Transcript Geriatric Staff Conference

Overview of Geriatric Medicine
Marian Suarez, M.D.
GERIATRIC OVERVIEW
GERONTOLOGY
Study of aging
GERIATRICS
Involves the health and social care of the
elderly
GERIATRIC MEDICINE
Sub-discipline within
geriatrics specifically
devoted to medical
care of the elderly
GERIATRIC MEDICINE
Defined in several ways
a. Nature of its clientele
 US: > 65 years old
 England: 75 years old
b. Care of chronically disabled patients
 < 65 years old
GERIATRIC MEDICINE
c. By its emphasis upon specific problem
complexes ( “The 5 I’s” )
1.
2.
3.
4.
5.
Iatrogenic disease
Incompetence (mental)
Incontinence
Immobility
Impaired homeostasis
What is the typical geriatric patient?
“Think of your oldest, sickest,
most complicated and frail
patient.”
William H. Hazzard
WORLD DEMOGRAPHICS
(US Bureau of Census, International Database, 1996)
Merck Manual, Geriatrics, 1999
1. Growth of 65+
 Increase dramatically 1996-2025
 % of ≥ 60 years old expected to increase
from 17% to 82% in Europe
About 200% in developing countries
2. Italy and Japan expected to have high
proportion of person ≥ 60 years old
1/3 of the population
WORLD DEMOGRAPHICS
(US Bureau of Census, International Database, 1996)
Merck Manual, Geriatrics, 1999
3.
China and India
Has the largest total population
Will have the largest absolute number of elderly
4.
2020: expected to have > 1 billion persons ≥ 60 y/o
Most will be living in developing countries
5.
85 y/o and over: “ oldest old” will increase to 18 million by
2050
6.
Centenarians will increase from 57,000 persons (1996) to
447,000 (2040)
WHAT’S DIFFERENT ABOUT
OLDER PATIENTS?
Heterogeneity of health status
Physiologic changes
Increased prevalence of disease
Tendency to have multiple diseases
Under reporting of symptoms
Atypical presentation of common diseases
Increase importance of social support
Increase rates of adverse effects to medications
and therapies
Different goals of therapy
Goals of Care in Geriatrics
Care vs. Cure
Improvement or maintenance of functional
status
Prevention of iatrogenic illness
Comfort for terminally ill
Aging is a progressive, predictable process that
involves evolution and maturation until death.
“Aging changes” = disease
+ disuse
+ normal aging
Physiologic function changes observed with
advancing age, approximately 1/3 is due to disease,
1/3 to disuse, and 1/3 to normal aging.
Rate of change varies greatly among
individuals.
SELECTED ANATOMIC AND PHYSIOLOGIC
CHANGES WITH AGING, HEALTHY ADULTS
SYSTEM
AFFECTED
CHANGE NOTED
AGE SPAN
TOTAL BODY WATER
MEN
WOMEN
20-80
 60% - 54%
 54% - 46%
MUSCLE MASS
30 % 
30-70
TASTE BUDS
70% 
30-70
CARDIAC RESERVE
 FROM 4.6 TO 3.3 X
RESTING
CARDIAC
OUTPUT
25-70
SELECTED ANATOMIC AND PHYSIOLOGIC
CHANGES WITH AGING, HEALTHY ADULTS
SYSTEM
AFFECTED
CHANGE NOTED
AGE SPAN
MAXIMUM HR
195 – 155 BEATS/MIN
25 – 70
LUNG VITAL CAPACITY
17% DECREASES
30 – 70
RENAL PERFUSION
REDUCED BY 50%
30 – 80
CEREBRAL BLOOD FLOW  BY 20 %
BONE
CONTENT
MINERAL  BY 25% – 30% IN
FEMALE
 BY 10% - 15% IN
MALES
30 – 70
40 - 80
SYSTEM
AFFECTED
BRAIN WEIGHT
CHANGE
NOTED
 BY 7%
AMOUNT
OF
LIGHT DIMINISHED BY 70%
REACHING THE RETINA
AGE SPAN
20 – 80
20 - 65
Adapted from Physiology of Aging, A synopsis, 1982
Normal Human Aging, The Baltimore Study of Aging, NIH Published 1984
AGE RELATED ALTERATIONS IN PHYSIOLOGY:
IMPACT ON DRUG METABOLISM
PHYSIOLOGIC CHANGE
IMPACT
 BODY SIZE
LEAN BODY MASS
 DOSAGE REQUIREMENT
 BODY FAT
 DISTRIBUTION OF FAT
SOLUBLE DRUGS
 BODY WATER
 FREE FRACTION
DRUG IN SERUM
OF
HEALTH ASSESSMENT OF THE OLDER
ADULT SHOULD INCLUDE:
FUNCTIONAL ASSESSMENT
Activities Of Daily Living (ADL’s)
Bathing
Grooming
Dressing
Toileting
Ambulating
Eating
Transferring
HEALTH ASSESSMENT OF THE OLDER
ADULT SHOULD INCLUDE:
INSTRUMENTAL ACTIVITIES OF DAILY
LIVING (IADL’s)
Handling of finances
Using a telephone
Transportation
Shopping
Meal preparation
House keeping
Taking medications
HEALTH ASSESSMENT OF THE OLDER
ADULT SHOULD INCLUDE:
LIVING SITUATION
Own home?
Alone / with caregiver
Home set up
MULTI-DISCIPLINARY
APPROACH
PRESERVATION OF FUNCTIONS
Consult PM and R
PT / OT
Home care
FOR
SPECIFIC GERIATRIC SYNDROMES
a.
Dementia
Multiple etiologies
Degenerative
AD/PD/Pick’s disease
Vascular
MID
Infectious
Jakob-Kreutzfeldt Disease
AIDS
Toxic
EtOH
Metabolic
B12/ thyroid deficiencies
SPECIFIC GERIATRIC SYNDROMES
b. DELIRIUM
Disorganized thinking
Hypersomnolent / hyperactive
Develops over short period of time and fluctuate
over course of day
ETIOLOGY:
Drug toxicity
Infectious
Metabolic disturbances
Hypoxia
SPECIFIC GERIATRIC SYNDROMES
c. INCONTINENCE
Involuntary leakage of urine
Reversible causes:
Mnemonic DIAPPERS
D – delirium
I – infection
A – atrophic urethreitis/vaginitis
P – pharmaceuticals
P – psychiatric disorders ( depression)
E – excessive urine output (hyperglycemia)
R – restricted mobility
S – stool impaction
SPECIFIC GERIATRIC SYNDROMES
d. OSTEOPOROSIS AND OSTEOMALACIA
Primary type due to menopause and agerelated changes
Others:
Endocrine: diabetes, hyperparathyroid
Drug related (steroids)
Malignant
SPECIFIC GERIATRIC SYNDROMES
e. FALLS AND FRACTURES
Usually due to gait
disturbance
Multiple causes:
environmental, medical
illness, medication side
effects
Fractures: 90% result from
falls
SPECIFIC GERIATRIC SYNDROMES
f.
PRESSURE ULCERS
4 STAGES
Stage 1:
Stage 2:
Stage 3:
Stage 4:
Non-blanchable erythema
partial thickness involving epidermis
full thickness involving subcutaneous tissue
full thickness to muscle or bone
PREVENTION IS THE BEST TREATMENT
SPECIFIC GERIATRIC SYNDROMES
g. POLYPHARMACY
Average elderly has  4 prescription medications,
average NH resident takes over 8 meds
“Beer’s Criteria” – listing of inappropriately used
drugs
SPECIFIC GERIATRIC SYNDROMES
h. SLEEP DISORDERS
Disturbed sleep
decrease continuity
daytime
sleepiness
complaints of elderly
are
common
C0MMON DISEASES IN THE
GERIATRIC POPULATION
A. CARDIOVASCULAR DISEASE
1. Hypertension
2. Syncope and orthostatic hypotension
3. PVD (Peripheral Vascular Disease)
4. Coronary artery disease remains most
common cause of death ≥ 65
5. Degenerative valvular disease (AS)
6. CHF
C0MMON DISEASES IN THE
GERIATRIC POPULATION
b. MUSCULOSKELETAL DISORDERS
Most Common:
OA
RA
Polymyalgic rheumatica
Gout
Bursitis
Tendinitis
Back pain
Lumbar stenosis
Cervical spondylosis
C0MMON DISEASES IN THE
GERIATRIC POPULATION
c. NEUROLOGIC DISORDERS
Stroke
infarcts
hemorrhage
Dizziness
Parkinson’s Disease
C0MMON DISEASES IN THE
GERIATRIC POPULATION
d. INFECTIOUS DISEASE
Aging itself compromises a host’s resistance to
infections
Diagnostic Approach in the Elderly: summed up
with 3 basic principles:
Infection must be considered in differential
diagnosis of an older person with
unexplained rapid decline in function
Fever generally caused by a serious infection
(often bacterial)
20-30% of older patients with bacteremia,
pneumonia, UTI, intra-abdominal infection,
or TB have no fever.
C0MMON DISEASES IN THE
GERIATRIC POPULATION
e. RESPIRATORY DISEASES
1. COPD
2. Chronic cough
? Drugs – ACE INHIBITORS
C0MMON DISEASES IN THE
GERIATRIC POPULATION
f. GI DISORDERS
– PUD 2º to NSAID use
– Diarrhea 2º to fecal impaction, intestinal
obstruction, laxative abuse, lactate
deficiency, colon cancer
3. Constipation: usually painless and associated
with increased transit time
4.Acute abdominal emergencies
Cholecystitis,
cholangitis,
intestinal
obstruction 2º to hernia, adhesions, cancer,
perforated diverticulitis, PUD, AAA
Emergency surgery associated with a
mortality rate 15-50%
C0MMON DISEASES IN THE
GERIATRIC POPULATION
g. ENDOCRINE AND METABOLIC DISORDERS
1. Thyroid disease in older patients 
double that of younger patients
2. DM – prevalence increases with age
C0MMON DISEASES IN THE
GERIATRIC POPULATION
h. RENAL DISEASE
Hyponatremia complicated in the elderly
by multiple drugs
lithium
diuretics
anti-depressants
THE JOYS OF AGING
I have become quite a frivolous old gal. Am
seeing 5 gentlemen everyday. As soon as I’m awake,
WILL POWER helps me out of bed. When he leaves, I
go see JOHN, then CHARLEY HORSE comes along
and when he is here, he takes a lot of my attention.
When he leaves, ARTHUR RITIS shows up and stays
the rest of the day. He doesn’t like to stay in one
place very long. So he takes me from joint to joint.
After such a busy day I’m really tired and ready to go
to bed with BEN GAY. What a day!
JOURNEY INTO ‘88
THE END