix
Anne Gunderson, ANP Larry E. Johnson, M.D., Ph.D.
College of Nursing Associate Professor
University of Illinois at Chicago Departments of Geriatric Medicine and Family and
Chicago, Illinois Preventive Care
University of Arkansas for Medical Sciences
Richard J. Ham, M.D.
Little Rock, Arkansas
Director, WVU Center on Aging
Medical Director
Professor of Geriatric Medicine and Psychiatry
Nursing Home Care Unit
Professor, Blanchette Rockefeller Neurosciences
Central Arkansas Veterans Healthcare System
Institute
North Little Rock, Arkansas
Robert C. Byrd Health Sciences Center
West Virginia University
Morgantown, West Virginia Richard King, M.D., Ph.D.
Senior Resident
Arthur E. Helfand, DPM Department of Neurology
Professor Emeritus Massachusetts General Hospital
Department of Community Health, Aging, Boston Massachusetts
and Health Policy
Temple University School of Podiatric Medicine
Temple University School of Medicine Clifford Y. Ko, M.D., MS, MSHS
Philadelphia, Pennsylvania Associate Professor
Department of Surgery
Cynthia Holzer, M.D., CMD, AGSF David Geffen School of Medicine
Director, Geriatric Education University of California Los Angeles
Roger Williams Medical Center Los Angeles, California
Providence, Rhode Island
Assistant Professor of Medicine
Boton University School of Medicine J. Eugene Lammers M.D., MPH
Boton, Massachusetts Medical Director
Center for Geriatric Medicine
Jamal Islam, M.D., MS Clarian Health/Methodist Hospital
Assistant Professor Indianapolis, Indiana
Director of Sponsored Clinical Trials Clinical Professor of Medicine, Adjunct
Department of Family Medicine Indiana University School of Medicine
University of Texas Medical Branch Indianapolis, Indiana
Galveston, Texas
Jerry Johnson, M.D. Timothy J. Lewis, M.D.
Professor of Medicine Assistant Professor
Geriatric Medicine Division Division of General Internal Medicine
University of Pennsylvania University of Cincinnati College of Medicine
Philadelphia, Pennsylvania Cincinnati, Ohio
Karin Johnson, DO, OD
Assistant Professor Anna Loengard, M.D.
Geriatrics Division Assistant Professor of Geriatrics
Department of General Medicine, Geriatrics The Brookdale Department of Geriatrics and Adult
and Palliative Care Development
University of Virginia The Mount Sinai School of Medicine
Charlottesville, Virginia New York, New York
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x Contributors
Robert J. Luchi Marcia L. McGory, M.D.
Professor of Medicine, Chief, Geriatric Section Resident Surgeon
Director, Huffington Center on Aging Department of Surgery
Baylor College of Medicine David Geffen School of Medicine
Houston, Texas University of California Los Angeles
Associate Chief of Staff for Geriatrics Los Angeles, California
and Extended Care
Houston VA Medical Center
David R. Mehr, M.D., MS
Houston, Texas
Professor
Department of Family Medicine
Scott L. Mader, M.D.
University of Missouri-Columbia
Clinical Director, Rehabilitation and Long Term
Columbia, Missouri
Care Division
Portland VA Medical Center
Associate Professor of Medicine Kurt P. Merkelz, M.D.
Oregon Health and Science University Medical Director
Portland, Oregon VITAS Healthcare of Texas, L.P.
Houston, Texas
Vincent Marchello, M.D., CMD
VP, Medical Affairs
R. Sean Morrison, M.D.
Metropolitan Jewish Health System
Professor
Medical Director
Department of Geriatrics and Adult Development
Metropolitan Jewish Geriatric Center
Professor
Brooklyn, New York
Department of Medicine
Assistant Professor of Medicine
The Mount Sinai School of Medicine
Department of Medicine
New York, New York
Mount Sinai School of Medicine
New York, New York
Laura Mosqueda, M.D.
Director of Geriatrics
Jennifer L. Martin, Ph.D.
Professor of Family Medicine
Multicampus Program in Geriatric Medicine and
Program in Geriatrics
Gerontology and Veterans Administration Greater
University of California, Irvine—School of Medicine
Los Angeles Healthcare System
Orange, California
Geriatric Research, Education, and Clinical Center
University of California, Los Angeles School
of Medicine Charles P. Mouton, M.D., MS
Los Angeles, California Professor and Chair
VA Sepulveda Ambulatory Care Center Department of Community Health and Family
Geriatric Research, Education and Clinical Practice
Center Howard University College of Medicine
North Hills, California Washington, D.C.
Marlene J. Mash, M.D.
Aman Nanda, M.D.
Department of Dermatology
Assistant Professor of Medicine
Norristown Dermatology
Brown Medical School
Plymouth Meeting, Pennsylvania
Providence, Rhode Island
Migy K. Mathew, M.D. Yuri Nakasato, M.D.
Assistant Professor of Geriatric Medicine Assistant Professor of Geriatrics and Rheumatology
The Donald W. Reynolds Department The Donald W. Reynolds Department of Geriatric
of Geriatric Medicine Medicine
University of Oklahoma Health Sciences Center University of Oklahoma Health Sciences Center
Oklahoma City, Oklahoma Oklahoma City, Oklahoma
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Contributors xi
Konrad C. Nau, M.D. Diana C. Schneider, M.D.
Associate Dean, Eastern Panhandle Clinical Campus Assistant Professor of Family and Internal Medicine
Associate Professor, Department of Family Medicine Medical Director, LAC+USC Adult Protection Team
Robert C Byrd Health Sciences Center Keck School of Medicine at USC
West Virginia University Los Angeles, California
Harper’s Ferry, West Virginia
Sonia R. Sehgal, M.D.
Assistant Clinical Professor
Bonny Neyhart, M.D.
Internal Medicine and Geriatrics
Clinical Professor
University of California, Irvine
Department of Family and Community Medicine
Irvine, California
University of California, Davis
Sacramento, California
Banu Sezginsoy, M.D.
Assistant Professor
Neil J. Nusbaum, J.D., M.D., FACP, FACHE
Department of Geriatric Medicine
Professor and Chair
The Donald W. Reynolds Department of Geriatric
Department of Medicine
Medicine
University of Illinois College of Medicine
University of Oklahoma Health Sciences Center
Rockford, Illinois
Oklahoma City, Oklahoma
Zachary Palace, M.D.
Richard V. Sims
Attending Physician
Associate Professor of Medicine and Chief
The Hebrew Home for the Aged at Riverdale
Geriatrics Section
Riverdale, New York
Birmingham VA Medical Center
Birmingham, Alabama
Jane F. Potter, M.D.
Harris Professor of Geriatric Medicine Amrit Singh
Chief, Section of Geriatrics and Gerontology Assistant Professor
Department of Internal Medicine Department of Family Medicine and Program
University of Nebraska Medical Center on Aging
Omaha, Nebraska University of North Carolina
Chapel Hill, North Carolina
Steven Record, OD
Richard Slevinski, M.D.
Director, Low Vision Center
President, Emergency Learning and Resource Center
University of Virginia
EMS Medical Director (Retired)
Charlottesville, Virginia
State of Florida
Pace, Florida
Barbara Resnick, Ph.D., CRNP, FAAN, FAANP
Professor
Philip D. Sloane, M.D., MPH
University of Maryland School of Nursing
Elizabeth and Oscar Goodwin Distinguished
Baltimore, Maryland
Professor of Family Medicine
Co-Director, Program on Aging, Disability and
Deborah W. Robin, M.D.
Long-Term Care
Assistant Professor of Medicine
Cecil G. Sheps Center for Health Services Research
Vanderbilt University Medical Center
University of North Carolina
Nashville, Tennessee
Chapel Hill, North Carolina
Carlos A. Salazar, M.D.
Mary Beth Slusar
Senior Fellow in Geriatrics
Doctoral Candidate in Sociology
Baylor College of Medicine
Ohio State University
Houston, Texas
Columbus, Ohio
Robert C. Salinas, M.D. Barbara J. Smith, Ph.D., RDH, MPH
Assistant Professor Assistant Professor
Department of Family and Preventive Medicine Department of Periodontics and Oral Medicine
The University of Oklahoma College of Medicine University of Michigan School of Dentistry
Oklahoma City, Oklahoma Ann Arbor, Michigan
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xii Contributors
William D. Smucker, M.D., CMD Heather M. Titman
Associate Director Fellow, Geriatric Medicine
Family Practice Residency Program Department of Internal Medicine
Summa Health System University of Nebraska Medical Center
Akron, Ohio Omaha, Nebraska
Professor
Family Medicine
Ingrid H. Valdez, DMD
Northeastern Ohio Universities College of Medicine
Director
Rootstown, Ohio
Geriatric Dentistry
Veterans Affairs Medical Center
Monica Stallworth, MA, M.D., MPH, CMD
Denver, Colorado
Faculty, Harvard Division on Aging
Harvard Medical School
Boston, Massachusetts Janice Weinhardt, MSN, APRN, BC
Geriatrician Clinical Nurse Specialist
Department of Medicine Stroke Center
The Cambridge Hospital Summa Health System
Boston, Massachusetts Akron, Ohio
Medical Director
Neville Centre at Fresh Pond Rehabilitation
Jonelle E. Wright, Ph.D., RN
and Nursing
Associate Professor of Research
Cambridge, Massachusetts
The Donald W. Reynolds Department
of Geriatric Medicine
Kenneth K. Steinweg, M.D.
University of Oklahoma College of Medicine
Professor of Family Medicine
Oklahoma City, Oklahoma
Director, Geriatric Division
Clinical Scientist
Brody School of Medicine
Research and Development
East Carolina University
Veterans Affairs Medical Center
Greenville, North Carolina
Oklahoma City, Oklahoma
Lorraine M. Stone, M.D., MSPH
Fellow in Geriatric Medicine Kathy Wright, MSN, APRN, BC
Duke University Medical Center and Veterans Affairs Advanced Practice Nurse
Medical Center STEPS CARE Trial
Durham, North Carolina Health Services Research and Education Institute
Summa Health System
Mark A. Stratton, PharmD, BCPS, CGP, FASHP Akron, Ohio
Professor of Pharmacy
Herbert and Dorothy Langsam Endowed Chair
Robert A. Zorowitz, M.D., MBA, FACP, AGSF
in Geriatric Pharmacy
Medical Director, Post-Acute Service
University of Oklahoma Health Sciences Center
Health Net of the Northeast, Inc.
Oklahoma City, Oklahoma
Shelton, Connecticut
George E. Taffet, M.D.
Associate Professor of Medicine
Department of Geriatrics
Baylor College of Medicine
Houston, Texas
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P R E F A C E
th
to the 5 Edition
Preparing this fifth edition has once again demon- Regarding terminology, it is possible that a few uses
strated how fast the field of geriatric medicine is of the word “providers” have slipped through the edi-
moving forward. The basic purpose of the book torial process, but we have tried to avoid that term.
remains the same: to teach those health profession- That it is useful, there is no doubt. But the concept of
als practicing primary care (physicians, nurse practi- “providing” health care like a measured commodity,
tioners, physician assistants), the currently when in fact all realize that the interaction between
recommended approaches to the problems elders clinician/prescriber and patient/family is far more
and their carers face, to disease prevention and complex than that—a negotiation of sorts, with rec-
health promotion, and to the reduction and post- ommendations made by one or more professionals and
ponement of morbidity and dependency, using a considered and acted upon (or not) by the other; a
case-based text, with the patients and families cast in partnership devoted to the objective of improved
the settings of primary care - the office, the emer- health, bringing different perspectives and responsi-
gency room, the hospital, the nursing home, and the bilities to each situation.
patient’s own place: home, the best place to get a Our patients are changing, as the cohorts we serve
realistic impression of how the person’s life really is, move forward in time. Our oldest patients experienced
and how the patient, family and carers are handling the Second World War and I still enjoy some reminis-
the difficulties they face. cences of the rather flatter areas of my home country
All the authors and editors in this new edition are, where the “Yanks” came and helped us out with their
as before, experienced in clinical primary care, yet also planes, their enthusiasm, their supplies, and their lives.
prepared to take an evidence-based approach, utilizing And I still treasure a few of the remaining “GI Brides”
the best possible evidence for all recommendations. who fell for all of that American charm and immi-
It is great to welcome two further editors to the grated (as, later, I did with my family) to a land with a
team in Marie Bernard, whose enthusiasm for “our” very different set of opportunities than Europe pre-
book attracted us, and who has been zealous in keep- sented at that time. For those of us who love old peo-
ing to deadlines and guidelines, and has shepherded in ple because of the history they represent, this
a large number of new authors and subjects, and Ellen movement forward in time is very intriguing. The
Flaherty, our lively nursing colleague, who has simi- music and events of the past that evoke their youth and
larly been responsible for new authors, new subjects young adulthood, or their “best” time, is gradually
and fresh approaches. moving forwards. And the expectations of younger
Recognizing that physician assistant and advance family members (we Baby Boomers) are a powerful
practice nursing students and practitioners have been influence on changing the patterns of care, and the
using this book since its first edition, we made the expectations of what medical care should be able to do,
decision this time to use the word “clinician” in the or should not attempt.
case materials and text, clarifying that it is not only For me, the originator of this book, these last few
physicians who practice primary care in our increas- years have been an immersion in the issues and chal-
ingly complex and diverse health care system, as we all lenges facing rural elders, now that I am relocated to
attempt to make good health care accessible to all West Virginia. I have come full circle: I was originally
Americans. recruited to the Midwest, to Springfield, Illinois, to
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