Geriatric Medicine Lecture Upload
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Transcript of Geriatric Medicine Lecture Upload
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Gatot Sugiharto, MD,
Internist
Faculty of Medicine,UWKS
Lecture - 2011
INTRODUCTION TO
GERIATRIC MEDICINE
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AGING
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Aging can be defined as a progressive and
generalised impairment of functionresulting in the loss of adaptive responseto stress and increased risk of age relateddiseases.
The overall effect of these alterations is anincrease in the probability of declininghealth and dying and which is also oftenassociated with social, emotional and
financial marginalisation in old age
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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
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ISSUES
Understanding basic concepts
Approaching the older patient
Age related physiological & pathological
states Demographic impact on geriatric health care
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BASIC CONCEPTS
Multiple diseases and multiple drugs. Diseases often chronic, progressive with
adverse consequences. Focus on functionalindependence
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
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PHYSIOLOGICAL CHANGES AND
THEIR IMPACT
CHANGE:DECREASE IN
IMPACT: DECREASEIN
Basal metabolicrate
Pulmonary function Renal function
Bone mineral
Gastro-intestinal
function
Sight
Dentition
Taste
Calorie needs
Exercise capacity
Ability to conc/diluteurine
Fracture resistance
Bowel motility
Independence
Eating ability
Appetite
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Physiologic Changes with Aging
Respiratory systemVital capacity decreases by as much
as 50%
Decreased recoil and elasticity of lungtissue
General loss of the muscle tissue
within the walls of the lower airways
Changes can make sudden respiratory
illness life-threatening
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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 poorperfusion
Resistance of blood vessels increases from
a loss of elasticity and generalized
arteriosclerosis
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PRINCIPLES OF GERIATRIC
ASSESSMENTGoal 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
Success Maintaining or improving quality of life
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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
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The basic components of the
Comprehensive Geriatric Assessment
(CGA)
1. Functional status ADL (Activity of DailyLiving), IADL (Instrumental Activity of DailyLiving)
2. Comorbidity (number, type and rating ofcomorbid conditions)
3. Cognition (Mini-Mental StatusExamination)
4. Depression (Geriatric Depression Scale)
5. Polypharmacy6. Nutrition (Mini-Nutritional Assessment)
7. Presence of Geriatric Syndromes(dementia, delirium, depression, failure to
thrive, neglect or abuse, osteoporosis,falls, incontinence)
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Functional Evaluation
Instrumental Activities of Daily Living
(IADLs)
Activities of Daily Living
(ADLs)
Executive Functioning
Gait & Balance
TOOLS TO ASSESS FUNCTIONAL
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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, takingmedications, doing laundry, doing
housework, shopping, managingown transportation
Get Up and Go test
Qualitative, timed, assesses gait,
balance, and transfers
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PHYSICAL ASSESSMENT
Complete physical
assessment
includes:
Nutrition
VisionHearing
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VISION
Cataracts, glaucoma, maculardegeneration, and abnormalitiesof accommodation worsen withage
Assess difficulties by askingabout everyday tasks
driving; watching TV; reading
Use performance-based
screening
ask to read from newspaper,magazine
use Snellen chart
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HEARING
Hearing loss is common among olderadults
Impaired hearingdepression, social
withdrawalAssess first for cerumen impaction
Use hand-held audioscope to test for
abnormalityloss of 40 dB tone at 1000 or 2000 Hz in oneor both ears is abnormal
refer for formal audiometry testing
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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, financialhardship
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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
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MMSE [Scoring / Cutoffs]
Total Number of Correct Answers
24-30 Correct : No Cognitive Imp.
18-23 Correct : Mild Cognitive Imp.
0-17 Correct : Severe Cog. Imp.
Influence by Educational Level
Race / Ethnicity
Socioeconomic Status?
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Clock Drawing Test
Different Versions
4 Point Scale Most Useful
1 Point- Circle 1 Point-Numbers
1 Point-Hands/Arrows
1 Point-Right Time
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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 Not Depressed
11-14 Possible Depression
14 Depression
Short Version
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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
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Common Clinical Problems in
Geriatrics are Syndromes:
Impotence
Incontinence
Incoherence
Irritable
bowels
Insomnia
Isolation
Immune
deficiency
Immobility Instability
Intellectual
impairment Infection
Impairments
Inanition
Iatrogenesis
Illiteracy
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UNCLASSIFIED SYMPTOMS IN OLD AGE
Weakness
Fatigue
Anorexia
Constipation
Altered taste
Breathlessness
Low muscle strength
Body aches
Confusion
Insomnia
ImpotenceFaints/ Falls
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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.
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Delirium
1. Acute change in mental status and2. Inattention
3. Disorganized thinking or
4. Altered level of consciousness
It is a geriatric emergency.
Inouye et al. Ann Int Med, 1993
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Differential Diagnosis
Always consider dementia and depression
as competing diagnoses.
Other: post-ictal state, psychiatric disorders,
nonconvulsive epilepsy.
Three types:
Organic (medical)
Post-operative
Terminal restlessness
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Etiology
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Dementia vs. Delirium
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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.
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