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Delta Med - Geriatrics Flashcards

1
Q

What are changes in the structure of the urinary tract with ageing?

A 
Decreased renal mass, cortex > medullla
decrease in # glomeruli prop to mass
glomeruli increasingly sclerosed
intrarenal vascular changes seen in all - larger vessels
decrease in bladder size
increase in detrusor activity
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2
Q

What are changes in renal physiology with ageing?

A

decreased renal blood flow 10% per decade
GFR decreases 8mls/min/decade
reduction in maximum and minimum urine osmolality
reduction in sodium conservation (prone to hypovolemia with volume depletion)

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3
Q

What are changes in the lower urinary tract with ageing?

A

variable reduction in bladder capacity and contractility
increased detrusor hyperactivity (URGE incontinence most common in elderly)
decreased urethral ouflow resistance in women, increased in men
increased nocturnal polyuria (reduced nocturnal ADH - drugs CCF, decreased bladder capacity also contribute

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4
Q

What are adrenal changes with ageing?

A

basal renin decreased by 30-50% (normal substrate)
reduction in aldosterone (reduced clearance also) - ratio remains constant
decreased aldosterone increases risk of hyperkalaemia
stimulus response preserved, magnitude decreased

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5
Q

What are liver changes with ageing?

A

37% reduction in volume, 50% reduction in wt, 35% reduction in renal blood flow (10% reduction per unit volume) - interferes with drug clearance

Functional changes are minimal - no significant change in LFTs, albumin does not decline in well elderly

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6
Q

What are cardiac changes in the elderly?

A

cardiac output at rest largely unchanged
decreased maximal heart rate (MHR = 220-age)
myocardial atrophy, increased LV wall thickness and L atrial size occurs with age
alterations in elastin/collagen and calcium deposition result in decreased arterial compliance and valve motility
reduced HR response to stress and respiration

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7
Q

What are age related changes in lung physiology?

A

20% reduction in size, secondary to elastic recoil loss
larger terminal air spaces and thinner alveolar walls
20% reduction in surface area
FEV1 and FVC fall (FEV1 faster as you age)
residual volume increased as terminal bronchioles close in dependent parts of lung w tidal breathing
V/Q mistmatching increases with increased dead space
vent resp to low PaO2 and inc PaCO2 blunted
diminished mucocilliary clearance

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8
Q

What are changes in the humoral immune system with ageing?

A

total Ig remains same, increase IgG, IgA
diminished antibody response (increased risk of autoantibodies)
monoclonal immunoglobulins increase >70y

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9
Q

What are changes in cell mediated immunity with age?

A

thymus involutes (

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10
Q

What are changes in the endocrine system with ageing?

A

increased insulin in response to insulin resistance
increase rate of AI thyroiditis
increased PTH with consequence increase in bone resorption
increased vasopressin and hence hyponatraemia risk, ANP rises in response to IV volume, leading to nocturia
rise in FSH/LH
uterine and vulval atrophy
decreased peroxide sec by lactobaciili - UTIs
decline in male testosterone - decreasing male sexual drive and effect on muscle mass
reduced GH

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11
Q

What are pharmacokinetic changes with ageing?

A

absorption is essentially unaltered - despite reduced H+
reduced 1st pass metabolism
reduction in lean body mass with increased fat = increased Vd for lipid soluble drugs = increased t1/2
water soluble drugs have a reduced Vd and higher concentration
reduced protein binding in unwell elderly can possibly increase free drug (e.g. warfarin)

reduced hepatic clearance (10% blood flow per unit volume) - minor decrease in metabolism

renal excretion reduced in parallel with GFR and tubular secretion (MTX, cyclophosphamide, platins, digoxin, gentamicin, penicillins, trimethoprim, doxy, Li, atenolol, sotalol)

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12
Q

What are features of delirium?

A

attention deficit
changes in alertness
diffuse cognitive changes
acute, fluctuating course
psychotic features
language disturbance
disrupted sleep-wake cycle
alterations in psychomotor behaviour (hyper/hypo-alert forms)
single/multifactorial precipitant
duration may be longer than initial insult
hypoalert often missed - poorer prognosis, less likely to fully recover
no relationship between form at aetiology
recover is often incomplete (4% resolved at D/C, 31% still present at 6/12)

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13
Q

In what situations is prevalence of delirium highest?

A

up to 80% inpatients medical
up to 83% ICU inpatients
Up to 70% RACP

Incidence same in medical and surgical inpatients

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14
Q

What are features of the CAM?

A

1) evidence of acute change, fluctuation
2) inattention
3) disorganised thinking
4) altered level of consciousness

1+2 and either 3 or 4 = diagnosis

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15
Q

What are epidemiological features of delirium?

A

30% have partial syndrome
1/3-2/3 missed by treating physician
incidence increasing with aged population
increased post dischage costs
2 x risk of hospital acquired complications
3-7x risk of admission to RACF
2.2 x increased LoS

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16
Q

what is the mortality of delirium?

A

15-30%
predicted by severity of medical illness - 12 month mortality 35-40%
5 year mortality 50%
patients with partial syndromes still at risk
5 year mortality 50%

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17
Q

What are features of the pathophysiology of delirum?

A 
reduced reserve
28% reduction in cerebral blood flow
neruonal loss (neocortex, hippocamp, Subst nig)
reduced GABA, serotonin, ACh
inflammatory CKs implicated
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18
Q

What premorbid RFs for delirium?

A 
Cognitive impairment RR 2.8 - 7.3
visual impairment RR 3.5
severe illness RR = 3.5
dehydration RR = 2.0
hearing impairment
psychoactive drug use
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19
Q

What are in-hospital risk factors for delirium?

A 
use of restrains RR = 4.4
malnutrition RR = 4.0
addition of >3 medications in 24 hrs RR = 2.9
IDC insertion RR = 2.4
iatrogenic event (any) = 1.9
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20
Q

What are first line Ix in delirium?

A

FBE, UEC, LFTs, Ca, troponin, CRP, TFT
MSU, other cultures
CXR
check drug chart repeatedly

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21
Q

What are 2nd line therapy in delirium?

A

CTB, EEG, LP

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22
Q

What are general management principles in delirium Mx?

A 
Manage underlying cause
provide familiarity
optimise sensory input
avoid complications - dehydration, malnutrition, pressure areas, constipation
no good evidence for efficacy
NO role for restraints
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23
Q

What are pharmacological measures in Delirium?

A

can give haloperidol PO at low doses (0.25-0.5mg) - titrate (1 RCT)
some small trial ssupport risperidone, olanzepine
BDZ may worsen prognosis, only use in withdrawal

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24
Q

What non-pharma interventions reduce rates of delirum?

A

multicomponent intervention targeting risk factors reduces rates of delirium

early geriatrics consultation reduces delirium in surgical inpatients (32 vs 50%)

no pharmacological interventions prevent delirium

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25
What is the prevalence of dementia?
rate doubles every 5.1 years | 1.2% in 65-74, 25%>85, 47% 90s
26
What is the Dx criteria for major neurocognitive disorder?
A) Evidence of significant cognitive decline in cog domains B) interference in IADLs C) not in context of delirium D) not better explained by other disorder
27
What are features of the MMSE test?
not effective for frontal/executive fucntion
28
What are Dx features of probable AD?
insidious, gradual progression cognitive loss documented by neuropsychological tests (rapid forgetting) + other cortex problem (praxis, speech, executive, visuospatial) no physical signs/lab evidence of other causes of dementia
29
What are risk factors for Dementia?
``` AGE (strongest) family female head injury MCI vascular disease decrease folate, b12 apolipoprotein E e4 allele Downs syndrome ```
30
What are current preventative factors in AD?
only with increasing evidence is physical activity in preventing cognitive and ADL impairment
31
What are features of Autosomal Dominant AD?
early onset
32
What are features of apolipoprotein in dementia?
E4 stron risk factor 50% homozygous E4 cog intact at 80 >50% late sporadic AD have E4 20% have at least one E4 mutation
33
What is the definition of vascular dementia?
cognitive loss cerebrovascular lesions on imaging (focal neurological signs which correlate to lesions) onset of dementia within 3m of a symptomatic stroke link between stroke and cognitive change
34
What are clinical features of vascular dementia?
early attention, executive function and self monitoring change memory often mildly affected early gait disturbance lesions on neuroimaging do not exclude AD MMSE = poor screening tool
35
What are features of LBD?
usually AD pathology criteria have high Sp but low Sn rapid onset with progressive decline (1-4yrs vs 5-9yrs) AChEI may be more effective (catastrophic withdrawal) neuroleptics should be avoided - quetiapine if needed
36
What are the Dx criteria for DLB?
progressive cognitive impairment - impaired memory, deficits in attention, exec function, visuospatial ability core features (2 = probable, 1 = possible) - fluctuating cognition, attention, alertness - recurrent visual hallucinations (typically people in room) - spontaneous motor parkinsonism
37
What are supporting features of DLB?
``` recurrent falls syncope transient LoC neuroleptic sensitivity systematised delusions sleep disturbance (REM sleep disorder) depression ``` PET can be useful to differentiate over lap clinically with PDD
38
What are features of FTD?
``` diverse group - behavioural - semantic dementia (fluent) - primary progressive aphasia (non-fluent) - motor subtypes (MND, PSP, CBD) 6th, 7th decased 1/2 have FHx assoc with MND, chromosome 17 (FTDP-17) TPD-43 also found ```
39
What are general clinical features in FTD?
personality and social conduct impaired disinhibition, apathy, perseveration, sterotypy, hyperorality impairment of drive, motivation, attention and planning memory often relatively preserved DDx is frontal variant AD
40
What are pathology features of dementia subtypes?
AD - plaques (amyloid), tangles (tau), lewy bodies (alpha synuclien) PD/DLB - lewy bodies and AD pathology FTD - 50% tau, 50% TDP 43 VaD - ischaemic changes +/- amyloid
41
What are appropriate first line Ix in dementia w/u?
FBC, UEC, TSH, Ca, B12, glucose, syphilis serology CT/MRI - useful in detecting causes and other path PET increasing used to RULE IN AD ApoE4 not recommended CSF biomarkers research only (AB42 decreased, p-tau increased) neuropsychology assessment
42
What are imaging findings in AD?
generalised atrophy, hippocampal volume decreased on MRI FDG-PET -hypometabolism of precuneus, and lat parietotemoral cortex PIB scan (amyloid)
43
What are imaging findings in DLB?
``` generalised atrophy (not sensitive) on cortex MRI FDG-PET - hypometabolism, occipial cortex, dopamine transporter scan ```
44
What are imaging findings in FTLD?
regional trophy on MRI | hypometabolism frontal/temporal areas
45
What is the principle of cholinergic medications in AD?
atrophy of nucleus basalis leads to deficiency in acetyl choline tranferase, with reduced synthesis of ACh impaired cholinergic transmission with intact cholineric receptors
46
What are examples of cholinesterase inhibitors?
Donepezil rivastigmine galantamine
47
What are SEs of cholinesterase inhibitors?
``` increased GIT motility - nausea, diarrhoea, anorexia sleep disturbance and vivid dream sagitations and derlirium vagotonic bradycardia risk of asthma exacerbation 1/12 have serious AEs ```
48
What are the results of cholinesterase inhibitors in AD?
modest mean bnefits, 10-33% will have discernable benefit no way of predicting benefit failure to decline - response peak efficacy at 3 months max difference between drug and placebo at 6 months cognitive decline continues later in treated patients >1year all equal in effectiveness improvement in ADL retention at 1 year
49
What is the role of cholinesterase inhibitors in other dementia subtypes?
``` VaD - unclear - modest benefit MCI - not genrally recommended, ? increased vasc deaths DLB - good quality data lacking PDD - modest ben in rivastigmine FTD - no role ```
50
What is the role of memantine in AD?
neuroprotective NDMA antagonist (blocks glutamate mediated cytotoxicity) may be used with cholinesterase inhibitors well tolerated rare lazarus effects studies in mod-severe AD and Vascular Dementia
51
What are non-pharmacological measures in dementia?
care giver training leads to sustained benefit OR of staying at home 5 cognitive training also useful
52
What are Mx options for behavioural disturbance?
risperidone in NH patients (0.5-2mg) | olanzapine also has evidence
53
What are features of MCI?
condition intermediary between normal cog and dementia normal function with subjective or objective memory impairment 0-34% annual conversion rates some rremain stable, and others revert to non-MCI no intervention works other than exercise PET shows extensive amyloid in those who subsequently convert to AD
54
What are predictors of progression in MCI?
``` increasing Age strong FHx of AD typical AD findings on imaging CSF biomarkers amnestic findings on neuropsych testing (rapid forgetting) ```
55
What are epidemiological features of falls?
``` 35-40% of comm dwellers have falls >65yo 6-40% cause fractures or serious injury fear of falling greatest fear in elderly 8% of total direct healthcare cost in australia decline in ADLS and social function ```
56
What are features of fall in RACF?
``` 30-50% fall per year 10x higher risk of hip fracture RFs: previous falls cognitive impairment lower limb neuro impairment/gait abn gait aid >4 medications very poor vision/poor contrast sensitivity ```
57
What are causes of syncope/falls?
``` neurocardiovascular: - carotid sinus hypersensitivity - vasovagal - orthostatic hypotension arrhythmias - SSS - AV block - brady-tachyarrhythmias ```
58
What risk factors for falls have the strongest evidence?
History of falls Advancing age ADL limitations then female, living alone, inactivity NO evidence for alcohol
59
What balance and mobility factors have the strongest evidence for falls?
impaired gait/mobility impaired STS impaired transfers then impaired stability in standing/leaning stab, slow voluntery stepping and least indaequate resp to ext pertumbation
60
What sensory/neuromuscular features have the strongest evidence for falls?
visual contrast sensitivity reduced peripheral sensation muscle weakness poor reaction time then visual field dependence, VA no evidence for vestibular function
61
What medical risk factors have the strongest evidence for falls?
impaired congition stroke parkinson's disease then depression, neuro signs, incontinence, acute illness, arthritis, foot problems, lowest dizziness no evidence for vestibular dz or orthostatic hypotension
62
What medication factors have the strongest association with falls?
psychotropic medication use >4 medications then antihypertenstive use no evidence for NSAIDs
63
What environmental factors have evidence for contribution to falls?
poor footwear | inappropriate spectacles
64
What interventions have evidence in reducing the risk of falls in community and RACF patients?
MDT - education, PT, OT medication review - incl psychoactives Vit D at daily doses exercise - balance component important (tai chi)
65
What interventions have evidence in reducing falls in community dwellers?
footwear/podiatry cataract repair need to fall 300 times/year to prevent 1 serious bleed on warfarin
66
What interventions have evidence in reducing falls in NH residents?
alarm mats scheduled toileting ?hip protectors
67
What are risk factors for hip fracture?
``` Age, female Hx of falls (esp prev adult #) cognitive impairment poor functional status psychoactive drug use (sedatives/hypnotics, TCA, anticonvulants, l-dopa) visual impairment osteopenia/osteoporosis ```
68
What is the outcome of hip fracture?
15-30% operative mortality at 1 year risk doubled if op delayed 2 days >20% never get home use of op therapies not universal on DC
69
What types of incontinence?
``` urge - common to have detrusor overactivity (most common) stress - esp in owmen mixed urge-stress (common) overflow functional faecal ```
70
What medications impair CNS control of voiding?
sedatives, hypnotics, antipsychotics, antidepressants, antiemetics, analgesics, alcohol can only cause incontinence in patients already susceptible
71
What medications impair bladder function?
anticholinergics - reduced flow rate and increased residual cholinergics - may precipitate or worsen urge symptoms or incontinence bladder irritants - cyclophosphamide, BCG, raditaion, caffeine
72
What are features of outflow resistance in incontinence?
decreased outflow resistance - alpha adrenergic blockers (Smooth muscle) - prazosin, labetalol drugs which induce striated muscle contraction - baclofen BDZ increased outflow resistance - TCAs, occ iproduce retention, alpha agonists (pseudoephedrine)
73
What are other drugs which worsen continence?
- constipators - anticholinergics (red peristalsis), ca antagonists (smooth muscle), diuretics (dehydration) - drugs that promote diuresis - diuretics, lithium
74
What are non-pharmacological methods of treating incontinence?
pelvic muscle exercises for geniuine stress incont (1st line, always) bladder retraining timing of oral fluids, reduce caffeine, rationalise meds treat constipation weight loss in obese
75
What are drug treatment options in incontinence?
urge incontinence in cognitively intact - antimuscarinic agent - oxybutynin, solifenacin, tolteridone, darifenacin (can have peripheral anticholinergic effects, delirium) Stress incontinence - topical oestrogens, not HRT little evidence for duloxetine surgery is last line!
76
What are interventions in polypharmacy?
Medication reviews - reduce inappropriate medications, changes sustained at 12 months, required fewer medical interventions, patients percieved outcomes unchanged.

Delta Med - Geriatrics (1 decks)

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