Module 4.1 (Geriatrics)

Question 1

What are geriatric syndromes?

Answer 1

“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

Question 2

What are some common geriatric syndromes?

Answer 2

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

Question 3

What are some physiological changes in the elderly?

Answer 3

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

Question 3

What are some physiological changes in the elderly?

Answer 3

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

Question 4

What are some pharmacodynamic changes with aging?

Answer 4

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

Question 5

Impact of falls on the elderly?

Answer 5

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

Question 6

What is impacted when an elderly person falls?

Answer 6

40% = hip and pelvis

17% = wrist and foreram

8% = shoulder

6% = spine

5% = ankle

Question 7

What are the outcomes of hip fractures in the elderly?

Answer 7

53% = transfer to other health service, a transitional care/rehab facility

30%= discharge to usual residence

11%= discharge to residential care

6%= death

Question 8

What are the factors that can contribute to falls?

Answer 8

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

Question 9

Outline what medications can cause the following falls risk:

A) blurred vision

B) confusion

C) agitiation

D) balance

Answer 9

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

Question 10

Outline what medications can cause the following falls risk:

A) syncope

B) gait abnormalities

C) dizziness/hypotension

D) urinary urgency

Answer 10

A)

Blood pressure medicines

Vasodilators

B)

Antidepressants

Antipsychotics

Anti-nauseants

Anti-epilipetics

Benzodiazepines

C)

Antihypertensives

Diuretics

Medications with anticholinergic effects

D)

Diuretics

Question 11

What are some age related vision conditions?

Answer 11

Glaucoma → causes tunnel vision

Cataracts → lazy effect

Macular degeneration → central part of vision

Question 12

What is glaucoma? What causes it?

Answer 12

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

Question 13

What is the clinical presentation for the following types of glaucoma:

A) open angle

B) acute closed angle-often symptomatic

C) chronic closed angle

Answer 13

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

Question 14

How to manage open angle glaucoma?

Answer 14

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.

Question 15

What is cataracts? What is the cause?

Answer 15

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

Question 16

How to manage cataracts?

Answer 16

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

Question 16

How to manage cataracts?

Answer 16

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

Question 17

What is the macula?

Answer 17

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

Question 18

What happens with age to the macula?

Answer 18

◼ 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

Question 19

From the previous questions, what is macular degeneration (AMD)

→ age related macular degeneration

Answer 19

AMD may occur with the development of a choroidal neovascular membrane (‘wet AMD’) or due to retinal atrophy (‘dry MD’)

Question 20

How to treat dry AMD?

Answer 20

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

Question 21

What is the the treatment of wet AMD (new blood vessels inappropriately forming in the macula)

Answer 21

Primary therapy is intravitreal antiangiogenic therapy

>Ranibizumab Lucentis® >Bevacizumab Avastin® >Anecortave Retaane® >Verteporfin Visudyne®

Question 22

What is delirium?

>dementia patients at risk of developing this

Answer 22

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

Question 23

What are some precipitants of delirium?

Answer 23

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

Question 24

What are the risk factors for delirium?

Answer 24

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

Question 24

What are the risk factors for delirium?

Answer 24

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

Question 25

What are the commonly implicated drug groups in delirium?

Answer 25

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).

Question 26

Delirium management?

Answer 26

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

Question 27

How to do good prescribing in older people?

Answer 27

• 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

Question 28

Case Study-MA

Answer 28

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