Principles of Geriatrics

1. Principles of Geriatrics ประเสริฐ อัสสันตชัย เวชศาสตร์ผู้สูงอายุ ภ.เวชศาสตร์ป้องกันฯ คณะแพทยศาสตร์ศิริราชพยาบาล

2. 1999 2050 Males Females Males Females Age Age 100+ 100+ 80 80 60 60 8 6 4 2 0 2 4 6 8 8 6 4 2 0 2 4 6 8 Percentage of population Percentage of population 40 40 20 20 0 0 The world population will be olderMore developed countries United Nations 1999

3. Special Characteristics in Geriatrics RAMPS • Reduced body reserve • Atypical presentation • Multiple pathology • Polypharmacy • Social adversity

4. Geriatric Giants -atypical presentation • Instability (Fall) • Immobility • Intellectual impairment • Incontinence • Inappetite • Iatrogenesis

5. What is “Geriatric Medicine” ? “….that branch of general medicine concerned with the • clinical (physical & mental) • rehabilitative • social • preventive aspects of illness and health in the elderly” British Geriatrics Society

6. Examples of atypical presentation diseasespresent asmechanism • hyperthyroidism apathy not agitated ↓ ß-receptor sense • hypothyroidism depression, weak sedentary life • infections no fever,leucocytosis ↓ interleukin I • peritonitis no guarding weak rectus M. • hypoglycemia no adrenergic ↓ ß-receptor sense • congestive heart no dyspnea, sedentary life failure confusion, ↓ function of liver & brain mild jaundice RUQ pain

7. General changes in Aging Physiologic changesClinical correlation • osteoporosis, loss real height, body vertebral compression massindex ? • ↑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

8. Dermatologic Changes in Aging Physiologic changesClinical correlation • ↓stratum corneum ↓frequency of local agent turnover 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

9. Cardiovascular Changes in Aging Physiologic changesClinical correlation • ↓ maximal heart rate stroke volume dependent = 208 – (0.95xage) cardiac output • ↓ heart rate response syncope when change of to postural stress, posture Valsalva manouvre • atrial fibrosis ↑ atrial fibrillation ↓ pacemaker cell in SAnode • impaired LV filling ↑reliance on atrial systole ↔LV contract&relax ↑hemodynamic effect from atrial fibrillation • ↓ maximal C.O. ↓hemodynamic reserve

10. Comparison of heart rate between the old and the young Actual heart rate Sympathetic stimulation Intrinsic heart rate Vagal tone Resting heart rate Age 20 Age 80

11. Cardiovascular Changes in Aging Physiologic changesClinical correlation • ↓inotropic, chronotrpic ↓response to β response to βadrenergic sti. receptor drugs • less distensible, ↑systolic BP ↓ compliance artery • ↑peripheral vascular ↑hypertension resistance • impaired autoregulation postural hypotension • degeneration of conducting ↑ heart block, tissue left axis deviation • calcification of aortic valve aortic stenosis/sclerosis

12. BP (mmHg) 160 Women 150 Men Systolic BP 140 130 120 90 Men 80 Women Diastolic BP 70 36 41 46 51 56 61 66 71 76 81 years Age Framingham – Study Blood pressure and age Kannel et al 1978

13. Distribution of systolic pressure with age among Thai elderlyP. Assantachai. Comprehensive study of the Thai elderly. Mahidol Fund 2000 central north south northeast

14. Respiratory Changes in Aging Physiologic changesClinical 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

15. Respiratory Changes in Aging Physiologic changesClinical correlation • thinning of alveolar wall, ↓alveolar surface area enlagement of terminal lung unit • ventilation-perfusion ↓PaO2 =(100-0.32x age) mismatching • ↓ FEV1, FVC inadequate cough less effective ciliary action • ↓ventilatory response to prolonged hypercapnia hypercapnia

16. Age Distribution of Respiratory Complications % 80 70 60 50 respiratory complications 40 30 20 10 0 years 0-4 5-9 10-19 20-39 40-49 50-59 50-69 +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 Dr.Prasert Assantachai, M.D., Division of Preventive Medicine, Siriraj Hospital

17. Endocrine Changes in Aging Physiologic changesClinical correlation • impaired 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

18. Changes in blood glucose levels with age Postprandial Fasting Elahi D, et al. Eur J Clin Nutr 2000; 54: S112-S120.

19. Dietary therapy: special considerations for older people with diabetes • financial difficulty • shopping difficulty due to mobility problems • poor food preparation skills esp. widowed men • ingrained dietary habits • difficulty following dietary instruction because of impaired cognitive function • ↓ taste • ↑ frequency of constipation

20. Hematologic Changes in Aging Physiologic changesClinical correlation • ↓ bone marrow reserve ↓response during stress • ↓ reticulocytosis to ↑ anemia erythropoitin • ↓ erythropoietin ↑ anemia production

21. Gastrointestinal Changes in Aging Physiologic changesClinical correlation • poor oral health ↑gingivitis, dental caries • maxillary bone loss poorly fitting denture, malnutrition • weakening of lower ↑hiatus hernia esophageal sphincter • ↓ parietal cell, ↓hydrochloric acid, atrophic gastritis bacterial over growth, anemia • ↓response to gastric ↑NSAID-induced PU mucosal injury

22. Gastrointestinal Changes in Aging Physiologic changesClinical 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 constipation contraction • weakening of muscular diverticulum, layer diverticulosis • ↓gut-associated lymphoid infection, malignancy tissue

23. Neurologic Changes in Aging Physiologic changesClinical correlation • loss of neurone & subdural hematoma after brain weight trivial head injury • impaired autoregulation ↓ brain blood flow • ↓ dendritic connections impaired memory retrieve • short term memory loss ↑interview time • ↓ dopamine activity ↑Parkinsonism • ↑ neurofibrillary tangle pathologic change of & senile plaques Alzheimer disease • ↓ acetylcholine activity ↑amnesia

24. Neurologic Changes in Aging Physiologic changesClinical correlation • ↓ serotonin activity :↑depression • change of sleep :unnecessary narcotic pattern drug • change of :↑sensitivity to pharmacodynamics benzodiazepines • slow central processing :↓ intelligence & reaction time

25. Neuropathological ChangesCharacteristic of Alzheimer disease Normal AD AP NFT AP = amyloid plaques NFT = neurofibrillary tangles Courtesy of George Grossberg, St Louis University, USA

26. N. basalis Meynert Cortex Hippocampus 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 Bartus et al., 1982; Cummings and Back, 1998, Perry et al., 1978

27. Peripheral Nervous System Changes in Aging Physiologic changesClinical 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

28. Renal Changes in Aging Physiologic changesClinical 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

29. Renal Changes in Aging Physiologic changesClinical correlation • ↓ 1-alpha hydroxylase ↓active vitamin D ↓ calcium absorption • ↓ distensibility of hyporeninemic juxtaglomerular apparatus hypoaldosteronism

30. 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

31. Genitourinary Changes in Aging Physiologic changesClinical 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

32. Muscle Changes in Aging Physiologic changesClinical correlation • ↓ muscle fiber sarcopenia • ↓ muscle strength except intact diaphragmatic diaphragm, activity • leg 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

33. Bone & Joint Changes in Aging Physiologic changesClinical correlation • ↓ rate of fracture healing longer duration of follow up • ↓ bone mass :cortical bone ↑ osteoporosis 0.6%,trabecular0.7%/yr. ↑ fracture • proteoglycans disordered cartilage glycosaminoglycans matrix ↑osteoarthritis

34. Bone Remodeling–Normal Bone Ca Ca Osteoblast Osteoclast

35. Bone Remodeling–Osteoporotic Bone Ca Ca Osteoblast Osteoclast

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

37. Immune System Changes in Aging Physiologic changesClinical correlation • ↓ cell-mediated immunity ↑ TB, leprosy macrophage function • ↑autoantibodies↑ temporal arteritis, ↑ bullous pemphigoid • lower affinity Ab production ↑nonresponders to vaccine • ↓delayed-type poor prognosis in hypersensitivity anergy case • ↓B cell production by serious infection in bone marrow malnutrition

38. Changes of Vision in Aging Physiologic changesClinical correlation • impaired dark adaptation fall 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

39. Changes of Audition in Aging Physiologic changesClinical 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

40. Changes of Other Sensory Functions in Aging Physiologic changesClinical correlation • ↓ smell ~ 50% ↓appetite • ↓thirst drive poor fluid intake dehydration • ↓ gustatory sense spicy, salty food • ↑threshold vestibular poor body balance responses

41. Approach to an elderly patient • Physical assessment • Mental assessment • Function assessment • Social assessment

42. Thank you for your excellent attention