Int Urol Nephrol (2006) 38:785–786
DOI 10.1007/s11255-005-0060-4
EDITORIAL
Feed-back between geriatric syndromes: general system theory
in geriatrics
Carlos G. Musso Æ Juan F. Macı́as Núñez
Accepted: 19 September 2005 / Published online: 11 December 2006
Ó Springer Science+Business Media B.V. 2006
Abstract Geriatrics has described three entities :
confusional syndrome, incontinente and gait dis-
orders, calling them geriatric giants. Aging process
also induces changes in renal physiology such as
glomerular filtration rate reduction, and alteration in
water and electrolytes handling. These ageing renal
changes have been named as nephrogeriatric giants.
These two groups of giants, geriatric and ne-
phrogeriatric, can predispose and potentiate each other
leading old people to fatal outcomes. These phenom-
enon of feed-back between these geriatric syndromes
has its roots in the loss of complexity that the ageing
process has. Complexity means that all the body sys-
tems work harmoniously. The process of senescence
weakens this coordination among systems under-
mining complexity and making the old person frail.
Keywords Geriatric giants Æ Nephrogeriatric
giants Æ general system
A clinical phenomenon often observed in the elderly
is the ‘‘feed-back’’ between geriatric syndromes,
which predispose to and potentiate each other, often
C. G. Musso
Hospital Italiano de Buenos Aires-Argentina, Buenos
Aires, Argentina
J. F. Macı́as Núñez (&)
Hospital Universitario de Salamanca-España, Salamanca,
Spain
e-mail: jfmacias@usal.ed
leading to fatal clinical events. Geriatrics has already
described three entities of its own: confusional syn-
drome, incontinence (fecal and/or urinary), and gait
disorders, calling them geriatric giants [1–4]. This
term reflects their prevalence and great importance in
the elderly.
These geriatric giants can appear as an acute event
or as an exacerbation of an already existing state,
often being the only clinical expression of various
diseases such as pneumonia, urinary infection, car-
diac infarction, etc. When one of these entities appear
in young people, it may present with such symptoms
as fever, cough, dysuria, chest pain, etc, while in old
people there may be none of those symptoms. This
situation has led to the misconception that illnesses in
the elderly have few symptoms whereas their symp-
tomatology is a rich one: the geriatric giants.
Aging process induces many changes in renal
physiology such as a reduction in glomerular filtra-
tion rate, in potassium secretion and in water and
sodium reabsorbtion capability. These major changes
have been described under the collective name of
nephrogeriatric giants [5].
These two groups of giants, geriatric and nephr-
ogeriatric, are a good example of what might be
termed a ‘‘feed-back’’ between geriatric syndromes,
i.e. clinical entities in the elderly that predispose to
and potentiate each other, leading to catastrophic
events. Two examples may clarify this concept:
An old person develops pneumonia and, because
of this he develops a confusional syndrome. The
123
786
accompanying fever and tachypnea lead him to lose
water and also, because of his confusion, to reduce
his water intake. Since old people already have a
reduced water reabsorbtion capacity, he develops
severe dehydration and hypernatremia, which wors-
ens the confusional state, giving way to a fatal clin-
ical event. This case represents an example of a
geriatric giant (confusional syndrome) that is made
worse by a nephrogeriatric one (reduced water reab-
sorbtion capacity).
Also, a nephrogeriatric giant can potenciate a
geriatric one leading to a fatal outcome. Thus, in very
hot weather an old person loses water (via sweating),
and since old people have a low water intake and a
low salt-and-water reabsorbtion capacity, this patient
develops hypotension, which causes dizziness, faint-
ing and an altered gait and a tendency to fall. This
situation worsen his salt and water deficiency leading
him further into a severe volume contraction and acute
renal failure. This is an example of a nephrogeriatric
giant (reduced water intake and reabsorbtion) that is
made worsen by a geriatric one (injury through
falling).
Both of these cases are examples of what can be
called the feed-back between geriatric syndromes.
The roots of this phenomenon are in the aging pro-
cess however and consists of loss of complexity [6, 7].
From the general systems theory, an organism is a
system that is constituted by other small ones (car-
diovascular, respiratory, etc) which are called mi-
crosystems since they comform to a larger one––the
macrosystem [8]. Complexity means that all these
microsystems work harmoniously together. Accord-
ing to the general systems theory, an organism
functions normally if there is a co-ordination among
its multiple microsystems, and this coordination or
complexity makes the organism flexible and capable
of overcoming environmental changes. The process
of senescence weakens the body’s microsystems and
123
Int Urol Nephrol (2006) 38:785–786
the co-ordination among them thus undermining
complexity and making the person frail. Old people
function normally under basal conditions but they
cannot handle extreme environmental changes, and
therefore an otherwise insignificant event, such as a
hot weather or a urinary tract infection, can lead old
people into severe compromise of body systems or
death [6–8].
Good strategies to avoid or minimize clinical
catastrophic events in the elderly are rehabilitation of
deteriorated functions (gait rehabilitation, etc),
avoidance of risky situations (exposure to hot
weather, etc), and close observation so as to recognize
signs of distress and so initiate treatment.
References
1. Perez Almeida E, Blanco Pascual E (2001) The patient with
immobile syndrome. In: Macias Nuñez JF, Guillén Llera F,
Ribera Casado J (eds) Geriatrı́a desde el principio, Glosa,
Barcelona, pp135–202
2. Verdejo Bravo C (2001) The patient with incontinence
syndrome. In: Macias Nuñez JF, Guillén Llera F, Ribera
Casado J (eds) Geriatrı́a desde el principio, Glosa, Barce-
lona, pp153–165
3. Illán Moyano J (2000) Falls and instability. In: Salgado A,
Guillén F, Ruipérez I (eds) Manual de Geriatrı́a, Masson
Barcelona, pp657–667
4. Gil Gregoria P (2001) The patient with psychiatric altera-
tions. In: Macias Nuñez JF, Guillén Llera F, Ribera Casado J
(eds) Geriatrı́a desde el principio, Glosa, Barcelona,
pp183–202
5. Musso CG (2002) Geriatric nephrology and the ‘nephroge-
riatric giants’. International Urology and Nephrology
34:255–256
6. Lipsitz L, Goldberger L (1997) Loss of ‘‘complexity’’ and
aging. JAMA 267:1806–1809
7. Goldberger A (1996) Non-linear dynamics for clinicians:
chaos theory, fractals, and complexity at the bedside. Lancet
347:1312–1314
8. von Bertalanffy L (1992) General system theory. Fondo de
Cultura Economica de Argentina, Buenos Aires 30–53