Transcript Guest - UNMC

Aging and Common
Geriatric Problems
Deb Mostek, M.D.
University of Nebraska Medical Center
March 23, 2004
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Objectives
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Describe common sensory and functional
limitations experienced by the geriatric
patient and how these conditions impact
care.
Discuss common cognitive difficulties in
the elderly and how to minimize behavioral
problems while providing care.
Discuss the prevalence of osteoporosis
and risk of fractures.
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Demographics of Aging
 65 and older: 35,000,000 (12.4%) in 2000;
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69,000,000 (20%) by 2030
Life expectancy: female 80.2 yrs; male 73.2 yrs
>65 y/o female:male 3:2
>85 y/o female:male 5:2
5% of elders (>65y/o) reside in NH;
(if >95 y/o 47% in NH)
 Better educated; less poverty
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Overview
  Mortality from many causes
 Biochemical changes in tissues
  physiologic capacity
  ability to adapt to environment
  susceptibility to disease
 Heterogeneous population:  variability
 Rate of aging--affected by genetics, life style,
environment
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Normal Aging
  Height (5 cm by age 75)
  Fat content,  lean body weight/muscle
mass,  body water content.
 Dry skin ( moisture content) vs. photoaging
(not normal aging—causes 90% of cosmetic
changes of aging)
 60%  grip strength (? due to inactivity)
  Stiffness due to  water content in
tendons/ligaments and  remodeling
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…Normal aging
  Brain weight 20%;  blood flow to brain
 Slower processing times
 Renal mass  by 25-30% by age 80
 Lungs:  elastic tissue of lungs
 Abdominal muscles necessary for
inspiration; elders expand lungs best in
standing position
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…Normal aging
 Swallowing less coordinated
 Decreased absorption of Ca++, iron,
lactose, Vitamin D
 Vitamin A & K, Cholesterol absorbed faster
 Slowed transit in large intestine
 Psychological stressors
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Barriers to care
 Poor communication between care
providers
 Sensory impairment
 Communication difficulties
 Cognitive impairment
 Polypharmacy
 Limited financial resources
 Under-reporting
 Poor social support
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Hearing Impairment
 Sensorineural hearing loss 25-40%;
associated with noise exposure
 Usually high frequency loss (consonants in
this range  trouble with conversational
speech)
 Emotional difficulties, cognitive impairment,
 physical functioning
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Audiograms
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Hearing Loss &
Tips for Communication
 Face person directly, to allow for lip
reading
 Minimize background noise
 Visual communication—written notes,
communication boards
 Amplifiers
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Vision and Aging
  Lens elasticity
 Adapts more slowly to changes in light;
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 night vision
Presbyopia—lens lose elasticity—need for
reading glasses
 visual acuity,  visual fields
 contrast sensitivity
 Sensitivity to glare
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Older Individuals Need 33% More
Illumination Than Younger People
AGE 20
AGE 60
AGE 78
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Vision Impairment (20/40 or less)
 10-25% > 75 y/o; (20/40 or less);
 Cataracts; Macular Degeneration; Diabetic
Retinopathy; Glaucoma
 Results in difficulties with ADLs, IADLs
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Cataracts
 Cataracts (38%)
 Risk factors: age (90% in > 90 y/o), sun,
smoking, diabetes, steroid use
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Cataracts
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Macular Degeneration
 Degeneration of cells in central vision
region of retina
 30% by age 75 years
 Leading cause of blindness in white
Americans
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Early Macular Degeneration
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Macular Degeneration
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Age Related Macular Degeneration
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Glaucoma
 Increased intraocular pressure
 Loss of visual fields
 Insidious, need routine screening to detect
early
 Most common cause of blindness in African
Americans
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Glaucoma
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Diabetic Retinopathy
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Management of Low Vision
 Bright illumination
  Contrast
 Magnification
 Low Vision Clinic
 Word-processing programs
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Neuropathy
  Vibratory and tactile sensation in fingers
and toes
 Diabetic neuropathy
 Tissue more vulnerable to injury--need to
protect from injury (pressure injury or burns)
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Mobility
 Upper extremity precautions
(e.g., hemiparesis)
 Lower extremity precautions
(e.g., hip replacement)
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Memory and Aging
 Takes longer to memorize a list, but then
remembers the same as younger person
 Longer retrieval time
 Slower response time
 More easily distracted
 Perform same on IQ test if given extra time
 General knowledge and vocabulary often
better
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Geriatric FUN FACT
 Average 22 y/o college grad—20,000 words
in vocabulary
 Average 60 y/o—60,000 words in vocabulary
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Dementia
 Memory problems with functional
impairment
 Alzheimer’s Disease (risk factors: age,
+FH); gradual onset, may be subtle at
first, progressive, depression, behavioral
problems; later: motor rigidity)
 Vascular Dementia (associated with
strokes; usually more acute in onset)
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Caring for Demented Patients
 Approach respectfully
 May have to repeat same information
 If becoming agitated, try to distract
(Change subject, give simple task to
perform, look thru old photo albums, play
music they enjoy)
 Remember behavioral problems are part
of the disease
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Delirium
 Difficulty with attention and responsiveness,
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often disorientation& confusion; fluctuating
symptoms
10-40% of hospitalized patients in >65y/o
usually a fairly sudden change
Associated with medical illness, medications
Patients with dementia are at risk for
developing delirium.
Need close supervision
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Depression
 Common in elderly patients in a primary care
setting (17-37%)
 Hospitalized: major depression (11%);
Mild-mod depression 25%
 Patients often deny depressed mood
 Sleep disturbance,  appetite, wt loss,
withdrawal, anxious, more common with
dementia
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Osteoporosis
 Low bone density with increased susceptibility to
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fractures. Prevalence: 10 million Americans
Asymptomatic until factures start occurring
Initially affects vertebral bodies, distal radius,
proximal femur, pelvis
1/3 women have a least one vertebral fracture
Risk factors: female, age, estrogen deficiency, white
or Asian race, inactivity, + FH, slight stature, smoking,
alcohol abuse, chronic corticosteroid or
anticonvulsant use, inadequate calcium intake,  sun
exposure, liver disease, hyperthyroidism
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Bone Mineral Density Testing
 Best predictor of fracture risk
 Normal: T score < -1 SD (young adult
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standard)
Osteopenia: T score <-2.5 but > -1
Osteoporosis: T score > -2.5
Screening controversial:
National Osteoporosis Foundationall
females greater than 65years of age;
US Preventive Services Task Force:
insufficient evidence for or against screening
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Prevention of Osteoporosis
 Regular weight-bearing exercise
 Calcium intake 1200+ mg daily
 Vitamin D 400-800 IU daily
 Smoking cessation
 Medical therapy in those with low BMD who are
at high risk to develop osteoporosis
 Fall prevention
 Prevention ideally starts in childhood.
Geriatric Review Syllabus, 5th Edition, 2002-2004
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“We do not quit playing
because we grow old,
we grow old because
we quit playing.”
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Summary
 Much variability in geriatric population—
don’t stereotype!
 Treat with respect, prepare patient for
procedure
 If dementia or delirium is present, provide
close supervision
 Enjoy the diversity and savor the stories of
the aged!
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