Geriatrics 2

Digestive System.- The Upper Gastrointestinal Tract. Esophagus, Stomach, Small Bowel, and Exocrine Pancreas.- A. Manifestations of Gastrointestinal Disease in the Aged.- B. Esophagus.- I. The Aging Esophagus.- II. Symptoms.- 1. Dysphagia.- 2. Pain.- 3. Heartburn.- 4. Bleeding.- 5. Impaction.- III. Diagnostic Modalities.- 1. Radiography.- 2. Esophagoscopy.- 3. Manometry.- 4. Acid Drip Test.- 5. Tests of Reflux, pH Probe, and Radioisotopic Scintigrams.- IV. Diseases of the Esophagus.- 1. Motility Disturbances of the Oropharynx and Upper Esophagus.- 2. Motility Disorders of the Middle and Lower Esophagus.- a) Achalasia.- b) Diffuse Spasm.- c) Collagen Vascular Disease.- d) Diabetes Mellitus.- 3. Reflux Esophagitis, Hiatus Hernia, and Barrett's Epithelium.- 4. Paraesophageal Hiatus Hernia.- 5. Lower Esophageal Rings.- 6. Infection of the Esophagus.- 7. Tumors of the Esophagus.- C. Stomach and Duodenum.- I. Anatomy and Physiology of the Aging Stomach.- II. Diagnostic Modalities.- 1. Radiography.- 2. Endoscopy.- 3. Gastric Analysis.- 4. Serum Gastrin.- III. Diseases of the Stomach and Duodenum.- 1. Functional Disease.- 2. Peptic Ulcer.- 3. Gastritis and Duodenitis.- 4. Bezoars.- 5. Tumors.- D. Small Intestine.- I. The Aging Small Intestine.- II. Diagnostic Modalities.- 1. X-ray.- 2. Tests of Malassimilation.- III. Diarrhea.- IV. Diseases of the Small Bowel.- 1. Regional Granulomatous Enteritis.- 2. Vascular Diseases.- 3. Maldigestion due to Gastric Surgery.- 4. Disaccharidase Deficiencies.- 5. Gluten-Sensitive Enteropathy.- 6. Bacterial Overgrowth Syndromes.- 7. Systemic Diseases Involving the Small Intestine.- 8. Malabsorption due to Drug Ingestion.- 9. Immunologic Deficiency Associated with Malabsorption.- 10. Whipple's Disease.- 11. Short Bowel Syndrome.- 12. Tumors.- a) Adenocarcinoma.- b) Lymphoma.- c) Leiomyosarcortia.- d) Premalignant Lesions.- e) Carcinoid Tumors.- f) Benign Tumors.- g) Telangiectasia and Angiodysplasia.- E. Exocrine Pancreas.- I. The Aging Pancreas.- II. Diagnostic Modalities.- 1. Radiography.- 2. Endoscopic Retrograde Pancreatography.- 3. Function Tests.- III. Diseases.- 1. Acute Pancreatitis.- 2. Chronic Pancreatitis.- 3. Tumors.- a) Adenocarcinoma.- b) Islet Cell Tumors.- c) Benign Tumors.- References.- The Large Intestine.- A. The Anatomy and Physiology of the Aging Large Intestine.- B. Diagnostic Modalities.- I. Radiography.- II. Endoscopy.- III. Fecal Examination.- C. Diseases of the Large Intestine.- I. Functional Bowel Disorders.- 1. Irritable Bowel Syndrome.- 2. Constipation.- 3. Incontinence.- II. Diverticular Disease.- III. Appendicitis.- IV. Vascular Insufficiency.- V. Vascular Ectasia.- VI. Infectious Disease.- 1. Bacteria.- 2. Parasites.- VII. Inflammatory Bowel Disease.- 1. Ulcerative Colitis.- 2. Crohn's Colitis.- VIII. Colorectal Cancer.- IX. Benign Tumors.- References.- The Liver and Biliary System.- A. Liver.- I. Physiological Aging.- 1. Anatomical Changes.- 2. Functional Changes.- a) Biochemical Changes.- b) Enzymatic Changes.- c) Hepatic Drug Metabolism in Old Age.- d) Changes in Liver Function Tests.- e) Bile Formation and Composition.- II. Diseases of the Liver in Old Age.- 1. Clinical Evaluation.- a) Biochemical Investigation.- b) Immunological Tests.- c) Haematology.- d) Radiology of the Hepatobiliary System.- e) Endoscopy.- f) Liver Biopsy.- g) Liver Imaging.- 2. Jaundice in Old Age.- a) Unconjugated (Prehepatic) Hyperbilirubinaemia.- b) Conjugated (Hepatic or Posthepatic) Hyperbilirubinaemia.- 3. Circulatory Disturbances.- a) Acute (Heart Failure, Shock).- b) Chronic Heart Failure.- c) Hepatic Vein Occlusion.- 4. Toxic Liver Injury.- a) Hepatic Necrosis.- b) Fatty Liver.- c) Hepatitis-like Reaction.- d) Intrahepatic Cholestasis.- 5. Inflammatory Diseases.- a) Viral Hepatitis.- b) Cholangitis.- c) Liver Abscess.- d) Chronic Inflammations.- 6. Cirrhosis.- a) Classification.- b) Incidence and Mortality.- c) Aetiology.- 7. Liver Failure.- 8. Infiltrations of the Liver.- a) Malignant Disease.- b) Amyloidosis.- 9. The Liver in Systemic Disorders.- a) Diabetes Mellitus.- b) Chronic Bowel Inflammation.- c) Collagen Diseases.- B. Biliary System.- I. Physiological Aging.- 1. Anatomical Changes.- 2. Functional Changes.- II. Disease of the Biliary System.- 1. Clinical Evaluation.- 2. Gallstones.- a) Clinical Features and Associations.- b) Silent Gallstones.- c) Medical Treatment of Gallstones.- d) Gallstones in the Common Bile Duct.- e) Gallstone Ileus.- 3. Cholecystitis.- a) Acute Cholecystitis.- b) Chronic Cholecystitis.- 4. Malignant Disease.- a) Carcinoma of Gallbladder.- b) Carcinoma of the Bile Ducts.- References.- Endocrine System.- Hypothalamo-Hypophyseal-Adrenal Axis.- A. Introduction.- I. Adaptation to Stress, Such as Surgery.- II. Hypothalamic-Pituitary-Adrenal Interrelationships.- B. Morphology.- I. Hypothalamus.- II. Pituitary.- III. Adrenal.- C. Basal Function.- I. Hypothalamus.- II. Pituitary.- III. Adrenal Cortex.- 1. Glucocorticoids.- 2. Mineralocorticoids.- 3. Androgens.- IV. Adrenal Medulla.- D. Dynamic Function.- I. Insulin Tolerance Test.- II. Metyrapone Test.- III. Dexamethasone Suppression Test.- IV. ACTH Test.- V. Surgery.- E. Clinical.- I. Anterior Pituitary.- II. Posterior Pituitary.- III. Adrenal Cortex.- IV. Adrenal Medulla.- V. Ectopic Humoral Syndromes.- VI. Iatrogenic Disease.- F. Conclusions.- References.- The Aged Thyroid Gland.- A. Morphology of the Elderly Thyroid.- B. Physiology of the Aged Thyroid.- I. Iodine Metabolism.- II. Thyroid Hormones.- III. Binding Proteins.- IV. Regulation by the Hypothalamic Anterior Pituitary System.- C. Nontoxic Goiter.- D. Hypothyroidism in Elderly Subjects.- I. Myxedema Coma.- E. Hyperthyroidism in Elderly Subjects.- F. Endocrine Ophthalmopathy.- G. Thyroiditis.- H. Struma Maligna.- I. Laboratory Diagnosis of Thyroid Diseases in Geriatric Patients.- I. TSH and theTRH-TSH Test.- II. Total Serum Thyroxine Concentration, Free Thyroxine, Binding Proteins, and Parameters for Determination of Free T4.- III. Total Triiodothyronine, Free T3, and Thyroid Antibodies.- IV. In Vivo Diagnostic Techniques.- References.- Diabetes Mellitus in Advanced Age.- A. Definition and Classification.- I. Primary Diabetes Mellitus.- II. Secondary Diabetes Mellitus.- III. Subclinical Diabetes Mellitus.- B. Epidemiology of Maturity Onset Diabetes.- C. Etiology and Pathogenesis.- D. Pathophysiology.- E. Diagnosis.- F. Diabetes Therapy in Advanced Age.- I. Dietary Measures.- II. Muscular Exercise in the Elderly Diabetic Patient.- III. Oral Antidiabetic Agents.- 1. Sulfonyl Ureas.- 2. Biguanides.- IV. Insulinization of the Maturity Onset Diabetic.- G. Acute Complications.- I. Coma Diabeticum.- II. Hypoglycemia.- H. Chronic Complications.- I. Diabetic Macroangiopathy.- II. Pyelonephritis.- III. Diabetic Neuropathy.- I. Prognosis.- References.- Sexual Function During Advancing Age.- A. Anatomic and Physiologic Considerations.- B. Totality of Factors in Human Sexuality.- C. Male Psychogenic Impotency.- D. Organic Basis of Impotency.- I. Systemic Illness.- II. Neurologic Deficit.- III. Vascular Problems.- IV. Chronic Hemodialysis.- V. Malignancy.- VI. Cosmetic Factors.- VII. Postoperative Impact.- VIII. Drugs.- E. Methods of Diagnosis of Sexual Impotency.- I. Clinical Acuity of Interviewer.- II. Testing Techniques: Mechanical Aids.- F. Therapy of Male Impotency.- I. Counseling.- II. Prosthetic Devices.- G. Therapy of Female Sexual Dysfunction.- H. Concluding Remarks.- References.- Kidney and Urogenital System.- The Kidney.- A. Characteristic Features of Geriatric Nephrology.- B. Aging of the Kidney.- I. Structural Changes.- 1. Loss of Nephrons.- 2. Glomerular Changes.- 3. Tubular Changes.- 4. Vascular Changes.- 5. Renal Hypertrophy.- II. Functional Changes.- 1. Renal Plasma Flow.- 2. Glomerular Filtration.- 3. Tubular Function.- 4. Fluid and Electrolyte Balance.- C. Disease of the Kidney - Geriatric Aspects.- I. Renovascular Disease.- II. Pyelonephritis and Urinary Tract Infection.- 1. Bacteriuria and Pyelonephritis.- 2. Predisposing Factors.- 3. Urosepsis.- 4. Treatment of Urinary Tract Infection in the Aged.- 5. Resistance Problems in Geriatric Wards.- 6. Treatment of Patients with Indwelling Catheters.- 7. Prognostic Significance of Bacteriuria.- III. Acute Glomerulonephritis.- IV. Nephrotic Syndrome.- V. Other Renal Diseases.- D. Uraemia.- I. Acute Renal Failure.- II. Chronic Renal Failure.- III. Treatment of the Uraemic Elderly Patient.- References.- Bladder and Prostate.- A. Bladder.- I. Embryological Origins.- II. Anatomy.- III. Nerve Supply.- IV. The Functioning Bladder.- V. Symptoms Associated with Bladder Dysfunction.- B. Special Diagnostic Methods.- I. The Cystometrogram.- II. Peak Flow Rate.- III. Micturating Cystogram.- IV. Urethral Pressure Profile.- V. Cystoscopy.- C. Prostate Gland.- I. Anatomy.- II. Benign Enlargement of the Prostate.- III. The Pathology of Prostatic Obstruction.- IV. Symptoms.- V. Diagnosis.- VI. Treatment.- D. Prostatic Carcinoma.- I. Symptoms.- II. Diagnosis.- III. Treatment.- E. Prostatitis.- I. Acute Prostatitis.- II. Chronic Prostatitis.- F. Carcinoma of the Bladder.- I. Pathological Staging.- II. Diagnosis.- III. Treatment.- G. Retention of Urine.- I. Causes.- II. Treatment.- H. Cystitis.- I. Causes.- II. Treatment.- I. Incontinence of Urine.- I. Causes.- II. Clinical Examination of the Incontinent Patient.- III. Treatment.- J. Drug Therapy in Incontinence.- References.- Haematological System.- Blood in the Aged.- A. Ageing of Bone Marrow.- B. Red Blood Cells.- I. Erythrocytes in the Aged.- II. Ageing of Erythrocytes.- III. Erythropoiesis in the Aged.- IV. Haemoglobin.- C. White Blood Cells.- I. General Aspects.- II. Granulocytes.- III. Monocytes.- IV. The Regulation of Granulocyte-Monocyte Production.- V. Lymphocytes and Lymphatic System.- D. Anaemias in the Aged.- I. Introduction.- II. Carential Anaemias.- 1. Iron Deficiency Anaemias.- 2. Megaloblastic Anaemias.- a) Pernicious Anaemia.- b) Folic Acid Deficiency Anaemia.- 3. Other Macrocytic, Non-Megaloblastic Anaemias.- 4. Therapy of Carential Anaemias in the Aged.- III. Haemolytic Anaemias.- IV. Aplastic Anaemias and Pancytopenias.- V. Anaemias Due to Chronic Diseases.- VI. Sideroblastic Anaemias.- E. Disorders of Leucocytes in the Aged.- I. Idiopathic Granulocytic Dysfunction.- II. Neutropenia (Agranulocytosis).- III. Leukaemias and Allied Disorders.- 1. Acute Leukaemias.- 2. Chronic Myelocytic Leukaemia.- 3. Chronic Lymphocytic Leukaemia.- 4. Malignant Lymphomas.- a) Non-Hodgkin's Malignant Lymphomas.- b) Hodgkin's Disease.- 5. Monoclonal Gammapathies.- a) Myeloma.- b) Waldenstrom Macroglobulinaemia.- 6. Miscellaneous Conditions.- a) Polycythaemia Rubra Vera.- b) Myelofibrosis.- c) Idiopathic Thrombocythaemia.- F. Disorders of Haemostasis in the Aged.- I. Blood Coagulation and Haemostasis in the Aged.- II. Haemorrhagic Diseases in the Aged.- 1. Congenital Hereditary Haemorrhagic Diseases.- 2. Acquired Haemorrhagic Diseases.- a) Acquired Coagulation Disorders.- b) Thrombocytopenias.- c) Haemorrhagic Syndromes Due to Intervascular Coagulation.- d) Haemorrhagic Syndromes Due to Vascular Factors.- e) Bateman's Purpura.- III. Thrombosis and Thrombo-Embolic Diseases in the Aged.- 1. Pathogenesis of Thrombophilia.- 2. Diagnostic Problems in Thrombophilia.- 3. Prophylaxis of Thrombophilic States.- 4. Thrombolytic Therapy.- References.- Respiratory System.- Physiological and Pathological Aspects of the Respiratory System.- A. Changes in Structure of the Lungs with Age.- I. Changes in the Alveoli.- II. Changes in Pulmonary Blood Vessels.- B. Changes in Lung Function with Age.- I. Elasticity and Distensibility of the Lungs.- II. Lung Volume.- III. Airway Closure and Distribution of Ventilation.- IV. Ventilation Perfusion Matching: Blood Gases.- V. Gas Transfer.- VI. Exercise.- C. The Appearance of the Chest Radiograph in Old Age.- D. Infection of the Respiratory Tract in Old Age.- I. Upper Respiratory Tract Infection.- II. Influenza.- III. Pneumonia.- IV. Unresolved Pneumonia.- V. Tuberculosis.- E. Conditions Associated with Airways Obstruction.- I. Chronic Bronchitis and Emphysema.- II. Asthma.- III. Obstruction of Large Airways.- F. Cancer of the Lung.- G. Pulmonary Fibrosis and Alveolitis.- I. Cryptogenic Fibrosing Alveolitis.- II. Extrinsic Allergic Alveolitis.- References.- Rehabilitation.- Rehabilitation - Physical and Clinical Aspects.- A. Definition.- B. The Importance of Geriatric Rehabilitation.- C. Legislative Background and Costs.- D. Biological Factors Governing Rehabilitation in Old Age.- I. Physiological Characteristics of Senescence: Diminished Adaptive Capacity and Exaggerated Interindividual Variation.- 1. Methods and Indices for Assessing Physical Capacity in Old Age.- II. Pathophysiological Characteristics: Variation of Clinical Symptoms Typical of Ageing and Multimorbidity; Extent and Consequences.- III. Exercise Tolerance and the Demands of Training.- IV. The Response to Training in Old Age.- V. Methods of Training for Elderly Handicapped Patients.- E. Indications for Rehabilitation in Old Age.- I. General Principles.- II. Assessment of the Need for Rehabilitation.- III. Assessment of the Potential Response to Rehabilitation.- IV. Criteria Which Exclude Rehabilitation.- F. Resources and Methods of Geriatric Rehabilitation.- I. Human Resources: The Rehabilitation Team.- 1. The Geriatrician.- 2. Physiotherapy.- 3. Occupational Therapy.- a) Mobile Occupational Therapy.- 4. Logopedia.- 5. Physical Medicine.- 6. Social Work.- 7. Psychology.- 8. Activating Care.- II. Institutional Resources: Rehabilitation Centers.- 1. Part-time Inpatient Care: The Geriatric Day Clinic.- 2. Inpatient Facilities.- a) The Geriatric Rehabilitation Clinic and the Department of Geriatric Rehabilitation.- b) The Long-Stay Hospital and the Old People's Home with Rehabilitation Facilities.- III. Ambulant Rehabilitation Measures.- 1. Measures Governed by Local Facilities.- a) The Human Resources.- b) The Material Resources.- 2. Measures Governed by the Patient's Circumstances.- IV. Other Therapeutic Ancillary Facilities at the Service of Geriatric Rehabilitation.- 1. The Depot of Medical and Self-help Aids.- 2. Social Services and District Nurses.- V. Other Aids and Supporting Services: Meals on Wheels, Shopping Services, and Sheltered Workshops.- G. The Practical Implementation of Geriatric Rehabilitation as Exemplified by Rehabilitation Hospital Procedures.- I. Initial Measures (Early Phase, Bedside Therapy).- II. Indoor Walking Phase.- III. Concluding Phase with Outdoor Therapy.- IV. Transition, Aftercare, and Reintegration.- H. Results of Geriatric Rehabilitation Measures.- References.- Nutrition.- Nutritional Characteristics of the Elderly.- A. Introduction.- B. Physiological Changes Influencing Nutrition.- I. Changes in Body Size and Composition.- II. Energy Expenditure.- III. Metabolism.- IV. Digestion.- C. Requirements of Essential Nutrients.- I. Protein and Essential Amino Acids.- 1. Protein.- 2. Essential Amino Acids.- II. Vitamins.- 1. Vitamin B6.- 2. Vitamin C.- 3. Vitamin D.- III. Minerals.- 1. Iron.- 2. Calcium.- D. Food Consumption and Nutritional Status of the Elderly.- E. Conclusions.- References.- The Role of Nutrition in Human Aging.- A. Introduction.- B. Multifactorial Nature of the Aging Process.- I. Physical Performance.- II. Changes in Energy Metabolism.- III. Lipid Metabolism and the Cardiovascular System.- IV. Nervous System and Sensory Changes.- V. Hormonal Changes.- VI. Kidney Changes.- VII. Skeletal Changes.- VIII. Skin Changes.- IX. Gastrointestinal Tract Changes.- X. Generalization.- C. Degenerative Diseases and Diet.- I. Common Dietary Restrictions.- II. Health Foods.- III. Generalizations.- D. Significance of Diet.- I. Nutrition Survey Evidence.- II. Population Differences.- III. Economic Effects.- IV. Transplanted Populations.- V. Diet and Cancer.- VI. Generalization.- E. Importance of Diet Components.- I. Crude Fiber.- II. Minerals.- III. Lipids.- IV. Trace Components.- V. Generalization.- F. Experience from Surveys and Feeding Programs.- I. Survey Data.- II. Feeding Programs.- III. Economic Considerations.- IV. Generalizations.- G. Conclusions.- References.- Protein and Amino Acid Metabolism and Nutrition During Human Aging.- A. Introduction.- B. Some Aspects of Body Composition in Relation to Aging.- C. Whole Body and Muscle Protein Metabolism.- D. Metabolism of Specific Proteins.- E. Status of Amino Acid Metabolism.- F. Protein and Amino Acid Requirements.- I. Requirements for Essential Amino Acids.- II. Requirement for Total Nitrogen (Protein).- G. Effects of Infection and Other Stressful Stimuli on Protein Metabolism and Requirements.- H. Summary.- References.- Vitamins and the Aging Process.- A. Introduction.- B. Definition.- C. Functions of Vitamins.- D. Some Aspects of Utilization of the Vitamins.- E. Vitamin Status of the Elderly.- F. Methods for Estimating the Vitamin Requirements in Adults.- G. Factors Affecting Vitamin Requirements in Elderly People.- H. Summary and Conclusions.- References.- Human Aging and Obesity.- A. Introduction.- B. The Relationship of Age and Obesity.- C. Effects upon Blood Pressure of Change in Weight Status from Childhood to Adult Life.- D. The Relationship Between Obesity, Mortality, and Coronary Heart Disease.- E. The Treatment of Obesity.- References.- Drug Treatment.- Drug Treatment in the Aged.- A. Introduction.- B. Pharmacokinetics.- I. Absorption.- II. Distribution.- 1. Plasma Proteins.- 2. Erythrocytes.- 3. Tissue Composition.- III. Metabolism.- IV. Excretion.- 1. Kidneys.- 2. Liver.- V. Side Effects.- 1. Glycosides.- 2. Diuretics.- 3. Antihypertensives.- 4. Analgesics.- 5. Anticoagulants.- 6. Sedatives.- 7. Antiparkinsonism Drugs.- 8. Antidepressive Drugs.- C. General Principles of Drug Therapy.- D. Drugs to Combat Ageing.- References.