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

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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

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.

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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.

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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
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Etiology

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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