Presented ByFarzana SultanaBPH : 04806682Department of PharmacyStamford University Bangladesh

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Common clinical disorders in elderly

Because of age-related physiological changes in the body’s organ systems, disease presentation has atypical features in the older patient. Moreover, because of the aging population worldwide and the association of chronic disease with advanced age, elderly patients often have multiple co-morbidities, thus complicating the clinical presentation of common disease states.The common clinical disorders in elderly are given below-

1. Infection Cell-mediated immunity declines with aging, resulting in an impaired response to antigens.5 Fatigue, anorexia, urinary or fecal incontinence, recent alteration of mental status, unexplained recurrent falls, loss of physical functional capacity, and non-specific malaise without fever are common symptoms of infection and bacteremia in the elderly.

Urinary incontinence was identified as an independent risk factor for nosocomial blood stream infections in older adults.

Streptococcus pneumoniae is the most common causative agent of community-acquired pneumonia in the elderly, while Mycoplasma pneumoniae is virtually non-existent.

Gram-negative bacilli are the predominant organisms in aspiration pneumonia, followed by anaerobic bacteria and Staphylococcus aureus. Symptoms of pneumonia – cough, dyspnea, and fever.

Among the elderly, E. coli, Proteus species, Klebsiella species, and Enterobacter species are common. S. saprophyticus is distinctly unusual as a cause of urinary tract infections (UTIs) in the elderly. UTIs may present with atypical symptoms, such as worsening or new-onset incontinence, lethargy, or confusion.

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Sensitivity and specificity of blood cultures is not influenced by age. The relationship between age and antimicrobial resistance in blood stream infections varies by organism. Blood stream infections due to methicillin-resistant Staphylococcus aureus (MRSA) are more prevalent in the elderly. However, vancomycin resistant enterococcal infections are not.

2. Pulmonary Embolism The incidence of venous thromboembolism increases with age. Older patients may present atypically with acute pulmonary embolism (PE). Moreover, increasing prevalence of alternative cardiopulmonary conditions may mimic PE in the elderly, potentially leading to delays in diagnosis and treatment. Syncope is a particularly important symptom of acute PE in older persons.

Treatment: Supportive therapy includes providing supplemental O2 to

achieve a Pao2 of 60 to 70 mm Hg, providing adequate intravascular fluid to maintain cardiac output, monitoring the patient for evidence of bleeding due to anticoagulant therapy, and avoiding drugs that adversely affect platelet function (eg, aspirin, other cyclooxygenase blockers).

Long-term anticoagulation is begun in the hospital with heparin and is continued after discharge, usually with warfarin.

Thrombolytic (fibrinolytic) therapy should be considered for patients with deep vein thrombosis involving the iliofemoral system.

Interruption of the inferior vena cava -usually with a Greenfield filter--may be required in patients who have a contraindication to anticoagulation; who do not respond to anticoagulant therapy

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3. Coronary Artery Disorder and Congestive Heart Disorder The prevalence of coronary artery disease and congestive heart failure increases with age. The spectrum of presentation of acute myocardial infarction (AMI) also changes. Chest pain or discomfort is less frequent, while syncope, shortness of breath and acute confusion are more common and sometimes the sole presentation.

Treatment: Medication ACE inhibitors, beta blockers, and water pills (diuretics). Lifestyle changes are also helpful Surgery including heart transplantation or the placement of

a mechanical assist device, biventricular pacemaker, or a cardioverter-defibrillator may be necessary.

4. Epilepsy Complex partial seizures are the most common seizure types after the age of 60, accounting for 70% of cases.The dendritic processes of neurons of cortical layer V are involved in the intracortical communication between adjacent areas of the brain. Advanced age is associated with a disproportionate loss of dendritic processes of neurons of cortical layers III and V. This may explain why partial seizures in the elderly have fewer propensities to spread to adjacent areas and generalize. Therefore, psychic symptoms and automatism are also less likely. Conversely, sensory and motor symptoms are more common manifestations of seizures due to the involvement of motor and sensory cortices secondary to cerebrovascular disease.

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Treatment:MedicationAnti-seizure medications are the most common treatment used to reduce or prevent seizure activity.

VNSVNS or vagus nerve stimulation is a treatment technique designed to prevent seizures by sending regular, mild pulses of electricity to the brain by stimulating the vagus nerve. VNS is done by surgically implanting a small device like a pacemaker that stimulates the vagus nerve to send signals to the brain. These signals can reduce or eliminate seizure activity and are usually placed in individuals that respond poorly to seizure medication.

SurgeryIn some patients who have partial or complex partial seizures and don't respond to medical therapy, brain surgery may be an alternative treatment.

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5. Parkinson’s Disorder The prevalence of Parkinson’s disease (PD) increases with age, given that age is the single most important risk factor. Bradykinesia, rigidity, tremor, and problems of gait and balance are commonly found in elderly people without any neurological illness. These may be difficult to differentiate from early PD. Non-motor symptoms of PD like constipation, incontinence, falls, orthostatic

hypotension, sweating abnormalities, dysphagia, dribbling, and psychiatric disorders may be more common at presentation.

Treatment- Medication Levodopa.

Other MedicationsSome drugs are used in combination with carbidopa-levodopa to either inhibit dopamine breakdown by the body or to improve the

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effectiveness of carbidopa-levodopa. Azilect, Eldepryl,and Zelapar inhibit dopamine breakdown while Entacapone and Tasmar can improve the effect of carbidopa-levodopa.Surgery: Deep Brain StimulationAnother treatment method, usually attempted as effectiveness of medical treatments for Parkinson's disease wane, is termed deep brain stimulation. The technique involves surgery to implant electrodes deep into the brain in the globus pallidus, thalamus, or the subthalamic nucleus areas.

6. Gastrointestinal Disorder The incidence of gastroesophageal reflux disease (GERD) and its complications increase substantially with age. Compared with younger individuals, older patients with GERD have more severe mucosal disease. Older individuals with GERD may have greater respiratory involvement.

There is a higher prevalence of Helicobacter pylori in the elderly and as the prescribing of NSAIDs increases. The prevalence of gastric ulcer in male and female patients aged ≥60 years (17.24% and 14.80%, respectively) is markedly higher than that in male and female patients aged <60 years (7.57% and 4.17%, respectively) (p < 0.001).

Treatment-

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Living Healthier

It is a lifelong disease; except for individuals who have their colons removed for ulcerative colitis and are cured of their disease. Appropriate and adequate treatment is critical, but because of the relapsing nature of the disease, it is important to learn how to deal with the flares with lifestyle changes, and stress management. The goal is to keep the symptoms from interfering with day-to-day life.

ExerciseExercise and other stress-reducing activities such as yoga, meditation, or tai chi promote feelings of well being and by reducing stress may reduce the perceived severity of symptoms.

SurgeryPatients with IBD commonly undergo surgery. In ulcerative colitis, surgery may be used for treating severe disease, disease that does not respond to treatment, and to prevent the development of cancer.

7. Thyroid Disorder Aging is associated with decreased production of T4 and T3, degradation of T4 and T3, reduced pulse amplitude of nocturnal TSH, thyroid gland uptake of iodine and TSH rise secondary to a decrease in T4 (Figure 2). The most frequent signs found in the elderly were - tachycardia, fatigue, and weight loss. Hyperactive reflexes, increased sweating, heat intolerance, tremor, nervousness, and increased appetite were rare.61 Age-related relative resistance to thyroid hormone action may underlie the paucity of symptoms in hyperthyroidism.

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Treatment- Antithyroid Drugs

There are two main antithyroid drugs available for use in the United States, methimazole (Tapazole) and propylthiouracil (PTU). These drugs accumulate in the thyroid tissue and block production of thyroid hormones. PTU also blocks the conversion of T4 hormone to the more metabolically active T3 hormone.Radioactive Iodine

Radioactive iodine is given orally (either by pill or liquid) on a one-time basis to ablate a hyperactive gland. The iodine given for ablative treatment is different from the iodine used in a scan. (For treatment, the isotope iodine 131 is used, while for a routine scan, iodine 123 is used.)Surgery

Surgery to partially remove the thyroid gland (partial thyroid) was once a common form of treatment for hyperthyroidism. The goal is to remove the thyroid tissue that was producing the excessive thyroid hormone.

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8. Parathyroid Disorder Classic presentations of hypercalcemia, such as renal colic, gastrointestinal pathology, and skeletal disease, are less common in the elderly. Parathyroid hormone levels have also been found to be higher. This may be due to a decline in parathyroid hormone stimulation of 1, 25-dihydroxyvitamin D, which leads to decreased calcium absorption and mild secondary hyperparathyroidism. Serum albumin falls with age; however, significant hypoalbuminemia is more commonly due to disease than aging. Therefore, in elderly patients, hypoalbuminemia is the most common cause of hypocalcemia.

9. Autoimmune Disorder The diagnosis of autoimmune diseases in the elderly may be difficult because of their insidious presentation, atypical features, and a high prevalence of autoantibodies. Antiphospholipid antibodies are found in 63.6%, rheumatoid factor in 47.7%, and anti-double-stranded DNA antibodies in 29.5% of the healthy elderly population.There is a tendency for decreased rheumatoid factor seropositivity in rheumatoid arthritis. Involvement of proximal joints may mimic polymyalgia rheumatica while a high frequency of normal creatine kinase levels in polymyositis and dermatomyositis may delay diagnosis.

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Treatment- There are several aspects to treating autoimmune diseases

Modifying the disease – there are several drugs that can reduce the severity and frequency of relapses

Treating exacerbations (or attacks) with high dose corticosteroids

Managing symptoms Rehabilitation both for fitness and to manage energy levels Emotional support

10. Mood Disorder Major depressive disorder affects about 1 percent of older

adults, and dysthymia, about 2 percent. Major depressive disorder is the most common late onset psychological problem.

Mania in late life does occur in the absence of acute medical precipitants. However, not enough is known about bipolar disorder in older adults, and it may be that it is underdiagnosed in adults over the age of 60.

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Mood disorders may present differently in older than in younger adults. For example, compared to younger adults, depressed older adults are more likely to have anxiety, agitation, memory problems, and bodily complaints. They are less likely to complain of depression or feeling sad. Feeling hopeless is often an important indicator of depression among the elderly.

11. Anxiety Disorders Population-based surveys have found that about 6 percent of

older people have anxiety disorders. Because anxiety disorders often coexist with affective disorders, medical disorders, and dementia, this rate may actually be higher.

A number of medical conditions are often mistaken for generalized anxiety disorder because anxiety and shortness of breath may be prominent early symptoms.

Obsessive-compulsive symptoms wax and wane throughout the life course and can present as a primary problem or secondary to depression.

Panic disorder rarely has a later-life onset, and, among those who developed it earlier, the symptoms usually recede by late adulthood. Some older adults report episodes of panic, but these are usually less severe and may coexist with physical illness or symptoms of depression.

Phobic disorders affect some older adults but are more common earlier in life.

Posttraumatic stress disorder can occur at any age and is a common symptom among older combat veterans and former prisoners of war.

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12. OsteoarthritisSymptoms of osteoarthritis typically develop slowly. Pain with use of the involved joint is a common symptom. Stiffness and pain immediately after being sedentary is a feature of osteoarthritis and is referred to as a "gel phenomenon." The morning stiffness of osteoarthritis typically lasts no more than 30 minutes. Hand involvement with osteoarthritis leads to knobby enlargements of the small joints of the fingers.

Treatment- Medication for OAThe pain and stiffness of osteoarthritis can be relieved with over-the-counter pain and anti-inflammatory medication, including aspirin, ibuprofen, or acetaminophen. Pain-relieving creams or sprays can also help when applied directly to the sore area. Persisting pain can be eased by injection of steroids or hyaluronans into the affected joint.Supplements

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While there are limited studies showing significant benefit of glucosamine and chondroitin, some individuals with osteoarthritis feel these food supplements help to reduce their joint pain. Chondroitin can affect the actions of certain blood thinners.

13. Delirium or Acute confusional state Rapid-onset, fluctuating mental status changes may

represent a delirium or acute confusional state.Delirium-related confusion and agitation are usually accentuated later in the day (so-called “sundowning”).

Predisposing factors to delirium include older age, metabolic disturbances, polypharmacy, infections, anesthesia, hip fracture, unfamiliar surroundings with loss of daily routine, sensory understimulation or overstimulation, disruption of sleep-wake cycle, a history of dementia or brain injury, and a number of other physical and psychological stressors.

Delirium generally remits when the precipitating factor is treated or removed.

14. Dementia Population-based research has found that the prevalence of

dementia increases dramatically with age, with estimates that 5 to 7 percent of those over age 65 and nearly 30 percent of those over age 85 suffer some form of this disorder. Up to 20 percent of patients have a partially or completely reversible form of dementia.

The most common types of age-associated dementia are those caused by Alzheimer’s disease and cerebrovascular pathology (most notably vascular dementia—formerly called multi-infarct dementia). Some older adults may have both Alzheimer’s disease and vascular dementia.

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Unlike milder forms of cognitive decline associated with normal aging, the cognitive deficits associated with dementia cause significant impairment in social and occupational functioning.

People with progressive dementias often evidence coexistent psychological symptoms, which may include depression, anxiety, paranoia, and behavioral disturbances.

Treatment- Donepezil, an acetylcholine esterase inhibitor, produces

modest improvements in symptoms of AD patient Arecholine, muscarinic agonist, produces minimal

improvement in cognitive function.

15. Psychotic Disorder Schizophrenia rarely occurs for the first time in older age.

Only 10 percent of people suffering from schizophrenia experience the onset of the disorder after age 40. Consequently, older adults with schizophrenia often have a

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history of chronic psychotropic use and institutionalization. Older age appears to be related to reduction in frequency and severity of positive symptoms of the disorder, such as hallucinations and delusions.

Schizophrenia Treatment –

Medications (Continued)

Mood swings and depression are common in patients with schizophrenia. In addition to antipsychotics, other types of medications are used.

Mood stabilizers include:

lithium (Lithobid) divalproex (Depakote) carbamazepine (Tegretol) lamotrigine (Lamictal)

Antidepressants include:

fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) venlafaxine (Effexor) desvenlafaxine (Pristiq) duloxetine (Cymbalta) bupropion (Wellbutrin)

The most common form of psychosis in later years is paranoia. Hearing loss may be one important risk factor for developing late-life paranoia. Other risk factors are social isolation, a long-standing personality disorder, dementia, and delirium. Paranoia in older adults tends to be characterized by beliefs that are less bizarre than those reported by younger adults. People may be able to function adequately and demonstrate normal cognitive functioning. Unfortunately, because older adults with paranoia often have delusions related to relatives, friends, and caregivers, the

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disorder is especially likely to result in increased social isolation.

16. Sexual DysfunctionNormal age-related changes in sexual functioning can be described as a generally slowed and slightly decreased response to stimulation at every stage of the sexual arousal cycle. However, these changes do not prevent arousal, sexual activities, or orgasm.

The incidence of sexual dysfunction increases with age for both men and women, mostly because of an increase in chronic health problems and increased medication use.

Medication can adversely affect sexual functioning. This is particularly the case with antihypertensive, antipsychotic, anxiolytic, antidepressant, and cardiac medications.

Health problems may also affect sexual functioning. Up to 50 percent of men with diabetes report erectile difficulties, and diabetic women often experience sexual dysfunctions as well. Older men often undergo a surgical procedure to reduce enlarged prostate, known as the transurethral resection of the prostate (TURP). Older age is associated with a higher risk of sexual difficulties after this procedure.

Neurological disorders are sometimes tied to a decline in sexual functioning, including Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, and stroke.

17. Sleep Disorder Sleep problems increase with age, and about half of people

over age 80 complain of a sleep difficulty. Insomnia is a common complaint among older adults, but hypersomnia is

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uncommon. Hypersomnia is characterized by excessive daytime sleepiness or prolonged periods of sleep. It does not refer to the naps that older adults often take.

Because older people may not need to adhere to a daily schedule, they are more likely to experience sleepwake schedule problems

Sleep apnea, episodes during which breathing stops briefly during sleep, increases with age and is a common problem among older adults. Severe apnea may be particularly dangerous because it can trigger rhythm problems of the heart, lead to increased blood pressure, and result in decreased cognitive functioning.

Periodic leg movements may also cause sleep disturbances in later adulthood. This twitching of the legs during sleep usually occurs earlier in the night and lasts from a few minutes to a few hours, often causing the individual to get out of bed repeatedly to relieve the discomfort.

Treatment- Regular sleep times A comfortable bed and quiet room at a comfortable,

temperature A darkened room Regular exercise, but not close to bedtime or late in the

evening A bedroom that is not used for work, watching television, or

other activities not related to sleep other than sex Avoid of stimulants (for example, caffeine, or tobacco),

alcohol, and large meals close to bedtime (avoid 2-4 hours before bedtime if possible)

Many people watch television before falling asleep. TV can be a very stimulating medium and needs to be closely evaluated if it adds to a person's insomnia.

Relaxation techniques such as breathing exercises or yoga No naps during the day

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Try drinking warm milk before bed. It is high in the amino acid tryptophan, which helps induce sleep.

18. Somatoform Disorders Hypochondriasis is the somatoform disorder most likely to be

found in later adulthood. From 10 to 15 percent of older adults exhibit a marked concern about their health and overestimate their level of physical impairment. Hypochondriasis may exist alone or coexist with a number of other disorders, such as depression, anxiety, and dementia.

Older adults with somatoform disorders are at risk for lack of appropriate attention from health care professionals who may minimize symptoms of real physical disorders. Those with somatoform disorders are also more likely to take unnecessary medications and to undergo unnecessary medical procedures, both of which are especially risky for them and may contribute to actual morbidity.

19. Abuse Disorders The prevalence of alcohol abuse and dependence in adults

65 years of age and older ranges from 2–5 percent for men and about 1 percent for women. There is a decline in substance abuse for adults over age 60 years.

Risk factors for alcohol abuse among all adults include genetic predisposition, being male, limited education, low income, and a history of psychiatric disorders, especially depression.

Stressors are more important contributors to late onset alcohol and drug abuse than to early onset abuse.Common stressors that contribute to alcohol and drug abuse in later adulthood include retirement,relocation, death of a spouse or close relative, conflict within the family, financial concerns, and physical health problems.

Older widowers have the highest prevalence rates of alcohol abuse among older adults.

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Regular alcohol consumption may lead to other medical problems for older adults because of the physiological changes that accompany aging. A major problem for older adults who consume excess alcohol is malnutrition, because they may fail to eat a balanced diet.

Excess alcohol consumption may lead to cirrhosis of the liver, one of the eight leading causes of death in older adults.

Another alcohol-related problem is osteomalacia, or thinning of the bones.

Excess alcohol intake is also related to a decrease in the ability of the stomach to absorb food.

The most frequent and serious problem with chronic alcohol use in older adulthood is a decline in cognitive functioning. Chronic alcohol abuse may lead to major declines in memory and information processing.

Over many years of alcohol abuse, the effects of these physical and cognitive changes lead to significant impairment in most persons who survive past middle age. The same is true for those who begin to drink heavily in later life.

The abuse of drugs by older adults typically takes the form of abuse of prescription medications, tranquilizers, and sedatives. One-fourth of medications used in this country are taken by adults over 65 years of age, including prescription drugs and over-the-counter medications. Some of the most commonly used drugs among older adults are tranquilizers and sleeping pills.

Because of physiological changes associated with aging, drug toxicity is more likely in later than in younger adulthood.

Combining alcohol and drugs, especially tranquilizers and sleeping pills, is especially dangerous, as there may be a cumulative depressant effect on the central nervous system.

20. Leg ulcer20

Leg ulcer are common in elderly. There are mainly two types : a. Venous b. Ischaemica. Venous:

Venous ulcers occur in patient with varicose veins who have valvular incompetence in deep veins, due to venous hypertension. It is associated with infection, eczema, and edema.

Treatment:

Elevation of the lower limps Exercise Compression bandages

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Local antiseptic creams when this evidence of infection, with or without steroid

Gell colloid occlusive dressingsb. Ischaemic ulcer:

Ischaemic ulcers occurs due to poor peripheral circulation and occurs on the toes, heels, foot and lateral aspect of the leg. They are painful and associated with sings of lower limb ischaemia.e.g. absent pluse or cold limp. There may be a history of smoking, diabetes or hypertension.

Treatment:

Do not respond well to medical treatment and patients should be assessed by vascular sergeon. OTHER PROBLEMS THAT MAY AFFECT OLDER ADULTS

Adjustment Disorder. The most common stressor that leads to adjustment disorder in later life is physicalillness. Other stressors which often precipitate adjustment disorders among older adults are those associated with late-life losses, e.g., relocation, retirement, financial problems, family problems, and lengthy hospitalization.

Personality Disorders (PDs). Most PDs, particularly those in Cluster B (i.e., Borderline, Narcissistic, Histrionic, and Antisocial) decline in frequency and intensity with age. However, PD presentation may take a modified form, and these “geriatric variants” are associated with difficulties in medical management and psychotherapeutic treatment. For example, the antisocial behavior of older adults may not be manifested in ways that lead to incarceration as with some younger persons with sociopathy, but may be exhibited as selfish, impulsive behavior towards community caregivers, resulting in abandonment of the older adults.

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Bereavement. Most older adults experience the loss of loved ones including spouses, other family members, and friends. While bereavement is a normal reaction to loss, pathological grief may develop. Symptoms of pathological grief among older adults are essentially the same as those for younger adults and include extensive guilt and preoccupation with death, a pervasive sense of worthlessness, marked psychomotor retardation, and functional impairment. The length of time spent in grieving is culturally determined and is also a function of resources of the individual and the circumstances of the death. In the United States, grief usually requires about 2 years for completion, with a great deal of variation around this average.

Elder Abuse. Some older adults are vulnerable to mistreatment by spouses, adult children, grandchildren,and caregivers. Elder abuse is much more likely to occur when the older person is experiencing physical,emotional, or cognitive problems. In a recent study, about 3 percent of community residing older adults reported being abused, including physical abuse, neglect, and chronic verbal aggression. This figure probably underestimates the problem because older adults are less likely to report domestic abuse. Sexual abuse is the most underreported form of abuse among older adults.

References:1. Office for National Statistics. Topic guide to older people. Newport, South Wales, UK: Author. http://www.statistics.gov.uk/ hub/population/ageing/older-people.2. Statistics Canada. Population projections: Canada, provinces, and territories. Ottawa: Author. http://www.statcan.gc.ca/dailyquotidien/ 100526/dq100526b-eng.htm.

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3. Fried LP, Storer DJ, King DE, Lodder F. Diagnosis of illness presentation in the elderly. J Am Geriatr Soc 1991;39:117–23.4. Abrams M. The health of the very elderly. In: Isaacs B (ed) recent advances in geriatric medicine 3. Edinburgh: Churchill Livingstone; 1985.5. Ben-Yehuda A, Weksler ME. Host resistance and the immune system. Clin Geriatr Med 1992;8:701–11.6. Kaye KS, Marchaim D, Chen TY, et al. Predictors of nosocomial bloodstream infections in the elderly. J Am Geriatr Soc 2011;59:622–7.7. Cacchione PZ, Culp K, Laing J, Tripp-Reimer T. Clinical profile of acute confusion in the long-term care setting. Clin Nurs Res 2003;12:145–58.8. Chassagne P, Perol M-B, Doucet J, Trivalle C, Ménard J-F, Manchon N-D, et al. Is presentation of bacteremia in the elderly the same as in younger patients? Am J Med 1996;100:65–70.9. Wasserman M, Levinstein M, Keller E, Lee S. Yoshikawa TT. Utility of fever, white blood cells, and differential count in predicting bacterial infections in the elderly. J Am Geriatr Soc 1989;37:537–43.10. Puxty JA, Horan MA, Fox RA. Necropsies in the elderly. Lancet 1983;1:1262–4.11. Wahba WM. The influence of aging on lung function: clinicalsignificance of changes from age twenty. Anesth Analg 1983;62:764–6.

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