Elderly - Frailty Flashcards
Is geriatric medicine an ageist concept?
Is it ageist to have a speciality just for old people – yes
Age vs frailty
No about people above a certain age, its about people with frailty
what is the Epidemiology and trends?
Ongoing demographic shift
Population of the world is getting older
Fertility rates are falling world wide and life expectancy is going up and going up more quickly in areas which were traditionally less good
how is life expectancy changing in the older age groups?
Better at keeping people that are 80 alive for longer
how is the number of people over 60 years old changing?
When you look at the proportion of people over 60, a higher and higher proportion of those are aged over 80
Aged 80 and over are much more likely to have issues with frailty compared to people aged over 60
Why are people getting older?
Increased resources availability
Better economic conditions
Improved screening programs with earlier diagnosis and treatment
Better outcomes following major events - Cardiac, Stroke, Surgery
what are the consequences of people getting older and liviing longer?
More people survive a major event
More people have several co-morbid conditions
Data graph from an oncology study - Important thing to note is all the yellow highlighted things become more common as we get older
As we look after someone as they get older they are more likely to be multimorbid – correct treatment for one thing may be contraindicated by another
what are the benefits of ageing
Increased experiential learning
what are the neutral effects of ageing?
Grey hair
Pastime preference
what are the detrimental effects of ageing?
Hypertension, decreased reaction time
Accumulation of disease
what are the different theories of ageing?
Stochastic - We Cumulative damage (due to micro trauma and free radicles and happen randomly and degrades systems over time), Random
Programmed - Predetermined, Changes in gene expression during various stages
Homeostatic failure (less reserve to cope with any environmental challenge, less able to maintain homeostasis)
Physiology of ageing:
- Affects virtually every _____________
- Marked ___________ variability in both development and magnitude of changes
- Inter-individual variability __________ with age
- Evidence very limited for ___
Differences between individuals get _______ as we get _____ e.g. 2 75 year olds are more physiologically different from each other than 2 25 year olds
organ/system
inter-individual
INCREASES
80+
greater
older
Ageing and the kidney: what is the effect?
As we get older our clearance of creatinine becomes poorer but accompanied by reduction in muscle bulk then if you measure serum creatinine then actually there isn’t much change as we get older but if you measure creatinine clearance then it drops much more markedly as we get older
Ageing and the cardiovascular system - what is the effect?
Systolic BP tends to go up as we get older
Beyond 6th decade diastolic BP begins to drop
If treating systolic BP with antihypertensive then more risk of dropping diastolic BP and increases risk of things like falls
CO tends to go down as we get older but as seen on this graph there is a great deal of scatter - All to do with trends (fornt of card)
Ageing and the respiratory system - what is the effect?
Demonstration of lack of evidence
Highest age is 65
Total lung capacity stays same but the useful bit the vital capacity tends to go down as you get older
Dyshomeostasis:
- The point of physiology is to maintain a ______ _____
- Impaired function of any organ system makes this more ________
- ______ is effectively progressive dyshomeostasis
Progressive reduction in our ability to deal with any given ____________ challenge
steady state
difficult
Frailty
environmental
what is frailty?
The core concept in Geriatric Medicine
A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge
When people present with facing an environmental challenge this causes loss of basic function
what are the “Frailty Syndromes”?
- Falls
- Delirium
- Immobility
- Incontinence
A person with frailty may have none of these problems until they are presented with an environmental challenge which changes the way they function as a human
Negative feedback loop for maintaining BP
Older people have decreased CO so less likely to be able to do this effectively
Fig. 1. Relationship between baroreflex sensitivity (BRS) and age in men (A) and in women (B)
Baroreceptor reflex gets less over time so don’t sense that drop of BP so cant maintain BP within safe limits resulting in things like falls and blackouts
normothermia - what happens in young and old
Young = no frailty
Older = frailty
Normothermia – room temp
cold stress- what happens in young and old?
When cold stress, less likely to vasoconstrict and increase heat production metabolically so more likely to present with hypothermia
heat stress - what happens in young and old?
When heat stress, unlikely to sweat, increase skin blood flow, increase CO and redistributing blood flow so more likely to present with heat stroke
“Social” dyshomeostasis:
Difficulty caused by environmental insults not only __________
Ageing often associated with whole system ____________
Different ability to __________ for e.g. death of spouse or daughter going on holiday
bio-medical
dyshomeostasis
compensate
how may the presentation of a medical condition change in someone with frailty?
Medical conditions might have different presenting signs and symptoms in people with frailty
Hyperthyroidism:
Classic presentation:
- Tremor
- Anxiety
- Weight loss
- Diarrhoea
Person with frailty:
- Depression
- Cognitive impairment
- Muscle weakness
- Atrial fibrillation
- Heart failure
- Angina
People with frailty present completely differently – and these things lead to falls, immobility, delirium, incontinence
What is the evidence gap?
Many conditions more common in older people
Few trials of medications in older people (because of interindividual variability)
Average age of people in this trail with heart failure was 60 (which is one of the least prevalent groups in heart failure as seen on the fornt of the card)
People with frailty respond different to medications so don’t know if this trial is relevant to them
Evidence form younger people is routinely applied to older people
More drugs you take = ?????
more likely you are to have an adverse reaction to these drugs
Practical implications:
________ number of older people with multiple co-existing medical conditions
(as we get older) Increased _____________ variability in organ function and homeostatic reserve
_________ presenting symptoms and signs
Presentation of different “illnesses” can be v ______
Multimorbidity and frailty are different but both issues for older people
People with frailty present to healthcare differently - may present with delirium but due to many different causes and hard to find what using the standard medical model
Increasing
inter-individual
Different
similar
Practical implications:
Relatively little evidence of drug efficacy and safety for patients ___
Pre-marketing development still largely involving young and middle age pts with fewer co-morbidities
Multiple medications - what can this lead to?
80+
Drug-drug interactions
Adverse drug reactions
Conclusions:
- Geriatrics is about ______
- Frailty is ____________
- People with frailty present ________
- Little evidence in _____ adults
frailty
dyshomeostasis
differently
older
