Geriatrics

 Physiological changes in elderly

_______________________________

Some definitions:
1. Senescence: organ are affected only by age (no disease)
2. Senility: organs affected by a disease (Rx)
3. Young old: 65-74 (inc. CVD)
4. Old old: 75-84
5. Oldest old: 85 or older (inc. neurological)
6. Lean body mass: muscle+organ

Theory:
1. Genetic: controlling process:
- limit number of cell division
- Dec. DNA repair
2. Accumulated injury:
- U.V rays
- Wear& tear
- Metabolism
- Past illness
3. Stress
4. Toxic
5. Free radicals: UVR, diet, inflammation, air pollution, radiation ( highly
reactive molecules as O2, h2O2, OH-)/ Rx by antioxidant.
6. Combined theory:Genetic + environmental

Stages:
1. Evolution
2. Maturation
3. Senescence
4. Elderly

 Aging Change
_______________________________

A. In cells:
1. Dec. division
2. Dec. regeneration
3. Inc. waste products
4. Inc. pigments
5. Inc. fat
6. Inc.fatty brown (Lipofuscin)
7. CT stiffness (rigid)
8. Changes in cell membrane (No O2)
9. Atrophy

B. In body shape
1. Inc. fat:
a. Central
b. 30%
c. Dec. lean body mass
2. Dec. bone
3. Dec. water
4. Dec. lean body mass

C. Musculoskeletal ( muscle + bone + 3 joints )

1. Dec. muscle mass & contractility (dec. function)
2. Dec. bone mainly in female after menopause
3. Changes in joints, synovial fluid, cartilage = stiffness & erode

D. Water & electrolyte

1. Dec. K, Ca, water with disturbed thirst center (wt loss)
2. Inc. Na & sensitivity to Na

E. Skin
1. A =atrophy & wrinkles
2. B = blood vessel fragility & bruises
3. C = subcutaneous: Dec. fat, sebaceous, sweat ( ulcers, injury,
hypothermia )
4. D = dry & heat
5. E = loss of elasticity
6. F = faint epidermis
7. G = grey hair with skin pigment lentigo
3

 F. Temperature
- Dec. 0.2-0.5o
- d.t Dec.:
1. Skeletal muscles
2. Subcutaneous fat
3. Subclinical hypothyroidism
4. Circulation
- So Inc. of 1o is serious

G. Respiratory system
1. Dec. elasticity (lung & thoracic muscles)
2. Dec. ciliary (pneumonia)
( senile emphysema )

H. Digestive system
1. Salivary gland: Dec. volume, enzymes & teeth
2. Oesophagus:
- diaphragmatic hernia d.t Dec. CT
- Regurgitation
3. Stomach: dec. secretion & HCL leading to Dec. digestion
4. Small intestine: malabsorption d.t Dec. pancreatic enzymes,
absorptive cells, blood supply
5. Colon:
- constipation d.t Dec. food & mastication, Dec. water, Dec. motility,
Dec. tone, irregular habit
- Diverticulosis d.t atrophy of muscle & elastic fibers
- Distension, Dec. Mastication, Dec. absorption
6. Liver
- Dec. size & weight
- 50% Dec. body fat = Dec. glucose
- Bilirubin, protein synthesis, PT, AST, ALT = normal
- Dec. protein catabolism, Dec. urea, Dec. albumin (d.t malnutrition &
dec. motility)
- Inc. cholesterol gall stones
7. Pancreas
- Dec. Enzymes
- Dec. blood supply
- Chronic fibrosing pancreatitis

 I. Renal : GFR Dec. 10ml/m/10 years,

1. Sclerosis of glomeruli after 40 years
2. Atheroma in renal vessel
3. Dec. creatinine don’t depend to RFT(use CC,CC)
4. Normal creatinine = 40% reduction in renal function
5. Incontinence
6. UTI

J. Nervous system :
- Dec.
1. Intellectual function
2. Muscle power
3. Deep reflex absent in 50-70%
4. Vibration sense
5. Special sense ( vision, smell, lacrimal , hearing, taste & appetite )
- emotional instability
- Tremors

K. Immune
1. Dec. lymphocyte
2. Infection, malignancy, autoimmune (Dec. suppressor T cells)

L. Endocrine: resistance with Dec. production

M. CVS (see later)

- So nutrition must be:

1. Inc. fluid ( kidney & colon ) [the most important]
2. Easy digest with full supplement food
3. Dec. calories (obesity)
4. Vegetable oil not animal fat
5. Dec. protein if liver & renal affection
6. Inc. fibre in ambulatory elderly
7. Dec. salt
8. Inc. Ca, Vit D

 - anti-aging measures:
* Aim:
- Dec. morbidity & death
- Inc. quality of life
1. Ideal body weight
2. Healthy diet
3. Avoid stress
4. Eat breakfast
5. Dec. fat & sugar
6. Avoid bad habits as smoking
7. Regular exercise
8. Regular check up

NOTES:
- multiple pathology
- Gradual to low normal
- Limited physiological reserve when exposed to acute stress
- Constiparion treated by:
a. Inc. fibres
b. Fluids
c. No eat at bedtime
d. Special hours for defecation
- Between the age of 30-70 Inc. SBP
- Between the age of 80-90 Dec. SBP
- Osteoporosis Rx & prevented by exercise
- Disease & atypical presentation:
a. Pneumonia = malaise, anorexia, confusion
b. MI = mild or no chest pain, confusion, weakness
c. UTI = absence of dysuria, incontinence, confusion
d. Thyrotoxicosis = lethargy, arrhythmia, fatigue, Wt loss
e. Infection = normal to low temperature
- So change in sensorium look fo underlying disease

Cardiovascular Changes in elderly:

1. Resting LV systolic function is normal in absence of CAD, HTN
2. SBP, pulse pressure is increased if arterial or myocardial stiffness
3. Sedentary life help in change
4. Lifestyle modification delay & partially reverse
5. Inc. systemic vascular impedance ( systemic HTN , LV
hypertrophy )

 6. Impaired ventricular diastolic relaxation = predispose to AF

7. Dec. responce to B adrenergic stimulation
- Dec. max. HR (B1&B2)
- Impair peripheral VD (B2)
8. Alter myocardial energy metabolism ( mitochondria can’t inc. ATP )
* thus implicate clinically:
a. Inc. preload & afterload
b. Impair inc. of COP to stress (physiological & pathological)
9. Endothelium:
- Dec. VD 40-70 years old
- No change VD to nitroglycerine
- Inc. by HTN, Inc. lipid, CAD, HF
- Dec. by aerobic exercise
10.Arrhythmia:
- Inc. elastic tissue & collagen
- Inc. fat around SA node
- Dec. SA node cell
- Calcify cardiac
- Slow AV node & proximal HP
- Inc. with HTN, CAD, amyloidosis
11. Echo:
- LV thick with age
- Dec. EF (with CAD, HTN )
12.CT
- Inc. coronary & aortic calcification
- Inc. with Increased pulse pressure, Dec. HDL, Inc. LDL, Inc. BS, smoking,
obesity

Clinical implications:
1. Inc. systolic BP 30-70Y.O & pulse pressure 80-90Y.O,Dec. SBP
2. inc. prevalence to AF
3. inc. prevalence to HF especially with preserved LV function
4. inc. prevalence of bradyarrhythmia & SSS
5. inc. prevalence for fall & syncope
6. Impair response to stress & other illness
7. Worse prognosis associated with CV disease

 Aging:
1. Inc. arterial stiffness
2. Impair B response
3. Dec. SA function
4. Marked Dec. CV reserve
5. Inc. myocardial stiffness
6. Impair endothelial function
7. Dec. baroreceptor response

Effect of aging on cardiac valves:

1. Thickness & calcification of AV d.t Inc. collagen deposition
2. Endocardial thickness on the atrial spect of MV
3. Calcification of mitral annulus (F>M)
4. Atheroma changes in and around AV, MV, Perivascular
5. No change on TV, PV

Diagnosis of cardiac aging in absence of a clinical disease:

1. Inc. left ventricular thickness
2. Dec. early diastolic filling
3. Inc. Atrial filling
4. Inc. Afterload
5. Dec. Cardiac reserve ( compensation )
6. Dec. Sympathetic drive
7. Inc. Arrhythmia

 Cardiovascular diseases
_______________________________

Risk factors:
A. HTN:
- Systolic: >65 ( potent risk even stroke )
- Diastolic evaluate: Dec. with age
- Pulse pressure: the most imp.
- HTN is the major for coronary Ht disease
- 29% inc. CHD with every 7.5mmHg inc. in DBP
B. Inc. cholesterol, Dec. HDL, Dec. cardiac motility with statin
C. Smoking
D. Inc. Homocysteine, lipoprotein A

Heart failure:
- aggravating :
a. Medications
b. New heart disease
c. Myocardial ischemia

- evaluate HF:
A. Risk factor
B. Heart disease, asymptomatic LV dysfunction
C. HF symptomatic
D. Refractory HF symptomatic

- stage of Rx:
A. Rx risk factor, avoid toxic + ACEI in selective patients
B. ACEI, B-blockers in selective patients
C. ACEI, B-blockers, diuretics, digitalis
D. Palliative, mech. Associated device, heart transplant

Arrhythmia:
- marked increase of supra-ventricular & ventricular ectopic beat
- Short run SVT occur in 1/3 of healthy older subject on 24 ambulatory
ECG
- Ventricular couples occur in 11% & short runs in 4% of healthy >60YO
- So No bad IF no HD
- Most common AF (lone)

 Aortic stenosis:
*C/P;
- symptoms:
a. Angina, dyspnea, syncope = ASD
b. Late d.t sedentary life

- Signs:
a. Harsh late peak systolic ejection murmur
b. Dec. A2 component of S2
c. LV heave & S4 gallop

Management:
- antibiotic prophylaxis
- AV replacement of choice with severe sym. AS
- Nitrate, VD, diuretic with caution esp. HF, Dec. BP
- Precut balloon aortic valvotomy not improve in1 year outcome but
bridging for replacement

N.B:
- most common cardiac procedure is coronary bypass surgery (52% in
>/ 65YO ) & pace maker application ( 76% in > 65YO & 49% in >/
75YO)
- Most mortality of CVD >/65 is d.t HF then coronary then MT then
CVS
- Smoking >65 inc. 50% coronary mortality
- CAD risk is ( 29%Male / 15% Female In 60-69YO) and
( 26%Male / 20%Female in 70-74YO)
- 4% deaths 65 & above d.t CVD
- CVD risk in known & major risk is age

10

 Age related CV disorders:

A. Coronary artery disease:(50% of all cardiac events & 85% of deaths)
B. Heart failure: ( incidence: 6-10% in old age ). It may be systolic or
diastolic (as in restrictive cardiomyopathy due to amyloidosis)
C. HTN: may be essential or isolated systolic HTN
D. arrhythmia:
- Lone AF: most common arrhythmia in elderly (1/3 of cases)
- Sick sinus syndrome = Brady-tachyarrhythmia (d.t loss pf pace maker
calls in SAN) / Rx : pacemaker
- A-V block (d.t deposition of amyloid material in conducting system)

E. Postural hypotension: d.t abnormal baroreceptor responce to dec. BP

& Dec. Peripheral venous tone
F. Valvular:
- calcific AS (most common)
- Calcification of nitric valve
G. Dilated aorta with medial calcification ( inc. SBP from age of 30 till mid
70s then Dec. in 80s & 90s )

How to diagnose subclinical CVD:

A. Coronary: by spiral CT coronary angiography
B. Carotid: by carotid doppler & measurement of intima to media
thickness (IMT)
C. Peripheral: by ankle-brachial index (ABI: normal=>0.95)

Coronary artery disease

_______________________________

Risk factors:
A. Traditional risk factors:
1. DM
2. HTN
3. Physical inactivity
4. Age
5. smoking
6. Dyslipidemia ( Inc. TG & total cholesterol/HDL d.t Dec. HDL & not
d.t significant Inc. in total cholesterol )

11

 B. New risk factors

1. C-reactive protein (CRP)
2. Lipoprotein A
3. Homocysteine
4. Fibrinogen
5. Microalbuminuria

Clinical picture:
•Symptoms :
A. in angina:
- the most common symptom is exertion dyspnea d.t inc. LVEDP by
myocardial ischemia
- Anginal pain is not the classical symptom ( d.t Dec. activity + inc.
incidence of silent ischemia)
- Other symptoms are palpitation, weakness, unexplained sweating,
indigestion and neck & shoulder pain.
B. In acute myocardial infarction (AMI):
- there are typical symptoms ( dyspnea, which is the commonest
symptom, confusion & syncope )
- Other uncommon symptoms are diaphoresis, neurogenic GIT
symptoms.

•Signs:
- faint heart sounds
- S4 d.t Dec. LV compliance
- Reversed splitting of S2 d.t BBB
- Transient MR
- Fever, pericardial rub, and basal crepitations in AMI

Diagnosis of CAD without MI:

1. Resting ECG: (may be normal ) OR (depressed ST segment >2mm in
>1 lead and T wave is flat)
2. Treadmill exercise stress test: the standard method
3. Exercise thallium scintigraphy: (96% sensitivity) if baseline ECG is
abnormal d.t conduction defects
4. Spiral CT coronary angio: 99% sensitivity
5. Coronary angiography: the definite diagnosis
6. 24h ambulatory holter monitoring: to diagnose silent myocardial
ischemia

12

 Diagnosis of AMI: in many elderly patients

- ECG changes: may be masked by conduction defects ( N.B: arrhythmia
masks elevation not depression)
- Chest pain >30min and inc. cardiac enzymes ( CK-MB or Troponin ) are
confirmatory

Complications of AMI:
1. pericarditis
2. Arrhythmia ( SVT,VT, and conduction defects )
3. CHF
4. Cariogenic shock
5. Pneumonia
6. Phlebitis
7. Drug toxicity
8. High mortality rate in young patients

DD of cardiac anginal chest pain:

Time

< 30 mins > 30 mins

+
Responds to nitrates or resolve CK-MB and
spontaneously + normal enzymes troponin

ECG High normal

Transient ST Normal ST MI UA
Segment segment
Elevation depression

vasospastic stable angina

Angina

13

 Treatment:
A. Treatment of angina
1. Non pharmacological:weight reduction, inc. physical activity, avoid
stress

2. Correct any risk factors:

- control BP
- Treatment of high LDL by statins
- Good glycemic control

3. Specific pharmacological treatment:

a. Nitrates: be cautious to avoid postural hypotension, headache or
syncope
- N.B: use sublingual nitrates during chest pain
b. CCB: diltiazem is the only CCB used in angina
- If diltiazem is used with BBs, use small dose cautiously
c. Aspirin and/or clopidogrel

4. In severe angina, PCI or bypass surgery in suitable cases

- N.B: avoid the following combinations:
a. Verapamil + BBs = heart block & CHF
b. Nitrates + nifedipine = postural hypotension

B. Treatment of AMI: give morphine & O2 and the following medications :

1. Thrombolytic therapy (PA): in 1st 3 hours of AMI (except if there are
peptic ulcer, bleeding tendency, severe HTN, recent surgery in the last
3months)
2. Full dose of anti-coagulants (Heparin): is often given to patients with
anterior MI because of the high risk of mural thrombi formation
3. Clopidogrel (plavix): 4 tablets in the first day, then one tablet/day
4. Rx risk factors and complications
5. Avoid prolonged bed rest

14

 Heart failure
_______________________________
Systolic HF:EF%<40% Diastolic HF:EF% N.

Causes 1. CAD:most common 1. Restrictive cardiomyopathy

2. Hypertensive heart disease 2. Concentric LVH
3. Valvular heart disease : 3. Calcific AS
- calcific AS (commonest) 4. Age related, common in females
- Calcification of mitral annulus 5. Functional as coronary ischemia
4. Cor-pulmonale:in Rt HF
5. Myocarditis
6. Thyroid disease
7. Idiopathic
C/P In both types: dyspnea, orthopnea, PND, swelling LLs, bilateral basal
crepitations & congested pulsation neck veins

S3 gallop S4 gallop

Echo EF% <40% EF% >40%

CXR 1. inc. cardiothoracic ratio>0.5 1. Normal cardiothoracic ration

2. Hilar congestion with indistinct 2. Hilar congestion
margins
3. Prominent superior pulmonary
veins
4. Fluids in interlobal tissue
5. Pleural effusion
6. Kerly B- lines
7. Alveolar edema
8. Peribronchial coughing
Medical 1. Lifestyle modification: fluid % salt restriction, stop smoking
Rx 2. Diuretics: thiazides 25-50mg/day, furosemide 20-100mg/day,
spironolactone 25mg/day
3. ACEI: captopril 6.25-25mg/day, Used both Dec. LVH and myocardial
ARBS are safer stiffness
4. BBs: used if no LL edema as
carvidolol (5.25mg), Metoprolol Used to dec. HR
(12.5-25mg in systolicHF)
5. CCBs: better avoided Used to dec. HR
6. Digoxin: used if there is AF or Not recommended
symptomatic HF
7. Warfarin is used if there AF
Surgical CABG, aortic valve replacement in AS, cardiac transplantation in patients
Rx <70 years

15

 N.B: some important points on drug treatment of HF in elderly:

1. First dose of ACEIs may show exaggerated drop pf BP
2. Monitoring postural BP, BUN, serum creatinine ( volume depletion ),
electrolytes and Mg.
3. Dose of digitalis in systolic HF must be adjusted according to
creatinine clearance
4. Digitalis toxicity may present with headache & other neurological
manifestations
5. Digitalis + systolic HF = headache & neurology

Prescription of elderly:
Why use of drug is difficult?
1. It require attention to change in body composition & physiology that
accompany aging.
2. Most patients given several medications at any given time
3. inc. incidence of poly pharmacy & inappropriate use of drug will
increase.
4. Use of non-prescription medication is common in old
5. Adverse drug reaction & interaction is common
6. Efficacy & toxicity of some medication vary from patient to another
according to renal & hepatic impairment
7. Difficult compliance because:
- cognitive deficit
- Visual
- Complicated regimens
8. Polypharmacy increase risk of cognition impairment& fall

Pharmacokinetics & aging:

Definition: age related + pathological changes which alter the effect of
absorption, distribution, metabolism and excretion of drugs

A. Absorption affected by:

1. Achlorhydria is more common ( ketoconazole, fluconazole,
tetracycline )= depend on gastric PH for absorption
2. dec. splanchnic blood flow No clinical significance
3. dec. motility

16

 B. Distribution affected by:

1. Dec. body mass & inc. body fat ( 33% Males / 50% Females )
2. dec. total body water so volume of distribution:
a. Dec. hydrophilic drugs ( digoxin )
b. inc. lipophilic drugs ( benzodiazepines inc. 1/2 life )
3. dec. serum albumin: lead to higher free levels of highly protein
bound drugs as digitalis, theophylline, warfarin & phenytoin

C. Metabolism affected by:

BBs, nitrates, CBBs, TCA =
1. dec. hepatic mass
effective at lower dose
2. dec. blood flow
3. Cytochrome P450 dec. with aging = drug-drug interaction

D. Excretion affected by: [RENAL]

1. Loss of renal mass
2. Obliteration of afferent arteriole at cortex
3. inc. sclerosed glomeruli
4. dec. numbers of tubules
5. Interstitial fibrosis
6. Dec. RBF & GFR
7. dec. GFR 10ml/m/decade occur after 4th decade of life

* inc. in creatinine may not be noted, why?

- renal cleared drugs:
1. Aminoglycosides
2. Acyclovir
3. Amantadine
4. Digitalis
5. Lithium
6. Atenolol
7. Vancomycin

Pharmacodynamics and aging:

Definition: age is associated with end organ response to drugs at receptor
or post-receptor level

Example:
- Dec. Sensitivity of B-receptors
- Inc. sensitivity to opiate & warfarin

17

 Risk factors of adverse drug reaction:

1. Age
2. Female
3. dec. body weight
4. Hepatic & renal insufficiency
5. History of drug reaction
N.B:
- it is the most common form of iatrogenic illness
- 1/4 of hospitalized patients >80 YO
- 1/10 of hospitalized patients 40-50 YO

Criteria of choice for older adult:

1. Establish efficacy
2. Compatible safety and adverse profile
3. Low risk of drug or nutrient interaction
4. 1/2 life <24h with no active metabolites
5. Elimination doesn’t change with age or known dose adjustment for renal
or hepatic function
6. Convenient dosing (single or twice/day)
7. Strength & dose recommended for old
8. Affordable by patient

Guideline for optimal pharmacotherapy:

1. Complete history about:
- medication now & previous
- Responce to drugs
- Allergy
- Nutritional supplement
- Alternative medication
- Habit ( alcohol, tobacco, caffeine & reactions drugs)
2. communicate with other consultant
3. Keep a list of active medication, review every visit
4. Stop unneeded medication
5. Monitor use of OTC drugs
6. Avoid prescription before diagnosis and consider non drug therapy &
eliminate drug without diagnosis
7. Use non pharmacological approach when possible , know (action, SE,
toxicity ) of a medication
8. Minimize number of pills/day
9. Once daily formulations
10.One drug to Rx 2 or more diseases

18

 11.Start chronic drugs with low dose then titrate according to tolerability &
response & may use drug level
12.Reach therapeutic dose then switch or add
13.Use combination cautiously
14.Use pillbox to avoid confusion
15.Avoid medication with common SE
16.Avoid drug to Rx SE of another drug
17.Keep current estimation of RF
18.Avoid drug from same class or similar action (alprazolam + zolpidem )
19.Inquire SE regularly
20.Identify barrier of compliance
21.Patient education :
- regimen
- Goal
- Cost
- SE
- Interaction
- Written instructions

Common drug-disease interactions: ( in elderly avoid that medications )

A. CHF
1. Dispyramide : muscle relaxant
2. Drugs with high Na content : antagonize
3. NSAIDS : salt & water retention
4. CCBs
5. Non selective BBs
B. COPD & asthma
1. BBs
2. Sedatives
3. Hypnotics
4. Opiated
C. Peptic ulcer
1. NSAIDs
2. ASA
3. KCl: irritative effect
4. Corticosteroids: delay healing
D. Clotting disorders
1. ASA
2. NSAIDs
3. Vit E
4. Ticlopidine
5. Warfarin

19

 E. BPH
1. Anti-cholinergics: urine retention
2. Antihistaminies : diphenhydramine
3. GI antispasmodics
4. Muscle relaxants
5. Narcotics
6. Bethanechol: cholinergic agonist
F. Seizures : neuroleptics
G. DM:
1. BBs if hypoglycemia problem
2. Corticosteroids
H. incontinence : alpha blocker
I. Constipation:
1. Anti-cholinergics: more constipation
2. Antihistaminies
3. GI antispasmodics
4. Muscle relaxants
5. Narcotics
6. Bethanechol
7. CCBs
8. Iron
J. Arrhythmia
1. Tricyclic anti-depressants
2. Neuroleptics
K. Insomnia
1. Decongestants
2. Theophylline
3. SSRIs
4. Beta agonists
L. Cognitive dysfunction: (CI)
1. Anti-cholinergics
2. Antihistaminies
3. Antispasmodics
4. Tricyclic anti-depressants
M. Osteoporosis:
1. Corticosteroids
2. Anticonvulsants

20

 N.B:
- Try to avoid :
1. Analgesics
2. Muscle relaxants
3. Anti emetic (extrapyramidal )
4. Antihistaminic
5. Anticholinergics
6. Sedative-hypnotics
- TCA = cardiotoxic not neurotoxic
Neuroleptic = act on SA node
- Acetyl choline = memory so anticholinergic = amnesia
- Why avoid BBs, b agonists: d.t dec. sensitivity of B receptors
- Decongestant take at night
- SSRIs take at morning

21

 Dementia and delirium

_______________________________

Dementia Delirium
Definition Progressive, gradual, global It is syndrome characterised by
decline in memory first then an acute disorder of attention
cognition & behavior & cognition function which is
interfering with daily living the most frequent complication
activity & social relationship of hospitalized elderly &
(brain failure) potential devastating problem
Types & A. Irreversible causes : (these Functional not structural lesion:
causes damage brain cells in both slow cortex & dec. cerebral
cortical & subcortical areas) oxidation metabolites with
1. Alzheimer’s disease: impaired cholinergic
- the MC cause of dementia transmission
accounting for 50% of all
cases Ppt:
- Abnormal protein deposits in D = drugs 40% & drug
the brain and destroys cells in withdrawal, depression,
the areas of the brain that deprivation, social stress
control memory & mental E= eye & ear problem
functions ( B-amyloid) L= low state
- People with Alzheimer’s have I= infection (occult) / ictal
lower neurotransmitters, convulsion, epilepsy
cholinergic plaque, tangle R= retention of urine
- Irreversible and no known U= under nutrition &
cure dehydration in hospital
underlying severe systemic
2. Vascular dementia:2nd MC
disease & brain disorder
accounting for 40% caused
M= metabolic
by atherosclerosis
hypo&hypernatremia, inc.
3. Parkinson’s disease: may calcium, acid-base,
develop late, but not everyone hypo&hyperglycemia, thyroid
with Parkinson’s has dementia & adrenal
F= failure(renal&hepatic)
4. Other: lowey body
dementia, Huntington disease, H= hypoxia & hyper capnia
Creutzfeldt-jakob disease, pick M=MI&HF
disease (fronto-temporal O=old age
dementia)

22

 Dementia Delirium
Types & *risk factors for irreversible
causes (Alzheimer’s):
a. Old b.FH c.rural area
d.education e.diet
f.enviromental (dec.Al & zink,
virus, no role for smoking)
g.head injury h.Down
syndrome
B. Reversible or partially
reversible causes:
1. Head injury: the resulting
damage of brain cells can lead
to dementia
2. Infections: meningitis &
encephalitis are primary
causes .other infections such
as HIV, syphilis can affects the
brain in later stages
3. Brain tumors
4. Toxic exposure especially
lead
5. Nutritional deficiencies
especially B vitamins if not
corrected
C/P
Onset Insidious (gradual, progressive, Rapid & acute
global)
1ry Loss of short term memory Inattention (cognition)
defect (normal attention)
Course Not fluctuating during the days Fluctuation during the day
except dementia with lowey
body affection
Visual Less common Common
hallucination

Reversible Irreversible reversible

Clock Can attend to MMSE or clock Can’t
MMSE draw but can’t perform well
23

 Dementia Delirium
Early warning signs: Cardinal features of acute
- gradual loss of short term onset & inattention:
memory - difficult with simple repetitive
- Mood or personality changes tasks, digital span & recitation
- Problem to find or speak of months backwards
right words - Other:
- Inability to recognize objects 1. Disorganize thought
- Forget to use simple objects process (cog / cons)
- Forget to turn off stove, 2. Lethargy with unaware
close windows, lock doors 3. Disorientation
4. Cognitive defect
5. Psychomotor agitation or
retardation
6. Perceptual disturbance
(hallucination, illusion)
7. Paranoid
8. Sleep reverse
Dx Early warning signs +evaluate: CAM criteria :
1. History 1. Acute onset & fluctuating
2. Physical examination course
3. Cognitive assessment: 2. Inattention
-attention -memory 3. Disorganized thinking
-language - visual 4. Alter level of consciousness
4. Lab
DSM-IV criteria :
5. Imaging:CT, MRI on
1. Disturbance of conscious
hippocampus
2. Change in cognition
6. Gold standard: biopsy after
3. Disturbance develop over
death from brain (senile
short period (hours to days)
plaques & neurofibrillatory
4. History, physical, lab,
tangles)
medical condition as ppt
factors
Rx No cure but aim to slow A. Non-phramacological Rx:
progression
*Prevention: 1. Interpersonal contact &
1. dec. fat, leinolic acid communication by:
2. inc. fish (omega 3), - verbal reorientation
antioxidants, statin - Frequent eye contact
3. Maintain normal BP - Hearing aids
4. Mental & social activity
24

 Dementia Delirium
*medical:Slow progression by: 2. Minimize disturbed influence
1. Ach esterase inhibitors of hospital by:
(donepezil)[Ach imp. For - clock, calendar apply
memory] - Quiet environment
2. Anti inflammatory - dec. light
3. Estrogen - Reassurance
4. Glutamate agonist: - Not left alone
memantine block NMDA
B. Pharmacological :
receptor that overtime.
*Indication:symptomatic -
Bad for brain.
interruption
*Rx behavioral problem: *role:all drugs of low dose &
1. Activity short duration
2. Psychological 1.neuroleptics with haloperidole
3. Family care (BEST):
4. Education -advantages: less SE, postural
hypotension, Lower
*support family members
anticholinergic SE
-SE: extrapyramidal: dystonia
-Dose: 0.5-1mg/ 30m
loading not more than 3-5mg
oral or parental/ maintenance
1/2 the loading
2. Short acting sedation as
benzodiazepines not
recommended as 1st line
(sedation, confusion) but may
be 1st in alcohol & sedative
withdrawal
3. Thiamine in alcohol

25

 N.B:
Dementia:
1. Risk for cognitive impact doubled every 2 decades
2. In US:
- 5-15% >65YO
- 20-50% >85YO
- 60-80% of dementia have Alzheimer’s disease (AD)
3. among patients with dementia:
- 50% AD
- 15% stroke (vascular), abrupt onset
- 15% AD+stroke
- 20% parkinsons, depression
4. Senile dementia (outdated term): any dementia in old
5. Age associated memory impairment: dec. shot term memory that
sometimes accompanies aging (benign senescent forgetfulness)
6. Old age is a major risk factor
7. Theory is mutation of B- amyloid
8. Aggravating factors of delirium in hospital are:
a. Environment:
1. Unfamiliar surroundings
2. Frequent room changing
3. Sensory overload or deprivation
b. Psychological:
1. Depression
2. Stress
3. Pain
4. Lack of social support

26

 Urinary incontinence
_______________________________

Definiton:
Involuntary loss of urine severe enough to cause social, hygiene problems
affecting individual physical & psychological & decrease quality of life.

Physiology:
- Continence require :
1. Mobility
2. Mentation
3. Motivation
4. manual skill

B adrenergic
Cholinergic receptor:
receptor:
contraction of detrusor
relaxation
muscle

A receptor: closure of
urethral sphincter

Transient Causes: ( DRIP)

1. Delirium
2. Restricted mobility, fractures arthritis
3. Inflammation, atrophic vagina, urethritis (PM)
4. Infection, UTI = dysuria, frequency
5. Impaction: stool impaction common ( hospital , immobility )
6. Polyuria: excess fluid intake, metabolic ( DM, hypercalcemia) DI,
malnutrition, diuretics
7. Psychogenic: depression and psychomotor retardation
8. Pharmaceutical : MC cause of transient

27

 Drugs causing urine incontinence:

Drug Nocturnal Stress Urge Overflow
effect diuresis incontinence incontinence incontinence
e.g: 1. CCBs 1. Alpha 1. Alcohol 1. Sedatives
2. NSAIDs blockers 2. Hypnotics 2. Anti-histaminic
3. Rosiglitazone 2. ACEIs 3. Anti-psychotics
as haloperidol
4. Tricyclic anti-
depressants

Drug Mechanism
Sedatives/ hypnotics Sedation, delirium
Alcohol Polyuria, frequency, urgency, sedation,
delirium,
Anti-cholinergics Worsen overflow incontinence
TCA/antidepressants Sedation, rigidity, immobility
Alpha-1 blockers Urethral relaxation= stress incontinence in
female
Alpha -1 agonists Urine retention in male
CCBs Urine retention & nocturnal diuresis
Diuretics Polyuria, urgency, frequency
thiazolidinediones (TZD) or nocturnal diuresis d.t fluid retention
giltazones
NSAIDs nocturnal diuresis d.t fluid retention
Vincristine Urine retention

28

 Established causes:
A. Urge incontinence (detrusor muscle overactivity )
- cause:the most common cause (2/3, 65%)
1. Idiopathic detrusor overactivity
2. Local or surrounding infection, inflammation, or irradiation of the
bladder
3. Neurogenic (reflex incontinence) it results from overactive nerves
controlling the bladder
- C/P:
1. Urine leakage after intense urge to urinate that cannot be expected
(in males it coexists with urethral obstruction)
2. Suprapubic tenderness +/- senile hematuria. Cystoscopy is needed
to reach the cause (stone, or tumor)
- Treatment;
1. Behavioral therapy: emptying the bladder every 2hs and increase by
1/2h tilll reaching 4-5hs
2. Pelvic floor exercises
3. Drugs:as oxybutynin (uripan) 2.5-5mg twice daily
4. Refractory: intermittent catheter, external collective device

B. Stress incontinence (urethral incontinence)

- Cause:urethral incontinence is due essentially to insufficient strength of
the pelvic floor muscles.
1. In women:(the 2nd MC cause in females):physical changes
resulting from pregnancy, childbirth, and menopause often contribute
stress incontinence. At that time, lowered estrogen levels may lead
to lower muscular pressure around the urethra, increasing chance of
leakage.
2. In men: (rare) common following prostatectomy
- C/P:
1. Instantaneous leakage of small amounts of urine associated with
coughing, laughing, sneezing, exercising, or other movements that
increase intra-abdominal pressure and thus increase pressure on the
bladder.(only at day. If say&night = overactivity)
2. If leakage is delayed for several seconds or persists, it suggests a
problem in bladder contraction. (If immediate = Stress incontinence)
- Treatment:(Stress incontinence is treatable)
1. Pelvic exercise in mild cases
2. Surgery in severe cases (last method but most effective )
3. Muscle electrical stimulation: sacral nerve stimulation
4. estrogen in atrophic vaginitis
5. Pessary (vaginal stenosis), inserted in vagina to prevent leakage.

29

C. Urethral obstruction (dripping incontinence)

- causes:
1. The 2nd MC cause in old males, causes in males are prostatic
enlargement, urethral stricture, and cancer prostate.
2. It is rare in females d.t: fibroid or ovarian tumors from advanced
vaginal prolapse causing kink in the urethra
- C/P & investigations:urge ( overactivity) or retention overflow
Dripping after voiding. U/S: to exclude hydronephrosis. Post voiding
residual urine >150ml (mixed).
- Treatment:
1. Surgical decompression is the most effective Rx especially if retention
2. Selective alpha-1 blockers: as Tamsulosin and Prazosin in BPH. If
non operable = catheterization

D. Overflow incontinence (detrusor muscle under activity)

- causes: ( the least common type in <10%): weak bladder muscle
(detrusor muscle) , resulting in incomplete emptying of the bladder
(allowing for urinary retention) this may be:
1. Idiopathic
2. Autonomic neuropathy from DM or other diseases (multiple
sclerosis)
3. Spinal cord injury
- C/P & investigations: nocturne, frequency& dripping without voiding or
few drops after few seconds from cough. Residual urine is about
>450ml (retention with overflow)
- Treatment:
1. Augmenting voiding by suprapubic pressure during voiding
2. Intermittent catheter with antibiotics for symptomatic infection or
prophylactic in intermittent catheter and not in indwelling catheter
3. Prophylactic antibiotics

Stress incontinence:
Instant leakage in response to stress = at the same moment.
- leakage after seconds = detrusor under activity (retention with
overflow), should be excluded by U/S = post voiding residual urine

Urethral obstruction:
Post voiding residual urine, so patient complain of dripping incontinence
after voiding
- if >150ml = renal U/S to exclude hydronephrosis

30

 In detrusor under activity (retention with overflow)

Retention of full capacity of urinary bladder = 450ml + in addition there is a
small amount of urine which frequently voided. So patient complain of
nocturia, frequent leakage of small amounts.
( UB capacity = 450 ml + small voided amounts)
- post voided residual urine 450ml

Stress incontinense: d.t urethral obstruction

- if during night
Ass.with detrusor overactivity
- If leakage after intense urge
(urge incontinence)
to urinate (not expected)
- but if there is delay in leakage after stress = stress induce UB
contraction (retention with overflow)

MCQ points
1. continence require :
a. Adequate mobility
b. Mentation
c. Motivation : conscious level need for micturition
d. Manual skill : skill of micturition
2. Transient causes: DRIP
3. The MC cause of transient incontinence is = Drugs esp. anticholinergics
4. MC of established incontinence (2/3, 65%) = detrusor overactivity
(urge incontinence)
5. MC cause of established incontinence in older females = urethral
incompetence (stress incontinence)
6. MC cause of established incontinence in older males= urethral
obstruction (mixed incontinence)
7. Least common cause of established incontinence (<10%)= detrusor
under activity (overflow incontinence)
8. Post voiding residual urine >150ml in urethral obstruction = renal U/S to
exclude hydronephrosis
9. Post voiding residual urine >450ml = detrusor under activity
10.Drug of choice in urge incontinence = oxybutinin
11.Most effective method in stress incontinence = surgery
12.Most effective method in urethral incontinence = surgery
13.Most effective method in urethral obstruction = surgical decompression
(in urine retention) but if NO retention = alpha-1 blocker (Tamsulgin)

31

 Falls in elderly
_______________________________

Epidemiology:
40% of elderly (>65YO) are suffering from falls and 25% of them are
injured or have fractures, women > men

Etiological classification:
A. Extrinsic factors
- going down a stair
- Poor lighting
- Improper fitting shoes
- Lack of equipment / aid
B. Intrinsic factors
- defect in balance
- Defect in mobility
- Defect in cognition
- Defect in sensory function
C. non-classifiable falls

Risk factors of fall:

A. Age associated changes and chronic diseases:
- >80 YO, previous falls, indicate risk for future falls and need for
assistance with activities of daily living. These characteristics cannot be
modified.
- N.B: clinician must pay attention to find treatable risk factors of fall.
(the most important modifiable risk factor for fall are balance, strength,
and gait impairment

B. Postural control:
- depends upon integration of visual, vestibular, and proprioceptive input
(sensory) by CNS (central processing). Fall risk has been linked to
mediolateral instability which can be tested by the ability to stand on
one leg which reduce the mediolateral base support.

C. Sensory input :
1. Vision:visual acuity is a measure if the finest detail a person can
make out. This function decrease as a person gets older making it
more difficult to distinguish between different shapes and contrasts.

32

 Yellowing of the lens of the eye makes it difficult for older people to
identify certain colors like blue, green, and violet
- inflexibility of the lens in the eye occurs as people get older. The eye
loses its ability to focus on close objects. It also cause a decrease in
the eye’s ability to accommodate for changes in depth such as is
needed when going up and down stairs
- With aging the lens of the eye can also become cloudy and form
cataracts. Because of this, eye glare can occur and cause a
temporary disturbance in a person’s vision. This becomes a problem
outside on sunny days and inside when bright lights are reflected off
shiny floors. Older people should be taught to wear wide brimmed
hats and sunglasses to shield them from the glare outside and to
shade inside windows.
2. Proprioception: is the sense that tells us our body’s position in space.
It is essential for balance, posture, and movement and becomes less
effective with age. Proprioceptive dysfunction can result in loss of
balance on walking in dark d.t dec. visual input.
3. Hearing loss and impaired vestibular function result in loss of balance
with dec. visual input.

D. Central processing
1. Dementia: may inc. risk of fall d.t cognitive impairment = impairs
judgement and affect perception
2. Depression: may inc. risk of fall d.t dec. concentration and
awareness of potential environmental hazards

E. Musculoskeletal impairment :
1. dec. muscle mass and strength with age
2. Foot problems as long nails, joint deformities

F. Postural hypotension
- definition: a drop in SBP >/ 20mmHg with change in position from lying
to standing
- Causes:
1. Medication related
2. Dehydration
3. Age-associated changes
4. Diseases affection autonomic control of vascular tone
- Postural hypotension is suspected in:
1. Persons complaining of dizziness
2. Patients who fall after getting up from a meal or soon after a
meal

33

 G. Medications :
- use of >/ 4 medications [prescribed or non-prescribed] d.t :
1. Multiple chronic diseases
2. Multiple prescribing physicians or consultant
3. Accumulation of medication over time
4. Lack of understanding about how to take medications (inc. risk of
falling)
- medications may cause postural instability by their expected effects
on :
1. Cognitive function
2. Fluid & electrolyte balance
3. BP
4. By adverse effects as (fatigue, altered mental status, impaired
balance)
- examples of medications causing fall:
1. Anticonvulsants
2. Psychotropics as (sedative hypnotics, antidepressants,
benzodiazepines or neuroleptics)
3. Antiarrhythmic drugs
4. Antihypertensive digoxin
5. Diuretics
( inc. number of drugs is linear to inc. fall so ask about medications every
visit)

H. Acute illness and hospital discharge:

1. Acute illness: as pneumonia, exacerbation of CHF may cause fall d.t
altered mental status, postural hypotension or weakness
2. Hospital discharge: the vulnerability after discharge is caused by
(admission illness, deconditioning, or medication effect)
- the risk of fall in these patients is 4 folds higher than other community
patients especially during 2 weeks after discharge

I. Changes to postural control:

- extrinsic factors as environmental hazards, together with intrinsic
factors, increase susceptibility to fall
- Environmental factors that are not risky in younger age may become
hazardous in olde age
- >1/2 cases of fall occur at home

34

 J. Opportunity to fall:
1. As older persons (with impaired balance & strength) carrying
activities beyond their capabilities as (climbing in a chair to reach
higher cabinets, rushing to answer telephone)
2. A desire to maintain independence
3. Poor judgment
4. Lack of family or friends to help

Risk factors for fall injuries:

1. Osteoporosis that increase risk of fracture
2. Characteristics of fall as:
a. Force of fall : increased by falling from greater hight and falling on
a hazardous surface
b. Direction of fall:
- falling sideways = inc. hip fracture
- Falling forward = inc. incidence of colle’s fracture

Fall with or without syncope:

With syncope Without syncope
1.Cardiac causes: 1.vertigo:
a.calcific AS -central: acoustic neuroma
b.AcuteMI -peripheral:
c.arrhythmia a.benign paroxysmal peripheral
d.pulmonary embolism vertigo (BPPV)
e.cardiomuopathy b.meniere’s disease
c.drugs
d.post trumatic
2.Orthostatic hypotension 2. Metabolic: a.DM
b.hypothyroidism
3.reflexes: 3.psychiatric: mood disorders
a.reflex cough
b.micturition reflex
c.vasovagal
4.CNS causes: 4.others: lead poisoning
a.seizure
b.cerebrovascular insufficiency
5.others:
a.anaemia
b.hypoglycemia
c.Hypoxia
35

 Complications:
1. Fall injuries (fracture, laceration) d.t:
a. Slow reaction time
b. Osteoporosis
c. Impaired protective mechanisms
2. Fracture (Hip, wrist, vertebrae), hip fracture is the MC (50% cannot
live independent, 20% die in first year)
3. Prolonged bed ridden state:
a. Bed sores
b. Electrolyte imbalance & dehydration
c. DVT
d. Infection
e. Pneumonia
4. Subdural hematoma, brain and spinal cord injuries (2nd leading cause of
brain and spinal cord injury)
5. Death (2/3 of deaths from injury in elderly d.t fall)
6. Others:
a. Fear of recurrent falls = loss of independence
b. Residual physical impairment affects quality of life & independence

Management of falls:
- fall prevention in community-dwelling older persons:
- Strategy for decreasing falls and fall injuries: the most effective fall
prevention programs require coordination of efforts by several health
care disciplines:
- The strategy includes:

A. Screen for fall risk:

1. All other persons seen for routine medical care should be screened
for fall risk by asking if they have fallen (at least once last year)
2. Olde persons should be observed about how getting up from chair,
walking across the room for any difficulty with any activity, for
unsteadiness and for use of an assist device
3. If no history of fall, and no problem in balance, mobility or gait = no
specific fall risk assessment is needed
4. In all healthy older adults:
- routine vision and hearing screening
- Review and reduction of prescribed medications
- Exercise prescription
- Screening and treatment of osteoporosis
- Discussion of home safety

36

 B. Multifactorial assessment:
- Indications:
1. If there is a history of one or more falls
2. Problems with mobility or gait
3. Potentially higher risk times as during acute illness, after hospital
discharge, or after introduction of a mew medications
- Determination of risk factors and all possible contributing factors for fall
is within the capability of primary care providers and needs coordination
among several specialists and referral to geriatric specialists:
- Assessment should include:
I. History:
a. Physical function:
- activities of daily living (ADL) as bathing, dressing, toileting, transfer,
continence and feeding
- Instrumental activities of daily living (IADL) as reading, writing,
cooking, shopping, using telephone and managing money
b. Previous falls & fractures and fall circumstances to detect specific
risk factors for future fall:
- location & time
- Relation to changes in posture, coughing, urination…etc
- Witnesses
c. Acute & chronic medical problems
d. Systemic review: CVS, chest, CNS, urinary incontinence…etc
e. Use of assistive devices
f. Medication review: including drug name, dose and frequency

II. Physical examination:

a. Vital signs :
- pulse :arrhythmia
- BP: postural hypotension (lying then standing after 3 mins)
b. Special senses: screening of hearing & visual acuity
c. Extremities:
- examine joints for arthritis, deformities, and range of movement
- Examine feet for deformities, callosity, ulcerations and poor fitting
shoes
d. Cardiovascular: examine for arrhythmia, carotid bruits, aortic
stenosis, carotid sinus sensitivity (massage carotid sinus gently for 5
seconds & observe if it precipitates profound bradycardia)

37

 e. CNS :
- mental state testing (MMSE = mini mental state exam),cranial
nerves
- Motor system: muscle weakness, spasticity, resting tremors
(Parkinsonism), heal shin test & sensory system especially joint
position sense (cerebellar lesion)
f. Review other systems: chest, abdomen, skin…etc

III. Laboratory testing

a. Nonspecific laboratory tests: CBC, fasting blood glucose,
electrolytes, BUN, and creatinine
b. TSH, B12 level and level of medications as digoxin and
anticonvulsants
c. Testing for osteoporosis and bone density
d. Cervical spine films, CT and MRI brain

IV. Physical performance testing

a. Test for gait and balance
b. Timed up and Go test (TUG test): the original purpose of the TUG
was to test basic mobility skills of trail elderly patients by a
measurement of the time in seconds for the patient to rise from
sitting from a standard arm chair, walk 3 meters, turn, walk back to
the chair and sit down

38

Timed up and Go test (TUG test)

1. Gait initiation :
- any hesitancy or multiple attempts to start 0
- No hesitancy 1
2. Step symmetry:
- right and left steps not equal (estimate) 0
- right and left steps equal 1
3. Step continuity
- Stopping or discontinuity between steps 0
- Steps appear continuous 1
4. Step symmetry
- right and left step lengths not equal (estimate) 0
- right and left steps equal 1
5. Path deviation
- Marked deviation 0
- Mild/moderate deviation or uses walking aid 1
- Straight without walking aid 2
6. Turning 360 degrees
Discontinuous steps, unsteady (grabs, staggers) 0
Continuous & steady 1
7. Getting up from a chair
Does not get up with single movement, pushes up with 0
Arms or moves forward in chair first
8. Sitting down in a chair
Plops in chair, does not land in center of chair 0
9. Step hight
10. Gait speed
>14seconds to stand & walk 3 meters and turn back & sit

V. Home environment:
a. Outside:
- Repair uneven pavement, cracked sidewalks
- Install railing for outdoor steps
- Use adequate lightning
- Keep shrubbery trimmed near walks

39

 b. Inside:
- floors:
• remove throw rugs
• use nonskid carpet backing,
•avoid wax or use nonskid wax
• mark high thresholds with reflecting tape
- Lightning:
•adjust to decrease glare.
•Adequate light between bedroom and bathroom at night.
• Light switches at top and bottom of stairs
- stairways:
• install railing on both sides.
•Make sure that railing ire secure.
•Ensure that stairs are free of clutter.
•Mark top and bottom steps with reflective tape
- Bathroom:
• install grab bars in bath and next to toilet if mobility is impaired.
•Use rubber mat in bath
- Kitchen:
• keep food and dishes within easy reach.
•Do not use cupboards that are too high or too low
C. Multidisciplinary treatment
1. Physical therapy:
a. Exercise to improve balance and mobility
b. Exercise program of minimum 10 weeks to increase bone mass &
muscle strength even in very old individuals
c. Exercise programs by physical therapist to improve confidence and
reduce fear of falling in old person
d. Teaching old persons how to get up from the floor as a result of a
fall to prevent a long lie
2. Correction of sensory deficit ( visual, hearing, vestibular and
proprioceptive)
3. Evaluation and treatment of postural hypotension
4. Review and reduction of medications
5. Treatment of foot problems
6. Treatment of underlying medical problems
7. Environmental modification and use of adaptive equipment, if indicated
8. Other strategies include: wearing an emergency call device in order to
ask for help or tp have a telephone within reach in case of fall
9. Treatment of osteoporosis to reduce the incidence of fracture
10.Hip protectors to prevent fracture hip in those with high risk of falling

40

 N.B:
- Hip protectors are consisting of foam or plastic pads placed inside
pockets on a stretchy under garments where the protractors lie over
the greater trochanter of each hip.
- The undergarments are designed to be easy to wear without affecting
walking or sitting.
- The main aim in managing falling problems is to keep the patient
moving but in a more safe situation. We do not restrict activity unless
clearly hazardous situation (e.g climbing over a chair to reach too high
objects should be avoided). This is important since restriction of activity
would lead the patient to immobility which itself has its serious
complications.
Post fall syndrome:
Definition: patient express great fear of falling when they stood erect,
tendency to grab and clutch at objects within their view and showing
remarkable hesitancy and irregularity in their walking attempts & thus
related to history of recent fall

Classification:
1. absent = walk safe without human support & no clutch with or without
aid
2. Moderate = as severe but with encourage can do it
3. Severe =
- patient fall with absent any neurological or orthopedic abnormality
- Patient unable to stand or walk unsupported
- If ask to do alone = fear, anxiety, clutch objects
- Appear of danger to fall
- When support reversed
N.B:
- Ptophobia: phobic reaction to stand or walk ( with history or no history
of falling)
- FOF (fear of falling): ongoing concern about falling that limit the
performance of daily activity with previous fall or not, with dec. physical
activity
- FOF=
1. Faller or not
2. dec. physical health
3. Not result in normal aging
4. Associated with but not only d.t anxiety & depression
5. With restrictive activity
6. More serious than fall
41

 Complications of long lie: (prolonged bed ridden)

Long lie = remain on ground >1h after fall
1. Rhabdomyolysis: d.t prolonged muscle compression (calves & lower
back)
- inc. K, P, myoglobin, CK
- May isolated inc. CPK = 12h peak 1-2days & dec. after 3-5 days
- Or AKI, inc. K = death 20%mortality
- Myoglubinuria
- <10% (triad of muscle pain, weakness, dark urine)
2. AKI
- d.t myoglubinuria
- Level of CK not directly related
- Common in patients with renal comorbidity
- Fluids in Rx
3. Hyperkalemia = arrhythmia
4. Hypocalcemia mainly asymptomatic
5. Dehydration
6. Pneumonia
7. Thromboembolic in prolonged bed ridden = pulm. Embolism & DVT.
- Rx by amputation or:
1. LL exercise while seated
2. Intermittent external pneumatic pressure device
3. Compression stocking
4. LMWH SC

N.B: the level of CK does not always predict the likelihood of severity of
complications in rhabdomyolysis

Hypothermia: categorized as mild (<35C), moderate (<32C) and severe

(<28C)

*Falls & reduced mobility can be a presentation of sepsis in older people

and hypothermia in this context may indicate severe sepsis

42

 N.B:
- Falls are the leading cause of accidental death in people over 65 in UK
and US
- The causes and consequences of falls and immobility are complex and
require careful assessment
- Falls and reduced mobility can be the presenting feature of an acute
illness in older people
- Gait assessment is an essential part of assessing a patient presenting
with a fall or reduced mobility
- Multi-disciplinary intervention significantly improves outcomes for falling
or immobile patients
- Falls in elderly = non-syncopal / not loss of consciousness
- In Parkinsonism : propulsion and retropulsion (unstoppable movement
forward-backward), low stoppage gait
- Aim in geriatric to handle fall: not only prevent fall but also change how
to fall
- Long lie after falling: increase risk of
1. Rhabdomyolysis
2. Pneumonia
3. Dehydration
4. Fractures
- MC complication of fall = FOF again
- Most important part of geriatric history preview = medication

Fall workup:

Comprehensive problem oriented approach

Diagnostic medical workup
physical rehabilitation team
Ix for medical disease to evaluate:
-DM -Gait
-Arthritis -Balance
-Osteoporosis -muscle
-CVD
-CNS

* if fallen >/2 times within 6months refer to geriatrics

43

Prevention of falls in elderly:

- 1/3 community dwelling adults >65YO fall each year
- Not all falls are pathological
•15% are of conditions cause falls in adults
•15% from single obvious cause (syncope)
•The rest are multi factors
- After person’s risk factors for fall has been determined = multi
disciplinary Rx plan can be put
- Not all interventions to reduce falls are equally effective

Effective intervention not effective intervention

1.effective exercise & physical 1.VitD supplements do not

therapy: reduce fall (only given to VitD
-group class or at home deficient persons
physiotherapy ( daily 600IU for 51-70YO)
-type of exercise: (daily 800IU for >70YO)
a.balance retraining
b. Muscle strengthening 2. Cognitive behavioral
-effective exercise program of 10 intervention and education
Weeks inc. bone mass & muscle regarding full prevention
Strength (not effective)

2. Safety modification and 3. Routine risk evaluation

Behavioral changes: + qualified and management of identified
Occupational therapist risk (not recommended)
strategy is beneficial for
3.Gradual withdrawal of medication selected patients (according
-psychotherapy medications circumstances of previous
-Patient specific prescribed falls and co-morbidities
medication

44

 Hyperthyroidism
_______________________________

Causes:
1. Multi nodular & uninodular (MC)
2. Iodine induce (amiodarone)
3. Factious
4. Graves
5. Subacute thyroiditis
6. T3 thyrotoxicosis

C/P:
- older patient have few symptoms & signs , 25% of >65 has typical
symptoms
- classical triad in old : tachycardia (>90BPM), fatigue, weight loss
- But in young: tachycardia , goiter, exophthalmus
- Goiter is present in 0.2-2%
- Ocular signs are usually absent
- NO reflexes nervous symptoms are uncommon
- Dec. appetite is common
- HF, angina, myopathy, osteoporosis is common
- MC complication: AF then depression then HTN, myopathy,
osteoporosis

Rx: best is radioactive I131

Thyroid storm:
- inc. thyroid h massively d.t I131 therapy or stressful illness = inc. HR, N,V,
confusion, HF
- T3,T4 as high as thyrotoxicosis

Euthyroid sick syndrome:

- abnormal thyroid function test in clinically euthyroid patient with severe
non thyroid systemic illness

45

 Hypothyroidism
_______________________________

Epidemiology:
15-10% subclinical
Elderly patient have low symptoms than young

Causes:
1. Hashimoto thyroiditis (MC)
2. Iatrogenic:
- surgical
- I13 (MC complication in hypothyroidism)
- Irreversible
3. Pitutary or hypothalamic (gI)
4. Iodine
5. ATD, lithium
6. Subacute thyroiditis

Manifestations may occur:

- non specific geriatric syndrome: confusion, anorexia, weight loss, fall,
incontinence, dec. mobility
- Non inflammatory effusion : arthralgia
- dec. body temperature

Less common manifestations:

- chillness, muscle cramps
- Weight gain, paresthesia
- Fatigue, weakness, depression
- Constipation, dry coarse skin
- NO arthritis
- NO prolonged relaxation time after muscle contraction

Complications:
- inc. lipid (most imp) & lipoprotein a = CAD
- HTN
- Pericardial, pleural effusion
- Myxedema coma
- dec. Na, glucose, inc. CO2

46

 Ix:
- Inc. TSH (most sensitive)
- Dec. free T4 (most specific)
- T3 normal in 1/3 cases
- Screening by TSH every 5years in (male >/65 YO / female >/55 YO)

Rx: L thyroxin 125µg/dl till 75µg/dl at morning

47

 Protein energy malnutrition (PEM)

_______________________________

- PEM has been used to describe macro nutrient deficiency

- Syndrome which include:
1. Kwashiorkor, marasmus & nutritional dwarfism in children
2. Wasting as with illness or injury in children & adults

1ry PEM:
1. Causes by lack of intake of nutrients
2. Usually affects child & elderly persons
3. Functional & structural abnormalities as with 1ry PEM are after
reversible with nutritional therapy but note that with prolonged 1ry PEM
irreversible functional & structural changes occur

2ry PEM:
1. Caused by illness that alter appetite, digestion, absorption or metabolism
of nutrients
2. In 2ry PEM, restoration of muscle mass is unlikely with nutritional
support alone, we also need to Rx the underlying disease

Some complications of PEM if prolonged:

1. dec. skeletal muscle mass, strength
2. dec. maximum breathing capacity
3. dec. COP
4. dec. bone mass
5. dec. GFR = deterioration of renal function
6. dec. hematocrit value
7. dec. immunity making the patient susceptible to infection ( UTI, chest
infection, skin infection)

N.B:
1. A rate of 1.2 cm every 20 years after the age of 40YO
2. In bed ridden patient we measure arm length to obtain hight
3. Significant PEM is considered if patient weight less than 85%
4. PEM can occur while body weight is still greater than 85%, this
condition is known by % body weight loss &/or upper arm
anthropometry
5. Significant obesity when weight is more than 30%

48

 Anthropometric measurements:
1. Upper arm Anthropometry
- triceps skin fold
- Mid arm circumference
- Mid upper arm muscle
2. sub scapular skin fold

*circumference = specific measure of PGM

Lab investigation for nutritional assessment:

1. Serum albumin level is traditional standard for nutritional assessment
2. Many elderly patients manage to maintain their serum albumin at
normal levels
3. Moderate to severe weight loss and a normal serum albumin levels
4. serum albumin level alone is not sufficient enough to exclude
malnutrition as it could be normal d.t skeletal muscle breakdown.
5. To exclude malnutrition: normal albumin / normal weight / normal
Anthropometric measurements
6. Serum albumin level normally should be >3.5g/dl
7. If less than 3.5g/dl then visceral protein depletion is present
8. Ix:
a. Anaemia is early manifestation of PEM
a. Thyroxin binding pre-albumin
b. Retinol binding protein
c. Serum transferrin
d. Total lymphocytic count is a good marker for nutritional problem

49

 Some vitamin deficiency in elderly

_______________________________

Vit B12 (Riboflavin):

- Eye: conjunctival congestion & vascularization of cornea
- Mouth:angular stomatitis & glossitis

Vit B6 (pyridoxine):
Angular stomatitis, cheilosis, glossitis, sideroblastic anemia

Vit B3 (niacin):
1. Dermatitis: start as erythtomatosis rash similar to sunburn, then
becomes rough, dry, scaly & pigmented
- distribution characteristics:
a. On exposed areas
b. On pressure sites
c. Symmetrical affection
d. Sharply demarcated
2. Diarrhea, dysphagia, glossitis
3. Dementia, peripheral neuropathy, babinski sign, sensory ataxia

Vit A:
- follicular hyperkeratosis, night blindness are early manifestations
- conjunctival dryness, biotic spots are late

Vit E:
- Neurological degeneration
- peripheral neuropathy
- suppressed cell mediated immunity
- its deficiency causes pellagra syndrome

50