GERIATRICS: an Overview Keerti Sharma, MD Assistant Professor of Medicine

1. GERIATRICS: an OverviewKeerti Sharma, MDAssistant Professor of Medicine AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2. 4 important take-home points • Common diseases can have uncommon presentations in the elderly • Temptation to overtreat should be avoided • Always start low and go slow when prescribing medications • A new symptom can be a medication side effect

3. History • Develop a symptom • Perceive a symptom • Communicate

4. REASONS FOR Underreporting(The Iceberg Phenomenon) • Fear of hospitalization • Fear of unpleasant investigations • Fear of treatment • Risk of involuntary removal to residential care • Imagining that symptoms are not amenable to treatment • Low health expectations • Lack of Information

5. GOALS OF CARE • Focus must remain on keeping the older person functional • If that goal becomes medically infeasible, the patient’s dignity and comfort must then become the primary focus Slide 5

6. NORMAL AGING VERSUSPATHOLOGICAL AGING • Normal aging = aging-related changes • Pathological aging = aging-associated changes • Normal aging: • Involves a great number of biologic processes • Is characterized by progressive, predictable, and inevitable changes that are independent of disease Slide 6

7. PHYSIOLOGIC CHANGESWITH AGING

8. General principlesOF NORMAL AGING • Organs in the same person age at different rates • Determinants of these rates include genetic makeup, personal choices, environmental exposures, and other factors • Aging changes are modifiable but inevitable Slide 8

9. Blood Pressure regulation • Higher risk for orthostatic or postural hypotension • Narrow range within which CNS perfusion maintained • Changes in antihypertensive drugs should be based on patient’s standing blood pressure Slide 9

10. Control of Body Temperature Increased susceptibility to both hypothermia and hyperthermia

11. Volume Regulation • Predisposition to both volume depletion and volume overload • Decreased thirst • Decreased ADH response to hypovolemia and renal response to ADH • Greater difficulty in excreting fluid overload • Results in predisposition to hyponatremia and CHF Slide 11

12. BARRIER DEFENSES • Skin’s effectiveness as a barrier is decreased • Mucous membranes are less effective barriers • Ciliary clearance slows • Repair rate of injured skin declines • Disease affects wound healing

13. Physical and Mechanical defenses • Urine is less acidic • Prostatic fluid has less antibacterial activity • Bladder is less completely emptied • Colonization of the vagina is more likely in estrogen-deficient women • Greater susceptibility to UTI and incontinence

14. Immune Response • Afebrile infection is common • Humoral antibody-mediated response is decreased • Antibody response to vaccine is decreased • Response to tuberculosis skin test decreases Slide 14

15. NERVOUS SYSTEM (1 of 2) • The weight of the brain decreases • The area of the cerebral ventricles may increase 34 • Most prominent loss occurs in the largest neurons • Cognitive loss is not a part of normal aging

16. NERVOUS SYSTEM (2of 2) • Changes affect the older person’s ability to distinguish between different stimuli • Reduced reaction time, resulting possibly in injuries and burns • Reduced balance • Greater risk of falls

17. Vision • Iris becomes more rigid • Lens yellows (due to photooxidation and accumulation of insoluble protein) • Increased sensitivity to glare • Decreased static acuity and dynamic acuity • Decline in contrast sensitivity

18. Avoid Mosaic floor patterns

19. HEARING • Drier cerumen, leading in greater risk of impaction • Tympanic membrane thickens • Ossicles undergo degenerative changes • Risk of high-frequency and low-frequency hearing loss

20. TASTE AND SMELL • Olfaction declines • May lead to decreased enjoyment of food and difficulty in sorting the tastes of mixed and combined foods • Gustatory function unchanged

21. CARDIOVASCULAR SYSTEM • Blood vessels: increased intimal thickness, increased wall thickness, increased smooth muscle • Leads to increased systolic and pulse pressure • Heart muscle: increased afterload • Leads to LVH, decreased cardiac output • Heart valves: left sides become sclerotic • Response to sympathetic stimulation: reduced • Leads to reduction in cardiac output during stress (eg, surgery) and increased risk of CHF

22. RESPIRATORY SYSTEM • Decreased effectiveness of cough • Decline in PO2 • Decreased pulmonary reserve during stress • Increased frequency of infection, increased likelihood of hypoxia

23. GASTROINTESTINAL SYSTEM(1 of 2) • Less effective chewing, even with intact teeth • Food is kept in the mouth longer and larger pieces of food are swallowed • Swallowing is less coordinated, which increases the risk of aspiration

24. GASTROINTESTINAL SYSTEM(2 of 2) • Lactase levels decline and intolerance of dairy products is common • Colon: slowed transit and increase in opioid receptor • May predispose the older person to drug-induced constipation • Liver: after age 30 there is 1% per year decline in liver mass and blood flow every year

25. RENAL SYSTEM • After age 20 GFR decreases 0.5% per year and renal blood flow decreases 1% per year • Serum creatinine is an imperfect marker of renal function in the elderly • Increased likelihood of adverse outcome from drugs with narrow therapeutic margins (eg, digoxin, aminoglycosides)

26. MUSCULAR SYSTEM (1 of 2) Age-related decrease in muscle mass and quality (sarcopenia)

27. MUSCULAR SYSTEM (2 of 2) • Lower-extremity strength is lost at a faster rate than upper-extremity strength • Water content decreases in tendons and ligaments, and stiffness increases

28. Endocrine System • Slight increase in fasting glucose, not clinically significant • Thyroid hormone levels unchanged • Vitamin D levels decline

29. ANATOMY • Loss of height: 5-cm decrease by age 75 due to increased hip and knee flexion, decreased vertebral body height, vertebral disc compaction, and flattening of foot arch • Fat compartment expands with age • Total body weight unchanged because of decrease in lean body mass

30. COAGULATION • No change in the absolute number of RBC, WBC, platelets • Chronic low-grade activation of clotting pathways • Doubling of d-dimer • ESR rate increases with age • Women = (age + 10) / 2 • Men = age / 2

31. ARTERIAL BLOOD GASES • Arterial pH and PCO2do not change with age • Arterial oxygen content and PO2 decline (3 mm Hg per decade) 100  (age / 3)

32. Serum Chemistry • Electrolytes unchanged • Creatinine unchanged • Minor decline in total protein and albumin • Uric acid and alkaline phosphatase increase slightly

33. CHANGES IN THEPhysical Examination

34. POSSIBLE EXPLANATIONS • Multiple comorbidities • Age-related physiological changes may alter perception to stimulus • Cognitive impairment may prevent patient from providing an accurate history

35. GASTROINTESTINAL DISEASES • Achalasia: lower incidence of chest pain • Respond equally well to pneumatic dilation

36. INTRA-ABDOMINAL INFECTIONS • Less likely to have nausea, vomiting or fever • More likely to be hypothermic and neutropenic • More likely to have biliary or pancreatic sources • Associated with significant mortality and morbidity

37. APPENDICITIS • Although more common in the young, associated with higher mortality in the elderly • Abdominal rigidity, decreased bowel sounds, and the presence of a mass appear to be more common in older patients

38. CHOLECYSTITIS May not present with the classic symptoms

39. BACTEREMIA • Less likely to have fever, rigors, and chills • More likely to have delirium, weakness, or fall

40. Myocardial infarction • Dyspnea and CHF are common • Delirium was presenting symptom in 13% • Syncope and stroke were presenting symptoms in 7%

41. Pneumonia • Atypical presentations occur more frequently • Nonspecific deterioration in a patient’s health status: decreased oral intake, fall, and confusion • Abrupt worsening of an underlying chronic medical condition

42. URINARY TRACT INFECTIONAND UROSEPSIS • Bacteriuria is increasingly common with advancing age • Lower tract infections (dysuria, urgency, suprapubic pain) usually missing • Upper urinary tract infection (flank pain, fever, and chills) usually missing • Confusion is a common presenting sign

43. workup • Avoid the temptation to overtreat • Treatment side effects must never be worse than the disease

44. 4 important take-home points • Common diseases can have uncommon presentations in the elderly • Temptation to overtreat should be avoided • Always start low and go slow when prescribing medications • A new symptom can be a medication side effect

45. Thank you for your time! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society