Week 2

GERIATRIC PT
PHTH 415
FALL 2020 - 2021
 Age related changes
Bodily changes associated with aging generally make people more
vulnerable to:
• Environmental conditions
• Side effects of medications
• Complications of medical procedures.
Changes in the regulation of the body systems increase the diversity among
older people.
All cells change as they age:
• Cells become larger.
• Their capacity to divide and reproduce tends to decrease.
Normal cells have built-in mechanisms to repair minor damage, but the
ability to repair declines in aging cells.
 Contents
• Age-related changes
➢ Cellular changes
➢ Tissue changes
➢ organ changes

• Demographics, mortality & morbidity

➢ People over 65
➢ Increased life expectancy
➢ Leading causes of death
➢ Leading causes of disability
➢ Socioeconomic factors
➢ Health care costs
 Age – related changes

Cellular changes

Increase in size: fragmentation of Golgi apparatus & mitochondria

Decrease in cell capacity to divide & reproduce

Cessation of DNA synthesis and cell division

Reduction in number of lysosomes and
mitochondria leads to decrease in
mitochondrial function and then the
metabolism is decreased to about 95 % of
their capacity by age 50 & 85% by age 70.
 Tissue changes

Accumulation of pigmented materials

Accumulation of lipids & fats

Connective tissue changes

Decreased
Degradation of Presence of
elastic
collagen pseudoelastins
component
 Organ changes

Decrease in functional capacity

Decrease in homeostatic efficiency

 The total amount of water in the body
gradually decreases. These changes in body
fat and water reduction are the main reasons
why the elderly respond differently to drugs
than the younger population.
Demographic, mortality & morbidity

Persons over 65:

• Lengthening of life expectancy

• Older women outnumber older men

• Caucasians represent about 82 % of people over 65; only 10% are non-
white and 8% are black.
Increased life expectancy:
• Advances in health care, improved infectious disease control

• Advances in infant/child care, decreased mortality rates

• Improvements in nutrition and sanitation

Leading causes to death:

• CHD , 31 %

• Cancer, 20 %

• Cerebrovascular disease (stroke)

• Chronic obstructive pulmonary disease (COPD)

• Pneumonia , flu.
Leading causes to disability:
• Arthritis, 49 %

• Hypertension, 31 %

• Hearing impairments, 30 %

• Cataracts & chronic sinusitis , 17 % each

• Orthopedic impairments, 16 %

• Diabetes & visual impairments, 9 % each

• 60% – 80% may have more than one conditions

Socioeconomic factors:
• Marriage and widowing status

• Income & poverty rate

• Educational level

• Institution and family setting

• Elderly living in nursing homes

Healthcare costs
• Older persons account for 12% of population & 36% of total health care
expenditures

• Older persons account for 33% of all hospital stays, 44% of all hospital
days of care
Although aging process
cannot be stopped, it can be
delayed with proper care
(Such as good health habits) or
modifiable by eliminating or
lowering risks (Such as weight
loss, Blood pressure control,
Exercise, smoking cessation…)
The geriatric care is either:
•preventive, curative, improving
or maintaining function and
quality of life.
•Also it is providing comfort of
terminally ill persons.
The aging process is commonly
accompanied by physical changes,
which may affect an individual’s
choice of food and the ability to digest
food and absorb nutrients.
Body cell mass may decrease with age,

reflecting changes in both skeletal muscle

and organs.
A decline in basal metabolic rate
accompanies the reduction in
metabolically active cells.

With aging there is decrease in glucose

tolerance and cardiovascular adaptation
to stress.
The decrease in body water has
implications for temperature regulation.
 Less body water
results in lower thermal
buffering so that older
people are more
susceptible to
environmental
hypothermia .
Elderly people are more susceptible to
dehydration. Consequently due to (diarrhea,
febrile and other conditions, which increase,
water loss and may put the elderly at great
risk of dehydration).
The elderly people are in need for:
* Nutritional supply for producing the
sufficient amount of energy to
maintain body weight.
* Proper amount of fat for absorption
of fat-soluble vitamin.
* Sufficient calcium to keep bone
status.
* Enough fluid to prevent
dehydration.
* Fiber rich food to prevent
constipation.
 In elderly people, malnutrition:

Affects a patient's functional status and

medical condition.

Decreases the elderly resistance to

infection and result in poor wound
healing.
* Also malnutrition can lead to increased skin

fragility, osteoporosis, anemia, diabetes, and

cardiovascular disease.
Prevention and early recognition of
malnutrition are essential in the process of
rehabilitation because good nutrition is a
component of positive outcomes in the
rehabilitation setting.
Risk Factors
For
Malnutrition
Biological factors

GIT abnormalities.

The losses of the sense of smell and

taste can indirectly reduce an
individual’s appetite and the
enjoyment of food.
 Psychosocial
factors
Depression

Living alone,
or relying on Cognitive
others for decline
meals.

Ignorance:
Restricted Financial
variety of limitations
diet
Assessment of Malnutrition
The patient's dietary history should include information
about the following:
Consistency of the diet, number of skipped meals,
alcohol use, use of nutritional or vitamin
supplements, and use of medications that affect
appetite or nutrients.
Nurses observe and record risk of skin

breakdown, (as pressure sores) which is a

result of poor nutrition. Cells become fragile

due to an inability to sustain metabolism.

Height and weight: Both items should be
recorded at every visit to detect BMI, and they
should be monitored closely while the patient is
in the rehabilitation unit. This information is
critical to evaluate the degree of over or under
nutrition.
 Physical features that can suggest malnutrition

include:

* Thinning of enamel on teeth.

* Thinning of the hair.

* Spoon nails.

* Dermatitis.
* Pallor.
* Edema.
* Bleeding gums.
* Peripheral neuropathy and dementia can also
be a sign of nutritional deficiency in the
elderly.
Serum protein levels are good

indicators of malnutrition.

Also, albumin levels used to monitor

nutritional status.
Hemoglobin (Hb) concentrations should be
obtained to rule out anemia from pathologic
processes such as iron deficiency anemia or
anemia of chronic disease.
 Vitamins A, C, and E
can also increase cell-
mediated immune
function by increasing
the absolute number
of T cells.
Vitamin D and ionized calcium levels can
aid in determining if supplementation is
needed to prevent osteoporosis .
 It is often assumed that with old age, organ
function decreases, physical activity decreases,
and lean body mass decreases that leads to
decrease metabolic rate. This may not
necessarily be the cause if physical activity is
maintained.
Energy intake decreases with age, partly
because of a lower metabolic rate
associated with decreased physical
activity.

About 16% of the geriatric population eat

less than 1000 kcal/day.

For geriatric patients, the recommended

daily intake is 25-35 kcal/kg.
 Complex carbohydrates should make up 55-60% of the diet
to meet the patient's fiber, vitamin, and mineral needs.

A daily fiber intake of 20-30 g is recommended for older

adults to help prevent constipation, to lower cholesterol
levels, and to decrease the risk of colon cancer.
Protein should be increased to 15-20% of the
diet in undernourished elderly patients,
especially postoperative patients, patients with
trauma, patients with pressure sores, and those
with active infections.
Fat calories should account for 10-

30% of the daily caloric intake;

however, fat requirements are not

standardized for the elderly.

Many commonly prescribed drugs can
affect absorption and nutritional status
such as:

•Metformin may result in vitamin B12 deficiency

•Steroids which impair vitamin C status
•Neomycin (Antibiotics) which results in
malabsorption of fat soluble vitamins and impairs
iron absorption.
Surgery is likely to affect nutritional status and
good nutrition before and after surgery
Patient education: (Diet tips)
 Eating a variety of food to get a balanced diet with all the nutrients and energy you need.

 Eating with friends or company is a pleasant social occasion.

 Eating regularly at least three times a day.

 Fruit and vegetables are an excellent source of vitamins and minerals, eating some each
day.

 Constipation can be a major problem. Fibers from fruit, vegetables and whole grain can
help.

 Drinking plenty of fluids (9-12 cups/day, as water, tea, juice, or soup)

With age, bones become more fragile
due to decreased calcium absorption;
thus, keeping a sufficient intake of
calcium-rich foods, e.g. milk and dairy,
green vegetables...
Immunity
 Immune function declines with aging, leading to infection,
cancer, and increased mortality.
 Protein energy malnutrition results in reduced number
and function of T-cells and phagocytic cells.
 Vitamin C stimulate immune system by elevating
interferon levels.
 Geriatric pharmacology
 Old people form a great part of the work of doctors in
general practice. With health care people tend to live
longer; they are more likely to suffer from one or two
chronic health conditions such as heart disease,
hypertension, diabetes, and rheumatic diseases…
 Special considerations are necessary
when prescribing drugs

 Aging alters pharmacokinetics (The time course, by

which the body absorbs, distributes, metabolizes, and
excretes drugs) .
Pharmacodynamics (The time course and effect
of drugs on cellular and organ function) affect
the choice, dose, and frequency of many drugs.
 In the elderly, the effects of similar drug concentrations at
the site of action may be larger or smaller than those in
younger persons.

 The difference may be due to :

- Changes in drug-receptor interaction.
- In post-receptor events.
- In adaptive homeostatic responses.
❖ Among elderly patients, the difference is often due to
organ pathology.

❖ Increased sensitivity due to aging must be considered

when drugs with serious adverse effects are used.
Drug-disease interactions (exacerbation of a
disease by a drug) can occur in any age group
but are especially important in the elderly.
Drug-drug interaction (the altered
pharmacokinetics or Pharmacodynamics of a
drug when taken concomitantly with one or
more other drugs) are countless.
Drugs that increase
bowel motility as
laxative may
prevent adequate
absorption
Elderly complain of a dry mouth due to a
decrease in salivation. When a drug is to be
administered sublingually it will not dissolve
readily and absorption through the mucous
membrane is decreased.
Considerations for Effective Pharmacotherapy

Dose must often be reduced in the elderly.

Starting doses of drugs with a low therapeutic
index are about one third to one half the usual
adult doses.
Polypharmacy: Many elderly patients routinely
receive drugs that are not essential and can cause
harm, directly or through interactions. A thorough
review of drugs can often reduce the number of
drugs used and, according to limited data,
improve patient outcomes.
Thank you very much