Principles of Geriatrics

ประเสร�ฐ อัสสนตชัยเวชัศาสตร�ผู้��ส�งอัาย�

ภ.เวชัศาสตร�ป�อังกันฯคณะแพทยศาสตร�ศ�ร�ราชั

พยาบาล

United Nations 1999

8 6 4 2 0 2 4 6 80

20

40

60

80

100+

Age

Males Females1999

Percentage of population8 6 4 2 0 2 4 6 8

Males Females2050

Percentage of population

0

20

40

60

80

100+

Age

The world population will be olderMore developed countries

Special Characteristics in Geriatrics

RAMPSReduced body reserveAtypical presentationMultiple pathologyPolypharmacySocial adversity

Geriatric Giants -atypical presentation

Instability (Fall)ImmobilityIntellectual impairment

IncontinenceInappetiteIatrogenesis

What is “Geriatric Medicine” ?

“….that branch of general medicine concerned with the

clinical (physical & mental) rehabilitative social preventiveaspects of illness and health in the elderly”

British Geriatrics Society

Examples of atypical presentation

diseases present as mechanism hyperthyroidism apathy not agitated ↓ ß-receptor

sense hypothyroidism depression, weak sedentary life infections no fever,leucocytosis ↓ interleukin I peritonitis no guarding weak rectus M. hypoglycemiano adrenergic ↓ ß-receptor sense congestive heart no dyspnea, sedentary life

failure confusion, ↓ function of liver & brain mild jaundice

RUQ pain

General changes in Aging

Physiologic changes Clinical correlation

osteoporosis, loss real height, bodyvertebral compression mass index ?↑fat to lean body mass ↑ distribution of fat- soluble

ratio drugs ↓ muscle mass poor indicator of serum

creatinine to glomerular filtration

↓ total body water ↓distribution of water-soluble drug

impaired shivering less febrile during infection

Dermatologic Changes in Aging

Physiologic changes Clinical correlation ↓stratum corneum ↓frequency of local

agentturnover rate

↓Pacinian corpuscle ↓high freq. vibration ↓Meissner corpuscle ↓low freq. vibration↓capillary, ↓urticaria, sign of

inflammatory cell cellulitis↓elasticity sodium depletion,

senile purpura↓sweat gland hyperthermia↓sebaceous gland xerotic dermatitis ↓ nail growth rate ↑duration of treatment

of onychomycosis

Cardiovascular Changes in Aging

Physiologic changes Clinical correlation

↓ maximal heart rate stroke volume dependent = 208 – (0.95xage) cardiac output

↓ heart rate response syncope when change of to postural stress, postureValsalva manouvre atrial fibrosis ↑ atrial fibrillation↓ pacemaker cell in SAnodeimpaired LV filling ↑ reliance on atrial systole ↔LV contract&relax↑ hemodynamic effect from

atrial fibrillation↓ maximal C.O. ↓ hemodynamic reserve

Comparison of heart rate between the old and the young

Sympathetic stimulation

Intrinsic heart rate

Age 20 Age 80Resting heart rate

Vagal tone

Actual

heart

rate

Cardiovascular Changes in Aging

Physiologic changes Clinical correlation↓inotropic, chronotrpic ↓response to β

response to βadrenergic sti. receptor drugsless distensible, ↑systolic BP

↓ compliance artery ↑peripheral vascular ↑ hypertension

resistanceimpaired autoregulation postural hypotensiondegeneration of conducting ↑ heart block,

tissue left axis deviationcalcification of aortic valve aortic stenosis/sclerosis

Framingham – Study Blood pressure and age

Kannel et al 1978

BP (mmHg)

70

80

90

120

130

140

150

160

36 41 46 51 56 61 66 71 76 81

WomenMen

WomenMen

Systolic BP

Diastolic BP

yearsAge

Distribution of systolic pressure with age among Thai elderlyP. Assantachai. Comprehensive study of the Thai elderly. Mahidol Fund 2000

110

120

130

140

150

160

170

60-64 65-69 70-74 75-79 80+

Men

Women

110

120

130

140

150

160

170

60-64 65-69 70-74 75-79 80+

Men

Women

110

120

130

140

150

160

170

60-64 65-69 70-74 75-79 80+

Men

Women

110

120

130

140

150

160

170

60-64 65-69 70-74 75-79 80+

Men

Women

central north

south northeast

Respiratory Changes in Aging

Physiologic changes Clinical correlation

kyphoscoliosis, costal ↓ chest wall compliance cartilage calcification ↑ work of breathing,

↑ diaphargm and abdominal muscle dependency

↓respiratory m.strength ↓ maximal inspiratory & expiratory pressure

↓ elastin in alveolar wall ↓alveolar elasticity recoil

↓ distal bronchiole diameter, ↑ closing volume

rearrangement in collagen

↑ residual volume ↓ vital capacity, tidal volume

Respiratory Changes in Aging

Physiologic changes Clinical correlation

thinning of alveolar wall, ↓ alveolar surface area

enlagement of terminal lung unitventilation-perfusion ↓PaO2 =(100-0.32x

age) mismatching↓ FEV1, FVC inadequate cough

less effective ciliary action↓ventilatory response to prolonged hypercapnia

hypercapnia

0

10

20

30

40

50

60

70

80

0-4 5-9 10-1920-3940-4950-5950-69 +70

%

age groups

Source: Betts FR, Douglas RG. Influenza virus. In: Mandsel GL, Douglas RG, Bennet JE, Eds. Principles and practice of infectious diseases, Churchill Livingstone Inc. 1990: 1306-1325

respiratory complications

Age Distribution of Respiratory Complications

years

Dr.Prasert Assantachai, M.D., Division of Preventive Medicine, Siriraj Hospital

Endocrine Changes in Aging

Physiologic changes Clinical correlationimpaired glucose tolerance ↑ DM

↑ BS 5.3 mg%/10yrs after 30 years old

↑ serum insulin metabolic syndrome

↓ DHEA ↓ libido

↓free testosterone

↓ T3 sick euthyroid syndrome

↑ PTH interpretation & ↓Ca

↓ vitamin D by skin ↓ Ca absorption

↑ serum homocysteine ↑ atherosclerosis

Changes in blood glucose levels with age

80.0090.00

100.00110.00120.00130.00140.00150.00160.00170.00180.00

age20 age30 age40 age50 age60 age70 age80 age90

Postprandial

Fasting

Elahi D, et al. Eur J Clin Nutr 2000; 54: S112-S120.

Dietary therapy: special considerations for older people with diabetes

financial difficultyshopping difficulty due to mobility problemspoor food preparation skills esp. widowed meningrained dietary habitsdifficulty following dietary instruction because of impaired cognitive function↓ taste↑ frequency of constipation

Hematologic Changes in Aging

Physiologic changes Clinical correlation

↓ bone marrow reserve ↓ response during stress

↓ reticulocytosis to ↑ anemia

erythropoitin

↓ erythropoietin ↑ anemia

production

Gastrointestinal Changes in Aging

Physiologic changes Clinical correlation

poor oral health ↑ gingivitis, dental cariesmaxillary bone loss poorly fitting denture,

malnutritionweakening of lower ↑ hiatus hernia

esophageal sphincter ↓ parietal cell, ↓ hydrochloric acid,

atrophic gastritis bacterial over growth, anemia

↓response to gastric ↑NSAID-induced PUmucosal injury

Gastrointestinal Changes in Aging

Physiologic changes Clinical correlation

↓liver size and blood flow ↓drug clearance esp. phase I metabolism

↓ cytochrome P450 prolonged half life of oxidation drug via liver

biotransformation ↓pancreatic mass dyspepsia↓effective colonic constipationcontractionweakening of muscular diverticulum, layer

diverticulosis↓gut-associated lymphoid infection, malignancytissue

Neurologic Changes in Aging

Physiologic changes Clinical correlation loss of neurone & subdural hematoma

after brain weight trivial head injury

impaired autoregulation ↓ brain blood flow ↓ dendritic connections impaired memory

retrieveshort term memory loss ↑interview time↓ dopamine activity ↑Parkinsonism↑ neurofibrillary tangle pathologic change of

& senile plaques Alzheimer disease↓ acetylcholine activity ↑amnesia

Neurologic Changes in Aging

Physiologic changes Clinical correlation↓ serotonin activity :↑depressionchange of sleep :unnecessary narcotic

pattern drug change of :↑sensitivity to

pharmacodynamics benzodiazepines slow central processing :↓ intelligence

& reaction time

Normal AD

AP NFT

AP = amyloid plaquesNFT = neurofibrillary tangles Courtesy of George Grossberg, St Louis University, USA

Neuropathological ChangesCharacteristic of Alzheimer disease

The Cholinergic Deficit in AD Underlies the Clinical Symptomatology Cholinergic deficit

progressive loss of cholinergic neurones

progressive decrease in available ACh

impairment in ADL, behaviour and cognition

Hippocampus

Cortex

N. basalis Meynert

Bartus et al., 1982; Cummings and Back, 1998, Perry et al., 1978

Peripheral Nervous System Changes in Aging

Physiologic changes Clinical correlation ↓ vibratory sense esp. interpretation of

feet neuropathy↓ thermal sensitivity ↑ injury esp.men ↓ size of large ↓propioceptive &

myelinated fiber vibratory sense ↓ two-point impaired use of

discrimination test fine instrument

Renal Changes in Aging

Physiologic changes Clinical correlation↓ 25%renal mass esp.cortex ↓ nephron, ↓excretion

↓ creatinine clearance of water soluble drugs ~ 10 ml/decade

↓ medullary tonicity poor concentrating & diluting ability

↑basal level of ADH 75% of SIADH >65 yr.

2-2.5 greater increase ↑tendency of ↓[Na]+

in ADH response to stress

↓ammonia production susceptibility to acidosis

Renal Changes in Aging

Physiologic changes Clinical correlation ↓ 1-alpha hydroxylase ↓ active vitamin D

↓ calcium absorption

↓ distensibility of hyporeninemic

juxtaglomerular apparatus hypoaldosteronism

Age-related changes in sodium-modulating factors

↓ functioning nephron number

↓ renin-angiotensin-aldosterone formation and effect

↓ insulin secretion

↑ atrial natriuretic peptide levels with relatively reduced effect

↑ plasma norepinephrine levels

↓ renal dopamine

↓ kallikrein-kinin activity

Genitourinary Changes in Aging

Physiologic changes Clinical correlation↓ elasticity of detrusor urgency incontinence muscle ↑ residual urine↓ prostatic secretion in urine↓ Tamm-Horsefall protein ↑ UTI ↔ refractory period for ↓ libido

erections for men ↓ intensity of orgasm for

men and women

Muscle Changes in Aging

Physiologic changes Clinical correlation↓ muscle fiber sarcopenia↓ muscle strength except intact diaphragmatic

diaphragm, activityleg weaker than arm tend to fall↑ fat infiltration ↑ fat to lean body

mass ratio↑ fatigability ↓ muscle endurance ↓ innervation (motor unit) poor fine movement↓ basal metabolic rate ↓nutritional 4%/decade after age50 requirement

Bone & Joint Changes in Aging

Physiologic changes Clinical correlation↓ rate of fracture healing longer duration of

follow up↓ bone mass :cortical bone ↑ osteoporosis

0.6%,trabecular 0.7%/yr. ↑ fractureproteoglycans disordered cartilage glycosaminoglycans matrix

↑ osteoarthritis

Bone Remodeling–Normal

Bone

OsteoblastOsteoclast

CaCa

Bone Remodeling–Osteoporotic

Bone

OsteoblastOsteoclast

CaCa

Normal Bone

Reproduced from J Bone Miner Res. 1986;1:15-21with permission of the American Society for Bone and Mineral Research

Osteoporotic Bone Loss

Immune System Changes in Aging

Physiologic changes Clinical correlation↓ cell-mediated immunity ↑ TB, leprosy

macrophage function↑autoantibodies ↑ temporal arteritis,

↑ bullous pemphigoidlower affinity Ab production ↑ nonresponders to

vaccine ↓ delayed-type poor prognosis in

hypersensitivity anergy case↓B cell production by serious infection in

bone marrow malnutrition

Changes of Vision in Aging

Physiologic changes Clinical correlation impaired dark adaptationfall at night denature of lens protein cataract, glaring

effect presbyopia bifocal lens↓dynamic acuity ↓seeing moving target↓contrast sensitivity ↓ color discrimination↓lacrimation dry eye↓aqueous humor reabsorption glaucoma

Changes of Audition in Aging

Physiologic changes Clinical correlation

↓ hair cells of organ of Corti presbycusis, high tone hearing loss

↓discriminating source of ↑ handicap

sound↓discriminating of verbal poor compliance to

sound from noise hearing aids↑ keratin wax content ear wax impaction

Changes of Other Sensory Functions in Aging

Physiologic changes Clinical correlation

↓ smell ~ 50% ↓ appetite↓thirst drive poor fluid intake

dehydration↓ gustatory sense spicy, salty food↑threshold vestibular poor body balance

responses

Approach to an elderly patientApproach to an elderly patientPhysical assessment

Mental assessment

Function assessment

Social assessment

Thank you for your excellent attention