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 Undifferentiated Somatoform
<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