Geriatric Medicine Dr Stanley Lipschitz Specialist Physician & Geriatrician

Geriatric Geriatric MedicineMedicine

Dr Stanley LipschitzDr Stanley Lipschitz

Specialist Physician & Specialist Physician & GeriatricianGeriatrician

““Growing old is not so Growing old is not so bad,bad,

when you consider thewhen you consider thealternativealternative ""

Woody Allen

Relationship Between Age & Relationship Between Age & FunctionFunction

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60

80

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Fu

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Age ( Years )

Multiple ChronicDiseases

Loss of HomeostaticReserve

Vulnerability toInsults

+

IN THE ELDERLY

Biological Aging

+

Loss of Homeostatic Loss of Homeostatic FunctionFunction

Regulation of critical functions such as Regulation of critical functions such as body Temperature, energy metabolism, body Temperature, energy metabolism, heart rate and BP.heart rate and BP.

Adrenergic responsiveness declines with Adrenergic responsiveness declines with aging - may influence the regulation of aging - may influence the regulation of these bodily functions in the elderly.these bodily functions in the elderly.

Such Homeostatic losses mean that Such Homeostatic losses mean that Diagnostic and Therapeutic Diagnostic and Therapeutic undertakings, acute illness, flares of undertakings, acute illness, flares of chronic disease and traumatic insults chronic disease and traumatic insults will have the potential for greater than will have the potential for greater than usual ill effectusual ill effect

Loss of Homeostatic Loss of Homeostatic FunctionFunction

OLD AGE

Decreased body water &Decreased lean body mass

Decreased volume of Distribution of drugs

Eg Phenytoin

Increased drugToxicity

Decreased clearence of drugs by the liver resulting inToxic blood levels (aminophylline & Cimetidine)

INCRESED PROBABILITY OF IATROGENIC PROBLEMSIN AGED PATIENTS

Atypical Disease Atypical Disease PresentationPresentation

Loss of Homeostatic Function

Biological Aging,Multiple Chronic Diseases

& Disability

+

Modification of Host Response

Commonly acute Illness presents Atypically

‘‘GIANTS OF GIANTS OF GERIATRICS’GERIATRICS’

ATYPICAL PRESENTATION of ATYPICAL PRESENTATION of DISEASEDISEASE

DELIRIUMDELIRIUM FALLSFALLS LOSS OF MOBILITYLOSS OF MOBILITY INCONTINENCEINCONTINENCE LOSS of ADL ABILITYLOSS of ADL ABILITY


UG Sepsis may cause Delirium UG Sepsis may cause Delirium without fever, polyuria or BOMwithout fever, polyuria or BOM

Pain response is often blunted – Pain response is often blunted – Delirium or breathlessness may be the Delirium or breathlessness may be the first response to AMIfirst response to AMI

Acute change in wellbeing or a decline Acute change in wellbeing or a decline in function or “something is different”, in function or “something is different”, may be the only indication of an acute may be the only indication of an acute Abdominal crisis in the ElderlyAbdominal crisis in the Elderly


Such warnings of subtle changes, especially by Such warnings of subtle changes, especially by observers intimately and regularly involved, observers intimately and regularly involved, should be taken seriously by the Clinician and are should be taken seriously by the Clinician and are often the only indication of a Potentially often the only indication of a Potentially overwhelming event.overwhelming event.

Nonspecific change in status always warrants Nonspecific change in status always warrants careful and detailed assessment in particular careful and detailed assessment in particular looking for “occult illness” such as UG sepsis, looking for “occult illness” such as UG sepsis, silent MI, Pneumonia, Abdominal crises and Drug silent MI, Pneumonia, Abdominal crises and Drug Toxicity.Toxicity.

Even when nothing is found – ongoing surveillance Even when nothing is found – ongoing surveillance is required. TIME, may be the most important is required. TIME, may be the most important Diagnostic tool! Diagnostic tool! Diagnostic DifficultyDiagnostic Difficulty

Narrow window of Narrow window of Therapeutic and Therapeutic and

Diagnostic TolerenceDiagnostic Tolerence The challenge in Geriatric Medicine is the critical The challenge in Geriatric Medicine is the critical narrowing of the diagnostic and therapeutic window narrowing of the diagnostic and therapeutic window due to loss of homeostatic function, multiple diseases due to loss of homeostatic function, multiple diseases and disabilities and atypical disease presentationand disabilities and atypical disease presentation

There is much more room for mistakes in judgement There is much more room for mistakes in judgement when caring for the frail elderly when caring for the frail elderly

A diagnostic test for one problem may adversely A diagnostic test for one problem may adversely effect the overall function of the patient due to a effect the overall function of the patient due to a disease in another system e.g. Contrast medium & disease in another system e.g. Contrast medium & Renal dysfunctionRenal dysfunction

A therapeutic agent may have adverse effects e.g. A therapeutic agent may have adverse effects e.g. Cimetidine used for a DU may result in a decline in Cimetidine used for a DU may result in a decline in Cognitive functionCognitive function

The COMPREHENSIVE The COMPREHENSIVE GERIATRIC GERIATRIC

ASSESSMENTASSESSMENT Comprehensive assessment of the elderly Comprehensive assessment of the elderly

patient is critical for the provision of proper patient is critical for the provision of proper health carehealth care

Should be Standard – absolutely essential Should be Standard – absolutely essential when there has been an acute change in social when there has been an acute change in social circumstance, physical or mental status, or a circumstance, physical or mental status, or a confusing constellation of signs and symptoms, confusing constellation of signs and symptoms, when a patients living situation has changed when a patients living situation has changed often due to deteriorating health, in a patient often due to deteriorating health, in a patient with a new medical problemwith a new medical problem

Also as an integral part of decision making Also as an integral part of decision making regarding placement in any Care Facilityregarding placement in any Care Facility


ASSESSMENTASSESSMENT To review in detail the Physical, To review in detail the Physical,

Mental and Social situation of the Mental and Social situation of the patientpatient

To correct any causes of Disability To correct any causes of Disability and to stabilise those that may be and to stabilise those that may be progressing unnecessarily progressing unnecessarily

The social and Physical environment The social and Physical environment may need to be modified to maximise may need to be modified to maximise independenceindependence


ASSESSMENTASSESSMENT The search for specific Diagnoses and The search for specific Diagnoses and

cures is less often a Primary Goal, than cures is less often a Primary Goal, than is the formulation of a Practical Plan to is the formulation of a Practical Plan to preserve function, autonomy and preserve function, autonomy and DignityDignity

Hospitalization is a major risk to the Hospitalization is a major risk to the precarious homeostasis of the Elderly precarious homeostasis of the Elderly and should only be resorted to for the and should only be resorted to for the treatment of acute, severe or Life treatment of acute, severe or Life threatening illness.threatening illness.

The COMPREHENSIVE The COMPREHENSIVE GERIATRIC ASSESSMENT –GERIATRIC ASSESSMENT –

covers 5 categoriescovers 5 categories

Physical healthPhysical health Mental healthMental health Socioeconomic statusSocioeconomic status EnvironmentEnvironment Functional statusFunctional status

Detecting AD – who to Detecting AD – who to screenscreen

screen

New patients > 65 yrs Established patients > 65 yrs

Patients with early warning signs

Memory Loss Cognitive Deficits

Change in Personality or Behavior

AD making the AD making the DiagnosisDiagnosis

Careful HistoryCareful History Alternate sources – family, work, nursing staff, Alternate sources – family, work, nursing staff,

friends.friends. Onset and Progression – insidious/acute, Onset and Progression – insidious/acute,

smooth/stepwise.smooth/stepwise. Isolated Memory vs Multiple Cognitive deficitsIsolated Memory vs Multiple Cognitive deficits Similarities/Differences, Abstract Thought, Similarities/Differences, Abstract Thought,

ProverbsProverbs MMSEMMSE Physical and Neurological examinationPhysical and Neurological examination Laboratory tests and Brain ImagingLaboratory tests and Brain Imaging

AD making the AD making the Diagnosis:Diagnosis:The MMSEThe MMSE

Take a careful history of Cognitive Take a careful history of Cognitive function before doing the MMSEfunction before doing the MMSE

Interpret the MMSE in a patient Interpret the MMSE in a patient specific manner – Education, specific manner – Education, Language, MoodLanguage, Mood

Don’t be kind – score down!Don’t be kind – score down! It takes 10 minutes – do it when It takes 10 minutes – do it when

appropriate!appropriate!

DSM IV CRITERIA - DSM IV CRITERIA - DEMENTIADEMENTIA

MEMORY IMPAIRMENTMEMORY IMPAIRMENT DYSPHASIADYSPHASIA DYSPRAXIADYSPRAXIA AGNOSIAAGNOSIA EXECUTIVE FUNCTIONEXECUTIVE FUNCTION OCCUPATIONAL/SOCIAL FUNCTIONOCCUPATIONAL/SOCIAL FUNCTION DECLINE FROM FORMER LEVEL OF DECLINE FROM FORMER LEVEL OF

FUNCTIONINGFUNCTIONING

Mini Mental State Mini Mental State Examination (MMSE)Examination (MMSE)

30 – point test to assess cognitive function - Orientation to time and place - Memory (registration and recall) - Attention and Calculation - Language - Visiospacial function

Normal >26

Mild 20-25

Moderate 10-19

Severe <10

Value of (CGA) Value of (CGA) assessmentassessment

The Primary goal is preservation of the The Primary goal is preservation of the patient’s function and independencepatient’s function and independence

If reversible problems are not detected If reversible problems are not detected – goal is to identify support needs, – goal is to identify support needs, mobilize community and family mobilize community and family resources and maintain function and resources and maintain function and autonomyautonomy

A full knowledge of what Community A full knowledge of what Community resources are available is essential resources are available is essential

Elderly patient in state of flux

Exacerbation of 1 of several

Chronic conditions

WorseningSocial

circumstance

Mentaldeterioration

Depression

CGA dissects the components of change and instability – to suggest strategies for at least small improvements in Function

Cure isLess

common

Concept ofSmall Therapeutic

gain

Strategy is often practical interventionTailored to the specific needs and

Resources of the patient

Concept ofConcept ofSmall Therapeutic GainsSmall Therapeutic Gains

MultipleChronic diseases

+ Disability

CURE isAlmost never

The Goal

RATHERPreservation or Restoration of

FUNCTION is the aim

It is therefore essential to set Realistic Therapeutic Goals.

Aiming for Cure in this population will only result

In frustration

PREVENTIONPREVENTION

Normal preventive medicine applies – glucose, Normal preventive medicine applies – glucose, BP, BMD, Lipids etcBP, BMD, Lipids etc

Identify SAFETY RISKS (home visit) – lighting, Identify SAFETY RISKS (home visit) – lighting, loose mats, handrails, stairs, showers/bath, loose mats, handrails, stairs, showers/bath, kitchen storagekitchen storage

Communication – telephone, alarmsCommunication – telephone, alarms Good Surveillance system – frequent visits from Good Surveillance system – frequent visits from

Dr, Community nurses, social workers etcDr, Community nurses, social workers etc NutritionNutrition PREVENTIVE REHABILITATION – for all PREVENTIVE REHABILITATION – for all

illnessillness

Management in the Acute Care Management in the Acute Care SettingSetting

Elderly Patient

More frequentlyhospitalised

Experience moreAdverse consequences

Stay longer

Often despite effectiveTreatment of theAcute condition

Decline in PhysicalAnd Cognitive function

Hospital associated Complications

Fluid & Electrolyte

Confusion Mobility IncontinenceMalnutritionPressure

Sores

PREMATURE DEATH or INSTITUTIONAL CARE

Falls

Management in the Acute Care Management in the Acute Care SettingSetting

TherapeuticBenefits

AdverseEffects

Hospital Care

Factors influencing Factors influencing ManagementManagement

in the Acute Care Settingin the Acute Care Setting

Those associated with AGINGThose associated with AGING Those associated with Those associated with

COEXISTENT DISEASECOEXISTENT DISEASE Those related to the PROCESS OF Those related to the PROCESS OF

CARE – Diagnostic and Treatment CARE – Diagnostic and Treatment relatedrelated


in the Acute Care Settingin the Acute Care SettingHOST AGINGHOST AGING

Gradual and variable decline in function over Gradual and variable decline in function over time – especially after 75 years, there is a time – especially after 75 years, there is a destinct loss of functional reserve (varies destinct loss of functional reserve (varies from organ to organ and person to person)from organ to organ and person to person)

This loss results in decreased ability to This loss results in decreased ability to handle stress (environmental or disease handle stress (environmental or disease related)related)

Impossible to focus on disease in one area, Impossible to focus on disease in one area, without being sensitive to changes in others without being sensitive to changes in others

Relationship Between Age & Relationship Between Age & FunctionFunction

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Fu

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Age ( Years )


in the Acute Care Settingin the Acute Care SettingHOST AGINGHOST AGING

The stress of illness usually manifests The stress of illness usually manifests itself first and prominantly in the itself first and prominantly in the organs with least functional reserve – organs with least functional reserve – usually the BRAINusually the BRAIN

Atypical presentation of disease (no Atypical presentation of disease (no fever/pain)fever/pain)

Physical variation/heterogeneity of the Physical variation/heterogeneity of the elderly patient – careful and elderly patient – careful and comprehensive individual assessmentcomprehensive individual assessment

‘‘GIANTS OF GIANTS OF GERIATRICS’GERIATRICS’

ATYPICAL PRESENTATION of ATYPICAL PRESENTATION of DISEASEDISEASE

DELIRIUMDELIRIUM FALLSFALLS LOSS OF MOBILITYLOSS OF MOBILITY INCONTINENCEINCONTINENCE LOSS of ADL ABILITYLOSS of ADL ABILITY


in the Acute Care Settingin the Acute Care SettingHOST DISEASEHOST DISEASE

Multiple illness/comorbidities are common – on Multiple illness/comorbidities are common – on average 3 per patientaverage 3 per patient

These interact with the changes of aging – further These interact with the changes of aging – further enhance vulnerability to stressenhance vulnerability to stress

Often comorbidities are subtle and nonspecific Often comorbidities are subtle and nonspecific (OA, BPH, Osteoporosis, Apathetic Thyrotoxicosis, (OA, BPH, Osteoporosis, Apathetic Thyrotoxicosis, etc) etc)

Careful delineation of all acute and chronic Careful delineation of all acute and chronic illnesses essentialillnesses essential

Identify the primary illness – place it accurately Identify the primary illness – place it accurately within the context of other illnesses and within the context of other illnesses and vulnerabilities – then investigate and treat vulnerabilities – then investigate and treat appropriatelyappropriately

Factors influencing Management in the Acute Factors influencing Management in the Acute Care SettingCare Setting

Effect of medical & nursing careEffect of medical & nursing careHOSPITALISATION

Clinical Iatrogenesis

Functional Iatrogenesis

Side effects of:

Medicalintervention

Diagnostic intervention

Therapeuticintervention

Side effects of:

The process ofThese Interventions

>50% of patients over 70 years experience a decline in Physical and/or

Cognitive function Unrelated to the admitting diagnosis

ATYPICAL DISEASE ATYPICAL DISEASE PRESENTATIONPRESENTATION

MULTIPLE PATHOLOGYMULTIPLE PATHOLOGY

MULTIPLE AETIOLOGYMULTIPLE AETIOLOGY

FALLSDELIRIUMPNEUMONIA

Multiplepathology

Primarydisorder

Secondarydisorder

Tertiary factors

Mobilityrestraint

ConfusionMuscle powerPolypharmacy

Secondary infection

Bed restimmobility Muscle

strength

Post hypotension

dehydration

constipationUrinaryretention

UTIincont

Renaldysfn

Fluid/electrolyte

Rx accumulationRx toxicity

hypoxia

hospitalization

Sleep deprivation

confusion

AgeOAVisionPDTCA

LESSONS LEARNEDLESSONS LEARNED

FAILURE TO LOOK BEYOND THE FAILURE TO LOOK BEYOND THE OBVIOUSOBVIOUS

AVALANCHE EFFECTAVALANCHE EFFECT SUPERMARKET EFFECTSUPERMARKET EFFECT

Factors influencing Management in the Acute Factors influencing Management in the Acute Care SettingCare Setting

Effect of medical & nursing careEffect of medical & nursing careThe prevailing disease-oriented and sequential approach to diagnosis and

treatment defers the Practice of Preventive Rehabilitation and Restorarive Rehabilitation until post Discharge

Excess BedrestImobilityFallsIncontinenceDeliriumAnorexia

Additional Complications -Pressure sores

DeliriumAgitationDVT & PE

Aspiration PneumoniaUTI’s

BacteraemiaDepression

Disruptive behavior

Additional Interventions – Restraints

PsychotropicsNG feedsCatheters

FUNCTIONAL LOSS

Acute Care Acute Care Assessment and Assessment and

ManagementManagement

Prehospital AssessmentPrehospital Assessment Admission AssessmentAdmission Assessment Acute Hospital CareAcute Hospital Care Discharge PlanningDischarge Planning

Acute Care – assessment and Acute Care – assessment and managementmanagement

Prehospital AssessmentPrehospital Assessment

Comprehensive Geriatric Assessment – detailed knowledge of:Coexistant medical problems

Nutritional statusPsychosocial strengths and vulnerabilities

Baseline Physical & Cognitive Function

Allows prediction of outcomes

Attempt to prevent unnecessary or inapproriate admissionsIt is possible to manage most illness as an outpatient!

You want my mother who has pneumonia to stay at home!!!

Is your medical insurance paid up?

Educate patient and carerCarer support and assistance

Appropriate and aggressive treatment for the acute illnessRegular follow up and reassessment

NutritionFluid and Electrolytes (subcutaneous fluids)

PREVENTIVE REHABILITATION


Admission AssessmentAdmission AssessmentRepeat CGA within 72 hours of admission

Assess changes in Physical & Cognitive Function Predict outcomes

Define clearcut specific goals aiming to regain and maintain Function


Acute Hospital CareAcute Hospital Care Identify acute event – accurately place this Identify acute event – accurately place this

within the context of other diseases and within the context of other diseases and disabilities…..then initiate appropriate disabilities…..then initiate appropriate investigations and interventionsinvestigations and interventions

Avoid the acute functional and cognitive decline Avoid the acute functional and cognitive decline associated with acute medical and nursing care.associated with acute medical and nursing care.

Close collaboration by the treating TEAM is Close collaboration by the treating TEAM is essentialessential

Allow the patient to retain maximal levels of self Allow the patient to retain maximal levels of self care, personal control, mobility, nutritioncare, personal control, mobility, nutrition

Retain basic daily functions while in hospital Retain basic daily functions while in hospital


Acute Hospital CareAcute Hospital CareA patient’s level of mental & physical function is the result of :

Diseases and DisabilitiesDeveloped prior to

hospitalization

Diseases and DisabilitiesAcquired during and as a

Consequence of the Management in hospital

Clinical Iatrogenesis Functional Iatrogenesis

THEREFORE if the goal is to achieve optimal medical & Functional outcomes for elderly patients……… THEN, treatment, Investigations, Fluid therapy and General Protocols must be modified TO PREVENT FUNCTIONAL DECLINE

Initial illness

Delirium

medications

Changed environment

dehydration ReducedOral intake

Incontinence

UTIFoleyscatheter

antibiotics

Constipation

immobilitydehydration

Nausea &vomiting

Anorexia &bloating

Malnutrician

Compromised Host Defense

Pneumonia

DepressionAspiration

HOSPITAL COURSECascade of illness & functional decline

Falls

ATYPICAL

PRESENTATION

OF DISEASE

PSYCHOSOCIAL FACTORS

DRUG MISUSE

MULTIPLE

AETIOLOGY

MULTIPLE PATHOLOGY

AGEING

DISEASE

DISUSE

HOSPITAL ASSOCIATED

DYSFUNCTIONLACK OF

EXPECTATION


Acute Hospital CareAcute Hospital Care

Creatinine Clearance (should be 30ml/min) – Creatinine Clearance (should be 30ml/min) – in most severely ill elderly falls within in most severely ill elderly falls within moderate renal failure range…. Adjust Rx moderate renal failure range…. Adjust Rx accordingly!accordingly!

Drugs with Hepatic metabolism…. Consider Drugs with Hepatic metabolism…. Consider drug interaction!drug interaction!

Consider Cardiac & Pulmonary reserve – Consider Cardiac & Pulmonary reserve – assume that acute illness results in decreased assume that acute illness results in decreased CO & increased ADH….. Adjust fluids!CO & increased ADH….. Adjust fluids!

Avoid Narcotics & Sedatives.Avoid Narcotics & Sedatives.

Rational approach to Modification of Medication & Fluids


Acute Hospital CareAcute Hospital Care

Initiate & withdraw one medication at a Initiate & withdraw one medication at a timetime

Adjustments should be made in small Adjustments should be made in small stepssteps

Continually review GoalsContinually review Goals Beware of Combination AnalgesicsBeware of Combination Analgesics

Rational approach to Modification of Medication & Fluids


DischargeDischarge DISCHARGE PLANNING begins at the DISCHARGE PLANNING begins at the

time of ADMISSION!time of ADMISSION! Regular TEAM MEETINGS – Doctor, Regular TEAM MEETINGS – Doctor,

Nurses, Social Worker, Physiotherapist, Nurses, Social Worker, Physiotherapist, Occupational Therapist, Community Occupational Therapist, Community Nurse etcNurse etc

At all times consider and avoid functional At all times consider and avoid functional and cognitive decline consequent to and cognitive decline consequent to hospitalizationhospitalization

Education of CAREGIVERS – Education of CAREGIVERS – DISCHARGE MEETINGSDISCHARGE MEETINGS

Define Premorbid

Status

Define Current

Status

Comprehensive Assessment

And Investigation

Correct ALL Treatable

Conditions

Restorative Rehabilitation

PHYSICAL COGNITIVE

PreventiveRehabilitation

Weeks 2 & 3Weeks 2 & 3Case StudiesCase StudiesHalf hour presentationsHalf hour presentations

At week 4At week 4

Case study and Treatment Case study and Treatment plan to be plan to be

Handed in for assessmentHanded in for assessment

Documents

Geriatric Medicine Dr Stanley Lipschitz Specialist Physician & Geriatrician