Common geriatric problems and their management

Common geriatric problems and their management

1. Common Geriatric problems and their management Dr Md Ruhul Amin Dept of Medicine JRRMCH

2. Aging Aging is the progressive, universal decline first in functional reserve and then in function that occurs in organisms over time. Aging is heterogeneous. Aging is not a disease; however, the risk of developing disease is increased.

3. Geriatric Syndromes Geriatric syndrome refers to a symptom presentation that is common in older adults. Most are multifactorial in origin.

4. Geriatric giants 4 Geriatric giants : 4 I Immobility Instability(falls) Incontinence Intelectual impairment

5. commmon Geriatric problems Dementia and Delirium Fall Urinary Incontinence Pressure Ulcers- due to immobility

6. Dementia and Delirium Dementia is a syndrome of progressive decline in which multiple intellectual abilities deteriorate, causing both cognitive and functional impairment. Dementia is a state of chronic confusion. Delirium is an acute state of confusion. It is important to differentiate delirium from dementia.

7. Dementia and Delirium cont… Both dementia and delirium are characterized by : Disorientation, Memory impairment, Paranoia, Hallucinations, Emotional lability , Sleep-wake cycle reversal.

8. Dementia and Delirium cont… Key features of delirium are: acute onset impaired attention altered level of consciousness.

9. care of a patient with dementia The main goals of care of a patient with dementia to improve cognitive and physical functioning. key goal is to identify and treat reversible causes of cognitive impairment such as : Infections Electrolyte abnormalities Vitamin deficiencies Thyroid disease Substance abuse Medication Psychiatric illnesses.

10. Falls Excludes falls occurring from seizure, stroke, syncope. Fall rates and risk of injury from falls increase with age. Annually ~30% of community dwelling adults >65 years fall. While 50% of individuals >80 years fall.

11. Falls cont… Most falls are multifactorial Falling is sometimes a symptom of another disease, such as: Infections Neurologic disorder Medication side effect Age-related physiologic changes

12. age-related physiologic changes Decreased proprioception , Increased postural sway, Declines in baroreflex sensitivity resulting in orthostatic hypotension.

13. RISK FACTORS FOR FALLS Muscle weakness History of falls Gait or balance abnormality Use of a walking aid Visual impairment Arthritis Impaired activities of daily living

14. RISK FACTORS FOR FALLS cont… Depression Cognitive impairment Age over 80 years Drugs: Polypharmacy (four or more drugs) Digoxin Diuretics Benzodiazepines , phenothiazines,antidepressants Type I anti- arrhythmics

15. History of fall The evaluation of a fall should begin with a history : Circumstances at the time of the fall, Associated symptoms, Thorough medication review of both prescription and over-the-counter medications.

16. physical examination of fall The physical examination should include postural vital signs, vision evaluation, gait and balance testing, musculoskeletal evaluation of joint stability and range of motion.

17. environmental assessment of fall An environmental assessment of the patient's home that can increase fall risk, such as: Loose carpets Poor lighting

18. Urinary Incontinence UI is a major problem for older adults Up to age 80 years, UI affects women twice as commonly as men After age 80, both sexes are equally affected.

19. risk factor for ui Advanced age Functional impairment Dementia Obesity Smoking Affective disorder Constipation

20. Reversible Conditions Associated with Urinary Incontinence driiipp D elirium  R estricted mobility—illness, injury, gait disorder, restraint  I nfection—acute, symptomatic urinary tract infection  I nflammation—atrophic vaginitis   I mpaction—of feces  P olyuria—diabetes, caffeine intake, volume overload P harmaceuticals—diuretics, -adrenergic agonists or antagonists, anticholinergic agents ( psychotropics , antidepressants, anti- Parkinsonians )

21. Urinary Incontinence Leaking of urine or urinary Incontinence occurs in four ways. Stress incontinence, Urge incontinence, Mixed stress and urge incontinence, Overflow incontinence.

22. incontinence evaluation Measurement of postvoid residual (PVR) should be part of an incontinence evaluation in all patients. Under sterile conditions, the patient's bladder is catheterized 5–10 min after the patient has voided. Generally, a PVR > 200 mL suggests detrusor underactivity or obstruction. The patient should be referred for further urologic evaluation.

23. Stress Incontinence Stress incontinence - urethral sphincter mechanisms are inadequate to hold urine during bladder filling, rare in men. leaking small amounts of urine during activities that increase intraabdominal pressure, such as: coughing, laughing, sneezing, lifting, or standing up.

24. Stress incontinence cont… Stress test - can be performed by patient stand with a full bladder and cough. The test is positive if urine leakage coincides with the cough.

25. Stress incontinence cont… Common in women due to insufficient pelvic support, causes: Childbearing Gynecologic surgery Decreased effects of estrogen on tissues of the lower urinary tract.

26. Treatment Stress incontinence Surgical interventions are the most effective treatments pelvic muscle exercises can be helpful Treatment failure is higher in patients who have two or more leakages per day.

27. Urge incontinence UI Urge incontinence also known as detrusor overactivity (DO), characterized by: Uninhibited bladder is the most common form of UI in older adults. Urinary frequency and nocturnal incontinence are common.

28. Urge incontinence UI Urge incontinence may be Idiopathic. Lesions of the central nervous system, stroke. Bladder irritation from infection, stones, or tumors.

29. treatment of urge incontinence Bladder retraining by encouraging the patient to void every 2 h or based on the patient's symptom frequency. The patient can also try urgency control. If no incontinence for 2 days, the voiding interval can be increased by 30–60 minutes until the patient is only voiding every 3–4 h.

30. treatment of urge incontinence cont … The anticholinergic drugs oxybutinin and tolterodine Patients using tolterodine have a reduced risk of dry mouth and fewer withdrawals due to side effects.

31. Mixed incontinence Mixed incontinence refers to UI where symptoms of both stress and urge incontinence are present.

32. Overflow incontinence Overflow incontinence is due to either bladder outlet obstruction or an atonic bladder. patients are Male, but rarely females. On physical examination, patients may have a palpable distended bladder.

33. Overflow incontinence causes MALE Prostatic hypertrophy, prostate cancer, Urethral strictures FEMALE Cystocele .

34. Causes for both male and fermale Detrusor atonicity or underactivity can be caused by Spinal cord disease Autonomic neuropathy Diabetes Alcoholism Vitamin B 12 deficiency Parkinson's disease Tabes dorsalis

35. treatment Overflow of incontinence Adrenergic blockers : Terazosin Doxazosin Tamulosin 5-reductase inhibitor – Finasteride The diagnosis of functional incontinence- individuals who have UI and have either cognitive or functional impairments which limit their ability to toilet themselves.

36. Pressure Ulcers Pressure ulcers, also known as pressure sores, bedsores, or decubitus ulcers, occur in older patients with reduced mobility. A pressure ulcer occurs when increased pressure between skin and a bony prominence produces tissue necrosis. While pressure ulcers can occur anywhere,

37. Pressure Ulcers cont… 80% of pressure ulcers occur over the heels, lateral malleoli , sacrum, ischia , and greater trochanters . Osteomyelitis and sepsis are important, morbid complications of pressure ulcers.

38. Pressure Ulcers

39. Pressure Ulcers cont… Repositioning patients at risk for developing pressure ulcers every 2 hrs. Providing bedbound patients mattresses with pressure-relieving capabilities are standard interventions to prevent pressure ulcers.

40. skin The skin of elderly bruise esily called senile purpura . Some people have skin like trasparent tissue paper described as Paparaceous skin especially back of the hand and forearm.

41. Paparaceous skin and senile purura

42. Constipation To prevent constipation: 1.Increase Fluid Intake 2. Daily Exercise 3. Increase fiber intake (e.g. fruits and vegetables) Complications associated with constipation : Haemorrhoids Anal fissures Rectal prolapse Fecal impaction

43. Postural Hypotension (PH) Measure to prevent PH 1.Get out of bed slowly and in stages. 2. Sleep with head of bed elevated several inches. 3. Daily fluid intake of 2 to 3 liters. 4. Avoid hot showers or baths, may cause venous dilatation thereby, venous pooling. 5. Avoid straining at stool. This may cause fall of BP warning signs of PH (e.g. dizziness, faintness, visual disturbances)

44. Postural Hypotension (PH) cont… 6. Avoid bending down and suddenly standing up again. 7. Rest for 60 minutes after meals. 8. Avoid hyperventilation. This lowers the BP. 9. Exercise regimen must be recommended. 10. Use thigh-length elastic stockings to reduce venous pooling. 11. Avoid prolonged standing.

45. THANK YOU