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Care for the elderly

Care for the elderly. Merck Manual of Geriatrics. Comprehensive Geriatric Assessment. Fractures in the Elderly. PATHOPHYSIOLOGY. Osteoporosis Remodeling does not occur in trabecular bone, therefore metaphysis is prone to fracture Pathologic Fractures Decreased muscle mass

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Care for the elderly

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  1. Care for the elderly

  2. Merck Manual of Geriatrics. Comprehensive Geriatric Assessment

  3. Fractures in the Elderly PATHOPHYSIOLOGY • Osteoporosis • Remodeling does not occur in trabecular bone, therefore metaphysis is prone to fracture • Pathologic Fractures • Decreased muscle mass • Postural changes • Decreased vibration sense and proprioception • Increased reaction time • Visuoperceptual decline • Impaired mobility

  4. Fractures in the Elderly PRIMARY PREVENTION SECONDARY PREVENTION • History and Physical Examination • FRAX and DEXA • Dietary modification and exercise regimen • Review of medications that may cause dizziness, syncope, etc • Regular eye exams • Safer home: • Slip guards and hand rails • Removing objects on floor • Storing items in easy to reach cabinets • Improve lighting in the home • Goal  rapid return to activities for independent living • Diagnosis • History and PE • X-ray • CT scan • Treatment • Immobilization • Surgical stabilization • Joint replacement National Center for Injury Prevention and Control  CDC Injury Center

  5. Fractures in the Elderly TERTIARY PREVENTION • Stiffness – daily active or passive ROM exercises of adjacent joints • Contractures – periodic changes in position • Swelling – elevation of limb • Pressure sores – daily inspection and padding of contact points • Functional impairment – gradual re-introduction of ADLs Merck Manual of Geriatrics. Fractures

  6. FRAX: WHO Fracture Assessment Tool

  7. Psychiatric Disorders Depression Somatoform Disorders

  8. Depression in the Elderly PRIMARY PREVENTION SECONDARY PREVENTION • History and Physical Examination • Diet and lifestyle modification • Taking medications correctly • Getting a pet • Maintain friendships • Develop hobbies and learning new skills • Review of prescription, OTC, and illicit drug and alcohol use • Ruling out organic cause • Treatment • Anti-depressant medications • Therapy: Supportive counseling, psychotherapy, Cognitive Behavioral Therapy, Support groups Merck Manual of Geriatrics. Psychiatric disorders

  9. Depression in the Elderly • Family members • Lack of enthusiasm and spontaneity • Loss of sense of humor • New forgetfulness • Caregivers • Anorexia • Sleep disturbances • Spouse • Loss of interest in sex

  10. Depression in the Elderly TERTIARY PREVENTION • Rule of Thirds • 1/3 get better and stay better • 1/3 get better but relapse • 1/3 do not improve or improve only marginally • Most elderly patients recover in late life but may take months • Prognosis is worse when complicated by disorder Merck Manual of Geriatrics. Psychiatric disorders

  11. Somatoform disorders “… group of disorders characterized by physical symptoms suggesting a medical disorder… represent a psychiatric condition because the physical symptoms present in the disorder cannot be fully explained by a medical disorder, substance use, or another mental disorder” • Differs from Malingering, in which disease is feigned for material gain and Factitious Disorder, wherein disease is feigned to occupy sick role  Both are rare in the elderly

  12. Somatoform disorders • Somatization • <0.2-1% of elderly patient • Increasing dependence of patients on care providers • Pain symptoms in 4 different locations, 2 GI symptoms, 1 sexual/reproductive symptom, 1 neurologic symptom • Undifferentiated Somatoform • 3-5% of elderly patients • Physical symptoms that persist for 6 months without objective evidence • Usual symptoms: chronic fatigue, appetite loss, abdominal pain, and GU symptoms • Hypochondriasis • unexplained physical symptoms related to fear of a specific medical condition • patient's misinterpretation of normal bodily processes or functions ( borborygmi, abdominal bloating and crampy discomfort, sweating, sneezing)

  13. Somatoform disorders Treatment “supportive relationship with a sympathetic health care provider is the most important aspect of treatment” • Fixed examinations with specific appointment times • Avoidance of consultation outside of scheduled appointment • Avoidance of referral to specialists • Protection of patient from unnecessary diagnostic procedures • Cognitive therapy and group therapy

  14. Nutrition in the elderly • Important in patient’s functional status and global medical condition • Nutritional deficiencies can lead to susceptibility to infection and result in poor wound healing • Malnutrition can lead to osteoporosis, diabetes, cardiovascular disease and anemia Geriatric Rehabilitation eMedicine Physical Medicine and Rehabilitation

  15. Physiologic factors in aging • Reduced metabolic requirements • Decreased total body protein level • Decreased total body water • Decreased BMD • Decreased taste and smell sensation • diminished levels of neurotransmitters that increase appetite, and early satiety Geriatric Rehabilitation eMedicine Physical Medicine and Rehabilitation

  16. Assessment of malnutrition Involves obtaining the following information: • Height and weight • consistency of the diet • number of skipped meals • alcohol use • use of nutritional supplements • use of vitamin supplements • use of medications that affect appetite or nutrients, and food preferences to improve caloric intake.

  17. Energy requirements in the elderly • Recommended daily intake 25-35kcal/kg • 20-30g daily fiber

  18. Treatment of malnutrition • Use of lactose free oral and enteral products that are well tolerated (unwanted side effect: diarrhea) • products should provide: • high protein levels • water, electrolytes • calorie supplementation Examples: oral low-residue formulas (eg Ensure), oral clear liquids (eg, Resource), diabetic formulas (eg, Choice DM, Glucerna), enteral low residue formulas (eg, Osmolite, Nutren), and enteral high-fiber formulas (eg, Jevity)

  19. MNA

  20. Sensory impairment in the elderly • Auditory impairment • Physiologic process: presbycusis- due to degeneration of the organ of Corti • Initial Otoscopic examination • Hearing loss can be due to cerumen obstruction or neurological process • Hearing loss can lead to difficulty in communication and decreased quality of life • Treatment: hearing aids

  21. Visual impairment • Physiologic process: presbyopia -gradual loss of the ability to focus on near objects • 92% of 75yr olds have presbyopia • Cataract formation (lens opacity) occurs to some degree in 95% of people > 65 years. • Ophthalmologic consult: >65years old twice a year • associated with increased physical disability, increased social isolation, low employment rates, reduced self-image, and depression

  22. Treatment of visual impairment: • Eyeglasses • Surgery

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