Ageing Flashcards
Causes of acute functional decline
About 4ish should be enough
- Worsening of known medical conditions
- New medical conditions e.g. stroke, infections, falls, delirium
- Initiation of new medications
- Electrolyte disturbances
- Acute kidney injury / dehydration
- Hypoglycaemia from glipizide with worsening renal function / poor oral intake
- Poor medication compliance
- Underlying dementia, frailty, caregiver / support issues
Strategies to prevent functional decline
Know all
- Being mindful of its likelihood
- Identifying and comprehensively assessing both general and body system specific high risk indicators
- Implementing preventive management strategies targeting ≥1 relevant domains, especially
- Cognition
- Emotional health
- Mobility
- Self-care
- Continence
- Nutrition
- Skin integrity
Determinants of Active Ageing
Know ALL
- Social
- Economic
- Health and Social services
- Behavioural
- Personal
- Physical
Determinants of Active Ageing
Know ALL
- Social
- Economic
- Health and Social services
- Behavioural
- Personal
- Physical
Health strategies in the management of function in the elderly
Know ALL
- Preventive - prevent health condition, reduce incidence
- Curative - cure, control disease and consequences
- Rehabilitative - restore full, or optimise function
- Supportive - preserve independence and autonomy, optimise QoL
Components of Rehabilitation Goal Setting
Memorise a few
- Ascertain what is important to the patient and family
- Explain likely degree of restoration of activity (acknowledge uncertainty)
- Explain what is required from the patient
- Discharge planning starts early
- Review goals as patient progresses
Factors predisposing to ADRs
Know a few
- Polypharmacy - more health conditions so more meds, DDIs
- Decline in renal and liver function - reduced clearance and excretion of drugs
- Cognitive impairment - under consume, over consume drugs
- Poor eyesight - under consume, over consume drugs
- Physical limitations - May not pack pills properly, break pills in half etc.
Complications of immobility
Know a few, at least 6
- Complications
- Muscles: decreased muscle strength, contractures (weakness)
- Skin: pressure ulcers
- Deconditioning
- Cardiovascular: decreased work capacity, DVT, postural hypotension
- Respiratory: decreased ventilation, V/Q mismatch, hypostasis pneumonia
- Joint: loss of full range of motion
- CNS: deterioration in balance and coordination
- Genitourinary: incomplete bladder emptying, incontinence
- GI: decreased appetite, constipation, GER & aspiration
- Metabolic: insulin Resistance, hypercalcemia
- Bone: bone loss, increased fracture risk
Predisposing factors for fall
- Neuromuscular change - e.g. old stroke, age
- Multiple comorbidities - polypharmacy, diabetes
- Age - increased sway, slower righting reflex
- Poor vision - age, DM
- Knee osteoarthritis
- Inactivity
- All lead to impaired strength and balance
Precipitating factors for fall
- Poor lighting
- Home hazard
- Medications
- Increased fall risk
- Intercurrent illness
- Hypotensive
- Tired / distracted
Broad reasons why elderly are prone to falls
Physiological changes with ageing
Pathological changes with ageing
Medications
Environment
Physiological changes with ageing
Know a few
- Loss of accommodation
- Loss of contrast acuity
- Increased postural sway
- Decreased proprioception
- Decreased muscle tone
- Slower righting reflex
- Slower reaction time
- (Reduced pulmonary vital capacity, GFR)
- Increased risk of postural hypotension
- Blunted baroreceptor response
- Decreased cardiac response to sympathetic stimulation
- Diuretic use and age-related changes to renal function
- Nocturia from decreased nocturnal ADH
Factors to consider when prescribing in elderly
Patient factors
- Physiological function
- Underlying illness
- Accurate clinical diagnosis
Drug factors
- Pharmacology
- MoA, Efficacy
- Safety - ADR, DDIs
- Suitability
Dealing with communication issues
- Hearing
- Face patient in bright room
- Lower tone, DO NOT SHOUT
- Eliminate noise
- Amplification device
- Dementia / confused, use simple commands
- Come up with more, generally should be intuitive - use visual aids, write down, shorter sentences etc.
Comprehensive Geriatric Assessment components
- Multidimensional
- Determine medical, functional, psychological capabilities
- To develop coordinated, integrated plan for treatment and long-term follow up
- Components
- Medical Assessment
- Problem list
- Comorbidities, disease severity
- Medications
- Nutritional status
- Function Assessment
- ADLs, IADLs
- Activity and exercise
- Gait and balance
- Psychological Assessment
- Mental status (cognitive) testing
- Mood/depression testing
- Social Assessment
- Informed support needs and assets
- Eligibility / financial assessment
- Environment Assessment
- Home safety
- Transportation
- Medical Assessment
ADLs and IADLs
- ADLs
- Dressing
- Eating
- Ambulating
- Toileting
- Hygiene
- Swallowing
- IADLs
- Shopping
- Housekeeping
- Accounting
- Food prep
- Take meds
- Transport
- Telephone
Physiological vs Pathological Ageing
Physiological - normal physiological processes that occur with ageing; typically begins in the third decade and is progressive (e.g. age related GFR and Vital Capacity declines)
Pathological - cumulative effects of age-associated diseases over time (e.g. BPH, cataracts)
Demography vs Epidemiology
Demography - The statistical study of populations
Epidemiology - Factors affecting the patterns of health and illness of populations
Life Course Approach to maintaining functional capacity
Early life - growth and development
Adult life - maintaining highest possible level of function
Older age - maintaining independence and preventing disability
(i.e. postpone chronic diseases and disability as much as possible by increasing and maintaining physiological reserves, above the disability threshold)
What is frailty
A complex, multidimensional and cyclical state of diminished physiological reserve
Increase vulnerability to adverse clinical outcomes such as disability, delirium, falls, and death
Increased vulnerability to stressors
Is a dynamic process and may be reversible
Age-related cognitive changes
Non-uniform (Affects some domains more than others)
Slowed speed of processing (“bottleneck”; decreased ability to reason well and quickly in novel situations)
Compensated for by gains in experiential-based (crystalline) intelligence
Large individual differences in cognitive function
Forgetfulness is inconsistent and non-progressive
Absence of significant effects on one’s accustomed community, home and self care functioning
Dementia risk factors
Non-modifiable
- Age
- Female gender
- Genetic factors
- Down’s syndrome
- Family history
Modifiable
- Hearing loss
- Traumatic brain injury
- Hypertension
- A lot of alcohol
- Obesity
- Smoking
- Depression
- Social isolation
- Physical inactivity
- Air pollution
- Diabetes
What is dementia
An ACQUIRED syndrome of decline in memory and other cognitive domains SUFFICIENT TO AFFECT DAILY FUNCTIONING
Progressive and disabling
Not an inherent aspect of aging
Different from normal cognitive lapses
A clinical diagnosis
Alzheimer’s Disease diagnosis
Amnesia + at least one of Apraxia, Aphasia, Agnosia or Executive dysfunction
Decline from baseline, impact on occupational and/or social functioning
(May see medial temporal lobe atrophy and small hippocampal volumes, and neurofibrillary tangles and amyloid plaques)
Dementia clinical features
Activities of daily living
- Loss of independence in accustomed ADLs
Behaviour
Cognitive
- Memory deficit (recent > remote)
- Other domains (disorientation, impaired judgement and problem solving, language, praxis, visuospatial)
Dementia impact
Caregiver burden, caregiver burnout and institutionalisation as needs outweigh resources
Role strain (demands of care, social impact and control over the situation)
Personal strain (psychological impact)
Chinese ethnicity - filial piety and obligation to care leads to greater worry about performance and caregiver stress
Depression
Mental disorder characterised by low mood and loss of interest and can present with affective, physical and cognitive symptoms - can become chronic or recurrent, and lead to substantial impairments in an individual’s ability to take care of one’s everyday responsibilities
Depression mechanisms
Monoamine hypothesis - decreased neurotransmitter concentrations
Cytokines
Neuropeptides
Risk factors for depression in older persons
Chronic pain
Impairment in physical function
Drugs (e.g. B-blockers)
Sensory deprivation (hearing, vision)
Dementia
Clinical features of depression
Affective (Mood) - low mood, sadness; loss of interest of pleasure in usual activities; guilt; worthlessness; suicidal ideas
Behavioural - psychomotor slowing or agitation; fatigue or loss of energy; poor sleep; altered appetite
Cognitive - poor memory, concentration or decision-making
Late-onset depression
First depression after age 65
- Higher risk of dementia, less likely to have family history
- Greater association with co-morbid conditions (“vascular depression” in hypertension, IHD, stroke)
- More emphasis on physical and cognitive symptoms, fewer mood symptoms
Why is late-onset depression under-diagnosed
- Mistaken for normal ageing
- Symptoms attributed to medical illness
- Reluctance to stigmatise patient with psychiatric diagnosis
- Non-specific, atypical presentation
- Overlapping symptoms with other conditions
Why treat depression
- Over-investigation of somatic symptoms
- Increased physician visits and hospitalisations
- Decreased QoL
- Can aggravate certain medical conditions (e.g. IHD)
- Increased caregiver stress
- Increased nursing home placement
- Risk of suicide
Delirium
Non-specific neuropsychiatric manifestation of a generalised disorder of cerebral metabolism and neurotransmission
High predisposing factors (e.g. Dementia, functional impairment) can result in less noxious precipitating factors (urinary retention, sleep deprivation) presenting as delirium
Common causes of delirium
Drugs and Infection
Also consider severe stuff like AMI, GI bleed etc.
D: Drugs
E: Eyes, ears
L: Low O2 states (AMI, GI bleed)
I: Infection
R: Retention (Urine or Faeces)
I: Ictal
U: Undernutrition, underhydration
M: Metabolic
S: Subdural
Confusion Assessment Method
CAM
Acute change in mental status AND Fluctuating course
AND
Inattention
AND
Either Disorganised thinking or Altered Level of Consciousness (Alert is normal, vigilant, lethargic, stupor, coma are abnormal)
Differentiate the 3Ds
Delirium vs Dementia vs Depression
Onset:
Acute vs Insidious vs Variable
Course:
Fluctuating vs Steadily Progressive vs Diurnal Variation
Consciousness and Orientation:
Clouded/Disoriented vs Clear until late stages vs Generally unimpaired
Attention and Memory:
Poor STM, inattention vs Poor STM without marked inattention vs Poor attention with relatively intact memory
Psychosis:
Common vs loss common vs small subset
Factora affecting successful rehabilitation
- Assessment: medical, physical, psychological, social domains
- Suitability: Adequate baseline physical and psychological functioning
- Type and Place: Acute hospital, rehab hospital, nursing home, day rehab center, at home
