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.

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Geriatric Medicine

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

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