old age conditions (falls) Flashcards
define ageing
progressive, generalised impairment of function resulting in a loss of adaptive response to disease
- random molecular damage during cell replication
- reduction in bodys adaptive reserve capacity (resilence)
ageing hypotheses
- DNA damage affecting cell repair
- mitochondria produce free radicals which produce oxidative stress which accumulates with age
- tips of telomeres shorten with cell division over time leads to cell senescence
- loss of elasticity in tendons, skins, blood vessels
hayflick limit = no. times a human cells can divide before division ceases
sarcopenia
age related loss of muscle mass, stength + muscle quality leading to decline in physical function, falls, frailty
-> reduction in type II, fast twitch, muscle fibres
diagnosis + management of frailty
diagnosis = presence of low muscle mass + either low muscle strength (hand grip) or low physical performance
Mx
- exercise - resistance training
- medication - no approved, some benefits with: growth hormone, vit D, amino acid suplements
- nutrition - promotes protein synthesis
frailty scoring
Rockwood frailty scale
- low of homeostasis + resilience
- increased vulnerability to decompensation after a STRESSOR EVENT
- minor illnesses can cause profound deterioration
elder abuse
- Some frail older adults are vulnerable to abuse
- Usually from close relative
- Financial, verbal, physical, sexual
- Scale underestimated
- 3% of over 65s report it
what does the comprehensive geriatric assessment comprise?
medical - problem list, conditions + disease severity, medication, nutrition
functioning - daily activity levels/status, gait + balance
psychological - mental status, cognitive function, mood/depression
social/environment - informal needs + assets, social circle, care resource eligibility
most emphasised point of comphrehensive geriatric assessment
problem list !!
not list of differential but most symptomatic, includes non medical issues
- weight loss, falls, confusion, polypharmacy
how does an MI presentation in an older person differ?
young -> chest pain
older
- no chest pain in 1/3
- collapse, delirium
- dizziness, breathlessness
how does a sepsis presentation in an older person differ?
BP may drop early – esp those on vasodilating antihypertensives
Tachycardiac response may be absent
Temperature often low, not high
CRP + WCC may not rise (or not much) – WCC made in bone, frail
Fluid balance may be hard – problem if low BP, or kidney problems
- Frail older people have less homeostatic reserve, they are often delicately balanced
Antibiotics should be targeted as higher risk C.Diff + antibiotic resistance
delirium
acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs
disturbance in attention
change in cognition
short onset (hrs-days)
tends to FLUCTUATE
subtypes of delirium
hyperactive - agitated, agressive, wandering -> easy to diagnose
hypoactive -> withdrawn, apathetic, sleepy, coma -> easily missed, 2x the mortality rate
(be wary of drowsy “quiet” patient)
causes of delirium
DELIRIUM
Drugs/medication
Electrolyte disturbances – hyponatraemia
Lack of drugs – withdrawal
Infection
Reduced sensory input, pain
Intracranial – stroke/subdural
Urinary retention/constipation
Metabolic – AKI, hypoglycaemia, hypothyroid, B12/folate
delirium pathophysio
not well understood
- Variable derangement of multiple neurotransmitters (particularly ACh)
- Direct toxic insults to brain also contribute – drugs, hypoxia, low sodium, low glucose
- Irregular stress responses probably also contribute – cortisol, prostaglandins, cytokine release
how does delirium differ from dementia + depression
sudden onset
short, flutuating course
usually reversible
agitated, restless / sleepy slow (hyper/hypoactive)
alertness FLUCTUATES
impaired attention
disorganised thinking
distorted perception (hallucinations)
delirium screening
all patients >65yrs on admission to hospital should be screened - even if asymptomatic
confusion assessment method
4-AT score
confusion assessment method
requires features of 1 + 2 and either 3 or 4
- acute onset + fluctuating course
- inattention
- disorganised thinking
- altered level of consciousness
4-AT score
> =4 = possible delirium
89.7% sensitivity + 84% specificity for delirium
tests
- alertness
- AMT4 (age, DOB, current location, current year)
- attention
- acute change or fluctuating course
delirium investigations
History – often collateral from fam
Full examination, neurological, MSK – may be difficult due to agitation/confusion
Blood sugar – elderly at big risk of blood sugar problems
- Medication review
- Triage any patients with high NEWS
Tests
o Bloods – FBC, U&Es, LFTs, CRP, calcium, B12/folate, TSH, Mg, glucose
o Blood cultures if septic
o ECG
o Imaging – will depend on presentation
o Bladder scan
o CT head if indicated – focal neurolgy/head injury
common medication culprits for delirium
Opioids – tramadol, codeine
Anticholinergics – amitriptyline, oxybutynin
Sedatives – benzos, sleep tablets, anti-histamines
Psychotropic – lithium, anti-psychotics, anti-depressants
Anti-epileptics – phenytoin, carbamezapine
Cardiac medications – digoxin, anti-hyptensives
Steroids, NSAIDs
Withdrawal of medications/alcohol/nicotine
Parkinsons medications – NEVER stop these acutely with d/w PD specialist
non-pharmacological management of distress/agitation in delirium
encourage mobilisation
optimise chronic disease
activity charts - useful if prolonged
sensory input important - glasses, hearing aids ok
fluid chart - dehydration will exacerbate
capacity considerations in delirium
may have capacity for personal care but not medication decisions
adults with incapacity (AWI) form should be completed if appropriate
- review regularly, can be revoked post-delirium
initiate TIME bundle
- Think + exclude possible triggers
- Investigate _ intervene to correct underlying cause
- Management plan
- Engage + explore
pharmacological management of distress/agitation in delirium
1st line = haloperidol 500mg - IM if unable to take orally
DO NOT USE IN PARKINSONS OR LEWY BODY DEMENTIA
-> in these patients use lorazepam 500mg
if requiring ongoing antipsychotic then early referral to POA is v important
(reserved when non-pharma failed + symptoms threaten safety or to others - significantly distressing psychotic symptoms)
preventing delirium
- Minimal moves in hospital, regular orientation, glasses + hearing aids
- Maintaining oral hygiene, nutrition/hydration
- Medication should be reviewed on admission
- Pain control post-op + early recognition of post-op complications
- Early mobilisations
- Regular review of bladder/bowel function
falls
Prevalence increases with age, 50% of over 80s fall at least one a year
o 3 fold higher incidence in care-home residents
Majority of falls are multifactorial
- Significant burden to patient + NHS
Assessment + management of a patient presenting with falls needs to be multifactorial
falls
Prevalence increases with age, 50% of over 80s fall at least one a year
o 3 fold higher incidence in care-home residents
Majority of falls are multifactorial
- Significant burden to patient + NHS
Assessment + management of a patient presenting with falls needs to be multifactorial
implication of falls
40-60% suffer injury
5% result in fracture or hospitalisation
- (hip fracture mortality 1yr post op = 15-36%
loss of confidencce -> social isolation -> functional decline
costs NHS 2.3billion a year
40% of hospital admissions
why are old people more likely to fall?
motor coordination
central processing + cognition - decrease reaction time
sarcopenia
decreased cardioresp fitness
vision - smaller pupils lens thickening (decrease light)
decrease peripheral sensation + proprioception - increase postural sway
fear of falling increases risk of falls - restricts physical activity -> unconditioned balance skills
intrinsic factors contributing to falls
age related changes in gait, postural reflexes, muscle strength
cognition
impaired vision + hearing
medical conditions
- diabetes -> diabetic neuropathy -> altered proprioception + poor vision
- arthritis, parkinsons, stroke -> altered gait pattern
- incontinence -> increase need to rush, mobilised at night
- acute illness -> almost anything
extrinsic factors contributing to falls
medications - diuretics, antihypertensives, sedatives, anticholinergics, hypoglycaemic agents
environmental - rugs, stairs
inadequate lighting
inappropriate footwear
inappropriate use of walking aids
vision problems associated with falls
Early cataract surgery reduces falls
Bifocal + varifocal glasses are assoc with INCREASED falls risk
Recent optician visit/new prescription glasses INCREASE fall risk
*ask about vision distortion – age-related macular degeneration
-> “misjudging curb…”, central vision distortion of doorframes + curbs
when is rombergs test positive
in proprioceptive + vestibular disorders
loss of balance when eyes shut (feet together)
functionally significant peripheral neuropathy
loss of heel reflexes
decreased vibratory sense that improves proximally
impaired sense at great toe
inability to maintain unipedal stance for 10secs in 3 attempts
(possible causes - diabetes, alcohol, vit B12 deficiency)
“drop attack”
an event whereby the person suddenly collapses without any preceding symptoms + without apparent loss of consciousness
-> Account for 20% of elderly patients presenting to falls services
orthostatic hypotension diagnosis
based largerly off history of symptoms + a drop >20/10mmHg within 3 mins of standing
causes of orthostatic hypotension
baroreflex dysfunction - loss of baroceptor sensitivity + vasoconstriction associated with ageing (+vascular disease)
medication or other circumstances - volume depletion, immobility, alpha-blockers (BPH)
conditions that cause peripheral neuropathy can cause autonomic neuropathy + orthostatic hypotension
parkinsons + LBD
management of orthostatic hypotension
stop culprit drugs - alpha-blockers (doxasin+tamsulosin), antihypertensives, diuretics, pregabilin, antidepressants
avoid sudden changes in movement
increase salt in diet
compression stocking
elevate legs
calf muscle exercises
** when failed -> fludrocortinsone, midodrine **
psychotropic drugs that contribute to fall risk
taking doubles fall risk, stopping reduces fall risk
some cause orthostatic hypotension - venlafaxine, duloxetine, risperidone, haloperidol
phenytoin may cause permanent cerbellar damage + unsteadinessin long term use at therapeutic dose
cardiac medications which contribute to fall risk
alpha-blockers
- used for prostatism
- doxazosin, indoramin, tamsulosin, prazosin
ACEi + betablockers should be maintained whenever poss
NICE =
- stop nitrates, CCB or other vasodilators - always check BP
- if no evidence of congestion - reduce diuretics
what BP in old is assoc with increased fall risk?
BP of 120 or below
target BPs in over/under 80s
over 80 = <150/90
under 80 = <140/90
