geriatric medicine

2. Dr. Safaa Hussein Ali
Lecturer of geriatric medicine
Ain Shams university
Cairo – Egypt
Senior registrar of geriatric medicine
Prince Mansour military hospital
Taif-KSA

3. Definition of Ageing
“The processes that occur during life which culminate in changes that
decrease an individual's ability to cope with biological changes”.
GERIATRICS: - A branch of medicine dealing exclusively with the problems of
ageing and the diseases of the elderly. It is derived from the Greek root ―ger-
gero- geronto‖ meaning SYNONYMS OF AGEING:
―old age‖ or ―the aged‖.
Senescence: is the process by which the capacity for cell division, growth and
function is lost over time, ultimately leading to an incompatibility with life i.e., the
process of senescence terminates in death.
Senility: This term is from the Latin origin ‗senilitus‘, which means the period of
physical and mental deterioration, associated with old age.
Senium: Identical to the term senility, one more term senium is also used in the
medical field; it is marked by the deterioration and weakness that may
accompany the age advancement.
Geria: This also indicates the old age.

4. CLASSIFICATION OF AGE
AGE
Chronological age - Psychological age –
Biological age – age
number of years age how
by body function
lived individuals feels it
CHRONOLOGICAL CATEGORIES
•Young-Old - (ages 65 - 74) Set Old Age
•Middle-Old - (ages 75 - 84) Old Old Age
•Old-Old - (age 85 and older) Ripe Old Age

5.  Greek word ―geros‖ mean the old age + Iatric
mean the medical treatment. This is the branch
of medicine concerned with the problems of
Ageing, including physiological, pathological,
and psychological problems.
 Nascher was the first to coin the term
Geriatrics. He published a paper in New York
medical journal in1909 and a textbook on it in
1914.
 Thus Geriatric came to be recognized as a
special branch in first decade of 20th century.

6.  Hippocrates noted conditions common in later life
 Aristotle offered theory of ageing based on loss of heat
 The word geriatrics was invented by Ignatz L. Nascher, a
vienna born immigrant to the united states
 Geriatric medicine was a product of the British NHS
 Nascher was the father of geriatrics and Majory Warren was
its Mother
 The 1st Geriatric service was started in U.K in 1947.
 Geriatric department at GH, Chennai was established in 1978.
 Post Graduate course in Geriatric medicine has been started
in 1996 at Madras medical college.

7.  Invented term ―geriatrics‖
 Two ancient Greek words
 “Geras” (Old-Age)
 ―Iatricos‖ (Relating to the physician)
 ―There should be a separate speciality to deal with
problems of senility‖
 Although conceived and named in US, geriatrics was
first fully practiced in UK..

8.  that branch of internal medicine which deals
with the prevention, diagnosis and treatment of
diseases specific to old age‖.

9.  The study of physical and psychological
changes that occur in old age is called
―gerontology‖.
 Geriatrics is the branch of general medicine
concerned with clinical, preventive, medical
and social aspects of illness in the elderly.
 The old age is defined as the age of
retirement. In our country it is fixed at 60
years and above.

11.  Reduced beds from 714 to 240 and increased
turnover 300%!
 Spare beds then used for TB/Chest Medicine
 Gifted advocate, innovator educator, mentor and
teacher
 Attracted interest from health minister when discharge
rate reached 25%‖!
 Published 27 papers in the 1940s and 50s on
rehabilitation and assessment of frail older people
 Most famously…
 Warren MW. Care of chronic sick. A case for treating
chronic sick in blocks in a general hospital. BMJ
1943;ii:822–3. BMJ 1943
 Warren MW. Care of the chronic aged sick. Lancet
1946;i:841–3.

12.  Advocated ―the speciality of Geriatric Medicine for medical
management, rehabilitation and long term care of older people.‖
 UCH (1st geriatric unit in London teaching hospital)
 Worked with Lord Amulree (later civil servant)
 First English Professor of Geriatric Medicine
 Worked with Doreen Norton, the first professor of gerontological
nursing (Norton Scale)
 Earlier discharges created beds for other specialities and high
profile attracted students and interest from government
 Founded first memory clinic
 Pioneered early ripple mattresses
 Research interests in previously neglected clinical areas

13.  Lionel Cosin
 General surgeon (war casualties)
 Originator of the geriatric day hospital (Oxford) 1957
 Pioneer of orthogeriatrics and rehabilitation..
 Responsibility for 300 ―chronic sick‖ beds.
 Admitted patients thought to require ―permanent care‖ after hip fracture
 Operated then started early rehabilitation with the help of a
physiotherapist, and many were discharged.
 Bobby Irvine
 Worked in Hastings with orthopaedic surgeon (who recognised his own lack
of specialist knowledge)
 Established world famous orthogeriatric unit widely studied as an example
 Operated on even the frailest patients
 Mobilised them
 ―The first step in rehabilitation is the first step‖

14.  Pioneers and Innovators
 From variety of clinical backgrounds ,
commitment and interest is what counts
 Challenging assumptions (―that‘s the way
we‘ve always done things)
 Challenging ageism/therapeutic nihilism
 Publishing and publicising
 Developing evidence base
 Mentorship, teaching, role models
 Spreading good practice to other units by
example and training

15.  Showing the benefits of geriatrics to the whole
system
 Once people see what you can do they can be
―won over‖ and usually want more
 Getting politicians and civil servants on board
 Alliances with other professions and
organisations (strength in numbers)
 Put the patients first in your arguments….(not
the profession)

16.  Awareness of atypical/ non-specific presentation of
acute illness in old age.
 Whole person approach to older people with co-
morbidity and complex disability.
 MDT team working and CGA
 Central importance of rehab.
 Recognition of caregivers‘ stress; respite care.
 The teaching of geriatric medicine to medical
undergraduates.

17.  General medical and geriatric facilities to be integrated.
 Posts for general physicians with an interest in geriatrics
 Multidisciplinary approach to elderly care.
 Undergrad/postgrad training in elderly care for every doctor.
 Elderly medicine to become component of MRCP syllabus.
 Increased involvement of general practitioners in the medicine
of old age.
 Local authority residential care review.
 Review of elderly mental health services.

18.  Increase in provision of complex social care at home
 More stroke units
 More falls clinics and services
 More Intermediate Care places
 Less overt age discrimination
 ―Spin off‖ benefits for older people from other targets
 But services still not ―fit for purpose‖ or ―age-proof‖
 Breaches of Dignity and deep-seated negative attitudes to
older people still common
 Skills, training and knowledge lacking
 General hospital care just as problematic
 Very few people actually receiving appropriate falls and OP
treatment
 Many people still not getting to stroke units
 Single assessment process rarely implemented

19.  DH want old people out of hospital and in ―community‖
 (But to what alternative services?)
 But UK geriatrics has become largely hospital-based
 So now we must persuade primary care organisations to
buy our services or take over the running of some
―intermediate care‖
 Many aren‘t interested – despite the evidence-base for
CGA etc
 There is little in the GP performance framework about
geriatrics
 But a perception from some GPs that geriatrics is ―easy‖
and its ―what GPs do anyway‖ .It doesn‘t need specialist
training or a separate speciality

20.  Service frameworks around older people
not funded
 Main performance targets for hospitals do
not focus on acute/subacute frail complex
older patients
 More around waiting lists and waiting times
 Payment systems mean that hospitals make
money from elective surgery and lose
money from acute unscheduled care
 So older people in beds are generally a
―problem‖ for the system rather than being
seen as the main customers!

21.  Negative societal and media attitudes to older people
 Most students, doctors and nurses still say they don‘t want to work
with old people (though that will be their job!)
 Negative attitudes to doctors/nurses who work with older people
 Medical values still favour ―high-tech‖ treatment, curative,
individualistic and basic science over…
 …low tech, long term incurable conditions, health services research
and multidisciplinarity
 Working with dementia, incontinence, falls or frailty isn‘t ―sexy‖
 Little private practice income in geriatrics
 Patients with legitimate and treatable medical illness still labelled as
having ―social admissions‖ or ―acopia‖ or ―bed blocking‖
 Older people themselves often do not wish to be on specialist wards
for older people and may not see themselves as old.
 Many professionals still don‘t see the need for a separate speciality

22.  ―Mainstream doctors are turned off by geriatrics,
because they do not have the faculties to cope with the
Old Crock. The Old Crock is deaf. The Old Crock has
poor vision. The Old Crock’s memory is impaired. With
the Old Crock, you have to slow down because he asks
you to repeat what you are saying. And the Old Crock
doesn’t just have a chief complaint—the Old Crock has
fifteen chief complaints. How in the world are you going
to cope with all of them? You’re overwhelmed. Besides,
he’s had a number of these things for fifty years or so.
You’re not going to cure something he’s had for fifty
years. He has high blood pressure. He has diabetes. He
has arthritis. There’s nothing glamorous about taking
care of any of those things.‖...

24.  Many general physicians questioned need
for separate specialty
 Considered inferior specialty for third rate
doctors who could not ―make the grade‖
elsewhere.
 Negative, disdainful attitudes from doctors
in training
 Medical students generally not inspired by
the image of geriatrics.

25.  MDT case conference.
 Geriatric day hospital.
 But
 Domiciliary visits requested by  Geriatrics more and more
GP
hospital based
 Community geriatrics.  Only 14% consultants
 Outreach clinics in general with dedicated
practitioner surgeries. community or long stay
care involvement
 Old age psychiatry.
 And increasingly involved
 Ortho-geriatric liaison. in acute general internal
 Stroke rehabilitation units and medicine
services.  Stroke becoming a
 Specialty clinics—for separate speciality with
example, falls, parkinsonism, st more acute focus
roke.
 Rapid assessment clinics.

27.  1980- 5.3%
 2000- 7.7%
 2025- 13.3% ( 1.2 billion )
 71% - Developing World

29.  Older people are the main customers of health
and social care
 Demographic change means this will continue
 So older patients with frailty, multiple long-term
conditions and disability, needing CGA
multidisciplinary input will continue to be central to
health care (not marginal)
 There is plenty of evidence for interventions
 If we apply them, both patients and the whole
system will benefit so win/win
(quality, access, capacity, cost)
 These might be the right arguments BUT…we
have to be more outspoken and unreasonable in
making this case

30.  80% GP consultations
 80% hospital days
 70% admissions
 70% health spending
 95% spending on 65+ population
 10% of inpatients account for 55% bed days
and 5% account for 40% of bed days
 Evercare Pilots, Case Management and
Community Matrons…

31.  Falls: 30% of over 65s per annum will fall. Falls
are 7th commonest reason for hospital
admission and commonest reason for
emergency attendance in over 60s
 Fractures: 1 in 2 women and 1 in 12 men or
200,000 p.a UK.
 Incontinence: 24% of >65s, 40-60% in
institutions
 Dementia: (e.g. 40% of long term care. 20%
emergency admissions >65)
 Delirium: 11-40% prevalence in hospital >65s
(often unrecognised)
 Stroke: 150,000 per annum. 85% 65, usuall
multiple co-morbidity

32. Confusion Pressure
sores
Falls
Geriatric
Vision
Giants
Immobility
Falls Hearing
Depression Incontinence

33. “Frailty is a failure to integrate responses in the
face of stress. This is why diseases manifest
themselves as the “geriatric giants”….functions
…such as staying upright, maintaining balance
and walking are more likely to fail, resulting in
falls, immobility or delirium‖
Rockwood Age Ageing 2004
i.e. Poor Functional Reserve

35.  3 or more of 5 criteria
 6.7% of community residing elderly
 3 year incidence —7%
 Increases with age: 3%-65; 26% -85-89
Fried L, et al J Gerontol Med Sci 2001: 560: M146-M156

37.  90,000 hip fractures per annum
 50% injury admissions and 66% of bed days from
injury in the NHS
 Median Age 81 years
 Falls, ostepporosis, multiple co-morbidity,
cognition, nutrition, confusion, intercurrent illness,
polypharmacy
 Following hip fracture high mortality, morbidity,
dependence
 Are Systems designed around needs?
 Are orthopaedic surgeons the right people to care
for them?
 Could outcomes be improved?
 What system would we design in an ―ideal world‖

38.  In-patient comprehensive geriatric assessment (CGA) may
reduce short-term mortality, increase the chances of living at
home at 1 year and improve physical and cognitive function.
 20 RCTs (10 427 participants) of in-patient CGA.
 Newer data confirm the benefit of in-patient CGA, increasing
the chance of patients living at home in the long term.
 For every 100 patients undergoing CGA, 3 more will be alive
and in their own homes compared with usual care [95%
confidence interval (CI) 1–6]. Most of the benefit was seen for
ward-based management units
 CGA does not reduce long-term mortality.
 This evidence should inform future service developments.

39.  ―a multi-dimensional, interdisciplinary,
diagnostic process to determine the medical,
psychological and functional capabilities of a
frail older person in order to develop a co-
ordinated and integrated plan for treatment and
long term follow up‖
Stuck et al Lancet 1994
 ―Applying CGA especially to patients with
frailty, functional impairment and multiple long
term conditions is what best defines what we
do as geriatricians‖
Rockwood K Age Ageing 2004

40. 10 RCTs.
1586 stroke patients were included; 766
were allocated to a stroke unit and 820 to
general wards.
The odds ratio (stroke unit vs general
wards) for mortality within the first 4
months (median follow-up 3 months) after
the stroke was 0.72 (95% CI 0.56-0.92),
consistent with a reduction in mortality of
28% (2p < 0.01). This reduction persisted
(odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05)
when calculated for mortality during the
first 12 months.

41.  ―studies investigating such interventions in
medical patients and those who have had
hip fracture have reported significant
reductions (of about a third) in incidence of
delirium and/or reduced severity and
duration of delirium‖

42.  Individually targeted, falls 31%
 Postural hypotension
 Sedative medications
 Use of ≥4 medications
 Transfer skills, grab bars
 Environmental hazards
 Gait training, assistive device
 Balance exercises, exercises against resistance
 Cost saving in higher risk group (4 of 8 risk factors)

43.  Referred from A & E
 Clinic based assessment and referral:
 Postural hypotension
 Visual acuity
 Balance
 Cognition
 Depression
 Carotid sinus studies
 Medication
 Home safety assessment and advice
 Falls 61%, cost neutral

44.  If we can get people to listen to the
arguments and respect the evidence
 Remember the data from Marjory Warren
1946 (714 beds down to 204)?
 Replicated by Adams in Belfast
 Or from Dr Bagnall in Leeds 1976 (40%
reduction in length of stay for older patients
on needs based unit)
 The benefits for the whole system are just
as relevant 60 years on
 E.g. recent ―real-life‖ examples from St
Thomas‘ hospital

45.  ―all progress is achieved by the actions of
the unreasonable man‖ (George Bernard
Shaw)

46.  They may not see themselves as frail
 Or old
 And may be reluctant to see specialists in
elderly care
 Or be admitted to elderly care wards
 We have to ―sell‖ it to them in the right way
 (i.e. more rehabilitation, experts in the
conditions they are suffering from, better
chance of getting home and staying there etc)

48.  Negative attitudes towards older people
persist
 Insufficient education and training for staff
 Routine breaches of dignity e.g.
 Respect for personhood
 Communication
 Confidentiality
 Privacy
 Toileting/Continence
 Nutrition
 End of life care

50.  And your health system…
 Culture and patient expectations
 System incentives
 Primary care and social services are different
 But…
 You do have a rapidly ageing population
 You do have state funded health care with
means tested social care
 You have recognised the health challenges of
the ageing population
 You are beginning to train geriatricians of the
future

51. • Multiple diseases and multiple drugs.
• Diseases often chronic, progressive with adverse
consequences. Focus on functional independence
• Prevention is more productive and rewarding
• Disease profile influenced by socioeconomic &
emotional status
• Symptoms may be silent: no pain in MI, no fever in
infection or may be atypical & unrelated. Weak link
organ symptoms: confusion, incontinence, faints,
falls, depression, heart failure-Geriatric Syndromes
• Features like reduced jerks, bacteriuria, IGT
common

52.  Do not be an ageist
 Have patience in history taking
 Optimize communication
 Make the patient safe & comfortable
 Get a full medication list
 Assess family‘s cooperation & attitude
 Assess care giver‘s stress

53. 􀃍 Waste Accumulation Theory
􀃍 Limited Number of Cell Divisions Theory
􀃍 Hay flick Limit Theory
􀃍 Death Hormone Theory (DECO)
􀃍 Thymic -Stimulating Theory
􀃍 Mitochondrial Theory
􀃍 Errors and Repairs Theory
􀃍 Redundant DNA Theory
􀃍 Cross-Linkage Theory
􀃍 Autoimmune Theory
􀃍 Caloric Restriction Theory
􀃍 Gene Mutation Theory
􀃍 The Rate of Living Theory
􀃍 Order to Disorder Theory
􀃍 The Telomerase Theory of Ageing
􀃍 Neuro Endocrine theory or Weak Link Theory
􀃍 Free Radical Theory of Ageing
53

54. FREE RADICAL THEORY
"Free radical" is a term used to describe any molecule that differs from
conventional molecules in that it possesses a free electron, a property that makes
it react with other molecules in highly volatile and destructive ways. The changes
induced by free radicals are believed to be a major cause of Ageing, disease
development or/and death

55. EFFECT OF FREE RADICAL DAMAGE

56. 56

57. 57

58. 58

59. 59

60. Selected Age-related Changes and their
Consequences
60

61. 1. Deprenyl
2. Human Growth Hormone
3. DHEA
4. Melatonin
5. Acetyl-L-Car nitine
6. Coenzyme Q10
7. Alpha Lipoic Acid
8. Cysteine and Procysteine
9. NADH
10. Lycopene
11. Vitamin E
12. Vitamin B5 (Pantothenic Acid)
13. Vitamin B6 (Pyridoxine)
14. Synthetic Antioxidants
15. Levodopa (L- Dopa)
16. Calorie Restriction
61

62. • Geriatric syndromes and conditions
• Diseases more common in older patients
• Psychosocial issues
• Disease prevention
• Ethical Issues
• Health Care Financing (Medicare)
• Cultural aspects of aging

63.  Dementia, delerium, depression
 common, not documented
 Inappropriate medications
 anticholinergic
 Gait and mobility impairment
 not documented
 Incontinence
 Iatrogenic complications
 constipation, pressure ulcers

64.  Dementia, Depression, Delerium
 Incontinence
 Osteoporosis
 Falls
 Hearing and vision impairment
 Sleep disorders
 Failure to thrive
 Iatrogenic (medications)

65.  Dementia, Depression, Delerium
 Cognitive screen, ask about depression, check
orientation and concentration (serial 7‘s)
 Delerium has variable orientation/concentration,
dementia doesn‘t
 Incontinence
 Stress, urge, overflow
 Stress – small volume; urge – larger volume
 Check for UTI with incontinence

66.  Osteoporosis
 Risk – asian > caucasian > AA/black
 Kyphosis on physical exam
 Dexa scan (femoral neck; L spine)
 Everyone gets 1000-1500 mg Ca + 400-800 IU Vit D
 Treatment: Alendronate > calcitonin; estrogen/reloxifene;
weight lifting
 Falls
 How many ―Any in past 6 months?‖
 What happened – ―trip, slip, drop‖
 Injury?
 Mandatory: test sensation, balance, GAIT (TUG test)

67.  Hearing and vision impairment
 Whisper test, check with glasses on
 Sleep disorders
 Normal aging – sleep cycles only 3-5 hours max
 Going to bed too early?
 ETOH; Tylenol PM?
 Depression/anxiety?
 Hot milk, read outside of bed, consider trazodone

68.  Failure to thrive
 ―Dwindling‖
 Weight loss
 Increased frailty
 Not able to live independently (without human
assistance)
 Check for cognition, mobility, medication side
effects
 Cancer?
 Consider hospice for refractory situation
(sometimes people get better with hospice!)

69.  Iatrogenic
 Medications
 Anticholinergics
 Narcotics - don‘t forget the laxative
 Stool softener alone will not be enough
 Antiarrhythmics
 Dilantin (nausea; vertigo)
 Neuroleptics
 PPIs – nausea, diarrhea; Aricept (diarrhea)
 Bed Rest (hospitalization)
 Rapid loss of muscle strength (>80 years: lose 1 ADL in 3-5
d)

70.  Neurologic (Parkinsons, stroke, TIA)
 Rheumatologic (RA, PMR, vasculitis)
 Genitourinary (BPH, sexual dysfunction)
 Cardiovascular (afib, CAD, CHF, HTN)
 Endocrine (hypothyroid, diabetes type II,
Paget‘s)
 Renal (HTN, fluid/lyte abnormalities)
 Infections (pneumonia, UTI, TB)
 Gastrointestinal (dysphagia, constipation, ‗tics)
 Oncologic (colon, breast, prostate,
hematologic)
 Psychiatric (depression, psychosis)

71. First rule of geriatrics
(similar to first rule of real estate sales)
―Function, Function, Function‖
Patients don‘t care about their
diagnoses, they care about their
function

72.  Maintenance of health in old age by
high levels of engagement and
avoidance of disease
 Early detection and appropriate
treatment of disease
 Maintenance of maximum
independence consistent with
irreversible disease and disability
 Sympathetic care and support during
terminal illness

73.  ―a multi-dimensional, interdisciplinary,
diagnostic process to determine the medical,
psychological and functional capabilities of a
frail older person in order to develop a co-
ordinated and integrated plan for treatment and
long term follow up‖
Stuck et al Lancet 1994
 ―Applying CGA especially to patients with
frailty, functional impairment and multiple long
term conditions is what best defines what we
do as geriatricians‖
Rockwood K Age Ageing 2004

74.  ADLs (Activities of Daily Living)
 IADLs (Independent Activities of Daily
Living)
 Mobility
 Incontinence
 Affect/Mood
 Cognition (Memory)

75. Test the following:
 Mobility – Timed Up and Go test- stand,
walk, turn, sit
 Cognition – Mini-Cog (3 item recall) or
MMSE (Mini Mental Status Exam)
 Affect – Two question Depression screen

76.  ―Timed Up and Go was 15 seconds, patient
walked slowly, unsteady, had to hold rail for
support‖
 ―Two question depression screen positive‖
 ―Patient only remembered 2 of 3 items on
Mini-Cog‖

77.  Diagnosis belongs in the ―Impression/Plan‖ section
 BUT….
 Rule #1: Avoid the trap of ―premature labeling‖

Problem 1. ―Falls‖ – (list the differential here)
 Not Problem 1. ―Probable spinal stenosis‖
 Or Problem 1. ―Musculoskeletal System‖

78.  Rule #2:
 You can start addressing functional
impairments without having a specific
diagnosis
 Patients appreciate a practical plan
 Home safety, mobility aids, social supports

79. Back to First rule of History and Physical Examination
….
―To prevent it, you have to document it‖
Learn about primary and secondary prevention
screening that maximizes function and minimizes
future impairment
Keep current about age-associated recommendations
for tertiary prevention (―treatment‖)

80.  Learn about cultural influences on health behavior
DNR, family involvement
 Learn about stressors that affect patients and
families
Caregiver stress, finances
 Know what resources are out there to help,Social
work (Turner clinic + other), types of assisted
living, medication assistance, Area Agency on
Aging, 3 day inpatient requirement for Medicare
payment of CNH!

81.  Ask the patient what THEY WANT TO DO
about their problem
 ―Do not assume your preference is their
preference!‖
 This will avoid more lawsuits than any other
intervention!

82.  Jenny Smith is an 83 year old woman with
hypertension and osteoporosis for which she is on
appropriate medication and follows a diet and
exercise program. Her doctor recently diagnosed
her with diabetes.
 She was initially treated with oral agents but now
has started taking insulin
 Jenny retired from her job as a high school English
teacher 15 years ago but keeps herself busy with
volunteer work as a tutor, church activities and
exercise classes at the Y.
 Jenny was widowed 5 years ago. She has 2 grown
daughters – one lives near her on the Upper West
Side, the other lives in California but calls
frequently.

83.  Visual impairment affects 20-30% of people over
the age of 75.
 Visual impairments that occur with greater
frequency as people age include
 Refractive error
 Cataracts
 Glaucoma
 Macular degeneration
 Diabetic retinopathy
 Blindness

89.  How could a fall interfere with Jenny‘s
ability to monitor and treat her diabetes?
 What other aspects of Jenny‘s life could be
affected by gait disturbance or a fall?
 What are some of the barriers to diagnosis
and treatment of gait abnormalities and falls
risk in the elderly?
 What roles can the different members of the
interdisciplinary team play help Jenny to
address her recent fall so that it does not
lead to additional functional decline?

90.  Gait disorders are common in the elderly
 At least 20% of community dwelling seniors
report gait problems requiring assistance
 In one study, >50% of those 85 and older
reported difficulty walking
 The presence of a gait disorder often heralds
functional decline
 The etiology of gait disorders is usually
multifactorial

91.  Falls
 30-40% of community dwelling seniors fall each year
 Falls often result in decreased independence
 Decreased functional status
 Increased rate of NH placement
 Increased use of medical services
 Increased fear of falling
 Falls result in injury and death
 Most result in soft tissue injury, 10-15% in fracture
 Complications from falls are the leading cause of death from
injury among those >65
 Death rate from falls increases with age
 Lifetime cost of falls related injuries for those >65 has been
estimated at $12.6 billion
 Etiology of falls multifactorial
 Includes medical, environmental, sensory and postural issues

97.  How could the development of dementia interfere
with Jenny‘s ability to monitor and treat her
diabetes?
 What other aspects of Jenny‘s life could be
affected by dementia?
 What are some of the barriers to diagnosis and
treatment of dementia in the elderly?
 How can the different members of the
interdisciplinary team help Jenny and her family in
addressing her dementia and maintaining
independence and function for as long as
possible?
 What are some of the key issues that need to be
addressed as she faces this progressively
debilitating and life limiting illness?
 If Jenny does not have dementia, what could she
do to try to prevent it?

98.  Alzheimer's Disease accounts for the vast
majority of dementias in the US
 Among people >65, the prevalence of AD is
6-8%
 Among people >85, the prevalence is 30%
 4 million people in the US currently suffer
from AD
 By 2040, AD patients will number 14 million

100.  Decreased quality of life for patient and family
 Loss of independence in ADLs and IADLs
 Need for supervision, outside caregivers
 Financial burdens on family and society
 Lost wages and direct costs for caregivers
 $100 billion spent annually in US on care
 Difficulties obtaining appropriate medical care
 Inability to give accurate history
 Inability to understand and follow directions and
medical regimens

101.  Dementia, in its early stages, is often
missed by medical professionals and
families
 Up to 50% of moderate dementias are
missed by physicians
 Patients can remain oriented to person,
place and time long after they have
developed serious impairments in other
areas of cognitive function

102.  Have a high index of suspicion
 Forgetfulness, getting lost, inability to follow
medical regimen, poor personal hygiene
 Use validated screening tools
 MMSE, animal naming test, clock drawing test
 Look for reversible causes of dementia
 B12 def, sensory def., depression, thyroid
disease
 Obtain history from other sources

105.  As the speciality grows you can begin to sub-
specialise and expand range of services and
outreach into other settings
 You must expect negative perceptions and
attacks and work hard to improve the ―image‖
of geriatrics and ―sell‖ it to potential recruits
and to colleagues in other specialities
 You need to think about the model of service
delivery (needs, age, integrated etc) and how it
fits with existing local services/facilities
 Be careful about being sucked into general
internal medicine so much that you neglect the
frail and the long-term

106.  Expect colleagues in other specialities (and even
 patients) to be hostile or not convinced. Don‘t let it
 worry you. We know we are right! You just need to sell the benefits
 Keep emphasising that older frailer people will be the main users of
health and social care – not a minority
 And that getting their care right will benefit the whole system
 You can be the solution to problems (and to other doctors who don‘t
really want to look after these patients)
 Keep emphasising the strong evidence base for much of what we do
 Grow the evidence base through your own research
 And keep good enough data to demonstrate the impact of your
service
 When people see what you can do they usually want more of your
service

107.  Geriatrics is a major part of healthcare so it
needs to be a major part of undergraduate
and postgraduate training for all adult
specialists – you cannot treat everyone
 You need to be a strong presence in the
medical schools
 So avoid research funding and performance
frameworks which prioritise basic science
over clinical and health services research

108.  You need to think about the model of care for service delivery
which makes most sense locally
 Primary care needs to focus more on the needs of older
people
 Generalists have advantages over super-specialisation for
complex patients with multiple illness – patients don‘t enjoy
being ―passed around‖ specialists with no overall co-
ordination
 But we have to convince patients themselves
 Finally, there is no point having targets or plans to improve
services without the right financial investment and
performance frameworks
 Perverse incentives in the system can make the care of older
people worse not better