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.

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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