Geriatric Medicine

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Geriatric Medicine

• Ming-Shyan Huang, MD, PhD
• Professor of Faculty of medicine
• Kaohsiung Medical University

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The elderly patient

• Persons aged 65
• Growing numbers of elderly person
• Elderly persons 7 ??? (82??)
• Cannot go on as we have new approaches are
  needed
• Taiwan 2004
• 65 year old 9.48
• 17-64 year old 71.19

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2004 TAIWAN
2003 JAPAN Male 77.6 Female 84.4
Male 73.60 Female 79.41
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Aging
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• Aging process is normal, progressive, and
  physiologically irreversible.
• Aging occurs despite optimal nutrition, genetic
  background, environmental surroundings, and
  activity patterns.
• Biological aging process, may demonstrate altered
  rates of progression in response to an
  individuals genetic background and daily living
  habits

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Goals of Care

• The usual fix-it model is inadequate for
  geriatric medicine
• The best possible outcome for an elderly patient
  must be defined by patients preferences and
  values
• Most treatments are only partially effective and
  carry both burdens and benefits, and reasonable
  persons differ in evaluating these
• Good decision making requires that the possible
  futures of the patient

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Age (years)
O2 maximum oxygen uptake MBC
maximum breathing capacity RBF renal blood flow
CI resting cardiac index FBSfasting
blood glucose
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Major theories on aging
Theory Mechanisms Manifestations
Accumulation of damage to informational molecules Spontaneous mutagenesis Failure in DNA, RNA, and protein synthesis Superoxide radicals and loss of scavenging enzymes Copying error Error catastrophe Oxidative cellular damage
Regulation of specific genes Appearance of specific proteins Genetically programmed senescence
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Home
Repeat Nursing Home
First Nursing Home
Hospital
Dead
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Components of assessment of the elderly
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Aging
Chronic diseases
Acute diseases
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Initial evaluation of geriatric patient

• Primary reason for visit
• Current medical problems
• Past medical and surgical history
• Current medications
• Medication allergies
• Vaccine status
• Influenza, pneumococcus, tetanus
• Social issue
• Living status
• Driving
• Smoking
• Drinking alcohol

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Potential difficulties in taking history from
elderly

• Communication
• Diminish vision
• Diminish hearing
• Slowed psychomotor performance
• Underreporting of symptoms
• Health belief, fear, depression, altered physical
  and psychological responses to disease process
• Cognitive impairment
• Vague or nonspecific symptoms
• As above
• Altered presentation of specific diseases
• Multiple complaints

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Important aspects of the history in the elderly

• Social history
• Living arrangement, relationships with family and
  friends, expectation of family or other care
  givers, economic status, abilities to perform
  activities of daily living, social activities and
  hobbies, mode of transportation
• Past medical history
• Surgical procedures, major illnesses and
  hospitalizations, immunization status, TB,
  medications, perceived beneficial or adverse drug
  effects

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Purposes and objectives of functional status
measures

• Description
• Screening
• Assessment
• Monitoring
• prediction

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Examples of measures of physical functioning

• Basic activities of daily living (ADL)
• Feeding, dressing, ambulation, toileting, bathing
  transfer (from bed and toilet), continence,
  grooming, communication
• Instrumental activities of daily living (IADL)
• Writing, reading, cooking, cleaning, shopping,
  doing laundry, climbing stairs, using telephone,
  managing medication, managing money, ability to
  perform paid employment or outside work, ability
  to travel

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Geriatric Problems

• Immobility
• Instability
• Incontinence
• Intellectual impairment
• Infection
• Impairment of vision and hearing
• Irritable colon

• Isolation (depression)
• Inanition (malnutrition)
• Impecunity
• Iatrogenesis
• Insomnia
• Immune deficiency
• Impotence

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Confusion

• 5 of older than 65 y/o, 20 of those older than
  75 y/o
• As a mental state in which reaction to
  environmental stimuli are inappropriate
• DD of confusion
• Delirium (acute)
• Dementias (more slowly)
• Impaired cognitive function associated with
  affective disorders and psychoses

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Depression

• Biological factor
• Family history, aging changes in
  neurotransmission
• Physical
• Specific diseases, chronic medical conditions,
  sensory deprivation, loss of physical function
• Psychological
• Unresolved conflicts, memory loss and dementia,
  personality disorders
• Social
• Losses of family and friends, isolation, loss of
  job, loss of income

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Treatment modalities for depression in the elderly

• Supportive measures
• Psychotherapy
• Drugs
• Sedative for associated anxiety or agitation
• Antipsychotics for associated psychoses
• Electroconvulsive therapy

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Incontinence

• Basic causes incontinence
• Acute causes incontinence
• Persistent causes incontinence

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Basic underlying causes
Neurologic
Urologic
Iatrogenic/ Environmental
Functional/ Psychological
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Acute and reversible forms of urinary incontinence

• D delirium
• R restricted mobility, retention
• I infection, inflammation, impaction
  (fecal)
• P polyuria, pharmaceuticals

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Types of persistent incontinence
Stress
Urge
Functional
Overflow
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Instability and falls

• Complications of falls in the elderly
• Injuries
• Painful soft tissue injuries
• Fracture hip, femur, humerus, wrist, ribs
• Subdural hematoma
• Hospitalization
• Complications of immobilization
• Risk of iatrogenic illnesses
• Disability
• Impaired mobility due to physical injury
• Impaired mobility from fear, loss of
  self-confidence, and restriction of ambulation
• Risk of institutionalization
• Death

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Extrinsic factors
Intrinsic factors
Medical and neuropsychiatric conditions
Medications
Improper prescription and/or use of assistive
devices for ambulation
Falls
Impaired vision and hearing
Environmental hazards
Age-related changes In neuromuscular
function, gait and posture reflexes
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Insomnia
Sedative-hypnotic drug
Morning delirium/lethargy
Fall
Hip fracture
Cascade of drug-induced illness
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Seizures
Phenytoin
Ataxia
Fall
Hip fracture
Cascade of drug-induced illness
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Immobility
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Common causes

• Musculoskeletal disorders
• Arthritides, osteoporosis, fractures.
• Neurological disorders
• Stroke, parkinsons disease.
• Cardiovascular diseases
• CHF (severe), CAD..
• Pulmonary diseases
• COPD (severe type)
• Sensory factors
• Fear, impairment vision
• Environmental causes
• Forced immobility..
• Others
• Malnutrition, malignancy, depression

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Complications

• Skin pressure sores
• Musculoskeletal muscular atrophy
• Cardiovascular thrombosis, embolism
• Pulmonary pneumonia, atelectasis
• GI constipation, anorexia, impaction
• GU incontinence, infection, retention
• Metabolic impaired glucose tolerance, altered
  drug pharmacokinetics
• Psychological depression, dementia, delirium

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General management

• Iatrogenesis
• Drug therapy
• Developing clinical expectations
• Long-term-care resources
• Nursing home care

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