Geriatric Medicine

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Geriatric Medicine

• Dr Stanley Lipschitz
• Specialist Physician Geriatrician

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Growing old is not so bad,when you consider
thealternative "
Woody Allen
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Relationship Between Age Function
Function
Age ( Years )
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IN THE ELDERLY
Multiple Chronic Diseases

Vulnerability to Insults
Loss of Homeostatic Reserve

Biological Aging
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Loss of Homeostatic Function

• Regulation of critical functions such as body
  Temperature, energy metabolism, heart rate and
  BP.
• Adrenergic responsiveness declines with aging -
  may influence the regulation of these bodily
  functions in the elderly.
• Such Homeostatic losses mean that Diagnostic and
  Therapeutic undertakings, acute illness, flares
  of chronic disease and traumatic insults will
  have the potential for greater than usual ill
  effect

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Loss of Homeostatic Function
OLD AGE
Increased drug Toxicity
Decreased body water Decreased lean body mass
Decreased volume of Distribution of drugs Eg
Phenytoin
Decreased clearence of drugs by the liver
resulting in Toxic blood levels (aminophylline
Cimetidine)
INCRESED PROBABILITY OF IATROGENIC PROBLEMS IN
AGED PATIENTS
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Atypical Disease Presentation
Biological Aging, Multiple Chronic Diseases
Disability
Loss of Homeostatic Function

Modification of Host Response
Commonly acute Illness presents Atypically
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GIANTS OF GERIATRICSATYPICAL PRESENTATION of
DISEASE

• DELIRIUM
• FALLS
• LOSS OF MOBILITY
• INCONTINENCE
• LOSS of ADL ABILITY

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Atypical Disease Presentation

• UG Sepsis may cause Delirium without fever,
  polyuria or BOM
• Pain response is often blunted Delirium or
  breathlessness may be the first response to AMI
• Acute change in wellbeing or a decline in
  function or something is different, may be the
  only indication of an acute Abdominal crisis in
  the Elderly

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Atypical Disease Presentation

• Such warnings of subtle changes, especially by
  observers intimately and regularly involved,
  should be taken seriously by the Clinician and
  are often the only indication of a Potentially
  overwhelming event.
• Nonspecific change in status always warrants
  careful and detailed assessment in particular
  looking for occult illness such as UG sepsis,
  silent MI, Pneumonia, Abdominal crises and Drug
  Toxicity.
• Even when nothing is found ongoing surveillance
  is required. TIME, may be the most important
  Diagnostic tool! Diagnostic Difficulty

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Narrow window of Therapeutic and Diagnostic
Tolerence

• The challenge in Geriatric Medicine is the
  critical narrowing of the diagnostic and
  therapeutic window due to loss of homeostatic
  function, multiple diseases and disabilities and
  atypical disease presentation
• There is much more room for mistakes in judgement
  when caring for the frail elderly
• A diagnostic test for one problem may adversely
  effect the overall function of the patient due to
  a disease in another system e.g. Contrast medium
  Renal dysfunction
• A therapeutic agent may have adverse effects e.g.
  Cimetidine used for a DU may result in a decline
  in Cognitive function

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The COMPREHENSIVE GERIATRIC ASSESSMENT

• Comprehensive assessment of the elderly patient
  is critical for the provision of proper health
  care
• Should be Standard absolutely essential when
  there has been an acute change in social
  circumstance, physical or mental status, or a
  confusing constellation of signs and symptoms,
  when a patients living situation has changed
  often due to deteriorating health, in a patient
  with a new medical problem
• Also as an integral part of decision making
  regarding placement in any Care Facility

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The COMPREHENSIVE GERIATRIC ASSESSMENT

• To review in detail the Physical, Mental and
  Social situation of the patient
• To correct any causes of Disability and to
  stabilise those that may be progressing
  unnecessarily
• The social and Physical environment may need to
  be modified to maximise independence

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The COMPREHENSIVE GERIATRIC ASSESSMENT

• The search for specific Diagnoses and cures is
  less often a Primary Goal, than is the
  formulation of a Practical Plan to preserve
  function, autonomy and Dignity
• Hospitalization is a major risk to the precarious
  homeostasis of the Elderly and should only be
  resorted to for the treatment of acute, severe or
  Life threatening illness.

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The COMPREHENSIVE GERIATRIC ASSESSMENT covers
5 categories

• Physical health
• Mental health
• Socioeconomic status
• Environment
• Functional status

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Detecting AD who to screen
screen
New patients gt 65 yrs
Established patients gt 65 yrs
Patients with early warning signs
Cognitive Deficits
Memory Loss
Change in Personality or Behavior
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AD making the Diagnosis

• Careful History
• Alternate sources family, work, nursing staff,
  friends.
• Onset and Progression insidious/acute,
  smooth/stepwise.
• Isolated Memory vs Multiple Cognitive deficits
• Similarities/Differences, Abstract Thought,
  Proverbs
• MMSE
• Physical and Neurological examination
• Laboratory tests and Brain Imaging

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AD making the DiagnosisThe MMSE

• Take a careful history of Cognitive function
  before doing the MMSE
• Interpret the MMSE in a patient specific manner
  Education, Language, Mood
• Dont be kind score down!
• It takes 10 minutes do it when appropriate!

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DSM IV CRITERIA - DEMENTIA

• MEMORY IMPAIRMENT
• DYSPHASIA
• DYSPRAXIA
• AGNOSIA
• EXECUTIVE FUNCTION
• OCCUPATIONAL/SOCIAL FUNCTION
• DECLINE FROM FORMER LEVEL OF FUNCTIONING

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Mini Mental State Examination (MMSE)
30 point test to assess cognitive
function - Orientation to time and place -
Memory (registration and recall) - Attention and
Calculation - Language - Visiospacial function
Normal gt26 Mild 20-25 Moderate
10-19 Severe lt10
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Value of (CGA) assessment

• The Primary goal is preservation of the patients
  function and independence
• If reversible problems are not detected goal is
  to identify support needs, mobilize community and
  family resources and maintain function and
  autonomy
• A full knowledge of what Community resources are
  available is essential

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Elderly patient in state of flux
Exacerbation of 1 of several Chronic conditions
Worsening Social circumstance
Mental deterioration
Depression
CGA dissects the components of change and
instability to suggest strategies for at least
small improvements in Function
Strategy is often practical intervention Tailored
to the specific needs and Resources of the
patient
Concept of Small Therapeutic gain
Cure is Less common
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Concept ofSmall Therapeutic Gains
Multiple Chronic diseases

Disability
RATHER Preservation or Restoration of FUNCTION is
the aim
CURE is Almost never The Goal
It is therefore essential to set Realistic
Therapeutic Goals. Aiming for Cure in this
population will only result In frustration
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PREVENTION

• Normal preventive medicine applies glucose, BP,
  BMD, Lipids etc
• Identify SAFETY RISKS (home visit) lighting,
  loose mats, handrails, stairs, showers/bath,
  kitchen storage
• Communication telephone, alarms
• Good Surveillance system frequent visits from
  Dr, Community nurses, social workers etc
• Nutrition
• PREVENTIVE REHABILITATION for all illness

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Management in the Acute Care Setting
Elderly Patient
More frequently hospitalised
Stay longer
Experience more Adverse consequences
Often despite effective Treatment of the Acute
condition
Decline in Physical And Cognitive function
Hospital associated Complications
Pressure Sores
Fluid Electrolyte
Confusion
Mobility
Incontinence
Malnutrition
Falls
PREMATURE DEATH or INSTITUTIONAL CARE
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Management in the Acute Care Setting
Therapeutic Benefits
Adverse Effects
Hospital Care
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Factors influencing Managementin the Acute Care
Setting

• Those associated with AGING
• Those associated with COEXISTENT DISEASE
• Those related to the PROCESS OF CARE Diagnostic
  and Treatment related

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Factors influencing Managementin the Acute Care
SettingHOST AGING

• Gradual and variable decline in function over
  time especially after 75 years, there is a
  destinct loss of functional reserve (varies from
  organ to organ and person to person)
• This loss results in decreased ability to handle
  stress (environmental or disease related)
• Impossible to focus on disease in one area,
  without being sensitive to changes in others

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Relationship Between Age Function
Function
Age ( Years )
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Factors influencing Managementin the Acute Care
SettingHOST AGING

• The stress of illness usually manifests itself
  first and prominantly in the organs with least
  functional reserve usually the BRAIN
• Atypical presentation of disease (no fever/pain)
• Physical variation/heterogeneity of the elderly
  patient careful and comprehensive individual
  assessment

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GIANTS OF GERIATRICSATYPICAL PRESENTATION of
DISEASE

• DELIRIUM
• FALLS
• LOSS OF MOBILITY
• INCONTINENCE
• LOSS of ADL ABILITY

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Factors influencing Managementin the Acute Care
SettingHOST DISEASE

• Multiple illness/comorbidities are common on
  average 3 per patient
• These interact with the changes of aging
  further enhance vulnerability to stress
• Often comorbidities are subtle and nonspecific
  (OA, BPH, Osteoporosis, Apathetic Thyrotoxicosis,
  etc)
• Careful delineation of all acute and chronic
  illnesses essential
• Identify the primary illness place it
  accurately within the context of other illnesses
  and vulnerabilities then investigate and treat
  appropriately

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Factors influencing Management in the Acute Care
SettingEffect of medical nursing care
HOSPITALISATION
Clinical Iatrogenesis
Functional Iatrogenesis
Side effects of
Side effects of
Medical intervention
Diagnostic intervention
Therapeutic intervention
The process of These Interventions
gt50 of patients over 70 years experience a
decline in Physical and/or Cognitive function
Unrelated to the admitting diagnosis
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ATYPICAL DISEASE PRESENTATION

• MULTIPLE PATHOLOGY
• MULTIPLE AETIOLOGY

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Multiple pathology
Secondary disorder
Primary disorder
Urinary retention
UTI incont
constipation
Age OA Vision PD TCA
Renal dysfn
Rx accumulation
Rx toxicity
Fluid/electrolyte
Post hypotension
dehydration
Bed rest immobility
Muscle strength
FALLS DELIRIUM
PNEUMONIA
hypoxia
Mobility restraint Confusion Muscle
power Polypharmacy Secondary infection
hospitalization
confusion
Sleep deprivation
Tertiary factors
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LESSONS LEARNED

• FAILURE TO LOOK BEYOND THE OBVIOUS
• AVALANCHE EFFECT
• SUPERMARKET EFFECT

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Factors influencing Management in the Acute Care
SettingEffect of medical nursing care
The prevailing disease-oriented and sequential
approach to diagnosis and treatment defers the
Practice of Preventive Rehabilitation and
Restorarive Rehabilitation until post Discharge
Additional Interventions Restraints Psychotropi
cs NG feeds Catheters
Excess Bedrest Imobility Falls Incontinence Deliri
um Anorexia
Additional Complications - Pressure
sores Delirium Agitation DVT PE Aspiration
Pneumonia UTIs Bacteraemia Depression Disruptive
behavior
FUNCTIONAL LOSS
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Acute Care Assessment and Management

• Prehospital Assessment
• Admission Assessment
• Acute Hospital Care
• Discharge Planning

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Acute Care assessment and managementPrehospital
Assessment
Comprehensive Geriatric Assessment detailed
knowledge of Coexistant medical
problems Nutritional status Psychosocial
strengths and vulnerabilities Baseline Physical
Cognitive Function
Allows prediction of outcomes
Attempt to prevent unnecessary or inapproriate
admissions It is possible to manage most illness
as an outpatient!
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You want my mother who has pneumonia to stay at
home!!!
Is your medical insurance paid up?
Educate patient and carer Carer support and
assistance Appropriate and aggressive treatment
for the acute illness Regular follow up and
reassessment Nutrition Fluid and Electrolytes
(subcutaneous fluids) PREVENTIVE REHABILITATION
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Acute Care assessment and managementAdmission
Assessment
Repeat CGA within 72 hours of admission
Assess changes in Physical Cognitive Function
Predict outcomes
Define clearcut specific goals aiming to regain
and maintain Function
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Acute Care assessment and managementAcute
Hospital Care

• Identify acute event accurately place this
  within the context of other diseases and
  disabilities..then initiate appropriate
  investigations and interventions
• Avoid the acute functional and cognitive decline
  associated with acute medical and nursing care.
• Close collaboration by the treating TEAM is
  essential
• Allow the patient to retain maximal levels of
  self care, personal control, mobility, nutrition
• Retain basic daily functions while in hospital

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Acute Care assessment and managementAcute
Hospital Care
A patients level of mental physical function
is the result of
Diseases and Disabilities Acquired during and as
a Consequence of the Management in hospital
Diseases and Disabilities Developed prior to
hospitalization
Clinical Iatrogenesis
Functional Iatrogenesis
THEREFORE if the goal is to achieve optimal
medical Functional outcomes for elderly
patients THEN, treatment, Investigations,
Fluid therapy and General Protocols must be
modified TO PREVENT FUNCTIONAL DECLINE
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HOSPITAL COURSE Cascade of illness functional
decline
Initial illness
medications
Delirium
Changed environment
dehydration
Reduced Oral intake
antibiotics
Incontinence
Malnutrician
UTI
Constipation
Foleys catheter
Anorexia bloating
Compromised Host Defense
immobility
dehydration
Nausea vomiting
Pneumonia
Falls
Depression
Aspiration
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AGEING DISEASE DISUSE
MULTIPLE AETIOLOGY
MULTIPLE PATHOLOGY
ATYPICAL PRESENTATION OF DISEASE
DRUG MISUSE
HOSPITAL ASSOCIATED DYSFUNCTION
LACK OF EXPECTATION
PSYCHOSOCIAL FACTORS
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Acute Care assessment and managementAcute
Hospital Care
Rational approach to Modification of Medication
Fluids

• Creatinine Clearance (should be 30ml/min) in
  most severely ill elderly falls within moderate
  renal failure range. Adjust Rx accordingly!
• Drugs with Hepatic metabolism. Consider drug
  interaction!
• Consider Cardiac Pulmonary reserve assume
  that acute illness results in decreased CO
  increased ADH.. Adjust fluids!
• Avoid Narcotics Sedatives.

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Acute Care assessment and managementAcute
Hospital Care
Rational approach to Modification of Medication
Fluids

• Initiate withdraw one medication at a time
• Adjustments should be made in small steps
• Continually review Goals
• Beware of Combination Analgesics

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Acute Care assessment and managementDischarge

• DISCHARGE PLANNING begins at the time of
  ADMISSION!
• Regular TEAM MEETINGS Doctor, Nurses, Social
  Worker, Physiotherapist, Occupational Therapist,
  Community Nurse etc
• At all times consider and avoid functional and
  cognitive decline consequent to hospitalization
• Education of CAREGIVERS DISCHARGE MEETINGS

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Define Premorbid Status
Define Current Status
Comprehensive Assessment And Investigation
Preventive Rehabilitation
Correct ALL Treatable Conditions
Restorative Rehabilitation
COGNITIVE
PHYSICAL
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Weeks 2 3Case Studies

• Half hour presentations
• At week 4
• Case study and Treatment plan to be
• Handed in for assessment