Common Geriatric problems

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It is the branch of medicine that
focuses on health promotion,
prevention and treatment of disease
and disability in later life.

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What does it mean?


The medical study of the aging process
is gerontology




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What is aging?

Aging is a normal developmental event
and refers to the process of "accruing
maturity with the passage of time."

Aging is progressive, and inevitable to
all living things.

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Ageing in societies
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Meaning of ageing in societies

People can be considered old because of certain
changes in their activities or social roles.

Examples: people may be considered old when:
1- They become grandparents
or
2- They begin to do less or
different workretirement
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what is the definition of
elderly?
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Most developed world countries have
accepted the chronological age of 65 years as
a definition of 'elderlyexcept in Africa less
i.e from (50-65y) .
why ??

Actual birthdates are quite often unknown
because many individuals in Africa do not
have an official record of their birthdates.


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Terms for old people

Include seniors (American usage)
senior citizens(British and American usage)
older adults (social sciences)
The elderly.


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Aging population in Saudi Arabia 1974-2004
% of Total
pop.
%Change Population
65+
Year
3.9 240,525 1974*
3.3 21.14 401,861 1992
3.5 44.28 575,723 2004
*The 1974 census put aged population under one age group (60 years
and over).
Source : Calculated from Saudi Arabia Population Censuses
1974,1992,2004.
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Saud Arabia Population Aged 65+ (1950-2050)
Aged 80+
%
Aged 80+
(thousands)
Aged 65+ %
of total
Aged 65 +
(thousands)
Year
.2 7 3.3 107 1950
.3 14 3.2 182 1970
.3 41 2.3 372 1990
.4 112 2.9 778 2010
.8 282 6.6 2,458 2030
2.6 1,180 13.0 5858 2050
U.N(United Nation) Population Division, World Population Prospects
2006:
The Population Data Base.

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Life expectancy at birth for 2001 in Middle-East
countries

Egypt 68.3 years
Iran, Islamic Republic of 69.8 years
Jordan 70.6 years
Syrian Arabic Republic 71.5 years
Qatar 71.8 years
Saudi Arabia 71.9 years
Oman 72.2 years
Libyan Arab Jamahirya 72.4 years
Lebanon 73.3 years
United Arabic Emirates 74.4 years
Bahrain 73.7 years
Kuwait 76.3 years


Source: Human Development Report 2003 (3)

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Life expectancy Year
49.75 1974
70.7 1992
75.23 2004
76.51 2010
78.33 2020
79.83 2030
81.03 2040
81.99 2050

Saudi Arabia Population life Expectancy
1974-2050
U.N. Population Division, World Population Prospects 2006:
The Population Data Base.
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Why NO of old people
increased?
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of old people increased? O Why N
The number of old people is growing around
the world chiefly because of :

Post-War War II baby boom .
(In the United States, approximately 79 million babies were
born during the Baby Boom) during 1946-1964

Improved health care and standard of living.

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In the United States the proportion of people
aged 65 or older increased

From 4% ... in 1900
To about 12% .. in 2000.

Population experts estimate
[citation needed]
that
more than 50 million Americansabout
17 % of the populationwill be 65 or older in
2020.

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General Principles of Aging:
Old Folks Are Different

Atypical Presentation Of Acute illness
Under-reporting Illness
Multiple Concurrent Losses

Expected Physiologic Aging Changes

Impact of health problems on the
ability of the person to remain
independent

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Three Strategies To Assess
Atypical Presentation Of Illness
Include:

(1) Vague Presentation of Illness;
(2) Altered Presentation of Illness;
(3) Non-presentation (Hidden illness) of
Illness.

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Vague Presentation
Of Illness

( )
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Aim of knowing Vague Presentation
Identification of acute illnesses with vague
presentation:
1-Enables early treatment of illness.
2-Reduced morbidity and mortality.
3-An enhanced quality of life of
elderly.

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Non-specific Symptoms
that may Represent Specific Illness
(Ham, 2002)
Confusion
Self-neglect
Falling
Incontinence
Apathy
Anorexia
Dyspnea
Fatigue
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Vague Presentation of Illness
Non-specific symptoms

Any changes in behavior or function
in an older adult are often a prodrome
of an acute illness, especially for frail
older adults.
e.g.
Mild confusion or changes in ability to
perform activities of daily living (ADL),
and decreased appetite , very often are
the first signs of illness in an older adult.
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Functional ASSESMENT

Basic Activities of Daily
Living (BADL)



Instrumental Activities of
Daily Living (IADL)
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Activities of Daily Living(ADL)
Most senior care providers and health professionals group the
activities of daily living into the following six categories:

Bathing: includes grooming activities such as shaving, and
brushing teeth and hair
Dressing: choosing appropriate garments and being able to
dress and undress, having no trouble with buttons,
zippers or other fasteners
Eating: being able to feed oneself
Transferring: being able to walk, or, if not ambulatory, being
able to transfer oneself from bed to wheelchair and back
Continence: being able to control ones bowels and bladder, or
manage ones incontinence independently
Toileting: being able to use the toilet

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Instrumental Activities of Daily Living(IADL)
The instrumental activities of daily living include the following:

Using the telephone: being able to dial numbers, look up numbers,
etc.
Managing medications: taking the appropriate medications and
correct dosages on time
Preparing meals: making appropriate food choices and preparing
meals safely
Maintaining the home: doing or arranging for housekeeping and
laundry
Managing finances: budgeting, paying mortgage/rent and bills on
time, etc.
Shopping: being able to shop for groceries and other small necessities,
and transport purchases from store to home
Using transportation: being able to drive or use public transportation
for appointments, shopping, etc.

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Altered Presentation
Of Illness
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Altered Presentation of Illness

The classic presentation of common illnesses in
a general adult population such as
Chest pain .during a myocardial infarction
Burning ...with a urinary tract infection
Sadness.with depression .

Change in mental status is one of the most
frequently presenting symptoms at the onset of
acute illness.

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Altered Presentation of Illness in Elderly Persons
Illness Atypical Presentation
Infectious
diseases
or
Infection
Absence of fever
Sepsis without usual leukocytosis
and fever
Falls, decreased appetite or fluid
intake, confusion, change in
functional status
"Silent" acute
abdomen
Absence of symptoms (silent
presentation)
Mild discomfort and constipation
Some tachypnea and possibly vague
respiratory symptoms

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Depression Lack of sadness
Somatic complaints, such as appetite
changes, vague GI symptoms, constipation,
and sleep disturbances
Hyper activity
Sadness misinterpreted by provider
as normal consequence of aging

Medical problems that mask depression
Medical illness
that presents as
depression
Hypo- and hyper- thyroid disease that
presents as diminished energy and
apathy

Altered Presentation of Illness in Elderly Persons
Illness Atypical Presentation

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Altered Presentation of Illness in Elderly Persons
Illness Atypical Presentation



"Silent"
malignancy
Back pain secondary to metastases from
slow growing breast masses
Silent masses of the bowel

"Silent"
myocardial
infarction
Absence of chest pain
Vague symptoms of fatigue, nausea and a
decrease in functional status.
Classic presentation: shortness of breath
more common complaint than chest pain


Thyroid disease
Hyperthyroidism presenting as "apathetic
thyrotoxicosis," i.e. fatigue and a slowing down
Hypothyroidism, presenting with confusion
and agitation


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Non-presentation of
Illness

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The illnesses in older adults may go
unrecognized for many years (Hidden
Illness) and significantly impact quality of
life .
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Hidden Illness
You Must Ask
"Hidden" Illness in Older Adults
Depression
Incontinence
Musculoskeletal stiffness
Falling
Alcoholism
Osteoporosis
Hearing loss
Dementia
Dental Problems
Poor nutrition
Sexual dysfunction
Osteoarthritis

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Why???
do we have under-reporting
illnesses !!!
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Under-Reporting Illness Due To:
Belief that symptoms as a "normal" part of
aging
Fear (burdensome tests) or denial
Concern of being ignored
Embarrassment (Concern about cost)
Concern about ill spouse
Mental impairment
Previous bad experience with health care
system
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Multiple Concurrent Losses
Have an impact on elderly health(PPS)
Loss of physical health
Loss social contacts: friends/family die
Loss of familiar roles: mother, wife, employed
person
Loss of financial security: retirement,
widowhood
Loss of independence and power
Loss of mental stability
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Changes Associated With Aging
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Changes Associated With Aging


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Physiological changes


There general physical decline, and people
become less active , Old age can cause:

Wrinkles and Liverspots on the skin due to loss of
subcutaneous fat.

Change of hair-color to gray or white *(The death
of the melanocyte stemcell causes the onset of
graying) or genetic cause.

Hair loss

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Physiological changes

Reduced mental/cognitive ability

Diminished, and decline in eyesight
( more difficult to read in low lighting and in smaller
print).

Decrease hearing (Presbycusis)
Of individuals 75 and older 48% of men
.37% of women
encounter difficulties in hearing.



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Physiological changes (Contd)
Changes in the vocal cords(Atrophy , thinner
& stiffer)Give typical "old person" voice.

Gradually declines of maxim. Lung function
{Decreases gas exchange and Vital capacity}

Arterial walls stiffen with age.
Increase in % body fat



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Physiological changes (Contd)
Decrease liver size, But LFT Normal
Decreases liver metabolism of substances with
aging (dose-related S/E).

Decrease renal size and number of glomeruli &
mass of the juxta-medullary nephrons falls.
Decrease creatinine clearance( which is a
measure for GFR).

Lessening or cessation of sex(erectile
dysfunction), or decline in libido)

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Impact of health problems on
the ability of the person to
remain independent
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Impact of health problems on the ability
of the person to remain independent
(functionally in their usual environment):-

1- Hearing loss (Presbycusis)
2- Visual impairment
3- Difficulty of gait and fall
4- Confusion
5- Iatrogenic disease almost always associated
with multiple medication use.
6- Urinary Incontinence








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1-hearing loss
(Presbycusis)

Frustration
Social isolation
Increased dependency on others.
Lack of appreciation for living
(Depression ,Loss of self-esteem, Loneliness)
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Assessment Of Hearing
Auditory Testing

USPSTF recommends screening by periodically
questioning them about their hearing.

Whispered voice test Stand 3 fts behind the
pat. & whispering series letters (6,1,9)or words.

Finger Friction: rub your thumb and index finger
in front of ear

Formal Audiometric evaluation& otoscopic
examination

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2- Visual impairment
Many elderly unaware of their visual deficits,
we should ask about :-

H/O Falling , Difficulty with driving,
watching T.V, reading .

Visual impairment such as :
Cataract, Glaucoma, Macular degeneration
and abnormalities of accommodation worsen
with ageing (Impaired of visual acuity= presbyopia).





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Assessment Of Vision

Visual testing
Read a sentence from
the newspaper
Snellen chart (to
screen for visual
acuity)
Diabetics need
annual dilated eye
exam. by
ophthalmologist


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3-difficulty of gait

Ataxia is defined as a difficulty of gait

Ataxia can result from:-
Damage to the sensory systems
(That provide feedback normal balance)
or
Problems with the several motor systems
(That are needed to respond to the constantly
changing environment while walking).



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Sensory systems
Sensory systems are important to gait
include :
Visual system
Vestibular system
Conscious proprioceptive system from the
lower limbs (especially the feet).

Any defect in one of them abnormal
balance (Ataxia).


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One of the most common causes of ataxia is loss of
proprioception in the feet.

This can be tested by examining:-
1. Vibratory and joint position sense at the great toe.
2. Posture control test (Romberg sign):
Pat. Stands with shoes off, feet together & eyes
closed ,he extend his hands. If he losses balance the
test +ve

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The motor systems
The motor systems that are necessary for
normal gait include:

Adequate strength to stay upright(UMN,LMN)
Coordination (the cerebellum)

Muscle tone and postures (extra-pyramidal
system).
Cortical function (Especially the frontal lobes)

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Falls among the elderly
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Falls
among the elderly
Prevalence. 30% of people above 65 y
fall annually
Half are repeat fallers

A single fall is not always a sign of a major
problem

Recurrent falls, defined as:
more than two falls in a six-month period,
should be evaluated for treatable causes.



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Falls are the leading cause of hospitalization
and injury-related death in persons >75 years

Major complication.# femur resulting
morbidity & mortality from surgery, D.V.T, P.E


The American Geriatrics Society and British
Geriatrics Society recommend that all adults older
than 65 years should be screened annually for
a history of falls or balance impairment.





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Falls are Multifactorial

Intrinsic Factors
Extrinsic Factors
FALLS
Medical
conditions

Impaired
vision and
hearing
Age related
changes
Medications

Improper use
of assistive
devices

Environment
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Conditions associated with fall
CVA, Parkinson's disease, Dementia
(Alzheimer's disease), Sever Osteoarthritis
(O.A), Rheumatoid Arthritis.

Medications(Diuretic, TCA, ACEI, Nifedipine)
Causing Orthostatic Hypotension
Factors associated with fall. (Contd)
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Factors associated with fall. (Contd)
Environment
1. Objects on the floor
(clutter, pets, throw
rugs, electrical cords)
2. Poor lighting
3. Unstable furniture
4. Low beds or low toilet
seats
5. Lack of grab bars
near bathtub and
toilet

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Fall-Related Physical Exam.
Vital signs (postural blood pressure)
Assess Gait & Balance: TimedUp-and-Go test
MMSE
Neurologic evaluation
Visual exam
Cardiac evaluation
Musculoskeletal (All joint including feet) exam.

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Task Get up out of a standard armchair (seat height of
approximately 46 cm [18.4 in.]), walk a distance of
3 m (10 ft.), turn, walk back to the chair and sit
down again.
Requirements Ambulate with or without assistive device and follow
a three-step command.
Trials One practice trial and then three actual trials. The
times from the three actual trials are averaged.
Time 1 to 2 minutes
Equipment Armchair, stopwatch (or wristwatch with a second
hand) and a measured path
Predictive results Seconds Rating
< 10 Freely mobile
< 20 Mostly independent
20 to 29 Variable mobility
> 30 Impaired mobility
Timed Up & Go Test

Geriatrics 66
Management and Prevention of Falls

Treat immediate medical problems & review
medications
Assess and alter environment factors

Consider Rehab (strengthening exercises)
Prescribe assistive devices, if necessary

Teach patient how to get up if they do fall
Consider a personal emergency response
system (Help, Ive fallen..)

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4-Confusion in the elderly
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Confusion in the elderly
Confusion is a common problem in elderly
over 65 years of age.

Decline in normal cognitive ability (ability
to think, concentrate, formulate ideas,
problem solve, reason and remember).

It may be acute, or chronic and progressive



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Confusion in the elderly patient is
usually a symptom of:-

Delirium ( Acute confusional state) or
Dementia (Gradual onset that cannot be
dated)

But it may also occur in Major depression
and Psychoses
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Delirium Dementia
Abrupt, precise onset with an identifiable date Gradual onset that cannot be dated
Acute illness, generally lasting days to weeks but
rarely more than one month
Chronic illness that characteristically progresses
over years
Usually reversible, often completely Generally irreversible and often chronically
progressive
Disorientation early Disorientation later in the illness, often after
months or years
Variability from moment to moment, hour to hour,
throughout the day
Generally stable from day to day (unless delirium
develops)
Prominent physiologic changes Less prominent physiologic changes
Clouded, altered and changing level of
consciousness
Consciousness not clouded until terminal stage
Strikingly short attention span Attention span not characteristically reduced
Disturbed sleep-wake cycle with hour-to-hour
variation
Disturbed sleep-wake cycle with day-night
reversal, not hour-to-hour variation
Marked psychomotor changes (hyperactive or
hypoactive)
Psychomotor changes characteristically occurring
late in the illness (unless depression develops)
Distinguishing Delirium from Dementia

Adapted with permission from Ham RJ. Confusion, dementia and delirium. In Ham RJ, Sloane PD, eds. Primary care
geriatrics: a case-based approach. 3d ed. St. Louis: Mosby, 1997:1067.

Common Causes of Delirium
Metabolic disorders
Electrolyte abnormalities
Acid-base disturbances
Hypoxia
Hypercarbia
Hypoglycemia or
hyperglycemia
Azotemia
Infections(pneumonia,UTI)
Drugs
(Opiates, anticonvalsant,
Sedative, L-dopa, post-G.A)
Stroke (small cortical)



Intoxication (alcohol and/or
other substances)
Decreased cardiac output
Dehydration
Acute blood loss
Acute myocardial infarction
Congestive heart failure
Hypothermia or hyperthermia
Acute psychoses
Transfer to unfamiliar
surroundings
Miscellaneous
Fecal impaction
Urinary retention

Adapted with permission from Kane RL, Ouslander JG, Abrass IB. Essentials of clinical geriatrics.
3d ed. New York: McGraw-Hill, 1994:91.
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Dementia
Dementia can be classified as reversible or
irreversible.
Potentially reversible causes include
1. Thyroid dysfunction,
2. Deficiencies of vitamins such as B
12
and folate,
3. Infections such as neurosyphilis,
4. Metabolic abnormalities such as uremia

The major irreversible causes of dementia include
Dementia of the Alzheimer's type[DAT], Vascular
dementia, CNS trauma, Parkinson's disease, and (HIV)
infection.

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Mini-Mental State Examination (MMSE) is used to
assess cognitive changes in patients with dementia.
MMSE covers six areas:

(1) Orientation (Time&Place). 10 score
(2) Registration. 3 score
(3) Attention and calculation. 5 score
(4) Recall. 3 score
(5) Language. 8 score
(6) Ability to copy a figure. 1 score
MMSE administered 30-item instrument screens for
cognitive deficits
A total score of 23 or less suggests dementia
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5-DRUGS IN ELDERLY
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Polypharmacy

20% of hospitalized elderly are a result of
iatrogenic disease .

These iatrogenic disease almost always
associated with multiple medication use.
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Polypharmacy
Average number of medications used by
institutionalized elderly is 8/day.

Its standard orders may increase to 13
medications per day

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Be aware about..
Polypharmacy
Alterations in drug disposition and tissue
sensitivity
Changes in renal/hepatic elimination
Be alert about drugs side effects
Drug-to-drug interactions


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ADR & drug- drug interaction
Propranolol . S/E depression and hallucination
(visual and auditory )

TCA, HCL-thiazide, ACE inhibitors, nifedipine and
benzodiazepines all associated with fall .

Beta blocker withdrawal.lead to angina .

Erythromycin and TheophyllineTheoph. toxicity
Digoxin and diuretic .ADR Low K. Digoxin
toxicity

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Be aware about..
Using one drug to treat S/E of another
( e.g. anti-depressant given to treat beta blocker
depression)
Using multiple drugs with similar actions
and toxicity
The patients may visit other prescribers
Medications errors
Ask about the use of OTCs and herbals


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Helpful Guidelines On Initiation Of
Drugs In The Elderly
General rule start very low and go very slow
No more than 50% of the adult dose.
No more than one drug at a time.
Increases not any more quickly than 1 week.
Formal drug review at least every 3 months
or at each visit including indication and
dosing. Also review OTC and herbal.

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6-Urinary Incontinence (UI)

The involuntary loss of urine sufficient
in amount or frequency to be a social
or health problem.

Urinary incontinence (UI) is a symptom, not
a specific disease.

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Prevalence : UI in elderly
In a community setting about 15-30%
(only half report so this is an estimate)

In acute care hospitals 30-35%
Institutionalized elderly 50%

Screening for Incontinence
Simple question do you have a problem with
urine leaks or accidents? is an acceptable
screening tool
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Causes Of Acute And Reversible UI-DIAPERS
D: Delirium
I : InfectionUTIs
A: Atrophic urethritis/vaginitis
P: Pharmaceuticals (Diuretics, Anticholinergics,
Calcium channel blockers, Narcotic analgesic)
P: Psychological
E: Excessive urine production(DM, D.I)
R: Restricted mobility
S: Stool impaction

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General Principles of Diagnosing UI
Complete history and P/E
Medication review
Cough stress test
Voiding diary
Urinalysis & Urine C/S
Blood chemistry (BUN, Cr, Glucose, Ca++)
PVR (post-void residual) determination
Imaging tests
Cystoscopy, and Uro-dynamic studies may be
needed in selected patients
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Types of UI
Stress
(Urethral
insufficiency)
Overflow Urge
(Detrusor
instability)
Functional
Involuntary
loss of urine,
usually small
amounts with
increased
intra-
abdominal
pressures
Leakage of
small amts.
resulting
from
mechanical
forces on an
overdis-
tended
bladder

Leakage,
usually large
amts, due to
inability to
delay voiding
after
sensation of
fullness
Urine loss due to
inability to toilet
bec. of :
Impaired
Cognition
Psychological
unwellingness
Environmental
barriers
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Common Causes Of UI
Weakness &
laxity of pelvic
floor muscle
due to obesity,
Child-brith,
Menopause &
aging
Urethral
sphincter weak

Outlet
obstruction
(BPH, fecal
impaction),
Urethral
stricture,
anticholinergic
meds,
DM neuropahy,
multiple
sclerosis
Local GU
conditions
(UTI, stones,
diverticuli),
Decreased
cortical
inhibition
(CVA,
dementia,
Parkinsons
tumor)
Sever dementia &
Closed head inj.
Psychological
factors(Depression
Regression, anger)
Environmental
barriers
(cluttered home,
poor lighting)
Stress Functional Urge Overflow
Pelvic muscle
(Kegels)exercis.
Weight loss,
Surgical
bladder neck
suspension
Estrogens(O, V)
Alpha-
adrenergic
agonists(Urethral
relaxion blocker)
Treatments UI
Surgical removal
of obstruction
(TURP) ,
Intermittent cath;
Timed voidings;
Trial of
cholinergic
drugs;
Trial of alpha-
blocker agents;

Treat infection
Behavioral
therapy (Bladder
training;Schedulet
oileting);
Bladder-relaxant
drugs
(anticholinergic
e.gOxybutynin )
Surgical removal
of irritating
pathology
Behavioral therapy
(Bladder training;
Schedule toileting);
Environmental
manipulation
Improve patient
mobility;
Use pads
Ext.collection device
Stress
Functional
Urge Overflow
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Thank you
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