Frailty Flashcards
Define frailty
A distinctive heath state related to the aging process which multiple body systems gradually lose their in built reserves.
What are the key concerns of frailty px?
Increased risk of deterioration
Worse outcomes of illness
Higher risk of acute hospital admission
Increase hospital stays
Care home admission
Death
What are the severity groups for frailty?
Managing Well
Mild/Severe frailty (negative outcomes = dependence)
What are the frailty syndromes? (5)
Falls
Immobility
Delirium
Incontinence
Susceptibility to s/e of medications
What are the 2 main screening tools for frailty?
Electronic frailty index
Rock wood clinical frailty scale
What are key features of comprehensive geriatric assessment? (2)
Multidisciplinary assessment of physical, psychological, functional and environmental factors.
Define polypharmacy.
Prescribing of multiple medications for a patient.
What are the 2 classes of polypharmacy?
Appropriate
Problematic
What are the 7 steps to appropriate polypharmacy?
What matters
Right/ unnecessary, effective, harmful and cost effective medicine.
Agree and share medicine plan.
Define deprescribing.
Process to ensure safe and effective withdrawal of inappropriate medications.
What are the toolkits used for deprescribing?
STOP/START
NO TEARS
BEERS criteria
STOPFRAIL
ACB
What are they key considerations for medicines management?
Poly pharmacy
Cognitive impairment/medication adherence/understanding (Paracetamol safety)
Risk of falls (BP including postural hypotension = Furosemide, Amlodipine, ACE) , Electrolyte disturbances (Lisinopril, Furosemide)
Drug-disease interaction:
- Renal function (older adults often have declining renal function = Metformin (lactic acidosis), ACEi (protective v nephrotoxic), Diuretics.
- GI risk (Aspirin = cardioprotective vs GI bleed)
- OA (paracetamol dose/risk/body weight
- OP (Rx calcium = vitamin D levels)
Citalopram and Escitalopram (QT prolongation)
Tolterodine (Anticholinergic s/e refer for incontience review. Also increases QT interval)
Amlodipine/simvastatin interaction
Clopidogrel/Omeprazole interaction
Digoxin (at doses > 125mcg / day with impaired renal function (eGFR < 50ml/min). Significantly increases riks of toxicity (e.g. nausea, diarrhoea and arrhythmias)
Dose reduction (Apixaban):
- Recommended dose = 2.5mg BD in px with NVAF and least 2 of the following characteristics: >= 80 yrs, body weight <= 60kg or serum creatinine >= 133mcmol/L.
Define delirium.
Affects people’s brains for short time. Common condition. May be confused/agitated and acting differently than usual. Can seem alert or drowsy.
What are the precipitating factors of Delirium?
New illness (infection, urinary retention/constipation)
Recent hospital discharge
Falls
Acute/chronic pain
Poor oral intake (fluid/nutrition)
Recent changes in environment
Comorbidities (COPD, Depression, terminal illness, catheterisation or dementia.)
Current meds or accidental overdose and recent drug cessation
Alcohol use
Sensory impairment (reduced vision/hearing, use of hearing aids/glasses)
What is the CAM criteria for delirium?
Sudden/fluctuating confusion
Inattention
Disorganised thinking
Altered level of consciousness
What is the DSM-5 criteria for delirium?
Attention disturbance (develops over a short period of time)
Cognitive disturbance (memory deficit, disorientation, language)
What is the 4A’s test?
Alertness, Cognitive, attention and presence of acute changes or fluctuating course.
What investigations is considered for precipitating factors?
Urinalysis (infection/hyperglycaemia)
Sputum culture (chest infection)
FBC (infection/anaemia)
Folate/B12 (vitamin deficient)
U+E (AKI, Electrolyte disturbance)
HbA1c (hyperglycaemia)
Calcium (hypercalcaemia or hypocalcaemia)
LFT (hepatic failure)
Inflammatory markers (ESR and CRP) = infection or inflammation
Drug levels (drug toxicity)
TFT (hyper/hypothyroidism)
CXR (pneumonia and HF)
ECG (arrhythmias)
What are the common side effects associated with Anticholinergic burden?
Sedation
Constipation
Urinary retention
Blurred vision
Confusion, delirium, falls (high risk)
What are the acute effects of Anticholinergic burden?
Eyes:
Pupillary dilation
Dry eyes
Blurred vision
Inability to accommodate
Mouth:
Reduced saliva secretion
Oral discomfort
Difficulty eating and swallowing
Dental infections
Malnutrition
Hands:
Reduced ability to sweat
Flushed skin
Hyperthermia
Urinary Tract:
- Hesitancy
- Retention
What are the long-term effects of Anticholinergic burden?
Brain:
Drowsiness
Inability to concentrate
Restlessness
Memory loss
Cognitive Impairment
Delirium
Hallucinations
Falls
Heart:
Tachycardia
Arrhythmias
Exacerbation of Angina
Worsening of HF
GI:
N+V
Constipation
GORD
Gastrointestinal obstruction
Give e.g. of drugs that have an ACB score of 0.
Mirabegron
Domperidone
Give e.g. of drugs that have an ACB score of 1.
Tramadol
Hydrocortisone
Prednisolone
Codeine
Warfarin
Nifedipine
Hydralazine
Ranitidine
Mirtazepine
Give e.g. of drugs that have an ACB score of 2.
Cetirizine
Sertraline
Prochlorperazine
Give e.g. of drugs that have an ACB score of 3.
Fesoterodine
Tolterodine
Darifenacin
Trospium
Oxybutynin
Chlorpheneramine
Promethazine
Amitriptyline
Solifenacin
What are the high risk combinations of NSAIDs?
ACE/ARB + diuretics
Existing renal disease
HF
Warfarin
> 65 yrs without PPI
SSRI
What are the implications of drugs and dehydration?
Withold drugs who are dehydrated due to risk of renal function:
NSAIDs
ACEi/ARB
Diuretics
Metformin
To be restarted when px improves.
What are the key points of constipation?
Adequate fluid intake, diet, movement to reduce risk.
Ispaghula husk preparation shouldn’t be Rx to px with limited mobility
What are the key points of respiratory disease?
Inhaler technique
Vaccination status are updated
What are the key points of Dementia?
Discontinue meds for AD = no response.
Don’t use antipsychotic for challenging behaviour.
If antipsychotics are used, time limited use and reviewed every 3 months with aim to gradually withdraw therapy.
What are the key points of Depression?
Given for min of 6 weeks before tx is considered ineffective.
SSRI has high risk of GI bleeds when co-Rx with NSAIDs/ Prednisolone.
Hyponatraemia (high risk). Report for signs of drowsiness, confusion or convulsion.
What are the key points of Bisphosphonates?
Should take calcium and vitamin D especially frail older people who is housebound.
Therapeutic dose for calcium/vitamin D 800mg/400iu daily.
High risk of GI problems and poor renal function (older px)
Identify and rectify other deficiencies - iron, vB12, VHD and folate.
What are the key points of Antihypertensives?
Start antihypertensives at lower dose and titrate up slowly to reduce postural hypotension. (PH)
Identify PH (sitting and standing BP)
Use ACEi cautiously when treating px with renal impairment and high risk of postural hypotension.
Diuretics (high risk of PH) leasing to falls. Lowest effective dose is Rx.
