Geriatric Medicine Lecture Upload

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
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
PHYSIOLOGICAL CHANGES AND

THEIR IMPACT
CHANGE:
DECREASE IN
IMPACT: DECREASE
IN
Basal metabolic
Calorie needs
rate
Pulmonary function
Renal function
Bone mineral
Gastro-intestinal
function
Sight
Dentition
Taste
Exercise capacity
Ability to conc/dilute
urine
Fracture resistance
Bowel motility
Independence
Eating ability
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
Hearts 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
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
Maintaining or improving quality of life
Success
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 familys cooperation & attitude
Assess care givers stress
The basic components of the

Comprehensive Geriatric Assessment
(CGA)
1. Functional status ADL (Activity of Daily
2.
3.
4.
5.
6.
7.
Living), IADL (Instrumental Activity of Daily

Living)
Comorbidity (number, type and rating of
comorbid conditions)
Cognition (Mini-Mental Status
Examination)
Depression (Geriatric Depression Scale)
Polypharmacy
Nutrition (Mini-Nutritional Assessment)
Presence of Geriatric Syndromes
(dementia, delirium, depression, failure to
thrive, neglect or abuse, osteoporosis,
falls, incontinence)
Functional Evaluation
Instrumental Activities of Daily Living
(IADLs)
Activities of Daily Living
(ADLs)
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
18-23 Correct
0-17 Correct
: No Cognitive Imp.
: Mild Cognitive Imp.
: 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
11-14
14
Short Version
<11
11
Not Depressed
Possible Depression
Depression
Not Depressed
Probable Depression
25
3-
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
Common Clinical Problems in

Geriatrics are Syndromes:
Impotence
Incontinence
Incoherence
Irritable
bowels
Insomnia
Isolation
Immune
deficiency
Immobility
Instability
Intellectual
impairment
Infection
Impairment
s
Inanition
Iatrogenesi
s
Illiteracy
UNCLASSIFIED SYMPTOMS IN OLD AGE

Weakness
Fatigue
Anorexia
Low muscle strength
Body aches
Confusion
Constipation
Insomnia
Altered taste
Impotence
Breathlessness
Faints/ Falls
3 Ds 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.
29
3-
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.
30
3-
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
31
Differential Diagnosis
32
Always consider dementia and depression

as competing diagnoses.
Other: post-ictal state, psychiatric disorders,

nonconvulsive epilepsy.
Three types:
Organic (medical)
Post-operative
Terminal restlessness
3-
Etiology
Dementia vs. Delirium
34
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.
35
3-

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What are some of the main physiological changes that occur with aging and their impact?

What are some of the main physiological changes that occur with aging and their impact?

What are some common clinical problems seen in geriatric patients?

What are some common clinical problems seen in geriatric patients?

INTRODUCTION TO

increase in the probability of declining

Approaching the older patient

adverse consequences. Focus on functional

PHYSIOLOGICAL CHANGES AND

Physiologic Changes with Aging

decline with age

Physiologic Changes with Aging

Degenerates with age

weight and widening and weakening of

Promote wellness, independence

Function, performance (gait, balance,

Physical, cognitive, psychologic, social

Ability to perform rapid screens to

APPROACHING THE OLDER

Have patience in history taking

The basic components of the

Living), IADL (Instrumental Activity of Daily

TOOLS TO ASSESS FUNCTIONAL

Bathing, dressing, transferring,

Qualitative, timed, assesses gait,

degeneration, and abnormalities

ASSESS NUTRITIONAL STATUS

depression, functional losses, financial

MMSE [Cognitive Domains]

MMSE [Scoring / Cutoffs]

Clock Drawing Test

Geriatric Depression Scale

Administered in about 5 Minutes

Common Clinical Problems in

UNCLASSIFIED SYMPTOMS IN OLD AGE

Low muscle strength

and functional abilities with associated

but not decreased cognition.

Always consider dementia and depression

Other: post-ictal state, psychiatric disorders,

Dementia vs. Delirium

Treatable in 75% of cases.

Untreated cases associated with 15%

Suicide rate in elderly is double the rate for all

Workup is identical for that of dementia.

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