Geriatric

• Differences between older and younger patients


  • Heterogeneity, Homeostenosis, Comorbidities, Different disease presentation, Chronic vs Acute disease
• Normal aging

  The normal deteriorative process that all human beings will experience such as hypothyroidism, stroke and CHF
• Homeostenosis


  The concept where normal aging decreases the body's ability to handle stress and challenges over time, also our functional capacity will decline and those are affected by genetic, diet, environment, personal habit
• Theories of Aging


  • Oxidative damage (free radicals)
  • Apoptosis (programmed cell death)
  • Immunological theories (damage to the immune system makes the body vulnerable to disease)
• Life expectancy


  The number of years a person would be expected to live from the day they were born
• Comprehensive Geriatric Assessment (CGA)


  A multi-aspect process in which we can evaluate the complaints, reach a diagnosis and submit the best management for our patient
• Polypharmacy


  Commonly defined as the usage of more than 5 drugs by the same patient at the same time, but in clinical practice it is more complex than just a number of drugs
• Criteria for identifying polypharmacy


  • Taking medications that have no obvious indication
  • Using therapeutic equivalents to treat the same illness
  • Concurrent usage of interacting medications
  • Using an inappropriate dosage
  • Utilizing other medications to treat adverse drug reactions
• Types of Polypharmacy


  • Therapeutic Polypharmacy (multiple drug regimens carefully monitored by clinicians and necessary for treatment)
  • Contra-therapeutic Polypharmacy (individual experiences unanticipated or unintentional adverse effects while on a drug regimen and is not monitored)
• Polypharmacy Confrontations and Outcomes in Geriatrics


  • Pharmacokinetic changes in the elderly (hepatic blood flow drops by 40%, half of elderly have some form of chronic kidney diseases, protein binding changes), polypharmacy significantly increases the chance for medication non-adherence, medication errors, and drug-drug, drug-food, and drug-disease interactions, the cost of providing healthcare for an older American is 3 to 5 times greater than the cost for someone younger than 65
• Solutions for Decreasing Polypharmacy


  • Professional (educational activities for providers or patients)
  • Organizational (polypharmacy clinics)
  • Financial (incentive programs)
  • Tools to Help Decrease Polypharmacy (Beers Criteria, STOPP Criteria, START Criteria)
• Falls Etiology


  • Accident
  • Poor Vision or Hearing
  • Muscle Weakness
  • Medications
  • Chronic Diseases
  • Environmental Hazards
• Candy dish method


  Dumping multiple medications into one bowl and fishing out the appropriate medication at the scheduled time
• Tools to Help Decrease Polypharmacy


  • Beers Criteria
  • STOPP Criteria
  • START Criteria
• Timed Up and Go Test


  The time patient take for stand up from standard armchair with hand resting on arm rest and walk distance of 3 meters, turn around, walk back to the chair and sit down
• Timed Up and Go Test Values


  • ≤ 10 seconds = normal
  • ≤ 20 seconds = good mobility, can go out alone but with high risk of fall
  • ≤ 30 seconds = problems, cannot go outside alone, requires gait aid
• Management of Falls includes: Treat underlying cause, Review medication and consider their necessity, Hip protector, Enhance mobility (walker, cane and rails)
• Dementia


  A general term for decline in the mental ability severe enough to interfere with daily life activity

  
• The first symptom of dementia are recognized by other family members rather than the patient himself

  
• Causes of Dementia


  • Alzheimer Dementia (AD)
  • Vascular Dementia (VaD)
  • Mixed AD & VaD
  • Dementia Lewy Body (DLB)
  • Frontotemporal Dementia (FTD)

  
• The prevalence of dementia worldwide are 5.2% of all individuals over 60 years. According to the WHO the prevalence in Jordan are 6% of all individuals over 60 years
• Symptoms of Dementia


  • Memory
  • Communication & Language
  • Reasoning & Judgment
  • Visual precipitation

  
• The Approach to Dementia


  1. Medical history

  2. Physical examination

  3. Cognitive & neurophysiological tests

  4. Blood tests (LFT, KFT, TFT, HbA1C, Vit. B12, Folate)

  
• Treatment of Dementia


  There are no cure from dementia but there are some drugs that will slow or stop the progression of the disease like Cholinesterase inhibitor and memantine
• Delirium


  An acute mental disturbance characterized by confused thinking and distributed attention usually accompanied by disorders in speech and hallucinations

  
• The mortality rate of delirium is 20% per year for those over 70 years. It will affect of 60% off older patient that are hospitalized for surgery
• Types of Delirium


  • Hyperactive delirium
  • Hypoactive delirium
  • Mixed delirium

  
• Delirium vs Dementia


  • Onset: Delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time
  • Attention: The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert
  • Fluctuation: The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day

  
• Causes of Delirium


  • Certain medications or drug toxicity
  • Alcohol or drug intoxication or withdrawal
  • Metabolic imbalances
  • Urinary tract infection, pneumonia or the flu
  • Exposure to a toxin, such as carbon monoxide, cyanide or other poisons
  • Surgery or other medical procedures that include anesthesia

  
• Symptoms of Delirium


  • Reduced awareness of the environment
  • Poor thinking skills
  • Behavior changes
  • Emotional disturbances
• Treatment of Delirium


  1. Non-pharmacological treatment (reorientation and behavioral intervention)

  2. Pharmacological treatment (Haloperidol, risperidone, olanzapine, lorazepam)

  
• Lasting depression is not a typical part of aging
• Causes of Depression


  • Low level of key neurotransmitter chemicals in the brain
  • Family history of depression
  • Traumatic life event
• Symptoms of Depression


  • Sadness
  • Feeling worthlessness
  • Crying spells
  • Lack of concentration
  • Change in the appetite
• Treatment of Depression


  Typical treatment for depression compose of combination of therapy, medication and lifestyle changes. Medication Therapy includes SSRIs, SNRIs, Tricyclic antidepressants, MAOIs