Dr Md Ruhul Amin
Dept of Medicine
JRRMCH

Aging
 Aging is the progressive, universal decline first in
functional reserve and then in function that occurs in
organisms over time.
 Aging is heterogeneous.
 Aging is not a disease; however, the risk of developing
disease is increased.

Geriatric Syndromes
 Geriatric syndrome refers to a symptom presentation
that is common in older adults.
 Most are multifactorial in origin.

Geriatric giants
4 Geriatric giants : 4 I
 Immobility
 Instability(falls)
 Incontinence
 Intelectual impairment

commmon Geriatric problems
 Dementia and Delirium
 Fall
 Urinary Incontinence
 Pressure Ulcers- due to immobility

Dementia and Delirium
 Dementia is a syndrome of progressive decline in which
multiple intellectual abilities deteriorate, causing both
cognitive and functional impairment.
 Dementia is a state of chronic confusion.
 Delirium is an acute state of confusion. It is important to
differentiate delirium from dementia.

Dementia and Delirium cont…
 Both dementia and delirium are characterized by :
 Disorientation,
 Memory impairment,
 Paranoia,
 Hallucinations,
 Emotional lability,
 Sleep-wake cycle reversal.

Dementia and Delirium cont…
 Key features of delirium are:
 acute onset
 impaired attention
 altered level of consciousness.

care of a patient with dementia
 The main goals of care of a patient with dementia to
improve cognitive and physical functioning.
 key goal is to identify and treat reversible causes of
cognitive impairment such as :
 Infections
 Electrolyte abnormalities
 Vitamin deficiencies
 Thyroid disease
 Substance abuse
 Medication
 Psychiatric illnesses.

Falls
 Excludes falls occurring from seizure, stroke, syncope.
 Fall rates and risk of injury from falls increase with
age.
 Annually ~30% of community dwelling adults >65
years fall.
 While 50% of individuals >80 years fall.

Falls cont…
 Most falls are multifactorial
 Falling is sometimes a symptom of another disease,
such as:
 Infections
 Neurologic disorder
 Medication side effect
 Age-related physiologic changes

age-related physiologic changes
 Decreased proprioception,
 Increased postural sway,
 Declines in baroreflex sensitivity resulting in
orthostatic hypotension.

RISK FACTORS FOR FALLS
 Muscle weakness
 History of falls
 Gait or balance abnormality
 Use of a walking aid
 Visual impairment
 Arthritis
 Impaired activities of daily living

RISK FACTORS FOR FALLS
cont…
 Depression
 Cognitive impairment
 Age over 80 years
 Drugs:
 Polypharmacy (four or more drugs)
 Digoxin
 Diuretics
 Benzodiazepines ,phenothiazines,antidepressants
 Type I anti-arrhythmics

History of fall
 The evaluation of a fall should begin with a history :
 Circumstances at the time of the fall,
 Associated symptoms,
 Thorough medication review of both prescription and
over-the-counter medications.

physical examination of fall
 The physical examination should include
 postural vital signs,
 vision evaluation,
 gait and balance testing,
 musculoskeletal evaluation of joint stability and range of
motion.

environmental assessment of fall
 An environmental assessment of the patient's home
that can increase fall risk, such as:
 Loose carpets
 Poor lighting

Urinary Incontinence
 UI is a major problem for older adults
 Up to age 80 years, UI affects women twice as
commonly as men
 After age 80, both sexes are equally affected.

risk factor for ui
 Advanced age
 Functional impairment
 Dementia
 Obesity
 Smoking
 Affective disorder
 Constipation

Reversible Conditions Associated with Urinary Incontinence
driiipp
Delirium
Restricted mobility—illness, injury, gait disorder, restraint
Infection—acute, symptomatic urinary tract infection
Inflammation—atrophic vaginitis
Impaction—of feces
Polyuria—diabetes, caffeine intake, volume overload
Pharmaceuticals—diuretics, -adrenergic agonists or antagonists,
anticholinergic agents (psychotropics, antidepressants, anti-
Parkinsonians)

Urinary Incontinence
 Leaking of urine or urinary Incontinence occurs in
four ways.
 Stress incontinence,
 Urge incontinence,
 Mixed stress and urge incontinence,
 Overflow incontinence.

incontinence evaluation
 Measurement of postvoid residual (PVR) should be part of an
incontinence evaluation in all patients.
 Under sterile conditions, the patient's bladder is catheterized 5–
10 min after the patient has voided. Generally, a PVR > 200 mL
suggests detrusor underactivity or obstruction.
 The patient should be referred for further urologic evaluation.

Stress Incontinence
 Stress incontinence - urethral sphincter mechanisms
are inadequate to hold urine during bladder filling,
rare in men.
 leaking small amounts of urine during activities that
increase intraabdominal pressure, such as:
 coughing, laughing, sneezing, lifting, or standing up.

Stress incontinence cont…
 Stress test - can be performed by patient stand with a
full bladder and cough. The test is positive if urine
leakage coincides with the cough.

Stress incontinence cont…
 Common in women due to insufficient pelvic support,
causes:
 Childbearing
 Gynecologic surgery
 Decreased effects of estrogen on tissues of the lower
urinary tract.

Treatment Stress incontinence
 Surgical interventions are the most effective
treatments
 pelvic muscle exercises can be helpful
 Treatment failure is higher in patients who have two
or more leakages per day.

Urge incontinence UI
 Urge incontinence also known as detrusor overactivity
(DO), characterized by:
 Uninhibited bladder is the most common form of UI in
older adults.
 Urinary frequency and nocturnal incontinence are
common.

Urge incontinence UI
 Urge incontinence may be
 Idiopathic.
 Lesions of the central nervous system, stroke.
 Bladder irritation from infection, stones, or tumors.

treatment of urge incontinence
 Bladder retraining by encouraging the patient to void
every 2 h or based on the patient's symptom
frequency.
 The patient can also try urgency control. If no
incontinence for 2 days, the voiding interval can be
increased by 30–60 minutes until the patient is only
voiding every 3–4 h.

treatment of urge incontinence cont…
 The anticholinergic drugs
 oxybutinin and tolterodine
 Patients using tolterodine have a reduced risk of dry
mouth and fewer withdrawals due to side effects.

Mixed incontinence
 Mixed incontinence refers to UI where symptoms of
both stress and urge incontinence are present.

Overflow incontinence
 Overflow incontinence is due to either bladder outlet
obstruction or an atonic bladder.
 patients are Male, but rarely females.
 On physical examination, patients may have a palpable
distended bladder.

Overflow incontinence causes
MALE
 Prostatic hypertrophy,
 prostate cancer,
 Urethral strictures
FEMALE
 Cystocele.

Causes for both male and fermale
Detrusor atonicity or underactivity can be caused
by
 Spinal cord disease
 Autonomic neuropathy
 Diabetes
 Alcoholism
 Vitamin B12 deficiency
 Parkinson's disease
 Tabes dorsalis

treatment Overflow of incontinence
 Adrenergic blockers :
 Terazosin
 Doxazosin
 Tamulosin
 5-reductase inhibitor – Finasteride
 The diagnosis of functional incontinence- individuals who
have UI and have either cognitive or functional
impairments which limit their ability to toilet themselves.

Pressure Ulcers
 Pressure ulcers, also known as pressure sores, bedsores, or
decubitus ulcers, occur in older patients with reduced
mobility.
 A pressure ulcer occurs when increased pressure between
skin and a bony prominence produces tissue necrosis.
While pressure ulcers can occur anywhere,

Pressure Ulcers cont…
 80% of pressure ulcers occur over the heels, lateral
malleoli, sacrum, ischia, and greater trochanters.
 Osteomyelitis and sepsis are important, morbid
complications of pressure ulcers.

Pressure Ulcers

Pressure Ulcers cont…
 Repositioning patients at risk for developing pressure
ulcers every 2 hrs.
 Providing bedbound patients mattresses with
pressure-relieving capabilities are standard
interventions to prevent pressure ulcers.

skin
 The skin of elderly bruise esily called senile purpura.
 Some people have skin like trasparent tissue paper
described as Paparaceous skin especially back of the
hand and forearm.

Paparaceous skin and senile purura

Constipation
To prevent constipation:
1.Increase Fluid Intake
2. Daily Exercise
3. Increase fiber intake (e.g. fruits and vegetables)
Complications associated with constipation :
 Haemorrhoids
 Anal fissures
 Rectal prolapse
 Fecal impaction

Postural Hypotension (PH)
Measure to prevent PH
1.Get out of bed slowly and in stages.
2. Sleep with head of bed elevated several inches.
3. Daily fluid intake of 2 to 3 liters.
4. Avoid hot showers or baths, may cause venous
dilatation thereby, venous pooling.
5. Avoid straining at stool. This may cause fall of BP
warning signs of PH (e.g. dizziness, faintness, visual
disturbances)

Postural Hypotension (PH) cont…
6. Avoid bending down and suddenly standing up again.
7. Rest for 60 minutes after meals.
8. Avoid hyperventilation. This lowers the BP.
9. Exercise regimen must be recommended.
10. Use thigh-length elastic stockings to reduce venous
pooling.
11. Avoid prolonged standing.