Challenges In Golden Years: Geriatric Syndromes Explored

Geriatric syndromes, while not classified as diseases, are prevalent clinical conditions among older adults and are linked to heightened morbidity and mortality. These conditions in old age encompass “multifactorial health conditions that arise when impairments in multiple systems accumulate, rendering an older person vulnerable to situational challenges.” Notable geriatric syndromes include urinary incontinence, delirium, falls, pressure ulcers, polypharmacy, and weight loss.

In essence, geriatric syndromes involve various interconnected abnormalities contributing to a singular phenomenon. Take delirium, for instance, where impaired cognition, severe illness, and aging collectively lead to its manifestation. The contrast in the usage of “syndrome” in traditional and geriatric medicine has led some to perceive geriatric syndromes as common age-related companions, lacking a specific qualifying disease and potentially affecting mood or function. Overall, it presents a challenging condition with no clear solution and limited prospects for improvement. Hence, we suggest categorising conditions as geriatric syndromes if they exhibit multifactorial origins, primarily occur in old age, and arise from the interplay of identifiable patient-specific impairments and situation-specific stressors. Many of these syndromes are not preventable, but interventions can target contributing factors, reducing the incidence or severity. In simpler terms, geriatric syndromes encompass age-related disorders with functional decline, involving multiple systems, featuring complex multifactorial causes, poor outcomes, and potential for treatment.

Delirium

‘He remained alert and clear-headed throughout the day, engaging in discussions about his favorite sport, football, particularly admiring Ronaldo’s style of play. However, a sudden and drastic change occurred in the evening. Following dinner, he became irrational, yelling about taking his wife to the office, despite her passing away three years ago. Bala Subramoniam’s personal assistant, Prema Kadambari, found him unmanageable as he refused medication. At 82, Balasubramaniam was admitted to our skilled nursing home due to living alone after his wife’s demise, with his daughters residing in Mysore.’

The following morning, his daughter Ranjini found him in an anxious state, alternating between mild fidgeting, abruptly sitting up, and lying sideways on the bed. He exhibited marked inattention, struggled to follow instructions, and couldn’t engage in coherent conversation. Confused about his surroundings, he claimed mistreatment by the caring staff. Ranjini noted her father’s growing “memory problems,” recent social isolation, and wandering tendencies. While the patient managed his daily activities, he had become increasingly reliant on family members for advanced tasks following a previous eight-day admission and treatment for chronic kidney disease exacerbation. Delirium occurs when an individual experiences sudden confusion or a rapid shift in mental status. Symptoms may include difficulty paying attention, unclear thinking, disorientation, and distraction. It’s important to note that delirium is not a disease but rather a altered mental state.

Most people, especially the laymen may treat this sudden confusion as dementia. Delirium and dementia have some similarities, but they are not the same. Delirium mostly affects a person’s attention, whereas Dementia is a memory issue. Again, Delirium is a temporary state that begins suddenly. Dementia is chronic (long-term) memory tampering that usually begins gradually and worsens over time. However, someone can have both delirium and dementia. In Balasubramaniam’s case, he has slight dementia and delirium is a later development. It is important to seek expert opinion quickly if a person, especially one with dementia, begins to show symptoms of delirium.

Two forms of delirium can be distinguished: hyperactive and hypoactive. In hyperactive delirium, the individual becomes excessively active, agitated, and restless. Conversely, hypoactive delirium, more prevalent, presents as under activity, with the person appearing sleepy, drowsy, and slow to respond. The manifestations of delirium can be perplexing, leading family members and healthcare providers to potentially mistake the condition for depression. Additionally, it’s possible for an aged person to experience both types of delirium simultaneously, transitioning from extreme alertness to drowsiness.

Distinct types of delirium exhibit varied symptoms. Prema was surprised by Bala Uncle’s behaviour because she had never witnessed such conduct in him before. Symptoms typically emerge abruptly and escalate over the following hours or days. Individuals with delirium may appear intoxicated, and a key symptom is an inability to focus. The symptoms often intensify toward sunset, a phenomenon known as sundowning.

Accurate diagnosis necessitates cognitive screening and careful clinical observation. Key diagnostic features include the abrupt onset and fluctuation of symptoms, alongside impaired cognition and consciousness levels. Additional clinical characteristics encompass disruptions in the sleep-wake cycle, sensory disturbances like hallucinations or illusions, delusions, psychomotor disturbances (either hypo- or hyper-activity), inappropriate behaviour, and emotional instability.

Detecting and addressing delirium early is crucial for preventing its recurrence. Optimal prevention involves a non-pharmacologic, multi-component approach, such as reducing psychoactive drugs, improving mobility, engaging in therapeutic activities, ensuring quality sleep, and providing vision and hearing aids.

Urinary Incontinence

For many people, a trip to the bathroom is something that can easily be delayed. But for millions of elderly who experience bladder leakage daily, it’s not that simple. It is more embarrassing and exhausting. Although incontinence can happen at any age, it’s generally more common in seniors. As you age, changes in the body can make elderly urinary incontinence more likely. One out of two women older than 65 experience bladder leakage sometimes, according to the Urology Care Foundation. It can be caused by typical aging, lifestyle choices, or a range of health conditions.

This article aims to discuss our insights into managing incontinence in older adults and shed light on its often neglected treatment. We will delve into the age-related changes in urinary function, explore causes and types, and explore potential management strategies. While the ureters exhibit minimal age-related changes, the bladder and urethra undergo notable transformations. Aging contributes to a reduction in the bladder’s elasticity, making it either weaker or more prone to overactivity. This leads to a decrease in the maximum volume of urine the bladder can hold, and an increase in residual urine after urination. Consequently, individuals may experience more frequent urination and a heightened susceptibility to urinary tract infections.

Similarly, the pelvic floor muscles, particularly in women who have given birth, can weaken over time. When both the bladder and these muscles lose their normal function, they might unexpectedly relax, leading to urine leakage. In women, the urethra undergoes shortening, and its lining becomes thinner. These alterations in the urethra diminish the urinary sphincter’s ability to tightly close, elevating the likelihood of urinary incontinence (UI).

Explore a few fundamental medical conditions. Certain elderly individuals experience health issues that harm the nerves regulating the bladder, such as diabetes, stroke, Parkinson’s disease, or other conditions impacting the brain or nerves. Mobility challenges can also arise, hindering an elderly person’s ability to reach the toilet promptly. Additionally, constipation is a prevalent issue among the elderly, with a domino effect on urinary incontinence (UI). When constipation leads to a full bowel, it exerts pressure on the bladder, influencing pelvic floor muscles and resulting in involuntary urine leakage.

Urinary incontinence may indicate urinary tract infections, particularly prevalent among the elderly. Another concern is the enlargement of the prostate gland, a condition exclusive to men. In elderly men, an enlarged prostate can exert pressure on the urethra, obstructing the normal urine flow. For many individuals, incontinence can be effectively addressed. If medications or specific medical conditions contribute to the issue, adjustments may be made to the medications or the underlying conditions treated. In cases of dementia or Alzheimer’s disease, incontinence may not always be treatable. In these instances, utilizing undergarments, bedpans, or urinary catheters can offer practical solutions.

The optimal non-invasive approach involves a blend of Kegel exercises and behaviour training, occasionally supplemented with biofeedback. Commitment and determination are essential for these treatments, but the outcomes typically justify the effort. If exercises and behaviour training prove ineffective, physicians may propose medication options. Certain medications aim to inhibit bladder contractions, while others support an increase in bladder capacity.

medications are employed in the treatment of incontinence, including antispasmodics such as Oxybutynin, Tolterodine, Solifenacin, and Trospium. These aid in enhancing bladder storage capacity and reducing spasms, thereby delaying the urge to urinate. Mirabegron is another medication used to relax smooth muscles in the bladder for those with urge incontinence. Alpha-blockers like Terazosin and tamsulosin facilitate easier urine flow, while 5-alpha-reductase inhibitors like Dutasteride and finasteride are utilised in men with BPH to reduce prostate size.

While not recommended for frail elderly individuals, bladder surgery stands out as the most effective remedy for stress incontinence. However, it may pose additional risks for older patients. Surgery can also address overflow incontinence caused by urinary tract obstructions or an enlarged prostate in men. Various surgical options exist, and the appropriate choice is determined by the doctor based on the specific case. Here are some strategies for managing incontinence:

1. Reduce the consumption of foods or beverages that may increase urination or irritate the bladder (e.g., coffee, tea, alcohol).
2. Maintain a high-fiber diet to prevent constipation, which can alleviate symptoms.
3. Cut down or quit smoking, as it can exacerbate existing urinary incontinence or raise the risk of developing it.
4. Exercise caution with high-impact activities, especially if experiencing stress incontinence, until symptoms improve.
5. Establish a routine for emptying the bladder, including before bedtime.
6. Consume small amounts of fluids regularly throughout the day but limit intake 2 to 3 hours before going to sleep.
7. Ensure complete emptying of the bladder during urination and make an extra effort to expel the last drops of urine.

Falls

Falls pose a significant health risk, particularly for individuals aged 65 and above, making them a primary concern. Among the elderly, falls rank as the foremost cause of unintentional injuries. As our population ages, the growing number of older individuals amplifies the likelihood of increased falls, resulting in casualties and hospitalisations.

While not every fall results in injury, each contributes to a loss of confidence in older individuals, fostering an enduring fear of falling. Even a single fall can prompt individuals to restrict their movements and curtail activity, heightening the risk of subsequent falls. However, most falls are preventable, offering an opportunity to avert injury. By exercising caution, adopting healthy habits, and understanding how to minimise risk, we can collectively contribute to preventing falls among older individuals.

Individuals in the elderly population residing alone, particularly those with a documented history of falls and identifiable risk factors for falling, should undergo periodic inquiries about their experiences with falls. Due to the apprehensions many seniors have regarding institutionalisation, a more thorough exploration becomes essential. Consequently, these individuals may not openly report falls as a primary concern, and there is a tendency to conceal actual facts.

The likelihood of injury from a fall is contingent upon the individual’s susceptibility, encompassing both physical and mental states, as well as environmental hazards. The frequency of falls correlates with the cumulative impact of various disorders compounded by age-related changes. While numerous risk factors for falls are acknowledged in literature, we won’t delve into the specifics here.

Factors contributing to falls can be intrinsic, involving age-related physiological shifts, diseases, and medications, or extrinsic, pertaining to environmental hazards. A single fall may stem from multiple causes, and recurring falls may each have distinct origins, necessitating an individualised evaluation for each incident. Normal aging-related changes, not associated with disease, reduce functional reserve, heightening susceptibility to falls when faced with challenges. While not all age-related changes are inherently “normal,” many are modifiable, and if necessary, these conditions should be addressed.

As previously mentioned, certain conditions heighten the risk of falling, including:

• 1. History of previous falls: Falling more than once in the past 6 months increases the likelihood of future falls.
• 2. Low blood pressure: Older individuals with naturally low blood pressure may experience lightheadedness, dizziness, or unsteadiness while moving.
• 3. Postural hypotension: A drop in blood pressure when changing position, such as from sitting to standing, elevates the risk of falls, especially in older individuals with postural hypotension.
• 4. Incontinence: Frequent trips to the toilet, particularly at night, can increase the risk of falling.
• 5. Diseases like Stroke, Parkinson’s, and Arthritis: These conditions alter movement patterns, making it challenging to react quickly and prevent stumbling.
• 6. Diabetes: Fluctuations in blood sugar levels can induce faintness, and diabetes may affect eyesight while reducing sensation in the feet and legs.
• 7. Depression: Older individuals with depression may take medications that increase their risk of falling.
• 8. Alzheimer’s disease and other dementia: Those with dementia may become less aware of their surroundings and less capable of reacting swiftly.

Bedsores

Bedsores, also known as pressure ulcers or decubitus ulcers, result from prolonged pressure on a specific body area, causing skin rupture. These sores are painful, challenging to heal, and can lead to severe skin or bone infections. While immobile patients of any age are susceptible, bedsores are more prevalent in elderly individuals with limited mobility. In this context, we aim to elucidate why bedsores are a concern for immobile elderly adults, how to recognise symptoms, and preventive measures to avoid them before they escalate into life-threatening issues.

Typically, our bodies engage in constant movement, even during sleep. Whether consciously or subconsciously, we continuously adjust our positions while watching TV, working at a desk, or lying in bed. However, circumstances such as post-surgery, spinal cord injuries, arthritis, or illnesses can diminish mobility in seniors, limiting or halting these movements. Without regular repositioning, the immobility-induced pressure on the body can impede blood flow and inflict damage to the skin.

Bedsores often form in areas with little padding from muscle and fat tissues, for example, near joints or prominent bones. The tailbone (coccyx), shoulder blades, hips, heels and elbows are common sites for bedsores. Bedsores generally form in elders who spend most of the day sitting or lying down. Pressure from limited mobility, friction and shear are the three main factors contribute to elderly bedsores.

Continued pressure on a body part can reduce blood flow to tissues there. The tissue and skin need blood flow to deliver oxygen and other nutrients and when it is cut off, the cells will die ultimately. Since the skin gets thinner and more fragile, a gentle friction can cause a wound. Shear occurs when the skin moves in one direction while the bone moves in another or stays still. This happens when the senior slide or a pulling of a bed sheet from underneath.

Bedsores range from just reddishness to open wounds prone to infection and which can develop to more serious conditions. Early-stage pressure ulcers are more easy to manage and treatable so family or caregivers should check for bedsore symptoms often. Bedsore treatment varies by stage and severity. Initial stage (state 1) bedsore can often be resolved at home, while later-stage pressure ulcers may need medical intervention. A qualified nurse will be needed to monitor and treat the bedsore closely as it can develop into worst stages very quickly if not monitored. Severe pressure ulcers may end up in debridement or plastic surgery and warrants prolonged admission.

Sleep disorders

Sleep disorders are a common complaint among the elderly, with various factors interfering with their sleep-wake cycles. Acute and chronic medical conditions, pain-related distress, medication side effects, psychiatric disorders, primary sleep issues, social changes, poor sleep habits, and circadian rhythm shifts can disrupt proper sleep. As individuals age, natural changes in sleep patterns may result in complaints of light sleep, frequent awakenings, and daytime fatigue.

Recognising sleep’s significance to well-being, akin to food and water, underscores the impact of adequate sleep on daily function and overall quality of life. Insufficient sleep can lead to notable consequences, including falls and accidents, particularly when sedating medications are chronically used. Sleep-disordered breathing may pose serious cardiovascular, pulmonary, and central nervous system risks, while sleep apnea can contribute to hypertension. In individuals with dementia or Alzheimer’s, sleep disruption often prompts increased use of sleep-inducing medications. Consequently, proper evaluation and treatment of sleep problems in elderly patients are crucial.

Under favourable conditions, the circadian rhythm orchestrates a daily cycle of nighttime sleep and daytime alertness. It’s common for people to desire an afternoon nap, reflecting a physiological mid-afternoon dip in alertness. It’s well-established that exposure to light strongly influences an individual’s circadian rhythm.

Contrary to the belief that elderly individuals require less sleep, they often achieve less total nighttime sleep compared to younger counterparts. While nighttime arousals and awakenings are more frequent in older adults, this can lead to daytime sleepiness. In the aging process, an aged person’s sleep-wake cycle may become fragmented, characterised by interrupted nighttime sleep and daytime wakefulness punctuated by short intervals of napping. While some deterioration in sleep quality is considered a normal part of aging, a complaint of significantly disrupted nighttime sleep or impaired daytime functioning due to excessive sleepiness in an elderly patient should be addressed.

Various factors contribute to sleeplessness, with poor sleep habits being a prevalent cause. Many older individuals, continuing work post-retirement, may adopt irregular sleep-wake patterns due to lifestyle or work demands, disrupting the circadian system’s ability to regulate sleepiness and wakefulness effectively. Consuming coffee with caffeine or alcohol in the evening can impact nighttime sleep, as caffeine maintains alertness, and alcohol, initially sedating, interferes with deeper sleep and increases arousals later in the night.

Acute and chronic clinical conditions like arthritis, prostatic hypertrophy, and cardiovascular, gastrointestinal, and pulmonary diseases can trigger sleep disruption. Pain and discomfort from these conditions may delay sleep onset and reduce sleep duration, contributing to a deterioration of the sleep-wake cycle. Neurodegenerative disorders, especially Alzheimer’s disease, may necessitate sleep aids to induce sleep, as do certain psychiatric conditions, such as insomnia associated with major depression.

Numerous medications are recognised for their stimulating effects, leading to sleep disruptions. Chief among them are certain antidepressants, notably selective serotonin reuptake inhibitors, as well as decongestants, bronchodilators, specific antihypertensives, and corticosteroids. Nighttime use of diuretics can predictably result in frequent awakenings for bathroom visits. Additionally, the potential sedative effects of medications, especially long-acting sedatives misused as sleep aids, should be considered, especially in patients reporting excessive daytime sleepiness.

Establishing good sleep habits and engaging in daily physical activity can contribute to creating an environment conducive to restorative sleep. While medications should not substitute for healthy sleep practices, they may offer temporary relief when needed.

Polypharmacy

Polypharmacy, defined by the World Health Organization (WHO) as the concurrent use of five or more medicines, is often deemed a necessary practice for older individuals managing multiple chronic conditions. Approximately two-thirds of adults aged 75 and over take five or more medicines, encompassing over-the-counter and complementary options.

While polypharmacy is often indispensable, it comes with potential drawbacks, especially for older individuals who are more susceptible to adverse effects due to increased frailty and age-related changes. As we age, our sensitivity to medication effects heightens, intensifying the seriousness of polypharmacy-related consequences.

Polypharmacy is linked to an elevated risk of adverse drug reactions, interactions, and non-adherence to prescribed medications. Given the multiple doctors prescribing medicines for various clinical conditions, potential errors and complications arise. The complexity of medication regimens increases with the number of medicines, amplifying the risk of mistakes such as taking the wrong dose or missing a dose.

The benefits of each additional medicine in polypharmacy tend to diminish, while the risk of medicine-related harm escalates. Some medicines, like opioids, antipsychotics, anticholinergics, and certain antidepressants, may cause sedation, dizziness, and confusion, elevating the risk of falls or delirium. Long-acting non-steroidal anti-inflammatory drugs in older adults can lead to kidney failure, gastrointestinal bleeding, and cardiac effects due to reduced kidney function.

The phenomenon known as the ‘prescribing cascade’ contributes to polypharmacy, wherein additional medicines are prescribed to counteract adverse effects mistakenly perceived as symptoms of a new condition. This issue is more prevalent among older individuals managing multiple medical conditions treated by different clinicians.

Addressing the unique needs of aging individuals requires a shift from the traditional approach of treating single diseases to a comprehensive consideration of geriatric syndromes. Specialists in geriatrics or social gerontologists with clinical expertise can effectively evaluate combined factors and implement suitable treatments for holistic care.