Ageing Flashcards
4 components of a comprehensive geriatric assessment?
Medical
Functioning
Psychological
Social/Environment
Why is acute illness in elderly likely to present in an atypical manner?
Co-morbidities
Impaired immune/physiological functioning
Polypharmacy
Criteria for sarcopenia?
Low muscle mass
+ 1/2 of:
Low muscle strength
Low physical performance
Sarcopenic obesity?
Loss of muscle mass with increased fat - BMI may remain the same
Interventions for sarcopenia?
Exercise - progressive resistance training and aerobic training
Reduce sedentary time
Rehabilitation?
Reablement?
Rehab - disabled by injury/disease achieve a full recovery
rebate - poor physical/mental health re-learn skills to accommodate illness
3 things which contribute to ageing?
- Random molecular damage during cell multiplication
- Inactivity, poor diet, inflammation etc
- Reduced ability of body’s adaptive reserve capacity (resilience)
3 things frailty causes?
Loss of homeostasis and resilience
Increased vulnerability to decompensation after a stressor event
Increased risk of falls, delirium, disability, death
Any sudden decline in health?
Multimorbidity?
Due to disease
Higher rates of adverse events and poorer QOL
Palliative care: Pain/SOB? Distress? Nausea/agitation? Res secretions?
Pain/SOB - morphine
Distress - midazolam
Nausea/agitation - Levomepromazine
Res secretions - Buscopan
AF increases stroke risk how much?
5x
Cardioembolic stroke?
Atheroembolic stroke?
Cardio - fibrin rich red thrombus - anticoagulant
Athero - platelet rich white thrombus - anti-platelet
Frontal lobe functions?
Lesion?
Function - personality, emotional response, social behaviour
Lesion - disinhibition, lack of initiative, antisocial behaviour, incontinence, impaired memory, grasp reflex, anosmia
Dominant parietal function?
Lesion?
Fun - calculation, language, planned movement, appreciation of size/shape/weight/texture (stereognosis)
Lesion - dyscalculia, apraxia, AGNOSIA, homonymous hemianopia - L/R DISORIENTATION
Non-dominant parietal function?
Lesion?
Function - spatial orientation, construction skills
Lesion - HEMISPATIAL NEGLECT, construction/dressing apraxia, homonymous hemianopia
Occipital function?
Lesion?
Function - Analysis of vision
Lesion - homonymous hemianopia with MACULAR SPARING, impaired facial recognition, visual hallucinations
Dominant temporal function?
Lesion?
Function - Auditory perception, speech, language, verbal memory, smell
Lesion - Wernicke’s dysphasia, dyslexia, homonymous hemianopia, poor memory, complex hallucinations (sound, smell, vision)
Non-dominant temporal function?
Lesion?
Function - auditory perception, music, tone sequences, non-verbal memory (faces, shapes, music), smell
Lesion - homonymous hemianopia, poor non-verbal memory, loss of music skills, complex hallucinations (visual, smell, sound)
Is delirium acute?
Yes
4 hallmark symptoms of delirium?
1 - acute and fluctuating
2 - inattention
3 - altered consciousness
4 - disorganised thinking
Hyperactive delirium?
Hypoactive delirium?
Hyper - agitated, aggressive, wandering
Hypo - withdrawn, apathetic, sleepy (coma)
–> easily missed, 2x higher mortality
2 Ix for delirium?
4AT: Alertness AMT4 (age, DOB, place, year) Attention (months of year backwards) Acute/fluctuating course
CAM:
- acute/fluctuating
- Inattention
- Disorganised thinking
- Altered consciousness
- -> 1 and 2 + 3 OR 4
Conservative management of delirium?
Environment and supportive factors
Identify and treat underlying cause
Symptom control
Medical management of Delirium?
Haloperidol - NOT IN PARKINSONS
Quetiapine - in Parkinsons/Lewy Body Dementia
Benzo - alcohol/benzo withdrawal or seizure (Lorazepam or Chlordiazepoxide) - however beware these can worsen delirium
Predisposing factors for delirium?
- Age
- Pre-existing dementia
- Co-morbidity
- Terminal illness
- Sensory impairment
- Polypharmacy
- Depression
- Alcohol dependency
- Malnutrition
5 things that link falls and immobilisation?
Hypothermia/Dehydration Pressure sores Rhabdomyolysis VTE Bronchopneumonia
5 physiological changes in ageing that can lead to falls?
- Central processing/cognition (reduced reaction)
- Vision (smaller pupil, thicker lens)
- Sarcopenia (less muscle mass and function)
- Peripheral sensation/proprioception (increased postural sway and poor sensory awareness)
- Reduced activity (decreased cardio fitness)
Risk factors for falls?
CVS, central processing, MSK, neuro, vision, other
CVS - dizziness, postural hypotension, heart disease
Central processing - cognitive impairment, depression
MSK - pain, arthritis, sarcopenia
Neuro - parkinsonism, stroke, neuropathy, balance
Vision - acuity, depth perception, contrast sensitivity
Other - low BMI, Hx of falls, age>80, female
What is postural hypotension?
Drop of >20/10mmHg on standing after 2 mins
8 Drug classes that increase fall risk?
- Benzos
- Neuroleptics
- Antihypertensives
- Antidepressants (SSRI hyponatraemia, TCA antivholinergic)
- Anticholinergics
- Class 1a anti-arrhythmatics (disopyramide)
- Diuretics
- anti-epileptics
Investigations for falls?
- HR, Cardio, postural BP
- Visual acuity
- Gait, balance, joints
3 Assessment tools for falls?
Timed get up and go
Berg Balance Test (Balance only - static and dynamic balance)
Tinetti Score (Balance AND Gait) - performance orientated mobility assessment (POMA)
Management of falls? (5)
- Risk modification
- Strength and balance training
- Vision optimisation
- Footwear and foot care
- Osteoporosis treatment
2 principles of drug absorption?
1 - acidic drugs need acidic environment (e.g. Phenytoin, Aspirin, Penicillin)
2 - Basic drugs need basic environment (e.g. diazepam, morphine, pethidine)
Pharmacodynamics in elderly?
Lower dose achieves same effect (e.g. alcohol)
However effects of some drugs are decreased (e.g. B-blockers and HR)
SE of amlodipine?
oedema (treat with furosemide)
SE of NSAIDs?
hypertension
GI bleeding
decline of GFR
Treat GI with H2 blockers, which can lead to delirium (from tiredness), which needs treated with haloperidol
SE of metoclopramide?
parkinsonism (treat with sinemet (carbidopa/levodopa))
SE of thiazides?
Gout (tread with NSAIDS, which may then require 2nd anti-hypertensive added)
SE of sedafed?
pseudoephedrine - sympathomimetic, used as nasal decongestant
Urinary retention (then need alpha blockers)
10 most common drugs likely to cause SE in elderly?
Warfarin Digoxin Insulin Benzos Diuretics NSAIDs Corticosteroids Anti-hypertensives Opioids (confusion, falls) Theophylline (insomnia, diarrhoea, irritability, headache, incontinence)
Why do elderly absorb basic drugs more readily?
1 - less acid production therefore increased stomach pH
2 - Acidic drugs bind albumin and Basic drugs bind A1-AG - elderly have low albumin and high A1-AG
Difference of lipophilic drugs in elderly?
Elderly have higher volume distribution (Vd) of lipophilic drugs
Grapefruit juice?
Interacts with simvastatin - CYP450 inhibition by grapefruit juice - myalgia
Cranberry juice?
Warfarin - increases INR - bleeding risk
4 things in pharmacokinetics?
ADME
Absorption
Distribution
Metabolism
Excretion
How to manage side effects?
Try changing to another drug - avoid treating SE with more drugs if possible
Therapeutic index?
Minimum toxic dose/minimum effective conc
