geriatric population. neurosensory and systemic changes in geriatrics
TRANSCRIPT
Let’s DiscussCommon neurosensory, systemic changes with aging
Symptoms of illness in aging differ from younger age
Atypical disease presentation
Clinical features associated with frailty
Research shows older people have…
SHORTER clinic visits
FEWER tests
LESS screening
LESS specialist referral
MORE untreated pain
Remember Your Senses
How do our senses change as we age?
CORNELL VIRTUAL HOUSE As you go through the house answer these 3 questions:
1. What sensory impairment is the most fearful to you?
2. What is the best something you learned that will help you in your practice?
3. Can you think of any personal experiences…
A
G
I
N
G
http://www.environmentalgeriatrics.org
Multimedia Course: 3D Animated Virtual Home
Select Launch The Course
Physical Changes in the EyeLoss of eye lid tone, decreased orbital fat,
receding eye ball
Changes in Hearing
Hearing occurs after sound vibrations cross the eardrum to the inner ear.
The vibrations are changed into nerve signals in the inner ear and carried to the brain by the auditory nerve.
Your ears have two jobs:
Hearing
Maintaining Balance
Changes Interfere With HearingExternal ear canal: Walls thin
Cerumen (Wax): Becomes drier, more tenacious, reduced activity and number of cerumen glands
Eardrum: Thickens and appears duller
Cochlea: Hair cells are lost, basilar membrane stiffens, auditory structures calcify, cochlear neurons are lost
Brain: Atrophic changes in temporal auditory cortex
Hearing Loss
0
5
10
15
20
25
Age 65-75 Age >75
10
25
Smokers have higher rates of hearing loss
% o
f p
op
ula
tio
n
Prevalence increases with age
Impact of Hearing Loss
Often considered benign, but affects quality of life
May contribute to family discord, social isolation,
loss of self-esteem, anger, depression
Treatment can improve quality of life by facilitating
interaction with family, friends, and caregivers
Improving Communication with Hearing Impaired
Have the person’s attention
Speak face-to-face
Repeat by paraphrasing
Speak normal to slightly
louder
Speak little more slowly
Stand within 2 - 3 feet
Reduce background noise
Pause at end of sentences
Avoid appearing frustrated
Write down key words if
the person can read
Have the person repeat to
be certain message was
understood
Use a deeper tone when speaking
A. Shortening of hair follicles
B. Increased cerumen production
C. Reduced activity of cerumen glands
D. Increased tortuosity of external canal
Which of the following changes in the external auditory canal contributes to an
increased incidence of cerumen impaction with increasing age?
HAVE EAR WAX REMOVED! C. Reduced activity & number of cerumen glands
CHANGES IN SMELL
S
M
E
L
LDensity/Sensitivity of nerve endings decrease
starts age 2 and continues until death
CHANGES IN SMELL
S
M
E
L
L
Ability to smell odors is blunted
Mucous membranes become thinner with fewer mucous secreting cells, nasal dryness and epistaxis
There is increased sensitivity of the parasympathetic vasomotor secretory fibers, increased rhinorrhea (runny nose)
Effects elderly –Smell and taste play a role in enjoyment and safety
Changes in the Oral Cavity
Decreased density & sensitivity of taste buds
Changes in the Oral CavityXerostomia (dry mouth)
Eduntulism (missing teeth)
Periodontal disease
Co-morbid illness
Medications
Oral devices
Changes in the Oral Cavity
The number of taste buds decreases
Remaining taste buds lose mass
Sensitivity to taste often declines after age 60
Mouth produces less saliva
Causes dry mouth, can affect taste
How do changes in the oral cavity effect taste?
Decreased appetite
Weight loss
Social isolation
Taste declines:
Bitter
Sour
Salt
Sweet
DECREAS
E
Changes in Skin
How do changes in skin effect the
sense of touch?
Reduced tactile sensation
Complicated by arthritis
Changes in Skin
↓collagen/elastin
↓tensile strength/elasticity
↓glands & blood vessels
↓ thermoregulation and healing
↓neural elements
↓sensation and ↑pain threshold
↓ subcutaneous fat
↓keratin and melanocytes
↓UV protection
↓vitamin D production
Decreased Skin Thickness
Loss of thickness in all three layers
Loss of elastin (tenting no longer reliable measure)
Flattening of dermal-epidermal junction
Decreased sensation of pressure related discomfort
Why do older people seem to get pressure sores so often?
A. Altered sense of touch
B. Altered sense of smell
C. Diminished appetite
D. Carbohydrate cravings
Which of the following increases risk for
foodborne illness in older adults?
B. Altered sense of smell
Cardiac Output
30%
Average
Vital Capacity,
Renal Blood Flow
50%
Decline
Max Breathing Capacity, Oxygen Uptake
60-70%
Age
30 to 80
Musculoskeletal Changes
Decreased bone mass
decreased osteoblast and
osteoclast activity
Altered cartilage composition
chondrocyte dysfunction
bony proliferation within
the joint
Muscle Mass Decreases
50
60
70
80
90
100
110
20 30 40 50 60 70 80 90Mu
sc
le M
as
s %
From age 20 to 70 strength decreases by50% in the legs
Age in years
Large Arteries Stiffen
Collagen & elastin changes
Stiffer arteries provide less
cushioning function
Diameter/length of aorta
increases
400
500
600
700
800
900
1000
1100
10 30 50 70 90
ST
IFFN
ESS (
PW
V IN
CM
/SEC
)
AGE (YEARS)
Why is systolic hypertension more common?
Lower Creatinine Clearance
Decreased:
1. concentrating &
diluting
2. renal blood flow & mass
3. drug clearance
How does kidney function deteriorate with age?
70
80
90
100
110
120
130
140
30 40 50 60 70 80
Progressive linear decline in creatinine clearance from 140 at age 30 to 97 at age 80
What is not
normal about
aging?
Cognitive Changes
Geriatric SyndromeDementia
Delirium
Falls
Incontinence
Constipation
Elder Abuse
Polypharmacy
Depression
Malnutrition
Dizziness & Syncope
Insomnia
Skin Breakdown
Osteoporosis
Substance Abuse
Disability
Diagnosis with multiple causes, frequently seen in older population
Geriatric ComplaintsConstipation
Insomnia
Pain
Weight Loss
Dizziness
Hearing Loss
Visual Impairment
Why is it so hard to diagnose disease
in the older population?
Heterogeneity
Homeostenosis
Higher function = longer the life expectancy
Disease Presentation in Old Age
Doctor may share patients’ views on aging
May attribute treatable conditions to aging
Prevalence of disability increases with age
1.6 to 2.3 times more likely Vitamin B12
deficiency
3.7 to 4 times more likely Vitamin D
deficiency
Disease Presentation in Old Age
Traditional model for medical practice
Mainly from presentation younger people
Account abnormality to single diagnosis
Deviation from traditional model
Multiple diseases often co-exist
Atypical presentation of disease
Disease in one organ may precipitate decompensation in
another organ
Atypical Disease Presentation
Late or silent presentations
Disease one site limits symptoms at another
Disease often presents in advanced state
Misinterpret symptoms as aging
Mobility problems limit activity
Dyspnea may not occur until heart failure is very advanced
Signs of illness in the
older patient…
Illness in General…An acute change in the patients functional
status or ability to perform daily activities
Abnormal temperature
Tachycardia or hypotension
Altered mental status
Unexplained dehydration and poor appetite
Fatigue with increased aches and pains
Fever & Pain
Many illnesses do not present
with pain
Patients with chronic pain,
may complain of acute
exacerbation of their pain
when sick
“Old men have little innate heat… for
this reason too, the fevers of old men
are less acute than others, for the body
is cold.”
Hippocrates
Nearly 20-30% of elderly with a bacterial or viral illness have NO temperature elevation
FRAILTY,
A COMMON
END?
Frailty
Biologic syndrome, decreased reserves in
multiple organ systems
It is initiated by physiologic changes of aging,
disease, lack of activity, or inadequate
nutritional intake
Decreased ability maintain homeostasis in stress
Statistics
20-25% older than 80 are frail
Frail elders at higher risk for:
Falls
Hospitalization
Disability
Increased Mortality
Post-operative complications
Fried’s Criteria
The clinical presentation of frailty is
measured by having three of the following:
Sarcopenia
Unintentional weight loss
Decreased caloric expenditure
Slow walking speed
Exhaustion
What Contributes to Frailty?Age-related changes
Medications
Chronic disease
Smoking
Depression
Physical inactivity
Social isolation
Environment
Obesity
Frail patients are more
likely to be socially
isolated and develop
depression
Frailty is associated with
decreased cognition and
increased brain plaques
OSTEOPENIA
ANOREXIA
SICKNESS BEHAVIOR
ALBUMIN
SYNTHESIS
SARCOPENIA
LOSS OF NITROGEN
ATHEROSCLEROSIS
EXTRAVASATION
OF ALBUMIN INTO
EXTRAVASCULAR SPACE
FRAILTY
IMPAIRED FUNCTION
IL-1
IL-2
IL-6
TNFa
Immunomodulation
Anemia
COGNITIVE DECLINE
INCREASED MORTALITY
Cytokines & Frailty
Besse Cooper 116 year
Birthday Party
Besse’s secrets to longevity
Minding your own businessNot eating junk food
Preventive Strategies to Slow the Onset of Frailty
Food intake maintained
Resistance exercises
Atherosclerosis prevention
Isolation avoidance
Limit pain
Tai Chi or other balance exercises
Yearly checks for deficiencies
A. It is genetically determined
B. It is related to his level of physical activity
C. It is most strongly related to losing weight
D. Make a lot of money
Your family member asks you what can he do to make his "golden years really golden?" Which of the following describes his best chance of living a long and healthy life?
B. It is related to his level of physical activity