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Essential facts in Geriatric
Medicine
The Role of GeriatricianDr Asso Fariadoon Ali Amin (MRCP)
GIM and Care of Elderly specialist
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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.
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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 17thcentury in the UK ( Church and
charities), after the 17thcentury 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
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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
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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
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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
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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
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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.
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Factors affecting active ageing
Social factors- education/literacy/human rights/socialsupport/ prevention of violence.
Personal factors- biology/genetics
Health and social services- health promotion anddisease prevention
Physical environment-housing urban/rural
Economic
Behavioural
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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
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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.
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Physiological/psychological changes
with ageing
Skin ( physical) Fine wrinkles,Dryness,Laxity
Campbell de-Morgan, seborrhoeic keratosis, cherryhaemangioma
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
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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
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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
Liverreduced in volume ,blood flow, and fall in liver collagen and
ascorbic acid reduce in hepatic drug metabolism but normalLFT
Gall Bladder- hypertrophy of muscle and elasticity of wall may reduce
Pancreas- Deposition of amyloid , reduce lipase but no change inamylase or bicarbonate, Duct hyperplasia Reduce fat absorption
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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)
Bonethinning 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
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Physiological/psychological changes
with ageing
o Blood vessels:- thickening of smooth muscle in arterial wall lead toperipheral 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
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Physiological/psychological changes
with ageing
Brian:-brain weight, gyri, meninges, nerve cell numbers changes
Hearing:- loss hair and ganglion cells in choclea, decrease averagenumbers 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
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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.
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Specific features of disease
presentation
NAMES
N:- non specific presentation
A:- a typical or uncommon presentationM:-multiple pathologies
E:- Erroneous attribution of symptoms in old age
S:- Single illness leading to catastrophicconsequences.
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Non specific presentation
Described as the Dragon by Dr Trevor Howell, and the giantsof geriatric by professor Bernard Isaac. Recently geriatricians
using Is.
Confusion, incontinence, contracture,bedsores, falls
Confusion, incontinence, immobility, falls
Intellectual failure, immobility, instability,iatrogenic
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Consequences of single pathology
Influenza
Atrial fibrilation
CCF Delirium
Bronchopneumonia
Death
Falls
Death
#
NOFimmob
ility
Bed
sore
Incontinence
Nursing
care
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Pharmacology and Elderly
Drug related illness is a significant problem in the elderly.
5-17% of hospital admissions are caused by adverse reactionto 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.
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Alteration of pharmacokinetic and
pharmacodyanamic
Renal clearance
Hepatic metabolism
Absorption is un changed
Volume distribution. Fat soluble versus water soluble.
alteration or receptors response
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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 8medication.
Discontinuation happens in as many as 40% of medication usually first
year.
10% can take medication of others and 20% non prescribed medication.
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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
E i