Marije HamakerDepartment of Geriatric Medicine

Diakonessenhuis

Utrecht, the Netherlands

Other geriatric syndromes

Treviso, Italy, 2016

Disclosure

Nothing to disclose

Programme

• Malnutrition

• Sarcopenia

• Osteoporosis

• Falls and mobility

• Disability

• Frailty

• Incontinence

Malnutrition

Prevalence

• 2-10% of free-living elderly population

• 30-60% of institutionalised elderly

• 40-85% nursing home residents

• 20-60% home care patients

A vicious circle

Malnutrition

Poor appetiteReduced

mobility

Reduced

feeding

capacity

Apathy, depression,

poor concentration

Loss of muscle

strength

Causes “Meals on wheels”

Medications

Emotional (depression)

Alcoholism, abuse

Late life paranoia

Swalling problems

Oral problems

Nosocomial infections

Wandering/dementia

Hyperthyroidism, hypercalcemia, hypoadrenalism

Enteric problems (malabsoption)

Eating problems (e.g. tremor)

Low salt, low cholesterol diet

Shopping and meal preparation problems

Consequences of malnutrition

• Malnourished elderly are:

– 2x more likely to visit the doctor

– 3x more likely to be hospitalized

– more prone to infections

– experience poor healing

– suffer from diminished muscle strength

Sarcopenia

• Syndrome characterised by progressive and

generalised loss of skeletal muscle mass and strength

• Risk of adverse outcomes such as physical disability,

poor quality of life and death

Assessment of sarcopenia

Age and Ageing 2010; 39: 412–423

Osteoporosis

• A systemic disorder of

the skeleton

characterized by a

loss of bone strength

and increased risk of

fractures

Epidemiology

• World wide: 200 million people

• European Union: 22 million women and 5.5 million

men

• United stated: 8 million women and 2 million men

• Effect:

1:3 women and 1:5 over the age of 50 years will have one or

more osteoporotic fractures in their lifetime

Ostoporosis risk

Diseases that can cause osteoporosis

• Decreased mechanical stress

• Weight loss

• Catabolic state

• Acidosis

• Chronic inflammation

• Medication

16

Sequelae of a hip fracture

• 25-33% mortality after 1 year

• In those >75 years: 50% mortality

• 25% permanent immobility

• Only 14-21% full recover of ADL capacity

Mobility impairment and falls

• Loss of symmetry of movement

• Difficulty initiating or maintaining gait

• Footdrop

• Short step length

• Wide based gait

• Stops walking when talking

Gait speed

J Geriatr Phys Ther. 2003;26(3):14-22.

0.82 m/s

BMJ2011;343:d7679

Falls

• Yearly, 1 in 3 adults over 65 years falls

• In nursing homes, 1 in 2

• In 40% to 60% of the elderly, a fall results in physical

damage, of which 10-15% serious damage

Medical risk factors

• Impaired musculoskeletal function, osteoporosis, gait

abnormality

• Cardiar arrythmias, blood pressure fluctuation

• Depression, dementia

• Athritis, hip weakness and imbalance

• Neurologic disorders

• Vision or hearing loss

• Side effect of medications

Other risk factors

• Lack of activity

• Intoxications

• Dehydration

• Malnutrition

• Shoes and walking aids

• Risk factors at home

The dangers of lying in bed

“Look at a patient lying long in bed. What a pathetic

picture he makes! The blood clotting in his veins, the

lime draining from his bones, the scybala stacking up in

this colon, the flesh rotting from his seat, the urine

leaking from his distended bladder and the spirit

evaporating from this soul.”

R. Asher. The dangers of lying in bed. BMJ 1946

Functional impairments

• Limitations in IADL 40%

• Limitations in ADL 28%

• Impaired mobility 34%

Ageing and disability

Incontinence

• Prevalence in women

– 20-39 years 7%

– 40-59 years 17%

– 60-79 years 23%

– ≥80 years 32%

– Nursing homes 60-80%

• Prevalence in men: approximately 1/3 in early years,

equal over 80 years

Etiology

• Changes in the lower urinary tract and innervation

• Patient level

– Comorbidities

– Medication

– Functional and mobility impairments

Consequences

• Impact on self-esteem

• Social withdrawal

• Falls risk

• Caregiver burden

Care giver burden

• 44% care givers for older cancer patients say that the

burden of care is too great

• In many cases, the caregiver is required to make

oncologic treatment feasible!

Frailty

• Interaction between diseases, psychosocial stressors

and subclinical illness leaving a patient vulnerable to

unwanted health outcomes

• Such as: functional decline after illness,

hospitalisation, increased risk of death

• (Interaction between) multiple etiological factors

• Final common pathway of ageing

Gerontology 2009;55:539–549

Fried frailty criteria

• Phenotypical description:

– Unintentional weight loss,

– Exhaustion,

– Muscle weakness,

– Slowness while walking, and

– Low levels of activity

Cumulative deficits model of frailty

• A state of decreased physiologic reserves

• Caused by the accumulation of decline across

multiple organ systems

• Resulting a decreased resistance to stressors

Ferrucci et al. JAGS 2004

Fit patient Frail patient

Geriatric assessment

• Multidimensional assessment of

health status across multiple domains

Take home message

• Many geriatric syndromes interact and amplify each other

• Geriatric syndromes and functional impairments are highly prevalent and easily missed if not specifically looked for

• The presence of geriatric syndromes reflects a patient’s fitness/vulnerability which has significant consequences for oncologic treatment