Geriatric care - 25

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Geriatric care by Dr Nikhil Bansal


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GERIATRIC CARE Presented By Dr Nikhil Bansal J.N.M.C.,Wardha



What is GERIATRICS ??????:

What is GERIATRICS ?????? The care of aged is called geriatrics or clinical gerontology .

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The study of the physical & psychological changes which are incidental to old age is clinical gerontology. What is clinical gerontology???




AGEING It is a progressive and generalized impairment of body functions resulting in, loss of adaptive responses to stress and increasing the risk of age-related diseases. People more than 60 yrs are considered elderly. Old age is not a disease but a normal and inevitable biological phenomenon.

Theories of aging:

Theories of aging Genetic theories- somatic mutation of genes. genetically determined life span. cross linkage/loss of important cellular components and DNA. Random damage theories- accumulation of toxic metabolites and free oxygen radicals. reduced physiological capacity and wear-n-tear of cells of vital organs. non-enzymatic glycosylation of proteins.

Branches of geriatrics:

Branches of geriatrics Gerontology Clinical gerontology Social gerontology Geriatric gynecology Experimental gerontology Preventive gerontology

Demography of geriatric population:

Demography of geriatric population World population: current >6.7688 billion(2009) projected >8 billion (by 2025) India has 16.94% of total population(2009) Population of elderly(>65 yrs) in the world: early 20th century-approx 12 million. In 2009-approx 80million. Population of elderly(>65yrs) in India: approx 8% of total population.

Indian population:

Indian population



Physiological changes due to aging and their consequences:

Physiological changes due to aging and their consequences Problems in elderly are multi-faceted and often a single problem may be the result of a complex chain of decompensation of body functions.

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Health problems of the aged :

Health problems of the aged Physical problem Psychological problems Social problem Economical

Physical problems:

Physical problems Ailments % of occurrence Visual complaints 88 % Locomotor system disorders 40 % Neurological complaints 18.7 % Cardiovascular system 17.4 % Source : Report of the Independent Commission on Health in India

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Respiratory system 16.1 % Skin conditions 13.3 % GI tract 9 % Psychiatric complaints 8.5 % Hearing loss 8.2 % Genito-urinary complaints 3.5 % Source : Report of the Independent Commission on Health in India

Visual complaints:

Visual complaints 88% of the complaints in old age is visual problems like Cataract Glaucoma Retinopathy

Eye /Ear:

Eye /Ear Physiological changes Consequences Effects Denaturation of lens protein Cataract Blindness Loss of accommodation Presbyopia Corneal clouding Arcus senilis

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Lax eyelids and reduced lacrimation Ptosis and dry eyes Xerosis Retinal degeneration Defective colour vision Blindness Degeneration of cochlear hair cells Presbyacusis Deafness

Locomotor system disorders:

Locomotor system disorders It forms 40% of the old age complaints They are: Fibrositis Osteoarthritis Rheumatoid arthritis Myositis Neuritis Gout Spondilitis of spine


MUSCULO-SKELETAL SYSTEM Irreversible loss of motor units and fibres Reduced muscle strength Locomotor disability Deposition of fat Loss of mineralisation Osteoporosis Pathological fractures Wear-n-tear of articular cartilage OA and RA Mobility problems

Neurological complaints:

Neurological complaints Neurological problems form 18.7% of the old age complaints These are: Dementia Parkinson's disease Alzheimer’s disease


CENTRAL NERVOUS SYSTEM Degenerative changes Impaired cognition and behavior Alzheimer's disease and other dementias Reduced transmitter substance synthesis Bradykinesia Slow activities Impaired thermoregulation Hypo/hyperthermia

Cardiovascular complaints:

Cardiovascular complaints CVS disorders for 17.4% of the different old age complaints These include: Atherosclerosis Thrombus formation Myocardial Infarction Hypertension

Cardiovascular system:

Cardiovascular system Reduced cardiac myocytes Reduced cardiac output Syncope Reduced nodal activity and conduction Arrhythmias and heart blocks Heart failure Rigid and narrow blood vessels Hypertension Syncope, IHD and stroke

Respiratory complaints:

Respiratory complaints Respiratory condition make 16.1% of the old age complaints These are: Chronic bronchitis Asthma Emphysema

Respiratory system:

Respiratory system Reduced cough reflex and ciliary action Aspiration RTI’s and pneumonias Reduced lung elasticity Dyspnoea COPD, asthma Reduced alveolar surface area Hypoxia/ hypercapnia

Skin conditions:

Skin conditions Skin conditions form a major part of old age complaints Skin conditions include: Senile wrinkles Scaly lesions Scaly dermatosis Blistering diseases Neoplastic disorders

Skin and its appendages:

Skin and its appendages Loss of elasticity of skin Wrinkling Loss of hair Alopecia and baldness Brittleness of fingernails Slurred speech

Gastrointestinal complaints:

Gastrointestinal complaints GI disorders for about 9% of the old age complaints These are: Peptic ulcer Constipation Ulcerative colitis Carcinoma of GIT

Gastro-intestinal tract:

Gastro-intestinal tract Reduced gastric acidity and intestinal motility Non-ulcer dyspepsia and constipation Poor absorption and deficiency states Reduced regenerative capacity of hepatocytes Impairment of metabolism and detoxification Hepatic failure

Endocrine system:

Endocrine system Impaired glucose tolerance hyperglycemia Diabetes mellitus Impaired thyroid function Hypo/hyperthyroidism Disturbed vit.D metabolism Osteomalacia Fractures Reduced sex hormones synthesis Impotence in males and Reproductive organ cancers in females

Hearing loss:

Hearing loss Hearing complaints form about 8.2% of the old age complaints These include Nerve deafness Conductive hearing loss

Genito-urinary complaints:

Genito-urinary complaints These form about 3.5% of the old age complaints They are: Enlargement of prostate Dysuria Nocturia Frequency and urgency of micturation

Genito-urinary tract:

Genito-urinary tract Reduced no. of nephrons Impaired excretion Accumulation of toxins in the body Reduced renal blood flow and reduced GFR Impaired excretion Accumulation of toxins in the body Reduced bladder capacity Urinary incontinence UTI Prostatic hyperplasia in men BHP Frequency

Geriatric Gynecology:

Geriatric Gynecology Atrophy of vaginal and urethral mucosa UTI’s and atrophic vaginitis Carcinoma cervix Weakening of pelvic muscles Prolapse of uterus Ulceration and carcinomatous change


Haematology Reduced bone marrow reserve Anaemias Reduced T-cell function Non-resolving infections Prone to infections Increased synthesis of auto-antibodies Auto-immune disorders

Psychiatric complaints:

Psychiatric complaints These form 8.5% of the old age complaints These include Alzheimer’s disease Depression Anxiety Delirium Schizophrenia Personality disorder Suicide and deliberate self harm


others Atrophy of mucous membrane of mouth Reduced food intake and change of taste and smell Nutritional deficiency states Loss of teeth same as above Decreased no. of taste buds same as above Decreased salivation same as above Decreased sensation of smell same as above



Psychological problems:

Psychological problems More reliable and are independent of age But, elderly patients less willing to talk about psychological problems Pay attention to: anxiety physical discomfort adaptation to a new lifestyle


PSYCHOLOGICAL SYMPTOMS Sleep Interest Guilt (“Are you a burden to others?”) Energy Concentration Appetite Psychomotor changes Suicidality (“Do you wish you could die?”)




INCIDENCE IN ELDERLY MAJOR DEPRESSION 3% community dwelling 14% two years after spouse dies 15% medically ill 25% long-term-care settings

Social problems:

Social problems Abuse Dependancy Insecurity Rehabilitation


Abuse Abuse of the old Mistreatment of older people – referred to as ‘‘elder abuse’’ – was first described in British scientific journals in 1975 under the term ‘‘granny battering’’ The abuse may be of a physical nature, it may be psychological (involving emotional or verbal aggression), or it may involve financial or other material maltreatment.

Elder Abuse:

Elder Abuse It refers to ill-treatment of an elderly person. It can be-physical abuse -psychological abuse -financial abuse -sexual abuse. It is a very sensitive issue and requires a high index of suspicion.

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Abuse is generally divided into the following categories: Physical abuse – The infliction of pain or injury, or physical or drug induced restraint. Psychological or emotional abuse .

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Financial or material abuse – The illegal or improper exploitation or use of funds or resources of the older person. Sexual abuse – Non-consensual sexual contact of any kind with the older person. Neglect – The refusal or failure to fulfill a care giving obligation. This may or may not involve a conscious and intentional attempt to inflict physical or emotional distress on the older person.


DEPENDANCY PHYSICAL, FINANCIAL, FUNCTIONAL and other dependancy has a major affect on the self esteem of the old.


Insecurity Insecurity of being abandoned by their children.


Rehabilitation This is one of the main problem of old age.

Economical problems:

Economical problems No or inadequate source of income Total economical dependence on children for their daily needs

Need for geriatrics:

Need for geriatrics Elderly population will keep on rising due to advancing medical technology. Diseases present atypically and at an earlier stage. Often a multi-organ system involvement. Worsening of pre-existing diseases are frequent. Burden over the health care system. Burden over the nations economy.

Health Care Expenditure :

Health Care Expenditure Elderly are seen as consumers of services rather than the producers. The world geriatric population accounts for >1/3 rd total health care expenses. In the US >12% geriatric population accounts for almost 30-35% of personal health care expenditure and by yr 2040 will use nearly half of the nations total personal health care resources.



Prevention and Management of Health Problems in Geriatrics:

Prevention and Management of Health Problems in Geriatrics One of the most important measure of how civilized we are is how we treat our elderly. According to Sir James Sterling Ross ”you do not heal old age, you protect it, you promote it and you extend it.”

Components of assessment:

Components of assessment Physical Functional Psychological- cognitive affective Socio-economical Environmental

Assessment of the elderly:

Assessment of the elderly AIMS – Cost effective use of services. Maintaining the elderly active. Providing quality care up to the max. satisfaction of the user.

Evaluation of newly discovered risk factors:

Evaluation of newly discovered risk factors Severe functional disability- hospitalization and detailed assessment. Mild to moderate dysfunction- cause found- drugs+ caregiver support+ rehabilitation cause not found caregiver support+ rehabilitation. Functional evaluation reveals good function- assurance.

Multi-disciplinary Geriatric Assessment (Geriatric Clinic):

Multi-disciplinary Geriatric Assessment (Geriatric Clinic) The concept of geriatric clinic suits best for assessment and management of diseases and disabilities in the elderly. Components- Gerontologist/Physician Physiotherapist Occupational therapist Ophthalmologist Audiologist Psychiatrist Dietitian Nurse and Social worker.

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Scope- This facility is available only at tertiary and few secondary health care centers. In a primary health care set-up, a trained physician, a trained nurse and a physiotherapist should be able to assess the elderly fairly well.



Preventive Health Care in Elderly:

Preventive Health Care in Elderly The role of prevention in geriatrics is to delay the onset of age-related decompensatory problems of body functions. It includes- Primary prevention. Secondary prevention. Tertiary prevention.

Primary prevention:

Primary prevention Health habits- Inadequate nutrition Addiction to smoking & alcohol Lack of exercise Inadequate sleep Predisposing factor for coronary heart disease Modifiable- smoking, obesity, HT, DM, hyperlipidemia, hypercholesterolemia, etc. Non-modifiable- age, sex, genetic factors, etc.

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Immunization- Influenza Pneumococcal Tetanus. Osteoporosis prevention- Calcium and vit-d supplementation. Hip protector devices.

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Injury prevention Burns accidents and falls should be prevented by;- Removal of obstacles Keep the floor dry Bright lighting Flat shoes Railing/holding bars in bathrooms Low level switches Easy and safe access to water .

Secondary prevention:

Secondary prevention Screening helps in early detection of modifiable risk factors and their adequate management. Hyper/hypotension, diabetes mellitus Dental problems Drug adverse effects Cancers Infections Nutritional deficiency states Eyes /ears Screening


Early detection and treatment is an important step in secondary prevention of disease and disability.

Tertiary prevention:

Tertiary prevention It deals with rehabilitation and caregiver support. Rehabilitation is a problem solving process focused on the patients functional abilities. Rehabilitation team includes; a physician, a physiotherapist, an occupational therapist, a speech and language therapist, a psychiatrist, a dietitian, a nurse and a social worker.



Interventions in rehabilitation:

Interventions in rehabilitation Hard interventions- drugs. physiotherapy. occupational therapy. aids and adaptation. speech and language therapist. Soft interventions- advice. education. counseling. encouragement. listening.

Supporting the caregiver:

Supporting the caregiver Social attitude Physicians support Organization of “day care centers” Hospitalization in c/o chronic illness Counseling the caregiver

Prevention and management of elder abuse:

Prevention and management of elder abuse Assessment of physical and mental capacity of the elderly. Assessment of general quality of care Assessment of relation with the abuser Assessment of abusers for their problems Counseling the abusers Institutionalization in old age homes



Laws in India to protect the old people:

Laws in India to protect the old people Section 125(1) (d): If any person having sufficient means neglects or refuses to maintain his father or mother, unable to maintain himself or herself, a Magistrate of the first class may, upon proof  of such neglect or refusal, order such person to make a monthly allowance for the maintenance of his wife or such child, father or mother, at such monthly rate not exceeding five hundred rupees in the whole, as such Magistrate thinks fit, and to pay the same to such person as the Magistrate may from time to time direct.

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Section 125(3): If any person so ordered fails without sufficient cause to comply with the order, any such Magistrate may, for every breach of the order, issue a warrant for levying the amount due in the manner provided for levying fines, and may sentence such person, for the whole or any part of each month’s allowance remaining unpaid after the execution of the warrant, to imprisonment for a term which may extend to one month or until payment if sooner made

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Sl. No. Name of the Ministry/Department Facilities/Benefits given to Senior Citizens 1 Ministry of Social Justice & Empowerment Ministry of Social Justice &Empowerment announced the National Policy on Older Persons which seeks to assure older persons that their concerns are national concerns.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 2.The Ministry is also implementing following schemes for the benefit of Senior Citizens: The Scheme of Assistance to Panchayati Raj Institutions/Voluntary Organisations /Self Help Groups for Construction of Old Age Homes/multi-service centres for older persons.  Under this Scheme, one time construction grant for  old age homes/multi-service centre is provided.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens b. An Integrated Programme for Older Persons has been formulated by revising the earlier scheme of “Assistance to Voluntary Organisations for Programmes relating to the Welfare of the Aged”.  Under this Scheme, financial assistance up to 90% of the project cost is provided to NGOs for establishing and maintaining old age homes, day care centers, mobile medicare units and to provide non-institutional services to older persons.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 2. Ministry of Rural Development 1.Under the National Old Age Pension Scheme,  Central Assistance of Rs . 75/- p.m. is granted  to destitute older persons above 65 years.  This Scheme has been transferred to the State Plan w.e.f . 2002-03. 2.Under the Annapurna Scheme, free food grains (wheat or rice) up to 10 kg.  per month are provided to destitute older persons 65 years or above.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 1 Ministry of Social Justice & Empowerment Ministry of Social Justice & Empowerment is the nodal Ministry responsible for welfare of the Senior Citizens. It has announced the National Policy on Older Persons covering all concerns pertaining to the welfare of older persons.  The National Policy on Older Persons recognizes a person aged 60 years and above as a senior citizen.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 2 Ministry of Finance Income tax rebate upto an income of Rs . 1.85 lakh p.a. Higher rates of interest on saving schemes of senior citizens. A Senior Citizens Savings Scheme offering an interest rate is 9% per annum on the deposits made by the senior citizens in post offices has been introduced by the Government through Post Offices in India doing savings bank work.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 3 Ministry of Road Transport and Highways i) Reservation of two seats for senior citizens in front row of the buses of the State Road Transport Undertakings. ii) Some State Governments are giving fare concession to senior citizens in the State Road Transport Undertaking buses and are introducing Bus Models, which are convenient to the elderly.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 4 Ministry of Health & Family Welfare Separate queues for older persons in hospitals for registration and clinical examination.

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Sl. No. Name of the Min./Department Facilities/Benefits given to Senior Citizens 5. Department of Telecommunications i) Faults/complaints of senior citizens are given priority by registering them under senior citizens category with VIP flag, which is a priority category. ii)  Senior citizens are allowed to register telephone connection under N-OYT Special Category, which is a priority category.

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Name of the Min./Department Facilities/Benefits given to Senior Citizens 6 Ministry of Railways a) Indian Railways provide 30% fare concession in all Mail senior citizens aged 60 years and above. b) Indian Railways also have the facility of separate counters for Senior Citizens for tickets. c) Ramps for wheel chairs movement are available at the entry to important stations. d)  Specially designed coaches with provisions of space for wheel chairs, hand rail and specially designed toilet for handicapped persons have been introduced.

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Name of the Min./Department Facilities/Benefits given to Senior Citizens 7 Ministry of Civil Aviation 1.  Indian Airlines is providing 50 per cent Senior Citizen Discount on Normal Economy Class fare for all domestic flights to Indian senior citizens who have completed the age of 65 years in the case of male senior citizens and 63 years in the case of female senior. 2.  Air is offering discount to senior citizens of 60 plus on flights to , and . Further, Air has now decided to reduce the age of 60 plus .

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Name of the Min./Department Facilities/Benefits given to Senior Citizens 8 Ministry of Consumer Affairs, Food and Public Distribution i) Under the Antyodaya Scheme, the Below Poverty Line (BPL) families which also include older persons are provided food grains at the rate of 35 kgs. per family per month. The food grains are issued @ Rs.3/- per kg. for rice and Rs.2/- per kg. for wheat. (ii)  Under the Annapoorna Scheme being implemented by the States/UT Administration, 10 kgs. of food grains per beneficiary per month.

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Name of the Min./Department Facilities/Benefits given to Senior Citizens 9. MCD(municipal cooperation of India) (i)MCD, has opened a separate counter to facilitate the senior citizens for submission of property tax bills. (ii) A rebate of 30% of the property tax due on the covered space of a building up to one hundred sq. mtrs . of the covered space has been allowed by the corporation in the case of any self-occupied residential building singly owned by a man who is 65 years or more in age.

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Facilities/Benefits given to Senior Citizens 10 Miscellaneous (i) Courts in the country accord priority to cases involving older persons and ensures their expeditious disposal. (ii)  Under the Old Age Pension Scheme, monthly pension is given at variable rates to the destitute old by various State Governments/UT Administrations.



Helpage India :

Helpage India Helpage India supports the following programmes to make life easier for older people: Free cataract operation Mobile Medicare units Income generation and micro-credits Old age home and day care centers Adopt a grant parents Disaster mitigation


References Park Textbook of Preventive and Social Medicine Oxford Book of Public and Health New Oxford textbook of Psychiatry


Acknowledgement We would like to thank the PSM dept and respected HOD, Dr. Goyal Sir for giving us this wonderful oppurtunity to learn about and present this assignment on the topic Geriatric care. We would like our guide Dr. Mudey Sir for his guidance Special thanks to Dr. Wagh sir and Dr. Dhawale sir.



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