Elderly Patient Flashcards
What is an elderly patient?
Patient > 65 y old
Aims of Mx of an elderly patient
Aim should be to:
- reduce polypharmacy
- reduce clinic and hospital attendance
- promote continence
- promote independence
- recognising both cognitive impairment and social needs
What’s frailty?
Frailty:
- health state
- related to the ageing process
- multiple body systems gradually lose their in-built reserves
What are syndromes associated with frailty?
Falls: collapse, legs gave way, ‘found lying on floor’
Immobility: sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’
Delirium: new acute confusion or sudden worsening of confusion in someone with previous dementia/memory loss
Incontinence: new onset or worsening of urine or faecal incontinence
Susceptibility to side effects of medication: confusion with codeine, hypotension with antidepressants
SEs (important for the elderly patients) of anticholinergics
- unsteadiness
- blurred vision
- dry mouth
- urinary retention
- confusion
SEs (important for elderly patients) of benzodiazepines
- falls
- regular use increases all-cause mortality
- confusion
SEs of opioids (important for an elderly patient)
- constipation
- falls
- delirium
SEs of NSAIDs (important for elderly patients)
- AKI
- gastric ulceration
SEs of antihypertensives (important for elderly patients)
- AKI
- falls
Differentials for delirium in an elderly patient (3)
- schizophrenia
- new dementia
- encephalitis
How does delirium present in an elderly patient?
- Memory impairment
- confusion
- hallucination
- sleep disturbance
- often fluctuating
- Hypoactive or hyperactive
- Falls
- incontinence
Causes of delirium in elderly patients
Infection: UTI and LRTI , also cellulitis
Pain
Constipation or urinary retention
Drugs: especially benzodiazepines, opiates, anticholinergics
Change in surroundings eg hospital or transfer to care home, poor lighting
Electrolytes: hyponatraeimia, hypercalcaemia, uraemia, hypo/er glycaemia
CVA, AKI and dehydration, ACS-NSTMI/STEMI
Hypoxia
Alcohol withdrawal (often day 3…more common than you would think! Get a collateral history)
Post surgery
Causes of falls
- Motor problems: gait and balance impairment, muscle weakness
- Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment
- Polypharmacy: benzodiazepines, opiate, anticholinergic, antihypertensive
- Cognitive or mood impairment: dementia, depression
- Environmental hazards such as loose rugs
- Orthostatic hypotension
- Co-morbidities
- Physical ageing, frality
Key components of fall prevention programme
•Exercise including strength and balance training
•Review of medication
•Vision assessment
•Home safety assessment with modifications as deemed necessary
What’s dementia?
Dementia:
- a syndrome
- chronic or progressive nature
- deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing
It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement
Types of dementia
- Alzheimer’s
- Vascular
- Lewy Body
- Fronto temporal
- Parkinson’s Disease
- Alcoholic
- Associated with Down’s syndrome
The assessment (3) used for cognitive assessment of an elderly patient in the primary care
- GP COG (General Practitioner Assessment of Cognition)
- MOCA (Montreal cognitive assessment)
- MMSE (Mini Mental State Examination)
GP COG assessment
- advantage
- components
- TakGeneral Practitioner Assessment of Cognitiones no longer than 5 minutes
- and comprises two components: a six item cognitive assessment with the patient and an informant questionnaire
MOCA
- use
- duration
- components
- results
Montreal Cognitive Assessment
- current gold standard for diagnosis and treatment monitoring
- Takes around 15 minutes to complete
- results out of 30
- Includes recognising animals and some reasoning/visuospatial awareness
- also tests higher functions such as special awareness
Presentation of Alzheimer’s
- Memory problems
- Behavioural change
- Gradual , insidious decline
- Problems completing ADLS
Pathophysiology of Alzheimer’s
- Amyloid plaques causing degeneration of cerebral cortex
- Reduced acetyl choline production (a neurotransmitter)
Exact cause unknown → perhaps genetic disposition and an environmental trigger
Pathological changes in Alzheimer’s
- macroscopic: widespread cerebral atrophy, particularly involving the cortex and hippocampus
- microscopic: cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
- biochemical: there is a deficit of acetylcholine from damage to an ascending forebrain projection
Pharmacological management of Alzheimer’s Disease
Pharmacological management
- acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) → mild to moderate Alzheimer’s disease
- memantine (an NMDA receptor antagonist) → ‘second-line’ treatment for Alzheimer’s if:
→ moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
→ as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
→ monotherapy in severe Alzheimer’s
Characteristic pathological changes seen in Pick’s disease
- Focal gyral atrophy with a knife-blade appearance (characteristic of Pick’s disease)
Macroscopic changes:
- Atrophy of the frontal and temporal lobes
Microscopic changes:
- Pick bodies - spherical aggregations of tau protein (silver-staining)
- Gliosis
- Neurofibrillary tangles
- Senile plaques
