Common Clinical disorders in elderly

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Presented By
Farzana Sultana
BPH : 04806682
Department of Pharmacy
Stamford 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
responseto 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.
 Urinaryincontinence 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 pneumoniain the elderly, while Mycoplasma
pneumoniaeis virtually non-existent. Gram-negative bacilli are the
predominant organisms in aspiration pneumonia, followed by anaerobic
bacteria and Staphylococcus aureus.Symptomsof 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 urinarytract infections (UTIs) in the elderly. UTIs may present
with atypical symptoms, suchas worsening or new-onset incontinence,
lethargy, or confusion.
 Sensitivity and specificity of blood cultures is not influenced by age. The
relationship between age and antimicrobial resistance in blood stream
infectionsvaries by organism. Blood stream infections due to methicillin-
resistant Staphylococcus aureus (MRSA) are more prevalent in the elderly.
However, vancomycin resistant enterococcalinfections are not.

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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.
Syncopeis a particularly important symptom ofacute 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
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

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 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.Thedendritic processesof 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 secondaryto
cerebrovascular disease.

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Treatment:
Medication
Anti-seizure medications are the most common treatment used to reduce or prevent
seizure activity.
VNS
VNS 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.
Surgery
In some patients who have partial or complex partial seizures and don'trespond to
medical therapy, brain surgery may be an alternative treatment.
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 symptomsof PD like constipation, incontinence, falls, orthostatic

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hypotension, sweating abnormalities, dysphagia, dribbling, and psychiatric
disorders may be more common at presentation.
Treatment-
Medication
Levodopa.
Other Medications
Some drugs are used in combination with carbidopa-levodopato either inhibit
dopamine breakdown by the bodyor to improve the effectiveness of carbidopa-
levodopa. Azilect, Eldepryl,and Zelapar inhibit dopamine breakdown while
Entacapone and Tasmar can improve the effect of carbidopa-levodopa.
Surgery: DeepBrain Stimulation
Another 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 mucosaldisease. Older individuals
with GERD may have greater respiratory involvement.

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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-
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.
Exercise
Exercise 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.
Surgery
Patients 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 productionof 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 symptomsin 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. PTUalso 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 isotopeiodine 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 dosecorticosteroids
 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 occurin 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.
 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

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are less likely to complain of depressionor feeling sad. Feeling hopeless is
often an important indicator of depressionamong 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 secondaryto depression.
 Panicdisorder 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.
 Posttraumaticstress disorder can occurat any age and is a common
symptom among older combatveterans and former prisoners of war.
12. Osteoarthritis
Symptoms 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.

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Treatment-
Medication for OA
The 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
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.

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 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.
 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.

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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
history of chronic psychotropic use and institutionalization. Older age
appears to be related to reduction in frequency and severity of positive
symptomsof 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)

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 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 disorder is especially likely
to result in increased social isolation.
16. Sexual Dysfunction
Normal age-related changes in sexual functioning can be described as a generally
slowed and slightly decreased responseto 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
procedureto 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.

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

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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. Thosewith somatoformdisorders are also more
likely to take unnecessary medications and to undergo unnecessary medical
procedures, bothof 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 substanceabuse 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
spouseor 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.
 Regular alcohol consumption may lead to other medical problems for older
adults because of the physiological changes that accompanyaging. 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.

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 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 ulcer
Leg ulcer are common in elderly. There are mainly two types :
a. Venous
b. Ischaemic
a. Venous:
Venous ulcers occurin patient with varicose veins who have valvular
incompetence in deep veins, due to venous hypertension. It is associated with
infection, eczema, and edema.

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Treatment:
 Elevation of the lower limps
 Exercise
 Compressionbandages
 Local antiseptic creams when this evidence of infection, with or without
steroid
 Gell colloid occlusive dressings
b. Ischaemic ulcer:
Ischaemic ulcers occurs due to poorperipheral circulation and occurs onthe
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.

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OTHER PROBLEMS THAT MAY AFFECT OLDER ADULTS
 Adjustment Disorder. The most common stressorthat 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.
 PersonalityDisorders (PDs). MostPDs, 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.
 Bereavement. Mostolder adults experience the loss of loved ones including
spouses, otherfamily 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 preoccupationwith death, a pervasive sense
of worthlessness, marked psychomotorretardation, 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.

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