Geriatric Medicine

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Geriatric Medicine

• Basic Principles
• Ronald M. Unice, D.O.

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Objectives

• Review the general principles and goals of
  Geriatric care
• Discuss the current and future demographics of
  the aged
• Review the unique physiological and psychosocial
  aspects of the elderly and their clinical
  importance

• Review the essential components of a
  comprehensive geriatric assessment
• Discuss the performance of a mini-mental status
  examination

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Geriatrics

• A very independent 94 year old male patient saw
  his family physician for a chief complaint of
  right knee pain.

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• After the examination was completed, the
  physician informed the patient that the pain was
  due to osteoarthritis. When asked what treatment
  was available, the physician responded that the
  problem was simply related to old age and to be
  expected at age 94.

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• The patient then responded, my left knee is 94
  years old, too, but it doesnt hurt!

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• The central principle of geriatric care is to
  maintain for our geriatric patients as much
  independence of function and quality of life as
  is possible. Recognition of the unique
  physiological and psychosocial characteristics of
  our geriatric population is essential to provide
  appropriate care.

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Demographic Characteristics Of The Elderly
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Centenarians on the March
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Gender Differences and Aging

• 100 women for every 68 men over age 65
• 100 women for every 39 men over age 85
• 49 of women over 65 are widowed
• 14 of men over 65 are widowed
• 41 of elderly women live alone in the community
• 15 of elderly men live alone in the community

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Functional Disability and Aging

• 5 of those 65 and over live in nursing homes
• 23 of those over 65 report limitations in at
  least on ADL
• 27 of those over 65 have limitations in IADL
• Fewer than half report receiving any assistance
  in ADL or IADL

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Male, Age 85

• Weight 65 kg
• (143 lbs..)
• Serum creatinine 1.2 (n.5-1.2)
• BUN 19

• Estimated creatinine clearance (N120ml/min) is
• 110 ml/min
• 41 ml/min
• 90 ml/min
• 60 ml/min

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Cockcroft and Gault

• Creatinine clearance
• (140 - age) (weight/kg)
• ----------------------------
• (72) (s. creatinine)
• (140 - 85) (65)
• ------------------
• (72) (1.2) 41 ml/min
• If female 41 x .85 35 ml/min

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• Ideal body weight for men
• 50.0 kg 2.3 kg per inch gt 5 feet tall
• Ideal body weight for women
• 45.5 kg 2.3 kg per inch gt 5 feet tall
• May use actual body weight if less than ideal
  body weight

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The Elderly Kidney

• Renal Blood flow and glomerular filtration rate
  decrease 5-10 per decade after age 30
• Impaired ability to excrete a potassium load
  (reduced renin production) increases risk of
  hyperkalemia
• Decreased concentrating and diluting capacity
  increase risks of dehydration and fluid overload

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• Protein binding of drugs may be altered by aging
• In patients 60 and older protein binding in 15
  to 25 of patients will
• A. Increase
• B. Decrease

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• Protein binding and serum albumin will decrease
  in 15 to 25 of patients 60 years or older
• Drugs therefore normally highly protein bound
  will have higher active free fractions with a
  normal measured serum concentration, clinical
  toxicity can be observed without laboratory
  evidence
• Examples Phenytoin, Diazepam, Warfarin, Digoxin

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• The percentage of male body fat changes with
  aging
• On average, the percentage of body fat between
  adulthood and age 75 will
• A. Increase from 15 to 30
• B. Decrease from 15 to 5
• C. Decrease from 15 to 10
• D. Increase from 15 to 20

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Increase from 15 to 30

• As a result the volume of distribution for many
  fat soluble drugs will increase dramatically
• This increases half-life and may produce
  prolonged duration of action and adverse effects
• Examples Phenothiazines, Benzodiazepines

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• A 10-15 decrease in total body water and a 30
  decrease in muscle needs will result in a reduced
  volume of distribution of water soluble drugs
  which will result in increased serum
  concentrations and potential toxicity
• digoxin
• aminoglycosides
• cimetidine
• propranolol)

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Rule of Thirds

• Aging Changes
• Disease (1/3)
• Disuse (1/3)
• Normal aging (1/3)

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Comprehensive Geriatric Assessment

• A multi-disciplinary diagnostic process designed
  to quantify an elderly patients medical,
  psychosocial and functional capabilities

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Components Of A Comprehensive Geriatric Assessment

• Chronic medical treatment needs
• Assessment of physical functioning
• Assessment of mental functioning
• Assessment of social support
• Assessment of physical environment

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An Appropriate Geriatric Assessment Will

• Improve diagnostic accuracy
• Assist in arriving at a comprehensive plan of
  treatment
• Help choose the most appropriate environment of
  care
• Assist in predicting outcomes and monitoring
  clinical change over time

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• The ultimate goals of a comprehensive geriatric
  assessment can only be achieved by performing
  thorough physical, functional and psychosocial
  assessments
• Inadequate assessments may lead to inappropriate
  long-term care placement and limit autonomy of
  our elderly

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Medical Treatment Needs

• Specialized equipment
• Specialized services
• Evaluate capacity of family to provide these
  services

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Assessment Of Physical Functioning

• Loss of functional skills is probably the most
  common cause of a need for long term care
• Appropriate treatment of functional disabilities
  can only be achieved after proper identification
  of the disabilities

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Assessment Of Mental Functioning

• Treatable psychiatric illnesses need to be
  recognized (e.g., depression, delirium,
  psychosis)
• Psychobehavioral problems need addressed in
  relationship to caregivers (wandering, agitation,
  abusive behavior)

• Accurate instruments not available
• Cognitive measurement instruments (e.g., folstein
  minn-mental status exam) helpful but not
  necessarily predictive of functional capabilities

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Assessment Of Social Supports

• Capabilities and wishes of family and friends
  frequently deciding factor in placement
• Involve social worker, home health, and
  appropriate agencies early
• Future demographic changes very strongly affect
  social supports

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Assessment Of Environmental Aspects

• Physical environment essential determinant in
  placement decisions
• Modifications in physical environment can improve
  function and increase safety

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Assessment Of Activities Of Daily Living

• Personal self-care
• Feeding
• Bathing
• Toileting
• Mobility
• Transferring
• Walking

• Continence
• Urine
• Feces

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Instrumental Activities Of Daily Living (Lawton)

• Within the home
• Cooking
• Housecleaning
• Laundry
• Telephone
• Finances

• Outside the home
• Shopping for food
• Shopping for clothing
• Use of transportation

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Osteopathic PhilosophyKirksville
ConsensusDeclaration 1953
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• Osteopathy, or Osteopathic Medicine is a
  philosophy, a science and an art. Its philosophy
  embraces the concept of the unity of body
  structure and function in health and disease.
  Its science includes the chemical, physical and
  biological sciences related to the maintenance of
  health and the prevention, cure, and alleviation
  of disease. Its art is the application of the
  philosophy and the science in the practice of
  osteopathic medicine and surgery in all its
  branches and specialties.

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• Health is based on the natural capacity of the
  human organism to resist and combat noxious
  influences in the environment and to compensate
  for their effects to meet, with adequate
  reserve, the usual stresses of daily life and the
  occasional severe stresses imposed by extremes of
  environment and activity.
• Disease begins when this natural capacity is
  reduced, or when it is exceeded or overcome by
  noxious influences.

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• Osteopathic medicine recognizes that many factors
  impair this capacity and the natural tendency
  towards recovery, and that among the most
  important of these factors are the local
  disturbances or lesions of the musculoskeletal
  system. Osteopathic medicine is therefore
  concerned with liberating and developing all the
  resources that constitute the capacity for
  resistance and recovery, thus recognizing the
  validity of the ancient observation that the
  physician deals with a patient as well as a
  disease.

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Mini-Mental Status Exam

• Good Screening Tool
• Measure of General Cognitive Function
• Score Ranges 0-30
• Helpful for Follow-up of Dementia Patients