Klinik Temasya
Primary Care Medicine

Giants of geriatrics - are you at risk?

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Giants of geriatrics are the impairment that appear in older people. It comprises of 5I's,  immobility, instability, incontinence, intelectual impairment and iatrogenic. Dr Bernard Isaac coined the phrase which indicated as the final common symptom pathways for many of the conditions in older patients resulting in significant disability. If this is not address early, it can often lead to increase need of transfer to institution such as nursing homes and increase rate of mortality and morbidity.

Immobility can be defined as an impairment of the ability to move independently which results in the limitation of lifespace. Immobility is not a natural part of ageing and can often lead to dire consequences such as loss of muscle mass ('sarcopenia'), blood clot formation (deep vein thrombosis), risk of infection (urinary tract infection, pneumonia), constipation and development of pressure ulcers. Managent of immobility is difficult and caregiver and family members are integral part of the process. Among it are repositioning every 2 hours, use of pressure reducing devices such as mattresses and pressure cushions, compression stockings, nutrition and hydration support and regular emollient to keep the skin intact and prevent development of pressure ulcer.

Instability leading to fall in elderly is increasing every year.  Risk factors for falls include muscle weakness, a history of falls, gait and balance abnormalities, the use of assistive devices, visual impairment, joint impairment, medication use and impaired  cognition. Fall in elderly is associated with high risk of morbidity and mortality. Major sequelae from fall is hip fracture, more commonly in women with osteoporosis. Instability can be prevent by focusing on  strength and balancing exercises, review of medications that can cause postural giddiness and sedation, environmental modification by removing loose carpets, cluttered furnitures and putting on rails in the toilet area. Elderly patient may also benefit from Vitamin D supplementation.

Incontinence can be defined as involuntary loss of ability to control urine. It is important to differentiate various causes of urinary incontinence such as urge incontinence, stress incontinence, infection (urinary tract infection), prostate enlargement, faecal impaction, medications and immobility issue (unable to get to toilet on time). Urinary incontinence can negatively impact on patient's quality of life, social wellbeing and overall health. Reversible causes such as delirium, urinary tract infection, atrophic vaginitis, hyperglycaemia and faecal impaction need to be corrected first. Other general measures include regular stool softeners, avoiding alcohol and caffeinated drinks, decreasing night time fluid intake and wearing pads.

Intelectual impairment can be classified as acute onset of confusion, which always require urgent medical attention and chronic cognitive impairment such as dementia and depression. Dementia refers to progressive decline in cognitive function, generally being present for longer than 6 months. Alzheimer's disease is the most common cause of dementia. Dementia also have significant behavioural and psychological symptoms leading to impairment in daily living. Reversible causes such as infection, vitamin B12 deficiency, electrolyte abnormalities, hypothyroidsm and normal pressure hydrocephalus need to be treated first. Treatment also include used of medication such as cholinesterase inhibitors to delay progression of dementia with or without use anti-pyschotic and anti-depressant for mood and behavioral control

Iatrogenic refer to illness or side-effects from use of medication or treatment. Elderly patient often have polypharmacy, taking more than five types of medication everyday. Because of physiological changes occuring with ageing, elderly patient are more prone to develop adverse drug reactions, decrease compliance and increase risk of hospitalisation due to side-effect from medications. Medications review need to be done regularly and minimised if possible.

Giants of geriatrics are not a normal ageing changes and can have serious consequences to the patient and their family. It is important if you or your family members who at risk be assess early by your doctor.

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