Geriatric Syndromes Flashcards
Define geriatric syndromes
Common health conditions in older adults that have multifactorial causes and do not fit into discrete disease categories
What are the implications of geriatric syndromes?
Predispose older adults to poor health outcomes, ↓ function and quality of life
What are some examples of geriatric syndromes?
Falls
Frailty
Cognitive impairment
Delirium
Urinary Incontinence
Iatrogenesis (including polypharmacy)
WHO Definition of Falls
An event which results in a person coming to rest inadvertently on the ground or other lower level
Best preictor of falls in geriatrics. Risk of falls?
Best predictor of future falls = having a previous fall
Risk of falls ↑ with age
What is the best predictor of future falls?
Best predictor of future falls = having a previous fall
Is there a difference in risk of falls between the sexes in geriatrics?
Females are at an increased risk compared to males
What are the implications of falls regarding geriatric patients health and quality of life?
Most common mechanism of injury causing death in older adults
#1 cause of traumatic hospitalizations/non-fatal injuries in older adults
5-10% of falls result in serious injury:
Bone fractures
Head injury
Laceration
Account for 95% of hip fractures in older adults
20% of those who suffer a hip fracture die within a year
Another 20% will never live independently again
What is a syndrome that may develop from increased fall risk in geriatric patients? Consequences?
Fear of falling syndrome
When individuals restrict their activities due to the fear of falling
Activity avoidance –> deconditioning –> ↑ fall risk
Also leads to social isolation, low mood, decreased quality of life (QoL)
What are some risk factors for falls?
Medical/Biological
Pharmacological
Environmental
Social/Economic
Behavioural
What are some medical and biological risk factors for falls?
Deconditioning
–> ↓ muscle strength, ↓ balance, poor gait pattern
Vision impairment
Hearing Impairment
Orthostatic hypotension
Heart rate or rhythm abnormalities
Dizziness/syncope
Pain
Neuropathy
What are some medical conditions that may contribute to falls?
Medical conditions
–> Dementia, Parkinson’s disease, previous strokes, depression, diabetes
Risk of Falls and Medical Conditions RAte
–> Risk of falling is at least 2x higher in older adults with ≥ 4 chronic conditions1
What are some environmental risk factors for falls?
Home hazards
Clutter, pets, throw rugs, lighting, lack of handrails or other supports
Community hazards
Snow/ice, uneven pavement, curbs, potholes, slippery floors, obstacles or tripping hazards
Lack of familiarity with surroundings
What are some social/economic risk factors for falls?
Social isolation
Living alone
Lack of community or family supports
Lack of transportation
Low income
What is the risk of social isolation?
Social isolation has the same mortality and risk factors as smoking a pack of cigarettes a day.
What are some behavioural risk factors for falls?
Improper footwear choices
Rushing
Impulsivity/risk-taking
Fear of falling/activity restriction
(Lack of) use of assistive devices
Alcohol use
What are some of the ways that drugs may contribute to falls?
Drugs can contribute to falls in many ways:
1) Cognitive changes (anticholinergic drugs, Z drugs)
2) Movement disorders (secondary Parkinsonism) –> Anti-psychotics (FGA higher risk), metoclopramide (DA blocking effect)
3) Gait and balance changes –> BZD’s, Anti-convulsants
4) Muscles weakness
5) Dizziness, drowsiness
6) Vision changes –> Eye ointments, anticholinergics
Are drugs contribution to falls a direct consequence? WHy or Why not? Examples?
May also contribute indirectly:
Example: diuretic –> urinary urgency/frequency –> fall rushing to the bathroom
Polypharmacy (4+ concurrent medications) = ↑ fall risk
Absence of appropriate drug therapy may also ↑ fall risk indirectly
Example: lack of appropriate treatment for pain or COPD –> ↓ activity tolerance –> ↑ fall risk
Why should medications be evaluated in the context of falls?
Medication are an important, potentially modifiable risk factor for falls
Numerous fall-risk increasing drugs (FRIDs)
–> Try to minimize exposure as much as possible
Studies have shown withdrawal of FRIDs reduces fall risk by 50%1
What are some drug classes that increase one’s fall risk?
BZD
Anti-psychotics
Antidepresants
Anticholinergic Medications
CV Medications
Hypoglycemics
Anti-convulsants
Opiods
BZD Reasons for Increasing Fall Risk
Muscle weakness, ↓ balance and coordination
Drowsiness, dizziness
Cognitive changes/confusion
Anti-psychotic Examples and Reason for Increasing Fall Risk
Typical (e.g., haloperidol, chlorpromazine)
Atypical (e.g., risperidone, quetiapine, olanzapine)
Atypicals –> orthostatic hypotension
Anti-depressants and fall risk examples
SSRIs
SNRIs
TCAs
Trazodone
Others (“any antidepressant”)
SSRI’s cause the same risk of falls as TCA”s
What is a major consideration for BZD’s, AP’s and AD’s fall risk increase?
Require a slow, gradual taper!
Anticholinergic Medication Risk of Falls
Effects of anticholinergic medications are cumulative
How can a pharmacist analyze fall-risk increasing medications?
Anticholinergic Burden Scale
Reducing anticholinergic burden
CV Medications and Fall Risk Example and Reason
Digoxin, Type I antiarrhythmic medication (e.g., procainamide, disopyramide) associated with ↑ risk
Data for antihypertensive medications is mixed
–> Monitoring BP, including postural vitals is important
–> Must weigh benefits of BP treatment with potential risks and adjust accordingly
Hypoglycemics and Fall Risk Example and Reason
Hypoglycemia ↑↑ fall risk in older adults
Insulin has also been associated with ↑ fall risk
–> Hypoglycemia
–> Insulin is usually used in individuals with more advanced diabetes – may also have neuropathy, retinopathy which further compound fall risk
Other diabetes medications that cause hypoglycemia also have the potential to ↑ fall risk
Sulfonureas –> Do not sulfonureas as cause hypoglycemia
Repaglinide –> Insulin secretion effect; contributes to hypoglycemia and falls
Anticonvulsants and fall risk examples and reason
Most data on ↑ fall risk with phenytoin, carbamazepine, and barbiturates
No comparative studies with newer anticonvulsants (e.g., lamotrigine, levetiracetam, pregabalin)
Meta-analyses analyzing anticonvulsants – any exposure ↑ risk
Opiods and Fall Risks Evidence
Studies show mixed results
Data is conflicting so it’s important to weigh the risk vs benefit of opioid use for each patient (e.g., pain control vs fall risk)
What is a way to assess fall risk? What is a major consideration in this assesment?
Multifactorial falls risk assessment recommended for:
Individuals that have fallen 2+ times in the past 12 months
After an acute fall
Gait or balance difficulties
Falls generally have multifactorial causes – interventions should be multifactorial as well
What are some examples of multifactorial interventions for fall prevention ?
Vitamin D
Evidence is mixed; some studies and meta-analyses have shown ↓ fall risk with vitamin D supplementation (particularly in those with vitamin D levels)
Low-risk, low-cost
Fracture Prevention
Will not help prevent falls, but assessment and treatment for osteoporosis may help decrease fractures from falls
Particularly hip fractures
Define frailty
Medical syndrome that increases an individual’s vulnerability to loss of independence and/or death
How can frailty be characterized? Who is it more likely in?
Characterized by decreased strength, endurance and functional reserves –>
↑ vulnerability to stressors
Associated with ↑ age, ↑ number of medical comorbidities, women > men,
↓ socioeconomic status
Is there a specific tool to identify frailty?
No universally-agreed-upon tool to identify who is “frail”
What is the best predictor of frailty?
Best single-item predictor for frailty = gait speed
Predicts functional decline and mortality
Gait speed < 0.8 m/s (usually measured over 20m) correlates with frailty
Describe the relationship between frailty and medications
Medication adverse effects may contribute to frailty
Medication –> nausea/GI upset –> ↓ appetite and weight loss –> Compounding muscle loss
Frailty also associated with ↑ risk of adverse drug reactions
–> Particularly for those on 5+ medications!
How can fralty be managed?
Multifactorial causes –> multifactorial approaches
Comprehensive geriatric assessment
Exercise programs
Aerobic, balance, and strength training
Optimize health status
Treat underlying conditions as per goals of care
Streamline medications as much as possible
Describe number of medications and some specific implications in:
1) falls
2) cognitive imapirment
3) functional status
4). nutrition
Anti[psychotic Syndromes
Cogntive imapirment
Falls
UI
Depression
Antidepressnat Syndromes
Delirium
Coigntive IMpairment
Falls
Unintentional weight Loss/Appetite Loss
UI
Anti-epileptics Syndromes
Delirium
Coigntive IMpairment
Falls
Unintentional weight Loss/Appetite Loss
UI
Depression
BZD Syndro,mes
Delirium
Cognitiove IMpairment
Falls
Hypnotic Syndromes
Delirium
Cognitiove IMpairment
Falls
Opiod Syndropmes
Delirium
Cognitivbe iMpairment
Falls
UI
Depressionm
Anti-HTN Syndromes
Falls
UI
Depression
Anti-arrthymic Sybndromes
Delirium
Cognitiove IMpairment
Falls
Antidiabetes Syndromes
Falls
Unintentional Weight Loss/Appetite Loss
Anticholinergic Syndromes
Delirium
Cogntive IMopairment
Falls
UI
