Common Geriatric Disorders

Actinic Keratosis (AK)

• Pre‐cancerous epidermal lesion → precursor of squamous-cell carcinoma (SCC).
• Morphology
  • Small (<1 cm), rough, scaly, pink-to-reddish papules or plaques.
  • Enlarge slowly over years.
• Distribution: Sun-exposed skin—cheeks, nose, neck, forearms, dorsal hands, chest.
• Epidemiology: Predominantly light-skinned, chronic UV exposure.
• Diagnostics
  • Definitive test: Skin biopsy (rule-out invasive SCC).
• Management
  • Few lesions → cryotherapy (liquid N₂).
  • Numerous/widely distributed lesions → topical 5-fluorouracil cream (field therapy).

Acute Angle-Closure Glaucoma (AACG)

• Typical patient: Older adult with abrupt ocular emergency.
• Presentation
  • Sudden severe eye pain ± headache, nausea/vomiting.
  • Blurred vision; halos around lights.
  • Exam: Conjunctival hyperemia, corneal edema/cloudiness, shallow anterior chamber, mid-dilated fixed/poorly reactive pupil.
• Action: Call 911—irreversible blindness within hours.
• ED work-up: Tonometry → markedly elevated intra-ocular pressure (IOP).

Cerebrovascular Accident (CVA)

• Definition: Neurologic deficit ≥24 h ("stroke").
• Major symptom spectrum depends on lesion site
  • Visual loss (hemianopia, blurred vision), aphasia/dysarthria, unilateral weakness/numbness, confusion, severe headache.
• Types: Ischemic (majority) vs. Hemorrhagic (intracerebral, subarachnoid).
• TIA: Reversible episode without infarction.

Colorectal Cancer (CRC)

• Red-flag clues
  • Unexplained iron-deficiency anemia, hematochezia/melena, tenesmus, ribbon-like stools, weight loss, abdominal pain, change in bowel habits.
• Up to 20\% have distant metastases at diagnosis.
• Screening (USPSTF)
  • Start 45 y → 75 y; individualized 76–85 y.
  • Options: Annual gFOBT, multitarget DNA stool q3 y, flex sig q5 y ± FOBT, colonoscopy q10 y, CT colonography q5 y.
• Diagnostics: Colonoscopy + biopsy (gold standard); CEA for prognosis.
• Management: GI + oncology referral; stage by TNM (I–IV).

Elder Abuse / Neglect

• Screen all older adults (alone if possible):
  • "Do you feel safe?" "Who handles finances?" "Who prepares meals?"
• Physical indicators: Unexplained bruises/skin tears, fractures, pressure injuries, poor hygiene, malnutrition.
• Sexual abuse clues: STIs, genital bleeding, breast bruises.

Hip Fracture

• Clues: Acute limp, groin/hip pain (may radiate to thigh/knee), shortened externally-rotated leg, inability to bear weight.
• High morbidity/mortality: \approx20\% die within 1 yr (pneumonia, thromboembolism, etc.).

Giant Cell Arteritis (Temporal Arteritis)

• S/Sx: Unilateral temporal headache ± scalp tenderness, jaw claudication, possible transient monocular blindness (amaurosis fugax).
• Labs: ↑ ESR & ↑ CRP.
• Definitive: Temporal artery biopsy.
• Ophthalmologic emergency → immediate high-dose steroids to prevent blindness.

Retinal Detachment

• S/Sx: Sudden ↑ floaters, flashes of light, “curtain” over vision.
• Risks: High myopia, post-cataract surgery, prior detachment.
• Emergency → laser surgery or cryopexy.

Severe Bacterial Infection in Older Adults

• Atypical: Often afebrile, normal WBC.
• Nonspecific clues: Acute confusion, falls, incontinence, functional decline.
• Common lethal infections: Pneumonia, pyelonephritis, sepsis; UTIs most frequent overall.

Leading Causes of Death ≥65 y

1. Heart disease
2. Cancer
3. COVID-19

Cancer Epidemiology in Older Adults

• \approx80\% of cancers occur >55 y.
• Highest mortality: Lung & bronchus > colorectal.
• Median diagnostic ages: Breast 62 y, Prostate 66 y, CRC 67 y, Lung 71 y.

Lung Cancer

• Risk: Smoking (≈80\% of cases); radon #2; second-hand smoke; pollution; occupational carcinogens.
• Type: Non-small-cell (~82\%).
• Screening: Annual LDCT 50–80 y with ≥20 pack-yr and current or quit <15 y; stop if quit ≥15 y or limited life expectancy.
• Classic presentation: Older smoker with chronic productive cough (bronchorrhea), hemoptysis, dyspnea, weight loss, dull chest pain.
• Work-up: CXR → CT chest with contrast → tissue biopsy; baseline labs (CBC, CMP, LFTs, LDH).

Multiple Myeloma

• Path: Clonal plasma-cell malignancy producing monoclonal Ig.
• Higher in African Americans; older age.
• Diagnostic criteria: Bone-marrow plasma cells >10\% OR plasmacytoma PLUS \text{CRAB} (↑Ca, Renal insuff., Anemia, Bone lesions).
• Presentation: Central skeleton bone pain, fatigue, anemia.
• Work-up: SPEP + immunofixation, free light chains, bone marrow biopsy, MRI/PET.
• Refer → Hematology/Oncology.

Pancreatic Cancer

• Worst prognosis; 5-yr survival \approx11\%.
• >90\% exocrine origin; metastatic at Dx.
• S/Sx: Asthenia, weight loss, epigastric/abdominal pain, jaundice, dark urine, nausea.
• Labs: AST, ALT, ALP, bilirubin, lipase, \text{CA 19-9} (prognostic).
• Imaging: Initial US/CT; then contrast-enhanced MDCT for staging; histologic confirmation.
• Refer → GI surgery (Whipple, etc.).

Atypical Disease Presentations in Elderly

• ↓ Immune response → muted fever, atypical labs.
• Polypharmacy, sensory changes, comorbidities mask symptoms.
• Examples
  • Acute abdomen: Mild pain, minimal guarding, slight/normal WBC.
  • MI: Dyspnea, weakness, N/V, syncope without chest pain (more in women/diabetics).
  • Pneumonia: Afebrile, confusion; S. pneumoniae still #1, but ↑ gram-negatives/aspiration.

Chronic Constipation

• Types: Idiopathic vs. Functional.
• Secondary causes: Meds (iron, CCBs, antihistamines, anticholinergics, opioids, etc.), neuro dz, endocrine.
• Lifestyle factors: Low fiber, dehydration, immobility, dairy excess.
• Classic presentation: Hard pellet stools, straining, laxative overuse, hemorrhoidal bleeding.
• Management hierarchy
  • Education/behavior modification; fixed toilet schedule.
  • Diet: Fiber 25–35 g/d, prunes, ↑ fluids, ↑ activity.
  • Pharmacologic classes (see below); avoid daily stimulant use.

Laxative Classes & Examples

• Bulk-forming: Psyllium, wheat dextrin, methylcellulose, polycarbophil.
• Stimulants: Bisacodyl, senna.
• Osmotics: Lactulose, PEG 3350, saline Mg preps.
• GCC agonists: Linaclotide, plecanatide.
• Chloride-channel activator: Lubiprostone.
• Prostaglandin analog: Misoprostol.
• Antigout agent: Colchicine.
• 5-HT$_4$ agonist: Prucalopride.
• Lubricant: Mineral oil.
• Surfactant: Docusate sodium.

Cognitive Assessment & Functional Scales

• Functional
  • ADLs (Katz Index: 0–6) – bathing, dressing, toileting, transferring, continence, feeding.
  • IADLs (Lawton Scale 0–8) – phone, shopping, cooking, housekeeping, laundry, transport, meds, finances.
  • Get Up & Go (fall risk; score 1–5).
  • Fried Frailty: Weight loss >10 lb, weak grip, exhaustion, slow walk, low activity (3+ = frail).
• Cognitive
  • MMSE 0–30 (≤24 suggests impairment).
  • Mini-Cog (3-word recall + clock) 0–2 dementia.
  • ACE-III: Detailed screening for MCI, AD, FTD.
• Mood/Social
  • GDS-SF (15-items), PHQ-9, RISE for social engagement.

Delirium

• Acute reversible confusional state (hrs–days), fluctuating attention.
• Etiologies: Meds (opioids, benzos, anticholinergics), withdrawal, infection (sepsis, UTI, PNA), metabolic, intoxication, ICU sensory overload.
• Tx: Treat precipitant; remove offending drug.
• Sundowning: Evening agitation—optimize lighting, routine, eliminate sedatives.

Dementia Overview

• Chronic, progressive cognitive & functional decline; irreversible.
• Common etiologies
  1. Alzheimer’s disease (AD) – β-amyloid plaques, neurofibrillary tangles.
  2. Vascular dementia – multi-infarct.
  3. Lewy-body dementia – α-synuclein aggregates (fluctuations, hallucinations, REM behavior disorder, parkinsonism).
  4. Parkinson’s dementia (40 % of PD pts).
  5. Frontotemporal dementia – personality/behavior change.
  6. Mixed, Wernicke-Korsakoff (thiamine B₁), Normal-pressure hydrocephalus (gait + cog + incontinence).

Mild Cognitive Impairment (MCI)

• Objective deficit > expected age but preserved ADLs; may progress, stabilize, or resolve.

Alzheimer’s Disease Clinical Stages

• Mild (independent): Word-finding, misplacing items, poor judgment, personality change.
• Moderate (longest): Wandering, speech difficulty, agnosia, behavioral changes.
• Severe: Fully dependent, mute/incoherent, incontinent, bedbound.
• "Four As": Amnesia, Aphasia, Apraxia, Agnosia.

Alzheimer’s Treatment

• Mild–Moderate (MMSE 10–26): Cholinesterase inhibitors – Donepezil 5 mg qd (titrate), Rivastigmine, Galantamine.
• Moderate–Severe (MMSE ≤18): Add Memantine 5 mg qd (NMDA antagonist) or use alone if intolerant.
• Severe (MMSE <10): Continue memantine or consider deprescribing.
• Adjuncts: Exercise, cognitive rehab, Vit E 1000 IU bid (discuss risk), safety planning, caregiver support, hospice in terminal stage.

Essential Tremor (ET)

• Action/postural tremor of hands ± head; improves with small alcohol dose, worsens with anxiety.
• 1st-line: Propranolol 60–320 mg/d (LA option).
• Alt: Primidone 25–750 mg hs; combo or 2nd-line (gabapentin, topiramate, benzos).
• Refer neurology for refractory cases.

Hypothyroidism in Elderly

• Common; insidious fatigue, constipation, dry skin, weight gain, memory issues; severe cases mimic dementia.

Neurocognitive Vocabulary

• Abulia, akathisia, akinesia, amnesia (anterograde/retrograde), anomia, aphasia, apraxia, astereognosis, ataxia, confabulation, dyskinesia, dystonia.

Osteoporosis

• USPSTF: Screen women ≥65 y or younger with FRAX risk.
• DEXA hip/spine: T ≤ -2.5 → osteoporosis; -1.5 to -2.4 → osteopenia.
• Lifestyle: Weight-bearing exercise 30 min ×3 wk, Ca 1200 mg + Vit D 800 IU daily, limit alcohol/caffeine, quit smoking.
• FRAX: 10-yr fracture probability (hip & major).
• Pharmacology
  • Bisphosphonates (1st-line): Alendronate, Risedronate. Take upright with 6–8 oz water; esophagitis risk; repeat DEXA after 2 y.
  • SERMs: Raloxifene (breast Ca risk ↓, but ↑ DVT/PE, stroke).
  • Others: Teriparatide (PTH analog, osteosarcoma in rats), Calcitonin, Calcitriol.

Parkinson’s Disease (PD)

• Dopamine depletion (substantia nigra).
• Cardinal: Rest tremor (pill-rolling), rigidity (cogwheel), bradykinesia, postural instability.
• Non-motor: Depression, dementia (~40\%), seborrhea.
• Tx
  • 1st-line symptomatic: Carbidopa/Levodopa 25/100 mg half-tab BID–TID with food; titrate.
  • Alt/adjunct: Dopamine agonists (pramipexole, ropinirole), MAO-B inhibitors (selegiline, rasagiline), anticholinergics (benztropine) for tremor, amantadine.
  • Watch for wearing-off, dyskinesia, impulse control disorders.
  • Non-pharm: PT, speech, exercise; DBS for advanced disease.

Urinary Incontinence (UI)

• Not "normal" aging—evaluate.
• Risk factors: Female, parity, vaginal delivery, age, obesity, menopause, smoking, diabetes.
• Dietary triggers: Caffeine, alcohol, carbonation, citrus, spicy foods; meds (diuretics).

UI Types & Therapies

1. Stress UI – Leakage with ↑ intra-abdominal pressure.
   • Tx: Lifestyle, Kegel, bladder training, topical estrogen, duloxetine 40 mg BID.
2. Urge UI (Overactive bladder) – Strong urge then leakage.
   • Tx: Kegel, bladder training; meds if needed:
     • Anticholinergics: Oxybutynin 2.5–5 mg TID, Trospium, Darifenacin (avoid in glaucoma, retention).
     • \beta_3 agonists: Mirabegron 25–50 mg ER daily; Vibegron 75 mg.
3. Overflow UI – Dribbling from retention (BPH, neurogenic).
   • Tx underlying cause.
4. Functional UI – Mobility/cognition barrier.
   • Tx: Environmental aids, PT.
5. Mixed UI – Combination → combine therapies.

• Behavioral: Bladder training (delay voiding), double voiding, fluid management.

Urinary Tract Infections ≥65

• Often afebrile; may present only with new confusion, falls.
• Test only with new classic GU symptoms (dysuria, urgency, suprapubic pain) due to high asymptomatic bacteriuria.

Polypharmacy & Beers Criteria

• Aging changes: ↓ renal clearance, ↓ P450, ↑ fat : lean mass → longer half-life for lipophilics.
• High sensitivity to benzos, hypnotics, TCAs, antipsychotics.
• Geriatric syndromes by drug class
  • Constipation: Anticholinergics, CCBs, opioids.
  • Dizziness: Anticholinergics, antihypertensives, sulfonylureas.
  • Delirium: Anticholinergics, benzos, corticosteroids, H2 blockers.
  • Falls: Anticonvulsants, antidepressants, antihypertensives (α-blockers), antipsychotics, benzos, opioids.
  • UI: Anticholinesterase inhibitors, antidepressants, antihistamines, CCBs, diuretics, α1-blockers.