Clinical Problems

Associated with Aging

Process
Contents
Fundamentals of Geriatric Care
Treatment of Common Diseases in Geriatric Population
Geriatric Syndromes and Conditions
Fundamentals of Geriatric Care
 Inter-Professional Teams and Co-Managed Care
 Person-Centered Care
 Evaluation of Geriatric Patient
 Prevention in Older Adult
 Treatment of Common Diseases in Geriatric Population

Key goals of geriatric care - Functional ability and quality of life

Evaluation of Geriatric Patient
Evaluation of older adults usually differs from a standard medical evaluation. For older patients,
especially those who are very old or frail, history-taking and physical examination may have to
be done at different times, and physical examination may require 2 sessions because patients
become fatigued.
Multiple disorders
Missed or delayed diagnosis
Polypharmacy
Multiple Disorders
The geriatric population requires different approaches to care for several reasons.
Close to half of those aged >80 have three, and about one-third have four or more chronic
conditions.
Missed or delayed Diagnosis
Disorders that are common among older adults are
frequently missed, or the diagnosis is delayed.
Clinicians should use the history, physical examination,
and simple laboratory tests to actively screen for disorders
that occur only or more commonly in older patients;
Early diagnosis frequently depends on the clinician’s
familiarity with the patient’s behavior and history,
including mental status.
Commonly, the first signs of a physical disorder are
behavioral, mental, or emotional. If clinicians are unaware
of this possibility and attribute these signs to dementia,
diagnosis and treatment can be delayed.
A series of screening questions can be useful as a
“geriatric review of systems” in clinical practice
with older patients because of the importance and
high prevalence of functional impairments and
disabilities, limited social support to assist with
functional limitations, cognitive and affective
disorders, and geriatric conditions that may go
undetected and cause patient safety issues and
complications
Physical Examination - Vital Signs
Weight should be recorded at each visit.
Height is recorded annually to check for height loss due to osteoporosis.
Temperature is recorded. Hypothermia can be missed if the thermometer cannot measure temperatures
more than a few degrees lower than normal. Absence of fever does not exclude infection.
Pulses and blood pressure (BP) are checked in both arms. Pulse is taken for 30 seconds, and any irregularity is
noted. Because many factors can alter BP, BP is measured several times after patients have rested > 5
minutes.
All older patients are checked for orthostatic hypotension because it is common. BP is measured with patients
in the supine position, then after they have been standing for 3 to 5 minutes. If systolic BP falls ≥ 20 mm Hg
after patients stand, or any symptoms of hypotension are detected, orthostatic hypotension is diagnosed.
A normal respiratory rate in older patients may be as high as 25 breaths/minute. A rate of > 25
breaths/minute may be the first sign of a lower respiratory tract infection, heart failure, or another disorder.
Polypharmacy
Prescription and over-the-counter drug use
should be reviewed frequently, particularly for
drug interactions and use of drugs considered
inappropriate for older patients. When
multiple drugs are used, electronic health
record−based management is more efficient.
Polypharmacy has been defined as the
prescription of multiple medications using
various thresholds (generally ranging from five
up to nine simultaneous drugs)
Driving in Older Adults
For many older adults in the United States,
driving is essential for maintaining
independence and driving cessation is
associated with negative outcomes including
social isolation and depression.
On the other hand, older adults have the
highest risk of being involved in fatal crashes
with up to a nine-time higher risk for those
85 years old compared to younger people.
Interpretation of diagnostic tests
Atypical presentations of medical conditions are a common feature of geriatric medicine.
Laboratory Tests - The large variation of many physiologic measures that is associated with
normal aging makes establishing what is “normal” for many tests challenging. For this reason,
the results of several diagnostic tests must be interpreted with caution. Examples include
creatinine clearance, pulmonary function, and sedimentation rate (which can confound the
diagnosis of polymyalgia).
Ambulatory cardiac monitoring - may identify a variety of arrhythmias, but they have a high
incidence in older people and must be linked with symptoms before considering potentially toxic
or invasive treatment.
Musculoskeletal imaging - such as an MRI of the spine, may reveal multiple abnormalities that
may or may not be related to symptoms.
Prevention in Older Adults - Screening
Prevention in Older Adults - Screening
Prevention in Older Adults - Vaccination
The use of vaccines in older adults is aimed at creating immunity against common infections that
could lead to serious complications, as well as for rebuilding previously obtained immunity.

Currently, the CDC recommends routine vaccination against influenza, pneumococcus and
shingles as they are prevalent in this age group.
Treatment of Common Diseases -
Hypertension
Hypertension –Blood pressure targets remain controversial. protective benefits versus the risk of
treatment-related adverse events must be considered in individual patients based on their
comorbidities.
For older patients with minimal comorbidity, no postural hypotension, and low risk of falls and volume
depletion, the benefit/risk ratio favors lower targets for systolic blood pressure (<130 mmHg measured
by a hand sphygmomanometer).
However, for those with diabetes, heart failure, history of stroke, postural hypotension, careful
treatment of blood pressure with higher systolic targets (< 150 mmHg) is probably a safer approach.
Treatment of Common Diseases –
Diabetes
The prevalence of diabetes in the older adult population is now over 25% and expected to increase
due to adverse lifestyle changes and an increased incidence of obesity.
Older diabetic patients are at significant risk of hypoglycemia because of potential medication
errors, progressive decline in renal function, and inconsistent oral intake among other reasons.
Hypoglycemic episodes are associated with progressive cognitive decline in older adults, especially
those with existing cognitive impairment.
On the other hand, uncontrolled diabetes is associated with an increased risk of all-cause
dementia.
The goals of treating diabetes in the geriatric population should be tailored to the patient’s
functional and medical status, social support, personal goals, perception of risk, and life
expectancy.
Osteoarthritis
Osteoarthritis - The approach to the management of symptomatic OA in the geriatric population
differs from the approach in younger patients because of the risks of toxicity of nonsteroidal
anti-inflammatory drugs (NSAIDs) in older patients. Nonpharmacologic interventions should be
the first line of treatment.
Many older patients respond well to a variety of non-pharmacologic interventions, including
stretching, strengthening, timely and appropriate use of heat and ice, massage, swimming and
whirlpool therapy, bracing, acupuncture, and therapeutic electrical stimulation.
Surgical interventions, including replacement of major joints, have improved over the last
several years, and even older patients with multi-morbidity may experience improved function
and quality of life.
Cancer
More than half of new cases of cancer and mortality associated with it occur after the age of 65.
Older adults generally experience decreases in functional status after receiving chemotherapy.
Most of this negative effect appears to be related to comorbidity and baseline functional status,
rather than due to age alone.
Lack of social support has been associated with poor outcomes after radiation and
chemotherapy, especially in older women.
Other important issues in cancer treatment planning include availability of transportation for
treatments, economic and insurance status, the patient’s ability to follow treatment plans, and
family and social support available during therapy, when adverse effects and functional decline
may occur.
Geriatric Syndromes
and Conditions
C O G N I T I V E I M PA I R M E N T
U R I N A RY I N C O N T I N E N C E
N E G L E C T A N D A B U S E O F T H E E L D E R LY
 Cognitive Impairment – Delirium and
Dementia
Delirium occurs in up to 40% of hospitalized older patients, and is associated with increased morbidity, need for
institutional care, and mortality in this population. While most episodes of delirium clear within a few days if the
underlying cause(s) are identified and treated, delirium may persist for weeks, and in a few cases for months, after an
acute hospitalization. No non-pharmacological or pharmacological intervention has been shown to prevent progression
to dementia.
The prevalence of dementia increases with age; by age 85 between 30 and 40% have a dementia syndrome.
Alzheimer’s disease and vascular dementia, which often occur together based on pathologic studies, account for most
dementias in older people.
Dementia with Lewy bodies accounts for up to 25% of dementia, and is characterized by Parkinsonian features early in
the disease (as opposed to dementia in Parkinson’s disease, which generally occurs years after the onset of
Parkinson’s), personality changes, alterations in alertness and attention, and visual hallucinations that can cause
paranoia.
Most dementia syndromes are slowly progressive over several years; however, dementia is a terminal illness among
patients who do not succumb to other comorbidities, and results in devastating loss of cognition and function in the
later stages.
Principle of Dementia
Management
There are four basic approaches to the
pharmacological treatment of dementia:
(1) avoid drugs that can worsen cognitive function,
mainly those with strong anticholinergic activity;
(2) agents that enhance cognition and function;
(3) drug treatment of coexisting depression, which
is common throughout the course of dementia; and
(4) pharmacological treatment of complications
such as paranoia, delusions, psychosis, and
behavioral symptoms such as agitation (verbal and
physical).
Urinary Incontinence
Urinary incontinence is curable or controllable in many geriatric patients, especially those who have
adequate mobility and mental functioning.
Even when it is not curable, incontinence can be managed in a manner that keeps people
comfortable, makes life easier for caregivers, and minimizes the costs of caring for the condition and
its complications.
Approximately one in three women and 15 to 20% of men aged >65 years have some degree of
urinary incontinence.
It can be followed by:
Isolation
Depression
Skin lesions
Nocturia
Elder Abuse and Neglect
Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults.
Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial abuse. Each type may
be intentional or unintentional. Poly-victimization (co-occurrence of multiple forms of abuse) is common. The
perpetrators are often adult children but may be other family members or paid or informal caregivers.
Physical abuse is use of force resulting in physical or psychologic injury or discomfort. It includes striking, shoving,
shaking, beating, restraining, forceful feeding, and unwarranted administration of drugs.
Psychologic abuse is use of words, acts, or other means to cause emotional stress or anguish. It includes issuing
threats (eg, of institutionalization), insults, and harsh commands, as well as remaining silent and ignoring the person.
It also includes infantilization (a patronizing form of ageism in which the perpetrator treats the older person as a
child), which encourages the older person to become dependent on the perpetrator.
Neglect is the failure or refusal to provide food, medicine, personal care, or other necessities; it also includes
abandonment. Neglect that results in physical or psychologic harm is considered abuse.
Financial abuse is exploitation of or inattention to a person’s possessions or funds. It includes swindling, pressuring a
person to distribute assets, and managing a person’s money irresponsibly.
Symptoms and signs of elder abuse may
erroneously be attributed to a chronic disorder.
However, the following clinical situations are
particularly suggestive of abuse:

 Delay between an injury or illness and the

seeking of medical attention
 Disparities in the patient’s and caregiver’s
accounts
 Injury severity that is incompatible with the
caregiver’s explanation
 Implausible or vague explanation of the injury
by the patient or caregiver
 Frequent visits to the emergency department
for exacerbations of a chronic disorder despite
an appropriate care plan and adequate
resources
 Absence of the caregiver when a functionally
impaired patient presents to the physician
 Reluctance of the caregiver to accept home
health care (eg, a visiting nurse) or leave the
older patient alone with a health care
practitioner
 Intervention
If the patient is in immediate danger, the physician, in consultation with the patient, should consider hospital admission, law enforcement
intervention, or relocation to a safe home. The patient should be informed of the risks and consequences of each option.
If the patient is not in immediate danger, steps to reduce risk should be taken but are less urgent. The choice of intervention depends on the
perpetrator’s intent to harm. For example, if a family member administers too much of a drug because the physician’s directions are
misunderstood, the only intervention needed may be to give clearer instructions. A deliberate overdose requires more intensive intervention.
In general, interventions need to be tailored to each situation. Interventions may include
Medical assistance
Culturally sensitive education (eg, teaching victims about abuse and available options, helping them devise safety plans)
Trauma-informed psychologic support (eg, short-term or long-term psychotherapy for the victim and possibly the family that recognizes and
addresses specific traumas and the role of trauma in the person's life)
Law enforcement and legal intervention (eg, arrest of the perpetrator, orders of protection, legal advocacy including asset protection)
Alternative housing (eg, sheltered senior housing, nursing home placement)
Referral to services to provide basic support (such as transportation and food assistance) and reduce social isolation
If victims have decision-making capacity, they should help determine their own intervention. If they do not, the interdisciplinary team, ideally
with a guardian or objective conservator, should make most decisions.
Thank you