Lecture 26 Clinical Implication of Aging Process

8/12/2019 Lecture 26 Clinical Implication of Aging Process

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CLINICAL IMPLICATION

OF AGING PROCESSdr. I Nyoman Astika, SpPD

Block Growth and Development2009


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Learning outcomes- To describe the changes associated

with aging- To know common problem of Geriatrics

(a series of Is) - To know components of assessment of

older patients


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The care of older patients differs from that ofyounger patients.

The changes that occur in the proces of aging.Normal aging and patologycal changes is criticalto the care of older people.Many of the changes associated aging result

from gradual loss (on cross sectional: lossfunction organ 1 % a year beginning age 30years ).


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MAJOR THEORIES ON AGING

Theory Mechanisms Manifestations

Accumulation ofdamage toinformationalmolecules

Regulation ofspecific genes

Spontaneous mutagenesis

Failure in DNA repair systems

Errors in DNA, RNA, and proteinsynthesis

Superoxide radicals and loss of

scavenging enzymes

Appearance of specific protein(s)

Copying errors

Errors catastrophe

Oxidative cellular damage

Genetically programmedsenescence


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Changes Asosiated With Aging

ITEM MORPHOLOGY FUNCTION

Overall Decreased height (vertebralcompression and stooped posturesecondary to increased kyphosis)Decreased weight (after age 80 inlongitudinal studies)Increased fat to lean body massratioDecreased total body water


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ITEM MORPHOLOGY

Skin Increased wrinkling Atrophy of sweatglands


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Cardiovascularsystem

Elongation andtortuosity of arteries,including aortaIncreased intimal

thickening of arteriesIncreased fibrosis ofmedia of arteriesSclerosis of heartvalves

Decreasedcardiac outputduring exerciseDecreased heart

rate response tostressDecreasedcompliance ofperipheral bloodvessles


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Changes Asosiated With Aging (continued) ITEM MORPHOLOGY FUNCTION

Kidney Increased number of abnormal glomeruli

Interstitial fibrosis

Decreased creatinine clearance

Decreased renal blood flowDecreased maximum urineosmolality


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Changes Asosiated With Aging (continued)


Gastrointestinaltract

Decreased hydrochloric acidFewer taste buds

Slowed intestinal motility


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ITEM MORPHOLOGY

Skeleton OsteoarthritisLoss of bone structure


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Eyes Arcus senilisDecreased pupilsizeGrowth of lens

DecreasedaccommodationHyperopiaDecreasedacuity

Decreased colorsensitivityDecreaseddepthperception


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Hearing Degenerative changes of ossiclesIncreased Obstruction of Eustachian tube Atrophy of external auditory meatus Atrophy of cochlear hair cellsLoss of auditory neurons

Decreased perception in highfrequenciesDecreased pitch discrimination


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Immune system Decreased T-cell activity


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Nervoussystem

Decreased brainweightDecreased corticalcell count

Increased motorresponse timeSlowerpsychomotorperformanceDecreasedintellectualperformanceDecreased complexlearningDecreased hoursof sleepDecreased hours ofrapid eye movement(REM) sleep


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CLASSIFYING GERIATRIC PROBLEMS

One aid to recalling some of the common problems ofgeriatrics uses a series of I (14 I) is:

ImmobilityInstabilityIncontinenceIntellectual impairment

InfectionImpairment of vision and hearingIrritable colonIsolation (depression)Inanitation (malnutrition)

ImpecunityIatrogenesisInsomniaImmune deficiencyImpotence


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IMPAIRMENTS of Sensory apparatus

Visual Presbiopy, cataracta lentis, retinopathydiabetic, glaucoma, macular degeneration(Increase in prevalence with age)

Hearing 1/3 of people over 65 reduced emotional, social & physical factor whispered voice exam (3 6 random item)

Taste ability

Smell ability Peripheral sensory ability , vibration


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Disease diagnosis in the elderly

should include 4 levelsDisease

Impai rmentDisabi l i ty

Handicap


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COMPREHENSIVE GERIATRIC ASSESSMENT (CG

IMPLIES : Physical HealthMental HealthFunctional StatusSocial Function

Environment(Multi or Inter-disciplinary Team)

Source: Forceia (2004), Reuben (2003)


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Evaluating The Elderly Patient

The factors interact in complexways influence the health &functional status of the elderlyComprehensive evaluation willrequire an assessment of each of

these domains.Funct io nal abi l it ies a centra lfocus o f the com prehens iveevaluation of an elderly individual.Diagnoses-physical-laboratory

findings are useful in dealing withunderlying etiologies & detectingtreatable conditions, in the elderly,measures of function are oftenessential in determining overallhealth.

Figure 1 : Components of assessment of the elderly

(David B Reuben )


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POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES Difficulty Factors involved Suggestions

Communication

Underreporting ofsymptoms

Diminished vision

Diminished hearing

Slowed psychomotor performance

Health beliefsFearDepression

Altered physical responses to diseaseprocessCognitive impairment

Use well-lit room

Eliminate extraneous noiseSpeak slowly in a deep toneFace patient, allowing patient tosee your lipsUse simple amplification devicefor severely hearing impaired

If necessary, write questions inlarge print

Leave enough time for thepatient to answer

Ask specific questions aboutpotentially important symptomsUse other sources of information(relatives, friends, othercaregivers) to complete thehistory


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POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES (cont inued)

Difficulty Factors involved Suggestions

Vague or nonspecific symptoms

Multiple complaints

Altered physical and physiologicalresponses to disease process

Altered presentation of specific diseaseCognitive impairment

Prevalence of multiple coexistingdiseasesSomatization of emotions maskeddepression (see Chap. 5)

Evaluate for treatable disease,even if the symptoms (or signs)are not typical or specificwhen there has been a rapidchange in functionUse other sources ofinformation to completehistory

Attend to all somaticsymptoms, ruling out treatableconditionsGet know the patientscomplaint: pay specialattention to new or changingsymptomsInterview the patient onseveral occasions to completethe history


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IMPORTANT APECTS OF THE GERIATRIC HISTORYSystem Review

System Key Symptoms

Genitourinary

Musculoskeletal

Neurological

Psychological

FrequencyUrgencyNocturiaHesitancy, intermittent stream, straining to voidIncontinenceHematuriaVaginal bleeding

Focal or diffuse painFocal or diffuse weakness

Visual disturbances (transient or progressive)Progressive hearing loss

Unsteadiness and/or fallsTransient focal symptoms

Depression Anxiety and/or agitationParanoiaForgetfulness and/or confusion


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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS

Physical findings Potential significance

Vital signs Elevated blood pressure

Postural changes in blood pressure

Irregular pulse

Increased risk for cardiovascular morbidity:therapy should be considered if repeatedmeasurements are high (see Chap. 11)

May be asymptomatic and occur in the

absence of volume depletion. Aging changes, deconditioning, and drugsmay play a roleCan be exaggerated after mealsCan be worsened and becomesymptomatic with antihypertensive,

vasodilator, and tricyclic anti depressanttherapy

Arrhythmias are relatively common inotherwise asymptomatic elderly; seldomneed specific evaluation or treatment (seeChap. 11)


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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued) Physical findings Potential significance

Vital signs

Tachypnea

Weight changes

Baseline rate should be accuratelyrecorded to help assess futurecomplaints (such as dyspnea) orconditions (such as pneumonia or hearthfailure)

Weight gaint should prompt search foredema or ascitesGradual loss of smallamounts of weight common; losses inexcess of 5% of usual body weight over

12 months or less should prompt searchof underlying disease


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General Appearance and Behavior

Poor personal grooming and hygiene(e.g., poorly shaven, unkempt, soiledclothing)

Slow thought processes and speech

Can be signs of poor overall function,caregiver neglect, and/or depression:often indicates a need for intervention

Usually represents an aging change:Parkinsons disease and depression canalso cause these signs


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COMMON PHYSICA FINDING AND THEIR POTENTIALSIGNIFICANCE IN GERIATRICS (continued)


Vital signs

Ulcerations

Diminished turgor

Lower extremity vascular and neuropathiculcers common

Pressure ulcers common and easilyoverlooked in immobile patients

Often results from atrophy of subcutaneoustissues rather than volume depletion; whendehydration suspected, skin turgor overchest and abdomen most reliable

Ears (see Chap. 13)

Diminished hearing High-frequency hearing loss common;patients with difficulty hearing normalconversation or whispered phrase next tothe ear should be evaluated furtherPortableaudioscopes can be helpful in screening forimpairment


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Eyes (see Chap. 13) Decreased visual acuity (often despitecorrective lenses)

Cataracts and other abnormalities

May have multiple causes, all patientsshould have thorough optometric orophthalmologic examinationHemianopsia is easily overlooked and canusually be ruled out by simple confrontation

testing

Fundoscopic examination often difficult andlimited; if retinal pathology suspected,thorough ophthalmologic examinationnecessary

Mouth

Missing teeth Dentures often present; they should beremoved to check for evidence of poor fitand other pathology in oral cavity

Area under the tongue is a common site forearly malignancies


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Cardiovascular

Irregular rhythms

Systolic murmurs

Vascular bruits

Diminished distal pulses

See vital signs, above

Common and most often benign; clinicalhistory and bedside maneuvers can helpto differentiate those needing furtherevaluationCarotid bruits may need furtherevaluation

Femoral bruits often present in patientswith symptomatic pepripheral vascuraldisease

Presence or absence should bediagnostically useful at a later time (e.g.,if symptoms of claudication or anembolism develop)


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Abdomen

Prominent aortic pulsation Suspected abdominal aneurysms should beevaluated by ultrasound

Genitourinary (see Chap. 8)

Athrophy

Pelvic prolapse (cystocele, rectocele)

Testicular atrophy normal; atropic vaginaltissue may cause symptoms (such asdyspareunia and dysuria) and treatmentmay be beneficial

Common and may be unrelated tosymptoms; gynecologic evaluation helpful ifpatien has bothersome, potentially relatedsymptoms


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Extremities Periart icular pain

Lim ited range of mot ion

Edema

Can result a variety of causes and is notalways the result of degenerative joint disease;each area of pain should be carefullyevaluated and treated (see Chap. 10)

Often caused by pain resulting from activeinflammation, scaring from old injury, orneurologic disease; if limitations impairfunction, a rehabilitation therapist could beconsulted

Can result from venous insufficiency and/or

heart failure; mild edema often a cosmeticproblem: treatment necessary if imparingambulation, contributing to nocturia,predisposing to skin breakdown, or causingdiscomfort.Unilateral edema should prompt search for aproximal obstructive process


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Neurologic

Abnormal mental status (i.e.,confusion, depressed affect)

Weakness

See Chaps. 6 and 7

Arm drift may be the only sign of residualweakness from a strokeProximal muscle weakness (e.g., inability toget out of chair) should be further evaluated;physical therapy may be appropriate


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LABORATORY ASSESSMENT OF GERIATRIC PATIENTS

Laboratory parameters unchanged*

Hemoglobin and hematocritWhite blood cell countPlatelet countElectrolytes (sodium, potassium, chloride, bicarbonate)Blood urea nitrogen

Liver function test (transaminases, bilirubin, prothrombin time)Free thyroxine indexThyroid-stimulating hormoneCalciumPhosphorus


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LABORATORY ASSESSMENT OF GERIATRIC PATIENTS(continued)

Common abnormal laboratory parameters

Parameter Clinical significance

Serum iron, iron binding capacity, ferritin

Prostate-specific antigen

Urinalysis

Decreased values are not an aging change andusually indicate undernutrition and/orgastrointestinal blood loss.

May be elevated in patients with benignprostatic hyperplasia. Marked elevation orincreasing values when followed over timeshould prompt consideration of furtherevaluation in patients for whom specific therapyfor prostate cancer would be undertaken if

cancer were diagnosied.

Asymptomatic pyuria and bacteriuria arecommon and rarely warrant treatment;hematuria is abnormal and needs furtherevaluation (see Chap. 8).


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LABORATORY ASSESSMENT OF GERIATRIC PATIENTS(continued)

Common abnormal laboratory parameters

Parameter Clinical significance

Chest radiographs

Electrocardiogram

Interstitial changes are a common age relatedfinding; diffusely diminished bone densitygenerally indicates advanced osteoporosis (see

Chap. 12).St-segment and T-wave changes, atrial andventricular arrhythmias, and various blocks arecommon in asymptomatic elderly and may notneed specific evaluation (see Chap. 11)

* Aging changes do not occur in these parameters; abnormal values should prompt further evaluation includes normal aging and other age related changes.


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EXAMPLES OF MEASURES OF PHYSICAL FUNCTIONING Basic ac t iv i t i es of d a i ly l iv ing (ADL)

FeedingDressing

AmbulationToiletingBathing

Transfer (from bed and toilet)ContinenceGrooming

CommunicationInstrumental activities of daily living (IADL)

WritingReadingCookingCleaning

ShoppingDoing laundryClimbing stairsUsing telephoneManaging medicationManaging money

Ability to perform paid employment duties or outside work (e.g., gardening) Ability to travel (use public transportation, go out of town)


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Comprehensive Geriatric Consultation

A comprehensive geriatric consultation includes the following:1. A geriatric oriented history and physical examination attending to issues

reviewed earlier in this chapter2. Medication review; in addition, geriatric patients should be questioned about

alcohol abuse3. Functional assessment4. environmental and social assessment, focusing especially on caregiver support

and other resources available to meet the patients need 5. Discussion of advance directives6. A complete list of the patients medical, functional, and psychosocial problems 7. specific recommendations in each domain


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EXAMPLE OF A SCREENING TOOL TO IDENTIFY POTENTIALLYREMEDIABLE GERIATRIC PROBLEMS

Problem Screening Measure Positive Result Poor vision

Poor hearing

Poor leg mobility

Ask, Do you have difficultydriving, watching television,reading, or doing any of your

daily activities because ofyour eyesight? If yes, then test acuity withSnellen chart, with correctivelenses

With audioscope set at 40 dB,test hearing at 1000 and 2000Hz.

Time the patient after asking,Rise from the chair. Walk 20feet briskly, turn, walk back tothe chair, and sit down.

Inability to read better than20/40 on Snellen chart

Inability to hear 1000 or 2000Hz in both ears or eitherfrequency in one ear

Unable to complete task in 15s


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EXAMPLE OF A SCREENING TOOL TO IDENTIFYPOTENTIALLY REMEDIABLE GERIATRIC PROBLEMS(continued)

Problem Screening Measure Positive Result Urinary incontinence

Malnutrition and weight loss

Memory loss

Depression

Ask, In the past year, have youever lost your urine and gottenwet? If yes, then ask, have you lossurine on at last 6 separate days?

Ask, Have you lost 10 poundsover the past 6 months withouttrying to do so? and then weightthe patient

Three item recall

Ask, Do you often feel sad ordepressed?

Yes to both questions

Yes to question or weight


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EXAMPLE OF A SCREENING TOOL TO IDENTIFYPOTENTIALLY REMEDIABLE GERIATRIC PROBLEMS(continued)

Problem Screening Measure Positive Result Physical disability Ask six question:

Are you able to: Do strenuous activities suchas fast walking or bicycling?

Do heavy work around thehouse like washing windows,walls, or floors?Go shopping for groceries orclothes?Get the places that are out ofwalking distance?Bathe: either a sponge bath,tub bath, or shower?Dress, including putting on ashirt, buttoning a zipping, andputting on shoes?

Source : From Moore and Siu, 1996, with permission.


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CHANGES ASSOCIATED WITH AGING ( Kane et al, 1999)Overall : - Weight, Height and Total Body water

- Fat-to-lean-Body mass ratioCardiovasculars: - Cardiac output, Heart Rate response to stress

- Increased intimal thickening- Sclerosis of heart valves- Decreased compliance of periph. Vessels.

Lungs : - Decreased elasticity & cilia activity, cough reflex

- Vital capacity, max O2 uptakeKidney : - Increased number of abnormal glomeruli

- Renal blood flow, creatinine cl., max. urine osmol.GI Tract : - Fewer taste buds, decreased saliva flow

- Decreased HCl prod. and enzymes.

Skeleton : - More osteoarthritis and osteoporosis.Endocrines : - T3 and free testosteron

- Insuline, norepinephr. Parathormone, vasopres.Nervous syst : - Decreased brain weight, intellect. compl. Learning

- Decreased hours of sleep, REM


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DEVELOPMENT FROM CHILDHOOD TO OLD-AGED

1. Body-length becomes shorter due to esp. osteoporosis, diseases ofbones and joins and body composition and postures.

2. Prevention of abdominal bulging (android obesity).3. Prevention of fall and fractures.4. Keep exercising (keep fit) not strenuous, not to heavy but regular

- non competitive, incl. intellectual and brain exercise.5. Use your intellectual capacity.6. Practice a balanced diet.7. Prevent degenerative diseases risk factors. 8. Keep practicing a Healthy life -style. Source: Boedhi-Darmojo, 2004


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Lecture 26 Clinical Implication of Aging Process

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