ACH - Preading

Question 1

How is frailty defined?

Answer 1

“a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, which increases the risk of adverse outcomes, including falls, delirium, and disability”

• In a frail person, an apparently small insult e.g. new drug, minor infection or small surgery –> causes disproportionate change in health state:
  
  • Independent –> to dependent
  • Mobile –> to immobile
  • Postural stability –> to fall prone
  • Lucid –> delirious

Image - green = fit elderly person, red = frail elderly person

Question 2

What are some common clinical presentations of frailty?

Answer 2

1. Falls - balance and gait impairment = major features of frailty
   
   • Hot-fall = related to a minor illness that ↓ postural balance below threshold needed to maintain proper gait
   • Spontaneous fall = more severe frailty, postural systems (e.g. vision, balance, strength) aren’t sufficient to navigate undemanding environments
2. Delirium (acute confusion) - characterised by rapid onset of fluctuating confusion and impaired awareness
   
   • ~30% of elderly persons admitted to hospital develop delirium
3. Fluctuating disability - day-to-day instability giving pts ‘good’ days and ‘bad’ days
4. Sarcopenia (loss of muscle mass + strength due to ageing)
5. Osteoporosis
6. Non-specific: extreme fatigue, unexplained weight-loss, frequent infections

Question 3

What 7 aspects are assessed as part of a ‘comprehensive geriatric assessment’

Answer 3

1. Medical diagnoses
2. Review of medication
3. Social circumstances
4. Assessment of cognition and mood
5. Functional ability - deficits in intrumental activitys of daily living (IADLs: banking, transportation, cooking, cleaning, shopping) or basic activites of daily living (BADLs: feeding, bathing, dressing, toileting)
6. Environmental assessment
7. Economic circumstances

Question 4

What is the predicitive value of urine dipsticks in elderly pts?

Answer 4

Positive predictive value of dipstick = rubbish (“might as well toss a coin”)

• Asymptomatic bacteriuria is common in older people
• Only a -ve result is considered useful as it eliminates UTI
• Give antibiotics for UTI in elderly if:
  
  • Pts have acute urinary symptoms or have bacteriuria and evidence of systemic inflammation (fever / ↑ inflammatory markers) without another more likely source of infection

Question 5

In elderly pts who can provide a history, what is required to diagnose UTI?

Answer 5

• NOT a urine dipstick!
• Only diagnose in the presence of at least 3 acute urinary symptoms:
  
  • Dysuria
  • Urgency
  • Frequency
  • Suprapubic tenderness

Question 6

If an elderly patient “sounds chesty” frequently and has recurrent pneumonia, what pathological mechnaism should you consider and what action should you take?

Answer 6

Consider recurrent aspiration (causing pneumonia)

Refer for SALT review

Question 7

What are the two stages of testing Capacity, both of which must be satisfied?

Answer 7

1. The patient cannot make a decision due to ‘a condition of mind or brain’
   
   • For elderly persons this is most often dementia or delirium, but can be due to learning disability or severe depression
   • It therefore follows that if a person does NOT have a condition of mind or brain, capacity should be assumed present
2. The person cannot: Understand, Retain, Weigh up, Communicate information relevant to the decision in question
   
   • Evidence of inability to do this relevant to the decision must be recorded

Question 8

What are the 5 symptoms in Fried’s frailty phenotype (3 or more of which have to present for someone to be labelled ‘frail’)?

Answer 8

3 or more of the following:

1. Walking speed - appear in slowest 20% by gender and height
   
   • Measure: timed 15 foot (5 metre) walk
2. Grip strength - weakest 20% by gender and BMI
   
   • Measure: dynanometer
3. Weight loss - loss of 10 lbs (4.5kg) in the past year
   
   • Measure: self report
4. Fatigue - self reported “trouble getting going”
5. Activity level - lowest 20% (males: 383 kcals/week, females: 270 kcals/week)
   
   • Measure: self report no. of calories expended

Question 9

What are the 6 categories of Elder Abuse?

Answer 9

1. Financial abuse
2. Neglect
3. Sexual abuse
4. Psychological abuse
5. Physical abuse
6. Racial / cultural abuse

Question 10

What are the 4 categories of Risk Factors for Elder Abuse?

What is in each category?

Answer 10

1. Factors relating to the older (abused) person
   
   • Cognitive impairment
   • Shared living
   • Functional dependency
   • Low income
2. Factors relating to the perpetrator
   
   • Psychiatric illness (including dementia)
   • Drug and alcohol dependency
   • Caregiver burden and stress
3. Relationship factors between perpetrator and abused
   
   • Family disharmony
   • Conflicted relationships
4. Environmental factors
   
   • Low social support
   • Shared living