Geriatrics Flashcards
common geriatric syndrome
incontinence, confusion, falls( high order function)
what cause reduced organ reserve( reduce ability to response to physiology stress)
- aged related changes
2. disease related changes
difference in elderly
reduced thermoregulation, cognitive reserve, postural instability, cardiac reserve, resp reserve, glucose intolerance, immune responses
pharmacokinetics changes in elderly
hepatic and renal clearance, little change of VD, increased T1/2, slower absorption
drug absorption changes?
delayed gastric emptying, slow transit time, increase PH( gastric congestion reduce absorption of diuretics, and PPI affects VB12 absorption)
drug metabolism changes
reduce hepatic size and hepatic blood flow
drug hepatic-ally metabolised has long T1/2
drug has longer T1/2 in the elderly due to liver changes?
lignocaine, propranolol, warfarin, barbiturates, verapamil, chlormethiazole, quinine
increase bio-availability of drug?
nortiptyline, metoprolol, diazepam
more drug and drug interaction in elderly?
paracetamol and warfarin
PPi and clopidogrel
drug excretion changes?
renal clearance decreased with ageing
renally excreted drug clearance reduced( require small dose), the drug include?
digoxin cephalexin morphine aminoglycosides pethidine lithium
what drug renal excretion enhanced in elderly
diuretics
trimethoprim, ACEI, spironolactone
what is triple whammy acute renal dysfunction
ACEi, NASIDS, and diuretics
how dose decreased albumin affects drug dose
higher free drug concentration( more toxicity esp digoxin) but total concentration to be measured is normal
body compartment
fat content increase, tissue volume stable, intracellular water drop, albumin drop
( shorter, fatter, drier, less muscly)
larger VD OR longer T1/2 for lipid soluble drug
diazepam
water soluble drug increased serum levels
digoxin and paracetamol
decreased muscle, shorter, surface area changed
chemotherapeutics agent prescription based on surface area
phrarmodynamic change
beta receptor down regulated
larger baroreceptor response ( risk of hypotension)
altered cerebral auto regulation( shift in range of MAP regulation)—> increase orthostatic hypotension
more resistant to Hypertension but more sensitive to low BP
why elderly have altered volume regulation( less able to maintain volume)
reduced renin and aldosterone, salt wasting, increase ANP, loss of thirst sense
systole dysfunction in elderly
cardiac muscle becomes stiff, restricted ventricular filing during diastole
ADR of diuretics?
dehydration, hyponatremia, falls
ADR of CCBs
oedema, falls
ADR of statins
muscle pain, rhabdomyolysis, ARF
ADR of amiodorone
thyroid, lung, taste alteration
ADR of verapamil
constipation
class 1 anti- arrhythmic
fall confusion
ADR of NSAIDS
oedema, ARF, CCF
ADR of atypical antipsychotics
stroke and CVD
high use of what drugs in elderly?
Psychotropics, hypnotics, sedatives, laxatives , CVS drug, OTC
effects of poly pharmacy?
increased ADR, drug interaction, noncompliance, complicated drug regimen, confusion and unreliable history
high risk drugs in elderly
anticholinergic drug( confusion , constipation risk0: anti-psychotropics, anti-depressants, antihypertensive ( increase risk of fall): diuretics, digoxin( narrow therapeutics window), narcotics,CNS acting drugs causing sedation ( antihistamine, Benzo, NSADIS, narcotics, stemetil
medications causing falls
central acting, anti-HTN benzo, antidepressant, antipsychotics, anti-HTN, anti-arrhythmic class 1( low dose, short time)
paucipharmacy condition
pain, HF, IHD, OP, AF
common error ( anti-HTN, sedative, anticholinergics)
- Oral hypoglycaemia: Increase mortality and falls
- Metformin in renal impairment
- Cox2 or NSAIDS with known heart or renal failure
- Develop oedema reduce plasma volume–> risk of hypotension and fall ( use compression stocking)
- Prescribe narcotic but not think of constipation ( treat pre-emptively)
-Cox2 or diuretics affect lithium clearance - Use anti-cholinergic drug (e.g. also digoxin) in confusion patient
-Verapamil not in pt with constipation
-Undetected postural hypotension ( change to do postural bp)
Failure to adjust dose in real impairment
diagnostic criteria of major neurocognitive disorder (DSM-V)
- evidence of cognitive decline
- infers with independence in DAL
- not due to delirium
- not explained by another mental disorders
mild cognitive impairment= minor NCD
- subjective cognitive concern or by relatives
- reduce 1-2SD below
- precursor for dementia,( better or the same)
Screening tool for dementia?
MMSE, MOCA, RUDAS, KICA, ACE
aspects of screening tool?
memory, orientation, judgment and problem solving, community affairs, home ad hobbies, personal care
types of dementia?
- alzheimer’s disease
- vascular dementia
- Lewy body dementia
- frontal temporal dementia
- alcohol
how to treat dementia?
advance care planing, risk factors modification
- cholinesterase inhibitor( Donepezil for AD MMSE>10)
- memantine( NMDA receptor, for severe AD mmse10-14)
- SSRI/SNRI
what is BPSD( Behavioural and psychological symptoms of dementia) =responsive behaviours
symptoms of disturbed perception, though content, mood, and behaviours frequently occurs in pt with dementia
behavioural symptoms in BPSD?
vocally disruptive behaviours agitation wandering aggression apathy hoarding sexual disinhibition culturally inappropriate behaviour
psychological symptoms in BPSD
depression anxiety hallucination delusions sleep disturbance
consequence of BPSD
cognitive impairment increased vulnerability stress-or unmet need( sleep, sleep) pain QOL, greater hospitalisation early institutionalisation caregiver burden
how to rate BPSD
Tier 1-7 ( common.y 4-5 in hospitalization)
1st line in mx BPSD
Non-pharmocologically strategies
patient factors contribute to BPSD
1 pre-morbid personality/ psychiatric illness
2 acute medical problem ( UTI, pneumonia, dehydration, constipation)
3 unmet needs( pain, sleep, fear, boredom, loss of control or purpose)
modifiable proximal factors in needs-driven dementia compromised behaviours (NDB)
physiological needs
psychological need
social environmental
physical environment
background factors in NBD
neurocongnitive factors
general health
personal characteristics
demographics
two models to explain BPSD (stress, unaddressed need)
- NDB: needs-driven dementia compromised behaviours
2. PLST: progressively lowered stress threshold
PLST means?
stress threshold lowered
environmental demands exceed a person ability to cope–>impaired function and behavioural symptoms
stressor accumulate during the day and pt can cycle between anxious and impaired function
need reduction of stress through intervention to diminish anxious behaviour and prevent impaired functioning
assessment tool for syndrome of dementia?
CMAI, RAWS-CD cornell depression scale geriatric Depression scale NPI (neuropsychiatric inventory) behave-AD
3 important foci for assessment and evaluate behaviours
antecedent( triggering events)
- behaviours( description of behaviours
- consequence( happen afterwards)
how to treat BPSD
- Address unmet needs (NBD)
- non-pharmacological strategies( address environmental precipitants, physical precipitants, psychological precipitants)
- sedation if extreme distress
- 12 wk anti-psychotropics drug
how to address under-treated pain in dementia
analgesic trails
self report if MMSE>19 using visual analogue an faces scale, simple verbal or numerical scales( recommended)
damage to pain processing networks in dementia
- sensory discriminative
- motivation affective
- behavioural responses
white matter lesion causing chronic neuropathic pain causing allodynia and hyperalgesia
PAINAD scale
1, breathing independent of vocalisation
- negative vocalisation
- facial expression
- body language
- consolability
pain management in dementia
paracetamol, opiates, adjuvants pregabalin
constipation treatment in dementia
bulking forming agents, stool softeners, osmotics, stimulants, enemas
cholinergic toxicity
sedation, confusion, cognitive decline, hallucination
anti psychotics in dementia
start low go slow( review at 12 wk)
- cause akathesia
- C/I for true psychosis, hallucination and delusion
- haloperidol,risperidone, olanzapine, quetiepine
anti psychotics side effect
neuroleptic sensitivity in lewy body dementia
increased risk of stroke and CVS if long term use
increased risk of falls, EPSE, tardive dyskinesia, long QT, stroke and death
respiratory depression , sedation
medications in dementia
anti-psychotics, anticonvulsants, antidepressants, cholineraserase inhibitor
what causes incontinence in general
reduced bladder capacity
atrophy of tissue post menopausal
why micturition is high order function
involves cortex, pons, spinal cord, peripheral autonomic, somatic and sensory afferent innervation of lower urinary tract
contience depends on
integrity of lower urinary tract system
adequate mentation, mobility, motivation and manual dexterity
incontinence a manifestation of
urological disease
neurological disease
gyn disease
why continence happens in elderly
cognitive impairment poor mobility heart failure prostate enlargement oestrogen deficiency increased detrusor involuntary contractions change in ADH secretion so nocturia
incontinence more common in M or F
F
effect of incontinence
Social Effects • social embarrassment because of odor • social withdrawal • stress on carer • Mood changes • early institutionalisation
Physical Effects • Skin excoriation • Skin infection • Pressure ulceration • Urinary Tract Infection • Sleep deprivation • Falls and fracture
types of incontinence
• stress (eg wetting with activity)
• urgency (eg wetting when unable to reach
bathroom in time)
• overflow (eg constant wetness without the urge
to void)
• sphincteric (eg loss of urine with upright posture)
• spasticity of an obstructed bladder overcoming cortical
control
stress incontinence causes
mechanical problem with weak pelvic floor structure, intrinsic sphincter deficiency( when intra-vesicle pressure> urethral pressure)
urge incontinence ( most common) causes
detrusor instability/ over-activity
detrusor hyperreflexia if SC above S2
overflow incontinence
obstrunction duet o BPH,
atonic bladder due to DM, alcoholics, SC below S2
how is urine volume in each incontinence
stress: small
urge: large
overflow: small dribbling
how to treat each incontinence
stress: pelvic floor exercise
urge: alpha agonist. bladder relexant ( anti-cholinergic, TCA, oxybutynin)
stress: remove obstrunction, finisteride, caterization
what drug precipitates each incontinence
urge: diuretics, caffeine, sedative, hypotics, alcohol
overflow: anticholinergic, alpha agonist, nacrotics, CCB
Neuro related cause of incontinence
Lesions above S2 produce detrusor hyperreflexia • Lesions below S2 produce detrusor areflexia
Aggravating Condition of incontinence
Acute medical illness • Rectal loading • Delirium • poor mobility • stroke • arthritis • hip fracture • pneumonia, CCF • Depression • Dementia • Diabetes with hyperglycemia • Obesity • alcohol excess • Drugs
what drug induces incontinence
hypnosedatives–>Excessive sedation
diuretics–>Frequency, urgency
Alpha blockers –>Bladder neck relaxation
anti-depressants–>constipation
Major Tranquillizers–>constipation, confusion
Analgesics –>constipation
Anti-hypertensives–>postural hypotension
NSAID’s–>Frequency, urgency
Functional Incontinence
• Environmental • sedatives/ hypnotics • physical mobility or access problems • drugs inducing diuresis
Neurological causes of incontinence
- dementia
- Stroke
- Muscle weakness
- Parkinson’s Disease
- peripheral neuropathy
- diabetes
- alcohol
- spinal cord injury
- Multiple sclerosis
- Brain Tumour
- Head Injury
- Hydrocephalus
normal pressure hydrocephalus triad
dementia, gait disturbance, and urinary incontinence.
Transient Cause for
UI
Delirium or other confusional state
• Infection
• Atrophic urethritis or vaginitis
• Drugs: diuretics, anticholinergics, opiods, alpha
blockers in women, alpha agonists in men, Ca
channel blockers
• Psychological, severe depression
Detrusor Instability
Commonest cause of incontinence in elderly
• usually assoc with strong sense of urgency
• uninhibited bladder contractions
• if assoc with CNS disease labelled Detrusor hyperreflexia
• may be assoc with impaired bladder contractility in the elderly
Urge Incontinence:
• Detrusor overactivity and uninhibitable bladder
contractions cause leakage
• Patient may describe sudden sensation of urgency
to void then involuntary loss of urine
• Voiding reflex is initiated when bladder volume is
well below capacity
• Associated with frequency due to small voiding
volumes
Drugs contributing to urge
incontinence:
- Diuretics
- Caffeine
- Sedative-hypnotics
- Alcohol
Drugs contributing to overflow
incontinence:
• Anticholinergics Calcium channel blockers • Alpha-adrenergic agonists • Beta-adrenergic blockers Antidepressants • Antipsychotics • Sedative-hypnotics • Antihistamines • CNS depressants • Narcotics • Alcohol
Atonic Bladder
- diabetes
- alcoholic neuropathy
- sacral spinal cord lesions below S2
- drugs blocking bladder contraction
Neurogenic
association with other neurol disease
Either idiopathic or caused by sacral LMN dysfunction
Leads to high post void residuals
• Mainstay of management is self-catheterisation
Stress incontinence: situational involuntary loss of urine with
• lifting, coughing,laughing,running
anatomical problem in stress incontinence
often due to loss of urethrovesical angle with descent of
bladder neck into pelvis
Ix for stress incontinence
• Marshall or Bonney test shows control of stress incontinence
when bladder elevated manually by the examiner
Pelvic floor excercises
for stress incontinence
for urge incontinence
drug for incontinence
• Anticholinergics, including tricyclic
antidepressants, relax the bladder and increase
its capacity
• Elderly people more sensitive to adverse effects
such as blurred vision, dry mouth, GOR,
constipation and confusion
Oxybutynin
Nonselective antimuscarinic agent that relaxes
bladder muscles and has local anaesthetic activity
atonic bladder tx
muscarinic agonist Bethanechol
Outlet obstruction tx
α₁-blocker: prazocin
Stress incontinence drug tx
oestrogens -topical
Two principles of Bladder Retraining
- Frequent voiding to keep the volume of urine in the
bladder low - Retraining of the CNS and pelvic mechanisms to
inhibit detrusor contractions
Kegel exercises
learned skill of muscle
contraction and relaxation that reduces urinary
incontinence by producing urethral closure by
contraction of the periurethral and other pelvic
muscles
why does women live longer( tho higher disability than man)
- biological( oestrogen protective against CVD), T4 Causes immunosuppresion, longevity enhancing genes on X chromosome
- social and behavioural factors
( risk, healthcare, nutrition)
why do women have poorer health status
more susceptible to chronic il, high risk of depression and anxiety, high prevalence of dementia( mitochondria protected against amyloid beta toxicity in younger, education and exercise)
childbirth impact
theory of ageing
complex system with lots of redundancy has higher rate of failure but still higher reserve
what is frailty
a state of increased vulnerability to stressor
reduced physiological reserve and ability to compensate for homeostasis disruption
frailty has increased risk of
disability, institutionalisation and death
3 main approaches to measure frailty
- clinical syndrome and phenotype
- subjective option ( checklist of age ass changes in appearance, combination and mobility)
- multidimensional risk state
frailty using fried phenotype include ( not consider depression , cognition and performance based)
3 or more of
- unintentional weight loss
- self reported exhaustion
- weak grip strength
- slow walking speed
- low physical activity
what measure to you need under subjective option (limited generality and rely on judgement)
clinical frailty scale
multi-dimensional risk states means
measure quantity when various deficits accumulate during the life( person becomes more frail)
what is deficits in deficits accumulation
symptoms, signs, disease, disability, abnormal lab measurement
accumulate with age, ass with AE, do not saturate, cross different domains, using the same item
how to measure deficits accumulation
frailty index
what is frailty index
construct from different numbers and the off variables
define risk of adverse outcomes ( than phenotype definition)
complex system= older person redundancy has been lost, what function fails first
high order function
upright bipedal ambulation
divided thinking
frailty predict what and not what
predict mortality
not predict hospital readmission
CAM sampled DSM 5 for delirium dx
- acute change and fluctuate in mental state and hehaviours
- inattention
- disorganised thinking
- altered consciousness ( not alert)
how to assess depression in elderly
geriatric depression scale( GDS)
Presentation of depression in late lif
§ No-sadness depression:
□ irritable, multiple complaints ( underlying mood problem can cause the presentation)
Treatment of delirium
Neuroleptics
Benzo is only tx if alcohol withdrawa
Delirium aetiology
§ Pre-exposing factors RF:
Old age, Male, lots of medication, severe illness ( UTI, pain, fracture)
Frailty: More fragility, more likely to have delirium
Pre-morbid cognitive impairment or dementia : limited cognitive reserve( new precipitating factors will make them more likely to delirium)
Precipitating factors
Look infection : UTI, chest infection, skin infection, IE, meningitis
Electrolytes : Na( hypoNa know chronic or acute, need to have significant drop acutely ), Ca( hyperCa)
Alcohol: alcohol withdrawal cause DT
Types of delirium
Active psychomotor
hypoactive
mixed
