Module 4.1 (Geriatrics) Flashcards
What are geriatric syndromes?
“Multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render person vulnerable to situational challenges”
>The result of a series of processes or changes, suggesting multiple contributors
>Management does not always depend on the underlying cause/s
What are some common geriatric syndromes?
Incontinence ◼ Insomnia ◼ Delirium ◼ Dementia
Falls ◼ Osteoporosis ◼ Weight loss/ sarcopenia (loss of muscle tissue) ◼ Poor vision
Frailty: A biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes
What are some physiological changes in the elderly?
Increased Gastric pH → slightly decreased absorption
Delayed gastric emptying
Reduced splanchnic blood flow
Decreased absorption surface
Decreased gastrointestinal motility
Increased body fat → increased volume of distribution and t½ of lipophilic drugs
Decreased lean body mass
Decrease total body water
Decreased serum albumin
Increase a1-acid glycoprotein
Decreased hepatic blood flow
Decreased hepatic mass
Decreased renal blood flow and glomerular filtration rate
What are some physiological changes in the elderly?
Increased Gastric pH → slightly decreased absorption
Delayed gastric emptying
Reduced splanchnic blood flow
Decreased absorption surface
Decreased gastrointestinal motility
Increased body fat → increased volume of distribution and t½ of lipophilic drugs
Decreased lean body mass
Decrease total body water
Decreased serum albumin
Increase a1-acid glycoprotein
Decreased hepatic blood flow
Decreased hepatic mass
Decreased renal blood flow and glomerular filtration rate
What are some pharmacodynamic changes with aging?
In older people, the effects of similar drug concentrations at the site of action may be greater or smaller than those in younger people
Several causes:
>altered receptor expresison
>reduces organ mass
>changed tissue response
Influences the likelihood of desirable and undesirable responses to drugs
Impact of falls on the elderly?
An event which results in a person coming to rest inadvertently on the ground or floor or other lower level
>A leading cause of death and disability for those >65
>Each year
30% – 40% of people in the community fall ◼ 50% of residential care residents fall
>For 20-30% this leads to loss of mobility, independence and risk of premature death
What is impacted when an elderly person falls?
40% = hip and pelvis
17% = wrist and foreram
8% = shoulder
6% = spine
5% = ankle
What are the outcomes of hip fractures in the elderly?
53% = transfer to other health service, a transitional care/rehab facility
30%= discharge to usual residence
11%= discharge to residential care
6%= death
What are the factors that can contribute to falls?
Physiological: weakness and frailty
Cardiovascular: syncope, postural hypotension, hypotension
Neurological: epilepsy/seizures, parkinson’s disease, peripheral neuropathy, dementia, drowsiness/sedation
Mechanical: inappropriate use of aids and footwear
Ophthalmological: cataracts, macular degeneration, glaucoma, blurred vision
Environmental: lighting, rugs, stairs/steps
Muscoskeletal: arthritis and deconditioning
Outline what medications can cause the following falls risk:
A) blurred vision
B) confusion
C) agitiation
D) balance
A)
◼ Eye drops ◼ Anticholinergics ◼ Medications with anticholinergic effects
B)
Benzodiazepines ◼ Narcotics ◼ Psychotropics ◼ Any medicine with anticholinergic effects
C)
Antidepressants ◼ Caffeine ◼ Antipsychotics ◼ Stimulants
D)
Anticonvulsants ◼ Benzodiazepines ◼ Antipsychotics ◼ Prochlorperazine
Outline what medications can cause the following falls risk:
A) syncope
B) gait abnormalities
C) dizziness/hypotension
D) urinary urgency
A)
Blood pressure medicines
Vasodilators
B)
Antidepressants
Antipsychotics
Anti-nauseants
Anti-epilipetics
Benzodiazepines
C)
Antihypertensives
Diuretics
Medications with anticholinergic effects
D)
Diuretics
What are some age related vision conditions?
Glaucoma → causes tunnel vision
Cataracts → lazy effect
Macular degeneration → central part of vision
What is glaucoma? What causes it?
Slowly progressive, insidious onset optic nerve damage leading to reduced vision
Typically due to increased intraocular pressue (IOP)
>mechanisms of pressure damage to nerve
>low tension glaucoma also possible
Classified by cause of increased IOP
>open angle
>closed angle
What is the clinical presentation for the following types of glaucoma:
A) open angle
B) acute closed angle-often symptomatic
C) chronic closed angle
A)
few symptoms until visual field loss, then disease is quite advanced
B)
severe pain, headache, sudden blurring of vision, intra-ocular pressure often >50mmHg
C)
Chronic closed angle
>fewer symptoms than acute angle closure
How to manage open angle glaucoma?
Prostaglandin analogues (bimatoprost, latanoprost, tafluprost, travoprost) → 1 doses a day → first line, increase aqueous outflow, most effective class, may cause iris hyperpigmentation and eyelash changes
Beta-blockers (betaxolol, timolol) → 1-2 doses per day → first line, decrease aqueous production, may cause systemic adverse effects e.g. bradycardia, generally avoided in severe or poorly controlled asthma
Alpha2 agonists (apraclonidine, briomonidine ) → 2-3 doses per day → second line, increase aqueous outflow and decrease its production, apraclonidine
Carbonic anhydrase inhibitors (brinzolamide, dorzolamide) → 2-3 doses per day → second line, decrease aqueous production
Cholinergic (pilocarpine 3-4 doses per day) → rarely used (angle closure glaucomas and some secondary glaucomas, seek specialist advice). Increases aqueous outflow, high incidence of adverse effects such as blurred vision and headache.
What is cataracts? What is the cause?
A cataract is any opacity in the lens
>Ageing most common cause; pathogenesis not well understood
→ protein aggregates scatter light rays and reduce lens transparency
>Other factors can be involved, e.g. trauma, toxins, systemic disease (e.g. diabetes), smoking, heredity
>Also associated with long term administration of corticosteroids (systemic or topical), some phenothiazines, amiodarone (amiodraone causes opacity of the lens)
>Age-related cataracts common cause of visual impairment. 50% aged 65–74; 70% for those over 75
How to manage cataracts?
Surgical replacement of clouded lens with intraocular lenses (IOL)
Postoperative therapy may involve short regimens of combinations of topical antibiotics (e.g. chloramphenicol) and NSAIDS (e.g ketorolac) and/or corticosteroids (e.g fluoromethalone)
>protocols may vary amongst individual specialists
How to manage cataracts?
Surgical replacement of clouded lens with intraocular lenses (IOL)
Postoperative therapy may involve short regimens of combinations of topical antibiotics (e.g. chloramphenicol) and NSAIDS (e.g ketorolac) and/or corticosteroids (e.g fluoromethalone)
>protocols may vary amongst individual specialists
What is the macula?
The central, posterior portion of the retina containing the densest concentration of photoreceptors within the retina
◼ Responsible for central high-resolution visual acuity, allowing a person to see fine detail, read, and recognise faces
What happens with age to the macula?
◼ With age, focal depositions of acellular, polymorphous debris occurs within the retina, called drusen
>Excess drusen leads to damage to the retina and destruction of the macula
From the previous questions, what is macular degeneration (AMD)
→ age related macular degeneration
AMD may occur with the development of a choroidal neovascular membrane (‘wet AMD’) or due to retinal atrophy (‘dry MD’)
How to treat dry AMD?
Smoking cessation
Moderate to severe AMD- antioxidant vitamins and zinc (eg, Ocuvite PreserVision).
>Doses should be consistent with the Age-Related Eye Disease Study 2 (AREDS2) formulation
What is the the treatment of wet AMD (new blood vessels inappropriately forming in the macula)
Primary therapy is intravitreal antiangiogenic therapy
>Ranibizumab Lucentis® >Bevacizumab Avastin® >Anecortave Retaane® >Verteporfin Visudyne®
What is delirium?
>dementia patients at risk of developing this
Acute transient, usually reversible, fluctuating disturbance in attention, cognition and consciousness level
Hallmarks are decreased attention span and a waxing and waning type of confusion
What are some precipitants of delirium?
Disease
Metabolic Disorder
Carcinoma
Infection
Neurological Disorder
Inflammation
Pain
Dehydration
Constipation
Malnutrition
Urinary retention/UTI
Sensory impairment
Drug effects (and interactions)
Drug/alcohol withdrawal syndromes
Lack of stimulation
Surgery
What are the risk factors for delirium?
Pre-existing dementia or brain injury
Frail elderly- the older the more susceptible
Comorbidity
Polypharmacy
Changes in medication
>when a new drug is started
>when a dose is changed
>when another drug is added, stopped or changed
>when a drug is stooped
- treated condition can get worse
- withdrawal side effects e.g. BZD, antidepressantsd
What are the risk factors for delirium?
Pre-existing dementia or brain injury
Frail elderly- the older the more susceptible
Comorbidity
Polypharmacy
Changes in medication
>when a new drug is started
>when a dose is changed
>when another drug is added, stopped or changed
>when a drug is stooped
- treated condition can get worse
- withdrawal side effects e.g. BZD, antidepressantsd
What are the commonly implicated drug groups in delirium?
Anticholinergics ◼
Benzodiazepines ◼
Opioids (including pethidine and tramadol) ◼
Corticosteroids ◼
Nonsteroidal anti-inflammatory drugs ◼
Dopaminergic drugs (eg levodopa, dopamine agonists, catechol-o-methyltransferase [COMT] inhibitors) ◼
Sotalol and propranolol (unlikely with other beta blockers) ◼
Alcohol and illicit drugs (eg cannabis, methamphetamine).
Delirium management?
Up to a third of delirium episodes in hospitalised elderly patients can be prevented using nonpharmacological approaches
The key principle in management is to identify and treat the underlying cause, relying primarily on nonpharmacological measures
>Pharmacological management is unnecessary for most delirious patients
>Antipsychotic treatment is sometimes required to control anxiety, agitation, aggression, delusions and/or hallucinations
→ a single dose is usually adequate → haloperidol worsens outcomes for people with delirium → use carefully
How to do good prescribing in older people?
- Carry out a regular medication review and discuss and agree all changes with the patient
- Stop any current drugs that are not indicated
- Prescribe new drugs that have a clear indication
- If possible, avoid drugs that have known deleterious effects in elderly patients, such as benzodiazepines, and recommend dosage reduction when appropriate
- Use the recommended dosages for elderly patients
- Use simple drug regimens and appropriate administration systems
- Consider using once daily or once weekly formulations and using fixed dose combinations when possible
- Consider non-pharmacological treatments if appropriate
- Limit the number of people prescribing for each patient if possible
- Where possible, avoid treating adverse drug reactions with further drugs
- Regular appropriate monitoring becomes of utmost importance when using medications in older people
- Predicting the effects of medications becomes more difficult in older people → pharmacokinetics and pharmacodynamics become more complicated with age, comorbidity and polypharmacy
Case Study-MA
Consider antiresorptive treatment and calcium supplementation
Reduce the dose of ISMN
Cease clopidogrel
Consider antiresorptive treatment and calcium supplementation
Minimise medications that may influence falls or injury
>No history of angina since admission to facility four years ago
>Is not prescribed PRN GTN
>Coronary arteries were stented over 15 years ago
→ Regular appropriate monitoring becomes of utmost importance when using medications in older people
