Transcript Geriatric Medicine

Geriatric Medicine
Basic Principles
Ronald M. Unice, D.O.
Objectives:
 Review the general
principles and goals of
 Review the essential
Geriatric care
components of a
 Discuss the current and
comprehensive
future demographics of
geriatric assessment
the aged
 Discuss the
 Review the unique
performance of a
physiological and
mini-mental status
psychosocial aspects of
examination
the elderly and their
clinical importance
Geriatrics
A very independent 94 year old male
patient saw his family physician for a
chief complaint of right knee pain.
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.
The patient then responded, “my left knee is
94 years old, too, but it doesn’t hurt!”
 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.
Demographic Characteristics Of
The Elderly
Year
Life Expect. Pop. >65
at Birth
Pop. >85
1900
47.3
4%
N/A
1990
75.5
12%
1.3%
2050
80.2
23%
5.1%
Centenarians on the March
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
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
Male, Age 85
 Weight 65 kg
– (143 lbs..)
 Serum creatinine 1.2
(n=.5-1.2)
 BUN 19
 Estimated creatinine
clearance
(N=120ml/min) is:
A
B
C
D
110 ml/min
41 ml/min
90 ml/min
60 ml/min
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
 Ideal body weight for men:
50.0 kg + 2.3 kg per inch > 5 feet tall
 Ideal body weight for women:
45.5 kg + 2.3 kg per inch > 5 feet tall
 May use actual body weight if less than
ideal body weight
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
 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
 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
 The percentage of male body fat changes
with aging
 On average, the percentage of body fat
between adulthood and age 75 will:
A.
B.
C.
D.
Increase from 15% to 30%
Decrease from 15% to 5%
Decrease from 15% to 10%
Increase from 15% to 20%
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
 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)
Rule of Thirds
“Aging Changes” =
Disease (1/3)
+ Disuse (1/3)
+ Normal aging (1/3)
Comprehensive Geriatric
Assessment
 A multi-disciplinary diagnostic process
designed to quantify an elderly patient’s
medical, psychosocial and functional
capabilities
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
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
 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
Medical Treatment Needs
 Specialized equipment
 Specialized services
 Evaluate capacity of family to provide these
services
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
Assessment Of Mental
Functioning
 Accurate instruments
 Treatable psychiatric
illnesses need to be
not available
recognized (e.g.,
 Cognitive
depression, delirium,
measurement
psychosis)
instruments (e.g.,
 Psychobehavioral
folstein minn-mental
problems need addressed
status exam) helpful
in relationship to
but not necessarily
caregivers (wandering,
predictive of
agitation, abusive
functional capabilities
behavior)
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
Assessment Of Environmental
Aspects
 Physical environment essential determinant
in placement decisions
 Modifications in physical environment can
improve function and increase safety
Assessment Of Activities Of
Daily Living
 Personal self-care
– Feeding
– Bathing
– Toileting
 Mobility
– Transferring
– Walking
 Continence
– Urine
– Feces
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
Osteopathic Philosophy
Kirksville Consensus
Declaration 1953
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.
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.
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.
Mini-Mental Status Exam
 Good Screening Tool
 Measure of General Cognitive Function
 Score Ranges 0-30
 Helpful for Follow-up of Dementia Patients