Geriatrics Internal Medicine PDF

DR.hazem & Essam Geriatrics Internal medicine 1  DR.hazem & Essam Aging and its effects on dif...

DR.hazem & Essam Geriatrics Internal medicine 1  DR.hazem & Essam Aging and its effects on different body systems The elderly includes individuals 65 years of age and older. There is great variation among individuals with age. Aging proceeds at different rates in different people & within different systems of the body. AGING is the progressive decline and deterioration of functional properties at the cellular, tissue, and organ level that led to a loss of homeostasis, decreased ability to adapt to internal or external stimuli, and increased vulnerability to disease and mortality. Effect of aging: Special sensations: Nervous system: ↓ Vision acuity & Vision field ↓intellectual function & speed of learning ↓ Smell sensation Gradual loss of Recent memory ↓ Taste sensation Sensory: ↓ in sensation Hypoesthesia (e.g.; Vibration) Motor: ↓ Muscle power / Senile tremors / Reflexes may be decreased or making food less appealing, decrease absent appetite& weight loss Psychological: Emotional instability st (1 sweety & salty then bitter & sour) ↓ Hearing sensation Respiratory system: ↓& damage of the Elastic tissue of the lungs>>Alveoli become dilated and thin Liver: walled ↓Ciliary transport system leading to decrease in mucous & foreign materials ↓ Size, Weight & Blood flow by clearance. 50%. Digestive system: ↓ Gag reflex leading to increased aspiration Functional derangements are slight: Mouth: absence of teeth &Inadequate mastication, will allow large particles of food to reach the intestine, resulting in incomplete digestion & colonic disturbance. Serum bilirubin N Salivary secretions: small in volume and in enzyme content. PT activity N Esophagus: due to atrophy of connective tissue support leads to Patulous cardia(GERD) and increase incidence of Diaphragmatic hernia Serum transaminase N Stomach: basal secretion is↓ in volume and in HCL. Albumin N or may be ↓due to Small intestine:↓Blood supply +no of absorptive cells+Enzymes activity malnutrition >Malabsorption Large intestine: constipation due to ↓intake of food and fluids, defective glucose output ↓ due to↓ in hepatic mastication & due to irregular bowel habits. blood flow &glycogen content. Diverticulosis due to atrophy and↓ tone of musculature & diminished elasticity of Urea output is↓due to↓liver cell mass connective tissue layer of the wall of the colon. Cholesterol in bile ↑due to ↑hepatic 2 secretion of cholesterol and bile acid synthesis, >>↑ cholesterol gall stones  DR.hazem & Essam The Pancreas Urinary system: ↓in volume & enzyme Progressive sclerosis of the glomeruli with aging. activities due to↓ blood supply Atheromatous changes in renal vessels, leading to reduction in GFR. and GFR is reduced by about 10mL/min per decade after 40years of age. increase incidence of chronic fibrosing pancreatitis. Urinary tract infections are common due to impaired bladder emptying. Serum creatinine should not be used as a test for renal function in old because there is decrease in muscle mass which is the source of serum creatinine. If serum creatinine is normal, we should assume that there is 40% reduction of renal function. We uses Creatinine clearance instead (as modifying drug dose) Effect on musculoskeletal: There is decrease in muscle cross section area and the volume of contractile tissue resulting in decrease force production. Bone mass decreases as people age, especially in female after menopause. Joints become stiffer & less flexible. The trunk becomes shorter as disks lose fluid& become thinner. Exercise is one of the best ways to slow changes in musculoskeletal system as have an impact on the size, strength& aerobic capacity of skeletal muscle in old people. Effect on cells: Tissues >> atrophy. Cells >> larger & are less able to divide/ ↑ pigments inside the cell : fatty brown pigment called lipofuscin collects in many tissues. Connective tissue become stiff, making organs, blood vessels & airways more rigid. The exchange of gases, nutrients & wastes become difficult. 3  DR.hazem & Essam Effect on skin: Wrinkles of the skin& graying of hair. The outer layer thins & Large pigmented spots (age spots) or lentigos may appear. Blood vessels of the dermis become more fragile, which results in easy bruising. Sebaceous glands produce less oil, making it harder to keep the skin moist, resulting in dryness & itching. The subcutaneous fat layer which provides insulation thins, increasing the risk of injury (pressure ulcers.) & reducing the ability to maintain body temperature. hypothermia can result when exposed to cold weather. The sweat glands produce less sweat with increasing risk for developing heat stroke when exposed to hot weather. Effect on Body Temperature: Body temperature in old people is lower by about 0.2- 0.5 degree centigrade than adults; due to ↓ in basal metabolic rate + atrophy of skeletal muscles + impairment of the circulation. Effect on body shape: Human body is made up of fat ,lean tissue(muscles& organs) bones, water. as we age the amount & distribution of these materials will change. Fat is increasingly deposited toward the center of the body. The proportion of body fat increases by as much as 30%. Lean body mass decreases. Bones lose their minerals, become less dense. There is reduction in total body water making old people more liable to dehydration. 4  DR.hazem & Essam Effect on Immune system: There is decrease in number of circulating lymphocytes. T cell response decrease in elderly which lead to increase susceptibility to infection & malignancy. There is increase production of autoantibodies. Effect on Endocrine System: Decrease hormone secretion. Decrease efficacy of hormones on target tissues. Changes in water & electrolytes: Potassium: ↓in old people >> due to reduced lean body mass. Total body water: ↓ >>due to Thirst & thermoregulatory mechanisms are disturbed in elderly. (Imp. to encourage old people to drink ample amount of water to avoid dehydration.) Calcium: ↓related to decrease absorption & decrease vitamin D Sodium: ↑with age, there is increased sensitivity to external sodium in diet. Antiaging measures: 1. Maintain ideal body weight. 2. Eat breakfast every day. 3. Get regular exercise. 4. Avoid stress & smoking. 5. Get 7-8hr sleep /day. 6. Regular checkup for early detection of diseases. 7. Ensure good nutrition: Adequate water intake to maintain healthy state of tissues, proper kidney function, digestive secretions & avoid constipation. The type food should be nourishing, containing mineral salts, trace elements & vitamins Total caloric intake better to be reduced to avoid obesity.  Fat: animal fat should be replaced by vegetable oil. 5  DR.hazem & Essam  Protein: protein intake is important to raise the immune function, should be reduced if there is impairment in kidney & liver functions.  Fiber: increase intake of fiber, better from natural source.  Salt intake should be reduced.  Calcium intake should be increased together with vitamin D to help its absorption. Atypical presentation to diseases: Due to Age related physiological changes / Interaction between Chronic & Acute illness / Under-reporting of symptoms leadings to absence of signs & symptoms Or Unusual symptoms Or Opposite to what expected Disorder Typical (Usual signs of illness) Atypical presentation in elder Depression Sad mood, ↑ sleeping hours, Fluctuation of body weight Confusion, Apathy, Absence of subjective feeling of depression Myocardial Shortness of breath , nausea & substernal chest pain Confusion, dizziness , mild or no chest pain infarction Pneumonia SOB , Cough , production of sputum , Fever Confusion, Malaise , anorexia , Absence of usual symptoms Thyrotoxicosis Restless , Tremors , Agitation & Rapid heart rate Confusion, Lethargy, Fatigue, weight loss , arrythmia Acute Fever , Tachycardia , Rt lower abdominal pain NO fever , NO Tachycardia , diffuse abdominal pain , appendicitis Urgency UTI Frequency , Urgency , Dysuria Confusion , anorexia , No dysuria , No incontinence Infection Fever , Tachycardia , ↑ WBCs Temp. N or decreased No tachycardia Slight ↑ or N WBCs When the organs are affected only by age , this is called senescence. When in addition some of the organs are affected by diseases that are precipitated by being old , this is called senility. 6  DR.hazem & Essam Cognitive changes in Elder Normal aging is associated with: 1. Brain atrophy & Replacement by increase in CSF Volume (This process is variable from one person to another , where exercise, good nutrition, listening to classic music, Reading delay atrophy process) 2. “Minimal Cognitive Impairment ” which is age associated impairment in short term memory (N.B long term memory remain intact till very end) 3. All reflexes are reduced Dementia: Definition: Progressive Global decline in cognitive & behavioral functions interfering with daily living activates and social relationships “Brain Failure”. Causes: 1. Alzheimer disease (Most common cause) 50% 2. Strokes (Vascular dementia) 15% 3. Both Alzheimer & Strokes 15% 4. 20% Others: Parkinsonism, Front-temporal disease, Lewy’s body disease Alzheimer disease: Age related primary degenerative brain disease characterized by Progressive irreversible ↓in memory /↓ ability to learn / ↓ability to perform routine task /↓ communication skills & Abstract thinking. MOST COMMON CAUSE OF DEMENTIA Risk factors: Old age (most imp factor) Rural population & low level of education +VE family history Female gender Obese Alcoholism DM Dietary (↓ B12 or ↑ Fatty acids/ Al /Zn / thiamine /Prions) HTN Genetic “Apo E4 Gene” 7  DR.hazem & Essam Pathophysiology: (no clear pathogenesis but theories) Accumulation of beta amyloid >> Liberate Free radicals >> induce Apoptosis of Cholinergic neurons(responsible for memory) Histopathology: Senile plaques (made of amyloid plaque) / neurofibrillary tangles (made of protein named tau link neurons together) / Neuronal degeneration. Early warning signs = indication to referral to geriatric physician= Mild stage: 1. Personality changes 2. Gradual loss of short term memory 3. Inability to recognize objects 4. Problem in communication and finding out right words 5. Forget how to use simple objects as spoon, pencil, turn off stove, Lock the door. 6. Moderate stage: (Verbal & Physical agitation, wandering, sleep disturbance) 7. Severe stage: (Bedridden, incontinence ) Evaluation: History: from Family or Friends about the degree of change in daily activities or personal behavior Physical examination: Rule out “Dementia mimicry” (Severe anemia / severe Hypothyroidism / severe B12 & Folate deficiency) Cognitive assessment by MMSE (Mini–Mental State Examination): score 18-25 = Dementia Lab test: CBC / Thyroid profile / Level of B12 & Folate Imagery: MRI >> show atrophy of hippocampus PET amyloid or PET Tau Scan Gold standard: Brain autopsy and biopsy to detect senile plaque & neurofibrillary tangles 8  DR.hazem & Essam Treatment: 1. Environment: cueing & scheduling all activities 2. Care for family: psych supportive therapy is essential as 50% of caregivers develop depression by 5y 3. Non-medical measures: Education / Psychosocial support / ongoing care & Follow up 4. Medical treatment: (stabilize and slow progression of the disease) Acetylcholine esterase inhibitor (Donepezil & Rivastigmine) increase level of Ach need for memory N.B used in mild – moderate stages where enough neuron present for Ach to act on. NMDA receptor blocker (memantine) Others: Anti-inflammatory drugs, Estrogen 5. Treatment of associated disorder as (Anxiety, sleep disorder, delirium) Delirium: Geriatric Emergency Acute onset + Cognitive & Attention impairment + Fluctuating course throughout the day. Not memory. Most frequent complication of hospitalization among elder. Risk factors: Modifiable: Non modifiable: Alcoholism / Alcohol withdrawal /Anemia Age > 65y Pain Parkinsonism Comorbid Associated diseases: CKD , CHF , Hepatic D. Drugs: (anticholinergic, sedative hypnotic, CTS, Neurological disease Polypharmacy) Male sex Endocrinal: (Thyroid or Adrenal disorder) Electrolyte disturbance: (Na, Mg, Ca, Gl, acid base disturbance) Emotional distress Food: poor nutrional status / Dehydration Hemorrhage intracranial or strokes Illness or acute infection as pneumonia 9 Vision & hearing impairment Immobilization  DR.hazem & Essam Treatment: Non pharmacological: Correction of any modifiable risk factor Pharmacological: Neuroleptics “Haloperidol” (Drug of choice) given in smallest dose & shortest time. 0.5-1 mg oral or parenteral and repeated every 30 min. until patient recovery Delirium Dementia Onset Acute Insidious Course Fluctuate throughout the day Don’t fluctuate (except lewy’s body dementia) Duration Hours – weeks Months-Years Defect Attention impaired Memory impaired Consciousness altered Attention / consciousness normal Associations Visual hallucinations common Uncommon MMSE Can’t attend MMSE Can attend but don’t perform well Reversibility Reversible Irreversible Risk factor See before See before 10  DR.hazem & Essam Drug prescription in elderly Pharmacokinetics: Absorption: Most of drugs are unaffected by age Yet some medication showed decreased absorption (Ca, Iron and vitamin D) due to decreased active transporter Decrease of serum albumin with age: Protein bound drugs tend to be higher in level as (Digoxin, Warfarin, Phenytoin and Thyroid hormone) If giving 2 protein bound drugs >> Competition will occur resulting in higher level in one of them thus need careful monitoring ↓ Total body water with age and age related ↑ Body fat: Change in volume of distribution of drugs: ↑ volume of distribution of hydrophobic drugs >> ↑ Half life of the drug >> eg: Diazepam / Benzodiazepine/ Anesthetics ↓ volume of distribution of hydrophilic drugs >> ↓ Half-life of the drug >> Eg: Digoxin Change in liver metabolism by liver: ↓ Liver mass + ↓ Liver blood flow + ↓ Endothelium of liver >> ↓ CYP450 activity and amount >> Drugs with first pass metabolism in liver will be effective at lower doses Eg: (Beta-blocker / Calcium channel blocker / Nitrate / ) Drug with second pass are preferred Change in renal excretion: ↓ Renal mass + Sclerosed glomeruli + Obliterated afferent arteriole >> ↓ GFR by “10ml/min./decade” after 4th decade Thus we need to adjust drugs which are renally cleared Eg: Digoxin, Lithium, Aminoglycosides, Antimycotic, Antiviral, Beta-blocker, H2- blocker. We adjust the dose of drugs depending on “Cockcroft equation” which depend on Creatinine clearance (140-age) x body wt. (kg.) Cr cl. = 72 x Serum Cr. N.B no aging of enzymes in kidney // Level of creatinine remain normal in elder due to decrease lean mass 11  DR.hazem & Essam Pharmacodynamics: Receptor and post receptor level: Change in end organ response to drugs ↓ Sensitivity to certain drugs eg: Beta blocker and beta agonis ↑ Sensitivity to certain drugs eg: Opiate and Warfarin Polypharmacy: >4 drugs “As older patients move through time, often from physician to physician, they are at increasing risk of accumulating layer upon layer of drugtherapy” Adverse effect of drugs: “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” Most common from of iatrogenic illness in elder Risk factors: Old age / Females / Polypharmacy / Hepatic impairment / Renal impairment / Decreased body weight / History of adverse effect Criteria to choose drug in elder: Established efficacy Compatible safety Half-life 0.125/day Meperidine Ticlodipine Antihistamines (esp Diphenhydramine-Benadryl!) Chlorpropamide NSAIDS (esp indomethacin) Propoxyphene DRUGS TO BE AVOIDED IN THE ELDERLY: ®Benzodiazepines such as Diazepam. ® Barbiturates. ® Analgesics such as NSAIDs. ® Muscle relaxants. ® Antiemetics-Prokinetics such as Metoclopramide. ® Antihistamines. ® Antidepressants and Combination antidepressant-antipsychotics. ® Anticholinergic antispasmodics. ® Cardiovascular drugs such as Methyldopa, Reserpine, Propranolol, Digoxin. 14  DR.hazem & Essam Urinary incontinence (UI) 1. It means involuntary loss of urine. 2. The Urinary incontinence is a major problem of elderly population one of “GIANTS OF ELDER” 3. Age is a risk factor for UI; however, it is not considered a normal consequence of aging. 4. It is about 2–3 times more common in women than in men until 80 y after which UI rates are similar. 5. It has high prevalence yet up to 1/2 cases may not be reported because individuals with UI may not seek medical intervention. Age-related changes within the urinary tract contribute to the increased prevalence of UI in the older population: 1. ↓ bladder compliance. 2. ↓bladder capacity. 3. ↓urethral closing pressure. 4. ↓Ability to postpone voiding. 5. ↑ involuntary detrusor contractions. 6. ↑ post void residual. 7. ↑ frequency of voiding. 8. weakened pelvic floor musculature (in women) and prostatic enlargement (in men). Impact of UI: 1. Affects psychological well-being and quality of life. 2. Impair sexual function. 3. Increased risk of UTIs, falls, fractures, and sleep disturbance. 4. Restrict activities, interfere with interpersonal relationships, decrease self-esteem. 5. Increase caregiver burden, and financial burden. 6. Causes anxiety or depression. 7. It is a common precipitant of institutionalization in older adults. Types: (According to pathophysiology and clinical picture) (1) stress urinary incontinence. (2) urge urinary incontinence. (3) overflow incontinence, (4) functional incontinence. N.B Mixed types of incontinence are common and may complicate diagnosis and treatment because of overlapping symptoms. 15  DR.hazem & Essam Type Stress (Urethral incontinence) Urge (Detrusor overactivity) Overflow (Detrusor underactivity) Functional Definition Involuntary loss of urine(small Leakage of urine (large involuntary release of urine from an Urinary accidents amount) with ↑intra-abdominal volumes) because of inability overfull urinary bladder, often in the associated with the pressure (coughing) to delay voiding after absence of any urge to urinate. inability to sensation of bladder toilet because of fullness is perceived impairment of cognitive and or physical functioning, psychological unwillingness, or environmental barriers Causes 1. Weak pelvic floor muscles. 1. Detrusor overactivity. 1. Anatomic obstruction by prostate, 1. Severe dementia 2. Bladder outlet or urethral 2. CNS disorder stricture, cystocele. or other neurologic sphincter weakness. 2. Acontractile bladder associated disorder. 3. Post-urologic surgery with diabetes or spinal cord injury 2. Psychological 3. Neurogenic associated with factors such as multiple sclerosis or other spinal cord depression. lesions. 4. Medications. Clinical Urine leakage occur Urine leakage occur with Incontinence where frequent leakage of ------------------------- picture instantaneously with stress as Urge (no time between desire small amount of urine + Nocturia laughing, coughing or lifting and act) heavy object Evaluation 1. Screening to identify patients because many patients do not report symptoms. By questions :“Do you ever leak urine when you do not want to?” / “Do you ever leak urine when you cough, sneeze?” 2. A bladder diary; liquid intake, number of trips to the bathroom, activities during leakage, strength of urge to void, and accidental leaks. And can measure treatment efficacy. 3. Take Good drug history. 4. Identification of reversible causes are very important. 5. An abdominal, rectal, and genital physical examination should be performed. 6. Urinalysis to rule out infection or glucosuria. 7. Determination of PVR Special Stand up and cough test Cystoscope and cytological Post voiding residual volume: > 450ml ------------------------- investigations analysis of urine as it may be Urodynamic study due to Stone or tumor in bladder 16  DR.hazem & Essam 1. Pelvic floor exercises: 1. Bladder training: 1. Augment voiding technique: Implement lifestyle Treatment (Kegel exercises) patient gradually increases Eg by suprapubic pressure interventions Effective in mild cases toileting intervals by resisting 2. Medications: Ask to contract pelvic floor sensation of urgency. Alpha receptor blocker: relax daily 30-60 times for 6w Learn to urinate according to a urethra 2. Devices: scheduled timetable. 5 alpha reductase inhibitor as Intravaginal support devices or Distraction and relaxation finasteride: for BPH treatment urethral occlusion inserts or techniques. Antibiotics: Pessaries Will increase bladder capacity. to guard against repeated infections 3. Medical treatment: The interval is initially based 3. Urinary catheters: 1. Duloxetine (used first line) on the patient voiding habits, with chronic bladder-emptying 2. Antimuscarinics then increased by 15-30 min/w difficulty and elevated PVR & Severe ill 3. α-Agonists (third line) until a voiding interval of 3–4 patients with chronic UI who are 4.Topical Estrogen: hours is achieved. bedridden. In post menopausal with 2. Pelvic floor exercise atrophic urethritis. 3. Medical treatment: Aiming to decrease bladder 4. Periurethral injection contraction of bulking agents (e.g., Eg: collagen): Antimuscarinics: improves urethral closure in SUI Oxybutynin 5. Artificial urinary Solifenacin sphincters: Darifenacin the most effective treatment for 4. Sacral nerve post-prostatectomy SUI stimulation: 6. Surgery: When medical ttt failed Last resort 5. Botulinum Toxin: Most effective treatment used in patients with detrusor Cure rate 75-85% overactivity 17  DR.hazem & Essam Notes: Lifestyle and behavioral interventions: Are the first-line treatment of choice in the elderly population including smoking cessation, caffeine and alcohol reduction, weight loss, and modified fluid intake. Pelvic floor exercises (Kegel exercises): Repetitive contraction and relaxation of the pelvic floor muscles is used to enhance the ability to voluntarily contract the external sphincter. Sacral nerve stimulation: Generator device is inserted in the lower back & electrical stimulation to S3 > decreased contraction of bladder. Support devices: Antimuscarinics: “The most commonly prescribed UI drug” Action: Decrease bladder contraction Oxybutynin: Gold standard antimuscarinic agent for UI. Other new formulas: extended-release formulation is preferred due to less anti-cholinergic side effects: Solifenacin & Darifenacin Duloxetine: Inhibit urinary bladder contraction Dose: 40 mg twice daily we start by small dose and increase it gradually to decrease side effect (Nausea) Estrogen: Only used Topical Commonest cause of Urinary incontinence in 18  DR.hazem & Essam Drugs that cause urinary incontinence: 1. ACEI, calcium channel blockers, loop diuretics. 2. Thiazolidinediones. In treatment diabetes. 3. Gabapentin and pregabalin. 4. Antipsychotics, sedative hypnotics. 5. NSAIDs, narcotic analgesics. 6. α-Adrenergic agonists Outlet obstruction (men), 7. α-Adrenergic blockers Stress leakage (women). 19  DR.hazem & Essam FALLS IN THE ELDERLY DEFINITION: Non-syncopal falls unintentional events in which a person comes to rest on the floor or ground that are not caused by loss of consciousness, stroke, seizure, or overwhelming force- may occur in different settings e.g., the community, skilled nursing facilities, and hospitals. INCIDENCE: The incidence increases steadily after age 60 years. Women are more likely to fall than men. More than half of all falls in the community happen at home. Falls in skilled nursing facilities and hospitals are almost three times that for community-dwelling elders. Etiology of Fall: (Risk Factors for Falling) i) Age-Associated Changes and Chronic Diseases Age greater than 80 years, need for assistance with activities of daily living, and previous falls, indicate risk for future falls. ii) Postural Control: Balance, or postural control is dependent upon the integration of visual, vestibular and proprioceptive input by the central nervous system. Fall risk has been linked to mediolateral instability; clinically this can be tested by the ability to stand on one leg. Persons who experience difficulty with standing balance tasks may walk more slowly and may lose balance easily if they had to hurry for any reason. iii)Sensory Input: Vision: decreased visual acuity, impaired contrast sensitivity (the ability to detect edges) and depth perception, Multifocal lenses. iv)Central Processing: Cognitive impairment caused by dementia may impair judgment and affect the perception and interpretation of sensory stimuli resulting in falls. Depression may increase fall risk because of decreased concentration or awareness of potential environmental hazards. v)Musculoskeletal Impairments: Foot problems such as calluses, bunions, long nails, or joint deformity, can affect balance and lead to fall. vi)Postural Hypotension: (A of drop in systolic blood pressure 20 mmHg or more with change in position from lying to standing) Postural hypotension, may result in instability and fall. Postprandial hypotension where persons complaining of dizziness fall after getting up from, or soon after a meal. 20  DR.hazem & Essam vii)Medications: Use of four or more medications increases the risk of falling. (because of multiple chronic diseases, multiple prescribing physicians and consultants.) Anticonvulsants // Sedative hypnotics // antidepressants //Benzodiazepines // Antiarrhythmic // anti-hypertensive and diuretics increase risk of fall. viii)Acute Illness and hospital Discharge: Acute illness such as pneumonia or exacerbation of congestive heart failure may present as a fall in older person Discharged from the hospital is fourfold higher than that for others in the community during the tint 2 weeks after discharge. ix)Opportunity to Fall: Older persons may do activities that are beyond their capabilities such as climbing on a chair or counter to reach high cabinets, hanging curtains, rushing to answer the telephone. Risk Factors for Fall injury: i)Osteoporosis: The presence of osteoporosis increases an older person's risk of fracture. ii)Characteristics of the Fall: Factors that increase the force of a fall include falling from a greater height, and landing on a hard surface. Falling sideways or directly onto the hip increases the likelihood of hip fracture. Falling forward onto an outstretched wrist increases the likelihood of a Cones' fracture. Complications of fall: 1)Injuries: Head trauma // Brain and spinal cord injuries // Hip fracture (more in females, most severe fall injury, 20% die within 1y & ½ cases cannot live independently) Elder are at high risk of injury due to: age-related changes such as slow reaction time, impaired protective responses, and comorbid diseases such as osteoporosis. 2)Post fall syndrome “Fear of fall syndrome”: Subdivided into: i)Severe: when following a fall and in the absence of any neurologic or orthopedic abnormality the patient is unable to stand or walk without human support from someone else. 21  DR.hazem & Essam ii)Moderate: patient showed anxiety, fear & tendency to clutch and grab but with encouragement was able to stand and walk without human support from someone else.(with or without walking aid). iii)Absent: when the patient was able to walk safely without human support (with or without a walking aid) and without any tendency to clutch and grab. Recent research has shown that this fear occurred also in elderly persons who have Not fallen before!! The term Fear of Falling (FOF) limits the performance of daily activities. This term "FOF" is now used to encompass both fullers and Non-fallers. (FOF) associated with restricted mobility Thus FOF may be more serious than falling it self. 3)Long lie complication: Long lie mean remaining on ground for more than 1hr which lead to complications: a) Pneumonia b) Dehydration c) Hypothermia: (Mild > Stand up >> Walk 3m at his usual pace >> Turn 180 >> walk back to chair and set down 4. If he takes ≥ 14sec. = Increased risk for fall If there is no history of falls and no problem with balance, mobility, or gait, then no specific fall risk assessment is necessary and re-assess after a year. If there is a history of one or more falls (significant Fall: more than twice in six months or once hut associated with injury), or if the person has problems with mobility or gait, then a more detailed fall risk assessment is needed. MULTIFACTORIAL ASSESSMENT: Indications: 1. After hospital discharge 2. Significant fall 3. Acute illness 4. Problem in Gait, mobility or balance 5. Abnormal Time up an GO test 6. New medication administration Done by: Geriatric specialist 23  DR.hazem & Essam Steps: History taking and medication review: Ask about activates of daily living as feeding, toileting, bathing and dressing Ask about previous fall (details of fall ;location, time of day, posture, frequency, associated injuries) Ask about chronic medical problem (CNS, CVS, Chest, Urinary tract) Drug history (Type of medication, Dose, Frequency) Examination: Mini mental state examination Cerebellar examination (Heel shin test) Motor system examination (weakness and spasticity) Sensory system examination (Joint position sense) Special sense examination (Hearing and vision acuity screening) CVS system examination (Arrythmia, Postural hypotension measure blood pressure lying then standing after 3 minutes) Extremities examination (Arthritis, Range of motion, deformities) Investigation: (No specific tetst done) Depend on history and physical examination Eg: CBC / BGL / TSH / B12 / Level of drugs as digoxin Test of osteoporosis: will determine the need for medication to improve bone density and decrease risk of fracture CT or MRI brain done only if clinical suspicion\ 24  DR.hazem & Essam Prevention of fall: Most of falls are multifactorial in origin Multidisciplinary treatment plan after determination of risk factor should be applied. Measures: Exercise: It must be tailored Individually (Not Group classes) Under guidance of physical therapist Minimum 10 weeks // at least 30min 5 times a week moderate exercise Avoid brisk walking Teach how to get up from fall to avoid long lie and its harm It was found that it improves muscle strength and bone mass Environmental measures: Safety modification in home (Floor, Light, Stairway, Bathroom and kitchen) Medications: Deprescribing strategy: Decrease number of medications as much as possible gradually Withdraw Psychotropic drugs Other measures: Wear emergency call device to ask for help in case of fall Encourage movement as much as he can in safe situation Treatment of osteoporosis Usage of walking aid if needed: 1. Must be of proper height (Handle at level of greater trochanter) 2. Cane should be held in hand opposite to side of diseased leg 3. Climbing upstairs should start with good leg first (Not diseased one) 4. Down stairs should start with diseased leg first 25  DR.hazem & Essam Measures not effective in reducing the fall: 1. Vitamin D supplement (unless Vitamin D deficiency present) 2. Education regard fall prevention 3. Multifactorial risk assessment as a routine for all elder Immobilization: Definition: Physical restriction of movement to body or body segment Complications: Skin: Pressure ulcer Muscles: Atrophy begin one day after immobilization Bones: Increased bone resorption and osteoporosis Joints: Stiffness, Pain and contracture CVS: Decreased stroke volume and cardiac output // Venous thrombosis and thromboembolic manifestation Pulmonary: Stasis of secretion may block airway leading to atelectasis and pneumonia GIT: Constipation Urinary: Decreased voiding of urine and increased risk of UTI BMR: Decreased basal metabolic rate 26  DR.hazem & Essam CARDIOVASCULAR DISORDERS IN THE ELDERLY AGE - related cardiovascular changes:**** 1. Loss of pacemaker cells in the sinus node & conduction fibers in the aging heart → sinus node dysfunction (the “sick sinus syndrome “) and Atrioventricular (AV) block. (only treatment is pacemaker implantation) 2. Amyloid deposit in heart → Arrhythmias and Amyloid heart disease → Restrictive Cardiomyopathy → heart failure in the elderly. 3. Most common arrhythmia seen is atrial fibrillation (⅓ in older individuals) and is often “lone” atrial fibrillation without an underlying cause. 4. Left ventricular stiffness → impaired diastolic filling which declines 50% between ages 20 and 80 → clinical syndrome of diastolic heart failure. Diastolic heart failure is the most common type of heart failure in elder. 5. The combination of sensitivity to filling volumes and impaired heart rate response to stress may explain the syndrome of postural hypotension in 20% of older individuals → Syncope. Most common type of blood pressure disorder in elder is postural hypotension. / Most common cause of it in elder is Anti-hypertensive medication. 6. Coronary Atherosclerosis is common → Coronary artery disease as Angina and Myocardial Infarction in the elderly.// Silent MI is the most common coronary event in elder 7. Heart valves thicken and stiffen, particularly the Mitral and Aortic (Stenosis) → flow murmurs. Most common type of valve disease in elder is aortic stenosis due to calcification. 8. The Aorta dilates and its walls thicken as medial walls calcify; with this loss of elasticity → secondary increase in systolic blood pressure (systolic BP ↑after age 30 years until the mid-70s, then ↓through the 80s and 90s). The most important principle in the approach to cardio-vascular signs and symptoms with advancing age is to recognize the narrowed homeostatic capacity of the elderly. 27  DR.hazem & Essam Coronary Artery Disease: (Angina / Acute MI / Acute coronary syndrome) The incidence of CAD increases with age. The traditional Risk Factors are: Hypertension, Diabetes, Lack of exercise, Ratio of high total cholesterol to high-density lipoprotein, Smoking, Age. Newer Risk Factors are: C-reactive protein, Lipoprotein a, Homocysteine, Microalbuminuria. How can subclinical cardiovascular disease be measured? 1. Carotid ultrasound can measure the degree of plaque in the carotid arteries to predict risk of stroke by plaque score and intima-media thickness. 2. Ankle-brachial index (ABI) = (normal ratio is > 0.9 – 0.95) 3. Electron-beam computerized tomography measures the amount of calcification in the coronary arteries. Angina is the most common presenting symptoms of coronary artery disease, occurring in 80% of the elderly. Clinical picture: The history of classic exertional angina may be difficult to obtain as the elderly patient who has limited activity and do not develop symptoms until late in the course of disease. 1. Dyspnea on exertion is a very common manifestation of coronary disease in the elderly. Other symptoms include 2. Palpitation, 3. Weakness, 4. Unexplained diaphoresis 5. Indigestion 6. Neck and shoulder pain. Signs: 1- Faint heart sounds. 2- S4 >> reduced left ventricular compliance. 3- Reversed splitting of S2 dt LBBB. 4- Transient Mitral regurge murmur. 28  DR.hazem & Essam Diagnosis of Angina: A. ECG: 1- Depressed ST segment > 2mm >1 lead. 2-Inverted or flat T-wave. B. Cardiac enzymes Normal. C. Treadmill D. 24-hour ambulatory monitoring: E. Coronary arteriography: remains the definitive test for the diagnosis coronary artery disease. Rest Angina (Unstable A) i.e., rapidly progressive angina, can occur frequently in the elderly. Treatment: a. Correct Precipitating factors: Physical activity / Weight management (optimal mass index ≤ 24) / Glycemic control /Blood pressure control / LDL cholesterol - lowering therapy (statin, fibrates and nicotinic acid) b. Medical treatment During attack: Sublingual NG. Between attacks: Nitrates (Dinitra): SE: orthostatic hypotension, headache, syncope. B blockers (contraindicated in vasospastic angina) SE: Fatigue, depression, bradycardia, heart block, hypotension. CCB. Anti-platelets : (Plavix)-aspirin. c. Interventional Therapy: PTCA (trans-luminal coronary Angioplasty) CABG (in left main vessel disease , 2 or 3 vessels disease) 29  DR.hazem & Essam Myocardial Infarction Clinical picture: Symptoms: Pain:Retrosternal / Stabbing, compressing / More than 30 min / Not relived by Nitroglycerine / Associated with fever and tachycardia / Radiate to left shoulder, jaw, inner aspect of left arm Signs: 1. Faint heart sounds. 2. S3 & S4 gallop. 3. Reversed splitting of S2. 4. Mitral regurge murmur. 5. Pericardial rub 6. Fine basal crepitation. ECG:STEMI 1. ST segment elevation. NSTEMI: 2. Reciprocal ST depression. 1. ST depression. 3. Hyperacute T-wave. 2. Inverted T-wave. 4. Q wave. 3. No pathological Q-wave Cardinal signs of MI: 1- Suggestive pain > 30 min. 2- ECG. 3- Increased cardiac enzymes. Atypical presentation in Elder MI: (Thus mortality of (MI) & incidence of complications is increased in elder) The presenting symptoms of (MI) can be quite atypical, especially in patients over age 80 , Dyspnea is very common early manifestation, Mental confusion, syncope, Gastrointestinal complaints. Elder have conduction defects on the ECG that may mask the changes of acute MI, so elevated specific cardiac enzymes confirming the MI. 30  DR.hazem & Essam Treatment of MI: In acute stage: Morphine Oxygen Nitroglycerine Best treatment is primary PCI If PCI is contraindicated as in left main vessel disease >> CABG Medically: as treatment of angina in between attacks. Full-dose anticoagulation therapy is often given to patients with anterior MI because of the high risk of mural thrombus and possible embolization. Tissue plasminogen activator during the first 3 hours of MI Heart failure: Precipitating causes of CHF: Myocardial ischemia / Myocardial infarction / Brady-or tachyarrhythmias / COPD exacerbation / Anemia / Hyperthyroidism. The causes of heart failure: Systolic dysfunction Diastolic heart failure: when the ejection fraction is less than 40% (normal ejection CHF have normal LV systolic function & Diastolic function fraction: often abnormal. 55-60%) 1-Coronary artery disease (most common) Functional Abnormalities: 2-Hypertensive heart disease Ischemia 3-Valvular heart disease: Calcium overload calcific degenerative aortic stenosis ATP depletion calcification of the mitral annulus Structural abnormalities: 4-Myocarditis Hypertrophy 5-Thyroid disease Fibrosis 6-Tachy or bradyarrhythmia Constriction 7-idiopathic (diagnosis of exclusion) 31  DR.hazem & Essam N.B DHF >> More prevalent with age / More common in females /Asymptomatic diastolic dysfunction more common than symptomatic THE INCIDENCE OF DIASTOLIC DYSFUNCTION IS AGE-RELATED AND HEART FAILURE DUE TO DIASTOLIC DYSFUNCTION RISES DRAMATICALLY WITH AGE. Classic physical findings of congestive heart failure: *Vital signs: Tachypnea / Cheyne -Stokes Respiration *Heart: S3 Gallop / Normal Heart Sounds *Neck: Jugular venous distention / Hepato -jugular reflux *Chest Bibasilar rales / Diffuse bubbling rales of pulmonary edema / Wheezing (cardiac asthma) /Signs of pleural effusion (flatness to percussion, decreased to absent breath sounds) *Abdomen, back and extremities: Large, tender liver / Ascites / Sacral edema / Peripheral edema / *Classic finding of congestive heart failure on chest X-ray: Increased heart size-cardiothoracic ratio > 0.50 / Large hila with indistinct margins / Prominence of superior pulmonary veins; cephalization of flow / Fluid in interlobar fissures / Pleural effusion / Kerley´s B lines due to interstial pulmonary congestion / Alveolar edema / Peribronchial cuffing Treatment of CHF due to systolic dysfunction: Treatment of CHF due to diastolic dysfunction: Diet + Exercise Diet Diuretics is essential to relieve symptoms Exercise ACE inhibitors + Beta-Blocks Main lines Diuretics angiotensin II receptor antagonists added if previous fail Other Pharmacologic Considerations Ivabradine (if sinus rhythm and heart rate > 70) Digoxin “Last resort” Vasodilators 32  DR.hazem & Essam Main way to diagnose heart failure is Clinical picture then ECHO and lately ECG ANP and BNP are non specific marker for heart failure. Tips for drug treatment in the elderly: Older people may show an exaggerated drop in blood pressure after the first dose of an ACE inhibitor. “First dose hypotension” Check postural blood pressures frequently and BUN/creatinine ratios at intervals to monitor volume depletion. Check serum electrolytes and magnesium, and replace when necessary. Digoxin is useful in treating CHF due to systolic dysfunction. Many older people will have some reduction in renal function. Therefore, give maintenance doses of digoxin on the basis of creatinine clearance. Digoxin toxicity can present atypically in the elderly with headache and other neurological manifestations. A 72 year‐old man is referred to you because of a precordial systolic murmur. On examination, there is a harsh mid-systolic crescendo‐ decrescendo murmur at the right parasternal 2nd ICS, radiating to the carotids. The patient is asymptomatic. Echocardiography reveals an aortic valve area of 1.2 cm2 and a mean systolic gradient of 30 mmHg and a normal LV systolic function. What is the most appropriate intervention for this patient at the present time? a) Percutaneous balloon aortic valvuloplasty b) Aortic valve replacement c) Conserve and follow‐up Diagnosis mild- moderate aortic stenosis and asymptomatic >> No treatment just conserve and follow up. A patient elder with newly‐discovered aortic regurgitation and severe chest pain should be considered to have: a) Myocardial infarction b) Acute pericarditis >> not associated with aortic regure c) Aortic dissection d) Syphilitic aortitis >> Chronic e) Ankylosing spondylitis >> Chronic 33