1 aging and common geriatric problems deb mostek, m.d. university of nebraska medical center march...

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Aging and Common Geriatric Problems

Deb Mostek, M.D.

University of Nebraska Medical CenterMarch 23, 2004

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Objectives

1. Describe common sensory and functional limitations experienced by the geriatric patient and how these conditions impact care.

2. Discuss common cognitive difficulties in the elderly and how to minimize behavioral problems while providing care.

3. Discuss the prevalence of osteoporosis and risk of fractures.

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Demographics of Aging

65 and older: 35,000,000 (12.4%) in 2000; 69,000,000 (20%) by 2030

Life expectancy: female 80.2 yrs; male 73.2 yrs

>65 y/o female:male 3:2 >85 y/o female:male 5:2 5% of elders (>65y/o) reside in NH;

(if >95 y/o 47% in NH)

Better educated; less poverty

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Overview

Mortality from many causes Biochemical changes in tissues physiologic capacity ability to adapt to environment susceptibility to disease Heterogeneous population: variability Rate of aging--affected by genetics, life style,

environment

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Normal Aging

Height (5 cm by age 75) Fat content, lean body weight/muscle

mass, body water content. Dry skin ( moisture content) vs. photoaging

(not normal aging—causes 90% of cosmetic changes of aging)

60% grip strength (? due to inactivity) Stiffness due to water content in

tendons/ligaments and remodeling

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…Normal aging

Brain weight 20%; blood flow to brain Slower processing times Renal mass by 25-30% by age 80 Lungs: elastic tissue of lungs Abdominal muscles necessary for

inspiration; elders expand lungs best in standing position

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…Normal aging

Swallowing less coordinated Decreased absorption of Ca++, iron,

lactose, Vitamin D Vitamin A & K, Cholesterol absorbed faster Slowed transit in large intestine Psychological stressors

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Barriers to care

Poor communication between care providers

Sensory impairment Communication difficulties Cognitive impairment Polypharmacy Limited financial resources Under-reporting Poor social support

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Hearing Impairment

Sensorineural hearing loss 25-40%; associated with noise exposure

Usually high frequency loss (consonants in this range trouble with conversational speech)

Emotional difficulties, cognitive impairment,

physical functioning

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Audiograms

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Hearing Loss & Tips for Communication

Face person directly, to allow for lip reading

Minimize background noise Visual communication—written notes,

communication boards Amplifiers

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Vision and Aging

Lens elasticity Adapts more slowly to changes in light;

night vision Presbyopia—lens lose elasticity—need for

reading glasses visual acuity, visual fields contrast sensitivity Sensitivity to glare

13AGE 20AGE 20 AGE 60AGE 60 AGE 78AGE 78

Older Individuals Need 33% More Older Individuals Need 33% More Illumination Than Younger PeopleIllumination Than Younger People

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Vision Impairment (20/40 or less)

10-25% > 75 y/o; (20/40 or less); Cataracts; Macular Degeneration; Diabetic

Retinopathy; Glaucoma Results in difficulties with ADLs, IADLs

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Cataracts

Cataracts (38%)

Risk factors: age (90% in > 90 y/o), sun, smoking, diabetes, steroid use

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Cataracts

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Macular Degeneration

Degeneration of cells in central vision region of retina

30% by age 75 years Leading cause of blindness in white

Americans

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Early Macular Degeneration

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Macular Degeneration

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Age Related Macular Degeneration

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Glaucoma

Increased intraocular pressure Loss of visual fields Insidious, need routine screening to detect

early Most common cause of blindness in African

Americans

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Glaucoma

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Diabetic Retinopathy

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Management of Low Vision

Bright illumination Contrast Magnification Low Vision Clinic Word-processing programs

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Neuropathy

Vibratory and tactile sensation in fingers and toes

Diabetic neuropathy Tissue more vulnerable to injury--need to

protect from injury (pressure injury or burns)

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Mobility

Upper extremity precautions

(e.g., hemiparesis) Lower extremity precautions

(e.g., hip replacement)

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Memory and Aging

Takes longer to memorize a list, but then remembers the same as younger person

Longer retrieval time Slower response time More easily distracted Perform same on IQ test if given extra time General knowledge and vocabulary often

better

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Geriatric FUN FACT

Average 22 y/o college grad—20,000 words in vocabulary

Average 60 y/o—60,000 words in vocabulary

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Dementia

Memory problems with functional impairment

Alzheimer’s Disease (risk factors: age, +FH); gradual onset, may be subtle at first, progressive, depression, behavioral problems; later: motor rigidity)

Vascular Dementia (associated with strokes; usually more acute in onset)

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Caring for Demented Patients

Approach respectfully May have to repeat same information If becoming agitated, try to distract

(Change subject, give simple task to perform, look thru old photo albums, play music they enjoy)

Remember behavioral problems are part of the disease

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Delirium

Difficulty with attention and responsiveness, often disorientation& confusion; fluctuating symptoms

10-40% of hospitalized patients in >65y/o usually a fairly sudden change Associated with medical illness, medications Patients with dementia are at risk for

developing delirium. Need close supervision

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Depression

Common in elderly patients in a primary care setting (17-37%)

Hospitalized: major depression (11%);

Mild-mod depression 25% Patients often deny depressed mood Sleep disturbance, appetite, wt loss,

withdrawal, anxious, more common with dementia

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Osteoporosis Low bone density with increased susceptibility to

fractures. Prevalence: 10 million Americans Asymptomatic until factures start occurring Initially affects vertebral bodies, distal radius, proximal

femur, pelvis 1/3 women have a least one vertebral fracture Risk factors: female, age, estrogen deficiency, white or

Asian race, inactivity, + FH, slight stature, smoking, alcohol abuse, chronic corticosteroid or anticonvulsant use, inadequate calcium intake, sun exposure, liver disease, hyperthyroidism

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Bone Mineral Density Testing

Best predictor of fracture risk Normal: T score < -1 SD (young adult

standard) Osteopenia: T score <-2.5 but > -1 Osteoporosis: T score > -2.5 Screening controversial: National Osteoporosis Foundationall

females greater than 65years of age; US Preventive Services Task Force:

insufficient evidence for or against screening

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Prevention of Osteoporosis

Regular weight-bearing exercise Calcium intake 1200+ mg daily Vitamin D 400-800 IU daily Smoking cessation Medical therapy in those with low BMD who are

at high risk to develop osteoporosis Fall prevention Prevention ideally starts in childhood.

Geriatric Review Syllabus, 5th Edition, 2002-2004

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“We do not quit playing because we grow old,

we grow old because we quit playing.”

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Summary

Much variability in geriatric population—don’t stereotype!

Treat with respect, prepare patient for procedure

If dementia or delirium is present, provide close supervision

Enjoy the diversity and savor the stories of the aged!