---Elderly and diabetic patients should be given the blood pressure measurements when they are lying down, immediately after getting up and two minutes after that.

---diagnosis: the systolic pressure rises above 140 mmHg or the diastolic pressure to above 90 mmHg.

---family medical history, the patient’s other somatic illnesses, medications and the patient’s lifestyle, clinical examination and laboratory tests.

---target organ damage: left atrial hypertrophy, kidney failure, retinal problems and damages to the large blood vessels of the lower limbs.

—losing between 5-10% of the weight of obese patient.

—The abdominal circumference should not exceed 102 cm for men and 88cm for women.

—giving up smoking

— doing moderate exercise five times a week for 30 minutes

—increasing the intake of potassium, calcium and polyunsaturated fats

—methods: medication treatment; diabetes and increased cholesterol levels treatment.

—When altering the medications and taking up new drugs, the patient’s blood pressure should be measured when the patient is standing up,especially foe elder people.

---monitoring the blood pressure treatment:

  ▲schedule monitoring  consultations every one or two months when timing or changing the medications, containing checking blood pressure, pulse, weight and the medications, asking the wellbeing and efficiency of the treatment, giving annually laboratory test

 ▲monitoring continue closely until the treatment goals reaching

▲symptoms: being suddenly, containing the insufficient functioning of the limbs either on one or both sides of the body; losses or disturbances in tactility; and problems with the production of speech，the corner of the patient’s mouth may be left hanging，may be have problems with vision, dizziness or incoherence

▲diagnostics：The aim of the diagnostics is to assess the cause and extent of the stroke, which makes CT and other imaging techniques used for examining brain circulation the most important methods；the risk factors；laboratory tests include CBC and thrombocytes, INR, CRP, blood sugar, electrolyte balance and arterial blood gas.

 

▲treatment：thrombolytic therapy，neurosurgical procedures if necessary

▲prevention: changing lifestyle, monitoring blood pressure and treating hypertension, Anticoagulants if necessarynstal.

 ▲Lifestyle adjustments: quitting smoking, physical exercise, weight loss and correct diet, good balance in the treatment of hypertension in the treatment of hypertension and diabetes.

 ▲Medication for coronary artery disease: acetylsalicylic acid/ clopidogrel; ACE  inhabitors/ atr blockers, statines, beta blockers.

Symptoms of coronary artery disease: short or long-acting nitros, beta blockers, calcium channel blockers.

 ▲Surgical treatment: coronary bypass surgery, bypass surgery of the arteries of the lower limbs, treatment of surgically incurable wounds

 ▲the active role of the patient is essential

 ▲the general purposes of treatment:
 HbA1c ＜53mmol/L, fasting glucose ＜7mmol/L, glucose level after eating ＜10mmol/L, LDL-cholesterol ＜ 2.5 mmol/L, blood pressure ＜ 140/80 mmHg

 ▲multi- professional monitoring of the treatment: the patient’s own blood pressure measurements, regular monitoring

 ▲progress of medicinal treatment: metformine, second/ third diabetes drug, insulin treatment

(2) Symptoms and diagnostics:

 ▲Classic symptoms: thirst and large amounts of urine, unexplained weight loss

 ▲Screening especially for risk groups

 ▲Fasting levels, 2 hour glucose tolerance test: fasting level ＞7mmol/L; glucose tolerance test ＞11mmol/L

 ▲HbA1c＞ 48mmol/L

 ▲The pre-stages of diabetes: slightly increased fasting and glucose tolerance rates

 ▲Type 1 diabetes, differential diagnostics: GAD-antibodies, islet cell antibodies

 ▲C-peptied: measurement for insulin production in the pancreas, the limit is 0.7nmol/L

  ▲Hypoglycaemia:  shaking, sweating, incoherence, unconsciousness, caused by excessive amounts of insulin, prevention, recognition, treatment.

 
▲Ketoacidosis: the insulin production in the pancreas seizes, fatty acids turn to ketone bodies, body acidifies, treated by insulin, rehydration, potassium replacement therapy.

 
▲diabetic nephropathy: insufficient renal functions, significant risk factor cardiovascular diseases

 
▲retinopathy: Changes in the retina(haemorrhaging inside the retina and blood vessel blockages)
--Treatable risk factors:  a bad glucose balance, high blood pressure, bad cholesterol and triglyceride, abdominal obesity, smoking and diabetic nephropathy.
 --prevention and screening: regular retinal examinations that can notice the problems on time.

 
▲neuropathy: pains, changes in tactility
---screening(including  tactility and nerve entrapments; erroneous positions of the feet; determining intestinal symptoms; and examining possible vertigo and erectile dysfunctions)
--- treatment(including physiotherapy, correct choice of footwear, pain management)

 ▲foot problems: decreased circulation, changes in tactility and badly healing wounds

--Prevention is the most important form of treatment for the feet.

--treatment: cleaning and supporting the wound area, treating the infections, pains and risk factors .

▲predisposing factors:  smoking, the heavy use of alcohol and red meat and processed meat, as well as obesity.

▲symptoms: changes in the functioning of the intestine like diarrhoea or blockages, weight loss and melena.

▲curing  treatment: surgery

(2) prostate cancer

▲symptoms : asymptomatic on most patients; casusing symptoms through bone metastases or by contacting the urinary tract which may lead to voiding symptoms or other urinary problems.

▲treatment: depending on the patient’s age, other diseases, the cancer’s behaviour and stage of its spreading as well as the patient’s own wishes. conservation treatment is for the cancer that is no aggressive causing no disturbance and the patient is older than 70. Other choices of treatment include  radical prostatectomy, radiation therapy and hormone therapy.

▲types: ductal carcinoma and lobular carcinoma

▲predisposing factors: cases in close family, hereditary factors, heavy use of alcohol, early menarche, late first childbirth and childlessness.

▲typical symptoms: a lump in the breast, changes in the size and shape of the breasts, textural changes, the inversion of the nipple and bloody fluid being secreted from the breast。

▲the method of screening ：mammography

▲treatment:  radiation therapy and surgery.

(4) lung cancer

▲predisposing factor: smoking. 

▲symptoms: unintentional weight loss, shortness of breath, bloody coughing and repeated pneumonia.

▲treatment: radiation therapy and chemotherapy

▲comprehensive assessment: the patient’s functionality, state of nutrition, cognition and psychological well being in addition to the situation of the cancer.

▲No form of treatment should be ruled out based on the patient’s age. 

▲The treatment of geriatric cancer patients’ should be based on an individual assessment of the risks and benefits of the treatmen.

▲diagnostics: The bone density measurements—-The definition of osteoporosis is said to be a bone density of over 2.5 smaller than the average bone density of women in the 20-40-years-old age group.

▲risk factors: Malnutrition, especially the lack of vitamin D and calcium,lack of vitamin K ,Insufficient physical exercise,female gender and age,Smoking ,usage of some medicine(glucocorticoids, predisposes patients to osteoporosis)

Different illnesses like Parkinson’s disease, amnesia, multiple sclerosis, the chronic obstructive pulmonary disease, osteoarthritis and heart diseases increase the risk of osteoporotic fractures.

▲laboratory tests and imaging:
bone biomarkers,Blood tests, DXA measurement(diagnosis based on) , x-ray imaging and CT or MRI can be useful tools.

▲location:  fractures can occur elsewhere in the body, but being typical in the wrist, the upper arm, the hip and the vertebrae.

▲preventing: Preventing falling is central to preventing the fractures,sufficient intake of calcium and vitamin D  ,Good nutrition,Physical exercise ,assessing the benefits of the medications,correct footwear,Treating poor eyesight ,Quitting smoking.

▲medicinal treatment: daily taking orally ingested bisphosphonates which prevent the bone loss, but can’t use for the patient  who has difficult insufficiencies in renal functions.

---Zoledronate is a form of bisphophonates injected intravenously.

---Denosumab is a fairly new osteoporosis drug. Its main benefit is that it is taken once every 6 months under the skin, and is suitable for patients with insufficient renal functions.

---Strontium ranelate increases the rate of bone formation and decreases the amount of bone loss more effectively than other drugs, but associated with a risk of life-threatening skin reactions and the development of heart diseases

---Teriparatide is a parathyroid hormone recombinant. can only be used once for the duration of at most 24 months.

---Oestrogens are suitable for preventing and treating osteoporosis on patients going through menopause. 

▲the treatment of fractures:

An early mobilisation is important in the treatment of both hip and vertebral fractures. Hip fractures should be operated as soon as possible and mobilisation exercises should start the day after the surgery.

▲Risk factors include age, obesity, cartilage injuries and heavy loads put on them, erroneous positions and developmental disorders, as well as genetic factors.

▲location:Typical places for the disease to occur are in the hinge joint of the first toe and the interphalangeal joints of the fingers; the knees; the hip and the spine

▲symptoms: lingering pain felt in the area of the inflamed joint.A cracking sound may be heard ,the joints degenerate erroneous positions may develop

▲examination: an external inspection of the joints.palpation.assessing the patient’s movements,The ability to squat and to get up,examination of the passive motions and a strength test.,

▲diagnosis: based on the typical symptoms, clinical findings and x-ray images.the WOMAC questionnaires for assessing questionnaires

▲trearment: 
---pain management, performing Non-medicinal treatmen, containing losing weight, physical exercise and if required, physiotherapy.

---The primary medication should be paracetamol. 

---surgical treatment:joint replacements and osteotomy

▲prevention:based on improving the patient’s health  :Physical exercise  and avoiding accidents.

—Aging is a tendency in nowadays. Aging is affected by both hereditary and environmental factors.

—Frailty syndrome has a typical clinical characteristics, including unexplained weight loss, sarcopenia, the loss of muscle mass, osteoporosis, tiredness, tendency to fall and a bad general condition.

—Frailty syndrome can be divided into primary and secondary forms. In primary frailty syndrome, the patient cannot be diagnosed with any specific disease or loss of functionality. Secondary frailty syndrome is linked with some comorbid disease such as dementia or cardiopulmonary disease.

---predisposing factors: age, the female gender, dark skin, cardiovascular disease, the number of comorbid diseases, losses of functionality, a subjective feeling of bad health, depression, BMI and smoking.

(3) diagnostics of frailty syndrome:

---diagnosis：in which three of the following five dimensions are exhibited unintentional weight loss, exhaustion, weakness, slowness and low levels of activity.

(4) treatment:
---The primary treatment of frailty syndrome is its prevention: physical exercise, nutrition and drugs.

---Disease specific risk factors should be individually assessed for every patient and preventative treatment should begin before the onset of problems.

▲symptoms： consist of the coughing and secretion of mucus caused by the inflammation, shortness of breath, wheezing especially when breathing out, often manifest during night time and in the mornings. 

▲treatment:
---goals of treatment: to ease the symptoms, return the normal pulmonary functions, prevent exacerbation.
--- factors affecting the success of treatment: commitment to treatment, other diseases, inhalation technique.
--- treatment mainly in primary health care: asthma nurse’s or doctor’s consultations annually, a doctors consultation at least every 3-5 years.
--- independent monitoring is essential: aggravation/change of symptoms, tolerance for stress, PEF rate, the response to drugs changes in it.

 ▲asthma medication:
--- treating drugs: inhaled cortisones, 
---drugs to reduce constriction: beta2 agonists, teophylline, nsaids can aggravate the symptoms.

▲background: chronic obstructive pulmonary disease( slowly developing chronic disease, bronchitis, emphysema—an inflammation of lung tissue, comorbid diseases); smoking is the most important risk factor

▲definition: Chronic obstructive pulmonary disease is a slowly developing chronic disease,associated with the permanent reduction in airflow in the bronchus, a chronic inflammation of the bronchus called bronchitis, along with the gradual destruction of pulmonary tissue and several comorbid diseases.

▲factors: tobacco and the toxic substances in the s

▲diagnostics: main symptoms( shortness of breath, especially under physical strain; chronic cough; sputum); history of smoking in pack years; work environment and asthma/family medical history; patient’s quality of life( cat MMRC); spirometry (FEV1/FVC)

▲symptoms:  shortness of breath, a chronic cough and sputum

▲treatment:
---goals of treatment: easing the symptoms, improving quality of life, prevent the development/exacerbation of the disease, quitting smoking is of primary importance

---influenza vaccinations every year;

---medicinal therapy: cannot repair damage, can prevent/reduce exacerbations

▲exacerbations of COPD:  symptoms increase
--- reasons: infection, cardiac insufficiency,smoking ETC.
--- treatment: antibiotics, drugs reducing constriction, systemic corticosteroids.

▲the effects of aging on immune system: 

—immune system simplifies in diversity: predisposal to infections, predisposal to cancer, autoimmune disease, reduced response to vaccinations,

(2) old age and pneumonia
▲most common cause is pneumococcus

▲predisposing factors: malnourishment and comorbidity, bad functioning of the pharynx and physical functions

▲symptoms: 
---atypical: exacerbation of a chronic disease and no fever

---cough, shortness of breath and fever,fever

▲the prognosis and treatment of pneumonia

morbidity:difficulty of pneumonia, bad or unfitting immune response to infection, comorbid diseases, age

treatment: bad general condition, patient falls ill at home—-peroral amoxicillin:750mg-1g x3; hospital treament—intravenous cefuroxime:1.5g x3.

▲symptoms: 
----shivering and fever for around 3 days; muscle pains , head ache and loss of strength; atypical symptoms among the elderly
---rehabilitation can take a long time

---pneumonia can be a complication.

▲diagnostics of influenza: 

—rapid diagnosis teats and PCR: the PCR method can recognize the different types of influenza.

▲treatment:
--- zanamivirin and oseltamivir, should begin within 48 hours of the onset of the symptoms.

—influenza vaccinations: ＞65-year-old; treatment personnel; seriously ill; close family of people predisposed to influenza; 6-35-months-old children; pregnant women.

---E.coli is the most common cause

▲predisposing factors: early urinary tract infections; urinary problems; weakened immunde system; chronic diseases requiring hospitalstion; usage of a urinary catheter

▲symptoms: dysuria, increased need to urinate, pain and stinging when urinating, fever, sensitivity to palpation at the urinary bladder, delirium

▲diagnosis: symptoms and positive findings in the bacterial culture from urine; chemical screening—leukocytes+nitrite

▲treatment: trimetoprim or nitrofurantoin; in hospital treatment intravenous cefuroxim 1.5g x3.

a common condition, under diagnosed, recognitions id essential, threat to independent survival

▲risk factors and causes:

degradation of the central nervous system, losses of loved ones, somatic illness, amnesia, long-term stress,medications, earlier bouts of depression.

▲symptoms：

often similar to regular depression; additionally, pseudodementia, pain , somatic symptoms, recognize the suicide risk, recognize the symptoms of psychosis.

---patient interview is the most important method: give the patient time to describe how they feel, be respectful and try to give a sense of trust, take the symptoms seriously, clarify how the patient sees the situation, talk with the family(with the patient’s agreement), screening questionnaires.

---somatic examinations: laboratory tests, ECG, BMI from patients who have lost weight, head MRI if required.

▲treatment:
---psychoeducation, good treatment of other sidseases, mapping out the support network, therapy and peer support,medication

---medication: antidepressants( mirtazapine, duloxetine and venlafaxine), in difficult cases antidepressants and antipsychotics, at the beginning of treatment hypnotics and anxiolytics, ensure that the combination of drugs is suitable

---hospital treatment: usually in a somatic ward, as short as possible, plan the home treatment.

---usually breaks out during young adulthood

---can be caused by somatic illnesses or the use of intoxicating substances
-- symptoms: different kinds of hallucinations – such as auditory or visual hallucinations –, paranoia and incoherence

(2)delirium：

--a sudden state of incoherence; 
---very common among the elderly; 
---is often left undiagnosed;
--- disruptions in consciousness are typical, as are cognitive changes and disruptions in the sleep-wake cycle; 
---predisposing factors: substance abuse, neurological disorders or brain injuries, sensory impairment or earlier bouts of delirium.

(3)special characteristics of aging:

--normal physiological, biological and psychological process; 

—normal aging process should be distinguished from illnesses; 

—the aging of the brains is a significant change for the central nervous system: is exhibited by EG, the diminished volume of brains and reduced brain circulation.

▲prevalence and etiology: As many as 30% of people treated at internal medicine units suffer from delirium

▲predisposing factors: advanced age, blood sugar imbalances,medications, functionality and difficult chronic diseases, memory disorders and other somatic disease.

▲Characteristic: fast onset, problems focusing, incoherent thoughts, altered consciousness

▲diagnostics: recognition and examination of the various background factors,s a careful patient interview( the patient’s functionality, the history of the symptoms, level of alertness and the usage of medications and intoxicating substances),  Confusion Assessment Method( CAM), Laboratory tests including CRP,CBC, electrolytes, blood sugar balance, troponine, urinalysis and ECG 

▲ typical symptoms of delirium : problems with memory and orientation, disruptions of the sleep-wake cycle, incoherent speech, restlessness, changes in mood, sweating and trembling. The condition is often most aggravated during evening and night times.

▲treatment:

Prevention is important, medications only if the symptoms are difficult, primarily haloperidol(antipsychotics), often combined with a sedative, hypnotics if the sleep-wake cycle needs fixing

▲prognosis:

The prognosis of a delirium patient is bad. The morbidity rate can be up to 30%.

▲diagnostics:
Based on the same examinations as on young patients, medical history and early mental illness important, careful interview, imaging of the head, assessment of cognition, differential diagnostics(Alzheimer’s disease and other memory disorders, delirium and delusionary thoughts)

▲treatment:

---Social safety network is important
--- a good treatment relationship
-- different kinds of therapy
-- medicinal treatment: primarily by second generation antipsychotics, if needed, ultiliz sedatives, antidepressants and/or hypnotics.

sleep diary for 1-3 weeks; the nature of the sleep disorder and the hindrance is causes? life situation, stress，mood; daily rhythm: exercise, coffeine, alcohol,naps; illnesses and medication

▲ examination
---psychological examination: interview and observations

---physical examination: ruling out organic causes and somatic diseases

---laboratory tests, ECG and imaging if required
---in prolonged and unclear cases: actigraphy, polysomnography.

▲differential diagnostics:

mental illness, neurologic illness, cardiopulmonary diseases, nocturia, oesophagael diseases, chronic and acute pains, sleep disorders caused by medications

▲treatment:

the negative effects of insomnia; a good treatment relationship is essential; non-medical treatment should be the first choice, combined with medications if required; a good treatment of illnesses and modifying the medications

▲non- medicinal treatment

--support and lifestyle advice;

---cognitive methods: control of stimulants; sleeping environment; circadian rhythm; relaxation; cognitive therapy.

(2) insomnia:
▲definition: Insomnia is characterised as either repeated problems with falling asleep, too short night sleeps, the bad quality of sleep, or insufficiently refreshing sleeps. And insomnia cause the daytime functional condition of the patients to be negative affected. Insomnia is classified by duration: transient ＜2 weeks; short term 2-12 weeks; long term ＞3months.

▲predisposing factors：

personality traits, life situation and changes in it, stress, stimulating factors, illnesses, medications

▲diagnostics:

in primary health care, thorough anamnesis and somatic and psychological statuses

recommended only for shooters treatment; limiting the use of drugs; medication foe chronic disease and removing harmful drugs

▲ hypnotics:

benzodiazepines(intermediate or long-acting; negative side-effects in long term use）；drugs similar to benzodiazepines

melatonin；sedative antidepressants

▲ giving up medical treatment：

drug dependence from long-term use; if the medications have been used for a long-term: phasing out the prescription; gradual smaller dosages; sedative antidepressants can help when treating benzodiazepine dependence

▲ special characteristics of treating the elderly

the physiological structure of sleep, and the changes in the requirement for sleep, increased number of diseases and medications; the effects of insomnia on functional capacity; the special characteristics of the teatment.

— pathogenesis：hereditary or randomly occurring; the deterioration and death of nerve and  gila cells; changes to the areas of the brain peculiar to each disease; cell internal and cell external protein accumulations.

—symptoms: disruptions to memory, logical thinking and functional capacity; aphasia, agnosia and apraxia; cognitive symptoms often continuously deteriorate; reasons for the disruptions in memory and functional capacity need to be cleared out

— diagnosis: medical history should be gone though with patient and their family; neurological status; MMSE and CERAD; laboratory tests for differential diagnostic purposes; imaging; cerebrospinal fluid biomarkers test

---accumulating beta-amyloid and abnomal tau-protein in the parts of the brain responsible for memory; prevalence increases with age.

▲definition: Alzheimer’s disease is the most common progressive memory disease causing dementia. the development of the disease is caused by insoluble deposits of beta-amyloid and abnormal tau-protein forming in the brain tissue, which lead to neuron destruction especially in the brain’s memory area.

▲risk factors: age, certain gene alleles, hypertension, high cholesterol and diabetes

▲diagnosis: a slowly advancing deterioration of short-term memory that in its early stages is connected with language problems and conceptualisation difficulties, which later develop to a wide-spectrum cognitive deterioration that cannot be linked to any other cause.

▲clinical picture:  

--the onset of the disease is difficult to notice and it develop slowly.

--early phases: problems with making and retrieving memories

—development: short-term memory and the recognition of illness suffer; in later phases the patient needs complete guidance and help with everything.

—in some cases depression,paranoia and even aggressively.

 ▲prognosis

—after 4-6 years of the disease: stooped posture, short steps; stiffness, slowness and loss of facial expression.

—urinary and fecal incontinence

—on average, the time between the onset of the symptoms and patient’s death is 12 years

—most common cause of death is aspiration pneumoniasta.

—around 15% of dementia cases; onset usually at 60-65 years-old

▲core symptoms: 
---symptoms of Parkinsonism like stiffness and slowness; alternating cognitive and concentration abilities and alertness; detailed visionary hallucinations.

—some learning ability and short-term memory can be retained

—problems with spatial memory

(4) Vascular dementia:

—15% of all memory disorder patients

—blockages in the large and small arteries

— a heterogeneous syndrome

—symptoms depend on the location of the damage

 

(5)The treatment of dementia patients:
▲medical treatment:

no cure; possible response is seen as improved functionality and easing of the cognitive and behavioral symptoms; acetylcholinesterase inhibitors(in mild and moderate Alzheimer’s); memantine( in moderate and difficult Alzheimer’s)

▲other treatment:

a safe environment and elimination of stress factors; active rehabilitation; support foe the patient and family at home ; outpatient care; institutional careo.

▲the ability of balance which is based on the working of the vestibular organ of the inner ear, the eyes, the optic chiasm and position sensation, gradually deteriorate through ageing. And vertigo is exhibited caused by the problems with the inner ear.

▲Vertigo caused by vestibular causes can be described as carousel-like, meaning the sensation only moves in one direction.The most common cause is BPPV(benign paroxysmal positioning vertigo), or benign paroxysmal positioning vertigo.

▲Vertigo caused by the central nervous system often causes the patient to fall and there is almost always another neurologic disorder in the patient’s neurologic status. Imaging of the central nervous system is in an important role in examining the symptoms.

▲Orthostatic hypotension predisposes patients to falling, and can be diagnosed by an orthostatic test in which the patient’s blood pressure is measured both lying down and standing up. If the systolic pressure drops below 20mmHg and/or the diastolic pressure below 10mmHg within three minutes of changing posture, the test result is positive.

The body’s muscle mass and strength deteriorate as an effect of ageing. sarcopenia leads to increased tendency for falling and greater mortality

(3) the effects of ageing on bones and the predisposal for fractures:

Through ageing, the bone mass slowly begins to diminish following the age of 40. Menopause and the bad remodelling of bone predisposes patients’ to osteoporosis and fractures

(4) prevention of falling:

▲Risk factors for vertigo:
medications, environmental factors like high thresholds, metabolic risk factors like dehydration, musculoskeletal factors like balance disorders and muscle weakness, neuropsychological factors like depression and a fear of falling and functional problems with different senses. 

▲Assessment:  patient’s mobility and balance, the risk of falling,medical assistance, assessing risk factors,patient’s chronic diseases and especially medications, Daily activities and the patient’s fear of falling .

▲prevention: 

dealing with the individual factors include vitamin D supplements, optimising medication, exercise, balance and muscle training and correcting deteriorated sensory functions like eyesight.

▲intervention :a program to increase muscle strength, walking and balance exercises, modifying the patient’s surroundings at home safer, the removal of medications predisposing to falling and optimising footwear.

---Typical injuries caused by falls are hip fractures, different kinds of upper limb injuries like the fractures of the clavicle, wrist bones, and elbow, as well as head injuries.

---The patients’ survival is affected most of all by comorbid diseases and health. It can be thought that age itself does not cause the patient to be any less healthy, but rather the chronic diseases affect the health.