1
Q
what is geriatric syndrome
A
- prevalent in elderly pts (eg frail)
- impairment in multiple organ system
- neg impact on FUNCTIONAL, QOL, MORTALITY
2
Q
frailty definition
A
- Increases vulnerability to stressors (acute illness, surgery etc) lead to poorer health outcomes
- Age is no longer considered a defining characteristics.
- Youth can be frail too
- Is a syndrome: group of s&sx that aggregate in hierarchical order, may trigger a cascade of alterations across other systems.
3
Q
physical characteristics (Fried Frailty Tool)
clinical use (need pt participation & specialised equip)
A
- Weak (poor hand grip strength, difficulty walking up 1 flight staris)
- Slow walking (>6-7s for 10 feet)
- Low physical activity
- Weight loss (≥5% weight loss in last year)
- Exhaustion (fatigued when performing daily activities)
□ Pre-frail: 1-2
□ Frail: >3
4
Q
frailty associated with
A
- Longer hosp stay, more post-op complication, greater likelihood of discharge institutionalization (if require surgery)
- Associated with other comorb and conditions
□ Polypharmacy
□ Osteoarthritis
□ Analgesic use
□ Heart failure and CVD
□ Risk of falling
□ Depressive sx
□ Cognitive dysfunction
5
Q
hypothesis model of frailty and adverse health outcomes
A
triggers:
- oxidative stress, mitochondrial dysfunction, DNA damage, cell senescence
- gene variation + environ
- INFLAM DISEASE
–> inflam, neuroendocrine dysregulation
Markers of frailty:
- (incr) CRP, IL-6, Cortisol
- (decr) IGF-1 insulin growth factor, DHEA-S dehydroepiandrosterone sulfate
—> clinical frailty (slow, weak, weight loss, low activity, fatigue)
6
Q
clinical manifestation of frailty (that leads to clinical frailty sx)
A
Negative energy balance
Sarcopenia
immune function decline
cognitive impairment
incr clotting
decr glucose metabolism
7
Q
clinical frailty scale (SG)
1-9
A
CFS 4 = pre-frail (mild frailty), functionally Independent, but symptoms of chronic illnesses are affecting activity tolerance
CFS 5 = Need assistance for all or some of the iADLs
CFS 6 = Need assistance for all outside activities and some of the bADLs (e.g. dressing ,bathing)
CFS 7 = Clinically stable but FULLY dependent for personal care
CFS 8 = Nearing end of life and FULLY dependent for personal care
CFS 9 = Terminally ill (<6 months) but not severely frail
8
Q
FRAIL scale (US)
A
fatigue
resistance (climb 1 flight of stairs)
ambulation (walk 80m)
illness (HTN, DM, cancer, chronic lung disease, asthma, HA, CHF, angina, stroke, arthritis, CKD) > 5 =1point
loss of weight (>5% in past year)
Pre-frail: 1-2
Frail: >3
9
Q
management of frailty
A
- establish goals ( assessing indiv pt physical, psychological, social and environmental needs)
- physical exercise/ OT
- nutritional intake
- med review
10
Q
possible cuases of low nutritional intake in frail pts
A
- Medication side effects
○ Suppress appetite, anticholinergics (dry mouth, decr saliva prod – affect swallowing and taste), sense of taste, sedation - Depression
- Access to food
○ Financial, physical restriction - Require assistance
- Chewing/ swallowing
○ Consistency of food - Unnecessary dietary restriction
○ Not impt to restrict for frail pts, need energy
11
Q
med review for frail pts
A
- DRPs affecting ability to take part in PT/OT and adequate nutritional intake
- Vit D suppl (bone, muscle, immune system)
- Explicit criterias (BEERS, STOPP)
12
Q
fall definition
A
At unexpected event in which a person comes to rest on the ground, floor or a lower surface
- Mostly multifactorial cases
- Adverse patient outcomes
- Pain, fracture, traumatic brain injury
- Concern about falling (vs fear of falling)
- Reduced QOL/ functional dependency
13
Q
routine checkup with HCP
3 key qns
A
1) fall past 12mnth
2) Do you feel steady when you stand/ walk?
3) Any concerns of falling?
yes to any –> further evaluation
14
Q
when presenting to HCP w/ fall or related injury/ Yes to key qn
A
assess fall severity
- injury
- ≥2 fall last yr
- frailty
- lie on floor unable to get up
- loss of consciousness/ suscepted syncope
if yes: HIGH RISK
15
Q
not high risk –> refer for gait, balance test
A
- Test:
□ Timed up and go (>15s)
□ gait speed ≤ 0.8m/s
□ Berg balance scale (retrieve object from floor)
□ Performance-orientated mobility assessment - Recommended for:
□ Persons who report single fall in past 12mnths (early detection of any deficits) to identify indiv who may need multifactorial assessment*
yes = intermediate risk
16
Q
low fall risk intervention
A
educate on fall prevention
advise on physical activity exercise
f/u 1yr
17
Q
intermediate fall risk
A
2nd prevention to improve MAJOR RISK FACTOR
* tailored exercise: balance, gait, strength
* educate on fall prevention
f/u 1yr
18
Q
high fall risk
A
2nd prevention and treatment
- multifactorial fall risk assessment
- individualised tailored interventiion…
f/u 30-90d
19
Q
multifactorial fall risk assessment
A
- Medication history
○ Acute, chronic medical prob (osteoporosis/ UI/ CVD) - Disease history
○ Cardiovascular disorder
○ Contributing disease/ atypical disease presentation
○ Depressive disorders - Mobility
○ Balance, gait, walking air/ footwear/ foot prob
○ muscle strength - Neurological function (cognitive function, lower extremity peri nerves, proprioception, reflex, test of cortical, extrapyramidal and cerebellar function)
○ Cognition, Delirium, Behaviour - Sensory function
○ Dizzy, vision, hearing - Activities of daily living
○ Functional ability - Autonomic function
○ orthostatic hypotension
○ Urinary incontinence - Nutrition history
○ Nutritional status
○ Vit D - Functional assessment
○ Indiv perceived functional ability and fear related to falling
○ Any concerns/ activities that contribute to deconditioning
○ ADL skills (use of adaptive equip, mobility aids) - Environment
20
Q
intrinsic factors for fall risk
A
lower extremity weakness, previous fall, gait and balance, visual impair, dep, functional and cog impairment, dizzy, low BMI, UI, OH, female, >80yo
21
Q
extrinsic factors for fall risk
A
polypharm, psychotropic meds, environ hazard, lack safety equip
22
Q
Identify Falls Risk Increasing Drugs (FRIDS) by mechanism:
A
Sedation
Orthostatic hypotension
Anticholinergics – slow down reaction time, drowsy, blurred vision, confusion
Hypoglycemia
23
Q
explicit criteria for FRIDS: STOPPFall drug classes
A
- OH induction: a-blockers, central antihypertensives, vasodilators, diuretics
- Opioids
- Psychotropics: antidep, antipsychotics, BZP/ Z-drugs
- Anticonvulsants
- Anticholinergics: 1st gen antihistamines, muscle relaxants
24
Q
dizziness definition
A
Dizziness important geriatric syndrome as it can result in
* Potentially serious etiologies (stroke, MI, traumatic brain injury) * Incr risk of fall * Incr risk of deconditioning (period of inactivity, reduced muscle strength) * Reduced QOL
25
4 types of dizziness
* Vertigo
○ Object spinning/ they are moving
○ Benign paroxysmal positional vertigo
* Pre-syncopal dizziness
○ Change in body posture pOH (dizziness goes away when u sit/ lie)
* Disequilibrium
○ Central etiologies
* Unspecified dizziness
○ Older adults can have more than 1 type of dizziness
○ Not enough to determine cause
26
differential dx of dizziness and vertigo
peripheral: BPPV, vestibular neuritis, Meniere disease, otosclerosis
central causes: vestibular migraine, CVB, meningiomas
others: psych, med induced, CVS/ metabolic/ OH
20% med related
27
TiTraTe approach to evaluate dizziness
Ti : Timing -- Continuous or Episodic (Onset, Freq, Duration)
Tr : Triggers -- head movement, posture change, spontaneous, intermittent
TE: Targeted Examination
28
Episodic Triggered: Dix-Hallpike maneuver
Positive: Benign Paroxysmal Positional Vertigo
Negativedap-like maneuver trigger: Orthostatic Hypotension
29
Episodic Spontaneous: further history
Unilateral hearing loss/sensation of ear fullness: Meniere Disease
Migraine Headache: Vestibular Migraine
Psychiatric symptoms: Panic attack, etc
30
Continuous vestibular
Trauma/toxin (drugs)
31
Spontaneous: HINTS Exam [Head Impulse/Nystagmus/Test of Skew]
Central: Stroke/TIA
Peripheral: Vestibular neuronitis
32
main 7 types of dizziness
after exlcuding serious and dangerous causes
- Benign paroxysmal positional vertigo (crystals loose)
- Orthostatic hypotension (med, dehydrate, neurogenic)
- Meniere's Disease (fluid in inner ear)
- Vestibular migraine
- Psychogenic dizziness (mood disorder)
- Drug-induced dizziness
- Vestibular neuronitis (inflammation)
33
vestibular suppressants indicated for __
* only if vestibular symptoms are prolonged (>30 mins) PO drugs take time to onset
* Almost all are Beers List drugs. Timely review and assess risk-benefit. Threshold to stop should be low
34
med classes for dizziness
* Strong anticholinergic effects
○ Antihistamine (1st gen): diphenhydramine/ dimenhydrinate/ meclizine
○ Phenothiazines: prochlorperazine/ promethazine
○ Anticholinergics: scopolamine (hyoscine hydrobromide)
* Benzodiazepine
○ Lorazepam/ diazepam/ clonazepam
* Antidopaminergic (anti-emetic effect)
○ Metoclopramide, ondansetron, prochlorperazine
* Calcium channel antagonists
○ Cinnarizine, flunarizine
* Histamine analogues
○ Betahistine (well tolerated)
35
Strong anticholinergic effects
for sx relief of dizzy
* Antihistamine (1st gen): diphenhydramine/ dimenhydrinate/ meclizine
* Phenothiazines: prochlorperazine/ promethazine
○ CI: PD, parkinsonism due to added antidopaminergic effects
* Anticholinergics: scopolamine (hyoscine hydrobromide)
○ Not hyoscine butylbromide (don’t cross BBB, antispasmolytic)
36
Benzodiazepine
Lorazepam/ diazepam/ clonazepam
* Not commonly used for elderly in sg (short term)
* SE: more sedating, fall risk (slower reaction), cognitive impairment, depression
37
antidopaminergic (anti-emetic)
Metoclopramide
CI: parkinsonism, PDD, PLB -- use ondansetron
38
Calcium channel antagonists
Cinnarizine, flunarizine
* MOA: incr circulation in cochlear
* SE: sedating, weight gain (antiH effect), risk movement disorder (caution in Parkinsonism)
39
Histamine analogues
Betahistine (well tolerated)
* MOA: H3 receptor antagonist, H1 partial agonist, H2 negligible agonist
* Caution: asthma (H1 agonist cause bronchospasm), monitor
* CI: active or hist of PUD
40
delirium definition
Acute neuropsychiatric disorders associated with medical conditions, medications, and/or substance intoxications
(excess Dopamine, deplete Ach)
* Geriatric medical emergency
○ Incr mortality
○ More severe functional decline
* But usually reversible. Has sudden onset, fluctuates and is characterized by inattention and disorganised thoughts and speech.
41
2 types of delirium
* Hyperactive delirium
○ Restless, agitation (resist care, climb out of bed, pull out IV/ catheter)
○ Inattention
○ Psychosis (delusions/ hallucinations)
* Hypoactive delirium
○ Slow response, incr sedation , lethargy and apathetic
○ More difficult to identify
42
risk factor for delirium
* Age ≥65yrs
* Cognitive impairment (past/ present) and/ or dementia
* Current hip fracture
* Severe illness
43
possible causes for delirium
I WATCH DEATH
* INFECTIONS: encephalitis, meningitis, UTI, pneumonia
* WITHDRAWAL: alcohol, barbiturates, BZP.
○ (atropine -- tachy); (benzhexol -- NMS, confusion)
* ACUTE METABOLIC DISORDER: electrolyte imbalance, hep, renal failure
* TRAUMA: head injury, postop
* CNS PATHOLOGY: stroke, hemorrhage, tumor, seizure disorders, Parkinson's
* HYPOXIA: anemia, cardiac failure, pul embolus
* DEFICIENCIES: vit B12, folic acid, thiamine
* ENDOCRINOPATHIES: thyroid, glucose, parathyroid, adrenal
* ACUTE VASCULAR : shock vasculitis, HTN, encepahalopathy
* TOXINS, substance use, MED (alcohol, anesthetics, narcotics
* HEAVY METALS: arsenic, lead, mercury
44
screening for delirium
4 AT (sg)
CAM
* alertness
* abbreviated mental test 4 (AMT4): DOB, age, place, current year
* attention (count backwards, 30-3-3-3)
* acuity
45
diagnosis of delirium
- Physical Examination
- Vitals signs
- Hydration Status
- Skin conditions
- Potential Infection foci
- History [Caregiver/Family member]
- Labs/Imaging Studies
46
prevention of delirium
- Sensory functions optimisations
- Hydration/nutrition
- Bowel movement/urination
- Early mobility
- Pain control
- Medication review !!!!!!
- Social interaction with loved ones
- Reorientation with clock/calendar/proper lighting
- Conducive environment
- Promote good sleep
- Address infection/hypoxia
47
approach to tx of pt with delirium
1. Prevent delirium (for at-risk pts)
2. Monitor cognitive function (4AT, CAM-ICU, ICDSU assessment)
3. Perform cognitive assessment and evaluate for delirium
4. Delirium confirmed
* Identify and address predisposing and precipitating factors
* Review meds, vital signs, hx, physical and neurological examination, labs
48
management of delirium
1) initiate supportive measures
2) Manage symptoms of delirium
3) compromise safety? px
49
1) initiate supportive measures
hydrate
avoid restraints
mobilise pt
reduce noise
orienting stimuli (time, calender etc)
reassurance
manage pain
* tx underlying medical conditions (anticholinergic drug use, CNS drugs, glucose, electrolyte, Abx regimen)
* Airway, volume status, nutritional support, pressure sores, mobilisation, DVT
50
2) Manage symptoms of delirium
* Non-pharm: for agitation (music, massage), maintain mobility and self care ability, sleep-wake cycle, family involvement
* Avoid physical restraint, catheter
* Pharm: reserve for severe agitation (harm, safety hazard)
* Low dose, adjust until effect achieved
* Maintain effective dose for 2-3 days
51
pharm for agitation
* APS (low anti-D effect/ PD friendly preferred) Quetiapine > olan > halo
* BZP (1st line for alcohol/Benzo withdrawal; Alt if APS not safe)
lorazepam PO/IV/SC 0.5-1mg
52
APS for agitation
(incr Ach? not promising, incr mortality)
Atypical
* Quetiapine PO 6.25-12.5mg BD ~ 100mg/day
* PD friendly + antihistamine effect (drowsy), less Qtc, EPSE
* Low anti-dopaminergic effect, not useful in pt with underlying schizo, unable to control agitation
* Olanzapine PO (orodispersible) 1.25 - 2.5mg~ 10mg/d
QTc safe
Typical
* Haloperidol SC/IM/PO 0.3 - 1mg BD ~ 5g/day (non-ICU)
CI: prolonged QTc, parkinsonism (DLB, PDD) - EPSE
53
ICU delirium
Typical APS
* Haloperidol ICU: 15mg IV
anxiolytics
* Dexmedetomidine (sedative agent) IV
54
hypoactive delirium
Do not treat hypoactive delirium (withdraw CNS suppressants, treat underlying cause)
55
urinary continence prerequisites (opp of UI)
* Normally functioning lower urinary tracts
* Adequate physical and cognitive functions to use toilets
Good urinary tract, body and brain
56
normal physiology of LUT
Bladder filling phase
a. Sympathetic NS activated (fight-flight) + PNS blocked
i. Activate b3 adrenergic receptor --> detrusor muscle relax (bladder fill)
ii. Activate b1 adrenergic receptor --> tighten bladder outlet/ urethra (prevent leak)
Bladder voiding phase
a. SNS blocked + Parasympathetic NS activated (rest-digest)
i. Activate M3 receptor in bladder --> bladder contract
57
5 types of UI
stress
urge
overflow
functional
mixed
58
stress UI
sx: leak with cough, sneeze, exercise
void diary: 5-10ml w/ activity
cough stress test
PVR < 50ml
* Involuntary loss of urine (small vol) with incr intraabdominal pressure (cough, laugh, exercise)
* Weak pelvic floor muscle
(childbirth, preg, menopause/ low E = low muscle)
* Bladder outlet or urethral sphincter weakness
(Post-urologic surgery)
59
urge UI
sx: urgency
void diary: variable vol loss, freq and nocturia
cough stress test show DELAYED LEAK
PVR < 50ml
Leakage of urine (can be large vol) because of inability to delay voiding after sensation of bladder fullness is perceived
* Sensory:
□ Detrusor overactivity (2* to BPH, sensitive bladder)
□ Local genitourinary conditions, irritation, inflamm (tumor, stones, diverticula, outflow ob)
- Need urinalysis lab results
* Neurologic: CNS disorder inability for cerebral inhibition of detrusor contract (stroke, parkinsonism, dementia, spinal cord injury)
60
overflow UI
sx: no sx with PA, urgency
void diary: varies
cough stress test: NIL
PVR >200ml
Leakage of urine (small vol) caused by either mechanical forces on an overdistended bladder (from stress leak?) or other urinary retention on bladder and sphincter function (cause urge leak)
* Obstruct outflow
□ Prostate (BPH), stricture, cystocele
* Neurogenic, unable to contract bladder
□ Underactive bladder. Sclerosis, spinal cord lesions
□ Acontractile bladder a/w DM, spinal cord injury
* Medication effect
61
functional UI
sx: cog. impair/ degree of immobility
void diary: may have pattern in circumstances
cough stress test: NIL
PVR varies
Cognitive, functional or mobility difficulties. (no failure in blader function or neurologic control of urination)
* Toileting difficulty
* psychological unwillingness, environmental barriers
* Severe dementia, other neurologic disorder
□ Don’t know what to do when there is urge
* Psychological factors (depression, hostility)
No good body/ brain
62
3 UI qn to identify cause
* during the past 3mnths have you leaked urine?
* did you leak urine: due to Physical activity (cough, sneeze)/ urge but cannot get to toilet fast enough/ no PA no Urgency
* leak most urine when: due to Physical activity (cough, sneeze)/ urge but cannot get to toilet fast enough/ no PA no Urgency/ about equal PA as urgency
PA: stress
urge: urge
equal: mixed
without: other causes...
63
DIAPPERS ddx for UI
Delirium
Infection (UTI)
Atrophic vaginitis
Pharmaceuticals
Psychological disorder (DEP)
Excess urine output (DM)
Reduced mobility (funct) or reversible/ drug urinary retention
Stool impact
64
dx of UI
1) assess for transient incontinece (DIAPPERS, med)
* treat reversible causes
2) assess for chronic incontinence (hx, 3 qn, voiding diary, physical exam - cough stress, PVR, lab)
3) presume type of UI
65
management of UI
- Address underlying cause(s), if any
- Non-Pharmacological treatments
- First line, to continue even if on medications. [cognition and motivation]
- Lifestyle modifications> Wt loss, normal bowel habit, reduce bladder irritants, water hygiene
- Bladder Retraining
- Kegel’s pelvic floor muscle exercise [SUI and UUI]
- Timed voiding [for patients who are functionally dependent]
- Continent products
66
voiding diary
* Freq of incontinence ep, amt of fluid intake, vol urination
○ Clarify type of incontinence
○ Act as baseline on severity, assess effectiveness of treatment
67
physical exam and lab test
* Physical examination
* Signs of vol overload, palpate for mass/ tenderness, extremities function, prostate exam.
* Cough stress test
* Labe test:
* Postvoid residual urine: >200ml (overflow)
* normal is <50ml
68
manage stress UI
- Kegel’s exercise
- Topical estrogen [may take up to 3 months for action onset, need counseling]
- Duloxetine, esp if depression present but not for patients with crcl <30 ml/min
- Surgery/Devices
69
manage UUI
- Kegel’s exercise
- Treat BPH [men]
- Topical estrogen [delayed onset]
- β- 3 adrenergic receptor agonist
- mirabegron, vibegron
- Antimuscarinic agents
- anticholinergic side effects
- prefer M3-selective agents such as solifenacin and darifenacin
- Botulinum toxin injection
- Sacral nerve stimulation etc
70
manage OUI
Bladder outlet obstruction
* Men: treat underlying cause (BPH, stricture, malignancy, stone etc)
* Female: usually structural (uterine prolapse)
Bladder underactivity
* Men: bethanecol (cholinergic), clean intermittent catherisation (spinal cord injury)
* Female: clean intermittent catherisation +/- bethanecol (cholinergic)
71
UI red flags for referral
UI w/ relapse or recurrent sx UTI
new onset of sx (muscle weak)
marked prostate enlargement
pelvic organ PROLAPSE
pelvic pain
hematuria, proteinuria, PVR >200ml
pelvic surgery, radiation
uncertain diagnosis
72
types of elder abuse :(
* Physical (chemical/ physical restraint)
□ Dope pt to be sedated for long period of time --> deconditioned (pressure ulcers, deterioration in health, muscle, pneumonia)
* Sexual
* Psychological
* Neglect (intentional, ignorance)
□ Withhold proper treatment
□ Diversions (sell/ take the meds themselves)
* Financial $$
73
risk for elder abuse in these older adults
Dementia (esp BPSD --> CAREGIVER STRESS)
Physical disability
Poor relationship with caregiver pre-morbidly (use to abuse them?)
74
risk factors in prepetrator
* Caregiver dependent on victims for material gains (financial abuse) -- food, shelter, money
* Caregiver with mental health issues
□ Depression
□ Substance use disorders (neglect: take elderly opioids)
* Caregiver who feels overwhelmed (overworked, underpaid)
* Caregiver who is victim of domestic violence
PR4152
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