Geriatric Syndromes Flashcards
xBriefly state the Clinical Frailty Scale (CFS) 5-8
CFS 5- IADL
CFS 6- ADL
CFS 7- Completely dependent for personal care, but stable and not at risk of dying
CFS 8- Completely dependent for personal care, but approaching end of life
CFS 9- Life expectancy <6 months
What are the 3 interventions to slow progression of frailty?
- Physical exercise, Occupational Therapy
- Nutritional intake
- Medication review
When do we give vestibular suppressants to elderly for dizziness?
If SSx >30 mins and non-pharm measures are not helpful
Name all the 7 vestibular suppressants
- First gen antihistamines
- Scopolamine (anticholinergic)
- BZDs
- Prochlorperazine, promethazine
- Metoclopramide
- Cinnarizine (caution in PD)
- Betahistine (caution in asthmatic pts; C/I in pt with active/ Hx of PUD)
Name the risk factors for delirium (10)
- > 65 y/o
- Hx of cognitive impairment (eg delirium) and/ or dementia
- Recent surgery
- Current hip fracture
- Hypoglycemia
- Hypoxia
- Severe illness
- Infection
- Stroke
- Metabolic disorders
What are the I-WATCH-DEATH causes of delirium?
Infection (UTI, pneumonia)
Withdrawal (BZDs, alcohols, barbiturates)
Acute metabolic disorder (hep/ renal imp, electrolyte balance)
Trauma
CNS pathology (PD, seizures)
Hypoxia
Deficiencies (vit B12, folic acid, thiamine)
Endocrinopathies (thyroid, glucose)
Acute vascular
Toxic substances
Heavy metals
What are the questions you need to ask yourself when evaluating the cause of delirium?
- Any recent drug withdrawal? (discontinuation of BZDs, alcohol, barbiturates, muscle relaxants, high dose SSRIs)
- Anticholinergic drug use
- Is pain control effective?
- Any other agents with CNS effect?
- Any drug-related causes of delirium?
Non-pharm Tx for delirium?
Orientation:
- Visual & hearing aids
- Encourage communication, reorient pt repetitively
- Familiar objects from pt’s home in hosp room
- Consistency in nursing staff
- Television in the day with daily news
- Non-verbal music
Environment:
- Sleep hygiene: lights off at night, on during day, sleep aids
- Control excess noise (staff, equipment, visitors) at night
- Ambulate or mobilize pt early and often
Clinical parameters:
- Maintain SBP > 90mmHg
- Maintain O2 saturation > 90%
- Tx underlying metabolic derangements & infections
When do we resort to pharmaco-Tx for delirium?
What is the pharmacoTx and doses?
When pt’s behaviours pose a threat to themselves/ others
Antipsychotics
(1) Haloperidol 0.3-1mg BD, up to 5mg/day
(2) Quetiapine 6.25-12.5mg BD, up to 100mg/day
(3) Olanzapine 1.25-12.5mg, up to 10mg/day
BZDs
(1) Lorazepam 0.5-1mg
(1st line for alcohol/ BZD withdrawal, alternative if antipsychotic not safe)
What are all the DDIs a/w Haloperidol? (4)
- Haloperidol as a CYP2D6 inhibitor → prevent metabolism and ↓ effect of prodrugs codeine & tramadol
- Haloperidol as a CYP2D6 substrate → conc. ↑ due to CYP2D6 inhibitors (eg bupropion, fluoxetine, paroxetine, duloxetine, sertraline)
- Haloperidol as a CYP1A2 substrate → ciprofloxacin which is a CYP1A2 inhibitor ↑ its conc.
- Haloperidol as a CYP3A4 substrate → CYP3A4 inhibitors (e.g. diltiazem, verapamil)↑ conc.
What is the DDI a/w quetiapine? (1)
Quetiapine as a CYP3A4 substrate → CYP3A4 inhibitors (e.g. diltiazem, verapamil)↑ conc.
What are the 5 types of UI?
- Stress
- Urge
- Mixed
- Overflow
- Functional
What is stress UI?
What are the drug-induced cases? (2)
Stress UI (sphincter weakness)
- SSx with coughing, sneezing, or exercise, no nocturia
- Voiding diary: small volume leakage (5-10mL) with activity
- Cough stress test: leakage coincides with coughing
PVR urine < 50mL
Drug-induced causes:
- alpha blockers (anti-HTN): dec urethral sphincter tone
- ACEi which may cause dry cough
Non-pharmacoTx and pharmacoTx for stress UI?
What are the counselling points regarding the pharmacoTx?
Non-pharmacoTx: Kegel’s exercise
Pharmaco-Tx:
1. Topical estrogen (may take up to 3 mths for action onset, need counselling)
2. Duloxetine (recc if pt also have MDD, but avoid if CrCl <30ml/min)
3. Surgery/ devices
What is urge UI? What are the drug-induced causes? (1)
- SSx of urgency
- Voiding diary: variable volume loss, frequency and nocturia
- Cough stress test: may show delayed leakage after cough
PVR urine < 50mL
Drug-induced causes: diuretics
Non-pharmacoTx (1) and pharmacoTx (6) for urge UI?
What are the counselling points regarding the pharmacoTx?
Non-pharmacoTx: Kegel’s exercise
PharmacoTx:
1. Treat BPH in men with a1 blocker, 5ARI
2. Topical estrogen (counsel on delayed dose)
3. b3-adrenergic receptor agonist (mirabegron)
4. Antimuscarinic agents (m3-selective agents preferred like solifenacin) BUT note anticholinergic SEs
5. Botulinum toxin
6. Sacral nerve stimulation
What is overflow UI?
Drug-induced causes? (6) [SASACO]
Due to bladder outlet obstruction OR bladder underactivity
- No SSx with physical activity or urgency
- Voiding diary: varies
- Cough stress test: No leakage
PVR urine > 200mL
Drug causes:
- CCB
- Opioids
- Skeletal muscle relaxants
- Antidepressants, anti-PD agents
- Sedatives/ hypnotics
- Antihistamines/ anticholinergicss
PharmacoTx for overflow UI?
Bladder outlet obstruction (2)
Bladder underactivity (2)
Bladder outlet obstruction:
- Men: usually BPH, treat accordingly (a1-blocker, 5ARI)
- Women: usually structural, see specialist + bowel habit optimisation
Bladder underactivity:
- Men: bethanechol may help in pts with spinal cord injury, clean intermittent catheterisation (CIC)
- Women: CIC +/- bethanechol
What is functional UI?
Drug-induced causes? (1)
Person unable to reach the bathroom in time to void, although urinary system functioning normally
- SSx may include cognitive impairment and degree of immobility
- Voiding diary: varies
- Cough stress test: No leakage
PVR urine > 200mL
Drug-causes: sedatives/ hypnotics
Non-pharmacoTx for UI? (6)
- Weight loss, normal bowel habit, reduce bladder irritants, water hygiene (don’t drink too much water past a certain time; 5pm, 6pm; don’t restrict overall fluid intake due to risk of dehydration)
- Bladder retraining
- Women: Kegel’s pelvic floor muscle exercise (stress and urge UI)
- Timed voiding [for pts who are functionally dependent]
- Continent products
- Devices
(Women: tampons, pessaries
Men: penile clamps, condom catheters)
What are the drug changes we need to consider to make to address UI?
Diuretics: consider discontinuing (otherwise, change dose to mid-late afternoon to prevent nocturnal diuresis)
ACEi -> ARB
Anticholinergics, sedatives, hypnotics: discontinue or dec dose if possible
