1. Essential facts in Geriatric
Medicine
The Role of Geriatrician
Dr Asso Fariadoon Ali Amin (MRCP)
GIM and Care of Elderly specialist

2. Essential Facts in Geriatric Medicine
Main Objectives
• Statistics on Elderly
• Main features of Geriatric Medicine
• Facts about the life of Elderly in the UK and some
developing countries
• The implication of ageing on the world
• Physiological changes in Elderly.

3. Age structure of population
 UK 2001 census was 58,789,194 of that 18.7% above 65
 Rate of increase of over 65 is by 2.4%
 Currently in developed countries 165 million elderly ,
expected to increase to 265 million by 2025
 Sweden highest number ,followed by the UK, Italy, Belgium
and France
 Elderly before the 17th century in the UK ( Church and
charities), after the 17th century Poor Law Act, after 19th
century welfare service
 By 2063, the number of 60-74 increase by 50% and over 75
by 70%, while 15-44 decline by 8%.
 Life expectancy in 2004 was 81 for female and 76 for men
compared to 49 and 45

4. Developing Countries
 It is a false assumption that elderly people in developing are not a problem
because they are few.
 The rate of increase in the elderly population will be 15 times of that of
the UK in Colombia, the Philippines and Thailand)
 France took 115 years to double their 65+ ( 7-14%) between 1865-1980,
while China takes 2000-2027 to do the same
 Life expectancy at age of 65 is similar to the of developing countries
 Currently have 50% of the 65+ population , estimated to increase to 75%
in 2020.
 Problems with primitive, patchy health care, political instability , financial
problems , and uneven( World Trade Organisations)
Sex Developed Undeveloped
countries (years) countries (years)
Women 19 15
Men 16 12

5. India and Africa
• WHO ( Ageing in India 1999)
 Life expectancy increase between 1961-2000 for both male
and female by 3-4 years ( 15.2 for men and 16.4 for women)
 60-75% relies on the extended family
 State pension is $1.00/month
 Commonest cause of death is CHD, 60% hearing impairment,
11 million blind 80% cataract, 9M hypertension, 5M Diabetic,
4M mental health problems, 0.35 M malignancy.
 Africa:- Life expectancy is less ( Cause??) , e.g Botswana in
Zimbabwe

6. The implication of aging
 Healthcare
• Disabilities and multiple pathology
• Demand more need for health assistance and medical care
• More chronic diseases
• More attendance to A&E
• Longer stay
• More GP and primary care visit.
 Social support
• Residential, Nursing homes and sheltered accommodation
• More carers

7. The implication of aging
 Economy ( Commission on Global Ageing)
• Housing
• Transport
• Infrastructure and town planning
• Pension, employment, tax
 Ethical dilemmas
 Political power of elderly “ gray lobby”

8. Active ageing
 WHO recommendation for active aging
 Prevent premature death
 Reduce disabilities associated with chronic
diseases
 Ensure older people remain healthy
 Encourage older people to make productive
contribution to the economy
 Reduce the number requires costly medical
and care service.

9. Factors affecting active ageing
• Social factors- education/literacy/human rights/social
support/ prevention of violence.
• Personal factors- biology/genetics
• Health and social services- health promotion and
disease prevention
• Physical environment- housing urban/rural
• Economic
• Behavioural

10. Affect of the world changing on the ageing
population
• Global Warming and disasters
 France (2003), Gujarat ( 2001 ), Tsunami ( 2004), Kurdistan (1991)
• Global Poverty
• Loss of Wealth more expenses for heating, housing, food...
• Retirement

11. Characteristic of Aging in the UK
• Gender
• Ethnic mix, 12% below the age of 16, 2.5% at age of 65, and only 1%
at age of 85.
• Geographical distribution- migration to villages, towns, and seaside.
• Health status:- 60% of 65+ have multiple pathologies, 37% disabling.
• Living compassions:- (in 2003) 34% of women and 19% of 65-74
years where living alone. Above 75 60% women and 30% men . Ethnic
minorities less likely to live alone
• Institution:- only 4.5% ( Nursing Homes, Residential homes), 95.5%
lives at their home including sheltered flats.

12. Physiological/psychological changes
with ageing
 Skin ( physical)
• Fine wrinkles, Dryness, Laxity
• Campbell de-Morgan, seborrhoeic keratosis, cherry
haemangioma
• Greying of hair due to loss of melanin from hair follicle
• Brittle slow-grow nails
o Histological
• Atrophy of epidermis
• Reduced melanocytes, Langerhans, Mast cells,
• Reduced in function and number of sweat gland
• Thickened blood vessels

14. Physiological/psychological changes
with ageing
 Gastrointestinal tract
 Mouth
 Reduced production of saliva
 Impaired muscles of mastication
 Tooth loss.
 Decrease in taste bud decrease in taste sensation.
 Decline in sense of smell.
 Enlargement of tongue and atrophic changes in jaw.
 Upper GI tract
 Pharyngeal muscle
 Oesophageal peristalsis and lower oesophageal sphincter
 Achlorydria

15. Physiological/psychological changes
with ageing
 Small bowel- shortening and broadening of villi
 Large Bowel
• Atrophy of mucosa
• Cell infiltration of lamina propria reduced motility and increase
• Hypertrophy of lamina muscularis transit time
• Increase in connective tissue
• Liver – reduced in volume , blood flow, and fall in liver collagen
and ascorbic acid reduce in hepatic drug metabolism but
normal LFT
• Gall Bladder- hypertrophy of muscle and elasticity of wall may reduce
• Pancreas- Deposition of amyloid , reduce lipase but no change in
amylase or bicarbonate, Duct hyperplasia Reduce fat absorption

16. Physiological/psychological changes
with ageing
 Kidney:-
• Size and weight of kidney
• reduced in number and size of nephrones reduced
• reduces in number of glomeruli and more sclerotic glomeruli GFR
• Loss of lobulation of glomerular tuft with thickening of membrane
• Degenerative changes in tubules
 Bladder , more trabeculation and pseudodiverticula, reduce capacity,
alteration in vasularity for submucosa ( increase risk of UTI)
 Bone – thinning trabeculae due to increased osteoclastic activity
 Heart
• Loss of myocytes in ventricle
• Increase in interstitial fibrosis and collagen result in LV stiffness
• Deposition of amyloid mainly in atria
• increase left atrial size
• Thickening of endocardium and valve
• reduction in pacemaker cella in SA nodes

17. Physiological/psychological changes
with ageing
o Blood vessels:- thickening of smooth muscle in arterial wall lead to
peripheral stiffness causing increase in systolic BP and widening of pulse
pressure.
 Respiratory
• Reduction in no of glandular epithelial cells mucosa
secretion
• Respiratory muscles
• ossification of costal cartilage
• Thinning of alveoli
• small increase in TLC , large increase in RV and fall in FEV1,VC, and
FEV1/VC ratio

18. Physiological/psychological changes
with ageing
• Brian:- brain weight, gyri, meninges, nerve cell numbers changes
• Hearing:- loss hair and ganglion cells in choclea, decrease average
numbers of fibres in cochlear nerve. Presbyacusis ( loss of
hearing for high frequencies)
• Eyes
 flatter cornea leading to astigmatism
 hardening of lens and iris
 floaters in vitreous humour
 reduced response from ciliary muscle impaired near vision and
 eyelid changes in muscle and skin astigmatism
 slow response of pupils to light

19. Physiological/psychological changes
with ageing
 Body temperature:-
• Inability to maintain temperature through thermo genesis.
• impaired sweating, and cutaneous vasoconstriction Hypothermia
• Impaired perception to low temperature.
 Hormonal
• Insulin, oestrogen, LH/FSH, GH, Thyroid, PTH
 Psychological
• Memory, intelligence, personality.

20. Specific features of disease
presentation
 NAMES
N:- non specific presentation
A:- a typical or uncommon presentation
M:-multiple pathologies
E:- Erroneous attribution of symptoms in old age
S:- Single illness leading to catastrophic
consequences.

21. Non specific presentation
 Described as the Dragon by Dr Trevor Howell, and the giants
of geriatric by professor Bernard Isaac. Recently geriatricians
using Is.

22. Consequences of single pathology
Bed Nursing
Falls sore care
#
Death NOF immobi Incontinence
lity

23. Pharmacology and Elderly
 Drug related illness is a significant problem in the elderly.
 5-17% of hospital admissions are caused by adverse reaction
to medicine. The risk of adverse reaction to medication
increases with age and the number of drugs prescribed.
 Several mechanism or changes may account for this
,including:-
• Alteration of pharmacokinetic and pharmacodyanamic
• Increased sensitivity of diseases tissue to medication
• Drug interaction
• Compliance
• In appropriate prescription of medication without consideration for non
medical management, or prescribing medication causing side effect or
interacting with other medication.

24. Alteration of pharmacokinetic and
pharmacodyanamic
 Renal clearance
 Hepatic metabolism
 Absorption is un changed
 Volume distribution. Fat soluble versus water soluble.
 alteration or receptors response

25. Compliance
 Poor compliance in 40-75% of patients:-
• acutely ill patient can take more than prescribed dose thinking it will
speed the process of getting better
• Forgetting because of too many medication. 25% of older patient take at
least three medication. Discharged patient can be on as many as 8
medication.
• Discontinuation happens in as many as 40% of medication usually first
year.
• 10% can take medication of others and 20% non prescribed medication.

26. Clinical Assessment
 Making a clinical diagnosis by:-
 Taking history from patient and others. who?
 Examination
• General examination and vital signs
• CVS, Respiratory, Abdomen, CNS, PNS, Musculoskeletal ands function.
• Investigation FBC, U&E, LFT, TFT, Glucose, Lipid profile, Ca/PO4,
CXR, ECG, Urinalysis.
 Medication review
 Cognitive function and consciousness GCS, AMTS, MMSE.
 Functional assessment
 Social circumstances
 Environmental
 Economic