HEALTH PROMOTION AND HEALTH MAINTENANCE

An Aging Population

By 2030, adults > 65 years will be 20% of population.

As the aging population expands, it will affect all aspects of society

Even in the elderly, preventive interventions can limit disease and disability.

Myth of Aging:  Disease and disability are inevitable part of aging

Health professionals must be diligent in avoiding age prejudice, as believing stereotypes can influence interactions between older adults and careivers.

MAINTENANCE CONTROLS

• Blood pressure: annual.
• Lipid Control: men over 35 and women over 45 years. Every 5 years.
• ECG: Once per year over 75 years.
• Bone densitometry: once a year at age 65.
• Annual fasting glucose.
• Annual Mental status examination.
• TSH, vitamin B12 every 5 years.
• Fecal occult blood: every 5 years
• Mammography every 1 or 2 years.
• Cytology: every 3 years.

• Digital rectal examination and PSA.
• Auditory and visual studies: annual.

HEALTH PROMOTION. NURSING INTERVENTION

Prevention and health promotion: developing specific programs.
Quality of preventive care, progressive, comprehensive and continuous in geriatric practice.
Recovery preventive function and in all phases of the disease.


Prevention:
- Primary: prevent the disease before it starts. Ej: Physical exercise and vaccination

- Secondary prevention: early detection of the disease to prevent or limit the occurrence of the events or their complications once instituted.

- Tertiary prevention: aims to minimize the consequences of the disease and facilitate the recovery.

Active and healthy aging
The concept of successful aging includes three components: 
      - low probability of having disease and disability
      - high functional capacity
      - physical and cognitive and maintaining an active life society

GERIATRIC RESOURCES

The goal of health care to the elderly is to prevent or, at least, delay, functional decline.

It requires specific assistance strategy which allows detection of problems. It is based on the selection of patients who will benefit most, especially those who are at risk of disability.

It designs a therapeutic strategy planning care and intervention capacity. An isolated evaluation is not enough, there must be a coordinated interdisciplinary work and subsequent monitoring of the patient.

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Levels of care:

1.   Acute geriatric units

2.   Functional recovery geriatric units or medium-stay units

3.   Geriatric Day Hospital

4.   Hospitalization at home

5.   Emergency Services

The design of an assistive device is the basis on which develop geriatric services activity. To be effective for the elderly should have the basic principles:

- Performance at an early stage of functional impairment.

- Selection of the target population.

- Comprehensive geriatric assessment of health status and care needs.

- Maintain control hospital the recommendations of the assessment.

- Functional capabilities.

- Multidisciplinary approach to the need for care.
- Establish an ongoing monitoring.

RESOURCES

Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

UNIT 4: COMMON DISORDERS IN THE AGING 4.8 END-OF-LIFE-CARE

Palliative care is undertaken by the multidisciplinary team. Its objective is to promote efficient and quality care to patients with terminally ills, with a prognosis of less than six months.

Terminal illness refers to an advanced and incurable disease, in which no patient response to treatment. This creates an emotional impact on both the illness in the family.

Integrating palliative and curative treatments has been shown to reduce pain, improve satisfaction, reduces costs and facilitates transitions between different stages of disease progression. Palliative care is offered as needs are developed and before that do not respond to any other curative treatment

Objectives to be achieved by professionals in palliative care are:

• Generate maximum comfort to the patient and family.

• Conduct comprehensive care encompassing physical spheres, psychic, emotional and spiritual needs of both patient and family.

• Control of symptoms, recognize them, have realistic goals, reasonable and tiered, assess, reassess. It is important to treat them because they influence the patient and family.

• Promote relaxation and calming techniques.

• Build confidence, giving emotional support to the patient and family.

• Check the patient's environment, generating a disease process good communication between professionals, patients, and family.

• Treatment of pain using analgesic scales.

• Maintain adequate nutrition in the patient.

• Treat gastrointestinal symptoms (anorexia, vomiting, nausea, constipation, diarrhea, etc.).

• Treatment of respiratory symptoms (dyspnea, rales, etc..).

• Maintain proper oral hygiene and cleanliness in the patient.

• Exchange of information, feelings, or thoughts between patient - professional - family. Close attention and empathy towards family.

• Emotional support during the grieving process and comprehensive home care.

Communication and information is also one of the basic tools of therapy in palliative care.

The goal of communication is to inform, guide and support the patient and family to have elements to participate in decision-making. This should be a dynamic process that suits the turning points of the disease. You should review the information and perception of health or disease with the patient and family and prepare to deterioration, dependence and even death itself.

It is important to check the patient's understanding and know how far you want to be informed.

The Last Chapter: End of Life Decisions. The 

program examines end-of-life care options and the need for advance directives.

 It focuses on empowering individuals in having the last word on how they live at the end of their lives.

REFERENCES:

Palliative Care Guide. Spanish Society for Palliative Care. Available at: http://www.secpal.com/guiacp/index.php

Treaty for geriatric residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

UNIT 4: COMMON DISORDERS IN THE AGING 4.7 GERIATRIC SYNDROMES: URINARY INCONTINENCE

Urinary continence is a basic function that should keep healthy elderly, regardless of age. It is important to stress that urinary incontinence is not a normal phenomenon of aging.

Urinary incontinence can be defined as "any urine leakage that cause discomfort to the patient" (Abrams P, 2002). It is part of geriatric syndromes, constituting a cause of disability and impaired quality of life.

The prevalence of urinary incontinence is higher in women, and it depends on the level of care: 30% in community, hospital 30%, chronic residential units or 50%. Among the risk factors for urinary incontinence in women include diabetes mellitus, lack of estrogen and high BMI restitution. Additionally, cognitive impairment increases its effects, although not a risk factor (Thüroff JW, 2011).

In the initial evaluation is recommended to ask:

- You lose urine when you do not like? Do you have you problems with your bladder, unintentionally gets wet? Or do you have small leaks of urine upon exertion, such as laughing or sneezing?

Also in the initial assessment must be excluded concomitant urinary incontinence causes acute (<4 weeks duration) such as urinary tract infection, diabetes, vaginal atrophy, fecal impaction, polypharmacy, etc. (PS Yim, 1996)

The impact generated by this health problem can be many and varied. Not directly depend on the severity of the leak. Influence of individual factors (age, sex, comorbidity, functional status, lifestyle), as well as the type of incontinence (especially emergency).

Importantly, the impact can affect different areas of the patient: (JS Brown, 2000).

- Medical: urinary tract infections, skin ulcers, infections, ulcers, falls, fractures, urinary tract infections

- Psychological: loss of self-esteem, anxiety, depression, isolation

- Social isolation, greater need for family support, greater need for health resources, increased risk of institutionalization, dependence on the caregiver ycarga

- Economic: increased costs of care and complications

Estrogen deficiency is a common cause of nocturia and urinary incontinence in women, so it is necessary to systematically investigate this deficiency before considering other therapies.

Before a diagnosis of stress urinary incontinence or urgency should indicate pelvic floor exercises and bladder training (RCOG Press at the Royal College of Obstetricians and Gynaecologist, 2006). Shipping should be considered if espcial (Thüroff JW, 2011):

- Frail elderly

- Added significant factors: hematuria, pain, etc..

- Coexisting disease: functional impairment, dementia

- Initial response to insufficient treatment

The following segment is about an incontinence nurse at Fremantle Hospital in Western Australia.

REFERENCES:

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.6 GERIATRIC SYNDROMES: CONSTIPATION

Constipation is a symptom, not a disease. It can be defined as the decrease of the number of times depositional (<3 times per week) or evacuating dry feces too slim. It is associated with hard consistency of stool.

It represents a major geriatric syndrome because of its prevalence, its serious complications and their significant impact on the quality of life of elderly. It affects mostly females. Only 5% of the elderly have fewer than 3 bowel movements a week, though more than 1/4 of those over 60 years meet other criteria for constipation. Approximately 80% of the institutionalized elderly are constipated.

Causes of constipation in the elderly are multiple and, in many cases, several causes coexist simultaneously. This should be taken into account when considering a diagnosis and treatment. Although most people suffering from constipation due to unsuitable lifestyle habits such as:

• A sedentary lifestyle

• A diet low in fiber.

• Drugs that decrease or slow down bowel motility.

• Emotional disturbances.

Constipation can also be secondary to diseases such as: structural colon lesions, postsurgical changes, metabolic disorders, neurological disorders, etc.

The symptoms experienced by people who suffer constipation are:

- Bloating.

- Abdominal pain.

- Pain on defecation.

- Changes in behavior.

The Recommendations and advice that we give the patient are:

• Increase fluid intake (if not contraindicated).

• A diet rich in fiber, increase your intake of fruits, vegetables and whole grains. And reduce food consumption astringent food.

• Avoid a sedentary lifestyle and exercise appropriate to the patient.

• Avoid drugs that slow or slow peristalsis.
 • Encourage the person intimacy when defecation.

• Administer laxatives (by prescription).

• Establishment of schedules defecation, intestinal rehabilitation.

• Encourage the practice of exercises that promote or strengthen pelvic muscles, like Kegel exercises.

• Control the number and shape of stools, great importance in geriatric institutionalized people with dependence.

From the point of view is also recommended nursing identify drugs that cause constipation, such as calcium antagonists, tricyclic antidepressants, antimuscarinic bladder and opiates.

The easier and cheaper treatment will be to implement changes in individual lifestyles. So it is necessary make a proper health education and prevention to patients.

REFERENCES:

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• From the Key Benito J A. Horsemen Anes M. Management of constipation in older people. Bulletin of Nursing in Primary Care of Talavera de la Reina, 2008. Available at: http://gaptalavera.sescam.jccm.es/web1/gaptalavera/prof_enfermeria/boletines/boletin_enfermeria6_2008.pdf

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.5 GERIATRIC SYNDROMES: FALLS AND INESTABILITY

The elderly has an increased risk of falling. Specifically, 20% of population over age 65 have some type of limitation in activities of daily living to facilitate falls (Cuesta-Triana F, 2001). In most cases occurs at home environment and many of these are produced by an inaccurate adjustment of the home environment.



The fall is multifactorial in origin, relevant in the elderly and may be a manifestation of disease. A fall can generate functional dependency, creating a vicious cycle, and which in turn relates to more falls (Tinetti ME, 2010). It can lead to a loss of independence in the elderly, generating a high health spending. This risk will result in the patient immobility, can worse the medical history or even the appearance of new diseases that may worsen the picture, and even the elderly can die.

It is therefore essential the fall risk assessment and all elderly person must be evaluated considering factors for falls risk presented (Scott V, 2007)

From the nurse’s point of view there are necessary implement security strategies in the elderly to reduce the incidence of falls and their complications. This requires identifying the population at risk and implement nursing interventions that are effective for the prevention of falls.
First it is important to identify the risk factors. It has been identified about 400 risk factors. The most common are:
- Weakness (sarcopenia)
- Gait disturbance
- Limitation of mobility
- Visual deficit
- Cognitive impairment
- Type 2 Diabetes Mellitus
- Sex female
- Functional dependence
- Drugs with sedative effect
- Orthostatic Hypotension
- Environmental factors: low visibility, bathrooms without bearing support, etc. (Masud T, 2001)

Downton Scale is useful for carrying out a risk assessment.

The first preventive measure is to inform patients and their caregivers about the existence of risk. From there work and collaborate in modifying home environments that can be dangerous, without compromising the functional independence of the elderly.
Usually, the patient with a fall, suffering a sharp process is revealed as a precipitating factor. Eg urinariom infection respiratory tract, anemia, angina, etc. (Kallin K, 2002).

After the fall, only 41% of elderly go to a medical service and more than half of them, have more than one fall per year.
To prevent a fall is necessary to know the risk factors, the characteristics of the fall and the patient's environment.
So when there is a fall, we must make appropriate records, performing a systematic assessment in the elderly, noting incidents, causes that led to the fall, and record the treatment and care that had to apply. Assess the factors related to the fall and notify relatives. And then make appropriate monitoring in the elderly for abnormalities produced as a result of the fall.

It is important to advise the elderly on existing measures and appropriate technical assistance to him, and informer the patient about economic aid that the health system provides.

REFERENCES :

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.4 GERIATRIC SYNDROMES: DEMENTIA AND DELIRIUM

Dementia is the progressive loss of cognitive function due to brain damage or brain disorders attributable beyond the normal aging. It is an age-related disease. It is a decline of higher functions: memory (in relation to the previous level of the patients),etc. And later, add psychological and behavioral changes, resulting in progressive disability the patient.

The geriatric syndrome of dementia must meet the following characteristics:

- Provide a level of normal consciousness.

- Be acquired and persistent over time.

- Affect different functions.

- Be of sufficient intensity to have an impact on personal functioning, or social work.

Dementias are Alzheimer's, Parkinson's disease, Huntington's disease and may also be secondary to metabolic processes, endocrine drugs, psychiatric diseases, toxic, etc.

Delirium is a syndrome characterized by acute onset with fluctuating course, with attention disorders, changes in alertness. Is multifactorial in origin and is an indicator of long hospital stay, increased morbidity and mortality. It is common in the elderly, especially elderly frail and dementia (Burns A, 2004). Mortality associated with delirium (25-33%) is as high as that associated with acute myocardial infarction or sepsis. (Ionuye SK, 1994) 

There are several factors of delirium: (Ionuye SK, 2007)

- Psychotropic drugs, opioids, diuretics, anticholinergic effect, etc.

- Fluid and electrolyte imbalance.

- Surgical Procedures.

- General anesthesia.

- Hypoxia.

- Neurological disorders.

- Use of benzodiazepines.

- Pain and Sleep Deprivation.

- Physical restrictions.

- Using tubes and catheters in general.

By detecting delirium in the elderly, they should get the precipitating causes and recommended referral to an emergency department for comprehensive assessment. (Francis J, 2011) The Confusion Assessment Method (CAM) is used for the rapid identification of delirium (Wei LA, 2008). It is recommended to ask the primary caregiver if the patient has had recent changes in behavior or consciousness. If the answer is yes, it would conduct an assessment using the CAM for the detection of delirium (Wei LA, 2008)

Therefore, the patient with loss of cognitive functions will present:

- Memory problems: often the first to appear. Limiting intellectual and social activities.

- Speech disturbances: decreases the ability to communicate orally and writing.

- Impairment of spatial orientation: become disoriented easily, even at home. They keep objects which will hardly be found.

- Inability to perform certain tasks: the end is manifest in the simplest tasks, such as greeting.

- Disorders of personality and behavior: agitation, etc.

- Changes: hallucinations, neurological disorders, anxiety, depressive features, motor incoordination, etc.

REFERENCES

-Treaty for geriatric residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

- Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.3 GERIATRIC SYNDROMES: IMMOBILITY

Immobility is the decreased ability to perform activities of daily living and it is caused by impairment of motor functions.

Immobility syndrome is the common pathway of disease presentation. It is generated by a series of pathophysiological changes in multiple systems, conditioned by immobility and disuse. Cause is multifactorial, potentially reversible and preventable.

Decreasing physical functionality is a known consequence of aging. Older adults show a large deterioration in motor skills due to the reduction in strength and muscle volume, decreased speed and skill of the march, leading to concomitant motor impairment and disability (AS Buchman, 2009).

Immobility syndrome prevention

1) Primary: The best preventive measure is to keep the degree of mobility. Several studies agree that physical exercise as the main factor preventing immobility. The benefits of exercise do not decrease with age. Improving muscle strength and therefore improves ambulation, increases bone mass, improving hyperglycemia, lowers blood triglyceride levels and increase HDL cholesterol, etc. It also reduces anxiety and depressive symptoms. It is recommended starting the exercise 2 or 3 days a week to reach 5.

Healthy elderly subjects are divided into two groups: <75 years: moderate exercise to high intensity aerobic and resistance, and in> 75 years moderate effort exercises.

2) Secondary prevention: Once detected the clinic may include a number of changes in the environment that encourage commuting and encourage the maintenance of autonomy. These measures include: avoiding architectural barriers, maintain the sensory, technical adjustments, encourage independence. On a practical level should be taken into account:

a. Doors: amplitude, weight, easy to open or close.

b. Rooms and corridors: amplitude, if accurate mobilization wheelchairs, etc.

c. Furniture: remove furniture that may interfere with ambulation, and place them as help or support point.

d. Railings: for support.

e. Lighting: adequate, with switches in accessible and comfortable.

f. Floors: carpet removal, cables or cords. Slip resistant surfaces and ramps instead of stairs.

g. WC: Using grab bars, lifts the toilet bowl, bathtub non-slip surface, easy entry and exit from the tub by seats.

h. Personal Hygiene: adaptations in the sponge, combs and brushes, care of the folds, mouth and dentures.

i. Dress: replacing zippers and Velcro buttons, garment open in front and slip resistant soles in shoes. To dress the lower body will be easier to do in supine starting with the extremity disabilities.

j. Chairs: solid, heavy, high back and arms.

k. Bedding: preferably height adjustable cushions person or use

3) Tertiary prevention: treatment of complications such as joint contractures, stiffness, muscle atrophy, osteoporosis, etc. It starts with postural control involves body alignment body symmetrically avoiding antalgic postures. Includes repositioning every two hours initially.

Technical aids: canes (support the 15.20% of total body weight), crutches, walkers, wheelchairs, etc..

RESOURCES:

Treaty for geriatric residents. Spanish Society of Geriatrics and Gerontology. 
[Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

UNIT 4: COMMON DISORDERS IN THE AGING 4.2 CARE OF AGEING SKIN AND MUCOUS MEMBRANES

Pressure ulcers (PU) are ischemic lesions localized to the skin and underlying tissues with loss of skin substance produced by prolonged pressure or friction between two hard flat.

They are a serious and common problem in older people. Represent one of the major complications of immobility situations. Its proper management is an indicator of quality.

It is estimated that at least 95% are preventable.

The incidence rate is 1.7% per year between the ages of 55-69 years and 3.3% between 70-75 years. In the residences is 9.5% in the first month of stay, and to 20.4% at two years.

Risk factors:

- Pathophysiological: skin lesions, > 40 years, nutritional deficits, disoriented, comatose state, oxygen transport disorders, Immobility (confinement to bed or wheelchair), sensory deficit (heat, pain), skin exposure to high temperatures moisture, fecal and / or urinary, pressure or external forces, friction and shear.

- Derivatives of treatment: immunosuppressive treatments, immobility

- The environment: lack of health education and patient caregivers, work overload, professional Discouragement               

- Situation: wrinkles on clothes, lack of hygiene, immobility, brush with objects.

Evidence:

• The Braden Scale and the Norton scale scales are used to identify elderly patients at risk of developing pressure ulcers.

• The Braden Scale has a sensitivity of 83-100% and a specificity of 64-77%, the Norton scale has a sensitivity of 73-92% and a specificity of 61-94%.

• The Braden Scale has been tested on medical-surgical units, intensive care units and nursing homes for elderly care. The Norton scale has been tested in hospitals with elderly.

• Research data show that measured functional concepts Braden scale are better predictors of risk than medical diagnoses.

• Essential laboratory tests include blood count, coagulation, ESR and biochemical.

• When there is a pressure sore eschar can not be accurately estadiate until the eschar is removed.

• There are research data linking high risk for pressure ulcers in individuals with spinal cord injuries and depression mean scores high.

• Alcoholism is an important risk factor.

• The participation of individuals in treatment and education regarding psychosocial care is associated with positive results ulcers.

• All individuals at risk should have a systematic evaluation of the skin at least once a day, paying special attention to bony prominences.

• The results of the skin assessment should be recorded. Inspect each site to assess the status and integrity of the individual's skin or for early signs of injury: erythema, temperature, fissures, dry or wet.

• Establish a routine cleaning of the skin. The frequency of skin cleansing should be individualized according to the needs.

• Use warm water and use cleaning agents that minimize irritation and dryness of the skin.

• During the procedure should be the minimum force and friction on the skin.

• Do not apply massage over bony prominences and minimize skin exposure to moisture caused by incontinence, perspiration or wound drainage

• Skin lesions due to friction or shear forces can be minimized through changes in the movement or transfer techniques and proper body position. They can also be reduced with the use of lubricants, protective dressings (such as hydrocolloids) and pads.

• Regarding nutritional assessment, this should include:

- Weight

- Signs of moisture

- Determination of minerals and vitamins need

- Laboratory data and lymphocyte count, serum albumin.

• Maintaining levels of activity, mobility of individuals through rehabilitation treatment.

• Use positioning devices such as pillows or foam wedges to protect bony prominences on direct contact between them, in people who are confined to bed.

• Mantain pressure distribution and no wrinkles on the bed. The pressure relief devices must be prescribed individually to be effective and to not interfere with other aspects of mobility and personal autonomy.

• The use of devices reducing pressure can increase the range of motion when the pressure is relieved. Although rubber devices cause venous congestion and edema.

• It is also important body alignment.

• Elderly people in bed should be repositioned every two hours, if it is consistent with the treatment of the individual.

• Suspend ankles in the air, using pillows or boots that rise.

• Lift without dragging the individual, using sheets of movement. Raise the peron's body for the position changes with the help of another person.

REFERENCES:

·         Abuchar Canyon, HM; Adarve Balcazar, M, Brown Duke, AV. Prevention of pressure ulcers in hospitalized adults. ACOFAEN Guides. Lascasas Library, 2005; 1. Available in http://www.index-f.com/lascasas/documentos/lc0028.php> [Accessed 13 May 2013]

·         Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

UNIT 4: COMON DISORDERS IN THE AGING 4.1 CHARACTERISTICS OF DISEASES IN THE ELDERLY

With aging physiological changes occur in all body systems. This determines the decreased functionality, limiting the ability to respond to increased demand and stress. But there is also a deterioration of the processes that maintain the functional integration between different organs and systems of the individual.

"Health in the elderly is measured in terms of function" (WHO). The concept of health in the elderly is not always linked to the absence of disease. Should include both physical and mental disorders as personal and socioeconomic circumstances.

The physiological aging will you meet accepted biological parameters for different ages and keep the ability to relate to the social environment. And be pathological when alter disease incidence and biological parameters such difficult social relations.


A direct consequence of the above would be the concept of atypical presentation of disease. This is many times a diagnostic challenge (eg., Pneumonia can manifest manifest with delirium without fever or cough or chest pain).

Often the elderly manifest nonspecific symptoms, not necessarily the typical picture of the particular disease. Diseases present with different signs and symptoms as they do young people (eg., Parkinson manifested by falls and not tremor). These differences in disease presentation regarding the younger population will be more pronounced the older the patient. This influence also other reasons, such as the frequent coexistence of multiple conditions or comorbidities, polypharmacy and more fragile, which mask individual frames.




For good health care to elderly patients it is necessary knowledge of:

- The heterogeneity of the population over 65 years old healthy, sick elderly, frail elderly and geriatric patient.

- The peculiarities of disease in them: atypical presentations of disease.

- The fragility as a marker of vulnerability in older people.

- Comorbidity and polypharmacy: Several diseases can affect different organs or systems related to each other or not. They are favored by many factors.

- The tendency to chronicity and frequent failure: high prevalence of chronic and degenerative diseases, which cause overload dependence of caregivers and high percentage of institutionalization.

- Less favorable forecast of disease: they settle in an organism with decreased functional reserve and responsiveness to external stressors. 
Although this should not justify delaying treatment.

- Diagnostic and therapeutic difficulties: both diagnostic and therapeutic attitudes in geriatrics should be guided by the risk / benefit always looking for the latter. It will take into account the views of the elderly and again following a comprehensive geriatric correct assessment.

- Increased use of health resources: the elderly are major consumers of health care resources.

- The hospital demand is characterized by:
              • hospitalization rate twice that of the general population, being      3 times more freccuent on the larger group of 80.
              • Large hospital stay linked in many cases to increased dependency and iatrogenesis.
              • Large number of readmissions.

- Increased need for rehabilitation: the causes of functional impairment in an elderly include: multiple and disabling.

- One of the objectives of geriatrics will be the maintenance of autonomy and function through the use of early rehabilitation.

- Frequent need to use social resources: in the elderly often the onset of disease causes or exacerbates social and family problems appear.

- Frequent ethical problems: in decision-making: in the final stages of life, longer life artificially in the absence of a living will of the individual, legal incapacities people with dementia ...


Problems that may occur:
- Incomplete medical diagnosis.
- Overprescribing drug.
- Under-utilization of rehabilitation.
- Poor coordination between services that prevent continuity of care.
- Institutionalization inadequate.

Importance of:
- Comprehensive geriatric assessment
- Comprehensive treatment (medical, functional, psychological and social
- Coordination through levels of care to ensure continuity of care,
- Institutionalized elderly supervision




GERIATRIC SYNDROMES
Geriatric syndromes are usually caused by a combination of diseases with high prevalence in the elderly. They are often the source of social functional disability or the elderly.
Are expressed in disease situations a set of symptoms, but also the beginning of many other problems that need to be taken into account from detection to establish a good prevention.
These syndromes can lead to increased morbidity and sometimes more serious consequences than the disease that occurs (eg., Immobility syndrome generated a CVA [stroke], without good prevention of pressure ulcers can occur and generate these more problems).

Your screening as "complaints" or "problems" to be included in the history of the elderly person history.

They are rarely addressed in clinical pathology books or in epidemiological studies because its manifestation is not in common diseases. They are a common form of presentation of illness in the elderly. They require a careful assessment of its meaning
and causes. Do not fall into the "ageism" to interpret the pathological situation of the elderly but it is important to interpret and meet geriatric syndromes.

• Immobility.
• Instability: (falls).
• Incontinence (urinary and fecal).
• Intellectual impairment: dementia and acute confusional state.
• Infection
• inanition: malnutrition
• Impairment of vision and hearing: changes in vision and hearing.
• Irritable colon: constipation, fecal impaction.
• Isolation (depression) / insomnia: depression / insomnia.
• iatrogenesis: iatrogenic.
• Immune deficiency.
• Impotence: Impotence or sexual dysfunction.


 Geriatric syndromes care:
- Multiple studies indicate that use primary care service 3 times more than the average population.
- Consumption of 1.5-2 times more drugs.
- Hospital admissions in those over 65 years is twice that in the general population, tripling the rate in over 80 years.
- His stays are longer.

- Summarized 2000 data that 49% of hospital stays up to age 65 years.



REFERENCES: 

 - Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

- Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. Journal of Comorbidity 2011; 1:28–44