What is Geriatric Medicine ?

 Geros – Iatrea
(old age) (to care)

 Definition
Geriatric medicine is a branch of general
internal medicine,
concerned with the clinical, preventive,
remedial and psycho-social aspects,
of health and disease in the elderly
(British Geriatric Association)
 Why Geriatric Medicine ?

 Changing demographic patterns

→ rapid increases in numbers of elderly people

 Radical improvement in public health :

 Spectacular reduction in infant mortality
 Elimination of infectious diseases

 Nutrition

 Environment

“to live to be old”

“Children are not just small adults,
as well as the elderly,
are not just older adults”

( Warren, M. et al, 1927 )

 Who is a Geriatric Patient ?
 Age ≥ 60 yrs

Characteristics of diseases in the elderly

 Etiology
 Endogenous
 Occult
 Multiple pathologic
 Cumulative
 Onset
 Asymptomatic
 Insidious
 Course
 Chronic
 Progressive (long disability prior to death)
 Not protective (increased vulnerability to other diseases)
 Great individual variation
 Psycho-social issues
 Polypharmacy (iatrogenic diseases)
 ILLNESS IN THE ELDERLY

YOUTH SENESCENCE
Etiology : Exogenous Etiology : Endogenous
Obvious Occult
Specific (single) Cumulative
Recent Multiple (superimposed)

Onset : Florid vs Onset : Insidious, asymptomatic

Course : Acute Course : Chronic

Self-limited Progressive (long disability death )

Immunizing Not protective (increased vulner-

ability to other diseases)
Little Individual variation Great individual variation
 Geriatric Giants

1. Cerebral Syndrome
2. Acute Confusion
3. Autonomic Disorders
4. Incontinence
5. Fall
6. Diseases of the Bone & Fracture
7. Pressure Ulcer
( Brocklehurst’s text book of Geriatric
Medicine and Gerontology, 1987,2004 )
* CEREBRAL SYNDROMES

 SYNDROMES DUE TO CEREBROVASCULAR

DISEASE
 ARTERIAL DISEASE

GREATEST SINGLE CAUSE OF MORBIDITY AND

DISABILITY IN THE ELDERLY
CEREBRAL CIRCULATION
 FOUR PILLARS
a. CAROTIS INTERNA
b. VERTEBRALIS
CERVICAL SPONDYLOSIS

DISC DEGENERATION CHANGES IN CERVICAL SPINE AS A

RESULT OF DISC DEGENERATION
NORMAL VALUES OF CEREBRAL BLOOD-
FLOW
CEREBRAL BLOOD FLOW

AGE
CHILD : 100 cc/100 gr/min
ADULT : 50 cc/100 gm/min
OLD AGE : 35 cc/100 gm/min

. DECREASE WITH INCREASING INTELECTUAL IMPAIRMENT

. CEREBRAL AUTOREGULATION (PROTECTIVE MECHANISM)
5 % > 65 YRS
20 % > 80 YRS
(47 % > 85 YRS)

VASCULAR DEMENTIA : - ASSOCIATED WITH CVD

- OVERLAP WITH AD
 VASCULAR DEMENTIA
Necessary Clinical course of sudden deterioration or fluctuation
features Dementia following stroke
Focal neurological signs
Infarcts in appropriate brain region on CT
Periventricular lucency (PVL) on CT

Supporting
Urinary incontinence, gait disorder
features
History of hypertension
Transient ischaemic attacks

Possible
vascular Stroke but not related in the time to dementia
dementia Neuroimaging unavailable
Gait disorder / incontinence + vascular risk factor + PVL

Clinical features of vascular dementia (National Institute of

Neurological and Communicative Disorder and Stroke, 2006)
 Dr. Alois Alzheimer
The most devastating & dehumanizing
among late – life illness
 Damage the ability to think, communicate and
perform
 STROKE

 CLEARLY A DISEASE OF
THE ELDERLY, RISES
STEEPLY WITH AGE
 > 75 % OCCURS IN THE
AGED
A Simple Pathological Classification of Stroke
 Primary Prevention
The “Big Five”
 Hypertension
 Smoking
 Lack of physical exercise
 Atrial fibrillation
 Diabetes Mellitus

Healthy Life Styles

 Treatment of Acute
Complication
 Ischaemic oedema
 Aspiration & pneumonia

 Urinary tract infection

 Pulmonary embolism & DVT

 Decubital ulcer

 Seizures
 Spesific Treatment
 Recanalizing therapy
 Anti thrombotic therapy
 Neuro protectants :
currently, no recommendation of these
agents, ( Indonesian Stroke Guideline,
2004 : controversial).
 DROP ATTACK

 A FALL OCCURS WITHOUT WARNING

 NO LOSS OF CONSCIOUSNESS
 UNABLE TO GET UP
 * 5-20 % OF THE ELDERLY IN THE COMMUNITY
* 30-50 % OF ELDERLY PATIENTS

DEFINITION :
A SYNDROME IN WHICH NORMAL COHERENCE OF THOUGHT AND ACTION IS
LOST.
CONFUSION : WHAT IS IT ?
Attentional deficit • to internal/external stimuli
• unable to selectively respond
- distractable
- rigid
• unable to order input
- spatial
- memory
and
Cognitive disorder • unable to order input
- errors
- misinterpretations
with
Acute onset (hours to days) and fluctuating course
 ACUTE CONFUSION

TOXIC CAUSES FAILURE OF HOMEOSTATIC MECHANISM OTHER CAUSES

Infection Diabetes Mellitus Urinary retension

esp Chest infections Ketoacidosis, lactic acidosis
Urinary tract infection And hypoglycaemia Severe pain
Subacute bacterial
endocarditis Hepatic Failure Sudden sensory deprivation
Cellulitis, boils, etc (e.g blindness)
Electrolyte imbalance
Septicaemia and Hyponatraemia, hypokalaemia Change of environment
toxaemia And hyperkalaemia
Alcoholism
Alcoholism Hypothermia
Paralytic ileus
Dehydration
Depression
Myxoedema hyperthyroidism
Carcinomatosis
Pyrexia
Faecal impaction

Insomnia
CEREBRAL CAUSES Drug induced
 COMMON CAUSES OF CONFUSION & MANAGEMENT
CONT.”
CEREBRAL CAUSES ACUTE CONFUSION

SUDDEN REDUCTION
OF BRAIN NUTRITIONAL
INTRA-CEREBRAL CAUSES SUPPLY

CARDIOVASCULAR RESPIRATORY IATROGENIC AND

CAUSES CAUSES OTHER CAUSES
Hypertensive encephalopathy
Cerebral oedema Chest infections Potent hypotensive
Myocardial infarction
Transient ischaemic attacks Pneumonia agent
Acute coronary ischaemia
Cerebrovascular accidents Bronchopneumonia Bleeding
Arrhytmias
Rapidly growing space Pulmonary embolism and anaemia
Cardiac failure
Occupying lesions Obstructive airways disease Hypoglycaemia
Others
Hydrochepalus Others Poisoning
Subacute bacterial
Vit B12 deficiency Bronchiectasis
endocarditis
Wernicke’s encephalopathy Myocarditis Lung abscess
Korsakoff’s psychosis Pericardial effusion Pleural effusion
Meningitis/encephalitis Failed pacemaker Pneumothorax
Abuse of sedatives Malignant hypertension
Tranquillizers/hypnotics Drugs
Potent hypotensives
Digoxin toxicity
Anti-arrhythmic drugs
HYPOTHALAMUS
CENTRE OF THE AUTONOMIC NERVOUS
SYSTEM

- POSTURAL HYPOTENSION
- BLADDER DYSFUNCTION

- DIFFICULTY IN SWALLOWING

- ACCIDENTAL HYPOTHERMIA

- etc
 REGULATION OF BODY TEMPERATURE
Warm Cold
environment environment
Stimulation of
temperature-
sensitive cells
Cutaneus Temperature regulating centre Cutaneus cold
warmth HYPOTHALAMUS Temperature
Temperature receptors
receptors Anterior Posterior

Increase heat loss Increase heat production

Cutaneus vasodilatation Shivering
Sweating Hunger
Increase respiration Increase secretion of TSH,
epinephrine and
nor-epinephrine
Increased voluntary activity
Decrease heat production
Anorexia Decrease heat loss
Apathy and inertia Cutaneus vasoconstriction
Decrease secretion of TSH Curling up
Horripilation
 * BODY TEMPERATURE LESS THAN 350 C
- 10 % OF OLD PEOPLE (IN THE WINTER)
- MORTALITY RATE 50 %

CLINICAL PRESENTATION
MANAGEMENT
TEMP. 32 C-35 C: MORTALITY RATE 30%
320C-350 * SLOW WARMING
- FATIGUE, APATHY, WEAKNESS - ACTIVE EXTERNAL RE-WARMING
- SLOWNESS OF GAIT, COOL SKIN - CORE REWARMING
- CONFUSION, SLURRED SPEECH
+ HYDROCORTISONE
- SHIVERING ?
TRI-IODOTHYRONINE
TEMP. 280C-320C : MORTALITY RATE 70%
+ HYPOPNEA, CYANOSIS “ NO ONE IS DEAD
+ ARRHYTHMIAS UNTIL
+ HYPOTENSION WARM AND DEAD”
+ COMA
TEMP. < 280C : MORTALITY RATE + 100
%
x RIGID & UNRESPONSIVE
x VENTRICULAR FIBRILLATION
x APNEA
 HIPOTENSI ORTOSTATIK

 Hipotensi postural

 Penurunan tekanan sistolik dan

/diastolik  20 mmHg
dari sikap berbaring ke sikap tegak,
setelah 2 menit
 Prevalensi 20 – 30 % pada usia > 65 th
 Urinary Incontinence : What is it ?
 A classic syndrome in geriatric medicine
 Persistent myth : normal consequence of
aging
 Age related changes predispose to UI
 Bladder capacity 
 Residual urine 
 Involuntary bladder contractions 
 An unpleasant, anti social condition
 A socially embarrasing condition
 Withdrawal from social activities
 Reduced quality of life

 Important implications: economic,

medical, psychosocial
 Definition International Continence Society (2004)

A condition in which involuntary loss

of urine is a social or hygienic problem
and is objectively demonstrable
 Prevalence
 Increases with age, female > male
( 2x) until age 80, equally affected
 15 – 35 %,  60 years, living in the
community
 Home bound elderly  50 %
 Hospitalized,  60 %

( ICS, 2001)
Classification of Geriatric Incontinence

 Transient :
Delirium or confusional state
I nfection, urinary
Atrophic vaginitis or urethritis
Pharmaceuticals
Psychologic, esp. severe depression
Excessive urine output (DM, CHF)
Restricted mobility
Stool impaction
BASIC UNDERLYING CAUSES OF
GERIATRIC
URINARY INCONTINENCE
Urologic Neurologic

Functional/ Iatrogenic/
psychological environmental

ACUTE & REVERSIBLE URINARY INCONTINENCE

D Delirium
R Restricted mobility, retention
I Infection,* inflammation,* impaction (fecal)
P polyuria, pharmaceuticals
BASIC TYPES OF PERSISTENT URINARY INCONTINENCE
Urge Stress

Functional Overflow
 Established / Persistent
 Detrusor overactivity (urge incontinence)
 Detrusor under activity (overflow in
continence)
 Urethral incompetence (stress
incontinence)
 Urethral obstruction

 Functional incontinence : unable to use

the toilet due to a physical disability or
intelectual problem
 Normal Function

Storage phase Emptying phase

Altered function

Top : Normal bladder physiology

Botton : Pathophysiology underlying established causes of UI
Fall :

 The true geriatric giant

 30 – 50% ≥ 65, in the community, female >
male
 ≤ 10% result in fracture ( hip fracture )
 May be a non spesific presenting sign of acute
illness / acute exacerbation of a chronic disease
 Psychologic impact of a fall : post fall anxiety
 Fear of falling → activity restriction,
dependance, increasing immobility
→ Further risk factors → Greater risk of
falling
 FALL (S)
- THE TRUE GERIATRIC GIANT
- + 1/3 > 65 YRS, FALL EVERY YEAR

- FRACTURE, FEAR OF FALLING AGAIN

MULTIFACTORIAL CAUSES OF FALLS
INTRINSIC FACTORS EXTRINSIC FACTOR
Medical and neuropsychiatric Medication
conditions

Inpaired vision Improper prescription

and hearing FALLS and/or use of
assistive devices for
Age-related changes ambulation
in neuromuscular
function, gait and Environmental
postural reflexes hazards

KANE et al. 1995

MANAGEMENT FOR ELDERLY PATIENTS WITH FALLS

Assess and treat physical injury
Treat underlying conditions Alter the environment*
Provide physical therapy and education Safe and proper-size furniture
Gait retraining Elimination of obstacles (loose rugs, etc.)
Muscle strengthening Proper lighting
Aids to ambulation Rails (Stairs, bathroom)
Properly fitted shoes
Adaptive behaviors
 Cycle of Osteoporosis
Fall

Old Age Osteoporosis Fracture

Immobility

 Strong association : Osteoporosis, Fall,

Fracture
 must be managed together
 Preventing both : osteoporosis & fall
 BONE DISEASE AND FRACTURE
OSTEOPOROSIS
- AFFECTS NEARLY 30 % OF THE ELDERLY (FEMALE
POPULATION)
- MAJOR RISK FACTOR OF FRACTURES

TWO BASIC TYPES OF AGE RELATED OSTEOPOROSIS

Type I (postmenopausal) Type II (senile)

Age (years) 51-75 >70

Sex ratio (F:M) 6:1 2:1
Type of bone loss Mainly trabecular Trabecular and cortical
Rate of bone loss Accelerated Not accelerated
Fracture sites Vertebrae (crush) and Vertebrae (multiple wedge)
distal radius and hip
Parathyroid function Decreased Increased
Calcium absorption Decreased Decreased
Metabolism of 25-OH-D to Secondary decrease Primary decreased
1,25-dihydroxy vitamin D

CLASSICAL OSTEOPOROTIC FRACTURES

-SPINE
-WRIST
-HIP
MANAGEMENT OF PATIENTS WITH ESTABILISHED OSTEOPOROSIS
-TREATMENT OF ACUTE FRACTURE PHYSICAL THERAPY (Rehabilitation)
- MEDICATIONS PREVENTION
REKOMENDASI PENGOBATAN OSTEOPOROSIS
Kelompok resiko tinggi Patah tulang dengan
Atau faktor resiko Rudapaksa minimal atau
Kekurangan massa tulang

Merubah gaya hidup

Diet, latihan fisik, merokok

Pengukuran kepadatan tulang

(Bone Densitometri)

Diatas + 1 SD +1SD to – 1 Sd -1SD to – 2.5 SD Dibawah –2.5 SD

Ulang 5 th lagi Ulang 1 th lagi Estrogen

Estrogen Bisfosfonat Kalsitriol Kalsitonin

Sumber : Harry Isbagyo. (IRA). Penatalaksanaan osteoporosis

 Pressure Ulcer
Working Definition :

“An area of localized damage,

to the skin and underlying tissue,
caused by pressure, shear, friction,
and or a combination of these”
(European Pressure Ulcer Advisory Panel, 1998)
 IMOBILITAS & DEKUBITUS

•AREA OF THE BODY IN •SHEARING FORCE

CONTACT WITH VARIOUS
SURFACES
Epidemiology

Estimates of Pressure Ulcer Incidence

 Up to 60% in high risk groups
 The elderly
 Spinal cord injured patients
 2% - 29% in acute care institutions

 3% - 38% in long term care settings

 6% - 29% among those receiving home health care

 2/3 of pressure ulcer occur in patients older than

70 yrs
 Classification System of Pressure Ulcer

Modification of Shea Classification System

 Stage I :
Non blanchable erythema of intact skin
 Stage II :
Superficial partial thickness skin loss
 Stage III :
Full thickness skin loss, underlying fascias
 Stage IV :
Full thickness skin loss, extensive destructions
National Pressure Ulcer Advisory Panel ( 1989 )
European Pressure Ulcer Advisory Panel ( 1998 )
 Multidisciplinary Approach
Stage I & II
 Internist / Geriatrician
 Rehabilitation Medicine specialist
 Psychiatrist
 Psychologist
 Dietitian
 Social worker
Stage III & IV :
usually need a surgical approach

Consultations
 General surgeon
 Plastic surgeon
 Orthopedic surgeon
 Urologist
 Neuro surgeon
 Education
Education on pressure ulcer prevention
 Patients

 Family

 Care givers

 Health care providers

High recurrence rates, as high as 90% in a

healed wound
(Wilhelmi B.J. 2006)
“ we are not getting older
we are getting better”

Thank you