L2 PDR GERIATRICS ● GOAL ORIENTED PATEINT CARE or PATIENT

THE OLDER ADULT CENTERED IS RESPECTFUL OF AND RESPONSIVE TO

Dr. Oh INDIVIDUAL PATIENT PREFERENCES, NEEDS, AND
April 2, 2019 VALUES, AND ENSURING THAT PATIENT VALUES
Gonzales, K. (Team Notes) GUIDE overall Clinical Decisions.
● New paradigms also highlight the importance of shifting
The Older Adult assessment to geriatric syndromes: fall outside
traditional disease models but strongly linked to ADLs.
● These syndromes are present in almost 50% of older
adults
● Managing these conditions - cognitive impairment, falls,
incontinence, body max index (BMI), dizziness,
impaired HEARING AND VISION Presents both
Opportunities and FOCUS ON HEALTHTY AND
SUCCESSFUL AGING .
● THE NEED TO MOBILIZED FAMILY, SOCIAL and
COMMUNITY SUPPORTS, THE IMPORTANT OF SKILLS
DIRECTED TO FUCTIONAL ASSESSMENT and THE
SIXTH VITAL SIGN.
● THE OPPORTUNITIES for PROMOTING THE OLDER
ADULTS LONG TERM HEALTH AND SAFETY.

The For Geriatric Approach for Primary Care

 1. LEARNED TO Identify FRAIL elderly THEY ARE MORE
VULNERABLE TO ADVERSE OUTCOME AND MOST
BENEFIT FROM A HOLISTIC APPROACH .
Introduction  2. LOOK FOR COMMON GERIATRIC SYNDROME
INCLUDING FALLS, DELIRIUM/COGNITIVE
● THE OLDER AMERICAN ADULT MORE THAN 43 IMPAIRMENT, FUNCTIONAL DEPENDENCE AND
MILLION PEOPLE, EXPECTED TO REACH TO URINARY INCONTENENCE IN EVERY PTS.,
80MILLION BY 2040 OR OVER 20% OF THE  3. LEARN ABOUT EFFICIENT TOOLS FOR GRIATRICS
POPULATION. AND GERIATRIC SYNDROME AND TEACH CLINICAL
● LIFE SPAN AT BIRTH IS CURRENTLY 81 YEARS FOR STAFF TO ADMINISTER THEM WHEN POSSIBLE.
WOMEN AND 76 YRS FOR MEN.  4. BE FAMILIAR WITH COMMUNITY, SUCH AS FALL
● THE POPULATION OVER AGE 85 IS PROJECTED TO PREVENTION PROGRAM, PACE PROGRAM, AND
MORE THAN DOUBLE FROM 6 MILLIOM IN 1913 TO SENIOR CENTERS,
OVER 14 MILLION IN 2040.  5. TAKE INTO ACCOUNT A PTS GOALS, LIFE
● THE DEMOGRAPHIC IMPERATIVE IS TO MAXIMIZE EXPECTANCY; AND FUNCTIONAL STATUS BEFORE
NOT ONLY THE LIFE SPAN BUT ALSO THE HEALTH CONSIDERING ANY TEST OR PRECEDURE.
SPAN.  6. Review advanced directives and goals of care
● AGING IS HARDLY CHRONOLOGIC, MEASURED BY TIME periodically.
IN YEARS, BUT ENCOMPASSES A WEALTH AND LIVED  7. Be knowledgeable about the Beers Criteria(972)use
EXPEREINCES AND INTERPLAY OF HEALTH AND them to ID potentially inappropriate medications in the
ILLNESS. elderly and inform periodic comprehensive medication
● THE AGING POPULATION IS HIGHLY HETEROGENOUS – review.
IN DISPOSITION, SOCIAL NETWORK, LEVEL OF  8.Adopt evidence –based approach to health screening
PHYSICAL ACTIVITY. especially in the frail elderly.
● FRAILTY IS ONE OF SOCIETY COMMON MYTH ABOUT  9. Watch carefully for mood disorders in thefraail
AGING. elderly and considerusing Geriatric-specific screening
● MORE THAN 95%OF THE AMERICANS OLDER THAN 65 tools, such as the five-item Geriatric Depression Scale.
YEARS LIVE IN THE COMMUNITY AND ONLY  10. Provide caregiver support when possible.
● 5% RESIDE IN INSTITUTIONAL FACILITIES. FOR THOSE
OVER 85 YEARS ONLY 10% LIVE IN INSTITUTION ANATOMY and PHYSIOLOGY: PHYSICAL EXAMINATIONS
FACILITIES .
● SELF RESPECT, HEALTH STATUS AND FUNCTIONAL VITAL SIGNS
STATUS SUPERSEDED IS ABILITY AS A MEASURE OF  BLOOD PRESSURE: SBP TEND TO RISE WITH
HEALTHY AGING. AGING:
● In 2009: 76% rated their health as good to excellent  The aorta and large arteries stiffen and become
In 1990: 49% atherosclerotic: the aorta becomes less distensible,
IN 2010: 41% a systolic hypertension with widened pulse
● 56% have at least one chronic condition. It says that pressure follows. DBP stop rising at the sixth
OBESITY MAY INCREASE LEVELS OF DISABILITY. decade. Orthostatic(postural) hypotension a
● OBESE - 38% OF 65 YEAR OLD AND ABOVE ARE OBESE sudden drop in BP when rising to standing
COMPARED TO 22% OF OVER 65 YEARS OLDFOR 1988 position.
TO 1994, AND IT IS NOT STRICTLY CLINICAL BUT REST
ON VARIABLES LIKE 1. Positive Cognition, 2. Mental Heart rate and rhythm
Health, 3. Physical Activities, and 4. Social Network.  Resting HR remain unchanged but there is decline
in the pacemaker cells of SA node and maximal HR:
 Atrial and ventricular ectopy, it is generally benign, Thorax and Lungs:
but some changes cause syncopy with temporary  chest wall becomes stiffer and harder to move
loss of consciousness.  respiratory muscles may weaken
 lungs lose some of their elastic recoil
Respiratory Rate and Temperature  Lung mass declines, and residual volume increases
 Hypothermia as the alveoli enlarges
 An increase in closing volumes of small airways
Skin, nails and hair: cells predisposes to atelectasis and risk of
 Skin wrinkled, lax and loses turgor, less vascular, pneumonia
looks paler and more opaque, purple patches or  coughing becomes less effective, O2 saturation
macules, termed actinic purpura remains 90%
 Nails lose luster with age and may yellow or
thicken, especially on the toes Cardiovascular System:
 Hair loss, n scalp and color loses its pigment, male Neck vessel:
hairline may recede from temple to the vertex.  -Lengthening and tortuosity of the aorta and its
Women is less severe but follows the same pattern. branches occasionally result in kinking or buckling
of the carotid artery
Head and Neck:  -Pulsatile mass seen in women with aneurysm,
 Eye and visual acuity; bony orbit may atrophy, sometimes seen in women with hypertension
making eyeball recede, dry eye, eyelid skin may  -tortuous aorta raises the pressure in the jugular
hang looser and wrinkled, fewer lacrimal secretion, veins on the left side of the neck, impairing their
may complain of dry eye; cornea loses luster. Pupils drainage within the thorax
are smaller, irregular, continue to show slow light  -systolic bruits heard in the middle or upper
reaction. Visual acuity remain fair (nearby objects). portions of the carotid arteries because
Constantly decreasing until old age of 70 years end atherosclerotic plaque
gradually loses its elasticity and progresses to lose Cardiac output:
accommodation and the ability to focus on nearby  -Myocardial contraction is less responsive to
objects; presbyopia noticeably during the fifth stimulant with b-adrenergic catecholamines
decade.  -Modest drop in resting heart rate
 Aging increases the risk of developing:  -Diastolic dysfunction arises from decreased early
1. Cataract diastolic filling and greater dependence on atrial
2. Glaucoma contraction
3. Macular degeneration Extra Heart Sounds—S3 and S4:
 Thickening and yellowing of the lens impairs the  -S3 strongly suggests heart failure from volume
passage of light to the retina, requiring more light overload of the left ventricle, like in coronary
for reading and doing fine works. arteryor valvular disease
 Cataract affects 10% of the patients in their 60 an  -S4 can be heard in otherwise healthy older people,
over 30% in their 80’s. but often suggests decreased ventricular
 Because the lens continue to expand with aging. It compliance and impaired ventricular filling
may push the iris forward, narrowing the angle Cardiac murmur:
between iris and cornea and increasing the risk of  -systolic aortic murmur is in one-third of people
the narrow-angle glaucoma. close to 60 years and half of those reaching 85
years because of fibrotic changes
Hearing: decline with age  -Calcification resulting in audible vibrations
 Early loses involve high-pitched sound beyond the  -Murmur increases to turbulence produced by
range of human speech. Gradually loss extend to blood flow into a dilated aorta
sounds in the middle and lower ranges. The person  -Aortic valve leaflets become calcified and
fails to hear the higher tones of words but still immobile, resulting in aortic stenosis and outflow
hears lower tones. Hearing loss associated with obstruction
aging, known as PRESBYCUSIS usually at age 50 Peripheral vascular system:
and up.  tortuous, harder and less resilient
 Increase stiffness and decrease endothelial
Mouth, Teeth and Lymph Nodes: function
 Salivary secretions  Loss of arterial pulsations, abdominal or back pain,
 Loss of taste possible aneurysm in the abdominal aorta
 Olfaction especially in male age 65 and above
 Sensitivity to bitterness and saltiness  temporal arteries in those older than 50 years
 Teeth may wear down and become abraded or fall develop giant cell, or temporal arteritis
out, due to dental caries and periodontal disease
 purse stringing of the mouth Breast and axillae:
 lower part of the mouth looks smaller and sunken,  Female breast may be soft, granular, nodular,
wrinkle radiating from the mouth lumpy or uneven texture, smaller and more flaccid,
 over closure of the mouth may lead to maceration and atrophies and replaced by fat
of the corner skin called angular cheilitis.  Male breast develop gynecomastia, increase in
 With aging the cervical lymph node becomes less breast fullness due to obesity and hormonal
palpable, in contrast the submandibular glands changes
may become easier to feel.
 Abdomen:  less speed and agility, skeletal muscle
 -Abdominal muscle weaken decreases in bulk
 -Decrease activity of lipoprotein lipase and fat may  atrophy of interosseous muscle
accumulate in the lower abdomen and near the  muscle wasting and strength is diminished
hips, protruding abdomen  tremors develop but disappear at rest (Not to
 -Changes in abdominal fat distribution increases be confused with Parkinsonism because the
the risk of cardiovascular disease opposite happens)
 -Pain may be less severe, fever is often less c. Position and vibratory senses; reflexes
pronounced and signs of peritoneal inflammation  Older adults lose vibratory senses
may diminish or even absent  Less commonly, position sense diminish and
disappear
 Male and Female Genitalia; Prostate:  Gag reflex, abdominal reflexes and ankle
 Male sexual interest remain intact, decline by 70 reflexes may decrease or is absent
years old  Knee reflexes are affected because of
 Erections more dependent on tactile stimulation musculoskeletal changes
and less responsive to erotic cues  Atrophy and reflex changes are asymmetric
 Protracted illnesses, inability to maintain erection,
 Older adult experience death, retirement form
erectile dysfunction, vascular causes like
work, diminish income, social isolation,
atherosclerotic arterial occlusive disease and
decrease physical capacity
corpora cavernosa venous leak
 Female ovarian function decline after menopause
Approach to Older Adult Patients:
 Symptoms range from flushing, sweating, and
◗◗ Adjusting the office environment
palpitations to chills and anxiety, sleep disruption
◗◗ Shaping the content and pace of the visit
and mood changes are common
◗◗ Eliciting symptoms from older patient
 Vaginal dryness, urge incontinence and
-Underreporting
dyspareunia
-atypical presentation of illness
 Pubic hair becomes sparse and gray
-geriatric syndrome
 Vagina narrows and shortens, mucosa becomes
thin, pale and dry and loses lubrication
 Uterus and ovaries decrease in size
 Suspensory ligament relaxes
 Sexual interest unchanged but women are
untroubled by partner loss, unusual work or life
stress
 Urinary incontinence increases with age, related to
decrease innervation and contractility of the
detrusor muscle and loss of bladder capacity,
urinary flow rate and the ability to inhibit voiding
 In male, prostatic hyperplasia (BPH), only about ◗◗ Eliciting symptoms from older patient
half will develop and the other half be traced to -Underreporting
coexisting disease, use of medication, and lower -atypical presentation of illness
tract abnormalities -geriatric syndrome
-cognitive impairment (Alzheimer and Dementia)
Musculoskeletal System:
 -Both men and women, lose cortical and trabecular Tips for Communicating Effectively with Older Adults:
bone mass; men more slowly, female more rapidly 1. Provide a well-lit, moderately warm setting with minimal
after menopause, which leads to increase of bone background noise and safe chairs and access to the
fraction, calcium resorption from bone, and examining table.
increase with aging as parathyroid level increases 2. Face the patient and speak in low tones; make sure the
 -Subtle loss of height in the trunk and reflects patient is using glasses, hearing devices, and dentures, if
thinning of intervertebral disc and shortening or needed.
even collapse of the vertebral bodies from 3. Adjust the pace and content of the interview to the
osteoporosis, shorten structure stamina of the patient; consider two visits for initial
 30% to 50% decline in muscle mass in relation to evaluations when indicated.
body weight 4. Allow time for open-ended questions and reminiscing;
 Sarcopenia is the loss of lean body mass and include family and caregivers when needed, especially if the
strength with aging; inflammatory and endocrine patient has cognitive impairment.
changes as well as sedentary lifestyle are the 5. Make use of brief screening instruments, the medical
factors record, and reports from allied disciplines.
6. Carefully assess symptoms, especially fatigue, loss of
Nervous System: appetite, dizziness, weight loss, and pain, for clues to
 mental status to motor function and reflexes are underlying disorders.
affected 7. Make sure written instructions are in large print and easy
 older adult maintain their self-esteem and adapt to read.
well to their changing capacities and circumstances
a. Mental status
 Memory problem, Alzheimer and dementia
b. Motor system
 Common Concerns:
◗◗ Activities of daily living (ADL)
◗◗ Instrumental activities of daily living

◗◗ Medications
-Beers criteria
◗◗ Acute and persistent pain

Assessment for preventing falls:

◗◗ Smoking and alcohol

-Smoking is harmful at all ages

◗◗ Nutrition Delirium and Dementia:

◗◗ Frailty
-Multifactorial geriatric syndrome characterized by an
age-related lack of adaptive physiological capacity that
can occur even in the absence of identifiable illness
◗◗ Advance directives and palliative care
-We want our patients to make their advanced directive
and palliative care instructions in the event that their
cognition or mental status fails

Health Promotion and Counseling

-Screen
-Exercise
-Immunization
-Spectrum of cognitive decline
-Elder mistreatment and abuse
-6 Vital Signs
-Recording of your findings
 Patients with intermediate word recall of 1–2 words are
classified based on the CDT (Abnormal = demented; Normal =
nondemented).

Note: The CDT is considered normal if all numbers are present in

the correct sequence and position, and the hands readably
display the requested time.

Screening for Dementia (MoCA):

Screening for Dementia:

Administration
The test is administered as follows:
1. Instruct the patient to listen carefully to and remember
3 unrelated words and then to repeat the words.
2. Instruct the patient to draw the face of a clock, either on
a blank sheet of paper or on a sheet with the clock circle
already drawn on the page. After the patient puts the
numbers on the clock face, ask him or her to draw the
hands of the clock to read a specific time.
3. Ask the patient to repeat the 3 previously stated words.

Scoring
Give 1 point for each recalled word after the clock drawing test
(CDT) distractor.
Patients recalling none of the three words are classified as
demented (Score = 0).
Patients recalling all three words are classified as nondemented
(Score = 3).