Table Of ContentM. s. John Pathy· Paul Finucane
Geriatric
Medicine:
Problems and Practice
With 67 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
M. S. J. Pathy, FRCP
Professor of Geriatric Medicine, University of Wales College of
Medicine, Cardiff, UK
P. Finucane, MB, MRCPI
Senior Lecturer in Geriatric Medicine, University of Wales College
of Medicine, Cardiff, UK
British Library Cataloguing in Publication Data
Geriatric medicine.
1. Geriatrics
1. Pathy, M.S.J. (Mahan Sankar John)
II. Finucane, Paul
618.97
Library of Congress Cataloging-in-Publication Data
Geriatric medicine: problems and practice 1M .S. John Pathy, Paul Finucane (eds.).
p. cm.
Includes bibliographies and index.
ISBN-13: 978-1-4471-1648-6 e-ISBN-13: 978-1-4471-1646-2
DOl: 10.1007/978-1-4471-1646-2
1. Geriatrics. 1. Pathy, M. S. J. II. Finucane, Paul, 1955-
[DNLM: 1. Aged. 2. Geriatrics. WT 100 G366366]
RC952.G394 1989
618.97 -dc19
DNLMlDLC
for Library of Congress 89-6013
CIP
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Preface
As medical students, we are taught that the successful practise of
medicine hinges on our ability to analyse the clinical presentation of
disease and thereby to apply the correct diagnostic label. Such a
label-orientated approach is often inadequate when dealing with
elderly people, where acute medical breakdown often presents with
a complex amalgam of physical dysfunction, cognitive impairment
and social incompetence. As underlying causation is often multi
factorial, accurate assessment and management relies on the iden
tification of problems rather than disease labelling. Precision of
diagnosis is no less important than in the young, but a problem
orientated approach is particularly relevant to the disorders of old
age.
That physiological competence declines with age is undoubted,
but insidious physical and intellectual deterioration is too often as
cribed to ageing when reversible pathology exists. Disease is best
understood by seeing man in the world in which he lives. Failure
to see disease in old age in relation to age-related physiological
changes, to the immediate and more remote environment, to soci
ety and the impact on it of epidemiological and demographic
changes prevents us from fully responding to the challenge of old
age, sometimes erroneously referred to as the problem of old age.
This book sets out to introduce the medicine of old age in a broad
perspective and in a problem-orientated way. It does not attempt to
comprehensively cover disease in later life, but rather to deal with
some of those aspects of disease which may be of practical everyday
use to the practising physician.
The principles of geriatric medicine are relevant to all countries.
In that the contents may be of particular use to family doctors pre
paring for the Diploma in Geriatric Medicine of the Royal College
of Physicians in England, it should also be relevant to family doctors
in other countries. The sections on demography, the delivery of
health care and social services and the legal aspects of medicine of
old age aim to fill the gaps left by wholly clinical textbooks.
Acknowledgements
Many people had their lives disrupted while this book was in prep
aration. In particularly the spouses, families and secretaries of the
various contributors had much to endure and deserve our sincere
thanks. Editors' prerogative allows us to select three - Norma
Pathy, Aileen Finucane and Shirley Green - for special mention.
University of Wales College of Medicine, M. S. John Pathy
Cardiff, February 1989 Paul Finucane
Contents
Section I. Ageing: An Overview
1 The Physiology of Ageing
D. G. Seymour and R. M. Seymour ............................... 1
Cardiovascular Function .............................................. 4
Cardiac output; Blood pressure
Respiratory Function .................................................. 6
Routine tests ofl ung function; Closing volumes; Defence
mechanisms and the lung; Central control ofr espiration
Renal Function ......................................................... 7
Gastrointestinal Function ............................................ 8
Motility; Absorption; Liver; Exocrine pancreatic function;
Glucose tolerance
The Nervous System and Ageing ................................... 10
The special senses; Cerebral function; Sleep; Peripheral
nervous system
Bone Mass ............................................................... 12
Body Temperature Control .......................................... 12
Combating Physiological Decline .................................. 13
2 Demography and Epidemiology of Old Age
Deirdre Hine ............................................................ 15
Demography ............................................................ 15
The Current Population Structure and Its Determinants ..... 15
Future trends
The Distribution of Old People ..................................... 20
Future trends
The Elderly Within the Community ............................... 22
Epidemiology ........................................................... 23
Population data; Mortality data; Morbidity data; Mortality;
Future trends
viii Contents
Section II. Clinical Problems in the Elderly
3 Headache and Facial Pain
T. P. L. Thomas ........ ........ ........................ ...... .......... 33
Headache ................................................................ 33
Tension headache; "Vascular headaches"; Meningeal
irritation; Raised intracranial pressure; Metabolic
vasodilation; Drugs and toxins; Other causes
Facial Pain ............................................................... 38
Herpes zoster; Post-herpetic neuralgia; Trigeminal
neuralgia; Glossopharyngeal neuralgia; Atypical facial
neuralgia; Cluster headache; Tumours; Referred pain
Clinical Evaluation ..................................................... 42
Investigation ............................................................. 42
4 Chest Pain
M. S. J. Pathy ........................................................... 45
Central Chest Pain ..................................................... 45
Myocardial ischaemia; Myocardial infarction; Pericarditis;
Mitral valve prolapse; Acute aortic dissection; Aneurysm of
the thoracic aorta; Pulmonary embolus; Oesophageal
disorders; Mediastinal tumours; Acute mediastinitus
Musculo-skeletal disorders; Manubriosternal and xiphoid
process syndromes; Psychogenic causes; Abdominal
disorders
Lateral Chest Pain ..................................................... 54
Herpes zoster; Cervical spondylosis; Costochondritis;
Trauma; Disorders ofl ungs and pleura; Spontaneous
pneumothorax
Clinical Evaluation ..................................................... 57
Management ............................................................ 58
5 Abdominal Pain
W. E. Wilkins ........................................................... 59
Perception of Abdominal Pain ...................................... 59
Visceral pain; Parietal pain
Acute Abdominal Pain ................................................ 60
Distension ofa viscus; Intra-abdominal sepsis; Vascular
disease; Miscellaneous causes
Chronic Abdominal Pain ............................................. 65
Upper gastrointestinal tract disorders; Mesenteric ischaemia;
Lower gastrointestinal disorders; Neuromuscular disorders;
Miscellaneous causes
Clinical Evaluation ..................................................... 67
Further Investigation .................................................. 68
Blood count and blood viscosity; Blood biochemistry;
Radiology; Ultrasonography and endoscopy
Management ............................................................ 70
Contents ix
6 Musculo-skeletal Pain
June Arnold ............................................................. 71
Joint Disorders .......................................................... 71
Osteoarthritis; Rheumatoid disease; Gout; Pseudogout;
Seronegative spondyloarthritides; Infective arthritis;
Haemarthrosis; Hypertrophic pulmonary osteoarthropathy
Soft Tissue Pain ......................................................... 79
Polymyalgia rheumatica; Frozen shoulder
Bone Pain ................................................................ 80
Paget's disease; Osteopenia; Osteomalacia; Bone tumours
Clinical Evaluation ..................................................... 82
Management ............................................................ 84
Pain relief; Surgery; Rest and exercise; Aids; Counselling
7 Dyspnoea
P. Finucane ............. .............................. ................... 89
Lung Disease ............................................................ 90
Pneumonia; Lung collapse; Pulmonary fibrosis; Pulmonary
oedema; Pulmonary embolism
Airways Disease ........................................................ 94
Chronic obstructive airways disease; Bronchial asthma
Disease of the Pleura .................................................. 95
Pleural effusions; Spontaneous pneumothorax
Chest Wall Disease .................................................... 96
Bone and joint disorders; Neuromuscular disorders
Psychogenic Factors ................................................... 96
Anxiety
Metabolic Acidosis ..................................................... 97
Clinical Evaluation ..................................................... 97
Further Investigation .................................................. 98
Chest radiology; Arterial blood gases; Respiratory function
tests
Management ............................................................ 98
Oxygen therapy
8 Hypertension
A. B. Davies ............................................................. 101
Complication of Hypertension ...................................... 103
Stroke; Myocardial infarction; Heart failure; Aortic
aneurysm; Malignant phase hypertension; Renal disease
Clinical Evaluation ..................................................... 108
Further Investigation .................................................. 109
Management ............................................................ 109
Non-drug treatment; Drug treatment
9 Lower Limb Oedema
T. Rudra ...................................................... ............ 115
Anatomy and Physiology ............................................. 115
x Contents
Local Disorders ......................................................... 117
Dependent oedema; Vascular disorders; Popliteal (Baker'S)
cyst; Gastrocnemius rupture; Lymphoedema; Lipoedema;
Infection
Systemic Disorders............ ................................. ........ 121
Congestive cardiac failure; Hypoproteinaemic states;
Thyroid dysfunction; Drugs; Exposure to extremes of
temperature
Clinical Evaluation ..................................................... 123
Management ............................................................ 124
10 Weight Loss
P. Finucane .............................................................. 125
Decreased Ingestion of Food ........................................ 126
Decreased appetite; Mouth disease; Neuromuscular
disorders oft he pharynx and oesophagus; Structural lesions
oft he pharnyx and oesophagus; Nausea and vomiting;
General debility; Poverty, ignorance and isolation
Decreased Digestion and Absorption of Ingested Food ....... 128
Pancreatic disease; Coeliac disease; Bacterial overgrowth;
Inflammatory bowel disease; Chronic mesenteric ischaemia;
Short bowel syndrome; Cardiac failure; Drugs
Increased Energy Requirements .................................... 132
Malignant disease; Infective illnesses; Hyperthyroidism;
Diabetes mellitus
Clinical Evaluation ..................................................... 134
Management of Weight Loss ........................................ 136
Oral supplementation; Enteral nutrition; Parenteral
nutrition; Other measures
11 Constipation and Diarrhoea
Jane Bradshaw .......................................................... 139
Constipation ............................................................. 139
Motility disorders; Intestinal obstruction; Colorectal
carcinoma; Endocrine disorders; Neurological disorders;
Depression; Drugs
Diarrhoea ................................................................ 143
Infective diarrhoea; Irritable bowel syndrome;
Malabsorption; Diverticular disease; Inflammatory bowel
disease; Faecal impaction with overflow; Villous adenoma;
Drugs; Endocrine disorders
Clinical Evaluation.... ... ........ ..... ..................... ....... ..... 147
Management ............................................................ 147
Constipation; Diarrhoea
12 Incontinence
Gladys M. Tinker 151
Urinary Incontinence.............. ..... ............ ... ........ .... .... 151
Bladder function
Contents Xl
Non-neurological Disorders ......................................... 153
Faecal impaction; Drug therapy; Impaired mobility;
Urinary tract infection; Atrophic urethritis; Urethral
obstruction; Pelvic floor incompetence; Psychological
disorders; Endocrine disorders
Neurological Disorders ............................................... 155
Uninhibited neurogenic bladder; Reflex neurogenic bladder;
Atonic bladder; Autonomous neurogenic bladder
Clinical Assessment .................................................... 157
Further Evaluation ..................................................... 158
Charting; Cystometry
Management ............................................................ 159
Drugs; Incontinence aids
Faecal Incontinence ................................................... 162
Faecal impaction; Neurogenic incontinence; Evaluation
and management
13 Visual Impairmeut
Lyn Beck and D. Jones ................. .............. .......... ...... 165
Clinical Evaluation ..................................................... 165
Sudden Loss of Vision in the White Eye .......................... 167
Retinal detachment; Retinal vein occlusion; Retinal artery
occlusion; Ischaemic optic neuropathy; Vitreous
haemorrhage
Gradual Loss of Vision in the White Eye ......................... 169
Cataract; Maculopathy; Chronic simple glaucoma
Visual Impairment in the Red Eye ................................. 173
Angle closure glaucoma; Acute iritis
Diabetic Eye Disease .................................................. 174
Management of Visual Impairment ................................ 175
Legal Aspects of Blindness in the Elderly ........................ 175
Social Aspects of Blindness in the Elderly ........................ 176
14 Hearing Problems
Carol Comlay and S. D. G. Stephens .............................. 177
Conductive Hearing Loss ............................................. 178
Chronic otitis media; Otosclerosis; Bone disorders
Sensorineural Hearing Loss .......................................... 179
Genetic disorders; Traumatic hearing loss; Ototoxic damage;
Vascular disorders; Metabolic disorders; Neoplasia;
Meniere's disorder
Clinical Evaluation .................................................... 181
Further Investigation ............ ,..................................... 182
Management ............................................................ 183
Evaluation; Remediation
