GERIATRICS: AN OVERVIEW

Keerti Sharma, MDAssistant Professor of

Medicine

THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

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

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HISTORY

• Develop a symptom• Perceive a symptom• Communicate

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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

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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

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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

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PHYSIOLOGIC CHANGESWITH AGING

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

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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

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CONTROL OF BODY TEMPERATURE

Increased susceptibility to both hypothermia and hyperthermia

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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

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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

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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

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IMMUNE RESPONSE

• Afebrile infection is common• Humoral antibody-mediated response is

decreased• Antibody response to vaccine is

decreased• Response to tuberculosis skin test

decreases

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NERVOUS SYSTEM (1 of 2)

• The weight of the brain decreases• The area of the cerebral ventricles may

increase 34• Most prominent loss occurs in the largest

neurons• Cognitive loss is not a part of normal

aging

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NERVOUS SYSTEM (2 of 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

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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

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AVOID MOSAIC FLOOR PATTERNS

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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

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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

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CARDIOVASCULAR SYSTEM• Blood vessels: increased intimal thickness,

increased wall thickness, increased smooth muscle

Leads to increased systolic and pulse pressure

• Heart muscle: increased afterloadLeads to LVH, decreased cardiac output

• Heart valves: left sides become sclerotic

• Response to sympathetic stimulation: reducedLeads to reduction in cardiac output during

stress (eg, surgery) and increased risk of CHF

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RESPIRATORY SYSTEM

• Decreased effectiveness of cough• Decline in PO2

• Decreased pulmonary reserve during stress

• Increased frequency of infection, increased likelihood of hypoxia

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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

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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

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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)

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MUSCULAR SYSTEM (1 of 2)

Age-related decrease in muscle mass and quality (sarcopenia)

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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

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ENDOCRINE SYSTEM

• Slight increase in fasting glucose, not clinically significant

• Thyroid hormone levels unchanged• Vitamin D levels decline

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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

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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

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ARTERIAL BLOOD GASES

• Arterial pH and PCO2 do not change with age

• Arterial oxygen content and PO2 decline (3 mm Hg per decade)

100 (age / 3)

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SERUM CHEMISTRY

• Electrolytes unchanged• Creatinine unchanged• Minor decline in total protein and albumin• Uric acid and alkaline phosphatase

increase slightly

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CHANGES IN THEPHYSICAL EXAMINATION

POSSIBLE EXPLANATIONS

• Multiple comorbidities• Age-related physiological changes may

alter perception to stimulus• Cognitive impairment may prevent patient

from providing an accurate history

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GASTROINTESTINAL DISEASES

• Achalasia: lower incidence of chest pain• Respond equally well to pneumatic

dilation

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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

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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

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CHOLECYSTITIS

May not present with the classic symptoms

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BACTEREMIA

• Less likely to have fever, rigors, and chills• More likely to have delirium, weakness, or

fall

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MYOCARDIAL INFARCTION

• Dyspnea and CHF are common• Delirium was presenting symptom in 13%• Syncope and stroke were presenting

symptoms in 7%

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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

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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

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WORKUP

• Avoid the temptation to overtreat• Treatment side effects must never be

worse than the disease

Slide 43

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

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www.americangeriatrics.org

THANK YOU FOR YOUR TIME!

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