Dra. Mariana Carné
In recent years, there has been an increase in the aging rates of the population due, among other reasons, to improved hygiene - dietary and sanitary conditions. Therefore, the doctor is faced daily with the problem of old age, both in the office, and in the short or long stay hospitalization.
This chapter reviews the general ideas that should be taken into account when consulting a geronte, since they require a wider diagnostic and therapeutic appreciation than a young patient. When evaluating an older adult, a multidisciplinary approach should be taken, quantifying the functional and psychosocial and medical problems and abilities of the elderly individual, with the intention of reaching an extensive treatment plan and long-term follow-up.
Old age is not a disease, but the specific characteristics of the elderly lead to greater morbidity. Aging produces a series of physical and psychological changes that make this stage of life difficult. Three types of factors are interrelated in the genesis of these changes. The first is a consequence of physiological changes that do not occur synchronously. The second factor is made up of the sum of acute and chronic diseases that leave their mark over time. And the third derives from the impact that environmental and psychosocial events have on the individual.
After the age of 60, the frequency of some type of disability doubles, and after the age of 80 that number triples. This allows us to consider physical, mental and social disability in the elderly, one of the great epidemics that the planet will have to face in the coming years.
Geriatric medicine implies knowledge of a series of characteristics of this population, which must be known to provide quality care:
- It constitutes a very heterogeneous group, there is an important individual variability because each individual ages differently, which results from the interaction of intrinsic and extrinsic factors that will be related to the social, economic, cultural and environmental aspects.
- Some diseases present differently than they do in middle-aged adults.
- Pluripathology is frequent, which generally conditions polypharmacy with the risk of producing iatrogenesis.
- There is a higher prevalence of degenerative diseases and chronic diseases, as age increases.
- When they require caregivers, their overload can generate mistreatment or an inadequate institutionalization that must be detected in time.
- It implies the greater use of health and social resources.
- Greater need for rehabilitation.
- The health problems in this group correspond to multiple causes and require a multidisciplinary approach, which differs from the traditional clinical model.
- Many times he is faced with situations that generate true ethical dilemmas.
- The individual may consult late for considering health problems as age-specific.
- Treatment is often focused on regaining function
The anatomophysiological changes that occur during the aging process are:
Skin and bushes: the skin loses its elastic tissues, becomes paler and loses turgidity. Wrinkles appear. The skin on the back of the hand becomes cold, shiny, and fragile. They appear purple spots (senile purple) due to the rupture of vessels due to the fragility of the capillaries, and pigment spots (senile lentigines). Senile sebaceous adenoma, can be seen on the face, is yellowish, flat, depressed in the center, 2 to 3 mm. diameter. Ruby nevi appear on the trunk and abdomen.
The hair loses its usual color and gray hair appears. The loss of this is more marked in man. After age 25 the implant line begins to recede, widening the forehead. Body, axillary and pubic hair are lost; hair may appear on a woman's upper lip
Eyes, Nose, and Ears: The eyes tend to sink into the sockets as the fatty tissue that lines the eyeball atrophies. In some patients, entropion (inversion of the lower eyelid) or ectropion (eversion of the lower eyelid) appear, which produce tearing. To this is added the poor drainage of the lacrimonasal ducts by weakening the tissues.
The senile arch or gerontoxon is a frequent finding, due to the deposition of cholesterol and phospholipids, this causes the normal brightness of the cornea to be lost and we see a whitish ring inside the limbus. The response to light slows down. The lenses are gray in the light of the flashlight. The development of cataracts and the appearance of glaucoma are frequent. Decreases the elasticity of the lenses, with loss of near vision or presbyopia.
A reduction in natural brightness is observed in the fundus with fine-tuning of the arterioles. Colloid bodies, round and yellowish white, the size of a pinhead can also be seen.
A decrease in hearing or hearing loss can be detected after age 55, especially against high-pitched sounds.
The teeth are lost due to a weakening of the support provided by the gums.
Chest: over the years the normal curvature of the spine is accentuated, due to deterioration and osteoporosis. The rupture of the vertebral bodies in its anterior face can occur, this is more frequent in women with postmenopausal osteoporosis, which leads to a progressive decrease in the vital respiratory capacity. The thorax widens at its base and in its anteroposterior axis, and its elasticity is reduced. The breath sounds decrease in intensity.
The left ventricular impulse becomes more difficult to palpate. The second noise loses intensity in its pulmonary component, and it is not easy to auscultate the physiological split. In the sinus node, excitable cells decrease due to fat deposition and elastic tissues, which reduces the heart rate and can predispose to arrhythmias. Murmurs may appear in the vessels of the neck due to the deposition of cholesterol plaques or atheromas.
Systolic pressure rises with age, due to hardening of the vessels or atherosclerosis. Pressure should be measured in a sitting and standing position, as it is not uncommon to observe a significant drop in blood pressure with the change in position, orthostatic hypotension. This can be manifested in the changes of decubitus, and is important in the evaluation of a patient who is going to surgery, since hypotension may appear due to anesthetic techniques. The phenomenon is due to a lower response of the baroreceptors with age.
Breasts: elastic and fatty tissue are reduced, with loss of support of the thoracic musculature, they take a pendulous and wrinkled shape.
Abdomen: The muscular wall is loosened and the belly becomes flat and hanging at the sides. The aorta should be palpated to investigate aneurysms and listen for murmurs.
Pelvis: pubic hair becomes thin and loses its pigment and waviness; the penis decreases in size and the testicles hang at the bottom of the scrotum.
In women, due to the lack of hormonal stimulation, the clitoris and labia minora are reduced. The vagina decreases in size and its mucosa becomes pale and thin, making gynecological examination (vulvar craurosis) sometimes difficult. Inguinal and femoral hernias may appear.
Osteoarticular system: the muscles lose relief; the tendons are more visible, especially on the back of the hand; joint mobility decreases; and there are changes due to osteoarthritis. During joint movement, small startles and crunches can be felt.
Nervous system: static and dynamic senile tremor appears. The reflexes are normal, they can diminish the abdominal cutaneous. Cerebral atrophy is observed, which may not manifest clinically and other times it is accompanied by deterioration of higher functions, with the appearance of senile dementia.
Ignorance of this knowledge can have dangerous consequences, since age-related changes can be erroneously attributed to a disease, which can generate ineffective and harmful interventions; also the disease can be taken as normal aging and be neglected; in other cases the doctor evades the elderly who have multiple problems with components related to age and disease.
The doctor must be placed in the context of the elderly; know and understand their limitations when establishing communication with him, in order to achieve a better understanding. The old man needs enough time in the interrogation, dedicated to listening to him; as well as patience to repeat the points of view and indications. The anamnesis must be detailed, collecting data on the clinic and also must provide information to make the functional evaluation of the elderly. The family plays a very important role in providing data; but in many cases it devalues or isolates it by considering it a burden, or by the lack of time to attend to it.