Geriatric Medicine

 What age?
 Why is it important?
 Aging Physiology
 Aging Pharmacology
Geriatric Medicine

 Geriatric Medicine involves care of

patients 65 and older

 How does it differ from Internal or Family

Medicine?
Differences
 Multiple illnesses  DM
 Unique mode of
presentation of illness
 HTN
 Multiple illnesses
together make Syndromes
 Elderly attribute a lot of  OA Fall
symptoms to old age and
not disease
 Marginal reserves
 BPH

 Cataracts
Differences

Changing
 Physiology

 Pharmacology

 Pathology

 Performance-functioning

 Perceptions

 Position----(social status/structure)

 Plan ( treatment)
H& P in Geriatrics
 Birth, childhood and at times family history
redundant
 Functional histories extremely important
 Corroboration essential at times
 Detailed drug histories
 Detailed ROS
 Exam has to focus on functional assessments
and involves special tests
Why is all this important?
Demographics
 Rapidly changing
 Increasing life spans
 Decreased mortality both perinatal and old
age

Life expectancy Males Females

19th century 45 49
2001 USA/UK 76 81
2004 Pakistan 63 65
Demographics
 Squaring of the Population Pyramid
 80s is the fastest growing decade in the
west

 Currently 5% of our population is elderly

 By 2012 12% will be elderly (WHO)
 2006-2008 figures show 16-18% of AKU
admissions are of 65 and older
CNS
 10%loss of neurons

 Demyelination

 Delayed nerve
conduction

 Decreased sensory
input
Special senses -Eye

Lens thickens

Pupil size reduced

Reduced depth perception

Macula degenerates
Special senses- Ear

Wax drier

Stiffness of ossicles

Cochlear and central

degeneration
Special Senses-Taste

 Loss of taste buds

CVS
Arterial stiffness

Decreased baroreceptors

Decreased conduction

LVH

Decreased blood flow

Respiratory
Weaker cough reflex

Chest wall stiffness

Decreased elastic recoil

Inc V/Q mismatch

GIT
Dental decay

Decreased acid

Gut slowing

Reduced absorption small

intestine

Reduced liver blood flow

Musculoskeletal
30% muscle lost

Joint degeneration

Increased bone
reabsorbtion

Decreased bone formation

Renal
10% decline in Creatinine
clearance/decade after 30

nephron loss

Decreased blood flow

Endocrine
Decreased Glucose
uptake
Decreased Insulin
release
Inc PTH
Decreased reproductive
hormones
Skin
Decreased

Elasticity

Gland activity

Sub Q fat

Nail bed function

Immune
Decreased interleukins

Declining Antibody levels

Impaired cellular immunity

Physiologic Effects
 CNS- minor forgetfulness, decreased sleep,
numbness in feet
 Special senses- decreased sight, hearing(esp.
high freq), smell and taste
 CVS- orthostatic BP drop,diminished exercise
capacity,rhythm changes
 Respiratory- weaker cough reflex, less
mucociliary clearance
 GIT- dry mouth, loss of appetite, constipation,
vit defeciencies
Physiologic Effects-CNS

10%loss of neurons Minor forgetfulness

Demyelination Decreased sleep

Delayed nerve Slower reflexes

conduction

Decreased sensory input Numbness in feet

Physiologic Effects-Special Senses
Lens thickens Decreased sight
Pupil size reduced Decreased central vision
Reduced depth perception
Macula degenerates

Wax drier Wax impaction

Stiffness of ossicles Hearing (esp. high freq)
Cochlear and central
degeneration

Loss of taste buds Smell and taste

Physiologic changes-CVS
Arterial stiffness Widened pulse pressure

Decreased baroreceptors
Orthostatic BP drop

Decreased conduction
Rhythm changes
LVH
Diminished exercise
Decreased blood flow capacity
Physiologic changes-Resp

Weaker cough reflex Less mucociliary clearance

Chest wall stiffness Decreased FEV1

Decreased elastic recoil Decreased Vital Capacity

Inc V/Q mismatch Increased dead space

Physiologic changes-GIT
Dental decay /loss of taste Dry mouth
Loss of appetite
Decreased acid

Gut slowing Constipation

Reduced absorption small Vitamin deficiencies

intestine

Reduced liver blood flow Cytochrome P450

Physiologic changes-MS
30% muscle lost Reduction in physical activity
Dexterity
Endurance

Joint degeneration
OA

Increased bone reabsorbtion

Decreased bone formation Osteoporosis
 Physiologic changes-Renal

10% decline in Creatinine

clearance/decade after 30

Nephron loss Decreased Creatinine

clearance
Decreased blood flow
Physiologic changes-Endocrine
Decreased Glucose uptake Glucose intolerance
Decreased Insulin release

Inc PTH Osteoporosis

Decreased reproductive Pelvic floor weakness

hormones
Physiologic changes-Skin
Decreased
Dry skin
Elasticity
Sub Q fat
Decreased sweating
Gland activity

Nail bed function

Thick nails
Physiologic changes- Immune

Decreased interleukins

Declining Antibody
Increased risk & poor
levels
response infections
(for e.g. fever)
Impaired cellular
immunity
Pharmacology
 Altered Pharmacokinetics

 Altered Pharmacodynamics

 Altered BBB

 Altered Hepatic and Renal Function

Pharmacokinetics
Absorption:
 Reduced gastric acid and emptying

 Reduced subcutaneous fat

Distribution:
Circulation changes
Decreased lean body mass
Increased fatty tissue
Pharmacokinetics
Metabolism:
 Reduced liver mass, blood flow

 Reduced enzyme activity

 Decreased plasma proteins

Excretion:
 Reduction in nephrons, blood flow

 Decreased GFR
Aging Pharmacology

 Multiple medications (Polypharmacy)

 More adverse effects

 More interactions
 100

percent of patients with ADR

10

1
0 2 4 6 8 10 12 14 16 18 20
number of drugs taken
Aging Pharmacology

 Rule of prescribing “ Start low and go

Slow”

 20% of all hospitalizations in elderly are related

to drugs they use!
Aging Pharmacology
 Ask patients to bring in meds not just prescriptions

Caution with use of

 All Anti

Cholinergics, Convulsants, Depressants, Histamines

Psychotics

 Benzodiazepines
Pharmacodynamics

 Altered cell receptor responses

 Greater CNS effects
 Increased Nephro and Hepatotoxicity
Case
 A 75 yr old male presents with falls.

What pertinent information do you need?

What physiologic/pathologic changes maybe

contributing to his falls?
Case

 He takes 7 medications which he takes all

together in the am.
 Occasionally skips when cant buy them

 What problems should you look for?

 What solutions can you offer?