Elderly people in KSA (over 65 years old)

The Elderly Survey (65+ years old) for 2017 AD.

The number of the Saudi elderly (65+ years) is (854281),i.e. (4,19 %) of
the total Saudi population. Out of this number (48.9 %) were male and
(51,1%) were female.
 Chronic diseases and treatment costs:

• The results of the Saudi Elderly Survey (65+ years) by chronic diseases
indicate that:
• Diabetes (28,7%).
• BP (28,5%).
• Arthritis (13,9%).
• Alzheimer (1,2 %).
• Depression (0,7 %).
• Fractures (0,6 %)
• Chronic disease (43,2 % Males , 56,8% Females).
 Geriatric syndrome
conditions that are highly prevalent, multifactorial, and associated with
substantial morbidity and poor outcomes in the elderly
• Dementia, incontinence, delirium, falls, hearing impairment,
visual impairment, sarcopenia, malnutrition, and frailty
• Immobility, gait disturbance, and pressure ulcers
• osteoporosis, failure to thrive, sleep disorder, and functional
dependency 80%.
• Less than 50% self-neglect, anorexia, and emesis.
Geriatric syndromes
• Dementia,
• incontinence,
• delirium,
• falls,
• hearing impairment,
• visual impairment,
• sarcopenia,
• malnutrition,
• frailty,
• immobility,
• gait disturbance,
2. Urinary incontinence
• Involuntary passage of urine. Most cases are female (80%). It has a
prevalence of 11% in those aged greater than 65 years. The
commonest variants include:

• Stress urinary incontinence (50%)

• Urge incontinence (15%)
• Mixed (35%)
Polypharmacy

Effects of polypharmacy
• Adverse drug reactions
• Falls: => 4 drugs
• Confusion
• Non compliance
• Overdose
• Electrolyte disorders
• Reduced quality of life
• How to reduce polypharmacy
1. Determine all medications being taken
2. Identify indication for each medication
3. Identify potential for adverse side effects
4. Eliminate drugs with no therapeutic benefit
5. Recommend drugs with fewer side effects
6. Give drugs with reduced frequency
7. Avoid starting another drug to treat a side effect
8. Simple drug regimes
9. Start at low dose and increase
10. Review drugs regularly, with doctor if needed
11. Encourage patients to keep a list
Delirium
• Common clinical syndrome
• Prevalence on medical wards: 20-30% (1); Prevalence in care homes:
<20%
• Characterised by disturbed consciousness, cognitive function or
perception, which has an acute onset and fluctuating course. It
usually develops over 1 to 2 days
• Delirium is a serious condition that is associated with poor outcomes
• Delirium can be prevented and treated if identified early
Delirium - Types
• Types of delirium

1. Hyperactive : patients may be restless, agitated or aggressive

2. Hypoactive : patients may become withdrawn, quiet and sleepy

Delirium –Risk Factors
• Age 65 years or older
• Cognitive impairment or dementia
• Current hip fracture
• Severe illness (a clinical condition that is deteriorating or is at risk of
deterioration)
Use the Confusion Assessment Method (CAM) or 4-AT

Feature
1. Acute onset and fluctuating course
2. Inattention
3. Disorganised thinking
4. Altered level of consciousness
Confusion Assessment Method (Positive if 1 and
2 and either 3 and 4 are present)
Ask the following questions:
 Is there evidence of an acute change in
mental status from the patients baseline?
 Does the (abnormal) behaviour fluctuate
during the day, that is, tend to come and go,
or increase or decrease in severity?
Does the patient have difficulty focusing
attention, for example being easily distracted or
having difficulty keeping track of what is being
said?
Does the patient tend to have irrelevant
conversation or change topics rapidly?
Rated as:
 Alert (normal)
 Vigilant (hyperalert)
 Lethargic (drowsy, easily aroused)
 Stupor (difficult to arouse)
 Coma (unarousable)
Delirium Causes
D rugs( anticholinergics) sedatives, opioids

E lectrolytes

L ack of drugs (ETOH w/d, Benzo w/d)

I nfection

R estraints; reduced sensory input

I ntracranial
U rinary retention, faecal impaction
M etabolic (decreased O2, uremia, ammonia, thyroid)
Comparison Delirium &Dementia

Feature Delirium Dementia

Onset Acute, fluctuating: days to Progressive: months to years
weeks

Consciousness Impaired Not impaired

Attention Distractable Relatively normal

Thinking Disorganised, delusional Paucity of thought

Hallucinations Visual hallucinations Occur at later stages of disease

Non pharmacological interventions
•
Assess for dehydration and constipation
• Assess hypoxia
• Treat infection
• Avoid cathetrisation
• Encourage mobility- mobilize soon after surgery; active movements if unable to mobilize
• Treat pain
• Medication review
• Nutrition review
• Treat sensory impairment: hearing and vision impairment
• Promote good sleep patterns
Dementia
Diagnosis Features
Vascular dementia •Recent cerebrovascular event
•Step wise decline
•Focal neurological signs

Lewy body dementia Extrapyramidal signs, falls, fluctuating

cognition, hallucinations, executive
function worse than memory

Fronto-temporal dementia personality changes: impulsivity,

disinhibition, self-neglect, socially
inappropriate

Normal pressure hydrocephalus Disturbed gait, incontinence

Jakob-Creutzfeld rapid progression, myoclonus
SARCOPENIA
• A geriatric syndrome
• Presence of low skeletal muscle mass and low muscle function
(strength or performance) with advancing age leading to disability,
poor quality of life and death (1)
• Prevalence of 5-13% of older adults aged 60-70 years and 11 to 50%
in people >80 years (6)
• All patients with sarcopenia are not frail; though sarcopenia can lead
to frailty
Sarcopenia

• Diagnostic criteria of 1 and 2 or 3

1. Low muscle mass (< 2 SD of the mean of the younger cohort)

• 2. Low muscle strength (reduced grip strength)

• 3. Low physical performance (Gait speed less than 0.8m/s)

MEASURMENT

• Muscle mass- CT/MRI gold standard in research

• Muscle strength: hand grip-grip strength is a good simple measure of muscle

strength, and it correlates with leg strength

• Performance: short physical battery test; gait speed; timed get up and go test
Sarcopenia :
Staging

• Presarcopenia: low muscle mass without impact on muscle strength

or physical performance
• Sarcopenia: low muscle mass, plus low muscle strength OR low
physical performance
• Severe sarcopenia: low muscle mass, low muscle strength AND low
physical performance
Management

• Moderate weight bearing exercise prevents the development of

sarcopenia
• Progressive resistance training 2-3 times per week by older people,
has been shown to improve gait speed, timed get-up-and-go, climbing
stairs, and overall muscle strength
• Protein intake at 0.8 g/kg/day is also beneficial
 FRAILTY
DEFINITION:

Age-associated decline in physiological and functional reserve leading to

increased vulnerability to everyday or acute stressors such as infection or
surgery

Rockwood et al 'multidimensional syndrome of loss of reserves (energy,

physical ability, cognition, health) that gives rise to vulnerability'
Clinical frailty scale
Score Frailty Description
1 Very fit People who are robust, active, energetic and
motivated. These people commonly exercise
regularly. They are among the fittest for their
age
2 Well People who have no active disease symptoms
but are less fit than category 1. Often, they
exercise or are very active occasionally, e.g.
seasonally
3 Managing well People whose medical problems are well
controlled, but are not regularly active beyond
routine walking
4 Vulnerable While not dependent on others for daily help,
often symptoms limit activities. A common
complaint is being slowed up, and/or being
tired during the day
5 Mildly frail These people often have more evident
slowing, and need help in high order IADLs
(finances, transportation, heavy housework,
medications). Typically, mild frailty
progressively impairs shopping and walking
outside alone, meal preparation and
housework
6 Moderately frail People need help with all outside activities
and with keeping house. Inside, they
often have problems with stairs and need help
with bathing and might need minimal
assistance (cuing,
standby) with dressing
7 Severely frail Completely dependent for personal care, from
whatever cause (physical or
cognitive). Even so, they seem stable and not
at high risk of dying (within ~ 6 months)
Scoring frailty in people with dementia
• The degree of frailty corresponds to the degree of dementia.

• Common symptoms in mild dementia include forgetting the details of

a recent event, though still remembering the event itself, repeating
the same question/story and social withdrawal.
• In moderate dementia, recent memory is very impaired, even though
they seemingly can remember their past life events well. They can do
personal care with prompting.
• In severe dementia, they cannot do personal care without help.