ITM 4 The Elderly Patient Flashcards
What is the life expectancy in the UK
82
(Males =80
Females = 83)
What are the potential reasons behind an elderly person having a fall
Arrhythmias Low BP Gait abnormalities Sensory loss Frailty Cognitive impairment Urinary incontinence
What is acopia
Term to describe patients who are unable to cope with activities of daily living
Often used to describe patient who don’t have acute medical problems and are deemed to be an inappropriate admission
What does concurrent mean
Presence of 2 or more medically diagnosed diseases in the same individual
Reasons for co morbidities
Increasing prevalence
Different risk factors
Increased susceptibility
Risk factors predisposing to multiple conditions
Chronic disease affecting many body systems eg T2DM
What are the geriatric giants
Dementia Delirium Incontinence Depression Falls and dizziness Orthostatic hypotension Osteoporosis
What is the difference between pharmacodynamics and pharmacokinetics
Pharmacodynamics- the effect of the drug on the body
Pharmacokinetics- the effect of the body on the drug
In what ways are pharmacokinetics altered in older people
Reduced 1st pass metabolism- reduced liver blood flow Age dependent decline in creatinine clearance Delayed gastric emptying Reduced gastric secretions Reduced splanchnic blood flow Reduced lean mass Increased body fat Decreased plasma albumin
Define frailty
A physiologic state of increased vulnerability to stressors that results from decreased physiologic reserves and dysregulation of multiple physiologic systems
Decreased reserve results in difficulty maintaining homeostasis in the face of perturbations
- extremes of temperature
- exacerbations of chronic disease
- acute illness or injury eg falls, delirium
Define disability
Difficulty or dependency in carrying out activities essential to independent living including:
- essential roles
- tasks needed for self care
- living independently in a home
- desired activities important to quality of life
Phenotype associated with frailty
Shrinking (unintentional weight loss of >5% in a year)
Weakness (grip strength in lowest 20%)
Poor endurance and energy indicated by self report of exhaustion
Slowness
Low physical activity
What is the PRISMA 7 questionnaire
An assessment of frailty
1) are you older than 85
2) are you male
3) in general do you have any health problems that require you to limit your activities
4) do you need someone to help you on a regular basis
5) in general do you have any health problems that require you to stay at home
6) in case of needs can you count on someone close to you
7) do you regularly use a stick or walker to get about
What is the Edmonton frail scale
Cognitive: draw a clock
General health: no hospitalisations in past year
Functional independence: ADLs that require help
Social support: someone to count on
Nutrition: weight loss eg clothes bigger
Medications: >5 prescription meds
Mood
Continence
Functional performance: TUAG
General health: self rating
What is a comprehensive geriatric assessment
A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly persons medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long term follow up
Define delirium
Disturbance of attention, orientation and awareness that develops within a short period of time
Presents as significant confusion or global neurocognitive impairment
Includes disturbance of behaviour and emotion and impairment in multiple cognitive domains
A disturbance in the sleep wake cycle including reduced arousal of acute onset or total sleep loss
Impact of delirium on the patient and family
Delays recovery - non complaint to treatment
Immobilisation and functional decline
Mortality
Psychological stress
Medical complications (VTE, pressure sores, aspiration and pneumonia, UTI, dehydration and malnutrition)
Care giver stress
Institutionalisation
Patient related risk factors for developing delirium
Age >70 Pre existing cognitive impairment Previous episode of delirium CNS disorder Increased BBB permeability Poor nutritional status Number and severity of comorbid illness
Illness related risk factors for delirium
Illness severity Dehydration Infection eg UTI Fracture Hypothermia or fever Hypoxia Metabolic / electrolyte disturbances eg low sodium Pain HIV Organ insuffiencey
Environment related risk factors for delirium
Social isolation Sensory extremes Visual deficit Hearing deficit Immobility Use of restraints Novel environment Stress
Intervention related risk factors for delirium
Peri-operative Type of surgery eg hip, cardiac Duration of operation Catheterisation Emergency procedure
Medication related risk factors for delirium
Poly pharmacy Drug or alcohol dependence Benzodiazepine use Addition of >3 new medications Psychoactive drug use
Describe the cognitive function change in delirium
Decreased concentration Slow responses Memory impairment Disorganised thinking Disorientation Reduced level of consciousness Shifting attention
Describe the physical function changes in delirium
Reduced mobility Reduced movement Motor restlessness Agitation Changes in appetite Sleep disturbances
Describe the changes in social behaviour in delirium
Lack of cooperation with reasonable requests
Withdrawal
Alterations in communication, mood and or attitude
What is the 4AT test for delirium
Assesses alertness: ask patient to state name and address
AMT 4: name, age DOB, place, year
Attention: months of year backwards
Acute change or fluctuating course: change in alertness, function or cognition, hallucinations in past 2 weeks
What is appropriate poly pharmacy
- all drugs prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient
- therapeutic objectives are being achieved
- drug therapy has been optimised to minimise the risk of adverse drug reactions
- patient is motivated and able to take all medicines as intended
What is inappropriate poly pharmacy
When one or more drugs are prescribed that are not or no longer needed because:
- no evidence based indication or indication has expired
- one or more medicine fail to achieve the therapeutic objectives they intend to achieve
- one or more medicines contribute to unacceptable ADRs
- patient is not willing or able to take one or more medicines as intended
What are the 7 steps to appropriate poly pharmacy
1) what matters to the patient: discuss medication beliefs with a patient
2) right medicine? - review medications to prevent rapid symptomatic decline
3) unnecessary medicine? Can any be replaced by lifestyle
4) effective medicine? Are therapeutic objectives being achieved
5) harmful medicine? Is the patient at risk of ADRs
6) cost effective?
7) agree and share? Is patient willing and able to take therapy as intended
Define dementia
A chronic or progressive syndrome that leads to disorientation in cognitive function, that is severe enough to have an impact on social or occupational function
What is mild cognitive impairment
Less severe than dementia
Not severe enough to impact upon daily life
Affects 5-20% of over 65s
At increased risk of progression to dementia
What are the sub types of dementia
Alzheimer’s disease (50-60%)
Vascular, mixed, dementia with Lewy bodies (40%)
Other- frontotemporal(20% of under 65s) , alcohol related, Parkinson’s
What is Alzheimer’s dementia
50-60%
Accumulation of B amyloid plaques in brain
Tau protein hyperphosphorylation causing neurofibrillary tangles
Parietal and temporal lobes most affected
Acetylcholine, norepinephrine and serotonin pathways affected
Symptoms of Alzheimer’s dementia
Early memory loss
Language problems
Visuospatial problems
Behavioural problems (apathy, reduced social interaction)
Wandering, aggression, delusions and psychosis
What is vascular dementia
1-4% in over 65s
Can occur due to a single cortical stroke or a number of sub cortical events which lead to cumulative deficits
Typically abrupt onset and deteriorates in step wise progression
Symptoms of vascular dementia
Slowness of thought
Personality change
Frontal executive features
CT scan will show evidence of vascular lesions
What is dementia with Lewy bodies
10-15% of dementias
Accumulation of Lewy bodies throughout brain
How is dementia with Lewy bodies different to Parkinson’s with Lewy bodies
In Parkinson’s disease the Lewy bodies are mainly found in the basal ganglia but in dementia they are spread throughout the brain
Symptoms of dementia with Lewy bodies
Parkinsonism Fluctuating cognitive impairment Visual hallucinations Delusions Falls Sleep disturbances
What is frontotemporal dementia
1-5%
More common in age 56-61
Abnormal processing of tau protein
Insidious and slow progression
Symptoms of frontotemporal dementia
Early personality changes Emotional blunting Loss of insight Inter-personal behavioural changes Memory and visuospatial ability preserved early on
How to diagnose dementia
Not a single diagnostic test
Should be diagnosed by a specialist through memory assessment service
Based upon history and cognitive examination
How to take a history when diagnosing dementia
Include a collateral history Ask about cognitive deficits: - memory loss - attention - language impairment - calculation - visuospatial problems - executive dysfunction
Behaviour changes: personality,sleep, delusions, hallucinations, continence
Cognitive tests used for diagnosing dementia
10 point AMT MMSE MOCA Addenbrookes Clock drawing test
Blood tests: B12, folate, Ca, thyroid function
Cerebral imaging: CT/ MRI
Pharmacological ways of managing dementia
Stop potentially harmful medications
Cholinesterase inhibitors eg rivastigmine, donepezil (used in mild - moderate AD)
Memantine - glutamate antagonist used in moderate to severe AD
Non pharmacological ways of managing dementia
Maximise function with daily routines and written down lists
Familiar calm environment
Occupational therapy
Home adaptations to improve safety
Education, support and rest bite for caregivers
What is end of life care
Helps all those with advanced, progressive, incurable illness to live as well as possible until they die
Enables supportive and palliative care needs to both patient and family to be identified and met throughout the last phase of life and into bereavement
What factors make a good death
Treated as an individual with dignity and respect
Without pain or other symptoms
Familiar surroundings
In the company of family or friends
What is the pathway to a good death
Identify people approaching end of life
Initiate discussions about preferences
Assess and anticipate needs, care plan and review
Co-ordinate care, high quality services (pain, pharmacist, doctor, nurse)
Last days of life
Support for carers during and after
What is the purpose of advanced care planning
Used as a opportunity to lay out the values, beliefs and preferences relating to daily life through to anticipated situations - the person may wish to specify explicitly the limits of treatment
Management of preventing falls
Manage osteoporosis and risk of fracture
Risk factors for falls
Lower limb weakness History of falls Gait and balance problems Visual impairment Arthritis of the lower limb joints Postural hypotension Poly pharmacy Cognitive impairment Incontinence Age over 65
Why does poly pharmacy increase risk of falls
Reflects multiple comorbidiiteis the patient has
Also drugs can interact with each other and cause problems
Why does incontinence increase risk of falls
Trying to get to the toilet quickly and falling over
Environmental factors that can cause falls
Cables
Rugs that Zimmer frame can trip on
Poor lighting
What is postural hypotension
Aka orthostatic hypotesnion
Blood pressure drop on standing
Common causes of postural hypotension
Drugs Dehydration Anaemia Sepsis Alcohol Prolonged bed rest Carotid sinus disease Autonomic failure Adrenal insufficiency
Things to notice in the PMH of someone having had a fall
Neurological conditions: previous stoke, Parkinson’s, MS (lower limb weakness), MSA
Diabetes (peripheral neuropathy - associated with autonomic failure and cognitive impairment
Diabetes
Alcohol
Arthritis of lower limbs
How to examine someone who has had a fall
Neurological examination
Cardiovascular examination
Musculoskeletal examination
Injuries or complications eg fractures
Gait, feet and footwear, visual acuity, cognitive assessment, hearing
Investigations to run after a fall
Bloods: to test for acute illness (B12- deficiency can cause degeneration of spinal cord and peripheral neuropathy, anaemia)
Postural hypotension (take BP lying, sitting, standing)
ECG
Osteoporosis risk factors and investigations
What is sedentary behaviour associated with in older adults
Higher plasma glucose Higher BMI and waist : hip ration Higher cholesterol Reduced muscle strength Reduced bone density Frailty and falls
What 3 postural synergies do we use to maintain dynamic balance
Ankle strategy- range of movement, sensation, muscle integrity in feet
Hip strategy - flexion at the hips- can be reduced with arthritis in knees or pain in hips
Stepping strategy - if someone pushes you you should be able to stabilise self by taking a step
How can exercise reduce fall rates
Highly challenging balance training
High dose (50+ hours)
3x per week
Progressive strength training
What test is used to determine what type of dementia someone has
Addenbrookes cognitive examination III
