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Aging and Common Geriatric Problems
Deb Mostek, M.D.
University of Nebraska Medical CenterMarch 23, 2004
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Objectives
1. Describe common sensory and functional limitations experienced by the geriatric patient and how these conditions impact care.
2. Discuss common cognitive difficulties in the elderly and how to minimize behavioral problems while providing care.
3. Discuss the prevalence of osteoporosis and risk of fractures.
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Demographics of Aging
65 and older: 35,000,000 (12.4%) in 2000; 69,000,000 (20%) by 2030
Life expectancy: female 80.2 yrs; male 73.2 yrs
>65 y/o female:male 3:2 >85 y/o female:male 5:2 5% of elders (>65y/o) reside in NH;
(if >95 y/o 47% in NH)
Better educated; less poverty
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Overview
Mortality from many causes Biochemical changes in tissues physiologic capacity ability to adapt to environment susceptibility to disease Heterogeneous population: variability Rate of aging--affected by genetics, life style,
environment
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Normal Aging
Height (5 cm by age 75) Fat content, lean body weight/muscle
mass, body water content. Dry skin ( moisture content) vs. photoaging
(not normal aging—causes 90% of cosmetic changes of aging)
60% grip strength (? due to inactivity) Stiffness due to water content in
tendons/ligaments and remodeling
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…Normal aging
Brain weight 20%; blood flow to brain Slower processing times Renal mass by 25-30% by age 80 Lungs: elastic tissue of lungs Abdominal muscles necessary for
inspiration; elders expand lungs best in standing position
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…Normal aging
Swallowing less coordinated Decreased absorption of Ca++, iron,
lactose, Vitamin D Vitamin A & K, Cholesterol absorbed faster Slowed transit in large intestine Psychological stressors
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Barriers to care
Poor communication between care providers
Sensory impairment Communication difficulties Cognitive impairment Polypharmacy Limited financial resources Under-reporting Poor social support
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Hearing Impairment
Sensorineural hearing loss 25-40%; associated with noise exposure
Usually high frequency loss (consonants in this range trouble with conversational speech)
Emotional difficulties, cognitive impairment,
physical functioning
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Audiograms
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Hearing Loss & Tips for Communication
Face person directly, to allow for lip reading
Minimize background noise Visual communication—written notes,
communication boards Amplifiers
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Vision and Aging
Lens elasticity Adapts more slowly to changes in light;
night vision Presbyopia—lens lose elasticity—need for
reading glasses visual acuity, visual fields contrast sensitivity Sensitivity to glare
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13AGE 20AGE 20 AGE 60AGE 60 AGE 78AGE 78
Older Individuals Need 33% More Older Individuals Need 33% More Illumination Than Younger PeopleIllumination Than Younger People
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Vision Impairment (20/40 or less)
10-25% > 75 y/o; (20/40 or less); Cataracts; Macular Degeneration; Diabetic
Retinopathy; Glaucoma Results in difficulties with ADLs, IADLs
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Cataracts
Cataracts (38%)
Risk factors: age (90% in > 90 y/o), sun, smoking, diabetes, steroid use
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Cataracts
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Macular Degeneration
Degeneration of cells in central vision region of retina
30% by age 75 years Leading cause of blindness in white
Americans
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Early Macular Degeneration
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Macular Degeneration
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Age Related Macular Degeneration
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Glaucoma
Increased intraocular pressure Loss of visual fields Insidious, need routine screening to detect
early Most common cause of blindness in African
Americans
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Glaucoma
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Diabetic Retinopathy
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Management of Low Vision
Bright illumination Contrast Magnification Low Vision Clinic Word-processing programs
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Neuropathy
Vibratory and tactile sensation in fingers and toes
Diabetic neuropathy Tissue more vulnerable to injury--need to
protect from injury (pressure injury or burns)
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Mobility
Upper extremity precautions
(e.g., hemiparesis) Lower extremity precautions
(e.g., hip replacement)
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Memory and Aging
Takes longer to memorize a list, but then remembers the same as younger person
Longer retrieval time Slower response time More easily distracted Perform same on IQ test if given extra time General knowledge and vocabulary often
better
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Geriatric FUN FACT
Average 22 y/o college grad—20,000 words in vocabulary
Average 60 y/o—60,000 words in vocabulary
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Dementia
Memory problems with functional impairment
Alzheimer’s Disease (risk factors: age, +FH); gradual onset, may be subtle at first, progressive, depression, behavioral problems; later: motor rigidity)
Vascular Dementia (associated with strokes; usually more acute in onset)
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Caring for Demented Patients
Approach respectfully May have to repeat same information If becoming agitated, try to distract
(Change subject, give simple task to perform, look thru old photo albums, play music they enjoy)
Remember behavioral problems are part of the disease
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Delirium
Difficulty with attention and responsiveness, often disorientation& confusion; fluctuating symptoms
10-40% of hospitalized patients in >65y/o usually a fairly sudden change Associated with medical illness, medications Patients with dementia are at risk for
developing delirium. Need close supervision
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Depression
Common in elderly patients in a primary care setting (17-37%)
Hospitalized: major depression (11%);
Mild-mod depression 25% Patients often deny depressed mood Sleep disturbance, appetite, wt loss,
withdrawal, anxious, more common with dementia
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Osteoporosis Low bone density with increased susceptibility to
fractures. Prevalence: 10 million Americans Asymptomatic until factures start occurring Initially affects vertebral bodies, distal radius, proximal
femur, pelvis 1/3 women have a least one vertebral fracture Risk factors: female, age, estrogen deficiency, white or
Asian race, inactivity, + FH, slight stature, smoking, alcohol abuse, chronic corticosteroid or anticonvulsant use, inadequate calcium intake, sun exposure, liver disease, hyperthyroidism
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Bone Mineral Density Testing
Best predictor of fracture risk Normal: T score < -1 SD (young adult
standard) Osteopenia: T score <-2.5 but > -1 Osteoporosis: T score > -2.5 Screening controversial: National Osteoporosis Foundationall
females greater than 65years of age; US Preventive Services Task Force:
insufficient evidence for or against screening
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Prevention of Osteoporosis
Regular weight-bearing exercise Calcium intake 1200+ mg daily Vitamin D 400-800 IU daily Smoking cessation Medical therapy in those with low BMD who are
at high risk to develop osteoporosis Fall prevention Prevention ideally starts in childhood.
Geriatric Review Syllabus, 5th Edition, 2002-2004
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“We do not quit playing because we grow old,
we grow old because we quit playing.”
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Summary
Much variability in geriatric population—don’t stereotype!
Treat with respect, prepare patient for procedure
If dementia or delirium is present, provide close supervision
Enjoy the diversity and savor the stories of the aged!