Overview of Geriatric Medicine

1. Overview of Geriatric Medicine Marian Suarez, M.D.

2. GERIATRIC OVERVIEW • GERONTOLOGY • Study of aging • GERIATRICS • Involves the health and social care of the elderly

3. Sub-discipline within geriatrics specifically devoted to medical care of the elderly GERIATRIC MEDICINE

4. GERIATRIC MEDICINE • Defined in several ways • Nature of its clientele • US: > 65 years old • England: 75 years old • Care of chronically disabled patients • < 65 years old

5. GERIATRIC MEDICINE • By its emphasis upon specific problem complexes ( “The 5 I’s” ) • Iatrogenic disease • Incompetence (mental) • Incontinence • Immobility • Impaired homeostasis

6. “Think of your oldest, sickest, most complicated and frail patient.” William H. Hazzard What is the typical geriatric patient?

7. WORLD DEMOGRAPHICS(US Bureau of Census, International Database, 1996) Merck Manual, Geriatrics, 1999 • Growth of 65+ • Increase dramatically 1996-2025 • % of ≥ 60 years old expected to increase from 17% to 82% in Europe • About 200% in developing countries • Italy and Japan expected to have high proportion of person ≥ 60 years old • 1/3 of the population

8. WORLD DEMOGRAPHICS(US Bureau of Census, International Database, 1996) Merck Manual, Geriatrics, 1999 • China and India • Has the largest total population • Will have the largest absolute number of elderly • 2020: expected to have > 1 billion persons ≥ 60 y/o Most will be living in developing countries • 85 y/o and over: “ oldest old” will increase to 18 million by 2050 • Centenarians will increase from 57,000 persons (1996) to 447,000 (2040)

9. WHAT’S DIFFERENT ABOUT OLDER PATIENTS? • Heterogeneity of health status • Physiologic changes • Increased prevalence of disease • Tendency to have multiple diseases • Under reporting of symptoms • Atypical presentation of common diseases • Increase importance of social support • Increase rates of adverse effects to medications and therapies • Different goals of therapy

10. Goals of Care in Geriatrics • Care vs. Cure • Improvement or maintenance of functional status • Prevention of iatrogenic illness • Comfort for terminally ill

11. Aging is a progressive, predictable process that involves evolution and maturation until death.

12. “Aging changes” = disease + disuse + normal aging Physiologic function changes observed with advancing age, approximately 1/3 is due to disease, 1/3 to disuse, and 1/3 to normal aging.

13. Rate of change varies greatly among individuals.

14. SELECTED ANATOMIC AND PHYSIOLOGIC CHANGES WITH AGING, HEALTHY ADULTS

15. SELECTED ANATOMIC AND PHYSIOLOGIC CHANGES WITH AGING, HEALTHY ADULTS

16. Adapted from Physiology of Aging, A synopsis, 1982 Normal Human Aging, The Baltimore Study of Aging, NIH Published 1984

17. AGE RELATED ALTERATIONS IN PHYSIOLOGY: IMPACT ON DRUG METABOLISM

18. HEALTH ASSESSMENT OF THE OLDER ADULT SHOULD INCLUDE: • FUNCTIONAL ASSESSMENT • Activities Of Daily Living (ADL’s) • Bathing • Grooming • Dressing • Toileting • Ambulating • Eating • Transferring

19. HEALTH ASSESSMENT OF THE OLDER ADULT SHOULD INCLUDE: • INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL’s) • Handling of finances • Using a telephone • Transportation • Shopping • Meal preparation • House keeping • Taking medications

20. HEALTH ASSESSMENT OF THE OLDER ADULT SHOULD INCLUDE: • LIVING SITUATION • Own home? • Alone / with caregiver • Home set up • MULTI-DISCIPLINARY APPROACH FOR PRESERVATION OF FUNCTIONS • Consult PM and R • PT / OT • Home care

21. SPECIFIC GERIATRIC SYNDROMES • Dementia • Multiple etiologies • Degenerative • AD/PD/Pick’s disease • Vascular • MID • Infectious • Jakob-Kreutzfeldt Disease • AIDS • Toxic • EtOH • Metabolic • B12/ thyroid deficiencies

22. SPECIFIC GERIATRIC SYNDROMES • DELIRIUM • Disorganized thinking • Hypersomnolent / hyperactive • Develops over short period of time and fluctuate over course of day • ETIOLOGY: • Drug toxicity • Infectious • Metabolic disturbances • Hypoxia

23. SPECIFIC GERIATRIC SYNDROMES • INCONTINENCE • Involuntary leakage of urine • Reversible causes: • Mnemonic DIAPPERS D – delirium I – infection A – atrophic urethreitis/vaginitis P – pharmaceuticals P – psychiatric disorders ( depression) E – excessive urine output (hyperglycemia) R – restricted mobility S – stool impaction

24. SPECIFIC GERIATRIC SYNDROMES • OSTEOPOROSIS AND OSTEOMALACIA • Primary type due to menopause and age-related changes • Others: • Endocrine: diabetes, hyperparathyroid • Drug related (steroids) • Malignant

25. SPECIFIC GERIATRIC SYNDROMES • FALLS AND FRACTURES • Usually due to gait disturbance • Multiple causes: environmental, medical illness, medication side effects • Fractures: 90% result from falls

26. SPECIFIC GERIATRIC SYNDROMES • PRESSURE ULCERS 4 STAGES • Stage 1: Non-blanchable erythema • Stage 2: partial thickness involving epidermis • Stage 3: full thickness involving subcutaneous tissue • Stage 4: full thickness to muscle or bone PREVENTION IS THE BEST TREATMENT

27. SPECIFIC GERIATRIC SYNDROMES • POLYPHARMACY • Average elderly has  4 prescription medications, average NH resident takes over 8 meds • “Beer’s Criteria” – listing of inappropriately used drugs

28. SPECIFIC GERIATRIC SYNDROMES • SLEEP DISORDERS • Disturbed sleep • decrease continuity • daytime sleepiness are common complaints of elderly

29. C0MMON DISEASES IN THE GERIATRIC POPULATION • CARDIOVASCULAR DISEASE • Hypertension • Syncope and orthostatic hypotension • PVD (Peripheral Vascular Disease) • Coronary artery disease remains most common cause of death ≥ 65 • Degenerative valvular disease (AS) • CHF

30. C0MMON DISEASES IN THE GERIATRIC POPULATION • MUSCULOSKELETAL DISORDERS • Most Common: • OA • RA • Polymyalgic rheumatica • Gout • Bursitis • Tendinitis • Back pain • Lumbar stenosis • Cervical spondylosis

31. C0MMON DISEASES IN THE GERIATRIC POPULATION • NEUROLOGIC DISORDERS • Stroke • infarcts • hemorrhage • Dizziness • Parkinson’s Disease

32. C0MMON DISEASES IN THE GERIATRIC POPULATION • INFECTIOUS DISEASE • Aging itself compromises a host’s resistance to infections • Diagnostic Approach in the Elderly: summed up with 3 basic principles: • Infection must be considered in differential diagnosis of an older person with unexplained rapid decline in function • Fever generally caused by a serious infection (often bacterial) • 20-30% of older patients with bacteremia, pneumonia, UTI, intra-abdominal infection, or TB have no fever.

33. C0MMON DISEASES IN THE GERIATRIC POPULATION • RESPIRATORY DISEASES • COPD • Chronic cough ? Drugs – ACE INHIBITORS

34. C0MMON DISEASES IN THE GERIATRIC POPULATION • GI DISORDERS • PUD 2º to NSAID use • Diarrhea 2º to fecal impaction, intestinal obstruction, laxative abuse, lactate deficiency, colon cancer

35. 3. Constipation: usually painless and associated with increased transit time 4.Acute abdominal emergencies • Cholecystitis, cholangitis, intestinal obstruction 2º to hernia, adhesions, cancer, perforated diverticulitis, PUD, AAA • Emergency surgery associated with a mortality rate 15-50%

36. C0MMON DISEASES IN THE GERIATRIC POPULATION • ENDOCRINE AND METABOLIC DISORDERS • Thyroid disease in older patients  double that of younger patients • DM – prevalence increases with age

37. C0MMON DISEASES IN THE GERIATRIC POPULATION • RENAL DISEASE • Hyponatremia complicated in the elderly by multiple drugs • lithium • diuretics • anti-depressants

38. THE JOYS OF AGING I have become quite a frivolous old gal. Am seeing 5 gentlemen everyday. As soon as I’m awake, WILL POWER helps me out of bed. When he leaves, I go see JOHN, then CHARLEY HORSE comes along and when he is here, he takes a lot of my attention. When he leaves, ARTHUR RITIS shows up and stays the rest of the day. He doesn’t like to stay in one place very long. So he takes me from joint to joint. After such a busy day I’m really tired and ready to go to bed with BEN GAY. What a day! JOURNEY INTO ‘88

39. THE END