Geriatric Medicine Lecture Upload

8/10/2019 Geriatric Medicine Lecture Upload

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Gatot Sugiharto, MD,

Internist

Faculty of Medicine,UWKS

Lecture - 2011

INTRODUCTION TO

GERIATRIC MEDICINE


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AGING

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Aging can be defined as a progressive and

generalised impairment of functionresulting in the loss of adaptive responseto stress and increased risk of age relateddiseases.

The overall effect of these alterations is anincrease in the probability of declininghealth and dying and which is also oftenassociated with social, emotional and

financial marginalisation in old age


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DEMOGRAPHICS

85% over age 65 have one chronic illness 60% over age 65 have 2 or more chronic

illnesses

17% age 65-74 functional limitations

29% age 75-84 functional limitations


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ISSUES

Understanding basic concepts

Approaching the older patient

Age related physiological & pathological

states Demographic impact on geriatric health care


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BASIC CONCEPTS

Multiple diseases and multiple drugs. Diseases often chronic, progressive with

adverse consequences. Focus on functionalindependence

Prevention is more productive and rewarding Disease profile influenced by socioeconomic

& emotional status

Symptoms may be silent: no pain in MI, no

fever in infection or may be atypical &unrelated. Weak link organ symptoms:confusion, incontinence, faints, falls,depression, heart failure-Geriatric Syndromes

Features like reduced jerks, bacteriuria, IGT


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PHYSIOLOGICAL CHANGES AND

THEIR IMPACT

CHANGE:DECREASE IN

IMPACT: DECREASEIN

Basal metabolicrate

Pulmonary function Renal function

Bone mineral

Gastro-intestinal

function

Sight

Dentition

Taste

Calorie needs

Exercise capacity

Ability to conc/diluteurine

Fracture resistance

Bowel motility

Independence

Eating ability

Appetite


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Physiologic Changes with Aging

Respiratory systemVital capacity decreases by as much

as 50%

Decreased recoil and elasticity of lungtissue

General loss of the muscle tissue

within the walls of the lower airways

Changes can make sudden respiratory

illness life-threatening


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Physiologic Changes

with Aging

Cardiovascular system

Stroke volume declines with age

Hearts pacemaker & conduction system

decline with age

With internal bleeding, elderly have a

diminished ability to increase heart rate and

stroke volume to compensate for poorperfusion

Resistance of blood vessels increases from

a loss of elasticity and generalized

arteriosclerosis


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PRINCIPLES OF GERIATRIC

ASSESSMENTGoal Promote wellness, independence

Focus Function, performance (gait, balance,

transfers)Scope Physical, cognitive, psychologic, social

domains

Approach Multidisciplinary

Efficiency Ability to perform rapid screens to

identify target areas

Success Maintaining or improving quality of life


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APPROACHING THE OLDER

PATIENT

Do not be an ageist

Have patience in history taking

Optimize communication

Make the patient safe & comfortable Get a full medication list

Assess familys cooperation & attitude

Assess care givers stress


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The basic components of the

Comprehensive Geriatric Assessment

(CGA)

1. Functional status ADL (Activity of DailyLiving), IADL (Instrumental Activity of DailyLiving)

2. Comorbidity (number, type and rating ofcomorbid conditions)

3. Cognition (Mini-Mental StatusExamination)

4. Depression (Geriatric Depression Scale)

5. Polypharmacy6. Nutrition (Mini-Nutritional Assessment)

7. Presence of Geriatric Syndromes(dementia, delirium, depression, failure to

thrive, neglect or abuse, osteoporosis,falls, incontinence)


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Functional Evaluation

Instrumental Activities of Daily Living

(IADLs)

Activities of Daily Living

(ADLs)

Executive Functioning

Gait & Balance

TOOLS TO ASSESS FUNCTIONAL


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TOOLS TO ASSESS FUNCTIONAL

STATUS

Activities of Daily Living (ADLs)

Bathing, dressing, transferring,toileting, grooming, feeding, mobility

Instrumental Activities of Daily

Living (IADLs)Using telephone, preparing meals,managing finances, takingmedications, doing laundry, doing

housework, shopping, managingown transportation

Get Up and Go test

Qualitative, timed, assesses gait,

balance, and transfers


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PHYSICAL ASSESSMENT

Complete physical

assessment

includes:

Nutrition

VisionHearing


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VISION

Cataracts, glaucoma, maculardegeneration, and abnormalitiesof accommodation worsen withage

Assess difficulties by askingabout everyday tasks

driving; watching TV; reading

Use performance-based

screening

ask to read from newspaper,magazine

use Snellen chart


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HEARING

Hearing loss is common among olderadults

Impaired hearingdepression, social

withdrawalAssess first for cerumen impaction

Use hand-held audioscope to test for

abnormalityloss of 40 dB tone at 1000 or 2000 Hz in oneor both ears is abnormal

refer for formal audiometry testing


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ASSESS NUTRITIONAL STATUS

Screen for malnutrition

Visual inspection Measure height, weight, body mass index

(BMI)

BMI = weight (kg) / height (m2)

low BMI < 20 kg/m2)

Unintentional weight loss > 10 lbs

Poor nutrition may reflect medical illness,depression, functional losses, financialhardship


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MMSE [Cognitive Domains]

Orientation/Time 5 points

Orientation/Place 5 points

Registration 3 points

Attention/Calculation 5 points

Recall of Three Words 3 points

Language 8 points

Visual Construction 1 point


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MMSE [Scoring / Cutoffs]

Total Number of Correct Answers

24-30 Correct : No Cognitive Imp.

18-23 Correct : Mild Cognitive Imp.

0-17 Correct : Severe Cog. Imp.

Influence by Educational Level

Race / Ethnicity

Socioeconomic Status?


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Clock Drawing Test

Different Versions

4 Point Scale Most Useful

1 Point- Circle 1 Point-Numbers

1 Point-Hands/Arrows

1 Point-Right Time


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Geriatric Depression Scale

Total Number of Questions

Long Version = 30

Short Version = 15

Administered in about 5 Minutes

Count the Missed Questions

Error Cut-Offs

Long Version

< 11 Not Depressed

11-14 Possible Depression

14 Depression

Short Version


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25 3 -


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COMMON GERIATRIC

DISORDERS

CVS: hypertension, IHD, heart failure, PVD,syncope

Resp: pneumonia, tuberculosis, asthma,

COPD

CNS: stroke, dementia, meningitis,

encephalopathy

Endo: diabetes, thyroid, sexual, metabolic

diseases Musculoskeletal: osteoporosis, OA, RA, falls,

fractur

GIT: dyspepsia, constipation, NSAID gastrop,

GERD


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Common Clinical Problems in

Geriatrics are Syndromes:

Impotence

Incontinence

Incoherence

Irritable

bowels

Insomnia

Isolation

Immune

deficiency

Immobility Instability

Intellectual

impairment Infection

Impairments

Inanition

Iatrogenesis

Illiteracy


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UNCLASSIFIED SYMPTOMS IN OLD AGE

Weakness

Fatigue

Anorexia

Constipation

Altered taste

Breathlessness

Low muscle strength

Body aches

Confusion

Insomnia

ImpotenceFaints/ Falls


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3 Ds of Geriatrics

Dementia, Delirium, and Depression These common disorders can look alike.

GAI often helps uncover or differentiate them.

All are associated with elder mistreatment.

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Delirium

1. Acute change in mental status and2. Inattention

3. Disorganized thinking or

4. Altered level of consciousness

It is a geriatric emergency.

Inouye et al. Ann Int Med, 1993


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Differential Diagnosis

Always consider dementia and depression

as competing diagnoses.

Other: post-ictal state, psychiatric disorders,

nonconvulsive epilepsy.

Three types:

Organic (medical)

Post-operative

Terminal restlessness

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Etiology


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Dementia vs. Delirium


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Depression

Treatable in 75% of cases.

Untreated cases associated with 15%mortality.

Suicide rate in elderly is double the rate for all

other age groups. Workup is identical for that of dementia.

Dementia and depression often coexist.

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Geriatric Medicine Lecture Upload