Geriatric Giants
- Memory
- Falls
- Incontinence
- Polypharmacy
5 Is of Geriatrics
- Immobility
- Intellect
- Incontinence
- Iatrogenesis
- Impaired homeostasis
1 In the elderly patient taking multiple medications, avoid polypharmacy by: – monitoring side effects.
– periodically reviewing medication (e.g., is the medication still indicated, is the dosage appropriate).
– monitoring for interactions.
Preventing Polypharmacy
- Consider drug: safer s/e profiles, convenient dosing schedules, conveninet route, efficacy
- Consider pt: other meds, clinical indications, medical co-morbidities
- Consider pt-drug interaction risk factors for ADRs (Adverse Drug Reactions)
- Review drug list regularly to eliminate medications with no clinical indication or with evidence of toxicty
- Avoid treating an ADR with another med
- Consult Beers Criteria for meds to avoid
- for >65yo
- eg. BZD, anticholingergics, sedatives
Approach to Medication Review in the Elderly – NO TEARS
- Need and indication & New Medications – start low and go slow
- Open-ended questions – to get pt’s perspective on medications
- tests and monitoring to assess dz control
- Evidence and guidelines
- Adverse events
- Risk reduction of adverse events such as falls
- Simplification / switches
Principles for Rx in the elderly – CARED
- Caution / Compliance
- Age (adjust dosage for age)
- Review regimen regularly
- Educate
- Discontinue unnecessary medications
Risk factors for Non-Compliance
- Number of medications (not age)
- increased frequency,
- complicated container design,
- financial constraints,
- cognitive impairment
2 In the elderly patient, actively inquire about non-prescription medication use (e.g., herbal medicines, cough drops, over-the-counter drugs, vitamins).
3 In the elderly patient, screen for modifiable risk factors (e.g., visual disturbance, impaired hearing) to promote safety and prolong independence.
Falls
Etiology – multifactorial
- Extrinsic
- Environmental: home layout, lighting, stairs, footwear, accidental, abuse
- Medications / substances – EtOH
- Sedative-hypnotic / anxioltyic: BZD
- Antidepressant: MAOI, SSRIs, TCAs
- Antipsychotics / Tranquilizers: Butyrophenones
- Antihypertensive drugs
- Antiarrhythmics – Class 1A
- Diuretics
- Systemic corticosteroids
- NSAIDs
- Anticholinergics
- Hypoglycemics
- Within 1 mo of hospital d/c, acute ilness, exacerbation of chronic illness
- Intrinsic
- orthostatic / syncopal
- age-related changes and dz associated with aging:
- MSK: arthritis, muscle weakness
- Sensory: visual, proprioceptive, vestibular
- Cognitive: depression, dementia, delirum, anxiety
- CV: CAD, arrhythmia, MI, low BP
- neurologic: stroke, ↓ LOC, gait disturbances / ataxia
- Metabolic: glucose, electrolytes
- Hx of fall within the past 1-2 yr is a predictor of MVA – evaluate their ability to drive & counsel about driving
Hx:
- Quick screen: ask about falls in past year & problems with gait or balance
- Further assessment if answered yes
Risk Factors:
- Age >80yo, female
- Previous falls
- Balance impairment / gait impairment & walking difficulty
- dizziness or orthostasis
- Decreased muscle strength, arthritis, pain
- visual impairment
- Polypharmacy >4meds ad psychoactive drugs
- depression, cognitive impairment
- Incontinence, functional limitations
- Diabetes
PEx: I HATE FALLING
- Inflammation of joints
- HoTN (orthostatic changes)
- Auditory & visual abnormalities
- Tremor
- Equilibrium (balance) problem: Romberg test, Pull Test
- Foot problems
- Arrhythmia, heart block or valvular dz
- Leg-length discrepancy
- Lack of conditioning (generalized weakness): “Get Up and Go test”, Chair stand
- Illness
- Nutrition
- Gait Disturbance: 20 foot walk with 360 turns
Ix
- Directed by Hx / PEx
- Comprehensive geriatric assessment to identify all potential causes
- CBC, lytes, BUN/Cr, Glucose, Ca, TSH, B12, U/A, cardiac enz, ECG, CT head
Tx
- Weakness of Leg Extension: Impaired chair stand / slow gait / poor stair climbing
- Resistance & Quadriceps training
- Poor Balance: Positive Romberg, Positive pull test, poor vision
- Balance training, widen support base (shoes, cane, walker)
- Correct vision
- Medication Toxicity
- Medication review
- reduce or eliminate nitrates, BZD, neuroleptics, antihypertensives if possible
- HoTN: Postprandial / Orthostatic
- Medicaiton review
- Behaviour changes: separate meals and meds, exercise
- Volume maintenance: compression stockings, salt intake
Prevention – for all pt
- Environmental risk factor / Home hazard assessment and modification
- Improve lighting, especially on stairs
- Caution while adjusting to new bifocal Rx (poor depth perception)
- Siderails in bathtubs
- Railings on steps
- Connect pt to lifeline button signaling systems
- Remove loose mats or carpets, telephone cords, and other tripping hazards
- Recommend support hose for varicose veins and swelling of ankles
- Multidisciplinary programs in the community
- Eyesight & footwear optimization
- Muscle strengthening, balance retraining, group / individualized exercise programs
- Rx of Vit D 1000 IU daily
- Tapering or gradually discontinuation of psychotropic medication
- Postural HoTN, heart rate, and rhythm abnormalities management
Frailty – Failure to Thrive
- Declining indenpendence and functional capacity with loss of energy, vigor and/or wt in older adults
- Not an inevitable consequence of aging
Etiology – My Pa Can’t Drive
- Malnutrition
- Physical / functional Impairment
- Cognitive Impairment
- Depression
Hx:
- Environment
- Social
- Somatic
- Decreased energy
- Increased catabolism
- Drugs
PE:
- GI – constipation
- Cardiac
- Respiratory
- Skin changes
- Sensory
Ix:
- MMSE
- ADL / IADL assessment
- “Up and Go Test”
- Geriatric Depression scale
- Nutritional assessment
- Medication Review
- Chronic dz evaluation
- Environmental assessment
Tx:
- Somatic causes – Tx general medical condition
- Depression – CBT, antidepressants, modifiy environment
- Malnutrition – SLP evaluation, Tx oral pathology, increase freq of feedings, nutritional supplements
- Cognitive Impairment – Optimize living conditions, Tx underlying depression, malnutrition, infection, Adm Dementia-delaying medications
- Functional Impairment – Physical therapy, OT, modify environment
- Discuss end of life options if no improvement with Tx
4 In the elderly patient, assess functional status to:
– anticipate and discuss the eventual need for changes in the living environment.
– ensure that social support is adequate.
Functional Assessment (ADLs + IADLs)
- can use formal assessment tools, eg. the Lawton-Brody Instrumental Activities of Daily Living Scale
ADLs: ABCDE-TT
- Ambulating
- Bathing
- Continence
- Dressing
- Eating
- Transferring
- Toileting
IADLs: SHAFT-TT
- Shopping
- Housework
- Accounting / Managing finances
- Food preparation
- Transportation
- Telephone
- Taking medications
Health Care Services and Institutions
Community Support Services
- For pt who can live independently at home or under the care of family members, professional care services
- ADL assistance: personal care and support
- IADL assistance: homemaking
- Community support services: transportation, meal delivery, day programs, caregiver relief, security checks
Residential
- Seniors Affordable Housing: live independently & manage own care, but prefer to live near other seniors
- Retirement / Nursing Home: Fairly independent & require minimal support with ADLs and IADLs
- Supportive Housing: Min to moderate assistance with daily activities while living independently; may offer PT & rehab services
- Long-term care / skilled Nursing facility: Around the clock nursing care & on-call physician coverage; often offer PT, OT, RT, rehab
- May be used short-term for caregiver respite or for supportive pt care to regain strength and confidence after leaving the hospital
- Hospice: Free-standing facility or designated floor in ahospitalornursinghomeforcareofterminallyillpt & families;
- Requires prognosis <3mo
- focus on quality of life
5 In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (e.g., pneumonia, appendicitis, depression).
Most Common Acute Disorders in the Elderly
- CV: CHF, CVA, MI
- #: hip, vertebrae, Wrist
- Medication-related
- Pneumonia
- Sepsis
References:
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