Geriatric Medicine

Dr. Musa

Geriatric Medicine
Biology of ageing:
Ageing is defined as a progressive generalized impairment of Function resulting in the
loss of adaptive responses to stress And a growing risk of age-associated diseases. Its
mechanisms are poorly understood but it is unlikely that
Ageing has evolved for it is own sake.
Ageing is not an intrinsic process, as it is occur in the context of the organisms'
interaction with the environment.

Physiological changes:
The physiological features of normal ageing have been identified By examining disease-
free population of older people, in order to separate the effects of pathology from those
due to time alone. Environmental factors, such as lack of exercise, poor diet, cigarette
Smoking and heavy alcohol consumption are thought to play a large part in the process
of ageing.

Changes with ageing clinical consequences

CNS
1. Neuronal loss
2. Cochlear degeneration
3. Increase lens rigidity
4. Lens opacification
5. Anterior horn cell loss
6. Dorsal column loss
increase risk of organic confusion
Presbyacusis/high tone hearing loss
Presbyopia/abnormal near vision
Cataract
Muscle weakness and wasting
Reduce position and vibration sense

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Respiratory system
1. reduce lung elasticity and
Alveolar support
2. Increased chest wall rigidity
3. Increased V/Q mismatch
4. Reduced Immune function
Cardiovascular system
1. reduced maximum heart rate
2. Dilatation of aorta
3. Reduce elasticity of conduit/
Capacitance vessels
4. reduced number of pacing
Myocytes in sinoaterial node
Endocrine system
1. Deterioration in pancreatic
B-cell function
Renal system
1. Loss of nephrons
2. Reduced glumerular
Filtration rate
Reduced tubular function
Gastrointestinal system
1. Reduced motility
Bones
1. Reduced bone mineral
density
Geriatric Medicine
Dr. Musa
reduce vital capacity and peak
expiratory flow
increased residual volume
reduced respiratory reserve volume
reduced arterial oxygen saturation
increased risk of infection
reduced exercise tolerance
widen aortic arch on x-ray
increased risk of postural
hypotension
increased risk of Aterial
fibrillation
increased risk of impaired glucose
tolerance
impaired fluid balance
increased risk of dehydration/ overload
impaired drug metabolism and excretion
constipation
increased risk of osteoporotic fracture
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 Geriatric Medicine
Dr. Musa

Presenting problems in geriatric medicine :

There are a number of features that are particular to
Older patients :
1-late presentation:
Many people accept ill health as a consequence of ageing and May tolerate symptoms
for lengthy periods before seeking Medical advice. comorbidities may also contribute to
late Presentation.

2-Atypical presentation :
Infection may present with acute confusion and without Clinical pointers to the organ
system affected. Stroke may present with falls rather than symptoms of Focal
weakness. M .I may present as a weakness and fatigue , without The classical of chest
pain or dyspnoea.co-existent Dementia may limit the patients ability to give a history Of
classical symptom.

3- acute illness and changes in function:

it follows from this that( failure to cope), (found on floor ), (confusion) and (off feet) are
presentation and not diagnosis. When an older patient present with any of these, the
possibility That an acute illness has been the precipitant must always be Considered.
4- Multiple pathology :
Presentation in older patients have a more divers differential Diagnosis because multiple
pathology is so common. It means that there are usually a number of causes for any
single Problem, and side effects from medication may be a contributory Factor. a patient
may fall because of osteoarthritis of the knees, Postural hypotension due to diuretic
therapy for hypertension, And Poor vision due to cataract.

Approach to presenting problems in old age:

The approach to most presenting problems in old age can be Summarized as follows:
1-the telephone test: find out the patients usual status (e.g. mobility , cognitive
state)from relative or carer.
2-check medication. have there been any recent changes?
3-search for and treat any acute illness.
4-Identify and reverse predisposing risk factors. These depend on presenting problem.

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 Geriatric Medicine
Dr. Musa

Falls :
Falls and unsteadiness are very common in older people. Around 30%of those aged 65
and over fall each year. This figure Rising to over 40% in those aged over 80 years.
Although only 10-15% of falls result serious injury, they are the Principal cause of
fractured neck of femur in this age group Falls also lead to loss of confidence and fear,
and are frequently The final straw that makes the older person decide to move to
Institutional care.
2. The approach to the patient varies according to the underlying cause of falls, as
follows:
1-accidental trip:
Those who have simply tripped may not require detailed Assessment unless they are
doing so frequently or have Sustained an injury.

2-Blckouts:
A proportion of older people who fall have in fact had a syncopal episode. It is
important about loss of consciousness And, if this is a possibility, to perform appropriate
investigations. Recent research suggests that in a small numbers of patients Carotid
sinus syndrome may be the cause of otherwise unexplained falls.

3-Acute illness:
Falling is one of the classical atypical presentation of acute Illness in frail. common
underlying illnesses include infection, Stroke , metabolic disturbances and heart failure.
Thorough Examination and investigation are required to identify these Acute illnesses. It
is also important to establish weather any Drug has been started recently, as this may
precipitate falls. Once an underlying acute illness has been treated, falls may No longer
be a problem.

3-Investigations to identify acute illness:

1. Full blood count
2. Urea and electrolytes, LFT, calcium and glucose
3. Chest X-ray
4. ECG
5. Urinalysis for leucocytes and nitrites; if positive, urine culture
6. C-protein; useful marker for occult infection
7. Blood culture if pyrexial

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 Geriatric Medicine
Dr. Musa

4-multiple risk factors:

Many patients, those with recurrent falls, are frail with multiple Medical problems and
chronic disabilities. Their tendency to fall is associated with risk factors that have Been
well established from prospective studies.

Risk factors for falls:

1. Muscle weakness
2. History of fall
3. Gait or balance abnormality
4. Use of a walking aid
5. Visual impairment
6. Arthritis
7. Impaired activity of daily living
8. Depression
9. Cognitive impairment
10.Age over 80 years
11.Drugs

Drugs:
1. Polypharmacy (4 or more drugs)
2. Digoxin
3. Diuretics
4. Drugs associated with sedation: benzodiazepine
5. Phenothiazines
6. Antidepressant
7. Type I anti-arrhythmics
The annual risk of falling increases linearly with the Number of risk factors presents,
from 8%with no risk Factor to 78%in those with four or more.

Prevention of falls in old age:

Effective interventions to prevent falls in elderly people include
3. Multidisciplinary
4. Multifactorial intervention
5. Muscle strength and balance training
6. Home hazard assessment and modification
7. Withdrawal of psychotropic medication

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 Geriatric Medicine
Dr. Musa

8. Cardiac pacing in falls with carotid sinus syndrome and Tai chi group exercise.

9. Multifactorial interventions to prevent falls :

Balance and exercise training.
Rationalization of medication, especially sedative drugs.
Correction of visual impairment.
Home environmental hazard assessment and safety Education.
Treatment of cardiovascular disorders, including Carotid sinus syndrome and postural
hypotension.
Management of postural hypotension:
Postural hypotension defined as a drop in blood pressure of< 20 mmHg systolic or <10
mmHg diastolic pressure on standing From supine. management include:
10. Correct dehydration.
11. Tilt up the head of the bed.
12. Support stocking (older people may struggle to get these on)
13. Non-steroidal anti-inflammatory drugs(increase circulating
Volume due to salt and water retention; gastric side effects limit
use.)
14. Fludrocortison(cause salt and water retention)

Bone protection :
Osteoporosis prophylaxis should be considered in older patients Who have recurrent
falls, particularly if they have already Sustained fractured. In female patients in
institutional care, calcium and Vitamin D3 Have been shown to reduce fracture rate, and
may also reduce Falls due to improvements in muscle function. Devices known as hip
protectors have also been shown to Reduce the risk of hip fracture in those in
institutional care.

DuAa DhArI

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