Frailty Flashcards
what is frailty
a state of increased vulnerability resulting from ageing
what scores on the Rockwood Clinical Frailty Scale indicate death within 6 months
7-9
at which point on Rockwood is the px completely dependent for personal care?
7 - severely frail
frailty, disabiility and X overlap
multimorbidity
what is the issue with strictly following guidelines with patients with frailty and multimorbidity?
dont provide guidance on multimorbidity so need to use clinical judgement
what is multimorbidity?
co-existence of 2+ chronic conditions where 1 is not necessarily more central than others w disctinctive cumulative effects for each px
what is multimorbidity assoc with?
inc rate of death, disability, AEs, use of healthcare resources, dec QoL
comorbidities can be divided into what 3 groups
clinically dominant
synegistic
coincidental
what is an example of a clinically dominant comorbidity
dementia trumps heart disease
what is an example of a synergistic comorbidity
COPD and heart disease
clinical reasoning and X are essential to managing comorbidity
shared decision making.
weight risks and benefits
what is the pathophysiology of frailty
increasing sarcopenia with age, loss of function and reduced physiological reserve. vulnerability can lead to sudden deterioration
what are the 5 frailty syndromes?
instability, immobility, delirium, incontinence, susceptibility to SE
give examples of susceptibility to SE of meds
confusion w codeine
hypotension w antidepressants
how to communicate frailty, avoid what?
labelling
say things like it can take longer to bounce back and vulnerability, lack of robustness, lack of resilience (dont sau complex sitch)
what score of the EFS means that a patient needs a full MDT assessment to prevent frailty?
5
what are the 2 comprehensive geriatric assessments to assess frailty
AMT
EFS
aim of comprehensive geriatric assessment
to make a coordinated integrated plan for Tx and long term support
what to ask px for EFS
on 5+ meds on regular basis
adherence + concordance
….
what interventions can we make for frailty?
med revs, identify and reverse diagnoses, nutritional support, exercises, home first
patients with a higher CFS are twice as likely to experience an ADR, true or false
true - frailty linked with increased risk AE
5 main reasons of problematic pharmacy
- no evidence based indication
- meds prexc to treat SE of other meds
- meds fail to acheive therap obj
- meds cause unacceptable ADRs
- demands of med taking are unacceptable to px/ px cant maintain adherence
what are some of the worst tolerated meds in frailty?
NSAIDS,
long acting benzos,
sulphonylureas,
anticholinergics,
sedatives,
hypnotics
what is the prescribing cascade
when ADR is misinterpreted as a medical condition and new medicines are started
what is the prescribing vortex
when each medication causes a SE that is caused by the next
give an example of presc vortex with oral bisphosphonate at start
oral bisphosp -> GI SE -> PPI -> increased fracture risk -> back to start
is increased ACB (anticholinergic burden) score associated with increased morbidity
yes
what score on the ACB means that a MAP review is needed
(meds, alternatives, px monitoring)
3
name 6 anticholinergic SEs
urinary retention
dry throat, mouth, constipation
feel hot, sweat
tachcardia
blurry vision, dry eyes
sedation, dizzy, confusion
What is MAP
medicines - is it essential
alternatives
patient monitoring - symptoms and SE
name 2 meds w highest ACB score
amitryptyline
chlorphenamine
what should be avoided with NSAIDs as they are high risk combinations?
ACEi/ARB, existing renal disease, HF, warfarin, no PPI and age over 75
what are high risk combinations with warfarin
antiplatelet (some exceptions), NSAID, macrolide, quinolone, metronidazole, azole antifungal
if someone has HF, what should be avoided
glitazones, NSAIDs, tricyclic antidepressants
which drugs are associated with rapid symptomatic decline if stopped or require cautious stepwise withdrawal
ACEi in HF, diuretics in HF, rate/rhythm control, opioids, antidepressants. antipsychotics, antiepileptics
what is delerium caused by
acute illness or drug toxicity, often reversible and affects attention
pts with dementia are not at increased risk of delirium, true or false
false
what condition: typically caused by anatomic changes in brain, slower onset, generally irreversible and affects memory
dementia
2 diagnostic tools for delirium
AMT
CAM
Pinch me acronym - causes of delirium
pain, infection, nutrition, constipation, hydration, medication, environment
what is hyperactive delirium
heightened arousal, restless, agitated, aggressive
what is hypoactive delirium
apathy, quiet confusion
often confused w depression
Who is at risk of falling?
visual impairment, cognitive impairment, physically frail, alcohol, mutilple meds, fear of falling
multifactorial falls risk assessment may include what?
identification of falls hx
assess gait, balance, mobility, muscle weakness
OP risk
visual impairment
urinary incontinence
…
how to measure a postural BP
lie for 5 mins then measure
when standing measure at 1,3 and 5 mins
remain standing!
postural hypotension = inability to maintain BP on upright position from supine, leading to drop of what mmHG?
at least 20/10 drop
important risk factors of post hypo
ageing (assoc w physical deconditioning)
meds affecting sympathetic tone (tamsulosin, antihypers, antideppressants SSRIs TCAs)
dehydration
what is reflex tachycardia
blood pressure lowers and the body compensates by increasing HR which increases blood pressure
which medicines cause postural hypotension
diuretics
nitrates
sildlenafil
ethanol
levodopa
TCA antideps
SSRIs
anti epileptics carbamazepine
anti psycho
anti musc
opiates
what is diabetes HbA1C target for someone with an advanced stage of frailty
over 70mmol/L
(use clinical judgement)
CFS 8, will pass away in next 6 months
should aspirin be used for primary prevention
no
lifestyle advice for postural hypotension
2L water, increase salt intake, get up slowly and clench muscles, not take hot baths, drink caffeinated drinks
pharmacological management of postural hypotension
fludrocortisone, midodrine
why must you not start risperidone/lorazepam in acute delirium in the elderly
increased fall risk
why is lactulose not a great choice for constipation
need lots of water to make it work and can cause abdominal discomfort
why should constipation be treated in the elderly
can lead to cognitive impairment and urinary retention
why would you not start a bisphosphonate in a pt with a CFS score of 7
