Statistics

Life expectation at birth: 77.8 years

Life expectancy at age 65: 18.7 years
Life expectancy at 85: 6.8 years
About of all deaths occur at age 85+
Cardiac deaths: 30%
Cancer: 22%
Cerebrovascular disease: 7.4%

Biology of Aging
Aging is a loss of homeostasis or a
breakdown in maintenance of specific
molecular structures and pathways

Mr. Baker
Mr. Baker is a 77 year old diabetic with
problems adhering to his therapy. He
has developed severe pain and numbness
in his feet and has fallen a number of
times because he has lost sensation of his
feet stepping on irregular surfaces. The
last time he fell, he fractured his hip.

Physiologic Changes
Nervous:
Decreased number of neurons
Decreased action potential speed
Decreased axon/dendrite branches
Decreased muscle innervation
Decreased fine motor control

Mrs. Chan
Mrs. Chan spent a lot of time as a child
helping out on her fathers farm, and got a
lot of sun exposure.
Recently she had noticed a mole on her
arm. It seems to be growing and changing
color.
A friend has told her to see you about
removing it.

Malignant melanoma

Physiologic Changes of Aging

Skin:
Decreased thickness
Increased collagen crosslinks
Loss of elasticity
Decreased melanocytes
Linear nail growth slows
Nails become brittle, dull,opaque,yellowish

Mrs. Grace
Mrs. Grace was a beautiful, thin model in the
1960s. She has retained her weight even after
two children, but recently fell and fractured her
wrist. It has healed.
Among her other complaints now are stiffness
when she gets up in the morning, decreased
ability to do the delicate art work she used to
do on the pottery she made as a hobby, and
even trouble turning the pages of a book.

Skeletal Changes of Aging

Decreased bone density
Stiffer, less flexible joints
Slower, more limited movement
Finger joints lose cartilage, bones thicken
Walking shows less arm swing
Shoulders narrow, pelvis widens

Mrs. Ohara
Mrs. Ohara has been feeling listless and short
of breath. She comes to you complaining she
cant go on her three mile hikes in the nearby
woods she enjoyed so much for many years.
You listen to her heart and notice an irregularly
irregular rhythm. An EKG confirms your clinical
diagnosis of atrial fibrillation. An
Echocardiogram shows diastolic dysfunction

Cardiovascular Changes of Aging

Increased left ventricular wall thickening
Valves may become thickened, calcified
Pacemaker cells are lost (10% per decade)
Heart less responsive to beta adrenergics
Blood vessels become stiffer, longer, rigid
Sensitivity to receptor-mediated agents
decreases
Elastin fibers are replaced by collagen

Mr. Chuang
Mr. Chuang is a 91 year old male who worked in
construction many years ago. He now lives with
his 63 year old son and sons wife.
The sons two grandchildren were visiting and
were just getting over respiratory infections, which
Mr. Chuang caught.
He now has a temperature of 100.7, chills, a
cough and feels very fatigued, just wants to sleep.

Pulmonary Changes of Aging

Increased residual volume (20 mL/year)
Decreased vital capacity (30% in 80 y/o)
Deceased quiet and forced breathing
Decreased exercise tolerance
Decreased pulmonary reserve

Mr. Grandpa
Mr. Grandpa, age 69, had nine children,
now has 23 grandchildren, and worked in
construction most of his life. The
grandchildren are mostly under 10 years,
visit frequently, and scream a lot.
Mr. Grandpa no longer joins in
conversation, doesnt listen to his wife,
just sits around watching TV and seems
vaguely depressed.

HEENT Changes of Aging

Difficulty focusing on near objects
Decreased accommodation
Decreased adaptation to the dark
Thickening of tympanic membrane
More low frequency conduction deafness
Sensorineural hearing loss in high
frequency range
Decrease in cochlear neurons

Mrs. Henry
Mrs. Henry has always eaten anything that
looks good, loves fast food and cookies. She
now weighs 293 lbs and you have to help
her onto and off of the exam table. Chronic
constipation has been a longtime problem.
Today she comes in with a low grade fever
and left lower quadrant abdominal pain. You
are concerned about diverticulitis as a
recent colonoscopy showed diverticulosis.

GI Changes of Aging
Increased dysphagia
Increased achlorhydria (think salmonella)
Decreased iron, B12 &calcium absorption
Diverticula
Increased transit time > constipation

Mrs. Stevens
Mrs. Stevens is 65 years old, lives on a ranch
and has a couple of horses.
She used to love riding her favorite horse,
Buttermilk, socializing with horsey friends,
dancing and even running. Not anymore
Now days, she just stays quietly on her ranch.
She has disclosed to you that she pees herself
unexpectedly, even with laughing, and is
reluctant to socialize. Her creatinine is 1.3 and
her urinalysis normal

Urinary Changes of Aging

Decreased kidney size, weight, glomeruli
Decreased glomerular filtration rate (GFR)
Decreased renal blood flow
Decrease in length, function of renal
tubules
Increase in prostate size
Increase in stress and urge incontinence

Mrs. Oldbody
While taking out garbage, Mrs. Oldbody,
age 87, cut her ankle accidently on a
protruding piece of glass, and sees you
right away.
The wound is superficial so you clean and
bandage it, noting current vaccination.
Two days later, Mrs Oldbody has a roaring
cellulitis and has to be hospitalized.

Endocrine/Immune Changes of
Aging
Decreased immune functioning
Increased autoimmune antibodies
Decreased T cell function
Atrophy of pituitary, thymus, thyroid
Decreased estrogen, testosterone,GH
Changes in response to stress
Increase in parathyroid hormone, Atrial naturietic
peptide, baseline cortisol and erythropoeitin

Mrs. Sluggish
Mrs. Sluggish, age 67, has hypothyroidism.
She is on a high dose of thyroid hormone,
yet her free T4 and free T3 are still low and
she feels tired. She is also anemic.
She says she always takes her medication
You discover that not only has she had a
gastric bypass long ago, she also takes her
iron, calcium & thyroid together after
breakfast

Drugs: Pharmacokinetics
ABSORPTION - how does the patient take the
drug? (fluoroquinolone absorption reduced if
taken with ca++)
DISTRIBUTION - lipid soluble drugs take longer
to reach steady state and be eliminated,
hydrophilic lower distribution vol.
METABOLISM - clearance by liver may be
reduced as liver has reduced mass, blood flow
ELIMINATION Creatinine clearance dcreases
with age by about 6-12 mL/min/1.73 M2 (steady
state = 5 half lives of drug)

Adverse Drug Events

Decreased heart rate: beta blockers, digoxin,diiltiazem,
verapamil
CNS effects: anticholinergic agents, benzos, antihistamines
SSRIs, opioids, metoclopramide, beta blocker
Falls: above plus diuretics, antiarrhythmics, seizure meds, Ca++
containing antacids (constipation), antihypertensives, etc
GI effects: NSAIDS, bisphosphanates, opioids (constipation),
calcium channel blockers, mg++ antacids (diarrhea)
Kidney effects: ACE inhibitors, ARBs, K+sparing diuretics (hyperkalemia)
hypokalemia (diuretics), NSAIDS (renal damage) SIADH (SSRIs)
Urinary retention: Opioids, Ca++ channel blockers, alpha adrenergic agonists,anticholenergics

Drug Interactions
Definition: Clinical response to drug
combination that differs from effects of
each agent given alone.
Cytochrome P-450 (genetically different
isozymes): 10% of Caucasians have
reduced CYP-2D6 and cannot convert
codeine and tramadol to active
metabolites

Geriatric Pharmacology: principles

Start low and go slow
Avoid benzos, strong anticholinergics,
barbituates, sedatives like
diphenhydramine
Have patients bring in all meds at visits
Explain purpose of meds, side effects
Be alert for drug-drug interactions
In patient with newly altered mental
changes CHECK MEDICATIONS

Mr. Brain
Mr. Brain comes to see you for the 1st time
for surgical clearance for knee arthroscopy
He is 72, had a CABG 14 years ago, has
well controlled diabetes type 2 and
hypertension. He used to play golf every
day till last year when his knee started
giving out and hurting.
He has gained 25 lbs since last year and
become a couch potato

Risk Factors for Surgery

History of ischemic heart disease
Prior or compensated heart failure
History of Cerebrovascular disease
Diabetes mellitus
Renal insufficiency
Morbid obesity
Serum albumen <3.5
Chronic Obstructive Pulmonary Disease
EKG shows ? Ischemia, LBBB, or LVH
Suggestive findings on physical like unexplained
dyspnea

Elective Surgery in the Elderly

Refer to cardiology (or stress testing)if:
Unstable angina
Myocardial infarct in the past month
Decompensated heart failure
Severe aortic stenosis
Significant arrhythmia
Symptomatic mitral stenosis
Surgery is higher risk, patient restricted in activity
(ie:cant climb flight of stairs, do lite housework etc)

Mr. Brain again

Mr. Brain went to the cardiologist and
needs a stent before his elective knee
surgery.
In the meantime, he needs an assistive
device to prevent falls on his trick knee

Mobility Aides
Canes
Straight
Quad (Four legs as base)
Forearm crutch (unilateral or bilateral)
Stationary or pick up walker
Two wheeled walker (brakes with downward
pressure)
Rollator (4 wheel walker with hand brakes)
Fitted wheelchair
Motorized scooter (Poor trunk support)

Gait assistance devices

Frailty (the dwindles)

Altered physiology with multiple components
Weakness
Low energy or exhaustion
Slowed walking pace
Low physical activity
Weight loss
Patients at high risk of bad outcomes like falls,
disability and dependency, and death

Mr. Delayed
Mr. Delayed is 73, lives in an assisted living
facility where meals are served, laundry
done, but he has his own room.
Lately, the residential caretaker has noted
that Mr. Delayed is falling a lot, and
attributes the falls to a mild clubfoot present
since birth.
Mr. Delayed refuses foot surgery but does
have cataract surgery and the falls stop.

Visual Impairment in Aging

Blindness is defined as 20/200 or less
Cataracts & refractive errors are common
and correctable
Age related macular degeneration can be
wet or dry
Screening for glaucoma should be done
every 1-2 years after age 50
Control of BP and glucose in DM reduces
retinopathy

What Can Happen to the Aging

Eye?
Decreased tear production
Blepharochalasis or drooping brow
Blepharoptosis or drooping of the eyelid
ca
Eversion or inversion of lid margins
Squaemous/basal cell cancer of eyelids?
Decreased contrast vision

Urgent Eye Problems

Central artery occlusion or giant cell arteritis
Retinal detachment
Scleritis
Ischemic optic neuropathy
Posterior uveitis/uveitis
Acute angle closure glaucoma
Bacterial keratitis
Corneal ulcers
Herpesvirus ophthalmicus

Common eye conditions in elderly

-

Red eyes due to:

subconjunctival hemorrhage
dry eye
blepharitis or conjunctivitis
lid malposition or exposure
allergic or viral conjunctivitis
chalazion

Floaters or flashers
Sudden decrease in vision
Diplopia (ore serious if binocular)

Mr. Grandpa again

Mr. Grandpa got fitted with hearing aides
which he said were too expensive.
He feels that using hearing aides makes him
look old, uses them for church, business
and social occasions, then takes them out at
home. Says there is nothing he wants to
hear anyway.
Now his wife, also your patient, is
depressed.

Age-related Changes in Hearing

Walls of external ear canal become thin
Cerumen becomes drier and tenacious
Ossicular joints undergo degeneration
Sensory hair cells in Organ of Corti are lost
Hearing loss can result from auditory dysfunction
from pinna to brain
Conductive hearing loss: problems in
external/middle ear (otosclerosis, cerumen etc)
Sensorineural hearing loss often caused by
cochlear problems

Hearing Problems: presbycusis

Sensorinural, usually symmetrical hearing loss
Begins with high frequencies, works down to lower
frequencies
Strial presbycusis: atrophy of striae vascularis,
starts early, amplification helps
Neural presbycusis: >50% cochlear neuronal loss,
poor speech descrimination, amplification
unhelpful
Conductive presbycusis: change in cochlear
mechanics, stiffness

Dx and Rx of Hearing Problems

Diagnosis:
Audiogram
Speech discrimination (Hearing Handicap Inventory for
the Elderly)
Otoscopic exam, removal of cerumen
Treatment:
Assistive listening devices (for office)
Communication strategies
Hearing aids{ many different styles for severity}
Special telephones, TV listening devices, flashing lights
etc

Dizziness in the Elderly

Types of dizziness include vertigo, presyncope,
dysequilibrium, mixed etc
Dizziness is associated withincreased fear of falling,
functionable disability and may be multifactoral (check
MEDICATIONS)
Vertigo: episodic feeling of rotation or spinning, can be
either subjective OR objective (benign paroxysmal &
Menieres
Presyncope: feeling of faintness, usually from brain
hypoperfusion, postural hypotension
Dysequilibrium: unsteadiness on walking, standing
usually from visual/proprioceptive problems

Ms. Vert Igo

Ms. Igo complains of dizziness. On in depth
questioning, it turns out that she feels
subjectively dizzy when she turns her head
to the left, gets out of bed, looks over her
left shoulder. She has no nystagmus and no
nausea, vomiting, fever. Neuro is normal.
You send her to your favorite physical
therapist, and she returns a new woman
praising the physical therapy.

Testing for Dizziness in the Elderly

- GOOD history and physical, including drugs,

neurologic exam, orthostatics, maneuvers (DixHallpike, Fukuda, head thrust)

Limited testing: CBC, metabolic panel, B12, folic
acid, TSH, EKG if cardiac
MRI ONLY for suspicion of posterior fossa
Tilt table for syncope, postural hypotension
Audiometry to distinguish Meniere from acoustic
neuroma

Mr. Jones
Mr. Jones is sent in by his wife to see you
because for years he has been having
more and more trouble getting an
erection. He also has to get up a number
of times a night to urinate. All of this is
very bothersome for his wife. Mr. Jones
gives this history very reluctantly, and is
even less happy at having to have a rectal
and genital exam and lab tests.

What changes to older men

experience?
About 10% of men have clinically significant low
levels of testosterone
The prostate grows larger and this can affect the
urinary tract
Fat tissue can convert testosterone to estrogen
Usually men retain lifelong the ability to make
sperm
However, male menopause can cause
osteoporosis, changes in fat distribution, less
sweat and body hair, diminished sexual interest
etc

Urinary Incontinence
UI: involuntary leakage of ANY urine
Urge UI: Compelling sudden need to void
Stress UI: Leakage from increased
abdominal pressure
Mixed UI: Features of urge and stress
Incomplete emptying: increased postvoid
residual, symptoms include
dribbling, LUTS (lower
urinary tract symptoms)

Meds Which Worsen UI

Alpha adrenergic agonists in men
Alpha adrenergic antagonists in women
ACEs causing cough
Anticholinergics-poor emptying, fecal impaction
CCBs- impaired detrusser contractility
Cholinesterase inhibitors
Estrogen worse stress, mixed leakage
Gabapentin,NSAIDS etc-pedal edema>nocturia
Loop diuretics-polyuria, frequency, urgency
Tricyclics-anticholinergic effects, sedation
Narcotics-fecal impaction

Treatment of Incontinence
Bladder training or prompted voids
Urge incontinence-oxybutynin, tolterodine,
other antimuscarinics
Stress incontinence-duloxetine, Kaegel
exercises
Surgery for stress incontinence including
retropubic suspension, vaginal sling,
periurethral bulking injections

Gait Impairment: types

Antalgic gait - pain induced limp
Cicumduction outward semicircle sweep of leg from hip
Festination gait acceleration
Foot drop weak ankle dorsiflexors
Foot slap audible foot/floor contact & steppage
Genu recurvatum knee hyperextension
Propulsion tendency to fall forward
Retropulsion tendency to fall backward
Sissoring knees cross in front of each other
Trendelemberg Hip droops from hip abductor
weakness
Turn en bloc whole body moves when turning

Causes of Gait Impairment

Peripheral neuropathy, proprioceptive deficits
Painful or deforming conditions
Focal myopathic/neuropathic weakness
Poor truncal control, other cerebellar problems
Parkinsonism with rigidity, bradykinesia, tremor
Hemiplegia/hemiparesis, arm/leg weakness, spasticity
Paraplegia with leg weakness
Normal pressure hydrocephalus, broad based gait,
dementia
Frontal lobe disease, dementia, with spasticity,
incontinence
Alzheimers, mid to late stage, and fear of falling

Testing Gait
Get up and Go test: good walkers cover >
1 meter a second
Timed Up and Go test: rise from chair,
walk 3 meters,
return, sit in <14 sec.
Functional Ambulation Classification Scale:
use of assistive devices, distance, degree of
human assistance needed and surfaces patient
can navigate

Improving Gait
Structured exercise programs
For foot drop: ankle-foot orthotics
Severe arthritis: joint
replacement surgery
Normal pressure hydrocephalus:
shunt
Proprioceptive changes: use of
sturdy shoes, firm surfaces for
walking
Compressive cervical myelopathy,
lumbar stenosis: ?surgery
Multiple: assistive devices

Types of assistive devices:

Canes
Quad canes
Pick up walkers
Front roller walkers
Specialized crutch
Walkers with seats
Canes with seats
Wheelchairs
Motorized wheelchairs
Motorized scooters
Etc

Falls
Complications from falls leading accidental cause of
death >65 yrs of age
Why?
- Visual: reduced acuity, depth perception,
contrast
sensitivity, depth perception
- Proprioceptive: reduced sensitivity in legs
- Vestibular: loss of hair cells in labyrinth,
vestibular ganglion and nerve cells
- Postural control changes
- Reduced ability to compensate for hypotension
- Medications

Prevention and Treatment of Falls

Minimize meds esp benzos, etc.
Evaluate cognition
Initiate tailored exercise program
Treat visual impairment
Manage postural hypotension
Manage heart rate/rhythm problems
Supplemental Vitamin D
Make sure footwear is optomized
Modify the environment
Hip protectors??

Osteoporosis
Disease characterized by low bone mass
& microarhitectural deterioration of bone
tissue causing bone fragility and fracture
Defined as bone mineral density (BMD) at
ANY bony site <2.5 standard deviations
below young adult BMD by DEXA scan
Fracture after gravity fall also defines
Common after menopause
Female:male = 4:1

Treatment of Osteoporosis
Exercise
Calcium (1200 mg/d/postmenopause)
Vitamin D, at least 800 IU/d
Bisphosphonates
Selective Estrogen Receptor Modulators
Calcitonin nasal spray
Parathyroid hormone (teriparatide inj)
Estrogen (controversal after WHI)

Osteoporosis: causes
Estrogen deficiency in women
More sex-hormone binding globulin in men
Ca++ deficiency > secondary
hyperparathyroidism and bone resorption
Lack of Vitamin D>poor Ca++absorption
Decreased osteoblast function in aging
Medications like steroids, anticonvulsants,
too much thyroid hormone, etc

Risk Factors for Osteoporosis

Age >70 in men, postmenopausal in women
Low body weight
10% decline from usual weight
Physical inactivity (couch potatoe)
Glucocorticoids
Prior fragility fracture
Anti-androgen therapy
Smoker/alcoholic
Poor calcium intake in diet
Spinal cord injury
Family history of osteoporosis

Dr. Teeth
Mrs. Teeth, an immaculately groomed,
intelligent woman of 79, is very worried
about her husband, a retired dentist, age 81.
For the past year, he has been forgetting
things he should know, is bothered by this.
Recently, she has had to take over the
familys finances, as he makes mistakes
Last week, he got lost driving to the store.

Dementias
Mild cognitive impairment: gradual onset and affects
primarily memory;12%a year go on to Alzheimers
Alzheimers: Gradual onset, affects memory, language
and visual-spacial skillsfollowed by apraxia plaques and
tangles
Vascular dementias: stepwise or sudden onset,
symptoms depend on area of ischemia, MRI changes
Lewy body dementia: Gradula onset, with memory,
visual-spacial problems, hallucinations and fluctuating
symptoms
Frontotemporal dementia: Onset before age 60, loss of
eecutive function, disinhabition, apathy, language issues
and possible memory impairment

Dementias: diagnostic testing

History, esp. family dementias, habits,
travel, MEDICATIONS, ADLs, IADLs ,
education
Physical exam, emphasis on visio, hearing
Mini-mental or other cognitive tests,
depression screening
Testing as indicated: thyroid function,
RPR, HIV, CBC, CMP, MRI etc

Dementia Treatment
Cholinesterase inhibitors for mild to
moderate Alzheimers
Memantine for moderate to severe
Alzheimers
Consider treating for depression in early
stages
Levodopa/carbidopa if movement
problems in Lewy Body dementia
Behavioral interventions

Mr. Graves
Mr. Graves has very mild dementia, and you are
taking care of him in the hospital after surgery for
Stage 2 colon cancer.
He tolerated the surgery well, but had to be
placed in a noisy room far from the nursing
station, with vital signs Q4H.
He has narcotics for pain, & sleep meds.
Nursing calls you as he has become disruptive,
but when you examine him, he is calm and
cooperative.

Delirium
Delirium is an acute confusional state with:
- Acute change in mental status
- Inattention
- Disorganized thinking
- Altered level of consciousness (vigilant,
lethargic,stuporous or comatose)
Potential causes:
-Drugs
-Electrolyte disturbance
-Withdrawal from drugs, uncontrolled pain
-Infection, esp. UTI and respiratory
-Reduced sensory input
-Urinary retention, fecal impaction
-Heart/lung like worse CHF, COPD, or MI, arrhythmia, hypoxia

Mood Disorders
Depression may lead to disability: geriatric
depression scale {GDS} &PHQ-9 are helpful in
diagnosis
Differentialte depression from mood disorder
due to medical condition
SSRIs are useful, may take 12 wks
Bipolar depression common, manic state may
present with confusion, distractibility, irritability
Mood stabilizers useful for bipolar
Psychotic depression: Delusions +depressed
mood {delusions may even sound plausable}

Common Dermatologic Disorders in

the Elderly
Normal changes of aging:
Photoaging: epidermis becomes flattened, decreased
fibroblasts and elastin in dermis
Hair: decrease in scalp hair density, short growth phase,
longer resting phase
Treatment: lifelong sun protection
{Topical tretinoin increases thickness of superficial skin
layers and increases collagen synthesis}
Xerosis: rough itchy skin or eczema craquele due to
reduced ability to retain water, treat with moisturizing
agents containing lactic or alpha hydroxy acids

Cosmetic changes
Width of nose and size of ears increase
Skin wrinkles
Skin dries

Dermatologic Conditions
Seborrheic dermatitis: pink patches
overlying greasy scaling (Scalp, face, etc)
Rx: selenium sulfide, ketoconazole etc
Roseacea: includes granulomatous,
phymatous, erythematotelangectatic, etc
Rx: topical antibiotics, oral if severe
Lichen simplex chronicus: chronic pruritic
condition with changes due to scratching
Rx: topical steroids, emollients, behavior

Roseacea

Seborrheic Dermatitis

Lichen simplex

Dermatologic Conditions
Intertrigo: Inflammatory condition of two closely opposed
skin surfaces
Bullous pemphigoid: Autoimune (C3 complment)
subepidermal blistering disease
Psoriasis: Well-demarcated plaques with overlying
silvery scale usually involving scalp, extensor surfaces,
gluteal cleft, can have pitted nails, arthritis
Guttate:small papules trunk /extremities
Inverse: lesions in skin folds
Pustular: sterile pustules and fever
Palmopustular:sterile pustules on palms, soles
rythrodermic: generalized erythema

Psoriasis

Bullous Pemphagoid

Intertrigo

Skin conditions
Veinous and arteriolar ulcers
Pressure ulcers
Shingles
Seborrheic keratosis
Cherry angiomas
Seborrheic keratosis
Basal cell carcinoma
Squaemous cell carcinoma
Melanoma

Shingles

Basal cell carcinoma

Squaemous cell carcinoma

Henrietta
Henrietta is a postmenopausal woman of
60. She shows you, her regular provider,
a number of red bumps on her neck and
chest that disturb her a lot. They came
when she was starting to go through
menopause and have become more
numerous.

Cherry angioma

Melanoma

Acral lentiginous melanoma

Seborrheic keratosis

Veinous stasis dermatitis and

ulcers

Bedsores (pressure ulcers)

Oral Diseases
Teeth become less sensitive with age >severe
unnoticed dental disease
Periodontal disease from plaque formatio n
Toothlessness, resulting in constricted diets
even with dentures
Major salivary glands OK normally, medications
and dehydration may compromise function
(Sjogrens syndrome)
Olfactory function declines with age as does
taste; medications can interfere with both
Swallowing difficulties can lead to aspiration

Respiratory Changes with Aging

Aging causes reduced size of airways/shallow
alveolar sacs
Diaphragmatic strength is reduced 25%
Chest wall compliance is reduced
Sarcopena causes intercostal muscle atrophy
FVC&FEV1 decline 25 mL/yr in non-smokers
FVC&FEV1 decline 60mL/yr in smokers
PaO2 declines with age (PaO2=110-{0.4xage)

Respiratory Complaints in the

Elderly
Rhinosinusitis-mostly viral, ?grandchildren
Dyspnia-doesnt correlate with
oxygenation or PFTs, many causes, get
history
Chronic cough-postnasal drip, GERD,
asthma, TB!
Wheezing- COPD, heart failure, asthma,
chronic bronchitis

Major Pulmonary Diseases

Asthma: 5-10% of adults > 65 meet criteria
COPD: Findings include barrel chest, hyperresonance on
percussion and exspiratory time > 9 seconds. FEV1:FVC
<80%
Obstructive sleep apnia: associated with MI, CVA, HTN,
mortality. Rx-CPAP
Idiopathic pulmonary fibrosis:restrictive ventilarory
defect+-reduced diffusing capacity
CXR-reticular opacities lower lungs>hi resolution CT
Pulmonary thromboembolism-suspect if unexplained
dyspnea, treatment is heparin (low molecular weight)
followed by warfarin for INR of 2-3

Common Cardiovascular conditions

in Aging
Acute Coronary Syndrome-symptoms can include chest
pain(declines with age), shortness of breath(increases
with age), confusion, dizziness, syncope
-EKG can be hard to interpret, ST elevation declines
with age
- Immediate Rx: ASA, O2, NTG, hospitalize
Chronic CAD-revascularization or medical care
Valvular heart disease-aortic stenosis commonest
Cardiac arrhythmias-AF most common
Peripheral arterial disease
Venous thromboembolic disease
Heart failure-systolic and dyastolic

Gastrointestinal Disorders:
Dysphagia
Dysphagia: inability to initiate swallow OR
sensation that food doesnt pass>endosopy
Dysphagia for both solids& liquids usually a
motility disorder
Intermittant dysphagia can be esophageal ring
or motility disorder like achalasia
Dysarthria/nasal regurgitation-palate, pharyngeal
muscle weakness
Odynophagia, painful swallowing-infection,
drugs, malignancy

Gastrointestinal Disease: Stomach

and Beyond
NSAID-induced: ulcers 3x greater with use
Peptic ulcers: US-H. pylori responsible for 80%
duodenal ulcers, 60% gastric ulcers
Biliary disease: gallstones can cause pain,
cholecystitis, cholangitis, pancreatitis
If status postcholecystectomy and biliary pain,
consider retained common bile duct stone
Constipation:affects 1/3 of adults above 65
Fecal incontinence: recurrent uncontrolled
passage of fecal material for >1 month-do rectal!

Stomach and Beyond, continued

Diverticulosis: 20% develope diverticulitis, 10% bleed
Irritable Bowel Syndrome: altered bowel motility,
enhanced perception of pain
Occult GI bleeding: multiple causes {including small
bowel angiodysplasia}
Colonic angiodysplasia: 5-10 mm dilated thin walled
vessels in mucosa/submucosa radiating from central
vascular core causing occult bleeding
Colonic ischemia: abdominal pain, lower GI bleed
C. difficile infection: pseudomembranous colitis
Acute colonic pseudo obstruction: acute massive colon
dilitation with no mechanical obstruction
Colon polyps and cancer

The Aging Kidney and its Problems

Under stress, kidneys may have poorer
ability to maintain homeostasis:
- Decreased sensation of thirst
- Medications like diuretics and NSAIDS
- SIADH from meds or malignancies
- Comorbidities interfering with kidney
function

Gynecologic Conditions
Pelvic organ prolapse
Atropic vaginitis
Vulvodynia (painful vulva)
Lichen sclerosis(can extend to perirectum)
Disorders of pelvic floor support
Postmenopausal vaginal bleeding

Geriatric Neurology: Parkinsons

Parkinsons Disease: progressive neurodegenerative
disease with neuronal destruction in substantia nigra
resulting in low brain dopamine causing:
Bradykinesia-slowness in initiating movement
Muscular rigidity-assymmetric at first (cogwheeling)
Pill-rolling tremor
Tachykinesia-small fast movements
Tachyphemia-fast speech, words come together
Micrographia-small handwriting
Festinating gait-faster smaller steps
Falling forward(proplsion)and backward(retropulsion)
Dementia

Treatment of Parkinsonism
PT and OT
Mild disease:dopamine agonists
(ropinirole,pramipexole)
Levodopa-carbidopa
On-off phenomenon with carbidopalevodopa-shorter time intervals to
symptoms
Side effects in older adults-carbi-levo can
cause confusion constipation, etc

Miscellaneous
Peripheral neuropathy: multiple causes
Restless leg syndrome: uncontrollable urge to
move legs-check iron, Rx ropinarole HS
Polymyalgia rheumatica (PMR): proximal joint
pain, fatigue, low grade fever, weight loss and
ESR >50
Temporal arteritis/giant cell arteritis: Associated
with PMR, do temporal biopsy, can cause
blindness