Geriatrics

1. GERIATRIC SYNDROME
General (Internal) Medicine
Update Course
National Postgraduate Medical College of Nigeria
Lecturer: Dr. Alfred E.A. JAIYESIMI
26th July 2022

2. PREAMBLE
• Worldwide, there has been a demographic shift as it relates to age-related
population distribution. Whilst infant mortality has improved in developed
nations as well as child-hood survival, reduced mortality due to infections
and western related life-style, non-communicable diseases predominates
as the main focus of health care delivery in developed Countries.
• Cancers, Cardiovascular disease and Neurologic disorders such as stroke,
Parkinson's disease and Dementia have accounted for most hospitalizations
and main cause of mortality.
• Also sedentary life-style, and diets rich in refined sugars has resulted in an
upsurge of obesity and Diabetes mellitus further contributing to upsurge of
Cardiovascular and Neurologic diseases.

3. UNDERSTANDING THE CONCEPT OF
GERIATRICS AND THE BURDEN IN NIGERIA
• Elderly Persons better described as individuals who are about 65 years old
and beyond. The word Geriatric derives from the Greek word “gēras” that
means old age. The suffix – iatric as in Pediatrics implies Physician or
Medicine. The terms Elderly Persons Medicine is often used in place of the
term Geriatrics. In the current practice Geriatrics is applied to a branch
(subspecialty) of Medicine that deals with the problems and of old age and
aging people.
• However, socially the less offensive terms have replaced and modified the
use of the word Geriatric.
• Geriatric is a noun and considered offensive. Likewise it is an adjective that
defines the specialty of Medicine that cares for older persons

4. UNDERSTANDING THE CONCEPT OF GERIATRICS
AND THE BURDEN IN NIGERIA (contd)
Demographic studies provide evidence that population dynamics
undergo changes over time. Of particular interest are the following
observations:
• Life expectancy has improved worldwide and most especially in
Countries where infant mortality have reduced and healthy
environments and access to health care have improved.
• Furthermore, economically affluent Countries with high levels of
education and social safety nets tend to have higher life expectancy.

5. UNDERSTANDING THE CONCEPT OF GERIATRICS
AND THE BURDEN IN NIGERIA (Contd)
In Nigeria it is difficult to statistically state the life expectancy
estimates. Reliable database of birth and death registration is lacking,
many deaths occur at home and low literacy levels have associated
with speculations on demographic records. Likewise Lack of regular
census has resulted in estimation of population growth rate and life
expectancy that are often difficult to plan with.
The lack of reliable data in Nigeria and the focus on the infant mortality
by government and institutions has been associated with lack of data
and understanding of the burden associated with older person.
Virtually all health providing facilities in Nigeria fail to provide aids,
equipment and appropriate psychosocial support. This failure is in
breach of the Nigerian Constitution.

6. UNDERSTANDING THE CONCEPT OF
GERIATRICS AND THE BURDEN IN NIGERIA
On February 10th 2021 Nigeria ratified a National Policy on Ageing for
older persons in Nigeria. The policy aims to promote an age-friendly
environments and uses the term Senior Citizens, Seniors or Older
persons.
The National Policy is intended to guarantee independence,
participation, and comprehensive care, self- fulfilment and dignity.
Furthermore the 1999 Federal Constitution of the Federal Republic of
Nigeria section 16, subsection 2(d) provides a social contract with social
policy of adequate and suitable shelter, suitable and adequate food as
well as old age care to be provided,

7. Worldwide Population Estimates For the
Elderly
Year Number(Million) World-wide Percentage
2015 908 12.3%
2030 1,402 16.5%
2050 2,092 21.5%

8. Worldwide Population Estimates For the
Elderly (Contd)
A United Nations 2009 estimate for Nigeria, suggested that 4.9% of Nigerian
population is above 60years. A further study “ Elderly population age 60
years and older in Nigeria from 2018 to 2020” Statistics August 2021 and
published February 1, 2022 shows an increase from 8,629,132 (2018) to
9,370,131. Similarly World Bank estimates that the population of Nigeria
aged 65 and above has risen from 1.3 million in 1960 to 5,829,073 in 2021.
The rise has been more steep since 2010 and the plot of increase in
geometric and no longer linear. Also 3.1% of the total population of Nigeria
are aged 65 and above. In a publication in Diabetes Therapy 2018 May 9(3)
titled: Prevalence and risk factors for Diabetes in Nigeria: A systemic Review
and Meta-Analysis
Andrew E. Uloko et al, an overall prevalence of DM in Nigeria was 5.77%

9. Common Geriatric Syndromes and General
Medicine
Having established that a significant population of Nigerians are old age
persons (Seniors), the lack of trained qualified Geriatricians, lack of special
facilities for care in Teaching Hospitals and General Hospitals and the
absence pf Geriatric Medicine in undergraduate Medicine makes this lecture
of great significance.
Elderly person are prone to develop stroke, parkinsons disease, Delirium and
Dementia; increased malignancy risks especially – gastrointestinal, skin.
Lymphoproliferative, prostrate cancer and gammopathies including
Amyloidosis, Hypertension, arrhythmic heart disease, ischemic heart disease
and Heart failure increase with age. Lung cancer mainly occurs in older
persons typically 65 years and above just as Chronic Obstructive lung disease
(COPD). The recent Covid-19 predominantly affected the elderly and had
greatest severity

10. Common Geriatric Syndromes and General
Medicine (Contd)
Type 2 Diabetes mellitus occurs more after the age of 45 years and
about 25% of adult have Diabetes whilst Arthritis tends to commonly
manifest at age 40 and above, older age is the greatest risk factor for
Osteoarthritis. The prevalence of Osteoarthritis increased from 33%
among those aged 60 – 70 to 43.7% among those above 80 years,
Renal mass begins to decrease from age 30 and the steepest decline
occurs after age 50 with a concomitant decline of Renal function with
kidney disease more prevalent over the age of 60 years in developed
Countries.

11. Common Geriatric Syndromes and General
Medicine (Contd)
The information provided on aging and disease is intended to draw
attention that all specialties are likely to encounter elderly persons as
patients and emphasize the fact that the older persons are likely to
have multiple medical conditions and be on multiple medications and
at risk of adverse drug reactions and complications.
This lecture on common Geriatrics syndrome is not exhaustive but
intended to highlight health problems that are common and peculiar to
Senior citizens. These health problems affect health and quality of life
such as ability to socialize be physically active and take good care of
themselves. Common geriatric syndromes also impact adversely on
self confidence, self worth and mental well-being of the elderly
persons.

12. Common Problems to check in the Elderly
• Falls, dizziness or syncope
• Memory decline, confusion – acute or chronic and behavioural changes –
withdrawal, anxiety, agitation and schizoid personality.
• Incontinence especially Urinary incontinence
• Pain and paraesthesia – such pains are often in multiple parts of the body,
may not be related to joints or movement and posture and could be
migratory as well as interfering with sleep
• Reduced mobility and gait instability which may affect transfers to and
from bed or chairs. There may be muscular deconditioning and lack of
exercise.
• Changes in ability of self-care- such as feeding, bathing, and dressing

13. Common Problems to check in the Elderly
• Polypharmacy – Use of multiple medications as a consequence of multiple
preexisting medical or surgical conditions and multiplicity of symptoms.
• Constipation
• Weight loss, wasting and loss muscle mass
• Hearing impairment. Tinnitus is present is over 50% of the elderly and
often precedes Presbycusis which is present in over 30% of persons over
age 65
• Sleep disorders such excessive daytime sleepiness, difficulty in falling
asleep, early wakefulness, sleep apnoea (SA) and periodic limb movements
in sleep (PLMS). Associated with sleep disordered breathing (SDB)
recurrent arousals from sleep. Intermittent hypoxaemia, cardiac
arrhythmias – atrial fibrillation, ventricular tachyrhytmias and pulmonary
oedema tend to occur.

14. Common Problems to check in the Elderly
• Skin changes – dryness, puritic marks, pigmentary changes,
seborrheic keratosis and pressure ulcers. In African elderly persons
variant of seborrheic keratosis referred to as dermatossi papulosa
nigra is common. Also malignant melanoma, naevus and squamous
cell carcinoma may occur

15. Common Problems to check in the Elderly
• Geriatric Syndromes are typically a functional decline as a
consequence ageing process, - multi-organ decrement in organ
function and limited homeostatic response to stress as well as
concomitant coexistence of multiple diseases

16. Clinical Condition Commonly Referred to as
Geriatric Syndromes
These are typically non-terminal illness, that affect function, mood and
quality of life. They complicate hospitalizations as they are kept in hospitals
and care homes for prolonged period. Common Geriatric syndromes are
amenable to treatment and rehabilitation especially when detected early.
The Royal College of Physicians and British Geriatrics Society in a joint
statement in 2001 stressed that:
➢Older persons with serious medical conditions do not present in a textbook
fashion but with falls, confusion, immobility or incontinence
➢Failure to appreciate the atypical presentation of elderly with medical
conditions often result in: misdiagnosis; delays in instituting appropriate
care and the attitude that an older persons health needs more social care
(Nursing Homes-rather than home, clinic and hospital management.

17. Clinical Condition Commonly Referred to as
Geriatric Syndromes(Contd)
In the 1930’s the concept of Geriatric syndromes requiring specialized
skill i.e. Geriatrics as a specialty developed. Thereafter Professor
Bernard Isaacs (a Professor of Geriatric Medicine) coined the term “
Geriatric Giants to refer to the following:
❖Instability (Falls and Syncope)
❖Immobility
❖Incontinence (persistent urinary or fecal incontinence)
❖Intellectual impairment (delirium and dementia)

18. Approach to Persons with Geriatric Syndrome
A multifactorial proceed of interplay of multiple factors occurring in
older persons, resulting in a specific reason for presenting for care
constitutes a geriatric syndrome
Symptoms may result from multiple impairment, and or diseases on a
background restriction of intrinsic ability of the elderly to respond to
cumulative minor stressors.
Documentation and assessment of baseline health status, quality of
life, performance of activities of daily living support facilities –
psychologic and emotional, availability of aids and equipment – hearing
aids, appropriate dentures, visual aids, as well as mobility and transfer
facilities.

19. Approach to Persons with Geriatric Syndrome
(contd)
Thus an older persons usual state of health prior to presenting to the
clinic or hospital is vital and mandatory.
In addition to the medical diagnosis, review of medicines and
concordance with drug therapy must be documented. Home
conditions – such as adequate lighting, risk for falls such as ceramic
tiled floors; clutter bedrooms, living rooms, kitchens, availability of
home support and helps.
The functional ability i.e. ability to perform activities of daily living
before and at presentation to the health facility.

20. Activities of Daily Living (ADL)
• Mobility including aids and appliances
• Degree of independence in performing bathing and dressing
• Continence
• Ability to feed, eat and drinking with or without assistance or aids.
• Shopping, cooking and cleaning
Detailed clinical assessment of mobility, gait and balance; hydration
status; presence or absence of mobility restriction and or pain in major
joints and spine. Presence of pain or areas of tenderness or swelling or
loss of muscle bulk. This is particularly important in the females who
may also have osteoporosis and low impact fractures.

21. Approach to Persons with Geriatric Syndrome
(contd)
Furthermore, a detailed skin assessment and examination at first
presentation in the clinic and hospital is vital and of medico-legal
importance. Bruises, ecchymosis, abrasions and wounds may indicate falls;
or abuse of the patient by family members or careers (Vulnerable persons)
Presence of pressure ulcers; gangrene from restraints or due to disease –
peripheral artery disease; as well as skin pigmentary changes as well as skin
cancers should be documented.
The elderly patient with a Geriatric syndrome will require an immediate
assessment for several factors that often simple may be of significance for
treatment, rehabilitation and post hospital care plan e.g blood glucose level,
hydration status.

22. Multidisciplinary Team Approach
A multidisciplinary Team Approach is vital in caring for the elderly.
These includes:
❑A trained Geriatrician
❑Geriatric Nurse and other Nurses e.g continence, skin care specialists,
oncology e.t.c
❑Rehabilitation – Physiotherapy, Occupational therapy staff.
❑Social worker

23. Multidisciplinary Team Approach (contd)
Following a multidisciplinary team assessment, a care plan is agreed
upon to address the following:
▪ Presenting Geriatric Syndrome
▪ Activities of Daily Living Deficit – such as feeding, mobility, gait and
balance, feeding, vision and dental care
▪ Skin care
▪ Underlying disease e.g CKD, Peripheral Artery Disease, COPD,
Ischemic heart disease, Heart failure, Anaemia, malignancies,
Gastrointestinal diseases, cognitive and visuo-spatial challenges.

24. Multidisciplinary Team Approach
A benefit of intervention is weighed against complications of treatment
is assessed and decision on degree of intervention decided. Patients
competence, autonomy and dignity are considered. Specialists are
carried along.
Patients environment – safety and required aids and home
modifications – wheel chairs, walking frames, ramps, hand rails etc are
assessed.

25. Framework of Assessment Tools
Framework of Assessment tools in the practice of Geriatrics,
❖The most common and detailed tool utilized at first encounter is the
comprehensive Geriatric Assessment (CGA).
❖Clinical Frailty Scale
❖Geriatric Depression Scale (GDS)
❖Geriatric Oral Health Assessment Index (GOHAI).
❖Tinetti Gait and Balance Assessment
❖Barthel Scale to assess performance in activities of daily living.
❖Cognitive assessment tools, validated for the culture, education level and
language.

26. Discharge Care Planning
The primary intent of Geriatric Medicine is to ensure reversible
conditions are addressed as early as possible and efforts to improve on
functional state such as activities of daily living, restore patient
confidence, improve mobility and treat depression.
It is vital to distinguish delirium from dementia and avoid hasty
decision of discharge of older persons to Nursing Home.
Discharge planning in older persons must factor in care planning. A
decision is based on patient progress and presence of cognitive ability.
Patients are discharged to any of the following:

27. Patients are Discharged to any of the
Following
• Home
• Continuing care Unit
• Nursing Home
• Hospice with Palliative Care.