Geriatrics 1 Geriatrics GERIATRICS HEALTH PROBLEMS WALEED A. ALMALIK MD. ASSISSTANT PROF, GERIATRICS...
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Geriatrics 1 Geriatrics GERIATRICS HEALTH PROBLEMS WALEED A. ALMALIK MD. ASSISSTANT PROF , GERIATRICS MEDICINE. KING SAUD BEN ABDULAZIZ UNIVERSITY FOR HEALTH SCINCES (KSAU-HS ). GERIATRICS MEDICINE , KING ABDULAZIZ MEDICAL CITY (KAMC).
Geriatrics 1 Geriatrics GERIATRICS HEALTH PROBLEMS WALEED A. ALMALIK MD. ASSISSTANT PROF, GERIATRICS MEDICINE. KING SAUD BEN ABDULAZIZ UNIVERSITY FOR HEALTH
Geriatrics 1 Geriatrics GERIATRICS HEALTH PROBLEMS WALEED A.
ALMALIK MD. ASSISSTANT PROF, GERIATRICS MEDICINE. KING SAUD BEN
ABDULAZIZ UNIVERSITY FOR HEALTH SCINCES (KSAU-HS ). GERIATRICS
MEDICINE, KING ABDULAZIZ MEDICAL CITY (KAMC).
Slide 2
Geriatrics 2 Life Expectancy Current ageMalesFemales At
birth68.976.6 55 y20.626.6 65 y13.918.3 75 y8.711.6 85 y5.56.9
Slide 3
Geriatrics 3 US Census Data and Projections YearPop. (millions)
Age 65+Age 75+ 1960181 m9.2 %3.1% 1980222 m11.2 %4.2 % 2000260
m12.2 %5.5 % 2020 est.290 m15.5 %5.9%
Slide 4
Geriatrics 4 Key Indicators of Well-Being Health Status The
leading causes of death for older Americans are heart disease,
cancer, and stroke (respectively). Mortality rates for heart
disease and stroke have declined by about a third since 1980.
Mortality rates for cancer have risen slightly over the same period
In 1995, 58% of persons over 70 reported having arthritis, 45%
reported hypertension, and 21% reported heart disease In 1998 4% of
persons 65-69 had moderate to severe memory loss compared to 36% of
persons 85+ 23% of persons 85+ reported severe symptoms of
depression
Slide 5
Geriatrics 5 Key Indicators of Well-Being (Contd) Health Risks
and Behaviors The majority of persons 70+ reported engaging in some
form of social activity during a 2-week period. 2/3 age 70+
reported satisfaction with their level of social activities In
1995, 1/3 of older Americans reported a sedentary lifestyle
Self-reporting re: diet: 21% good, 67% need improvement, 13% poor
Older persons are much less likely to be victims of both violent
and property crime than persons age 12-64
Slide 6
Geriatrics 6 Key Indicators of Well-Being (Contd) Health Care
Older persons of all ages are generally satisfied with their health
care and few report difficulty obtaining health care services In
1996 average annual expenditure on health care: age 65-69: $5,864;
age 85+: $16,465 In 1997, 4% of population 65+ resided in nursing
homes; were women Older persons receiving home care in 1994: 64%
relied exclusively on informal (unpaid) care, 8% received only
formal care and 28% received a combo of informal and formal
care
Slide 7
Geriatrics 7 General Principles of Aging: Old Folks Are
Different Atypical presentation of acute illness Multiple
concurrent problems Non-specific symptoms Hidden illness
Under-reporting Multiple losses condensed into a short time span
Expected physiologic aging changes
Slide 8
Geriatrics 8 Atypical Presentation of Acute Illness Only 40% of
elderly fit the classic one symptom=one disease model Acute
myocardial infarction without chest pain Acute hyperthyroidism
without tachycardia, weight loss, etc. Acute infection without
rising WBC count or typical fever Fatigue as chief presenting
complaint of CHF
Slide 9
Geriatrics 9 Non-Specific Symptoms Confusion Self-neglect
Falling Incontinence Apathy Anorexia/weight loss Dyspnea Fatigue
Taking to bed
Slide 10
Geriatrics 10 Hidden Illness: You Must Ask, They Wont Tell!
Sexual dysfunction Depression Incontinence Musculoskeletal
stiffness Alcoholism Hearing loss Memory loss
Slide 11
Geriatrics 11 Under-Reporting Due To: Belief that symptoms are
due to old age Fear or denial Concern about cost Embarrassment
Mental impairment Concern about ill spouse Previous bad experience
with health care system Fear of institutionalization
Slide 12
Geriatrics 12 Multiple Concurrent Losses Loss of physical
health Loss social contacts: friends/family die Loss of familiar
roles: mother, wife, employed person Loss of financial security:
retirement, widowhood Loss of independence and power Loss of mental
stability
Slide 13
Geriatrics 13 Normal Aging vs. Disease Aging is NOT a disease
Learn to separate pathologic processes from the aging process
Concentrate on how physical problems interfere with the ability of
the person to remain independent (functional in their usual
environment)
Slide 14
Geriatrics 14 Normal Aging vs. Disease (Contd) Normal aging
Crows feet Presbycusis Seborrheic keratoses; loss of skin
elasticity Benign forgetfulness Decreased blood vessel compliance
Increase in % body fat Disease Macular degeneration
Tympano-sclerosis Basal cell CA Dementia Athero-sclerosis
Hypertension Obesity
Slide 15
Geriatrics 15 Laboratory Values that Do Not Change with Aging
Hepatic function (ALT, AST, GGPT, Bilirubin) Coagulation tests
Chemistries: electrolytes, total protein, calcium, phosphorus ABGs:
pH, PaCO2 Hemoglobin, RBC indices, platelet count
Slide 16
Geriatrics 16 Laboratory Values that Do Change with Aging
Decreases: Serum albumin, magnesium, PaO2, T3, T4, Creatinine
clearance, white blood cell count Increases: Alkaline Phosphatase,
uric acid, blood sugar, TSH, BUN/Creatinine
Slide 17
Geriatrics 17 Health Maintenance in the Elderly Recommend
primary and secondary disease prevention screening Review all
medications Control all chronic medical problems Optimize function
Verify the presence of an adequate support system Discuss and
document advanced directives
Slide 18
Geriatrics 18 Primary Preventing the occurrence of disease or
injury Examples: Immunizations, Safety Equipment or Clean water
Secondary Early detection and intervention preferably before the
condition is clinically apparent Screening programs: Breast cancer
screening BP screening Tertiary Minimizing the effects of disease
and disability by surveillance and maintenance aimed and preventing
complications Prevention
Slide 19
Geriatrics 19 Primary and Secondary Preventions BP screening
Influenza, pneumonia, tetanus immunizations Obesity (height and
weight) Smoking cessation Consider ASA to prevent MI/CVA
Cholesterol screening Diabetes Mellitus screening Osteoperosis
screening - females
Slide 20
Geriatrics 20 Cancer Screening Breast Cervical usually not
>65 Colorectal Prostate-discussion Skin (Risk-based)
Hearing/visual impairment screening Cognitive impairment screening
Consider TSH in women Primary and Secondary Preventions
(Contd)
Slide 21
Geriatrics 21 Iatrogenesis: A Definition Any illness that
results from a diagnostic/therapeutic intervention or the omission
of such intervention that is not a natural consequence of the
patients disease
Slide 22
Geriatrics 22 Caring for Hospitalized Elderly 20-36% of older
patients have their hospitalization prolonged by major adverse
events One study compared those under 65 to those over 65:
complication rate was 29% vs. 45% Another study showed hospital
related complications in 40.5% of those > 70, and 8.5% of those
< 70
Slide 23
Geriatrics 23 The Hospital Cascade of Disasters Hospitalization
new environment and new medications acute delirium more new drugs
and/or restraints more agitation; Foley inserted poor oral intake
dehydration IV fluids increased and/or NG tube placed for feeding
We now have the potential for congestive heart failure,
thrombophlebitis, pulmonary embolism, aspiration pneumonia, falls
and fractures, pressure sores, urosepsis, septic shock, etc...
Slide 24
Geriatrics 24 Drugs: Polypharmacy Alterations in drug
disposition and tissue sensitivity Drug-to-drug interactions
Changes in renal/hepatic elimination Medications errors Medication
side effects (expected) The Hospital is a Hazardous Place...
Slide 25
Geriatrics 25 The Hospital is a Hazardous Place... (Contd) Bed
rest and immobility General cardiac and muscle deconditioning
Postural lightheadedness, hypovolemia, hypotension Pressure sores
Constipation/fecal impaction Atelectasis and pneumonia
Thrombophlebitis and thromboembolism Urinary incontinence
Slide 26
Geriatrics 26 Therapeutic and diagnostic procedures Angiography
GI endoscopy and its preparation TUBES: IVs, NGs, Foleys,
restraints, dialysis and transfusions Surgery and anesthesia
Nosocomial Infections Pneumonia, C. difficile, MRSA The Hospital is
a Hazardous Place... (Contd)
Slide 27
Geriatrics 27 The Hospital is a Hazardous Place... (Contd)
Under nutrition Cognitive impairment Social isolation Poor
dentition Impaired thirst perception Limited access to food and
fluids Chronic disease
Slide 28
Geriatrics 28 Keys to Prevention A Checklist to Monitor the
Hospitalized Diagnosis Medications Nutrition Continence Cognition
Emotional status Mobility The Caregiver
Slide 29
Geriatrics 29 Diagnosis Keep accurate medical and surgical
diagnosis lists Prioritize medical therapies, addressing reversible
problems first Clarify the specific medical goals of the
hospitalization Carefully select diagnostics: Is this procedure
necessary and how will it change my management?
Slide 30
Geriatrics 30 Medications Make an accurate list of all
medications on admission, including OTCs and herbals Always
consider adverse drug effects as the cause of new symptoms Monitor
appropriate blood levels (Digoxin, dilantin) Try to control pain
without narcotics first Monitor/review need for medications
daily
Slide 31
Geriatrics 31 Nutrition Avoid long NPO periods if possible
Albumin and total cholesterol signal poor nutritional state Provide
vitamin supplementation Adjust fluid therapy on an individual basis
Ask about nausea/anorexia, food satisfaction daily The hospital is
an excellent place to obtain a professional nutritional
consultation
Slide 32
Geriatrics 32 Maintain mobility and cognitive function to avoid
incontinence Reduce IV fluid rates at night Avoid anti-cholinergic
medications Reassure the patient that new urinary incontinence is
usually temporary Monitor bowel function early and daily to prevent
incontinence, constipation and food refusal Continence
Slide 33
Geriatrics 33 Cognition Premorbid cognitive disorders lead to a
very high incidence of delirium--expect it, prevent it Carefully
monitor fluids and electrolytes Minimize psychoactive medications
Use acetaminophen around the clock to manage fever and/or pain Use
environmental strategies (lights, family sitters during the night)
Address hearing and vision problems
Slide 34
Geriatrics 34 Emotional Status Address anxiety, pain and
insomnia early Depression common: 20-60% of hospitalized elderly;
treat it Frequently update family; hold patient/family conferences
to allay fears and clarify the plan
Slide 35
Geriatrics 35 Mobility Avoid physical restraints including
Foleys Encourage patient range of motion activities and resistive
exercises in bed Expect self-sufficiency Enlist PT/OT therapists
early for those with poor mobility and transfer skills If bed
immobile, inspect for skin pressure areas daily
Slide 36
Geriatrics 36 The Care Giver Is there a competent, willing and
acceptable caregiver? Assess care giver burden/burnout Identify
patients at risk for skilled nursing facility placement Anticipate
post-hospital needs such as medical equipment, oxygen and home care
services
Slide 37
Geriatrics 37 Drug Therapy in the Elderly Prescription drug
expenses make up ~ 7% of total health care spending in elderly 65%
of Americans age 65+ use at least one prescription medication
Elderly (65+) use 30% of Rx drugs and 40% of OTC drugs Elderly with
drug coverage average-18 prescriptions per year Elderly in nursing
homes receive an average of 7 different medications
Slide 38
Geriatrics 38 Pharmacokinetics: Absorption Physiologic change
No significant change in gastric pH; decreased absorptive surface
and splanchnic blood flow; generally preserved gastric emptying
time Clinical significance Little to none
Slide 39
Geriatrics 39 Pharmacokinetics: Distribution Increased body fat
Significance: Fat soluble drugs cross membranes more easily and
spread widely (diazepam) Decreased lean body mass Significance:
Water soluble drugs cross barriers less easily and are largely
confined to lean body tissue (cimetidine, digoxin, ethanol)
Slide 40
Geriatrics 40 Pharmacokinetics: Distribution (Contd) Decreased
serum albumin and lower protein binding Significance: Lower protein
binding in elderly (theophylline, warfarin, cimetidine) Exception:
lidocaine binds primarily to alpha-1-acid-glycoprotein and it shows
higher binding in the elderly
Slide 41
Geriatrics 41 Pharmacokinetics: Hepatic Metabolism Physiologic
change Decreased liver mass and hepatic blood flow Clinical
significance Phase 1 reactions altered (oxidation, reduction,
hydrolysis) Phase 2 reactions (conjugation) not significantly
affected
Slide 42
Geriatrics 42 Pharmacokinetics: Renal Elimination Physiologic
change Creatinine clearance reduced with aging or disease Clinical
significance Dose adjustments required for drugs predominantly
excreted by the kidneys (digoxin, LMWH)
Slide 43
Geriatrics 43 Contributors to Noncompliance in Older Adults
Complex treatment regimens and dosing schedules Medication side
effects Physical disability (dysphagia, arthritis) Cognitive
impairment Poor communication Inadequate understanding of therapy
High cost of medications
Slide 44
Geriatrics 44 Contributors to Polypharmacy Patient Borrowing or
sharing medications Failing to understand instructions Saving
medication for later use Combining Rxs with OTCs and Herbals
Visiting more than one physician Doctor Failing to review the
patients medications Prescribing medications for common and
non-life threatening symptoms Treating multiple symptoms or
illnesses with several drugs
Slide 45
Geriatrics 45 Principles of Appropriate Drug Prescribing Be
alert to the possibility of drug interactions and adverse drug
reactions Consider efficacy, cost (generic vs. brand), and ease of
administration Avoid using multiple drugs with similar actions and
toxicity Do not prescribe drugs longer than necessary; discontinue
if no longer indicated
Slide 46
Geriatrics 46 Principles of Appropriate Drug Prescribing
(Contd) Keep the drug regimen simpleonce or twice daily dosing Be
aware that patients may visit other prescibers Initiate therapy
with the lowest recommended dose and increase slowly (Start low, go
slow) Justify the use of each drugwhat is the active problem you
are treating?? Understand the pharmacokinetics and pharmacodynamics
of drugs prescribed
Slide 47
Geriatrics 47 Principles of Appropriate Drug Prescribing
(Contd) Psychotropic drugs (all of them) and cardiovascular drugs
(all of them) cause undesirable side effects. Use them with caution
Review all meds at each patient visit (brown bag test) including
indications and dosing Ask about the use of OTCs and herbals
Involve the patient in decision making and maintain open
communication Encourage the patient to report any new or unusual
symptoms
Slide 48
Geriatrics 48 Goals of Geriatric Assessment Improve diagnostic
accuracy Define functional impairment Limit iatrogenesis Prevent
cascade of disasters Recommend optimal living situation Predict
outcomes Monitor clinical change over time
Slide 49
Geriatrics 49 Data-Gathering Listen to patient but verify with
competent observers May be very time intensive--use two or more
sessions if necessary Chief complaint may be misleading Medication
history is pivotalbrown bag Tailor the review of systems Family
history often unhelpful Always seek data regarding functional
abilities
Slide 50
Geriatrics 50 Review of Systems/(Function) Appetite/weight
change Fatigue Falling/gait/balance Sleep Depression Hearing/visual
loss Alcohol use Joint pain, stiffness, ROM Cough/Dyspnea
Constipation/laxativ e use or abuse Incontinence Frequency/Nocturia
Memory loss/confusion Headache Transient weakness or visual
symptoms (TIAs)
Slide 51
Geriatrics 51 Areas of Assessment Functional assessment
Mobility, gait and balance Sensory and Language impairments
Continence Nutrition Cognitive/Behavior problems Depression
Caregivers See Appendix A at End of Chapter
Slide 52
Geriatrics 52 Functional Assessment Activities of Daily Living
(ADL): Feeding, dressing, ambulating, toileting, bathing, transfer,
continence, grooming, communication Instrumental ADL (IADL):
Cooking, cleaning, shopping, meal prep, telephone use, laundry,
managing money, managing medications, ability to travel
Slide 53
Slide 54
Geriatrics 54 Mobility, Gait and Balance Get up and go test:
rise from a sitting position with arms crossed, walk in a straight
line for 15-20 feet, turn, return to chair and sit down Maintain
standing balance when receiving a slight sternal nudge Bend down
and reach as if to pick up an object Shoulder/hand function Feet:
structural problems, neuropathy, proper foot wear
Slide 55
Geriatrics 55 Sensory Impairments Visual testing Read a
sentence from the newspaper Pocket Snellen chart Diabetics need
annual dilated eye exam by ophthalmologist Auditory Testing Assess
hearing during history-taking Whisper words behind the back Finger
Friction: rub your thumb and index finger in front of ear Formal
audiometric evaluation
Slide 56
Geriatrics 56 Continence A hidden disease; you must ask Simple
screening questions Office evaluation often adequate to make a
major difference Incontinence section to follow
Slide 57
Geriatrics 57 Nutrition Assess any patient admitted to the
hospital or nursing home Assess for weight change, anorexia,
chewing or swallowing problems Questions about alcohol a MUST (use
CAGE) Low albumin and total cholesterol may be clues 2-3 day diet
journal may be the most helpful screening tool Establish and record
serial weights (minimum yearly) and heights (minimum Q3Y)
Slide 58
Geriatrics 58 Cognitive Problems Goals of cognitive screening
Detect unsuspected mental impairment Provide baseline for future
encounters Discover those at risk for delirium Provide concrete
data for competency/decision-making opinions Dementia section to
follow
Slide 59
Geriatrics 59 Depression Commonly missed Somatic complaints
often predominate Many, many drugs should be suspected Suicide in
elderly males is high Target your search: recent bereavement,
psychosocial losses, dementia, functional impairment, severe
illness or surgery Geriatric Depression Scale See Appendix B at End
of Chapter
Slide 60
Geriatrics 60 Care Givers Lack of a willing or capable care
giver is a prominent reason for ECF placement Is the care giver
acceptable to the elder? Is the care giver evidencing burn-out? Is
there evidence of elder abuse or neglect? Zarit Burden Interview is
a short instrument that can introduce the topic of caregiver stress
in a non-threatening way
Slide 61
Geriatrics 61 Putting it All Together: the Care Plan List all
problems (physical, social, functional) List the strengths you find
in the present situation and build on them Reduce the list to those
problems that are out of control and/or you can remedy Treat acute
medical problems with appropriate aggressiveness Manage chronic
problemscontrol, not cure Address routine health maintenance Do the
medications relate 1:1 to an active problem?
Slide 62
Geriatrics 62 What functional problems are most amenable to
intervention? Is there evidence of chronic uncontrolled pain? Is
there evidence of dementia or depression? Treat it Are there any
geriatric syndromes to address? Is the living situation
appropriate? Is there evidence of a willing, capable, appropriate
and acceptable care giver? Would any community resources benefit
the situation? The Care Plan (Contd)
Slide 63
Geriatrics 63 Mistreatment of Elders Elder abuse shall mean an
act or omission which results in harm or threatened harm to the
health or welfare of an elderly person. Abuse includes intentional
infliction of physical or mental injury; sexual abuse; or
withholding of necessary food, clothing and medical care to meet
the physical and mental needs of an elderly person by one having
the care, custody or responsibility of an elderly person
Slide 64
Geriatrics 64 Types of Abuse and Neglect Physical abuse:
Intentional infliction of physical discomfort, pain or injury
Hitting, slapping, inappropriate use of restraints, sexual assault
Psychological abuse: Intentional infliction of mental anguish or
provocation of fear of violence or isolation Name-calling, chronic
verbal aggression, intimidation, threats of institutionalization,
withholding security and affection, withholding contact with family
or friends
Slide 65
Geriatrics 65 Types of Abuse and Neglect (Contd) Material
abuse: misappropriation or misuse of funds or possessions Fraud,
theft, extortion/use of undo influence to persuade elderly to
relinquish control, use or ownership of funds or possessions
Neglect: withholding of physical, material, or emotional
necessities of physical and mental health whether intentionally or
unintentionally
Slide 66
Geriatrics 66 Risk Factors for Maltreatment Female, living
alone, over age 75 Poor health/functional status Cognitive
impairment Abuser suffers substance abuse/mental illness Dependence
of abuser on victim (such as shared living arrangements) Elders
needs exceed caregivers abilities Social isolation History of
family violence/antisocial behavior
Slide 67
Geriatrics 67 Presentations Suggesting Abuse Delay between
injury/illness and seeking care Disparity in history from patient
and suspect Implausible or vague explanations provided by either
party Frequent visits to the ER for exacerbations of chronic
disease despite a plan for medical care and apparently adequate
resources
Slide 68
Geriatrics 68 Presentations Suggesting Abuse (Contd) Numerous
injuries at various stages of healing Elder presents with poor
nutrition, hygiene, or misses appointments Presentation of impaired
elder without a caregiver
Slide 69
Geriatrics 69 Abuse/Neglect Indicators No food, or rotten food
in the house Clothes extremely dirty or uncared for Not dressed
appropriately for the weather Utilities cut off Gross accumulation
of garbage, papers and clutter Signs checks over to others; out of
money by second week of the month
Slide 70
Geriatrics 70 Abuse/Neglect Indicators (Contd) Swollen eyes or
ankles, decayed teeth or no teeth Bites, fleas, sores, lacerations
Untreated pressure sores Broken glasses frames or lenses Medication
non-compliance Refusal to accept presence of visitors Unjustified
pride in self-sufficiency Vague health complaints
Slide 71
Geriatrics 71 AMA Proposed Screening Questions Has anyone at
home ever hurt you? Has anyone ever touched you without your
consent? Has anyone ever made you do things you didnt want to do?
Has anyone taken anything that was yours without asking? Has anyone
ever scolded or threatened you?
Slide 72
Geriatrics 72 Have you ever signed any documents that you didnt
understand? Are you afraid of anyone at home? Are you alone a lot?
Has anyone ever failed to help you take care of yourself when you
needed help? AMA Proposed Screening Questions (Contd)
Slide 73
Geriatrics 73 Documentation is Essential Use quotations or
verbatim comments made by the patient in describing an event or
situation Detail descriptions of all injuries, using body charts
and/or color photographs
Slide 74
Geriatrics 74 Management of Confirmed Mistreatment Two pivotal
questions: Does the patient accept or refuse intervention? Does the
patient retain decision-making capacity?
Slide 75
Geriatrics 75 Intervention Currently there is no therapy of
choice Many victims refuse help Victims often deny abuse Most
elderly persons would rather receive inadequate care living with
their family than excellent care in an institution Do not attempt
or initiate individual heroic rescues
Slide 76
Geriatrics 76 Intervention (Contd) Hospitalize if emergency
intervention is required Report incident to Adult Protective
Services Decompress the situation: Adult day care, respite housing,
counseling, support groups Legal aid Home Health Assistance
Slide 77
Geriatrics 77 Medical Care in the Nursing Home Skilled nursing
beds: 1.5-2 million in US 5% of those over 65 live in a NH 45% of
NH residents are over age 85 75% of NH residents are female 60%
have moderate-to-severe dementia 50% admitted to NH die there Cost:
$20-45K per patient per year
Slide 78
Geriatrics 78 Types of NH Residents Short-stayers: 1-6 months
Terminally ill Short term rehabilitation Debilitated post-acute
care hospitalization Long-stayers: 6 months to years Primarily
cognitively impaired Significant impairments of both cognitive and
physical functioning Primarily physically impaired
Slide 79
Geriatrics 79 Factors Precipitating NH Placement Care
requirements exceed the ability of care giver Behaviors due to
dementia: nocturnal wandering, aggressive behavior,etc Bed bound
status requiring total ADL support Bowel and/or bladder
incontinence Recurrent falling Insufficient financial resources to
maintain help at home
Slide 80
Geriatrics 80 Falling: A Geriatric Syndrome 30% of persons 65+
fall at home each year 50% of persons 80+ fall at home each year
66% of fallers will fall again in six months If an elder is
hospitalized due to a fall, only 50% will be alive in a year Falls
are common in the hospitalized, most on the night of admission
Falls result in 250,000 hip fractures per year
Slide 81
Geriatrics 81 Complications of Falls Medical Fractures Subdural
hematoma Sprains, bruises, hematomas, lacerations Psychological FFF
(3F syndrome): Fear of further falling: Decreased confidence
isolation and withdrawal depression reluctance to go outdoors
Slide 82
Geriatrics 82 Complications of Falls (Contd) Social Loss of
independence Risk of nursing home placement Increased
immobilization Further loss of muscle tone and strength
DVT/pulmonary embolism Hypothermia Dehydration Osteoporosis
Pulmonary infections
Slide 83
Geriatrics 83 Medical Risk Factors for Falls Poor vision:
cataracts, glaucoma,macular degeneration CV: postural hypotension,
syncope, arrhythmias, drop attacks Lower extremity dysfunction:
arthritis, weakness, foot problems, peripheral neuropathy Gait and
Balance: CVA, Parkinsons, myelopathy, cerebellar disorders
Slide 84
Geriatrics 84 Types of Falls: Intrinsic vs. Extrinsic Intrinsic
factors: Changes in postural control: Decreased proprioception,
righting reflexes, muscle tone and strength; increased postural
sway Decreased foot swing height, slower gait Decreased depth
perception, clarity, dark adaptation, color sensitivity, visual
fields; Increased sensitivity to glare
Slide 85
Geriatrics 85 Types of Falls (Contd) Extrinsic factors Poor
lighting Objects on the floor (clutter, pets, throw rugs) Unstable
furniture Poor or absent railings Low beds or low toilet seats
Slide 86
Geriatrics 86 Take a Fall History Inquire about the
circumstances of the fall Inquire about injuries or loss of
continence Medication history Are there any risk factors?
Geriatrics 88 Management and Prevention of Falls Treat
immediate medical problems Assess and alter environment as
necessary Attempt to modify any risk factors Consider rehab
(strengthening exercises) Prescribe assistive devices, if necessary
Teach patient how to get up if they do fall Consider a personal
emergency response system (Help, Ive fallen..) Hip protectors
reduce fracture incidence by 50%
Slide 89
Geriatrics 89 Urinary Incontinence: A Geriatric Syndrome The
involuntary loss of urine sufficient in amount or frequency to be a
social or health problem. Urinary incontinence (UI) is a symptom,
not a specific disease
Slide 90
Geriatrics 90 UI: Prevalence 15-30% in community dwelling
elders (only half report so this is an estimate) 30-35% of elderly
in acute care hospitals 50% of those living in nursing homes UI is
never a normal part of aging, despite ubiquitous advertising for
absorbents
Slide 91
Geriatrics 91 UI: Risk Factors Females 2:1 Age Parity Dementia
Polypharmacy UI is independently and positively associated with
poor self-rated health
Slide 92
Geriatrics 92 Basic Bladder Anatomy and Physiology
Functionally, urinary incontinence is due to: Failure to store
urine (because of bladder OR because of the urethra) Failure to
empty urine (because of bladder OR because of the urethra)
Slide 93
Geriatrics 93 Physiology Emptying the bladder involves
stimulation of cholinergic receptors and inhibition of alpha and
beta adrenergic receptors Filling the bladder involves inhibition
of cholinergic receptors and stimulation of adrenergic receptors
Stimulation of alpha adrenergic receptors increases sphincter and
urethral tone, and inhibition decreases it
Geriatrics 95 General Principles of Diagnosing UI Basic history
and physical Urinalysis PVR (post-void residual) determination
Voiding diary Labs: BUN, Cr, Glucose, Ca++ Imaging tests Urodynamic
and endoscopic tests rarely needed to diagnose
Slide 96
Geriatrics 96 Types of UI Stress (Urethral insufficiency)
Overflow Urge (Detrusor instability) Functional Involuntary loss of
urine, usually small amounts with increased intra- abdominal
pressures Leakage of small amts. resulting from mechanical forces
on an overdis- tended bladder Leakage, usually large amts, due to
inability to delay voiding after sensation of fullness Urine loss
due to inability to toilet; impaired cognition or physical
functioning Environmental barriers
Slide 97
Geriatrics 97 Symptoms Stress Functional UrgeOverflow Urine
loss with coughing, sneezing, etc. Loss of small amts of urine. PVR
> 100 cc Sudden urge to urinate. Loss of moderate amts. PVR <
100 cc Loss of small to large amounts PVR minimal
Slide 98
Geriatrics 98 Cystometric Findings StressFunctionalUrgeOverflow
Normal Little or no detrusor contractions despite high bladder
volume Involuntary detrusor contractions that can not be suppressed
Normal
Geriatrics 100 Kegels, weight loss, various surgical
proceduresest rogens, alpha- adrenergic agents; pessaries Primary
Treatments TURP, intermittent cath; timed voidings; trial of
cholinergic drugs; trial of alpha-blocker agents; urologic referral
Bladder training; scheduled toileting; trial of antispas-modics;
Kegel exercises Remove or replace offending drugs; improve patient
mobility; night-time urinal or bed side commode; scheduled
toileting StressFunctionalUrgeOverflow
Slide 101
Geriatrics 101 Delirium An acute confusional state Transient
reduction in the clarity of awareness of the environment
Fluctuating level of consciousness A syndrome, usually referable to
an underlying disease process
Slide 102
Geriatrics 102 Risk Factors for Delirium in Hospitalized Four
strong predictors of delirium Age > 80 Prior cognitive
impairment Fracture on admission Institutionalization prior to
admission Other predictors: Systemic infection, narcotic or
neuroleptic use
Geriatrics 104 Causes of Delirium (Contd) Drugs: ANY, ANYTHING
NEWLY ADDED Anticholinergics (including anticholinergic
antidepressants, and antihistamines) Antibiotics Narcotics
Neuroleptics Anticonvulsants Digoxin & other antiarrhythmics
Alcohol/alcohol withdrawal
Slide 105
Geriatrics 105 Causes of Delirium (Contd) Neurologic causes
Subdural hematoma CVA Cerebral infections Raised intracranial
pressure Miscellaneous Postoperative delirium Sensory deprivation
Recent institutionalization Change of living arrangement
Slide 106
Geriatrics 106 Assessment of Delirium History Prior functional
status: ADLs/IADLs Alcohol use: they wont tell you Prior cognitive
function Time course of changes in consciousness Medications used,
both RX and OTC Physical examination Neurologic examination
(including mental status) Rectal (fecal impaction)
Slide 107
Geriatrics 107 Assessment/Treatment (Contd) Initial labs Chem
profile CBC w. diff UA CXR EKG Pulse ox or ABGs Serum albumin
Consider Ammonia level Blood/urine cultures CT/ MRI of head Drug
levels Serum/urine drug screens (alcohol) Thyroid function PVR
urine CSF exam Folate/B12 levels
Slide 108
Geriatrics 108 Dementia Memory impairment Cognitive impairment
as evidenced by one of the following: aphasia, apraxia, agnosia,
disturbance in executive functioning The cognitive deficit causes
significant impairment in social or occupational functioning Does
not occur exclusively during the course of delirium
Slide 109
Geriatrics 109 Types of Dementia Alzheimers disease (AD)-- >
60% Vascular (multi-infarct) dementia-- 15- 20% Mixed dementia: AD
+ vascular features All others rare: AIDS, Parkinsons, Lewy-body
dementia, Downs syndrome Reversible dementias: depression, thyroid
disease, vitamin deficiency, infections, normal pressure
hydrocephalus
Slide 110
Geriatrics 110 Alzheimers Disease Pathologically deposits of
plaques (amyloid) and neurofibrillary tangles (tau protein) Average
time between diagnosis and death: 10 years Early: personality
changes, irritability, anxiety, depression Late: 50% develop
agitation, delusions, hallucinations, or paranoia
Slide 111
Geriatrics 111 Vascular Dementia Dementia is present Two or
more of the following are present: Focal neurological signs on
physical exam Onset was abrupt, step-wise or stroke- related Brain
imaging shows multiple strokes Diagnosis requires presence of
cardiovascular disease, dementia and a definite temporal
relationship between the two
Slide 112
Geriatrics 112 Lewy Body Dementia Dementia present Two of the
following core features: Fluctuating cognition with pronounced
variation in attention and alertness Recurrent well-formed visual
hallucination Spontaneous motor features of Parkinsonism Supportive
features: repeated falls, syncope, transient LOC, neuroleptic
sensitivity, systematized delusions
Geriatrics 114 Depression vs. Dementia Depression can look like
dementia (pseudodementia) Duration is weeks to months, not months
to years Islands of recent and long term memory loss Language
preserved History of depression usually positive Responds to
questions with I dont know Patients impression of disability:
exaggerated Screen with Yesavage Geriatric Depression Scale
Slide 115
Geriatrics 115 Diagnostic Tools Focused medical and family
history Physical examination and laboratory tests Functional status
examination Mental status examinations Assessment for Depression
Brain scans (CT or MRI) Neuropsychological testing usually not
needed
Slide 116
Geriatrics 116 Common Laboratory Tests: Rule Out Reversible
Causes CBC Comprehensive chemistry profile Thyroid function tests
Vitamin B12 & Folic acid ESR VDRL HIV if high risk
Slide 117
Geriatrics 117 Mental Status Screening Tests Mini Mental Status
Exam (Folstein) Considered the gold standard screen Maximum score
of 30, cut-off of 21-23 for dementia Requires verbal and written
responses No time limit Reproducible over time Specificity goes
down, sensitivity rises with higher educational levels
Slide 118
Geriatrics 118 Mental Status Screening Tests (Contd) CAST:
Cognitive Assessment Screening Test (AFP 54: 1957-62) Written,
self-administered test No time limit Set Test Category fluency:
name 10 colors, towns, fruits, animals 80% of demented score less
than 15/40 Considered a measure of executive,i.e., frontal lobe
functioning
Slide 119
Geriatrics 119 Mental Status Screening Tests (Contd) Clock
Drawing Person is presented a paper with a 4-6 circle drawn and is
asked to write the numbers and draw hands of a clock to show 10
past 11 Use as a qualitative, not quantitative screen Yesavage
Geriatric Depression Screen Previously described
Slide 120
Geriatrics 120 Dementia Management (YES, Dementia is Treatable)
Maximize function and independence Maintain safe and secure
environment Maintain adequate nutrition and hydration Enhance
cognition (medications available) Treat mood and behavior problems
Educate/support care givers Expect regular physician office
visits
Slide 121
Geriatrics 121 Cholinesterase Inhibitors Widespread use and
multiple trials confirm that these drugs offer a plateau in
functional decline and positively influence behavioral
manifestations Cognitive decline is postponed, but these drugs do
not influence neuronal decline All patients in whom AD is
clinically confirmed and categorized as mild to moderate should be
offered a long term therapeutic trial Probably help vascular and
Lewy body dementia too, though not labeled
Slide 122
Geriatrics 122 Cholinesterase Inhibitors (Contd) Donepezil:
(Aricept) HS dosing, 5-10 mg., metabolized by P-450 system
Rivastigmine: (Exelon) 1.5-6 mg BID with meals; available in liquid
form Galantamine: (Reminyl) 4-12 mg BID with food; avoid with
hepatic impairment
Slide 123
Geriatrics 123 Other Non-Traditional Drugs Antioxidants
(Vitamin E) & Ginkgo Biloba extract: benefit supported by a
single clinical trial NSAIDs and estrogen replacement therapy:
benefit supported by epidemiologic evidence but not confirmed by
prospective trials
Slide 124
Geriatrics 124 Behavioral Modifications Create a predictable
schedule: active day, quiet night Maintain a familiar, calm
environment Foster reminiscence: photos, music, objects Keep life
simple; reduce choices Match activities to capabilities and
preferences Avoid overwhelming situations (family reunions) and
challenges (shopping) Learn dementia speak: dont reason or argue
with a demented person
Slide 125
Geriatrics 125 Drug Therapy for Behaviors: The Last Resort
Behavior must present clear danger to self or others Behavior
prevents necessary care (feeding, hygiene, wound care) Discuss
indications in progress notes and with patient advocate Use
time-limited medication trials Antipsychotics, benzodiazepines,mood
stabilizers
Slide 126
Geriatrics 126 End Stage Care Palliative management of medical
problems Focus on quality of life Be firm about aggressive medical
interventionsthese are rarely indicated Institute and follow DNR
instructions