Pre-reading

Question 1

What age-related differences are there medically in older people?

• Clinical findings
• Rehab
• Pathologies
• Presentations
• Homeostasis
• Immunity

Answer 1

• Clinical findings - may not necessarily be pathological, e.g. lung crackles
• Rehab - is more essential to return to ADLs and will take longer
• Pathologies - multiple pathologies likely
• Presentations - atypical presentations likely may present with medical problems in disguise e.g. as falls
• Homeostasis - reduced reserve e.g. CO response decreased
• Immunity - reduced, signs may not be typical e.g. no fever with infection, abdomen not rigid in peritonitis, WCC many not ↑ - hypothermia instead!

Question 2

What are the geriatric giants?

Answer 2

Common presentations of different illnesses:

1. Immobility
2. Falls
3. Incontinence
4. Confusion / delirium

Question 3

What are common sources of sepsis in older people?

Answer 3

• UTIs
• Chest infections
• Biliary tract infections

Question 4

Define frailty

Answer 4

→ vulnerability to poor homeostasis after a stressor event. The result of cumulative decline over a lifetime that depletes homeostatic reserve. Minor events then lead to a disproportionate change in health status.

Question 5

What are some common clinical presentations of frailty? x6

Answer 5

1. Falls - balance and gait impairment = major features of frailty
   
   • Hot-fall = related to a minor illness that ↓ postural balance below threshold needed to maintain proper gait
   • Spontaneous fall = more severe frailty, postural systems (e.g. vision, balance, strength) aren’t sufficient to navigate undemanding environments
2. Delirium (acute confusion) - characterised by rapid onset of fluctuating confusion and impaired awareness
   
   • ~30% of elderly persons admitted to hospital develop delirium
3. Fluctuating disability - day-to-day instability giving pts ‘good’ days and ‘bad’ days where professional help is needed
4. Sarcopenia (loss of muscle mass + strength due to ageing)
5. Osteoporosis
6. Non-specific: extreme fatigue, unexplained weight-loss, frequent infections

Question 6

What are the 2 types of fall?

Answer 6

1. Hot-fall = related to a minor illness that ↓ postural balance below threshold needed to maintain proper gait
2. Spontaneous fall = more severe frailty, postural systems (e.g. vision, balance, strength) aren’t sufficient to navigate undemanding environment, often present repeatedly and are associated with a fear of furhter falls

Question 7

What 7 aspects are assessed as part of a ‘comprehensive geriatric assessment’?

Answer 7

1. Medical diagnoses
2. Review of medication
3. Social circumstances
4. Assessment of cognition and mood
5. Functional ability - deficits in intrumental activitys of daily living (IADLs: banking, transportation, cooking, cleaning, shopping) or basic activites of daily living (BADLs: feeding, bathing, dressing, toileting)
6. Environmental assessment
7. Economic circumstances

Question 8

What are Instrumental activities of daily living? IADLs

Answer 8

IADLs: banking, transportation, cooking, cleaning, shopping

Question 9

What are basic ADLs? BADLS

Answer 9

feeding, bathing, dressing, toileting

Question 10

What are the 5 symptoms in Fried’s frailty phenotype (3 or more of which have to present for someone to be labelled ‘frail’)?

Answer 10

3 or more of the following:

1. Walking speed - appear in slowest 20% by gender and height
   
   • Measure: timed 15 foot (5 metre) walk
2. Grip strength - weakest 20% by gender and BMI
   
   • Measure: dynanometer
3. Weight loss - loss of 10 lbs (4.5kg) in the past year
   
   • Measure: self report
4. Fatigue - self reported “trouble getting going”
5. Activity level - lowest 20% (males: 383 kcals/week, females: 270 kcals/week)
   
   • Measure: self report no. of calories expended

Question 11

In elderly pts who can provide a history, what is required to diagnose UTI?

Answer 11

NOT a urine dipstick!

Only diagnose in the presence of at least 3 acute urinary symptoms:

• Dysuria
• Urgency
• Frequency
• Suprapubic tenderness

Question 12

What is the POSITIVE predicitive value of urine dipsticks in elderly pts?

Answer 12

Positive predictive value of dipstick = rubbish (“might as well toss a coin”)

• Asymptomatic bacteriuria is common in older people
• Only a -ve result is considered useful as it eliminates UTI
• Give antibiotics for UTI in elderly if:
  
  • Pts have acute urinary symptoms
  • or have bacteriuria and evidence of systemic inflammation (fever / ↑ inflammatory markers)
  • without another more likely source of infection

Question 13

What are the 4 categories of Risk Factors for Elder Abuse?

What is in each category?

Answer 13

1. Factors relating to the older (abused) person
   
   • Cognitive impairment
   • Shared living
   • Functional dependency
   • Low income
2. Factors relating to the perpetrator
   
   • Psychiatric illness (including dementia)
   • Drug and alcohol dependency
   • Caregiver burden and stress
3. Relationship factors between perpetrator and abused
   
   • Family disharmony
   • Conflicted relationships
4. Environmental factors
   
   • Low social support
   • Shared living