Kristen Mauk

Background

Although gastroesophageal reflux disease (GERD) is common among older adults, the true prevalence is not known. Many patients with GERD-related symptoms never discuss their problems with their primary care provider. GERD is thought to occur in 5–7% of the world’s population, with 21 million Americans affected (International Foundations for Functional Gastrointestinal Disorders, 2008). It is found in both men and women.

Signs and symptoms

Pathophysiological changes that occur in the esophagus, hiatal hernia, and certain medications and foods increase the risk for GERD. Obesity (Corely , Kubo, Levin et al., 2007) and activities that increase intra-abdominal pressure such as wearing tight clothes, bending over, or heavy lifting have also been linked to GERD (MedlinePlus, 2005a). The cardinal symptom of GERD is heartburn; however, older adults may not report this, but rather complain of other symptoms such as pulmonary conditions (bronchial asthma, chronic cough, or chronic bronchitis), a hoarse voice, pain when swallowing foods, chronic laryngitis, or non-cardiac chest pain (Pilotto & Franceschi, 2009). The chronic backflow of acid into the esophagus can lead to abnormal cell development (Barrett esophagus) that increases the risk for esophageal cancer.

Diagnosis

Older adults often have atypical symptoms, making the diagnosis of GERD very challenging. As people age, the severity of heartburn can diminish, while the complications, such as erosive esophagitis, become more frequent. Therefore, endoscopy should be considered as one of the initial diagnostic tests in older adults who are suspected of having GERD (Pilotto & Franceschi, 2009). Examination of the esophagus, stomach, and duodenum through a fiber-optic scope (endoscopy) while the person receives conscious sedation, allows the gastroenterologist to visualize the entire area, identify suspicious areas, and obtain biopsies as needed. Helicobacter pylori (H. pylori), a chronic bacterial infection in humans, is a common cause of GERD, affecting about 30% to 40% of the U.S. population. Testing for H. pylori can be done during the endoscopy or by other tests (Ferri, 2011).

Treatments

The objectives of treatment for GERD include: (1) relief of symptoms, (2) healing of esophagitis, (3) prevention of further occurrences, and (4) prevention of complications (Pilotto & Francheschi, 2009). Lifestyle and dietary modifications are important aspects of care. It is widely recommended that persons with GERD should stop smoking, limit or avoid alcohol, and limit chocolate, coffee, and fatty or citrus foods. Medications should be reviewed and offending medications modified, since certain medications decrease the lower esophageal sphincter (LES) tone, allowing acid to backflow into the esophagus. These include anticholinergic drugs, some hormones, calcium channel blockers, and theophylline. Avoidance of food or beverages 3–-4 hours prior to bedtime, weight loss, and elevation of the head of the bed on 6-to-8 inch blocks are some other interventions that may help alleviate symptoms. Pharmacological treatments with antacids in conjunction with histamine 2 (H2) -blockers (Tagmet, Zantac, Axid, and Pepcid) are used for mild GERD. If these are ineffective in controlling symptoms, then the proton pump inhibitors (PPIs) are the next drugs of choice. These include medications like Nexium and Dexilant. With lifestyle modifications and appropriate medications, older adults can manage their GERD symptoms so that quality of life is maintained.

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Burlington, MA: Jones and Bartlett Publishers. Used with permission.

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Background

Once thought to be mainly a disorder of children, recurrent seizures or epilepsy is thought to be present in about 7% of older adults (Spitz, 2005) and is usually related to one of the common comorbidities found in older adults (Bergey, 2004; Rowan & Tuchman, 2003). Epilepsy affects up to 3 million Americans of all ages (Velez & Selwa, 2003). Davidson & Davidson (2012) summarized findings of most studies on epilepsy in older adults with these main points:
Seizures can be caused by a variety of conditions in older persons, but “the most common cause of new-onset epilepsy in an elderly person is arteriosclerosis and the associated cerebrovascular disease” (Spitz, 2005, p. 1), accounting for 40–50% of seizures in this age group (Rowan & Tuchman, 2003). Seizures are associated with stroke in 5–14% of survivors (Spitz, 2005; Velez & Selwa, 2003). Other common causes of epilepsy in the elderly include Alzheimer’s disease and brain tumor.
There are three major classifications of epilepsies, although there are many additional types. Generalized types are more common in young people and associated with grand mal or tonic-clonic seizures. A number of cases have an un¬determined origin and may be associated with certain situations such as high fever, exposure to toxins, or rare metabolic events. In older adults, localized (partial or focal) epilepsies are more common, particularly complex partial seizures (Luggen, 2009). In contrast to young adults, Rowan and Tuchman (2003) cite other differences in seizures in the elderly: low frequency of seizure activity, easier to control, high potential for injury, a prolonged postictal period, and better tolerance with newer antiepileptic drugs (AEDs). Additionally, older adults may have coexisting medical problems and take many medications to treat these problems.

Risk Factors/Warning Signs

Risk factors for seizures in older adults include cerebrovascular disease (especially stroke), age, and head trauma. The most obvious signs and symptoms of epilepsy are seizures, although changes in behavior, cognition, and level of consciousness may be other signs. Also, note that exposure to toxins can cause seizures that are not epilepsy. Complex partial seizures in older adults may include symptoms such as “confusion, memory loss, dizziness, and shortness of breath” (Davidson & Davidson, 2012, p. 16). Automatism (repetitive movements), facial twitching with following confusion, and coughing are also signs of the more-common complex partial seizure (Luggen, 2009).

Diagnosis

Diagnosis is made by careful description of the seizure event, a thorough history, and physical. Eyewitness accounts of the seizure incident can be quite helpful, although many community-dwelling older adults go undiagnosed because their seizures are never witnessed. In addition, complete blood work, neuroimaging, chest X-ray, electrocardiogram (ECG), and electroencephalogram (EEG) help determine the cause and type of seizure (National Institute for Health and Clinical Excellence {NICE}, 2012).

Treatment

Treatment for epilepsy is aimed at the causal factor. The standard treatment for recurrent seizures is antiepilepsy drugs (AEDs). The rule of thumb, “start low and go slow,” for medication dosing in older adults particularly applies to AEDs. The elderly tend to have more side effects, adverse drug interactions, and problems with toxicity levels than younger people.
Research has suggested that older adults may have better results with fewer side effects with the newer AEDs than the traditional ones, though about 10% of nursing home residents are still medicated with the first-generation AEDs (Mauk, 2004). The most common older medications used to treat seizures include barbiturates (such as phenobarbital), benzodiazepines (such as diazepam/Valium), hydantoins (such as phenytoin/Dilantin), and valproates (such as valproic acid/Depakene) (Deglin & Vallerand, 2005; Resnick, 2008).
Several newer drugs are also used, depending on the type of seizure. Second-generation AEDs, including gabapentin (Neurontin), lamotrigine (Lamictal), oxcarbazepine (Trileptal), levetiracetam (Keppra), pregabalin (Lyrica), tiagabine (Gabitril), and topiramate (Topamax), are generally recommended over the older AEDs; however, older AEDS such as phenytoin (Dilantin), valproate (Depakote), and carbamazepine (Tegretol) are the most commonly prescribed treatment options (Resnick, 2008). Each of these medications has specific precautions for use in patients with certain types of medical problems or for those taking certain other medications. Regarding side effects in older patients, watch for potential stomach, kidney, neurological (especially poor balance or incoordination), and liver problems. Additionally, some newer extended-release AEDs are thought to be better tolerated and have a lower incidence of systemic side effects (such as tremors) (Uthman, 2004).

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care.Burlington, MA: Jones and Bartlett Publishers. Used with permission.

Most of us have New Year’s resolutions. One of my new goals for 2020 is to age better. Andrew Weil, MD, in his bestseller Healthy Aging: A Lifelong Guide to Your Well-Being (2005) said, “to age gracefully requires that we stop denying the fact of aging and learn and practice what we have to do to keep our bodies and minds in good working order through all the phases of life” (p. 7). You may well ask, “how does one do that”? For me, it means actually practicing what I preach. We are fortunate today to have so much research and information on aging that we can pinpoint some specific areas that are common to successful aging. I have taught these to numerous students and groups of older adults, but it wasn’t until I joined the over 50 age group that this knowledge seemed more personally applicable. So, let me share with you five keys that both scientists and the oldest old persons in our society have found contribute to healthy aging.

Have a positive attitude towards life. This includes having good coping skills and being able to deal with grief and loss appropriately.  Most centenarians will say that you should always having something to look forward to. Make a list of places you want to travel this year, vacations to take, people you need to visit, or things that need to be fixed around the house. Then start to cross them out as you do them, and bask in your accomplishments.

Maintain key relationships. These include having a stable marriage and/or being involved in a religious or social community. In George Vaillant’s book Aging Well (2002), he reported the results of the Harvard Study of Adult Development. Generativity, or selfless investment in others (including the next generation), was found to be the best predictor of a long and happy marriage. Likewise, studies show that older persons who affiliate with a religious organization, such as attending church regularly, report better health and better social support systems, and tend to remain independent longer.

Maintain a healthy weight through proper nutrition. Eat a diet with plenty of fiber, fruits, vegetables and water. Limit saturated fats, salt, processed foods, and less useful calories from alcohol or sugary drinks.

Stay active. Physically, do some moderate exercise on most days of the week. For persons who are older and unable to do strenuous activity, remember that regular daily chores that include continuous motion such as doing laundry, gardening, or cleaning house can count as exercise and can also be spread throughout the day to accumulate the recommended 30 minutes of activity. If able, brisk walking is highly recommended. Keep your mind active as well. Resolve to take up a new hobby such as a craft, learning to play an instrument, or studying a foreign language. Working puzzles, playing cards, and reading are also good ways to stimulate your brain function and keep your memory sharp.

Avoid negative behaviors such as overeating or drinking too much alcohol.  Adopt an attitude of “everything in moderation”. Don’t smoke, and if you do smoke, stop. Sadie Delany (1994) at over 100 years of age wrote in her book Having Our Say, “so you want to live to be 100. Well, start with this: No smoking, no drinking, no chewing” (p. 11).

Resolve with me to age more gracefully during 2020 and let’s see how we do. Do you have any secrets of healthy aging that have worked for you or your parents/grandparents? Please share them with us.

And the Oscar Goes to…
Watching the Oscars can be quite entertaining. Imagine the vision, creativity, and artistry that it takes for scores of people to come together to make a film that captivates the country by bringing a story to life! The coveted gold statue represents the pinnacle of one’s profession, a universally recognizable prize that causes a seasoned actor to forget his acceptance speech or lose her gracefulness while tripping over a ridiculously expensive gown. It made me wonder: What if there were Oscars awarded to the people who influenced healthcare? Here are some suggestions for the most deserving:

Best Picture: an award for radiologists viewing the film of a cancer-free survivor

Actor/Actress in a Leading Role: the oncologists who don’t let their patients see them cry after having to give a terminal diagnosis

Actor/Actress in a Supporting Role: the nurse who provides comfort to the parents of a dying child

Best Adapted Screenplay: the rehabilitation team members who help survivors find new life again after stroke

Cinematography: for persons who capture the inspiring moments of the Special Olympics
Costume design: the prosthetists, orthotists, and biomechanical engineers who create both function and beauty to clothe persons needing artificial limbs

Directing: the heads of national organizations that lead the way in research and education in a specialty area

Best Makeup: the funeral home directors who help make our loved ones look their best for the final goodbye

Best Visual Effects: the burn specialists and plastic surgeons who reconstruct the facial features of a firefighter or war veteran after severe burns

Best Sound Mixing: the audiologists and manufacturers of hearing devices that help us to listen and attend to the sounds around us

Best Film Editing: the skilled surgeons who remove the bad parts and recreate our inward parts so that our life picture is the best it can be
Best Original Song: the one sung by the double lung transplant survivors, like Charity Tillman-Dick, and made possible by the lung transplant team

I wish that we gave such awards to the people who make a real difference in the lives of so many. There are hundreds of unsung heroes of healthcare who influence our world but go unnoticed. When you come across one, won’t you tell them how much they are valued and appreciated? They may never win an Oscar, but without them we couldn’t shine.