Care of the Elderly & Dementia Flashcards
What is dementia?
Dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function.
Mini Mental State Examination
Mini Mental State Examination (out of 30)
Normal: 26-30
Mild dementia : 21-25
Moderate dementia: 10-20
Severe dementia: 0-9
What is a mild cognitive impairment?
Syndrome defined as cognitive decline greater than expected for an individual’s age and education level but that does not interfere notably with activities of daily life. (10% per year develop A.D.)
Which drugs can contribute to cognitive impairment?
Anti-cholinergics – e.g. Oxybutynin
Anti-psychotics – e.g. Chlorpromazine
Anti-histamines
Anxiolytics – e.g. Benzodiazepines
Antidepressants – e.g. TCA’s, SSRI’s
Anticonvulsants – e.g. Phenytoin
Opiates
PD drugs
Lithium
Steroids
Is drug induced cognitive impairment reversible?
Yes
What are the main symptoms of Alzheimer’s Disease?
Memory loss, personality changes, global cognitive dysfunction and functional impairments
Visual spatial disturbances (early finding)
Apraxia (loss of the ability to perform activities that a person is physically able and willing to do)
Language disturbances
Personality changes
Delusions/hallucinations (usually later in course)
What drugs are normally used to treat Alzheimer’s Disease?
Cholinesterase inhibitors
- (Donepezil, Rivastigmine & Galantamine)
- Low levels of acetylcholine in A.D.
Mild to Moderate disease
Initiate under specialist care
Continue only if worthwhile effect
What is Mermantine and when should it be used?
NMDA receptor antagonist (blocks action of glutamate)
- Excess glutamate in mid-late stage interferes with neurotransmission & contributes to neurone loss.
Used in:
- Moderate disease (if intolerant of or contraindication to acetylcholinesterase inhibitors)
- Severe disease
Who needs to go to a falls clinic?
Recurrent fallers – no cause identified
Poor balance
Undiagnosed “dizziness”
Syncope – unknown cause
What needs to be tested when a patient falls?
Full examination
- GAIT
- Pulse, heart murmurs
- Cerebellar testing
- Joints
- Proprioception & sensation in feet
Blood tests (including Vitamin D)
Lying & standing BP
ECG
Tilt table test
CT brain
Postural Hypotension
Fall of 20 mmHg in SBP or 10 mmHg in DBP on assuming upright position
Prevalence 30% in over 75 yo
Increased all-cause mortality
Impaired capacity to increase vascular resistance on standing
Mostly treatable but easily missed
What are common symptoms of postural hypotension?
Postural dizziness or pre-syncope
Falls
Syncope
Visual disturbance
Weakness, lethary
“Coathanger” ache
What are common causes of postural hypotension?
Medication
- Antihypertensives: esp. diuretics & Doxazosin
- TCA’s, PD meds, antipsychotics
Intercurrent illness
Bed rest
Autonomic dysfunction
- DM, PD, paraneoplastic, Addison’s, post infective autonomic dysfunction, alcohol
What can be used to treat postural hypotension?
MEDICATION REVIEW
Conservative measures
- Increase fluid input
- AEDs
- Advice
Medication
- Fludrocortisone
- Midodrine
What factors can affect digoxin levels?
Renal function
Frailty
Hypokalaemia
- Use K+ sparing diuretics with loop diuretics
Other drugs (see next)
What are the symptoms of Digoxin toxicity?
Systemic
- Anorexia, n/v, diarrhoea
- Lethargy/fatigue
- Confusion
- Blurred vision – yellow/green halos
Cardiac
- Bradycardia
How do you manage digoxin toxicity?
Mild:
- Stop digoxin for 2-3 days
- Replace K+
- Repeat level and start at lower dose
Severe:
- Digibind (iv)
Why is prescribing more difficult in older people?
Multiple pathology
Polypharmacy
- Increased drug interactions, side effects
- Decreased adherence
Difficulties with adherence
Altered drug handling
- Physical changes
- Pharmacokinetics
- Pharmacodynamics
What are some unintentional reasons for non-adherence in the elderly?
Difficulty with packaging or devices
Difficulty swallowing
Confusion/memory problems
Poor communication/misunderstanding
Polypharmacy/complicated regimen
What are some intentional reasons for non-adherence in the elderly?
- Deliberate adjustments
- Lack of confidence in medicines or prescriber
- Side effects or concerns about these
- Polypharmacy/complicated regimen
- Poor communication/lack of information
How can you improve adherence in elderly patients?
Assess use of medicines
Large print labels and leaflets
Plain tops on bottles
Medication reminder cards
Multi-compartment compliance aids (MCAs)
How is ABSORPTION affected in elderly patients?
Reduced rate of absorption but extent of absorption unchanged
- Reduced salivary flow, emptying time, surface area and blood flow
- Increased gastric pH
Exceptions
- Decreased absorption of vitamins
- Increased absorption of levodopa
How is DISTRIBUTION affected in elderly patients?
Reduced perfusion
- slow distribution throughout the body
Reduced body water
- increased plasma conc of water-soluble drugs
Increased body fat
- prolonged effects of fat soluble drugs
Reduced albumin
Reduced muscle
How is METABOLISM affected in elderly patients?
Reduced hepatic perfusion
Reduced first pass metabolism
Reduced hepatic enzymes
BUT - large reserve, so ? clinical significance
