Treating the elderly

January 1, 2008

It's not uncommon for elderly patients to have co-morbid conditions and be taking several medications, a fact that wound care practitioners and other clinicians need to be aware of. Drugs such as urinary incontinence medications and benzodiazepines have anti-cholingeric effects that can diminish cognitive functioning and, particularly with benzodiazepines, increase drowsiness, putting the elderly at increased risk of falling and developing a trauma such as a leg ulcer. If elderly patients fall more than twice, wound care practitioners should refer elderly patients to a geriatrician. Elderly patients may also have conditions like depression or dementia that affects their ability to adhere to therapy. In such cases, referral to a geriatric psychiatrist is warranted.

Key Points

London, Ontario - Woundcare practitioners and other healthcare providers need to carefully screen elderly patients for co-morbid conditions and their use of medication to ensure that events such as falls do not occur, says Madhuri Reddy, M.D., M.Sc., director of the chronic woundcare program at Hebrew Rehabilitation Center, Boston, and director of the woundcare clinic at Leahy Hospital, Burlington, Mass.

Speaking at the annual meeting of the Canadian Association of Wound Care, Dr. Reddy says clinicians cannot conclude that age is the cause of diminished mental or physical functioning in patients, and musts consider that in their approach to woundcare in the elderly.

"You can't just focus on the wound," says Dr. Reddy.

She gives the example of a patient who has developed a leg ulcer because she struck her leg while drowsy while on benzodiazepines.

"The leg ulcer can be interpreted as a warning that the patient could fall and break their hip.

"If you focus on the fact that they have a leg ulcer because they hit their leg, you may miss the sign that they are on their way to breaking their hip," she says.

She adds that if a patient has fallen more than twice, the patient should be referred for a geriatric assessment to evaluate his or her ability to perform daily living tasks.

In addition, older patients may not need as much sleep as younger people, and should not be automatically placed on sleeping pills, such as benzodiazepines. There are also other reasons for poor sleep, such as depression and urinary frequency.

"As patients age, they require less sleep. They may have needed seven or eight hours of sleep when they were younger, but they may now only need four or five hours of sleep," Dr. Reddy says.

It is paramount that woundcare practitioners and other clinicians are aware of all the medications that a patient is taking. It is common for elderly patients to be part of a medication "prescription cascade," in which patients are prescribed a medication to overcome the side effects of another condition.

It may be that a drug is the source of symptoms that led to the development of a wound, such as in the case of benzodiazepines causing drowsiness.

"Woundcare practitioners should look at the list of medications. Some of the symptoms that they complain about may be due to the medications. If you see a long list of medications, you need to refer them to geriatric medicine," Dr. Reddy says.

Non-pharmacologic therapies can be explored to treat a condition such as urinary incontinence, a condition that can exacerbate a sacral pressure ulcer. Clinicians can recommend behavioral modifications for their patients, such as avoiding drinking fluids after dinner if urinary incontinence is present, as well as minimizing caffeine intake.

"Putting a patient on a drug to treat urinary incontinence may make some severe symptoms even worse," says Dr. Reddy, noting many of the urinary incontinence medications are anti-cholinergics and can have the undesirable side effect of increasing cognitive impairment.

Antihistamines can also have unattractive anti-cholinergic effects, so their routine prescription to elderly patients should be curbed.

At the same time that some medications may be routinely prescribed, clinicians may be reluctant to put elderly patients on an anti-hypertensive drug or beta blocker after myocardial infarction, because they see the drug as offering little benefit, Dr. Reddy says.

Elderly patients with atrial fibrillation and at risk for stroke could benefit from blood thinners such as warfarin, but clinicians have been loath to prescribe these therapies due to the perceived risk of bleeding.

"The key is to start slow at low doses and monitor carefully," Dr. Reddy says.

Apart from falls, other possible factors include possibility of confusion, adverse drug reactions, significant weight loss, smoking, dementia or depression, all of which can affect the incidence of wounds and/or wound healing, she says.

Depression or dementia undetected may be larger medical issues in an elderly patient with a wound. Woundcare practitioners need to refer the patient to a geriatrician or geriatric psychiatrist in the presence of such co-morbidities, Dr. Reddy says.

"Those issues can be far more severe than the wound itself. Don't just assume that older patients are not adhering to therapy.

"It may be that they are cognitively impaired or depressed, which is why the patients may not be adhering to therapy. They should be sent to a geriatrician or geriatric psychiatrist for an evaluation," Dr. Reddy says.

Age should not be an absolute contraindication to surgery for older patients, for surgery can improve their quality of life.

"If patients are well and healthy, you should not be biased based on their age alone.

"We have to be careful that we are not ageist in any way. Woundcare practitioners have the potential to make a huge impact in the care of this older population," Dr. Reddy says.