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Geriatric Medicine

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Title: Geriatric Medicine


1
Geriatric Medicine
  • Basic Principles
  • Ronald M. Unice, D.O.

2
Objectives
  • Review the general principles and goals of
    Geriatric care
  • Discuss the current and future demographics of
    the aged
  • Review the unique physiological and psychosocial
    aspects of the elderly and their clinical
    importance
  • Review the essential components of a
    comprehensive geriatric assessment
  • Discuss the performance of a mini-mental status
    examination

3
Geriatrics
  • A very independent 94 year old male patient saw
    his family physician for a chief complaint of
    right knee pain.

4
  • After the examination was completed, the
    physician informed the patient that the pain was
    due to osteoarthritis. When asked what treatment
    was available, the physician responded that the
    problem was simply related to old age and to be
    expected at age 94.

5
  • The patient then responded, my left knee is 94
    years old, too, but it doesnt hurt!

6
  • The central principle of geriatric care is to
    maintain for our geriatric patients as much
    independence of function and quality of life as
    is possible. Recognition of the unique
    physiological and psychosocial characteristics of
    our geriatric population is essential to provide
    appropriate care.

7
Demographic Characteristics Of The Elderly
8
Centenarians on the March
9
Gender Differences and Aging
  • 100 women for every 68 men over age 65
  • 100 women for every 39 men over age 85
  • 49 of women over 65 are widowed
  • 14 of men over 65 are widowed
  • 41 of elderly women live alone in the community
  • 15 of elderly men live alone in the community

10
Functional Disability and Aging
  • 5 of those 65 and over live in nursing homes
  • 23 of those over 65 report limitations in at
    least on ADL
  • 27 of those over 65 have limitations in IADL
  • Fewer than half report receiving any assistance
    in ADL or IADL

11
Male, Age 85
  • Weight 65 kg
  • (143 lbs..)
  • Serum creatinine 1.2 (n.5-1.2)
  • BUN 19
  • Estimated creatinine clearance (N120ml/min) is
  • 110 ml/min
  • 41 ml/min
  • 90 ml/min
  • 60 ml/min

12
Cockcroft and Gault
  • Creatinine clearance
  • (140 - age) (weight/kg)
  • ----------------------------
  • (72) (s. creatinine)
  • (140 - 85) (65)
  • ------------------
  • (72) (1.2) 41 ml/min
  • If female 41 x .85 35 ml/min

13
  • Ideal body weight for men
  • 50.0 kg 2.3 kg per inch gt 5 feet tall
  • Ideal body weight for women
  • 45.5 kg 2.3 kg per inch gt 5 feet tall
  • May use actual body weight if less than ideal
    body weight

14
The Elderly Kidney
  • Renal Blood flow and glomerular filtration rate
    decrease 5-10 per decade after age 30
  • Impaired ability to excrete a potassium load
    (reduced renin production) increases risk of
    hyperkalemia
  • Decreased concentrating and diluting capacity
    increase risks of dehydration and fluid overload

15
  • Protein binding of drugs may be altered by aging
  • In patients 60 and older protein binding in 15
    to 25 of patients will
  • A. Increase
  • B. Decrease

16
  • Protein binding and serum albumin will decrease
    in 15 to 25 of patients 60 years or older
  • Drugs therefore normally highly protein bound
    will have higher active free fractions with a
    normal measured serum concentration, clinical
    toxicity can be observed without laboratory
    evidence
  • Examples Phenytoin, Diazepam, Warfarin, Digoxin

17
  • The percentage of male body fat changes with
    aging
  • On average, the percentage of body fat between
    adulthood and age 75 will
  • A. Increase from 15 to 30
  • B. Decrease from 15 to 5
  • C. Decrease from 15 to 10
  • D. Increase from 15 to 20

18
Increase from 15 to 30
  • As a result the volume of distribution for many
    fat soluble drugs will increase dramatically
  • This increases half-life and may produce
    prolonged duration of action and adverse effects
  • Examples Phenothiazines, Benzodiazepines

19
  • A 10-15 decrease in total body water and a 30
    decrease in muscle needs will result in a reduced
    volume of distribution of water soluble drugs
    which will result in increased serum
    concentrations and potential toxicity
  • digoxin
  • aminoglycosides
  • cimetidine
  • propranolol)

20
Rule of Thirds
  • Aging Changes
  • Disease (1/3)
  • Disuse (1/3)
  • Normal aging (1/3)

21
Comprehensive Geriatric Assessment
  • A multi-disciplinary diagnostic process designed
    to quantify an elderly patients medical,
    psychosocial and functional capabilities

22
Components Of A Comprehensive Geriatric Assessment
  • Chronic medical treatment needs
  • Assessment of physical functioning
  • Assessment of mental functioning
  • Assessment of social support
  • Assessment of physical environment

23
An Appropriate Geriatric Assessment Will
  • Improve diagnostic accuracy
  • Assist in arriving at a comprehensive plan of
    treatment
  • Help choose the most appropriate environment of
    care
  • Assist in predicting outcomes and monitoring
    clinical change over time

24
  • The ultimate goals of a comprehensive geriatric
    assessment can only be achieved by performing
    thorough physical, functional and psychosocial
    assessments
  • Inadequate assessments may lead to inappropriate
    long-term care placement and limit autonomy of
    our elderly

25
Medical Treatment Needs
  • Specialized equipment
  • Specialized services
  • Evaluate capacity of family to provide these
    services

26
Assessment Of Physical Functioning
  • Loss of functional skills is probably the most
    common cause of a need for long term care
  • Appropriate treatment of functional disabilities
    can only be achieved after proper identification
    of the disabilities

27
Assessment Of Mental Functioning
  • Treatable psychiatric illnesses need to be
    recognized (e.g., depression, delirium,
    psychosis)
  • Psychobehavioral problems need addressed in
    relationship to caregivers (wandering, agitation,
    abusive behavior)
  • Accurate instruments not available
  • Cognitive measurement instruments (e.g., folstein
    minn-mental status exam) helpful but not
    necessarily predictive of functional capabilities

28
Assessment Of Social Supports
  • Capabilities and wishes of family and friends
    frequently deciding factor in placement
  • Involve social worker, home health, and
    appropriate agencies early
  • Future demographic changes very strongly affect
    social supports

29
Assessment Of Environmental Aspects
  • Physical environment essential determinant in
    placement decisions
  • Modifications in physical environment can improve
    function and increase safety

30
Assessment Of Activities Of Daily Living
  • Personal self-care
  • Feeding
  • Bathing
  • Toileting
  • Mobility
  • Transferring
  • Walking
  • Continence
  • Urine
  • Feces

31
Instrumental Activities Of Daily Living (Lawton)
  • Within the home
  • Cooking
  • Housecleaning
  • Laundry
  • Telephone
  • Finances
  • Outside the home
  • Shopping for food
  • Shopping for clothing
  • Use of transportation

32
Osteopathic PhilosophyKirksville
ConsensusDeclaration 1953
33
  • Osteopathy, or Osteopathic Medicine is a
    philosophy, a science and an art. Its philosophy
    embraces the concept of the unity of body
    structure and function in health and disease.
    Its science includes the chemical, physical and
    biological sciences related to the maintenance of
    health and the prevention, cure, and alleviation
    of disease. Its art is the application of the
    philosophy and the science in the practice of
    osteopathic medicine and surgery in all its
    branches and specialties.

34
  • Health is based on the natural capacity of the
    human organism to resist and combat noxious
    influences in the environment and to compensate
    for their effects to meet, with adequate
    reserve, the usual stresses of daily life and the
    occasional severe stresses imposed by extremes of
    environment and activity.
  • Disease begins when this natural capacity is
    reduced, or when it is exceeded or overcome by
    noxious influences.

35
  • Osteopathic medicine recognizes that many factors
    impair this capacity and the natural tendency
    towards recovery, and that among the most
    important of these factors are the local
    disturbances or lesions of the musculoskeletal
    system. Osteopathic medicine is therefore
    concerned with liberating and developing all the
    resources that constitute the capacity for
    resistance and recovery, thus recognizing the
    validity of the ancient observation that the
    physician deals with a patient as well as a
    disease.

36
Mini-Mental Status Exam
  • Good Screening Tool
  • Measure of General Cognitive Function
  • Score Ranges 0-30
  • Helpful for Follow-up of Dementia Patients
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