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Better Health While Aging

Practical information for aging health & family caregivers

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The Geriatrics For Caregivers Blog

Learn practical ways to improve the health and wellbeing of older adults!

Written especially for family caregivers of older adults, but useful for all who want to learn how geriatricians help aging adults.

5 Types of Medication Used to Treat Sundowning & Difficult Dementia Behaviors

by Leslie Kernisan, MD MPH 188 Comments

medication for Alzheimer's behavior

One of the greatest challenges, when it comes to Alzheimer’s disease and other dementias, is coping with sundowning and with difficult behaviors. 

These are symptoms beyond the chronic memory/thinking problems that are the hallmark of dementia. They include problems like:

  • Delusions, false accusations, paranoid behaviors, or irrational beliefs
  • Agitation (getting “amped up” or “revved up”) and/or aggressive behavior
  • Restless pacing or wandering
  • Disinhibited behaviors, which means saying or doing socially inappropriate things
  • Sleep disturbances

These are technically called “neuropsychiatric” symptoms, but regular people might refer to them as “acting crazy” symptoms. Or even “crazy-making” symptoms, as they do tend to drive family caregivers a bit nuts.

And when these behaviors happen in the late afternoon or early evening, it’s usually called “sundowning“. (In most cases, sundowning is triggered by fatigue; anticholinergic medications may cause sundowning symptoms as well.)

Because these behaviors are difficult and stressful for caregivers — and often for the person with dementia — people often ask if any medications can help.

The short answer is “Maybe.”

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles Tagged With: alzheimer's, dementia, medication, paranoia

COVID & Aging Adults: 2023 & 2022 Updates

by Leslie Kernisan, MD MPH 44 Comments

Since the COVID-19 pandemic emerged in early 2020, COVID has become one of the top causes of illness and death in the US, and has especially impacted aging adults, for both health and social reasons.

Older age is one of the top risk factors for severe COVID; it’s even a stronger risk factor than vaccination status. So this is an important issue for us to follow in geriatrics.

On this page, I’ll be posting updates related to COVID and older adults, for 2023. I’ll be focusing on important developments and what I think is most important for older adults and their families to know, to be safer and manage these COVID times we are living through.

I also have a section below on general COVID safety principles for older adults; they held true for all of 2022 and I expect them to continue to hold as we move into the endemic phase of COVID.

 

Covid & Aging Adults: COVID News Summer 2023

Here is my most recent video update, from June 6, 2023:

[Read more…]

Filed Under: Aging health, Featured, Geriatrics For Caregivers Blog, Helping Older Parents Articles

4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory

by Leslie Kernisan, MD MPH

Image Credit: BigStock.

A few years ago, while I was at a family celebration, several people mentioned memory concerns to me.

Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the memory of their parents. And a few were older adults who have noticed some slowing down of their own memory.

“But you know, nothing much that can be done at my age,” remarked one man in his eighties.

Wrong. In fact, there is a lot that can and should be done, if you notice memory or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.

First among them: identify medications that make brain function worse.

This is not just my personal opinion. Identifying and reducing such medications is a mainstay of geriatrics practice. Among other reasons, we do find that in some people, certain medications are causing memory loss symptoms — or other cognitive symptoms — to be worse.

And the expert authors of the National Academy of Medicine report on Cognitive Aging agree: in their Action Guide for Individuals and Families, they list “Manage your medications” among their “Top 3 actions you can take to help protect your cognitive health as you age.”

Unfortunately, many older adults are unaware of this recommendation. And I can’t tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.

What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimers.

Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.

And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.

You should also know that most of these drugs affect balance, and may increase fall risk. So there’s a double benefit in identifying them, and minimizing them.

Below, I share the most commonly used drugs that you should look out for if you are worried about memory problems.

Featured Download: Get my free list of medications that can affect memory and thinking in aging adults. This handy PDF includes all the medications I usually check for.  Click here to download.

The Four Most Commonly Used Types of Medications That Dampen Brain Function

1. Benzodiazepines. This class of medication is often prescribed to help people sleep, or to help with anxiety. They do work well for this purpose, but they are habit-forming and have been associated with developing dementia.

  • Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
  • For more on the risks of benzodiazepines, plus a handout clinically proven to help older adults reduce their use of these drugs, see “How You Can Help Someone Stop Ativan.”
  • Note that it can be dangerous to stop benzodiazepines suddenly. These drugs should always be tapered, under medical supervision.
  • Alternatives to consider:
    • For insomnia, there is no easy and fast alternative. Just about all sedatives — many are listed in this post — dampen brain function. Many people can learn to sleep without drugs, but it usually takes a comprehensive effort over weeks or even months. This may involve cognitive-behavioral therapy, as well as increased exercise and other lifestyle changes. You can learn more about comprehensive insomnia treatment by getting the Insomnia Workbook (often available at the library!) or something similar.
    • For anxiety, there is also no easy replacement. However, there are some drug options that affect brain function less, such as SSRIs (e.g. sertraline and citalopram, brand names Zoloft and Celexa). Cognitive behavioral therapy and mindfulness therapy also helps, if sustained.
    • Even if it’s not possible to entirely stop a benzodiazepine, tapering to a lower dose will likely help brain function in the short-term.
  • Other risks in aging adults:
    • Benzodiazepines increase fall risk.
    • These drugs sometimes are abused, especially in people with a history of substance abuse.
  • Other things to keep in mind:
    • If a person does develop dementia, it becomes much harder to stop these drugs. That’s because everyone has to endure some increased anxiety, agitation, and/or insomnia while the senior adjusts to tapering these drugs, and the more cognitively impaired the senior is, the harder it is on everyone. So it’s much better to find non-benzo ways to deal with anxiety and insomnia sooner, rather than later. (Don’t kick that can down the road!)

 2. Non-benzodiazepine prescription sedatives. By far the most commonly used are the “z-drugs” which include zolpidem, zaleplon, and eszopiclone (brand names Ambien, Sonata, and Lunesta, respectively). These have been shown in clinical studies to impair thinking — and balance! — in the short-term.

  • Some studies have linked these drugs to dementia. However we also know that developing dementia is associated with sleep problems, so the cause-effect relationship remains a little murky.
  • For alternatives, see the section about insomnia above.
  • Occasionally, geriatricians will try trazodone (25-50mg) as a sleep aid. It is thought to be less risky than the z-drugs or benzodiazepines. Of course, it seems to have less of a strong effect on insomnia as well.
  • Other risks in aging adults:
    • These drugs worsen balance and increase fall risk.

3. Anticholinergics. This group covers most over-the-counter sleeping aids, antihistamines such as Benadryl, as well as a variety of other prescription drugs. These medications have the chemical property of blocking the neurotransmitter acetylcholine. This means they have the opposite effect of an Alzheimer’s drug like donepezil (brand name Aricept), which is a cholinesterase inhibitor, meaning it inhibits the enzyme that breaks down acetylcholine.

You may have heard that “Benadryl has long-term side effects on the brain.” That’s because diphenhydramine (brand name Benadryl) is strongly anticholinergic.

A 2015 study found that greater use of anticholinergic drugs was linked to a higher chance of developing Alzheimer’s, and a 2021 Cochrane review found that these drugs may increase the risk of cognitive decline or dementia.

Drugs vary in how strong their anticholinergic activity is. Focus your energies on spotting the ones that have “high” anticholinergic activity. For a good list that classifies drugs as high or low anticholinergic activity, see here. Or, you can look up any of your medications using this handy “anticholinergic burden scale” calculator.

I reviewed the most commonly used of these drugs in this video:

 

I also cover them in an article here: “7 Common Brain-Slowing Anticholinergic Drugs Older Adults Should Use With Caution.” Briefly, drugs of this type to look out for include:

  • Sedating antihistamines, such as diphenhydramine (brand name Benadryl).
  • The “PM” versions of over-the-counter analgesics (e.g. Nyquil, Tylenol PM); the “PM” ingredient is usually a sedating antihistamine.
  • Medications for overactive bladder, such as the bladder relaxants oxybutynin and tolterodine (brand names Ditropan and Detrol, respectively).
    • Note that medications that relax the urethra, such as tamsulosin or terazosin (Flomax and Hytrin, respectively) are NOT anticholinergic. So they’re not risky in the same way, although they can cause orthostatic hypotension and other problems in older adults. Medications that shrink the prostate, such as finasteride (Proscar) aren’t anticholinergic either.
  • Medications for vertigo, motion sickness, or nausea, such as meclizine, scopolamine, or promethazine (brand names Antivert, Scopace, and Phenergan).
  • Medications for itching, such as hydroxyzine and diphenhydramine (brand names Vistaril and Benadryl).
  • Muscle relaxants, such as cyclobenzaprine (brand name Flexeril).
  • “Tricyclic” antidepressants, which are an older type of antidepressant which is now mainly prescribed for nerve pain, and includes amitryptiline and nortriptyline (brand names Elavil and Pamelor).

There is also one of the popular SSRI-type antidepressants that is known to be quite anticholinergic: paroxetine (brand name Paxil). For this reason, geriatricians almost never prescribe this particular anti-depressant.

For help spotting other anticholinergics, ask a pharmacist or the doctor, or check your medications with this handy “anticholinergic burden scale” calculator.

Alternatives to these drugs really depend on what they are being prescribed for. Often non-drug alternatives are available, but they may not be offered unless you ask. For example, an oral medication for itching can be replaced by a topical cream. Or the right kind of stretching can help with tight muscles.

Aside from affecting thinking, these drugs can potentially worsen balance. They also are known to cause dry mouth, dry eyes, and can worsen constipation. (Acetylcholine helps the gut keep things moving.)

4. Antipsychotics and mood-stabilizers. In older adults, these are usually prescribed to manage difficult behaviors related to Alzheimer’s and other dementias. (In a minority of aging adults, they are prescribed for serious mental illness such as schizophrenia. Mood-stabilizing drugs are also used to treat seizures.) For dementia behaviors, these drugs are often inappropriately prescribed. All antipsychotics and mood-stabilizers are sedating and dampen brain function. In older people with dementia, they’ve also been linked to a higher chance of dying.

  • Commonly prescribed antipsychotics are mainly “second-generation” and include risperidone, quetiapine, olanzapine, and aripiprazole (Risperdal, Seroquel, Zyprexa, and Abilify, respectively).
  • The first-generation antipsychotic haloperidol (Haldol) is still sometimes used.
  • Valproate (brand name Depakote) is a commonly used mood-stabilizer.
  • Alternatives to consider:
    • Alternatives to these drugs should always be explored. Generally, you need to start by properly assessing what’s causing the agitation, and trying to manage that. A number of behavioral approaches can also help with difficult behaviors. For more, see this nice NPR story from March 2015. I also have an article describing behavioral approaches here: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
    • For medication alternatives, there is some scientific evidence suggesting that the SSRI citalopram may help, that cholinesterase inhibitors such as donepezil may help, and that the dementia drug memantine may help. These are usually well-tolerated so it’s often reasonable to give them a try.
  • If an antipsychotics or mood-stabilizer is used, it should be as a last resort and at the lowest effective dose. This means starting with a teeny dose. However, many non-geriatrician clinicians start at much higher doses than I would.
  • Other risks in older adults:
    • Antipsychotics have been associated with falls. There is also an increased risk of death, as above.
  • Caveat regarding discontinuing antipsychotics in people with dementia: Research has found that there is a fair risk of “relapse” (meaning agitation or psychotic symptoms getting worse) after antipsychotics are discontinued. A 2015 study of nursing home residents with dementia concluded that antipsychotic discontinuation is most likely to succeed if it’s combined with adding more social interventions and also exercise.
  • You can learn more about medications to treat dementia behaviors in this article: “5 Types of Medication Used to Treat Difficult Dementia Behaviors“

A Fifth Type of Medication That Affects Brain Function

Opioid pain medications. Unlike the other drugs mentioned above, opioids (other than tramadol and meperidine) are not on the Beer’s list of medications that older adults should avoid. That said, they do seem to dampen thinking abilities a bit, even in long-term users. (With time and regular use, people develop tolerance so they are less drowsy, but seems there can still be an effect on thinking.) As far as I know, opioids are not thought to accelerate long-term cognitive decline.

  • Commonly prescribed opiates include hydrocodone, oxycodone, morphine, codeine, methadone, hydromorphone, and fentanyl. (Brand names depend on the formulation and on whether the drug is mixed with acetaminophen.)
  • Tramadol (brand name Ultram) is a weaker opiate with weaker prescribing controls.
    • Many geriatricians consider it more problematic than the classic Schedule II opiates listed above, as it interacts with a lot of medications and still affects brain function. It’s a “dirty drug,” as one of my friends likes to say.
  • Alternatives depend on what type of pain is present. Generally, if people are taking opiates then they have pain that needs to be treated. However, a thoughtful holistic approach to pain often enables a person to get by with less medication, which can improve thinking abilities.
  • For people who have moderate or severe dementia, it’s important to know that untreated pain can worsen their thinking. So sometimes a low dose of opiate medication does end up improving their thinking.
  • Other risks in older adults:
    • There is some risk of developing a problematic addiction, especially if there’s a prior history of substance abuse. But in my experience, having someone else — usually younger — steal or use the drugs is a more likely problem.

Where to Learn About Other Drugs That Affect Brain Function

Many other drugs that affect brain function, but they are either not used as often as the ones above, or seem to affect a minority of older adults.

Notably, there has been a lot of concern in the media about statins, but a meta-analysis published in 2015 could not confirm an association between statin use and increased cognitive impairment. In fact, a 2016 study found that statin use was associated with a lower risk of developing Alzheimer’s disease.

This is not to say that statins aren’t overprescribed or riskier than we used to think. And it’s also quite possible that some people do have their thinking affected by statins. But if you are trying to eliminate medications that dampen brain function, I would recommend you focus on the ones I listed above first.

For a comprehensive list of medications identified as risky by the experts at the American Geriatrics Society, be sure to review the 2019 Beers Criteria.

You can also learn more about medications that increase fall risk in this article: 10 Types of Medications to Review if You’re Concerned About Falling.

What to Do if You or Your Relative Is On These Medications

So what should you do if you discover that your older relative — or you yourself — are taking some of these medications?

If it’s an over-the-counter anticholinergic, you can just stop it. Allergies can be treated with non-sedating antihistamines like loratadine (brand name Claritin), or you can ask the doctor about a nasal steroid spray. “PM” painkillers can be replaced by the non-PM version, and remember that the safest OTC analgesic for older adults is acetaminophen (Tylenol).

If you are taking an over-the-counter sleep aid, it contains a sedating antihistamine and those are strongly anticholinergic. You can just stop an OTC sleep aid, but in the short term, insomnia often gets worse. So you’ll need to address the insomnia with non-drug techniques. (See here for more: 5 Top Causes of Sleep Problems in Aging, & Proven Ways to Treat Insomnia.)

You should also discuss any insomnia or sleep problems with your doctors — it’s important to rule out pain and serious medical problems as a cause of insomnia — but be careful: many of them will prescribe a sleeping pill, because they haven’t trained in geriatrics and they under-estimate the risks of these drugs.

If one or more of the medications above has been prescribed, don’t stop without first consulting with a health professional. You’ll want to make an appointment soon, to review the reasons that the medication was prescribed, alternative options for treating the problem, and then work out a plan to reduce or eliminate the drug.

I explain how to find a geriatric doctor near you here: How to find a geriatrician — or a medication review — near you.

To prepare for the appointment, try going through the five steps I describe in this article: “How to Review Medications for Safety & Appropriateness.”

I also recommend reviewing HealthinAging.org’s guide, “What to Ask Your Health Provider if a Medication You Take is Listed in the Beers Criteria.”

Remember, when it comes to maintaining independence and quality of life, nothing is more important than optimizing brain function.

We can’t turn back the clock and not all brain changes are reversible. But by spotting problem medications and reducing them whenever possible, we can help older adults think their best.

Now go check out those medication bottles, and let me know what you find!

 

We are at 200+ comments, so comments on this post have been closed. If you have a question about your medications, we recommend consulting with your usual health provider or discussing with a pharmacist.

Filed Under: Aging health, Featured, Geriatrics For Caregivers Blog, Helping Older Parents Articles Tagged With: alzheimer's, brain health, dementia, medications, memory

8 Things to Have the Doctor Check After an Aging Person Falls

by Leslie Kernisan, MD MPH

Image Credit: BigStock.

If you want to prevent dangerous falls in an aging adult, here’s one of the very best things you can do: be proactive about getting the right kind of medical assessment after a fall.

Why? There are three major reasons for this:

  • A fall can be a sign of a new and serious medical problem that needs treatment. For instance, an older person can be weakened and fall because of illnesses such as dehydration, or a serious urinary tract infection.
  • Older adults who have fallen are at higher risk for a future fall. Although it’s a good idea for any older person to be proactive about identifying and reducing fall risk factors, it’s vital to do this well after a fall.
  • Busy doctors may not be thorough unless caregivers are proactive about asking questions. Most doctors have the best intentions, but studies have shown that older patients often don’t get recommended care. By being politely proactive, you can make sure that certain things aren’t overlooked (such as medications that worsen balance).

All too often, a medical visit after a fall is mainly about addressing any injuries that the older person may have suffered.

Obviously, this is very important; one doesn’t want to miss a fracture or other serious injury in an older person.

However, if you want to help prevent future falls, it’s also important to make sure the doctors have checked on all the things that could have contributed to the fall.

This is really key to preventing falls in an aging adult. Even if you’re pretty sure your loved one just tripped and stumbled, a good evaluation can uncover issues that made those trips and stumbles more likely.

In this article, I’ll list eight key items that you can make sure the doctors check on, after an older person falls. This will help you make sure your loved one has had a thorough work-up, and can reduce the chance of future serious falls.

This list is partly based on the American Geriatrics Society’s Clinical Practice Guidelines on Preventing Falls. 

8 Things the Doctors Should Check After a Fall

Free Fall Assessment Cheatsheet: The 8 things doctors should check after an aging person falls, in a handy PDF checklist that you can print or save. Click here.

1. An assessment for an underlying new illness. Doctors almost always do this if an older person has been having generalized weakness, delirium, or other signs of feeling unwell. Be sure to bring up any symptoms you’ve noticed, and let the doctor know how quickly the changes came on.

Just about any new health problem that makes an older person weak can bring on a fall. Some common ones include:

  • Urinary tract infection
  • Dehydration
  • Anemia (low red blood cell count), which can be brought on by bleeding in the bowel or by other causes
  • Pneumonia
  • Heart problems such as atrial fibrillation
  • Strokes, including mini-strokes that don’t cause weakness on one side

2. A blood pressure and pulse reading when sitting, and when standing. This is especially important if you’ve been worried about falls — or near falls — that are associated with light-headedness, or fainting.

If your older relative takes blood pressure medication, you should make sure the doctor confirms that he or she isn’t experiencing a drop in blood pressure with standing. (Note that tamsulosin — brand name Flomax — is a popular prostate medication that also causes drops in blood pressure.)

A 2009 study of Medicare patients coming to the emergency room after fainting found that checking sitting and standing blood pressure was the most useful test. However, it was only done by doctors 1/3 of the time.

For more information, see “6 Steps to Better High Blood Pressure Treatment for Older Adults”.

3. Blood tests. Checking an older person’s blood tests is often a good idea after a fall. Falls can be worsened by problems with an older person’s blood count, or by things like blood sodium getting too high or too low.

Generally, a complete blood cell count (CBC) and a check of electrolytes and kidney function (metabolic panel, or “chem-7”) are a good place to start.

For more on blood tests that are often useful, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.

Be sure to ask the doctor to explain any abnormalities found in the blood work, whether they might be related to falls, and how the doctor plans to address them.

If your loved one has diabetes and takes insulin or other medications to lower blood sugar, be sure to bring in the glucometer or a blood sugar log. Episodes of low blood sugar (hypoglycemia) are an important risk factor for falls, but a laboratory blood test generally doesn’t show moments of low blood sugar.

4. Medications review. Many older adults are taking medications that increase fall risk. These medications can often be reduced, or even eliminated. Be sure to ask the doctor to address the following types of medications:

  • Any sedatives, tranquilizers, or sleeping medications. Common examples include zolpidem (Ambien) for sleep, or lorazepam (Ativan) for anxiety. Antipsychotic medications for restless dementia behaviors, such as risperidone or quetiapine, can also increase sedation and fall risk.
  • Blood pressure and diabetes medications. As noted above, it’s not unusual for older adults to be “over-treated” for these conditions, meaning they are taking a level of medication that causes the blood pressure (or blood sugar) be lower than is really necessary for ideal health.
  • “Anticholinergic” medications. These medications are commonly taken by older adults, who often have no idea that these medications worsen balance and thinking! They include medications for allergies, overactive bladder, vertigo, nausea, and certain types of antidepressants which may also be given for nerve pain. For more on identifying and avoiding anticholinergics, see here.
  • Opiate pain medications, especially if they are new.

The Centers for Disease Control recommends that older adults concerned about falls request a medication review. To learn more about which medications should be reviewed, and what should be done about risky drugs, see this article:
“10 Types of Medication to Medications to Review if You’re Concerned About Falling.”

 5. Gait, balance, and leg strength. At a minimum, a gait assessment means that the doctor carefully watches the way the older person is walking. Asking the older person to stand up from a chair (without using the arms) can help assess leg strength. There are also some simple ways to check balance.

Simple things to do, if gait, balance, or leg strength don’t seem completely fine, are:

  1. Address any pain or discomfort, if that seems to be a cause of problems. Many older people are reacting to pain in their feet, joints, or back.
  2. Refer to physical therapy for gait and balance assessment. These assessments will usually include checking the older person’s leg strength. A physical therapist can often recommend suitable strengthening and balance exercises for seniors, and also can help fit the older person for an assistive device (e.g. a walker) if appropriate. For more on the proven Otago physical therapy program to reduce falls — including videos demonstrating the exercises — see “Otago and Proven Exercises for Fall Prevention.”

6. Evaluation for underlying heart conditions or neurological conditions. These chronic conditions are different from the “acute” types of illnesses that we usually look for right after a fall.

In a minority of cases, an older person may be falling because he or she has developed a chronic problem with the heart or blood pressure system. An example of this would be paroxysmal rapid atrial fibrillation, which causes the heart to sometimes race, or sick sinus syndrome, which can cause the heart to beat too slowly. 

It’s also possible for older people to develop a new chronic neurological condition, such as Parkinson’s disease.

If you’re worried about these possibilities, ask the doctor “Do you think a heart condition might have caused this fall? Or do you think an underlying neurological condition could have caused this fall?”

It’s particularly useful for you to ask about these kinds of problems if the falls or near-falls keep happening, especially if you’ve already minimized risky medications and over-treatment of high blood pressure.

7. Evaluation for osteoporosis and fracture risk. Many older adults, especially women, develop thinner bones in later life. Osteoporosis isn’t technically a risk factor for falls, but it’s certainly a major risk factor for injury from a fall. In particular, people with osteoporosis are at much higher risk of having a hip fracture or other type of fracture when they fall.

For this reason, after an older person falls, it’s important to check and make sure they’ve been assessed for osteoporosis.

The US Preventive Services Task Force recommends that all women aged 65 or older be screened for osteoporosis., however many older women end up not getting screened.

If they do have osteoporosis, then it should be treated. Treatment with bisphosphonate medications has been proven to reduce fracture risk.

Calcium and vitamin D supplementation may also help, especially in older adults who have low levels of vitamin D. Other lifestyle changes can also help treat osteoporosis; for more on this, see here.

Note: The United States Preventive Services Task Force and other expert groups used to recommend vitamin D supplementation to help prevent falls, because research had initially identified an association between low vitamin D levels and falls. However, randomized trials were not able to show that vitamin D supplementation decreases falls, so vitamin D is no longer recommended for fall prevention.

8. Vision, podiatry, and home safety referrals. Could your loved one be in need of a vision check, podiatry care, or a home safety evaluation? If you’ve brought an older person in after a fall, it’s a good idea to talk to the doctor about whether these services might help.

I especially recommend home safety evaluations, if they are available in your area. Even something as simple as installing grab bars can make a difference, and home safety evaluations often uncover other simple changes that can prevent falls. Vision checks are also an excellent idea if the older person hasn’t had one recently.

How to use this information

Overwhelmed by this list? Here’s an idea for you:

Print out this post  — or download our free cheat sheet — and bring it along next time you take an older person to see the doctor after a fall. If the doctor overlooks certain points, don’t be shy about asking why.

Free Fall Assessment Cheatsheet: The 8 things doctors should check after an aging person falls, in a handy PDF checklist that you can print or save. Click here.

For more practical information on why older adults fall and how you can prevent falls, see my article Why Older People Fall & How to Reduce Fall Risk . You can also learn more about clinically proven exercises that reduce falls here.

 

Filed Under: Aging health, Featured, Geriatrics For Caregivers Blog, Helping Older Parents Articles Tagged With: fall prevention, falls

How to Help Doctors Notice What’s Wrong: The story of the missed pelvic fracture

by Leslie Kernisan, MD MPH

Pelvic X-Ray

Once upon a time, the ER missed a pelvic fracture in one of my older patients.

Actually, this kind of thing has happened more than once, and perhaps it’s happened to your family too.

As much as we’d like to believe that our older loved ones will get the right care when they are sick or injured, the truth is that our healthcare system is imperfect, and it’s fairly common for serious problems to be missed.

Unless, of course, a proactive family caregiver knows to help the doctor focus on what’s newly wrong.

Here is a true story about why geriatricians pay attention to “changes in function” and why it’s essential that you help doctors spot any changes in function or ability.

The case: An ER mystery

My patient with dementia, 85-year-old Mr. C.,  sat down short of his easy chair at home and fell. Within minutes, his daughter found him on the floor. She helped him to the chair, and they watched some TV. But half an hour later, he was unable to get up again and walk. She took him to the emergency room for evaluation.

“I’m fine. Nothing hurts,” Mr. C. told the busy ER staff more than once. “I just want to go home.” X-rays of his hips and pelvis revealed nothing, and so — after an exam that probably lasted only a minute or two — he was discharged.

Back home, however, he still couldn’t walk. He still insisted nothing hurt. “I’m a tough old bird,” he told his daughter. Later that night, though, she noticed that he grimaced every time he rolled over in bed. She knew something was wrong. But what?

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles Tagged With: falls

Age-Related Hearing Loss (Presbycusis):
What to Know & What to Do

by Leslie Kernisan, MD MPH

Have you noticed that an older relative seems to be having trouble hearing you at times?

Or perhaps you’ve realized that sometimes YOU are the one saying “What?”

These situations are extremely common. Sometimes the issue is that one is trying to communicate in a noisy place and there is no need for concern.

But in many cases, these kinds of issues can indicate that an older person (or even a middle-aged person) is being affected by age-related hearing loss. (The medical term is “presbycusis”)

You probably already know this: chronic hearing impairment becomes very common as one gets older. The National Institute on Aging reports that one in three adults aged 65-74 has hearing loss, and nearly half of those aged 75+ have difficulty with hearing.

Hearing loss also affects a significant number of people earlier in life. A 2011 study on the epidemiology of hearing loss documented hearing loss in 11% of participants aged 45-54, and 25% of those aged 55-64.

In short, research confirms that quite a lot of people experience hearing loss. But sadly, research also confirms that hearing loss is often under-recognized and inadequately addressed.

This is a major public health issue, for older adults and also for the many middle-aged adults experiencing hearing loss. At this point, we know quite a lot about: [Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles Tagged With: brain health, hearing

How to find geriatric care — or a medication review — near you

by Leslie Kernisan, MD MPH

Medications & Aging

A caregiving daughter brought up a common question during a Helping Older Parents Q&A call:

“How can I find a geriatrician near me to review medications, and help care for my mother with dementia?”

As you may have noticed if you’re a regular reader, I often emphasize the importance of spotting and reducing risky medications, especially those associated with falls or memory problems.

Understandably, this caregiver wants to find a geriatrician who can review her mother’s medications, and otherwise oversee her mother’s care.

Now, medication review is usually included in geriatrics primary care. Geriatric care, after all, means healthcare modified to be a better fit with what happens as people get older. And being careful with medications is pretty integral to this approach.

But, although geriatric primary care is certainly worth looking for, it can be hard to find. (Read on for suggestions below.)

So it’s good to have a plan B, which can be getting a medication review — and fall risk assessment — outside of geriatric primary care. This can also be a good option if your parents are reluctant to change primary care doctors.

In this article, I’ll describe 3 places to look for geriatric primary care, and then 3 options for medication review.

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles, Q&A Tagged With: medication safety

How to Detect & Treat Vitamin B12 Deficiency in Older Adults

by Leslie Kernisan, MD MPH

Vitamin B12

Everyone knows that vitamins and nutrition are important for health, and many older adults take a multivitamin.

But did you know that even among older persons who do this, many still end up developing a serious deficiency in one particular vitamin?

It’s Vitamin B12.

If there’s one vitamin that I’d like all older adults and family caregivers to know more about, it would be vitamin B12.

(Second on my list would be vitamin D, but it’s much harder to develop low vitamin D levels if you take a daily supplement, as I explain in this post. Whereas vitamin B12 deficiency does develop in many older adults who are getting their recommended daily allowance.)

A deficiency in any vitamin can be catastrophic for health. But vitamin B12 deficiency stands out because a) it’s very common — experts have estimated that up to 20% of older adults may be low in this vitamin — and b) it’s often missed by doctors.

Geriatricians also like to pay attention to vitamin B12 because a deficiency can cause — or usually worsen — cognitive impairment or walking problems.

But if you know the symptoms and risk factors, you can help ensure that you get a vitamin B12 deficiency detected. Treatment is safe and effective, as long as you catch the problem before permanent damage occurs. Here’s what to know.

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog Tagged With: dementia, nutrition, vitamin b12

5 Questions to Ask Yourself on National Healthcare Decisions Day

by Leslie Kernisan, MD MPH

Since 2008, April 16th has been designated as “National Healthcare Decisions Day” (NHDD).

It’s an initiative meant to “inspire, educate and empower the public and providers about the importance of advance care planning.”

In other words, National Healthcare Decisions Day is meant to get you to plan for your future…a future time during which you might be ill and others — most likely your family — will have to make decisions about your healthcare.

It’s basically a great opportunity to address end of life planning, and equip your family to know what they should do during a medical emergency.

This is not a particularly unlikely scenario. Between the present-at-all-ages possibility of being in a bad accident and the increased likelihood of illness as one gets older, you’d actually have to be quite lucky — or unlucky, depending on how you see it — to reach the end of your life without anyone else ever having to make a medical decision on your behalf.

Still, studies and surveys generally find that many of us have not yet taken the needed steps to “make our wishes known.”

And even among those who have “made their wishes known,” there’s usually more to it than they realize, and they often have skipped an important piece of the process.

[Read more…]

Filed Under: Geriatrics For Caregivers Blog, Aging health

How You Can Help Someone Stop Ativan

by Leslie Kernisan, MD MPH

Ativan

Have you heard of Ativan (generic name lorazepam), and of the risks of benzodiazepines drugs in older adults? Is an older person you care for taking prescription medication for sleep, anxiety, or “nerves”?

Would you like an easy, practical tool to help someone stop a drug whose risks often outweigh the benefits?

If so, I have good news: a wonderful patient education tool has been created by a well-respected expert in geriatrics, Dr. Cara Tannenbaum. Best of all, a randomized trial has proved that this tool works.

As in, 62% older adults who received this tool — a brochure with a quiz followed by key information — discussed stopping the medication with a doctor or pharmacist, and 27% were successful in discontinuing their benzodiazepine. The brochure includes a handy illustrated guide on slowly and safely weaning a person off these habit-forming drugs.

This is big news because although experts widely agree that long-term benzodiazepine use should be avoided in older adults, getting doctors and patients to work together to stop has been tough. It is, after all, generally easier to start a tranquilizer than to stop it!

But through a patient education brochure, Dr. Tannenbaum’s team was able to make this tricky process much more doable for older adults, their families, and their doctors.

Why it’s important to try to stop lorazepam & other benzodiazepines

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles Tagged With: brain health, medication safety, medications, sleep

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