Transcript Geriatric_Giants_Jane_Courtney - E-Ageing: E
THE GERIATRIC GIANTS
MEDICINE 400 Jane Courtney Hollywood Private Hospital 30 th June 2008
Immobility Instability Incontinence Impaired intellect/memory
Impaired vision Impaired hearing Delirium Poly-pharmacy Care provision
Assessment Multi-disciplinary Functional - adl’s - iadl’s Problem oriented
FALLS
INCIDENCE – 30% community dwellers >65 years – 50% long term care – 60% fall in last year
CONSEQUENCES • 10 –15% fracture • Decrease in functional status • 2% injurious falls result in death
COSTS • 8% ED presentations >70 years • 33% of these admitted • Median stay 8 days
RISKS • Rarely single cause
Falls usually occur when a threat to the normal homeostatic mechanisms that maintain postural stability is superimposed on age-related declines in balance,ambulation and cardiovascular function.
Threat •Acute illness •Environmental stress •Unsafe walking surface
RISK FACTORS • Age • Female • Past fall • Cognitive impairment • Lower limb weakness • Balance disturbance
RISK FACTORS • Psychotropic meds • Arthritis • Past CVA • Orthostatic hypotension • Dizziness
AGE RELATED FUNCTIONAL DECLINE • Visual • Proprioceptive • Vestibular
ENVIRONMENT • FOOTWEAR • HOME MODIFICATIONS • BEHAVIOUR • SAFETY DEVICES • SOCIAL INTEGRATION
DISEASE RELATED FUNTIONAL DECLINE
• CVA • Parkinsons • Cerebellar • Neuropathy • Dementia • Delerium • Epilepsy neurological
cardiovascular • Arrythmia • Orthostatic hypotension • Anatomical • Vasomotor instability
GIT • Bleeding • D&V • Defecation syncope
• Hypothyroid • Hypoglycemia • Hypokalemia • hyponatremia metabolic
UGS • Micturition syncope • Nocturia • Incontinence
musculoskeletal • Arthritis • Myopathy • Deconditioning
• Anxiety • Depression Psychiatric
medications • Antihypertensives and cardiac • Antidepressants • Antipsychotics • Benzodiazepines • Levadopa • Narcotics
• Alcohol toxins
MECHANISM • SYNCOPE /HYPOTENSION • SEIZURE • DIZZINESS / BALANCE • GAIT DISTURBANCE • PAIN / WEAKNESS • MECHANICAL FALL
FUNCTIONAL IMPAIRMENT • BP regulation • Central processing • Gait • Neuromotor function • Postural control • Proprioception • Vestibular • vision
EVALUATION • History esp of fall • Examination esp BP, balance, vision, gait • Get up and go • Divided attention • Tests
PREVENTION • Strength and balance • Education • Medications • Environmental mods
PREVENT COMPLICATIONS
DEMENTIA
Causes of Cognitive Impairment
J-0
1 Delirium • Sepsis • Hypoxia • Biochemical disturbances Calcium, sodium, glucose,urea,hepatic
DEFINITION • An
acute
organic mental syndrome characterized by: • Global cognitive impairment • Reduced consciousness • Disturbed attention • Psychomotor activity • Sleep-wake cycle disturbance
2 Neurological disease • Brain tumour • Stroke • Subdural
3 Psychiatric Disease • Depression • Anxiety • Alcohol or other substance abuse
4 Medications
• Thyroid • B12 • Folate 5 “Classics”
6 Benign Forgetfulness
7 Dementia
Definition of Dementia • The development of multiple cognitive deficits manifested by both memory impairment and one or more of the following – Aphasia -Apraxia -Agnosia – Disturbance in executive functioning • These cognitive deficits cause significant impairment in social or occupational functioning • The course is characterized by gradual onset and continuing cognitive decline • The cognitive deficits are not due to other CNS, systemic, or substance induced conditions • The deficits do not occur exclusively during the course of a delirium • The disturbance is not better accounted for by another Axis I disorder
Reference: DSM-IV, pp 133-155.
A-2
CRITERIA FOR DIAGNOSIS • MEMORY IMPAIRMENT • OTHER COGNITIVE IMPAIRMENT – Language, motor skills, perception • ADL IMPAIRMENT • INSIDIOUS ONSET • DETERIORATING • NO OTHER CAUSE – Systemic,neurological, psychiatric
CRITERIA FOR DIAGNOSIS • PATHOLOGY- autopsy or brain biopsy
Comparison delirium and dementia • Sudden onset • Usually reversible • Short duration • Fluctuations • Altered consciousness • Associated illness • Inattention • Always worse at night • Impaired variable recall • Insidious onset • Slowly progressive • Long duration • Relatively stable • Normal consciousness • Not associated • Attention not sustained • Can be worse at night • Memory loss
TYPES OF DEMENTIA • PRIMARY NEURODEGENERATIVE – CORTICAL • Alzheimer’s disease • Fronto-temporal dementias (Pick’s disease) – SUBCORTICAL • Progressive supra nuclear palsy • Huntington’s • Lewy Body Disease
TYPES OF DEMENTIA • VASCULAR – Multi-infarct – Biswangers disease • INFECTIVE – Creutzfeld-jacob – AIDS – Neurosyphilis
TYPES OF DEMENTIA • TRAUMA – Sub dural – Dementia pugulistica – radiotherapy • NORMAL PRESSURE HYDROCEPHALUS
TYPES OF DEMENTIA • ASSOCIATED WITH OTHER DISEASES – Parkinson’s – Wilson’s – Multiple sclerosis – Tumours – Vasculitis
Alzheimer’s Disease Diagnosis • Acquired decline in cognitive function of an insidious and progressive nature – Loss of memory – Impairment of at least one of; • Language • Perception • Praxis • Problem solving, planning, organization • Judgement, insight or abstract thought – Decline in ability to perform activities of daily living
A-1
A B • (A) Immunocytochemical staining of NFTs in the isocortex of human AD brain with the anti-tau antibody AT8 • (B) Immunocytochemical staining of senile plaques in the isocortex of human AD brain with the anti-amyloid antibody 4G8
A-7
Cholinergic Hypothesis • Role – Acetylcholine (ACh) is an important neurotransmitter in areas of the brain involved in memory formation (eg. hippocampus, cerebral cortex, and amygdala) • Impact – Loss of ACh occurs early in AD and correlates with the impairment of memory • Treatment approach – Enhancement or restoration of cholinergic function may significantly reduce the severity of cognitive loss
Reference: Mayeux R, et al. N Engl J Med. 1999;341:1670-1679.
A-9
TREATMENT
Overall Management • Is it Alzheimers? OR what?
• Are there any reversible components?
• Any specific treatments?
• Educate and support carer/family.
• Treat symptoms as they arise.
• Treat intercurrent problems.
Medications • Can cause cognitive impairment • Can treat memory loss (Alzheimer’s, DLB) • Can treat symptoms • Can prevent (vascular)
Cause Cognitive Impairment • Sedatives • Antidepressants • Analgesics • “SIADH” • Antiepileptics • Specials – Digoxin, cimetidine, lithium.
Treat Memory • Cholinergics • ?oestrogens
• Vitamin E • Selegeline
Treat Symptoms • Treat family • Non pharmacological • Antipsychotics • Benzodiazepines • ANTIDEPRESSANTS
Number of Drug Uses (000)
Drug Utilization Trends in
1500 1000
Dementia
Aricept Risperdal Haldol Ativan Vitamin E Zoloft Zyprexa 500 0 1995 1996 1997 Source: NDTI (Diagnosis codes: 3310, 2900, 2901, 2902, 2903, 2904), 1999. 1998 1999 T-5
Drug Reminyl ® Aricept ® Exelon ® Feature Comparison MoA AChEI, nAChR AChEI AChEI Binding Dose Escalation Dosing Competitive, reversible Noncompetitive, 4/6-week steps od reversible Pseudo irreversible 4-week steps 1-week steps bd (od) bid
T-10
Presynaptic nerve terminal
Neuron and Acetylcholine
M receptor Postsynaptic nerve terminal M-4
AD REM 8 59
Reminyl ® Dual Mechanism of Action
M-6 Presynaptic nerve terminal M receptor Postsynaptic nerve terminal
AD REM 8 60
INCIDENCE • 15% - 30% community-dwelling • 30% hospitalized • 50% long-term care
Predisposes to • Rashes • Pressure sores • Urinary tract infections • Falls • Fractures • Increased risk of institutional care
INCONTINENCE IS A SYMPTOM Incontinence is abnormal at any age.
Prevalence increases with age.
At no age does it affect the majority of individuals.
Even with severe dementia not all people are incontinent NEW INCONTINENCE MUST BE INVESTIGATED
• Transient or established.
• Urge, stress or overflow.
• Clinical.
• D • I • A • P • P • E • R • S Transient delirium infection atrophic vaginitis pharmaceuticals psychological (depression) excessive output restricted mobility stool impaction
pharmaceuticals • Anticholinergics • Alpha agonists (men) • Alpha antagonists (women) • Calcium channel blockers • ACE inhibitors (cough) • Diruretics • Sedatives (and alcohol)
Established Patho-physiological mechanisms detrusor overactivity detrusor underactivity obstruction outlet incontinence Each can be either neurogenic or non neurogenic
WHAT DO WE DO?
HISTORY EXAMINATION INVESTIGATIONS.
TYPE FREQUENCY PATTERN MEDICAL MEDICATIONS FUNCTION
FULL PHYSICAL….GUIDED
PELVIC RECTAL NEUROLOGICAL STRESS
VOIDING CHART U&E, CALCIUM, GLUCOSE URINALYSIS+/- MSU RESIDUAL VOLUME ULTRASOUND URODYNAMICS CYSTOSCOPY
TREATMENT FIRST THE CAUSE IN TRANSIENT STRESS- PELVIC FLOOR EXERCISES - WEIGHT LOSS - OESTROGEN - SURGERY OBSTRUCTION - ALPHA ANTAGONIST - SURGERY
DO - ANTICHOLINERGIC DU - CATHETER PADS, BOTTLES, COMMODES
A LAST WORD ABOUT
POLYPHARMACY
THE GERIATRICIAN’S PEN v’s A BALANCING ACT