Bladder

1
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2
Bladder
CONSTRICTIONPara sympathetic
DILATATION Beta adrenergic
C
B
INTERNAL SPHINCTERalpha adrenergic
A
EXTERNAL SPHINCTER Neuro-muscular Junction
0
3
Urinary Incontinence

• Urge
• Stress
• Overflow
• Functional

4
Selected Age-Related Changes and Their
Consequences
BODY COMPOSITON

• ? TOTAL BODY WATER60 ? 45

? Volume of distribution
water-soluble drugs
? Effective dosing in older gtvs younger for
the same dose
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Selected Age-Related Changes and Their
Consequences
BODY COMPOSITION
? BODY FAT Young 20 Elderly 30
? Volume of distribution
fat-soluble drugs
Increased storage of lipophilic drugs

• LEAN BODY MASS
• BMR
• Production of body heat

6
Musculoskeletal 7

• Overall, lower-extremity muscle strength is lost
  at a relatively faster rate than upper-extremity
  strength. Exercise could mitigate many of the
  effects of loss of power with ageing There is an
  increase in hyaluronic acid in cartilage, but a
  decrease in synovial fluid

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Physiological Changes with AGING

• Decrease in Lean Body Mass .(LBM)..
• Decrease in muscule power. (Grip strength).
• Decrease in bone mass.
• Decrease in glucose tolerance.
• Decrease plasma cholestrol concentration.
• Increase in free radical activity.
• Decrease in immune response.

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Control Food Consumption Young Roberts JAMA
1994.
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Selected Age-Related Changes and Their
Consequences
OROPHARINX
GASTROINTESTINAL
The gums recede
Rate of salivary flow no change
Taste perception ?
Swallowing ?
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Swallowing Mechanism

• Structure Muscles, Fibrotic tissue,
  Cartilage.
• Function Feedback neurological mechanism
  controlled by CNS.

• Changes with aging
• Decreased mass.
• Lower nerve conduction velocity.
• CNS damageCVA,ALS, Parkinson,Alzheimer.
• Deconditioniing.

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Dysphagia in C.V.A.

• Magnitude of problem
• About 50 of all cases

• Types
• Cortical
• Bulbar
• Temporary

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Rehabilitation in DysphagiaRole of
interdisciplinary team

• GeriatritianNeurological diagnosis
• Nurse GeriatritionFunctional skills
• PhysiotherapistImproving muscular power
• Occupational Therapist Eating devices
• Speech therapist Swallowing
• Social worker Social support
• NutritionistAppropriate nutritional diet

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Refusal to Eat

• Way of expression
• Depression
• Dementia

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Selected Age-Related Changes and Their
Consequences
GASTROINTESTINAL (cont)
Presbyesophagus

• Gastric acidity

• Absorption of nutrients Vitamins, Ca , Iron ,
  Lactose

Colonization of HP
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The Stomach in Aging

• Decreased defense against acidity.
• Decreased Acid production.
• Increased incidence of GERD and Diaphragmatic
  Hernias.
• Decreased mass.

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Lower Acid Production in Stomach- Consequences.

• Decreased protein digestion.
• Decresed Iron and Calcium absorption.
• Decreased Vitamin B12 absorption.
• Increased intestinal bacterial flora.

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Acute Illness HospitalizationAs cause of
malnutrition in the elderly.

• Failure to maintain adequate intake.
• Failure to consider increased requirements.
• Iatrogenic (NPO).
• Delay in nutritional support
• Leading to accelerated Failure to Thrive..

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Diseases Associated with Increase in Nutritional
Needs.

• Severe Congestive Heart Failure- CHF.
• Chronic Obstructive Airways Disease.
• Thyrotoxicosis.
• Infections.
• Parkinson.
• Inflamatory diseases.
• Malignancies.

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Malnutrition in Pulmonary Disease.

• Hypoxemia.
• Respiratory muscles efforts.
• Dyspnea while swallowing.
• Malabsorption - secondary to hypoxemia.
• Increase in Cachexin.

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ANOREXIA IN AGING
? Opioids? NPY? Nitric oxide
Decreasedfood intake (MgtF)
? Smell
? Taste
Vagus nerve
? Leptin
? TNF - ?
? Adaptive Relaxation
? Fatmass
Antral stretchoccurs earlier
?Cholecystokinin
? Testosterone
? Rate ofgastric emptying
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Weight Loss Summary of 5 studies on 448
subjects in and out patients, mean age gt 62.

• Neoplasm 6-36
• Gastrointestinal 6-18
• Endocrine 4-10
• Cardiopulmonary 2-14
• Psychiatric 9-42
• Others 8-22
• Unknown 10-36
• Depression

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?

Mortality Rate Per 1000
85
75-84
65-74
lt18.5 18.5-24.9 25-29.9
30-34.9 35
BMI Category
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Factors Influencing Nutritional Status of Elderly
Decreased physiological function Malabsorption
and gastrointestinal disorders Drugs Disease Physi
cal Disability Dental Poverty Social/Psychological
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Nutritional Status Assessment of the Elderly
History Antropometric Physical
examination Laboratory tests
weight variation, appetite
BMI, fat
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Nutrition Role in Aging

• For the Patients
• Metabolic and physiologic role
• Psychosocial role
• For the Clinician
• Monitoring tool

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Nutrition as monitor

• Monitoring changes
• Acute illness.
• Subacute illness.
• Dementia.
• Depression.

• Parameters of monitoring
• Eating habits.
• Food consumption.
• Eating schedule.
• Swallowing.
• Food preferences.

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CGAComprehensive Geriatric Assessment

• Yitshal Berner M.D. MPH
• Meir Hospital Kfar Saba
• Affiliated to Tel Aviv University Sackler Medical
  school

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HOLISTIC VIEW
Comprehensive Geriatric Assessment
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CGA

• Inter disciplinary approach
• Holistic view
• Team work
• core team MD,RN,CSW
• strengthen by PT,OT, ST,RD more
• Problem solving orientation
• Leadership of MD

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CGA-History TakingContext, nature of patient,
nature of illness, preoccupations of MD

• Medical surgical history
• Medication (including OTC and food additives).
• Nutrition

• Social
• Family
• Sexual
• Functional
• Preference of care

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CGA-Physical Examination

• Senses
• Mouth and Teeth
• Skin
• Muscles
• Joints

• Heart
• Vessels
• Lungs
• Neurological examination Sensor and motor
  capacities and CNS.

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Impact of Aging on Disease.

• Decline in functional reserve.
• Individualization of manifestations
• Underreporting of symptoms0interpretation.
• Multiple pathology.
• Functional loss
• Non specific and altered presentation.

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Decline in Functional Reserve

• Decrease in mass muscles, bones.
• Metabolic changes.
• Decreased ventilation-respiratory changes.
• Cardiac changes.
• Changes in tissue proteins structure.
• Impaired immunity.

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Non Specific and Altered Presentation of Disease.

• Locus of deficit is less reliable guide in
  elderly, vulnerable systems decompensate from
  systemic disease, usually in the weakest link.
• Painless MI Bayer AJ JAGS 198634,263
• Latent Pneumonia. Osler W
• TTX Apathetic Thomas FB Ann Int Med 197072,679.

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INDIVIDUALIZATION OF MANIFESTATIONS

• Individual disease burden.
• Norms.
• Expectation-decline with aging.
• Late recognition and outcome.
• Neglect-professional,personal and supportive.
• Levkoff SE J Gerontol 198742,114
• Ferraro K J Health Soc Behav 19802,21 377.

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CGA-Function

• SCALES for measurements basic ADL
• Katz
• Bartel
• FIM
• Others
• Instrumental ADL, Advanced ADL.

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Katz Index of Activities of Daily Living( ADL
)ABBREVIATIONS I, independent A, assistance
D, dependent

• 1. Bathing (sponge, shower, or tub)
  2. Dressing
• 3. Toileting
• 4. Transfer
• 5. Continence
• 6. Feeding

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Mahoney F,Barthel DFunctional
EvaluationBarthel IndexMaryland State Med
J19651461-65

• Activity Indp. With Help
• Walking on level surface 15 10
• Ascend descend stairs 10 5
• Dressing 10 5
• Controlling bowels 10 5
• Controlling bladder 10 5

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Mahoney F,Barthel DFunctional
EvaluationBarthel IndexMaryland State Med
J19651461-65

• Activity Indp. With Help
• Feeding 10 5
• Moving from wheelchair to bed 15 10-15
• Personal toilet 5 0
• Getting on and off toilet 10 5
• Bath self 5 0

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• Clock Completion Test CCT
• The score is given for the mistakes
• each of the 3 first quadrants, if mistaken, is
  given 1 point.
• The fourth, if mistaken, is given 4 points.
• Norms
• Normal score range between 3-0,
• Abnormal score range between 7-4.

-1
-4
-1
-1
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Assessment of Cognitive IssuesScreening
instruments

•  MMSE (Mini-Mental State Examination)
•  Clock drawing
•  CASI (Cognitive Abilities Screening
  Instrument)

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CGA-Function-FIM

• FIM Functional Independence Measurement
• From 1987, started for rehabilitation
• Personal treatment Feeding,Cleanliness, Bathing,
  Dressing upper and lower body, Toileting, bladder
  and control.
• Mobility Bed, wheelchair, toilet, walking ,
  stairs.
• Cognition and Communication Memory, problem
  solving,and social response
• 18 question with 7 grades from total dependence
  to total independence.

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Lawton Instrumental ADLLawton MP, Brody
EMAssessment of older peopleself-maintaining
and instrumental activities of daily
living.Gerontologist 1969 ( 179-186.
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Lawton Instrumental ADL2- dependent, 1- with
help, 0- independent

• Using telephone
• Shopping
• Food preparation
• Housekeeping
• Laundry
• Travel, use of transportation
• Managing medication
• Managing finances

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Rate of needed help in ADLUS Bureau of census
1990
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Functional Life ExpectancyS.Katz NEJM
19833091218-1224
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Function

• It is most effectively delivered by an
  interdisciplinary team.

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CGA- Support

• Family
• Finances
• Culture
• Formal community support
• Abuse and neglect
• Living capacities

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Sociodemographic changes with age

• Income
• seniors living alone
• seniors with support
• of seniors in long-term care

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Geriatric Rehabilitation

• A combination of physical , occupational, and
  speech therapy psychiatric or psychologic
  counseling social work nursing and medical
  supervision to help debilitated persons maintain
  or recover physical capacities.

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MFA-Musculoskeletal Function AssessmentMartin
DP, Engelberg R, Agel J, Snapp D, Swionostkowski
MEDevelopment of musculoskeletal extremity
health status instrumentthe Musculoskeletal
Function Assessment InstrumentJ Orthop Res
1996,14173-181.
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MFA-Musculoskeletal Function Assessment

• Health status instrument with 100 self reported
  items.
• Ten categories of questions yes/no answers
• self-care sleep/rest mobility
• hand/fine-motor coordination housework
  leisure/recreation family/relationship cognit
  ion/thinking employment/work emotional/adjustment/
  coping/adaptation

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OARSThe Older Americans Resources and
ServicesDuke University Center for the Study of
aging annd Human DevelopmentMultidimensional
Functional Assessment The OARS Methodology, a
manual.Ed 2 pp 61-90. Durham North Carolina,
Duke University. 1978.
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OARS(total score/29)x100

• 15 question
• 13 questions begin with can you
• use telephone get to place out
  of walking distance
• go shopping for groceries and cloths
• prepare your own meals eat
  dress and undress
• take care of your appearance do
  your own housework
• handle your own money take your
  own medicines
• walk get in and out of bed
  take a bath or shower
• 2- without help 1- with some help 0-completely
  unable to do
• Do you ever had trouble getting to bathroom on
  time 2-no 0-yes
• Is there someone helping you with shopping,
  housework, bathing, dressing, or getting around.
  1-yes 0-no

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TESSToronto Extremity Salvage ScoreDavis AM,
Wright JG, Williams JI, Bombardier C, Griffin A,
Bell RC.Development of a measure of physical
function for patient with bone and soft tisuue
sarcoma.Qual Life Res 1996 5 508-510.
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TESS

• Disease specific measure for patient undergoing
  limb preservation surgery for tumor of extremity.
• Self administrated for physical disability.
• Consist of thirty questions e.g. putting the
  shoes is impossible1/not at all difficult5/
  and all possibilities in between.
• Score(total raw score-lowest possible raw
  score/raw score range)x100

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SF-36Short Form 36McHorney CA, Ware JA, Razeck
AE.The MOS 36-items Short Form Health Survey
(SF-36) II Psychometric and clinical tests of
validity in measuring physical physical and
mental health constructs.Med Care 1993
31247-263
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SF-36

• Validated generic health status measure with
  eight subscales physical function role
  limitations due to physical health role
  limitations due to emotional problems vitality men
  tal health social function bodily pain general
  health
• Results are presented as a profile of score from
  each subscale.

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WOMACWestern Ontario and Mac Master University
Osteoarthritis IndexBellamy NPain assessment
in osteoarthritisexperience with WOMAC
osteoarthritis index.Sem Arthrit
Reumat18(supplement 2) 198914-17
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WOMAC

• Consist of three sections
• 1. Pain 5 questions
• 2. Stiffness 2 questions
• 3. Physical function 17 questions.

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TUGTime Up to GoPodsiado D, Richardson SThe
Time Up to Go, a test of basic basic functional
mobility in frail elderly persons.J Am Ger Soc
1991 39 142-148.
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TUG

• Measures the time it takes to rise from an
  armchair,walk 3 meters, turn, walk back and sit
  down again.

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SCIMSpinal Cord Independence MeasureCatz A,
Itzkovitch M, Steinberg F al, The
Catz-Itzkovitch SCIM a revised version of the
Spinal Cord Independent Measure. Disability and
Rehabilitation 2001 23263-268.
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SCIMSpinal Cord Independence Measure

• Special questionnaire for assessment of
  disability from spinal cord damage.
• Personal Treatment eating grooming washing of
  upper and lower part dressing of upper and
  lower part
• Respiratory tract and continence respiratory
  tract urine fecal personal hygiene

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SCIM-IISpinal Cord Independence Measure

• Special questionnaire for assessment of
  disability from spinal cord damage.
• Room mobility bed mobility transfers bed to
  chair transfer chair toilet
• Outdoor mobility distance at home moderate
  distance more than 100m stairs chair/car transfer

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LEMLower Extremity MeasurementJaglal S,
Lakhani,Schatzker JReliability,validity and
responsivenes of Lower Extremity Measure for
Patients with Hip FractureThe J of Bon and Joint
Surgery 2000 82955-962.
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LEM

• 29 questions with five answers
• 1. Impossible-completely unable to do.
• 2. Extremely difficult.
• 3. Moderately difficult.
• 4. A little bit difficult
• 5.Not at all difficult
• 9. Task not applicable

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LEM

• Getting out of bed getting in/off
  toilet showering putting on pants putting on
  stockings putting on shoes rising from
  chair standing upright kneeling getting up from
  kneeling bending to pick something up of the
  floor sitting walking upstairs downstairs
  walking outside inside

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LEM

• walking up/down a ramp getting in/out an
  automobile using public transportation socializin
  g with friends/family doing usual daily
  activities gardening/yardwork preparing own
  meals finishing usual daily activities spending
  usual amount of time on ADL light housework
  heavy housework food shopping

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Functionally Recovery Score for Elderly Hip
Fracture PatientsI DevelopmentII Validity
reliabilityZuckerman JD, Kenneth K,Aharanoff GB,
Hiebert R, Skvorn MLJ of Orthop Trauma 2000
14I 20-25II26-30
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Functionally Recovery Score for Elderly Hip
Fracture Patients

• 16 components
• a. 4 items representing independence in BADL
• feeding without help,
• bathing,
• going to toilet,
• dress without help.

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Functionally Recovery Score for Elderly Hip
Fracture Patients

• 16 components
• b. 6 items representing independence in IADL
• food shopping
• prepare food
• take care of banking and finance laundry
• light housework
• use public transportation
• get in/out a car

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Functionally Recovery Score for Elderly Hip
Fracture Patients

• 16 components
• c. 4 items representing independence in mobility
• walk outdoor
• walk indoors
• transfer be to chair and chair to bed
• use flight of stairs

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Functionally Recovery Score for Elderly Hip
Fracture Patients

• 16 components
• d. 1.item representing freedom from pain
• e. 1 item representing having intact memory

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RE-evaluation of two simple prognostic scores of
outcome after proximal femoral fractures

• Thomas M, Eastwood H
• Injury 1996 27111-115

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Belfast ScoreWallace RGH, Lowry JH, et alA
simple geading system to guide the prognosis
after hip fractures in the elderly.Br Med J
1986 iii 665-668
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Belfast Score

• Satisfactory general health-1
• Satisfactory general health past history of
  illness-2
• Poor health-3
• Independent-1
• Lives alone with help-2
• Lives in institution-3

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Newcastle ScoreIons GK, Stevens JPrediction of
survival in patients with femoral neck fractursJ
Bone and Joint Surg (Br) 1987 69B 384-389.
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Newcastle Score

• Age 65-84-1
• Good health-1
• Mentally allert-1
• Age gt85-2
• Poor current health-2
• Confused mental state (Hodkinsom lt7/10)

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Social Dependency ScaleThomas TG,Stevens
RSocial effects of fractures of the femurBr Med
J 1974 iii456-459.
86
Social Dependency Scale

• 1. Independent in domestic and social activities.
• 2. Needs minimal help in shoppingmay use meals
  on wheels.
• 3. Dependent family or home help up to three
  times a week.

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Social Dependency Scale

• 4. Dependent family or home help more than three
  times a week.
• 5. In residential home or supported at home by
  more than daily visit. Extended home care
  provided.
• 6. In nursing home or long-stay hospital.

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Mobility-Social-Care-Living ScoreHoofwijk
AGMSevere lower limb ischemia. Dissertation
physical Doctor. University of Utrecht 1990.
89
Mobility-Social-Care-Living Score

• Mobility 1-10
• Social function 2-10
• No social contact, demented 1
• ADL 2-10
• Totally dependent 1
• Living situation level of dependency 2-10
• Nursing home 1