Consideration of Anticoagulation: Surgical Care for the Elderly in Current Geriatrics Reports Abstract Introduction The geriatric population in the USA is growing at a dramatic rate. As this segment of the population increases in number, surgical providers will increasingly treat and evaluate patients with age-specific needs that affect surgical or trauma management. Consequently, surgeons should be familiar with trends in prescribing oral anticoagulants (OACs), their association with outcomes, and the guidelines for reversing and prescribing these medications. Results Warfarin was the only oral anticoagulant available in the USA until 2010 when non-vitamin K antagonist oral anticoagulants (NOACs) were introduced to the market. Since then, they have rapidly gained a majority of the US market share. The implications of NOAC use on bleeding complications such as in traumatic brain injury (TBI) are unclear, but evidence suggests that NOACs may be safer than warfarin. Guidelines for anticoagulation reversal in life-threatening bleeding associated with warfarin are well established, but optimal utilization is evolving for most NOAC agents. Conclusion The use of anticoagulation therapy has changed dramatically over the last decade. These changes are multifactorial and include the increasing prevalence of OAC use, and the introduction of NOACs. Consequently, challenges associated with managing OAC in the elderly will only become more complicated over time. Surgical providers need to be aware of these changes and update their practice on the shifting epidemiology of this population, evolving guidelines, and new reversal agents.

Mobility Challenges Among Older Adult Mobility Device Users Abstract Purpose of Review This review describes recent research regarding challenges to mobility experienced by older adult mobility device users. Recent Findings Different elements that affect mobility in this population were highlighted using the Human Activity Assistive Technology model. Key constructs in this model include the human (personal factors); the desired activity (mobility); assistive technology (mobility devices); and context (physical and social environmental factors). Poor mobility skills and lack of mobility confidence are personal factors that can limit the places that older adults go. However, new mobility devices are being developed to facilitate independent mobility. The design of the built environment and poor signage are aspects of the physical environment that can constrain mobility and impair wayfinding. Likewise, social factors including funding and prescription policies can reduce access to devices and needed services, and stigma can cause older adults to self-limit their mobility. Summary Addressing these challenges could reduce the difficulties that users encounter while navigating the environment and facilitate the mobility and social participation of older adults.

Aging Patients in Correctional Settings Abstract Purpose of the Review The United States (US) has the highest number of incarcerated people in the world. This incarcerated population is aging disproportionately compared with the general population. Correctional facilities need to develop geriatric competencies to respond to this aging crisis. Recent Findings Older inmates have an increased burden of chronic medical conditions. This leads to higher healthcare utilization and costs across correctional systems. Daily symptoms, such as pain, and geriatric syndromes, such as cognitive impairment, frailty, and sensory impairment, are common but are frequently undertreated. Summary There is a national shortage of geriatricians and minimal geriatric expertise within the correctional system. Geriatric models of care need to be embedded within correctional facilities to help patients maintain function, health, and dignity as people age within the criminal system.

The Role of Palliative Care in the Elderly Surgical ICU Patient Abstract Purpose of Review Management of geriatric trauma patients is a multidisciplinary effort. The purpose of this paper is to review recent literature and further elucidate the role of palliative care in the geriatric trauma patient population. Recent Findings Recognition of the resources provided by palliative care continues to increase. Adoption of early consultations may improve both patient and family experiences especially in end-of-life situations. Summary Early identification of at risk patients allows for proper utilization of consultative resources. Palliative care has several defined roles in the elderly trauma population which include end-of-life decision-making, spiritual support, family support, and symptom management. Integration of palliative care into the multidisciplinary team caring for geriatric trauma patients should be undertaken.

Exercise and Protein Supplementation for Prevention and Treatment of Sarcopenia Abstract Purpose of Review Sarcopenia results in disability and negatively impacts older adults’ ability to live independently. The purpose of this review is to summarize the recent literature regarding the effectiveness of exercise and nutritional supplementation as a treatment for sarcopenia. Recent Findings A number of recent studies demonstrated improvements in muscle mass and function in sarcopenic adults through resistance training and combination resistance+aerobic exercise training. Variability in program design, duration, and intensity leads to inconsistent findings in the literature. The addition of protein supplementation to resistance training appears to lead to more consistent improvements in muscle mass and function in sarcopenia. Summary Appropriately dosed exercise and dietary interventions improve muscle mass and function. Whether sarcopenia can be “cured” through these interventions, or if improved function and prevention of further declines should be the treatment goal, is unknown. Future research is needed to optimize the exercise prescription for treatment of sarcopenia.

Pressure Injury in the Critically Ill Elderly Patient Abstract Purpose of Review Pressure injuries are a major problem for all people, but they are especially problematic in the elderly patient. The goal of this review is to provide strategies for reducing the incidence of these problem wounds in the geriatric population. The review asks: what are the risk factors for developing pressure injuries? And how are these risks magnified in the elderly population? Recent Findings There are several wound healing organizations that have developed definitions and strategies for dealing with pressure injuries. Risks can be divided into “intrinsic” and “extrinsic” factors. “Intrinsic” risk factors include limited mobility, malnutrition, comorbidities, and aging. “Aging” leads to inexorable body and skin changes. There are “intrinsic” skin alterations—wrinkling, thinning, sagging, increased fragility—that occur in everyone as they age. One can accelerate age-related changes in the skin with “extrinsic” factors—exposure to ultraviolet light, smoking, and other stresses. All of these “intrinsic” risks interact with “extrinsic” risk factors that are the forces that cause the actual injury. “Extrinsic” risk factors include pressure from a firm surface, friction, and moisture. Summary By addressing the specific risk factors that predispose the elderly to pressure injuries, any clinician can reduce the incidence of these problematic wounds.

Living In Place: the Impact of Smart Technology Abstract Purpose of Review To discuss impact of smart technology and highlight specific types of technologies that would be supportive of older adults to Live In Place. Recent Findings Smart technology has potential to increase the ability of older adults to remain in their homes by monitoring health, safety, and falls, preventing potential accidents and injuries. Several types of smart technology were identified in the literature as supportive of Living In Place. These include sensor systems with predictability analysis, wearable technology, information and communication technology, and smart homes. In general, the less intrusive and less high maintenance a smart technology, the better received it is by an older adult. Several considerations need to be made when choosing an appropriate smart technology device. Older adults’ views, beliefs, and comfort regarding smart technology play a large role in adoption rate. Smart technology use requirements also need to match the older adult’s abilities, while supporting areas of impairment. Finally, clinicians need to consider ethics regarding smart technology, such as privacy concerns and informed consent. As a result, a comprehensive assessment process is necessary in order to make appropriate recommendations. Summary Smart technology is an increasingly large part of our world with more devices being developed every day. It is important to take into consideration the older adult’s needs, abilities, and tolerance for technology in general, while also considering the features of devices before making recommendations. The appropriate smart technology has the potential to increase the ability of older adults to remain in their homes by supporting their independence in daily activities.

Mental Health Care of Older Adults: Does Cultural Competence Matter? Abstract Purpose of Review Minority and limited English proficiency seniors are consistently found to have multiple health care disparities, including higher incidence and prevalence of various mental health conditions. The purpose of this paper is to review current literature on culturally competent mental health care for older adults. Recent Findings The US population is aging and becoming increasingly more diverse. Minority and underserved groups of seniors are known to suffer from lower health literacy, limited English proficiency, and poorer health care outcomes. Quality mental health care is particularly dependent on being able to deliver services that are culturally and linguistically component. Federal agencies, accreditation and regulatory bodies, and mental health advocacy groups all offer online resources to facilitate and empower providers and mental health care organizations to enhance their ability to provide culturally competent services. Summary There is evidence that cultural competence training improves provider awareness of disparities and cultural needs of a given target population. There are also trends that suggest that culturally competent care improves patient satisfaction and perceptions of providers. Future research is needed to further define the degree to which culturally competent care, and which aspects of that care, can reduce disparities and improve patient outcomes.

Managing Infectious Disease in the Critically Ill Elderly Patient Abstract Purpose of the Review Infections and subsequent sepsis are an increasing cause of hospital admission and critical illness in the elderly population. The risk factors that predispose elderly patients to infections, such as comorbidities and frailty, also contribute to prolonged recovery times and subsequent mortality. Recent Findings Elderly patients may present with atypical symptoms such as delirium and remain afebrile thus delaying the diagnosis of infections. White blood cell count is not as useful in the diagnosis of infection as other biomarkers such as procalcitonin. Once an infection has begun, the elderly patient has less physiologic cardiac and respiratory reserve and develops end organ damage more rapidly. Frailty itself is strongly associated with high rates of first time sepsis. Mortality risk from sepsis clearly increases with age. Appropriate antibiotics and source control are necessary components of sepsis management as is early fluid resuscitation. Fluid resuscitation must be performed judiciously with appropriate endpoints utilizing bedside cardiac ultrasound and IVC collapsibility to avoid fluid overload. Acute kidney injury (AKI) occurs in 1/3–2/3 of elderly septic patients and increases mortality. AKI is potentially preventable with appropriate and timely fluid resuscitation and avoiding nephrotoxic medications including loading doses of vancomycin, limiting aminoglycoside exposure to < 3 days, and minimizing colistin use. Source control within 12 h when appropriate improves outcome. Specific infections, including Clostridium difficile, community-acquired pneumonia, and urinary tract infection, pose unique challenges in the elderly. Early goals-of-care discussions emphasizing potential complications and undesirable outcomes must be discussed when caring for critically ill elderly patients. Summary Early recognition of sepsis via identification of atypical signs and symptoms in elderly patients is critical. This allows for timely and appropriate therapy to decrease the incidence of end organ damage and mortality in high-risk elderly patients.

Non-invasive Ventilatory Support in the Elderly Abstract Purpose of Review The first description of non-invasive ventilation use began in the 1920s. Since then, its role in patient care has evolved through increased clinical knowledge and scientific advancements. The utilization of non-invasive ventilation has broadened from initial application in acute in-hospital ICU settings to now include the outpatient settings. This review discusses the history of non-invasive ventilation and its role in acute in-hospital chronic obstructive pulmonary disease (COPD) exacerbations, cardiogenic pulmonary edema, and weaning from mechanical ventilation in the elderly. The elderly population represents a significant portion of patients hospitalized for the aforementioned conditions. These groups often have more limitations related to the use of invasive mechanical ventilation (IMV); therefore, it is essential to understand the impact of non-invasive ventilation on hospital outcomes. Recent Findings There is strong clinical evidence supporting the use of non-invasive ventilation in patients with respiratory failure secondary to acute COPD exacerbations and cardiogenic pulmonary edema. When compared to standard medical management of these conditions, there is a consistent and significant reduction in the rate of endotracheal intubation and in-hospital mortality. Summary The basis of non-invasive ventilation applicability has been determined by significant reduction in mortality and intubation rates. Although survival benefits have been observed, there still remain limitations to the clinical applicability of non-invasive ventilation in certain patient populations and conditions that require further investigation.