Dr. Safaa Hussein Ali   Lecturer of geriatric medicine        Ain Shams university            Cairo – EgyptSenior registra...
Definition of Ageing         “The processes that occur during life which culminate in changes thatdecrease an individuals ...
CLASSIFICATION OF AGE                               AGE  Chronological age -                          Psychological age – ...
   Greek word ―geros‖ mean the old age + Iatric    mean the medical treatment. This is the branch    of medicine concerne...
   Hippocrates noted conditions common in later life   Aristotle offered theory of ageing based on loss of heat   The w...
   Invented term ―geriatrics‖   Two ancient Greek words   “Geras” (Old-Age)   ―Iatricos‖ (Relating to the physician) ...
   that branch of internal medicine which deals    with the prevention, diagnosis and treatment of    diseases specific t...
   The study of physical and psychological    changes that occur in old age is called    ―gerontology‖.   Geriatrics is ...
   Reduced beds from 714 to 240 and increased    turnover 300%!   Spare beds then used for TB/Chest Medicine   Gifted a...
   Advocated ―the speciality of Geriatric Medicine for medical    management, rehabilitation and long term care of older ...
   Lionel Cosin   General surgeon (war casualties)   Originator of the geriatric day hospital (Oxford) 1957   Pioneer ...
   Pioneers and Innovators   From variety of clinical backgrounds ,    commitment and interest is what counts   Challen...
   Showing the benefits of geriatrics to the whole    system   Once people see what you can do they can be    ―won over‖...
   Awareness of atypical/ non-specific presentation of    acute illness in old age.   Whole person approach to older peo...
   General medical and geriatric facilities to be integrated.   Posts for general physicians with an interest in geriatr...
   Increase in provision of complex social care at home   More stroke units   More falls clinics and services   More I...
   DH want old people out of hospital and in ―community‖   (But to what alternative services?)   But UK geriatrics has ...
   Service frameworks around older people    not funded   Main performance targets for hospitals do    not focus on acut...
   Negative societal and media attitudes to older people   Most students, doctors and nurses still say they don‘t want t...
   ―Mainstream doctors are turned off by geriatrics,    because they do not have the faculties to cope with the    Old Cr...
   Many general physicians questioned need    for separate specialty    Considered inferior specialty for third rate    ...
   MDT case conference.   Geriatric day hospital.                                          But   Domiciliary visits re...
   1980- 5.3%   2000- 7.7%   2025- 13.3% ( 1.2 billion )   71% - Developing World
   Older people are the main customers of health    and social care   Demographic change means this will continue   So ...
   80% GP consultations   80% hospital days   70% admissions   70% health spending   95% spending on 65+ population ...
   Falls: 30% of over 65s per annum will fall. Falls    are 7th commonest reason for hospital    admission and commonest ...
Confusion       Pressure                              sores   Falls                 Geriatric                             ...
“Frailty is a failure to integrate responses in the   face of stress. This is why diseases manifest   themselves as the “g...
   3 or more of 5 criteria   6.7% of community residing elderly   3 year incidence —7%   Increases with age: 3%-65; 26...
   90,000 hip fractures per annum   50% injury admissions and 66% of bed days from    injury in the NHS   Median Age 81...
   In-patient comprehensive geriatric assessment (CGA) may    reduce short-term mortality, increase the chances of living...
   ―a multi-dimensional, interdisciplinary,    diagnostic process to determine the medical,    psychological and function...
10 RCTs. 1586 stroke patients were included; 766  were allocated to a stroke unit and 820 to  general wards.  The odds rat...
   ―studies investigating such interventions in    medical patients and those who have had    hip fracture have reported ...
   Individually targeted, falls 31%       Postural hypotension       Sedative medications       Use of ≥4 medications...
   Referred from A & E   Clinic based assessment and referral:     Postural hypotension     Visual acuity     Balance...
   If we can get people to listen to the    arguments and respect the evidence   Remember the data from Marjory Warren  ...
    ―all progress is achieved by the actions of    the unreasonable man‖ (George Bernard    Shaw)
   They may not see themselves as frail   Or old   And may be reluctant to see specialists in    elderly care   Or be ...
   Negative attitudes towards older people    persist   Insufficient education and training for staff   Routine breache...
   And your health system…   Culture and patient expectations   System incentives   Primary care and social services a...
•   Multiple diseases and multiple drugs.•   Diseases often chronic, progressive with adverse    consequences. Focus on fu...
   Do not be an ageist   Have patience in history taking   Optimize communication   Make the patient safe & comfortabl...
􀃍   Waste Accumulation Theory􀃍   Limited Number of Cell Divisions Theory􀃍   Hay flick Limit Theory􀃍   Death Hormone Theory...
FREE RADICAL THEORY"Free radical" is a term used to describe any molecule that differs fromconventional molecules in that ...
EFFECT OF FREE RADICAL DAMAGE
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Selected Age-related Changes and theirConsequences                         60
1. Deprenyl2. Human Growth Hormone3. DHEA4. Melatonin5. Acetyl-L-Car nitine6. Coenzyme Q107. Alpha Lipoic Acid8. Cysteine ...
•   Geriatric syndromes and conditions•   Diseases more common in older patients•   Psychosocial issues•   Disease prevent...
   Dementia, delerium, depression     common, not documented   Inappropriate medications     anticholinergic   Gait a...
   Dementia, Depression, Delerium   Incontinence   Osteoporosis   Falls   Hearing and vision impairment   Sleep diso...
   Dementia, Depression, Delerium       Cognitive screen, ask about depression, check        orientation and concentrati...
   Osteoporosis     Risk – asian > caucasian > AA/black     Kyphosis on physical exam     Dexa scan (femoral neck; L s...
   Hearing and vision impairment     Whisper test, check with glasses on   Sleep disorders     Normal aging – sleep cy...
   Failure to thrive     ―Dwindling‖     Weight loss     Increased frailty     Not able to live independently (withou...
   Iatrogenic   Medications       Anticholinergics       Narcotics - don‘t forget the laxative         Stool softener...
   Neurologic (Parkinsons, stroke, TIA)   Rheumatologic (RA, PMR, vasculitis)   Genitourinary (BPH, sexual dysfunction)...
First rule of geriatrics(similar to first rule of real estate sales)    ―Function, Function, Function‖    Patients don‘t c...
   Maintenance of health in old age by    high levels of engagement and    avoidance of disease   Early detection and ap...
   ―a multi-dimensional, interdisciplinary,    diagnostic process to determine the medical,    psychological and function...
   ADLs (Activities of Daily Living)   IADLs (Independent Activities of Daily    Living)   Mobility   Incontinence   ...
Test the following: Mobility – Timed Up and Go test- stand,  walk, turn, sit   Cognition – Mini-Cog (3 item recall) or  ...
   ―Timed Up and Go was 15 seconds, patient    walked slowly, unsteady, had to hold rail for    support‖   ―Two question...
   Diagnosis belongs in the ―Impression/Plan‖ section   BUT….   Rule #1: Avoid the trap of ―premature labeling‖    Pro...
   Rule #2:   You can start addressing functional    impairments without having a specific    diagnosis   Patients appr...
Back to First rule of History and Physical Examination  ….―To prevent it, you have to document it‖Learn about primary and ...
   Learn about cultural influences on health behavior    DNR, family involvement   Learn about stressors that affect pat...
   Ask the patient what THEY WANT TO DO    about their problem   ―Do not assume your preference is their    preference!‖...
   Jenny Smith is an 83 year old woman with    hypertension and osteoporosis for which she is on    appropriate medicatio...
   Visual impairment affects 20-30% of people over    the age of 75.   Visual impairments that occur with greater    fre...
   How could a fall interfere with Jenny‘s    ability to monitor and treat her diabetes?   What other aspects of Jenny‘s...
   Gait disorders are common in the elderly      At least 20% of community dwelling seniors      report gait problems re...
   Falls       30-40% of community dwelling seniors fall each year       Falls often result in decreased independence  ...
   How could the development of dementia interfere    with Jenny‘s ability to monitor and treat her    diabetes?   What ...
   Alzheimers Disease accounts for the vast    majority of dementias in the US   Among people >65, the prevalence of AD ...
   Decreased quality of life for patient and family       Loss of independence in ADLs and IADLs       Need for supervi...
   Dementia, in its early stages, is often    missed by medical professionals and    families   Up to 50% of moderate de...
   Have a high index of suspicion       Forgetfulness, getting lost, inability to follow        medical regimen, poor pe...
   As the speciality grows you can begin to sub-    specialise and expand range of services and    outreach into other se...
   Expect colleagues in other specialities (and even   patients) to be hostile or not convinced. Don‘t let it   worry y...
   Geriatrics is a major part of healthcare so it    needs to be a major part of undergraduate    and postgraduate traini...
   You need to think about the model of care for service delivery    which makes most sense locally   Primary care needs...
Geriarics
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Geriarics

  1. 1. Dr. Safaa Hussein Ali Lecturer of geriatric medicine Ain Shams university Cairo – EgyptSenior registrar of geriatric medicine Prince Mansour military hospital Taif-KSA
  2. 2. Definition of Ageing “The processes that occur during life which culminate in changes thatdecrease an individuals ability to cope with biological changes”.GERIATRICS: - A branch of medicine dealing exclusively with the problems ofageing and the diseases of the elderly. It is derived from the Greek root ―ger-gero- geronto‖ meaning SYNONYMS OF AGEING: ―old age‖ or ―the aged‖.Senescence: is the process by which the capacity for cell division, growth andfunction is lost over time, ultimately leading to an incompatibility with life i.e., theprocess of senescence terminates in death.Senility: This term is from the Latin origin ‗senilitus‘, which means the period ofphysical and mental deterioration, associated with old age.Senium: Identical to the term senility, one more term senium is also used in themedical field; it is marked by the deterioration and weakness that mayaccompany the age advancement.Geria: This also indicates the old age.
  3. 3. CLASSIFICATION OF AGE AGE Chronological age - Psychological age – Biological age – age number of years age how by body function lived individuals feels itCHRONOLOGICAL CATEGORIES•Young-Old - (ages 65 - 74) Set Old Age•Middle-Old - (ages 75 - 84) Old Old Age•Old-Old - (age 85 and older) Ripe Old Age
  4. 4.  Greek word ―geros‖ mean the old age + Iatric mean the medical treatment. This is the branch of medicine concerned with the problems of Ageing, including physiological, pathological, and psychological problems. Nascher was the first to coin the term Geriatrics. He published a paper in New York medical journal in1909 and a textbook on it in 1914. Thus Geriatric came to be recognized as a special branch in first decade of 20th century.
  5. 5.  Hippocrates noted conditions common in later life Aristotle offered theory of ageing based on loss of heat The word geriatrics was invented by Ignatz L. Nascher, a vienna born immigrant to the united states Geriatric medicine was a product of the British NHS Nascher was the father of geriatrics and Majory Warren was its Mother The 1st Geriatric service was started in U.K in 1947. Geriatric department at GH, Chennai was established in 1978. Post Graduate course in Geriatric medicine has been started in 1996 at Madras medical college.
  6. 6.  Invented term ―geriatrics‖ Two ancient Greek words “Geras” (Old-Age) ―Iatricos‖ (Relating to the physician) ―There should be a separate speciality to deal with problems of senility‖ Although conceived and named in US, geriatrics was first fully practiced in UK..
  7. 7.  that branch of internal medicine which deals with the prevention, diagnosis and treatment of diseases specific to old age‖.
  8. 8.  The study of physical and psychological changes that occur in old age is called ―gerontology‖. Geriatrics is the branch of general medicine concerned with clinical, preventive, medical and social aspects of illness in the elderly. The old age is defined as the age of retirement. In our country it is fixed at 60 years and above.
  9. 9.  Reduced beds from 714 to 240 and increased turnover 300%! Spare beds then used for TB/Chest Medicine Gifted advocate, innovator educator, mentor and teacher Attracted interest from health minister when discharge rate reached 25%‖! Published 27 papers in the 1940s and 50s on rehabilitation and assessment of frail older people Most famously… Warren MW. Care of chronic sick. A case for treating chronic sick in blocks in a general hospital. BMJ 1943;ii:822–3. BMJ 1943 Warren MW. Care of the chronic aged sick. Lancet 1946;i:841–3.
  10. 10.  Advocated ―the speciality of Geriatric Medicine for medical management, rehabilitation and long term care of older people.‖ UCH (1st geriatric unit in London teaching hospital) Worked with Lord Amulree (later civil servant) First English Professor of Geriatric Medicine Worked with Doreen Norton, the first professor of gerontological nursing (Norton Scale) Earlier discharges created beds for other specialities and high profile attracted students and interest from government Founded first memory clinic Pioneered early ripple mattresses Research interests in previously neglected clinical areas
  11. 11.  Lionel Cosin General surgeon (war casualties) Originator of the geriatric day hospital (Oxford) 1957 Pioneer of orthogeriatrics and rehabilitation.. Responsibility for 300 ―chronic sick‖ beds. Admitted patients thought to require ―permanent care‖ after hip fracture Operated then started early rehabilitation with the help of a physiotherapist, and many were discharged. Bobby Irvine Worked in Hastings with orthopaedic surgeon (who recognised his own lack of specialist knowledge) Established world famous orthogeriatric unit widely studied as an example Operated on even the frailest patients Mobilised them ―The first step in rehabilitation is the first step‖
  12. 12.  Pioneers and Innovators From variety of clinical backgrounds , commitment and interest is what counts Challenging assumptions (―that‘s the way we‘ve always done things) Challenging ageism/therapeutic nihilism Publishing and publicising Developing evidence base Mentorship, teaching, role models Spreading good practice to other units by example and training
  13. 13.  Showing the benefits of geriatrics to the whole system Once people see what you can do they can be ―won over‖ and usually want more Getting politicians and civil servants on board Alliances with other professions and organisations (strength in numbers) Put the patients first in your arguments….(not the profession)
  14. 14.  Awareness of atypical/ non-specific presentation of acute illness in old age. Whole person approach to older people with co- morbidity and complex disability. MDT team working and CGA Central importance of rehab. Recognition of caregivers‘ stress; respite care. The teaching of geriatric medicine to medical undergraduates.
  15. 15.  General medical and geriatric facilities to be integrated. Posts for general physicians with an interest in geriatrics Multidisciplinary approach to elderly care. Undergrad/postgrad training in elderly care for every doctor. Elderly medicine to become component of MRCP syllabus. Increased involvement of general practitioners in the medicine of old age. Local authority residential care review. Review of elderly mental health services.
  16. 16.  Increase in provision of complex social care at home More stroke units More falls clinics and services More Intermediate Care places Less overt age discrimination ―Spin off‖ benefits for older people from other targets But services still not ―fit for purpose‖ or ―age-proof‖ Breaches of Dignity and deep-seated negative attitudes to older people still common Skills, training and knowledge lacking General hospital care just as problematic Very few people actually receiving appropriate falls and OP treatment Many people still not getting to stroke units Single assessment process rarely implemented
  17. 17.  DH want old people out of hospital and in ―community‖ (But to what alternative services?) But UK geriatrics has become largely hospital-based So now we must persuade primary care organisations to buy our services or take over the running of some ―intermediate care‖ Many aren‘t interested – despite the evidence-base for CGA etc There is little in the GP performance framework about geriatrics But a perception from some GPs that geriatrics is ―easy‖ and its ―what GPs do anyway‖ .It doesn‘t need specialist training or a separate speciality
  18. 18.  Service frameworks around older people not funded Main performance targets for hospitals do not focus on acute/subacute frail complex older patients More around waiting lists and waiting times Payment systems mean that hospitals make money from elective surgery and lose money from acute unscheduled care So older people in beds are generally a ―problem‖ for the system rather than being seen as the main customers!
  19. 19.  Negative societal and media attitudes to older people Most students, doctors and nurses still say they don‘t want to work with old people (though that will be their job!) Negative attitudes to doctors/nurses who work with older people Medical values still favour ―high-tech‖ treatment, curative, individualistic and basic science over… …low tech, long term incurable conditions, health services research and multidisciplinarity Working with dementia, incontinence, falls or frailty isn‘t ―sexy‖ Little private practice income in geriatrics Patients with legitimate and treatable medical illness still labelled as having ―social admissions‖ or ―acopia‖ or ―bed blocking‖ Older people themselves often do not wish to be on specialist wards for older people and may not see themselves as old. Many professionals still don‘t see the need for a separate speciality
  20. 20.  ―Mainstream doctors are turned off by geriatrics, because they do not have the faculties to cope with the Old Crock. The Old Crock is deaf. The Old Crock has poor vision. The Old Crock’s memory is impaired. With the Old Crock, you have to slow down because he asks you to repeat what you are saying. And the Old Crock doesn’t just have a chief complaint—the Old Crock has fifteen chief complaints. How in the world are you going to cope with all of them? You’re overwhelmed. Besides, he’s had a number of these things for fifty years or so. You’re not going to cure something he’s had for fifty years. He has high blood pressure. He has diabetes. He has arthritis. There’s nothing glamorous about taking care of any of those things.‖...
  21. 21.  Many general physicians questioned need for separate specialty Considered inferior specialty for third rate doctors who could not ―make the grade‖ elsewhere. Negative, disdainful attitudes from doctors in training Medical students generally not inspired by the image of geriatrics.
  22. 22.  MDT case conference. Geriatric day hospital.  But Domiciliary visits requested by  Geriatrics more and more GP hospital based Community geriatrics.  Only 14% consultants Outreach clinics in general with dedicated practitioner surgeries. community or long stay care involvement Old age psychiatry.  And increasingly involved Ortho-geriatric liaison. in acute general internal Stroke rehabilitation units and medicine services.  Stroke becoming a Specialty clinics—for separate speciality with example, falls, parkinsonism, st more acute focus roke. Rapid assessment clinics.
  23. 23.  1980- 5.3% 2000- 7.7% 2025- 13.3% ( 1.2 billion ) 71% - Developing World
  24. 24.  Older people are the main customers of health and social care Demographic change means this will continue So older patients with frailty, multiple long-term conditions and disability, needing CGA multidisciplinary input will continue to be central to health care (not marginal) There is plenty of evidence for interventions If we apply them, both patients and the whole system will benefit so win/win (quality, access, capacity, cost) These might be the right arguments BUT…we have to be more outspoken and unreasonable in making this case
  25. 25.  80% GP consultations 80% hospital days 70% admissions 70% health spending 95% spending on 65+ population 10% of inpatients account for 55% bed days and 5% account for 40% of bed days Evercare Pilots, Case Management and Community Matrons…
  26. 26.  Falls: 30% of over 65s per annum will fall. Falls are 7th commonest reason for hospital admission and commonest reason for emergency attendance in over 60s Fractures: 1 in 2 women and 1 in 12 men or 200,000 p.a UK. Incontinence: 24% of >65s, 40-60% in institutions Dementia: (e.g. 40% of long term care. 20% emergency admissions >65) Delirium: 11-40% prevalence in hospital >65s (often unrecognised) Stroke: 150,000 per annum. 85% 65, usuall multiple co-morbidity
  27. 27. Confusion Pressure sores Falls Geriatric Vision GiantsImmobility Falls Hearing Depression Incontinence
  28. 28. “Frailty is a failure to integrate responses in the face of stress. This is why diseases manifest themselves as the “geriatric giants”….functions …such as staying upright, maintaining balance and walking are more likely to fail, resulting in falls, immobility or delirium‖Rockwood Age Ageing 2004i.e. Poor Functional Reserve
  29. 29.  3 or more of 5 criteria 6.7% of community residing elderly 3 year incidence —7% Increases with age: 3%-65; 26% -85-89 Fried L, et al J Gerontol Med Sci 2001: 560: M146-M156
  30. 30.  90,000 hip fractures per annum 50% injury admissions and 66% of bed days from injury in the NHS Median Age 81 years Falls, ostepporosis, multiple co-morbidity, cognition, nutrition, confusion, intercurrent illness, polypharmacy Following hip fracture high mortality, morbidity, dependence Are Systems designed around needs? Are orthopaedic surgeons the right people to care for them? Could outcomes be improved? What system would we design in an ―ideal world‖
  31. 31.  In-patient comprehensive geriatric assessment (CGA) may reduce short-term mortality, increase the chances of living at home at 1 year and improve physical and cognitive function. 20 RCTs (10 427 participants) of in-patient CGA. Newer data confirm the benefit of in-patient CGA, increasing the chance of patients living at home in the long term. For every 100 patients undergoing CGA, 3 more will be alive and in their own homes compared with usual care [95% confidence interval (CI) 1–6]. Most of the benefit was seen for ward-based management units CGA does not reduce long-term mortality. This evidence should inform future service developments.
  32. 32.  ―a multi-dimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail older person in order to develop a co- ordinated and integrated plan for treatment and long term follow up‖ Stuck et al Lancet 1994 ―Applying CGA especially to patients with frailty, functional impairment and multiple long term conditions is what best defines what we do as geriatricians‖ Rockwood K Age Ageing 2004
  33. 33. 10 RCTs. 1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards. The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months.
  34. 34.  ―studies investigating such interventions in medical patients and those who have had hip fracture have reported significant reductions (of about a third) in incidence of delirium and/or reduced severity and duration of delirium‖
  35. 35.  Individually targeted, falls 31%  Postural hypotension  Sedative medications  Use of ≥4 medications  Transfer skills, grab bars  Environmental hazards  Gait training, assistive device  Balance exercises, exercises against resistance Cost saving in higher risk group (4 of 8 risk factors)
  36. 36.  Referred from A & E Clinic based assessment and referral:  Postural hypotension  Visual acuity  Balance  Cognition  Depression  Carotid sinus studies  Medication Home safety assessment and advice Falls 61%, cost neutral
  37. 37.  If we can get people to listen to the arguments and respect the evidence Remember the data from Marjory Warren 1946 (714 beds down to 204)? Replicated by Adams in Belfast Or from Dr Bagnall in Leeds 1976 (40% reduction in length of stay for older patients on needs based unit) The benefits for the whole system are just as relevant 60 years on E.g. recent ―real-life‖ examples from St Thomas‘ hospital
  38. 38.  ―all progress is achieved by the actions of the unreasonable man‖ (George Bernard Shaw)
  39. 39.  They may not see themselves as frail Or old And may be reluctant to see specialists in elderly care Or be admitted to elderly care wards We have to ―sell‖ it to them in the right way (i.e. more rehabilitation, experts in the conditions they are suffering from, better chance of getting home and staying there etc)
  40. 40.  Negative attitudes towards older people persist Insufficient education and training for staff Routine breaches of dignity e.g.  Respect for personhood  Communication  Confidentiality  Privacy  Toileting/Continence  Nutrition  End of life care
  41. 41.  And your health system… Culture and patient expectations System incentives Primary care and social services are different But… You do have a rapidly ageing population You do have state funded health care with means tested social care You have recognised the health challenges of the ageing population You are beginning to train geriatricians of the future
  42. 42. • Multiple diseases and multiple drugs.• Diseases often chronic, progressive with adverse consequences. Focus on functional independence• Prevention is more productive and rewarding• Disease profile influenced by socioeconomic & emotional status• Symptoms may be silent: no pain in MI, no fever in infection or may be atypical & unrelated. Weak link organ symptoms: confusion, incontinence, faints, falls, depression, heart failure-Geriatric Syndromes• Features like reduced jerks, bacteriuria, IGT common
  43. 43.  Do not be an ageist Have patience in history taking Optimize communication Make the patient safe & comfortable Get a full medication list Assess family‘s cooperation & attitude Assess care giver‘s stress
  44. 44. 􀃍 Waste Accumulation Theory􀃍 Limited Number of Cell Divisions Theory􀃍 Hay flick Limit Theory􀃍 Death Hormone Theory (DECO)􀃍 Thymic -Stimulating Theory􀃍 Mitochondrial Theory􀃍 Errors and Repairs Theory􀃍 Redundant DNA Theory􀃍 Cross-Linkage Theory􀃍 Autoimmune Theory􀃍 Caloric Restriction Theory􀃍 Gene Mutation Theory􀃍 The Rate of Living Theory􀃍 Order to Disorder Theory􀃍 The Telomerase Theory of Ageing􀃍 Neuro Endocrine theory or Weak Link Theory􀃍 Free Radical Theory of Ageing 53
  45. 45. FREE RADICAL THEORY"Free radical" is a term used to describe any molecule that differs fromconventional molecules in that it possesses a free electron, a property that makesit react with other molecules in highly volatile and destructive ways. The changesinduced by free radicals are believed to be a major cause of Ageing, diseasedevelopment or/and death
  46. 46. EFFECT OF FREE RADICAL DAMAGE
  47. 47. 56
  48. 48. 57
  49. 49. 58
  50. 50. 59
  51. 51. Selected Age-related Changes and theirConsequences 60
  52. 52. 1. Deprenyl2. Human Growth Hormone3. DHEA4. Melatonin5. Acetyl-L-Car nitine6. Coenzyme Q107. Alpha Lipoic Acid8. Cysteine and Procysteine9. NADH10. Lycopene11. Vitamin E12. Vitamin B5 (Pantothenic Acid)13. Vitamin B6 (Pyridoxine)14. Synthetic Antioxidants15. Levodopa (L- Dopa)16. Calorie Restriction 61
  53. 53. • Geriatric syndromes and conditions• Diseases more common in older patients• Psychosocial issues• Disease prevention• Ethical Issues• Health Care Financing (Medicare)• Cultural aspects of aging
  54. 54.  Dementia, delerium, depression  common, not documented Inappropriate medications  anticholinergic Gait and mobility impairment  not documented Incontinence Iatrogenic complications  constipation, pressure ulcers
  55. 55.  Dementia, Depression, Delerium Incontinence Osteoporosis Falls Hearing and vision impairment Sleep disorders Failure to thrive Iatrogenic (medications)
  56. 56.  Dementia, Depression, Delerium  Cognitive screen, ask about depression, check orientation and concentration (serial 7‘s)  Delerium has variable orientation/concentration, dementia doesn‘t Incontinence  Stress, urge, overflow  Stress – small volume; urge – larger volume  Check for UTI with incontinence
  57. 57.  Osteoporosis  Risk – asian > caucasian > AA/black  Kyphosis on physical exam  Dexa scan (femoral neck; L spine)  Everyone gets 1000-1500 mg Ca + 400-800 IU Vit D  Treatment: Alendronate > calcitonin; estrogen/reloxifene; weight lifting Falls  How many ―Any in past 6 months?‖  What happened – ―trip, slip, drop‖  Injury?  Mandatory: test sensation, balance, GAIT (TUG test)
  58. 58.  Hearing and vision impairment  Whisper test, check with glasses on Sleep disorders  Normal aging – sleep cycles only 3-5 hours max  Going to bed too early?  ETOH; Tylenol PM?  Depression/anxiety?  Hot milk, read outside of bed, consider trazodone
  59. 59.  Failure to thrive  ―Dwindling‖  Weight loss  Increased frailty  Not able to live independently (without human assistance)  Check for cognition, mobility, medication side effects  Cancer?  Consider hospice for refractory situation (sometimes people get better with hospice!)
  60. 60.  Iatrogenic Medications  Anticholinergics  Narcotics - don‘t forget the laxative  Stool softener alone will not be enough  Antiarrhythmics  Dilantin (nausea; vertigo)  Neuroleptics  PPIs – nausea, diarrhea; Aricept (diarrhea) Bed Rest (hospitalization)  Rapid loss of muscle strength (>80 years: lose 1 ADL in 3-5 d)
  61. 61.  Neurologic (Parkinsons, stroke, TIA) Rheumatologic (RA, PMR, vasculitis) Genitourinary (BPH, sexual dysfunction) Cardiovascular (afib, CAD, CHF, HTN) Endocrine (hypothyroid, diabetes type II, Paget‘s) Renal (HTN, fluid/lyte abnormalities) Infections (pneumonia, UTI, TB) Gastrointestinal (dysphagia, constipation, ‗tics) Oncologic (colon, breast, prostate, hematologic) Psychiatric (depression, psychosis)
  62. 62. First rule of geriatrics(similar to first rule of real estate sales) ―Function, Function, Function‖ Patients don‘t care about their diagnoses, they care about their function
  63. 63.  Maintenance of health in old age by high levels of engagement and avoidance of disease Early detection and appropriate treatment of disease Maintenance of maximum independence consistent with irreversible disease and disability Sympathetic care and support during terminal illness
  64. 64.  ―a multi-dimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail older person in order to develop a co- ordinated and integrated plan for treatment and long term follow up‖ Stuck et al Lancet 1994 ―Applying CGA especially to patients with frailty, functional impairment and multiple long term conditions is what best defines what we do as geriatricians‖ Rockwood K Age Ageing 2004
  65. 65.  ADLs (Activities of Daily Living) IADLs (Independent Activities of Daily Living) Mobility Incontinence Affect/Mood Cognition (Memory)
  66. 66. Test the following: Mobility – Timed Up and Go test- stand, walk, turn, sit Cognition – Mini-Cog (3 item recall) or MMSE (Mini Mental Status Exam) Affect – Two question Depression screen
  67. 67.  ―Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support‖ ―Two question depression screen positive‖ ―Patient only remembered 2 of 3 items on Mini-Cog‖
  68. 68.  Diagnosis belongs in the ―Impression/Plan‖ section BUT…. Rule #1: Avoid the trap of ―premature labeling‖ Problem 1. ―Falls‖ – (list the differential here) Not Problem 1. ―Probable spinal stenosis‖ Or Problem 1. ―Musculoskeletal System‖
  69. 69.  Rule #2: You can start addressing functional impairments without having a specific diagnosis Patients appreciate a practical plan  Home safety, mobility aids, social supports
  70. 70. Back to First rule of History and Physical Examination ….―To prevent it, you have to document it‖Learn about primary and secondary prevention screening that maximizes function and minimizes future impairmentKeep current about age-associated recommendations for tertiary prevention (―treatment‖)
  71. 71.  Learn about cultural influences on health behavior DNR, family involvement Learn about stressors that affect patients and families Caregiver stress, finances Know what resources are out there to help,Social work (Turner clinic + other), types of assisted living, medication assistance, Area Agency on Aging, 3 day inpatient requirement for Medicare payment of CNH!
  72. 72.  Ask the patient what THEY WANT TO DO about their problem ―Do not assume your preference is their preference!‖ This will avoid more lawsuits than any other intervention!
  73. 73.  Jenny Smith is an 83 year old woman with hypertension and osteoporosis for which she is on appropriate medication and follows a diet and exercise program. Her doctor recently diagnosed her with diabetes. She was initially treated with oral agents but now has started taking insulin Jenny retired from her job as a high school English teacher 15 years ago but keeps herself busy with volunteer work as a tutor, church activities and exercise classes at the Y. Jenny was widowed 5 years ago. She has 2 grown daughters – one lives near her on the Upper West Side, the other lives in California but calls frequently.
  74. 74.  Visual impairment affects 20-30% of people over the age of 75. Visual impairments that occur with greater frequency as people age include  Refractive error  Cataracts  Glaucoma  Macular degeneration  Diabetic retinopathy  Blindness
  75. 75.  How could a fall interfere with Jenny‘s ability to monitor and treat her diabetes? What other aspects of Jenny‘s life could be affected by gait disturbance or a fall? What are some of the barriers to diagnosis and treatment of gait abnormalities and falls risk in the elderly? What roles can the different members of the interdisciplinary team play help Jenny to address her recent fall so that it does not lead to additional functional decline?
  76. 76.  Gait disorders are common in the elderly  At least 20% of community dwelling seniors report gait problems requiring assistance  In one study, >50% of those 85 and older reported difficulty walking  The presence of a gait disorder often heralds functional decline  The etiology of gait disorders is usually multifactorial
  77. 77.  Falls  30-40% of community dwelling seniors fall each year  Falls often result in decreased independence  Decreased functional status  Increased rate of NH placement  Increased use of medical services  Increased fear of falling  Falls result in injury and death  Most result in soft tissue injury, 10-15% in fracture  Complications from falls are the leading cause of death from injury among those >65  Death rate from falls increases with age  Lifetime cost of falls related injuries for those >65 has been estimated at $12.6 billion  Etiology of falls multifactorial  Includes medical, environmental, sensory and postural issues
  78. 78.  How could the development of dementia interfere with Jenny‘s ability to monitor and treat her diabetes? What other aspects of Jenny‘s life could be affected by dementia? What are some of the barriers to diagnosis and treatment of dementia in the elderly? How can the different members of the interdisciplinary team help Jenny and her family in addressing her dementia and maintaining independence and function for as long as possible? What are some of the key issues that need to be addressed as she faces this progressively debilitating and life limiting illness? If Jenny does not have dementia, what could she do to try to prevent it?
  79. 79.  Alzheimers Disease accounts for the vast majority of dementias in the US Among people >65, the prevalence of AD is 6-8% Among people >85, the prevalence is 30% 4 million people in the US currently suffer from AD By 2040, AD patients will number 14 million
  80. 80.  Decreased quality of life for patient and family  Loss of independence in ADLs and IADLs  Need for supervision, outside caregivers Financial burdens on family and society  Lost wages and direct costs for caregivers  $100 billion spent annually in US on care Difficulties obtaining appropriate medical care  Inability to give accurate history  Inability to understand and follow directions and medical regimens
  81. 81.  Dementia, in its early stages, is often missed by medical professionals and families Up to 50% of moderate dementias are missed by physicians Patients can remain oriented to person, place and time long after they have developed serious impairments in other areas of cognitive function
  82. 82.  Have a high index of suspicion  Forgetfulness, getting lost, inability to follow medical regimen, poor personal hygiene Use validated screening tools  MMSE, animal naming test, clock drawing test Look for reversible causes of dementia  B12 def, sensory def., depression, thyroid disease Obtain history from other sources
  83. 83.  As the speciality grows you can begin to sub- specialise and expand range of services and outreach into other settings You must expect negative perceptions and attacks and work hard to improve the ―image‖ of geriatrics and ―sell‖ it to potential recruits and to colleagues in other specialities You need to think about the model of service delivery (needs, age, integrated etc) and how it fits with existing local services/facilities Be careful about being sucked into general internal medicine so much that you neglect the frail and the long-term
  84. 84.  Expect colleagues in other specialities (and even patients) to be hostile or not convinced. Don‘t let it worry you. We know we are right! You just need to sell the benefits Keep emphasising that older frailer people will be the main users of health and social care – not a minority And that getting their care right will benefit the whole system You can be the solution to problems (and to other doctors who don‘t really want to look after these patients) Keep emphasising the strong evidence base for much of what we do Grow the evidence base through your own research And keep good enough data to demonstrate the impact of your service When people see what you can do they usually want more of your service
  85. 85.  Geriatrics is a major part of healthcare so it needs to be a major part of undergraduate and postgraduate training for all adult specialists – you cannot treat everyone You need to be a strong presence in the medical schools So avoid research funding and performance frameworks which prioritise basic science over clinical and health services research
  86. 86.  You need to think about the model of care for service delivery which makes most sense locally Primary care needs to focus more on the needs of older people Generalists have advantages over super-specialisation for complex patients with multiple illness – patients don‘t enjoy being ―passed around‖ specialists with no overall co- ordination But we have to convince patients themselves Finally, there is no point having targets or plans to improve services without the right financial investment and performance frameworks Perverse incentives in the system can make the care of older people worse not better
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