Pathy's Principles and Practice of Geriatric Medicine

By John E. Morley and Bruno Vellas

This new edition of the comprehensive and renowned textbook Principles and Practice of Geriatric Medicine offers a fully revised and updated review of geriatric medicine.  It covers the full spectrum of the subject, features 41 new chapters, and provides up-to-date, evidence-based, and practical information about the varied medical problems of ageing citizens.

The three editors, from UK, USA and France, have ensured that updated chapters provide a global perspective of geriatric medicine, as well as reflect the changes in treatment options and medical conditions which have emerged since publication of the 4th edition in 2006.  The book includes expanded sections on acute stroke, dementia, cardiovascular disease, and respiratory diseases, and features a new section on end-of-life care. 

In the tradition of previous editions, this all-encompassing text continues to be a must-have text for all clinicians who deal with older people, particularly geriatric medical specialists, gerontologists, researchers, and general practitioners.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from Google Play or the MedHand Store.

Praise for the 4th edition:
"...an excellent reference for learners at all clinical and preclinical levels and a useful contribution to the geriatric medical literature."
—Journal of the American Medical Association, November 2006

5th edition selected for 2012 Edition of Doody's Core Titles™

• Language: English
• Publisher: Wiley
• Release date: Mar 13, 2012
• ISBN: 9781119954149

Book preview

cover_image

Table of Contents

Dedication

Title Page

Copyright

About the Editors

List of Contributors

Preface to the Fourth Edition

Preface to the Fifth Edition

Foreword

Introduction: Historical Perspectives

Introduction

The Earlier Writers on Old Age

The Birth of Modern Geriatric Medicine

British Developments

An Overview of Early Geriatric Medicine in the United Kingdom

The Early Pioneers in Geriatric Medicine

The Second Wave of Geriatricians

Geriatrics in the United States

Geriatrics in the Rest of the World

Teaching Geriatric Medicine

Achievements of Geriatric Medicine

Problem Areas

References

Part 1: Ageing: Biological, Social and Community Perspectives

Chapter 1: A Biological Perspective of Ageing

Introduction

Ageing Populations

Why do We Grow Old?

The Evolutionary Perspective of Ageing—Key Concepts

Changing Concepts in the Biology of Ageing

The ‘Theories of Ageing’

Subcellular Components of Ageing

Cellular Components of Ageing

Systemic Components of Ageing

The Biology of Ageing and Geriatric Medicine

References

Chapter 2: The Demography of Ageing

Introduction

Models of Chronic Disease and Mortality Trends

Mortality Selection and Trajectories

Discussion

References

Chapter 3: The Physiology of Ageing

Ageing of Organs

References

Chapter 4: Psychological Aspects of Ageing

Introduction

Life Stage Perspective

What do We Know?

Age-Related Psychological Changes

Chapter 5: Ageing of the Brain

Is there Physiological Ageing for the Brain?

Pathological Ageing: Proposed Cellular and Molecular Mechanisms

Changes in Large Neuroendocrine Systems and in General Behaviour During Ageing

Assessing Age-Related Physiological and Pathological Changes in Brain Anatomy and Function: The Input of Brain Imaging

References

Chapter 6: Epidemiology of Ageing and Disability

Ageing and Chronic Disease Epidemiology

Disability and Ageing

Decision-making

The Interprofessional Care Team

Conclusion

References

Chapter 7: Social and Community Aspects of Ageing

Introduction

Demography of Ageing

Growing Older—The Social Process

Poverty

Housing Problems

Retirement

The ‘Golden Age’ Myth

Ageism

The Effect of Social Factors on the Aging Process

Lifestyle, Nutrition and Healthy Ageing: Lessons from the SENECA Study

Religion and Spirituality

Anti-ageing Medicine

The Environment and the Genome

Elder Abuse

The Internet

Cultural Competency

Disasters

References

Chapter 8: The Developmental Origins of Ageing

Introduction

Developmental Plasticity

Developmental Influences and Mortality

Developmental Influences and Age-Related Disease

Developmental Influences and Ageing of the Musculoskeletal System

Developmental Influences and Ageing at the Cellular and Molecular Level

A Life Course Approach to Ageing and its Relevance to Clinical Practice

References

Chapter 9: Sexuality and Ageing

Introduction

Sexual Health

Sexuality and the Older Woman

Erectile Dysfunction

Andropause

Sexuality and Disease

The Older Homosexual

Paraphilias

Sexuality in the Nursing Home

Conclusion

References

Chapter 10: Physical Fitness and Exercise

Introduction

What is Exercise?

Does Exercise Increase Life Expectancy?

Preserving Exercise Capacity with Age via An Active Lifestyle

Optimization of Body Composition with Ageing

Promotion of Psychological Well-Being

Exercise and Cognitive Function

Disease Prevention Through Exercise

Evidence for the Role of Exercise in the Treatment of Disease

Exercise and the Prevention and Treatment of Disability

Conclusion and Directions for Future Research

References

Chapter 11: Health Literacy and Cultural Sensitivity

Introduction

The Importance of Health Literacy in Health Care

Cultural Sensitivity in Geriatrics

Resources

References

Part 2: Medicine and Prescribing in Old Age

Chapter 12: Preventive Geriatrics

Introduction

Background

The Health Maintenance Clinical Glidepath

References

Chapter 13: Polypharmacy

Introduction

Pharmacokinetics

Metabolism and Drug Clearance

Elimination and Renal Excretion

Pharmacodynamics

Pharmacogenetics

Prescribing for Geriatric Patients

References

Chapter 14: Patient Safety

Introduction

Patient Safety and Older People

Why are Older People More Susceptible to Healthcare-Associated Harm than Younger Patients?

Improving Patient Safety for Older People

Priorities for Improving the Safety and Quality of Care for Older People

Conclusion

References

Section 1: Eating Disorders and Nutritional Health

Chapter 15: Epidemiology of Nutrition and Ageing

Introduction

Body Weight, Body Composition and Health

Dietary Intake, Dietary Patterns, Diet Scores in Relation to Mortality: Differences Within and Between Populations

Determinants of Food Choice and Vulnerable Groups

Effect of Nutritional Supplements on Health Indices in Frail Elderly People

Dietary Guidelines

References

Chapter 16: The Anorexia of Ageing

The ‘Paradox’ of Undernutrition in Older People

‘Ideal’ Body Weight in Older People

Weight Loss in Older People

Cachexia in Older People

Undernutrition in Older People

Causes of Undernutrition in Older People

Causes of the Physiological Anorexia of Ageing

Hormones and Neurotransmitters: a Selective Review (Table 16.3)

Diagnoses and Treatment of Undernutrition in Older People

References

Chapter 17: Weight Loss

Introduction

The Relationship of Weight Loss to Mortality

Effect of Weight Loss on Comorbid Conditions

Causes of Weight Loss

Evaluation of Weight Loss

Interventions

For Sarcopenia

Conclusion

References

Chapter 18: Dehydration

Introduction

Water Loss

Regulation of Water Balance

Water Regulation in Older Adults

Dehydration, Intravascular Fluid Loss and Hypovolaemia

Diagnosis of Dehydration

Urine Colour

Problems with the Diagnosis of Dehydration

Consequences of Dehydration

Treatment of Dehydration

Prevention of Dehydration

Conclusion

References

Chapter 19: Vitamins and Minerals

Introduction

Prevalence/Scope of the Problem

Dietary Reference Intakes

Factors Affecting Nutrient Intake in the Elderly

The Antioxidants

Vitamin D

Vitamin K

Folate

Vitamin B12

Vitamin B6

Zinc

Copper

Chromium

Conclusion

References

Chapter 20: Obesity

Age-related Changes in Body Composition

Assessment of Obesity with Increasing Age

Prevalence of Obesity in Older People

Consequences of Obesity in the Elderly

Management of Obesity in the Elderly

Multidisciplinary Management of the Obese Elderly

Conclusion

References

Section 2: Gastro Disorders

Chapter 21: Changes in Gastrointestinal Motor and Sensory Function Associated with Ageing

Introduction

Control of Gastrointestinal Motility and Sensation

Pathophysiology of the Ageing Gut

Oesophagus

Stomach and Duodenum

Small Intestine

Systemic Disorders Associated with Disturbance of Gastrointestinal Motility

Functional Disorders

References

Chapter 22: Gastrointestinal Bleeding

Introduction

Economic Impact

Clinical Presentation

Clinical Course

Causes of GI Bleeding

Evaluation and Management of GI Bleeding

Conclusion

References

Chapter 23: Liver and Gall Bladder

Age-Related Hepatobiliary Changes

Hepatic Diseases of the Elderly

Diseases of the Gallbladder and Biliary Tract

References

Chapter 24: Sphincter function

Introduction

Anatomy and Physiology of the Anal Canal and Rectum

Prevalence and Importance

Risk Factors and Causes of Faecal Incontinence

Clinical Subgroups

Evaluation of Faecal Incontinence

Treatment

Conclusion

References

Chapter 25: Constipation

Defining Constipation

Epidemiology, Pathophysiology and Impact

Aetiology of Constipation

Clinical Approach

Treatment

Special Categories of Constipation

Conclusion

References

Chapter 26: Management of Diarrhoea

Overview of Diarrhoeal Illness

Acute Diarrhoea

Chronic Diarrhoea

Conclusion

References

Chapter 27: Diseases of the Pancreas

The Ageing Pancreas

Inflammatory Diseases of the Pancreas

Pancreatic Tumours

References

Section 3: Haematological Disorders

Chapter 28: Anaemia

Introduction

Definition and Prevalence

Differential Diagnosis

Management

Conclusion

References

Chapter 29: Disorders of haemostasis

Introduction

Disorders of Platelet Number

Hereditary Coagulation Defects

Acquired Coagulation Defects

Vascular Disorders

Thrombotic Disorders

Thrombophilia

References

Chapter 30: Disseminated Intravascular Coagulation

Introduction

Pathophysiology

Diagnosis

Management

Chronic Disseminated Intravascular Coagulation

References

Chapter 31: Anticoagulants

Introduction

The Elderly are more Prone to Thromboembolism

Anticoagulant Response Differs in the Elderly

The Elderly are more Prone to Haemorrhage

Anticoagulants are Effective in the Elderly

The Risk–Benefit Equation: How to Optimize it in the Elderly

Conclusions

References

Chapter 32: Myelodysplasia

Introduction

Epidemiology and Clinical Presentation

Diagnosis

Classification

Prognosis

Treatment

Supportive Care

References

Chapter 33: Management of Myelodysplastic Syndromes and Acute Leukaemia

Introduction

Myelodysplastic Syndromes

Acute Myelogenous Leukaemia (AML)

Acute Lymphoblastic Leukaemia (ALL)

Conclusion

References

Section 4: Cardiovascular Diseases and Health

Chapter 34: Epidemiology of Heart Disease

Introduction

Coronary Heart Disease

Heart Failure

Valvular Heart Disease

Rhythm Disorders

Conclusion

References

Chapter 35: Cardiac Ageing and Systemic Disorders

Introduction

Changes in Cardiac Structure with Ageing

Changes in Cardiac Physiology with Ageing

Cardiac Manifestations of Non-Cardiac Disease

Endocrine Abnormalities and the Cardiovascular System

Conclusions

References

Chapter 36: Arrhythmias

The Elderly Heart

Symptomatic Bradycardias

Atrial Tachyarrhythmias

Atrial Fibrillation

Anticoagulation

Ventricular Arrhythmias

References

Chapter 37: Ischaemic Heart Disease

Introduction

Clinical Manifestations

Recognized and Unrecognized MI

Diagnostic Techniques

Coronary Risk Factors

Therapy of Stable Angina

Acute Coronary Syndromes

Therapy of STEMI

Therapy After MI

Hormone Replacement Therapy

Revascularization

References

Chapter 38: Lipid Management

Introduction

Cholesterol in the Elderly

Clinical Signs

Lipoproteins and Their Measurement

Diagnosis

LDL-C as a Target of Therapy with Statins

Specific Prescribing Points in the Elderly

HDL-Cholesterol

Patients Older than 80 years

Conclusion

References

Chapter 39: Hypotension

Orthostatic Hypotension

Postprandial Hypotension

Post-Exercise Hypotension (PEH)

References

Chapter 40: Hypertension

Definition and Prevalence

Pathophysiology

Related Clinical Entities

The Effect of Treating Hypertension in the Elderly—An Overview of Clinical Trials

Clinical Assessment and Diagnosis²

Management

Conclusion

Acknowledgement

References

Chapter 41: Heart Failure

Introduction

Pathophysiology

Clinical Features

Management

Prevention

Future Directions

References

Chapter 42: Cardiac Surgery

Introduction

Cardiac Surgery Outcomes in the Elderly

Assessment of the Elderly Patient for Cardiac Surgery

Coronary Artery Bypass Graft Surgery

Valve Surgery

Combined Coronary Artery Bypass Graft and Valve Surgery in the Elderly

Anticoagulation Management in the Elderly

Non-Pharmacological Curative Therapy for Atrial Fibrillation

Thoracic Aortic Surgery

Cardiac Transplantation

Conclusions

References

Chapter 43: Peripheral Arterial Disease

Introduction

Epidemiology

Pathophysiology

Diagnosis

Treatment

Acknowledgments

References

Chapter 44: Venous Thromboembolism

Epidemiology and Pathogenesis

Primary Prophylaxis of VTE

Management of Suspected DVT or PE

References

Chapter 45: Cardiac Rehabilitation

Cardiac Diseases and Rehabilitation Services

Cardiac Rehabilitation: Definition and Aims

The Structure of Cardiac Rehabilitation Programmes

The Physiological Effects of Aerobic Training

Evidence-Based Results of Cardiac Rehabilitation in Different Cardiac Conditions

References

Section 5: Respiratory Diseases

Chapter 46: Epidemiology of Respiratory Infection

Community-Acquired Pneumonia

Nursing Home-Acquired Pneumonia

Hospital-Acquired Pneumonia

Tuberculosis

Non-Influenza Viral Respiratory Infection

References

Chapter 47: Pneumonia

Introduction

Causative Agents

Clinical Presentation of Pneumonia in the Elderly

Differential Diagnosis of Lower Respiratory Tract Infection

Hospitalization and Further Investigations in Elderly Persons with a Suspected Diagnosis of Community-Acquired Pneumonia

Therapy of Pneumonia in the Elderly

Further Reading

Chapter 48: Aspiration Pneumonia

Aspiration Pneumonia and Aspiration Pneumonitis

Mechanisms for Development of Aspiration Pneumonia or Aspiration Pneumonitis

Treatments for Aspiration Pneumonia and Aspiration Pneumonitis

Strategies for the Prevention of Aspiration Pneumonia (Figure 48.2)

Prevention of Pneumonia Among the Elderly by Vaccines

Conclusion

References

Chapter 49: Interstitial Lung Disease and Lung Cancer

Interstitial Lung Disease

Lung Cancer

References

Chapter 50: Chronic Obstructive Pulmonary Disease and Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

References

Chapter 51: Pulmonary Hypertension

Introduction

Definition

Classification of Pulmonary Hypertension

Epidemiology of Pulmonary Hypertension

Common Features of Pulmonary Hypertension

Pathology and Pathophysiology of Pulmonary Hypertension

Clinical Aspects of Subgroups of Pulmonary Hypertension

Conclusion

References

Chapter 52: Pulmonary Rehabilitation

Introduction

Organization

Patient Selection

Components of Pulmonary Rehabilitation

Outcomes

Maintenance Following Pulmonary Rehabilitation

Conclusion

References

Section 6: CNS Disorders

Chapter 53: Neurological Signs of Ageing

Introduction

Neurological Signs of Ageing

Cognitive Function

Cranial Nerves, Including Special Senses

Sensorimotor Function: Motor Systems

Sensorimotor Function: Sensory Systems

Conclusion

References

Chapter 54: Sleep Apnoea and Sleep Disorders

Background

Assessment

Diagnosis and Treatment

References

Chapter 55: Headache

Introduction

Diagnosis and Clinical Description of Headaches

Primary Headaches in the Elderly

Secondary Headache Disorders

Other Head and Facial Pain Syndromes Affecting the Elderly

References

Chapter 56: Normal Pressure Hydrocephalus

Introduction

Aetiology and Pathophysiology

Clinical Presentation

Differential Diagnosis

Diagnostic Modalities

Treatment

Outcome and Prognosis

Long-Term Care and Follow-Up

References

Chapter 57: Acute Stroke Care and Management of Carotid Artery Stenosis

Introduction

Stroke Aetiology

Prognosis of Stroke

Clinical Evaluation and Stroke Syndromes

Prehospital Care

Initial Investigations and Imaging

In-Hospital Care

Thrombolysis and Recanalization

Neuroprotective Drugs

Neurosurgery for Ischaemic Stroke

Palliative Care

Stroke Units

Secondary Prevention

Carotid Artery Stenosis

Carotid Artery Stenting

Vertebral and Intracranial Arterial Stenting

Intracranial and Subarachnoid Haemorrhage

Discussion

References

Chapter 58: Stroke and Stroke Rehabilitation

Introduction

The Neurological Basis of Recovery

Patterns of Recovery

Objectives of Rehabilitation

Process of Rehabilitation

Common Problems in Stroke Rehabilitation

Conclusion

References

Chapter 59: Communication Disorders and Dysphagia

Communication

Ageing and Communication

Diagnosis and Assessment of Communication Disorders

Swallowing

Dysphagia

References

Chapter 60: Acute and Chronic Subdural Haematoma

Introduction

Acute Subdural Haematoma

Chronic Subdural Haematoma

Subdural Hygroma

References

Chapter 61: Epilepsy

Introduction

Aetiology

Diagnosis

Differential Diagnosis

Seizure Classification

Investigations (Table 61.4)

Treatments

Status Epilepticus

Driving

References

Chapter 62: Syncope and Non-Epileptic Attacks

Introduction

Syncope

Other Non-Epileptic Attack Disorders

References

Chapter 63: Parkinson's Disease

Introduction

Signs and Symptoms of Very Late-Onset Parkinson's Disease

Differential Diagnosis of Parkinson's Disease

Advanced Parkinson's Disease

Management of Parkinson's Disease in the Elderly

Further Reading

Chapter 64: Non-Parkinsonian Movement Disorders

Introduction

Chorea

Restless Legs Syndrome and Periodic Limb Movements During Sleep and While Awake

Dystonia

Tremor

Chapter 65: Diabetic Neuropathy

Introduction

Pathogenic Mechanisms

Clinical Presentation and Diagnosis

Conclusion

References

Chapter 66: Disorders of the Neuromuscular Junction

Introduction

Myasthenia Gravis

Diagnostic Investigations: Bedside

Diagnostic Investigations: Laboratory

Management

Lambert–Eaton Myasthenic Syndrome

Peripheral Nerve Hyperexcitability

Acknowledgement

References

Chapter 67: Muscle Disorders

Introduction

Clinical Assessment

Laboratory Investigations

Acquired Myopathies

Inherited Myopathies

Acknowledgements

References

Chapter 68: Motor Neurone Disease

Introduction

Definition and Terminology

Clinical Features

Clinical Course

Differential Diagnosis and Diagnostic Pitfalls

Cervical and/or Lumbar Spondylosis

Other Spinal Pathology

Inflammatory Lower Motor Neurone Disorders

Other Neuropathies

Differential Diagnosis of Bulbar MND

Investigations that Aid Diagnosis

Diagnosis of MND

Epidemiology

Pathology of MND

Aetiology and Pathophysiology

Symptomatic Treatment

Advances in Drug Treatment

Multidisciplinary Team Approach

References

Chapter 69: Control of Chronic Pain

Introduction

Age-Related Changes in the Nociceptive System

Assessment

Management Strategies

References

Chapter 70: Multiple Sclerosis

Introduction

Pathophysiology, Aetiology and Epidemiology

Clinical Spectrum, Diagnosis and Treatment

Prognosis

Comorbidities

Complementary and Alternative Medicine (CAM)

Access to Healthcare

Fostering Healthy Living and Resilience

References

Title Page

Copyright

Section 7: Dementia and Cognitive Disorders

Chapter 71: Delirium

Overview

History and Pathophysiology

Prevalence and Incidence for Various Sites and Situations

Associated Adverse Outcomes

The Comprehensive Approach to Delirium

Physical Restraints

Pharmacological Restraints

References

Chapter 72: Memory Clinics

Introduction

Developments Around The World

Why The Need?

Are They Effective?

The Memory Clinic Team

What Happens in a Memory Clinic?

What Interventions can be Offered?

The Memory Clinic as Part of Local Dementia Services

References

Chapter 73: Alzheimer's Disease

Introduction

Neuropathology

Epidemiology and Genetics

Diagnostic Criteria

Evaluation of the AD Patient

Management

Future Therapies

Conclusion

Acknowledgements

References

Chapter 74: Mild Cognitive Impairment

Introduction

History

Definitions and Terminology

Case Examples

Why Does it Matter?

Epidemiology

Neuropathology

Approaching The Patient and Their Caregiver

Natural Progression of Disease and Outcomes

Treatment

Advance Care Planning

Future Directions

Conclusion

References

Chapter 75: Vascular Dementia

Introduction

Definition, Physiopathology and Classification

Diagnosis

Epidemiology

Clinical and Neuropsychological Features

Preventive and Curative Therapies

Conclusion

References

Chapter 76: Mental Stimulation and Dementia

Introduction

Cognitive (Mental) Interventions

Supporting Evidence

Mechanisms

Targets of Intervention

Implementing Interventions

Conclusion

Acknowledgement

References

Chapter 77: Exercise and Dementia

Introduction

Physical Activity and The Prevention of Dementia in Clinical Research

Physical Activity and Executive Function

Frailty, Physical Activity and Cognitive Reserve

Biological Mechanisms of Physical Activity in Preventing Cognitive Decline

Clinical Practical Applications: Physical Activity and Prevention of AD

Physical Activity in AD Populations

Practical Clinical Applications: Physical Activity for Demented Patients

Conclusion

References

Chapter 78: Drug Development and Alzheimer's Disease

Introduction

Impact on Cholinergic Deficit

Anti-Amyloid Therapies

Drugs to Target Tau Protein

Neuroprotective Agents

Neurorestorative Approaches

Other Potential Therapeutic Strategies

Non-Pharmaceutical Therapies

Prevention and AD

Conclusion

References

Chapter 79: Other Dementias

Introduction

Vascular Cognitive Impairment/Vascular Dementia

Lewy Body Disease

Dementia with Lewy Bodies

Progressive Supranuclear Palsy

Corticobasal Degeneration

Multiple System Atrophy

Frontotemporal Lobar Degeneration

Depression

Medications

Dementia with Parkinsonism

Conclusion

References

Chapter 80: Treatment of Behavioural Disorders

Introduction

Physical Causes of Behavioural Symptoms

Conceptual Framework of Behavioural Symptoms of Dementia

Dementia and Personality

Functional Impairment

Mood Disorders

Delusions and Hallucinations

Dependence in Activities of Daily Living (ADLs)

Inability to Initiate Meaningful Activities

Anxiety

Spatial Disorientation

Rejection of Care

Food Refusal

Insomnia

Apathy and Agitation

Elopement and Interference with Others

Environmental Factors

References

Chapter 81: Geriatric Psychiatry

Introduction

Epidemiology

Challenges in Geriatric Psychiatry

The Psychiatric Interview of an Older Adult

Work-Up

Interdisciplinary Approach and Individualized Care Plan

Depression

Bereavement

Severe Mental Illness

Bipolar Affective Disorder and Late-Onset Mania

Schizophrenia

Late-Life Psychosis

Cognitive Disorders

Substance Abuse

Anxiety Disorders

Geriatric Psychiatry Emergencies

Other Common Mental Health Problems in Older Adults

Special Populations in Geriatric Psychiatry

Palliative and End-of-Life Care

Geriatric Psychopharmacology

Electroconvulsive Therapy

Psychotherapy and Other Psychosocial Interventions

Spirituality and Geriatric Psychiatry

Prevention in Geriatric Psychiatry

Best Practice Models for Geriatric Psychiatry Services

Long-Term Care Homes

Geriatric Psychiatry in Primary Care Offices

Successful Ageing

Future Research

References

Chapter 82: Organization of Services in Geriatric Psychiatry

Introduction

Developments in the UK 2005–2010

Services

Patients' Views and Involvement

Carers

Additional Responsibilities for Geriatric Psychiatry Services

Other Issues

An International Perspective

Conclusion

References

Chapter 83: Depression in Later Life: Aetiology, Epidemiology, Assessment, Diagnosis and Treatment

Introduction

Varieties of Late-Life Depression

Epidemiology of Late-Life Depression

Course of Late-Life Depression

Non-Suicide Mortality

Suicide

Aetiology

Diagnosis

Treatment

Conclusion

References

Chapter 84: The Older Patient with Down Syndrome

Introduction

Genes and Down Syndrome

The Physician, and The Patient with Down Syndrome

Disorders Associated with Down Syndrome

Conclusion

References

Section 8: Special Senses

Chapter 85: Disorders of The Eye

Introduction

Definitions, Treatments, and Risk Factors

Summary

References

Chapter 86: The ageing auditory system—pathology and epidemiology of age-related hearing loss

The auditory system

Epidemiology of hearing

Conclusion and the future

References

Chapter 87: Disorders of the Vestibular System

Introduction

Vestibular Anatomy

Physiology and Ageing of the Vestibular Apparatus

Clinical Aspects and Diagnostic Strategy

Peripheral Vestibular Disorders

Central Vestibular Disorders

Management

References

Chapter 88: Smell and Taste

Introduction

Characterization of Chemosensory Problems

Anatomy of The Olfactory System

Anatomy of The Gustatory System

Clinical Tests of Olfactory and Gustatory Function

Age-Related Changes in Olfactory Function

Age-Related Changes in Gustatory Function

Causes of Smell Dysfunction in the Elderly

Causes of Taste Dysfunction in The Elderly

Evaluating and Managing Elderly Patients with Chemosensory Dysfunction

Acknowledgments

References

Section 9: Bone and Joint Health

Chapter 89: Paget's Disease of Bone

Introduction

Pathology of Paget's Disease

Sequelae of Paget's Disease

Presentation of Paget's Disease

Epidemiology of Paget's Disease

Aetiology of Paget's Disease

Treatment of Paget's Disease

Final Considerations in Paget's Disease

References

Chapter 90: Management of Osteoporosis; Its Consequences: A Major Threat to Quality of Life

Introduction

Epidemiology of Osteoporosis and Fractures

Bone Remodelling Throughout Life

Pathogenesis of Osteoporosis and Fractures

Diagnosis of Osteoporosis

Fracture Risk Assessment

Investigation

Lifestyle Measures

Drug Treatment

Future Treatments

References

Chapter 91: Gait, Balance and Falls

Introduction

Balance

Gait

Falls

Clinical Presentation of Falls

Consequences of Falls

Diagnostic Assessment

Therapeutic Approach

Prevention

Acknowledgment

Appendix 91.1

Appendix 91.2

Appendix 91.3

References

Chapter 92: Foot Problems

Introduction

Risk Disorders with Pedal Manifestations

Keratotic Lesions

Ulcers

Toenails

Bursitis

Scarring

Fissures

Management Considerations

Foot Care

Footwear

Orthotics

References

Chapter 93: Hip Fracture and Orthogeriatrics

Background

Diagnosis and Classification

Preoperative Care

Fracture Repair and Perioperative Care

Postoperative Care

Surgical Complications

Secondary Fracture Prevention

Orthogeriatric Collaboration and Orthogeriatric Models

References

Chapter 94: Diseases of the Joints

Introduction

Osteoarthritis

Rheumatoid Arthritis

Gout

Calcium Pyrophosphate Deposition Disease

Connective Tissue Disease

Infectious Arthritis

Treatment

Physical Therapy

Medications

Surgery

References

Section 10: Endocrine and Metabolic Disorders

Chapter 95: Endocrinology of Ageing

Introduction

Hormonal Regulation and Ageing

Effects of Ageing and Related Diseases on Endocrine Diseases

Insulin Resistance Syndrome and Ageing

The Hormonal Fountain of Youth

References

Chapter 96: Water and Electrolyte Balances in Ageing

Introduction

Normal Physiology

Water Homeostasis in the Elderly

Workup and Treatment of Hyponatraemia

Workup and Treatment of Hypernatraemia

Conclusion

References

Chapter 97: The Pituitary Gland

Introduction

Anatomy

Anterior Pituitary Disorders—Clinical Manifestations

Anterior Pituitary Disorders—Treatment

Anterior Pituitary Hormone Secretion—Functional Changes With Age

Posterior Pituitary Gland

References

Chapter 98: Thyroid Disorders

Introduction

Age-Related Modifications in Thyroid Function

Prevalence of Thyroid Disease in Older Populations

Hypothyroidism

Hyperthyroidism

Non-Thyroidal Illness (NTI)

Thyroid Nodules and Nodular Goitre

Conclusion

References

Chapter 99: Ovarian Function and Menopause

Introduction and Definitions

Epidemiology

Endocrinology and Neuroendocrinology of Menopause

Ovarian Ageing and Sex Steroids Changes

Specific Healthcare Problems in Relation to The Menopause

Hormone Therapy in Postmenopausal Women

Androgen Therapy in Postmenopausal Women

Conclusion

Further Reading

Chapter 100: Testicular Function

Introduction

Ageing and Testicular Function

Diagnosis of Late-Onset Hypogonadism

Treatment of Late-Onset Hypogonadism

Benefits of Testosterone Replacement Therapy

Risks of Testosterone Replacement Therapy

Symptom Relief

Monitoring Patients on TRT

Precautions and Contraindications for TRT

Conclusion and Recommendations

References

Chapter 101: Diabetes Mellitus

Introduction

Epidemiology, Pathogenesis and Modes of Presentation

Impact of Diabetes Mellitus

Care Home Diabetes

Prevention

Conclusion

References

Chapter 102: New Therapies for Diabetes Mellitus

Why Do We Need New Antiglycaemic Medications and the ‘Diabetes Conundrum’?

Definition of Type 2 Diabetes Mellitus: Disease or Risk Factor?

Current Adjunctive Therapies for T2DM

Currently Approved Antiglycaemic Therapies

Metformin: Life Begins at 50

Sulfonylureas (SUs)

Meglitinides (Glinides): Faster is not Always Better

Thiazolidinediones (TZDs): The Bloom is Off the Rose and the Pie is in the Sky (Rosiglitazone and Pioglitazone)—Downsizing Expectations

α-Glucosidase Inhibitors (AGIs)—the Drugs that Get no Respect

Colesevelam: LDL and A1c Lowering—a Match Made in Heaven

Bromocriptine: Born Again

Incretin Therapies: The New Kid on the Block

Amylin Analogues—Pramlintide

Emerging but not Yet Approved Antiglycaemics

Conclusion

References

Section 11: Urogenital Disorders

Chapter 103: Gynaecology and The Older Patient

Introduction

Effect of Ageing on the Genital Tract

Hormonal Changes

The Menopause and HRT (Hormone Replacement Therapy)

Common Symptoms in the Elderly

Postmenopausal Bleeding (PMB)

Discharge Per Vagina

Uterovaginal Prolapse

Urinary Incontinence

Sexuality and Old Age

Vulval Disorders

Gynaecological Cancer

HIV and Old Age

Conclusion

References

Chapter 104: The Ageing Bladder

Introduction

Anatomy of the Ageing Bladder

Bladder Physiology and Correlation to Anatomy of the Ageing Bladder

Special Disease States

Pharmacology as it Relates to the Ageing Bladder

Surgical Disease of the Ageing Bladder

Conclusion

References

Chapter 105: Prostate Diseases

Introduction

Benign Prostatic Hyperplasia

Prostate Cancer

Prostatitis

References

Chapter 106: Urinary Incontinence

Introduction

Pathophysiology and Types of Urinary Incontinence

Complications and Impact of Incontinence

Diagnosis and Assessment of Urinary Incontinence

Management of Urinary Incontinence

References

Chapter 107: Geriatric Nephrology

Introduction

Normal Ageing: Glomerular Level

Diseases: At the Glomerular Level

Normal Ageing: Renovascular Level

Diseases: Reno-Vascular Level

Normal Ageing: Tubular-Interstitial Level

Diseases: Tubular-Interstitial Level

Acute Kidney Injury (AKI)

Chronic Kidney Disease (CKD)

Renal Pharmacology

References

Section 12: Cancer

Chapter 108: Cancer and Ageing

Introduction

Epidemiology and Disparities

Ageing and Tumour Development

Cancer Prevention

Cancer Screening

Cancer Treatment

Supportive Care

Multidisciplinary Care Models

Survivorship

Conclusion

References

Chapter 109: Oncological Emergencies

Introduction

Haematological Emergencies

Metabolic Emergencies

Cardiovascular Emergencies

Neurological Emergencies

Structural Emergencies

Acute Pain Emergencies

The Role of Geriatric Evaluation in the Prediction of Oncological Emergencies

Conclusion

References

Chapter 110: Breast Cancer

The Presentation

Stage of Presentation

Variation in Care and Undertreatment in the Elderly

Screening in the Elderly

Risk Factors in the Elderly

Natural History of Breast Cancer in the Elderly

Treatment of Operable Disease

Role of Radiotherapy

Adjuvant Endocrine Therapy

Chemotherapy

Treatment of Advanced Disease

Prognostic Factors in Elderly Breast Cancer

Quality of Life Issues

Conclusion

Guidelines for Therapy

References

Chapter 111: Maintaining Functional Status

Introduction

A Role for Geriatricians in Cancer Care

Staging the Ageing of the Elderly Cancer Patient

Exercise

Conclusion

References

Section 13: Functional Disorders and Rehabilitation

Chapter 112: Multidimensional Geriatric Assessment

Introduction

Components of Geriatric Assessment

Settings of Geriatric Assessment

Effectiveness of Geriatric Assessment Programmes

Conclusion

References

Chapter 113: Frailty

Introduction

Pathophysiology of Frailty

Conclusion

References

Chapter 114: Rehabilitation

Introduction

Terminology and Classifications

Determinants of Activity and Participation Restrictions

Principles of Rehabilitation

The Rehabilitation Process

The Rehabilitation Setting

Emerging Technologies and Rehabilitation

Specific Rehabilitation Problems

Future Challenges

References

Section 14: Iatrogenic Infections

Chapter 115: Tuberculosis

Introduction

Epidemiology

Pathogenesis

Clinical Characteristics

Diagnosis

Treatment

Infection Control Issues

References

Chapter 116: Valvular Heart Disease and Infective Endocarditis

Introduction

Epidemiology and Pathophysiology

History and Clinical Assessment

Aortic Stenosis

Aortic Regurgitation

Mitral Stenosis

Mitral Regurgitation

Mixed Valve Disease

Interventional Treatment in the Elderly

Prosthetic Valves in the Elderly

Infective Endocarditis

Prosthetic Valve Endocarditis

Conclusion

Chapter 117: Infections of the Central Nervous System

Meningitis

Focal Central Nervous System Infections

Encephalitis

Postpolio Syndrome

Creutzfeldt–Jakob Disease

References

Section 15: Special Issues

Chapter 118: Elder Abuse: A UK Perspective

History of Elder Abuse Management in the UK

Defining Elder Abuse

Prevalence of Elder Abuse

Risk Factors for Elder Abuse

Abuse in Institutions

Detecting Abuse

Management of Abuse

Preventing Abuse

Conclusion

References

Chapter 119: Good Quality Care: Abuse

Definitions

A Reminder of the Main Ethical Principles

Multidimensional Aspects of Abuse

But Who Abuses?

Conduct to Embrace

Article 434-3 of the Penal Code

The Laws

Other Contributions

MobiQual—Mobilization for the Improvement of the Quality of Professional Practices

Further Comments

Conclusion

Suggested Reading

Chapter 120: Alcohol Consumption and Cognition

Evidence From Studies

Prospective Evidence

Conclusion

References

Chapter 121: Drug Misuse and The Older Person: A Contradiction in Terms?

Introduction

Drug Abuse

Medications and The Elderly: Geriatric Characteristics, Adverse Drug Reactions and Drug Misuse

Prevention of Iatrogenic Incidents in Practice: General Rules for Individual Prescription

Prevention of Iatrogenic Incidents in Practice: Tools for Collective Evaluation

References

Chapter 122: The Use and Abuse of Prescribed Medicines

Introduction

Use and Harmful Use

Pharmacology

Prevalence and Correlates

Benzodiazepines

Illicit Drug Misuse

Aetiology

Polysubstance Misuse

Detection

Detection of Benzodiazepine Use

Treatment

Prognosis

Conclusion

References

Chapter 123: Transportation, Driving and Older Adults

Introduction

Illness and Transportation

What do We Need to Know to Assess Our Older Patients?

Conclusion

References

Chapter 124: Smart Homes

Introduction

What is a Smart Home?

Applicability to Elderly People

Ensuring User Friendliness

Some Examples of Usage

Appropriate Design

The Difficulty of Behaviour Monitoring

The Importance of Communication with the User

Quality of Life Issues

Links with the Outside World

Experience of Usage

Infrastructure Needed for Introduction

Future Trends

Conclusion

Acknowledgements

References

Chapter 125: Skin Disorders

References

Chapter 126: The Prevention and Management of Pressure Ulcers

Clinical Staging of Pressure Ulcers

Prevention of Pressure Ulcers

Treatment of Pressure Ulcers

Conclusion

References

Chapter 127: Perioperative and Postoperative Medical Assessment

Introduction

Outcomes of Surgery in the Elderly

Ageing Physiology

Emergency Surgery

Preoperative Medical Assessment of the Geriatric Patient

Postoperative Management of the Geriatric Patient

Conclusion

References

Chapter 128: Anaesthesia

Introduction

Outcome of Surgery and Anaesthesia in the Elderly

Cardiovascular Morbidity Associated with Surgery and Anaesthesia

Respiratory Morbidity Associated with Surgery and Anaesthesia

Central Nervous System Morbidity Associated with Surgery and Anaesthesia

Renal Morbidity Associated with Surgery and Anaesthesia

Perioperative Hypothermia

Preoperative Assessment

Pain Assessment and Management in the Elderly

Ethical Considerations for Perioperative Care of the Elderly

Strategy to Reduce Postoperative Morbidity and Mortality in the Elderly

Conclusion

References

Chapter 129: Health Issues in the Ageing Female

Cancer

Menopause

Osteoporosis

References

Chapter 130: Antiageing Strategies

Introduction

The Demographic Revolution

What is Antiageing Medicine?

Can Death be Delayed?

Can the Course of Disability and Functional Dependence be Reversed?

Can Disability and Functional Dependence be Delayed?

Caloric Restriction (CR)

Epigenetics

Translation of Results into Humans

Stem Cell Ageing

The Hormonal Fountain of Youth

Preventive Gerontology

Ethical Issues

Conclusion

References

Chapter 131: Ethics in Geriatric Medicine

Scenes from Everyday Life in the Geriatrics Unit, or how do you do what's Right?

The 10-Point Approach

Conclusion

Further Reading

Chapter 132: Participation of Older People in Clinical Trials

Introduction

Summary of Existing Clinical Trials Involving Older People

Determinants of Participation of Older People in Clinical Trials

Facilitating the Access of Older People to Clinical Trials

Conclusion

References

Chapter 133: Restraints and Immobility

Introduction

Immobility

Physical Restraints

Siderails

Risk Factors and Justification

Complications

Outcomes of Restrictive Device Reduction

Approaches to Reduce Restrictive Device Usage

Conclusion

References

Chapter 134: Centenarians

An Optimistic View

Compression of Morbidity Versus Disability

Nature Versus Nurture

Centenarian Offspring: Following in the Footsteps of Their Parents

Genetic Findings

A Proposed Multifactorial Model for Exceptional Longevity and Exceptional Survival Phenotypes

Conclusion

References

Chapter 135: End-of-Life and Palliative Care

Introduction

Palliative and Hospice Care

Symptom Assessment and Treatment

Communication

Psychosocial and Spiritual Domains

Cross-Cultural Issues

Care Transitions in End-of-Life Care

References

Chapter 136: End-of-Life Care: Special Issues

Palliative Care

Withholding and Withdrawing Treatment

Care Planning

Terminal Care

Assisted Dying

Bereavement

Conclusion

References

Part 3: Global Healthcare Systems

Chapter 137: Improving Quality of Care

Introduction

The History of Quality

Quality in the Nursing Home

Quality in Acute Care Practices

Quality in the Community Setting

Future Initiatives in Healthcare Quality

Conclusion

Appendix 137.1 Healthcare quality organizations

References

Chapter 138: Clinical Audit of Healthcare

Definition

Background

The Audit Cycle

Planning an Audit

Determining Standards

Determining Audit Criteria

Collecting Data

Dissemination and Change

Re-Audit and Sustaining Improvement

Conclusion

References

Chapter 139: Carers and the Role of the Family

Introduction

Definitions of Caring

Assessment of Family Carers

Arranging Services to Support Carers

Discussion

References

Chapter 140: Nursing Home Care

Introduction

Comparison of Nursing Homes in Different Countries

References

Chapter 141: Geriatric Occupational Therapy: Achieving Quality in Daily Living

Overview

Conceptual Foundations of Geriatric Occupational Therapy

Scope of Occupational Therapy Services

Occupational Therapy Process

Conclusion

References

Chapter 142: Geriatric Medicine Education in Europe and the United States

Introduction

Geriatric Education in Europe

Undergraduate Geriatric Medicine Education in Europe

Geriatric Medicine Teaching at the Postgraduate Level

Continuing Medical Education

Undergraduate Geriatric Education in the United States

Postgraduate Geriatric Education in USA

Initiatives for Improving Undergraduate and Postgraduate Geriatric Education: United States

Conclusion

References

Chapter 143: Systems of Healthcare: The United States

Introduction

Overview of Healthcare Demographics

Development of Geriatric Medicine

Home Healthcare

Nursing Home Care

Hospital Care

Academic Geriatrics

Conclusion

References

Chapter 144: Systems of Healthcare: Australia

Overview of Healthcare Demographics

Development of Geriatric Medicine

Home Healthcare

Nursing Home Care

Hospital Care

Academic Geriatrics

References

Chapter 145: Systems of Healthcare: The United Kingdom

Introduction

Overview of Healthcare Demographics

Development of Geriatric Medicine

Home Healthcare

Nursing Home Care

Hospital Care

Academic Geriatrics

Conclusion

References

Chapter 146: Geriatric Medicine in China

Introduction

The Elderly Population in Hong Kong SAR, Macau SAR and Taiwan

Policies toward Ageing in Mainland China

Health of the Elderly in Mainland China and Hong Kong SAR

Geriatric Medicine in China and Hong Kong SAR

The Health and Long-Term Care System for the Elderly in Hong Kong SAR

History of the Development of Geriatric Medicine in Hong Kong SAR

Lack of a Systematic Approach in Acute Geriatrics Care in Hong Kong SAR

Issues in Primary Healthcare for the Elderly in Hong Kong SAR

Geriatric Healthcare at Residential Care Homes for the Elderly (RCHES) in Hong Kong SAR

Service Gap and Duplication Issues for Health and Long-Term Care of the Elderly

Recommendation for an Integrated Health and Social Care Delivery System in Hong Kong SAR

Conclusions

References

Chapter 147: Ageing in Developing Countries

Introduction

Ageing and Health

Health Care and Geriatric Medicine

References

Chapter 148: Geriatric Medicine in the European Union: Towards Unification of Diversity

Introduction

Demography

Healthcare and Health Systems

Health and Ageing Trends

Geriatric Medicine

Geriatric Organizations

Recent Developments in EU Policy

Acknowledgements

References

Appendix: Function assessment scales

Components of the geriatric assessment

Activities of daily living (ADLs) and instrumental activities of daily living (IADLs)

Dental

Hallpike Manoeuvre

Osler Manoeuvre for pseudohypertension

Simplified Nutrition Assessment Questionnaire (SNAQ)

The Mini-Nutritional Assessment (MNA) Scale

Saint Louis University social activities assessment

The Confusion Assessment Method (CAM) diagnostic algorithm

Index

To my mother, Ivy, and father, Radovan, for giving me the opportunity.

–Alan J. Sinclair

To all my older friends and patients who have taught me geriatrics, to my wife Pat and my children Robert, Susan and Jacqueline who have supported me throughout my career, and to my grandchildren Amanda, Conor, Katelyn, Nicole, Paige and John who are my eternal joy and hope for my future of elder care.

–John E. Morley

To all the teams working at the Gérontopôle, to my father Professor Pierre Vellas who created the Universities of the Third Age, and to Professor J.L. Albarede, our mentor.

–Bruno Vellas

Title Page

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Library of Congress Cataloging-in-Publication Data

Pathy's principles and practice of geriatric medicine / edited by Alan J. Sinclair, John E. Morley, Bruno Vellas.–5th ed.

p. ; cm.

Principles and practice of geriatric medicine

Rev. ed. of: Principles and practice of geriatric medicine. 4th ed. c2006.

Includes bibliographical references and index.

ISBN 978-0-470-68393-4 (cloth)

I. Sinclair, Alan (Alan J.) II. Morley, John E. III. Vellas, B. J. (Bruno J.) IV. Pathy, M. S. J. V. Principles and practice of geriatric medicine. VI. Title: Principles and practice of geriatric medicine.

[DNLM: 1. Geriatrics–methods.WT 100]

LC classification not assigned

618.97–dc23

2011032652

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

About the Editors

Alan Sinclair

UnFigure

Alan Sinclair is Dean and Professor of Medicine at the Bedfordshire & Hertfordshire Postgraduate Medical School at the University of Bedfordshire, UK. He was a founding member and Academic Director of the European Union Geriatric Medicine Society (EUGMS) and previously Charles Hayward Professor of Geriatric Medicine at the University of Birmingham, UK. His principle research interests are in the areas of diabetes, older people, nutrition and frailty. He is the recipient of both national and international research awards. Alan recently established the Institute of Diabetes for Older People (IDOP), which is the first institute of its kind to be solely dedicated to the enhancement of quality diabetes care in older people.

John Morley

UnFigure

John Morley is the Dammert Professor of Gerontology, Director, Division of Geriatric Medicine and Director, Endocrinology at Saint Louis University Medical Center. Dr Morley is the Editor-in-Chief of the Journal of the American Medical Directors Association.

Bruno Vellas

UnFigure

Bruno Vellas is Professor of Internal Medicine and Geriatrics, Chair of the Gérontopôle in Toulouse, France, including the Alzheimer's Disease Research and Clinical Centre. Professor Vellas is President of the IAGG (International Association of Gerontology and Geriatrics) and Editor-in-Chief of the Journal of Nutrition, Health and Aging.

List of Contributors

Ahmed H. Abdelhafiz

Rotherham General Hospital, Rotherham, Yorkshire, UK

Mohammed T. Abou-Saleh

St George's, University of London, London, UK

Charlotte grup

University College of London Hospitals NHS Trust and University College London, London, UK

Avan Aihie Sayer

Southampton General Hospital, University of Southampton, Southampton, UK

Stewart G. Albert

Saint Louis University School of Medicine, St Louis, MO, USA

Suraj Alakkassery

Saint Louis University Medical Center, St Louis, MO, USA

Cristina Alonso Bouzón

Hospital Universitario de Getafe, Madrid, Spain

Sandrine Andrieu

University of Toulouse III, INSERM Unit 1027, Toulouse, France

Jean-Pierre Aquino

Clinique Médicale de la Porte Verte, Versailles, France

Hiroyuki Arai

Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan

H. James Armbrecht

St Louis Veterans' Affairs Medical Center and Saint Louis University School of Medicine, St Louis, MO, USA

Wilbert S. Aronow

New York Medical College, Valhalla, NY, USA

Jaffer Babaa

University of South Florida, pre-medical student, Tampa, FL, USA

Marco Baccini

University of Florence and Azienda Ospedaliero—Universitaria Careggi, Florence, Italy

Abhay Bajpai

St George's, University of London, London, UK

Laurent Balardy

Gérontopôle, CHU Toulouse, Toulouse, France

Mario Barbagallo

University of Palermo, Palermo, Italy

Karen F. Barney

Saint Louis University, St Louis, MO, USA

Bedanta P. Baruah

Cardiff University, Cardiff, Wales, UK

Nazem Bassil

Saint Louis University Medical Center, St Louis, MO, USA

Antony Bayer

Cardiff University, Cardiff and University Hospital Llandough, Penarth, UK

Joël Belmin

Groupe Hospitalier Pitié-Salpétrière-Charles Foix and Université Pierre et Marie Curie (Paris 6), Ivry-sur-Seine, France

Mario Belvedere

University of Palermo, Palermo, Italy

Susan Mary Benbow

Staffordshire University, Stafford, Staffordshire and Older Mind Matters Ltd, Manchester, UK

Rachelle E. Bernacki

Brigham and Women's Hospital, Boston, MA, USA

Chantal Bernard-Marty

Institut Claudius Regaud, Toulouse, France

Kimberly C. Berni

University of Missouri, Columbia, MO, USA

Peter McL. Black

Harvard Medical School, Boston, MA, USA

François Blanchard

Hôpital Maison Blanche, Reims, France

Michael Blank

Firelands Regional Medical Center, Sandusky, OH, USA

Dan G. Blazer

Duke University Medical Center, Durham, NC, USA

Martin M. Brown

Institute of Neurology, University College London, London, UK

Rhona Buckingham

Royal College of Physicians, London, UK

A. John Camm

St George's, University of London, London, UK

Elizabeth A. Capezuti

New York University, New York, NY, USA

Gideon A. Caplan

Prince of Wales Hospital, Sydney, Australia

David Carr

The Rehabilitation Institute of St Louis, St Louis, MO, USA

Marta Castro Rodríguez

Hospital Universitario de Getafe, Madrid, Spain

Pierre Celsis

INSERM Unit 825, Toulouse, France

Oscar A. Cepeda

Saint Louis University School of Medicine and St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

Ian M. Chapman

University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia

Richard Y.T. Chen

Changi General Hospital, Singapore

Antonio Cherubini

Perugia University Medical School, Perugia, Italy

Leung-Wing Chu

Sau Po Centre on Ageing, University of Hong Kong and Queen Mary Hospital, Hong Kong

Nicola Coley

University of Toulouse III, INSERM Unit 1027, Toulouse, France

Cynthia L. Comella

Rush University Medical Center, Chicago, IL, USA

Simon Conroy

University of Leicester, Leicester, UK

Claudia Cooper

University College London, London, UK

Cyrus Cooper

Southampton General Hospital, University of Southampton, Southampton, UK

Pamela M. Crawford

York Hospital, York, UK

Suzanne Crowe

Adelaide Meath and National Children's Hospital, Dublin, and University of Dublin, Dublin, Ireland

Alfonso J. Cruz-Jentoft

Hospital Universitario Ramón y Cajal, Madrid, Spain

Dulce M. Cruz-Oliver

Saint Louis University, St Louis, MO, USA

James M. Cummings

University of Missouri, Columbia, MO, USA

Lenise A. Cummings-Vaughn

Saint Louis University School of Medicine and St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

Jean-François Dartigues

INSERM Unit 897, and Université Bordeaux Segalen, Bordeaux, France

Sam Dawkins

John Radcliffe Hospital, Oxford, UK

Lisette C.P.G.M. de Groot

Wageningen University, Wageningen, The Netherlands

Olivier Deguine

Hôpital Purpan and Université Toulouse III, CNRS, Toulouse, France

Julien Delrieu

Gérontopôle, Toulouse University Hospital and INSERM Unit 558, University of Toulouse III, Toulouse, France

Jean-François Démonet

Leenaards Memory Centre, CHUV, Lausanne, Switzerland

Michael J. Denham

Wellcome Trust Centre for the History of Medicine at UCL, London, UK

Abhilash K. Desai

Sheppard Pratt Hospital, and University of Maryland School of Medicine, Baltimore, MD, USA

David Doig

Institute of Neurology, University College London, London, UK

Ligia J. Dominguez

University of Palermo, Palermo, Italy

Richard L. Doty

Smell & Taste Center, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Nicolas Doumerc

Gérontopôle, CHU Toulouse, Toulouse, France

Christopher Dyer

Royal United Hospital, Bath, UK

Pamela M. Enderby

University of Sheffield, Sheffield, UK

Francesco Fattirolli

University of Florence and Azienda Ospedaliero—Universitaria Careggi, Florence, Italy

Maria A. Fiatarone Singh

University of Sydney, New South Wales, Australia; Hebrew Rehabilitation Center for Aged, Roslindale, MA, USA and Tufts University, Boston, MA, USA

Ilora G. Finlay

Cardiff University and Velindre Hospital, Cardiff, UK

Paul Finucane

Graduate-Entry Medical School, University of Limerick, Limerick, Ireland

Joseph H. Flaherty

Saint Louis University School of Medicine and St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

Roger M. Francis

Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK

James E. Galvin

New York University Langone Medical Center, New York, NY, USA

Julie K. Gammack

Saint Louis University School of Medicine, and St Louis Veterans' Affairs Medical Center, Geriatric Research Education and Clinical Center, St Louis, MO, USA

Clement Gaudin

Gérontopôle, CHU Toulouse, Toulouse, France

Andrea R. Genazzani

University of Pisa, Pisa, Italy

Stephane Gerard

Gérontopôle, CHU Toulouse, Toulouse, France

George T. Griffing

Saint Louis University Medical Center, St Louis, MO, USA

George T. Grossberg

Saint Louis University School of Medicine, St Louis, MO, USA

Renato Maia Guimarães

Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil

Ramzi R. Hajjar

American University of Beirut Medical Center, Beirut, Lebanon and Saint Louis University School of Medicine, St Louis, MO, USA

Kingsley K. Hampton

Royal Hallamshire Hospital, Sheffield, UK

Arthur E. Helfand

Temple University, Philadelphia, Thomas Jefferson University Hospital, Philadelphia, and Philadelphia Corporation for Aging, Philadelphia, PA, USA

Robert D. Helme

Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia

David Hilton-Jones

John Radcliffe Hospital, Oxford; Milton Keynes Hospital Foundation Trust, Milton Keynes, Buckinghamshire; Muscular Dystrophy Campaign Muscle and Nerve Centre, Oxford, and Myasthenia Gravis Association Myasthenia Centre, Oxford, UK

Michael Horowitz

University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia

Philippe Huber

University Hospital of Geneva, Geneva, Switzerland

Jonathan Ilowite

Winthrop University Hospital, Mineola, NY, USA

Radha Indusekhar

University Hospital of North Staffordshire, Stoke-on-Trent, UK

Donald F. Jessett

Formerly of University of Wales Institute, Cardiff, UK

David Jolley

Manchester University, Manchester, UK

Seema Joshi

Veterans Affairs Medical Center, Leavenworth, KS, USA

Lalit Kalra

King's College, London, UK

Anjali S. Kamat

Saint Louis University Health Sciences Center, St Louis, MO, USA

Benny Katz

St Vincent's Hospital and LaTrobe University, Melbourne, Victoria, Australia

Rafi T. Kevorkian

Saint Louis University School of Medicine and St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

Joan Khoo

Changi General Hospital, Singapore

Heidi D. Klepin

Wake Forest University School of Medicine, Winston-Salem, NC, USA

Katie Kompoliti

Rush University Medical Center, Chicago, IL, USA

Christine Lafont

Toulouse University Hospital and Centre of Geriatric Medicine, Toulouse, France

James F. Lamb

Ohio State University College of Medicine and Public Health, Columbus, OH, USA

Andrew J. Larner

Walton Centre for Neurology and Neurosurgery, Liverpool, UK

Luc Letenneur

INSERM Unit 897, and Université Bordeaux Segalen, Bordeaux, France

Wee Shiong Lim

Tan Tock Seng Hospital, Singapore

Milta Oyola Little

Saint Louis University Medical Center, St Louis, MO, USA

Gill Livingston

University College London, London, UK

Susannah Long

Imperial College London, London, UK

Gordon D.O. Lowe

University of Glasgow, Glasgow, UK

Linda M. Luxon

University College of London Hospitals NHS Trust and University College London, London, UK

Gerald M. Mahon

Saint Louis University School of Medicine, St Louis, MO, USA

Suzanne M. Mahon

Saint Louis University, St Louis, MO, USA

Aneil Malhotra

John Radcliffe Hospital, Oxford, UK

Leocadio Rodríguez Mañas

Hospital Universitario de Getafe, Madrid, Spain

Robert E. Mansel

Cardiff University, Cardiff, Wales, UK

Kenneth G. Manton

Duke University, Durham, NC, USA

Niccolò Marchionni

University of Florence and Azienda Ospedaliero—Universitaria Careggi, Florence, Italy

Mathieu Marx

Hôpital Purpan and Université Toulouse III, CNRS, Toulouse, France

Giulio Masotti

University of Florence and Azienda Ospedaliero—Universitaria Careggi, Florence, Italy

Graydon S. Meneilly

University of British Columbia, Vancouver, BC, Canada

Jean-Pierre Michel

University Hospital of Geneva, Geneva, Switzerland

Paul Montgomery

University of Oxford, Oxford, UK

Kim J. Moon

Saint Louis University School of Medicine and St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

Terry L. Moore

Saint Louis University Medical Center, St Louis, MO, USA

Jo Moriarty

King's College London, UK

John E. Morley

Saint Louis University School of Medicine and St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

John S. Morris

Princess of Wales Hospital, Bridgend, UK

Loic Mourey

Institut Claudius Regaud, Toulouse, France

Emmanuel Moyse

Hôpital Purpan, Toulouse, France

Carlos G. Musso

Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

Joseph M. Mylotte

University at Buffalo, Buffalo, NY, USA

Robert A. Norman

Dr Robert A. Norman & Associates, Tampa, FL, USA

Fatima Nourhashemi

Toulouse University Hospital, Toulouse, France

P.M. Shaughn O'Brien

University Hospital of North Staffordshire, Stoke-on-Trent, UK

Dennis S. Oh

Tufts University School of Medicine, Springfield, MA, USA

Takashi Ohrui

Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan

Fidelma O'Mahony

University Hospital of North Staffordshire, Stoke-on-Trent, UK

Desmond O'Neill

Trinity College Dublin, Dublin, Ireland

Dimitrios G. Oreopoulos

University Health Network, Toronto, ON, Canada

Francesco Orso

University of Florence and Azienda Ospedaliero—Universitaria Careggi, Florence, Italy

Roger Orpwood

University of Bath and Royal United Hospital, Bath, UK

Hardev S. Pall

University of Birmingham and University Hospital Birmingham Foundation Trust, Birmingham, UK

Miguel A. Paniagua

Saint Louis University School of Medicine, St Louis, MO, USA

Thomas T. Perls

Boston University School of Medicine, Boston, MA, USA

Horace M. Perry III

Saint Louis University School of Medicine and Geriatric Research, Education and Clinical Center, St Louis Veterans' Affairs Medical Center, St Louis, MO, USA

Ronald C. Petersen

Mayo Clinic, Rochester, MN, USA

Carolyn D. Philpot

Saint Louis University Medical Center, St Louis, MO, USA

Antoine Piau

Gérontopôle, Toulouse University Hospital, Toulouse, France

Nicola Pluchino

University of Pisa, Pisa, Italy

Jonathan Potter

Formerly Royal College of Physicians of London, London, UK

Bayard L. Powell

Wake Forest University School of Medicine, Winston-Salem, NC, USA

Charlene M. Prather

Saint Louis University, St Louis, MO, USA

Bernard D. Prendergast

John Radcliffe Hospital, Oxford, UK

Terence J. Quinn

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland, UK

Shobita Rajagopalan

Los Angeles County Department of Public Health, Los Angeles, CA, USA

Christopher K. Rayner

University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia

Kathleen C. Reid

Women's College Hospital, Toronto, ON, Canada

Michael W. Rich

Washington University School of Medicine, St Louis, MO, USA

Lucio A. Rinaldi

University of Florence and Azienda Ospedaliero—Universitaria Careggi, Florence, Italy

Richard C. Roberts

University of Dundee, Dundee, Scotland, UK

Miriam B. Rodin

Saint Louis University Medical Center, St Louis, MO, USA

Yves Rolland

INSERM Unit 1027, F-31073; University of Toulouse III, Gérontopôle of Toulouse, France

David S. Rosenthal

Harvard Medical School, Boston, MA, USA

Philip A. Routledge

Cardiff University School of Medicine, Cardiff, Wales, UK

Geneviève Ruault

French Society of Geriatrics and Gerontology, Suresnes, France

Laurence Z. Rubenstein

University of Oklahoma College of Medicine, Oklahoma City, OK, USA

Natalie Sachs-Ericsson

Florida State University, Tallahassee, FL, USA

Abdi Sanati

Southwest London and St George's NHS Trust, Sutton Hospital, Sutton, UK

Sivakumar Sathasivam

Walton Centre for Neurology and Neurosurgery, Liverpool, UK

Eric Schmidt

Hôpital Purpan, Toulouse, France

Marie-Laure Seux

Assistance Public Hôpitaux de Paris, Hôpital Broca, Paris, France

Dennis J. Shale

Cardiff University, University Hospital of Wales, Cardiff, Wales, UK

Lindsay Dianne Shepard

University of Oxford, Oxford, UK

Hamsaraj G.M. Shetty

University Hospital of Wales, Cardiff, Wales, UK

Stephen D. Silberstein

Thomas Jefferson University, Philadelphia, PA, USA

Tomasso Simoncini

University of Pisa, Pisa, Italy

Alan J. Sinclair

Institute of Diabetes for Older People (IDOP), Luton, UK

Peter Spiegler

Winthrop University Hospital, Mineola, NY, USA

Richard M. Stone

Harvard Medical School, Boston, MA, USA

David J. Stott

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK

Elsa S. Strotmeyer

University of Pittsburgh, Pittsburgh, PA, USA

Andreas E. Stuck

Geriatrics Inselspital University Hospital, Bern, Switzerland

Adam Szafranek

University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK

Peggy A. Szwabo

Saint Louis University School of Medicine, St Louis, MO, USA

Eric G. Tangalos

Mayo Clinic, Rochester, MN, USA

Syed H. Tariq

Saint Louis University School of Medicine, St Louis, MO, USA

David R. Thomas

Saint Louis University Health Sciences Center, St Louis, MO, USA

Florian P. Thomas

St Louis Veterans' Affairs Medical Center and Saint Louis University School of Medicine, St Louis, MO, USA

Debbie T. Tolson

Glasgow Caledonian University, Glasgow, UK

Nina Tumosa

St Louis Veterans' Affairs Medical Center and Saint Louis University School of Medicine, St Louis, MO, USA

Allan R. Tunkel

Drexel University College of Medicine, Philadelphia, PA and Monmouth Medical Center, Long Branch, NJ, USA

Wija A. van Staveren

Wageningen University, Wageningen, The Netherlands

Bruno Vellas

Gérontopôle, Toulouse University Hospital and INSERM Unit 558, University of Toulouse III, Toulouse, France

Joe Verghese

Albert Einstein College of Medicine, Bronx, NY, USA

Adie Viljoen

Lister Hospital, Stevenage, Hertfordshire, and Bedfordshire and Hertfordshire Postgraduate Medical School, Luton, Hertfordshire, UK

Charles Vincent

Imperial College London, London, UK

Aaron I. Vinik

Eastern Virginia Medical School, Norfolk, VA, USA

Ladislav Volicer

University of South Florida, Tampa, FL, USA

Ulrich O. von Oppell

University Hospital of Wales, Cardiff and Vale University Health Board, and University of Cardiff, Wales, UK

Martha Wadleigh

Harvard Medical School, Boston, MA, USA

Adrian Wagg

University of Alberta, Edmonton, Alberta, Canada and Royal College of Physicians, London, UK

Laura M. Wagner

New York University, New York, NY, USA

Michael Watts

Graduate-Entry Medical School, University of Limerick, Limerick, Ireland

Ryan Westhoff

University of Kansas Medical Center, Kansas City, KS, USA

Victoria J. Wheatley

Aberdare General Hospital, Aberdare, UK

Anthony S. Wierzbicki

Guy's & St Thomas' Hospitals, London, UK

Tanya M. Wildes

Washington University School of Medicine, St Louis, MO, USA

Margaret-Mary G. Wilson

Formerly Saint Louis University Health Sciences Center and Veterans' Affairs Medical Center, St Louis, MO, USA

Gary A. Wittert

University of Adelaide, Adelaide, Australia

Thomas T. Yoshikawa

UCLA School of Medicine and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

William B. Young

Thomas Jefferson University, Philadelphia, PA, USA

Preface to the Fourth Edition

I offer no apology for the publication of this volume. The subject is one of the highest importance, and yet it has been strangely overlooked during the last half-century by the physicians of all countries.

–George Edward Day (1815–1872)

George Day's introduction to his textbook Disease of Advanced Life, published in 1848, regrettably remains appropriate for textbooks published over 150 years later. Modern physicians can still fail to recognize the differences in disease presentation and management between middle-aged and older adults. It is our hope that this Fourth Edition of Principles and Practice of Geriatric Medicine will help increase the awareness of geriatric principles and improve the treatment of older individuals. John Pathy's original vision for the first edition was to provide, in a single volume, a comprehensive reference source for all those involved in the medicine of old age. We have endeavored to adhere to this vision, but inevitably the size of the textbook has grown. While in any text of this size some overlap with general texts of medicine will occur, the emphasis is on those assessments and disorders that are particularly of relevance to older persons.

Over the seven years since the last edition of this text was published, there have been dramatic advances in our understanding of the pathophysiology of disease as it interacts with the physiological processes of aging. There has been a continuing validation of assessment tools for older persons and the development of some new ones. Large-scale studies of the efficacy of various geriatric systems such as Acute Care for the Elderly Units, Geriatric Evaluation and Management Units, and Home Care Systems have been carried out. All of these have demonstrated the value and cost-effectiveness of the geriatric specialist approach to managing older people. In comparison, most studies assessing Coronary Care Units and Intensive Care Units have failed to come close to demonstrating the effectiveness that has been shown for geriatric units. Despite this, all major hospitals have highly expensive critical care units, while fewer have developed geriatric units. The last decade has also seen an increased awareness of the need to enhance the quality of long-term care. This increase in geriatric knowledge has been recognized by the addition of nearly 40 new chapters in this edition. In addition, many of the previous chapters have been totally rewritten to allow the recognition of the changes that have occurred in our understanding of the care of older persons.

Previous editions of this textbook were edited by a single person, John Pathy. With the rapid increase in geriatric knowledge and John's desire for the Fourth Edition to reflect the input of other academic minds, he has added two new editors to share the burden with him, namely, Alan Sinclair and John Morley. This has allowed a more even distribution of the editing tasks, though John Pathy has continued to carry the lion's share. In recognition of the globalization of the world, in general, and geriatrics, in particular, one of the new editors, John Morley, is from the United States, while Alan Sinclair draws on his European experiences. In addition, a major effort has been made at the end of the text to recognize the differences (as well as the similarities) of geriatrics as it is practiced around the world. The enormous good fortune the editors had in recruiting a stellar class of contributors from around the world has, we hope, allowed this text to be truly representative of a global view of geriatric medicine. From the beginning, John Pathy has made this a goal of his text, and the editors feel that this edition has truly achieved an international view of old-age medicine as originally developed by Marjorie Warren and her colleagues in the United Kingdom.

The general outline of the text still follows that of the first edition. The first sections provide a general perspective of old age, the processes of aging, and social and community perspectives. The chapter on preventive medicine now focuses on issues of particular importance to older persons. In Part III Medicine in Old Age, the section Eating Disorders and Nutritional Health has been increased to recognize the increased importance and understanding of nutrition in old age. Chapters on frailty, sarcopenia, palliative care, and women's health have been added to recognize the increasing importance of these issues in older persons. The final part on Health Care Systems focuses first on the emergence of continuous quality improvement, geriatric systems and evidence-based medicine as the foundation of high-quality geriatric medicine. The development of novel education systems is discussed. Finally, unique aspects of geriatric care around the world are examined.

In an attempt to improve the readability of the text, we have asked the authors to make liberal use of tables and figures, and key points have been added at the end of each chapter. References have been limited, and at the beginning of the reference list, authors identify a few key references to allow for further reading. The new editors have tried to keep the easy reading style of the previous editions, but, as can be imagined, this has been a difficult task as we have increased the number of contributors from around the world.

Overall, we hope our readers enjoy and learn from this textbook; for the three of us, it has been a true labor of love. We particularly would like to thank our contributors for the excellent job they have done. We would also like to thank Layla Paggetti from John Wiley & Sons for her tireless efforts in making sure this book came to fruition. Finally, we would like to thank our families for their forbearance. This book is dedicated to all those who care for older persons.

M.S. John Pathy, Alan J. Sinclair, John E. Morley

December 2005

Preface to the Fifth Edition

The Fifth Edition of this widely known international textbook incorporates the latest evidence of research into the often complex management of common clinical problems in older people. We as Editors embarked on this edition with the knowledge that John Pathy would be there to guide us with all his wisdom and incredible grasp of the discipline of Geriatric Medicine. His untimely departure from this world left a major gap for us, but we have worked very closely as an editorial team, supported by Wiley-Blackwell, and hope that this edition fulfils all the expectations and objectives that were set when we originally sat down with John Pathy to discuss the textbook. We pay tribute to John Pathy as a tremendous role model for aspiring geriatricians all over the world and hope that his textbook will continue to educate all those who seek enlightenment in caring for older people.

We have used, wherever possible, an evidence-based approach to developing each chapter and asked all authors to think hard on what are the key messages. Chapters that have been revised and updated were edited closely to ensure that the clinical pathway is still highly relevant and that the references also reflected an in-depth revision process. A new layout of chapters will be apparent and is based on grouping chapters with similar clinical relevance and where similar pathophysiological mechanisms may be operating. In a majority of chapters, we have leading international authors who are experts in the field.

Wide clinical experience is the hallmark of a sound geriatrician or other healthcare specialist who claims expertise in managing older people who are hospitalized or who have clinically deteriorated in the community. This may take many years of training, although at an early stage of their careers, recognition of the varying nature of illness in old age and how both simple and focused interventions can lead to health gain are prerequisites for enhancing clinical care. This textbook should complement these activities irrespective of the status of the practitioner but, as always, reading a book and acquiring knowledge must be accompanied by a practical clinical care approach aligned with compassion and understanding of the critical issues affecting older people.

Professor Alan Sinclair would like to thank Caroline Sinclair, and Professor John Morley would like to thank Susan Brooks, for their tremendous assistance in helping them to complete their editorial tasks, and the Editors would like to express their appreciation of the incredible patience and support from Gill Whitley and Robyn Lyons at Wiley-Blackwell.

Alan J. Sinclair

John E. Morley

Bruno Vellas

Foreword

One of my earliest memories is of my father at work in his small study: he would be surrounded by what, to a child's eye, appeared to be a chaotic mass of books, journals, papers and slides. He never seemed to rest. The time not occupied by professional work was filled with hard labour in the garden or, with the constant support of his devoted wife Norma, in bringing up five children.

One of the results of the drive and determination in that time spent in his study was the first edition of Principles and Practice of Geriatric Medicine in 1985. I had become a medical student by that time, and remember the work involved in the production of that first edition. Twenty-five years on, I