An Introduction to Geriatric Medicine

Roshan Gunathilake, MD, FRACPAdvanced Trainee

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Clinical CompetenciesClinical Competencies

• Geriatric syndromes and conditions• Diseases more common in older

patients• Psychosocial issues• Disease prevention• Ethical Issues• Cultural aspects of aging

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Geriatric SyndromesGeriatric Syndromes• Dementia, delirium, depression• Gait and mobility impairment• Incontinence• Frailty• Iatrogenic complications

- constipation, pressure ulcers

Bernard Isaacs’ Geriatric Giants: immobility, instability, incontinence and impaired intellect

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Geriatric SyndromesGeriatric Syndromes• Dementia, Depression, Delirium

Check orientation and attention (serial 7’s) Delirium hallmark is inattention Cognitive screen - MMSE, CDT, Mini-Cog, MOCA Ask about depression

• Incontinence Stress, urge, overflow, mixed Stress – small volume; urge – larger volume Check for UTI with incontinence Ditropan can worsen cognition

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Geriatric SyndromesGeriatric Syndromes

• Falls How many “in past 12 months?” What happened – “trip, slip, drop” Neurocardiac symptoms? Injury? Test postural BP, vision, sensation, GAIT (TUG test)

• Osteoporosis Kyphosis on physical exam Dexa scan (femoral neck; L spine) 1000-1500 mg Calcium + 400-800 IU Vit D Treatment: IV zolendronate, SC denosumab

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Geriatric SyndromesGeriatric Syndromes“Iatrogenesis”•Medications

Anticholinergics Narcotics - don’t forget the laxative Cardiovascular drugs Neuroleptics Anticoagulants Polypharmacy, interactions

•Bed Rest (hospitalization) Rapid loss of muscle strength (>80 years: lose 1 ADL in 3-5 d) Remove restraints ASAP

•Interventions

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Common Diseases in ElderlyCommon Diseases in Elderly• Neurologic (Parkinson’s, stroke/TIA)

• Rheumatologic (OA, RA, PMR)

• Genitourinary (BPH, sexual dysfunction)

• Cardiovascular (AF, CAD, CHF, HTN)

• Endocrine (thyroid dis, diabetes, Paget’s)

• Renal impairment

• Infections (pneumonia, UTI)

• Oncologic (colon, breast, prostate, hematologic)

• Psychiatric (depression, psychosis)

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Functional assessment: Ask about….

• ADLs: Basic & Instrumental• Mobility: walking aids, falls• Incontinence• Affect/Mood• Cognition (Memory)

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These items go into the historyThese items go into the history

Either “Social History” or“Functional History”

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Physical ExamPhysical ExamConsider the following:

Mobility – Timed Up and Go test- stand, walk, turn, sit

Cognition – Mini-Cog (3 item recall), AMT or MMSE

Affect – Two question Depression screen

1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?

2. During the past month, have you often been bothered by little interest or pleasure in doing things?

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Timed Up and Go

Community Dwelling Frail Older Adults > 14s associated with high fall risk

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The results go in the Physical The results go in the Physical ExamExam

“Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support”

“Two question depression screen positive”

“Patient only remembered 2 of 3 items on Mini-Cog”

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SynthesisSynthesis

Issues:

Medical, Psychological, Social

Diagnosis:

Rule #1: Avoid the trap of “premature labeling”

e.g.

Problem 1. “Falls” – (list the differential here)

Not Problem 1. “Probable spinal stenosis”

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Develop a Plan of ManagementDevelop a Plan of Management

Rule #2:You can start addressing functional impairments before arriving at a specific diagnosis

Patients appreciate a practical plan

Home safety, mobility aids, social supports

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PreventionPrevention

Learn about primary and secondary prevention Screening that maximizes function and minimizes future impairmente.g. exercise, vaccination, Mammography, FOBT

Keep current about age-associated recommendations for tertiary prevention (“treatment”)

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Social, Ethical, CulturalSocial, Ethical, CulturalLearn about cultural influences on health behaviour

DNR, family involvement

Learn about stressors that affect patients and families

Caregiver burden, finances, family dynamics

Know what resources are out there to help

ACAT, access to homecare services, types of assisted living, community resources

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Social, Ethical, CulturalSocial, Ethical, CulturalAsk the patient (and carers) what THEY WANT TO DO about their problem

“Do not assume your preference is their preference!”

This will avoid unnecessary investigations and interventions