Geriatrics lectures

2019
By
Staff members of Geriatrics Unit
Alexandria University

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 Drug prescribing for the geriatric patient
Prof. Dr. Suzan Abou-Raya
Drug prescribing for older adults is complicated by a variety of factors.
Physiologic changes as patients get older result in alterations in drug
metabolism and susceptibility to adverse event. The presence of multiple
chronic conditions and multiple medications leads to potentially complex
drug-drug and drug-disease interactions, as well as the need to balance
multiple competing recommendations.
Changes in cognitive function, manual dexterity, and social supports
complicate adherence to medications, and heterogenous goals of care require
special attention. Atypical presentation and increase in adverse drug reactions
also present challenges in drug prescribing in the elderly.
Drug metabolism and physiologic effects in older adults
Pharmacokinetics
Pharmacokinetics refer to how the body handles a drug from the time it is
ingested to the time it is excreted. This includes the processes of absorption,
distribution, metabolism, and elimination. While each of these processes can
vary with age, they are typically more influenced by genetic factors and by an
individual’s diseases, environmental, and other medications.
For most older patients, changes in renal function have the greatest impact on
pharmacokinetics.
Absorption
Absorption of the drug is impacted by the size of absorptive surface, gastric
pH, splanchnic blood flow, gastrointestinal tract motility. Most of these are
relatively unaffected by age but can be substantially affected by certain
diseases and medications.

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Some medications, including vitamin B12, calcium, and iron, have decreased
absorption in older adults as a result of reduced activity of active transport
mechanisms.
Distribution
Older patients have an increased fat to lean body mass ratio, decreased total
body water, and sometimes decreased serum albumin. Drugs that distribute in
fat (eg, diazepam) may thus have a larger volume of distribution. Hydrophobic
medications (eg, digoxin) will have a decreased volume of distribution,
resulting in higher serum levels.
Drugs that bind to serum proteins reach an equilibrium between
bound(inactive) and free(active) drug. Use of two or more drugs that compete
for protein binding (eg, thyroid hormone, digoxin, warfarin, phenytoin) can
result in higher levels of free drug, requiring careful monitoring of drug levels
and effects.
In the case of testosterone, age-associated increase in sex-hormone binding
globulin can result in normal serum levels of total testosterone.
Drug metabolism
The hepatic metabolism of many drugs is reduced, in some case in the order of
30-50%. This appears to be secondary to age related changes in hepatic blood
flow, liver mass and hepatic endothelium rather than ageing changes to drug
metabolizing enzymes or their expression.
Drug excretion
It has been accepted that there is a marked age-related reduction in the
creatinine clearance in older people, even in the presence of a normal serum
creatinine. The Cockcroft Gault equation is often used to determine the
creatinine clearance in older people in order to adjust the maintenance dose of
renally cleared drugs with narrow therapeutic indices such as aminoglycosides,
digoxin and lithium.

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Main Pharmacokinetic Changes
There is an age-related decline in lean body mass and subsequent increase in
body fat (fat can increase to 33% and 50% of body mass in men and women
respectively). Total body water also decreases with age.
These changes result in a decreased volume of distribution (Vd) for
hydrophilic drugs and an increase in Vd for lipophilic drugs. This means that
lipophilic Benzodiazepines will have a longer half-life due to an increased Vd.
On the other hand, the Vd for hydrophilic drugs, such as digoxin is decreased
and results in a higher level given the same amount of drug.
Serum albumin levels tend to decrease with age, leading to higher free levels
of highly protein-bound drugs such as digoxin, Theophylline, warfarin, and
phenytoin.
Alterations in metabolism occur as a result of decreased hepatic mass and
blood flow. Drugs with a first-pass effect in the liver may be effective at lower
doses (e.g., beta blockers, nitrates, calcium channel blockers, and Tricyclic
antidepressants). Cytochrome P450 oxidation declines with aging and drug-
drug interactions involving these enzymes are important to recognize.
Excretion is altered as a result of the change in renal structure and function
which include a loss of renal mass, obliteration of afferent arterioles in the
cortex, increased number of sclerosed glomeruli, reduction in the number of
tubules, interstisial fibrosis, and a decline in renal blood flow and glomerular
filtration rate (GFR).
A decrease in GFR of approximately 10 ml\min\decade occurs after the fourth
decade of life. An increase in serum creatinine may not be noted, because there
is a proportional decrease in lean body mass.
Keep these changes in mind when prescribing medications that are renally
cleared ( e.g., aminoglycosides, acyclovir, amantadine, digoxin, lithium,
atenolol, and vancomycin).

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Pharmacodynamics and aging
Aging is associated with changes in the end-organ responsiveness to drugs at
the receptor or post receptor level. For example, there is decreased sensitivity
of beta-receptors with aging along with a possible decreased clinical response
to beta-blockers and beta-agonists.
Increased sensitivity to drugs such as opiates and warfarin has also been noted.
Adverse Drug Reactions
Adverse drug reactions represent the most common form of iatrogenic illness.
One fourth of hospitalized patients >80 yrs experience an adverse drug
reaction compared to one-tenth of those aged 40-50.
Risk factors for adverse drug reactions include age, polypharmacy, female
gender, lower body weight, hepatic or renal insufficiency, and history of drug
reactions.
Guidelines For Optimal Pharmacotherapy
1. Identify all of the medications the patient is taking. Obtain a complete
drug history. Ask about previous treatments and responses as well as
about other prescribers. Ask about allergies, OTC drugs, nutritional
supplements, alternative medications, alcohol, tobacco, caffeine, and
recreational drugs.
2. Communicate with other consultants and prescribers. Don't assume
patients will—they assume you do!
3. Keep a list of active medications readily available in the chart to review
every visit. Review medications regularly and before prescribing a new
medication. D/C medications that have not had the intended response or
are no longer needed. Monitor the use of OTC drugs.
4. Avoid prescribing before a diagnosis is made. Consider nondrug
therapy. Eliminate drugs for which no diagnosis can be identified.

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5. Use non-pharmacologic approaches whenever possible.
6. Know the actions, adverse effects, and toxicity profiles of the
medications you prescribe. Consider how these might interact or
complement existing drug therapy.
7. Minimize the number of pills taken per day.
8. Choose once daily formulations.
9. Attempt to use one drug to treat two or more conditions.
10. Start chronic drug therapy at a low dose and titrate dose on the basis of
tolerability and response. Use drug levels when available.
11. Attempt to reach a therapeutic dose before switching or adding another
drug.
12. Use combination products cautiously. Establish need for more than one
drug. Titrate individual drugs to therapeutic doses and switch to
combinations if appropriate.
13. Encourage the use of a pillbox to avoid confusion.
14. Avoid medications with common side effects.
15. Avoid using one drug to treat the adverse events caused by another.
16. Avoid using drugs from the same class or with similar actions (eg,
alprazolam and zolpidem).
17. Keep a current estimation of renal function.
18. Inquire about side effects from prescriptions regularly.
19. Avoid using one drug to treat the adverse events caused by another.
20. Identify financial barrier to compliance.
21. Educate patient and/or caregiver about each medication. Include the
regimen, the therapeutic goal, the cost, and potential adverse effects or
drug interactions. Provide written instructions.

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Criteria for drugs of choice for older adults
 Established efficacy.
 Compatible safety and adverse-event profile.
 Low risk of drug or nutrient interactions.
 Half-life <24 h with no active metabolites.
 Elimination does not change with age or known dose adjustments for
renal or hepatic function.
 Convenient dosing—single or twice daily.
 Strength and dosage forms match recommended doses for older adults.
 Affordable to the patient.
COMMON DRUG -DISEASE INTERACTIONS
 Congestive Heart Failure:
 Disopyramide
 Drugs with high sodium content
 NSAIDs
 Calcium channel blockers
 Beta blockers (non-selective)
 Diabetes Mellitus:
 Beta blockers (if hypoglycemia is a problem)
 Corticosteroids
 COPD and Asthma:
 Beta blockers
 Sedative-Hypnotics
 Opiates
 Peptic ulcer:
 NSAIDs
 ASA

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  Potassium chloride
 Corticosteroids
 Seizures:
 Neuroleptics
 Clotting Disorders:
 ASA
 NSAIDs
 Vitamin E
 Ticlopidine
 Warfarin
 Benign Prostatic Hyperplasia:
 Anticholinergics
 Antihistamines
 GI antispasmodics
 Muscle relaxants
 Narcotics
 Bethanechol
 Incontinence:
 Alpha Blockers
 Constipation:
 Anticholinergics
 Antihistamines
 GI antispasmodics
 Muscle relaxants
 Narcotics
 Bethanechol
 Calcium Channel Blockers
 Iron

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 Arrhythmia:
 Tricyclic antidepressants
 Neuroleptics
 Insomnia:
 Decongestants
 Theophylline
 SSRIs
 Beta agonists
 Cognitive dysfunction:
 Anticholinergics
 Antihistamines
 Antispasmodics
 Tricyclic antidepressants
 Osteoporosis:
 Corticosteroids
 Anticonvulsants

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 Ageing and cognition
Prof. Dr. Suzan Abou-Raya
Magnitude of the problem
 Dementia is a significant and growing health care problem as more of
the population is living long enough to get it.
 5-15% over the age of 65 is demented.
20-50% over 85 is demented.
60-80% of demented have AD.
 Among patients with dementia 50% have AD alone, 15% have had
strokes (vascular dementia), and 15% suffer from both AD and strokes.
The remaining 20% have dementia secondary to Parkinson’s, NPH,
depression, frontotemporal, Lewy body dementia etc.
Definitions
• Dementia = a progressive, global decline in cognitive and behavioral
functioning that interferes with daily living activities and social
relationships ―Brain Failure‖.
• Senile Dementia = an outdated term once used to refer to any form of
dementia that occurred in older people.
• Presenile Dementia
• Age-associated memory impairment = A decline in short-term
memory that sometimes accompanies aging- ―benign senescent
forgetfulness‖.
• Alzheimer’s Disease = an age-related disease(primary degenerative
brain disease) commonest cause of dementia among older people
marked by progressive irreversible declines in memory, performance of
routine tasks, language and communication skills, abstract thinking and
the ability to learn and carry out calculations.

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 • Dementia of the Alzheimer’s Type (DAT)
• Non-Alzheimer’s Dementias
• Pseudo dementia
Alzheimer’s Disease
Risk Factors
• Old age
• Positive family history / Genetic - ApoE4 + AD
• Female gender
• Rural populations
• Level of education
• Environmental factors-Aluminum, zinc, viruses and prions
• Diet + nutritional factors(thiamine, fatty acids).
• Head injury
• Down’s Syndrome
Pathophysiology
• AD is characterized by the development of senile plaques and
neurofibrillary tangles, which are associated with neuronal destruction,
particularly in cholinergic neurons.
• Apoptosis is recognized increasingly due to one of the following
mechanisms: oxidative stress, mitochondrial defects or deficiency of
survival factors.
• Alzheimer’s disease is associated with the progressive accumulation of
beta-amyloid which leads to accumulation of free radicals which
stimulate apoptosis.
II. Recognition
How important is early detection and diagnosis of AD?

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Early warning signs include:
• Gradual loss of short-term memory
• Mood or personality changes
• Problems finding or speaking the right word
• Inability to recognize objects
• Forgetting how to use simple, ordinary things, such as a pencil
• Forgetting to turn off the stove, close windows and lock doors
III. Evaluation
1. History (family, friends)-degree of change in ADL and in personal behavior
2. Physical examination
3. Cognitive assessment-attention, memory, executive function, language,
visuospatial
4. Laboratory tests
5. Imaging studies
6.‖Gold standard‖ and special tests
Delirium Dementia
 Rapid onset  insidious onset
 Primary defect in attention  Primary defect in short term
memory, Attention often normal
 Fluctuates during the course of a day  Does not fluctuate during day
(Dementia with Lewy bodies does!)
 Visual hallucinations common  Visual hallucinations less common
 Often cannot attend to MMSE or  Can attend to MMSE or clock draw,
clock draw but cannot perform well
 Psychomotor activity varied
 Triggering factor!
 Reversible

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IV. Management
A. Medical
1. Prevention
2. Reversal (intoxication, depression, cerebral lesions)
3. Stabilization/ slowing of progression:-
a. Acetyl cholinesterase inhibitors
b. Anti-inflammatory drugs
c. Estrogens
d. Other drugs
4. Treating behavioral problems
Acetyl cholinesterase Inhibitors used in the Treatment of Alzheimer's
Disease
Drug Pharmacologic actions Dosage
Donepezil Acetyl cholinesterase Start at 5 mg once daily, taken at
(Aricept)5 inhibitor bedtime; after 6 weeks, increase
to 10 mg once daily.
Rivastigmine Acetyl cholinesterase Start at 1.5 mg twice daily, taken
(Exelon)6 inhibitor with food; at 2-week intervals,
Butyrylcholinesterase increase each dose by 1.5 mg, up
inhibitor to a dosage of 6 mg twice daily.
Memantine Glutamate is a chemical in There is evidence that
the brain that acts on overstimulation of these receptors
receptors known as may be bad for brain cells. The
NMDA receptors. medication Memantine, blocks
NMDA receptors

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B. Functional- (―Cueing and scheduling‖), activity
C. Psychosocial
D. Education
E. Care of the family
F. On-going care

DELIRIUM
 An acute disorder of attention and cognitive function
 Is the most frequent complication of hospitalization among the elderly.
 A potentially devastating problem.
Potentially modifiable risk factors:
 Sensory impairment (hearing or vision)
 Immobilization (catheter or restraints)
 Medications (for example, sedative hypnotics, narcotics, anticholinergic
drugs, corticosteroids, polypharmacy, withdrawal of alcohol or other
drugs)
 Acute neurological diseases (for example, acute stroke; usually right
parietal, intracranial hemorrhage, meningitis, encephalitis)
 Intercurrent illness (for example, infections, iatrogenic complications,
severe acute illness, anemia, dehydration, poor nutritional status,
fracture or trauma, HIV infection)
 A variety of metabolic and electrolyte disorders including:
 hypernatremia or hyponatremia,
 hypercalcemia, acid base disorders,
 hypoglycemia and hyperglycemia

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  Thyroid or adrenal disorders
 Surgery
 Environmental (for example, admission to an intensive care unit)
 Pain
 Emotional distress
 Sustained emotional deprivation
Nonmodifiable risk factors:
 Dementia or cognitive impairment.
 Advancing age more than 65 years.
 History of delirium, stroke, neurological disease, fall or gait disorder
 Multiple comorbidities.
 Male sex.
 Chronic renal or hepatic disease, myocardial dysfunction
Treatment
Non-pharmacological:
Correct all the precipitating /triggering factors
Pharmacological:
 Any drug chosen should be given in the lowest dose for the shortest time
possible.
 Neuroleptics are preferred - Haloperidol is the drug of choice.
 Haloperidol causes less side effects :
The recommended starting dose 0.5 to 1 mg of haloperidol orally or
parenterally, repeated every 30 min after the vital signs have been
rechecked until sedation has been achieved. The end point should be an
awake but manageable patient.

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 — Urinary incontinence in Elderly
— Ass. Prof. Dr. Marwa Saad

 Is one of the major problems facing the elderly.

 Continence requires adequate mobility, mentation, motivation and
manual skill.
 So problems outside the bladder often result in geriatric incontinence.
 Causes of urinary incontinence in elderly is either ―transient‖ or
―established‖
A) Transient causes
1. Delirium: Clouded sensorium impedes recognition of both the need to
void and the location of the nearest toilet. Once delirium clears,
incontinence usually resolves.
2. Infection: Urinary tract infection causes or contributes to urgency and
incontinence.
3. Psychologic factors: severe depression with psychomotor retardation
may impede the ability or motivation to reach a toilet.
4. Excess urine output: may overwhelm the ability of an older person to
reach the toilet in addition to diuretics, common causes include excess
fluid intake, metabolic abnormalities e.g.; hyperglycemia,
hypercalcemia, diabetes insipidus associated with peripheral edema like
in heart failure, venous insufficiency, malnutrition, cirrhosis and use of
calcium channels blockers or N.SAIDs.
5. Restricted mobility.
6. Atrophic urethritis and vaginitis: Because it usually coexists with
atrophic vaginitis. The latter can be diagnosed by presence of vaginal

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 mucosal telengiectasia, petechiae, erosions erythema or friability.
Urethral inflammation may contribute to incontinence in women and
can be improved by trial of topical or oral estrogen.
7. Stool impaction: Commonly causes urinary incontinence in
hospitalized or immobile patients. The mechanism is still unknown.
Clinical clue to its presence is the onset of both urinary and fecal
incontinence. Disimpaction restores both fecal and urinary incontinence.
Drugs; Drugs are of the most common causes of transient incontinence
including: -
Drug Example Effect
Sedative/hypnotics Diazepam, Sedation, delirium
flurazepam
Alcohol Polyuria, frequency, urgency,
sedation, delirium and immobility
Anticholenergics Sedating anti- Overflow incontinence
histamines
Anti-psychotics Haloperidol Anticholenergic action, sedation,
rigidity, immobility
Tricyclic Anticholenergic action + sedation
antidepressant &
Antiparkinsonism
Narcotic Analgesic Sedation, delirium, urine retention
α- adrenergic prazosin Urethral relaxation may precipitate
blockers stress incontinence, in women
α- adrenergic Nasal decongestant Urine retention in men
agonists

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 Drug Example Effect
Calcium channel Urine retention, nocturnal diuresis due
blockers to fluid retention
Potent diuretics Furosemide, Polyuria, frequency, urgency
bumetanide
Angiotensin lisinopril Drug induced cough can precipitate
converting Enzyme stress incontinence in women and in
inhibitors some men with previous
prostatectomy
Thiozolidendione Nocturnal diuresis due to fluid
retention
Vincristine Urinary retention

Selective inhibitor Rofecoxib, Nocturnal diuresis due to fluid

of cyclooxygenase 2 celecoxib retention

Treatment of transient cause is treatment of the cause

B) Established causes
1. Detrusor over activity (Urge incontinence):
 The term refers to uninhibited bladder contractions that cause leakage.
 It is the most common cause of established geriatric incontinence,
accounting for ⅔ of cases and is usually idiopathic.
 In women, they complain of urinary leakage after the onset of an intense
urge to urinate that cannot be expected. In men symptoms are similar but
detrusor over activity commonly coexists with urethral obstruction due to
benign prostatic hyperplasic.

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  Detrusor over activity may be due to bladder stones or tumors, so urge
incontinence especially if accompanied by perineal or suprapubic
discomfort or sterile hematuria should be investigated with cyctoscopy
and cytologic examination of a urine specimen.
Treatment:
1. Behavioral therapy; patients must void every 1-2 hours while awake;
when continence is restored, the intervals is increased by 30 minutes
until it reaches 4-5 hours, most of continent patients at day are also
continent at night.
If this is impossible patient should be asked if they need to void at
suitable intervals
2. Pelvic floor exercises; can be added to behavioral approaches; is helpful
in training patient with intact cognitive functions and well-motivated.
If the above is insufficient, drug therapy to relax the Detrusor muscle
should be attempted.
3. Drugs:
 Oxybutinin (2.5-5 mg) 3 or 4 times daily, also (long acting Oxybutinin
5-15 mg daily) or
 Tolterodine 1-2 mg twice daily may reduce episodes of incontinence.
In refractory cases if intermittent catheterization is possible, the physician
may intend to induce urine retention with bladder relaxant then to empty
the bladder 3-4 times daily.
If all measures fail, external collection device or protective pad or
undergarment may be required.
2. Urethral incompetence (Stress incontinence):
 Is characterized by instantaneous leakage of urine in response to a stress
maneuver.

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  It is the second most common cause of established urinary incontinence
in older women.
 It commonly coexists with Detrusor over activity.
 Urine loss occurs with laughing, coughing, or lifting heavy objects. The
leakage is worse or occurs only during day unless another abnormality
coexists as Detrusor over activity.
Diagnosis: it is diagnosed by stand up & cough test:
Patients must relax her perineum and cough vigorously a single cough, while
standing with a full bladder. Instantaneous leakage indicates stress
incontinence if retention with overflow has been excluded by sonography
―post voiding residual determination‖. A delay of several seconds or persistent
leakage suggests that the problem is caused by urinary bladder contraction
induced by coughing.
Treatment:
 Surgery is the last method but it is the most effective treatment leading to
cure 75-85% even in older women.
 In mild to moderate cases, pelvic muscle exercise is effective; it can be
combined with electrical stimulation or vaginal cones.
 Pelvic floor exercise can be done by asking the patient to contract the
muscle that is used to stop the flow of urine 30-60 exercises daily for 6
weeks is performed before significant improvement will be noticed.
 Topical or oral estrogen is of low effect unless atrophic vaginitis with
urethral irritation is present.
 Occasionally a pessary may provide some relief for women with vaginal
stenosis.
3. Urethral obstruction:
 Is the second most common cause of established incontinence in older
men due to prostatic enlargement, urethral stricture, bladder neck
contracture or cancer prostate.

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  It is rare in women. It may present as dribbling incontinence after
voiding, urge incontinence due to Detrusor over activity, which usually
coexist with the obstruction or overflow incontinence due to retention.
 Renal US is required to exclude hydronephrosis in men with post
voiding residual urine exceeding 150 ml. For diagnosis urodynamic
confirmation of obstruction is strongly advised.
Treatment:
 Surgical decompression is most effective treatment, especially if it is
associated with retention of urine.
 For the non-operative candidate with urinary retention intermittent or
indwelling catheterization is used.
 In men with prostatic obstruction without retention and who refuses
surgery. He must be treated with α- blocking agent e.g. trazosin 1-10 mg
daily, Prazosin 1-5 mg orally twice daily or tamsulosin 0.4-0.8 mg
daily may relive symptoms.
4. Detrusor under activity: - (Over flow incontinence)
 Is the least common cause of incontinence (<10%)
 Etiology: Idiopathic or due to sacral lower motor nerve dysfunction
 Here incontinence is associated with urinary frequency, nocturia and
frequent leakage of small amounts (capacity of bladder =450 ml + small
amounts that are voided frequently.
 It is differentiated from detrusor over activity by the presence of post
voiding residual volume over 450 ml. Also it differentiates it from
incontinence. In men it needs urodynamic study to differentiate it from
urethral obstruction.
Treatment:
 If bladder is poorly contractile, augmented voiding techniques as double
voiding, suprapubic pressure often prove effective.

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 If patient needs further emptying, intermittent or indwelling catheter is
the only option.
 Antibiotics should be used only for symptomatic infection or as
prophylaxis against recurrent symptomatic infection, i.e. in-patient using
intermittent catheterization. But not used as prophylaxis with an
indwelling catheter.

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 — Falls in the elderly
— Dr. Nahed M E Hamad
ILO’s
The student should know the following by the end of the lecture:
i- complications of falls in the elderly
ii-assess (by history &physical examination) for risk of falling in the elderly
iii-perform timed up & go test
iv-select elderly patients at risk for falling to be referred for specialist care
v-describe effective interventions to reduce falls in the elderly
Definition
Falls are common in older persons. Prior to the 1940s, a fall was considered
an unpredictable event that could not be prevented. In the past 20 years,
however, research studies have shown the incidence and consequences of falls,
revealed their multifactorial etiology, and demonstrated that they can be
prevented by treating the factors that increase an older person’s risk of
falling. Effective treatment requires a multidisciplinary approach. Perhaps
because of this, fall prevention is not widely practiced in clinical settings
outside of specialized geriatric assessment clinics; thus, falls remain an
undertreated public health issue.
Nonsyncopal falls: unintentional events in which a person comes to rest on
the floor or ground that are not caused by loss of consciousness, stroke,
seizure, or overwhelming force- may occur in different settings—e.g the
community, skilled nursing facilities, and hospitals .
Reasons for falling and, therefore, interventions differ by site .
Incidence and consequences (complications)of falls
Approximately 40% of persons age 65 years and over fall in a given year; half
of persons who fall do so more than once. The incidence increases steadily

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after age 60 years. Women are more likely to fall than men. More than half of
all falls in the community happen at home. The rates for falls in skilled nursing
facilities and hospitals are almost three times that for community-dwelling
elders, and are estimated at 1.5 falls per bed per year.
Fall Injuries
Although young children and athletes also have a high incidence of falls, older
persons are at high risk of injury with a fall because of age-related changes
such as slow reaction time, impaired protective responses, and comorbid
diseases such as osteoporosis.
As a result, serious fall injuries, including fractures, lacerations, serious
soft-tissue injuries, and head trauma, occur in 5% to 15% of falls in the
community. Injury rates are higher, from 10% to 25% of falls, in institutional
settings.
Falls are the second leading cause of brain and spinal cord injury in older
adults.
Hip Fractures
Hip fractures are probably the most dreaded fall-related injury, as
approximately half of older persons who sustain a hip fracture cannot
return home or live independently after the fracture, and up to 20% die
within a year of the fracture. The incidence of hip fracture is higher for
women than men.
Death
Falls are the cause of two-thirds of the deaths resulting from injuries in the
elderly.
Other Consequences of Falling
Falls are costly for older persons, both in terms of health care expenses and in
loss of physical function and independence.

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Falls also take a toll on an older person’s independence and quality of life. In
addition to immediate diminution of activity, older persons who have a fall
injury may restrict activity for several months or longer after the injury
because of residual physical impairment or because of fear of falling again.
Older persons are often unable to get up from the ground or floor after a
fall, resulting in long lies with the risk of pneumonia, dehydration, and
rhabdomyolysis.
Fear of falling occurs in at least 50% of those who fall, and leads to restriction
of activities .
Finally, falls and fall injuries are a major determinant of nursing home
placement.
POST FALL SYNDROME :
 The term post fall syndrome was first proposed by Murphy & Isaacs in
1982 when they reported a peculiar reaction of the elderly after they had
had a fall.
 pts expressed great fear of falling when they stood erect, tending to
grab and clutch at objects within their view, and showing
remarkable hesitancy and irregularity in their walking attempts.
So gross were these signs and so obviously related to history of recent falls,
that the term (post – fall syndrome) was proposed to describe the picture.
The post fall syndrome was subdivided into severe – moderate – absent
 where severe syndrome was said to be present when following a fall
(and in the absence of any neurological or orthopedic abnormality which
in itself may adversely influence gait and balance )the patient was
unable to stand or to walk unsupported When asked to do so, the pt
assumed an expression of fear and anxiety clutched to any object within
the field of vision staggered, stumbled or rushed forward and appeared
to be in imminent danger of falling .When these pts were provided

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 support their behaviour was modified and fairly normal pattern of
stepping took place.
 in the moderate degree of the syndrome the pt. presented features of
anxiety, hesitancy and tendency to clutch and grab but with
encouragement was able to stand and walk without support .
 the syndrome was said to be absent when the pt was able to walk safely
without human support and without any tendency to clutch and grab
with or without a walking aid
 ― ptophobia‖ i.e. the phobic reaction to standing or walking was
largely believed to be a consequence of falling resulting from the
psychological trauma of the fall
 Recent research has shown that this fear occurred also in elderly persons
who have Not fallen before !!
 The term Fear of Falling (FOF) is now being used and is defined as an
ongoing concern about falling that ultimately limits the
performance of daily activities. This term ―FOF‖ is now used to
encompass both fallers and Non-fallers .
Other systematic reviews and research studies have come up with the
following conclusions :
 FOF occurs both in fallers and Non-fallers It is Not only a postfall
reaction
 FOF is associated with a decline of physical health and balance
impairments (e.g. osteoarthritis, visual impairments ,general perception
of poor health) … It is Not a result of normal ageing
 FOF is associated with (but Not only due to ) anxiety and depression
 FOF is associated with restricted activity ,sedentary life style and lack
of social interaction and support.

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  FOF may be a more serious problem than falls in older adults.
Etiology of falls and fall injuries
While observation may suggest that one factor predominates, more often it is
the interaction of multiple factors that results in a fall .
Risk Factors for Falling
i) Age-Associated Changes and Chronic Diseases
Studies show that the risk of falling increases with the number of risk factors a
person has. Age greater than 80 years, need for assistance with activities of
daily living, and previous falls, indicate risk for future falls.
While these characteristics cannot be modified, they serve as indicators for
clinicians to pay increased attention to the presence of other, treatable risk
factors for falls. The most important modifiable intrinsic risk factors for falls
are balance, strength, and gait impairments.
ii ) Postural Control
Balance, or postural control, is dependent upon the integration of visual,
vestibular, and proprioceptive input by the central nervous system.
Fall risk has been linked to mediolateral instability; clinically this can be
tested by the ability to stand on one leg which reduces the mediolateral
base of support.
Persons who experience difficulty with standing balance tasks may walk more
slowly and therefore spend a greater part of the gait cycle in more stable
double stance with a wider base of support. A loss of balance may thus be
caused by the speed or magnitude of displacement.
iii)Sensory Input
Vision is affected by age and disease. While decreased visual acuity may be
important, impaired contrast sensitivity (the ability to detect edges) and
depth perception have been found to be the most significant visual risk

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factors for falls. Multifocal lenses, commonly worn by presbyopic older
persons, are problematic because the lower, near-vision lenses impair distance
depth perception in the lower visual field where tripping hazards would be
seen.
Hearing loss & impaired vestibular function can lead to loss of balance
when there is decreased visual input. Proprioceptive dysfunction can result in
loss of balance on uneven ground or in situations, such as walking in the dark,
where there is decreased visual input.
iv) Central Processing
Cognitive impairment caused by dementia may impair judgment and affect
the perception and interpretation of sensory stimuli, resulting in falls even
without the presence of a muscle or gait disorder. Depression may increase
fall risk because of decreased concentration or awareness of potential
environmental hazards.
v) Musculoskeletal Impairments Musculoskeletal impairments increase the
risk of falling. Muscle mass and strength decline with age, disease, and
inactivity. Foot problems, such as calluses, bunions, long nails, or joint
deformity, can affect balance by compensatory strategies as a consequence of
pain or impaired sensory input.
vi) Postural Hypotension
Postural hypotension, may result in instability. A of drop in systolic blood
pressure 20 mmHg or more with change in position from lying to standing
may be medication-related, caused by dehydration, or a result of age-
associated changes or diseases that affect autonomic control of vascular tone.
Postprandial hypotension may be suspected in persons complaining of
dizziness or who fall after getting up from, or soon after, a meal.
vii) Medications
Several studies show that the use of four or more prescription and non-
prescription medications increases the risk of falling. Older persons often

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take more than four medications each day because of multiple chronic
diseases, multiple prescribing physicians and consultants, accumulation of
medications over time, lack of understanding about how to take medications.
Increased risk of falls with anticonvulsants and any psychotropic
medication use, including sedative/ hypnotics, antidepressants, short- or
long-acting benzodiazepines, or neuroleptics. In addition, antiarrhythmic
medications, antihypertensives, digoxin, and diuretics.
Fatigue, altered mental status, somnolence, dizziness, and impaired balance,
listed as side effects of many medications, are also risk factors for falls.
viii) Acute Illness and Hospital Discharge
Acute illness, such as pneumonia or exacerbation of congestive heart failure,
may present as a fall in a frail older person because of altered mental status,
postural hypotension, or weakness. Older persons are also vulnerable after
hospitalization because of the illness that caused their admission,
deconditioning, or medication effects.
The risk of a fall in older persons recently discharged from the hospital
and receiving home care is about fourfold higher than that for others in the
community during the first 2 weeks after discharge.
ix) Challenges to Postural Control
Extrinsic risk factors for falls include environmental hazards that, in
concert with intrinsic factors, increase susceptibility to falls.
More than half of older persons’ falls occur at home, there are checklists
available to use in reviewing home safety.
Environmental factors that were not considered as a risk previously may
become hazardous to an older person with declining balance and mobility
(e.g., transfers in and out of a bathtub).
x) Opportunity to Fall
Additional factors contributing to fall risk are an older person’s risk taking
behaviour and opportunity for a fall. Older persons with impaired balance or

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strength may do activities that are beyond their capabilities—such as
climbing on a chair or counter to reach high cabinets, hanging curtains,
rushing to answer the telephone— because of poor judgment, a desire to
maintain independence, or lack of family or friends to help.
Risk Factors for Fall Injury
i) Osteoporosis
 Injury with a fall is dependent upon factors in addition to those for
falling.
 The presence of osteoporosis increases an older person’s risk of fracture.
ii) Characteristics of the Fall
The force of a fall increases the likelihood of injury, particularly of fracture.
Factors that increase the force of a fall include falling from a greater height,
and landing on a hard surface. Falling sideways or directly onto the hip
increases the likelihood of hip fracture; falling forward onto an outstretched
wrist increases the likelihood of a Colles’ fracture.
SCREENING for FALL RISK
 Determination of risk factors for falls is within the capability of the
primary care provider
 All older persons seen for routine medical care should be screened
for fall risk by asking, at least once a year, if they have fallen.
 They should be observed getting up from a chair and walking across
a room for difficulty with the activity, unsteadiness, or use of an
assistive device(Timed Up and Go Test).
 If there is no history of falls and no problem with balance, mobility, or
gait, then no specific fall risk assessment is necessary .and re-assess
after a year.

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  If there is a history of one or more falls(significant fall :more than
twice in six months ), or if the person has problems with mobility or
gait, then a more detailed fall risk assessment is needed
 However, in all healthy older adults, routine vision and hearing
screening, regular review and reduction, when possible, of
medications, screening for and treatment of osteoporosis, exercise
prescription(bone & muscle mass respond well to exercise even in
the oldest age ranges), and discussion of home safety can aid
prevention
MULTIFACTORIAL ASSESSMENT
 Routinely conducting an in-depth multifactorial risk evaluation and
comprehensive management of identified risks of falls are not
recommended
 This strategy may be beneficial only to selected patients, depending on ,
circumstances of previous falls and comorbidities
 If there is a history of one or more falls, (significant fall :more than
twice in six months ), or if the person has problems with mobility or
gait, then a more detailed fall risk assessment is needed.(Other
potentially high-risk times are during acute illness, after hospital
discharge, or after introduction of new medications.)
 Referral to a geriatric specialist with resources to coordinate
multidisciplinary care may be the most effective way to accomplish fall
risk assessment and treatment.
THE ASSESSMENT SHOULD INCLUDE:
i) History taking & medication review
ii) Physical examination
iii) Physical performance testing
iv) Assessment of home environment

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i) History taking& medication review history should focus on:
a) Physical function
Activities of daily living (ADL):bathing, dressing, toileting, transfer,
continence &feeding Instrumental activities of daily living (IADL):
reading, writing, cooking, shopping, using telephone ,managing money.
b) previous falls & fractures if the patient has fallen details of fall
circumstances; location & time of the day relation to change in posture,
turning of head, cough, urination.. etc. witnesses these data can help
determine specific risk factors for future falls.
c) Acute or chronic medical problems: system review (CVS, chest, CNS,
urinary incontinence...etc.)
d) Use of assistive devices e.g. a cane or a walker
e) medication review
list of ALL medications received, doses & frequency, including over the
counter medications drugs most commonly implicated include:
anticonvulsants, psychotropic medications including sedative/hypnotics,
antidepressants, short- or long-acting benzodiazepines, or neuroleptics. In
addition, antiarrhythmic medications, antihypertensives, digoxin, and diuretics.
The risk of falling increases with increased number of medications taken .
ii)Physical examination& laboratory testing:
Key points in physical examination related to fall risk include:
a- Vital signs: pulse check for arrhythmia
Blood pressure check for postural hypotension(lying then standing
after 3 minutes)
b- Special senses : hearing acuity & visual acuity screening

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 c- Extremities: examine for arthritis ,deformities ,range of motion
Examine feet for deformity ,calluses ,bunions, ulcerations, poorly
fitting or worn-out shoes.
d- Cardiovascular :examine for arrhythmias, carotid bruits, aortic stenosis,
Carotid sinus sensitivity(massage carotid sinus gently for 5 seconds &
observe if it precipitates profound bradycardia )
e- CNS: mental state testing (MMSE= mini mental state exam),cranial
nerves, motor system: muscle weakness, spasticity, resting tremors
(parkinsonism),cerebellar (heel shin test ),sensory system especially
joint position sense.
LABORATORY TESTING:
There is no specific battery of tests for fall assessment, actually lab work up
is determined according to findings ( history and physical examination), and
may include a complete blood count, fasting blood glucose, electrolytes, blood
urea nitrogen (BUN) and creatinine, thyroid stimulating hormone (TSH), B-12
level, and levels of medications such as digoxin and anticonvulsants.
Testing for osteoporosis will determine the need for medication to improve
bone density (to reduce risk of fracture). Radiographs, such as cervical spine
films, and computed tomography or magnetic resonance imaging of the brain,
are only indicated if diseases that would be diagnosed by these tests are
suspected.
iii) Physical performance testing(functioning)
a) Tests of functional gait and balance(standing & sitting balance both
static &dynamic)during usual activities are part of a fall risk
assessment .
b) The Timed Up and Go Test can be done in less than 1 minute in an
office setting and has high sensitivity and specificity in predicting
fall risk.

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Timed UP & GO test :
Position change or ABNORMALITY IN PERFORMANCE THAT
balance maneuver INDICATES FALL RISK
Getting up from a Does not get up with single movement; pushes up with
chair arms or moves forward in chair first; unsteady on first
standing
Sitting down in a Plops in chair; does not land in center of chair
chair
Gait initiation Hesitates; stumbles; grabs object for support
Step height (raising Does not clear floor consistently (scrapes or shuffles);
feet with stepping) raises foot too high (more than 2 in.)
Step continuity After first few steps, does not consistently begin raising
one foot as other foot touches floor
Step symmetry Step length not equal (pathologic side usually has
longer step
length—problem may be in hip, knee, ankle, or
surrounding muscles)
Path deviation Does not walk in straight line; weaves side-to-side
Turning Stops before initiating turn, staggers; sways; grabs
object for support
Gait speed Takes equal to /or more than 14 seconds to stand up
from chair, walk 3 meters, turn, walk back to chair and
sit

USE HARD CHAIR FOR THE TEST ... From Tinetti ME and Ginter SF.
Identifying mobility dysfunctions in elderly patients. JAMA. 259:1190, 1988.

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iv) HOME ENVIRONMENT:
outside
-- Repair uneven pavement
-- Install railings for outdoor steps
-- Use adequate lighting
Inside
 Floors
-- Remove throw rugs
-- Tack down or tape carpet edges
-- Avoid wax
-- Remove clutter and furniture from traffic areas
-- Make sure that telephone can be reached from floor, or have emergency call
device
 Lighting
-- Adjust to decrease glare
-- Have adequate lighting from bedroom to bathroom at night
-- Have lights with switches at top and bottom of stairways
 Stairways
-- Install railings on both sides, extending full length of stairs
-- Make sure railings are secure
-- Mark top and bottom step with reflective tape
 Bathroom
--Install grab bars in bath and next to toilet if mobility impaired
--Use rubber mat in bath or shower
--Install raised toilet seat if needed
 Kitchen
--Keep food, dishes within easy reach
--Do not use cupboards that are too high or too low

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PREVENTING FALLS IN THE ELDERLY
 Approximately one third of community-dwelling adults older than 65
years fall each year..
 Approximately 15% of falls are the result of a single obvious cause,
such as syncope. The rest are multifactorial in origin
 Once the older person’s risk factors for falls have been determined, an
individually tailored, multidisciplinary treatment plan can be put in
place.
Not all interventions to reduce falls in elderly are equally effective
(A) Effective Interventions to Reduce Falls
1) Exercise
- Exercise program of minimum 10 weeks has proven effective in
increasing bone mass & muscle strength even in very old
individuals.
- Progressive exercises under the guidance of a physical therapist can
help the older person improve confidence and reduce fear of falling.
- Exercise interventions include balance, gait, and strength training
- Older persons can also be taught how to get up from the floor in
order to prevent a long lie as a result of a fall.
- Exercise and physical therapy interventions should be
individualised in order to be effective in fall prevention
- group classes are good for general health and well-being of the
elderly but for effective fall prevention : programs must be
tailored individually
- It is recommended that older adults get at least 150 minutes per
week of moderate-intensity as well as muscle-strengthening

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 activities twice per week, also balance training 3 or more days
per week.
(Note: Nice Guidelines it is recommended AGAINST brisk
walking as it increases fall risk in the elderly )
2) Safety modifications and behavioral changes in the home were
effective at reducing falls, particularly when conducted by a
qualified occupational therapist and for people with severe visual
impairments
3) Gradual withdrawal of psychotropic medication and patient-
specific modification of drug prescription by general practitioners
both reduced falls.
(B) Interventions NOT effective in Reducing Falls
a) In general, vitamin D supplementation did not lower fall rate, unless it
was given to elderly to correct vit D deficiency.
The recommended daily allowance for vitamin D is 600 IU for adults 51
to 70 years old and 800 IU for adults older than 70 years
b) Cognitive behavioral interventions and education regarding fall
prevention also did not lower fall rate
c) routinely conducting an in-depth multifactorial risk evaluation and
comprehensive management of identified risks of falls are not
recommended
- This strategy may be beneficial only to selected patients,
depending on , circumstances of previous falls and comorbidities
NOTES:
Other strategies for older persons include
i- wearing an emergency call device in order to ask for help or to have a
telephone within reach in case of a fall.

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ii-Treatment of osteoporosis can reduce the likelihood of a fracture with a
fall.
iii- Hip protectors may be of help to prevent fracture hip in those with high
risk for falling. (Hip protectors consist of foam or plastic pads placed inside
pockets on a stretchy undergarment so that the protectors lie over the greater
trochanter of each hip. The undergarment is designed to be fairly easy to wear
without affecting walking or sitting) .
iv- Note that the main aim in managing falling problem 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. Immobility in itself has its serious complications.
COMPLICATIONS OF A LONG LIE
- pneumonia - rhabdomyolysis
- dehydration - hypothermia
RHABDOMYOLYSIS
Patients who have fallen are at risk of developing rhabdomyolysis secondary
to prolonged muscle compression associated with a long lie.
Long lie is defined as remaining on the ground for greater than one hour
after a fall
The commonest muscle groups affected are the calves and lower back .
Rhabdomyolysis
results in the leakage of potassium, phosphate , myoglobin and creatine kinase
(CK) into the circulation and is a clinical syndrome ranging from isolated
raised CK to acute kidney injury (AKI) , hyperkalemia and death . CK levels
rise in rhabdomyolysis within twelve (12) hours of the onset of muscle injury ,
peak in 1-3 days and decline 3-5 days after the cessation of muscle injury .

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Myoglobulinuria can be screened for in the ED (emergency department) with
simple urine analysis which reads positive for haemoglobin if
myoglobulinuria is present .True myoglobinuria can be identified by formal
lab testing . In any patient who has been found on the floor , the possibility of
rhabdomyolysis should be considered , especially in those with signs of
pressure damage , compartment syndrome , or other musculoskeletal injuries .
The classic triad of ― muscle pain ,weakness , and dark urine ― is seen in less
than 10% of patients. Complications of Rhabdomyolysis include:
1- Acute kidney injury (AKI) : due to myoglobin causing renal tubular
obstruction .
Treatment is prompt aggressive IV rehydration , bladder catheterisation
, and monitoring of urine output aiming for 200-300 ml/hr. In patients
with known heart failure fluid resuscitation must be carefully balanced .
The longer it takes for fluid resuscitation to start the more likely AKI
will develop .In patients whose renal function is Not responding to IV
rehydration a period of renal replacement therapy is needed.
2- Hyperkalemia : due to direct release of potassium into the circulation ,
managing the underlying cause and optimising rehydration are essential
in the management .Emergency treatment with calcium gluconate and
an insulin-dextrose infusion may also be required . Arrhythmias are
more common in patients with cardiac comorbidity .
3- Hypocalcemia : Often asymptomatic , but parenteral calcium
replacement should be administered if there is significant derangement .
Patients with rhabdomyolysis should be admitted for IV rehydration
,monitoring of blood profiles and management of potential complications.
Patients with renal or cardiac comorbidities and frail elderly may require
monitoring for 24-48 hours due to increased risk of life threatening
arrhythmias .

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HYPOTHERMIA
Mild ............ < 35 *C ,
Moderate .... < 32 * C
Severe .......... < 28 * C
HOW TO USE WALKING CANES CORRECTLY
i) proper height : handle of the cane at the level of greater
trochanter
ii) during walking : the cane should be held in the hand opposite to
the side of
the diseased leg
iii) climbing upstairs : Both hands must be supported
patient goes up with the Good leg first
iv) going downstairs : Both hands must be supported
patient goes down with the diseased leg first.

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 Effect of Aging on different Body Systems & Anti-
Aging Measures
Prof. Dr. Noha El-Sabbagh
Senescence & Senility
Aging population has become a global concern. The elderly are expected to
make up close to 20% of the total population by the year 2030.
When the organs are affected only by age , this is called senescence. When in
addition some of the organs are affected by diseases that are precipitated by
being old , this is called senility.
Who are elderly?
The elderly include individuals 65 years of age and older. Aging begins the
day we are born. Aging is highly individualized. There is great variation
among individuals with age . Aging proceeds at different rates in different
people & within different systems of the body.
Characteristics of Geriatric patient
When considering the approach to geriatric patient, it is important to remember
that the changes in patient characteristics with age result in atypical
presentation or altered response to disease. In general, there is decline in
function of many organs more or less reaching the low normal values. Old
people have limited physiologic reserve. When exposed to acute stress, there
will be rapid deterioration of function.
Typical versus Atypical presentation of illness in Older Adults
 Typical presentations: the usual signs and symptoms of illness or disease
 Atypical presentations: Patients with no signs and symptoms or unusual
signs and symptoms / unrelated or even the opposite of what is usually
expected.

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Possible causes of atypical illness presentation in older adults
1. Age-related physiologic changes
2. Age-related loss of physiologic reserve
3. Interactions of chronic conditions with acute illnesses
4. Underreporting of symptoms

Disorder ―Typical‖ presentation ―Atypical‖ presentation

Absence of the usual
Cough, SOB, Production of
Pneumonia symptoms, malaise, anorexia,
Sputum
confusion
Mild or no Chest pain,
Myocardial Severe substernal chest pain,
confusion, weakness,
infarction SOB, nausea
dizziness
Absence of dysuria,
Urinary Tract
Dysuria, frequency, hematuria confusion, incontinence,
Infection
anorexia

Thyrotoxicosis
Rapid bead rate, restlessness, Lethargy, cardiac arrhythmias,
( hyperthyroid
agitation, tremor fatigue, weight loss
emergency )

Diffuse abdominal pain,

Right lower quadrant
Acute confusion, urinary urgency,
abdominal pain, fever,
appendicitis absence of fever or
tachycardia
tachycardia
Temperature normal or below
Fever, tachycardia elevated normal, absence of
Infection
white blood cell count tachycardia, slightly elevated
white blood cell count
Confusion, apathy, absence of
Sad mood, increased sleep subjective feeling of
Depression depression
time, fluctuations in weight

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Aging Theory
No one really knows how people change as they get older. Some theories
claim that aging is caused by accumulated injuries from ultraviolet light, wear
and tear on the body, by products of metabolism, so on. Other theories view
aging as predetermined, genetically-controlled process. Most gerontologists
feel that aging is the cumulative effects of the interaction of many lifelong
influences including heredity, environment, past illness.
Theories of aging
 Genetic theories:
 somatic mutation of genes.
 genetically determined life span.
 cross linkage/loss of important cellular components and DNA.
 Random damage theories:
 accumulation of toxic metabolites and free oxygen radicals.
 reduced physiological capacity and wear-n-tear of cells of vital organs.
 non-enzymatic glycosylation of proteins.
Biologic Theories of aging
1. Theories related to alterations in macromoleculer error in protein synthesis,
DNA synthesis, mutations, transcription or translation.
2. Free radical Theory: Free Radicals are highly reactive atoms or molecules
bearing an unpaired electron and can cause damage to:
 Structural proteins
 Enzymes
 Lipids
3. Organ System Theory - Pace Maker Theory
a) immune system
b) Neuroendocrine system

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4. Genetic Theory: Hayflick and moorhead fibroblasts in tissue culture showed
a finite eplicatve capacity.

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Inflammaging
Inflammaging denotes an upregulation of the inflammatory response that
occurs with age, resulting in a low-grade chronic systemic proinflammatory
state.
It is characterized by raised levels of proinflammatory cytokines IL-1, IL-6,
TNF alpha , all of which have been shown to rise with age, and be involved in
the pathogenesis of most age-associated diseases.

Aging changes in cells.

 Cells become larger & are less able to divide.
 There is increase in pigments fat inside the cell. A fatty brown pigment
called lipofuscin collects in many tissues.

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  Connective tissue become stiff, making organs, blood vessels &
airways more rigid. The exchange of gases, nutrients & wastes become
difficult.
 Many tissues lose mass= atrophy.
Aging changes in body shape.
 Human body is made up of fat ,lean tissue(muscles& organs) bones,
water, as we age the amount & distribution of these materials will
change.
 Fat is increasingly deposited toward the center of the body. The
proportion of body fat increases by as much as 30%.
 Lean body mass decreases.
 Bones lose their minerals, become less dense.
 There is reduction in total body water making old people more liable to
dehydration.
Aging changes in the skin.
 Wrinkles of the skin, graying of hair . The outer layer thins. Large
pigmented spots (age spots) or lentigos may appear. There is reduction
in skin strength & elasticity.
 Blood vessels of the dermis become more fragile, which results in easy
bruising.
 Sebaceous glands produce less oil, making it harder to keep the skin
moist, resulting in dryness & itching.
 The subcutaneous fat layer which provides insulation thins, increasing
the risk of injury & reducing the ability to maintain body temperature.
 Because there is less natural insulation, hypothermia can result when
exposed to cold weather.

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  The sweat glands produce less sweat. This makes harder to keep cool,
with increasing risk for developing heat stroke when exposed to hot
weather.
 The skin changes , thin subcutaneous fat as well as nutritional
deficiencies contribute to pressure ulcers.
Body Temperature
 Body temperature in old people is lower by about 0.2- 0.5 degree
centigrade then adults; due to reduction in basal metabolic rate, atrophy
of skeletal muscles , impairment of the circulation. So a minimal rise of
0.5- 1 degree have a grave significance in old age.
Changes in water & electrolytes
 Total potassium is found to be reduced in old people, due to reduced
lean body mass.
 Total body water declines, this may account for much of weight loss
seen in old. Thirst & thermoregulatory mechanisms are disturbed in
elderly. It is important to encourage old people to drink ample amount
of water to avoid dehydration.
 Total sodium increases with age, there is increased sensitivity to
external sodium in diet.
 Total calcium decreases related to decrease absorption & decrease
vitamin D.
Aging changes in musculoskeletal system
 There is decrease in muscle cross section area and the volume of
contractile tissue resulting in decrease force production. There is
evidence that exercise can have an impact on the size, strength& aerobic
capacity of skeletal muscle in old people.

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  Bone mass decreases as people age, especially in female after
menopause. The trunk becomes shorter as disks lose fluid& become
thinner.
 Joints become stiffer & less flexible.
 Exercise is one of the best ways to slow changes in musculoskeletal
system.
Changes in the respiratory system
 There is reduction and damage of the elastic tissue of the lungs.
 Alveoli become dilated and thin walled.
 Decrease in ciliary transport system leading to decrease in mucous &
foreign materials clearance.
 Decrease gag reflex leading to increased aspiration.
Changes in the digestive system
 Inadequate mastication, absence of teeth, will allow large particles of
food to reach the intestine, resulting in incomplete digestion,
consequently absorption is impaired , greater amount of food will reach
the caecum, giving rise to colonic disturbance.
 Salivary secretions: small in volume and in enzyme content.
 Esophagus: high incidence of diaphragmatic hernia due to atrophy of
connective tissue support. Patulous cardia leads to regurgitation of acid
contents into lower esophagus and heart burn.
 Stomach: basal secretion is reduced in volume and in Hcl.
 Small intestine: shows impaired absorption due to reduction in the
enzymatic activity, reduction in the number of absorptive cells &
reduction in blood supply.
 Colon: There is high incidence of constipation among old , due to
reduced intake of food and fluids, defective mastication & due to

189
 irregular bowel habits. There is high incidence of diverticulosis due to
atrophy and decrease tone of musculature & diminished elasticity of
connective tissue layer of the wall of the colon.
Senescent Liver
 Liver: There is decrease in size & weight of the liver in aging, there is
about 50% reduction in liver blood flow. Functional derangements are
slight: Serum bilirubin & prothrombin activity are within normal value.
Serum transaminases are within normal indicating good cellular
integrity.

 Serum albumin may be reduced in elderly who have decreased mobility

or who suffer from malnutrition.
 Cholesterol saturation of bile increases with age due to enhanced
hepatic secretion of cholesterol and decreased bile acid synthesis, this
explain the increased incidence of cholesterol gall stones.

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  Hepatic glucose output is found to be low in senescent liver due to
decrease in hepatic blood flow & decrease glycogen content.
 Hepatic urea output is reduced after a protein meal due to reduced
liver cell mass in the elderly.
The Pancreas
 There is reduction in volume & enzyme activities due to decrease blood
supply and increase incidence of chronic fibrosing pancreatitis.
Changes in the urinary system
 There is progressive sclerosis of the glomeruli with aging.
 There is atheromatous changes in renal vessels, leading to reduction in
GFR.
 Urinary tract infections are common in the elderly due to impaired
bladder emptying.
 Serum creatinine should not be used as a test for renal function in old
because there is decrease in muscle mass which is the source of serum
creatinine. If serum creatinine is normal we should assume that there is
40% reduction of renal function.
Changes in nervous system
 The intellectual functions are reduced. The speed of learning
decreases, there is gradual loss of memory specially for recent events.
 Psychological disturbances & emotional instability occur.
 Motor system : reduction in muscle power, superficial reflexes may be
absent. Deep reflexes may be absent in 50-70% of normal old. Senile
tremors are present in 15-20% of old.
 Sensory system: decrease vibration sense & hyposthesia.

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  Special senses: reduction in visual acuity, narrowing of visual field,
decrease in lacrymal secretions, decrease lysozymes, decrease blink
reflex.
 There is reduction of hearing , smell and taste sensations making food
less appealing, decrease appetite& weight loss. Sweet &salty tastes are
lost first, followed by bitter & sour.
Changes in immune system
 There is decrease in number of circulating lymphocytes.
 T cell response decrease in elderly which lead to increase susceptibility
to infection & malignancy.
 There is increase production of autoantibodies.
Endocrine System
 Decrease hormone secretion.
 Decrease efficacy of hormones on target tissues.
Good Nutrition
To maintain proper health, certain rules must be respected:
 Adequate water intake to maintain healthy state of tissues, proper
kidney function, digestive secretions & avoid constipation.
 The type food should be nourishing, containing mineral salts, trace
elements & vitamins.
 Total caloric intake better to be reduced to avoid obesity.
 Fat: animal fat should be replaced by vegetable oil.
 Protein: protein intake is important to raise the immune function,
should be reduced if there is impairment in kidney & liver functions.
 Fiber: increase intake of fiber, better from natural source.
 Salt intake should be reduced.

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  Calcium intake should be increased together with vitamin D to help its
absorption.
Anti-Aging Measures
 Maintain ideal body weight.
 Eat breakfast every day.
 Avoid eating excess fat & sugary foods.
 Get regular exercise.
 Avoid stress.
 Get seven to eight hours sleep /day.
 Avoid bad habits like smoking.

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 Cardiovascular Disorders in the Elderly
Prof. Dr. Azza Hassan Mohamed
AGE - related cardiovascular changes
Many important changes occur in the aging heart and help to explain some
common age-associated cardiac disorders
 Loss of pacemaker cells in the sinus node and conduction fibers in the
bundle branches in the aging heart → sinus node dysfunction (the ―sick
sinus syndrome ―) and Atrioventricular (AV) block.
 Amyloid may be a frequent cause of cardiac conduction system disease
→ Arrhythmias and Amyloid heart disease → Restrictive
Cardiomyopathy → heart failure in the elderly.
 Most common arrhythmia seen is atrial fibrillation (⅓ in older
individuals) and is often “lone” atrial fibrillation without a detectable
underlying illness.
 Left ventricular stiffness → impaired diastolic filling which declines
50% between ages 20 and 80 → clinical syndrome of diastolic heart
failure.
 The combination of sensitivity to filling volumes and impaired heart rate
response to stress may explain the syndrome of postural hypotension in
20% of older individuals → Syncope.
 Coronary Atherosclerosis is common → Coronary artery disease as
Angina and Myocardial Infarction in the elderly.
 Heart valves thicken and stiffen, particularly the Mitral and Aortic
(Stenosis) → flow murmurs.
 The Aorta dilates and it’s walls thicken as medial walls calcify; with
this loss of elasticity → secondary increase in systolic blood pressure

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 (systolic BP ↑after age 30 years until the mid-70s, then ↓through the 80s
and 90s).
 The most important principle in the approach to cardio-vascular signs
and symptoms with advancing age is to recognize the narrowed
homeostatic capacity of the elderly.

Coronary Artery Disease (Angina, Acute MI, Acute coronary syndrome)

The incidence of CAD increases with age. Over 50% of all coronary events
and 85% of all deaths from coronary artery disease occur after the age of 65.
*The traditional Risk Factors are:
 Hypertension
 Diabetes

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  Lack of exercise
 Ratio of high total cholesterol to high-density lipoprotein.
 Smoking
 Age
Newer Risk Factors are:
 C-reactive protein
 Lipoprotein a
 Homocysteine
 Microalbuminuria.
How can subclinical cardiovascular disease be measured?
Several measures have been developed to determine subclinical atherosclerotic
disease:
1. Electron-beam computerized tomography measures the amount of
calcification in the coronary arteries.
2. Carotid ultrasound can measure the degree of plaque in the carotid
arteries to predict risk of stroke.
3. Ankle-brachial index (ABI)
(normal ratio is > 0.9 – 0.95)
Angina
Angina is the most common presenting symptoms of coronary artery disease,
occurring in 80% of the elderly.
 The history of classic exertional angina may be difficult to obtain as
the elderly patient who has limited activity and do not develop
symptoms until late in the course of disease.

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 Dyspnea on exertion is a very common manifestation of coronary
disease in the elderly .
Other symptoms include
 Palpitation,
 Weakness,
 Unexplained diaphoresis
 Indigestion
 Neck and shoulder pain.
 Rest Angina (Unstable A) i.e., rapidly progressive angina, can occur
frequently in the elderly.
Signs:
 1- Faint heart sounds.
 2- S4  reduced left ventricular compliance.
 3- Reversed splitting of S2 dt LBBB.
 4- Transient Mitral regurge murmur.
Diagnosis of Angina
 *ECG:
1- Depressed ST segment > 2mm >1 lead.
2-Inverted or flat T-wave.
 Cardiac enzymes  Normal.
 Treadmill
 Thallium Scintigraphy
 24-hour ambulatory monitoring
 Coronary arteriography :remains the definitive test for the diagnosis
coronary artery disease.

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Treatment
a. Correct any factors that may have precipitated coronary artery disease by:
 increased physical activity
 weight management (optimal mass index ≤ 24)
 glycemic control
 blood pressure control
 LDL cholesterol - lowering therapy (statin, fibrates and nicotinic acid)
b. Medical treatment
During attack:
Sublingual NG.
Between attacks:
 Nitrates (Dinitra): SE: orthostatic hypotension, headache, syncope.
 B blockers (contraindicated in vasospastic angina)
SE: Fatigue, depression, bradycardia, heart block, hypotension.
 CCB.
 Anti-platelets : (Plavix)-aspirin.
c. Interventional Therapy:
 PTCA (trans-luminal coronary Angioplasty)
 CABG (in left main vessel disease , 2 or 3 vessels disease)
Myocardial Infarction
How to suspect clinically?
Symptoms:
Pain:
 Retrosternal.

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  Precordial.
 Stabbing, compressing.
 More than 30 min.
 Not relived by Nitroglycerine.
 Associated with fever and tachycardia.
 Radiate to left shoulder, jaw, inner aspect of left arm.
*Signs:
1. Faint heart sounds.
2. S3 & S4 gallop.
3. Reversed splitting of S2.
4. Mitral regurge murmur.
5. Pericardial rub (maybe).
6. Fine basal crepitation.
STEMI/Q-wave
 ST segment elevation.
 Reciprocal ST depression.
 Hyperacute T-wave.
 Q wave.
NSTEMI:
 ST depression.
 Inverted T-wave.
 No pathological Q-wave.

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Cardinal signs of MI
 1- Suggestive pain > 30 min.
 2- ECG.
 3- Increased cardiac enzymes.
 The mortality of (MI) in the elderly is higher than in younger people.
 The presenting symptoms of (MI) can be quite atypical, specially in patients
over age 80
 Dyspnea is very common early manifestation,
 Mental confusion, syncope,
 Gastrointestinal complaints.
 Elderly patient with (MI) have increased incidence of complications
 Many patients have conduction defects on the ECG that may mask the
changes of acute MI, but elevated specific cardiac enzymes confirming that
MI did occur.

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201
Treatment of MI
• Full-dose anticoagulation therapy is often given to patients with anterior
MI because of the high risk of mural thrombus and possible
embolization.
• Tissue plasminogen activator during the first 3 hours of MI has been
shown to be more effective thrombolytic agent with the potential for less
hemorrhagic complication.
• The indication for PTCA or coronary bypass surgery after MI in elderly
patients depend on the severity of symptoms.

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 • The elderly are especially sensitive to the deconditioning effects of bed
rest and require early mobilization .
In acute stage:
• Morphine
• Oxygen
• Nitroglycerine
• Best treatment is primary PCI
• If PCI is contraindicated as in left main vessel disease  CABG
• Medically: as treatment of angina in between attacks.
Heart failure
• It is a common disease in the elderly
• about 6-10% of people older than 65 years old have heart failure.
Precipitating causes of CHF
• Non-compliance.
• Myocardial ischemia.
• Myocardial infarction.
• Brady-or tachyarrhythmias.
• COPD exacerbation.
• Anemia.
• Hyperthyroidism.
What Causes Heart Failure ?
The causes of heart failure must be broken down into systolic or diastolic
dysfunction

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a. Systolic dysfunction: is present when the ejection fraction is less than 40%
(normal ejection fraction: 55-60%)
– coronary artery disease (most common )
– hypertensive heart disease
– valvular heart disease:
• calcific degenerative aortic stenosis
• calcification of the mitral annulus
– cor pulmonale
– myocarditis
– thyroid disease
– Tachy –or bradyarrhythmias
– idiopathic (diagnosis of exclusion )
b. Diastolic heart failure:
• 30-50% of patients with CHF have normal LV systolic function.
• These patients may have comorbid conditions accounting for symptoms.
• Diastolic function often abnormal.
Patients with DHF
• More prevalent with age
• More common in females
• Asymptomatic diastolic dysfunction more common than symptomatic .
Causes of Diastolic Dysfunction
Structural Abnormalities:
- Hypertrophy.
- Fibrosis.
- Constriction.

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Functional Abnormalities:
- Ischemia.
- Calcium overload.
- ATP depletion
 The incidence of diastolic dysfunction is age-related and heart failure
due to diastolic dysfunction rises dramatically with age.
Classic physical findings of congestive heart failure
*Vital signs:
 Tachypnea.
 Cheyne -Stokes Respiration
*Heart:
 S3 Gallop.
 Normal Heart Sounds.
*Neck:
 Jugular venous distention.
 Hepato -jugular reflux.
*Chest
 Bibasilar rales.
 Diffuse bubbling rales of pulmonary edema
 Wheezing (cardiac asthma)
 Signs of pleural effusion (flatness to percussion, decreased to absent
breath sounds)
*Abdomen, back and extremities:
 Large, tender liver

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  Ascites
 Sacral edema
 Peripheral edema
Classic finding of congestive heart failure on chest X-ray
 Increased heart size-cardiothoracic ratio > 0.50.
 Large hila with indistinct margins.
 Prominence of superior pulmonary veins; cephalization of flow.
 Fluid in interlobar fissures.
 Pleural effusion.
 Kerley´s B lines.
 Alveolar edema.
 Peribronchial cuffing.
Treatment of CHF due to systolic dysfunction
 Diet
 Exercise
 Diuretics
 ACE inhibitors and angiotensin II receptor antagonists
 Digoxin
 Vasodilators
 Beta-Blockers
Treatment of CHF due to diastolic dysfunction
 Diet
 Exercise
 Diuretics
 Other Pharmacologic Considerations.

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 Treatment of HFrEF

ESC Guidelines 2016

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ESC Guidelines 2016

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ESC Guidelines 2016

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Tips for drug treatment in the elderly
• Older people may show an exaggerated drop in blood pressure after the
first dose of an ACE inhibitor.
• Check postural blood pressures frequently and BUN/creatinine ratios at
intervals to monitor volume depletion.
• Check serum electrolytes and magnesium, and replace when necessary.
• Digoxin is useful in treating CHF due to systolic dysfunction.
• Many older people will have some reduction in renal function.
Therefore, give maintenance doses of digoxin on the basis of creatinine
clearance.
• Digoxin toxicity can present atypically in the elderly with headache and
other neurological manifestations.

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