NSSO data (1995) underlines that at any time almost 50% of elderly are ill, and 75% of them have more than two diseases. Multiple diseases co-exist together in elderly, in a study in elderly population between 65-74 years suffered from an average 4-6 chronic diseases, for those over 75 years the mean number was 5.8 and only 10% reported absence of any problem.
Special hazards of illness :
In elderly due to poor physiological reserve, diseases manifests early but are reported late due to socio economic factors, dementia or marking of symptoms by co-morbidities. Hence, elderly usually presents with advanced disease and as disease in one organ may trigger failure of other systems, multi system manifestations are common. Certain diseases like ischemic heart diseases, strokes, osteoarthritis are commoner in elderly, while others like Parkinson’s disease, Multisystem atrophy of CNS, Alzheimer’s
disease, Polymyalgia rheumatica is seen only in elderly. Co-existence of multiple diseases may mask or exacerbate symptoms for e.g., dementia of Alzheimer’s disease may be exacerbated by concurrent presence of hearing loss. Certain pattern of presentation of diseases are particular to old people i.e.,immobility, instability (falls), incontinence and intellectual impairment. These four is having been designated as giants of geriatrics. Diseases in an elderly invariably presents with a decline in functional capacity. These functional declines usually have a rule of thirds i.e., only a third is due to disease, another one third is due attributable to disuse and the remaining is due to normal ageing
1/3rd Normal ageing+1/3rd disuse+1/3rd disease Functional decline due to disease and disuse parts can be managed and reversed to a large extent; but normal ageing process is irreversible. Geriatric functional assessment is crucial to problem detection, planning, prevention and monitoring in old people.
Clinical presentations of diseases differ markedly in elderly; clinical features may be muti-factorial and nonspecific; co-morbidities may mask, mimic or aggravate clinical features. Clinical features of diseases
has to be differentiated from those due to normal ageing or disuse phenomenon clinical features of an organ system disease may manifest in multiple organ system; camouflaging the main problem. Adverse drug reactions or drug interactions may change the clinical presentations. Certain conditions may be present without signifying disease like asymptomatic bacteriuria or benign aortic sclerosis. Similarly, due to decreased muscle mass, creatinine clearance is not good enough for assessing renal impairment; it has to be corrected by following formula.
[Creatinine clearance = age in years wt. in kg/ 72 Screatinine (mg/dl)] to be multiplied by a factor of 0.85 in case of females
Goals of management:
As elderly will have multiple problems, lot of which are amenable to treatment the care plan must address all the problems detected. As a clinical problem may be multi-factorial; addressing all factors will have an additive effect on overall improvement for e.g., anemia in
elderly may be caused by combination of iron, Vit. B12 deficiency and worm infestation which all shall be tackled for good results.Goals have to be individualized. In most of the circumstance, the first goal is to control the disease and make patient functionally independent. Treatment priorities shall be based upon life expectancy of the patient, effectiveness of therapeutic intervention; co-morbidities,goals of care set by patient and attendants. Viz, tight glycemic controls may be abandoned if it means placement of elderly with life expectancy of less than 5 years, in a nursing home
Problems in management:
Due to poor physiological reserve and multiple diseases adverse drug reactions (ADRs) are common Viz., antihistamines (Viz.,diphenhydramine) may cause confusion, loop diuretics may precipitate incontinence and digoxin may induce arrhythmia even at normal serum levels. Due to polypharmacy, drug interactions, poor compliance and dosage errors are quite common.Elderly people are usually not treated with anticoagulants due to fear of intracranial bleed, though studies have clearly proven that anticoagulant treatment has favorable risk benefit, due to fear of side effects,
Geriatric physician often grapple with ethical dilemmas, older patients are particularly vulnerable and family members may have to be involved in decision making like surgery or nursing home placement. The physician must be knowledgeable about the complexities of medical care in elderly.Geriatrics is inherently interdisciplinary. A well functioning, interdisciplinary team is critical for comprehensive care of elderly. At the same time geriatric care needs involvement of family or care giver to ensure compliance with the treatment. Attention should also be given to the needs and health of care giver to ensure long term care of elderly patient.
Impairment is the alteration of physical or physiologic function at the organ level. Rehabilitation is the process of helping a person reach the optimal functional potential consistent with his/her physiologic or anatomic impairment, environmental limitations, and desired life plans.Rehabilitation is the process of helping a person reach his/her optimal functional potential. Rehabilitation can be provided at different sites and is not limited to inpatient rehabilitation units. A systematic approach to assessing the cause of disability leads to development of a care plan that facilitates the rehabilitation process.Different disabilities require different rehabilitation plans.Rehabilitation interventions should be comprehensive and should include early recognition of potential disability and prevention.There are several ways in which geriatric rehabilitation can be utilized.
The Process of Rehabilitation
Stabilization of the primary problem. Maintenance of function must be part of the management of the acute illness. Prevent secondary complications. Common complications and hazards of hospitalization include delirium, de-conditioning, depression, malnutrition, pressure sores, and incontinence. Restore lost function. Even in the face of irreversible medical conditions, attempts can be made to restore function to optimum. Adaptation of person to new disability. Adaptation of the living facility.Working with the family.