Gynecologic issues continue throughout a woman’s lifespan. Elderly patients are less likely to report symptoms than younger patients, especially when pertaining to gynecologic concerns and sexual dysfunction. Sensitive history taking with careful attention to risk factors and sexual history is an important part of caring for older women. If a pelvic exam is going to be performed, adjustments may need to be made. This chapter focuses on the most common gynecologic issues of the elderly: vulvovaginitis and other vulvar conditions, menopausal symptoms, pelvic floor prolapse, sexual dysfunction, and gynecologic malignancies.

Hematologic abnormalities occur commonly in the elderly. The prevalence of anemia appears to increase with age and may be caused by various underlying etiologies, including iron deficiency, anemia of inflammation, or myelodysplastic syndrome. Thrombocytopenia due to underlying comorbidities, medications, or immune thrombocytopenia (ITP) may also occur. Hematologic malignancies such as chronic lymphocytic leukemia (CLL) and multiple myeloma also become more prevalent with age. A systematic approach to the evaluation of these hematologic abnormalities is imperative to help guide diagnosis and management. For acute or progressive conditions, a multidisciplinary team of both geriatricians and hematologists is essential to ensure proper diagnosis, frailty assessment, and initiation of appropriate therapies. Novel therapies for the various hematological malignancies are well tolerated, turning life-threatening illnesses into chronic disease that can be managed while preserving quality of life.

Driving is an essential and highly valued instrumental activity of daily living that becomes increasingly difficult to safely maintain with age-related medical conditions. Health-care providers are uniquely positioned to (1) identify and modify risk factors associated with on-road safety, (2) offer rehabilitation strategies to improve safety and extend driving life, and (3) combine clinical information with resources related to driving to support safe continued community for older patients. Clinicians face myriad challenges in assessing patients' medical fitness to drive, including multiple comorbidities, polypharmacy, and reluctance to address driving issues due to the potential impact on the relationship with the patient, as well as legal/ethical concerns. However, assessment and intervention are important to prevent injury and the potential loss of driving privileges, the latter which may have a negative impact on quality of life. This chapter describes the functional abilities necessary to be a safe driver at any age; acute and chronic medical risk factors for driving impairment; clinical tools to stratify risk of medical impairment to drive; opportunities to intervene or refer patients flagged for impairments; resources to support patients transitioning from driver to nondriver; and ethical and legal concerns for clinicians advising patients on driving.

In the USA, the majority of people living with HIV infection are older than 50 years of age. As these individuals get older, they face many of the challenges common to the aging experience but often earlier and more often. Cardiovascular, renal, bone, and liver disease, as well as mental health and substance use disorders, are more prevalent among people living with HIV than the general population. While factors related to HIV and its therapies can contribute to the risk of comorbid conditions associated with aging, data suggests more traditional factors are the main drivers. As such, clinicians caring for those living with HIV must be attuned to these risk factors, especially those for which interventions can prevent or delay their onset. All clinicians should recognize the importance of screening for HIV infection, starting with a good sexual and substance use history. Pre-Exposure Prophylaxis (PrEP) is a safe and effective biomedical intervention that can prevent HIV acquisition and should not be avoided or neglected as an option for those over 50, a population that makes up 15% of new diagnoses of HIV.

Dementia is a clinical syndrome characterized by global cognitive decline, involving deficits in memory and at least one other area of cognition, and affects over 47 million persons worldwide. While Alzheimer’s dementia is the most common cause, it commonly co-occurs with other dementia-related pathologies such as cerebrovascular disease and Lewy body disease. The evaluation and differential diagnosis of dementia involves history taking with outside informants, thorough medication review, examination focused on phenomenology and associated features, and a workup for potential causes. Depression and delirium due to other medical causes may overlap with symptoms of dementia, and should be considered in a dementia evaluation. The four pillars of dementia care are: (1) disease-oriented treatment, (2) symptomatic treatments, (3) supportive care for the patient, and (4) supportive care for the caregiver. Management usually involves psychological, social, and environmental adjustments. Disease-modifying pharmacotherapy for dementia is still under development, and has largely been unsuccessful. Although symptomatic treatments such as cholinesterase inhibitors and memantine are available, they provide a modest and temporary stabilization of cognitive changes associated with the disease, and do not reverse or stop the degenerative process.

Dizziness and imbalance are common complaints in the elderly, with etiologies ranging from benign (e.g., benign paroxysmal positional vertigo) to potentially life-threatening (e.g., cerebellar stroke). Therefore, the stakes can be high and an organized and methodical approach to the history and examination is essential. The days of classifying based on the symptom quality alone – “dizzy,” “vertigo,” “lightheadedness” – are over, as this approach is often misleading and can result in an incorrect diagnosis. Instead, identifying the timing and onset, duration, triggers, and associated symptoms allows the clinician to substantially narrow the differential diagnosis. From the history, a focused examination is be performed depending on the clinical scenario (e.g., Dix-Hallpike for positional vertigo; the “HINTS” exam in the acute vestibular syndrome), and the most appropriate test(s) can then be selected when appropriate. In the elderly, there are many potential non-neuro-vestibular contributors that must also be considered (e.g., polypharmacy, blood pressure), and to complicate the history and examination further, dizziness and imbalance are often multifactorial. This chapter offers a practical step-by-step approach to the evaluation of elderly patients presenting with balance and vestibular disorders.

Cancer is one of the leading causes of mortality and morbidity in the developed world. Age is a primary risk factor for developing cancer, and geriatric oncology is a rapidly emerging field that aims to address the specific needs of older patients with cancer. All clinicians who treat elderly patients should have knowledge of cancer risks, screening, and management principles. This chapter will review the principles of geriatric oncology, including geriatric assessment in the oncology population. We will then discuss the four most common solid tumors encountered in elderly patients: breast, prostate, colorectal, and lung cancer. Each section will include risk factors, screening and prevention, presentation, staging, prognosis, and multidisciplinary management of early- and late-stage disease.

While most older people are mentally healthy, persons over age 65 are vulnerable to the same spectrum of psychiatric disorders as are younger people. The heart of the psychiatric evaluation is the mental status examination, the here-and-now data-gathering equivalent of the physical examination, that allows a systematic examination of the major aspects of the patient’s mental state. Mood disorders, such as depression, are the most frequently clinically diagnosed and the most treatable psychiatric disorders in older people. Depression can commonly co-occur with anxiety, and clinicians must become comfortable asking their older patients about suicidal ideation, as rates of suicide are consistently higher among the elderly than for other age groups. The psychopharmacologic treatment of mood disorders and anxiety has advanced considerably, and many effective antidepressant and anxiolytic medications are available. Whichever medication the clinician chooses, one should start at a low dose and titrate up to a therapeutic dose gradually and slowly to prevent adverse effects. Psychotherapy is also an important part of treatment. No one approach is best; rather, a pluralistic approach that emphasizes life review and focuses on specific issues of concern is most effective for older people.

Delirium is a serious neuropsychiatric condition characterized by an acute change in cognition and attention that affects a significant proportion of hospitalized older adults and is associated with significant morbidity and mortality. Prevention of delirium is an important part of the care of hospitalized older adults. The Hospital Elder Life Program is a multicomponent intervention that has been shown to reduce the incidence of delirium. As many cases of delirium are overlooked, its diagnosis is important and can be achieved using the Confusion Assessment Method, which relies on four cardinal features of delirium: acute onset, inattention, altered level of consciousness, and disorganized thinking. The etiology of delirium is often multifactorial with contributions from predisposing factors (such as sensory impairment, chronic illness, and cognitive impairment) and precipitating factors (such as infection, polypharmacy, or illness). Once diagnosed, delirium should be evaluated with a thorough history, complete physical, medication review, and targeted tests in an effort to identify these factors. Management should focus on addressing the noted precipitating and predisposing factors with limited use of low-dose antipsychotic medications in patients at risk of self-harm.

Age-related changes in bone metabolism are reviewed as well as the impact of age-related diseases on bone health. Current guidelines for osteoporosis screening and treatment are provided. Management of other metabolic bone disorders of older adults is detailed, including the conditions of osteomalacia, hyperparathyroidism, Paget ’s disease, and renal osteodystrophy.

This chapter takes an historical perspective in describing and analyzing the first 6 months of the COVID-19 pandemic in nursing facilities in the United States. Optimal institutional infection control practices in nursing facilities in the pre-COVID-19 era are described, as are many of the challenges faced by nursing facilities in response to the COVID-19 pandemic. The role of the nursing facility medical director is described within the historical context. The structure and content of medical care within the post-acute and long-term care institutional setting are presented. Resources are presented to assist clinicians practicing in nursing facilities.

Alcohol use disorder and other substance use disorders are a growing, yet under recognized, health problem in older adults. Generally, screening tests and diagnostic examinations for these disorders are geared toward a younger population. There is a growing body of literature, however, that specifically addresses screening, diagnosis, and treatment substance use disorders in older adults. Several treatment strategies and medications are being used successfully to treat this older population. Physicians and other health-care providers must remain diligent in considering a diagnosis of substance use disorder in all their patients, regardless of age, gender, socioeconomic status, and comorbid conditions.

As the population continues to age, clinicians will increasingly encounter neurological conditions in routine clinical practice. Neurological problems in the elderly have a profound impact on quality of life and can at times be life-threatening. Diagnosis and management of geriatric neurological problems is complicated by often vague presentations and the presence of comorbid conditions, as well as complex physiology and pharmacology in this age group. Moreover, when caring for these patients it is of utmost importance to have a holistic approach and include family and caregivers when developing care plans. In this chapter we review muscle weakness, sensory loss, seizure disorders, and headaches in the elderly patient. Causes, impact on quality of life, and available treatment options are discussed. Other topics including delirium, dementia, cerebrovascular disease, and gait disorders will be covered elsewhere.

Decreased vision in the aged population poses significant morbidity and decreases quality of life. At least one third of the American population over age 65 has significant vision compromise due to ophthalmic disease. Decreased vision limits independence and poses significant economic and societal burdens. Ophthalmic disease in the elderly poses significant challenges to patients and providers due to the vast and diverse spectrum of ophthalmic conditions, and therefore requires specialized care by optometrists and ophthalmologists.

Ophthalmic diseases are seen at a higher frequency in aged patients and include structural changes, malignancies, and infections of the eyelids and orbit. In addition, diseases such as cataracts, age-related macular degeneration (ARMD), glaucoma, and ischemic optic neuropathy are seen at a significantly higher incidence in elderly patients and can result in severe vision loss. Routine ophthalmic care is required to identify, manage, and treat such diseases in order to prevent sequelae, optimize independence, and preserve vision. Medical therapies, surgical intervention, low-vision aids, and social support systems can be utilized to aid in treatment.

Falls are common in older adults. Falls are the number one cause of injury and death in the geriatric population. Fortunately, falls can be prevented. When evaluating falls acute triggers of falls should be distinguished from chronic predisposing factors. Syncopal/pre-syncopal episodes comprise the minority of falls causes. Gait and balance deficits are the most important culprits contributing to falls. Exercise is the only single intervention shown to prevent falls in older adults. Multicomponent medical and biomechanical interventions should be utilized to successfully treat falls.

Aging leads to progressive deterioration of physiological function and predisposes to pathological processes. Common geriatric syndromes (such as depression, dementia, falls, mobility impairment, delirium, and osteoporosis), along with age-related impairment in appetite, absorption, and food intake, affect nutrition, symptom presentation, and response to therapy of common gastrointestinal (GI) disorders in the elderly. Age-associated changes in drug metabolism and polypharmacy can result in potential interactions and side effects of drugs used in the treatment of GI diseases, which in turn complicates their management. Polypharmacy, which is common in the elderly, can also exacerbate digestive symptoms. Elderly patients with neurocognitive decline often have atypical presentation of their GI disorders. These factors can make the diagnosis of GI diseases in the elderly more challenging, as they may require different management approaches. In this chapter, we discuss the common GI disorders that affect the elderly with special focus on age-related pathophysiology and clinical implications.

This chapter focuses on resources, strategies, and interventions when working with older adults with low health literacy. Integrating practical ways of engaging this population can enhance and improve older adults’ health status, and enhance the interaction and relationships with health-care providers. As patients are asked to take a more active role in the management of their health, enabling participation and better communication, the patients’ involvement can have a dramatic effect in improving health outcomes and patient satisfaction. Health professionals can encourage clear health communication to promote the overall health and well-being of older adults.

Engaging and working with older adults with low health literacy is critical to improving health outcomes. For those with low health literacy, it's important to ensure health messages, both verbal and written, are communicated clearly so that patients can understand what they need to do, in order to achieve better health and make informed decisions about their care. Older adults may be more hesitant to ask questions of their health providers, or lack the skills to find, evaluate, and utilize health information online. Other factors, such as physical, cognitive, and social age-related changes, can also impact older adults’ ability to understand and process health information.