A Holistic Approach to Geriatric MedicineProf. Dr. S. N. Ojha M.D Phd
Geriatrics is defined as department of medicine dealing especially with the problems of ageing and disease of elderly. It aims to promote health and to prevent and treat diseases & disabilities in older adults
The term itself can be distinguished from gerontology, which is the study of the aging process itself.
Ageing is a slow process that refers to the impact of passage of time on structure and function of different systems of body.
“Geriatrics” is cognate with Jara in Sanskrit which also means old.
JARA – OLD AGE
– 60 Years (Charaka )
– 70 Years (Sushruta)
– 65 Years (W.H.O.)
Maximum Life Span Period
– 100 years Ayurvedic and contemporary ancient Indian literature
– 125 years (Modern Science)
AYU V/S VAYA :
– Ayu – Chronological Age
– Vaya – Biological Age
- JAYAS (That Which Has Grown)
- VARSHIAS (Fully Evolved Or Matured)
- JYESHATHA (That Which Is Older In Age)
- VARISHTH (That which is many years old)
- Other Synonyms Used For Old Age Are:
JARAN, JARATI, JARAUT, BRIDH
- Old Age Female are also referred as :
NISHAPHALA, GATAARTAVA, PILANKANI, SENESCENCE
l World population of the elderly is increasing and by the year 2050, adult older than 65years will comprise 1/5th of the global population.
l In India 3.8% population are older than 65 years of age.
l It is estimated that the likely number of old age people in India by 2016 will be around 113 million
Ageing A Continuous Process
Acharya Sharangdhara described decade wise ageing.
|2||Vriddhi||Growth & Development||Kashmari, Bala|
|4||Medha||Sharpeness in perception||Shankhapushpi|
|5||Twak||Skin & Appendages||Bhringraj, Jyotismati|
|6||Drishti||Visual Acuity||Trifala, Shatavari|
|7||Shukra||Potency & Fertility||Atmagupta, Ashwagandha|
|9||Buddhi||Cummulative, Intellect & Cognitive functioning||Brahmi|
|10||Karmindriya||Physical capacities||Bala, Ashwagandha|
l Finally there is loss of ultimate i.e. functions of mind and life substance.
l The process of ageing begins the day we are born or even conceived and continues till death
-“Womb to Tomb” concept of ageing.
l Kalasya parinam – Swabhawaja Or Essential By Charak
l Other Ayurvedic Literature Mentions Few Specific Hetu For Jara Especially Aakal-Jara
l Pantha – Excessive Travelling Or Physical Activities
l Sheetam – Taking Unwholesome Or Chilled Food
l Having Sexual Desires For Olderwomen Or To Remain Sexually Active Even After Onset Of Old-age.
l Kaddana : Taking Tubers In Excess In Food.
l Manaspratikoolta; To Remain Under Continuous mental stress.
l Overindulgence of Gramyahara
l Factor related to diet and dietetic habits
l Factor related to daily routine activities
l Factor related to psyche and personality
l Provocation of Vata Dosha
l Sithali bhawanti Mamsani
l Vimunchyate Sandhya
l Vishandate cha na alpameda
l Shukram na pravartate
Features of Jara
l Glayti (Physical and mental exertion)
l Sidati (Muscular laxity of the body)
l Nidratandralasya samanvita (Excess sleepiness, drowsiness and laziness)
l Nirutsaha (Loss of enthusiasm)
l Swasiti (Breathlessness)
l Asamartha chestanam sharir- manasinam (Deterioration of physical and mental activity)
l Nashta smriti budhichaya (Loss of memory, intellect and lusture of the body)
l Roganam adhisthanabhuta (Becomes seat of diseases)
l Nasaravamayu (Incomplete lifespan)
l Sharirshaktiheena- Regression Of Physical Capacities
l Smiritinasha – Diminishing Memory
l Manasik Glani – Loss Of Cheerfulness And Alertness
l Valinam – Appearance Of Wrinkles
l Palitya – Greying Of Hair
l Dantashaithilya – Loosening Of Denture
l Swabhava Vipparya – Change In Personality Components.
l Kasa Swasa Pravritti – Proneness To Repeated Coughs And Dyspnoea On Effort
l Sarvakriya Asamarthata ; Loss Of Physical, Perceptual And Mental Faculties
FEATURES OF VATAVRIDDHI IN OLD AGE
FEATURES OF DOSHA, DHATU AND MALA KSHAYA IN OLD AGE
l Mandachesta – Slowness Of Physical And Mental Activities
l Aapraharsh – Unsatisfying Nature
l Mudhasangyata – Slowness Of Perception And Resolution
l Nishprabhava – Loss Of Lusture
l Rukshata – Dryness And Wasting
l Sandhisaithilya – Unstability Of Joints
l Manoshunyata – Lack Of Ideation
l Shramm – Easy Fatigability
l Shirashaithilya – Prominant And Tortuous Blood Vessels
l Sfeek, Greeva, Udar Shuskata : Wasting Of Muscles
l Asthi Shool – Degenerative Bone Disease
l Klaibya – Erectile Dysfunctions And Sterility
FEATURES OF OJA KSHAYA IN OLD AGE
l Durbalata- General debility
l Rukshata – Dryness Of Skin
l Vyathitendriya – Ailments And Diminished Capacities Of Indriyas.
l Duschaya – Lack Of Lusture
l Durmana – Decreased Mental Capacities
Examination plays an important role in older people since findings which are abnormal in the younger people are relatively common in the aged person.
Thus CROWN TO HEEL Examination Is Very Important
1) Face & Full Body Posture –
Should be noted to rule out CVA, TIA; since with age tendency of atherosclerosis, hypertension etc. increases which can lead to above problems.
2) Eyes –
● Blurred vision,
● Lens opacification
3) Ears –
● Difficulty discriminating words
● High frequency activity
● Thus bone conduction, Air conduction should be noted
4) Dentures –
● True Or False
● If True – The condition, strength, activity noted.
● If False – The proper denture set may be given.
5) Respiratiory System –
● With age decrease lung elasticity and increase chest wall stiffness is seen leading to ventilation / perfusion mismatch and ↓ PO2 leading to Dyspnea; hypoxia.
● Older women are more likely to have breast cancer.
● Thus breast examination is important which may be overlooked by an old lady.
7) Cardiovascular System :
● Decrease ß-adrenergic responsiveness – Decrease cardiac output and heart rate response to stress → heart failure.
● Systolic murmur of aortic sclerosis is common.
● 4th heart sound in elderly does not imply significant cardiac disease.
● Peripheral pulse – to rule out peripheral vascular disease, coarctation of aorta etc.
● B.P. with Postural (on sitting and standing) – to rule out postural hypotension.
8.) Gastro intestinal system :
● Decrease hepatic function – Cirrhosis
● Decrease Gastric acidity – B12 deficiency, Iron deficiency, Anemia
● Decrease Colon motility – Fecal impaction.
● Decrease Anorectal function – Fecal incontinence
● Organomegally should be noted
● Prolapse of rectum should be noted
9) Renal System
● Increase frequency – Diabetes Mellitus
Urinary tract infection
● Nephropathy is also important complication with ageing.
● Distended bladder is mainly to be looked upon and treated.
● Incontinence is to be noted which may be due to Diabetic, Detrusor overactivity etc.
10) Genito-Urinary System
● Vaginal / Urethral, Mucosal atrophy
● Senile Vaginitis – yellow white discharge
● Prolapse of Uterus, Urethra, bladder, Intestine due to weakness of muscle, less of oestrogen etc. is common.
● Dyspareunia (difficult coitus)
● Impotency/ Erectile dysfunction Both should be ruled out as complication of Diabetes Mellitus. Depression or Neuropathy.
11) Musculo Skeleton System
● Joint movement → rule out O.A., R.A.
● Muscle strength → wasting should be noted.
● Bony growth → osteoarthritic changes should be noted.
● Tenderness at Intervertebral disc is as important
12) Nervous System
● Reflexes – hyper/hypo – rule out upper / lower motor neuron deformity.
● Stiffer gait – Indicating Parkinsonism due to decreased dopaminergic synthesis.
● Rombergs sign – to rule out peripheral / central sensory deficit.
13) Endocrine System
● Impaired Glucose tolerance – Diabetes Mellitus
● ↓ Thyroxine – Thyroid Dysfunction
● ↓ Vitamin D absorption – Osteomalacia, Fracture
● ↓ Testosterone – Impotence
14) Mental Status
● Mild degree of Dementia, usually retain their social graces and may mask intellectual impairment by cheerful manner.
● Cognitive status i.e. identifying of person, object, self.
● Early awakening, sleep apnea
● Tension or continuous thinking or solved / unsolved topics.
● delirium etc are to be noted
l CARE, ATENTION, LOVE can solve nearly 50% of geriatrics problems
l It is the mental instability which is one of the important cause of Ageing Disease.
l If a careful attention, love is given, and if we are able to remove the loneliness in life we can treat major problems.
l Depression, confusion state, sleep apnea, early awakening, can be treated with care.
l Careful listening to his problems, stories,
l Serving him, entertaining him / her
l Keeping them busy in things which are interesting for them and which are helpful.
l Samshodhan is mandatory before Rasayan therapy but in aged person Vaman, Virechan are contraindicated.
l Mrudu Virechan with help of aragwada, draksha is helpfull
l Acharyas believe that if panchakarma is essential mrudu samshodhan is indicated specially mrudu basti
l Our Acharya have listed the rasayan kalpa for increasing good and healthy life span.
l Medicine which will improve the activity of organ as well as do the nutrition of the organ.
l Amalaki shatavari etc are the ones which prevent free radical formation (Aam) act as antioxidant and increase life span
l Method to control / slow down /arrest the ageing process in human being.
l Unique because of its ability to promote longevity and influence all expect of health.
l Main utility in functional and degenerative disorders that have chronic or long standing nature.
l Ashwagandha (Withania somnifera) used as herbal adaptogen containing. Withanotides and other alkaloids which stimulate the immune system.
l Guduchi (Tinospora cordifolia) a rich source of natural vitamin C that has been proved to be effective in inhibiting the growth of bacteria and in building up the immune resistance, it also increases the killing ability of macrophages
l Gokshura (Tribulus terrestris) contains saponins that may improve the heart function by dilating coronary arteries, thereby boosting circulation to heart
l Arjuna (Terminalia arjuna) increases HDL to total cholesterol ratio and an overall improvement in cardiovascular profile
l Haritaki (Terminalia chebula) a very rich content of Vitamin C and has strong anti-mutagenic activity.
l Kapikacchu (Mucuna pruriens) a good natural source of L. Dopa maintains optimum performance of nervous system
l Kakamachi (Solanum nigrum) suppresses the oxidative degradation of DNA and therefore has a hepatoprotective
l Kasani (Cichorium intybus) has a inhibitory effect on free radical induced DNA damage.
l Kumkuma (Crocus sativus) contains number of carotenoid pigments generally known for their antioxidant properties. It is also a natural source for Riboflavin and Thiamine.
l Guggulu (Commiphora mukul) increases WBC count and has a strong immuno-modulating properties.
l Garcinia (Garcinia cambola) contains biologically active compounds Hydroxy Citric Acid which inhibits synthesis of lipids and fatty acids. It contains significant amount of Vitamin C and used as heart tonic.
l Yashtimadhu (Glycyrrhiza glabra) acts as anti mutagen preventing damage to genetic material that can eventually result in cancer.
l Meshashringi (Gymnema sylvestre) increases insulin production, regeneration of pancreas cells and the site of insulin production.
l Similarly herbs like Shatawari (Asparagus racemosus)
l Vridha daraka (Argyreia speciosa)
l Nagarmusta (Cyperus scariosus)
l Shigru (Moringa pterygosperma) contains pterygospermin an antibiotic like substance
l Jatamansi (Nardostachys jatamansi)
l Pippali (Piper longum)
l Sunthi (Zingiber officinale)
l Musali (Asparagus adscendens)
l Mandukaparni (Centella asiatic)
l Bhringaraj (Eclipla alba)
l Ghrut, taila internal & external use is essential for the elderly people
l In general vatadosha samanya upakrama should be followed which can reduce dhatukshaya janya vataprakopa
l Shiroabhyanga & shirodhara are useful in mental stress.
l Medicines reducing hypertension, atherosclerosis D.M etc. should be taken according to medical advice.
l Dose of insulin or hypoglycaemic drug should be given depending on FBSL & PP BSL in Diabetic person since tendency of patient going in hypoglycaemic / non–ketotic hyperosmolar shock is more
l Digoxin may induce depression with normal serum levels.
l Sympathominetics may precipitate urinary retention
l Iatrogenic drug reaction should be noted
l Diet should include
l Vegetables – they decrease inflammation
l Cabbage. Cauliflower, Potatoes, Tomatoes, Asparagus which are Glutathione rich foods. In fact without glutathione, other antioxidants such as vitamins C & E cannot do their job and protect you adequately against disease.
l Fish are the natural resource of omega – 3 fatty acids it helps to decrease inflammation.
l Cod liver Oil in effective in treating arthritic joint pain and even slowing or reversing the destruction of joint cartilage
l Omega 3 fatty acid is present in Mackerel, Salmon, Sardines, Tuna Whitefish.
l Use of flaxseed oil in cooking is a good source of Omega 3 fatty acids.
l Olive oil has high concentrations of unsaturated fatty acids which decreased inflammation.
l Soya-bean decreases pain, it has other great benefits including being dairy free, low in saturated fat and excellent meat substitutes. It decreases the rate of heart diseases, breast cancer, prostate cancer and osteoporosis.
l Fruits such as Grapes, Oranges, Peaches watermelon are good source of glutathione.
l Pineapple contains enzyme called bromelain which help reduce inflammation mainly related with osteoarthritis and rheumatoid arthritis
l Flavonoid are a family of more than four thousand compounds that include polypherols and they give colour to fruits and vegetables. These nutrients are powerful antioxidants and may hold key to disease prevention.
l Green tea, onions, apples, soy and grapes are rich source of flavonoid.
l Milk must be the most important dietary content of adult.
l 1 cup (250 ml) of 2%-fat milk contains 285 mg of calcium, which represents 22% to 29% of the daily recommended intake (DRI) of calcium for an adult.
l Depending on the age, milk contains 8 grams of protein, and a number of other nutrients (either naturally or through fortification) including:
l Biotin, Pantothenic acid, Iodine, Potassium, Magnesium, Selenium
Thiamine, Vitamin A, Vitamin B12, Riboflavin, Vitamins D, Vitamin K
l Calcium from dairy products has a greater bioavailability than calcium from certain vegetables, such as spinach.
l Studies show possible links between low-fat milk consumption and reduced risk of arterial hypertension, coronary heart disease, colorectal cancer and obesity.
l Overweight individuals who drink milk may benefit from decreased risk of insulin resistance and type 2 diabetes.
l Milk is a source of Conjugated linoleic acid.
l It appears to be effective at promoting muscle growth
Treatment & Prevention are more effective for example
l Benefits of treatment of Hypertension prevent chances of T.I.A.
l Immunization against influenza & pneumococal pneumonia.
l Increase bone calcium density to prevent fracture.
l Improve balance, strength of legs, reduce peripheral oedema.
l Eliminate environmental hazard, prevent accident
l Replete nutritional deficit.
l Prevent adverse modification which induce orthostatic, confusion, extrapyramidal stiffness
l Give proper lens, improve vision.
l Reduce extra physical mental stress
l Give thrombolytic, ß-Blocker to prevent thrombus etc.
l Endocrine supplement like thyroxine, oestrogen etc.
l ↑ Calcium Supplement and other nutritional component
l Counseling is important
LOVE THEM AND LET THEM LIVE LONG AND HEALTHY LIFE.
l Geriatric nursing is the specialty that concerns itself with the provision of nursing services to geriatric or aged individuals.
l Geriatric nursing
l . Due to their complexity, aged people always deserve personal attention.
l Nurses address physical, psycho social, cultural and family concerns as well as promoting health and emphasizing successful aging.
l Life expectancy is rising at rates which call for the proper preparation of nurses to take good care of the rapidly increasing number of the aged.
l . Geriatric medications need to be managed so as to avoid too much use of medicine since this group receives a lot of medication if poor care is taken.
l Multiple medications can cause a variety of drug interaction in older people.
l Pressure injuries
l A pressure ulcer is a lesion caused by unrelieved external pressure resulting from occlusion of the blood flow, tissue ischemia and cell death.
l Pressure ulcers are often viewed as a complication of an acute or chronic illness.
l The older people have an aged skin and due to exposure to the sun the skin wrinkles, epidermis thins, blood vessels recede, dermal-epidermal ridges flatten and the skin appears thin and fragile.
l . When treating an ulcer wound treatment should focus on wound healing.
l For a chronic, non healing ulcer, comfort should be a top priority.
l For pressure injury careful positioning padding to reduce the risk of pressure ulceration is critical..
l Cardiovascular disease
l Cardiovascular disease is common in 50% of the population over the age of 65, and accounts for 40% of deaths in this group
l When diagnosing look out for cases of fainting, continuous chest pain, nausea, shortness of breath, rapid heart rate, rapid weight gain, pain in the abdomen, swelling of legs among others. Then address the issue of hypertension, high blood cholesterol, diabetes, obesity and overweight, smoking, hereditary issues.
l Treatment includes medication and physical exercises.
l Respiratory issues
l Nurse should draw a plan for treatment which includes working with other specialties like heart experts.
l Genitourinary issues
l Nurses should be careful with the language while carrying diagnosis so they can obtain as much information as possible.
l Diabetes melitus
l Nurse should emphasize nutrition and exercise which are vital for victims.
l For older people monitoring for complications which can lead to lower extremity amputation, hypertension, myocardial infarction, stroke, vision loss, or nephropathy should be carried out especially in type 2 diabetic patient.
l . Nurse Practioneers have a responsibility to evaluate and manage thyroid disorders by applying strategies specific to older adults.
Ethical and medico-legal issues
l Elder abuse. Elder abuse is a general term used to describe certain types of harm to older adults
l Power of attorney (endurable & durable). A power of attorney (POA) or letter of attorney in common law systems or mandate in civil law systems is an authorization to act on someone else’s behalf in a legal or business matter
l End of life issues & Do Not Resuscitate (DNR) orders.
l Euthanasia. Euthanasia (from the Greek meaning “good death”: ευ-, eu- (well or good) + thanatos (death)) refers to the practice of ending a life in a painless manner