The document discusses several factors that should be considered for syndromes associated with the geriatric population, including diminished physiological reserve, loss of complexity, and higher basal sympathetic activity. It then presents several clinical scenarios involving an elderly male with diabetes and hypertension presenting with malaise and fatigue, an elderly female who fell and injured her leg, and an elderly male with urinary incontinence. It discusses conditions like frailty, falls, pressure ulcers, urinary incontinence, and cognitive impairment that are common in geriatric patients.

1. DISABILITY IN ELDERLY
Dr SRINIVAS

2. INTRODUCTION
Que:- What factors should be considered for the very precipitation of
syndromes associated with geriatric population?
• Homeostenosis
• Diminished physiologic reserve
• Loss of complexity
• Enhanced variability (intra & interindividual)
• Higher basal sympathetic activity
• Excessive response to stressors
• Diminished end organ responsiveness
• Loss of negative feedback
• Allostatic load

3. CLINICAL SCENARIO
• A 72 years old elderly male accompanied by his son on a wheelchair, a
known diabetic & hypertensive on regular treatment. The patient had
been routinely following up at, by his family physician.
• From past 4 months patient complains of malaise, generalized fatigue
& finds himself not at ease & gives a history of decreased mobility.
• Patient is referred to a geriatric facility for further evaluation.
• Initial evaluation shows BP of 156/86, PR-88bpm, RR-16cpm & SpO2
of 97% in RA, Systemic examination didn’t have any abnormality.

4. FRAILTY
Multimorbidity
Area of biomarkers

5. Characteristics of Frailty
• Increased vulnerability
• Reduced physiological reserve
• Decreased resistance to stressors
• Reduced capacity to maintain
internal homeostasis
• Loss of resilience
• Multisystem dysregulation
• Failure to thrive
• Accumulation of deficits
• Impaired mobility
• Disability
• Comorbidity
• Cognitive impairment
• Poor health function
• Poor psychological functioning
• Functional decline
• Dependence on daily activity
• Gait abnormality

6. • Slow walking speed
• Decreeased balance
• Low energy expenditure
• Low physical activity
• Low fitness
• Poor endurance
• Exhaustion
• Impaired vibration sense
• Depression
• Unintentional weight loss
• Sarcopenia/weight loss
• Weakness
• Low Strength
• Slow motor performance
• Vision or hearing deficits

7. DEFINITION OF FRAILTY
• “medical syndrome with multiple causes and contributors
characterized by diminished strength, endurance, and reduced
physiologic function that increases an individual’s vulnerability for
developing increased dependency and/or death”
• frailty is a dysregulation of the stress response systems responsible for
organismal resilience, leading to loss of homeostatic capabilities,
increased susceptibility to stress, and the emergence of a distinct
syndromic phenotype that is predictive of a range of clinical adverse
outcomes

10. CRITERIA FOR FRAILTY SYNDROME
ACCORDING TO FRIED AND COLLEAGUES
• CHARACTERISTICS OF FRAILTY
• Weight loss (unintentional)/sarcopenia
(loss of muscle mass)
• Weakness
• Exhaustion/poor endurance
• Slowness
• Low activity
• CARDIOVASCULAR HEALTH STUDY MEASURE
• > 10 lb lost unintentionally in prior year
• Grip strength: lowest 20% (by gender, body mass
index)
• “Exhaustion” (self-report)
• Walking time/15 ft: slowest 20% (by gender, height)
• kcal/wk: lowest 20% males: <383 kcal/wk; females: < 270
kcal/wk

12. CLINICAL SCENARIO
• An elderly female while having a normal stroll, suddenly she
encountered a slippery segment of path, leading to fall, patient
complained of excruciating pain and couldn’t stand upon her own and
was rushed to hospital, in ER, her vitals were stable with her right
lower limb attitude external rotation with lateral aspect of the foot
along the horizontal plane of the bed.

13. FALLS
• More common in female than males
• Increases with advancing age
• 5th largest cause of mortality among elderly
• Need for long term hospitalization & institutionalization
• Lead to functional limitation, fear of falling, social isolation
• Definition:-A fall is an unexpected event in which the participant
comes to rest on the ground, floor or lower level
• Considered a classical geriatric syndrome

14. INTRINSIC FACTOR

15. EXTRINSIC FACTOR

16. • In older patients the falls are commonly due to intrinsic factor
• Other risk factors include osteoporosis, fall direction, low body
weight
• Components of posture

22. • Home assessment and modification for high-risk individuals
• Exercise programs that include strength, gait, and balance exercises, such as
physiotherapy.
• Vitamin D supplementation in doses greater than 700 IU/d
• Review medications, minimizing psychoactive medications and reducing the total
number of medications
• Management of postural hypotension Expedite cataract surgery on the first affected eye
• Consider pacing in cardioinhibitory carotid sinus hypersensitivity and recurrent falls
• Management of foot problems and recommend use of antislip shoe devices for the
outdoors
• Patient and caregiver education, especially of the
• importance of specific environmental improvements

23. PRESSURE ULCERS
Pressure ulcers are caused when an area of skin and the tissues below
are damaged as a result of being placed under pressure, sufficient to
impair its blood supply. They are also known as pressure sores,
bedsores, and decubitus ulcers. Pressure ulcers have important
consequences both for patients and for the health care system. They
can lead to severe or intolerable pain, are prone to infection, and are
associated with high mortality rates.

25. Prevention is the most important aspect in an elderly frail patient who
is susceptible to develop pressure ulcers. Risk factor assessment on
hospital visit and application of appropriate preventive measures, such
as, improving general health, minimizing external forces, and
promoting educational programs about pressure ulcers to caregivers
are the keystones in this

26. • Reduction of extrinsic factors—in particular, pressure relief—is a
cornerstone of therapy: this may be done with the use of pressure-
reducing devices like low-air loss or air fluidized bed, or static devices such
as foam or fluid-filled mattresses or supports, in patients who can change
positions independently.
• Debriding of necrotic tissue, cleansing the wound, managing bacterial load
and colonization, and selecting a wound dressing are other important
components of ulcer management. Debridement, however, is not
recommended for heel ulcers that have stable, dry eschar without edema,
erythema, fluctuance, or drainage. Appropriate antibiotic therapy is
instituted in infected pressure ulcers

27. • Nutritional assessment is important, as patients who are
malnourished have more bony prominences and are therefore at
greater risk for pressure ulcers.
• Microbiological evaluation should be done with an aim to distinguish
between bacterial invasion and colonization.
• Blood cultures or cultures of deep tissue biopsy specimens generally
are more clinically significant than are cultures of superficial swab
specimens or aspiration of the pressure ulcer

28. CLINICAL SCENARIO
• An elderly male rather reticent regarding his problems in his life
comes to a geriatric clinic. Patient provides a history of wetting his
underpants especially when he tries to do yogasanas or other
exercise postures during his morning routine with his friends in a
park.
However, patient doesn’t have such symptoms during his usual day to
day activities.
Patient had the initiation of such symptoms from past 4 months, but
has significantly increased since then.

29. URINARY INCONTINENCE
• Urinary incontinence is an involuntary loss of urine that is objectively
demonstrable and leads to a social or hygienic problem. UI is a
troubling and common disorder among geriatric patients.
• A practical approach to incontinence in elderly patient is based on its
duration (acute or chronic).

30. • Acute or transient incontinence refers to cases of short course
incontinence (lasting less than four weeks), including those situations
in which loss of continence is considered to be functional, without
any associated structural disorder. The causes for these include:
• D Delirium Dementia Diabetes
• R Restricted mobility Retention
• I Infection Inflammation Impaction of stool
• P Pharmaceutical agents/Psychological causes

31. • Chronic or established incontinence: When the incontinence lasts longer
than four weeks and is commonly associated with structural disorders,
either in the urinary tract or outside of it (e.g. nervous system).
• Urge incontinence presents as urgency, frequency and nocturia. It is
associated with a strong urge to void. It is caused by an overactive detrusor
muscle causing excessive involuntary bladder contraction, UI is associated
with various neurological conditions including stroke, spinal cord lesions,
dementias, and Parkinson’s disease.

32. • Stress incontinence is associated with actions that
increase intra-abdominal pressure such as coughing,
sneezing, bending, lifting, or laughing. The cause is
pelvic muscular weakness causing urethral hyper
mobility, multiparity, hypoestrogenism, obesity, and
pelvic surgical procedures like prostatic resection.
• Overflow incontinence occurs when the bladder muscle
is overdistended. May present with stress or urge
symptoms. The cause is an underactive bladder muscle,
or a bladder outlet or urethral obstruction leading to
overdistension and overflow.
• Functional incontinence occurs when a physical or
psychological impairment impedes continence despite a
competent urinary system.

36. CLINICAL SCENARIO
An 86 years old lady was brought by her daughter to the OPD for her
evaluation. According to her, patient had a brief period of illness (fever
for a period of 5 days) for which she was hospitalized a month back,
now patient has history of forgetfulness which has become excessive &
at times putting her at harms way.
Daughter also wants to institutionalize the patient as she finds it
difficult to manage her mother’s needs & her family at the same time.
Patient however says that her memory is at its best, and it’s the
daughter who is forgetful. She also narrated a incident of her childhood
in a continuous flow.

37. COGNITIVE IMPAIRMENT
• Alzheimer disease is traditionally believed to be the most common
cause of dementia at older age. However, the categorization of
different forms of dementia is quite a complex (and probably
meaningless) exercise in advanced age. In fact, it cannot be ignored
that:
• 1) a clear pathophysiological mechanism for many types of dementia
is not yet defined) and
• 2) the age-accumulation of subclinical and clinical deficits leads to a
cloud of different causes (frequently overlapping and all potentially
valid) no specific treatment able to reverse the neurodegenerative
process (whatever the etiology) is available to date.

38. COGNITIVE IMPAIRMENT
• Alzheimer disease is traditionally believed to be the most common
cause of dementia at older age. However, the categorization of
different forms of dementia is quite a complex (and probably
meaningless) exercise in advanced age. In fact, it cannot be ignored
that:
• 1) a clear pathophysiological mechanism for many types of dementia
is not yet defined) and
• 2) the age-accumulation of subclinical and clinical deficits leads to a
cloud of different causes (frequently overlapping and all potentially
valid) no specific treatment able to reverse the neurodegenerative
process (whatever the etiology) is available to date

40. • Delirium is an acute, fluctuating syndrome of altered attention,
awareness, and cognition precipitated by an underlying condition or
event, in vulnerable persons. Delirium is frequently described using
terms like altered mental status, acute confusional state, sundowning,
encephalopathy, and acute organic brain syndrome.
• Delirium is a serious complication for older adults because an episode
of delirium can initiate a cascade of deleterious clinical events,
including prolonged hospitalization, loss of functional independence,
reduced cognitive function, and death.

41. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for
delirium include:
• A. disturbance in attention and awareness (reduced orientation to the
environment).
• B. develops over a short period of time (usually hours to a few days),
and tends to fluctuate in severity during the course of a day.
• C. disturbance in cognition (e.g. memory deficit, disorientation, language,
visuospatial ability, or perception).
• D. The disturbances in Criteria A and C are not explained by another pre-
existing, established, or evolving neurocognitive disorder and do not occur
in the context of a severely reduced level of arousal, such as coma.
• E. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e. due to
a drug of abuse or a medication), or exposure to a toxin, or are due to
multiple etiologies.