lecture 26 clinical implication of aging process
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CLINICAL IMPLICATION
OF AGING PROCESSdr. I Nyoman Astika, SpPD
Block Growth and Development2009
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Learning outcomes- To describe the changes associated
with aging- To know common problem of Geriatrics
(a series of Is) - To know components of assessment of
older patients
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The care of older patients differs from that ofyounger patients.
The changes that occur in the proces of aging.Normal aging and patologycal changes is criticalto the care of older people.Many of the changes associated aging result
from gradual loss (on cross sectional: lossfunction organ 1 % a year beginning age 30years ).
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MAJOR THEORIES ON AGING
Theory Mechanisms Manifestations
Accumulation ofdamage toinformationalmolecules
Regulation ofspecific genes
Spontaneous mutagenesis
Failure in DNA repair systems
Errors in DNA, RNA, and proteinsynthesis
Superoxide radicals and loss of
scavenging enzymes
Appearance of specific protein(s)
Copying errors
Errors catastrophe
Oxidative cellular damage
Genetically programmedsenescence
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Changes Asosiated With Aging
ITEM MORPHOLOGY FUNCTION
Overall Decreased height (vertebralcompression and stooped posturesecondary to increased kyphosis)Decreased weight (after age 80 inlongitudinal studies)Increased fat to lean body massratioDecreased total body water
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Changes Asosiated With Aging
ITEM MORPHOLOGY
Skin Increased wrinkling Atrophy of sweatglands
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Changes Asosiated With Aging
ITEM MORPHOLOGY FUNCTION
Cardiovascularsystem
Elongation andtortuosity of arteries,including aortaIncreased intimal
thickening of arteriesIncreased fibrosis ofmedia of arteriesSclerosis of heartvalves
Decreasedcardiac outputduring exerciseDecreased heart
rate response tostressDecreasedcompliance ofperipheral bloodvessles
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Changes Asosiated With Aging (continued) ITEM MORPHOLOGY FUNCTION
Kidney Increased number of abnormal glomeruli
Interstitial fibrosis
Decreased creatinine clearance
Decreased renal blood flowDecreased maximum urineosmolality
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Changes Asosiated With Aging (continued)
ITEM MORPHOLOGY FUNCTION
Gastrointestinaltract
Decreased hydrochloric acidFewer taste buds
Slowed intestinal motility
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Changes Asosiated With Aging (continued)
ITEM MORPHOLOGY
Skeleton OsteoarthritisLoss of bone structure
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Changes Asosiated With Aging (continued) ITEM MORPHOLOGY FUNCTION
Eyes Arcus senilisDecreased pupilsizeGrowth of lens
DecreasedaccommodationHyperopiaDecreasedacuity
Decreased colorsensitivityDecreaseddepthperception
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Changes Asosiated With Aging (continued) ITEM MORPHOLOGY FUNCTION
Hearing Degenerative changes of ossiclesIncreased Obstruction of Eustachian tube Atrophy of external auditory meatus Atrophy of cochlear hair cellsLoss of auditory neurons
Decreased perception in highfrequenciesDecreased pitch discrimination
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Changes Asosiated With Aging (continued)
ITEM MORPHOLOGY FUNCTION
Immune system Decreased T-cell activity
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Changes Asosiated With Aging (continued) ITEM MORPHOLOGY FUNCTION
Nervoussystem
Decreased brainweightDecreased corticalcell count
Increased motorresponse timeSlowerpsychomotorperformanceDecreasedintellectualperformanceDecreased complexlearningDecreased hoursof sleepDecreased hours ofrapid eye movement(REM) sleep
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CLASSIFYING GERIATRIC PROBLEMS
One aid to recalling some of the common problems ofgeriatrics uses a series of I (14 I) is:
ImmobilityInstabilityIncontinenceIntellectual impairment
InfectionImpairment of vision and hearingIrritable colonIsolation (depression)Inanitation (malnutrition)
ImpecunityIatrogenesisInsomniaImmune deficiencyImpotence
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IMPAIRMENTS of Sensory apparatus
Visual Presbiopy, cataracta lentis, retinopathydiabetic, glaucoma, macular degeneration(Increase in prevalence with age)
Hearing 1/3 of people over 65 reduced emotional, social & physical factor whispered voice exam (3 6 random item)
Taste ability
Smell ability Peripheral sensory ability , vibration
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Disease diagnosis in the elderly
should include 4 levelsDisease
Impai rmentDisabi l i ty
Handicap
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COMPREHENSIVE GERIATRIC ASSESSMENT (CG
IMPLIES : Physical HealthMental HealthFunctional StatusSocial Function
Environment(Multi or Inter-disciplinary Team)
Source: Forceia (2004), Reuben (2003)
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Evaluating The Elderly Patient
The factors interact in complexways influence the health &functional status of the elderlyComprehensive evaluation willrequire an assessment of each of
these domains.Funct io nal abi l it ies a centra lfocus o f the com prehens iveevaluation of an elderly individual.Diagnoses-physical-laboratory
findings are useful in dealing withunderlying etiologies & detectingtreatable conditions, in the elderly,measures of function are oftenessential in determining overallhealth.
Figure 1 : Components of assessment of the elderly
(David B Reuben )
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POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES Difficulty Factors involved Suggestions
Communication
Underreporting ofsymptoms
Diminished vision
Diminished hearing
Slowed psychomotor performance
Health beliefsFearDepression
Altered physical responses to diseaseprocessCognitive impairment
Use well-lit room
Eliminate extraneous noiseSpeak slowly in a deep toneFace patient, allowing patient tosee your lipsUse simple amplification devicefor severely hearing impaired
If necessary, write questions inlarge print
Leave enough time for thepatient to answer
Ask specific questions aboutpotentially important symptomsUse other sources of information(relatives, friends, othercaregivers) to complete thehistory
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POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES (cont inued)
Difficulty Factors involved Suggestions
Vague or nonspecific symptoms
Multiple complaints
Altered physical and physiologicalresponses to disease process
Altered presentation of specific diseaseCognitive impairment
Prevalence of multiple coexistingdiseasesSomatization of emotions maskeddepression (see Chap. 5)
Evaluate for treatable disease,even if the symptoms (or signs)are not typical or specificwhen there has been a rapidchange in functionUse other sources ofinformation to completehistory
Attend to all somaticsymptoms, ruling out treatableconditionsGet know the patientscomplaint: pay specialattention to new or changingsymptomsInterview the patient onseveral occasions to completethe history
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IMPORTANT APECTS OF THE GERIATRIC HISTORYSystem Review
System Key Symptoms
Genitourinary
Musculoskeletal
Neurological
Psychological
FrequencyUrgencyNocturiaHesitancy, intermittent stream, straining to voidIncontinenceHematuriaVaginal bleeding
Focal or diffuse painFocal or diffuse weakness
Visual disturbances (transient or progressive)Progressive hearing loss
Unsteadiness and/or fallsTransient focal symptoms
Depression Anxiety and/or agitationParanoiaForgetfulness and/or confusion
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS
Physical findings Potential significance
Vital signs Elevated blood pressure
Postural changes in blood pressure
Irregular pulse
Increased risk for cardiovascular morbidity:therapy should be considered if repeatedmeasurements are high (see Chap. 11)
May be asymptomatic and occur in the
absence of volume depletion. Aging changes, deconditioning, and drugsmay play a roleCan be exaggerated after mealsCan be worsened and becomesymptomatic with antihypertensive,
vasodilator, and tricyclic anti depressanttherapy
Arrhythmias are relatively common inotherwise asymptomatic elderly; seldomneed specific evaluation or treatment (seeChap. 11)
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued) Physical findings Potential significance
Vital signs
Tachypnea
Weight changes
Baseline rate should be accuratelyrecorded to help assess futurecomplaints (such as dyspnea) orconditions (such as pneumonia or hearthfailure)
Weight gaint should prompt search foredema or ascitesGradual loss of smallamounts of weight common; losses inexcess of 5% of usual body weight over
12 months or less should prompt searchof underlying disease
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued) Physical findings Potential significance
General Appearance and Behavior
Poor personal grooming and hygiene(e.g., poorly shaven, unkempt, soiledclothing)
Slow thought processes and speech
Can be signs of poor overall function,caregiver neglect, and/or depression:often indicates a need for intervention
Usually represents an aging change:Parkinsons disease and depression canalso cause these signs
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued)
Physical findings Potential significance
Vital signs
Ulcerations
Diminished turgor
Lower extremity vascular and neuropathiculcers common
Pressure ulcers common and easilyoverlooked in immobile patients
Often results from atrophy of subcutaneoustissues rather than volume depletion; whendehydration suspected, skin turgor overchest and abdomen most reliable
Ears (see Chap. 13)
Diminished hearing High-frequency hearing loss common;patients with difficulty hearing normalconversation or whispered phrase next tothe ear should be evaluated furtherPortableaudioscopes can be helpful in screening forimpairment
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued)
Physical findings Potential significance
Eyes (see Chap. 13) Decreased visual acuity (often despitecorrective lenses)
Cataracts and other abnormalities
May have multiple causes, all patientsshould have thorough optometric orophthalmologic examinationHemianopsia is easily overlooked and canusually be ruled out by simple confrontation
testing
Fundoscopic examination often difficult andlimited; if retinal pathology suspected,thorough ophthalmologic examinationnecessary
Mouth
Missing teeth Dentures often present; they should beremoved to check for evidence of poor fitand other pathology in oral cavity
Area under the tongue is a common site forearly malignancies
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued)
Physical findings Potential significance
Cardiovascular
Irregular rhythms
Systolic murmurs
Vascular bruits
Diminished distal pulses
See vital signs, above
Common and most often benign; clinicalhistory and bedside maneuvers can helpto differentiate those needing furtherevaluationCarotid bruits may need furtherevaluation
Femoral bruits often present in patientswith symptomatic pepripheral vascuraldisease
Presence or absence should bediagnostically useful at a later time (e.g.,if symptoms of claudication or anembolism develop)
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued) Physical findings Potential significance
Abdomen
Prominent aortic pulsation Suspected abdominal aneurysms should beevaluated by ultrasound
Genitourinary (see Chap. 8)
Athrophy
Pelvic prolapse (cystocele, rectocele)
Testicular atrophy normal; atropic vaginaltissue may cause symptoms (such asdyspareunia and dysuria) and treatmentmay be beneficial
Common and may be unrelated tosymptoms; gynecologic evaluation helpful ifpatien has bothersome, potentially relatedsymptoms
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued) Physical findings Potential significance
Extremities Periart icular pain
Lim ited range of mot ion
Edema
Can result a variety of causes and is notalways the result of degenerative joint disease;each area of pain should be carefullyevaluated and treated (see Chap. 10)
Often caused by pain resulting from activeinflammation, scaring from old injury, orneurologic disease; if limitations impairfunction, a rehabilitation therapist could beconsulted
Can result from venous insufficiency and/or
heart failure; mild edema often a cosmeticproblem: treatment necessary if imparingambulation, contributing to nocturia,predisposing to skin breakdown, or causingdiscomfort.Unilateral edema should prompt search for aproximal obstructive process
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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued) Physical findings Potential significance
Neurologic
Abnormal mental status (i.e.,confusion, depressed affect)
Weakness
See Chaps. 6 and 7
Arm drift may be the only sign of residualweakness from a strokeProximal muscle weakness (e.g., inability toget out of chair) should be further evaluated;physical therapy may be appropriate
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LABORATORY ASSESSMENT OF GERIATRIC PATIENTS
Laboratory parameters unchanged*
Hemoglobin and hematocritWhite blood cell countPlatelet countElectrolytes (sodium, potassium, chloride, bicarbonate)Blood urea nitrogen
Liver function test (transaminases, bilirubin, prothrombin time)Free thyroxine indexThyroid-stimulating hormoneCalciumPhosphorus
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LABORATORY ASSESSMENT OF GERIATRIC PATIENTS(continued)
Common abnormal laboratory parameters
Parameter Clinical significance
Serum iron, iron binding capacity, ferritin
Prostate-specific antigen
Urinalysis
Decreased values are not an aging change andusually indicate undernutrition and/orgastrointestinal blood loss.
May be elevated in patients with benignprostatic hyperplasia. Marked elevation orincreasing values when followed over timeshould prompt consideration of furtherevaluation in patients for whom specific therapyfor prostate cancer would be undertaken if
cancer were diagnosied.
Asymptomatic pyuria and bacteriuria arecommon and rarely warrant treatment;hematuria is abnormal and needs furtherevaluation (see Chap. 8).
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LABORATORY ASSESSMENT OF GERIATRIC PATIENTS(continued)
Common abnormal laboratory parameters
Parameter Clinical significance
Chest radiographs
Electrocardiogram
Interstitial changes are a common age relatedfinding; diffusely diminished bone densitygenerally indicates advanced osteoporosis (see
Chap. 12).St-segment and T-wave changes, atrial andventricular arrhythmias, and various blocks arecommon in asymptomatic elderly and may notneed specific evaluation (see Chap. 11)
* Aging changes do not occur in these parameters; abnormal values should prompt further evaluation includes normal aging and other age related changes.
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EXAMPLES OF MEASURES OF PHYSICAL FUNCTIONING Basic ac t iv i t i es of d a i ly l iv ing (ADL)
FeedingDressing
AmbulationToiletingBathing
Transfer (from bed and toilet)ContinenceGrooming
CommunicationInstrumental activities of daily living (IADL)
WritingReadingCookingCleaning
ShoppingDoing laundryClimbing stairsUsing telephoneManaging medicationManaging money
Ability to perform paid employment duties or outside work (e.g., gardening) Ability to travel (use public transportation, go out of town)
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Comprehensive Geriatric Consultation
A comprehensive geriatric consultation includes the following:1. A geriatric oriented history and physical examination attending to issues
reviewed earlier in this chapter2. Medication review; in addition, geriatric patients should be questioned about
alcohol abuse3. Functional assessment4. environmental and social assessment, focusing especially on caregiver support
and other resources available to meet the patients need 5. Discussion of advance directives6. A complete list of the patients medical, functional, and psychosocial problems 7. specific recommendations in each domain
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EXAMPLE OF A SCREENING TOOL TO IDENTIFY POTENTIALLYREMEDIABLE GERIATRIC PROBLEMS
Problem Screening Measure Positive Result Poor vision
Poor hearing
Poor leg mobility
Ask, Do you have difficultydriving, watching television,reading, or doing any of your
daily activities because ofyour eyesight? If yes, then test acuity withSnellen chart, with correctivelenses
With audioscope set at 40 dB,test hearing at 1000 and 2000Hz.
Time the patient after asking,Rise from the chair. Walk 20feet briskly, turn, walk back tothe chair, and sit down.
Inability to read better than20/40 on Snellen chart
Inability to hear 1000 or 2000Hz in both ears or eitherfrequency in one ear
Unable to complete task in 15s
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EXAMPLE OF A SCREENING TOOL TO IDENTIFYPOTENTIALLY REMEDIABLE GERIATRIC PROBLEMS(continued)
Problem Screening Measure Positive Result Urinary incontinence
Malnutrition and weight loss
Memory loss
Depression
Ask, In the past year, have youever lost your urine and gottenwet? If yes, then ask, have you lossurine on at last 6 separate days?
Ask, Have you lost 10 poundsover the past 6 months withouttrying to do so? and then weightthe patient
Three item recall
Ask, Do you often feel sad ordepressed?
Yes to both questions
Yes to question or weight
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EXAMPLE OF A SCREENING TOOL TO IDENTIFYPOTENTIALLY REMEDIABLE GERIATRIC PROBLEMS(continued)
Problem Screening Measure Positive Result Physical disability Ask six question:
Are you able to: Do strenuous activities suchas fast walking or bicycling?
Do heavy work around thehouse like washing windows,walls, or floors?Go shopping for groceries orclothes?Get the places that are out ofwalking distance?Bathe: either a sponge bath,tub bath, or shower?Dress, including putting on ashirt, buttoning a zipping, andputting on shoes?
Source : From Moore and Siu, 1996, with permission.
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CHANGES ASSOCIATED WITH AGING ( Kane et al, 1999)Overall : - Weight, Height and Total Body water
- Fat-to-lean-Body mass ratioCardiovasculars: - Cardiac output, Heart Rate response to stress
- Increased intimal thickening- Sclerosis of heart valves- Decreased compliance of periph. Vessels.
Lungs : - Decreased elasticity & cilia activity, cough reflex
- Vital capacity, max O2 uptakeKidney : - Increased number of abnormal glomeruli
- Renal blood flow, creatinine cl., max. urine osmol.GI Tract : - Fewer taste buds, decreased saliva flow
- Decreased HCl prod. and enzymes.
Skeleton : - More osteoarthritis and osteoporosis.Endocrines : - T3 and free testosteron
- Insuline, norepinephr. Parathormone, vasopres.Nervous syst : - Decreased brain weight, intellect. compl. Learning
- Decreased hours of sleep, REM
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DEVELOPMENT FROM CHILDHOOD TO OLD-AGED
1. Body-length becomes shorter due to esp. osteoporosis, diseases ofbones and joins and body composition and postures.
2. Prevention of abdominal bulging (android obesity).3. Prevention of fall and fractures.4. Keep exercising (keep fit) not strenuous, not to heavy but regular
- non competitive, incl. intellectual and brain exercise.5. Use your intellectual capacity.6. Practice a balanced diet.7. Prevent degenerative diseases risk factors. 8. Keep practicing a Healthy life -style. Source: Boedhi-Darmojo, 2004
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