Bwire

1. APPROACH TO DISEASE IN
ELDERLY
Bwire PGY 3
CUHAS/MMED/6000504/T/21
Facilitator: Prof. Robert Peck

2. Elderly
Defined as people aged 65 years and above
20% aged 65+ (2020), Expected to be >40% 2050,
• Progressive declines in structure and function,
• Impaired Maintenance and repair systems,
• Increased susceptibility to disease
• Major independent risk factor for chronic diseases [cardiovascular disease,
cancers, and neurodegenerative disorders]

3. How are elderly patients different?
• Physiological changes
• Increased disease susceptibility ( change in pattern of illness)
• Atypical presentation of illness
• Symptom in one organ system often reflects abnormalities in another
• Increased reliance on social supports
• Increased role of adverse effects to meds and therapies
• Predisposing factors – advanced age, hepatic or renal insufficiency, small body
size, polypharmacy

4. Other Characteristics of the Older Patient
• Goals of treatment may be different – care vs cure
• Greater emphasis on function and quality of life
• But – we need to be careful not to withhold treatment
• Individualize and analyze the morbidity/mortality of each treatment and
effect of withholding – taking into account patient’s values

5. Clinical Approach to the Elderly Patient
• History – needs to address the problems and concerns prevalent in
this group.
• discuss cognitive and sensory impairments,
• social history
• functional status
• detailed review of medications – prescribed/ over the counter
• Get history from caregivers, family members, spouses – those most likely to
notice subtle changes in the patient’s status

6. Clinical Approach to the Elderly Patient…
• Ask the questions – patients will usually not report falls, incontinence,
cognitive dysfunction, sexual dysfunction, depression – unless they
are asked
• Advanced Directives
• discussion concerning end of life care should begin in the outpatient setting
while the patient is well and still able to fully express their wishes

7. Geriatric Assessment
• Frailty: impaired ability to cope
with everyday or acute stressors
brought by age-related declines in
physiological reserve and function
across multiple organ
systems(who)
• characteristics:
• unintentional weight loss,
• self-reported exhaustion,
• weakness,
• slow walking speed,
• low physical Activity]
Frail=3 or more criteria;
robust=none, prefrail=1 ore 2 criteria
Assessment
• Evaluation of physical and mental
health
• Determination of functional status
• Social and economic status
• Screening for elder abuse and
caregiver burnout

8. Components of the Geriatric Assessment
• Functional Assessment
• Evaluation of Gait
• Evaluation of Cognitive Function
• Evaluation of Mood
• Social Assessment
• Economic Assessment

9. Functional assessment
Components of functional status - evaluate three levels of activities of
daily living:
• Activities of daily living (ADLs)
• Instrumental activities of daily living (IADLs)
• Advanced activities of daily living (AADLs)

10. Functional assessment…
Activities of Daily Living (ADL)
• Bathing
• Dressing
• Feeding
• Toileting
• Transfers
• Continence
• Walking unsupported
Assessed by Katz index of independence in
activities of daily living
Instrumental Activity of Daily Living (IADL)
• Shopping
• Doing Housework
• Doing Laundry
• Managing Money
• Meal Preparation
• Use of Transportation
• Telephone use
• Driving
• Taking Medications
Assessed by the Lawton instrumental activities
of daily living scale
Kojima et al, 2019

11. Functional assessment…
Advanced activities of daily
living(AADLs) require higher level of
understanding and integration into
societal and community roles
• Occupational,
• Recreational, and
• Travel activities.

12. Gait evaluation
Abnormal gait- Risk for recurrent falls and osteoporotic fractures
Aetiology
• Decreased range of motion
• Muscle weakness
• Sensory/Balance Deficit
• Spasticity
• Pain
Observe the patient in the exam
room
• Get Up and Go Test
• Rise from a chair - without the use
of armrests(muscle strength)
• Walk 3 meters(10 Feet)
• Turn, walk back and sit down
>13 seconds to walk 10M ↑recurrent falls; Walking <0.8 meters/second are likely to have shorter survival .
Slow gait speed - initiating preventive strategies eg. physical therapy, exercise

13. Evaluation of Cognitive Function
• Incidence of dementia ↑with
age, common >85yrs
• Dementia often goes undetected
• Evaluation of cognitive function:
• collateral information-gathering,
• detailed mental status
examination
• tests to evaluate medical
conditions(B12, TSH)
• depression assessment, and/or
• radiographic imaging [CT/MRI]

14. Mood disorder
• Depression is a serious health concern in elderly.
• Leads to:-
• suffering,
• impaired functional status,
• increased mortality, and
• excessive use of health care resources
• Depression can remain underdiagnosed or inadequately treated.

15. Delirium
acute onset of disturbance in consciousness in which cognition or
perception is altered
Delirium risk assessment [Medical
Inpatient Prediction Rule]
• Severe Illness
• High BUN/Cr
• Cognitive Impairment
• Vision Impairment
Mini-Cog[asses risk of delirium]
3 item recall (up to 3 points)
scores of 0,1or 2 – carries a 4-5X risk for
delirium
• Low Risk (0) – 10 % risk
• Intermediate Risk (1-2) – 25 % risk
• High Risk (3-4) – 80% risk
Diagnostic criteria for delirium
• Acute onset of AMS
• Inattention
• Disorganized thinking
• Altered level of consciousness
The diagnosis of delirium requires the presence of
features 1 AND 2 plus either 3 OR 4.

16. Delirium prevention
Modifiable Risk Factors
Cognitive Impairment
Immobility
Visual Impairment
Hearing Impairment
Dehydration
Sleep Deprivation
Prospective Interventions
Orienting communication
Early mobilization, reduce restraints
Visual Aides; adaptive equipment
Amplifiers; adaptive equipment
Prevent and correct dehydration
Uninterrupted sleep, nonpharmacologic aides

17. Social and Financial assessment
• Wellbeing of older adults is greatly influenced by social and
environmental factors (medical morbidity and functional
impairments)
• Determine if can function independently in the home environment or
need adequate help
• Patients with functional impairment/diseases require caregiver
(family, friends, or paid caregivers)
• Financial security and safety- To earn a living and health care
• Caregivers provide assistance with ADL and IADL tasks.

18. Social and Financial assessment..
• Caregiver must be identified for help (illness, finance, social support)
• Caregiver should be screened for signs of burnout
• Be alert for signs of elder abuse/neglect
• someone other than the usual caregiver bringing patient
• behavioral changes witnessed in the presence of the caregiver - agitation or
fearfulness
• delay between injury and sought treatment
• mechanism of injury inconsistent with findings
• missed appointment or evidence of nonadherence with medications, etc.

19. Approach to Infection
Consider when prescribing drugs
• Absorption- Diminished due to ↑gastric pH, atrophy of mucosal
surfaces, and ↓gastric motility
• Distribution -influenced by drug solubility, serum proteins, and
cardiac output.
• Elimination- impaired due to reduced hepatic and renal function,
↓eGFR [dosed according to the estimated GFR ]
• Choice of agent — Generally consider local susceptibility and
resistance patterns (same as in young)

20. Polypharmacy [≥5 drugs]
Due to More disease conditions
• 50% receive ≥5 medications
• Increased risk for
• drug-drug interactions,
• adverse drug events
• increased risk of hospital
admission & prolonged hospital
stay
• poor drug adherence,
• decreased physical and cognitive
capability .
• Review medications at each visit
[ prescription medications, over
the counter medicines, vitamins,
herbs, or supplements]

21. Nutritional assessment
Aetiology of malnutrition in elderly
• Inadequate dietary intake
• Appetite loss (anorexia)
• Disuse or muscle atrophy (sarcopenia)
• Inflammatory effects of disease (cachexia)

22. Nutritional assessment…
(Subjective Global Assessment)
Medical history
• Weight change
• Change Dietary intake
• Gastrointestinal symptoms
• Functional impairment
Physical examination
• Evidence of
• Loss of subcutaneous fat
• Muscle wasting
• Oedema
• Ascites
Normal nutrition,moderate,severe
malnutrition
Protein:
0.80 g/kg/d ≥51yrs; 1 to 1.2 g/kg /d↓ risk of
functional disability; 1.2 to 2.0 g/kg/d for
malnourished older adults with illness

23. Elderly patients being discharged from hospital
Elderly patient who lives alone – Its time for anxiety, loneliness.
Determine whether more care is needed after leaving hospital (if needs
little or no care)
Identify family member or other corers
Provide geriatrics care training to family/caregiver

24. Home follow-up
• Focus on preventive/ improvement in QOL
• Programs include
• Visiting nurse trained in geriatric care
• Physical therapist
• Social worker, Psychologist [psychosocial therapy]
• Reduction in functional decline as well as overall mortality

25. References
• Nobili A, Garattini S, Mannucci PM. Multiple Diseases and Polypharmacy in the Elderly: Challenges for the Internist of the Third Millennium. Journal of
Comorbidity. 2011;1(1):28-44. doi:10.15256/joc.2011.1.4
• ncoa.org [Internet]. Arlington, VA: National Council on Aging.[cited 2021 Sep 18]. Available from: https://www.ncoa.org/article/the-top-10-most-
common-chronic-conditions-in-older-adults
• Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: implications and challenges for health care policy. Risk Manag Healthc Policy. 2019 Feb 14;12:23-30.
doi: 10.2147/RMHP.S168750. PMID: 30858741; PMCID: PMC6385767.
• https://www.uptodate.com/contents/approach-to-infection-in-the-older adult?search=geriatrics&source=search_result &selected Title=4~150&usage
_type=default&display_rank=4
• https://www.hmpgloballearningnetwork.com/site/pcn/mini-mental-state-examination-mmse
• Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults.Clin Pharmacol Ther 2009;85(1):86–98.
• Stuck AE, Siu AL, Wieland GD, et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342:1032
• Jennings LA, Laffan AM, Schlissel AC, et al. Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare
Beneficiaries. JAMA Intern Med 2019; 179:16
• Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc
2001; 49:1691.
• Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173:489.
• Reuben DB, Borok GM, Wolde-Tsadik G, et al. A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. N Engl J
Med 1995; 332:1345