After completing this note you will be able to take a focused history, perform a targeted examination, order and interpret the key investigations, and outline the immediate and definitive management plan for common geriatric problems in Kenya. Always verify drug choices, doses and local protocols against the Kenya MoH guideline and your hospital formulary.
Definition
Geriatric medicine is the branch of internal medicine that addresses the health care needs of adults aged ≥ 65 years, with emphasis on multimorbidity, functional decline, poly‑pharmacy, and the social‑environmental context that influences ageing in Kenya.
Anatomy and physiology you need
| System | Key age‑related change | Clinical relevance |
|---|---|---|
| Cardiovascular | Reduced arterial compliance, LV diastolic dysfunction | ↑ systolic BP, orthostatic hypotension, heart failure |
| Respiratory | Decreased elastic recoil, weaker cough | ↑ risk of pneumonia, TB re‑activation |
| Renal | ↓ GFR, impaired concentrating ability | Drug accumulation, electrolyte imbalance |
| Musculoskeletal | Sarcopenia, osteopenia | Falls, frailty, limited ADL |
| Neurologic | Neuronal loss, slower conduction | Cognitive decline, gait disturbance |
| Immune | Immunosenescence | Higher infection susceptibility (HIV, malaria, TB) |
| Gastro‑intestinal | Delayed gastric emptying, reduced motility | Constipation, malabsorption |
Causes and risk factors
- Non‑communicable diseases: hypertension, type 2 diabetes, ischaemic heart disease, chronic kidney disease, COPD.
- Infectious diseases prevalent in Kenya: HIV (long‑term ART effects), pulmonary TB (reactivation), malaria (recurrent anaemia), chronic hepatitis B/C.
- Tropical haematological disorders: sickle cell disease (organ damage, vaso‑occlusive crises), schistosomiasis (fibrosis).
- Rheumatic conditions: rheumatoid arthritis, systemic lupus erythematosus – contribute to functional limitation.
- Lifestyle & socioeconomic: tobacco use, alcohol, low physical activity, poor nutrition, limited access to health services, low health literacy.
- Environmental: indoor air pollution, heat stress, inadequate housing leading to falls.
Pathophysiology
Aging → cellular senescence → ↓ regenerative capacity → organ‑specific functional loss
↓ → impaired homeostasis (BP, glucose, electrolytes) → vulnerability to stressors (infection, dehydration)
↑ → chronic inflammation (“inflamm‑ageing”) → atherosclerosis, sarcopenia, neurodegeneration
HIV/TB/malaria → immune activation + organ injury → accelerated ageing phenotype
Poly‑pharmacy → drug‑drug interactions + renal/hepatic clearance decline → toxicity → further functional decline
Clinical features
History – key questions
| Domain | Questions to ask | Why it matters |
|---|---|---|
| Functional status | “Can you walk unaided? How many stairs can you climb? Do you need help with bathing, dressing, feeding?” | Decline in ADL/IADL signals frailty, sarcopenia or early cognitive impairment. |
| Falls & balance | “Any falls in the past year? Any near‑falls or unsteadiness?” | Falls are the common presentation of orthostatic hypotension, neuropathy, visual loss, polypharmacy or cardiac arrhythmia. |
| Cognition & mood | “Do you have memory problems? Any confusion, disorientation, mood changes, loss of interest?” | Early dementia, delirium, depression or medication side‑effects may mimic or worsen geriatric syndromes. |
| Polypharmacy | “What medicines (prescribed, OTC, herbal) do you take? Any recent changes?” | Drug‑drug interactions, anticholinergic burden and renal/hepatic clearance affect presentation and safety. |
| Chronic diseases | “Do you have hypertension, diabetes, heart disease, HIV, TB, malaria, sickle cell, rheumatic disease?” | Co‑morbidities drive organ‑specific symptoms (e.g., dyspnoea from heart failure, neuropathy from HIV). |
| Nutrition & weight | “Any recent weight loss or gain? Appetite? Dietary restrictions?” | Malnutrition, sarcopenia, and micronutrient deficiencies (e.g., B12) influence frailty and wound healing. |
| Social & environmental | “Who lives with you? Access to water, sanitation, transport? Any recent travel?” | Social isolation, poor housing, and exposure to endemic infections (malaria, TB) affect risk and adherence. |
| Urinary & bowel | “Frequency, urgency, incontinence, constipation?” | Urinary tract infection, prostate disease, neurogenic bladder or constipation can precipitate delirium. |
| Pain & sensory | “Any joint pain, back pain, numbness, tingling?” | Osteoarthritis, rheumatoid arthritis, peripheral neuropathy (diabetes, HIV) limit mobility. |
| Sleep & fatigue | “Difficulty sleeping? Daytime sleepiness?” | Sleep apnea, restless legs, depression, medication side‑effects contribute to functional decline. |
Examination – what to look for and why
| System / Sign | What to assess | Pathophysiologic rationale |
|---|---|---|
| General | Weight, BMI, skin turgor, hair, nails, frailty phenotype (shrinking, weakness, slowness, low activity, exhaustion) | Detects malnutrition, sarcopenia, chronic disease cachexia. |
| Vital signs | Blood pressure (supine & standing), heart rate, respiratory rate, temperature, oxygen saturation | Orthostatic hypotension, fever (infection), tachyarrhythmia, hypoxia. |
| Cardiovascular | JVP, heart sounds, peripheral pulses, edema | Heart failure, valvular disease, peripheral vascular disease. |
| Respiratory | Chest expansion, breath sounds, percussion | Pneumonia, COPD, TB, pleural effusion. |
| Neurological | Mental status (MMSE/6‑CIT), cranial nerves, gait (timed up‑and‑go), reflexes, sensation, coordination | Delirium, dementia, stroke, peripheral neuropathy (diabetes, HIV, sickle cell). |
| Musculoskeletal | Joint range, deformities, muscle bulk, grip strength | Osteoarthritis, rheumatoid arthritis, sarcopenia. |
| Abdominal | Liver size, tenderness, ascites | Hepatomegaly (viral hepatitis, TB), portal hypertension. |
| Skin | Rashes, ulcers, bruises, fungal lesions | Pressure sores, cellulitis, drug eruptions, opportunistic infections (HIV). |
| Genitourinary | Prostate exam (men), pelvic exam (women if indicated) | BPH, prostate cancer, urinary infection. |
| Sensory (vision, hearing) | Visual acuity, fundus, hearing test (whisper) | Visual impairment contributes to falls; hearing loss to social isolation and delirium. |
Differential diagnosis
| Condition | Points toward it | Distinguishing features |
|---|---|---|
| Heart failure (HF) | Dyspnoea on exertion, orthopnoea, peripheral edema, elevated JVP | Pulmonary crackles, S3 gallop, BNP elevation, cardiomegaly on CXR |
| Chronic obstructive pulmonary disease (COPD) | Chronic cough, wheeze, smoking history, barrel chest | Reduced breath sounds, hyperinflated lungs on CXR, FEV1/FVC <0.7 |
| Tuberculosis (pulmonary/extrapulmonary) | Chronic cough, night sweats, weight loss, HIV positive | Positive sputum GeneXpert, cavitary lesions on CXR, lymphadenopathy |
| HIV‑associated neurocognitive disorder | HIV positive, gradual memory loss, motor slowing | CD4 count <200, CSF pleocytosis, exclusion of other causes |
| Dementia (Alzheimer’s, vascular) | Progressive memory loss, disorientation, ADL decline | Neuroimaging shows cortical atrophy (AD) or infarcts (vascular) |
| Delirium | Acute change, fluctuating consciousness, recent infection/med change | Inattention, altered level of consciousness, reversible cause |
| Osteoarthritis | Joint pain worsened by use, crepitus, limited ROM | X‑ray shows joint space narrowing, osteophytes |
| Diabetic peripheral neuropathy | Diabetes history, stocking‑glove numbness, loss of ankle reflexes | Symmetrical distal sensory loss, normal nerve conduction if early |
| Malaria (severe) | Recent travel to endemic area, fever, anaemia | Positive rapid diagnostic test, parasites on smear |
| Sickle cell crisis | Known sickle cell disease, vaso‑occlusive pain, jaundice | Peripheral smear with sickled cells, hemolysis labs |
| Rheumatic disease (RA) | Symmetrical small joint pain, morning stiffness >1 h | Positive rheumatoid factor/anti‑CCP, erosions on X‑ray |
Investigations
| Test | What it answers | Interpretation |
|---|---|---|
| Full blood count | Anaemia, infection, leukopenia | Low Hb → chronic disease, iron deficiency, hemolysis; neutrophilia → bacterial infection; lymphopenia → HIV |
| Electrolytes & renal panel | Kidney function, electrolyte disturbances | Creatinine ↑ → CKD; Na⁺ ↓ → SIADH or dehydration |
| Liver function tests | Hepatocellular injury, cholestasis | ALT/AST ↑ → viral hepatitis, TB meds; ALP ↑ → bone disease |
| Fasting glucose / HbA1c | Diabetes status | HbA1c ≥6.5 % → diabetes; >8 % suggests poor control |
| Lipid profile | Cardiovascular risk | LDL ↑ → atherosclerosis risk |
| BNP or NT‑proBNP | Cardiac stretch | Elevated → heart failure; helps differentiate from COPD |
| Chest X‑ray | Pulmonary pathology | Consolidation → pneumonia; cavitation → TB |
| ECG | Arrhythmia, ischemia | A‑fib, LVH, ST changes |
| Spirometry | Obstructive vs restrictive lung disease | FEV1/FVC <0.7 → COPD; reduced FVC → restriction |
| Urinalysis & culture | UTI, proteinuria | Leukocyte esterase + nitrites → infection; protein → renal disease |
| HIV test (4th generation) | HIV status | Positive → need CD4, viral load |
| CD4 count & viral load (if HIV+) | Immune status, treatment response | CD4 <200 → opportunistic infection risk |
| Sputum GeneXpert / AFB smear | TB detection | MTB detected → start anti‑TB |
| Rapid malaria test | Malaria infection | Positive HRP‑2 → treat malaria |
| Serum B12 & folate | Macrocytic anaemia, neuropathy | Low B12 → neuropathy, cognitive decline |
| Bone mineral density (DXA) | Osteoporosis | T‑score ≤‑2.5 → high fracture risk |
| Cognitive screen (MMSE/6‑CIT) | Baseline cognition | Score <24 → probable dementia |
| Geriatric Depression Scale | Mood disorder | Score ≥5 → depression |
Diagnosis and severity
- Identify the dominant syndrome (e.g., frailty, heart failure, dementia, infection). Use validated tools:
- Frailty phenotype – ≥3 criteria = frail; 1–2 = pre‑frail.
- NYHA class for heart failure severity.
- GDS stage for dementia (mild, moderate, severe).
- Stage according to organ involvement:
- Renal – eGFR >60 mL/min/1.73 m² (stage 1), 30‑59 (stage 2), <30 (stage 3).
- Liver – Child‑Pugh if cirrhosis present.
- Risk stratification: combine functional status (ADL/IADL), comorbidity burden (Charlson index), and acute illness severity (e.g., CURB‑65 for pneumonia).
- Document: primary diagnosis, secondary comorbidities, frailty status, and severity grade. This guides the intensity of monitoring, need for multidisciplinary input, and goals of care (curative vs palliative).
Management
Immediate stabilisation
- Airway, Breathing, Circulation – treat hypoxia with supplemental O₂; ensure patent airway, especially in patients with dysphagia or reduced cough reflex.
- Fluid balance – correct dehydration with isotonic crystalloids; avoid rapid over‑correction in chronic hyponatraemia.
- Pain control – give paracetamol first line; consider weak opioid (e.g., tramadol) if pain uncontrolled, monitoring for constipation and sedation.
- Fall risk – place on low‑bed, assist with transfers, remove hazards, apply hip protectors if high fracture risk.
Definitive treatment
| Problem | First‑line drug class / intervention | Rationale |
|---|---|---|
| Hypertension (SBP ≥ 150 mmHg) | ACE‑inhibitor or ARB | Reduces cardiovascular events; renal‑protective in diabetics. |
| Diabetes mellitus (HbA1c > 8 %) | Metformin (if eGFR ≥ 30 ml/min) + lifestyle | Improves glycaemic control, low hypoglycaemia risk. |
| Dyslipidaemia | Statin (moderate‑intensity) | Proven mortality benefit in >65 yr. |
| Osteoporosis | Calcium + Vitamin D + bisphosphonate | Reduces vertebral and hip fracture risk. |
| Depression | SSRI | Safe in older adults, minimal anticholinergic load. |
| Chronic heart failure | Loop diuretic + beta‑blocker + aldosterone antagonist | Improves symptoms, reduces rehospitalisation. |
| HIV (if present) | Integrase‑strand transfer inhibitor‑based regimen | Potent, fewer drug‑drug interactions. |
| TB (pulmonary) | Rifampicin‑based short‑course therapy | Standard 6‑month regimen; monitor liver function. |
| Malaria (severe) | Intravenous artesunate | Rapid parasite clearance, safe in elderly. |
| Rheumatic disease flare | Low‑dose glucocorticoid + disease‑modifying agent | Controls inflammation, limits joint damage. |
| Sickle cell crisis | Hydration, analgesia, oxygen, exchange transfusion if severe | Prevents vaso‑occlusion, improves oxygen delivery. |
Monitoring & follow‑up
- Vital signs every 4 h initially, then daily once stable.
- Renal function & electrolytes after diuretics, ACE‑I/ARB, and any nephrotoxic drug.
- Blood glucose fasting and post‑prandial; adjust oral agents if hypoglycaemia occurs.
- Liver enzymes when on TB therapy, ART, or statins.
- Bone health DEXA at baseline, repeat every 2–3 yr.
- Functional status – gait assessment, ADL questionnaire every 3 mo.
Contra‑indications & safety
- Avoid anticholinergic drugs (e.g., first‑generation antihistamines) – precipitate delirium.
- NSAIDs contraindicated in CKD, heart failure, or active ulcer disease.
- Benzodiazepines only for short‑term severe anxiety or insomnia; high fall risk otherwise.
- Polypharmacy review each visit; stop drugs without clear indication.
Complications and prognosis
- Functional decline – loss of independence, increased need for caregiver support.
- Falls & fractures – hip fracture mortality up to 30 % within one year.
- Cognitive impairment – delirium may progress to dementia if precipitating factors persist.
- Cardiovascular events – hypertension, diabetes, and dyslipidaemia accelerate atherosclerosis; early control improves 5‑year survival.
- Renal insufficiency – cumulative drug nephrotoxicity and age‑related GFR decline; monitor to avoid irreversible loss.
- Infections – immunosenescence plus comorbid HIV/TB increase morbidity; vaccination (influenza, pneumococcal, COVID‑19) reduces risk.
- Polypharmacy complications – adverse drug reactions, drug‑drug interactions, medication non‑adherence.
Prognosis improves markedly with comprehensive geriatric assessment, optimisation of chronic disease, fall prevention, and regular monitoring.
High‑yield exam points
- Look‑alike conditions: Delirium vs. dementia vs. depression; differentiate by acute onset, fluctuating course, and reversible precipitants.
- Common wrong first step: Starting a high‑dose benzodiazepine for insomnia in an elderly fall‑prone patient.
- Examiner bedside question: “Explain how you would assess frailty in this 78‑year‑old and why it matters for management.”
- Key safety query: “What medication classes would you deprescribe first in a polypharmacy patient with CKD stage 3?”
- Investigations nuance: When is a urinary dipstick insufficient for diagnosing UTI in an elderly with confusion? (Answer: need culture if asymptomatic bacteriuria likely).
Clinical case
Case: 82‑year‑old male, known hypertension, type 2 diabetes, presents with a 2‑day history of sudden confusion, urinary incontinence, and a fever of 38.5 °C. Examination shows a systolic BP 160 mmHg, heart rate 98 bpm, dry mucous membranes, and a tender suprapubic area. No focal neurological deficit.
Questions
- What is the most likely diagnosis?
Answer: Acute delirium secondary to urinary tract infection (UTI).
- What immediate management steps should be taken?
Answer: Secure airway if needed, give supplemental O₂, start IV fluids to correct dehydration, obtain urine culture, begin empiric oral nitrofurantoin (or appropriate local guideline) pending results, and address fall risk.
- Which medication should be reviewed and possibly stopped?
Answer: Any anticholinergic or high‑potency benzodiazepine, as they can worsen delirium.
Practice questions
Question 1
An 88‑year‑old woman with osteoarthritis falls from a chair, sustaining a displaced intertrochanteric hip fracture. She is haemodynamically stable. What is the next best step?
A. Immediate total hip arthroplasty
B. Closed reduction and percutaneous pinning
C. Delay surgery until pain is fully controlled
D. Start low‑molecular‑weight heparin and arrange surgery within 48 h
Answer: D. start low‑molecular‑weight heparin and arrange surgery within 48 h
Explanation: Early anticoagulation reduces venous thromboembolism; surgery within 48 h improves mortality without increasing blood loss.
Question 2
A 75‑year‑old man with chronic kidney disease stage 3 presents with confusion, a temperature of 38 °C, and a urinary dip‑stick positive for leukocytes and nitrites. Which statement is correct?
A. Treat with oral ciprofloxacin without culture
B. Obtain urine culture before starting antibiotics
C. Diagnose delirium and start antipsychotic immediately
D. Assume asymptomatic bacteriuria and observe
Answer: B. obtain urine culture before starting antibiotics
Explanation: In the elderly, dip‑stick alone is insufficient; culture guides therapy and avoids unnecessary antibiotics.
Question 3
A 70‑year‑old woman on a high‑dose ACE‑inhibitor presents with a serum potassium of 5.8 mmol/L and eGFR 28 ml/min. What is the safest action?
A. Continue ACE‑inhibitor, add loop diuretic
B. Stop ACE‑inhibitor, start calcium‑channel blocker
C. Reduce ACE‑inhibitor dose, monitor potassium weekly
D. Switch to an ARB at the same dose
Answer: B. stop ACE‑inhibitor, start calcium‑channel blocker
Explanation: Hyperkalaemia and reduced GFR are contraindications to ACE‑I; a CCB controls BP without affecting potassium.
Question 4
An elderly patient with known HIV presents with a persistent cough, weight loss, and a chest X‑ray showing upper‑lobe cavitation. Which investigation is essential before starting anti‑TB therapy?
A. Sputum smear for acid‑fast bacilli
B. CD4 count only
C. Full liver function panel
D. Serum electrolytes
Answer: A. sputum smear for acid‑fast bacilli
Explanation: Microbiological confirmation guides regimen and infection control; CD4 count and LFTs are done later.
Question 5
A 78‑year‑old man with mild cognitive impairment is scheduled for elective cataract surgery. Which pre‑operative assessment is most important?
A. Full‑body CT scan
B. Review of current medications for anticholinergic load
C. Stress test for cardiac ischemia
D. Serum vitamin B12 level
Answer: B. review of current medications for anticholinergic load
Explanation: Reducing anticholinergic burden lowers peri‑operative delirium risk; other tests are not routinely required for cataract surgery.
Drafted with AI assistance from standard references and reviewed for structure. Check details against your lecture notes and the Kenya MoH guideline.