Geriatrics – How different ?

  Dr.Kaushik Ranjan Das

MBBS,DFM,DGC,FGSI,FCGP,CCGGM(GSI),PGDCE&DM

Certificate Courses in Geriatric Medicine,Clinical Cardiology,

-- Psychiatry&Psychosexual Disorder&Dementia

Consultant Family Physician and Geriatrician

---Ilya Ilyich Mechnikov -

In 1903 he coined the term Gerontology, where “Geron” means old man and “Logos” means to study.

 Dr.Ignatz Leo Nascher :The term “Geriatrics” has been coined in 1909 by Dr. Ignatz Leo Nascher (former chief of clinic in the Mount Sinai Hospital, New York City).Where Greek “Geron “ means old man & iatros means “healer”.

Geriatrics :

Geriatrics or Geriatric Medicine is the branch of medicine that concerned with the diagnosis , treatment & prevention of diseases in older people and the problems specific to ageing,including socio economic issues.

 Dr.Marjorie Warren - is one of the first geriatricians and considered the mother of modern geriatric medicine. In 1943 and 1946, she published two papers in the British Medical Journal. Dr.Warren argued for the creation of the specialty of geriatric medicine, On the basis of these papers, the Ministry of Health became involved in this emerging field, and in the 1950s, geriatric medicine was recognised as a medical speciality by the National Health Service (NHS).

Why Basic Geriatrics ?

• Diseases in elderly are diverse
• Management of them are multifaceted.
• Also different from their adult counterpart.
• Geriatric Medicine has intricacies .
• Beginners should have basic understanding on different aspects of Geriatric care.

What are the basics ?

1. Homeostenosis: As age advances , there has been age related decline (that starts from 3rd decade of life) in functions of body systems .

2.Heterogeneity :

Age related decline in function ( decrease in physiological reserve) of body system does not occur uniformly , that is why individuals are not alike as age advances (heterogenous). This heterogeneity has been encountered in action and adverse effects of drugs in elderly.

3.Effects of Homeostenosis :

Due to decrease in physiological reserve (Homeostenosis), elderly people exhibits increased disturbance following minor insults and so also they exhibit much improvement of their problem ( increased functional recovery) due to little improvement of different symptoms.

4.Picture contrast to adult counterpart :

• Symptomatology of disease in adult is often due to single disease (Law of parsimony / unitary model ) ,
• But often it does not exist in elderly ( multiple diseases / pathology may be present in a person at a time )
• Therefore, holistic approach is required in treating/ caring elderly.
• There may be some hidden diseases ( Viz. enlarged prostate, visual and hearing problem, constipation , sleep disturbance etc.) ,
• Hidden diseases are thought to be normal for aging by elderly needs to be searched out ;
• Management of such hidden diseases confers improved functionality and quality of life to elderly.

5.Atypical Presentation :

Why ?

1. Due to age related decline in body function , decreased immunity etc. presentation of a disease in elderly is often atypical.

Examples :

• Pneumonia may not present with cough , fever etc.; presenting symptom may be confusion or a fall.
• Urinary tract infection may not present with increased frequency , burning etc. It may present with weakness only or cough and breathlessness ( CHF precipitation ) may be the symptom, may be with urinary incontinence or confusion ( due to septicaemia ) etc.
• Myocardial infarction may not present with chest pain , diaphoresis etc. instead it may present with sudden deterioration of health or breathlessness or dyspepsia .
• Thyrotoxicosis may not be present with palpitation, tremor etc. rather may present with symptoms of heart failure.
• Acute abdomen may not present with classical symptoms, instead it may present with abdominal distension, tachycardia, tachypnoea etc.
• Due to decreased neuronal sensitivity , mass in the abdomen may be without bowel symptom ( mass without symptoms ).

6.Weakest Link:

1. Diseases of an organ may manifest as symptoms of organs vulnerable ( i.e. weakest link ).

• Vulnerable organs are – Nervous system , Cardiovascular system , Urinary system and Musculo skeletal system .

Thus, presenting symptoms may be – Syncope, breathlessness , urinary incontinence, falls , confusion etc.

7. Pharmacodynamics and Pharmacokinetics :

Pharmacokinetics of drugs ( what body does with a drug ) Pharmacodynamics of drugs ( what drug does with the body)

Why altered ?

As age advances , there is decrease in lean body mass and increase in fat content of the body,leading to increased chance of toxicity of water soluble drugs ( Viz. digoxin , acetaminophen, gentamycin etc. ) Increased duration of action of fat soluble drugs (Viz. diazepam , rifampicin etc.) . Also due to age related decline in body functions changes occur. that is reflected to the response after taking a drug , all of dissolution , absorption , metabolism and excretion of drugs may be affected , also receptor sensitivity may be increased or decreased .

Desired practice in prescribing drugs in elderly-

(a) Well tested drugs to be prescribed in elderly , comparatively newer drugs better to be avoided.

(b) Starting with low dose of a drug and gradually titrating the dose to have maximum effect (start low and go slow ).

8. Iatrogenesis :

• Elderly presenting with symptoms are often caused by drugs taken (Iatrogenesis ) .
• This iatrogenesis occurs due to taking multiple drugs by many elderly

• Polypharmacy- taking 5 or more drugs .

• Also due to adverse drug reaction (ADR) due to age related changes in the body ; though exact cause of ADR yet to be elucidated .

1. Examples of Iatrogenesis in Elderly:

• Haematuria may be due to NSAID intake , blood thinners.
• Mental confusion , day time sleepiness may be due to Benzodiazepines , antidepressant , cough syrup intake ;
• Syncope and fall may be due postural hypotension caused be antihypertensives, drugs used for benign prostatic enlargement etc. ;

• Urinary retention may follow intake of anticholinergics etc.

• Other Drugs used for comorbidities – Hypertension, Diabetes Mellitus , Arthritis , Parkinson’s disease, Dementia etc.

Beers criteria may be a guide for choosing drugs in elderly .

Beers Criteria :

• The Beers Criteria were first introduced in 1991 and are updated periodically, with the most recent update occurring in 2023,

• The AGS Beers Criteria is an explicit list of PIMs( potentially inappropriate medications) that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions.
• Widely used by clinicians, educators, researchers, healthcare administrators, and regulators.
• The 2023 AGS Beers Criteria is based on the best available evidence and supports person-centered decision-making that takes into account what matters to an older person, considers both drug and non-drug approaches to care, and is focused on maximizing health while minimizing unnecessary risk.

Categories of Beers Criteria :

05(Five) categories -

• Medications considered potentially inappropriate,

• Medications potentially inappropriate in patients with certain diseases or syndromes,
• Medications to be used with caution,

• Potentially inappropriate drug-drug interactions,

• Medication with dosage adjustments based on renal function.

Special Mention:

Prescribing cascade ( prescribing drugs for adverse effect a drug without taking care of the offender) needs to be avoided.

Brown Bag : A geriatric patient should take his/her all medication in a bag (Brown bag )when visits doctor.

Team approach in the management of geriatric patient is necessary and rewarding .

9.Geriatric Care Team :

A geriatric team requires to be constituted as per requirement of a particular patient ( Individualized ). Attending physician can constitute a team for caring his /her elderly patient in domiciliary setting also.

A geriatric medical team comprises of –

a) Geriatrician / Primary physician - Team leader

b) Nurse - Member

c) Geriatric Social Worker - Member

d) Therapist-physical/ speech/ occupational etc. – Member

e) Psychiatrist / other specialist - Member.

10. Focus of Geriatric care -

a) Care not cure.

b) To preserve functionality or regaining functionality.

c) To keep the patient independent.

d) To prevent iatrogenesis.

AN APPEAL –

a) Let us think elderly as wisdom not as burden

b) Let us take part in comprehensive care of elderly

c) Our goal be – “To die young as late as possible”.

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