Geriatric Syndromes Flashcards
What is GS? Examples of GS
GS includes conditions:
1. Prevalent in elderly (Frailty)
2. Multi-organ impairment
3. Negative impact: functional, QOL, mortality
Examples:
- Frailty
- UI
- Falls
- Delirium
- Elder Abuse
Physical Characteristics of Older Adults with Frailty using Fried Frailty Score
Prefrailty: 1-2
Frail: 3 or more
- Weight loss (≥5% of body weight in last year)
- Exhaustion (positive response to questions regarding effort required for activity)
- Weakness (decreased grip strength)
- Slow walking speed (gait speed) (>6 to 7 seconds to walk 15 feet)
- Decreased physical activity
More for clinical research
Frailty Screening Tools (FRAIL/CFS)
FRAIL:
- Fatigue
- Resistance (like climb stairs)
- Ambulation
- Illness (HTN, DM, cancer, chronic lung disease, asthma, MI, CHF, angina, stroke, arthritis, CKD)
- Loss of weight (5%)
1-2: pre frail
3: frail
CFS:
- 1-3: non frail
- 4: pre frail but independent just chronic illness
- 5: frail and cannot do or need help with IADL
- 6: frail and cannot do or need help with BADL
- 7: severe frail and dependent but clinically stable
- 8: very severely frail and dependent but clinically unstable (near end of life)
- 9: terminally ill (<6mths)
Interventions for Frailty
- Physical exercise (resistance exercise)
- Occupational therapy
- Nutritional intake with oral supplementation (milk feeds)
- med s/e: LOA, Anticholinergics (drying and food end up no taste), taste, sedation
- depression
- access to food
- assisted feeding
- chewing or swallowing issues
- unnecessary dietary restriction - Med Review
- DRP affecting PT and OT activities
- Vit D supplementation (if <10ng/L associated with dysfunctional immune system)
Multi domain assessment for falls (AGS,BGS)
- Hx of falls
- Meds
- Gait, balance, mobility
- Visual acuity
- Neurological impairments
- Muscle strength
- HR, Rhythm
- Postural Hypotension
- Feet and footwear
- Env hazards
Fall Risk Increasing Drugs (FRIDS) - Mechanism + Medications
Mechanism:
- Sedation: BZD, sedative medications
- OH
- Anticholinergics: blurred vision, drowsy, delirium, slow reaction time
- Hypoglycemia
Explicit criteria: STOPPFALL
- OH: alpha blockers, central anti-HTN, vasodilator, diuretics
- Opioids
- Psychotropics: AD, FGA/SGA, BZD, Z-hypnotics
- ASM
- Anticholinergics: 1st gen antihistamine, muscle relaxants
Med Review for Older Patients with High Fall Risk
- Explicit criteria
- Implicit: what matters most to patient, risk vs benefits
- Monitor efficacy and s/e
Stratify High, Intermediate, Low Risk for Falls
High
- Fall + risk factors
Intermediate
- Fall + no risk factors + gait ≤ 0.8m/s and TUG > 15s
Low
- No falls
- Fall + no risk factors + gait > 0.8m/s and TUG < 15s
Risk factors:
- injury
- > 2 per year
- loss of consciousness/syncope
- lie down on floor and cannot get up
- frailty
What are the 4 types of dizziness + subtypes that are not dangerous
- Vertigo - objects are spinning
- Presyncopal dizziness - postural
- Dysequilibrium - general feeling of being “off balance,
- Unspecified
Vertigo and pre syncopal — can have overlaps
- BPPV —> experience vertigo but sit down and lie down will not go away but pre syncopal (sit or lie down will go away)
Dizziness (exclude serious cause):
- BPPV: reposition to shake crystals out of semicircular canal
- OH
- Menirere: — overproduction of the fluid in inner ear —> reduce fluid (cut down on sodium intake and thiazide diuretics) and add on vestibular suppressant (e.g: betahistine) for a period of time + gentamicin (hearing loss and refractory meniere’s disease)
- vestibular migraine: treat migraine
- psychogenic: treat psychological cause
- drug induced –> remove drug
- vestibular neuronitis: use steroids to bring down inflammation
TiTraTE approach for Dizziness Evaluation
Timing of the symptoms
Triggers that provoke the symptoms
Targeted Examination
Episodic Triggered Dizziness
Brief episodes of intermittent dizziness lasting seconds to hours
Common triggers: head motion on change of body position (dix hallpike maneuver)
Usually consistent with diagnosis of BPPV
(+): BPPV
(-): OH but verify there is change in postural BP
Episodic Spontaneous Dizziness
Episodes of dizziness that last seconds to days
No trigger –> patient hx establish diagnosis
Common diagnosis considerations:
1. Meniere disease (unilateral hearing loss/sensation of ear fullness)
2. Vestibular migraine: s/s associated with lying down are more likely to be vestibular
3. Psychiatric disorders (anxiety, panic attacks)
Continuous Vestibular Dizziness
Persistent dizziness lasting from days to weeks
Along with N&V, nystagmus, gait instability, head motion intolerance
Triggers: traumatic or toxic exposure (temporal relationship)
Absence of trauma/exposures: likely to be vestibular neuritis or central etiologies
Central causes can also occur with patterns triggered by movement
Continuous Spontaneous Dizziness
HINTS: Head impulse, nystagmus, test of skew
- sometimes do Nystagmus test first —> to see if have central etiology —> most likely stroke if central
Central: Stroke/TIA
Peripheral: Vestibular neuronitis (viral infection) –> use steroid to reduce inflammation but add on suppressants if needed
Types of Vestibular Suppressants
Use only if symptoms > 30mins (drugs are all in beer’s list) –> treshold to stop should be low
Antihistamine: Diphen, Dimen, Meclizine
Phenothiazine: Prochlorperazine, Promethazine
- Additional antidopaminergic efect –> caution in PDD/DLB
Anticholinergic: scopolamine (hyoscine HYDROBROMIDE)
BZD: Lorazepam, Diazepam, Clonazepam
-more sedating –> incr fall risk
- cause cognitive impairment and depression if used long term
Antidopaminergic (N&V associated with dizziness): metoclopramide / ondansetron(PDD)
Ca Channel Antagonist: Cinnarizine / Flunarizine
- S/E: weight gain, antihistaminerigc effect, sedating
- Caution: parkisonism
- High dose for peripheral vascular disease
Histamine analogues: Betahistine (type 3 HRA, partial agonist at H1 and some at H2)
- Caution in asthma (bronchospasm)
- CI; active or hx of PUD
Which GS is a geriatric medical emergency?
Delirium: increased mortality and functional decline
Subtypes of Delirium
Hyperactive:
- Agitation
- Inattention
- Psychosis
Hypoactive:
- Slow response
- Increased sedation
Risk Factors for Delirium
- Age 65s or older
- Cognitive impairment (past or present) and/or dementia
- Current hip fracture
- Severe illness (a clinical condition that is deteriorating or is at risk of deterioration)
Assessment & Diagnosis of Delirium
4AT:
- Alertness,
- AMT4 (DOB, Age, Pace, Year),
- Attention (read mths backwards)
- Acute Changes of Fluctuating Course (acuity)
Critical Care: CAM-ICU and ICDSC instead of 4AT
Diagnosis:
- Physical exam: vitals, hydration, skin condition, potential infection foci
-Hx
- Lab/imaging studies
Common Causes of Delirium
IWATCHDEATH
Infectious
Withdrawal (alcohol, barbituates, BZD)
Acute metabolic disorder
Trauma
CNS
Hypoxia
Deficiencies
Endocrine
Acute vascular
Toxin, substance use, meds
Heavy metals
Drugs that increase delirium
Strong anticholinergics –> stop if newly started and avoid unless diphen used for severe allergies
BZD –> not 1st line for insomnia but do not cease abruptly esp if use for seizure, rem sleep behaviour and anxiety
Z-hypnotics –> not 1st line for insomnia
Opioids esp pethidine –> paracet first but if need opioids start low go slow (avoid pethidine), regular bowel regimen
H2RA –> PPI preferred or famotidine at renal adjusted dose
antimicrobials (quinolones, cefepime)
Corticosteroids –> steroid effect and change pt behaviour
Dopamine agonist –> delirium and impulse control
Herbs
Propantheline
Hypoglycemics
ASM
ADs
CV drugs –> digoxin
Muscle relaxants
Other psychoactive agents: Li
Non pharm mgmt of delirium
Prevention
- Sensory function optimisation
- Hydration/nutrition
- Bowel movement/urination
- Early mobility
- Pain control
- Med review
- Social interaction
- Reorientation with clock, calendar, lighting
- Conducive env
- Promote good sleep
- Address infection/hypoxia
Pharmacotherapy for Agitation in Delirium
Last line resort if pt is harming themselves or posing threat (hyperactive delirium)
- 1st Gen Antipsychotic
- SC/IM/PO: Haloperidol 0.3 - 1mg BD (max: 5mg/day for non ICU)
- CI: Prolonged QTC, Parkinsonism - 2nd Gen Antipsychotic
- PO Quet 6.25-12.5mg BD (max: 100mg/day) –> PD friendly
- PO ORS Olanzapine 1.25-2.5mg (max:10mg/day) –> safest QTc wise - BZD
- 1st line for alcohol/benzo withdrawal
- alternative if FGA/SGA unsafe
- PO/IV/SC: lorazepam 0.5-1mg
Urinary Continence & Physiology
Pre-requisites:
- Normal functioning LUT
- Adequate physical and cognitive function to use toilet
Physiology of LUT:
- SNS activated, PNS blocked: bladder relax and tightening ot the bladder outlet (beta-3 and a-1 adrenergic receptor activated)
- SNS blocked, PNS activated: bladder contract (m3 receptor activated)
