ELDERLY HEALTH CARE by Rojee OCH Nepal.pptx

taking about the old age patient/ elderly patient, and prospective of care.

1. ELDERLY HEALTH CARE - Rojee Khatri , OCH

2. According to WHO, elderly people refers to age group 60-75. 75-90 : senile, >90 : long liver. Many developed countries classify a person as aged when he/she reach 65 years but GON classifies 60 years as elderly/aged population. At present, roughly 9% of population fall in elderly group. In Australia and USA, it is 16% with increasing trend.

3. In Nepal, most elderly patient visit health facility only when they are sick. Common problems in elderly population include: Headache : Usually secondary to arteritis, tumor, Medication overuse headache. (Migraine: overuse of analgesics can cause rebound headache, analgesics use>2 days, >14 days in a month increases chances of rebound headache, chronic opiod use>90 days a/w rebound headache )

4. Dental Problems : cavities, decayed teeth, gingivitis, d/t inadequate dental hygiene) Breathing difficulties : COPD, Asthma, RTI, PTB GERD/ Acute gastritis : Typical/atypical/ extra- oesophageal (cough, change in voice), Trial of PPI for 4-8 weeks can be done, a/w antacid, H2 receptor blocker, prokinetic agents. If not improved, endoscopy, CBT should be considered.

5. Long term PPI use is a/w disturbance in vitamin b12, iron, and vit c absorption. Also increases risk of intestinal infection and sepsis and increse gastrin secretion leading to formation of gastric polyps. Urinary Problems : In male, Usually BPH. Finasteride : 5 a- reductase inhibitor, decreases prostate stimulation bt 5-HT. Tamsulosin : A-1 blocker, relaxes peri urethral prostatic soft tissue, increase urinary flow. Can also cause dizziness and fainting. In women, UTI, cystocele, neurogenic bladder. Lower limb swelling : CKD, CCF (systolic/diastolic), SA nodal dysfunction, Cor-pulmonale .

6. Vision/Hearing problems : Cataract, glaucoma, presbycusis Bone problems : OA, very common, chronic, can cause disability, fall. Contibuting factors: atherosclerosis: disrupts blood flow, DM, HTN: increases oxidative stress, tissue injury, obesity, Genetics, previous trauma. NSAIDs per Oral and LA can be prescribed, exercise, hot or cold compression, healthy eating to manage DM, cholesterol, weight reduction and supportive devices such as braces, cane/walker can be suggested. IA steroid, hyaluronic acid gel can also be given.

7. Uterine prolapse : surgical management if complete prolapse. Grade 2-3 can be managed with ring pessary , should be washed with soap and water every 3 months, kegal exercise. Post-menopausal Syndrome : present with hot flushes, vaginal dryness, dyspareunia, palpitation, inability to sleep etc etc. should be given HRT with low dose estrogen and intermittent progesterone, LA of estrogen cream can also be applied. SSRIs can also be helpful in hot flushes. Calcium and vitamin D supplementation should be given (daily requirement: about 1200mg in>50, and 400-800 IU of D3). Bisphosphonates 35-70 mg weekly can also be given, inhibts bone resorption .

8. Prescribing medications in elderly Various criterias has been implemented and studied Improves medication appropriateness. Prevents adverse drug events. Reduces drug cost.

9. 1. START criteria (Screening Tool to Alert Doctors to Right Treatment). cvs Prescibe warfarin in patients with chronic AF or aspirin if warfarin is contra-indicated. Aspirin if h/o atherosclerotic CAD, cerebral, vascular disease. Anti hypertensive if BP is consistently high >160 ACEIs in patients with CHF. ACEIs following acute MI. B blockers in chronic stable angina.

10. GI PPIs in severe GERD. MSK DMARDs with active moderate to severe rheumatic disease >12 weeks. Bisphosphonates in patients taking corticosteroids. Calcium and D3 in osteoporosis. Endocrine Metformin in T2DM ACEIs or ARBs in DM with nephropathy. Anti platelet and statin in DM with major CV risk factors. Respiratory Regular B2 agonist inhaler for mild to moderate asthma/COPD Regular inhaled Steroid for moderate to severe asthma/COPD. CNS Anti- depressant therapy in moderate to severe depressive symptomsif lasting > 3 months.

11. STOPP Criteria (Screening tool of older people potentially inappropriate prescribing) GI Loperamide for treatment of diarrhoea of unknown cause. Stemetil / metoclopramide in pts with parkinsonism. PPI for PUD for > 8 weeks. Anticholinergic anti spasmodics (atropine, buscopan ) on patients with chronic constipation.

12. Respiratory Nebulised ipratropium with glaucoma Theophylline as monotherapy . MSK NSAIDs with PUD w/o PPI or H2 receptor antagonist. NSAIDs with mod to severe HTN Warfarin and NSAIDs together. Corticosteroids for >3 months for RA/OA Long term NSAIDs or colchicine for chronic gout. Urogenital Bladder antichoinergic (oxybutynin) used in overactive bladder with dementia, glaucoma, chronic constipation. Alpha blockers ( prazosin ) in males with frequent incontinence.

13. Endocrine: Glyburide in T2DM. Estrogens in venous thromboembolism. B blockers in pts with DM and frequent hypoglycemic episodes. Drugs that adversely affect fallers: 1 st generation anti-histamines, BDZ, neuroleptic drugs, long term opiates. Analgesic drugs: Long term opiates. Regular opiates in those with chronic constipation, dementia.

14. BEER’s criteria: (potentially inappropriate) Anti cholinergics : promethzine , chlorphniramine Anti spasmodics : hyosyamine , dicyclomine . Nitrofurantoin : pulm toxicity.

15. Screening in elderly: Colon cancer: colonoscopy at 50 and every 10 years. Lung cancer : at age 55-80, if smoking >30 pack year or quit w/I last 15 year. Aortic aneurysm: 1 time screening in 65-75 who have ever smoked. Cervical cancer: 30-65, cytology every 3 year or cytology + HPV testing every 5 year. Breast cancer : for women>50, routine mammography every 2 year should be advised.

16. THANK YOU….