Author: kindredcirclecare

Why is Motion Important?

Most people take free, comfortable movement for granted. Motion is meant to be smooth and painless. The ligaments, tendons, muscles, and joint capsules that surround each joint in the body work best if they are used regularly. As people get older, however, muscles gradually lose their strength, endurance, and flexibility. We experience a progressive loss of muscle mass at an average rate of 4% per decade from 25 to 50 years and 10% per decade thereafter. In addition, the joints in older people change, often becoming stiff and difficult or painful to move. Tissues in the joints sometimes become swollen or inflamed, hindering movement, and making the joints more prone to injury. As a result, people tend to move less as they age. This is the worst thing we can do. Lack of activity worsens the changes that occur with aging. Research confirms that regular exercise can slow or reverse many changes associated with the age-related loss of strength, endurance, and flexibility.

When people are not physically active, every cell and system in the body is affected. The body’s cells and systems begin to lose the ability to perform their specialized functions. When movement is difficult, people experience a general decline in quality of life. Self-image often suffers. Lack of activity and exercise can lead to heart disease, diabetes, stroke, and other health problems. Decreased mobility hinders one’s ability to feed and clothe oneself, to grocery shop, and to attend to personal hygiene. It promotes mental deterioration and loss of independence. In addition, when muscles are not used, they continue to weaken. Muscle weakness increases the risk of falls, and, therefore, of fractures. The risk of falling increases with age. Falls are the leading cause of injury death for people ages 65 and older. 9 Enjoyable Activities for Seniors with Limited Mobility – DailyCaring

What kinds of Motions are Best?

There are four types of exercise:

→ Strength

→ Stretching

→ Endurance (also known as Cardiovascular)

→ Range of Motion

Exercise benefits people of all ages. Regular exercise can slow or reverse the decrease in mobility that contributes to disease and disability in the elderly.

Strength: Even a small change in muscle size can make a big difference in strength. That is why strength exercises are so important. Improving muscle size by lifting small weights helps people build their capacity to do such things as walk, climb stairs, and carry a package. These kinds of activities can mean the difference between keeping one’s independence and relying on others.

Stretching: Stretching exercises that gently stretch the muscles and tendons help ensure flexibility. Stretching exercises do not build strength or endurance. Clinical research has demonstrated that most elderly, even the frail, benefit from a combination of flexibility and strengthening exercises. It helps them maintain function and mobility, prolong independence, and improve their quality of life.

Endurance: Walking, Running, Bicycling, and Swimming are examples of endurance exercise. By spending time in motion, the body and muscles become able to endure for longer periods of time, and the heart and lungs become stronger.

Range of Motion: Range of Motion exercises are designed to increase flexibility. Range of motion (ROM) is the normal amount a person’s joints can be moved in certain directions, or the range in which you can move a body part around a joint. Limited range of motion is a reduction in the normal distance and direction through which a joint can move. When a joint is not fully extended on a regular basis, over time it will become permanently unable to extend beyond a certain fixed position. To keep the joints, tendons, ligaments, and muscles loose and flexible, ROM exercises are used. These exercises move the joints through a full range of motion, helping to prevent stiffening.

Getting Started

Get started by doing a little exercise regularly, even in small ten-minute increments several times a week, it is possible to offset a variety of health problems. Exercise can help produce new red blood cells, strengthen the immune system, and improve bone density. Physical Activity, even at low intensity in short sessions, may reduce the risk for certain chronic diseases. Exercise also helps relieve depression.

Exercise Tips

→ Move joints through their full range of motion 1–2 times a day.

→ Do each exercise 3–10 times.

→ Move slowly. Do not bounce.

→ Breathe while you exercise. Count aloud.

→ Begin exercises slowly, doing each exercise a few times and

gradually building up.

→ Try to achieve full range of motion by moving until you feel a slight stretch, but don’t force a movement.

→ Stop exercising if you have severe pain.

→ Encourage clients with limited mobility to bear weight during transfers from bed to chair, and to walk whenever possible.

Range of Motion exercises that can be done while seated.

• Neck (Breathe with the movements, breathing out when the head moves down, breathing in when it moves up. Don’t let the shoulders or upper body sway to the side.)

1. Turn head slowly to the right, then to the left. Repeat three to four times.

2. Tilt head toward one shoulder, then toward the other shoulder. Repeat 3–4 times.

• Arms and Shoulders

1. Raise shoulders up toward ears and hold. Make full circles: up, forward, down, and back.

2. Take a deep breath, extend arms overhead. Exhale slowly, dropping arms.

• Hands and Fingers

1. Massage each hand, one at a time. Take your time; go in between each finger.

2. Raise hands up and back. Slowly rotate hands down and around in circles.

3. Close hand in a fist. Open hands fully, stretching fingers and thumbs out wide.

• Chest and Upper Body

1. With hands on waist, tilt to the right, return to center, then tilt to the left and return to center. Exhale as the movement goes down; inhale as the movement comes up. Don’t allow upper body to tilt forward. Don’t try to hold head up; instead, let it relax to the side.

2. Sit straight in chair with hands on your hips. Gently rock hips from side to side.

• Legs

1. Raise right leg up and forward. Repeat with left leg.

2. Sit up straight, knees together, with legs extended forward as far as possible, keeping feet on floor. Slowly stretch forward, sliding both hands down to ankles.

Hold 10–15 counts.

3. Grasp one knee with both arms, pull to chest, and hold for five counts. Repeat with opposite leg.

• Ankle and Foot

1. Point toes toward floor. Point toes toward ceiling. Slowly rotate feet in circles.

2. Cross right leg over left knee. Rotate foot slowly, making large complete circles—ten rotations to the right, ten to the left. Repeat for left leg.

Passive Range of Motion Exercises

When an individual can perform range of motion exercises with minimal assistance, the person is doing active range of motion. When an individual is unable to perform range of motion exercises, a caregiver should move the person’s joints in passive range of motion exercises at least once or twice a day.

Know these Terms!

Flexion: Forward Bending

Extension: Straighten Out

Hyperextension: Backward Bending

Lateral flexion: Sideways Bending

Internal Rotation: Turn toward the body.

External Rotation: Turn away from the body.

Circumduction: Move in a circle

Abduction: Move away from the body. (Think of “abduct,” or “take away”)

Adduction: Move toward and/or across the body. (think “add to the body”)

Inversion: Move or twist inward

Eversion: Move or twist outward

Supination: Turn or lie upward; face up

Pronation: Turn or lie downward; face down

Positioning:

Everyone positions themselves when they sit, stand, move, and lie down. The position we use for these activities affects circulation, joint pressure, and muscle use. People with limited mobility who sit or lie down for long periods of time are prone to skin breakdown and deterioration of muscles or nerves. Using correct positioning can prevent these problems. It is important to limit pressure over bony parts of the body by changing positions. Use pillows to keep knees and/or ankles from touching each other. Clients who are bedridden should avoid lying directly on their hipbones when on their sides. Help clients to use positions that spread weight and pressure evenly, with pillows placed to provide support and comfort. A person in a chair or wheelchair should use a cushion. Avoid donut-shaped cushions because they reduce blood flow and cause tissue to swell. People sitting in chairs or wheelchairs should change positions every hour. Good posture and comfort are both important.

Some Basic Rules of Positioning

→ Always be familiar with a client’s plan of care. Specific issues such as fractures, skin integrity, and health condition will determine the type of positioning that should be done.

→ Turn individuals who cannot turn themselves at least every two hours when in bed. A person in a wheelchair should change positions at least every hour. External pressure from staying in one position compresses the skin’s blood vessels and obstructs circulation, especially over the bones, leading to skin breakdown.

→ When moving a client, lift rather than drag. Dragging creates friction and heat, which can lead to skin breakdown.

→ Straighten sheets and clothing to remove wrinkles.

Bed Positioning Tips

→ Position the spine in alignment.

→ Position the hips straight without

leg rotation.

→ Position the upper extremities away from the body.

→ Support the arms when the client is lying on his side.

→ Keep the knee joints flexed 15 degrees when the client is supine (lying on the back).

→ Turn the client from side to side and prone (lying face down) on a scheduled basis.

→ Keep the head in a straight, midline position.

Positions

Supine (on back)

→ Place a pillow under the head.

→ Place pillows under both arms. When bedridden clients lie on their back with forearms and palms facing down, pressure can damage wrist nerves.

→ Place pillows under legs from midcalf to ankle to keep heels off the bed. Do not put a pillow under the knees only, as doing so will cause the heel to rub against the bed.

→ Hand rolls (Roll washcloths and place in hands to prevent freezing of finger joints).

→ Use foot-positioning devices such as shoes, boots, and footboards.

Lying on Side

→ Position client up in bed if needed.

→ Position client to one side of bed. Turn client by sliding arm under the shoulders and head; lift upper body over, then move hips and legs.

→ Cross the client’s top ankle over the bottom ankle or flex top knee.

→ Turn the client by placing one hand on the shoulder and one hand on the hip.

→ Place pillow under head and another behind client’s back.

→ Support flexed extremities with pillows and positioning devices.

→ Ensure proper body alignment.

Prone (On Stomach)

→ Lift client toward you.

→ Bend arm up around head.

→ Place other arm at side.

→ Place pillow under abdominal muscles.

→ Roll client on stomach.

→ Support ankles with pillows.

Positioning While Seated

→ Seat client in a chair that supports the back.

→ Keep ears in line with the hips.

→ Support the curve of the lower back with a rolled-up towel or lumbar roll.

→ Knees should be level with the hips.

→ Feet should be flat on the floor or on a footrest.

Positioning While Standing (To help clients learn balance when using walkers or canes.)

→ Position the feet a few inches apart.

→ Position the hips in front of the ankles.

→ Position the shoulders over the hips.

→ Keep the head balanced over the hips.

→ Keep the spine straight.

Range of Motion exercises and proper positioning can help prevent permanent disabilities and life-threatening complications that often result from immobility. Caregivers need to intervene to prevent physical decline and deterioration. We can accomplish this by keeping clients moving!!

The Structure of the Skin and what it is:

Epidermis: The thin, top layer of the skin surface.

Dermis: The thicker layer underneath the

Surface.

The dermis contains:

Blood Vessels: Tubes that carry blood through the body, with oxygen and food.

Nerves: Fibers that carry sensations to and from the brain.

Oil Glands: Organs that secrete an oily lubricating fluid.

Sweat Glands: Organs that separate waste products from the blood and secrete them as sweat.

Hair Follicles: Organs that create hair.

Fatty Tissue: Layer of fat under the skin.

Although it is not part of the skin, the fatty tissue provides a protective layer of padding (to prevent injury to underlying bones and muscles) and insulation (to keep heat in).

The Aging of Skin: What Happens?

⇒The skin and fatty tissue layer gets thinner.

⇒The skin becomes less elastic.

⇒Oil glands produce less oil, so skin is drier.

⇒Blood vessel walls get thinner and more delicate, so they break easily.

⇒Circulation of the blood slows down, so the skin is not getting as much oxygen and nutrition from the blood, causing the skin to become poorly nourished and fragile.

Because of these changes in the skin, older

people:

• Tend to feel cold

• Suffer from skin tears

• Heal slowly

• Become wrinkled

• Develop pressure sores

Caring for Older Skin: What to do!

• Keep skin clean.
• Pat skin – do not rub when washing or drying.
• Use powder sparingly, excess powder can cause irritation.
• Keep skin lubricated.
• Use lotions liberally.
• Frequent bathing with soap will dry the skin—use lotion cleansers.
• Keep skin creases and folds dry.
• Keep clothes and bedding dry.
• Eat nutritious food and drink lots of water.
• Change position often to improve circulation and prevent pressure sores.
• Do not disturb moles.
• Massage the skin, but avoid bony projections and irritated areas:
• Massage around but not directly on irritated or sensitive areas.
• Use chair cushions and good beds.
• Inspect skin daily for redness, tears, blisters, scrapes, or irritated areas.
• Report any problems to a nurse or doctor.

Skin Problems

Decubitus Ulcers (Bed Sores or Pressure Sores)

Causes:

• Sustained pressure on the skin compresses the blood vessels and prevents nutrition and oxygen from getting to the skin cells. Over time, the skin tissue dies, and Decubitus Ulcers develop.
• The skin is under pressure where the bones press against the skin tissue, especially when the weight of the body or a body part is pushing down on a pressure point.
• Body fluids such as Urine and Feces contain damaging chemicals. When they remain on the skin, they cause moist areas that become irritated and develop sores.
• Friction from clothing or bedding can injure the skin and lead to skin ulcers.

What to report to the Nurse, Doctor, or Supervisor:

• A red pressure area that does not become

normal after 20 minutes without pressure

• A reddened area of the skin that does not turn white when you push on it.
• A skin area that is warm or hot to the touch.
• Any swelling
• Any opening in the skin
• Blisters, tears, craters, rashes, or holes
• Scrapes or Abrasions
• Drainage or weeping from the skin.

• Be especially alert when you are caring for residents that are frail, do not move around much, or have poor nutrition. Patients with little or no feeling in parts of the body, such as stroke victims, must be watched because they cannot feel pressure spots and need to frequently change positions.

Preventing Skin Problems

• Encourage or help patients to walk or exercise several times a day.
• Encourage or help patients to keep their skin clean, dry, and lubricated.
• Encourage or help patients to keep their bedding free of wrinkles.
• Encourage or help patients to eat well and drink plenty of liquids.

For patients who are in chairs most of the time:

• Encourage or help them to stand, walk, or shift their weight every 15 minutes.
• Teach them how to do chair push-ups with their arms.
• Teach them how to sit with their knees at the same level as their hips, with their thighs horizontal to the chair. This

will distribute their weight along their thighs and away from pressure points.

• If a patient cannot do these things, he or she should return to bed after an hour in a chair.

For patients who are in bed most of the time:

• Teach them how to use the side rails and the trapeze to change position frequently, at least every two hours. Be available to assist them if necessary. Even small shifts in body weight are helpful.
• When you are helping a patient to change position, move him or her carefully so you do not create friction and shearing between the skin and the bedding or clothes.
• The head of the bed should be raised as little as possible, no more than 30 degrees, to prevent sliding and pressure on the bony areas. If it must be raised higher for eating, it should be lowered an hour later.
• Massage the skin when possible but avoid massaging pressure points or irritated areas.

For patients who use special chair cushions or mattress overlay pads:

• Check to be sure that the pads are thick enough to do the job. Place your hand under the pad while the resident is on top of it—if you can feel the patient’s body through the cushion, the pad is too thin.

For patients with pressure sores:

• Keep weight and pressure off any reddened areas and wounds.
• Use pillows to elevate or separate body parts and keep pressure off an area, such as a pillow under the calf to raise the heel off the bed, or a pillow between the legs to keep the knees from touching each other.

Emalee Walton 5/26/21

Sources:

Caring for Aging Skin : AJN The American Journal of Nursing (lww.com)

Aging Adults and Skin Care | Caring for Our Skin as We Age (parentgiving.com)

Elderly Skin Care: Tips for Taking Care of Aging Skin and Avoiding Disease – Caring People (caringpeopleinc.com)

What causes urinary incontinence?

People who cannot control when or where they urinate suffer from urinary incontinence, or U.I. There are things that can be done to improve this condition, but it is important to know what the cause is so the right care and treatment can be given.

This condition is not the person’s fault, and it is not a necessary or normal part of growing older. It is not caused by laziness or meanness. U.I. is a health problem with several possible causes. Some of the most common causes include the following:

• Urinary tract infections (U.T.I.)
• Confusion and forgetfulness
• Muscle weakness
• Vaginal problems (in women)
• Prostate problems (in men)
• Medication reactions
• Problems with clothing
• Trouble getting to the bathroom.
• Constipation

What are the symptoms of urinary incontinence?

Any patient who wets the bed or him- or herself, leaks urine on the way to the bathroom, or must use protective pads or padded briefs is suffering from U.I. If you notice a resident, a bed, or a room that has urine stains or a urine odor, then you know the resident needs help with this condition.

However, you probably do not know what kind of U.I. the resident might have. You can often determine this by watching the resident closely and keeping track of his or her urinating habits on a bladder tracker.

There are three different types of U.I.:

• Urge incontinence. With this type, people may leak urine on their way to the bathroom, after they drink just a little bit of liquid, or as soon as they feel the urge to go.

• Stress incontinence may cause urine to leak when they sneeze, cough, or laugh, or when they exercise or move a certain way (getting out of bed nor up from a chair, walking, lifting). This is common in women.

• Overflow incontinence causes people to feel they need to urinate again right after going, or to feel as though they never totally empty the bladder, or to pass small amounts of urine without feeling any need to go. It may be a sign of prostate problems in men.  

What can YOU do to help a patient with urinary incontinence?

Your first responsibility is to report U.I. to your supervisor or the patient’s doctor. A doctor or nurse should check a resident with U.I., and your observations about the resident, such as a bladder record, will help them determine the cause and type of U.I.

The three treatments for U.I. are:

1. Medicine.
2. Surgery.
3. Behavioral treatments, which help people control their urine and use the toilet at the right time. They work well for patients who have problems getting to the bathroom or are not able to tell you when they need to urinate.

Behavioral Treatments for Urinary Incontinence

Scheduled Toileting

Use scheduled toileting for patients who cannot get out of bed or cannot get to the bathroom alone. To do this treatment, assist the patient to the bathroom every two to four hours on a regular schedule.

Prompted Voiding

Use prompted voiding for patients who know when they have a full bladder but do not ask to go to the bathroom. To do this treatment:

1. Check the Patient for Wetness
2. Ask “Do you want to use the Toilet?”
3. Help the Patient to the Toilet
4. Praise the Patient for being dry.
5. Tell the Patient when you will be back to take them to the toilet again.

Habit Training

Use habit training at the same time every day.

To do this:

1. Watch the patient to find what times he or she urinates. A bladder record can help you do this.
2. Take the patient to the bathroom at those times every day.

3. Praise the patient for being dry and using the toilet.

For all behavioral treatments, remember these things.

1.    Be patient. These treatments take time.

2.    Treat the patient as an adult.

3.    Do not rush the patient.

4.    Give the patient plenty of time to completely empty his or her bladder.

5.    Give privacy by closing the door, even if you must stay in the bathroom.

6.    NEVER yell or be angry with the patient if he or she is wet. Say, “You can try again next time.”

7.    Respect dignity and confidentiality.

Other ways to help patients with Urinary Incontinence.

1. Pelvic exercises can make muscles around the bladder stronger and help with U.I. These are called Kegel exercises, and to do them, the person tightens the pelvic muscles that stop and start the flow of urine. The muscles should be squeezed tightly for a few seconds and then released, up to ten times at

one sitting, four times every day. Then, whenever the person feels that urine might leak, he or she tightens those same muscles and prevents urine from leaking.

• People who cannot get out of bed or cannot get to the bathroom for some reason may need to use a

bedpan, urinal, or bedside commode. These articles, if needed, should be kept by the bed.

• If a patient uses a wheelchair, walker, or cane to get to the bathroom, you can help by keeping the item near the bed and keeping the path to the bathroom clear and well lit.

• Encourage the patient to wear clothes that are easy to remove and that have simple fasteners.

• If a patient needs to wear special pads or clothing to help keep the skin dry, they should be changed often. Use soft pads and clothing, keep them wrinkle-free, keep the skin clean and dry, and use protective skin creams if allowed. Remember that wet skin can develop sores and rashes.

• If the patient wets the bed at night, it might be helpful to restrict evening liquids, but you should only do this if a doctor or nurse orders it. This is usually done in the three hours before bedtime. The patient should use the bathroom just before going to bed.

• Some patients need to use a urinary catheter, which is a tube inserted into the bladder by a doctor or nurse. It drains urine into a bag. Sometimes men use a condom catheter that fits over the penis. Catheters can cause infections, and condom catheters that are too tight can be harmful. Catheters should be checked often. They are not recommended for most incontinence problems.

What causes bowel incontinence?

People who cannot control when or where they pass gas or stool suffer from bowel incontinence. There are things that can be done to improve this condition, but it is important to know what the cause is so the right care and treatment can be given. This condition is not the person’s fault, and it is not a necessary part of growing older. It is a health problem that is not caused by laziness or bad behavior.

Some of the most common causes include:

• Incorrect diet or fluid intake

• Confusion and forgetfulness

• Muscle injury or weakness (the anal muscles)

• Nerve injury

• Medication reactions or laxative abuse

• Trouble getting to the bathroom

• Constipation or impaction

• Diarrhea

What can YOU do to help a patient with bowel incontinence?

Your first responsibility is to report episodes of bowel incontinence to your supervisor or the patient’s doctor. A doctor or nurse should check the resident, and your observations may help them determine the cause of the problem. Treatments for bowel incontinence include:

1. Medicine
2. Surgery
3. Dietary management
4.  Bowel management and retraining, with establishment of a habit regimen.
5. Biofeedback

Two of these treatments involve the care you provide: Diet Management and Bowel Retraining. These treatments are the same as those used to help people with constipation.

What causes constipation?

People usually say they are constipated when they are having infrequent bowel movements, but constipation is also used to refer to a sense of bloating or intestinal fullness, a decrease in the amount of stool, the need to strain to have a bowel movement, or the need to use laxatives, suppositories, or enemas to maintain regular bowel movements. It is normal for most people to have bowel movements anywhere from three times a day to three times a week, but some people may go a week or longer without discomfort or harmful effects.

Many things can cause constipation, but the most common causes include:

• Inadequate fiber and fluid intake

• Inactivity or a sedentary lifestyle

• Change in routine

• Abnormal growths or diseases

• Damaged or injured muscles (sometimes from

repeatedly ignoring the urge to go)

• Medication side effects and laxative abuse (it is

NOT necessary to have a B.M. every day)

Constipation may be diagnosed if movements occur fewer than three times weekly on an ongoing basis.

What can YOU do to help a patient with constipation?

Your first responsibility is to report a patient’s constipation problems to your supervisor or the patient’s doctor. A doctor or nurse should check the patient, and your observations may help them determine the cause of the problem.

Treatments for constipation include:

1. Medicine

2. Surgery

3. Dietary management

4. Bowel management and

retraining, with establishment of a

habit regimen.

Dietary management for Urinary Incontinence

Although there is no dietary treatment for urinary incontinence, some foods and drinks can irritate the bladder, such as sugar, chocolate, citrus fruits (oranges, grapefruits, lemons, limes), alcohol, grape juice, and caffeinated drinks like coffee, tea, and cola. Patients with U.I. could try eliminating these foods and beverages from their diet and see if the condition improves.

Dietary management for bowel incontinence and constipation

The average American diet contains 10–15 grams of fiber a day. The amount of fiber recommended for good bowel function is 25–30 grams of fiber per day, plus 60–80 ounces of fluid. Look at the table below to get an idea of the fiber we get in different foods. Most people can successfully treat their bowel irregularities, both incontinence and constipation, by adding high fiber foods to their diets, along with increasing fluid intake to desired levels. Increase dietary fiber slowly to give the bowel time to adjust.

People with diverticulosis or diverticulitis should not consume a high-fiber diet.

Type of Food	Lower Fiber Foods	Fiber grams	Higher Fiber Alternatives	Fiber grams
Breads	White bread, 1 slice	0.50	Whole wheat bread, 1 slice	2.11
Cereals	Corn flakes, 1 oz.	0.45	Oat bran cereal, 1 oz.	4.06
Rice	White rice, ½ cup	1.42	Brown rice, ½ cup	5.27
Vegetables	Lettuce, ½ cup raw	0.24	Green peas, ½ cup	3.36
Beans	Green beans, ½ cup	1.89	Pinto beans, ½ cup	5.93
Fresh Fruits	Banana, 1 medium	2.19	Blackberries, 1 cup	7.20

Food sensitivities

Some people are sensitive to, or even allergic to, certain foods that cause them constipation or diarrhea. Dairy products such as milk and cheese, wheat products such as bread, and foods containing chocolate are some of the more common problem foods. A physician should evaluate a resident who seems to have food sensitivities. Bowel retraining for bowel incontinence and constipation.

Habit training

Habit training means designating a specific time each day to have a bowel movement. Keep a record of the patient’s bowel habits, just as you do with a bladder record. If a pattern develops, that pattern can be used to set up a habit regimen that will reinforce a scheduled time each day to have a bowel movement.

If no pattern can be seen in the patient’s bowel activities, then a regimen can be established by selecting a convenient time each day, or even three times a day in the case of someone with bowel incontinence, for the patient to try to have a bowel movement. Be sure to help the patient stick with this schedule, even when he or she does not feel the need to go. Over time, the body will develop a habit that conforms to the scheduled routine.

Exercises

The Kegel exercises that are used to prevent urinary incontinence can be slightly modified to strengthen the anal muscles that control the outflow of stool. To do them, the person tightens the muscles around the rectum. The muscles should be squeezed tightly for a few seconds and then released, up to ten times at one sitting, four times every day.

Emalee Walton 5/19/2021

Want to learn more about constipation in the elderly? Management of Constipation in Older Adults – American Family Physician