Geriatric Syndromes

Dr. Sri Sunarti, SpPD K-Ger

Divisi Geriatri dan Gerontology
SMF/Lab. IPD FKUB/RSSA Malang
the phrase "geriatric syndrome" to describe the
unique features of common health conditions in
older people that do not fit into discrete disease
categories
 What are they ?
• Conditions, not diseases
• Common in the elderly
• Typically:
Multifactorial
Share risk factors
Linked with functional decline, increasing frailty
and poor health outcomes
 objectives
Describe the prevalence and risk factors associated
with falls, gait abnormalities, incontinence, sleep
disorders and pressure ulcers in the elderly.

Identify the components of evaluation for the above

conditions: history and physical examination.

Discuss interventions for the above conditions in the

elderly.
 Geriatric Team

 Geriatrician
 Geriatric Nurse Practitioner
 Social Worker
 Clinical Nurse Case Manager
 Therapists (PT/OT)
 Other Geriatric Specialists
 Comprehensive Geriatric Assessment
 Screen for Depression: Geriatric Depression Scale (GDS)
 Screen for Cognition: MMSE, SLUMS (slide 9), Mini-Cog
 Functional Status: Activities of Daily Living (ADLs) and
Instrumental Activities of Daily Living (IADLs) (see slide 10)
 Mobility Status: Get Up and Go Test (see slide 11)
 Nutritional Assessment: Mini Nutritional Assessment
 Medication Review
 Comprehensive History and Physical Exam
 Functional Status

ADLs IADLs
 Bathing  Telephone
 Dressing  Traveling
Independent
 Toileting  Shopping
 Transfer  Preparing meals
 Continence Assistance  Housework
 Feeding  Repairs

Dependent Laundry
 Medication
 Money
 Get Up and Go Test
Ask the patient to perform the
following series of maneuvers:
1. Sit comfortably in a straight-
backed chair.
2. Rise from the chair.
3. Stand still momentarily.
4. Walk a short distance
(approximately 3 meters).
 Observe the patient's
movements for any deviation
from a confident, normal
performance. Use the
following scale:
 1 = Normal
 2 = Very slightly abnormal
 3 = Mildly abnormal
 4 = Moderately abnormal

5. Turn around.  5 = Severely abnormal

6. Walk back to the chair.  A patient with a score of 3 or

7. Turn around. more on the Get-up and Go is
8. Sit down in the chair. at risk of falling.
 History Taking and the Older Patient

Geriatric Syndromes
 Dementia- “Do you feel like you have a problem with memory?”
 Delirium- “Have you noticed a sudden change in behavior or
confusion?”
 Falls- “Have you had any falls recently” or “Do you fall
frequently?”
 Urinary Incontinence- “Are you able to make it to the bathroom
without any accidents”
 Depression- “Are you depressed?”
 Malnutrition- “How’s your appetite?” or “Do you feel hungry?”
or “How do you get your meals everyday?”
 Insomnia- “Do you have difficulty with sleep?”
Falls
Falls
 Complications of falls are the leading cause of death
from injury in adults over age 65
 33% of adults over age 65 report falling within the
past year
 Most result in minor soft tissue injuries
 10-15% result in fractures
 5% result in more serious soft tissue injury or head
trauma
 Cost is considerable – ED visits, admission surgery
etc.
Contributing Factors

 Age related changes

 Disease related effects
 Medication effects
 Environmental
Age related changes

 Visual decline
 Vestibular loss of hair cells, ganglion cells
 Postural control declines
 Muscle mass declines
 Baroreceptor and autonomic nervous system
efficiency decline
Disease related effects

 Acute systemic illness

 Parkinson’s
 CVA
 Osteoarthritis
 Neuropathy
 Visual impairments
Medication Effects

 Psychotropic Medications
 Benzodiazepines
 SSRIs
 Antipsychotics
 Cardiac – orthostatic hypotension
 Hypoglycemic agents
 Anticholinergics
Risk Factors

 Cognitive impairment
 Impaired mobility / gait / balance
 Fall history
 Acute or chronic illness
 Elimination problems
 Environmental factors
 Sensory deficits
 Medication
 Depression
 Use of assistive devices
 Frailty / deconditioning
 Fear of Falling
 Alcohol use
 Postural hypotension
Protective Factors Against Injury of
Fracture

Estrogen therapy
Weight gain after age 25
Walking for exercise
Adequate dietary calcium intake
Evaluation of a Fall

History

a. Activity at the time of the fall

b. Premonitary symptoms: light-headedness, palpitations, dyspnea, chest pain,

vertigo, confusion, incontinence, loss of consciousness, tongue biting

c. Location of fall

d. Witnesses to fall

e. History of previous falls (of same or different character); history of falls may be
difficult to elicit

f. Past medical history

g. Medications
Evaluation of falls
Physical examination

a. Visual acuity

b. Cardiovascular system: blood pressure, pulse (supine and standing), arrhythmia,

murmur, bruits

c. Extremities: arthritis, edema, podiatric problems, poorly fitting shoes, ROM

strength

d. Neurologic system: mental status testing, gait and balance assessment, i.e. the
timed “up and go” (patient rises from an arm chair, walks 3 meters, and returns to
chair—see scoring tables 6), walking, bending, turning, reaching, ascending and
descending stairs, standing with eyes closed

e. (Romberg test), sternal push

f. Injuries

g. Use of assistive devices

Interventions supported by medical literature
(see Intrinsic and Extrinsic Factors)

 Minimize medications
 Prescribe exercise strength training
 Treat visual impairments
 Manage postural hypotension
 Supplement Vitamin D 800IU/day
 Manage foot and footwear issues
 Assistive devices and supervision as needed
 Modify home environment
Gait Abnormalities

Demographics

• From 8-19% of non-institutionalized older adults have

difficulty walking or require the assistance of another person or
special equipment to walk.

• In older adults 85 and older, the incidence of gait

abnormality can be as high as 40% in non-institutionalized
patients and 60% in nursing-home residents.
Evaluation of Gait Abnormality
Disordered gait is not an inevitable consequence of aging, but rather a reflection of the
increased prevalence and severity of age-associated diseases.

The presence of slowed gait speed or deviations in smoothness, symmetry, or synchrony of

body movement may indicate that gait is disordered. However, they also may provide the older
adult with a safer, independent gait pattern. (GALS EXAMINATION)

Standardized assessment tools

o See the “Tinetti Balance and Gait Evaluation,”

o See the “Performance-Oriented Mobility Assessment (POMA)”
Treatment of Gait Abnormality

The management of gait abnormality includes improvement in

functional ability and treatment of specific diseases, however
many conditions causing a gait abnormality are only partly
treatable.

Substantial improvement occurs in the medical treatment of

disorders secondary to vitamin B12 and folate deficiency,
thyroid disease, knee osteoarthritis, Parkinson’s disease and
inflammatory polyneuropathy.

Moderate improvement, but with residual disability, can occur

after surgical treatment for cervical myelopathy, lumbar
stenosis, and normal-pressure hydrocephalus.
Urinary Incontinence
Definition : an involuntary loss of urine that is objectively demonstrable and
leads to a social or hygienic problem

Risk Factors :
Immobility
Diabetes
Impaired cognition
Stroke
Medications
Estrogen depletion
High-impact physical activities
Pelvic muscle weakness
Environmental barriers
Childhood nocturnal enuresis
Urinary Incontinence

 Affects 15-30% of adults over age 65

 Affects 60-70% of long term care residents
 Can lead to cellulitis, ulcerations, social
isolation, falls, institutionalization
 Improvements can be made with an
organized approach
Types of UI
 Urge
 Detrusor hyperactivity
 Stress
 Pelvic floor relaxation and increased intra-abdominal
pressure
 Mixed
 Incomplete emptying
 Dilated bladder with impaired contractility may also have
detrusor hyperactivity with impaired contractility
Evaluation
 Multifactorial
 Assess comorbidities, functional status and
medication effects
 U/A for hematuria and pyuria
 No routine culture. Positive culture may reflect
asymptomatic bacteriuria
 Consider post void residual
 PVR >300 should lead to assessment of renal function and
urology referral within 2 months
 PVR 200-300 evaluate renal function within 3 months
 PVR <200 maximize overall medical status
Management

 Behavioral
 Incontinence supplies
 Surgical
 Pharmacologic
 Catheters
 Insomnia
 Difficulty in initiating or maintaining sleep
 NOT excessive daytime sleepiness
 Usually due to a primary sleep disorder (sleep apnea,
narcolepsy, periodic limb movement disorder)
 Most commonly due to
 Psychiatric illness
 Pyschophysiologic problems

 Drug or Alcohol Dependence

 Restless Leg Syndrome
Insomnia
 Extremely common in community dwelling older
adults
 Difficulty falling asleep 40%
 Nighttime awakening 30%
 Early morning awakening 20%
 Daytime sleepiness 20%

 At least one half of community dwelling older adults

use OTC or prescription sleep medications
Age-Related Changes in Sleep

 Total sleep time decreases

 Time to fall asleep (latency) increase or no
change
 Sleep efficiency decreases
 Daytime napping increases
 Percent REM sleep decreases
 Wake after sleep onset increases
Common Causes of Sleep Problems

 30-60% associated with psychiatric disorders

(depression, anxiety)
 Pain
 GE Reflux
 Nocturia
 Periodic Limb Movements
 Sleep related breathing disorders
 Dementia
 Medication effects
 Treatment for Insomnia

 Alter the environment to make it less disturbing at night . . . minimize

night time lighting, sounds and procedures (labs and vitals) and make
the bed comfortable (the fewer restraints the better).
 Make sure the patient is active (not napping) during the day with
physical therapy, family, and volunteers to help keep the patient
company.
 Evaluate the medications and make sure the patient’s pain is well
controlled.
 Warm milk/tea, relaxing music/white sound, and massages can be
helpful.
 Safer medications for the geriatric population include low dose
Trazodone or Mirtazapine.
Non-Pharmacologic Treatment
 Sleep hygiene measures
 Regular times for sleep
 Bed for sleep only
 Exercise daily
 Relax before bed
 Limit food intake, stimulants, alcohol before bed
 Dark quiet environment, comfortable
temperature for sleep
 Exposure to bright light during the day
Non-Pharmacologic Treatment

 Behavioral techniques to emphasize sleep

hygiene
 Relaxation techniques
 Cognitive interventions
 Bright light therapy to correct circadian rhythm
disturbance
Pharmacologic Treatment
 Try non-pharmacologic measures
 Avoid benzodiazepines
 Associated with falls
 Rebound insomnia
 Sedation into the daytime
 Tolerance and withdrawal syndrome
 Short acting nonbenzodiazepine-benzodiazepine receptor agonists NBRA’s
(zaleplon, zolpidem, eszopiclone)
 Rapid onset take right before bed
 No rebound
 Only use 2-3 nights per week
 Sedating antidepressants (mirtazapine, trazodone) for patients with depression
 OTC Sleep Agents
 Avoid antihistamines - anticholinergic effects
 Melatonin – may be helpful
 Valerian no good evidence of efficacy
 Kava – risk of hepatotoxicity
Pressure Ulcers

Epidemiology

1. The prevalence varies widely as a function of care quality, venue,

patient population, and the rigor with which pressure ulcers are identified.

2. Prevalence of pressure ulcers in acute care ranges from 3% to 32%, with

an overall prevalence of 10%.

3. Prevalence in skilled care and nursing homes is estimated at

approximately 23%.

4. Incidence among all elderly people at home is less than 1%; however,
among those who receive nursing care in their homes, incidence is 4-5%,
with prevalence 10-15%.
Risk Assessment

1. Extrinsic Risk Factors: pressure, friction, shear, chemical

effects of moisture, urine, and stool.

2. Intrinsic Risk Factors: dermal thickness, subcutaneous

adiposity, collagen tensile strength, and skin elasticity all
decrease with aging; nutrition and hydration; conditions
associated with immobility, impairment of sensation and
reduced level of consciousness.

3. Assessment Tool (included): see the “Braden Scale for

Predicting Pressure Sore Risk”.
Pathophysiology

There are four physical factors that can lead to the development of pressure ulcers:

(a) Pressure – Mild pressure can produce ischemia in tissue after only two hours. This
ischemia can then lead to tissue necrosis.

(b) Shear – A shearing force is produced where the skin is against a fixed exterior surface
while the subcutaneous tissues are subjected to lateral forces.

(c) Friction – When the skin moves across another surface, abrasions can occur and cause
burns.

(d) Moisture – Moisture can lead to tissue maceration. If urinary

or fecal incontinence is present, this can add a chemical irritant.

 Skin Care and Early Treatment

a. Inspect the skin at least daily and document assessment results.

b. Individualize bathing frequency, use a mild cleansing agent, avoid hot water and excessive friction.
c. Assess and treat incontinence.

d. Use moisturizers for dry skin; minimize environmental factors leading to dry skin.
e. Avoid massage over bony prominences.

f. Use proper positioning, transferring and turning techniques to minimize skin injury.

g. Use dry lubricants (cornstarch) or protective coverings to reduce friction injury.

h. Identify and correct factors compromising protein / calorie intake and consider nutritional
supplement / support for nutritionally-compromised persons.

i. Institute a rehabilitation program to maintain or improve mobility / activity status.

j. Monitor and document interventions and outcomes

Mechanical Loading and Support Surfaces

a. Reposition bed-bound persons at least every 2 hours, chair-bound persons

every hour.
b. Use a written repositioning schedule.
c. Place at-risk persons on a pressure-reducing mattress/chair cushion. Do no use
donut-type devices.
d. Consider postural alignment, distribution of weight, balance and stability, and
pressure relief when positioning persons in chairs or wheelchairs.
e. Teach chair-bound persons, who are able, to shift weight every 15 minutes.
f. Use lifting devices to move rather than drag persons during transfers and
position changes.
g. Use pillows or foam wedges to keep bony prominences such as knees and
ankles from direct contact with each other.
h. Use devices that totally relieve pressure on the heels.
i. Avoid positioning directly on the trochanter when using the side-lying position.
j. Elevate the head of the bed as little and for as short a time as possible.
Education

a. Implement educational programs for the

prevention of pressure ulcers.

b. Include information on etiology and risk

factors, risk assessment tools, skin assessment,
support surfaces, skin care, positioning, and
documentation.
 STAGING OF PRESSURE ULCERS
(1 of 5)
Stage Definition
Suspected • Purple or maroon
deep tissue localized area of
injury discolored intact skin or
blood-filled blister due to
damage of underlying
soft tissue from pressure
and/or shear
• The area may be
preceded by tissue that is
painful, firm, mushy,
boggy, warmer, or cooler
than adjacent tissue
Staging according to the National Pressure Ulcer Advisory Panel
Comments
• Deep tissue injury can be
difficult to detect in individuals
with dark skin tones
• Evolution can include a thin
blister over a dark wound bed
• The wound can further evolve
and become covered by thin
eschar
• Evolution can be rapid and
expose additional layers of
tissue, even with optimal
treatment
 STAGING OF PRESSURE ULCERS
(2 of 5)
Stage Definition
Stage I • Intact skin with nonblanchable
redness of a localized area
usually over a bony
prominence
• Darkly pigmented skin may not
have visible blanching; its color
may differ from the surrounding
area
Stage II • Partial-thickness loss of dermis
presenting as a shallow open
ulcer with a red-pink wound
bed, without slough
• Can also present as an intact
or open/ruptured serum-filled
blister
Comments
• The area may be painful, firm,
soft, and warmer or cooler than
adjacent tissue
• Stage I can be difficult to detect
in individuals with dark skin
tones
• Presents as a shiny or dry
shallow ulcer without slough or
bruising (the latter indicates
suspected deep tissue injury)
• This stage should not be used to
describe skin tears, tape burns,
perineal dermatitis, maceration,
or excoriation
 STAGING OF PRESSURE ULCERS
(3 of 5)

Stage Definition Comments

Stage III • Full-thickness tissue loss • Depth varies by anatomic
• Subcutaneous fat can be location The bridge of the nose,
visible but bone, tendon, or ear, occiput, and malleolus do
muscle are not exposed not have subcutaneous tissue,
• Slough may be present but and Stage III ulcers can be
does not obscure the depth shallow
of tissue loss • In contrast, areas of significant
• Can include undermining adiposity can develop extremely
and tunneling deep Stage III pressure ulcers
Bone/tendon is not visible or
directly palpable
 STAGING OF PRESSURE ULCERS
(4 of 5)

Stage Definition Comments

Stage IV • Full-thickness • Depth varies by anatomic location
tissue loss with • The bridge of the nose, ear, occiput, and
exposed bone, malleolus do not have subcutaneous
tendon, or muscle tissue, and these ulcers can be shallow
• Slough or eschar • Stage IV ulcers can extend into muscle
can be present on and/or supporting structures (eg, fascia,
some parts of tendon or joint capsule), making
wound bed osteomyelitis possible
• Often include • Exposed bone/tendon is visible or
undermining and directly palpable
tunneling
 STAGING OF PRESSURE ULCERS
(5 of 5)

Stage Definition Comments

Unstageable • Full-thickness • Until enough slough and/or
tissue loss in which eschar is removed to expose the
the base of the base of the wound, the true
ulcer is covered by depth (and therefore stage)
slough (yellow, tan, cannot be determined
gray, green, or • Stable (dry, adherent, intact
brown) and/or without erythema or fluctuance)
eschar (tan, brown, eschar on the heels serves as
or black) in the “the body's natural (biological)
wound bed cover” and should not be
removed
 RISK FACTORS

 Intrinsic: physiologic factors or disease states that

increase the risk for pressure ulcer development
 Age
 Nutritional status
 Decreased arteriolar blood pressure

 Extrinsic: external factors that damage skin

 Pressure, friction, shear
 Moisture, urinary, or fecal incontinence
 FACTORS PREDICTIVE OF
PRESSURE ULCER DEVELOPMENT

 Age 70+  Many other disorders:

 Impaired mobility malignancy, diabetes,
 Current smoking stroke, pneumonia,
CHF, fever, sepsis,
 Low BMI
hypotension, renal
 Confusion failure, dry skin, history
 Urinary and fecal of pressure ulcers,
incontinence anemia, lymphopenia,
 Malnutrition hypoalbuminemia
 Restraints
 RISK ASSESSMENT INSTRUMENTS

Widely used tools for identifying older patients at

risk of developing ulcers:
 Norton scale
Sensitivity = 73%–92%, specificity = 61%–94%
 Braden scale
Sensitivity = 83%–100%, specificity = 64%–77%

Both are recommended by Agency for Healthcare

Research and Quality
 NORTON SCALE

Provides method for assessing a patient’s

pressure ulcer risk by evaluating:
○ Physical condition
○ Mental condition
○ Level of physical activity
○ Mobility
○ Continence or incontinence
 BRADEN SCALE

Provides method for assessing pressure ulcer risk

by evaluating:
 Sensory perception: ability to respond to pressure-
related discomfort
 Moisture: degree of exposure to moisture
 Activity: degree of physical activity
 Mobility: ability to change and control body position
 Nutrition: usual food intake

http://www.bradenscale.com/
 PREVENTION

An evidence-based approach to preventing

pressure ulcers focuses on:
○ Skin care
○ Nutrition
○ Mechanical loading
○ Mobility
○ Support surfaces
 PREVENTION: SKIN CARE (1 of 2)

 Daily systematic skin inspection and cleansing

 Especially bony prominences
 Use warm water and mild cleanser

 Reduce factors that promote dryness

 Avoid low humidity and exposure to cold
 Moisturize dry skin

 Avoid massaging over bony prominences

 PREVENTION: SKIN CARE (2 of 2)

 Reduce moisture
 Incontinence
 Perspiration
 Drainage

 Minimize friction and shear

 Use proper repositioning, turning, transferring
techniques
 Use lubricants, protective films, dressings, padding
 PREVENTION: NUTRITION

 Maintaining optimal nutrition continues to be part

of national pressure ulcer prevention guidelines
 However, the relationship between protein-calorie
malnutrition and its relationship with pressure
ulcer development is unclear

 Avoid over-supplementing patients who do not

have protein, vitamin, or nutritional deficiency
 Review goals of care prior to considering enteral
or parenteral nutrition
 PREVENTION:
MECHANICAL LOADING

 Reposition at least every 2 h (may use pillows, foam

wedges)
 Use lubricants and protective dressings/pads
 Keep head of bed at lowest elevation possible
 Use lifting devices to decrease friction and shear
 Remind patients in chairs to shift weight every 15 min
 “Doughnut” seat cushions are contraindicated, as
they may cause pressure ulcers
 Pay special attention to heels (account for 20% of all
pressure ulcers)
 PREVENTING HEEL ULCERS (1 of 2)

 Assess heels of high-risk patients every

day
 Use moisturizer on heels (no massage)
twice a day
 Apply dressings to heels:
 Transparent film for patients prone to friction
problems (eg, stroke patients)
 Single or extra-thick hydrocolloid dressing for
those with pre-stage I reactive hyperemia
 PREVENTING HEEL ULCERS (2 of 2)

 Have patients wear:

 Socks to prevent friction (remove at bedtime)
 Properly fitting sneakers or shoes when in wheelchair

 Place pillow under legs to keep heels off bed

 Turn patients every 2 hours, repositioning heels
 MANAGEMENT: DRESSINGS (1 of 3)

 Transparent film: stage I, protects from friction

Contraindicated: draining, suspected infection or
fungus
 Foam island: stages II, III
Contraindicated: excessive exudate; dry, crusted
wound
 Hydrocolloid: stages II, III
Contraindicated: poor skin integrity, infection, wound
needs packing
 Petroleum-based nonadherent: stages II, III, graft sites
 MANAGEMENT: DRESSINGS (2 of 3)

 Alginate: stages III and IV, excessive drainage

Contraindicated: dry or superficial wound with
maceration
 Hydrogel, amorphous: stages II, III, IV; must combine
with gauze dressing
Contraindicated: maceration, excess exudate
 Hydrogel, sheet: stage II, skin tears
Contraindicated: maceration, moderate to heavy
exudate
 MANAGEMENT: DRESSINGS (3 of 3)

 Gauze packing: stages III, IV

Contraindicated: deep wounds, especially those with
tunneling, undermining

 Consider silicone-based dressings to decrease pain

 Silver dressings: malodorous wounds, exudative wounds,
and those highly suspicious for critical bacterial load
Contraindicated: systemic infection, cellulitis, fungus,
interstitial nephritis, skin necrosis, concurrent use with
proteolytic enzymes
 MANAGEMENT: NUTRITION

 Ensure adequate diet; prevent malnutrition

 Weak evidence for nutritional support that
achieves 30 to 35 calories/kg/day and 1.25 to
1.5 g of protein/kg/day
 Weak evidence for supplemental vitamins
and minerals
 MANAGEMENT: SURGICAL REPAIR

 May be used for stage III and IV ulcers

 Direct closure, skin grafting, skin flaps,
musculocutaneous flaps, free flaps

 Risks and benefits of surgery must be carefully

weighed for each patient:
 Many stage III and IV ulcers heal over a long time
with local wound care
 Rate of recurrence of surgically closed pressure
ulcers is high
 MANAGEMENT:
ADJUNCTIVE THERAPIES

 No data to support low-energy laser irradiation,

therapeutic ultrasound, hyperbaric oxygen
 Promising research continues:
 Recombinant platelet-derived growth factors
 Electrical stimulation
 Vegetative pressure wound therapy
 SUMMARY

 Older adults are at high risk of developing

pressure ulcers
 Pressure ulcers may result in serious morbidity
and mortality
 Techniques that reduce pressure, moisture,
friction, and shear can prevent pressure ulcers
 Pressure ulcers should be treated with proper
cleansing, dressings, debridement, or surgery as
indicated
Terimakasih
Semoga Manfaat