Geriatrics Lecture 1 Outline

Age in a Graying America: Numbers, Profiles, Trends

 Why we have a “gray crisis”
o Improved life expectancy
o Decreased birth rate
o Public health improvements
 Antibiotics, vaccinations, fewer cardiac deaths
 Life expectancy – It’s going up!
o 1900: 47.3 yrs o At age 65… 1900: 11.9 yrs
o 1950: 68.2 yrs o 1950: 13.9 yrs
o 2000: 77 yrs o 2000: 18.2 yrs
 By 2010-2050 we will double the number of 65 year-olds
 By 2050, 30% of the population will be >65yo (82.5million ppl)

 Biology of aging: key theories

1. Genetic predisposition
2. “wear and tear”
o Rule of Fourths: ¼ disease, ¼ disuse, ¼ misuse, ¼ physiology

 Characteristics of Aging
o Increased mortality with age after maturation
o Biochemical composition of tissues changes with age
o Physiological capacity decreases
o Decrease in response to environmental stimuli
o Increased vulnerability to disease

 Age related physical changes:

o Blood pressure regulation: orthostasis
o Volume regulation: dehydration
o Thermoregulation: generally colder
o Impaired immune response: increased infection
o Heart: adult max HR 195, geri max HR 155
o Skin: reduced elasticity
o Kidneys: reduced by 50% perfusion
o GI: reduced peristalsis/secretions

 Age related sensory changes:

o Vision: reduced lens elasticity
o Hearing: increased vestibular sensitivity, reduced acoustic sensitivity
o Taste
o Smell
o Touch: reduced reflex

 From the table he put from the book:

o System or Function Affected: and then the change noted
 Body composition: decreased body water vs increased body fat %
 Brain weight: decreased 7% w/ atrophy common
 Sleep patterns: markedly reduced stage 3 and 4 sleep w/ more frequent awakenings and reduced sleep
efficiency
 Vision:
o Lens accommodation: Reduced after age 40-50
o Light reaching retina: reduced up to 70%
o Color perception: reduced intensity (especially blues and greens)
 Hearing: acuity decline starts age 12, mostly in high pitches
Geriatrics Lecture 1 Outline
Age in a Graying America: Numbers, Profiles, Trends
 Taste:
o Taste buds reduced by 70%
o Change in preferences: increased tolerance of sweet and very salty food d/t reduced perception
 Renal perfusion: reduced by 50%
 Bone mineral content: diminished by 10-30%
 Prostate gland: size increased by 100%
 Sexual function:
o Men: reduced intensity and persistence of erections, decreased ejaculate and flow
o Women: menopause; reduced lubrication, vaginal atrophy

Concept of Diminished Reserve

 Physiological examples:
o Pulmonary capacity decreased
o Renal clearance 1/10th of population: CKD 8th cause of death (not sure what this meant exactly)
 Clinical examples:
o Increased sleep requirement
o Decreased calorie needs (less activity)
o Skin alteration that results in decreased protection
o Nocturia
 Consequences:
o Atypical presentation of disease
o Failure of Occam’s Razor (simplest answer is usually correct, this is not the case with geriatrics)
 Most geriatric problems are multifactorial, should assume this
o Decreased physiological compensation
o Increased risk of iatrogenic consequences of illness (polypharmacy d/t increased problem list)

Prevention of Aging
 Disengagement
o Letting go of trappings of younger life
o Retirement communities of the 50-80s
 Activity
o Stay active and fit to stay young
o Much more prevalence to stay active now, but still less integration
 Health issue  physical activity (from a table in the ppt)
o Cardiovascular health  increasing aerobic activity
 Improves myocardial, contractility, everything good with the heart, improves blood lipid profile, reduces sys &
dia BP, improves endurance and muscle capillary blood flow
o Body composition  Increasing aerobic activity
 Decreased abd adipose tissue, increased muscle mass
o Metabolism  increasing aerobic activity
 Increases energy spent, improved protein synthesis, reduced cholesterol/LDL/TGs/VLDL, increases HDL and
glucose tolerance
o Bone health  increasing weight-bearing exercise
 Slows decline in bone mineral density, increased total body [Ca] and nitrogen
o Psychological well-being  increasing aerobic activity
 Improves perceived well being and happiness, decreased stress hormones, improved cognition and attn. span,
increased slow wave and REM sleep, provides sense of accomplishment, decreased anxiety and better mood

Immunizations
 Influenza: 1 dose annually
 Td/Tdap: 1 initial dose + booster every 10 year
 Varicella: 2 doses (if never had chx pox)
Geriatrics Lecture 1 Outline
Age in a Graying America: Numbers, Profiles, Trends
 Zoster: 1 dose
 MMR: 1 dose (if never had dz, but born before 1957 assumed to be immune)
 Pneumococcal: 1 dose unless high risk then 1 booster after 5 yrs
 Hepatitis A: vaccinate only if high risk (behavior or travel)
 Hepatitis B: only in high risk (behavior or travel)

Screening
 Breast CA: biennial mammography 50-74yo, probably no SBE >40
 Colon CA: FOBT, sigmoidoscopy, or colonoscopy annual 50-75yo, not routine from 76-85yo, no screening >85yo
o Edematous polyps 90% premalignant for 5-10yrs
 Cervix & Prostate: No PAP or PSA screening over 65yo; exception is if woman has never had a PAP, and then no further
PAPs if 2 are negative.

Flaws in the Care of Elders

 Agism: withholding rx or intervention secondary to age
o Lack of respect of cognition
 Failure to recognize acute change of mental status (continuity vs baseline)
 Poor communication from setting to setting (EMR, POLST, f/u)
o Hospitalists, specialists, long-term care
 Failure to utilize critical team members
o Pharmacy, rehab, nutrition
o Rehab: PT, OT, Speech therapy is what qualifies a patient as a “rehab” vs “convalescent” pt
 Failure of providers to accept Medicare/MediCal
o i.e. Coverage of PT/OT
 Medicare
o Difficult to navigate
o Medicare D: prescription drug coverage

Diagnosis vs Treatment
 Looking for a solution to disease
 Quality of Life
 Risks vs benefit
o Coumadin/anti-coagulation
 Polypharmacy
o >65yo 13% of pop but 33% of all prescriptions
o Majority of 65yo plus have 5+ prescriptions

Iatrogenic Disease
 Side effect vs intended effects
o 1/3 of 65+ have had an adverse effect
o AKI: 2/3 of pt 65+ and 7-10% of those hospitalized have had one
o Reduced surgical outcomes for all
o Careful what you look for
o Know when to send to specialist

Some history bullshit

 Britain’s post WWII initiation of Nat’l Health Service
 US: institute of Medicine report determined that geriatricians would be teachers of other physicians rather than
become primary care providers

Why we need geriatric medicine

 Demographic burden: ethnic, cultural, and socioeconomic
Geriatrics Lecture 1 Outline
Age in a Graying America: Numbers, Profiles, Trends
 Medical Perspective: different diseases, presentation of diseases, treatment needs of older pts, multiple concurrent
chronic diseases

 Diversity
o California diversity
o Elder diversity: “young old” vs 85+
o Singles couples
o Fit vs disabled
o Independent living vs institutional
o Secure $$ vs worried$$
o Cognitively fit vs impaired

Age Bias and Medicine

 Training: lack of training to manage multi-problem patient, lack of training to manage psychosocial issues
 Takes more time
 Communication issues
o Sensory diminished hearing, vision, and speech; cognitive reliability
 Reimbursement: ~60%

TB and the Elderly

 Common especially in long-term care
 Seek history of prior dz and immune limitations
 Screening: PPDx2, blood, CXR, and check for weight loss, fever, night sweats