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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 4  |  Page : 213-216

Geriatric syndromes: A therapeutic challenge


College of Nursing, AIIMS, Jodhpur, Rajasthan, India

Date of Submission25-Jul-2022
Date of Decision10-Oct-2022
Date of Acceptance11-Dec-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Vandna Pandey
College of Nursing, AIIMS Jodhpur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_36_22

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  Abstract 


Aging is a natural phenomenon that is irrevocable. The older adult population is increasing rapidly in India, projected to increase from 6% to nearly 20% in 2050. Clinical conditions found among the elderly that do not fit into discrete disease categories and result from accumulated impairments in multiple systems are called geriatric syndromes. The authors have done a literature search of research papers from indexed and nonindexed journals e databases, Google Scholar, PubMed, and Scopus, Science Direct, Research Gate, and Cochrane. The search terms included were geriatric population, geriatric syndrome, geriatric care, elderly health problem, and comprehensive approach. The management of geriatric syndromes is a challenge to modern geriatric clinical practice. The comprehensive assessment of older adults using standardized tools must be carried out in any healthcare facility to ensure that their needs are met through care and treatment. Evidence-based standards of practice need to be implemented to provide nursing care for dealing with the therapeutic challenges of various geriatric syndromes.

Keywords: Aging, comprehensive approach, geriatric assessment, geriatric syndromes


How to cite this article:
Pandey V, Kurien N, Mohan R. Geriatric syndromes: A therapeutic challenge. J Indian Acad Geriatr 2022;18:213-6

How to cite this URL:
Pandey V, Kurien N, Mohan R. Geriatric syndromes: A therapeutic challenge. J Indian Acad Geriatr [serial online] 2022 [cited 2023 Feb 8];18:213-6. Available from: http://www.jiag.com/text.asp?2022/18/4/213/365770




  Introduction Top


Aging is irreversible and inevitable. It is a complex process that can be described chronologically, physiologically, and functionally. Increased medical knowledge and technological advances have led to increased life expectancy. The older adult population is increasing rapidly in India and worldwide. According to the World Health Organization (WHO), the absolute number of populations aged over 60 will increase to 137 million in 2021.[1] According to the State of World Population 2019 report by the United Nations Population Fund, India's population in 2019 stood at 1.36 billion, growing from 942.2 million in 1994, 6% of India's population was of the age 60 years and above. It is projected to increase from 6% to nearly 20% in 2050.[2] As per the 2001 census report of India, there were 75.93 million Indians aged 60 years and above. Moreover, till the year 2051, the projections are: 96.30 million (2011), 133.32 million (2021), 178.59 (2031), 236.01 million (2041), and 300.96 million (2051).[3] As per the 2011 census, 8.6% of the total population is of 60 years or more of age.[4]


  Methods Top


Search strategy

A literature search is conducted with the following five databases:

Science Direct, PubMed, Google Scholar, Research Gate, and Cochrane. Search terms included were aging, geriatric population, geriatric syndrome, elderly health problem, and comprehensive approach. Articles were read and assessed for relevance.

Inclusion criteria

  • Peer-reviewed academic journals published in English
  • Focus on the elderly population and their health concerns, geriatric assessment, and comprehensive care of the elderly
  • Articles with accessible abstracts and full text.


Exclusion criteria

  • Incomplete text
  • Duplicated study.


After screening the articles, 16 relevant studies are included in the review.

The major themes are geriatric syndromes, assessment tool, nursing implications/nursing considerations.

Objectives

To identify the various clinical conditions of the elderly population which do not fit into the discrete disease category.

To summarize the geriatric assessment and nursing implications.

Geriatric syndromes are clinical conditions found among the elderly which do not fit into discrete disease categories.[5] These are clinical conditions occurring in the aged population, where more than one abnormality “runs together” to cause a single phenomenology.

Geriatric syndromes are conditions in which “symptoms result not merely from discrete diseases but also from accumulated impairments in multiple systems” and develop when the accumulated effect of these impairments in multiple domains compromises compensatory ability. For example, in urinary incontinence (UI), the cumulative effects of multiple contributors (impaired bladder contractility, severe illness, lack of physical capacity to go to the toilet, old age, etc.) result in the phenomenology of UI.[6] In an attempt to standardize the definition of geriatric syndromes, a 2007 paper by Inouye et al. defined geriatric syndromes as “multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render (an older) person vulnerable to situational challenges.”[7]

In geriatric syndrome, various heterogeneous factors across organ systems along with their multifactorial causative nature lead to unified manifestations [Figure 1].[8]
Figure 1: Heterogenous factors leading to geriatric syndromes[8]

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Geriatric syndromes

The management of geriatric syndromes forms a major component of modern geriatric clinical practice. UI, dementia, delirium, falls, frailty, hearing impairment, visual impairment, sarcopenia, malnutrition, immobility, gait disturbance, and pressure ulcers are included as geriatric syndromes by Asian-Pacific geriatric societies.[9] The common risk factors of geriatric syndromes include - age, cognitive impairment, functional impairment, and impaired mobility. Major geriatric syndromes identified are falls, UI, pressure ulcers, delirium, functional decline, visual impairment, hearing impairment, sarcopenia, malnutrition, dementia, and frailty.

Falls

Falls and their consequences are major public health problems among the elderly population. According to the WHO global report on falls prevention, people aged 65 years and above fall about 28%–35% each year, and this proportion increases as age and frailty level increase.[10] The prevalence of falls in India, above the age of 60 years, is reported to range from 14%–53%.[11]

Urinary incontinence

UI is more common in the elderly, especially women and is a widespread health concern among older adults. UI substantially influences individuals' quality of life, particularly their social and psychological health status. The risk factors of UI in the elderly are the number of childbirths, previous hysterectomy or prostatectomy, obesity, various medical problems (e.g. infection), and chronic disease (e.g. stroke). About 4.4% of the elderly population is reported to have UI.[12]

Pressure ulcers

Pressure ulcers add to geriatric syndromes consisting of multifactorial pathological conditions like peripheral vascular disease, immobility, or nutritional deficiencies. The management of a pressure ulcer requires a comprehensive approach. Pressure ulcers can be treated by enhancing or optimizing regional blood flow, providing adequate caloric and protein intake, and promoting wound healing by avoiding any preventable contributing factor like immobility.[13]

Delirium

Delirium is a geriatric syndrome that comprises an array of neuropsychiatric symptoms. It is a state of sudden mental confusion. The cardinal features of delirium are acute onset, fluctuating course, impaired attention, and cognitive changes. Nonpharmacological multidisciplinary approaches are widely accepted as the single most effective strategy for the management of delirium. Multicomponent intervention strategy includes proactive geriatric consultation along with a familial caregiver, re-orientation, provision of vision and hearing adaptations, involvement in therapeutic activities, promotion of sleep, and maintenance of adequate hydration and nutrition.[9]

Functional decline

Functional decline is a frequent problem in geriatrics. The functional decline of the elderly is also multifactorial (psychological, medical, social, and financial); like other geriatric syndromes which contribute to impaired functional status. Interventions to improve function in the elderly should point out to manage underlying impairment as well as relevant personal and environmental factors.[6]

Visual impairment

Visual impairment is a stumbling block to independent living. With aging, anatomical and physiological processes of an eye decline. The eyes experience a loss of elasticity and tone, age-related protein changes leading to cataracts, changes in visual accommodation, and neuromuscular decline.[14] The realization that one's vision is deteriorating is often associated with psychological reactions such as grief, confusion, anger, fear, anxiety, diminished emotional security, loss of self-esteem, and in some cases, depression. Whiteside, M found that persons with vision impairments had a risk of depression 2.3 times greater than those without a vision problem.[15]

The physical consequences of visual impairment range across a very broad spectrum, from the seemingly innocuous hindrance in performing activities of daily living (ADLs) to more obvious, life-threatening effects such as accidents During the aging process, neuromuscular decline produces postural instability, along with visual impairment predisposes elderly persons to falls.

Dementia

Dementia is a chronic deterioration in the cognitive ability of a person. It has become a common diagnosis in aging populations. The prevalence of dementia in India is reported to be 2.7%.[16] As the age increase, the prevalence of dementia increases. Dementia is associated with a considerably increased risk of other geriatric syndromes such as malnutrition, delirium, incontinence, etc.[16]

Frailty

Frailty gives way to unfavorable clinical outcomes among older people. It can be described as the gradual loss of energy, endurance, power, and motor control. Frailty is a clinical geriatric syndrome characterized by increased “latent vulnerability” resulting from the reduction of physiological reserves and the decreased capacity to cope with exogenous as well as endogenous stresses.[17]

Sarcopenia

Sarcopenia is a geriatric syndrome that is associated with a decrease in muscle mass and subsequently strength. The multifactorial cause, with declines in activity and nutrition, disease states, inflammation, declines in neuromuscular junctions, and aging-related changes in mitochondria, apoptosis leads to increased prevalence of sarcopenia in the elderly.[18]


  Assessment Tool Top


Comprehensive geriatric assessment

Comprehensive geriatric assessment (CGA) is a multidimensional geriatric assessment tool. The core components of CGA that should be evaluated are functional capacity, fall risk, cognition, mood, polypharmacy, social support, financial concerns, goals of care, nutrition/weight change, urinary continence, sexual function, vision/hearing, dentition, living situation, and spirituality [Figure 2].[19],[22]
Figure 2: Interacting dimensions of comprehensive geriatric assessment. (Source: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S: Geriatric medicine and Gerontology, 6th Edition)[22]

Click here to view



  The Rapid Geriatric Assessment Top


Rapid Geriatric Assessment (RGA) consists of four short screening questionnaires and an inquiry into the presence of advanced directives. These four tools can help healthcare providers quickly identify most geriatrics syndromes. The RGA screening questionnaires are The FRAIL scale, the SARC-F scale for sarcopenia, the Simplified Nutritional Appetite Questionnaire (SNAQ), and the Rapid Cognitive Screen (RCS) [Figure 3].[8]
Figure 3: Component of rapid geriatric assessment[8]

Click here to view


Scores range of the FRAIL scale is from 0 to 5, with a higher score indicating more frailty. A score of zero indicates a healthy older adult, a score of 1–2 indicates prefrail or early decline, and a score of 3 or more indicates decline and frailty. Scores range of the SARC-F scale is from 0 to 10 with a score of 4 or more indicating sarcopenia. The SNAQ score of 14 or less is predictive of weight loss over the following 6 months. The scoring of the RCS is from 0 to 10. A score of 0–5 indicates dementia, 6–7 indicates mild cognitive impairment and 8–10 is normal. The ending question of the RGA is, “Do you have an advanced directive?” This question is foremost because advanced directives are how a person communicates his desired care goals. Health care personnel can ensure these goals are met when he is not able to express his wishes.[8]

The respondent should answer the questions based on how they usually feel most of the time, not just on the day of the office visit or screening tests.


  Nursing Implications/Nursing Considerations Top


Nurses are central and essential to the care of older adults across all healthcare settings. Thoughtful partnership with family members in nursing care planning further ensures the respectful care that older person deserves. Evidence-based standards of practice are implemented to provide nursing care for dealing with various Geriatric syndromes.[20] Older adults in any healthcare facility must be assessed for geriatric syndromes and ensured that their needs are met through care and treatment.

Broad areas of assessment are as follows:

  • Current symptoms and current medications
  • Relevant past illness or hospitalization
  • Assessment of mobility and balance
  • Ability to carry-out ADL
  • Cognitive status
  • Nutritional status and needs
  • Bowel and bladder functioning
  • Overall personal and social functionality
  • Family situation
  • Sleep pattern
  • Current emotional health and substance abuse
  • Expectations related to health care.


When collecting nursing history and conducting physical examinations maintain good therapeutic communication.[21] Use open-ended statements. Be attentive to nonverbal communication. The nurse must focus on identifying the medical, social, and psychological problems of the old adult which can lead to the formation of a plan of care including spiritual needs and rehabilitation.

Recommendations

As medical facilities are improving, life expectancy is also increasing. Healthy living and accessibility to medical care and social security is the right of every individual including the senior population. There is no clear evidence on the number or intensity of elderly suffering from geriatric syndrome. A targeted integrated geriatric community-based care point is recommended. This dedicated healthcare to the elderly at primary healthcare settings is true for every society, especially those with aging and super-aging populations.


  Conclusion Top


As the medical field is advancing, so is life expectancy increasing. Worldwide, as well as in India, the number of aged populations is growing. Nurses equipped with knowledge about age-related changes along with the skill to use proper assessment tools can play a vital role in improving geriatric standards of practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organisation. Aging and Life Course. Aging in India. Available from: https://www.who.int/ageing/publications/india/en/. [Last accessed on 2022 May 19].  Back to cited text no. 1
    
2.
Share of Population over Age of 60 in India. The Economic Times. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/share-of-population-over-age-of-60-in-india-projected-to-increase-to-20-in-2050-un/articleshow/68919318.cms?from=mdr. [Last accessed on 2019 Apr 17].  Back to cited text no. 2
    
3.
Operational Guidelines: National Programme for Health Care of the Elderly (NPHCE). New Delhi: Ministry of Health and Family Welfare, Government of India; 2011.  Back to cited text no. 3
    
4.
World Health Organization. Aging and Health. Available from: https://www.who.int/india/health-topics/ageing. [Last accessed on 2022 May 19].  Back to cited text no. 4
    
5.
Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc 2003;51:574-6.  Back to cited text no. 5
    
6.
Bhardwaj N, Kashyap M. Study of the association of geriatric syndromes with functional dependence in the elderly. Int J Med Health Sci 2018;7:16-20.  Back to cited text no. 6
    
7.
Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc 2007;55:780-91.  Back to cited text no. 7
    
8.
Little MO. The rapid geriatric assessment: A quick screen for geriatric syndromes. Mo Med 2017;114:101-4.  Back to cited text no. 8
    
9.
Won CW, Yoo HJ, Yu SH, Kim CO, Dumlao LC, Dewiasty E, et al. Lists of geriatric syndromes in the Asian-Pacific geriatric societies. Eur Geriatr Med 2013;4:335-8.  Back to cited text no. 9
    
10.
World Health Organization. WHO Global Report on Falls Prevention in Older Age. Available from: http://www.who.int/ageing/publications/Falls_prevention7March.pdf. [Last accessed on 2022 Jul 19].  Back to cited text no. 10
    
11.
Dsouza SA, Rajashekar B, Dsouza HS, Kumar KB. Falls in Indian older adults: A barrier to active aging. Asian J Gerontol Geriatr 2014;9:33-40.  Back to cited text no. 11
    
12.
Das PC, Chatterjee P. Prevalence and predictors of geriatric syndromes in an outpatient clinic at a tertiary care hospital in India. J Aging Res Clin Pract 2013;2:117-20.  Back to cited text no. 12
    
13.
Jaul E. Assessment and management of pressure ulcers in the elderly: Current strategies. Drugs Aging 2010;27:311-25.  Back to cited text no. 13
    
14.
Saaddine JB, Narayan KM, Vinicor F. Vision loss: A public health problem? Ophthalmology 2003;110:253-4.  Back to cited text no. 14
    
15.
Whiteside MM, Wallhagen MI, Pettengill E. Sensory impairment in older adults: Part 2: Vision loss. Am J Nurs 2006;106:52-62.  Back to cited text no. 15
    
16.
National Health Portal. Government of India. Available from: https://www.nhp.gov.in/disease/neurological/dementia. [Last accessed on 2022 Jun 05].  Back to cited text no. 16
    
17.
Chen X, Mao G, Leng SX. Frailty syndrome: An overview. Clin Interv Aging 2014;9:433-41.  Back to cited text no. 17
    
18.
Cruz-Jentoft AJ, Landi F, Topinková E, Michel JP. Understanding sarcopenia as a geriatric syndrome. Curr Opin Clin Nutr Metab Care 2010;13:1-7.  Back to cited text no. 18
    
19.
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993;342:1032-6.  Back to cited text no. 19
    
20.
Kim J, Miller S. Geriatric syndromes: Meeting a growing challenge. Nurs Clin North Am 2017;52:9-10.  Back to cited text no. 20
    
21.
Brown-O'Hara T. Geriatric syndromes and their nursing implications. Nursing 2013;43:1-3.  Back to cited text no. 21
    
22.
Section a. assessment. Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S(Eds.). Hazzard's Geriatric Medicine and Gerontology, 6e. McGraw Hill. 2009. https://accessmedicine.mhmedical.com/content.aspx?bookid=371&sectionid=41587615.  Back to cited text no. 22
    


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