What are common changes in geriatric patients?

Common Changes in Geriatric Patients

Geriatric patients experience predictable physiological changes across multiple organ systems, combined with increased vulnerability to geriatric syndromes—multifactorial conditions including frailty, falls, cognitive impairment, incontinence, and polypharmacy—that fundamentally alter their response to illness and injury. 1

Physiological Changes by System

Cardiovascular and Metabolic Changes

• Reduced glucose-induced insulin release and increased insulin resistance in peripheral tissues (primarily muscle and adipose tissue) develop with aging 1
• Abdominal obesity increases with elevated free fatty acids and inflammatory markers (TNF-α, IL-6), further worsening insulin resistance 1
• Impaired endothelial function occurs through suppressed nitric oxide formation and reduced flow-mediated dilation 1
• Altered drug metabolism with reduced renal clearance affects medication dosing, particularly for renally-excreted drugs 2

Musculoskeletal and Functional Changes

• Sarcopenia develops: disproportionate loss of muscle mass and strength accompanied by declining physical activity, functionality, and performance 1
• Decreased bone density increases fracture risk, particularly in cervical spine, ribs, hip, and extremities 1
• Reduced joint flexibility and muscle strength impair mobility 1
• Loss of adaptive and regenerative capacity makes returning to baseline function after illness extremely difficult 1

Sensory and Neurological Changes

• Decreased vision and hearing are common age-related changes 1
• Slower reflexes and poorer balance increase fall risk 1
• Impaired motor and cognitive function affects medication adherence and self-care abilities 1
• Elevated renal threshold for glycosuria masks typical hyperglycemia symptoms like polyuria and polydipsia 1
• Impaired thirst mechanisms increase dehydration risk 1

Immune and Inflammatory Changes

• Impaired leukocyte function including decreased phagocytosis, bacterial killing, and chemotaxis leads to increased infection risk 1
• Activation of NF-κB pathway with production of proinflammatory cytokines and oxidative stress 1
• Increased vascular permeability and mitochondrial dysfunction occur with acute stress 1

The Geriatric Syndromes Framework

Core Geriatric Syndromes

The most clinically significant syndromes include: 1, 3

• Frailty: increased vulnerability to stress from cumulative decline across physiological systems, affecting approximately 25% of persons aged ≥85 years 1
• Falls: ground-level falls are the most common injury mechanism, with 6% sustaining fractures and 10-30% developing polytrauma 1
• Cognitive impairment/dementia: permanent cognitive decline affecting treatment decisions and medication adherence 1
• Delirium: acute cognitive impairment often precipitated by illness or medications 1
• Urinary incontinence: impairs quality of life and increases fall risk 3
• Polypharmacy: older adults account for >700,000 emergency visits annually for adverse drug events, with insulin and warfarin being leading causes 1
• Depression: commonly co-occurs with cognitive decline and affects treatment adherence 1

Shared Risk Factors Across Syndromes

Four risk factors consistently predict multiple geriatric syndromes: 3

• Older age (particularly ≥80 years)
• Baseline cognitive impairment
• Baseline functional impairment
• Impaired mobility

Nutritional and Metabolic Vulnerabilities

Anorexia of Aging

• Inadequate caloric intake is the primary cause of malnutrition, not the underlying illness itself 1
• Unintended weight loss >5% in 6 months or >10% beyond 6 months defines malnutrition in older adults 1
• Vitamin D deficiency increases osteoporosis and fracture risk 1

Clinical Consequences

• Increased infection rates and pressure ulcers 1
• Prolonged hospital stays and convalescence 1
• Higher mortality rates directly correlate with malnutrition 1

Altered Response to Stress and Injury

Trauma-Specific Changes

• Reduced physiological reserve across multiple systems makes compensation during acute illness difficult 1, 4
• Frailty is an independent mortality risk factor in elderly trauma patients 1
• Motor vehicle crashes are the second most common injury mechanism but the leading cause of traumatic death 1
• Chest injuries in one-quarter of motor vehicle crash victims exacerbate preexisting cardiopulmonary disease 1

Medication-Related Vulnerabilities

• Anticholinergics, antipsychotics, benzodiazepines, corticosteroids, and opioids all worsen cognitive impairment 1
• Diuretics, β-blockers, and glucocorticoids adversely affect carbohydrate metabolism 1
• Lower body weight (<55 kg) increases risk of medication toxicity and adverse effects 5

Social and Functional Considerations

Social Determinants

• Social isolation is a significant predictor of mortality in older adults 1
• Living conditions, caregiver presence, and financial status directly impact treatment feasibility 1
• Multicomplexity: the intersection of multiple chronic conditions with social determinants fundamentally alters care management 1

Functional Assessment Priorities

• Activities of daily living (ADL) independence is jeopardized by acute illness combined with age-related changes 1
• Autonomy and quality of life are the primary goals of geriatric medicine, not disease cure 1
• Reduced capacity for rehabilitation means many patients cannot return to baseline function 1

Clinical Pitfalls to Avoid

• Attributing symptoms to "old age": weight loss, fatigue, and confusion require investigation, not dismissal 1
• Missing atypical presentations: elderly patients often lack typical symptoms (e.g., no polyuria/polydipsia with hyperglycemia) 1
• Overlooking medication burden: systematically review all medications for appropriateness and deprescribing opportunities 1
• Ignoring cognitive status: cognitive impairment affects informed consent, medication adherence, and self-care abilities 1
• Failing to assess frailty: frailty predicts outcomes better than chronological age alone 1