Geriatric Medicine

GERIATRIC MEDICINE

LECTURE-1

AgingDefinition

Aging is the progressive, universal decline first in functional reserve and then in function that occurs in organisms over
Aging is heterogeneous.
It varies widely in different individuals and in different organs within a particular individual.
Aging is not a disease; however, the risk of developing disease is increased, often dramatically, as a function of age.
The biochemical composition of tissues changes with age; physiologic capacity decreases, the ability to maintain homeostasis in adapting to stressors declines, and vulnerability to disease processes increases with age .

Demography of Aging

Improvements in environmental (e.g., clean water and improved sanitation) and behavioral (nutrition, reduced risk exposures) factors and the treatment and prevention of infectious diseases are largely responsible for the 30-year increase in life expectancy since 1900.
In the United States, by 2030, 1 person in 5 will be >65 years.


Global Aging
At present 59% of older adults live in the developing countries of Africa, Asia, Latin America, the Caribbean, and Oceania.
The developed world has the largest absolute number of older adults and is experiencing the largest percentage increase.













Elderly people are incompetent and incapable of making decisions or handling their own affairs.

Most elderly live in nursing homes

All elderly people live in poverty


Older people are lonely and unhappy

Elderly do not want to work

“Old Age” begins a 65

Retirement ends your active life

Physical Changes of Aging
Most physical changes that occur with aging are gradual and take place over a long period of time. In addition, the rate and degree of change varies among individuals.

Factors such as disease can increase the speed and degree of the changes. Lifestyle, nutrition, economic status, and social environment can also have effects.
If an individual can recognize the changes as a/an normal part of aging, the individual can usually learn to adapt to & cope with change

Integumentary SystemChanges

Production of new skin cells decreases
Oil and Sweat glands become less active
Circulation decreases

Fatty tissue layer of skin diminishes

Lines and wrinkles appear
Nails become thick, tough, and brittle
Increased sensitivity to temperature

Circulatory System changes

With circulatory changes:
Avoid strenuous exercise or over exertion
Periods of rest
Moderate exercise, according to individual’s tolerance

High Blood Pressure =

Diet low in salt
Decrease fat intake
Exercise as recommended by physician

Respiratory Changes

Respiratory muscles become weaker
Rib cage more rigid
Alveoli thinner & less elastic which decreases exchange of gases - emphysema


Changes may cause the elderly to experience:
Dyspnea
Breathing increases in rate
Difficulty coughing up secretions
Increases susceptibility to infections such as a cold or pneumonia

Nervous System Changes

Blood flow to brain decreases & there is a progressive loss of brain cells - - Interferes with
Thinking - Reacting
Interpreting - Remembering

Senses of taste, smell, vision, & hearing are diminished

Nerve endings less sensitive
Decreased ability to respond to pain and other stimuli
Decrease in taste& smell frequently affects appetite

Changes in vision

Problems reading small print
Seeing objects at a distance
Decrease in peripheral vision
Decrease in night vision
Increased sensitivity to glare
Cataracts
Glaucoma


Changes in hearing
Hearing loss usually gradual
Person may speak louder than usual
Ask for words to be repeated
Not hear high frequency sounds
May not hear well in crowded places

Decreased sensation to pain & other stimuli = more susceptible

Burns
Frostbite
Cuts
Fractures
Muscle strain and other injuries

Digestive Changes

Fewer digestive juices and enzymes produced
Muscle action becomes slower & peristalsis decreases
Teeth are lost
Liver function decreases

Dysphagia is frequent complaint

Less saliva
Slower gag reflex
Loss of teeth
Poor fitting dentures
Slower digestion of food
indigestion


Urinary Changes
Kidneys decrease in size & become less efficient
Bladder becomes less efficient
May not hold as much
May not empty completely
incontinence

Endocrine Changes

Increased production of some hormones and decreased of others
Immune system less effective
BMR decreases
Intolerance to glucose

Reproductive System Changes

Decrease of estrogen / progesterone in female
Thinning of vaginal wall
Decrease vaginal secretions
Inflammation of vagina common

Psychosocial Changes

Some individual cope with psychosocial changes, and others experience extreme frustration and mental distress


Fears of a sick person:
Death
Chronic illness
Loss of function
Pain

Confusion and Disorientation

Talking incoherently
Not knowing their name
Not recognizing others
Wandering aimlessly
Lacking awareness of time or place

Diseases:

CVA
Arteriosclerosis
Atherosclerosis
Cause TIA’s ministrokes which result in temporary periods of diminished blood flow to the brain.


Dementia
Loss of mental ability characterized by a decrease in intellectual ability, loss of memory, impaired judgement, personality change, and disorientation

Acute dementia

When the symptoms are caused by temporary reason:
High fever, dehydration, hypoxia
Chronic dementia
When symptoms are caused by permanent, irreversible damage to brain cells

TYPES OF DEMENTIA

PRIMARY NEURODEGENERATIVE
CORTICAL
Alzheimer’s disease
Fronto-temporal dementias (Pick’s disease)
SUBCORTICAL
Progressive supra nuclear palsy
Huntington’s
Lewy Body Disease

VASCULAR

Multi-infarct
Biswangers disease
INFECTIVE
Creutzfeld-jacob
AIDS
Neurosyphilis


TRAUMA
Sub dural
Dementia pugulistica
radiotherapy
NORMAL PRESSURE HYDROCEPHALUS

ASSOCIATED WITH OTHER DISEASES

Parkinson’s
Wilson’s
Multiple sclerosis
Tumors
Vasculitis

Alzheimer’s Disease

Form of dementia that causes progressive changes in brain cells

The patient may develop seizures

Loses weight despite eating a balanced diet
Becomes totally dependent
Lapses into a coma
Dies


GERIATRIC MEDICINE
LECTURE-2

FALLS

CONSEQUENCES
10 –15% fracture
Decrease in functional status
2% injurious falls result in death

Falls usually occur when a threat to the normal homeostatic mechanisms that maintain postural stability is superimposed on age-related declines in balance, ambulation and cardiovascular function.

Threat

Acute illness
Environmental stress
Unsafe walking surface

RISK FACTORS

Age
Female
Past fall
Cognitive impairment
Lower limb weakness
Balance disturbance


AGE RELATED FUNCTIONAL DECLINE
Visual
Proprioceptive
Vestibular

MECHANISM

SYNCOPE /HYPOTENSION
SEIZURE
DIZZINESS / BALANCE
GAIT DISTURBANCE
PAIN / WEAKNESS
MECHANICAL FALL

Delirium

Sepsis
Hypoxia
Biochemical disturbances
Calcium, sodium, glucose,urea,hepatic

DEFINITION

An acute organic mental syndrome characterized by:
Global cognitive impairment
Reduced consciousness
Disturbed attention
Psychomotor activity
Sleep-wake cycle disturbance


Comparison delirium and dementia
Sudden onset
Usually reversible
Short duration
Fluctuations
Altered consciousness
Associated illness
Inattention
Always worse at night
Impaired variable recall
Insidious onset
Slowly progressive
Long duration
Relatively stable
Normal consciousness
Not associated
Attention not sustained
Can be worse at night
Memory loss

Treat Memory

Cholinergics
?estrogens
Vitamin E
Selegeline


Treat Symptoms
Treat family
Non pharmacological
Antipsychotics
Benzodiazepines
ANTIDEPRESSANTS

WEIGHT LOSS IN ELDERLY PEOPLE

Disease
Dentition
Depression
Dysgeusia
Drugs
Dysfunction
Dementia
Diarrhea/ Malaborption
Dysphagia

• The Nine “Ds” of Inadequate Food Intake and Weight Loss

• In The Elderly:


In about 25% of cases, there is no clear etiology for weight loss.
When etiology is established the most frequent reasons are:
Depression
GI (peptic ulcer or motility disorders)
Cancer

Which of the following medications may cause loss of appetite in the elderly?

NSAIDS
Psuedoephedrine
Theophylline
Megestrol Acetate
Antineoplastics
Antihistamines

• Appetite loss:

• Psuedoephedrine, Theophylline, Antineoplastics.
• Increased appetite:
• NSAIDS, “Megace” and Antihistamines.