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 CHAPTER

335 Geriatric Syndromes

Dinesh Gupta,  Gursimran Kaur,  Akriti Gupta

“Do not go gentle into that good night, old age should burn and rave at close of day;
Rage, rage against the dying of the light”
–Dylan Thomas

ABSTRACT
Geriatric syndromes refer to “multifactorial health conditions that cross organ systems and discipline-
based boundaries. Five major geriatric syndromes are: (i) Falls; (ii) Urinary incontinence (UI); (iii)
Pressure ulcers; (iv) Delirium; (v) Functional decline. Frailty is the common end product of these
geriatric syndromes. The diagnostic workup of geriatric syndromes should consist of a search for
both a possible single disease that may have precipitated the symptom(s), and of a multiple risk
factor assessment. It includes assessment of several domains, including physical, mental, social, economic,
functional and environmental, with the goal of guiding the selection of interventions to restore or preserve
health of the aging individual. Correction of reversible precipitants and contributing factors is critical
and lifestyle and behavioral modifications are beneficial. Besides this, nutritional assessment and
correction and pharmacotherapy and nonpharmacological measures are of immense help. Patient and
care giver education and qualtiy nursing care can not be over emphasized.

Five major geriatric syndromes are:

INTRODUCTION
Physical aging is a part of normal biological process
involving physiological degeneration of various organs,
and requires no treatment. As people are living longer,
the prevention of disability forms the basis of healthy
aging. Geriatric syndromes refer to “multifactorial
health conditions that occur when the accumulated
effects of impairments in multiple systems render
(an older) person vulnerable to situational changes”.
A geriatric syndrome usually involves multiple
factors and multiple organ systems, and reporting of
unique features of common health problems in older
people.
These syndromes cross organ systems and discipline-
based boundaries, along with their multifactorial
nature. For example, an elderly patient having urinary
tract infection (UTI) may present to the emergency
room with delirium and altered cognitive and neural
functions.1
The criteria for defining a geriatric syndrome
therefore, include: (1) age-related disorder; (2) with
functional decline; (3) involving multiple systems; (4)
with complex multifactorial etiology, (5) poor outcome;
(6) but treatable.
1. Falls
2. Urinary incontinence (UI)
3. Pressure ulcers
4. Delirium
5. Functional decline.
The common risk factors of these giants of the
geriatric syndromes include:
zz Age
zz Cognitive impairment
zz Functional impairment
zz Impaired mobility.2
Frailty is the common end product of these geriatric
syndromes. The main feature of frailty is the reduced
ability to regain physiological homeostasis after a
stressful and destabilizing event. The age-related decline
of physiological reserve and function of multiple organ
systems, in elderly, renders them inept to cope with the
acute stresses. Frailty in turn, may further intensify the
shared risk factors and the geriatric syndromes.3
FALLS
A fall is an unintentional event that results in the
person coming to rest on the ground or another lower

335.indd 1753 12/28/2015 1:35:17 PM

 level. Falls can be described in terms of three phases.
Initiating events involve extrinsic factors such as
SECTION 27
environmental hazards; intrinsic factors such as
unstable joints, muscle weakness, and unreliable
postural reflexes; and physical activities in progress at
the time of the fall. The second phase involves a failure
of the systems for maintaining upright posture to detect
and correct this displacement in time to avoid a fall.
This is generally the factor intrinsic to the individual,
such as loss of sensory function, impaired central
Geriatrics
processing, and muscle weakness. The third phase is an
impact of the body on environmental surfaces, usually
30
the floor or ground, which results in the transmission
of forces to body tissue and organs. This is followed by
Section 
phase of sequelae, which may be physical, psychological
or social—all with disabling prospects. Falls are
extremely common among older adults. Each year,
about one out of three people older than age 65 years
who is living in the community falls; this rate increases
with advanced age and is higher among people who are
living in institutional settings. Falls cause considerable
mortality and morbidity. The risk factors for falls
include:
Intrinsic risk factors:
zz Gait and balance impairment
zz Peripheral neuropathy
zz Vestibular dysfunction
zz Muscle weakness
zz Vision impairment
zz Medical illness
zz Advanced age
zz Impaired activities of daily living (ADLs)
zz Orthostasis
zz Dementia
zz Drugs.
Extrinsic risk factors:
zz Environmental hazards
zz Poor footwear
zz Restraints.
Assessment for Falls
History of previous falls, gait/balance impairment,
use of psychoactive medication and decreased muscle
strength are the most important predictors of falls.4
The assessment of fall patient includes, a detailed
history of the circumstances of the falls, which
can point to a specific etiology or narrow down the
differential diagnosis. This includes sudden rise from
a lying or sitting position (orthostatic hypotension),
trip or slip (gait, balance or vision disturbance or an
environmental hazard), drop attack (vertebrobasilar
insufficiency), looking up or sideways (arterial or
carotid sinus compression) and loss of consciousness
(syncope or seizure). History should also be taken for
evaluation of risk factors including careful review of
medication, functional and environmental assessments.
1754 Physical examination should include gait assessment,
335.indd 1754
sensory assessment (including hearing and vision),
measurement of orthostatic vital signs, and neurologic
and musculoskeletal assessment, as well as depression
and cognitive impairment screening. The examination
should also include a review of footwear and gait aid
appropriateness.
Depending on the results of this risk assessment,
appropriate multifactorial interventions may be
undertaken for preventing ambulatory falls:
Home assessment and modification for high-risk
zz
individuals
Exercise programs that include strength, gait, and
zz
balance exercises, such as physiotherapy or Tai Chi
zz Vitamin D supplementation in doses greater than
700 IU/d
zz Review medications, minimizing psychoactive
medications and reducing the total number of
medications
zz Management of postural hypotension
zz Expedite cataract surgery on the first affected eye
zz Consider pacing in cardioinhibitory carotid sinus
hypersensitivity and recurrent falls
zz Management of foot problems and recommend use of
antislip shoe devices for the outdoors
zz Patient and caregiver education, especially of the
importance of specific environmental improvements.5
URINARY INCONTINENCE
Urinary incontinence is an involuntary loss of urine
that is objectively demonstrable and leads to a social or
hygienic problem. UI is a troubling and common disorder
among geriatric patients. Additionally, many older and
especially frailer persons require caregivers, and UI can
lead to caregiver stress and institutionalization of the
frail elder. The urinary continence is maintained due
to the integrity of the lower urinary tract, the nervous
system, the visceral supporting mechanism (pelvic floor)
and the urine production mechanism. Also, it requires
perception and interpretation of the urge, and physical
capacity to go to the toilet and to perform the activity.
With aging the lower urinary tract (LUT) undergoes a
series of morphological and functional changes, which
alter these functions.
Some of these alterations include, bladder
overactivity and urgency, impaired bladder contractility
and increased residual urine, and decreased functional
bladder capacity. Prostatic hypertrophy—benign, or
due to malignancy may cause UI and LUT symptoms.
Estrogen deficiency in women causes increased
incidence of atrophic vaginitis and related symptoms,
along with increased incidence of recurrent UTIs, which
further increase UI. Age-related changes in the actions
of central neurotransmitters, their receptors, or the
cellular events they stimulate may contribute to the
development of UI in frail older persons.6
A practical approach to incontinence in elderly
patient is based on its duration (acute or chronic).
12/28/2015 1:35:17 PM
 Acute or transient incontinence refers to cases of
short course incontinence (lasting less than four weeks),
including those situations in which loss of continence
is considered to be functional, without any associated
structural disorder. The causes for these include:
D Delirium
Dementia
Diabetes
R Restricted mobility
Retention
I Infection
Inflammation
Impaction of stool
P Pharmaceutical agents
Psychological causes.
Chronic or established incontinence: When
the incontinence lasts longer than four weeks and is
commonly associated with structural disorders, either
in the urinary tract or outside of it (e.g. nervous
system). Transient incontinence may eventually be
established or chronic in some cases. This established
incontinence might be further classified depending on
the etiopathogenesis.
zz Urge incontinence presents as urgency, frequency
and nocturia. It is associated with a strong urge to
void. It is caused by an overactive detrusor muscle
causing excessive involuntary bladder contraction,
UI is associated with various neurological conditions
including stroke, spinal cord lesions, dementias, and
Parkinson’s disease.
zz Stress incontinence is associated with actions that
increase intra-abdominal pressure such as coughing,
sneezing, bending, lifting, or laughing. The cause is
pelvic muscular weakness causing urethral hyper­
mobility, multiparity, hypoestrogenism, obesity, and
pelvic surgical procedures like prostatic resection.
zz Overflow incontinence occurs when the bladder
muscle is overdistended. May present with stress
or urge symptoms. The cause is an underactive
bladder muscle, or a bladder outlet or urethral
obstruction leading to overdistension and overflow.
There are two different mechanisms: bladder outlet
obstruction (prostatic hyperplasia, urethral stenosis,
fecal impaction) and bladder contractile impairment
(spinal cord lesions, peripheral and/or autonomic
neuropathy, detrusor myopathy, anticholinergic
drugs).
zz Functional incontinence occurs when a physical
or psychological impairment impedes continence
status despite a competent urinary system.7
Mixed type of incontinence, including features of
more than one aforementioned type, may also occur.
Assessment for Urinary Incontinence
History should include UI onset, frequency, volume,
timing, and associated factors or events. Physical
examination should include cognitive and functional
335.indd 1755
assessments along with potential comorbid conditions
associated with UI. Rectal examination is used to
CHAPTER 335
assess for masses, tone, and prostate nodules or
firmness in men (not size). The neurologic evaluation
should include evaluation of sacral cord integrity with
perineal sensation. Vaginal mucosa should be evaluated
for severe atrophy, and the pelvic examination should
include evaluation for pelvic organ prolapse (cystocele,
rectocele, uterine prolapse) with straining. Urine
analysis is done to look for hematuria (and glycosuria
Geriatric Syndromes
in diabetics). Pyuria and/or bacteriuria likely represent
asymptomatic bacteriuria—in women without dysuria,
fever, or other signs of UTI, especially if UI is not acute.
Ultrasound or catheterization is used to look for post-
void retention, especially in frail elderly with recurrent
UTIs and neurological concerns. A clinical stress test, by
making a relaxed patient give a single vigorous cough
may be helpful in documenting in patients with stress
UI. Cystoscopy and urodynamic studies may be used
when etiology is questionable and intervention may be
required.7
Treatment
Correction of reversible precipitants and contributing
factors is critical. Lifestyle and behavioral modifications
that are beneficial include avoiding extremes of fluid
intake, especially in the evening for nocturia, minimizing
caffeinated beverages, and alcohol; weight loss and
smoking cessation. The two main behavioral therapies
are bladder training and pelvic muscle exercises, both
of which are effective for urge, mixed, and stress UI and
are often used in combination.
Pharmacologic treatment is largely limited to anti­
muscarinic agents for urge UI, overactive bladder, and
mixed UI. Of these, oxybutynin (immediate and extended
release, and topical patch), tolterodine (immediate and
extended release), solifenacin, darifenacin, and trospium
have been used widely. Pessaries may benefit women
whose stress or urge UI is exacerbated by bladder or
uterine prolapse. Duloxetine is used for moderate to
severe stress UI, especially in women. Alpha-blockers
are beneficial in men with LUT symptoms, but have
to be given cautiously due to hemodynamic effects.
Desmopressin is avoided in elderly UI due to its
propensity to precipitate hyponatremia. Catheterization
may be required in the cases of chronic urinary retention
or bladder impaired contractility, in which the patient
keeps high post-void residual urine. Minimally invasive
therapies available for those with urge UI refractory to
antimuscarinics, include botulinum toxin injection into
the bladder wall and sacral neuromodulation. Surgery
may be beneficial in refractory cases, especially in
women with stress incontinence.6-8
PRESSURE ULCERS
Pressure ulcers are caused when an area of skin and the
tissues below are damaged as a result of being placed 1755
12/28/2015 1:35:17 PM
 under pressure, sufficient to impair its blood supply. tenderness, purulent discharge, and presence of foul
They are also known as pressure sores, bedsores, odor. However, because of associated comorbidities
SECTION 27

and decubitus ulcers. Pressure ulcers have important
consequences both for patients and for the health care
system. They can lead to severe or intolerable pain,
are prone to infection, and are associated with high
mortality rates.
National Pressure Ulcer Advisory Panel (NPUAP)/
European Pressure Ulcer Advisory Panel
Geriatrics
and advanced age, systemic signs, such as fever and
leukocytosis, may be minimal or absent, and even local
signs of inflammation may not be obvious. One should
assess for the presence of exudate, odor, sinus tracts,
necrosis or eschar formation, tunneling, undermining,
infection, healing (granulation and epithelialization),
and wound margins. The staging of ulcers should be
done accordingly.

(EPUAP) International classification of pressure

Nutritional assessment is important, as patients
ulcers:
who are malnourished have more bony prominences
30

Stage I: Nonblanchable erythema of intact skin.

and are therefore at greater risk for pressure ulcers.
Stage II: Partial-thickness skin loss involving the Microbiological evaluation should be done with an
Section 

epidermis or dermis; lesions may present as an abrasion, aim to distinguish between bacterial invasion and
blister, or superficial ulcer. colonization. Blood cultures or cultures of deep-
tissue biopsy specimens generally are more clinically
Stage III: Full-thickness skin loss that may extend
significant than are cultures of superficial swab
to, but not through, the fascia; the ulcer may be
specimens or aspiration of the pressure ulcer. Imaging
undermined.
studies are useful in the evaluation of pressure ulcers
Stage IV: Full-thickness skin loss involving deeper for determination of the presence of osteomyelitis and
structures, such as muscle, bone, or joint structures. for delineation of the extent of deep-tissue involvement.
It includes plain radiography, CT and MRI and
Unstageable ulcer (depth unknown): Full thickness
radionuclide scintigraphy.11
tissue loss in which the base of the ulcer is covered by
slough (yellow, tan, gray, green or brown) and/or eschar
(tan, brown or black) in the wound bed. Management of Pressure Ulcers
Reduction of extrinsic factors—in particular, pressure
Suspected deep tissue injury (depth unknown):
relief—is a cornerstone of therapy: this may be done
Purple or maroon localized area of discolored intact
with the use of pressure-reducing devices like low-air
skin, or blood-filled blister due to damage of underlying
loss or air fluidized bed, or static devices such as foam-
soft tissue from pressure and/or shear.9
or fluid-filled mattresses or supports, in patients who
Risk factors for the development of pressure ulcers
can change positions independently.
are either intrinsic or extrinsic. Among the intrinsic
Debriding of necrotic tissue, cleansing the wound,
risk factors, limited mobility and poor nutrition are the
managing bacterial load and colonization, and selecting
strongest predictors of development of pressure ulcers.
a wound dressing are other important components
Elderly persons have less subcutaneous fat, decreased
of ulcer management. Debridement, however, is
dermal thickness, and decreased sensory perception.
not recommended for heel ulcers that have stable,
These factors make elderly patients prone to more rapid
dry eschar without edema, erythema, fluctuance, or
tissue injury and less likely to respond to tissue cues to
drainage. Appropriate antibiotic therapy is instituted
change position. Beside these, incontinence, diabetes
in infected pressure ulcers.
mellitus, stroke, white race, skin abnormalities, and
Urinary catheters or rectal tubes may be needed to
male sex have been implicated in some studies. The
prevent bacterial infection from feces or urine.
extrinsic factors that predict increased risk include
Prevention is the most important aspect in an elderly
pressure, friction, shear stress, and moisture. Of these,
frail patient who is susceptible to develop pressure
pressure is the most significant predictor of pressure
ulcers. Risk factor assessment on hospital visit and
sores. The most common sites for pressure ulcers are the
application of appropriate preventive measures, such
sacrum, heels, ischial tuberosities, greater trochanters,
as, improving general health, minimizing external
and lateral malleoli. Friction can damage superficial
forces, and promoting educational programs about
skin, and shear stress can crimp the deeper vessels,
pressure ulcers to caregivers are the keystones in
leading to increased ischemia. Moisture can increase
this. The emphasis of quality nursing care cannot be
pressure ulcer risk, and also increase incidence of
overemphasized in this regard.11,12
infection in the sore.9,10

Assessment for Pressure Ulcers DELIRIUM

Thorough clinical examination is critical to the Delirium is an acute, fluctuating syndrome of altered
identification of pressure ulcers that may serve as attention, awareness, and cognition precipitated by an
an occult focus for infection. Look for signs of soft- underlying condition or event, in vulnerable persons.
1756 tissue involvement, such as warmth, erythema, local Delirium is frequently described using terms like altered

335.indd 1756 12/28/2015 1:35:17 PM

 mental status, acute confusional state, sundowning,
encephalopathy, and acute organic brain syndrome.
Delirium is a serious complication for older adults
because an episode of delirium can initiate a cascade
of deleterious clinical events, including prolonged
hospitalization, loss of functional independence,
reduced cognitive function, and death.
The clinical diagnosis is based on history from
collateral sources (family members, caregivers, etc.)
and bedside observations. Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) criteria for
delirium include:
A. A disturbance in attention (i.e. reduced ability
to direct, focus, sustain, and shift attention) and
awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time
(usually hours to a few days), represents a change
from baseline attention and awareness, and tends to
fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory
deficit, disorientation, language, visuospatial ability,
or perception).
D. The disturbances in Criteria A and C are not
explained by another pre-existing, established, or
evolving neurocognitive disorder and do not occur
in the context of a severely reduced level of arousal,
such as coma.
E. There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is a direct physiological consequence of
another medical condition, substance intoxication
or withdrawal (i.e. due to a drug of abuse or a
medication), or exposure to a toxin, or are due to
multiple etiologies.13
Development of delirium depends on a complex
interaction of multiple risk factors. The risk factors
are divided into ones that the patient arrives with
(predisposing factors) and the iatrogenic factors
(precipitating factors). In elderly patients, dementia is
the most prominent risk factor, being present in up to
two-thirds of all cases of delirium. Other predisposing
factors include severe medical illness, comorbid
psychiatric disorder like depression, alcoholism, poor
functional status, inactivity, malnutrition, male gender,
and hearing or vision impairment, social isolation.
Common precipitating factors involving drugs, of which
sedative hypnotics, narcotics, anticholinergic drugs,
corticosteroids, and other psychoactive medication are
common culprits. Beside the polypharmacy, infection
(urinary tract, lungs, skin, blood), metabolic disturbances
(fluid, electrolytes, nutrition), structural upsets (surgery,
trauma, cardiac ischemia, central nervous system
and pulmonary insults), and retention problems (fecal
impaction, constipation) may be involved.14
Assessment for Delirium
Clinically, in delirium, patients may be hyperactive
(agitation, restlessness, hypervigilance), or hypoactive
335.indd 1757
(apathetic, lethargic) or mixed. In geriatric delirium,
more subtle manifestations include new-onset
CHAPTER 335
incontinence, falls or refusal to mobilize, dysphagia,
dysarthria, mild disorientation, and slowing in the
speed of mental processing. The detailed history
of the mental status change and identification of
potential predisposing, precipitating, or perpetuating
factors, such as recent medication changes or signs
of medical illnesses is of utmost significance. The
Confusion Assessment Method is the most effective
Geriatric Syndromes
tool in identifying delirium. The physical examination
should be comprehensive and should include a careful
search for cardiorespiratory, neurologic, and infectious
disorders.
Treatment
The mainstay of treatment remains the diagnosis
and treatment of the conditions predisposing to,
precipitating, or perpetuating the delirium. Medications,
particularly psychotropic, narcotic, and anticholinergic
medications, should be reduced or discontinued
whenever possible. Physical illnesses should be treated
promptly. If needed, pharmacological therapy in the
form of minimal possible doses of antipsychotic drugs
may be used. Nonpharmacological measures are of
immense help, and including measures like reducing
noise; providing soft lighting, clocks, and calendars;
orienting the patient to time and place; correcting
sensory deficits with eyeglasses and hearing aids;
increasing the patient’s sense of control) may reduce
symptoms.15
FUNCTIONAL DECLINE
Functional status is determined by the ability to
perform activities of daily living (ADLs)—self-care
activities that a person performs daily like, eating,
dressing, bathing, ambulating, and toileting, and
instrumental activities of daily living (IADLs)—which
a person performs to live independently, like shopping
for groceries, meal preparation, housework, getting to
places beyond walking distance, managing medications,
managing finances, and using a telephone.
Common health problems in elderly, which cause
functional decline, include cardiopulmonary diseases,
neurologic conditions, diabetes mellitus, cancer, obesity,
dementia, affective disorders, ophthalmologic and
auditory disorders, and fractures. In geriatric population,
the presence of more than one health issue may have a
more disabling effect than predicted. Some combinations
of conditions have predominant effects on self-care (e.g.
arthritis and stroke), whereas others primarily affect
mobility (e.g. arthritis and heart disease).16
During hospitalization, the elderly patient often
experiences reduced mobility and activity levels.
Functional decline, including changes in physical
status and mobility, has been identified as the leading
complication of hospitalization for the elderly.17 1757
12/28/2015 1:35:17 PM
 Assessment of Functional Status
History taking, with emphasis on characterization
SECTION 27
of the functional disability itself and focusing on the
course of functional decline, associated symptoms, and
specific tasks that have been affected by the disability,
including basic ADLs is important. An assessment of the
existing comorbid conditions, cognition, mood disorders,
pain, poor nutrition, adverse medication reactions,
sensory impairments, and muscular weakness should
Geriatrics
be done. The physician should also assess contextual
factors, including social support, financial resources,
30
and environmental factors.
Treatment
Section 
Medical and surgical interventions that typically
increase capacity (e.g. cataract surgery, hip
replacement, oxygen supplementation, medications
to improve cardiac output) should be undertaken
promptly. Also, exercise, nutritional supplements, and
prosthetic devices (e.g. hearing aids) greatly improve
the overall functional status. During hospital stay, early
mobilization protocols, timely removal of catheters,
reorientation programs should be undertaken.18
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