INTRODUCTION TO

GERIATRIC MEDICINE
Gatot Sugiharto,
MD, Internist
Faculty of
Medicine, UWKS
Lecture - 2011

AGING
Aging

can
be
defined
as
a
progressive
and
generalised
impairment of function resulting in
the loss of adaptive response to
stress and increased risk of age
related diseases.

The
2

overall
effect
of
these
alterations is an increase in the
probability of declining health and
dying and which is also often

DEMOGRAPHICS
85% over age 65 have one chronic illness
60% over age 65 have 2 or more chronic

illnesses
17% age 65-74 functional limitations
29% age 75-84 functional limitations

GERIATRIC MEDICINE:MAIN ISSUES

Understanding basic concepts
Approaching the older patient
Age related physiological & pathological

states
Demographic impact on geriatric health care

BASIC CONCEPTS
Multiple diseases and multiple drugs.
Diseases often chronic, progressive with adverse

consequences. Focus on functional independence

Prevention is more productive and rewarding
Disease profile influenced by socioeconomic &
emotional status
Symptoms may be silent: no pain in MI, no fever
in infection or may be atypical & unrelated. Weak
link organ symptoms: confusion, incontinence,
faints, falls, depression, heart failure-Geriatric
Syndromes
Features like reduced jerks, bacteriuria, IGT
common

PHYSIOLOGICAL CHANGES AND

THEIR IMPACT
CHANGE:
DECREASE IN

IMPACT: DECREASE IN

Basal metabolic rate

Calorie needs

Pulmonary function

Exercise capacity

Renal function

Ability to conc/dilute urine

Bone mineral

Fracture resistance

Gastro-intestinal function

Bowel motility

Sight

Independence

Dentition

Eating ability

Taste

Appetite

Physiologic Changes with Aging

Respiratory system
Vital capacity decreases by as

much as 50%
Decreased recoil and elasticity of
lung tissue
General loss of the muscle tissue
within the walls of the lower airways
Changes can make sudden
respiratory illness life-threatening

Physiologic
Changes with Aging
Cardiovascular system
Stroke volume declines with age
Hearts pacemaker & conduction

system decline with age

With internal bleeding, elderly have a
diminished ability to increase heart
rate and stroke volume to compensate
for poor perfusion
Resistance of blood vessels increases
from a loss of elasticity and
generalized arteriosclerosis

Physiologic Changes with

Aging
Musculoskeletal system
Degenerates with age
Decreased total musculoskeletal

weight and widening and weakening of

the bones
Generalized osteoporosis increases
the potential for fractures with mild
mechanism of injury
Must maintain a high level of suspicion
of fractures with falls

PRINCIPLES OF
GERIATRIC ASSESSMENT
Goal

Promote wellness, independence

Focus

Function, performance (gait, balance,

transfers)
Physical, cognitive, psychologic, social
domains

Scope
Approach

Multidisciplinary

Efficiency

Ability to perform rapid screens to

identify target areas
Maintaining or improving quality of life

Success

APPROACHING THE OLDER

PATIENT
Do not be an ageist
Have patience in history taking
Optimize communication
Make the patient safe & comfortable
Get a full medication list
Assess familys cooperation & attitude
Assess care givers stress

The basic components of the

Comprehensive Geriatric Assessment (CGA)
1. Functional status ADL (Activity of Daily

2.
3.
4.
5.
6.
7.

8.

Living), IADL (Instrumental Activity of Daily

Living)
Comorbidity (number, type and rating of
comorbid conditions)
Cognition (Mini-Mental Status Examination)
Depression (Geriatric Depression Scale)
Polypharmacy
Nutrition (Mini-Nutritional Assessment)
Presence of Geriatric Syndromes (dementia,
delirium, depression, failure to thrive,
neglect or abuse, osteoporosis, falls,
incontinence)
Socio-economic factors

Functional Evaluation
Instrumental Activities of Daily

Living
(IADLs)
Activities of Daily Living
(ADLs)
Executive Functioning
Gait & Balance

TOOLS TO ASSESS FUNCTIONAL

STATUS
Activities of Daily Living (ADLs)

Bathing, dressing,
transferring, toileting,
grooming, feeding, mobility
Instrumental Activities of Daily

Living (IADLs)

Using telephone, preparing

meals, managing finances,
taking medications, doing
laundry, doing housework,
shopping, managing own
transportation
Get Up and Go test

PHYSICAL ASSESSMENT
Complete

physical
assessment
includes:
Nutrition
Vision
Hearing

VISION
Cataracts, glaucoma, macular

degeneration, and abnormalities

of accommodation worsen with
age
Assess difficulties by asking
about everyday tasks
driving; watching TV; reading
Use performance-based
screening
ask to read from newspaper,
magazine
use Snellen chart

HEARING
Hearing loss is common among older

adults
Impaired hearing depression, social
withdrawal
Assess first for cerumen impaction
Use hand-held audioscope to test for
abnormality
loss of 40 dB tone at 1000 or 2000 Hz in
one or both ears is abnormal
refer for formal audiometry testing

ASSESS NUTRITIONAL
STATUS
Screen for malnutrition
Visual inspection
Measure height, weight, body

mass index (BMI)

BMI = weight (kg) / height (m2)
low BMI < 20 kg/m2)
Unintentional weight loss > 10 lbs

Poor nutrition may reflect medical

illness, depression, functional

losses, financial hardship

MMSE

[Cognitive Domains]

Orientation/Time

5 points
Orientation/Place
5 points
Registration
3 points
Attention/Calculation 5 points
Recall of Three Words 3 points
Language
8 points
Visual Construction 1 point

MMSE

[Scoring / Cutoffs]

Total Number of Correct Answers

24-30 Correct: No Cognitive Imp.
18-23 Correct: Mild Cognitive Imp.
0-17 Correct : Severe Cog. Imp.
Influence by
Educational Level
Race / Ethnicity
Socioeconomic Status?

Clock Drawing Test

Different Versions
4 Point Scale Most Useful
1 Point- Circle
1 Point-Numbers
1 Point-Hands/Arrows
1 Point-Right Time

Geriatric Depression Scale

Total Number of Questions
Long Version = 30
Short Version = 15

Administered in about 5 Minutes

Count the Missed Questions

Error Cut-Offs
Long Version
< 11

Not Depressed

11-14 Possible Depression

14

Depression

Short Version
<11

Not Depressed

11

Probable Depression

25

3-

COMMON GERIATRIC
DISORDERS
CVS: hypertension, IHD, heart failure, PVD, syncope
Resp: pneumonia, tuberculosis, asthma, COPD
CNS: stroke, dementia, meningitis, encephalopathy
Endo: diabetes, thyroid, sexual, metabolic diseases
Musculoskeletal: osteoporosis, OA, RA, falls, fractur
GIT: dyspepsia, constipation, NSAID gastrop, GERD
Urogenital: UTI, BPH, menopause, incontin, prolaps
Cancers: breast, lung, prostate, cervical, haematol
Spl senses & iatrogenic: eye, ear, taste, skin, ADRs

Common Clinical Problems inGeriatrics

Immobilit
are Syndromes: y
Impotence
Incontinence
Incoherence
Irritable

bowels
Insomnia
Isolation
Immune
deficiency

Instability
Intellectu

al
impairme
nt
Infection
Impairme
nts
Inanition
Iatrogene
sis

UNCLASSIFIED SYMPTOMS IN OLD AGE

Weakness
Fatigue
Anorexia
Constipation
Altered taste
Breathlessness

Low muscle strength

Body aches
Confusion
Insomnia
Impotence
Faints/ Falls

3 Ds of Geriatrics
Dementia, Delirium, and Depression
These common disorders can look alike.
GAI often helps uncover or differentiate

them.
All are associated with elder mistreatment.

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Dementia
Dementia is a progressive decline in

cognitive and functional abilities with

associated psychiatric disturbances.
Normal aging leads to a slowing of

performance but not decreased cognition.

8% of patients over 65 years old have

dementia.

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Delirium
1. Acute change in mental status and
2. Inattention
3. Disorganized thinking or
4. Altered level of consciousness

It is a geriatric emergency.
Inouye et al. Ann Int Med, 1993
31

Differential Diagnosis
Always consider dementia and

depression as competing diagnoses.

Other: post-ictal state, psychiatric

disorders, nonconvulsive epilepsy.

Three types:

32

Organic (medical)

Post-operative

Terminal restlessness
3-

Etiology

Dementia vs. Delirium

34

Depression
Treatable in 75% of cases.
Untreated cases associated with 15%

mortality.
Suicide rate in elderly is double the rate

for all other age groups.

Workup is identical for that of dementia.

Dementia and depression often coexist.

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