1- Introduction to Clinical Geriatrics

Define aging.

The inevitable, irreversible decline in organ function that occurs over time

What are the 1st systems impacted by aging?

CV, renal, and CNS

What is the term for the theory that human cells have the ability undergo mitosis a finite number of times?

replicative senescence

What are the 4 theories regarding aging?

· Alleles linked to Disease states

· Evolutionary Senescence

· Oxidative Damage/Free Radicals

· Replicative Senescence

Geriatric medicine considers ___________ and ___________ to determine benefits and harms of work-up and treatment plans.

prognosis and lifespan

What are the clinical manifestations for age related changes to body composition?

Changes in medication levels ↑

↓ strength

Risk of dehydration

What are the physiologic age related changes for body composition?

↓ lean body mass

↓ muscle mass

↓ creatinine production

↓ skeletal mass

↓ total body water

↑ percentage adipose tissue (until age 60)

What are the physiologic age related changes for cells?

↑ DNA damage

↓ oxidative capacity

↑ cell deterioration

↑ fibrosis

What are the clinical manifestations for age related changes to cells?

↑ cancer risk

What are the physiologic age related changes for CNS?

↓ dopamine receptors

↑ alpha-adrenergic responses

↑ muscarinic parasympathetic responses

What are the clinical manifestations for age related changes to CNS?

Tendency to having stiffer muscles, less flexibility, impaired balance, and loss of spontaneous movements

What are the physiologic age related changes for PNS?

↓ baroreflex responses

↓ beta-adrenergic responsiveness

↓ signal transduction

↓ muscarinic parasympathetic responses

Preserved alpha-adrenergic responses

What are the clinical manifestations for age related changes to PNS?

Susceptible to syncope

↓ response to beta-blockers

Exaggerated response to anticholinergic medications

What are the physiologic age related changes for joints?

Degeneration of cartilaginous tissue

Fibrosis

↑ glycosylation

Loss of tissue elasticity

What are the clinical manifestations for age related changes to joints?

Tightening of joints

Susceptibility to OA

What are the physiologic age related changes for the heart?

Blunted baroreflex

↓ diastolic relaxation

↑ AV conduction time

↑ atrial and ventricular ectopy

What are the clinical manifestations for age related changes to the heart?

Susceptibility to syncope

↓ EF

↑ rates of afib

↑ rates of diastolic dysfunction and HF with ↓ EF

What are the physiologic age related changes for the vascular system?

↓ endothelin-dependent vasodilation

↑ peripheral resistance

What are the clinical manifestations for age related changes to the vascular system?

Susceptible to HTN

What are the physiologic age related changes for the pulmonary system?

↓ vital capacity

↓ lung elasticity (compliance)

↑ residual volume

↓ FEV1

↑ V/Q mismatch

What are the clinical manifestations for age related changes to the pulmonary system?

↑ likelihood of SOB during vigorous exercise or high altitudes

↑ risk of death due to PNA

↑ risk of complications for pt with pulmonary disorders

What are the physiologic age related changes for the immune system?

↓ T-cell function

↓ B-cell function

What are the clinical manifestations for age related changes to the immune system?

↑ risk of infections and cancer

↓ Ab response to immunization or infection ↑ auto-Abs

What are the physiologic age related changes for the nose?

↓ smell

↑ mucosal thinning and/or capillary fragility

What are the clinical manifestations for age related changes to the nose?

↓ taste and ↓ appetite

↑ incidence of nasal bleeding

What are the physiologic age related changes for the ears?

Loss of high-frequency hearing

What are the clinical manifestations for age related changes to the ears?

↓ ability to recognize speech

What are the clinical manifestations for age related changes to the eyes?

Presbyopia

↑ glare and difficulty adjusting to changes in light

↓ visual acuity

What are the physiologic age related changes for the eyes?

↓ lens flexibility

↑ time for pupillary reflexes

↑ incidence of cataracts

What are the physiologic age related changes for the GI tract?

↓ splanchnic blood flow

↑ transit time

What are the clinical manifestations for age related changes to the GI tract?

Susceptibility to constipation and diarrhea

What are the physiologic age related changes to the liver?

↓ hepatic mass

↓ hepatic blood flow

↓ activity of CYP450 enzyme system

What are the clinical manifestations for age related changes to the liver?

Changes in medication levels

What are the physiologic age related changes for the kidneys?

↓ renal mass

↓ renal blood flow

↓ GFR

↓ renal tubular secretion and reabsorption

What are the clinical manifestations for age related changes to the kidneys?

Changes in medication levels

↑ risk of adverse drug effects

Susceptibility to nocturia

What are the physiologic age related changes for the endocrine system?

↑ insulin resistance and glucose intolerance

What are the clinical manifestations for age related changes to the endocrine system?

↑ incidence of diabetes

What are the physiologic age related changes for female reproductive system?

Menopause --> ↓ estrogen and progesterone secretion

↓ testosterone secretion

↓ GH secretion

↓ vit. D absorption and activation

↑ incidence of thyroid abnormalities

↑ bone mineral loss

↑ secretion of ADH

What are the clinical manifestations for age related changes to female reproductive system?

Vaginal dryness, dyspareunia

↓ muscle mass

↓ bone mass

↑ fracture risk

Changes in skin

Susceptibility to water intoxication

What common complication of aging occurs bc of renal perfusion increases when lying down and how can you manage it?

nocturia

management- Encourage fluids early in the day; diuretics qam; treat BPH

What common complication of aging occurs bc of reduced stamina leading to frailty and how can you manage it?

fatigue

management- Encourage nutrition, naps and adequate rest

What common complication of aging occurs due to post-operative patients; brain functional reserve down; anesthesia and how can you manage it?

delirium

management- Minimize sedation and anticholinergic meds

What common complication of aging occurs bc of neuromuscular mechanisms decreased and how can you manage it?

falls

management-

o Tripping on edge of rug, cord- eliminate hazards!

o Widened doorways; motion sensors for lights

What are some factors that can impact hx taking in the geriatric pt?

•Sensory deficits

•Underreporting of symptoms

•Unusual manifestations of disorders

•Functional decline as the only manifestation

•Difficulty recalling

•Fear

•Age-related disorders and problems

What is key to establish when interviewing the older pt?

establishing a rapport!!!

What should always be asked for PMHx?

o Ask about disorders that used to be common (ex- rheumatic fever and polio)

o Do not forget to ask about outdated tx

o Immunization hx

What should medication hx include?

•Medication used

•Dose

•Dosing schedule

•Prescriber

•Reason for taking the medication

•Medication allergies with reaction

What is included in the general survey?

Observe pt and their movements

o Walking into exam room

o Sitting or rising from chair

o Getting on and off the exam table

o Putting on and taking off socks and shoes

Personal hygiene

General appearance

What should be included in the VS for a geriatric pt?

· Weight: each visit

· Height: annually

· Temperature

· Blood pressure- Both arms & Including orthostatics

· Pulse

· Respiratory Rate

· Pulse ox

What should skin and nails be evaluated for?

•Malignant and premalignant lesions

•Tissue ischemia

•Pressure injuries

•Ecchymoses

What are the normal aging findings associated with the face?

o Eyebrows that drop below the superior orbital rim

o Dry skin

What needs to be checked during the PE for the face?

o Temporal A. tenderness and thickening

What are the normal aging findings associated with the eyes?

o Loss of orbital fat

o Entropion

o Ectropion

o Arcus senilis

What needs to be checked during the PE for the eyes?

o Visual acuity

o Visual fields

o Ophthalmoscopic examination

o Eye examination by ophthalmologist or optometrist recommended every 1-2 years

What is the eye exam recommendation for geriatric pts?

every 1-2yrs

What are the normal aging findings associated with the nose?

o Progressive descent of the nasal tip

What is the recommendation for eye exams by an ophthalmologist or optometrist in geriatric pts?

every 1-2yrs

What are the normal aging findings associated with the ears?

o Cerumen

o Decreased hearing

What needs to be checked during the PE for the ears?

o Hearing

o If positive HHIE score then refer to audiologist for further testing

What are the normal aging findings associated with the mouth?

o Darkened teeth

o Benign migratory glossitis (geographic tongue)

If a pt pt has a + HHIE score what should be done?

refer to audiologist for further testing

What needs to be checked during the PE for the mouth?

o Bleeding or swollen gums

o Broken or loose teeth

o Fungal infections

o Signs of cancer

o Denture fit

What are the normal aging findings associated with TMJ?

degeneration

What needs to be checked during the PE for TMJ?

osteoarthritis

What are the normal aging findings associated with the neck?

arthritis

What needs to be checked during the PE for the neck?

o Thyroid - enlargement and/or nodules

o Carotid bruits

o ROM

What are the normal aging findings associated with the heart?

o Fourth heart sounds = common in older patients without evidence of cardiovascular disorders

What needs to be checked during the PE for the heart?

o Palpate apex

o Auscultation- rate, regularity, murmurs, clicks, rubs

What are the normal aging findings associated with the lungs?

o Basilar rales will disappear in a few deep breaths

What needs to be checked during the PE for the lungs?

o Percussion

o Auscultation

o Diaphragmatic excursion

What are the normal aging findings associated with the back?

kyphosis

What needs to be checked during the PE for the back?

curvature

tenderness

What are the normal aging findings associated with GI?

o Weakened abdominal muscles

What needs to be checked during the PE for GI?

o Auscultation

o AAA

o Splenomegaly

o Hepatomegaly

o Suprapubic tenderness

o Anorectal exam—including fecal occult blood test

What are the normal aging findings associated with male repro?

o Enlarged prostate

What needs to be checked during the PE for male repro?

o Prostate- Nodules, tenderness, consistency

o Signs of infection

What are the normal aging findings associated with female repro?

o Vaginal atrophy

o Non-palpable ovaries

What needs to be checked during the PE for female repro?

o Prolapse- Urethra, vagina, cervix and uterus

o Urine leakage

o Signs of infection

What are the normal aging findings associated with MSK?

o Stiffened joints

o Decreased flexibility

o Arthritis

o Feet:

----Hallux valgus

----Hammer toe

----Claw toe

What needs to be checked during the PE for MSK?

o Joints- Tenderness, Swelling, Subluxation, Crepitus, Warmth, Redness, Active ROM, and Passive ROM

o Presence of contractures

o Osteoarthritis- Heberden nodes and Bouchard nodes

o Rheumatoid arthritis

----Subluxation of MCP joints with ulnar deviation of fingers

----Swan-neck deformity

----Boutonniere deformity

o Foot exam- Referral to podiatry if pathology arises

What are the normal aging findings associated with Neuro?

o Visual deficits

o Hearing deficits

o Arthritis of hips and shoulders may impact motor function

What needs to be checked during the PE for Neuro?

o Cranial nerves

o Motor function

o Muscle strength

o Coordination

o Gait

o Posture

o Fall Risk

o Reflexes

o Sensation

o Mental status

What is the MC systolic murmur heard at the base (between apex and sternum)?

aortic valve sclerosis

What type of murmurs are abnormal at ANY age?

diastolic murmurs

What are the benefits regarding a COMPREHENSIVE geriatric assessment?

•Increased identification of conditions

•Improved functional and mental status

•Reduced mortality

•Decreased use of nursing homes and acute care hospitals

•Greater satisfaction with care

What are the 4 principle domains?

•Functional ability

•Physical Health

•Cognition and mental health

•Socioenvironmental situation

What are some examples of daily functional abilities?

•Eating

•Dressing

•Bathing

•Transferring between bed and chair

•Using the toilet

•Control bowel and bladder function

•Preparing meals

•Doing housework

•Taking medications

•Going on errands

•Managing finances

•Using the telephone

What are some assistive devices (personal and environmental) used to help difficulty in functional abilities?

o Personal devices- cane, walker, wheelchair, O2

o Environmental devices- grab bars, shower bench, hospital bed

Examples of preventative measures?

· Regularity of BP

· FOBT

· Colonoscopy

· Immunizations

· TSH screening

· Dental Care

· Intake of calcium and vitamin D

· Regularity of exercise

· Use of smoke detectors