Age-related differences Flashcards
What are the age-related differences which affect older people’s assessment, investigations and management?
Multiple pathologies
Atypical presentation
Reduced homeostatic reserve
Impaired immunity
What are the geriatric giants?
Incontinence
Immobility
Instability (falls and syncope)
Intellectual impairment (delirium and dementia)
What are examples of activities of daily living?
Mobility including aids and appliances.
Washing and dressing Continence
Eating and drinking
Shopping, cooking and cleaning
What are the common sources of sepsis in older people?
The common sources of sepsis in older people are the chest, urine and biliary tract.
What is involved in the comprehensive geriatric assessment?
Medical diagnoses
Review of medicines and concordance with drug therapy
Social circumstances
Assessment of cognitive function and mood
Functional ability (i.e. ability to perform ADL)
Environment
Economic circumstances
What are the pharmacokinetic differences in older age?
Age-related changes lead to differences in absorption, distribution, metabolism and elimination of drugs.
There is a reduced volume of distribution for many drugs because of reduced total body water and an increase in the percentage of body weight as fat. For example, diazepam is a lipid-soluble drug so a relative increase in body fat may cause toxicity in an older patient.
Liver metabolism is reduced leading to slower drug inactivation. Care should be given when prescribing drugs metabolised in the liver and have a narrow therapeutic index such as warfarin and phenytoin.
Renal blood flow and mass reduce significantly with age, leading to a reduction in the clearance of many drugs such as digoxin and lithium.
What are the pharmacodynamic differences in older ages?
There is an increased sensitivity to drugs in general, and lower doses are often required compared to younger adults, primarily due to changes in drug receptors and impaired homeostatic mechanisms.
What are common disease-drug interactions?
Benzodiazepines, levodopa and antimuscarinics cause worsening confusion in patients with dementia.
Antimuscarinics and metoclopramide cause worsening symptoms and deteriorating movement disorder in px with Parkinson’s disease.
Antibiotics, analgesics, antidepressants, antipsychotics, theophyllines and alcohol cause reduced seizure threshold in px with seizure disorders.
Antimuscarinics causes worsening glaucoma
Beta-blockers and benzodiazepines cause bronchospasm/respiratory suppression in px with COPD/asthma
Diltiazem, verapamil and NSAIDs cause worsening heart failure in px with heart failure
Antihypertensives, diuretics, TCA and levodopa can cause postural hypotension and falls in px with orthostatic hypotension.
Digoxin can worsen hypokalaemia leading to arrhythmias
Antimuscarinics and alpha-blockers can cause urinary retention in px with BPH or bladder outflow obstruction.
Antimuscarinics, TCA, analgesics such as opioids can cause worsening constipation.
Steroids and enzyme-inducing drugs can cause accelerated osteoporosis.
What are common reasons for polypharmacy?
Failure to review medication
Failure to discontinue unnecessary medication
Prescribing cascade
Admission to nursing home
More than one physician involved in medical care
Several chronic diseases
What is frailty?
Frailty is 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
An apparently small insult (eg, a new drug, minor infection, or minor surgery) results in a striking and disproportionate change in health state—ie, from independent to dependent, mobile to immobile, postural stability to proneness to falling, or lucid to delirious.
What is the pathophysiology of frailty?
Frailty is a disorder of several inter-related physiological systems. A gradual decrease in physiological reserve occurs with ageing but, in frailty, this decrease is accelerated and homoeostatic mechanisms start to fail.
What is the clinical presentation of frailty?
Non-specific
-Extreme fatigue, unexplained weight loss, and frequent infections.
Falls
-Balance and gait impairment are major features of frailty and are important risk factors for falls.
Delirium
-Delirium (sometimes called acute confusion) is characterised by the rapid onset of fluctuating confusion and impaired awareness.
-Delirium is related to reduced integrity of brain function and is independently associated with adverse outcomes.
Fluctuating disability
-Fluctuating disability is day-to-day instability, resulting in patients with ”good”, independent days, and ”bad” days on which (professional) care is often needed.
What is a hot fall?
A so-called hot fall is related to a minor illness that reduces postural balance below a crucial threshold necessary to maintain gait integrity.
When are spontaneous falls more likely?
Spontaneous falls occur in more severe frailty when vital postural systems (vision, balance, and strength) are no longer consistent with safe navigation through undemanding environments.
Spontaneous falls are typically repeated and are closely associated with the psychological reaction of fear of further falls that causes the patient to develop severely impaired mobility.
What is the frailty index?
The Frailty Index (FI) takes a contrasting view to frailty as a syndrome, seeing frailty instead as a state of vulnerability that arises in relation to the accumulation of health deficits.
People with few deficits are relatively fit; those with many are relatively frail.
