IC3 Geriatric Syndromes Flashcards
fried frailty tool
1) weak = poor hand grip strength, difficulty walking up 1 flight of stairs
2) slow walking (>6-7 sec to walk 10ft)
3) low phy activity
4) weight loss (≥5% in last year)
5) exhaustion (fatigue when performing daily activities)
1-2 = pre frail
≥3 = frail
FRAIL scale
Fatigue
Resistance (difficult climbing 1 flight of stairs)
Ambulation (walking one block, 80m)
Illness (>5 illness of HTN, DM, cancer, chronic lung disease, asthma, heart attack, CHF, stroke, arthritis, KD)
Loss of weight (>5 % in past yr)
1-2 pre frail
≥3 frail
likely pathophysiology of frailty
combination of genetic and environmental factors = increased inflammation, neuroendocrine dysregulation = increased CRP and IL6 / change in growth or sex hormones = anorexia, sarcopenia, cognition, clotting… etc .
eventually results in slowness, weakness, weight loss, low activity, fatigue…
not inevitable part of ageing
Interventions for frailty (purpose, when and wat)
for cfs 4 and 5
to slow down/reverse progression
1) what matters most = goals of therapy
2) physical exercise, occupational therapy (resistance type to reduce muscle loss/improve function)
3) nutritional intake
4) med review
- any DRP affecting physical therapy and nutrition
- vit D supplementation
why are OPIOIDS included in stoppfall (when to remove)
remove IF
slow reaction, sedation, impaired balance
types of dizziness
vertigo
- sensation of motion without moving
pre syncopal dizziness
- postural hypo = dizzy/unstable
dysequlibrium
- walking unsteadiness
unspecified dizziness
- light headnedness
what are falls risk increasing drugs (FRIDs)
MECHANISM?
sedation
- reduced awareness of environmental hazards
orthostatic
- perfusion to brain , eye, leg is limited = weakness in legs = give away
- poor baroreflex
anticholinergics
hypoglycaemia
why are DIURETICS included in stoppfall (when to remove)
remove IF
OH, hypotension, electrolyte disturbance, urinary incontinence?
considerations for nutritional intake in frailty intervention
oral nutritional supplements
- milk feeds? enteral feeds?
- vit D?
medi SE
- affect taste? sedation?
eg anticholinergic affect taste reduce appetite = affect swallowing
depression
- not eating (untreated/not treated properly)
access to food
- unable to buy food
- not enough money to buy nutritional food
(causes obesity)
swallowing/chewing
- affected by dementia, lack of teeth, etc.
risk assessment for falls (simple) (AGS/BGS)
1) obtain relevant PMH, PE, cognitive and functional assessment
2) determine multifactorial fall risk:
- hx of falls
- medications
- gait, balance, mobility
- visual acuity
- other neurological impairments
- muscle strength
- HR and rhythm
- postural hypotension
- feet / footware
- environmental hazards
- hearing impairment
why dizziness is an important geriatric syndrme>?
1) may be the result of potentially serious etiologies (stroke, MI, traumatic brain injury)
2) increased fall risk
3) increase reconditioning risk (= less likely to move + discomfort with dizziness = decondition = reduce QOL and socially withdrawn)
4) reduced QOL
FRIDs drugs –> stoppfall
what are the drugs listed
OH: alpha blockers, central antihypertensives (methyldopa), vasodilators (nitrates), diuretics (baroreflex)
opioids
psych: antidepressants (TCA), antipsychotics, benzodiazepines, z hypnotics.
AEM: ataxia
anticholinergics: first gen antihistamines, muscle relaxants
OTHERS: oral hypoglycaemic (SU higher risk)
why are ANTIDEP included in stoppfall (when to remove)
remove if
hyponatremia, OH, dizziness, sedation
key points for dizziness and implications
high proportion due to age
high proportion with dizziness lasting several minutes at most
= medication management may not have benefit (takes time to take effect)
high proportion with serious etiology
approach to evaluating dizziness
TiTraTE
timing = continuous or episodic (onset, freq, duration)
triggers = head movement, posture change
targeted examination
classification of dizziness (differential diagnosis)
episodic triggered (e.g., dix hall pike manoeuvre)
= positive = beneign paroxysmal positional vertigo
= negative = orthostatic hypo
episodic Spontaneous: further history
= Unilateral hearing loss/sensation of ear fullness: Meniere Disease
= Migraine Headache: Vestibular Migraine
= Psychiatric symptoms: Panic attack, etc
continuous vestibular
= Trauma/toxin (drugs)
continuous spontaneous: HINTS Exam [Head Impulse/Nystagmus/Test of Skew]
= Central: Stroke/TIA
= Peripheral: Vestibular neuronitis
how to manage dizziness
when should vestibular suppressants be used
if vestibular symptoms are prolonged (>30 min)
because all the drugs are beers list = need review
- assess risk vs benefit and stop ASAP when possible.
consider non phx intervention such as vestibular rehab
list of vestibular suppressants
antihistamines
phenothiazines
anticholinergics
benzodiazepines
antidopaminergic
calcium channel antagonist
histamine analogues
anticholinergic vestibular suppressants
FG antihistamine = diphenhydramine, dimenhydrinate, meclizine
anticholinergic
- scopolamine (hyosicne hydrobromide)
phenothiazine
- prochlorperazine, promethazine
BZP vestibular suppressants
lorazepam
diazepam
clonazepam
x a few days
- sedating
- risk of falls
- cognitive impairment
- depression
calcium channel antagonists vestibular suppressants
cinnarizine (and flunarizine)
- increase circulation to the cochlear
- sedating
- weight gain (increased appetite?)
- caution in parkinsonism
antidopaminergic vestibular suppressants
metoclopramide
ondansetron (if contraindication to meto)
- more for N/V
histamine analogue vestibular suppressants
betahistine
type 3 histamine receptor antagonist, partial H1 receptor agonist (no effect on H2)
- caution in asthma
- c/I active or pmh PUD
potential list of drugs that may cause dizziness (pertenint drugs only and their mechanism)
drugs with cardiac effects: hypotension , TDP, OH, arrhythmia
anticholinergic effect (central)
cerebellar toxicity = BZP, AEM, lithium
hypoglycaemia
ototoxicity = aminoglycosides, antirheumatic agents
bleeding complications (anticoagulants) and bone marrow suppression (anti thyroid meds)
what are the delirium subtypes
hyperactive delirium
- agitation
- inattention
- psychosis
hypoactive delirium
- slow response
- increased sedation
(associated with worse outcomes)
4at detection of delirium
risk factors for delirium
> 65yo
cognitive impairment and/or dementia
current hip fracture
severe illness
etiologies for delirium
I WATCH DEATH
Infection
Withdrawal (alcohol, barbiturates, BZP)
Acute metabolic disorder (electrolyte imbalance, hepatic/renal failure)
Trauma
CNS (stroke, haemorrhage, tumour, seizure, pD)
Hypoxia (anemia, HF, pulmonary embolus)
Deficiency (b12, folic, thiamine)
Endocrinopathy (thyroid, glucose, parathyroid, adrenal)
Acute vascular shock (shock, vasculitis, hypertensive encephalopathy)
Toxins, substance use, medications
Heavy metals (arsenic lead mercury)
drugs commonly associated with delirium
strong anticholinergic
benzodiazepine
z hypnotics
opioids
H2RA
others:
= antimicrobials* (FQ, cefepime) - must renal adjust
= GC
= dopamine agonists* (ropinirole, pramipaxole)
= AEM* (particularly levetiracetam)
= TCA
= muscle relaxants
= lithium* (if not used properly can change patient’s neuropsychiatric condition).
delirium prevention strategies
sensory function optimisation
nutrition
hydration
bowel movement / urination
early mobility
pain control
med review
social interaction with loved ones
reorientation w/clock/calendar/proper lighting
conducive environment
good sleep
infection/hypoxia management
what labs to cover when managing delirium
CBC = leukocytosis, anemia
glucose = hypoglycaemia
electrolyte imbalance
renal (creatinine, BUN) = indicates drug excretion
urinalysis = infection
spO2 = hypoxia
phx management of delirium
last resort only if interferes with QOL
only sparingly for short period of time
only for hyperactive delirium (do not give for hypo, address underlying causes)
= SC/IM/PO haloperidol 0.3 - 1 mg BD
(up to 5mg/day)
= atypical antipsychotics
(quetiapine PO 6.25 - 12.5 mg BD up to100mg/day)
(olanzapine PO 1.25-2.5mg up to 10mg/day)
= BZP
first line for alcohol or benzodiazepines wihdrawal
(lorazepam 0.5 -1 mg)
what is stress incontinence (and common causes)
involuntary loss of urine due to increased intra abdominal pressure (coughing exercise laughing)
weak pelvic floor muscle (childbirth, pregnancy, menopause)
post urologic surgery, urethral sphincter weakness
what is urge incontinence (and common causes)
leakage of urine because of inability to delay voiding after sensation of bladder fullness is perceived
- detrusor overactivity
- local genitourinary conditions (tumours) or cns disorders (stroke, PD, dementia)
what is functional incontinence (and common causes)
urinary accidents
- cognitive impairment e.g dementia
- phyiscal impairment
- psych unwillingness
- environmental barriers
what is overflow incontinence (and common causes)
leakage of small amt of urine by
(i) mech forces on over distended bladder = stress leakage
(ii) effects of urinary retention on bladder and sphincter function = urge leakage
- anatomic obstruction (prostate, stricture, cystocele);
- acontractile/underactive bladder (DM, spinal cord injury)
- neurogenic
- medication effect
differential diagnosis of UI
DIAPPERS
delirium
infection (acute UTI)
atrophic vaginitis (assoc with menopause)
pharma (drugs)
psych (depression)
excessive urine output (hyperglycaemia)
reduced mobility (functional incontinence)
stool impaction
drugs that can cause or worsen UI
Allergy
- antihistamines (FG)
- decongestants
analgesic
- benzo
- opioids
anticholinergic
- antimsucarinic
- anciholinergic anti PD
cardio
- acei
- diuretics
- alpha blocker
psych
- antidepressant
- antipsychotics
others
- SMR
- estrogen
- alcohol and caffeine
- calcium channel blockers
- GABAnergic (gabapentin, pregabaline)
- thiazolidinediones (Pioglitazone)
management of UI algorithm (general)
1) address underlying cause
2) non phx
- lifestyle mod [weight loss, normal bowel habit, reduce bladder irritant foods (caffeine), water hygiene]
- bladder retraining (more for cognitively intact pt)
- kegel pelvic floor muscle exercise (strengthen pelvic floor)
- timed voiding (q1-2 hours)
CONTINUE EVEN IF ON MEDS
management of stress UI
kegel pelvic floor muscle exercise
topical estrogen (up to 3 months onset, caution women with PMH breast cancer)
duloxetine (esp if depression present, c/I crcl <30)
surgery? devices? e.g., estradiol ring got eormn
management of urge UI
kegel pelvic floor muscle exercise
treat BPH
topical oestrogen
b3 adrenergic receptor agonist (mirabegron, vibegron)
antimsucarinics
- Solifenacin, darifenacin
(risk of anticholinergic SE)
botulinum toxic injection (bladder emptying SE)
sacral nerve stimulation
management of overflow UI
if bladder outlet obstruction
- men: treat BPH
if bladder under activity
- men and women: bethanechol +/- clean intermittent cathetirzation (CIC)
types of elder abuse
physical (chemical or physical restraint)
sexual
psych
neglect
financial
risk factors for elder abuse
dementia
- bpsd = caregiver stress
physical disability
poor relaitonship with caregiver pre morbid
caregiver with mental health issues
*substance abuse, depression
caregiver dependent on victim for material gains
caregiver who feels overwhelmed
caregiver is a victim of domestic violence
