GERIATRICS: an Overview Keerti Sharma, MD Assistant Professor of Medicine

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GERIATRICS an OverviewKeerti Sharma,
MDAssistant Professor of Medicine
AGS
THE AMERICAN GERIATRICS SOCIETY Geriatrics Health
Professionals. Leading change. Improving care for
older adults.
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4 important take-home points

• Common diseases can have uncommon presentations
  in the elderly
• Temptation to overtreat should be avoided
• Always start low and go slow when prescribing
  medications
• A new symptom can be a medication side effect

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History

• Develop a symptom
• Perceive a symptom
• Communicate

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REASONS FOR Underreporting(The Iceberg
Phenomenon)

• Fear of hospitalization
• Fear of unpleasant investigations
• Fear of treatment
• Risk of involuntary removal to residential care
• Imagining that symptoms are not amenable to
  treatment
• Low health expectations
• Lack of Information

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GOALS OF CARE

• Focus must remain on keeping the older person
  functional
• If that goal becomes medically infeasible, the
  patients dignity and comfort must then become
  the primary focus

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NORMAL AGING VERSUSPATHOLOGICAL AGING

• Normal aging aging-related changes
• Pathological aging aging-associated changes
• Normal aging
• Involves a great number of biologic processes
• Is characterized by progressive, predictable, and
  inevitable changes that are independent of
  disease

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PHYSIOLOGIC CHANGESWITH AGING
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General principlesOF NORMAL AGING

• Organs in the same person age at different rates
• Determinants of these rates include genetic
  makeup, personal choices, environmental
  exposures, and other factors
• Aging changes are modifiable but inevitable

Slide 8
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Blood Pressure regulation

• Higher risk for orthostatic or postural
  hypotension
• Narrow range within which CNS perfusion
  maintained
• Changes in antihypertensive drugs should be based
  on patients standing blood pressure

Slide 9
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Control of Body Temperature

• Increased susceptibility to both hypothermia and
  hyperthermia

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Volume Regulation

• Predisposition to both volume depletion and
  volume overload
• Decreased thirst
• Decreased ADH response to hypovolemia and renal
  response to ADH
• Greater difficulty in excreting fluid overload
• Results in predisposition to hyponatremia and CHF

Slide 11
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BARRIER DEFENSES

• Skins effectiveness as a barrier is decreased
• Mucous membranes are less effective barriers
• Ciliary clearance slows
• Repair rate of injured skin declines
• Disease affects wound healing

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Physical and Mechanical defenses

• Urine is less acidic
• Prostatic fluid has less antibacterial activity
• Bladder is less completely emptied
• Colonization of the vagina is more likely in
  estrogen-deficient women
• Greater susceptibility to UTI and incontinence

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Immune Response

• Afebrile infection is common
• Humoral antibody-mediated response is decreased
• Antibody response to vaccine is decreased
• Response to tuberculosis skin test decreases

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NERVOUS SYSTEM (1 of 2)

• The weight of the brain decreases
• The area of the cerebral ventricles may increase
  3?4?
• Most prominent loss occurs in the largest neurons
• Cognitive loss is not a part of normal aging

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NERVOUS SYSTEM (2 of 2)

• Changes affect the older persons ability to
  distinguish between different stimuli
• Reduced reaction time, resulting possibly in
  injuries and burns
• Reduced balance
• Greater risk of falls

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Vision

• Iris becomes more rigid
• Lens yellows (due to photooxidation and
  accumulation of insoluble protein)
• Increased sensitivity to glare
• Decreased static acuity and dynamic acuity
• Decline in contrast sensitivity

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Avoid Mosaic floor patterns
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HEARING

• Drier cerumen, leading in greater risk of
  impaction
• Tympanic membrane thickens
• Ossicles undergo degenerative changes
• Risk of high-frequency and low-frequency hearing
  loss

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TASTE AND SMELL

• Olfaction declines
• May lead to decreased enjoyment of food and
  difficulty in sorting the tastes of mixed and
  combined foods
• Gustatory function unchanged

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CARDIOVASCULAR SYSTEM

• Blood vessels increased intimal thickness,
  increased wall thickness, increased smooth muscle
• Leads to increased systolic and pulse pressure
• Heart muscle increased afterload
• Leads to LVH, decreased cardiac output
• Heart valves left sides become sclerotic
• Response to sympathetic stimulation reduced
• Leads to reduction in cardiac output during
  stress (eg, surgery) and increased risk of CHF

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RESPIRATORY SYSTEM

• Decreased effectiveness of cough
• Decline in PO2
• Decreased pulmonary reserve during stress
• Increased frequency of infection, increased
  likelihood of hypoxia

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GASTROINTESTINAL SYSTEM(1 of 2)

• Less effective chewing, even with intact teeth
• Food is kept in the mouth longer and larger
  pieces of food are swallowed
• Swallowing is less coordinated, which increases
  the risk of aspiration

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GASTROINTESTINAL SYSTEM(2 of 2)

• Lactase levels decline and intolerance of dairy
  products is common
• Colon slowed transit and increase in opioid
  receptor
• May predispose the older person to drug-induced
  constipation
• Liver after age 30 there is 1 per year decline
  in liver mass and blood flow every year

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RENAL SYSTEM

• After age 20 GFR decreases 0.5 per year and
  renal blood flow decreases 1 per year
• Serum creatinine is an imperfect marker of renal
  function in the elderly
• Increased likelihood of adverse outcome from
  drugs with narrow therapeutic margins (eg,
  digoxin, aminoglycosides)

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MUSCULAR SYSTEM (1 of 2)

• Age-related decrease in muscle mass and quality
  (sarcopenia)

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MUSCULAR SYSTEM (2 of 2)

• Lower-extremity strength is lost at a faster rate
  than upper-extremity strength
• Water content decreases in tendons and ligaments,
  and stiffness increases

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Endocrine System

• Slight increase in fasting glucose, not
  clinically significant
• Thyroid hormone levels unchanged
• Vitamin D levels decline

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ANATOMY

• Loss of height 5-cm decrease by age 75 due to
  increased hip and knee flexion, decreased
  vertebral body height, vertebral disc compaction,
  and flattening of foot arch
• Fat compartment expands with age
• Total body weight unchanged because of decrease
  in lean body mass

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COAGULATION

• No change in the absolute number of RBC, WBC,
  platelets
• Chronic low-grade activation of clotting pathways
• Doubling of d-dimer
• ESR rate increases with age
• Women (age 10) / 2
• Men age / 2

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ARTERIAL BLOOD GASES

• Arterial pH and PCO2 do not change with age
• Arterial oxygen content and PO2 decline (3 mm Hg
  per decade)
• 100 ? (age / 3)

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Serum Chemistry

• Electrolytes unchanged
• Creatinine unchanged
• Minor decline in total protein and albumin
• Uric acid and alkaline phosphatase increase
  slightly

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CHANGES IN THEPhysical Examination
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POSSIBLE EXPLANATIONS

• Multiple comorbidities
• Age-related physiological changes may alter
  perception to stimulus
• Cognitive impairment may prevent patient from
  providing an accurate history

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GASTROINTESTINAL DISEASES

• Achalasia lower incidence of chest pain
• Respond equally well to pneumatic dilation

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INTRA-ABDOMINAL INFECTIONS

• Less likely to have nausea, vomiting or fever
• More likely to be hypothermic and neutropenic
• More likely to have biliary or pancreatic sources
• Associated with significant mortality and
  morbidity

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APPENDICITIS

• Although more common in the young, associated
  with higher mortality in the elderly
• Abdominal rigidity, decreased bowel sounds, and
  the presence of a mass appear to be more common
  in older patients

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CHOLECYSTITIS

• May not present with the classic symptoms

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BACTEREMIA

• Less likely to have fever, rigors, and chills
• More likely to have delirium, weakness, or fall

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Myocardial infarction

• Dyspnea and CHF are common
• Delirium was presenting symptom in 13
• Syncope and stroke were presenting symptoms in 7

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Pneumonia

• Atypical presentations occur more frequently
• Nonspecific deterioration in a patients health
  status decreased oral intake, fall, and
  confusion
• Abrupt worsening of an underlying chronic medical
  condition

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URINARY TRACT INFECTIONAND UROSEPSIS

• Bacteriuria is increasingly common with advancing
  age
• Lower tract infections (dysuria, urgency,
  suprapubic pain) usually missing
• Upper urinary tract infection (flank pain, fever,
  and chills) usually missing
• Confusion is a common presenting sign

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workup

• Avoid the temptation to overtreat
• Treatment side effects must never be worse than
  the disease

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4 important take-home points

• Common diseases can have uncommon presentations
  in the elderly
• Temptation to overtreat should be avoided
• Always start low and go slow when prescribing
  medications
• A new symptom can be a medication side effect

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Thank you for your time!
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