Common Geriatric Conditions: Dementia, Osteoporosis, Falls, Incontinence, and Polypharmacy

Introduction

Geriatric conditions are health problems that become more prevalent with age and often involve multiple body systems. They frequently impact function, independence, and quality of life. Management requires a comprehensive, interdisciplinary approach focusing on maintaining function rather than solely treating disease.

Dementia

Types

Type	Percentage	Pathology	Distinguishing Features
Alzheimer disease	60-80%	Beta-amyloid plaques, neurofibrillary tangles (tau)	Insidious onset, gradual progression; early: short-term memory loss
Vascular dementia	10-20%	Cerebrovascular disease, multi-infarct, microvascular ischemia	Stepwise progression; associated with vascular risk factors; focal neurologic signs
Dementia with Lewy bodies	5-15%	Lewy bodies (alpha-synuclein aggregates) in cortex	Fluctuating cognition, visual hallucinations, Parkinsonism, REM behavior disorder
Frontotemporal dementia	5-10%	Tau or TDP-43 pathology affecting frontal/temporal lobes	Early: personality change, behavior disinhibition, language problems (memory relatively preserved early)
Mixed dementia	10-50% of older dementias	Alzheimer + vascular (most common combination)	Features of both types
Parkinson disease dementia	30-50% of PD patients	Lewy bodies in cortex	Occurs late in Parkinson disease (>1 year after motor symptoms)
Normal pressure hydrocephalus	1-5%	Impaired CSF reabsorption	Triad: gait apraxia, urinary incontinence, cognitive decline; may improve with CSF drainage

Cognitive Screening Tests

Test	Time	Sensitivity	Specificity	Cutoff	Notes
Mini-Mental State Exam (MMSE)	7-10 min	80-90%	80-90%	<24/30 (education-adjusted)	Copyrighted; not free; poor for frontal lobe, visuospatial
Montreal Cognitive Assessment (MoCA)	10-15 min	90%	87%	<26/30 (1 point for <12 years education)	Better for MCI; covers executive function, visuospatial
Mini-Cog	2-4 min	76-99%	89-95%	Abnormal recall (0/3 words) or abnormal 1/3 recall + abnormal CDT	Quick, validated, minimally affected by education/language
SLUMS (St Louis University Mental Status)	7 min	Similar to MoCA	Similar to MoCA	<27 (high school education); <25 (<HS)	Free alternative to MMSE
AD8 (Informant interview)	3 min	84%	80%	2+ “yes” responses	Informant-rated; not diagnostic

Management

Aspect	Pharmacologic	Non-Pharmacologic
Cognitive symptoms	Cholinesterase inhibitors: donepezil (Aricept), rivastigmine (Exelon patch), galantamine (Razadyne) for mild-moderate Alzheimer; Memantine (Namenda) for moderate-severe Alzheimer	Cognitive stimulation, structured routines, memory aids
Behavioral/psychiatric symptoms (BPSD)	Atypical antipsychotics (risperidone, olanzapine, quetiapine) - BLACK BOX warning for death in elderly; SSRIs (citalopram, sertraline) for depression/anxiety; anticonvulsants (valproate, carbamazepine) for agitation	Environmental modification, behavioral interventions, caregiver training, music therapy, validation therapy
Safety	Assess driving, wandering risk, fall risk, medication management	Home safety assessment, ID bracelet (wandering), driving evaluation

Osteoporosis

Diagnosis

Category	T-Score (BMD at hip or spine)
Normal	T-score > -1.0
Osteopenia (low bone mass)	T-score -1.0 to -2.5
Osteoporosis	T-score < -2.5
Severe/established osteoporosis	T-score < -2.5 + fragility fracture

FRAX Score (10-Year Fracture Risk)

Fracture Probability	Intervention Threshold
Major osteoporotic fracture (hip, spine, forearm, proximal humerus)	>20%: treat (especially in US)
Hip fracture alone	>3%: treat (especially in US)

Pharmacologic Treatment

Drug Class	Examples	Efficacy (Vertebral Fracture Reduction)	Dosing	Side Effects
Bisphosphonates (oral)	Alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva)	40-70%	Weekly or monthly	GI upset, esophagitis (take with water, upright 30 min); rare: ONJ, atypical femur fracture
Bisphosphonates (IV)	Zoledronic acid (Reclast), ibandronate (Boniva IV)	60-70%	Yearly (zoledronic acid)	Acute phase reaction (first dose), renal impairment, hypocalcemia
RANKL inhibitor	Denosumab (Prolia)	60-70%	SQ every 6 months	Rebound fracture if delayed; hypocalcemia; infection risk
SERM	Raloxifene (Evista)	30-50% (vertebral only)	Daily	VTE risk, hot flashes; no hip fracture reduction
Anabolic agent	Teriparatide (Forteo), abaloparatide (Tymlos)	65-90%	Daily SQ for 2 years	Nausea, dizziness, leg cramps; black box (osteosarcoma, animal studies)
Anabolic (Dual-action)	Romosozumab (Evenity)	70-80%	Monthly SQ for 1 year	CV risk (not for recent MI/stroke)

Falls

Risk Assessment (Screening)

Screen	Components	Interpretation
STEADI (CDC)	Stay independent; Ask about falls; Evaluate; Demonstrate; Intervene	Multi-step algorithm
TUG (Timed Up and Go)	Rise from chair, walk 10 feet, turn, return, sit	>12-14 seconds = increased fall risk
Berg Balance Scale	14-item balance assessment	<45/56 = fall risk
4-Stage Balance Test	Feet together, semi-tandem, tandem, single leg	Unable to hold tandem >10 sec = risk

Fall Prevention Interventions

Strategy	Components	Evidence
Exercise	Tai chi, Otago exercise program, strength + balance training 3x/week	Strong (30-50% reduction)
Home safety	Remove rugs, improve lighting, grab bars, railings, non-slip mats	Moderate
Medication review	Deprescribe sedatives, antihypertensives, hypoglycemics, psychotropics	Strong
Vision correction	Annual eye exam, cataract surgery	Moderate
Footwear	Low heel, non-slip sole, proper fit; avoid going barefoot	Moderate
Vitamin D + calcium	800 IU vitamin D + 1000 mg calcium daily	Moderate (especially if deficient)
Hip protectors	Wearable padded hip protectors	Moderate (if adherent)

Urinary Incontinence

Types and Management

Type	Mechanism	Prevalence	Treatment
Stress incontinence	Urethral hypermobility, intrinsic sphincter deficiency	30% of women with UI	Pelvic floor PT, vaginal cones, pessary, mid-urethral sling
Urge incontinence	Detrusor overactivity, overactive bladder (OAB)	40% of men and women with UI	Bladder training, anticholinergics, beta-3 agonists, Botox, PTNS
Mixed incontinence	Combination of stress and urge	30-40%	Treat predominant component
Overflow incontinence	Incomplete bladder emptying	10% (more common in men with BPH)	Catheterization, treat cause (BPH, obstruction), alpha-blockers

Behavioral Modifications

Strategy	Description
Timed voiding	Void on schedule (q2-4 hours), not waiting for urge
Bladder training	Gradually increase intervals between voids
Double voiding	Void, wait 30 seconds, void again
Pelvic floor muscle training (Kegels)	Contract pelvic floor muscles; daily program
Fluid management	Limit caffeine, alcohol; adequate total fluids (6-8 cups/day)
Weight loss	5-10% weight reduction reduces incontinence episodes

Polypharmacy

Definition and Risks

Aspect	Detail
Definition	Use of 5+ medications (some define as 10+)
Prevalence	40% of community-dwelling elderly >65; 50% of those >80
Adverse drug events	15-40% of elderly experience an ADE annually
Hospitalization	10-30% of geriatric hospitalizations due to ADEs
Contributing factors	Multiple comorbidities, multiple prescribers, OTC use, herbal supplements, medication cascades

BEERS Criteria (AGS) - Key Medications to Avoid in Elderly

Medication/Class	Concern	Recommendation
Benzodiazepines (all)	Fall risk, cognitive impairment, dependence	Avoid
Non-BZD hypnotics (zolpidem, zaleplon, eszopiclone)	Same as benzodiazepines	Avoid
Anticholinergics (diphenhydramine, hydroxyzine, oxybutynin, amitriptyline)	Delirium, fall risk, constipation, urinary retention	Avoid
Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin)	Anticholinergic, orthostasis	Avoid; safer alternatives exist
Long-acting sulfonylureas (glyburide)	Prolonged hypoglycemia	Avoid
NSAIDs (chronic use)	GI bleeding, renal impairment, hypertension, HF exacerbation	Avoid chronic use
Antipsychotics (for dementia)	Increased mortality (black box warning)	Avoid for behavioral symptoms unless severe
Digoxin >0.125 mg/day	Toxicity	Avoid higher doses
Skeletal muscle relaxants (cyclobenzaprine, carisoprodol)	Anticholinergic, falls, sedation	Avoid
PPIs (continuous >8 weeks)	C. diff, bone loss, B12 deficiency	Avoid unless high-risk indication

Deprescribing Process

Step	Action
1	Comprehensive medication review (all prescribed, OTC, supplements)
2	Identify potentially inappropriate medications (BEERS, STOPP criteria)
3	Assess risk vs benefit of each medication
4	Determine if indication is still present
5	Check for medication cascades (drug treating side effect of another drug)
6	Taper (do not stop abruptly for many medications)
7	Monitor for withdrawal or return of condition
8	Document changes and communicate with all prescribers

Pressure Ulcers (Bedsores)

Staging

Stage	Description	Management
1	Non-blanchable erythema over intact skin	Offload, pressure redistribution, moisture management
2	Partial-thickness skin loss (epidermis/dermis); shallow open ulcer with red/pink wound bed; no slough	Keep clean, moist wound healing, transparent film or hydrocolloid dressing
3	Full-thickness skin loss; subcutaneous fat visible; slough may be present; no exposed bone/tendon/muscle	Debridement (if necrotic/slough), wound cleansing, appropriate moisture, manage exudate
4	Full-thickness tissue loss with exposed bone, tendon, or muscle; slough/eschar may be present	Debridement, wound care, possibly surgical closure (flap, graft)
Unstageable	Full-thickness with slough/eschar covering the base (cannot determine stage)	Debride to determine stage

Prevention

Strategy	Evidence
Risk assessment (Braden Scale) at admission	Recommended
Repositioning every 2 hours	Standard of care
Pressure redistribution surfaces (specialty mattresses, overlays)	Reduces incidence
Nutritional support (protein 1.2-1.5 g/kg/day)	For malnourished patients
Moisture management (incontinence care)	Reduce maceration
Heel elevation (float heels)	Simple, effective

Delirium

Diagnosis (CAM - Confusion Assessment Method)

Feature	Description
1 - Acute onset and fluctuating course	Acute change from baseline; symptoms wax and wane
2 - Inattention	Difficulty focusing, easily distracted
3 - Disorganized thinking	Rambling, irrelevant conversation, illogical flow
4 - Altered level of consciousness	Hyperalert, lethargic, stuporous

Delirium diagnosed if features 1 and 2 + either 3 or 4

Hyperactive vs Hypoactive Delirium

Type	Features	Often Missed
Hyperactive	Agitation, restlessness, hallucinations, aggression	Less commonly missed
Hypoactive (more common)	Withdrawn, quiet, decreased movement, lethargy, slow responses	Frequently missed (60-70%)
Mixed	Fluctuates between hyperactive and hypoactive

Causes (DELIRIUM Mnemonic or PINCH ME)

Mnemonic	Factors
P - Pain, Pneumonia, Pulmonary embolus
I - Infection (UTI most common in elderly)
N - Nutritional (dehydration, thiamine deficiency, electrolyte disorders)
C - Constipation, fecal impaction, CNS (stroke, subdural)
H - Hospitalization (sleep deprivation, sensory deprivation, restraints), Hypoxia
M - Medications (anticholinergics, benzodiazepines, opioids, steroids, polypharmacy)
E - Environmental (change in setting, unfamiliar surroundings, sensory impairment)

Prevention and Management

Strategy	Intervention
Prevention (multi-component)	Orientation (clock, calendar), early mobilization, sleep hygiene, hearing/vision optimization, hydration, avoid deliriogenic meds
Non-pharmacologic	Reassurance, family presence, familiar objects, minimize room changes, avoid restraints
Pharmacologic (only for severe agitation)	Haloperidol 0.5-1 mg (low dose); atypical antipsychotics (olanzapine, quetiapine); avoid benzodiazepines (except alcohol/benzodiazepine withdrawal)
Treat underlying cause	Identify and treat contributing medical condition