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Chapter: Medicine Study Notes : Health Care of the Elderly

Age Related Problems

Hospitalisation is dangerous to older people, especially leading to: drug toxicity, injury and mental deterioration.

Age Related Problems


Iatrogenic Disease


·        Hospitalisation is dangerous to older people, especially leading to: drug toxicity, injury and mental deterioration

·        There is often a decline in functional status following discharge, unrelated to disease process

·        Elderly have ­susceptibility to variety of stressors


·        Bed rest (eg in hospital, especially if on drips, monitors etc) generally leads to ¯outcomes, due to:

o   ¯Muscle strength and aerobic activity 

o   Volume depletion therapy (also results from bed rest) + age related vasomotor instability ® postural hypotension 

o   Supine position worsens V/Q mismatch

o   Bone demineralisation

o   ­Urinary incontinence due to high beds or distance from toilet

o   Pressure sores

o   Sensory deprivation (eg boring rooms, not wearing glasses or hearing aids) 

o   ¯Nutrition (altered dietary habits, unappetising food, ¯social component to eating)

o   All lead to a cascade of interaction

·        Most deterioration happens in first two days in hospital.  Examples of prevention include:

o   Low bed without rails

o   Carpeting

o   Minimisation of tethers

o   Encouragement and assistance

o   Orientate with clocks, calendars, dressing, undressing, communal dining

o   Sensory stimulation: proper lighting, decoration, glasses, hearing aids, available recreation




·        Can be measured through body weight (eg BMI), body composition, or direct measurement of micro-nutrients


·        Under-nutrition in the elderly can be due to: 

o   Age related ¯ in gastro-intestinal function predisposes to poor nutrition (eg ¯teeth, ¯pancreatic secretion, etc) 

o   Life-style factors: inability to shop, prepare and cook food, living alone, alcohol abuse, poverty

o   Diseases: eg stroke, arthritis, dementia make eating harder

o   Anorexic effect of illness and drugs

·        Management: 

o   Multidisciplinary: dietician to advise on what and how much to eat. Occupational therapist to advise on food preparation. Meals on wheels. Social worker in involve family and ensure adequate finance 

o   Medication review

o   Nutritional supplements: eg add milk powder to food, eat high-density foods, take supplements




·        In elderly, refers to a fall during an activity that is usually safe


·        25 – 35% of those over 65 fall each year.  Occurrence ­ with age

·        < 5% of falls cause a fracture (40% of these to proximal femur).  Soft tissue injury in 40%

·        Staying upright (a homeostatic function) requires:

o  Safe environment 

o  Information on body position: visual, vestibular, mechanoreceptors, proprioception, central processing

o  Motor systems: cortex, brainstem, cerebellar, spinal chord, muscles

o  Stable base: joints, limbs, feet

o  Intact judgement

·        Causes of falls: 

o  „Threshold model‟ in which a number of factors combine to ­risk 

o  Sedative use, cognitive impairment, abnormalities of balance and gait, polypharmacy, history of stroke, hypotension 

o  Fall over things that are safe to others Þ changing the person more important than changing the environment. But check for rugs, clutter, cords. In hospital, care with ability to transfer, agitation and frequent toileting


·        Associated diseases:

o  Nervous system: stroke, Parkinson‟s, dementia, seizure, peripheral neuropathy, ¯visual acuity

o  Musculoskeletal: proximal muscle weakness, arthritis of lower extremity

o  Cardiac: aortic stenosis, arrhythmia, postural hypotension

o  Iatrogenic: sedatives, psychotropic medication, alcohol

·        Assessment:

o  Previous history of falls

o  When, where, what was experienced, associated environmental factors

o  History of vertigo, dizziness, imbalance, blackouts, medication

o  Examination: postural changes in BP, vision and hearing 

o  Observation: stand up without using hands, observe gait, stop smoothly, turn around, stand with eyes closed, stand on one leg, reach up, bend over, heal toe walking, can they speed up, nudge them, sit down without hands 

·        Management: 

o  Active management of injuries: watch for occult pelvic fractures, hypothermia. Care with soft tissue wounds – can easily go on to ulcers

o  Acute precipitating illness that requires treating: eg stroke, MI

o  Identification of risk factors 

o   Rehabilitation: active mobilisation after a fall. Interventions targeted at identified risk factors, including medical review of medication, physiotherapy for transfer skills and exercise program

o  Avoid giving psychotropic medication to people at risk; it WILL make them fall over


Visual Impairment


·        Major causes of ¯visual acuity in adults are :

o  Cataract: due to ­bulk of the lens and discolouration. Age, diabetes, and UV light are the main risk factors. Treatment by extraction and implantation improves visual acuity in about 90% but a smaller proportion benefit in terms of activities of daily living 

o  Age related macular degeneration: Variety of causes. More serious ones include choroidal neo-vascularisation ® detachment and scarring

o  Glaucoma

o  Diabetic neuropathy


·        Senile arcus: ring of lipid and calcium salts in a ring at the junction of the cornea and sclera. Very common in elderly. Not a sign of hyperlipidaemia (as it is in the young)

·        Ectropion: low lid falls away and tears don‟t drain into lacrimal sac


·        Lens becomes thicker and less flexible (Presbyopia) Þ can‟t accommodate, need reading glasses


Elder Abuse


·    When a person aged over 65 experiences harmful physical, psychological, sexual, material or social effects caused by the behaviour of another person with whom they have a relationship implying trust (Age Concern definition)


·        Elder abuse can be:

o  Physical: physical pain, injury, force, under/over medication 

o  Psychological: causing emotional anguish or fear, including intimidation, humiliation, harassment, threats, removal of decision making powers

o  Sexual

o  Financial: improper use of funds or other resources

·        Can be:

o   Active neglect: conscious deprivation by a carer of basic necessities 

o   Passive neglect: refusal/failure of a carer to provide the basis necessities due to inadequate knowledge, infirmity, or dispute over the value of services


·        Prevalence: Significant under-reporting due to cognitive impairment, fear, life long pattern of abuse, access to someone to complain to, stigma associated with domestic violence. ?About 5% of elderly people subject to abuse, usually by a spouse, child or relative


·        Risk factors for abuse:

o   Dependence by the older person for all or part of their care

o   Cognitive impairment, especially disruptive or aggressive behaviour

o   Substance abuse or mental illness of the abuser

o   Shared living arrangements

o   External stress

o   Social isolation

o   History of violence

·        Screening for elder abuse:

o   Will not be volunteered: need to ask the right questions

o   Watch for injuries or health or emotional problems with vague or inconsistent explanations

o   Observe interactions, especially in own environment

o   Question older person away from carer:

§  Do you feel safe at home?

§  Are you afraid of anyone at home?

§  Have you ever been hit or pushed? 

o   Question carer in empathetic not confrontational way: Caring for X must be difficult… How do you cope…. Have you ever lost control?

o   Careful physical examination and documentation of findings

·        Management: 

o   Age Concern have people trained in the assessment of abuse, plus case workers and advisory groups

o   Use ATR social workers

o   If person accepts intervention, then initiate a safety plan

o   If person declines intervention (but has the capacity to do so) then educate and review 

o   If person declines but doesn‟t have the capacity to make this judgement, then family court can decide on welfare guardianship through the Protection of Personal and Property Rights Act (PPPR Act)




·        50% of 76 – 80 year olds still have a licence, 27% of those over 80.  Half still drive regularly

·        Driving depends on cognitive function, motor function and sensori-perceptual function

·        Elderly are only 14% of those killed in crashes, but have a higher death to injury ratio

·        Older drivers more likely to be at fault in accidents involving intersections, merging and manoeuvring

·        In elderly people with Alzheimer‟s, crash rates approach those of 15 – 25 year old males 

·        Age associated changes affecting driving include: vision, psychomotor function, strength and dexterity, cognitive function (especially attention to multiple stimuli and finding ones way, ¯ in dementia) 

·        Medical assessment a legal requirement at 75, then 80 and every two years thereafter (including vision check). Cognitive screening should be included due to the profound effect on driving, the insidious nature of cognitive impairment, good social facades by patients, and frequent lack of insight. Psychoactive drugs (especially BDZs) ® ¯psychomotor function 

·        Practical test performed by the Ministry of Transport is required at 80 and every two years thereafter


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