Aging and Common Geriatric Problems

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Aging and Common Geriatric Problems

• Deb Mostek, M.D.
• University of Nebraska Medical Center
• March 23, 2004

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Objectives

• Describe common sensory and functional
  limitations experienced by the geriatric patient
  and how these conditions impact care.
• Discuss common cognitive difficulties in the
  elderly and how to minimize behavioral problems
  while providing care.
• 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
  
• gt65 y/o femalemale 32
• gt85 y/o femalemale 52
• 5 of elders (gt65y/o) reside in NH
• (if gt95 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 agingcauses 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 communicationwritten notes, communication
  boards
• Amplifiers

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Vision and Aging

• ? Lens elasticity
• Adapts more slowly to changes in light
• ? night vision
• Presbyopialens lose elasticityneed for reading
  glasses
• ? visual acuity, ? visual fields
• ? contrast sensitivity
• ? Sensitivity to glare

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Older Individuals Need 33 More Illumination
Than Younger People
AGE 20 AGE 60 AGE 78
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Vision Impairment (20/40 or less)

• 10-25 gt 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 gt 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 grad20,000 words in
  vocabulary
• Average 60 y/o60,000 words in vocabulary

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Dementia

• Memory problems with functional impairment
• Alzheimers 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 gt65y/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 lt -1 SD (young adult standard)
• Osteopenia T score lt-2.5 but gt -1
• Osteoporosis T score gt -2.5
• Screening controversial
• National Osteoporosis Foundation?all 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 populationdont
  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!