Geriatrics Mbchb4

DELIRIUM

1. Definition
a. Mental state characterised by –
i. loss of attn - easily distracted, cant focus
1. person may be drowsy or agitated
2. test – recite the days of the week
ii. confusion
1. disorientated to time and place
2. unclear or illogical train of thought
iii. fluctuating course
1. varies greatly over days/hours
2. often worse at night
iv. acute/subacute onset
1. comes on over hours/days
2. Diagnosis
a. Requires presence of 1 and 2 + either 3 or 4 (above)
b. Dementia – Ø loss of attention, fluctuating course or acute onset, only confusion
c. It can be difficult to diagnose delirium w/o a hx from someone who knows the pt well
3. Other features
a. +/- hallucinations
b. +/- emotional upset
c. Disturbed sleep/wake cycle
4. Epidemiology
a. Prevalence at admis ~20%
b. Prev during hospital stay – 6-56%
c. Prev in older persons in ICU - >70%
5. Risk factors
a. >75 yrs age (and the very young or in a severe inf such as malaria)
b. physical frailty
c. severe or multiple illnesses – in the older pt, a UTI can cause a delirium
d. dementia
e. visual impairment
f. deafness
g. malnutrition
h. multiple meds
6. Most common precipitants
a. LRTI
b. Urosepsis (UTI)
c. Catheters
d. Constipation
e. Electrolyte disturbance
f. Drugs
i. Anticholinergics
ii. TCAs
iii. Benzos
iv. Opiates
v. Anticonvulsants
g. Pain
h. Note – infection and drugs are the two most common causes
7. Management
a. Prevention is better than tx
i. Dx and tx of medical illnesses
ii. Avoid all unnecessary drugs
iii. Avoid urinary retention, constipation (rehydration) and pain (analgesia)
b. Benzos – only if risk or self injury or aggressive behaviour

DISABILITY – EPIDEMIOLOGY AND CONSEQUENCES

1. International classification of function
a. Impairment – eg CP on exertion
b. Disability – eg cant up stairs or carry heavy weights
c. Handicap – eg looses job as labourer
2. ADL Scales (Activities of daily living)
a. Personal ADL scales eg barthel
b. Extended ADL scales eg Nottingham extended ADL
3. Measurement Scales – Disability
a. Barthel scale – sens of 19%, NPV of 40% in discriminating disabled COPD subjects from healthy subjects
4. Depr and COPD in old age
a. Clinical depr in subjects w COPD disability – 42%
b. Similar in Parkinsons dis
c. Point prev of depr in most chr disabling dis in old age 20-35%
d. Depr ↓ QOL and ↑ disability (vicious cycle)
5. Institutional care
a. In nz – 50% of older people are sad or v sad to be there
b. 75% of those who considered institutional care but remained at home are happy or v happy to be there
6. Community care
a. In nz – only 17% of all social care expenditure on the 65+ age grp is spent on community care (lowest in the OECD)

DRUGS AND THE ELDERLY

1. What is an ADR?
a. Undesirable clinical manifestation of a drug(s)
b. May not be recognised
c. May be attributed to aging
d. 5x more common in the elderly
e. 10% of hospital admissions due to ADRs
2. Kramer’s Algorithm
a. Previous experience +/- 1
b. No alternative illness +/- 2
c. Timing of events +/- 1
d. Drug levels +/- 1
e. Dechallenge +/- 1
f. Rechallenge +/- 1
g. <0 unlikely, 0-3 possible, 4-5 probable, 6-7 definite
3. Inappropriate drug use
a. Potentially 66% of >70 yrs age
b. Comprehensive medication reviews – will reduce inappropriate drug use
c. Most commonly benzos + anti-HTN meds
d. Drugs appropriate in past may no longer be so
4. Age related changes
a. Absorption
i. Esophageal motility ↓
ii. Gastric emptying ↑
iii. Achlorhydria ↑ (↓ HCL prodn)
b. Metabolism
i. Liver weight ↓
ii. Liver blood flow ↓
iii. Minor effect except for drugs w high hepatic first pass metabolism – Ex. Morphine, Diazepam
c. Distribution
i. Body fluid ↓ → water soluble drugs achieve higher conc – Ex. Digoxin
ii. Relative fat ↑ → lipid soluble drugs have a longer ½ life and prolonged duration of action – Ex. Diazepam
iii. Altered protein binding – albumin the major carrier protein, albumin tends to change more in illness than age related → greater drug effect (particularly in higher bound drugs) – Ex. Warfarin
d. Receptor sensitivity
i. May be altered in elderly
e. Excretion
i. Normal decline in renal function w age
ii. Cr clearance - ↓ 10 mls/min/10 yrs from age 30-40 yrs age
iii. Creatinine level Ø an accurate measure in the elderly
iv. Result → prolonged duration of action and drug toxicity
v. Ex – lithium, digoxin, gentamicin
vi. Estimation of cr.clearance (cockcroft-gault equation)
1. CL (mL/s) = (140-age) x weight
5. Common adverse reactions
a. Confusion
b. Constipation
c. Postural hypotension
d. Falls
e. Extra-pyramidal side effects
6. Handling of drugs
a. Memory impairment
i. Keep simple regimes
ii. Daily dosing
iii. Minimise drug numbers
iv. Avoid take as directed
b. Visual impairment
i. Typed instructions
ii. Large print
iii. Clear bottles
iv. Vary size, shape and colour
c. Lack of dexterity
i. Blister packs
ii. Avoid child resistant bottles
iii. Dosette boxes
d. Other factors
i. cost
7. Most impt → Is the drug really necessary?
8. Drug Interactions
a. ACEIs and NSAIDs
b. Allopurinol and Azathioprine
c. Amiodarone and anticoagulants* (serious)
d. Anticoagulants and cotrimox
e. Carbamazapine and erythromycin
f. SSRIs and tramadol* (common)
g. Digoxin and amioadorone
h. Isoniazid and phenytoin
i. Lithium and thiazides*
9. Use with caution
a. Digoxin - toxicity can occur within normal range
b. Diuretics – incontinence, hypotension
c. Benzos – falls (10x ↑ risk)
d. NSAIDs – gastropathy, renal toxicity
e. Phenothiazines (eg maxalon) – parkinsonism
f. TCAs – constipation, postural hypotension, confusion
g. Glibenclamide – avoid in the elderly
h. Carbamazapine – sedation
i. Thyroxine – start slow
j. Levodopa – start slow
k. SSRIs – watch sodium
10. Non-compliance
a. Assoc w ↑ poor outcomes, esp if unintentional
b. ~40% of the elderly
c. Assoc w – poor vision, complex regimen, smoking hx, depr, living alone, absence of assistance w meds
11. Key points
a. ADRs – 5x more common in elderly
b. Aging effects on liver only a have a minor effect on drug metabolism
c. Impaired GFR in elderly pts
d. ADRs can occur within the normal range – eg digoxin
e. Benzos ↑ the risk of falls in the elderly 10x
f. Older pts more sensitive to warfarin than younger pts
g. Most new agents have not been thoroughly evaluated in older popns

ELDER ABUSE AND NECLECT

1. Definition
a. Harmful physical, sexual, financial/material and/or social effects caused by the behav of another person with whom they have a r/ship implying trust
b. A single or repeated act, or lack of appropriate action, occurring within any r/ship where there is an expectation of trust which causes harm or distress to an older person
2. Epidemiology
a. 3-10% of older popn
b. Under-reported
3. Types of Abuse
a. Pschological
b. Financial / material
c. Physical
d. Sexual
e. Neglect – active, passive
4. Clues to physical abuse
a. Multiple traumas
b. Lots of attendances at clinic
c. Injuries not matching the story
d. Postponed med tx
e. Changing GPs
f. Reaction to caregiver
g. Reluctance for ix
5. Clues to psychological abuse
a. Removal of decision making
b. Humiliation
c. Dehumanisation
d. Treats of abandonment
e. Institutionalization
f. Intimidation, coercion
g. Lack of eye contact
6. Financial abuse
a. Signing documents at times of crisis
b. Who has the card/pin number
c. Missing valuables
d. Selling house
e. No money for basics
f. Large toll bills
7. Clues to neglect
a. Withholding – eg warm clothes, heating, food, money for teeth/glasses/hearing aids/prescriptions, social opportunities etc
b. Confinement
c. Abandonment
8. Detection
a. Be aware
b. Ask routinely – open questions
c. Examples – How are things at home?, Do you feel you are getting enough care?, Do you feel safe?, Does your caregriver every get stressed or angry with you?, Are they kind to you?
d. Talk to the caregiver and older person separately
9. Similar to other forms of abuse but has unique features -
a. Dementia
b. Changing health status
c. Communication difficulties – eg speech, hearing, vision
d. Role reversal and care giving
e. Inheritance
f. Residential care
g. Non family members
10. Why does it happen?
a. Disempowerment, discrimination, ageism
b. Family issues
c. Carer stress, lack of knowledge, support training and supervision
d. Undervaluing role of careworkers
11. Who abuses?
a. Family members 70%
b. Sons and daughters 40%
c. Residential care – 66% still attributed to family members
12. Prevention
a. Rights based approach – independence, participation, care self fulfilment, dignity
b. Empowerment of older people
c. Raise awareness of elder abuse, educate
d. Change ageist attitudes and behaviour
e. Positive intergenerational r/ships
13. Ageism
a. A deep and profound prejudice against the elderly
b. Process of systematic stereotyping of and discrimination against people just bec they are old
14. Attitudes → Influenced by – society, medial training and professional attitudes, personal knowledge and experience
15. Language → shapes attitudes, reinforces stereotyping, influences dx, influences mgt
16. Interventions
a. Multi-disciplinary / multi-level → counselling, support, home help, respite, financial advice, specific medical interventions, legal
b. Age concern elder abuse and neglect prevention services
c. Local older peoples health services
d. Develop a plan, identify key worker

FALLS

1. Epidemioloy
a. 20% of older pts present with fall
b. Top 3 injury related death in older people – falls, MVA, suicide
c. Specific subgroups
i. Parkinsons dis – 6x ↑ risk of fall
ii. Lewy body dementia or intolerant of psychotropic meds → injury 10x more likely
d. Older people are more likely to fall because –
i. ↑ reaction time
ii. ↑ muscle response time
iii. ↓ muscle strength
iv. ↓ muscle power
v. Vestibular system impairment
vi. Visual impairment
2. Reasons for falling
a. Extrinsic – hazard
b. Instrinsic – syncope, MI, Hb etc (incr likelihood as pts age gets older)
c. Alcohol
d. CVA, LOC, Seizure
3. Classification
a. Hot falls – acute medical problem (inf, CV event, multifactorial, loss of consciousness)
b. Cold falls – non-acute (multifactorial)
c. Hazards
4. Hx
a. How did you fall? – hazards, mechanism of injury
b. Was there a loss of consciousness?
c. How were you feeling just before the fall and during the fall? - syncope, CP, confusion, weakness
d. What happened after the fall?
5. Exmn
a. Lying and standing BP (Postural hypotension when sys >20 / diastolic >10)
b. General – nutrition
c. CV exam – arrhythmia, CHF
d. Neurological – cognition, CVA, TIA, weakness
e. MS – strength (lower limb), balance, timed up and go, rhombergs, sternal push
6. Hot falls
a. New or old
b. Acute unwell? – intrinsic causes of falls, stroke, MI, other CV inf, constipation, dehydration
c. Meds? Assumed med as cause until proven otherwise – new meds, interaction, ADR
d. Has person injured themselves?
e. Clinical exmn
i. Hx + exmn
ii. Gait and balance – timed up and go (stand up from a chair w/o arms, walk a few paces, then sit down again (if they can do this, low chance of falling)
iii. Consider ALL meds
iv. ECG
v. Hb, MSU, U/Es
vi. Do they require 2ndry care?
f. Management
i. Tx any cause identified – eg inf, CV, meds, Parkinsons, Lewy body dementia
ii. Tx injury
iii. Expect loss of confidence and fear of falling
iv. Prevent further falls
7. Risk factors for falling
a. Physical Health
i. Episode of serious illness
ii. Balance and gait impairment
iii. Reduced lower limb strength
iv. Hx of arthritis, Parkinsons
v. Near vision loss >20%
vi. Hearing loss
vii. Foot problem
viii. Urinary incontinence
b. Medications and Mental Health Hazards
i. Sedatives ↑↑↑
ii. >3 drugs ↑
iii. Fear of falling ↑↑↑
iv. Depr
v. Impaired cognition
vi. >1 bedroom hazard
vii. Use of cane or walker
c. Sociodemographic and lifestyle
i. Age >80 yrs
ii. Home alone >16 hrs /day
iii. Fall in prev 2 years
iv. >1 fall related injury
v. Supported accommodation
vi. Leaves residence <1 /week
vii. Low SN score
viii. Needs help >1 ADL
8. Prevention
a. Community
i. Medications
ii. Individualised exercise program
iii. ↓ of sedatives
iv. Etal modification exercise and education
v. Visual assessment
vi. OT home assessment for those with low vision
b. Residential care
i. Exercise based interventions – lower leg strength
ii. Vit D (common during winter, osteomalacia → proximal myopathy)
iii. Hip protectors prevent hip #
iv. NOT education or risk assessment

OLD AGE – HEALTH OR SICKNESS?

1. Convergence effect
a. Several factors converge leading to → eg. a fall
b. Factors incl –
i. Poor vision
ii. Cluttered house
iii. Drugs
iv. Confusion
v. Incontinence
vi. Arthritis
vii. Postural drop
viii. Pets
2. Cascading
Ex. - Broken light bulb
Fall
Hip #
Pn
Hypoxia
Confusion
Sedation
Starvation
Death
3. Cycling
a. Respiratory depression → Hypoxia → Confusion → Sedation → Respiratory depression → …..
4. Unmasking
a. Angina fixed with stent
b. → pt more mobile therefore needs Hip pain fixed with surgery
c. → can now drive again but needs cataract fixing

REHABILITATION

1. Definition
a. Rehab = the process of helping a person to reach the fullest physical, psychological, social, vocational and avocational and educational potential consistent with his/her physiological or anatomical impairment, evtal limitations and desires of life plans
b. Pts, families and the rehab team work together to determine realistic goals and to develop and carry out plans to obtain optimal function and adjustment to disability, despite residual functional limitations
2. Rehabilitation Concept
a. Comprehensive and holistic – includes prevention and early recognition as well as inpatient, outpatient and extended care programs
b. Function is the main area of interest for a rehab physicain
3. Anticipated pt outcomes of integrated rehab process should incl –
a. ↑ independence (via improved/optimised function)
b. Improved QOL
4. Rehab model
a. Differs from the medical model in several ways –
i. Mgt of disability emphasised, rather than on tx of dis
ii. Rehab specialist is considered a teacher and facilitator as well as a knower or doer
iii. Pt is an active rather than a passive participant
iv. Interdisciplinary team approach
5. Commonly used terms
a. WHO
b. ICIDH 1980 – International classification of impairments, disability and handicaps
c. ICIDH-2 2001 - Revision
6. ICIDH-2
a. Impairments
i. Problems in body function or structure as a sig deviation from or loss
ii. Residual limitation resulting from dis, injury, congenital defect
iii. Eg – loss of motor strength of lower limb following spinal cord injury
b. Activity Limitations (Disabilities)
i. Difficulties an individual may have in executing activities
ii. Inability to perform a functional skill – eg walking
c. Participation restrictions (handicaps)
i. Problems an individual may experience in life situations
ii. The interaction of a disability with the evt
iii. Eg – Being unable to enter a restaurant bec it is not wheel chair accessible
7. Principles of Rehab
a. Prevention of complications
b. Restoration of function (function)
c. Adaptation of function (function and personal)
d. Provision of aids and appliances
e. Re-integration
8. MDT = Multi-disciplinary team
a. Effective rehab requires the perspectives, knowledge and skills of multitude of professionals
b. The medical professional is NOT the most impt member of the team, though by convention, they are often the leader of it
c. Team members
i. Medical
ii. Physiotherapy (PT)
iii. Occupational therapy (OT)
iv. Speech/Language Therapy (SLT/SALT)
v. Dietician
vi. Nursing
vii. Social worker
viii. Psychology/Podiatry/Orthotics
9. Rule of thumb → For every one day spent in bed, 4 days reconditioning is reqd
10. Neurological Rejuvenation
a. Myth – the adult CNS is hard wired and the consequences of damage immutable
b. Three Rs –
i. Retraining reorganises neural circuits and networks
ii. Replacement of cells and chemical messengers
iii. Regrowth of axons, dendrites and synaptic connections
11. Measuring success of rehabilitation
a. Some models of measurement (eg QALYs) are discriminatory – eg older adults
12. Key Points
a. Improvement do continue to occur after 12 months
b. Community occupational therapy improves outcome – it improves function and prevents deterioration in ADL after stroke

SECONDARY STROKE PREVENTION

1. Epidemiology
a. Recurrence rates for stroke in first 6 months – up to 10%
b. About 15% pa after first year
c. Stroke survivors more likely to die of MI than recurrent stroke
2. ABCD Score for TIAs
a. Age
i. Age >60 yrs = 1
b. BP at assessment
i. SBP >140 or DBP >90 = 1
c. Clinical feats
i. Unilat weakness = 2
ii. Speech disturbance (Ø weakness) = 1
iii. Other = 0
d. Duration
i. >60 mins = 2
ii. 10-59 mins = 1
iii. <10 mins = 0
3. 7 day risk of stroke
a. Score <5 – Risk = 0.4%
b. Score 5 – Risk = 12%
c. Score 6 – Risk = 31%
4. Secondary prevention or Stroke - Pharmacological
a. Anti-platelets
i. Aspirin – low dose, almost all pts
ii. Dipyridamole – dubious but widely used when aspirin fails
1. ESPRIT Study
a. 3 arms → aspirin, aspirin and dipyridamole, warfarin w INR 2-3
b. Primary outcome event composite of – vasc death, non-ftal stroke, non-fatal MI, major bleeding
c. Outcome events – 13% combo tx vs 16% monotherapy (RRR = 18% pr year / NNT = 104 pr year)
iii. Clopidogrel
1. CAPRIE Study
a. Subgroup analysis of those w symptomatic stroke or IHD
b. 75 mg Clopidogrel vs 325 mg ASA (asprin)
c. ARR 3.4%, NNT 29 for 3 yrs (non-sig)
2. MATCH Study
a. Clopidogrel 75 mg vs ASA 75 mg + Clopidogrel 75 mg
b. ARR 1% (non-sig)
c. ARI of ICH (intracranial hem) of 1.3% (non-sig)
iv. Warfarin
1. Definite Indications –
a. AF (INR 2-3 target)
b. Prosthetic heart valves (2.5-3.5 target INR)
2. Probable indications – usu 3-6 months, INR 2-3 (not EBM)
a. Mural thrombus
b. Arterial dissection
b. Diabetes
i. Tight control might ↓ recurrent macrovascular events – no trials
ii. Tight control does not ↓ microvascular events
iii. No evidence re early mgt
c. Homocysteine Lowering
i. VISP Study
1. Post cerebral infarct pts
2. Low dose folate 2.5 mg vs High dose 20 mg
3. High dose ↑ reduction in homocysteine but NO effect on stroke, MI or death
ii. NORVIT and HOPE2 Study – post Mi pts, no advantages
d. Blood pressure
i. PROGRESS Study
1. Tx – perindolpril + indapamide
2. 28% RRR
3. 3.7% ARR
4. NNT = 27 (NNT 23 in those w the lowest starting BP)
ii. Effect of tx indep of starting BP
iii. Usu need 2 agents
iv. Perindopril (and possibly all ACEs) not effective on own
v. The lower the better
e. Cholesterol
i. Heart protection study
ii. Tx w Simvastatin 40 mg
iii. ARR 5.1%, NNT = 20
iv. Irrespective of starting cholesterol level
f. Key points – tx BP and cholesterol (measuring not reqd – give tx regardless), ignore homocysteine
5. Secondary prevention of stroke – Lifestyle changes
a. Stop smoking
b. Limit drinking
c. If obese – loose weight
d. Reduced added salt
e. Exercise 30-60 mins / week (Brisk)
6. Carotid Srugery
a. ONLY for those w carotid territory strokes
b. >70% stenosis
c. Good surgeon - <6% mortality/mobidity
d. Otherwise well
e. Early is best
f. CEA = Carotid endarterectomy – excision of occluding material (including intima and most of the media from a carotid artery)
g. Stents
i. SAPPHIRE Study
1. High risk pts – angio vs stent vs CEA
2. No difference found
ii. CAVATAS Study
1. Angioplasty +/- Stent vs CEA
2. No difference
iii. Summary
1. v small data base
2. an option for those where CEA not possible
7. Cost Effectiveness – per event avoided
a. Cheap
i. Diuretics
ii. Aspirin
iii. Warfarin for AF
iv. Stopping smoking
b. Moderate
i. ACE
ii. Aspirin and dipyridamole
iii. Statin
c. Expensive and ?unnecessary
i. Clopidogrel
ii. CEA

STROKE REHABILITATION

1. Stroke Facts
a. Leading cause of adult disability and 3rd leading COD in USA and NZ
b. Overall incidence of Strokes is on the decline – esp for European NZers but on the incr for M/PI
2. What is stroke rehab?
a. Reiterative, education, problem-solving process
b. Aims to minimise handicap and stress
c. Helps pt to regain the functional abilities they may have lost as a result of the stroke
d. Discover new ways of adapting to disabilities that are slow to recover – eg learning to write with the opposite hand
e. Independence to ADL, domestic activities, community activities, hobbies and return to employment
f. Support the pt and the family physically, socially and emotionally
g. Precise nature varies according to the pts needs
3. When does stroke rehab begin?
a. On the first day of the stroke, provided the pt is conscious enough to participate
b. Beginning rehab as soon as possible produces better results
4. Stroke in left (dominant) hemisphere
a. R visual field deficit and L gaze preference
b. Aphasia
c. R hemiparesis and R hemisensory loss
d. Easily frustrated
e. Slowness, Clumsiness
f. Overwhelming urges to perform or repeat some actions
g. Difficulty structuring and planning beh
h. Poor motiv
i. Difficulty dealing w numbers (arthrimitc)
5. Stroke MDT
a. Doctors , Nurses, PT/OT, SLT, Neuro-psychologist, Dietician, Social worker, Pharmacist, Specialist in orthotics/prosthetics
6. Stroke outcomes in rehab; to reduce -
a. Recurrent events
b. Stroke related disability
c. Post stroke cogv impairment/dementia
d. Post stroke dper
e. Other stroke related complications
f. Stroke deaths – 12% risk at 7 days, 19% at 30 days, 31% at one year, 60% at 5 yrs
7. Example of Stroke Rehab
a. Plantar flexor spasticity 2ndry to stroke → decreases mobility and reduces function
b. Botulinum toxin tx can reduce spasticity
8. Complications of Stroke
a. Aspiration pn
b. Recurrent stroke or CV events
c. Skin b/down
d. DVT/PE
e. Depr and mood d/os
f. Behal probs
g. Falls
9. Rehab
a. Goal setting – intermediate and LT goals set by stroke pts
b. Duration and nature of rehab depends on the pts needs, goals and response to rehab
c. Rehab may be provided in hospital acute and rehab units, at home, hospital or other community outpatient establishments
10. Prevention and Rehab; stroke may be prevented by -
a. Lifestyle
i. Exercise regularly
ii. Incr intake of fruit and veges
iii. Smoking cessation
iv. Drink alcohol in moderation – 1-2 units/day
v. Maintain healthy weight
b. Medical
i. BP monitoring – keep in safe range
ii. Low dose aspirin – 75 mg OD
iii. Keep chr medical conditions under control – eg high cholesterol, AF, DM
iv. Seek medical care if sxs of stroke, even if sxs stop
11. Prognosis at 12 months
i. 1/3 have died
ii. 20-30% dependent on another person for everyday activities – eg washing, dressing, mobilising
iii. 40-50% are indep
b. Major clinical factors predictive of independence at 6 months after a storke
i. Age
ii. Living alone prior to stroke
iii. Independence w ADLs prior to the stroke
iv. Normal verbal GCS = 5
v. Able to lift both arms to horizontal
vi. Able to walk w/o help of another person/aid
c. Indicators of poor survival after stroke
i. Depr
ii. Urinary incontinence
iii. Papillary abnormalities
iv. Gaze paresis
v. Severe limb weakness
vi. Bilat extensor plantar responses
vii. Cardiac failure
viii. AF

SUMMARY - GERIATRICS

Old Age – health or sickness

1. Convergence effect – eg several factors such as poor vision, drugs, incontince, arthritis, postural drop etc lead to a fall
2. Cascading – eg broken light bulb → fall → hip # → hospital → pn → confusion → sedation → starvation → death
3. Cycling – respiratory depr → hypoxia → confusion → sedation → respiratory depression
4. Unmasking – eg angina fixed with stent, pt more mobile, now requires hip surgery, then can drive so cataract surgery etc

Falls

1. Epidemiology
a. 20% of older people present with a fall
b. one of the top 3 injury related death in older people – mva, suicide, falls
2. Reasons for falling
a. Extrinsic – hazard
b. Intrinsic – syncope, MI, ↓ hb etc
c. Alcohol
d. CVA, loss of consciousness, seizure etc
3. Classification
a. Hot falls – acute medical problem – eg inf, CV event, loss of consciosness
b. Cold falls – non-acute (multifactorial)
c. Hazards
4. Hot falls
a. Acutely unwell – eg stroke, MI, infection, constipation, dehydration
b. Drugs
5. RFs for falling
a. Physical health
i. Illness
ii. Bal and gait impairment
iii. ↓ lower limb strength
iv. Arthritis
v. Parkinsons
vi. Vision loss
b. Medications and mental health hazards
i. Sedatives
ii. Polypharmacy
iii. Fear of falling
iv. Depression
c. Sociodemographic and lifestyle
i. Age >80
ii. Home alone >16 hrs/day
iii. Leaves residence <1 /week
6. Prevention
a. Community – meds, IEP, ↓ sedatives, etal modification, eyesight tested, OT home assessment for visually impaired
b. Residential care – ↑ lower limb strength exercises, Vit D (oseteomalacia and prox myopathy), hip protectors

Delirium

1. Definition
a. Mental state characterized by –
i. Attention loss – may also be drowsy or agitated
ii. Confusion – unclear or illogical train of thought
iii. Fluctuating course – varies over the day, often worse at night
iv. Acute/subacute onset – comes on over hours/days
b. Requires 1 and 2 + either 3 or 4
c. Other features that may be present – hallucinations, emotional upset
d. Dementia – confusion but no attn loss, no fluctuating course and not acute onset
2. Epidem – 20% prev at admis, 6-56% during stay
3. RFs - >75 yrs, physical frailty, severe or multiple illnesses, visual impairment, deafness, malnutrition, polypharmacy
4. Most common precipitants → infection and drugs two most common causes
a. LRTI
b. UTI
c. Catheters
d. Constipation
e. Elyte disturbance
f. Drugs – Benzos, opiates, anticholinergics, TCAs
g. Pain
5. Mgt
a. Prevention better than tx
b. Dx and tx all medical illnesses
c. Avoid all unnecessary drugs
d. Avoid urinary retention, constipation (fluids) and pain (analgesia)
e. Benzos – only use if risk of self injury or aggressive behaviour

Drugs and the elderly

1. ADR
a. 5x more common in elderly
b. 10% of hospital adm
2. Common adverse reactions – confusion, constipation, postural hypotension, falls
3. Age related changes
a. Liver metabolism – only minor effect
b. Distbn – body fluid ↓ so water sol drugs achieve higher concentration (eg digoxin)
c. Excretion – renal function ↓ with age
4. Handling of drugs + practical strategies
a. Memory impairment – keep regimes simple, daily dosing, minimize drug numbers, avoid take as directed
b. Visual impairment – typed instructions, large print, clear bottles, vary size/shape/colour
c. Lack of dexterity – blister packs, avoid child resistant bottles
5. Examples of drug interactions
a. ACEIs and NSAIDs
b. SSRIs and tramadol
c. Lithium and thiazides
6. Examples of cautions
a. Diuretics – incontinence, hypotension
b. Benzos - ↑ falls risk 10x
c. NSAIDs – gastropathy, renal tox
d. Glibenclamide – hypoglycaemia
e. SSRIs – hyponatremia

Elder abuse and neglect

1. Def – a single or repeated act, or lack of appropriate action, occurring within any r/ship where there is an expectation of trust which causes harm or distress to an older person
2. Epidem – 3-10% of older popn
3. Types of abuse
a. Psychological
b. Financial
c. Physical
d. Sexual
e. Neglect – active or passive
4. Clues to physical abuse
a. Removal of decision making
b. Humiliation
c. Dehumanization
d. Threats of abandonment
e. Institutionalisation
Intimidation, coercion
f. Lack of eye contact
5. Why does it happen
a. Disempowerment, discrimination, ageism
b. Family issues
c. Carer stress, lack of knowledge, support training and supervision
d. Undervaluing role of careworkers
6. Ageism
a. Deep seated prejudice against the elderly

Disability – epidemiology and consequences

1. International classification of function
a. Impairment – problems in body function/structure as a sig deviation eg loss motor limb strength following spinal cord injury
b. Activity limitations (disabilities) – difficulties an individual may have in executing activities – eg difficulty walking
c. Handicap – problems individuals may experience in life situations (interaction of disability with evt) eg cant enter restaurant due to lack of wheel chair access
2. ADL Scales
a. Personal eg barthel
b. Extended ADL scales eg nottingham

Rehabilitation

1. Def
a. Process of help a person reach their fullest physical, psychological, social, vocational and educational potential consist w their physiological impairment, environmental, limitations etc
b. Pts, families and rehab team work together to determine realistic goals, carry out plans to obtain optimal function and adjustment to disability, despite functional limitations
2. Rehab concept – holistic and comprehensive → improve qol and indepdence
3. Rehab model
a. Mgt of disability emphasized rather than tx
b. Pt active participant
c. Interdisciplinary team approach
4. Rehab principles
a. Prevent complications
b. Restore function
c. Adaptation of function
d. Provision of aids and appliances
e. Re-integration
5. MDT – medical, PT, OT, SLT, Dietician, Nursing, social worker, psychology, podiatry/orthotics

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