Geris Flashcards
Define Delirium
State of confusion that develops quickly and fluctuates in intensity
What are the features of delirium?
Acute onset
Fluctuating course
Inattention
Altered level of consciousness
Usually reversible
Associated w/ underlying medical cause
What are the risk factors for delirium?
Dementia (x5)
Multiple comorbidities
Physical frailty
Older age
Sensory impairment
What are some precipitating factors of delirium?
Drug initiation
Medical illness
Systemic infection
Metabolic derangement
Surgery
Pain
Stroke
Seizures
Systemic organ failure
What are the different types of delirium?
Hyperactive
Mixed
Hypoactive
What assessments can be used for delirium?
4-AT
CAM
AMT
What are the 1st line Ix?
BLOODS - WBC + CRP (infection) / U&Es / LFTs / Glucose / TFTs
CXR
Urinalysis
ECG
What are the 2nd line Ix?
BLOODS - serum calcium, B12 and folate
ABG
Blood / sputum culture
CT / MRI head
EEG
Toxicology screen
Bladder scan - retention
LP
What are some causes of delirium?
Infection
Drug use - w/drawal / new meds
reduced sensory input - blind / deaf / changing environment
Intercranial problems - stroke / seizures / hemorrhage
Electrolyte imbalances
Constipation
Urinary retention
Heart problems - MI / arrhythmias
How is delirium managed?
Treat underlying cause
- Dug review doe poly-pharmacy
- Analgesia
- Laxatives
- Abx for infection
- Correct electrolytes
Manage the environment
- Involve family
- Soft lighting
- Clocks and calendars
- Sleep hygiene
- Correct sensory impairment eg glasses / hearing aids
- Keep mobile and active
- Avoid multiple rooms + different staff
- Minimise provocation eg noise)
What should you monitor in delirium?
Vital signs
Bowels
Nutrition
Hydration
Pressure areas
Electrolytes
Response to abx
When do you use drugs in delirium?
What are the indications for drugs?
In tx failure
rapid tranquilsation of agitated pts where there is imminent risk of harm
short term control of distress
What drugs do you use?
Haloperidol
Lorezapam (given in Parkinson’s / Lewy body dementia due to the EPSEs of haloperidol)
What percentage of delirium patients never recover?
20%
What are the consequences of falls?
Loss of confidence
Serious injury
Fragility fracture
Complications from long lie
What are some environmental (extrinsic RFs) causes of falls in the elderly?
Polypharmacy
Bifocals
Walking aids
Home hazards - Loose rugs / Pets / Furniture etc
Unstable footwear
What are some intrinsic risk factors for falls?
Female
Neurological disease
Cognitive decline
Muscle weakness
What are some power / balance cause of falls in elderly people?
Inactivity leading to – muscle weakness
Dizziness/loss of balance/loss of proprioception (vertigo)
Pain/MS – osteoarthritis
Previous fall leading to decreased confidence
What are some cardiovascular causes of falls in elderly people?
Vasovagal syncope (fainting)
Situational syncope – e.g. micturition (old men, night time)
Postural hypotension
Myocardial infarction
Arrhythmia
Dehydration/shock
What are some neurological causes of falls in elderly people?
Stroke
PD
Gait disturbance
Visual impairment
Peripheral neuropathy
Vertigo
Myopathy e.g. statin or steroid myopathy
What are some medications that increase risk of falls in elderly people?
Beznodiazepines - sedative so impair coordination
Diuretics
Anti-hypertensives – ACEi, CCB, Beta blockers
Antidepressants
Antipsychotics
Polypharmacy
What are some other causes of falls in elderly people?
Infection/sepsis
Delirium / Dementia
Hypoglycaemia
Incontinence
Alcohol – intoxication, neuropathy, Korsakoff’s/Wernicke’s
Falls are the leading cause of _____ and are associated with increased ________
Falls are the leading cause of fractures and are associated with increased mortality
Falls lead to a loss of ________ + __________
Falls lead to a loss of confidence + independence
Define frailty
State of increased vulnerability resulting from ageing associated decline in functional reserve
Across multiple physiological systems
Resulting in compromised ability to cope with everyday or acute stressors
What is the impact of frailty on elderly people and how does it change how they need to be cared for?
Different type of doctor – geriatricians are experts in frailty
Poor functional reserve – trivial insult to a younger person has a large impact on an older person
Failure to integrate responses in the face of stress
Vulnerable to decompensation when faced with illness, drug side effects and metabolic disturbance
Frailty correlates with increasing ___, _____ + _____
Frailty correlates with increasing age, disease + disability
What is the Frailty Phenotype as defined by the Fried model?
The presence of 3 or more of:
- Unintentional wt loss
- Weakness evidenced by poor grip strength
- Self reported exhaustion
- Slow walking speed
- Low level of physical activity
What are individuals w/ one or 2 characteristics classed as?
Pre-frail
What is phenotypic frailty predictive of?
A higher risk of falls, hospitalisation, disability + death
What is the frailty index?
A count of health deficits
IE - the more deficits the frailer the person and the greater the risk of deterioration and death
What is the best known frailty index?
Rockwood Frailty Index
What counts as a deficit in the frailty index?
How are they weighed?
Symptoms / Signs / Diseases / Disabilities / Ix findings
Each one is weighed the same
How is the Ratio calculated? (frailty index)
Number or deficits / Total number of deficits considered
What is the limitation of the frailty index?
Detailed measurements and collation of pt data is needed.
What are physiological markers of frailty?
Increased inflammation - EG CRP / IL6 / Factor VIII + Fibrinogen
Elevated insulin and glucose levels in fasting state
Low albumin
Raised D dimer and alpha anti-trypsin
Low Vit D levels
What are the different categories on the Frailty index?
Very fit
Well
Managing well
Vulnerable
Mildly frail
Moderately frail
Severely frail
Very seriously frail
Terminally ill
What does Very Fit mean on the Frailty index?
Very fit = <0.09 – robust, active, energetic, motivated
What does Well mean on the Frailty index?
Well – no active disease and exercise occasionally
What does Managing Well mean on the frailty index?
Managing well – medical problems are well controlled but not regularly active beyond walking
What does Vulnerable mean on the frailty index?
Vulnerable – symptoms limit activities, tired during day
What does Mildly Frail mean on the frailty index?
Mildly frail = 0.27 – need help for high order ADLs e.g. finance
What does Moderately Frail mean on the frailty index?
Moderately frail – need help with house keeping and bathing
What does Severely Frail mean on the frailty index?
Severely frail = 0.42 – completely dependent for personal care, not at high risk of dying
What does Very Seriously Frail mean on the frailty index?
Very seriously frail – completely dependent, approaching end of life
What does Terminally Ill mean on the frailty index?
Terminally ill – life expectancy <6 months but may not be evidently frail
What are some interventions for frailty?
Physical activity (Exercises focusing on strength and balance)
Protein-calorie supplementation
Vit D supplements
Minimisation of polypharmacy to reduce risk of frailty
