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
Men

19
16

15
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 Housing

( Commission on Global Ageing)

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 Hypertrophy of lamina muscularis Increase in connective tissue reduced motility and increase transit time

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

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. hearing for high frequencies) Presbyacusis ( loss of

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

impaired near vision and astigmatism

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

NAMES N:- non specific presentation A:- a typical or uncommon presentation M:-multiple pathologies E:- Erroneous attribution of symptoms in old age S:- 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.
Confusion, incontinence, contracture, bedsores, falls

Confusion, incontinence, immobility, falls

Intellectual failure, immobility, instability, iatrogenic

Consequences of single pathology

Influenza

Atrial fibrilation

Bronchopneumonia

CCF

Delirium Death
# NOF Falls immob ility Bed sore Nursing care

Death

Incontinence

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