Care of the Elderly
Seán Keenan
2022
,Disease in the Elderly and Frailty
Description
Advancing age is associated with increased risk of diseases and co-morbidities. Increasing complexity with normal
degeneration of the body with age can alter clinical presentations and make diagnosis more difficult. Frailty is a
common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among
older adults. Frailty is associated with weakness, decreased energy, lower activity, and in severe cases, unintended
weight loss. Frailty has been identified as a risk factor for the development of dementia.
Diseases in the Elderly
Presentation Gastrointestinal
- Key: Normal presentations can be altered in elderly - Constipation: Reduced gut motility + immobility
- Typical: Disease presents as expected - NB: Can increase risk of delirium
- Atypical: Features may be masked by altered cognition - Colon: Diverticular disease ➔ Diverticulitis
- Silent: Pt. has reduced awareness of sx + under-reports - Liver: ↓ Hepatic clearance ↑ risk of SE from drugs
- Complexity: Multiple pathologies can overlap Urinary
Cardiac - UTIs: Increased risk of urosepsis
- Arrythmia: AF is more common with advanced age - BPH: Urinary retention
- Ischaemia: Myocardial infarction - Incontinence: Overactive bladder
- Heart Failure: CCF; DCM Musculoskeletal
Neurological - OA: Cartilage degeneration ➔ Osteoarthritis
- Brain: Cerebral atrophy ➔ ↑ Haemorrhage risk - NB: Increased risk of CPPD
- NB: ICP increases less drastically due to less space - Deficiency: ↓ VitD ➔ Osteoporosis + Malaise
- Stroke: ↑ Risk of ischaemic + haemorrhagic stroke - Sarcopenia: Loss of skeletal m. with age
- Sleep: Circadian rhythm is altered ➔ Insomnia Endocrine
Sight and Hearing - Homeostasis: Hypothalamic-Pituitary axis degen.
- Sight: Presbyopia; ARMD; Glaucoma - NB: Dysregulation of temperature, appetite, etc
- Hearing: Presbyacusis; Vertigo ➔ Imbalance Haematological
Respiratory - AID: Abnormal immune fxn leads ↑ risk of AID
- Deformity: Kyphoscoliosis ➔ Restrictive disease - Marrow: Myelofibrosis; MDS; PCT
- Fibrosis: Pulmonary fibrosis
Screening Tools
Cognitive Occupational Therapy
- 4-AT: Delirium assessment (See Delirium notes) - Barthel Index: Evaluates dependency
- AMTS: 10 point Abbreviated Mental Test score - NB: Post-stroke
- MMSE: Cognitive assessment (see Alzheimer’s notes) Nutritional
- MoCA: Cognitive assessment (see Alzheimer’s notes) - MUST: Screens for malnutrition risk
Frailty
- PRISMA-7: > 3 indicates frailty
- Rockwood: Range of 1-9 (very fit ➔ terminally ill)
, Pathologies and Ageing
Ageing
Factors Affecting Ageing Rates of Ageing
- Types: Intrinsic (individual); Extrinsic (environmental) - Normal: ↔ Rate of ageing with population
- Genetic theory: Pre-determined; Telomere length - Retarded: ↓ Rate of ageing
- Error theory: Oxidative damage with time - Accelerated: ↑ Rate of ageing (Progeroid syn.)
- Environment: Diet (Calorie intake); Exercise; Lifestyle - DM: Mild ↑ in ageing (Glucose ↑ oxidative stress)
Hutchinson-Gilford Progeria
Description Presentation
- Inheritance: Autosomal dominant (sporadic) - Onset: Onset typically after first few years of life
- Genetics: Mutation in Lamin A gene ➔ Progerin - Sx: Beaked nose; Scleroderma-like skin; Alopecia
- Path: Progerin protein lodges in nuclear membrane + Prognosis
limits cell division; Poor DNA repair mechanisms - Lonafarnib: Extends survival
- NB: Sx associated with ageing manifest at early age - Px: Early-mid teens (90 % die of MI or stroke)
Bloom Syndrome
Description Presentation
- Incidence: 1:48k Ashkenazi Jews (⅓ of all cases) - Onset: Onset typically after first few years of life
- Inheritance: Autosomal recessive - Sx: Short stature; UV sensitivity; Red rash on cheeks
- Path: BLM gene Δ ➔ Impaired DNA repair Prognosis
- NB: 150-300x more likely to develop cancer - Px: ~25 years (CoD is usually cancer)
Werner’s Syndrome
Description Presentation
- Incidence: 1:100k in Japan; 1:1M worldwide - Onset: Typical onset is early 20s
- NB: 1:59k in North Sardinia (founder effect) - Sx: Beaked nose; Scleroderma-like skin; Alopecia
- Inheritance: Autosomal recessive Prognosis
- Path: WRN gene Δ ➔ Impaired DNA repair - Px: Late 40s-Early 50s (CoD usually CVS or Cancer)
Cockayne Syndrome
Description Presentation
- Incidence: 1:2M worldwide - Onset: Usually first year of life (type dependent)
- Inheritance: Autosomal recessive - Sx: ↓ Foetal size; Short stature; Microcephaly
- Path: CSA + CSB mutations ➔ Impaired DNA repair Prognosis
- Types: Multiple different types - Px: 10-20 YO (type C 40-50 YO)
Seán Keenan
2022
,Disease in the Elderly and Frailty
Description
Advancing age is associated with increased risk of diseases and co-morbidities. Increasing complexity with normal
degeneration of the body with age can alter clinical presentations and make diagnosis more difficult. Frailty is a
common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among
older adults. Frailty is associated with weakness, decreased energy, lower activity, and in severe cases, unintended
weight loss. Frailty has been identified as a risk factor for the development of dementia.
Diseases in the Elderly
Presentation Gastrointestinal
- Key: Normal presentations can be altered in elderly - Constipation: Reduced gut motility + immobility
- Typical: Disease presents as expected - NB: Can increase risk of delirium
- Atypical: Features may be masked by altered cognition - Colon: Diverticular disease ➔ Diverticulitis
- Silent: Pt. has reduced awareness of sx + under-reports - Liver: ↓ Hepatic clearance ↑ risk of SE from drugs
- Complexity: Multiple pathologies can overlap Urinary
Cardiac - UTIs: Increased risk of urosepsis
- Arrythmia: AF is more common with advanced age - BPH: Urinary retention
- Ischaemia: Myocardial infarction - Incontinence: Overactive bladder
- Heart Failure: CCF; DCM Musculoskeletal
Neurological - OA: Cartilage degeneration ➔ Osteoarthritis
- Brain: Cerebral atrophy ➔ ↑ Haemorrhage risk - NB: Increased risk of CPPD
- NB: ICP increases less drastically due to less space - Deficiency: ↓ VitD ➔ Osteoporosis + Malaise
- Stroke: ↑ Risk of ischaemic + haemorrhagic stroke - Sarcopenia: Loss of skeletal m. with age
- Sleep: Circadian rhythm is altered ➔ Insomnia Endocrine
Sight and Hearing - Homeostasis: Hypothalamic-Pituitary axis degen.
- Sight: Presbyopia; ARMD; Glaucoma - NB: Dysregulation of temperature, appetite, etc
- Hearing: Presbyacusis; Vertigo ➔ Imbalance Haematological
Respiratory - AID: Abnormal immune fxn leads ↑ risk of AID
- Deformity: Kyphoscoliosis ➔ Restrictive disease - Marrow: Myelofibrosis; MDS; PCT
- Fibrosis: Pulmonary fibrosis
Screening Tools
Cognitive Occupational Therapy
- 4-AT: Delirium assessment (See Delirium notes) - Barthel Index: Evaluates dependency
- AMTS: 10 point Abbreviated Mental Test score - NB: Post-stroke
- MMSE: Cognitive assessment (see Alzheimer’s notes) Nutritional
- MoCA: Cognitive assessment (see Alzheimer’s notes) - MUST: Screens for malnutrition risk
Frailty
- PRISMA-7: > 3 indicates frailty
- Rockwood: Range of 1-9 (very fit ➔ terminally ill)
, Pathologies and Ageing
Ageing
Factors Affecting Ageing Rates of Ageing
- Types: Intrinsic (individual); Extrinsic (environmental) - Normal: ↔ Rate of ageing with population
- Genetic theory: Pre-determined; Telomere length - Retarded: ↓ Rate of ageing
- Error theory: Oxidative damage with time - Accelerated: ↑ Rate of ageing (Progeroid syn.)
- Environment: Diet (Calorie intake); Exercise; Lifestyle - DM: Mild ↑ in ageing (Glucose ↑ oxidative stress)
Hutchinson-Gilford Progeria
Description Presentation
- Inheritance: Autosomal dominant (sporadic) - Onset: Onset typically after first few years of life
- Genetics: Mutation in Lamin A gene ➔ Progerin - Sx: Beaked nose; Scleroderma-like skin; Alopecia
- Path: Progerin protein lodges in nuclear membrane + Prognosis
limits cell division; Poor DNA repair mechanisms - Lonafarnib: Extends survival
- NB: Sx associated with ageing manifest at early age - Px: Early-mid teens (90 % die of MI or stroke)
Bloom Syndrome
Description Presentation
- Incidence: 1:48k Ashkenazi Jews (⅓ of all cases) - Onset: Onset typically after first few years of life
- Inheritance: Autosomal recessive - Sx: Short stature; UV sensitivity; Red rash on cheeks
- Path: BLM gene Δ ➔ Impaired DNA repair Prognosis
- NB: 150-300x more likely to develop cancer - Px: ~25 years (CoD is usually cancer)
Werner’s Syndrome
Description Presentation
- Incidence: 1:100k in Japan; 1:1M worldwide - Onset: Typical onset is early 20s
- NB: 1:59k in North Sardinia (founder effect) - Sx: Beaked nose; Scleroderma-like skin; Alopecia
- Inheritance: Autosomal recessive Prognosis
- Path: WRN gene Δ ➔ Impaired DNA repair - Px: Late 40s-Early 50s (CoD usually CVS or Cancer)
Cockayne Syndrome
Description Presentation
- Incidence: 1:2M worldwide - Onset: Usually first year of life (type dependent)
- Inheritance: Autosomal recessive - Sx: ↓ Foetal size; Short stature; Microcephaly
- Path: CSA + CSB mutations ➔ Impaired DNA repair Prognosis
- Types: Multiple different types - Px: 10-20 YO (type C 40-50 YO)
