INTRODUCTION TO GERIATRIC

MEDICINE

Gatot Sugiharto, MD,

Internist
Faculty of Medicine,
UWKS
Lecture - 2011
 AGING
 Aging can be defined as a progressive and
generalised impairment of function resulting in
the loss of adaptive response to stress and
increased risk of age related diseases.

 The overall effect of these alterations is an

increase in the probability of declining health
and dying and which is also often associated
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
 GERIATRIC MEDICINE:MAIN ISSUES

 Understanding basic concepts

 Approaching the older patient
 Age related physiological & pathological states
 Demographic impact on geriatric health care
 BASIC CONCEPTS
• Multiple diseases and multiple drugs.
• Diseases often chronic, progressive with adverse
consequences. Focus on functional independence
• 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
common
PHYSIOLOGICAL CHANGES AND THEIR
IMPACT
CHANGE: DECREASE IN IMPACT: DECREASE IN
 Basal metabolic rate  Calorie needs
 Pulmonary function  Exercise capacity
 Renal function  Ability to conc/dilute
 Bone mineral urine
 Gastro-intestinal  Fracture resistance
function  Bowel motility
 Sight  Independence
 Dentition  Eating ability
 Taste  Appetite
 Physiologic Changes with Aging
 Respiratory system
 Vital capacity decreases by as much as 50%
 Decreased recoil and elasticity of lung tissue
 General loss of the muscle tissue within the
walls of the lower airways
 Changes can make sudden respiratory illness
life-threatening
Physiologic Changes
with Aging
 Cardiovascular system
 Stroke volume declines with age
 Heart’s pacemaker & conduction system decline with
age
 With internal bleeding, elderly have a diminished
ability to increase heart rate and stroke volume to
compensate for poor perfusion
 Resistance of blood vessels increases from a loss of
elasticity and generalized arteriosclerosis
 Ability to respond to changes in BP is slower
Physiologic Changes with Aging
 Musculoskeletal system
 Degenerates with age
 Decreased total musculoskeletal weight and
widening and weakening of the bones
 Generalized osteoporosis increases the potential
for fractures with mild mechanism of injury
 Must maintain a high level of suspicion of
fractures with falls
 PRINCIPLES OF GERIATRIC
ASSESSMENT
Goal 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
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 family’s cooperation & attitude
 Assess care giver’s stress
 The basic components of the Comprehensive
Geriatric Assessment (CGA)

1. Functional status ADL (Activity of Daily Living),

IADL (Instrumental Activity of Daily Living)
2. Comorbidity (number, type and rating of comorbid
conditions)
3. Cognition (Mini-Mental Status Examination)
4. Depression (Geriatric Depression Scale)
5. Polypharmacy
6. Nutrition (Mini-Nutritional Assessment)
7. Presence of Geriatric Syndromes (dementia,
delirium, depression, failure to thrive, neglect or
abuse, osteoporosis, falls, incontinence)
8. Socio-economic factors
Functional Evaluation
 Instrumental Activities of Daily Living
 (IADL’s)
 Activities of Daily Living
 (ADL’s)
 Executive Functioning
 Gait & Balance
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, taking medications,
doing laundry, doing housework,
shopping, managing own transportation
 “Get Up and Go” test
Qualitative, timed, assesses gait, balance,
and transfers
PHYSICAL ASSESSMENT
 Complete physical
assessment includes:

 Nutrition
 Vision
 Hearing
 VISION
 Cataracts, glaucoma, macular
degeneration, and abnormalities of
accommodation worsen with age
• Assess difficulties by asking about
everyday tasks
—driving; watching TV; reading
• Use performance-based screening
 ask to read from newspaper,
magazine
 use Snellen chart
HEARING
• Hearing loss is common among older adults
• Impaired hearing  depression, social withdrawal
• Assess first for cerumen impaction
• Use hand-held audioscope to test for abnormality
—loss of 40 dB tone at 1000 or 2000 Hz in one or both
ears is abnormal
—refer for formal audiometry testing
 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, financial hardship
 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
 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?
Clock Drawing Test

 Different Versions
 4 Point Scale Most Useful
 1 Point- Circle
 1 Point-Numbers
 1 Point-Hands/Arrows
 1 Point-Right Time
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
 <11 Not Depressed
 ≥11 Probable Depression
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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
• Urogenital: UTI, BPH, menopause, incontin, prolaps
• Cancers: breast, lung, prostate, cervical, haematol
• Spl senses & iatrogenic: eye, ear, taste, skin, ADRs
 Common Clinical Problems in
Geriatrics are Syndromes:
 Impotence  Immobility
 Incontinence  Instability
 Incoherence  Intellectual
impairment
 Irritable bowels
 Infection
 Insomnia
 Impairments
 Isolation  Inanition
 Immune  Iatrogenesis
deficiency  Illiteracy
UNCLASSIFIED SYMPTOMS IN OLD AGE

 Weakness
Low muscle strength

 Fatigue Body aches

 Anorexia Confusion

 Constipation Insomnia

 Altered taste Impotence

 Breathlessness Faints/ Falls

 “3 D’s” 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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 Dementia
 Dementia is a progressive decline in cognitive and
functional abilities with associated psychiatric disturbances.
 Normal aging leads to a slowing of performance but not
decreased cognition.
 8% of patients over 65 years old have dementia.

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 Delirium
1. Acute change in mental status and
2. 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
 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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