IC3: Geriatric Syndromes Flashcards
What are the 5 geriatric syndromes?
Frailty
Falls
Dizziness
Delirium
Urinary Incontinence
What are the 5 characteristics associated with frailty in the Fried Frailty Scale?
Weak → poor hand grip strength, difficulty walking up 1 flight of stairs
Slow walking → >6-7 seconds to walk 10 feet
Low physical activity
Weight loss → 5% or more weight loss in the last year
Exhaustion → fatigue while performing daily activities
What does the bADL acronym DEATH stand for?
dressing
eating
ambulating
transferring, toileting
hygiene
What are the 3 interventions for frailty?
- establishing goals of therapy for PT and OT
- nutritional intake w oral nutritional supplements
- medication review
What are the 3 key questions to ask for falls?
- any falls in the past 12 months?
- do u feel unsteady when walking or standing?
- any worries about falling?
What are the most common mechanisms of FRIDS causing harm? (4)
- anticholinerics
- hypoglycemia
- sedation
- orthostatic hypotension
What are the explicit criteria for FRIDS? (5)
- OH inducers (alpha blockers, antihypertensives, vasodilators, diuretics)
- opioids
- psychotropics
- anticonvulsants
- anticholinergics
What are the 4 types of dizziness?
- vertigo
- pre-syncopal dizziness (usually bc of OH)
- dysequilibrium
- unspecified dizziness
Should medication be given for dizziness most of the time? Why or why not?
No. Oral medication onset of about 30-60 minutes, most dizziness spells are not frequent and last for a minute
Briefly describe the pathogenesis of Benign Paroxysmal Positional Vertigo (BPPV)
Occurs when loose otoconia (canaliths) becomes dislodged and enters the semicircular canals
How should BPPV be managed?
by physiotherapist
avoid vestibular suppressants
Briefly describe the pathogenesis of vestibular migraine?
Usually due to central pathologies relating to the vestibular nuclei, cerebellum, brainstem and vestibular cortex
Briefly describe the pathogenesis of Meniere disease?
Caused by excess endolymphatic fluid pressure leading to inner ear dysfunction, causing vertigo and unilateral hearing loss
How should Meniere disease be managed? (3)
take measures to decrease water in ears (eg. lower Na intake, loop diuretics, vestibular suppressant like beta-histine)
Briefly describe the pathogenesis of vestibular neuritis?
Viral infection, diagnosed based on clinical history and physical examination, causing severe rotary vertigo (HINTS)
How should vestibular neuritis be managed?
use steroid to lower inflammation first and consider short term vestibular suppressant (takes weeks to months to get better)
What does TiTraTE stand for in approaching dizziness?
- Timing (episodic/continuous)
- Triggers (head movement, posture change)
- Targetted examination (pt hx)
In what cases should vestibular suppressants be given?
Only short term for symptomatic relief if symptoms are prolonged (> 30 min) because almost all are beers list drugs
What are the 7 classes of drugs under vestibular suppressants?
1st gen antihistamines
anticholinergics
phenothiazines
bzd
antidopaminergics
ca channel antagonists
type 3 histamine receptor antagonists
What are the 1st gen antihistamine vestibular suppressants?
diphenhydramine
dimenhydrinate
meclizine
What is the one anticholinergic vestibular suppressant?
scopolamine
What are the phenothiazine vestibular suppressants?
prochlorperazine, promethazine
What are the bzd vestibular suppressants?
lorazepam, diazepam, clonazepam
What are the antidopaminergic vestibular suppressants?
metoclopramide, ondansetron
What is the one Ca channel antagonist vestibular suppressant?
cinnarizine
What is the one type 3 histamine receptor antagonist vestibular suppressant?
betahistine
In what cases should betahistine be used with caution and is contraindicated in?
asthma (risk of bronchospasm from histamine activity)
history of PUD (h2 receptor activity)
What are the 2 main types of delirium?
Hyperactive delirium → agitation, inattention, psychosis
Hypoactive delirium → slow response, increased sedation (hard to identify)
What are the components of 4AT in delirium detection? (4As)
- alertness level
- abbrevieted mental test 4
- attention (reciting months backwards or 30-3-3)
- acuity
What are the components of abbreviated mental test 4?
DOB, age, place, current year
I WATCH DEATH is an acronym for causes of delirium. What does it stand for?
infectious
withdrawal
acute metabolic d/o
trauma
CNS pathology
hypoxia
deficiencies
endocrinopathies
acute vascular (shock)
toxins
heavy metals
What are the 5 main classes of drugs assocaited with increased delirium risk?
- strong anticholinergics
- bzd
- z-hypnotics
- opioids (esp pethidine)
- H2RA
What other medications can prolong delirium?
(A CHAD L)
antidepressants
corticosteroids
hypoglycemics
anticonvulsants (esp levetiracetam)
dopamine agonists (impulse control)
lithium (too high worsens delirium, too low worsens bpd)
What are 11 delirium prevention measures?
4 med related
5 daily living
2 social
med related:
1. Medication review
2. Addressing infection and hypoxia
3. Sensory function optimisation
4. Pain management
daily living:
5. early mobility
6. hydration and nutrition
8. bowel movement and urination
8. condusive environments
9. good sleep
social
10. social interaction w loved ones
11. reorientation w clock, calendars and lighting
When should pharmacotherapy be started for delirium in elderly?
Last resort, only if patient’s behaviours are dangerous (because most of these medications can precipitate delirium)
What are the 2 classes of drugs that can be given for delirium in elderly?
Antipsychotics
BZD
What are the 3 antipsychotics that can be given for delirium in the elderly?
SC/IM/PO haloperidol
PO quetiapine
PO olanzapine
What are the contraindications for haloperidol for delirium in elderly?
QTc prolongation
DLB/PDD
What are the benefits of quetiapine and olanzapine for delirium in the elderly?
Quetiapine is safe for PD
Olanzapine is safe for QTc prolongation
When should bzd be given over antipsychotics in delirium in the elderly? (2)
If antipsychotics not tolerated well
1st line for alcohol or bzd withdrawal
What are the 2 prerequisites to urinary continence
normally functioning lower urinary tracts
adequate physical and cognitive function to use the toilets
Which nervous systems are activated and blocked in the bladder FILLING phase?
SNS activated
PNS blocked
Which two adrenergic receptor activations result in what physiological outcomes during bladder FILLING?
β-3 activated: bladder relaxation
α-2 adrenergic activated: tightening of bladder outlets and urethra
Which nervous systems are activated and blocked in the bladder VOIDING phase?
PNS activated
SNS blocked
Which receptor activation result in what physiological outcomes during bladder VOIDING?
M3 receptors activated: bladder contraction
What are the 4 types of urinary incontinence?
Stress
Urge
Overflow
Functional
What is stress UI?
Increasing intraabdominal pressure (cough, laugh, exercise)
What are the causes of stress UI? (2)
Weak pelvic floor muscles from childbirth, pregnancy
Bladder outlet or urethral sphincter weakness
What is urge UI?
Leakage due to inability to delay voiding after sensation of bladder fullness is received
What are causes of urge UI? (2)
Detrusor overactivity
CNS disorders (stroke, parkinsonism, dementia)
What is overflow UI?
Leakage due to mechanical forces on overdistended bladder
What are the causes of overflow UI? (3)
Anatomic obstruction by prostate (BPH)
Overactive bladder
Medication effect
What is functional UI?
Urinary accidents associated with ability to toilet
What are the causes of functional UI? (2)
Severe dementia or other neurologic disorder
Psychological factors like depression (no motivation) and dementia (does not know what to do when feeling urgent)
DIAPPERS underlines UI causes that are reversible. What does it stand for?
- Delirium
- Infection (acute UTI)
- Atrophic vaginitis
- Pharmaceuticals
- Psychological disorders, especially depression
- Excessive urine output (eg. hyperglycemia, SGLT2i can increase urine output and increase UI risk)
- Reduced mobility (functional incontinence) or reversible drug-induced retention
- Stool impaction
What are the 2 classes of allergy drugs that can contribute to UI?
What are their mechanisms of action?
- 1st gen antihistamines (decr contractility)
- decongestants (incr sphincter tone)
What are the 2 classes of analgesics and opioid drugs that can contribute to UI?
What are their mechanisms of action?
- bzd (impaired function via muscarinic effect)
- opioids (decr sensation of fullness)
What are the 3 classes of anticholinergics drugs that can contribute to UI?
What is one example of each class?
What is their common mechanism of action?
- antimuscarinics (oxybutynin)
- antispasmodics (scopolamine)
- parkinsonian agents (trihexyphenidyl)
(decr contractility via antichol effect)
What are the 5 classes of CV drugs that can contribute to UI?
What are their mechanisms of action?
- ACEi (decr contractility)
- alpha agonists (incr sphincter tone)
- alpha blockers (decr sphincter tone)
- diuretics (incr urine production)
- DHP CCBs (selectively dilates arteries, risk of nocturia)
What are the 2 classes of psychotropic drugs that can contribute to UI?
What are their mechanisms of action?
- antidepressants (SNRIs, TCAs) (incr sphincter tone, decr contractility)
- antipsychotics (mixed effect)
How do caffeine and alcohol contribute to UI respectively?
caffeine: incr contractility + irritant (bad for overactive bladder)
alcohol: decr contractility
What are the recommended management options for stress UI? (4)
- Kegel’s exercises
- Topical estrogens (may take 2 weeks to 3 months)
- Duloxetine (especially if pt is depressed, but not for pts CrCl < 30)
- Surgery or devices (but not advisable for elderly who are frail)
What are the recommended management options for Urge UI? (7) (some are meds)
- Kegel’s exercises
- Topical estrogen (delayed onset)
- Treat BPH in men
- Beta-3 adrenergic receptor agonists (mirabegron, vibegron) (ensure that PVR ius not too high if not can result in acute urinary retention)
- Antimuscarinic agents, preferably M3-selective agents like darifenacin or trospium (watch out for anticholinergic SE)
- Botulinium toxin injection
- Sacral nerve stimulation
What are the recommended management options for Overflow UI? (3) (obstruction and underactivity)
Obstruction: treat BPH in men, encourage bowel habits
Underactivity: bethanechol, clean intermittent catheterisation for women
What are the recommended management options for Functional UI? (2)
- If pt has physical disability, commode or continence pad
- If pt has cognitive impairment, get helper to assist
What are the 5 types of elder abuse?
physical (chemical or physical restraint)
sexual
psychological
neglect
financial
What are risk factors for patients to receive elder abuse? (3)
dementia
physical disabiloty
poor rs w caregiver pre-morbidly
What are the risk factors for perpetrators of elder abuse? (4)
caregiver dependency on victims (food, money, shelter)
caregiver w mental health issues (depression, substance abuse)
professional caregiver overwork
victim of domestic violence
What can pharmacists do if we suspect elder abuse?
Report to social worker
