Treatment of elderly patients is not always away. It is important to realise that age is not always the true indication of the ageing process. Many people look aged even at fifty-five when they usually retire from services, while others look healthy and relatively younger even at sixty or seventy years. The study of the ageing process is known as “Gerontology”. In medical practice it is now a speciality, known as “Geriatrics”.
Modern research suggests that the ageing process may be related to immune mechanism. The involution of the thymus gland is a universal accompaniment of ageing process. Involution of cellular mass of the thymus begins at a sexual maturity and completes by 45 to 50 years. Several polypeptide hormones are synthesized in the thymus and released into the blood, which influence life cycle of lymphocyte.
These thymic hormones can no longer be detected in normal humans over 60 years of age. (The Medical Clinics of North America, March 1983). A physician must assess the patient from that angle to decide how much ageing has taken place.
An active, extrovert patient at seventy-five with diabetes mellitus, high blood pressure or coronary ischaemia may be less difficult to treat than an introvert, sedentary, senile looking patient with constipation and flatulence at sixty or even at fifty years.
A careful inspection of the patient is very rewarding if the doctor is conversant with the art of clinical methods. Old people may have grey hair, arcus senilis, loss of subcutaneous fat, wrinkled skin, but his attitude and mobility, his gait and posture will indicate a lot about his ageing process. Note specially his muscle strength, spinal curvature, evidence of osteoporosis, his coordination and balance. Hearing is often impaired, specially in high frequency range. Vision may be impaired, especially if there is cataract.
Sense of smell is often impaired considerably. Sideroblastic anaemia may sometimes be encountered, which responds to pyridoxine therapy.
This is a very important aspect in the assessment of an aged patient. A few simple questions will suffice to assess the patient roughly. It is essential to assess his memory, orientation, thinking power and personality. Some old people ignore symptoms, so that they may attribute anginal pain to gas and gastrointestinal symptoms of carcinoma, to wind in the tummy or dyspepsia. Self- treatment is common with the assistance of lay magazines, till the disease is far advanced.
On the other hand, some old hypochondriacs may develop a mountain of symptoms. Psychological attitude is to be considered carefully. At times sound advice offered by the relatives is often ignored by the old folk until the same guidance comes from the doctor. Thus a general practitioner can do a great deal to maintain health of the old people. The old has to be advised to learn the art of enjoying their old age through hobbies or some kind of pleasant occupation. Investigation
The most important thing is to take a good history from the patient as well as from his close relatives or friends, who have known him for quite some time and intimately. Direct questioning is very necessary. How much activity? How much food? How much sleep? Drug habit, alcohol and smoking habits? All these must be noted. Besides a thorough physical examination, special examination, including ophthalmoscopy and rectal or vaginal examination may be necessary. Look for varicocoeles, hernia, enlarged prostate, operation scars, lumps in breast, testes and epididymis.
Routine urine test and blood sugar test two hours after full meal must be done, while lipid profile, X-ray chest and ECG may be ordered if indicated. In case of sedentary people who indulge in rich food, alcohol and smoking etc., six-monthly check-up must be recommended by the family doctor. Many symptoms, e.g. non-articular rheumatism, constipation, insomnia, fatigue, acidity and gas etc. can be cured without many drugs but by adjustment of posture, regular exercise, walking in fresh air and adjustment of diet and eating habits.
A patient aged 55 years was referred to me for suspected coronary disease because of nocturnal discomfort off and on. History revealed that he used to leave his house after breakfast (consisting of two fried eggs, vegetables, “parathas” and coffee) and did not eat anything but tea or coffee during the whole day. On return at 8 p.m. to his house, he used to consume three large pegs of whisky followed by one full chicken curry and a few “chapaties” before going to bed. No wonder, his eating and drinking habits needed change. No coronary dilators were necessary.
An aged patient came for consultation with symptoms of dyspnoea on slight exertion. He smoked about 40-50 cigarettes a day and his alcohol consumption was little over half a bottle of whisky per day. He wanted to be treated, if possible without any change in his habits.
Management of old patients depends not only on the age and degree of senility, but also upon the background disease, if any.
Common causes of severe disablement are:
(a) Hemiplegia or paraplegia
(b) Parkinsonism which is often missed in early cases
(c) Cardiac diseases, such as I.H.D. or hypertension with or without failure.
(d) Chronic bronchitis leading to emphysema which can be a leading factor of disability in the elderly. These patients are usually heavy smokers.
(e) Obesity alone can be a cause of great handicap. It can lead to hypoventilation and even cardiac failure.
(f) Result of fractures or effects of accidents
(g) Chronic bowel diseases including severe constipation or chronic diarrhoea. Colonic carcinoma can remain silent for a long time.
(h) Osteoarthritis, non-articular rheumatism, cervical spondylosis and gout.
(i) Intellectual failure — may be due to cerebral arteriosclerosis or confusional states due to infection, electrolyte imbalance, drugs, alcohol and narcotic habits.
(j) Progressive visual and auditory failure.
Management therefore should include review of family background, economic and housing condition, feeding problems, toilet and hygienic facilities as well as diagnosis of underlying diseases.
The following principles should be remembered in the management of very old patients:
(a) Proper nursing care by nurse or domestic attendant. The nurse may train a domestic assistant in such a way that the patient can be taken care of ultimately without a regular nurse.
(b) The family doctor is the person who should supervise by periodical visits or calling the patient, if possible.
(c) Drugs should be used very carefully and encouragement should be made to “Do it yourself’ way, as much as possible.
(d) Advice should be given regarding bath, toilet, care of mouth, denture, as well as how to combat pressure-sore. Pressure-sore is one of the most horrible complications in very old patients and bed-ridden people.
Some of the common symptoms in old people should be treated as follows, while investigation may be carried out:
(a) Anorexia:
Light physical exercise, especially yogic exercise or walking, may be helpful, Acid-bitter- mixtures or alkaline-bitter mixtures may be prescribed:
Occasionally small dose of steroids, e.g. prednisolone 2.5 mg. twice a day for a week or so, may be very useful, provided there are no contraindications.
(b) Halitosis:
This can be a very unpleasant symptom and is often due to neglect of oral hygiene.
(c) Hiccough:
May be due to too much chillies, betel chewing, tobacco chewing, alcohol or even serious organic disorders. If persistent, it needs investigation to exclude local causes but may be relieved with antacid, non-spicy diet, regular meals and drugs like metclorpropamide or chlorpromazine.
(d) Skin Rash and Pruritus:
Unhygienic condition of the skin, nail, hair, genitalia, perineum and body folds may lead to skin infection and ulcer. Pruritus may be due to allergic dermatosis, drug rash, fungal infection, diabetes mellitus, chronic renal failure, also lack of skin care.
(e) Chest Pain:
Should always be taken seriously and properly investigated. Investigation of chest pain includes ECG as well as proper clinical evaluation.
(f) Dyspnoea:
Chronic bronchitis, emphysema, pulmonary fibrosis, gross obesity, cardiac failure, anaemia, skeletal fixation, are the most common causes of dyspnoea in old people. Rarely, myasthenia gravis may be responsible. Chronic renal failure or spondylitis may also cause dyspnoea when the disease is advanced.
(g) Cough:
Treatment depends on the underlying pathology. Do not neglect a persistent cough which may be due to chronic bronchitis, cardiac failure or pulmonary carcinoma.
(h) Joint Pains and Rheumatism:
Inactivity is often responsible for so-called rheumatism in the old. Stiffness and slowness of movements are common especially during early hours in the morning. This is due to replacement of elastic tissue by fibrous tissue in the structure around the joints, gentle exercise, local heat and massage are helpful. Osteoarthritis is not uncommon, but encouragement to active life as much as possible, is the real answer. Osteoporosis should be looked for and properly treated with calcium, Vitamin D. Vitamin C and short course of anabolic steroids. Active physiotherapy is more valuable than drugs in old age.
However, drugs when necessary should be cautiously used. Avoid corticosteroids. Ibuprofen, Diclofenoc sodium, Flurbiprofen etc. may be prescribed in exceptional cases under careful supervision. Some old people tolerate aspirin quite well while others may not. In any case, investigate the underlying cause and treat cautiously.
(i) Insomnia:
Old people may keep good health with five to six hours of sleep. Proper assessment is necessary before sleeping drugs are prescribed. Sometimes small dose of tranquilisers or even placebo may help. A night cap of warm milk or artificial milk-preparation may be useful.
A table-spoon of brandy well diluted with soda or warm water may be useful and more effective as well as harmless than continuous use of sleeping tablets in old people. Psychological problem is the most important and single cause of insomnia. This factor can be carefully investigated by psychoanalysis and treated by psychoanalysis and psychotherapy. Lastly, be careful about the use of sleeping drugs, tranquilisers and narcotics in the old. Sometimes combination of drugs may be fatal.
(j) Constipation:
May occur when the patient is dehydrated, hyperpyrexic or is acutely ill. Insufficient food intake, lack of roughage in food, drugs, e.g. opium and ganglion-blocking agents, aluminium hydroxide etc., may lead to constipation. But organic causes should be kept in view, e.g. rectal or pelvic and colonic diseases, diabetes mellitus and myxoedema. Psychological disorder may sometimes cause severe constipation.
For treatment of constipation diet adjustment and regular exercises are methods of choice. Avoid regular use of paraffin- containing drugs or proprietary laxatives as far as possible. Many Ayurvedic drugs like “Trifala”, ‘Isabgool’, ‘Senna pod’, Bael-fruit etc., if properly used, are far more effective and safe. Adequate water should be ingested.
(k) Bleeding P.R:
Do not diagnose it as bleeding piles and dismiss the case. Rectal examination and proctoscopy must not be forgotten. There may be underlying rectal or colonic malignancy in old age group.
(l) Bleeding P.V:
Any unusual bleeding per vagina should be taken seriously. Opinion of gynaecologist is a must. If a gynaecologist is not available in rural practice, the doctor himself must do a P.V. examination and if in doubt refer the patient to the nearest hospital.
(m) Miscellaneous Symptoms:
Painful feet often result from callosities and other minor abnormalities, relieved by local treatment. Peripheral vascular disease may lead to burning sensation or paraesthesia in the feet, mostly felt at night. Foot bath with warm water is helpful. Some drugs are useful such as nicotinic acid 50 to 100 mg twice or thrice a day or other vasodilators are of some use. Muscular cramps especially of calf muscles usually precipitated by sudden stretching movement. Relief may be obtained by standing up and thrusting the feet downwards. If not relieved, drugs such as tolazoline may be needed.
Dizziness:
It is a distressing symptom in advanced old age. It is mostly subjective symptom to describe the effects of different clinical syndromes. Commonly light headedness, postural hypotension, instability and cerebral ischaemia. A proper history and symptomatic treatment is of value.