Geriatric Medicine.ppt


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Geriatric Medicine.ppt

  2. 2. INTRODUCTION <ul><li>A specialty of medicine that is concerned with the disease and health problems of older people, usually those over 65 years of age. </li></ul><ul><li>Considered a subspecialty of internal medicine. </li></ul><ul><li>Ageing may be considered to be the loss of adaptability of an individual with time. </li></ul>
  3. 3. <ul><li>For men, life expectancy is 16 yr at age 65 and 9 yr at age 75. </li></ul><ul><li>For women, life expectancy is 19 yr at age 65 and 12 yr at age 75. </li></ul><ul><li>Overall, women live about 5 yr longer than men, probably because of genetic, biologic, and environmental factors. </li></ul><ul><li>These differences in survival have not changed, despite changes in women's lifestyle (eg, increased smoking, increased stress). </li></ul>
  4. 4. <ul><li>Maximum human life span (estimated at 110 to 120 yr) has increased modestly compared with the substantial increase in average life expectancy during this century but continues to increase without slowing of the rate. </li></ul><ul><li>People > 65 are in better health than their predecessors and remain healthier longer. </li></ul><ul><li>Because of these improvements in health, decline tends to be most dramatic in the oldest old. </li></ul>
  5. 5. SELECTED PHYSIOLOGIC AGE-RELATED CHANGES Changes in drug levels  Strength Tendency toward dehydration  Lean body mass  Muscular mass  Creatinine production  Skeletal mass  Total body water  Percentage adipose tissue (until age 60, then .until death) Body composition Clinical Manifestations Physiologic Change Affected Organ or System
  6. 6.  Cancer risk DNA damage and  DNA repair capacity  Oxidative capacity Accelerated cell senescence  Fibrosis Lipofuscin accumulation Cells Clinical Manifestations Physiologic Change Affected Organ or System
  7. 7.  Ability to recognize speech Loss of high-frequency hearing EARS Tendency to parkinsonian symptoms (eg,  muscle tone,  arm swing)  Number of dopamine receptors  alpha-Adrenergic responses  Muscarinic parasympathetic responses CNS Clinical Manifestations Physiologic Change Affected Organ or System
  8. 8.  Muscle mass  Bone mass  Fracture risk Vaginal dryness Changes in skin Water intoxication Menopause,  estrogen and progesterone secretion  Testosterone secretion  Growth hormone secretion  Vitamin D absorption and activation  Incidence of thyroid abnormalities  Incidence of diabetes (  insulin sensitivity or  insulin resistance)  Bone mineral loss  Secretion of ADH in response to osmolar stimuli Endocrine system Clinical Manifestations Physiologic Change Affected Organ or System
  9. 9. Tendency toward constipation and diarrhea  Splanchnic blood flow  Transit time GI TRACT Presbyopia  Glare and difficulty adjusting to changes in lighting  Visual acuity  Lens flexibility  Time for pupillary reflexes (constriction, dilation)  Incidence of cataracts EYES Clinical Manifestations Physiologic Change Affected Organ or System
  10. 10. Tendency toward syncope  Ejection fraction  Intrinsic heart rate and maximal heart rate Blunted baroreflex Cardiac acceleration  Diastolic relaxation  Atrioventricular conduction time  Atrial and ventricular ectopy HEART Clinical Manifestations Physiologic Change Affected Organ or System
  11. 11. Tendency toward some infections and possibly cancer  Antibody response to immunization or infection but  Autoantibodies  T-cell function  B-cell function IMMUNE SYSTEM Clinical Manifestations Physiologic Change Affected Organ or System
  12. 12. Changes in drug levels with  risk of adverse drug effects Tendency toward dehydration  Renal blood flow  Renal mass  Glomerular filtration  Renal tubular secretion and reabsorption  Ability to excrete a free-water load KIDNEYS Tightening of joints Tendency toward osteoarthritis Degeneration of cartilaginous tissues Fibrosis  Elasticity JOINTS Clinical Manifestations Physiologic Change Affected Organ or System
  13. 13.  Taste and consequent  appetite  Likelihood (slightly) of Nosebleeds  Smell NOSE Changes in drug levels  Hepatic mass  Hepatic blood flow  Activity of P-450 enzyme system LIVER Clinical Manifestations Physiologic Change Affected Organ or System
  14. 14. Tendency toward syncope  Response to beta-blockers Exaggerated response to anticholinergic drugs  Baroreflex responses  beta-Adrenergic responsiveness and number of receptors  Signal transduction  Muscarinic parasympathetic responses Preserved alpha-adrenergic responses PERIPHERAL NERVOUS SYSTEM Clinical Manifestations Physiologic Change Affected Organ or System
  15. 15.  Likelihood of shortness of breath during vigorous exercise if people are normally sedentary or if exercise is done at high altitudes  Risk of death due to pneumonia  Risk of serious complications for patients with a pulmonary disorder  Vital capacity  Lung elasticity (compliance)  Residual volume  FEV1  V/Q mismatch PULMONARY SYSTEM Clinical Manifestations Physiologic Change Affected Organ or System
  16. 16. Tendency toward hypertension  Endothelin-dependent vasodilation  Peripheral resistance VASCULATURE Clinical Manifestations Physiologic Change Affected Organ or System
  17. 17. <ul><li>Most age-related biologic functions peak before age 30 and gradually decline linearly thereafter; the decline may be critical during stress, but it generally has little or no effect on daily activities. </li></ul><ul><li>Therefore, disorders, rather than normal aging, are the primary cause of functional loss during old age. </li></ul><ul><li>Also, in many cases, the declines that occur with aging may be due at least partly to lifestyle, behavior, diet, or environment and thus can be modified. </li></ul>
  18. 18. <ul><li>For example, aerobic exercise can prevent or partially reverse declines in maximal exercise capacity (O2 consumption per unit time, or Vo2max), muscle strength, and glucose tolerance in healthy but sedentary older people. </li></ul><ul><li>The un-modifiable effects of aging may be less dramatic than thought, and healthier, more vigorous aging may be possible for many people. </li></ul>
  19. 19. PROBLEMS IN GERIATRICS <ul><li>Many of the problems in geriatrics fall into the so-called big four </li></ul><ul><ul><li>Intellectual impairment/confusion </li></ul></ul><ul><ul><li>Immobility </li></ul></ul><ul><ul><li>Instability </li></ul></ul><ul><ul><li>Incontinence </li></ul></ul><ul><li>In addition to this there are many other problems, but most of what is seen in gerontology is a summation of, what would be on their own, minor pathologies, adding together to render an individual in some way handicapped - i.e. unable to fulfill a particular role in society. </li></ul>
  20. 20. Confusion <ul><li>Confusion exists in two major syndromes. </li></ul><ul><li>The acute syndrome , referred to as delirium, broadly corresponds to a transient, reversible, and functional, episode of cognitive impairment with no permanent structural alteration in the CNS. </li></ul><ul><li>The chronic syndrome , dementia, corresponds to a fixed or progressive neuroanatomical abnormality. </li></ul>
  21. 21. <ul><li>Note that confusion, delirium and dementia are descriptive terms. </li></ul><ul><li>Confusion describes some form of disorientation, delirium a more specific type of acute toxic confusional syndrome and dementia a patient who appears to chronically have lost some form of higher mental function. </li></ul><ul><li>Also note that not all people who seem to acutely confused have delirium, and not all those who appear chronically confused are confused at all. </li></ul>
  22. 22. Common causes of delirium <ul><li>Hypoxia </li></ul><ul><li>Infection </li></ul><ul><li>Drugs </li></ul><ul><li>Endocrine, e.g. diabetes </li></ul><ul><li>Metabolic, e.g. hyper/hypocalcaemia </li></ul><ul><li>Alcohol </li></ul><ul><li>Psychosis </li></ul>CAUSES of DELIRIUM
  23. 23. Delirium can be caused by: <ul><li>Reduced cerebral oxygen supply </li></ul><ul><li>Primary neurological conditions </li></ul><ul><li>Infections </li></ul><ul><li>drugs </li></ul><ul><li>Metabolic disorders </li></ul><ul><li>Pain/discomfort, e.g. fractures - plus other factors- and possibly constipation </li></ul><ul><li>Physical causes acting: directly on the brain, e.g. concussion, intracranial hypertension; indirectly, e.g. hypothermia </li></ul><ul><li>Vasculitic e.g. cranial arteritis </li></ul>
  24. 24. <ul><li>In elderly patients, delirium may result from bladder distension or fecal impaction, a silent chest or urinary tract infection, nutritional deficiencies or increased sensitivity to barbiturates, digitalis or other drugs; removal from home may cause acute confusion. </li></ul>
  25. 25. Common causes of dementia <ul><li>Alzheimer's disease </li></ul><ul><li>Multi-infarct dementia </li></ul><ul><li>Dementia with Lewy bodies </li></ul><ul><li>A more detailed etiology of dementia may be considered in terms of: </li></ul><ul><li>Frequency of the causes </li></ul><ul><li>Reversible causes </li></ul>CAUSES of DEMENTIA
  26. 26. CLINICAL FEATURES <ul><li>Possible clinical features of delirium include: </li></ul><ul><li>Impairment of consciousness. </li></ul><ul><li>Disorientation, perceptual errors, hallucinosis - usually visual hallucinations. </li></ul><ul><li>Motor disturbance - overactivity in acute delirium; mild irritability in subacute delirium. </li></ul><ul><li>Emotional symptoms - panic, terror may be present because the patient misperceives their environment. </li></ul><ul><li>Delusional ideas - unformulated delusional ideas may be present. Delusional ideas are often persecutory. </li></ul><ul><li>Mood - suspicion, fear, anxiety or violence. </li></ul>
  27. 27. <ul><li>Acute delirium compromises: </li></ul><ul><li>Impairment of consciousness </li></ul><ul><li>Hallucinosis </li></ul><ul><li>Overactivity </li></ul><ul><li>Subacute delirium, or the confusional state, comprises: </li></ul><ul><li>Impairment of consciousness </li></ul><ul><li>Perplexity </li></ul><ul><li>An incoherent thought pattern </li></ul>
  28. 28. CLINICAL FEATURES <ul><li>Widespread deterioration in mental function. This refers to the loss of a variety of abilities in the spheres of: </li></ul><ul><ul><li>Areas of memory </li></ul></ul><ul><ul><li>Analytic thought </li></ul></ul><ul><ul><li>Judgment and planning </li></ul></ul><ul><ul><li>The handling of language and spatial relationships </li></ul></ul><ul><ul><li>Social responsiveness </li></ul></ul><ul><ul><li>Conduct and feeling </li></ul></ul><ul><ul><li>The basic tasks of self-care </li></ul></ul>Dementia may generally be described as referring to a widespread deterioration in mental function, without impairment of consciousness.
  29. 29. <ul><li>If impairment of consciousness is present together with general intellectual impairment, then the condition is defined as delirium or confusional state - acute or sub-acute. </li></ul><ul><li>The clinical picture at any one time is determined by: </li></ul><ul><li>The patient's previous personality and intellectual endowment </li></ul><ul><li>The nature of the pathological process and the stage that it has reached </li></ul>
  30. 30. INVESTIGATIONS <ul><li>History and examination, including </li></ul><ul><li>Mental status questionnaire, are vital parts of the investigation of an acutely confused patient. </li></ul>
  31. 31. Emergency investigations, probably essential in all patients, and the rationale behind them include: <ul><li>CXR : pneumonia, heart failure etc </li></ul><ul><li>ECG : silent MI, arrhythmias </li></ul><ul><li>FBC : anaemia, WBC for infection </li></ul><ul><li>U+E : hydration state, renal function, serum sodium and potassium </li></ul><ul><li>Blood sugar : hypoglycaemia, diabetes </li></ul><ul><li>Urinalysis : infection </li></ul><ul><li>Cultures : urine as a routine, sputum if available, blood if febrile or clearly ill for no obvious reason </li></ul>
  32. 32. The following investigations are useful in many patients: <ul><li>Blood gases : hypoxia </li></ul><ul><li>Blood cultures : occult infection </li></ul><ul><li>Drug screen : retrospective diagnosis </li></ul>Second line investigations depending on the indication, and whether a definite diagnosis has been established, include: <ul><li>B12 and Folate : to look for deficiencies, may also include assessment of all Vit. B status </li></ul><ul><li>T4 and TSH : depending on physical signs and whether diagnosis is established </li></ul><ul><li>ESR : vasculitis </li></ul><ul><li>CT scan : subdural haematoma, tumour, etc. </li></ul>
  33. 33. DELIRIUM Vs DEMENTIA <ul><li>Key : Del = delirium; Dem = dementia </li></ul><ul><li>Mode of onset : acute or subacute (Del); chronic or subacute (Dem) </li></ul><ul><li>Poor attention : characteristic (Del); late event (Dem) </li></ul><ul><li>Conscious level : often affected - may be wild fluctuations (Del); normal (Dem) </li></ul><ul><li>Hallucinations and misinterpretations : common (Del); late events (Dem) </li></ul><ul><li>Fear, agitation and aggression : common (Del); not common in the early stages (Dem) </li></ul>
  34. 34. <ul><li>Totally disorganised thought with palpably unreal ideas : common - often flight of ideas (Del); late feature - usually poverty of thought (Dem) </li></ul><ul><li>Motor signs : postural tremor, myoclonus, asterixis (Del); none, or late feature (Dem) </li></ul><ul><li>Speech : slurred (Del); normal (Dem) </li></ul><ul><li>Dysphasia : none (Del); often present (Dem) </li></ul><ul><li>Dysgraphia : often prominent (Del); if present, in keeping with degree of dementia (Dem) </li></ul><ul><li>Short and long term memory : poor (Del); often normal until late (Dem) </li></ul>
  35. 36. YOGA PRACTICES <ul><li>YOGA IS BALANCE (SAMATVAM) </li></ul><ul><li>I A Y T CORRECTS IMBALANCES </li></ul><ul><li>AIMS : </li></ul><ul><li>STRESS REDUCTION </li></ul><ul><li>RELIEF OF PAIN </li></ul><ul><li>MEDICATION REDUCTION </li></ul>
  36. 37. Ánandamaya Kôùa Vijòanánmaya Kôùa PERFECT HEALTH Manômaya Kôùa Annamaya Kosa Pranamaya Kosa ÁDHIJA VYÁDHIS YOGA Panchakosa concept
  37. 38. PROMOTION OF POSITIVE HEALTH <ul><li>Breathing practices </li></ul><ul><li>Hands in and out breathing </li></ul><ul><li>Ankle stretch breathing </li></ul><ul><li>Tiger breathing </li></ul><ul><li>Rabbit breathing </li></ul><ul><li>Sasankasana breathing </li></ul><ul><li>Straight leg raise breathing </li></ul><ul><li>Sithilikarana vyayama (loosening exercise) </li></ul><ul><li>Jogging </li></ul><ul><li>Forward and Backward bending </li></ul><ul><li>Side bending </li></ul><ul><li>Twisting </li></ul><ul><li>Pavanamuktasana kriya </li></ul><ul><li>Suryanamaskar </li></ul>
  38. 39. <ul><li>Yogasanas </li></ul><ul><li>Standing </li></ul><ul><li>Ardhakati cakrasana </li></ul><ul><li>Ardha cakrasana </li></ul><ul><li>Padahastasana </li></ul><ul><li>Prone </li></ul><ul><li>Bhujangasana </li></ul><ul><li>Salabhasana </li></ul><ul><li>Dhanurasana </li></ul><ul><li>Supine </li></ul><ul><li>Sarvangasana </li></ul><ul><li>Matsyasana </li></ul><ul><li>Cakrasana </li></ul><ul><li>Sitting </li></ul><ul><li>Pascimottanasana </li></ul><ul><li>Vakrasana/Ardha Matsyendrasana </li></ul><ul><li>Sasankasana/ Yogamudra </li></ul><ul><li>Ustrasana </li></ul><ul><li>Deep relaxation technique (DRT) </li></ul>
  39. 40. <ul><li>Pranayama </li></ul><ul><li>Kapalabhati </li></ul><ul><li>Vibhaga pranayama (Sectional breathing) </li></ul><ul><li>Nadi suddhi </li></ul><ul><li>Meditation (Dhyana Dharana) </li></ul><ul><li>Nadanusandhana </li></ul><ul><li>OM meditation </li></ul><ul><li>Kriyas </li></ul><ul><li>Jala Neti </li></ul><ul><li>Sutra Neti </li></ul><ul><li>Vaman Dhouti </li></ul>
  40. 41. SPECIFIC PRACTICES <ul><li>General considerations : The physical abilities of elderly persons may vary considerably. Generally strenuous physical activity is less tolerated, the risk of fractures increases (e.g. when falling), and various chronic diseases are more common. </li></ul>
  41. 42. <ul><li>Contraindications : Extreme and long term backward bending of cervical spine may cause dizziness and restrict the blood flow blood in vertebral arteries which supply the brain. Contraindications are also related to specific health problems. Most elderly people do not feel comfortable in Savasana without a pillow or pad under their head (without it the rounded thoracic spine would bend the neck backward to much). </li></ul><ul><li>Recommendations : There are many gentle and suitable practices which should be selected according to individual needs (e.g. Pavanmuktasana, when sitting on a chair). </li></ul>