2. Differential Diagnoses of Common Presentations Flashcards
Describe: Frailty (1)
clinically-recognizable state of decreased reserve in older adults with increased vulnerability to acute stressors resulting from functional decline across multiple physiologic systems
Describe: Functional decline
progressive limitation in the ability to carry out basic functional activities
The Clinical Frailty Scale is shown to predict what?
to predict death and need for institution
Describe: Clinical Frailty Scale (9)

Describe: Dementia Frailty Scale (3)
Degree of frailty corresponds to degree of dementia.
-
Mild Dementia
- Common symptoms include forgetting details of recent event, though still remembering the event itself. Repeating the same question/story and social withdrawal.
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Moderate Dementia
- Recent memory is very impaired, although can remember past life events well. Can do personal care with prompting.
- Severe Dementia: Cannot do personal care without help.
Describe: Physical Frailty (PF) Phenotype (Fried et al.) (5)
Frail = 3 or more criteria; at-risk or pre-frail = 1 or 2 criteria
- Shrinking: unintentional weight loss (baseline: >10 lbs or 5% total body weight lost in prior year)
- Weakness: grip strength in lowest 20% (by gender, BMI)
- Poor endurance: as indicated by self-report of exhaustion
- Slowness: walking time/15 feet in slowest 20% (by gender, height)
- Low activity: kcals/wk in lowest 20% (males: <383 kcals/wk, females: <270 kcals/wk)
Describe: Cumulative Deficit Approach (Rockwood et al.) (2)
- balance between assets (e.g. health, attitudes, resources, caregiver) and deficits (e.g. illness, disability, dependence, caregiver burden) that determines whether a person can maintain independence in the community
- Frailty Index = number of deficits present/number of deficits possible
Describe: Screening Tool for Frailty (5)
FRAIL
- Fatigue: “Are you fatigued?”
- Resistance: “By yourself and without aids, do you have any difficulty walking up 10 steps without resting?”
- Ambulation: “By yourself and without aids, do you have any difficulty walking several hundred yards?”
- Illnesses: more than five
- Loss of weight: greater than five percent
Frailty: “Yes” to 3 or more questions
Pre-frailty: “Yes” to 1-2 questions
Name: Etiologies of Frailty (5)
- Physiologic Changes with Aging
- Immune System
- Endocrine System
- Dysregulated Stress Dysregulation of autonomic nervous system
- Age related changes in renin-angiotensin system and mitochondria likely impact sarcopenia and inflammation
Describe mechanism of this etiology of frailty: Physiologic Changes with Aging (4)
- Sarcopenia (age-related loss of skeletal muscle and strength)
- decreased mass
- increased stiffness of organs
- decreased reserve capacity of systems
Describe mechanism of this etiology of frailty: Immune system (3)
- Elevated levels of circulating interleukin-6, C-reactive protein, white blood cells, and monocytes associated with skeletal muscle decline
- Elevated clotting markers (factor VIII, fibrinogen, D-dimer) upregulates clotting cascade
- Chronic inflammation
Describe mechanism of this etiology of frailty: Endocrine system (4)
Decreased skeletal muscle mass via:
- Decreased growth hormone and IGF-1
- Increased cortisol levels
- Decreased DHEA-S
- Decreased 25 (OH) vitamin D
Describe: Comprehensive Geriatric Assessment (5)
- includes:
- Past Medical History, Medications, Allergies, Social History, Function, Physical Exam, and Geriatric Review of Systems (cognition, mood, sleep, pain, nutrition, falls, continence, vision/ hearing, skin, and safety)
- interdisciplinary primary care
- pharmaceutical care and medication optimization
- management of geriatric syndromes (e.g. falls, cognitive impairment, incontinence)
- caregiver support
Define: Delirium (2)
- acute and potentially reversible disturbance in cognition, attention, or level of consciousness
- screened using the Confusion Assessment Method: delirium likely if 1 + 2 and either 3 or 4 are present
- 1: acute onset and fluctuating course
- 2: inattention
- 3: disorganized thinking
- 4: altered level of consciousness
Name Differential Diagnosis of Delirum (3)
3Ds (dementia, delirium, depression) can present with overlapping cognitive changes
Describe work-up of delirium (4)
work-up is not universal, and depends on possible causes based on history and physical exam:
- Drugs: medication review
- Infection, Infarction, Inflammation: CBC, urinalysis, urine culture, blood culture, chest x-ray, ECG/ troponin
- Metabolic: basic and extended electrolytes, Vit B12, TSH, LFT, toxicology screen
- Structural: neurologic exam, CT head
Describe: Delirium Prevention in Elderly (6)
- ensure optimal vision and hearing to support orientation (e.g. appropriate eyewear and hearing aids)
- provide adequate nutrition and hydration (up in chair to eat and drink whenever feasible)
- encourage regular mobilization to build and maintain strength, balance, and endurance
- avoid unnecessary medications and monitor for drug interactions
- avoid bladder catheterization
- ensure adequate sleep at night and wakefulness during the day
Describe use of antipsychotics for treatment of delirium (1)
There is no evidence that antipsychotics shorten the course of delirium, reduce mortality risks, or improve quality of life in hospitalized patients
Describe: Dementia
- Onset
- Duration
- Natural History
- Level of Consciousness
- Attention
- Orientation
- Behaviour
- Psychomotor
- Sleep-Wake Cycle
- Mood and Affect
- Cognition
- Memory Loss
- Onset: Gradual or step-wise decline
- Duration: Months to years
- Natural History: Progressive, usually irreversible
- Level of Consciousness: Normal
- Attention: Intact initially
- Orientation: Intact initially
- Behaviour: Disinhibition, loss of ADL/ IADLs, personality change
- Psychomotor: Normal
- Sleep-Wake Cycle:
- Mood and Affect: Fragmented sleep at night
- Cognition: Labile but not usually anxious
- Memory Loss: Decreased executive function, paucity of thought
Describe: Delirum
- Onset
- Duration
- Natural History
- Level of Consciousness
- Attention
- Orientation
- Behaviour
- Psychomotor
- Sleep-Wake Cycle
- Mood and Affect
- Cognition
- Memory Loss
- Onset: Acute (hours to days)
- Duration: Days to weeks
- Natural History:
- Fluctuating, reversible
- High mobidity/mortality in very old
- Level of Consciousness: Fluctuating
- Attention: Impaired, difficulty concentrating
- Orientation: Impaired, fluctuates
- Behaviour: Severe agitation/retardation
- Psychomotor: Fluctuates between extremes
- Sleep-Wake Cycle: Reversed sleep-wake cycle
- Mood and Affect: Anxious, irritable, fluctuating
- Cognition: Fluctuation preceded by mood changes
- Memory Loss: Marked short-term
Describe: Depression
- Onset
- Duration
- Natural History
- Level of Consciousness
- Attention
- Orientation
- Behaviour
- Psychomotor
- Sleep-Wake Cycle
- Mood and Affect
- Cognition
- Memory Loss
- Onset: Subacute (weeks to months)
- Duration: Variable
- Natural History: Recurrent, usually reversible
- Level of Consciousness: Normal
- Attention: -
- Orientation: Intact
- Behaviour: Importuning, self-harm/ suicide
- Psychomotor: Slowing
- Sleep-Wake Cycle: Early morning awakening
- Mood and Affect: Depressed, stable
- Cognition: Concentration impaired
- Memory Loss: Short-term
Define: Falls (2)
- an event resulting in a person coming to rest inadvertently on a lower level
- other than as a consequence of sudden paralysis, epileptic seizure, or overwhelming external force
Describe epidemiology: Falls (5)
- 30-40% of people >65 yr old and ~50% of people >80 yr old fall each year
- equally common between men and women, but more likely to result in injury in women and death in men
- falls are the leading cause of death from injury in persons ≥65 yr
- 25% associated with serious injuries (e.g. hip fracture, head injury, bruises, laceration)
- between 25-75% do not recover to previous level of ADL function after injurious falls
