6. Affected Organ or
System
Physiologic Change Clinical Manifestations
Body composition ↓ Lean body mass
↓ Muscle mass
↓ Creatinine production
↓ Skeletal mass
↓ Total body water
↑ Percentage adipose
tissue (until age 60,
Changes in drug levels (usually ↑)
↓ Strength
Tendency toward dehydration
Selected Physiological Changes wi
7. HEALTH CONCERNS OF THE
ELDERLY
• Financial dependency
• Functional decline
• Elder abuse and neglect
• Socializing
• Health
8. COMMON DISEASES SEEN IN
THE ELDERLY PATIENT
Geriatric
syndromes
➤Pressure
Ulcers
➤Incontinence
➤Falls
➤Functional
Other
conditions
➤Diabetes
➤Hypertension
➤Chronic pain
➤Malignancy
➤Infections
9. GOALS OF THE
GERIATRIC
ASSESSMENT
1. Focus on preventive
medicine
2. Focus on improving or
maintaining functional ability
3. Provide a long-term solution
for “difficult to manage” patients
4. Aid in the diagnosis of health-
related problems.
5. Develop plans for treatment
and follow-up care.
6. Establish plans for
coordination of care.
7. Determine the need and site
of long-term care as
appropriate.
8. Determine optimal use of
10. PRESSURE
ULCERS
• Incidence
• 15% in nursing home
population;
• 30-% in hospitals
• Constant turning of bed ridden
patients required to prevent ulcer
formation
• Classification: 4 stages +
suspected deep tissue injury and
Unstageable
• Risk factors: Extrinsic and Intrinsic
• Braden tool is most commonly
used for pressure ulcers
• Treatment: Decrease risk factors,
11.
12. URINARY
INCONTINENC
E
• Involuntary leakage of urine.
• Affects 30% female, 15% males.
Incidence increases with age.
• Urinary incontinence not normal
consequence of aging
• Types – Urge, Stress, Overflow and
Mixed
• History evaluation includes:
• Losing urine at inopportune times,
Diapers, Dribbling, Urinary
Hesitancy
• Pharmacological and Behavioral
therapies
13. FALLS
• Incidence of falls increase with age.
• 30-40% of elderly in the community
fall, 50% of those in nursing homes
fall
• Always assess fall risk.
• Screen for falls within last year.
Independent brochure.
• If positive —> Use STEADI
algorithm
• Causes: multifactorial
• Intrinsic – e.g. Arthritis, Age > 80,
illness
• Extrinsic – e.g. Home obstacles,
poor lighting
15. FUNCTIONAL
DECLINE
• May be the only manifestation of
a disorder
• Important to ask about activities
of daily living
• Ask about independent living
activities
• Shopping
• Finance management
• Driving
• Household chores
• Dressing
• Use Katz scale for ADL
16.
17. POLYPHA
RMACY
• Polypharmacy - 4 or
more prescribed drugs
• Can be costly to patient
• Every drug has potential
side effects and
interactions.
• Review patient’s
medication at least yearly
and remove unnecessary
drugs
• Polypharmacy increases
chance of non-
compliance and adverse
reactions
18. DELIRIUM
• Change in cognition and attention that
develops rapidly usually temporary
• Types
• Hyperactive delirium
• Hypoactive delirium
• Mixed type delirium
• Search for underlying cause
• E.g.: Infection, hypoxia, electrolyte
abnormality
• Risk Factors
• Age>65, Chronic kidney disease,
polypharmacy, malnutrition
• Treatment
• Treat underlying cause
• Pharmacological therapy: typically
antipsychotic e.g. haloperidol
• Environmental changes: Familiar places
and things can help
19. DEPRES
SION
• Affects close to 6 million U.S. elderly patients
• Screening: PHQ-2, PHQ-9, Geriatric Depression Scale
• Not usually obvious
• May preset as: insomnia, anorexia, and fatigue
• Suspect if: chronically ill or institutionalized
• Biopsychosocial approach to therapy
• Rule out secondary causes: E.g. Hypothyroidism.
• Pharmacotherapy: Selective Serotonin Reuptake
inhibitors
• Psychosocial therapy: CBT, Supportive therapy
• Always ask about suicidal ideation in suspected
depressed patients
21. ELDER
ABUSE
• is physical or psychologic mistreatment,
neglect, or financial exploitation of the
elderly..
• 1 in 10 incidences reported
• Types
• Physical; Emotional; Sexual; Neglect;
Abandonment; Financial
• Home or in Nursing home
• Presentation
• Caregiver: insistence on being
present, answering for patient, anger
or indifference
• Patient: Poor eye contact, afraid to talk
freely, unexplained fearfulness of
caregiver, frequent bruising, grip
bruises of the upper arms
23. HEALTHCARE & THE
ELDERLY: ARE WE GUILTY?
• Ageism is the systematic stereotyping and
discrimination against people because they are
elderly
• Which leads to:
• Age Discrimination – Treating an individual differently
due to age
• Direct Age Discrimination – unjustifiably different
treatment of individuals with the same needs on the
basis of age
• Indirect Age Discrimination – equal treatment of
individuals of different ages with different needs so
that those with particular needs are disadvantaged
• Age Differentiated Behaviour – appropriate and
24. HOW CAN WE
IMPROVE?
• WHO has created a global initiative to address
these 5 priority areas of action:
• Commitment to Healthy Aging.
• Aligning health systems with the needs of older
populations.
• Developing systems for providing long-term
care.
• Creating age-friendly environments.
25. REFERENCES
•Besdine, R. (2017). Evaluation of the geriatric patient. [online] Merck manuals.
Available at: http://www.merckmanuals.com/professional/geriatrics/approach-to-
the-geriatric-patient/evaluation-of-the-elderly-patient#v1131142 [Accessed 21 Nov.
2017].
• Birrer RB, Vemuri SP. Depression in Later Life: A Diagnostic and Therapeutic
Challenge. American Family Physician. 2004 May 15;69(10).
• Boss GR, Seegmiller JE. Age-related physiological changes and their clinical
significance. Western Journal of Medicine. 1981 Dec;135(6):434.
• Center for Disease Control. Vaccines and Preventable Diseases. Recommended
Vaccines by Age. Retrieved from: https://www.cdc.gov/vaccines/vpd/vaccines-
age.html
• Google Images
• Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of
fall risk in primary care settings. The Medical clinics of North America. 2015
Mar;99(2):281.
• Rakel RE. Textbook of Family Medicine E-Book. Elsevier Health Sciences; 2007.
Editor's Notes
Recently, U.N. estimates 8% of global population is above the age of 65 (7.5 billion x.0848= 638 million) and in 2050 >1.5 billion and 2060 >2 billion. This also means lots of elderly patients to take care of!
Above figure: Population pyramids comparing 1970, 2015 and 2060. Note how the pyramid in 1970 is slowly changing to a dome-like shape in 2015 and still more in 2060.
1970- World population mostly young people. Higher birth rates and higher child mortality than in 2015 and 2060 (especially in developing nations). As birth rates decreased and public health and hygiene (running water and proper waste disposal and better health care) among other factors decreased child mortality, people began having less babies and also started living longer. The elderly population made pyramids more top heavy.
In the past, the global burden of disease involved more communicable diseases and less non-communicable diseases (Proportionally, CDs>NCDs the further in the past you go). This was especially true in non-developing countries. But recently, healthcare progress has shifted the global burden of disease towards non-communicable diseases. In fact, In the future, there will be virtually no difference between the impact of NCDs on low, middle and high income countries as healthcare becomes increasingly more accessible.
But it is clear that the risks of having a NCD is non-random. If we use statistics from the United States for example, we can see that the older population groups have been affected precipitously more than the younger population groups.
DALY - The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death. (Wikipedia). One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability (WHO).
Biopsychosocial model of health
Biological: Organ systems E.g. Decreased hormones, immune function
Psychological: E.g. Depression, Personality change and Loss of appetite
Social: Isolation, Loneliness, Dependency.
Of course patients are not universally identical. During the aging process patients will have variation amongst them that will influence the aging process and their overall well being. For example, Mary may be physically healthy with very little organ system decline but has significant decline in her social well being as she ages as her friends have passed away and her children have left home. On the other hand Tyronne may have overwhelming social support with alive friends and family but may have end stage chronic kidney disease.
Generally aging is associated with a decline in these three components of the Biopsychosocial model of health for the elderly person.
“Geriatric Syndromes are multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems renders a person vulnerable to situational challenges.
Dementia Delirium Urinary Incontinence* Falls* Gait Disturbances Dizziness* Syncope* Hearing Impairment Visual Impairment Osteopenia Malnutrition* Eating and Feeding Problems Pressure Ulcers Sleep Problems*
Functional Assessment
A primary goal of the geriatric assessment is to identify interventions to help patients maintain function and stay at home in independent living situations.
Psychological Assessment
The psychological assessment screens for cognitive impairment and depression, two conditions that significantly impact both the patient and the family.
Social Assessment
It is important to assess the patient’s living situation and social support when performing a geriatric assessment. The living situation should be evaluated for potential hazards, especially if the patient is identified as being at risk of falling. The social assessment also includes questions about financial stressors and caregiver concerns.
ressure ulcers are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces. They are caused by pressure in combination with friction, shearing forces, and moisture. Risk factors include age > 65, impaired circulation and tissue perfusion, immobilization, undernutrition, decreased sensation, and incontinence. Severity ranges from nonblanchable skin erythema to full-thickness skin loss with extensive soft-tissue necrosis
us-PUs are those covered with debris or eschar, which does not allow assessment of depth. Stable, nonfluctuant heel lesions with dry eschar should never be debrided for the sake of staging.
Suspected deep tissue injury is a newer category of findings that suggest damage to underlying tissue due to pressure and/or shearing forces. Findings include purple to maroon areas of intact skin, and blood-filled vesicles or bullae. The area may feel firmer, boggier, warmer, or cooler compared with surrounding tissue.
Because patients often do not volunteer that they are incontinent, ask about it specifically. Incontinence is not a normal consequence of aging and should always be investigated.
The 4 types of urinary incontinence are urge, stress, overflow, and functional. Even some longstanding causes of incontinence are reversible.
• Do at least a urinalysis, urine culture, serum BUN and creatinine, and measurement of postvoid residual volume on all incontinent patients.
• Consider bladder training and Kegel exercises.
• Direct drug therapy toward correcting the mechanism of bladder dysfunction.
AGS (American geriatric society) and BGS recommends screening all adults aged 65 years and older for fall risk annually. This screening consists of asking patients whether they have fallen 2 or more times in the past year or sought medical attention for a fall, or, if they have not fallen, whether they feel unsteady when walking.
Patients who answer positively to any of these questions are at increased risk for falls and should receive further assessment. People who have fallen once without injury should have their balance and gait evaluated; those with gait or balance abnormalities should receive additional assessment. A history of 1 fall without injury and without gait or balance problems does not warrant further assessment beyond continued annual fall risk screening.
A falls history should include determining the number of falls in the past year as well as their circumstances, including any premonitory symptoms, location, activity, footwear, use of assistive device (if prescribed), use of glasses (if typically used), ability to get up after the fall, time of day, any injuries sustained, and any medical treatment received. Corroboration by a witness can be helpful in cases of recurrent, unexplained falls, because such falls may be caused by unrecognized syncope.
Goals for fall risk management include (1) reduce the chances of falling, (2) reduce the risk of injury, (3) maintain the highest possible level of mobility, and (4) ensure ongoing follow-up.
Reducing chances of falling include: Non skid mats, shower or tub grab bars, handrails by stairs, adequate lighting and removing areas of clutter.
Medication classes that increase fall risk: Antidepressants Antipsychotics Sedative hypnotics Benzodiazepines
The functional assessment focuses on activities of daily living (ADLs) and risk screening for falls. The basic ADLs include eating,
dressing, bathing, transferring, and toileting. The instrumental ADLs (IADLs) consist of shopping, managing money,
driving, using the telephone, housekeeping, laundry, meal preparation, and managing medications. Home health and social services referral should be considered for patients who have difficulty with the ADLs.
Elderly patients have altered pharmacokinetics and pharmacodynamics, Monitor kidney and liver function. Remove medications that are intolerable.
Review patient’s medication at least yearly and remove unnecessary. Ensure there is an indication. Ensure patient is being adherent. Is medication still needed?
Chronic diseases associated with high rates of depression include stroke (30 to 60 percent), coronary heart disease (8 to 44 percent), cancer (1 to 40 percent), Parkinson’s disease (40 percent), Alzheimer’s disease (20 to 40 percent), and dementia (17 to 31 percent).
Signs of depression include frequent office visits or use of medical services; persistent reports of pain, fatigue, insomnia, headache, changes in sleep or appetite, and unexplained gastrointestinal symptoms; and signs of social isolation and increased dependency, anhedonia.
Effective management requires a biopsychosocial approach, combining pharmacotherapy and psychotherapy. Lab investigations should be performed first to rule out any secondary cause of depression. E.g. general blood chemistry screen, complete blood count, and determination of thyroid-stimulating hormone, vitamin B12, folate, and medication levels.
Pharmacotherapy: Common side effects include weight loss, agitation and insomnia (with fluoxetine [Prozac]), fatigue, dry mouth and constipation (with paroxetine [Paxil]), nausea and diarrhea, headache, and anxiety.
Older adults often have better treatment compliance, lower dropout rates, and more positive responses to psychotherapy than younger patients
The Geriatric Depression Scale screens for seven characteristics of depression in the elderly: somatic concern, lowered affect, cognitive impairment, feelings of discrimination, impaired motivation, lack of future orientation, and lack of self-esteem. The yes-or-no questionnaire is administered orally, and one point is scored for each answer in parentheses. A score of 10 or more indicates depression (84 percent sensitivity; 95 percent specificity). The sensitivity diminishes in patients with a score of less than 24 on the Mini-Mental State Examination.
There are also 10 and 4 item short form versions of this test.
Acts of Omission: What is not done; neglect
Acts of Commission: Things that are done, like physical and sexual abuse
Ask directly about abuse if you suspect. Also classified by: Domestic abuse or Institutional abuse. Risk Factors: Social isolation, Shared living space, History of Dementia, Care-giver stress. Signs Caregiver: insistence on being present, answering for patient, anger or indifference Patient: Poor eye contact, afraid to talk freely, afraid of caregiver. Patient/Physical: Poor hygiene, Pressure ulcers, Poor nutrition, Injuries
In addition to seasonal flu (influenza) and Td or Tdap vaccine (tetanus, diphtheria, and pertussis), people 65 years and older should also get:
Pneumococcal, which protect against pneumococcal disease, including infections in the lungs and bloodstream (recommended for all adults over 65 years old, and for adults younger than 65 years who have certain chronic health conditions)
Zoster vaccine, which protects against shingles (recommended for adults 60 years or older)
All physicians should exhibit Age Differentiated Behavior but never discriminate.
Commitment to Healthy Ageing. Requires awareness of the value of Healthy Ageing and sustained commitment and action to formulate evidence-based policies that strengthen the abilities of older persons.
2 Aligning health systems with the needs of older populations. Health systems need to be better organized around older people’s needs and preferences, designed to enhance older peoples intrinsic capacity, and integrated across settings and care providers. Actions in this area are closely aligned with other work across the Organization to strengthen universal health care and people-centred and integrated health services.
3 Developing systems for providing long-term care. Systems of long-term care are needed in all countries to meet the needs of older people. This requires developing, sometimes from nothing, governance systems, infrastructure and workforce capacity. WHO’s work on long-term care (including palliative care) aligns closely with efforts to enhance universal health coverage, address non-communicable diseases, and develop people-centred and integrated health services.
4 Creating age-friendly environments. This will require actions to combat ageism, enable autonomy and support Healthy Ageing in all policies and at all levels of government. These activities build on and complement WHO’s work during the past decade to develop age-friendly cities and communities including the development of the Global Network of Age Friendly Cities and Communities and an interactive information sharing platform Age-friendly World.
5 Improving measurement, monitoring and understanding. Focused research, new metrics and analytical methods are needed for a wide range of ageing issues. This work builds on the extensive work WHO has done in improving health statistics and information, for example through the WHO Study on global AGEing and adult health (SAGE)
In addition to the above challenges include: GPs are less likely to discuss life style changes like weight reduction with older people than younger people.
Percentage of home visit consultations has fallen from 22% in 1971 to 4% in 2006
“if you are over 70 years old and ill or in pain and have to walk to the surgery more chance of a home visit from a doctor would be nice” – Bristol Older People’s Forum, 2006
Out of hours services
Creates barriers to access for older people who prefer face to face contact and fear travelling at night to a treatment centre
Access to GP services
Access from home
Over 65s visit GP 7 times per year (4 for younger adults)
Transport problems
Mobility problems
