Primary and Preventive Health Care for Older Women
Morton A. Stenchever
Table Of Contents
Morton A. Stenchever, MD
Professor and Chairman Emeritus, Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washingon (Vol 1, chap 108)
SCREENING FOR DISEASE|
At the beginning of the twentieth century, life expectancy for women was just over 50 years. Now, thanks to advances in health care, as this century begins women can expect to live, on average, nearly 80 years, and in all likelihood, this life expectancy will increase in the near future.1 Consequently, women will spend at least one third of their lives in the postmenopausal years and it has become a challenge for medicine and society to make these years as productive and free of morbidity as possible.
The specialty of obstetrics and gynecology has progressed during the past century from the care of women only during the reproductive years to health care for women throughout their lifetime. This chapter addresses issues related to primary and preventive care for women, including disease screening; nutrition; exercise; sexuality; immunization; safety; psychological issues, social problems such as depression, dementia, grief and loss, domestic violence and abuse; and potential problems of drug interaction. In addition, it addresses problems that can be managed by the obstetrician-gynecologist, such as mild-to-moderate hypertension. Issues of a gynecologic nature, such as hormone replacement therapy (HRT), management of urinary and rectal incontinence, pelvic floor dysfunction, and other gynecologic complaints of the elderly are addressed in other chapters.
Heart disease is the leading cause of death in women over the age of 65 (1735 per 100,000). Cancer is the second most common cause of death (871.2 per 100,000). Stroke (423 per 100,000), chronic obstructive pulmonary disease (167 per 100,000), pneumonia and influenza (211.1 per 100,000), diabetes (116.2 per 100,000), and accidents (70.7 per 100,000) are also major causes of death.2 The physician’s objective when caring for older women should be to prevent mortality from these causes and to delay morbidity as long as possible. Thus, health care providers should encourage patients in this age group to follow healthy practices. These include good dietary habits and nutrition, adequate sleep (7 to 8 hours per night), reasonable exercise, smoking cessation, limiting alcohol use, awareness of safety factors such as using seatbelts, wearing protective helmets during certain recreational activities, wearing safe footwear, moving about with caution, and avoiding strenuous tasks and activities. Because older patients tend to use a variety of medications for many purposes, physicians should review prescriptions and other medications annually to ensure that there are no chances for drug interactions, and should counsel the patient about the possibility of using HRT. Appropriate screening tests, in order to make early diagnosis of acute and chronic illness and the maintenance of immunization records are also important priorities in the care of older women.
|SCREENING FOR DISEASE|
The gynecologist conducting the annual health maintenance visit is well positioned to screen women for acute and chronic illnesses. At the first visit, a complete medical history and physical examination should be performed. At repeat annual health maintenance visits, an interim history and complete physical examination should be performed. The following are among the more important conditions for which the gynecologist should screen the patient.
Coronary Artery Disease
Coronary artery disease is perhaps the most important health risk for which physicians should screen. Each year in the United States, 2.5 million women are hospitalized and 500,000 die because of coronary artery disease.3 Women may complain of angina, but they may experience sudden death caused by myocardial infarction just as frequently. Risk factors for coronary artery disease include cigarette smoking; hypertension; diabetes mellitus; age over 55 or premature menopause without the use of estrogen replacement therapy; family history of premature coronary artery disease; and high-density lipoprotein (HDL) of less than 40 mg/dL. A negative risk factor is HDL above 60 mg/dL (Table 1).4 In addition, obesity and little physical activity may also be increased risk factors for coronary artery disease. The gynecologist can help reduce these risk factors wherever possible by counseling patients to stop smoking and referring them to therapy for this purpose, treating hypertension and diabetes, and using estrogen replacement therapy when there are no contraindications. The patient should be screened every 3 to 5 years for total cholesterol and HDL. If the total cholesterol is elevated above 200 mg/dL or the HDL is less than 40 mg/dL, a fasting lipid panel should be ordered and the problem of hypercholesterolemia should be addressed medically. A low-fat, low-calorie, low-cholesterol diet should be instituted for patients with low-density lipoprotein (LDL) values above 130 mg/dL and for patients who have two or more of the listed risk factors. This diet should also be instituted for patients with LDL greater than 160 mg/dL even if there are no risk factors. The National Cholesterol Education Program, which suggests these therapeutic standards, also states that drug therapy should be initiated in postmenopausal women if LDL is greater than 160 mg/dL and there are two or more risk factors, or if LDL is greater than 190 mg/dL and there are no risk factors. In addition, if the patient has been diagnosed with coronary artery disease, dietary therapy should be initiated, and if the LDL is greater than 100 mg/dL, drug therapy should be initiated.4
Positive risk factors
Men—45 years and over
Family history of positive coronary artery disease
HDL < 40 mg/dL
(Obesity and physical inactivity are areas of potential intervention)
Negative risk factors
HDL > 60 mg/dL
ERT, estrogen replacement therapy; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
Cerebrovascular disease is the third leading cause of death in the United States after heart disease and cancer. Risk factors include hypertension, smoking, and diabetes. The Fifth Report of the Joint National Commission on the Detection, Evaluation, and Treatment of High Blood Pressure listed normal systolic blood pressure as less than 130 and normal diastolic blood pressure as less than 85. High-normal blood pressures are considered to be systolic blood pressure between 130 and 139 and diastolic blood pressure between 85 and 89. Mild hypertension is denoted by systolic blood pressure between 140 and 159 and diastolic blood pressure between 90 and 99. Moderate hypertension is systolic blood pressure between 160 and 179 and diastolic blood pressure between 100 and 109. Severe hypertension is systolic blood pressure between 180 and 209 and diastolic blood pressure between 110 and 119. Very severe hypertension is systolic blood pressure over 210 and diastolic blood pressure over 120.5
In general, individuals with mild hypertension can be treated with a diet and exercise regimen.6 Generally, this should be tried before drug therapy is considered. Drug therapy should be initiated for sustained blood pressures in the moderate and severe ranges. In the Systolic Hypertension in the Elderly Program (SHEP), cessation of smoking and blood pressure reduction demonstrated 36% fewer fatal and nonfatal strokes and 27% fewer fatal and nonfatal myocardial infarctions in treated individuals versus the placebo-treated control group. These benefits were noted in all groups regardless of age, race, gender, or blood pressure subgroup.7
Diabetes mellitus is a group of diseases characterized by the inability to process glucose properly. Insulin-dependent diabetes (type 1) occurs because of the destruction of the pancreatic islet cells. Although it usually occurs in childhood, it may occur at any time in life. Type 2 diabetes is usually seen in older individuals because of a relative insulin and glucose insensitivity and an impairment of insulin release. It may, however, occur at any time in life and is becoming more common in obese children and adolescents. Approximately 8% of the United States female population is affected and obesity is definitely a risk factor.8 Long-term complications include cardiovascular disease, renal failure, neuropathy, and blindness. Although studies have not definitely documented the benefit of early diagnosis of type 2 diabetes, periodic fasting blood sugars should be performed on all older individuals, and screening should be performed on women with risk factors such as obesity and family history of diabetes, or women who have had gestational diabetes. If glucose intolerance is found, diet therapy and weight loss can be useful. An elevated fasting or 2-hour postprandial glucose determination may be helpful in detecting individuals with overt diabetes, but most individuals with glucose intolerance are diagnosed with an oral glucose tolerance test.9
Hypothyroidism is much more common in older than younger individuals. Symptoms and signs include lethargy, constipation, dry skin, alopecia, memory impairment, and depression. The individual is often obese and may have elevated cholesterol. The prevalence of hypothyroidism is approximately 5% in otherwise healthy individuals.10 Thyroid-stimulating hormone (TSH) is a good screening test. Many authorities believe that it is reasonable to screen older individuals every 1 to 2 years, but there is no consensus.11 Certainly individuals with elevated cholesterol or with the symptoms listed should be screened and patients without symptoms should probably be screened periodically. Hyperthyroidism is less common in the elderly, but does occur. Symptoms include decreased energy, weight loss, muscle weakness, rapid pulse, and elevated systolic blood pressure. Elderly individuals may also present with atrial fibrillation or congestive heart disease when they have hyperthyroidism.12,13 Certainly, individuals with these symptoms should be screened.
Anemia is common in elderly people.14 Iron-deficiency anemia, vitamin B12 deficiency, and folate deficiency all occur. Iron-deficiency anemia may be associated with blood loss, such as bleeding from a gastrointestinal source, and the gastrointestinal tract should be investigated if this is found. Whereas there is some controversy as to whether or not a complete blood count should be performed annually, there is agreement that a hematocrit should be performed. If anemia is found, the type should be defined, and the reason for the anemia should be determined.
Osteoporosis occurs because of increased bone absorption and reduced bone formation. This leads to decreased bone density.15 It is generally a slow process beginning in the fourth decade of life and is accelerated by several risk factors. These include a positive family history, white or Asian race, hypothyroidism, hyperparathyroidism, prolonged use of corticosteroids, smoking, alcohol abuse, early oophorectomy or premature menopause, history of lactose intolerance, sedentary lifestyle, immobilization, small, lean body habitus, and low calcium intake (Table 2).16 Bone density surveys can be performed periodically and should be applied every few years in women, particularly those with multiple risk factors. Estrogen therapy reduces the risk of osteoporosis, but it does not stop the process completely.17,18,19,20 Statin drugs are useful in treating osteoporosis and osteopenia.
Gender (female > male)
Ideally, it is desirable to detect cancer in either the precancerous or early invasive stage. This is possible with cervical cancer with the Pap smear and for breast cancer with the use of mammography. It is more difficult in lung and ovarian cancers, which may be far advanced before symptoms are apparent. Colorectal cancer and endometrial cancer may be detected relatively early because of their tendency to bleed, and certainly postmenopausal bleeding and rectal bleeding should be investigated immediately. All cancers are more common in older people and cancer is the second greatest cause of mortality after coronary artery disease in older individuals. The incidence of lung cancer has increased dramatically in the second half of the twentieth century, probably because of an increased number of women who smoke.21,22 Currently, deaths from of lung cancer are more common than deaths from breast cancer, even though the incidence of breast cancer is much greater (182,000 new cases each year versus 70,000 cases of lung cancer each year).2
Routine screening with a Pap smear should be carried out throughout the lifetime of a woman. There is disagreement about how frequently Pap smears should be performed, but the American College of Obstetricians and Gynecologists (ACOG) suggests screening at the discretion of the physician after three consecutive normal examinations in low-risk women.23 Likewise, annual mammography after age 50 is recommended by the American Cancer Society and the ACOG, and should be continued throughout a woman’s lifetime.23,24 Age is definitely a risk factor for breast cancer with approximately a 2% risk at age 50 and a 12% risk at age 90.25,26
There are several risk factors for breast cancer. These include age, family history of breast cancer or cancer-prone family, heavy radiation exposure, past history of breast cancer, carcinoma in situ of the breast found on biopsy, atypical hyperplasia, and a history of multiple breast biopsies.27 In addition, individuals known to be carrying the BRCA 1 or BRCA 2 gene mutation are at high risk (Table 3). There are also minor risk factors including nulliparity or late first pregnancy, early menarche, or late menopause. There are several possible risk factors including prolonged estrogen therapy, high-fat diet, obesity, moderate-to-heavy alcohol use, sedentary lifestyle, or history of abortion before first full-term pregnancy. The known risk factors account for only one half of all breast cancers, and all women should be screened as recommended.
Major risk factors
Minor risk factors
Nulliparity or late first pregnancy
Possible risk factors
Colorectal cancer affects approximately 5% of all women in the United States.28 Most colon cancers arise from adenomatous polyps in the distal colon and may be seen on endoscopic examination.29 Not all polyps become cancer and the degeneration to cancer generally takes 5 to 10 years. Screening takes two forms. The first is testing the stool for occult blood. Such bleeding may occur from a number of causes and may originate from polyps or from cancer. Sigmoidoscopy or colonoscopy is appropriate for visualizing the colon. Certainly, sigmoidoscopy is a good screening test because most cancers occur in the lower colon. For patients with a high risk factor, those found to have polyps in the lower colon, or those found to have positive screening for occult blood without polyps in the lower colon should be offered colonoscopy. The American Cancer Society currently recommends testing the stool for occult blood annually beginning at age 50.30 It should be noted that not only cancers bleed and that bleeding may occur from benign sources. The American Cancer Society also recommends the routine use of flexible sigmoidoscopy screening in all adults beginning at age 50. Whereas there is some controversy about how often this should be repeated, most authorities suggest that it be repeated every 5 years. There is controversy between several organizations with respect to the frequency of testing, but there is general agreement that testing for occult blood should be performed annually.
Risk factors for colorectal cancer include first-degree relatives with colon cancer, history of colorectal, breast, endometrial, or ovarian cancer, history of adenomatous polyps, or ulcerative colitis. Women in the highest risk group are those who have two or more first-degree relatives with colorectal cancer, family cancer syndromes, or family history of polyposis coli. Individuals in the highest risk group should be examined periodically with colonoscopy testing (Table 4).
First-degree relative with colon cancer
The risk of skin cancer increases with age. Risk factors for melanoma include fair skin and hair color, positive family history for melanoma, large congenital nevi, and the presence of pigmented lesions meeting the criteria for dysplastic nevi. Dysplastic nevi have the following characteristics: (1) macular and papular components; (2) irregular borders; (3) variegated pigmentation within the same lesion; and (4) diameter of 5 to 12 mm.31 An annual full skin examination is recommended for people over 50 years in order to detect evidence for squamous cell cancer, basal cell cancer, and melanoma. Squamous and basal cell cancers are commonly found in areas exposed to the sun (head and neck).32 Squamous cell cancers arise from actinic keratosis. When actinic keratoses are found, they may be destroyed with liquid nitrogen. Squamous and basal cell tumors should be removed surgically.
Vision and Hearing
A gynecologist can perform cursory examinations of the patient for visual or hearing impairments. The patient should be tested at least every 2 years for evidence of glaucoma (increased anterior chamber pressure) and for the presence of cataracts.33 An ophthalmoscopic examination may help to detect cataracts in the lens and also to inspect the retina for signs of vascular disease. If the physician is not comfortable testing the patient for these problems, a referral to an ophthalmologist should be made every 2 years.
General testing of hearing is also useful and should be recommended to older patients periodically.
Dementia and Depression
Individuals should be screened for evidence of dementia and depression and these conditions will be addressed in detail later in the chapter.
As a woman ages a number of factors can influence her nutritional status. First, her metabolic needs tend to change after menopause with the cessation of ovarian function.34 In general, this decreases the need for calories; the recommended dietary allowance of calories that is usually related to age and body mass prior to menopause is generally considered to be only 1900 calories daily after age 50.35 Second, her nutritional needs may be affected by illness or disease states that can develop as she ages. Third, medications that she may be taking for specific conditions may alter her nutritional state by affecting appetite, metabolism, absorption, and interfering with nutrients within her body. Fourth, social factors may be in play. If she is widowed and bereaved, she may not prepare nutritional meals as she did when she was cooking for herself and her family. If she is disabled, she may not be able to get to the store to obtain, fresh, nutritious ingredients and may therefore subsist on a variety of foods that can be stored in bulk. Finally, if the patient suffers from depression or dementia, she may not have the interest or ability to prepare an appropriate nutritional diet.
Although total caloric intake should be approximately 1900 calories daily for women over age 50, there is some disagreement about the composition of this allowance. It is generally agreed that 30% of the recommended caloric intake may be in fat, and that cholesterol should not exceed 300 mg/day.35 It is also recommended that diets of elderly individuals should consist of 45% to 50% carbohydrates and that 55% to 60% of this should be complex carbohydrates.35 Most foods containing complex carbohydrates are high in vitamins and minerals, making them particularly attractive for the elderly. There is some disagreement over the amount of protein in the diet of elderly people, because studies on nitrogen balance in the elderly have been difficult to reproduce.36 However, protein stores diminish with aging because of the decline in lean body mass and there is some disagreement as to whether or not body protein synthesis is decreased in the elderly.37 Serum albumin levels do decline with aging and protein metabolism is dependent on kidney function that may decline with aging.38 Taking all of these uncertainties into consideration, it has been recommended that elderly individuals consume 12% to 14% of their calories as protein, but larger amounts may be needed for those who are undernourished or who may be suffering from certain illnesses related to nitrogen loss.37
Vitamin deficiencies commonly occur in older individuals for a variety of reasons from low intake to an increased incidence of atrophic gastritis, pernicious anemia, excessive alcohol use, and interference with absorption or metabolism because of the action of medications the patient may be taking. Common deficiencies are of vitamin B12, folic acid, and vitamin D.37 Deficiencies of fat-soluble vitamins are usually less frequent.34 There is some evidence that the supplementation of certain vitamins and minerals may have health benefits in the elderly. Consumption of large amounts of vitamin C, E, and beta carotene has been reported to be associated with lower rates of coronary artery disease, possibly because of their antioxidant properties.39,40,41,42 Vitamin E may also have a positive effect on the immune system. Niacin may help reduce serum cholesterol.35
Several trace elements are probably useful also. Zinc deficiency has been associated with anorexia, taste abnormalities, macular degeneration, T-cell dysfunction, and poor wound healing.35 In most elderly individuals, the intake of zinc does not meet the recommended daily requirement of 8 mg. Individuals with diabetes mellitus, those who abuse alcohol, and those who may be taking diuretics are at particular risk.34
Chromium may have a role in preventing hyperglycemia, hypercholesteremia, and opacities of the cornea, but most of information on this trace element comes from animal studies and has not been proven in humans.34 Selenium deficiency has been associated in the elderly with cancer, coronary artery disease, and immune system dysfunction.34 Again, the information is indirect. A high prevalence of cancer has been noted in areas where crops are low in selenium and animal studies have tended to support this finding. A recommended daily dose is 50 to 200 μg. Higher doses may lead to toxicity, which includes garlic odor on the breath, fingernail changes, and peripheral neuropathy.34
Iron deficiency is common in the elderly for a number of reasons including absorption. This may lead to anemia, but older people are also at risk for bleeding from neoplasms, particularly of the gastrointestinal tract, and this should always be kept in mind when an elderly person is determined to be anemic. The recommended daily dose of iron is 8 mg/day. For women over 51, Table 5 lists the recommended daily dietary allowances for a number of vitamins and minerals. Megadoses of vitamins are contraindicated and may be harmful, therefore prescribing large doses of vitamins for older individuals should be avoided.
*From Food and Nutrition Board, Institute of Medicine, National Academy of Science, 2002.
Calcium and vitamin D supplementation are accepted as important for older women and 800–1500 mg of calcium per day is recommended along with 5 μg of vitamin D to help prevent osteoporosis.43
Women of all ages should be encouraged to exercise. Even if they suffer from chronic illness, exercise may improve symptoms or even arrest the condition.44 There are three types of exercises in which women should be encouraged to participate. They are endurance, resistance, and balance training. Endurance training improves the cardiovascular status. This status depends upon cardiac output, which is heart rate × stroke volume, and the ability of muscles to extract oxygen. Cardiovascular endurance decreases with age at a rate of approximately 1 mm3 oxygen per kilogram of body weight per year. Maximum heart rate decreases with age at a rate of about one heartbeat per year. While the decrease in heart rate is usually not changed by physical conditioning, cardiovascular endurance is. Muscle mass also decreases with age even in very active individuals, but is more marked in sedentary people.45
Endurance training is defined as the rhythmic contraction of large muscle groups at a specific heart rate for a specific period of time, and may be either weight-bearing or non-weight–bearing. The weight-bearing type has an additional beneficial effect on bone mass, but may have a negative effect on problems involving the hip, knee, or ankle. Thus, the type of the endurance exercise should depend on the patient’s general health and condition and what she is capable of doing.46 It has been shown that endurance training can improve cardiovascular conditioning by as much as 10% to 30% depending on how hard the individual exercises and the number of muscle groups involved in the exercise.45 The American College of Sports Medicine recommends that individuals get 30 minutes cumulative exercise per day at least 3 days per week.44 Weight-bearing exercises include walking, jogging, stair-climbing, cross-country skiing, and aerobic dance. Non-weight–bearing exercises include swimming, rowing, and upper-body exercises. Endurance training improves cardiovascular condition and generally gives the individual greater energy.
The goal of resistance training is improved muscle mass. Muscles are composed of two types of muscle fibers: slow twitch and fast twitch. Fast-twitch fibers account for rapid and powerful movements, and with age fast-twitch fibers tend to decrease in number, whereas slow-twitch fibers remain relatively stable.44 Weightlifting exercises help increase the number of fast-twitch fibers and the size of the muscle, thereby increasing muscle strength. Exercises utilizing weights can be performed by individuals of all ages and conditions, and should be done, at least at the start, under the direction of a personal trainer. This service may be obtained in any number of ways, including the YWCA, health clubs, or private practitioners. Personal trainers charge from $25 and up per hour. Women can work in groups of two or more, thereby sharing the cost. Specific muscle groups can be exercised as determined by the patient’s needs or the exercises may be generalized.
Posture and balance training is important for the elderly because it may decrease the tendency to fall.45 It will also improve posture. It integrates the sensory and motor systems and helps the individual to react more quickly to changes in the environment. Balance training can be separated into static and dynamic components. Static exercises include balancing the center of gravity or standing in the same spot. The exercises may begin on a wide base, but then are performed on progressively narrower bases going gradually from a double-leg support to a semitandem, to a tandem, to a single-leg support, and finally to static support on toes. Exercises may be sit-to-stand or cervical spine rotation or twist, side bending, and scapular retraction and elevation. Dynamic balance is maintaining the balance during movements and can be made progressively more difficult by narrowing the base of support and using side steps, crossover steps, forward or backward steps, high steps, heel-to-toe walking, and toe tapping. Aerobic dance can be useful in carrying out such exercises.45
A well-rounded exercise program includes attention to endurance, resistance training, and balance, and often can be obtained at a YWCA or health club setting. In addition to the obvious benefits of improving endurance, muscle mass, strength and balance, many individuals with chronic illness experience an improvement in their symptoms. Pain relief in arthritis sufferers has been noted and patients with high blood pressure, chronic obstructine pulmonary disease, congestive heart failure, pulmonary hypertension, left ventricular dysfunction, angina, and cardiac arrhythmias often experience symptomatic relief.44
In the United States, recommendations for immunization are regularly reviewed and updated by the Immunization Practice Advisory Committee under the auspices of the Centers for Disease Prevention and Control (CDC).47 Currently, the basic recommendation for adults is a tetanus-diphtheria booster every 10 years, annual influenza vaccine starting at age 50, and a pneumococcal vaccine at about age 60, with the possibility of repeating every 5 years. It has been estimated that in the United States, roughly 20,000 deaths in older adults are caused by influenza annually. Because the influenza vaccine has an estimated efficiency of 70%, and only 30% of at-risk individuals receive the vaccine, a greater use of the vaccine in older individuals could prevent 9800 deaths annually.48,49,50,51,52 It is also estimated that 40,000 deaths occur among older individuals because of pneumcoccal infection. The pneumococcus vaccine has an estimated vaccine efficiency of 60%, but only 14% of exposed individuals have been vaccinated. Therefore, it is estimated that 20,640 deaths could be prevented annually if the vaccine were used more widely.49
Most living Americans have been immunized against tetanus and diphtheria in childhood, the major problem, however, is keeping vaccinations current. Physicians should remind their patients of the need for tetanus-diphtheria booster shots every 10 years.
Other vaccinations should be offered to specific high-risk groups. Hepatitis B vaccine should be offered to older individuals, health care workers, public safety workers, recipients of blood products, intravenous drug users, or the household or sexual contacts of hepatitis B carriers. In the older population, dialysis recipients and blood product recipients are more common. These individuals should be immunized.53,54
All older individuals should be offered influenza vaccines annually, but this is particularly important for those suffering from chronic diseases and those who are residents in long-term care facilities. Likewise, such individuals should be offered pneumococcal vaccine and subsets of older individuals, such as those who have lost spleens or those who may have a problem with their immune systems, such as HIV infection, should be given pneumococcal vaccine.49
Recently, the hepatitis A vaccine has become available and probably should be offered to all individuals. Certainly older individuals who travel a great deal outside of the United States should be offered this vaccination.
Inactivated polio vaccine (IPV) should be offered to older individuals who have never been vaccinated or whose vaccination was several years ago and require a booster shot. This is certainly important for those who deal with young children who may have recently been given polio vaccine (live vaccine) or for those who travel to countries where polio is still a problem. Table 6 summarizes vaccinations that should be considered for older individuals.
In addition, older individuals who travel outside the United States should be adequately immunized for diseases that may be prevalent in the areas in which they are traveling. In such situations, it is best to consult the CDC or a travel clinic to determine what is recommended. Such individuals should be offered malaria prophylaxis if they are planning trips to areas where malaria is prevalent.
Most safety issues should be common sense to both physicians and patients, and yet are often not considered as carefully as they should be. The annual health maintenance visit is a good time to remind patients of safety issues, particularly as they might affect an aging person. The national media has emphasized the need for using seat belts while traveling in vehicles, and yet it is primarily the elderly who were raised at a time when seat belts were not present in vehicles who fail to use them. It is important to stress the need for seat belts. In addition, many active older individuals ride bicycles, horses, and motorcycles, and a few roller skate or ice skate. Use of helmets during these activities should be stressed. Again, individuals in this generation are not in the habit of using helmets for such activities, and indeed, have been participating in such activities all of their lives without utilizing helmets. Still, reflexes are slower in older than younger individuals, and stamina may be decreased. Helmets prevent head injuries and their use should be emphasized.
It is also important to encourage older women to use safe footwear. Many women in their 60s and 70s were young when 4-inch heels were popular on dress shoes. Many still attempt to wear such heels when they dress up. It should be pointed out that balance is not as good in the older individual and that lower heels can be just as stylish. Likewise, good footwear for athletic activities should be emphasized. Older women who were young during the “sneakers” era do not necessarily avail themselves of the benefits of current training shoes. Their value should be stressed. On a related topic, older women should be cautioned not to move as rapidly as they have been used to moving. A decrease in balance may lead to falls and this can be avoided by slowing down.
It is important to stress that inappropriate and strenuous exercises should be avoided. While exercise is excellent for older individuals, pushing the body to extreme fatigue may result in challenging a compromised cardiovascular system. It may also cause bone and joint pain that may be bothersome. In general, safe tasks and activities should be encouraged. Those that may pose possible danger should be avoided.
It is important to discuss whether or not firearms are present in the house. It has been estimated that 70% of American households have firearms, which may be discharged by accident or in anger. If firearms are present in the household, the individual with access to them should be aware of safety precautions. In general, they should be stored unloaded. Certainly, in households where a tendency to violence exists, firearms should be locked up. As with many other issues, asking the patient about this may bring forth information of which the physician is unaware.
Finally, as emphasized earlier, the physician should evaluate the senses of the patient, particularly vision and hearing, and make recommendations for corrective measures if the vision or hearing is found to be inadequate. Corrective lenses or hearing aids can be obtained when necessary and referral for cataract surgery or other corrective eye procedures can be made.
Medications and Drug Interactions
It is difficult to reach older age without suffering some illness or at least unpleasant symptoms. Branch55 noted that 15% of elderly individuals took two or more prescription medications daily and Law and Chalmers56 reported that 87% of patients over the age of 75 receive some form of drug therapy regularly; 34% of their patients took 3 to 4 drugs daily. Medications are used for many and diverse reasons, and conceivably lead to symptoms or problems because of the effect they have on various organ systems of the body. In addition, multiple drug therapy creates a genuine opportunity for drug/drug interactions. Also, older individuals may have an increased vulnerability to drugs because they metabolize or excrete drugs differently than younger individuals and because physiological changes in the older individual may lead to poor or accelerated absorption of a given drug.57
Older individuals may use drugs improperly. Misuse may be because of hearing loss, which makes it difficult for them to understand instructions, visual impairment, which makes it difficult for them to read instructions or to even read the label of a drug container correctly, and memory loss or confusion, which may lead to difficulty in comprehending the use of a drug or even to remember if they took the drug on a given day. For all these reasons, physicians prescribing drugs to elderly individuals may have a more difficult time obtaining compliance and appropriate drug response than they do with younger patients.
Problems with drug absorption take place for a number of reasons. These include a loss of acidic gastric fluid pH; a slower gastric emptying time; a decreased intestinal mobility; a decreased gastrointestinal fluid secretion, including volume and composition; a decreased or compromised gastrointestinal blood flow; gastrointestinal disease; and general health problems of the patient.58
Drug distribution in the body is also an important issue. With aging, total body water and blood volume tend to decrease. Lean body mass (i.e., muscle tissue), tends to decrease.59 There is a relative increase in body fat. Body fat increases from 18% to 36% of total body weight in men and from 33% to 45% of total body weight in women with aging. Thus, drugs that are readily soluble in fat are more readily stored in older patients, and to a greater extent in women than in men. A drug that is stored in fat would have a greater volume of distribution and when a single dose is administered, it would have a lower plasma volume compared with drugs that are not readily stored in fat.59
Another important feature is drug metabolism. Liver size decreases with age and liver blood flow also decreases. Thus, drugs that are metabolized in the liver are cleared more slowly and have a longer plasma half-life. For some drugs, the plasma half-life is increased as much as 75% in older women.57
Aging may pose an additional problem for drugs that are excreted by the kidney. Kidney function decreases with age, with the result that drugs that are eliminated by the kidney show an increased plasma half-life and a decreased clearance rate. Beginning in the fourth decade of life, changes in renal blood flow, glomerular filtration rate, and active tubular secretion and absorption begin to occur.60
Because of all these factors, older individuals are often sensitive or more responsive than younger adults, but this is not universally true. In some situations, older individuals are less responsive to certain drugs. For example, the beta-adrenergic blocker, propanolol, is required in larger amounts to obtain the desired physiologic effect in older individuals. This may be because β-receptors become less sensitive with age or it may be that the sensitivity of older individuals to drugs that act on β-receptors is decreased.61
Some commonly used medications are definitely related to an increased sensitivity in older individuals. One example is diazepam. Reidenberg and colleagues62 showed that the dose of diazepam that caused depression was inversely related to age. In addition, drug plasma levels at which depression occurred were inversely related to age. Cook and colleagues63 studied individuals being prepared for dental or endoscopic procedures. They found that patients 80 years of age or older required an average dose of 10 mg of diazepam compared with 30 mg for patients 20 years of age, and that plasma levels required for sedation in individuals over 80 were one third to one half the amount required for younger individuals. Similarly, older patients are more sensitive to warfarin.64 As patients in this age group often require anticoagulation, this must be taken into consideration.
While not life-threatening, many drugs (e.g., some antihypertensive drugs), may have adverse effects on sexual performance and urinary or bowel function. Central sympatholytics, beta-adrenergic blockers, and alpha-adrenergic blockers frequently impair sexual performance, and even thiazide diuretics can cause problems.65,66 Many of the psychotropic drugs can cause sexual dysfunction, but so can other frequently used drugs, such as cimetidine and metoclopramide.58 Anticholinergic drugs may be associated with decreased libido and even impotence.66
Some older individuals can have Parkinson’s disease-like symptoms induced by major tranquilizers, antiemetics, methyldopa, reserpine, and diazepam.67 Because such interactions of medications may occur, physicians must choose the medications that they prescribe for an older patient carefully, keeping in mind that a drug may change the rate of absorption and enhance the bioavailability of another drug. A drug may increase the rate of metabolism or a drug may decrease the rate of metabolism. A drug may decrease the rate of excretion of another drug or a drug may increase the protein binding of another drug. In addition, drug absorption may be affected by the fact that it binds within the gastrointestinal tract by changes in the stomach pH, decrease in gastrointestinal mobility, changes in the intestinal flora, and the change of drug metabolism within the wall of the intestine.
It is suggested that physicians caring for older individuals take a careful drug history, including all medications currently being taken, prescription and nonprescription. It is best to have the patient bring all medications with her to her annual health visit. Physicians should prescribe only drugs for which there is a clear need and where the chance of benefit clearly outweighs the cost of adverse effects. The patient should be well aware of the goals of therapy and the need for medication, and should clearly understand how the medication is to be administered. The patient should be asked for feedback on their response to the drug with emphasis on adverse effects. Whenever possible, a family member should be included so that the instructions are clearly understood and the need for feedback is met. Patients should be frequently and carefully evaluated to ensure that the desired effect of the drug is being realized and that adverse effects are not present. If the patient has unfavorable symptoms, the role of the drug in these symptoms must be considered. In the case of the elderly, lower doses should always be prescribed first, given in small increments at longer intervals than would be prescribed in younger patients. If the patient has difficulty in swallowing tablets, liquid preparations may be substituted.
The patient should be given written instructions for medication use. Be sure that the patient can read the instructions and review the instructions with the patient at each visit. Be certain that the patient can open the drug container and read the label. The patient should know the reason for the use of each drug. Whenever possible, use a once-per-day dosage schedule and assist the patient in taking the drug on some daily schedule so that she will know if she has taken the drug. If necessary, use plasma drug levels for guidance for drug dosage and interval between dosages.
Hormone Replacement Therapy
This author believes that there are many benefits to HRT that have been well demonstrated. Healthy patients without contraindications should be encouraged to utilize estrogen preparations or estrogen and progesterone if a uterus is present. A detailed discussion of this topic is offered elsewhere in this book.
Urinary and Rectal Incontinence and Pelvic Support Problems
Problems of relaxed pelvic support and urinary and rectal incontinence are extremely frequent in older women. Physicians should use the annual health maintenance visit to question patients about symptoms relating to these problems and to evaluate the symptoms on physical examination. Many patients will not bring up the subject of urinary or rectal incontinence because of embarrassment or because they believe that nothing can be done to alleviate the problem. Thus, the physician must have a high index of suspicion that such conditions may be present in an older woman and ask specific questions accordingly. A broader discussion of these problems is provided in other chapters of this book.
Sexuality is a behavioral phenomenon influenced by many factors including the health and physiologic state of each person and the couple, as well as the importance that each member of a couple places on sexual activity as a source of comfort and gratification. It is strongly influenced by other associations that are part of a person’s life. With advancing age, there is almost always a decrease in sexual function and satisfaction. Failing health and many medications may contribute to this.
In one study of more than 4000 adults over the age of 50, most individuals stated that they were still sexually active and those who were reported happier marriages and relationships than did sexually inactive persons of the same age.68 In general, older women showed a more marked decline than men in the desire to remain sexually active.68 Masturbation as a form of sexual gratification remains stable in women, but declines in men with age.68 Other studies have shown a decline in orgasmic response in older women, but not all women respond in the same fashion. In one study, 49% of women reported a decline in sexual activity after menopause, but 38% reported no change, and 15% actually reported an increase in sexual interest.69 In the very old, sexual intercourse is less likely, but caressing behavior generally continues. Older women and men often report an increased interest in caressing and masturbation, but decreased interest in intercourse.70
The sexual interest and response of older women often is related to the ability of their partner, and therefore relates as much to the health and vigor of the partner as to the health and vigor of the woman herself. Women who perceive their marriages to be good generally have greater satisfaction in their sexual relationships.71 Women who complain of depression frequently note a decrease in sexual satisfaction.
After menopause, levels of estrogen, progesterone, and testosterone are all decreased and even in women on estrogen replacement therapy, the thickness and elasticity of the vagina and urinary tract may be decreased as is the amount of vaginal lubrication. Acidity of the vagina usually decreases after menopause and women may be more susceptible to vaginal irritation and low-grade infections.72
There is often an increase in the amount of time necessary for sexual arousal and a decrease in the number and intensity of orgasmic contractions after menopause.73 With aging, there is generally a loss of elasticity and smoothness of facial and body skin that may be perceived as a loss of attractiveness and may contribute to a decrease in sexual interest in one or both members of the couple in some cases. With illness, there may be a need for medication that may affect many aspects of the sexual response, although to some extent, estrogen replacement therapy prevents some of these changes. In addition, psychosocial factors may influence a couple’s desire for sexual activity. Some cultural stereotypes of older people include a perception that they may be desexualized or unattractive. In some cases, society may view sexuality in women who have passed the childbearing age with suspiscion. When this is the case, the older woman may see her sexual desires as abnormal. Finally, as women outlive men, older women may find fewer males for relationships. In addition, older women suffer many losses that may lead to a grief reaction, and this may limit the amount of emotional energy available for sexual activity.
With a lack of estrogen, genital appearance may change, including thinning and dryness of the vaginal epithelium, decrease of fullness of the clitoris and labia, and a reduction in pubic hair. The vagina may shrink in length and become narrow in diameter. If intercourse is not practiced for a long time, it may actually close with adhesions. As atrophy develops in the vaginal tissue, women are more susceptible to vaginal infection, vaginal tears, and other irritation. These factors may convince a woman to avoid intercourse.72
Because sexual function is under the influence of the autonomic nervous system, medications that affect the autonomic nervous system may also affect sexual desire or orgasm. The parasympathetic nervous system via the neurotransmitter, acetyl choline, is responsible for arousal. Thus, medications that interfere with acetyl choline will frequently decrease sexual desire. Women so affected often state that when they attempt to have sexual relations, after a period of time they become aroused, and that orgasm is normal. However, medications that interfere with the sympathetic nervous system by interfering with the neurotransmitter norepinephrine, may block orgasm. Women affected by this circumstance may note normal arousal, but may suffer an inability to attain a normal degree of orgasmic function or any orgasm at all. Likewise, the male of the couple may also be influenced by medications that affect the autonomic nervous system and may suffer impotence or difficulty maintaining an erection. Table 7 lists many families of drugs that affect sexual functioning and the effects that they may produce. It is appropriate to discuss sexual function with couples and if it appears that medication may be interfering with normal function, it may be possible to adjust medications to alleviate this problem.
A few sexual dysfunctions may occur in older women. The first is vaginismus. This is generally a result of painful vaginal experience, ranging from irritation with an infection, scarring after surgery, or even because of a sexual assault. The problem should be looked at as a defensive reaction and when the cause has been removed, such as treating an infection, dilating or cutting adhesions, or dealing with the assault on a psychosocial basis, the patient may be offered desensitizing exercises. In general, these consist of digital dilatation of the vagina, first by the patient, and then by her partner, in a safe situation over time without attempting intercourse. When the levator ani muscles, which have been in spasm, are taught to relax, intercourse may be attempted. Occasionally, vaginal dilators may be used in a progressive manner for this purpose. In general, treating vaginismus with desensitizing exercises is not difficult and is almost always successful if the cause has been removed.74
Women who complain of anorgasmia or difficulty in achieving orgasm, may be helped by learning masturbatory techniques. These can be taught to or shared with their partners. It is often necessary for an increase in stimulation to be used to bring about orgasm in some older women. Occasionally a vibrator may be used for stimulation during coitus to help with orgasm.74
Finally, dyspareunia should be evaluated carefully and the cause removed. Dyspareunia may lead to vaginismus, but it may, because of the painful experience, limit the amount of coital activity that the patient attempts. In each case, a careful investigation of the cause should be performed, and where possible, the problem should be alleviated.
Physicians are often reluctant to raise issues of a sexual nature, but patients need to know that sexuality is a normal psychosocial activity that can and should be enjoyed by the elderly. A caring physician who asks the correct questions may be in a position to perform a very important and appreciated service to the older woman by helping her and her partner continue this normal function.
Domestic Violence Issues
Older women can be the victims of domestic abuse and violence as can all women. The abuse may be physical or it may be verbal, involving threats, intimidation, or neglect. Physical abuse may be any activities that involve throwing an object, throwing an object at someone, pushing, slapping, kicking, hitting, biting, threatening with or using a weapon. A woman may be the victim of a spontaneous act of abuse or an act that is premeditated.75
The Select Committee on Aging investigating domestic violence in the elderly estimated that between 500,000 and 2,500,000 cases of abuse involving the elderly occur annually in the United States. Whereas the husband or significant other may be the abuser, others living in their household victimize many older women. Indeed, abused women past the age of 75 are often physically impaired, generally white, widowed, and living with relatives. The abuser is often an adult child within the family, but may be any other member of the household.76
Physicians caring for geriatric patients should be on the alert for signs and symptoms of domestic abuse. The abused woman may have frequent somatic complaints such as headaches, insomnia, choking sensation, hyperventilation, or chest, back, or pelvic pain. Other signs or symptoms that may be noted are shyness, fright, embarrassment, evasiveness, jumpiness, passivity, frequent crying, evidence of alcohol abuse, or a history of overdose of medication, such as sleeping pills.75 In addition, physical evidence such as bruises, scratches, bite marks, or burns are often noted, and if these are observed, the patient should be asked how she received these injuries. It is appropriate to ask older women if anyone in their household or among their acquaintances has injured them, threatened to injure them, or made other threats or intimidated them in any way. Widowed women living with family members are particularly susceptible and should be asked these questions routinely.77
All 50 states have passed legislation protecting the elderly from domestic violence and neglect. Most states have mandatory reporting laws.75 As with other domestic violence problems, older women who are found to be the victims of abuse or intimidation should be counseled about their rights, which center on the fact that they have the right not to be intimidated or abused. Social service agencies, the police, and other legal agencies may be consulted with the permission of the patient to either remove the perpetrator from the home, or to find a safe haven for the patient. Physicians can help these patients by identifying an abuse situation and helping the patient to identify her options.
Depression, Dementia, and Delirium
It has been shown that 50% to 60% of patient visits to primary care physicians are for complaints that have a behavioral or emotional component and 25% of the patients visiting primary care physicians have psychiatric disorders.78 Women have 2 to 3 times the risk of depression in their lifetime as do men.79
Dementia, which involves the destruction of brain cells as a result of organic brain damage, is common in the elderly. Roughly 5% of people over the age of 65 have severe dementia and 10% have mild dementia. By the age of 80, a full 20% suffer from this disorder.80 Delirium, on the other hand, is a disorder of brain physiology and is often reversible.80
Depression is quite common and may be associated with bereavement, disappointment, or other types of loss. It may be transient and frequently requires no therapy. Mild antidepressive agents may be helpful over the short term. In the case of bereavement or grief because of other types of loss, in general, kindness from friends and family as well as the medical profession is usually all that is necessary to assist a woman through such circumstances. Social isolation, however, may intensify the problem. The cure for depression, secondary to bereavement or loss, is to replace the loss with other activities. Encouraging women who suffer from bereavement to reach out to others and to develop new activities is an important direction to follow.81 Major depression, however, is a more significant problem. The average woman has approximately a 20% chance of having a major depression disorder sometime during her life. Depressed women appear tired, sad, and disinterested. They often speak slowly, have difficulty concentrating, and answer questions after several seconds of delay. Some can put on a good front when necessary and disguise the depression with other symptoms or complaints, therefore, the diagnosis of depression is missed in primary care clinics as often as 50% to 90% of the time, as health care providers deal with symptoms rather than with the whole patient.80
A good screening technique for diagnosing depression is offered by the American Psychiatric Association and is provided in Table 8. The presence of five or more items mentioned is considered indicative of depression with the first two, namely depressed mood and loss of interest or pleasure in most activities, considered the most serious symptoms of depression.
Evidence for depression is particularly common at the time of menopause. The stresses and changes in a woman’s life that occur at this time may be enough to bring these symptoms to the surface. Therefore, the loss of estrogen is often blamed for the depression and patients are given estrogen in the hopes that it will treat the depression. Because estrogen is a mood elevator, it will frequently help for a short period of time, but as with all mood elevators, larger and larger doses are required to alleviate the symptoms. The patient must realize that the usual dose of estrogen is all that they need to relieve physiologic problems, and that depression, if it is found, should be treated with antidepressive measures.
If a patient is depressed, it is important to determine if she is suicidal. It is appropriate to ask her directly, “Have you thought of injuring yourself or taking your life?” It is also important, if the answer is yes, to ascertain if she has taken steps to carry this out. Women who entertain thoughts of suicide or are planning to commit suicide require acute management in the form of a referral to a mental health specialist.
Women who are not suicidal, but have evidence for depression may be considered for treatment with three basic models. The first is medication (e.g., antidepressant drugs). These drugs basically fall into two classes: the selective serotonin uptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), and aroxetine (Paxil), and tricyclic medications, the most common of which are amitriptyline (Elavil), doxepin (Sinequain or Adepin), and imipramine (Tofranil). There are also several new medications that are being introduced. These medications require up to a month to be effective and instant improvement is usually due to a placebo effect and will not necessarily continue. Patients should be cautioned that they will not feel considerably better for up to a month and that the dose may require adjustment. As with any medication, there are side effects. In the case of tricyclics, the drug usually has an anticholinergic effect that may cause dryness in the mouth in older patients, hesitancy in voiding, and at times, delirium. Occasionally, blood pressure will be lowered significantly, leading to a tendency for the patient to faint when she arises at night. With respect to SSRI drugs, the side effects may include decrease in appetite and sexual desire.81
The psychological treatment model consists of either psychotherapy or self-help therapy. It is aimed at solving social problems that the patient may have that are contributing to the depression. These may be interpersonal relationships, problems with trust and coping, or difficulty in solving problems. Problems may also include a parental history of psychological disorders, history of alcohol abuse, personality disorders, or history of emotional, physical, or sexual abuse.81
The final model is a social model and utilizes social service agencies or social workers. These are most helpful in depression caused by domestic violence, severe financial difficulty, social isolation, bereavement, or decrease in functional abilities. Often a combination of these three models is necessary for the individual patient.
Dementia is quite common in elderly women. By age 80, 20% will suffer severe dementia.81 In dementia, there is impairment of both short- and long-term memory, abstract thinking, and the ability to consider and solve problems in a logical fashion. The woman who experiences dementia may have difficulty putting her thoughts into words and may even have difficulty speaking. The condition is the result of brain cell damage and there may be a motor problem causing gate difficulty or difficulty in performing tasks. Along with these changes, there are almost always personality changes.81 Dementia is caused by a number of conditions that cause destruction of neurons. Table 9 lists these conditions. Regardless of the cause, the brain destruction is irreversible. When dementia is identified, the patient should be referred to geriatric services that have the ability to make specific diagnoses and offer therapy that may alleviate symptoms.
HIV, human immunodeficiency virus.
Delirium is an organic brain problem of a physiologic nature. As such, it is often reversible. It is commonly seen in an older patient when the brain experiences a global disruption of metabolic equilibrium. This may be the result of a variety of conditions listed in Table 10. The recognition of delirium depends on the application of certain diagnostic criteria listed in Table 11.
Delirium generally begins with a sudden onset of mental status change, usually marked by disorientation, confusion, inability to remember new information and varying levels of consciousness.81 These symptoms may vary over hours from near-normal mental status to significant impairment of orientation. The patient may appear sleepy, hallucinate, or lose a sense of time. Delirium is frequently seen in older people who undergo surgical procedures and may be due to transient lack of oxygen, an imbalance of fluids or electrolytes, or a decreased ability of their body to nourish their brain cells as with hypoglycemia or other metabolic problems related to the anesthetic or operation itself. It may also be seen in patients who are using certain drugs that cannot be cleared adequately in the usual period of time. One such drug is diazepam (Valium) that must be prescribed in lower doses for older people or delirium often occurs. Treatment of delirium is usually support of the patient and the removal of its cause. In most cases, recognition is the most important factor in the beginning of therapy. However, susceptibility to delirium in older people may be an indication of physiologic brittleness and may have severe prognostic implications with respect to longevity.
Grief and Loss
Throughout a lifetime, everyone suffers losses. In the young, the losses may be the ending of a relationship or the loss of a friend or relative by separation or death. It may also be the result of the inability to conceive, miscarriage, or the death of a child. It may be because of such experiences as the loss of a job or the loss of a pet. For older individuals, losses may tend to accumulate, including not only the loss of friends and relatives through separation and death, the loss of a spouse because of divorce or death, but also may include the loss of children, jobs, the ability to participate in sports and other activities, the loss of body parts, and the loss of pets. Pet loss in some elderly individuals may cause a severe reaction because they may be limited in their contact with other people.82
Any loss may produce a grief reaction, which is usually accompanied by both physical and emotional symptoms. In the 1940s, Lindemann,83 a psychiatrist, described the grief reaction as a tightening of the throat and chest, a choking sensation, shortness of breath, frequent sighing, an empty feeling in the abdomen, muscle weakness, a feeling of tension and mental pain, and guilt. Most of these symptoms usually occur acutely after a loss. They may last for as long as 6 to 24 months depending on the ability of the individual to replace their loss with other people or activities in her life. Cultural variations exist and may influence the way in which an individual grieves.83
The death of a child is probably the most severe loss that a woman can experience.83 This experience can create a grief reaction that lasts for prolonged periods of time, but may be modified by the presence of other children in the home or a new pregnancy. Older women, however, are often faced with the death of an adult child during wartime because of battle casualty or because of sickness or violent death. With the acquired immune deficiency syndrome (AIDS) epidemic, such occurrences have become more common. Often young adults with AIDS will return home to be cared for by their mothers during their prolonged illness. Thus, the mother’s grief will involve not only the loss of the child, but the need to deal with the prolonged process of dying associated with the condition.
The loss of a spouse through death or divorce will usually cause psychological distress.84 However, the type of emotional problems a woman demonstrates is generally related to her usual behavior.85 Thus, if she is an anxious person or tends to be depressed, these symptoms will usually become more severe during the grieving process.
Lindemann83 described a number of situations and grief reactions that he labeled morbid grief because the reaction was abnormal and could, in many cases, have other serious consequences. The first morbid grief reaction is a delay in reaction, which is an extremely interesting phenomenon. It is usually seen when the patient herself is in a life-threatening situation and does not have the capability of grieving appropriately for the loss of a loved one. For example, a husband and a wife are in a car accident in which the husband dies and the wife is seriously injured. This situation may result in the delay of the grief reaction in the wife until she has recovered adequately from her physical injuries. Thus, the full-blown grief reaction may not occur until several months after the accident and may appear inappropriate when it does. However, the health care provider should be aware that this may happen and be prepared to manage it when it does.
Another morbid grief reaction is the distorted grief reaction. This is frequently seen in the adult daughter who has lost her mother to whom she was very close. She may not show evidence of grief, but may take on the mannerisms of the deceased. She may style her hair, dress, and even walk like her deceased mother. If her mother died of an illness, the daughter may even take on the symptoms of the illness that her mother demonstrated. This type of reaction may go on for a long time, but generally will subside eventually as the individual grieves more normally and returns to her usual behavior pattern.
Individuals who have demonstrated illness with psychosomatic overtones such as asthma, ulcerative colitis, or rheumatoid arthritis will often have a flare-up at the time of loss. Lindemann83 classified this type of reaction in the morbid grief category.
Pathologic alterations in relationships are frequently seen in the bereaved, leading to altered relationships with friends and relatives. This may occur because the bereaved blames these individuals, in part, for the death of a loved one, or because of guilt on the part of the bereaved. An extreme variation would be blame placed by a father on a child whose mother died while giving birth. This can have long-term complications in a relationship between father and child well into the adult life of the child.
Inappropriate behavior patterns are often seen in individuals suffering from abnormal grief reactions. These may include inappropriate fears, such as being afraid to leave the home, the belief that others are trying to harm them, or fearing to engage in normal activities such as driving a car. The bereaved may develop compulsions that require them to act out certain behavior patterns and they may have difficulty sleeping and may walk the streets at night without any obvious purpose.
An extreme example of morbid grief is the development of psychotic behavior patterns. In this situation, a person may hear voices instructing her to perform certain commands or she may sit for long periods of time staring blankly at a wall. This is particularly more common in people who have had previous psychotic behavior experiences, but it has been reported in otherwise normal-appearing individuals.
Bereaved individuals may have the inability to make decisions or to take initiatives and this problem may last 1 to 2 years after the loss of a loved one. In this situation, they may become susceptible to predators, which may include people who have been close to them. Likewise, another form of abnormal grief is a more active destructiveness. In this case, the grieving individual may carry out actions that may injure her financially, such as signing over her property to children or other family members, and running away. While this type of reaction is seen often after a divorce, it may also occur after the death of a spouse.
The final morbid grief reaction noted by Lindemann83 was agitated depression. This is probably the most dangerous of reactions, because though it is often seen in mourning mothers who lose children, it may occur with other losses as well. In this situation the bereaved becomes despondent and agitated. She cannot sleep. Guilt and anger become mixed in her thought process. She may also be depressed and contemplate suicide.
Grief reaction is often seen with the loss of an organ or body part, particularly one that relates to the self-image of the individual. Depression is frequently a strong component. Some investigators have defined four stages of incorporation that a patient must experience before accepting the loss of an important body part. These are impact, retreat, acknowledgment, and destruction. During the impact period, the woman may not even hear that the organ will be removed. She may actually deny that such information was given to her. However, during the retreat aspect, the individual usually tries to find an alternative to the recommendation that has been made to her. Thus, if a hysterectomy is recommended, she may seek second opinions in order to find an alternate therapy. This is probably healthy and should be encouraged. Acknowledgment occurs when the indivdual accepts the fact the organ will be removed and then asks many questions about how the procedure will be performed, the type of anesthetic that will be used, and the length of hospital stay. She may also wish to know how she will feel after the operation and the amount of time she may miss from work and other activities. During the final or reconstructive phase, she will question what she will be like after the procedure and how others will respond to her. In the case of a woman undergoing a hysterectomy, she may wish to know what she will be like sexually after the procedure, and how she may expect her husband to relate to her. In such matters, it is important to involve both members of the couple in these discussions, so that inappropriate fantasies are not considered. If a woman goes through the stages appropriately before the procedure is performed, she is less likely to experience depression and grief than if she is rushed into the procedure.86
The loss of a pet may set off an acute grief reaction, particularly in women with few human contacts within their life. This is frequently seen in the case of an elderly person living alone and is often relieved only when another pet is obtained.82 For many women, the loss of a job or the inability to perform a physical activity that they have enjoyed may also bring on some form of grief reaction.
It is particularly important for a physician caring for older people to understand a person’s reaction to impending death. In 1969, Elizabeth Kubler-Ross revolutionized our thinking about death by observing that death has always been distasteful to people and was never considered a possible outcome for their own lives. She found that people looked on death as a bad act, a frightening happening, and sometimes that death, in itself, called for retribution and punishment.87
Kubler-Ross described five stages through which a person progresses in the acceptance of the inevitability of death. These are: denial, anger, bargaining, depression, and acceptance. The denial stage is usually temporary and is brought about by the shock of learning that one is facing a condition from which she cannot recover. She may not remember that she has been told this, and it may be necessary to repeat the information to her on several occasions. Transition to particular acceptance may depend on the nature of her illness and the amount of time that she has left before death is expected to occur. It may also depend on the way in which she had prepared herself during her life to cope with a serious illness. As with the loss of an organ, she will often seek second opinions when given such information. This is healthy and should be encouraged.
The next stage is reached when the patient accepts the fact that death will occur in the foreseeable future and is usually represented by anger. She may be difficult to deal with during this period of time because she may take her anger out on both health care workers and family. This behavior may make these individuals less likely to want to deal with her, and this, of course, is the exact opposite of what she wants. It is best to approach a patient in this circumstance with understanding and patience.
The next stage is bargaining, at which time the patient essentially tries to put her life in order. She may rediscover her religious roots and make peace with family members and friends with whom she has quarrelled. She will often put her financial affairs in order and update her will. The bargaining aspect is probably carried out in the hopes of a reprieve, undoubtably from God. However, she will generally derive mental satisfaction from this stage.
Depression may occur at any time and it may be deep enough to necessitate treatment. This is often related to the person’s personality type and the way in which she copes with problems in general.
The final stage is acceptance. If the patient lives long enough, she will frequently get to this stage. It has been speculated that the acceptance stage may be simply the wearing down of an individual by the symptoms of a disease and that death may actually be a relief. Kubler-Ross, however, found in her studies that many people who were not suffering severe symptoms achieved acceptance.
Everyone will die sooner or later, but it helps for a physician to understand what a dying individual is experiencing so that she or he may be able to treat them with patience and kindness, and where possible make the final transition as reasonable as it can be.
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