Med 5th year geriatrics lecture 2020.

1. Professor Mohamed Al-Shekhani.
MBChB-CABM-FRCP-EBGH.
Geriatrics:
For 5th year students
COM ; Univ of Sulaimani.
2020

3. AGING
 Biological rather than chronological age considered specially when
making clinical decisions about appropriate invest/ intervention.
 Geriatric medicine is concerned particularly with frail older people,
in whom physiological capacity is so reduced that they are
incapacitated by even minor illness.
 They frequently have multiple co-morbidities& acute illness may
present in non-specific ways, such as confusion, falls, or loss of
mobility& day-to-day functioning.
 They are prone to adverse drug reactions, partly because of
polypharmacy &age-related changes in pharcodynamics&kinetics.
 Disability is common, but patients’ function can often be improved
by the interventions of the multidisciplinary team.

4. FRAILTY
• Characteristic feature of geriatrics.
• Frailty indicates increased vulnerability to loss of function.
• Frailty is the loss of an individual’s ability to withstand minor
stresses because the reserves functions of several organ systems are
so severely reduced that even a trivial illness or adverse drug
reaction may result in organ failure & death.
• Disability is established loss of function.

12. Decisions about investigation: depends on
• The patient’s general health:
• Does this patient have the physical & mental capacity to tolerate
the proposed investigation? e.g;
• Does he have the aerobic capacity to undergo bronchoscopy?
• Will her confusion prevent her from remaining still in MRI scanner?
• The more comorbidities a patient has, the less likely he or she will
be able to withstand an invasive or complex intervention.

13. Decisions about investigation:
• Will the investigation alter management?
• Would the patient be fit for, or benefit from, the treatment that
would be indicated if investigation proved positive?
• Comorbidity is more important than age itself in this regard.
• Example: When a patient with severe heart failure& old disabling
stroke presents with a suspicious mass lesion on chest X-ray,
detailed investigation & staging may not be appropriate if he is not
fit for surgery, radical radiotherapy or chemotherapy.
• On the other hand, if the same patient presented with dysphagia,
as he would be able to tolerate endoscopic treatment: for example,
to palliate an obstructing oesophageal carcinoma.

14. Decisions about investigation:
• The views of the patient& family
• Older people wishes should be sought &respected.
• If the patient is not able to express a view or lacks the capacity to
make decisions, because of cognitive impairment or communication
difficulties, then relatives’ input becomes particularly helpful.
• They may be able to give information on views previously expressed
by the patient.
• Families should never be made to feel responsible for difficult
decisions.

15. Decisions about investigation:
• Advance directives:
• ‘living wills’ may be respected by doctors if clinically sound.

16. Characteristics of geriatric presenting problems:
• 1.Late presentation:
• Accept ill health due to ageing by the elder ,relatives and even
doctors.
• May tolerate symptoms before seeking medical advice.
• Comorbidities e.g if mobility is limited by stroke, angina may only
present when CAD is advanced.

17. Characteristics of geriatric presenting problems:
• 2.Atypical presentation:
• Infection may present with acute confusion & without clinical
pointers to the organ system affected.
• Stroke may present with falls rather than symptoms of focal
weakness.
• Myocardial infarction may present as weakness & fatigue, without
the classical symptoms of chest pain or dyspnoea.
• The reasons for these:
• Reduced perception of pain.
• Reduced pyretic response.
• Cognitive impairment limit ability to give H/O classical symptoms.

18. Characteristics of geriatric presenting problems:
• 3. Acute illness & changes in function:
• This must always be considered & excluded.

19. Characteristics of geriatric presenting problems::
• 4. Multiple pathology
• Is common.
• There are frequently a number of causes for any single problem,
&adverse effects from medication often contribute.
• For example a fall may be from:
• OA of the knees.
• Postural hypotension due to diuretics for hypertension
• Poor vision due to cataracts.

23. Approach to presenting problemse in old age:
• Obtain a collateral history.
• Find out the patient’s usual status (e.g. mobility, cognitive state)
from a relative or career. Call these people by phone if they are not
present.
• Check all medication.
• Have there been any recent changes?
• Search for & treat any acute illness.
• Identify & reverse predisposing risk factors. depending on the
presenting problem.

24. Major presenting problems in old age:
• Falls.
• Delirium (acute confusion).
• Urinary incontinence.
• Adverse drug reactions.
• Dizziness.

25. Other presenting problems in old age:
• Hypothermia
• Under-nutrition
• Infection
• Fluid balance problems
• Heart failure
• Hypertension
• Atrial fibrillation
• Diabetes mellitus
• Peptic ulceration
• Anaemia
• Painful joints, Bone disease &fracture • Immobility • Stroke •
Dementia

26. 1.Falls:epidemiology
• 30% >65 years fall each year- 40% >80.
• 10–15% of falls result in serious injury,the cause of > 90% of hip
fractures partly due to increasing osteoporosis in elderly.
• Falls also lead to loss of confidence, fear& frequently the ‘final
straw’ that makes an older person decide to move to institutional
care.

27. Falls : management
• Management :Vary according to the underlying cause.
• 1.Acute illness:
• The classical atypical presentations of acute illness in frail people.
• The reduced reserves in neurological function make them less able
to maintain balance when challenged by an acute illness.
• Common underlying illnesses: infection, stroke, metabolic
disturbance & heart failure.
• Thorough examination& investigation are required.
• Search drugs as a precipitant, such as a psychotropic or hypotensive
agent.

28. Falls : management
• 2. Blackouts:
• Due to a syncopal episode.
• Ask about loss of consciousness & perform appropriate
investigations.

29. Falls : management
• 3.Mechanical & recurrent falls: requiring investigations.
• A. Those who have tripped or are uncertain how they fell.
• B. Those who have >one fall in the past year.
• C. Those with abnormal ‘Get up & go’ test.
• Patients with recurrent falls are commonly frail, with co-mobidities ,
chronic disabilities,acute illness or syncope& at risk of further falls
even when the acute illness has resolved.
• If problems are identified with muscle strength, balance, vision or
cognitive function, causes revealed by specific investigation &trt.
• Common pathologies: CVA, PD,OA, osteoporosis.
• Osteoporosis risk factors reviewed &DEXA bone density scan
considered, particularly if they have already sustained a fracture.

30. Falls & fractures prevention
• Multiple risk factor intervention, individualized to specific patient:
• Most effective is balance & strength training by physiotherapists.
• An assessment of the patient’s home environment for hazards by an
occupational therapist.
• Rationalizing psychotropic medication to reduce sedation, although
many elders are reluctant to stop hypnotics.
• If postural hypotension is present (BP drop of > 20 mmHg systolic or
> 10 mmHg diastolic on standing from supine), reducing or stopping
hypotensive drugs is helpful.
• New glasses to correct visual acuity.
• Podiatry, can also have a significant impact on function.

31. Falls & fractures prevention
• If osteoporosis is diagnosed:
• In females, calcium / vitamin D can reduce fracture rates& reduce
falls by reversing the changes in neuromuscular function associated
with vitamin D deficiency.
• For those with osteoporosis living in the community,
bisphosphonates are first-line therapy.

35. 2.Delirium (acute confusion):
• It is very common, up to 30% of older hospital inpatients either at
admission or during their hospital stay.
• Associated with high rate mortality, complication,
institutionalization & longer lengths of stay.
• Characteristic features must be present, but it may be missed unless
routine cognitive testing with an Abbreviated Mental Test is
performed.
• It is often occurring in patients with dementia.
• >one of the precipitating causes of delirium is often present.
• Its pathophysiology is unclear.

36. Delirium (acute confusion): Clinical assessment
• Confused patients will be unable to give an accurate history, so
obtained from a relative or carer.
• Symptoms suggestive of physical illness, as an infection or stroke,
should be elicited.
• An accurate drug/alcohol history is required.
• A full physical examination should be performed, specially:
• A. Conscious level B. Pyrexia & any signs of infection in the chest,
skin, urine or abdomen C.Oxygen saturation
• Signs of alcohol withdrawal, as tremor or sweating.
• Any neurological signs.
• A range of investigations are needed to identify the common causes

37. Delirium (acute confusion): Management
• Specific treatment of the underlying cause(s).
• Symptoms of delirium also require specific management.
• The environment should be kept calm& not unduly noisy, with the
patient’s spectacles & hearing aids in place.
• Good nursing is needed to preserve orientation, prevent pressure
sores , falls&maintain hydration, nutrition & continence.
• The use of sedatives should be kept to a minimum, as they can
precipitate delirium&many confused patients are lethargic&
apathetic rather than agitated.

38. Delirium (acute confusion): Management
• Sedation is appropriate if patients’ behaviour is endangering
themselves or others &ifextremely agitated or hallucinating& to
allow investigation or treatment.
• Small doses of haloperidol (0.5 mg) or lorazepam (0.5 mg) are tried
orally first, increased doses given if the patient fails to respond.
• Sedation can be given intramuscularly but only if absolutely
necessary.
• In those with alcohol withdrawal,a reducing course of a
benzodiazepine should be prescribed.
• The resolution of delirium in old age may be slow&incomplete.
• Delirium may be the first presentation of an underlying dementia&
a risk factor for subsequent dementia.

42. 3.Urinary incontinence:
• Involuntary loss of urine:
• Present when severe to cause a social or hygiene problem.
• Occurs in all ages but > in elders, 15% of women & 10% of men>65
years.
• If severe may lead to skin damage & social restriction.
• Age-dependent changes in the lower urinary tract occurs but it is
not inevitable consequence of ageing& requires investigation &
appropriate treatment.
• Urinary incontinence is frequently precipitated by acute illness in
old age &commonly multifactorial.

43. Urinary incontinence: 3 Types
• A. Urge incontinence is usually due to detrusor overactivity.
• B. Stress incontinence is almost exclusive to women due to pelvic
floor muscles weakness, which allows leakage of urine when intra-
abdominal pressure rises, e.g. on coughing.
• Both may be compounded by atrophic vaginitis, associated with
oestrogen deficiency in old age&can be treated with oestrogen
pessaries.
• C. Overflow incontinence most commonly in elder men with
prostatic enlargement, which obstructs bladder outflow.

44. Urinary incontinence:
• In patients with severe stroke disease or dementia, treatment may
be ineffective, as frontal cortical inhibitory signals to bladder
emptying are lost& a timed/prompted toileting programme may
help.
• Other than in overflow incontinence, urinary catheterisation should
never be viewed as first-line management but may be required as a
final resort if the perineal skin is at risk of breakdown or quality of
life is affected by intractable incontinence.

46. 4.ADR:
• May result in symptoms, abnormal physical signs & altered
laboratory test results
• The cause of 5% of all hospital admissions but up to 20% of
admissions in >65 years because of POLYPHARMACY; 4 or more
drugs which may not always be appropriate.
• The more drugs, the greater the risk of an ADR,due to age-
related changes in pharmacodynamic& pharmacokinetic
factors&by impaired homeostatic mechanisms, such as
baroreceptor responses, plasma volume&electrolyte control.

47. ADR:
• Older people are thus especially sensitive to drugs that can
cause postural hypotension or volume depletion.
• Non-adherence to drug therapy also rises with the number of
drugs prescribed.
• For any presenting problem in elders, the possibility ADR as a
contributory factor should always be considered.
• Failure to recognize this may lead to the use of a further drug to
treat the problem, making matters worse.

50. 5.Dizziness
• Very common, affecting 30% >65 years.
• Frequently multifactorial.
• Acute dizziness is relatively straightforward & common causes
include:
• Hypotension due to arrhythmia, MI, GIB or PE.
• Onset of posterior fcirculation stroke.
• Vestibular neuronitis.
• Lightheadedness, suggestive of reduced cerebral perfusion.
• Vertigo, suggestive of labyrinthine or brain-stem disease
• Unsteadiness/poor balance, suggestive of joint or neurological
disease.