Presentation of Disease in Older Adults Dr John S. Platt - PowerPoint PPT Presentation

Presentation of Disease in Older Adults Dr John S. Platt Consultant Physician in General Medicine and Medicine for the Elderly 28/2/13

The geriatrician’s role in care of older people • Unselected acute medical • Orthopaedic liaison admissions • Psychogeriatric liaison • Ward rounds and • Referrals from other multidisciplinary meetings departments • Outpatient clinics • Support of general • Stroke and TIA services medical wards • Falls service • Day hospital • Other specialist clinics eg • Domiciliary visits Parkinson’s disease, • Teaching and training memory , incontinence • Management

Leonardo da Vinci 1452-1519

Jeanne Calment 1875 -1997

Emma Freud re: father Clement Freud. Guardian 24/4/10 • He was 84 and hated being old. He was many stone overweight, his legs hurt constantly, he was slow and lame, and things were going on in the waterworks area with which I refused to engage. • For the last 10 years of his life he was actively waiting for his death.

Physical Ageing • Intrinsic age-related causes of cellular damage • Extrinsic causes of cellular damage over a long period of time : diet, tobacco, alcohol , excess / inadequate exercise, sunlight • Diseases : especially those of increased prevalence in old age, often multiple

Effects of ageing on function • Reduced functional capacity • Reduced ability to cope with challenges • Impaired homeostasis

Effects of ageing on physical function • Impaired homeostasis: • Increased sway hypothermia, dehydration • Impaired postural reflexes • Reduced immunity • Impaired kidney function: • Age related memory drug toxicity impairment • Reduced muscle strength • Increased brain sensitivity and bone mass to drugs and alcohol

Effects of ageing • Lean body ( fat free ) mass declines after 40yrs : reduced skeletal muscle ‘sarcopaenia’ • Fat mass increases : 25% - 41% between 25 and 75yrs in women • Vertebral bone loss begins at 3 rd decade in women accelerates after menopause, modified by diet, smoking, exercise and age of menopause

Succesful ageing -an 86 yr old lady

Effects of ageing on body temperature • Failure to cope with extremes • Reduced perception • Reduced behavioural responses • Lack of skin vasodilatation and sweating in heat • Lack of skin vasoconstriction and shivering in cold • Lack of response to pyrogens in infection

Frailty • Vulnerability to health state change following minor stressor events • Sarcopaenia, anorexia, osteoporosis, fatigue, risk of falls, poor physical health • Associated with adverse health outcomes including increased disability, admission to long term care and increased mortality • Interventions to limit progression have potential to prevent disability and improve general health and well-being

Fried frailty model • Weight loss : > 4.5kg or >=5%/yr • Exhaustion : self reported • Low energy expenditure : <383Kcal/wk male, <270Kcal/wk female • Slowness : standardised 15 foot walk times • Weakness : grip strength • 3 or more = frail : 8.5% women , 4% men aged 64-74 ( n 638 )

Ageing and Disease • The effects of disease far outweigh the effects of ageing • The aged are very heterogenous • Many diseases are of very high prevalence in old age and seldom seen in younger people • Multiple pathology is common • Older people may present with non-specific symptoms , in atypical ways or at a late stage of the disease

Geriatric Giants • Immobility • Instability • Incontinence • Intellectual impairment • … off legs, falls, incontinent, confused

Late presentation of disease • Low expectations of health ‘it’s just my age’ • Fear of hospitalisation , investigations, operation • Misinterpretation of significance of symptoms • Depression and dementia • Failure or ageism by health professionals • Atypical features

Atypical presentation of disease • No single disease dominates clinical picture • No single major symptom • One organ failure leads to another • Reduced pain perception – ‘silent presentations’ • As a social crisis

RAMPS • Reduced reserve • Atypical presentation of disease • Multiple pathology • Polypharmacy • Social isolation

Polypharmacy

Increased use of drugs with common and serious side effects eg warfarin

Delirium • Acute confusional state • Acute decline in attention and cognition • Common in admissions and post operative • Associated with increased mortality • Hyper and hypo active forms • May not be recognised

Confusion assessment method • 1. Acute onset and fluctuating course • 2. Inattention • 3. Disorganised thinking – rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable switching of subjects • 4. Altered level of consciousness : vigilant ( hyperalert) , lethargic,( drowsy, easily roused ) , stupor ( difficult to rouse ) , coma ( unrousable) • 1+2+at least one from 3 or 4 suggests delirium

Dementia • Clinical syndrome • Cluster of symptoms/signs characterised by memory difficulties, disturbance in language, psychological and psychiatric changes and impairments of daily life • Chronic • Global • Progressive • Usually irreversible

Neurological diseases of high prevalence in old age • Stroke and transient ischaemic attack ( TIA) • Parkinson’s disease • The dementias :Alzheimer’s disease , vascular dementia, Lewy body dementia

Approximate prevalence of dementia • Doubling 5 yearly > 60 • 1% 60 • 2% 65 • 4% 70 • 8% 75 • 16% 80 • 32% 85

Types of Dementia • Alzheimer’s disease 50% • Vascular dementia 25% • Mixed AD-VaD 25% • Lewy body dementia 15% • Fronto-temporal, Parkinson’s disease dementia etc 5%

Assessment of dementia • History from patient • Corroborative history from partner/family/carer : cognitive and behavioural • General examination • Cognitive tests : Abbreviated mental test score, Mimi-mental state examination, clock drawing test, ACE-R, MOCA etc

Treatable causes of dementia syndrome • Is it delirium ? Infection, metabolic, alcohol withdrawal, drugs etc • Cerebral space occupying lesion : tumour or chronic subdural haematoma • Depression • Hypothyroidism • B12 or folate deficiency • Normal pressure hydrocephalus • Chronic alcohol abuse

Dementia screen • FBC, ESR • U/E, LFT,Calcium • TFT • Serum B12 • Red cell folate • Chest radiograph • ECG • Urinalysis • CT brain - +/- MRI brain

Cardiovascular disease of high prevalence in old age • Ischaemic heart disease – angina, myocardial infarction, heart failure- at post mortem 72% men,54% women > 70yrs had > 75% stenosis of >=1 coronary artery • Atrial fibrillation : 5% 60-70yrs ,14% 71- 90yrs • Hypertension – 50% 65-74yrs • Valvular heart disease

Respiratory diseases of high prevalence in old age • Chronic Obstructive Pulmonary Disease • > 30% over 65s in one study : 2/3 on no treatment • Carcinoma of bronchus • Pneumonias

Endocrine diseases of high prevalence in old age • Diabetes mellitus 1.7% 20-44yrs US white 8.2% 45-54yrs 12.5% 55-64yrs 17.9% 65-74yrs Worldwide 2000 20.1% > 65 • UK prevalence in adults 7.4% • UK older adults: white 9% > 65 , S.Asian 27.8% 60-79 • Classified as Type 1 or Type 2 ( over 90%) • Thyroid disease : hypothyroidism : tired, forgetful, weight gain, dry skin, feel the cold :up to 5 % in older men, 15 % in women

Diseases more common in South Asian Elders • Diabetes mellitus : 6 x more common than the general population • Diabetes increases risk of stroke x 2-4 • Ischaemic heart disease is also more common and is increased in diabetic patients • Tuberculosis affecting the lungs or other organs more common and may present atypically • Osteomalacia : bone disease due to inadequate vitamin D synthesis in the skin

Complications of diabetes mellitus • Eyes : retinopathy, blindness • Kidneys : diabetic nephropathy - leading cause of end stage disease needing dialysis • Nervous system : stroke, peripheral neuropathy , autonomic neuropathy • Cardiovascular system : ischaemic heart disease , peripheral vascular disease, amputation • Infections • Acute illness with diabetic coma : ketoacidosis, hyperosmolar, lactic acidosis, hypoglycaemia

Musculo-skeletal system • Osteoarthritis 17% m , 30% f > 60, lifetime risk of knee OA by 85yrs of 45% • 140,000 knee and hip replacements / yr in E&W: 97% due to OA • Osteoporosis and resultant fracture – vertebral, proximal femur, pelvis • Rheumatoid arthritis • Polymyalgia rheumatica • Paget’s disease of bone

J.G.Ballard 1930-2009. ‘Miracles of Life’. 2008 • In 2006, after a year of pain and discomfort that I put down to arthritis, a specialist confirmed that I was suffering from advanced prostate cancer that had spread to my spine and ribs. Curiously, the only part of my anatomy that did not seem affected was my prostate, a common feature of the disease.