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Geriatric Medicine
 

Geriatric Medicine

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Geriatrics is a sub-specialty of medicine that focuses on health care of the elderly. It aims to promote health and to prevent and treat diseases and disabilities in older adults.

Geriatrics is a sub-specialty of medicine that focuses on health care of the elderly. It aims to promote health and to prevent and treat diseases and disabilities in older adults.

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    Geriatric Medicine Geriatric Medicine Presentation Transcript

    •  
      • Is a specialty of medicine concerned with physical, mental, functional & social conditions in acute, chronic, rehabilitative, preventative & end of life care of older patients
      www.geriatrics.org
      • is the progressive decline in functional reserve and function in an organisms over time
      • biochemical composition of tissues changes
      • ability to maintain homeostasis in adapting to stressors declines
      • vulnerability to disease processes increases with age
      • Older adults is expected to increase from 420 to 974 M in 2030
      • At present 59% of older adults live in the developing countries
      • 13% of 80 years old live in the US
      • >40% of those 80 yo live in Asia
      • chronic diseases causes 20M deaths worldwide among 70 yo
      • The major disease contributors:
      • >Cardiovascular disease -30%,
      • >Cancer-13%
      • >Chronic respiratory disease-7%
      • >DM-2%
      • 1) Functional Assessment:
      • functional status: best indicator of prognosis and longevity
      • Defined: how well a person is able to provide for his own daily needs
      • Changes in function may signal a medical illness, advancing cognitive impairment, changes in social support, depression, substance abuse, or a combination
      • Documentation of a patient's baseline functional status is essential so that changes can be identified and addressed.
      • is a clinical measure of balance in older adults
      • Pt is observed and timed as he rises from a chair, walks 3m, turns around, & returns to sit down in the chair
      • Healthy: should be able to complete the test in <10 s
      • Difficulty doing the test: increased fall risk & warrants further evaluation of mobility.
      • consists of three item recall test
      • followed by a clock-drawing test
      • Pt is then asked to recall the 3 words.
      • PT receives 2 points for a normal clock
      • A score of 0–2 is a positive screen for dementia.
      • is used for diagnosing delirium in a patient with altered mental status.
      • DX: when the confusional state is:
      • 1) acute in onset with a fluctuating course
      • 2) associated with inattention
      • 3) manifested by disorganized thinking
      • 4) an altered level of consciousness
      • Jaeger card for testing near vision
      • Snellen chart for testing far vision
      • tests most commonly used in office-based practices.
      • Visual impairment: unable to read the 20/40 line or worse
      • the examiner covers the opposite ear of the patient being tested, exhales completely, & whispers an easily answered question from a distance of 2 ft from the ear being tested
      • Treatment: amplification by a hearing aid
      • Hearing impairment can lead to decreased physical function, depression, and social isolation.
      • Definition:
      • (1) involuntary wt loss 4.5 kg over 6 mos or 4% in 1 year
      • (2) abnormal BMI: < 22 or > 27
      • (3) hypoalbuminemia : <38 g/L
      • (4) hypocholesterolemia (<160 mg/dL)
      • (5) specific vitamin or micronutrient deficiency (Vit B 12 ).
      • If any one of these is present, a multidimensional assessment should be undertaken
      • MD should review the patient's access to food. Are there any barriers?
      • Any dental problems that interfere with eating?
      • Are there any medical illnesses interfere with digestion/absorption of food?
      • Is the pt unable to prepare meals/feed himself?
      • Does the pt have food preferences?
    •  
      • a symptom presentation that is common in older adults, mostly multifactorial in origin
      • Dementia and Delirium
      • Falls
      • Urinary Incontinence
      • Pressure Ulcers
      • Dementia : a syndrome of progressive decline in w/c multiple intellectual abilities deteriorate, causing cognitive & functional impairment
      • Delirium : an acute state of confusion, impaired attention, and altered level of consciousness.
      • Both : char by disorientation, memory impairment, paranoia, hallucinations, emotional lability, & sleep-wake cycle reversal.
      • to maintain an optimal quality of life
      • to maximize cognitive & physical functioning
      • key goal: older patient w/ cognitive impairment is to identify & treat reversible causes: infections, electrolyte abno, vit def, thyroid dse, substance abuse, meds & psychiatric illnesses
      • Is the pt safe in the community?
      • Is the pt able to perform his own ADL & IADL?
      • What assistance is needed to maximize the patient's functioning in his living situation?
      • If the patient has dangerous behaviors(leaving the stove), increased patient supervision should be done
      • As dementia progresses, more care-giving services to be added to support the patient in the community
      • Predictors of nursing home admission (Alzheimer's dse):
      • aggression, assault, paranoia, nighttime wandering & loss of capacity to recognize the caregiver
      • Adult day care programs & Support groups help educate caregivers & decrease stress.
      • When dementia pts has agitated behaviors, medical illnesses(infections, pain) must be ruled out
      • If agitated behavior is harmful to patient/others & unresponsive to non-pharmacologic tx, then low doses psychotropic medication is helpful.
      • Delusions/hallucinations:
      • Low-dose risperidone (0.25–1.5 mg/d)
      • Olanzapine (2.5–10 mg/d)
      • Antidepressants : citalopram (10–30 mg/d)
      • Pts on antipsychotics should be monitored for any EPS. Lowest dose should be used; dosage reductions should be attempted, at 6-month intervals
      • Fall rates & risk of injury increases with age
      • Yearly, 30% of community dwelling adults >65 years fall
      • 50% of individuals >80 years fall
      • Injuries in 20–30% of fallers reduce subsequent mobility and independence
      • 3–5% of falls resulting in fracture.
      • decreased proprioception
      • increased postural sway
      • declines in baroreflex sensitivity resulting in orthostatic hypotension
      • History
      • the circumstances at the time of the fall
      • any associated symptoms
      • thorough medication review(prescription & over-the-counter meds).
      • PE: postural vital signs, vision evaluation, gait and balance testing, & musculoskeletal evaluation (joint stability & range of motion)
      • low creatinine clearance (< 65 mL/min)
      • low serum 25-hydroxyvitamin D levels (< 39 nmol/L) and high serum PTH levels
      • Insomnia
      • fear of falling
      • General exercise and balance training
      • t'ai chi
      • psychotropic medication elimination
      • multidisciplinary, multifactorial, risk factor screening and intervention
      • &quot;DRIIIPP&quot; mnemonic is useful when evaluating patient for reversible conditions that may cause/contribute to UI
      • If these conditions are identified & treated, the older adult benefits from relief of UI and symptoms of other comorbidities
      • D elirium 
      • R estricted mobility -illness, injury, gait disorder, restraint 
      • I nfection —acute, symptomatic UTI
      • I nflammation -atrophic vaginitis 
      • I mpaction -of feces 
      • P olyuria -diabetes, caffeine intake, volume overload
      • P harmaceuticals —diuretics, adrenergic agonists or antagonists, anticholinergic agents (psychotropics, antidepressants, anti-Parkinsonians)
    •  
      • results when the urethral sphincter are inadequate to hold urine during bladder filling
      • SX: leaking small amounts of urine during activities that increase intraabdominal pressure (coughing, laughing, sneezing, lifting)
      • Stress Test: let the patient stand with a full bladder and cough.
      • (+): if urine leakage coincides with the cough
      • causes: insufficient pelvic support due to childbearing, gynecologic surgery & decreased effects of estrogen on the lower urinary tract tissues
      • Surgery: most effective treatments
      • Pelvic muscle exercises can be helpful
      • Char by uninhibited bladder contractions
      • most common form of UI
      • SX: uncontrollable need to void. Urinary frequency and nocturnal incontinence accompanied by loss of larger urine volumes (>100 mL)
      • idiopathic, lesions of CNS(stroke), bladder irritation from infection, stones, or tumors.
      • DX: based on a patient's symptoms in the absence of urinary retention and the leakage of urine with stress maneuvers.
      • Measurement of postvoid residual should be part of an incontinence evaluation
      • Patient's bladder is catheterized 5–10 min after the patient has voided.
      • PVR > 200 mL suggests detrusor underactivity or obstruction.
      • TX: bladder retraining by voiding q2 h or based on the patient's symptom frequency
      • If no incontinence for 2 days, the voiding interval can be increased by 30–60 minutes until the patient is only voiding every 3–4 h
      • Anticholinergic: (oxybutinin & tolterodine) which cause bladder relaxation.
      • SX: stress & urge incontinence are present
      • 3 incontinence questions (3IQ) may help to classify
      • Q1 : asks if pt has leaked urine in the past 3 months
      • Q2 : familiarizes patients with types of incontinence: stress, urge, or other
      • Q3 : asks the patient for the category of incontinence based on symptoms during the past 3 months: stress, urge, mixed, or other
      • The 3IQ improved the chance of a positive diagnosis of urge incontinence (+likelihood ratio of 3.29) and of stress incontinence (+likelihood ratio of 2.13).
      • due to either bladder outlet obstruction or an atonic bladder
      • Male, may complain of dribbling after voiding , an incessant urge to urinate, or straining to urinate
      • PE: palpable distended bladder
      • BPH, prostate CA & urethral strictures are the common in men, while a cystocele in women
      • Urodynamic testing used to distinguish urethral obstruction from detrusor underactivity
      • TX: bladder outlet obstruction: surgical removal of obstruction
      • BPH and are not in retention:
      • Adrenergic blockers : terazosin, doxazosin, or tamulosin can decrease symptoms of urinary frequency and nocturia.
      • 5-reductase inhibitor : Finasteride w/ doxazosin for decreasing LUTS due to BPH w/ a prostate volume of 25 mL.
      • Increased pressure between skin & bony prominence produces tissue necrosis.
      • occur in 80% over the heels, lateral malleoli, sacrum, ischia, and greater trochanters
      • Shear forces, cause stretching & angulation of blood vessels,
      • frictional forces cause separation of the epidermal/dermal layers  tissue necrosis & open ulceration.
      • Osteomyelitis & sepsis: morbid complications
      • Repositioning of patients every 2 h
      • providing bedbound patients mattresses with pressure-relieving capabilities are standard interventions to prevent pressure ulcers
    •  
      • Diabetic ulcers: by pressure in extremities compromised by neuropathy & vascular disease
      • Venous stasis ulcers seen on the lower extremities due to incompetent valves of the veins
      • Arterial ischemic ulcers develop at sites of decreased blood flow. Since adequate blood supply is necessary for tissue to heal, assessment of pulses and ankle-brachial indices (ABI) for ulcers of the lower extremities is needed
      • ABI of <0.4 is associated with a low likelihood of wound healing. If pt not a surgical candidate for revascularization, the goal of care: to keep the wound free of infection and to alleviate any related patient discomfort
    • by the National Pressure Ulcer Advisory Panel
      • Debridement : surgical/chemical is necessary to remove necrotic tissue & allow new granulation tissue to grow.
      • Cleansing : helps to lower bacteria counts. Normal saline is best, as it protects new granulation tissue
      • In infected wounds, bacteriocidal agents(1% povidine-iodine, 0.25% acetic acid, 0.5% sodium hypochlorite (Dakin's solution) used as disinfectants, not for more than a week at a time as they are cytotoxic to fibroblasts and delay wound healing
      • Dressing should be based on the ulcer stage.
      • stage 1 & 2- heal in days to weeks
      • stage 3 & 4 ulcers -take many months to heal.
      • Adequate nutrition is fundamental to healthy aging.
      • In general, energy req decrease w/ age due to a dec in lean body mass & physical activity
      • Older adults may be at risk of undernutrition due to medication side effects; functional, visual, or cognitive impairment; oral disease, swallowing disorders,; depression & social isolation; & chronic illnesses.
      • The requirements of protein, fat, and carbohydrates do not change with age, calories from carbohydrate sources gradually substitute for those from fat
      • To maintain adequate caloric intake and promote cardiovascular health, substitution of monounsaturated (olive oil), omega-3 (sardines) & omega-6 (liquid vegetable oils) fatty acids for trans fatty acids may be beneficial.
      • Although vitamin requirements do not change with age, older adults are particularly prone to inadequate intake of vitamins D, B 12 and calcium, and supplementation should be considered
      • Exercise improves body composition, psychological well-being & disease outcomes, and reduces risk of injurious falls
      • Physical and cognitive exercise reduces risk of dementia
      • An exercise prescription may be beneficial & should consider flexibility, endurance, strength, and balance but should be preceded by attention to musculoskeletal problems, footwear, and risk factors for cardiovascular disease
      • Falls risk assessment is addressed
      • Exercise decreases risk
      • Seatbelt use should be encouraged
      • Moderate alcohol consumption has many salutary effects, but has many consequences for older adults who are at risk for alcohol side effects at lower levels of consumption
    •  
      • Immunizations:
      • Influenza vaccination is recommended annually
      • all adults > 65 should receive the pneumococcal vaccine at least once
      • Tetanus vaccinations should be administered every 10 years
      • Bone Health:
      • 70% of women 80 years have osteoporosis
      • all women >65 years should receive dual-energy x-ray absorptiometry (DEXA) screening at least once
      • minimum of 2 years: recommended to measure a change in bone density
      • Breast Cancer:
      • incidence of breast cancer increases with age & peaks in the eighth decade
      • Sensitivity&specificity of mammography reaches its maximum in the ninth decade
      • Annual clinical breast examination (CBE) is a screening alternative to mammography, since the postmenopausal atrophy of breast tissue improves CBE sensitivity in older women
      • Prostate Cancer:
      • U.S. Preventive Services Task Force has concluded that evidence to recommend for or against screening is lacking
      • American Cancer Society and American Urological Society recommend screening among those with at least a 10-year life expectancy
      • Colorectal Cancer:
      • Annual or biennial fecal occult blood testing (FOBT) reduces mortality in those >80
      • sigmoidoscopy (every 5 years)
      • colonoscopy (every 10 years)
      • No one method has been shown to be superior, and all methods are cost effective.
      • (DRE) alone or with FOBT is not recommended
      • Colonoscopy: colon can be completely visualized and biopsies taken if the examination is positive
      • If negative, it does not need to be repeated for 10 years
      • Lung Cancer:
      • Although lung cancer is also a leading killer, no screening interventions have been shown to be effective.
      • Smoking cessation & BP reduction, results in greater gains in life-years than do medical and surgical therapies, especially in men
      • lower levels of risk factors in mid-life are associated with survival free of major morbidity to age 85.
      • A person is never too old to benefit from smoking cessation.
    •