CLINICAL IMPLICATION OF AGING PROCESS

dr. I Nyoman Astika, SpPD

Block Growth and Development 2009

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

The care of older patients differs from that of younger patients. The changes that occur in the proces of aging. Normal aging and patologycal changes is critical to the care of older people. Many of the changes associated aging result from gradual loss (on cross sectional: loss function organ 1 % a year beginning age 30 years).

MAJOR THEORIES ON AGING

Theory Mechanisms Manifestations
Copying errors

Accumulation of Spontaneous mutagenesis damage to informational Failure in DNA repair systems molecules Errors in DNA, RNA, and protein synthesis Superoxide radicals and loss of scavenging enzymes Regulation of specific genes Appearance of specific protein(s)

Errors catastrophe

Oxidative cellular damage

Genetically programmed senescence

Changes Asosiated With Aging

ITEM
Overall

MORPHOLOGY
Decreased height (vertebral compression and stooped posture secondary to increased kyphosis) Decreased weight (after age 80 in longitudinal studies) Increased fat to lean body mass ratio Decreased total body water

FUNCTION

Changes Asosiated With Aging

ITEM
Skin

MORPHOLOGY
Increased wrinkling Atrophy of sweat glands

Changes Asosiated With Aging

ITEM
Cardio vascular system

MORPHOLOGY
Elongation and tortuosity of arteries, including aorta Increased intimal thickening of arteries Increased fibrosis of media of arteries Sclerosis of heart valves

FUNCTION
Decreased cardiac output during exercise Decreased heart rate response to stress Decreased compliance of peripheral blood vessles

Changes Asosiated With Aging (continued)

ITEM Kidney MORPHOLOGY Increased number of abnormal glomeruli Interstitial fibrosis FUNCTION Decreased creatinine clearance Decreased renal blood flow Decreased maximum urine osmolality

Changes Asosiated With Aging (continued)

ITEM Lung MORPHOLOGY Decreased elasticity Decreased activity of cilia FUNCTION Decreased forced vital capacity and forced expiratory volume Decreased maximal oxygen uptake Decreased cough reflex

Changes Asosiated With Aging (continued)

ITEM Gastrointestinal tract MORPHOLOGY Decreased hydrochloric acid Fewer taste buds FUNCTION Slowed intestinal motility

Changes Asosiated With Aging (continued)

ITEM Skeleton MORPHOLOGY Osteoarthritis Loss of bone structure

Changes Asosiated With Aging (continued)

ITEM MORPHOLOGY FUNCTION

Eyes

Arcus senilis Decreased pupil size Growth of lens

Decreased accommodation Hyperopia Decreased acuity Decreased color sensitivity Decreased depth perception

Changes Asosiated With Aging (continued)

ITEM
Hearing

MORPHOLOGY
Degenerative changes of ossicles Increased Obstruction of Eustachian tube Atrophy of external auditory meatus Atrophy of cochlear hair cells Loss of auditory neurons

FUNCTION
Decreased perception in high frequencies Decreased pitch discrimination

Changes Asosiated With Aging (continued)

ITEM
Immune system

MORPHOLOGY

FUNCTION
Decreased T-cell activity

Changes Asosiated With Aging (continued)

ITEM MORPHOLOGY FUNCTION

Nervous system

Decreased brain weight Decreased cortical cell count

Increased motor response time Slower psychomotor performance Decreased intellectual performance Decreased complex learning Decreased hours of sleep Decreased hours of rapid eye movement (REM) sleep

Changes Asosiated With Aging (continued)

ITEM
Endocrine

FUNCTION
Decreased triiodothyronine (T3) Decreased free (unbound) testosterone Increased insulin Increased norepinephrine Increased parathormone Increased vasopressin

CLASSIFYING GERIATRIC PROBLEMS

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

Immobility Instability Incontinence Intellectual impairment Infection Impairment of vision and hearing Irritable colon Isolation (depression) Inanitation (malnutrition) Impecunity Iatrogenesis Insomnia Immune deficiency Impotence

FALL
DEFINITION: A fall is said to occur when the center of mass falls outside the support base and correction does not occur in time

AGE RELATED FACTORS THAT INCREASE THE RISK OF FALLING

Musculoskeletal System stiff connective tissue decreased muscle strength Nervous System slower central processing decreased proprioception slowed righting reflex decreased vision & hearing

IMPAIRMENTS of Sensory apparatus

Visual Presbiopy, cataracta lentis, retinopathy diabetic, 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

RISK FACTORS Blood Pressure Tobacco

RISK FACTORS CONCEPT DEGENERATIVE DISEASES SPIDER MODEL Heart disease Stroke Hypertension Dementia CORE Diabetes M Cancer

Dyslipidemia
Improper food/Obesity Glucose Personality/ Stress Physical inactivity

Osteoporosis
Liver disease Renal failure Respiratory disease

Alcohol
Environment Oral hygiene

Gambar 1. Faktor risiko dan penyakit degeneratif (FR harus dihindari/dihilangkan sedini mungkin supaya lebih berhasil) - Boedhi-Darmojo, Orasi, 6 Januari 2001, Sidang Konsorsium Ilmu Kesehatan (KDK) 2000.

Disease diagnosis in the elderly should include 4 levels

Disease
Impairment Disability Handicap

COMPREHENSIVE GERIATRIC ASSESSMENT (CGA IMPLIES : Physical Health Mental Health Functional Status Social Function Environment (Multi or Inter-disciplinary Team)
Source: Forceia (2004), Reuben (2003)

Evaluating The Elderly Patient

Figure 1 : Components of assessment of the elderly (David B Reuben )

The factors interact in complex ways influence the health & functional status of the elderly Comprehensive evaluation will require an assessment of each of these domains. Functional abilities a central focus of the comprehensive evaluation of an elderly individual. Diagnoses-physical-laboratory findings are useful in dealing with underlying etiologies & detecting treatable conditions, in the elderly, measures of function are often essential in determining overall health.

POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES

Difficulty
Communication

Factors involved
Diminished vision Diminished hearing

Suggestions
Use well-lit room Eliminate extraneous noise Speak slowly in a deep tone Face patient, allowing patient to see your lips Use simple amplification device for severely hearing impaired If necessary, write questions in large print Leave enough time for the patient to answer Ask specific questions about potentially important symptoms Use other sources of information (relatives, friends, other caregivers) to complete the history

Slowed psychomotor performance

Underreporting of symptoms

Health beliefs Fear Depression Altered physical responses to disease process Cognitive impairment

POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES

(continued)

Difficulty Vague or non specific symptoms

Factors involved Altered physical and physiological responses to disease process Altered presentation of specific disease Cognitive impairment

Suggestions Evaluate for treatable disease, even if the symptoms (or signs) are not typical or specific when there has been a rapid change in function Use other sources of information to complete history Attend to all somatic symptoms, ruling out treatable conditions Get know the patients complaint: pay special attention to new or changing symptoms Interview the patient on several occasions to complete the history

Multiple complaints

Prevalence of multiple coexisting diseases Somatization of emotions masked depression (see Chap. 5)

IMPORTANT ASPECTS OF THE GERIATRIC HISTORY

System Review
Ask questions about general symptoms that may indicate treatable underlying disease such as fatigue, anorexia, weight loss, insomnia, recent change in functional status. Attempt to elicit key symptoms in each organ system, including the following:

System
Respiratory

Key Symptoms
Increasing dyspnea Persistent cough Orthopnea Edema Angina Claudication Palpitations Dizziness Syncope Difficulty chewing Dysphagia Abdominal pain Change in bowel habit

Cardiovascular

Gastrointestinal

IMPORTANT APECTS OF THE GERIATRIC HISTORY

System Review System
Genitourinary

Key Symptoms
Frequency Urgency Nocturia Hesitancy, intermittent stream, straining to void Incontinence Hematuria Vaginal bleeding Focal or diffuse pain Focal or diffuse weakness Visual disturbances (transient or progressive) Progressive hearing loss Unsteadiness and/or falls Transient focal symptoms Depression Anxiety and/or agitation Paranoia Forgetfulness and/or confusion

Musculoskeletal

Neurological

Psychological

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS

Physical findings Elevated blood pressure Potential significance

Vital signs
Increased risk for cardiovascular morbidity: therapy should be considered if repeated measurements are high (see Chap. 11) May be asymptomatic and occur in the absence of volume depletion. Aging changes, deconditioning, and drugs may play a role Can be exaggerated after meals Can be worsened and become symptomatic with antihypertensive, vasodilator, and tricyclic anti depressant therapy Arrhythmias are relatively common in otherwise asymptomatic elderly; seldom need specific evaluation or treatment (see Chap. 11)

Postural changes in blood pressure

Irregular pulse

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Tachypnea Potential significance Vital signs Baseline rate should be accurately recorded to help assess future complaints (such as dyspnea) or conditions (such as pneumonia or hearth failure) Weight gaint should prompt search for edema or ascitesGradual loss of small amounts of weight common; losses in excess of 5% of usual body weight over 12 months or less should prompt search of underlying disease

Weight changes

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Potential significance General Appearance and Behavior Poor personal grooming and hygiene Can be signs of poor overall function, (e.g., poorly shaven, unkempt, soiled caregiver neglect, and/or depression: clothing) often indicates a need for intervention Slow thought processes and speech Usually represents an aging change: Parkinsons disease and depression can also cause these signs

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings
Ulcerations Diminished turgor

Potential significance Vital signs

Lower extremity vascular and neuropathic ulcers common Pressure ulcers common and easily overlooked in immobile patients Often results from atrophy of subcutaneous tissues rather than volume depletion; when dehydration suspected, skin turgor over chest and abdomen most reliable Ears (see Chap. 13)

Diminished hearing

High-frequency hearing loss common; patients with difficulty hearing normal conversation or whispered phrase next to the ear should be evaluated furtherPortable audioscopes can be helpful in screening for impairment

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings
Decreased visual acuity (often despite corrective lenses)

Potential significance
Eyes (see Chap. 13) May have multiple causes, all patients should have thorough optometric or ophthalmologic examination Hemianopsia is easily overlooked and can usually be ruled out by simple confrontation testing Fundoscopic examination often difficult and limited; if retinal pathology suspected, thorough ophthalmologic examination necessary Mouth Dentures often present; they should be removed to check for evidence of poor fit and other pathology in oral cavity Area under the tongue is a common site for early malignancies

Cataracts and other abnormalities

Missing teeth

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Multiple lesions Potential significance Skin Actinic keratoses and basal cell carcinomas common; most other lesions benign Chest Abnormal lung sounds Crackles can be heard in the absence of pulmonary disease and heart failure; often indicate atelectasis

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Irregular rhythms Potential significance
Cardiovascular

See vital signs, above

Systolic murmurs

Common and most often benign; clinical history and bedside maneuvers can help to differentiate those needing further evaluation Carotid bruits may need further evaluation
Femoral bruits often present in patients with symptomatic pepripheral vascural disease Presence or absence should be diagnostically useful at a later time (e.g., if symptoms of claudication or an embolism develop)

Vascular bruits

Diminished distal pulses

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Prominent aortic pulsation Potential significance Abdomen Suspected abdominal aneurysms should be evaluated by ultrasound

Genitourinary (see Chap. 8)

Athrophy Testicular atrophy normal; atropic vaginal tissue may cause symptoms (such as dyspareunia and dysuria) and treatment may be beneficial

Pelvic prolapse (cystocele, rectocele) Common and may be unrelated to symptoms; gynecologic evaluation helpful if patien has bothersome, potentially related symptoms

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Periarticular pain Potential significance Extremities Can result a variety of causes and is not always the result of degenerative joint disease; each area of pain should be carefully evaluated and treated (see Chap. 10) Often caused by pain resulting from active inflammation, scaring from old injury, or neurologic disease; if limitations impair function, a rehabilitation therapist could be consulted Can result from venous insufficiency and/or heart failure; mild edema often a cosmetic problem: treatment necessary if imparing ambulation, contributing to nocturia, predisposing to skin breakdown, or causing discomfort. Unilateral edema should prompt search for a proximal obstructive process

Limited range of motion

Edema

COMMON PHYSICA FINDING AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS (continued)

Physical findings Abnormal mental status (i.e., confusion, depressed affect) Weakness Potential significance Neurologic See Chaps. 6 and 7

Arm drift may be the only sign of residual weakness from a stroke Proximal muscle weakness (e.g., inability to get out of chair) should be further evaluated; physical therapy may be appropriate

LABORATORY ASSESSMENT OF GERIATRIC PATIENTS

Laboratory parameters unchanged*
Hemoglobin and hematocrit White blood cell count Platelet count Electrolytes (sodium, potassium, chloride, bicarbonate) Blood urea nitrogen Liver function test (transaminases, bilirubin, prothrombin time) Free thyroxine index Thyroid-stimulating hormone Calcium Phosphorus

LABORATORY ASSESSMENT OF GERIATRIC PATIENTS

(continued)
Common abnormal laboratory parameters Parameter Clinical significance

Sedimentation rate
Glucose

Mild elevations (10-20 mm) may be an age related change

Glucose tolerance decreases (see Chap. 12); elevations during acute illness are common. Because lean body mass and daily endogenous creatinine production decline, high-normal and minimally elevated values may indicate substantially reduced renal function. Average values decline (< 0.5 g/mL) with age, especially in acutely ill, but generally indicate underdutrition. Mild asymptomatic elevations common; liver and Pagets disease should be considered if moderately elevated.

Creatinine

Albumin

Alkaline phosphatase

LABORATORY ASSESSMENT OF GERIATRIC PATIENTS

(continued)
Common abnormal laboratory parameters Parameter Serum iron, iron binding capacity, ferritin Clinical significance Decreased values are not an aging change and usually indicate undernutrition and/or gastrointestinal blood loss. May be elevated in patients with benign prostatic hyperplasia. Marked elevation or increasing values when followed over time should prompt consideration of further evaluation in patients for whom specific therapy for prostate cancer would be undertaken if cancer were diagnosied. Asymptomatic pyuria and bacteriuria are common and rarely warrant treatment; hematuria is abnormal and needs further evaluation (see Chap. 8).

Prostate-specific antigen

Urinalysis

LABORATORY ASSESSMENT OF GERIATRIC PATIENTS

(continued)
Common abnormal laboratory parameters Parameter Chest radiographs Clinical significance Interstitial changes are a common age related finding; diffusely diminished bone density generally indicates advanced osteoporosis (see Chap. 12). St-segment and T-wave changes, atrial and ventricular arrhythmias, and various blocks are common in asymptomatic elderly and may not need specific evaluation (see Chap. 11)

Electrocardiogram

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

EXAMPLES OF MEASURES OF PHYSICAL FUNCTIONING

Basic activities of daily living (ADL) Feeding Dressing Ambulation Toileting Bathing Transfer (from bed and toilet) Continence Grooming Communication Instrumental activities of daily living (IADL) Writing Reading Cooking Cleaning Shopping Doing laundry Climbing stairs Using telephone Managing medication Managing money Ability to perform paid employment duties or outside work (e.g., gardening) Ability to travel (use public transportation, go out of town)

FACTORS THAT PLACE OLDER ADULTS AT RISK FOR MALNUTRITION

Drugs (e.g., reserpine, digoxin, antitumor agents) Chronic disease (e.g., congestive heart failure, renal insufficiency, chronic gastrointestinal disease) Depression Dental and periodontal disease Decreased taste and smellLow socioeconomic level Physical weaknessIsolation Food fads

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 chapter 2. Medication review; in addition, geriatric patients should be questioned about alcohol abuse 3. Functional assessment 4. environmental and social assessment, focusing especially on caregiver support and other resources available to meet the patients need 5. Discussion of advance directives 6. A complete list of the patients medical, functional, and psychosocial problems 7. specific recommendations in each domain

EXAMPLE OF A SCREENING TOOL TO IDENTIFY POTENTIALLY REMEDIABLE GERIATRIC PROBLEMS

Problem
Poor vision

Screening Measure
Ask, Do you have difficulty driving, watching television, reading, or doing any of your daily activities because of your eyesight? If yes, then test acuity with Snellen chart, with corrective lenses
With audioscope set at 40 dB, test hearing at 1000 and 2000 Hz.

Positive Result
Inability to read better than 20/40 on Snellen chart

Poor hearing

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

Poor leg mobility

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

Unable to complete task in 15 s

EXAMPLE OF A SCREENING TOOL TO IDENTIFY POTENTIALLY REMEDIABLE GERIATRIC PROBLEMS

(continued)
Problem
Urinary incontinence

Screening Measure
Ask, In the past year, have you ever lost your urine and gotten wet? If yes, then ask, have you loss urine on at last 6 separate days? Ask, Have you lost 10 pounds over the past 6 months without trying to do so? and then weight the patient Three item recall Ask, Do you often feel sad or depressed?

Positive Result
Yes to both questions

Malnutrition and weight loss

Yes to question or weight <100 lb

Memory loss Depression

Unable to remember all three after 1 min Yes to the question

EXAMPLE OF A SCREENING TOOL TO IDENTIFY POTENTIALLY REMEDIABLE GERIATRIC PROBLEMS

(continued)
Problem
Physical disability

Screening Measure
Ask six question: Are you able to: Do strenuous activities such as fast walking or bicycling? Do heavy work around the house like washing windows, walls, or floors? Go shopping for groceries or clothes? Get the places that are out of walking distance? Bathe: either a sponge bath, tub bath, or shower? Dress, including putting on a shirt, buttoning a zipping, and putting on shoes?

Positive Result

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

SUGGESTED RORMAT FOR SUMMARIZING THE RESULTS OF A COMPREHENSIVE GERIATRIC CONSULTATION

1. 2. 3.

Identifying data, including referring physician

Reason(s) for consultation

Problems a. Medical Problem List b. Functional Problem List c. Psychological Problem List Recommendations Standard documentation a. History, including medications, significant past medical and surgical history, system review b. Social and environmental information c. Functional assessment d. Advance directive status e. Physical exam f. Laboratory and other test data

4. 5.

CHANGES ASSOCIATED WITH AGING ( Kane et al, 1999)

: - Weight, Height and Total Body water - Fat-to-lean-Body mass ratio Cardiovasculars: - 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 uptake Kidney : - 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 Overall

DEVELOPMENT FROM CHILDHOOD TO OLD-AGED

1. Body-length becomes shorter due to esp. osteoporosis, diseases of bones 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