Essential facts in Geriatric Medicine

The Role of Geriatrician Dr Asso Fariadoon Ali Amin (MRCP)GIM and Care of Elderly specialist

Essential Facts in Geriatric Medicine Main Objectives

• Statistics on Elderly • Main features of Geriatric Medicine• Facts about the life of Elderly in the UK and some

developing countries • The implication of ageing on the world• Physiological changes in Elderly.

Age structure of population UK 2001 census was 58,789,194 of that 18.7% above 65 Rate of increase of over 65 is by 2.4% Currently in developed countries 165 million elderly ,

expected to increase to 265 million by 2025 Sweden highest number ,followed by the UK, Italy, Belgium

and France Elderly before the 17th century in the UK ( Church and

charities), after the 17th century Poor Law Act, after 19th century welfare service

By 2063, the number of 60-74 increase by 50% and over 75 by 70%, while 15-44 decline by 8%.

Life expectancy in 2004 was 81 for female and 76 for men compared to 49 and 45

Developing Countries It is a false assumption that elderly people in developing are not a problem

because they are few. The rate of increase in the elderly population will be 15 times of that of

the UK in Colombia, the Philippines and Thailand) France took 115 years to double their 65+ ( 7-14%) between 1865-1980,

while China takes 2000-2027 to do the same Life expectancy at age of 65 is similar to the of developing countries Currently have 50% of the 65+ population , estimated to increase to 75%

in 2020. Problems with primitive, patchy health care, political instability , financial

problems , and uneven( World Trade Organisations)

Sex Developed countries (years)

Undeveloped countries (years)

Women 19 15

Men 16 12

India and Africa • WHO ( Ageing in India 1999) Life expectancy increase between 1961-2000 for both male

and female by 3-4 years ( 15.2 for men and 16.4 for women) 60-75% relies on the extended family State pension is $1.00/month Commonest cause of death is CHD, 60% hearing impairment,

11 million blind 80% cataract, 9M hypertension, 5M Diabetic, 4M mental health problems, 0.35 M malignancy.

Africa:- Life expectancy is less ( Cause??) , e.g Botswana in Zimbabwe

The implication of aging

Healthcare • Disabilities and multiple pathology• Demand more need for health assistance and medical care• More chronic diseases• More attendance to A&E• Longer stay• More GP and primary care visit.

Social support• Residential, Nursing homes and sheltered accommodation• More carers

The implication of aging Economy ( Commission on Global Ageing)• Housing• Transport• Infrastructure and town planning• Pension, employment, tax

Ethical dilemmas

Political power of elderly “ gray lobby”

Active ageing WHO recommendation for active aging Prevent premature death Reduce disabilities associated with chronic

diseases Ensure older people remain healthy Encourage older people to make productive

contribution to the economy Reduce the number requires costly medical

and care service.

Factors affecting active ageing• Social factors- education/literacy/human rights/social

support/ prevention of violence.

• Personal factors- biology/genetics• Health and social services- health promotion and

disease prevention• Physical environment- housing urban/rural

• Economic• Behavioural

Affect of the world changing on the ageing population

• Global Warming and disasters France (2003), Gujarat ( 2001 ), Tsunami ( 2004), Kurdistan (1991)

• Global Poverty • Loss of Wealth more expenses for heating, housing, food...

• Retirement

Characteristic of Aging in the UK

• Gender • Ethnic mix, 12% below the age of 16, 2.5% at age of 65, and only 1%

at age of 85. • Geographical distribution- migration to villages, towns, and seaside.

• Health status:- 60% of 65+ have multiple pathologies, 37% disabling.

• Living compassions:- (in 2003) 34% of women and 19% of 65-74 years where living alone. Above 75 60% women and 30% men . Ethnic minorities less likely to live alone

• Institution:- only 4.5% ( Nursing Homes, Residential homes), 95.5% lives at their home including sheltered flats.

Physiological/psychological changes with ageing

Skin ( physical)• Fine wrinkles, Dryness, Laxity• Campbell de-Morgan, seborrhoeic keratosis, cherry

haemangioma• Greying of hair due to loss of melanin from hair follicle• Brittle slow-grow nails

o Histological• Atrophy of epidermis• Reduced melanocytes, Langerhans, Mast cells, • Reduced in function and number of sweat gland• Thickened blood vessels

Physiological/psychological changes with ageing

Gastrointestinal tract Mouth Reduced production of saliva Impaired muscles of mastication Tooth loss. Decrease in taste bud decrease in taste sensation. Decline in sense of smell. Enlargement of tongue and atrophic changes in jaw.

Upper GI tract Pharyngeal muscle Oesophageal peristalsis and lower oesophageal sphincter Achlorydria

Physiological/psychological changes with ageing

Small bowel- shortening and broadening of villi Large Bowel • Atrophy of mucosa• Cell infiltration of lamina propria reduced motility and increase • Hypertrophy of lamina muscularis transit time• Increase in connective tissue

• Liver – reduced in volume , blood flow, and fall in liver collagen and ascorbic acid reduce in hepatic drug metabolism but normal LFT

• Gall Bladder- hypertrophy of muscle and elasticity of wall may reduce

• Pancreas- Deposition of amyloid , reduce lipase but no change in amylase or bicarbonate, Duct hyperplasia Reduce fat absorption

Physiological/psychological changes with ageing

Kidney:- • Size and weight of kidney• reduced in number and size of nephrones reduced

• reduces in number of glomeruli and more sclerotic glomeruli GFR• Loss of lobulation of glomerular tuft with thickening of membrane • Degenerative changes in tubules

Bladder , more trabeculation and pseudodiverticula, reduce capacity, alteration in vasularity for submucosa ( increase risk of UTI)

Bone – thinning trabeculae due to increased osteoclastic activity Heart • Loss of myocytes in ventricle• Increase in interstitial fibrosis and collagen result in LV stiffness• Deposition of amyloid mainly in atria• increase left atrial size• Thickening of endocardium and valve • reduction in pacemaker cella in SA nodes

Physiological/psychological changes with ageing

o Blood vessels:- thickening of smooth muscle in arterial wall lead to peripheral stiffness causing increase in systolic BP and widening of pulse pressure.

Respiratory• Reduction in no of glandular epithelial cells mucosa

secretion• Respiratory muscles• ossification of costal cartilage• Thinning of alveoli• small increase in TLC , large increase in RV and fall in FEV1,VC, and

FEV1/VC ratio

Physiological/psychological changes with ageing

• Brian:- brain weight, gyri, meninges, nerve cell numbers changes

• Hearing:- loss hair and ganglion cells in choclea, decrease average numbers of fibres in cochlear nerve. Presbyacusis ( loss of hearing for high frequencies)

• Eyes flatter cornea leading to astigmatism hardening of lens and iris floaters in vitreous humour reduced response from ciliary muscle impaired near vision and eyelid changes in muscle and skin astigmatism slow response of pupils to light

Physiological/psychological changes with ageing

Body temperature:- • Inability to maintain temperature through thermo genesis.• impaired sweating, and cutaneous vasoconstriction Hypothermia

• Impaired perception to low temperature.

Hormonal • Insulin, oestrogen, LH/FSH, GH, Thyroid, PTH

Psychological • Memory, intelligence, personality.

Specific features of disease presentation

NAMESN:- non specific presentationA:- a typical or uncommon presentationM:-multiple pathologiesE:- Erroneous attribution of symptoms in old ageS:- Single illness leading to catastrophic

consequences.

Non specific presentation Described as the Dragon by Dr Trevor Howell, and the giants

of geriatric by professor Bernard Isaac. Recently geriatricians using Is.

Consequences of single pathology

Falls

Death#

NOF immobility

Bed sore

Incontinence

Nursing care

Pharmacology and Elderly Drug related illness is a significant problem in the elderly. 5-17% of hospital admissions are caused by adverse reaction

to medicine. The risk of adverse reaction to medication increases with age and the number of drugs prescribed.

Several mechanism or changes may account for this ,including:-

• Alteration of pharmacokinetic and pharmacodyanamic • Increased sensitivity of diseases tissue to medication• Drug interaction• Compliance • In appropriate prescription of medication without consideration for non

medical management, or prescribing medication causing side effect or interacting with other medication.

Alteration of pharmacokinetic and pharmacodyanamic

Renal clearance Hepatic metabolism Absorption is un changed Volume distribution. Fat soluble versus water soluble. alteration or receptors response

Compliance Poor compliance in 40-75% of patients:-• acutely ill patient can take more than prescribed dose thinking it will

speed the process of getting better • Forgetting because of too many medication. 25% of older patient take at

least three medication. Discharged patient can be on as many as 8 medication.

• Discontinuation happens in as many as 40% of medication usually first year.

• 10% can take medication of others and 20% non prescribed medication.

Clinical Assessment Making a clinical diagnosis by:- Taking history from patient and others. who? Examination • General examination and vital signs• CVS, Respiratory, Abdomen, CNS, PNS, Musculoskeletal ands function.• Investigation FBC, U&E, LFT, TFT, Glucose, Lipid profile, Ca/PO4, CXR,

ECG, Urinalysis. Medication review Cognitive function and consciousness GCS, AMTS, MMSE. Functional assessment Social circumstances Environmental Economic