1. Essential Facts in Geriatric Medicine

8/13/2019 1. Essential Facts in Geriatric Medicine

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Essential facts in Geriatric

Medicine

The Role of GeriatricianDr Asso Fariadoon Ali Amin (MRCP)

GIM and Care of Elderly specialist


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Essential Facts in Geriatric Medicine

Main Objectives

Statistics on Elderly

Main features of Geriatric Medicine

Facts about the life of Elderly in the UK and some

developing countries

The implication of ageing on the world

Physiological changes in Elderly.


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Age structure of population

UK 2001 census was 58,789,194 of that 18.7% above 65 Rate of increase of over 65 is by 2.4%

Currently in developed countries 165 million elderly ,

expected to increase to 265 million by 2025

Sweden highest number ,followed by the UK, Italy, Belgium

and France

Elderly before the 17thcentury in the UK ( Church and

charities), after the 17thcentury Poor Law Act, after 19th

century welfare service

By 2063, the number of 60-74 increase by 50% and over 75

by 70%, while 15-44 decline by 8%.

Life expectancy in 2004 was 81 for female and 76 for men

compared to 49 and 45


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Developing Countries

It is a false assumption that elderly people in developing are not a problem

because they are few. The rate of increase in the elderly population will be 15 times of that of the

UK in Colombia, the Philippines and Thailand)

France took 115 years to double their 65+ ( 7-14%) between 1865-1980,

while China takes 2000-2027 to do the same

Life expectancy at age of 65 is similar to the of developing countries

Currently have 50% of the 65+ population , estimated to increase to 75%

in 2020.

Problems with primitive, patchy health care, political instability , financial

problems , and uneven( World Trade Organisations)

Sex Developed

countries (years)

Undeveloped

countries (years)

Women 19 15

Men 16 12


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India and Africa

WHO ( Ageing in India 1999)

Life expectancy increase between 1961-2000 for both male

and female by 3-4 years ( 15.2 for men and 16.4 for women)

60-75% relies on the extended family

State pension is $1.00/month

Commonest cause of death is CHD, 60% hearing impairment,

11 million blind 80% cataract, 9M hypertension, 5M Diabetic,

4M mental health problems, 0.35 M malignancy.

Africa:-Life expectancy is less ( Cause??) , e.g Botswana in

Zimbabwe


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The implication of aging

Healthcare Disabilities and multiple pathology

Demand more need for health assistance and medical care

More chronic diseases More attendance to A&E

Longer stay

More GP and primary care visit.

Social support Residential, Nursing homes and sheltered accommodation

More carers


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The implication of aging

Economy ( Commission on Global Ageing) Housing Transport

Infrastructure and town planning Pension, employment, tax

Ethical dilemmas

Political power of elderly gray lobby


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Active ageing

WHO recommendation for active aging Prevent premature death

Reduce disabilities associated with chronic

diseases Ensure older people remain healthy

Encourage older people to make productive

contribution to the economy

Reduce the number requires costly medical

and care service.


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Factors affecting active ageing

Social factors- education/literacy/human rights/socialsupport/ prevention of violence.

Personal factors- biology/genetics

Health and social services- health promotion anddisease prevention

Physical environment-housing urban/rural

Economic

Behavioural


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Affect of the world changing on the ageing

population

Global Warming and disasters France (2003), Gujarat ( 2001 ), Tsunami ( 2004), Kurdistan (1991)

Global Poverty Loss of Wealth more expenses for heating, housing, food...

Retirement


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Characteristic of Aging in the UK

Gender

Ethnic mix, 12% below the age of 16, 2.5% at age of 65, and only 1%at age of 85.

Geographical distribution- migration to villages, towns, and seaside.

Health status:- 60% of 65+ have multiple pathologies, 37% disabling. Living compassions:- (in 2003) 34% of women and 19% of 65-74

years where living alone. Above 75 60% women and 30% men . Ethnic

minorities less likely to live alone

Institution:- only 4.5% ( Nursing Homes, Residential homes), 95.5%lives at their home including sheltered flats.


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Physiological/psychological changes

with ageing

Skin ( physical) Fine wrinkles,Dryness,Laxity

Campbell de-Morgan, seborrhoeic keratosis, cherryhaemangioma

Greying of hair due to loss of melanin from hair follicle

Brittle slow-grow nails

o Histological Atrophy of epidermis

Reduced melanocytes, Langerhans, Mast cells,

Reduced in function and number of sweat gland

Thickened blood vessels


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with ageing

Gastrointestinal tract Mouth Reduced production of saliva

Impaired muscles of mastication

Tooth loss.

Decrease in taste bud decrease in taste sensation.

Decline in sense of smell.

Enlargement of tongue and atrophic changes in jaw.

Upper GI tract Pharyngeal muscle Oesophageal peristalsis and lower oesophageal sphincter

Achlorydria


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with ageing Small bowel- shortening and broadening of villi

Large Bowel

Atrophy of mucosa

Cell infiltration of lamina propria reduced motility and increase

Hypertrophy of lamina muscularis transit time

Increase in connective tissue

Liverreduced in volume ,blood flow, and fall in liver collagen and

ascorbic acid reduce in hepatic drug metabolism but normalLFT

Gall Bladder- hypertrophy of muscle and elasticity of wall may reduce

Pancreas- Deposition of amyloid , reduce lipase but no change inamylase or bicarbonate, Duct hyperplasia Reduce fat absorption


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with ageing Kidney:- Size and weight of kidney

reduced in number and size of nephrones reduced

reduces in number of glomeruli and more sclerotic glomeruli GFR

Loss of lobulation of glomerular tuft with thickening of membrane

Degenerative changes in tubules

Bladder , more trabeculation and pseudodiverticula, reduce capacity,alteration in vasularity for submucosa ( increase risk of UTI)

Bonethinning trabeculae due to increased osteoclastic activity

Heart

Loss of myocytes in ventricle Increase in interstitial fibrosis and collagen result in LV stiffness

Deposition of amyloid mainly in atria

increase left atrial size

Thickening of endocardium and valve

reduction in pacemaker cella in SA nodes


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with ageing

o Blood vessels:- thickening of smooth muscle in arterial wall lead toperipheral stiffness causing increase in systolic BP and widening of pulse

pressure.

Respiratory

Reduction in no of glandular epithelial cells mucosa secretion

Respiratory muscles

ossification of costal cartilage

Thinning of alveoli small increase in TLC , large increase in RV and fall in FEV1,VC, and

FEV1/VC ratio


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with ageing

Brian:-brain weight, gyri, meninges, nerve cell numbers changes

Hearing:- loss hair and ganglion cells in choclea, decrease averagenumbers of fibres in cochlear nerve. Presbyacusis ( loss of

hearing for high frequencies)

Eyes flatter cornea leading to astigmatism

hardening of lens and iris

floaters in vitreous humour

reduced response from ciliary muscle impaired near vision and eyelid changes in muscle and skin astigmatism

slow response of pupils to light


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with ageing

Body temperature:-

Inability to maintain temperature through thermo genesis.

impaired sweating, and cutaneous vasoconstriction Hypothermia

Impaired perception to low temperature.

Hormonal

Insulin, oestrogen, LH/FSH, GH, Thyroid, PTH

Psychological

Memory, intelligence, personality.


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Specific features of disease

presentation

NAMES

N:- non specific presentation

A:- a typical or uncommon presentationM:-multiple pathologies

E:- Erroneous attribution of symptoms in old age

S:- Single illness leading to catastrophicconsequences.


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Non specific presentation

Described as the Dragon by Dr Trevor Howell, and the giantsof geriatric by professor Bernard Isaac. Recently geriatricians

using Is.

Confusion, incontinence, contracture,bedsores, falls

Confusion, incontinence, immobility, falls

Intellectual failure, immobility, instability,iatrogenic


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Consequences of single pathology

Influenza

Atrial fibrilation

CCF Delirium

Bronchopneumonia

Death

Falls

Death

#

NOFimmob

ility

Bed

sore

Incontinence

Nursing

care


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Pharmacology and Elderly

Drug related illness is a significant problem in the elderly.

5-17% of hospital admissions are caused by adverse reactionto medicine. The risk of adverse reaction to medication

increases with age and the number of drugs prescribed.

Several mechanism or changes may account for this

,including:- Alteration of pharmacokinetic and pharmacodyanamic

Increased sensitivity of diseases tissue to medication

Drug interaction

Compliance In appropriate prescription of medication without consideration for non

medical management, or prescribing medication causing side effect or

interacting with other medication.


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Alteration of pharmacokinetic and

pharmacodyanamic

Renal clearance

Hepatic metabolism

Absorption is un changed

Volume distribution. Fat soluble versus water soluble.

alteration or receptors response


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Compliance

Poor compliance in 40-75% of patients:-

acutely ill patient can take more than prescribed dose thinking it will speed

the process of getting better

Forgetting because of too many medication. 25% of older patient take at

least three medication. Discharged patient can be on as many as 8medication.

Discontinuation happens in as many as 40% of medication usually first

year.

10% can take medication of others and 20% non prescribed medication.


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Clinical Assessment

Making a clinical diagnosis by:- Taking history from patient and others. who?

Examination

General examination and vital signs

CVS, Respiratory, Abdomen, CNS, PNS, Musculoskeletal ands function.

Investigation FBC, U&E, LFT, TFT, Glucose, Lipid profile, Ca/PO4,CXR, ECG, Urinalysis.

Medication review

Cognitive function and consciousness GCS, AMTS, MMSE.

Functional assessment

Social circumstances

Environmental

E i

Documents

1. Essential Facts in Geriatric Medicine