Elderly – TN2014

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
  1. Weakness of Leg Extension: Impaired chair stand / slow gait / poor stair climbing
    • Resistance & Quadriceps training
  2. Poor Balance: Positive Romberg, Positive pull test, poor vision
    • Balance training, widen support base (shoes, cane, walker)
    • Correct vision
  3. Medication Toxicity
    • Medication review
    • reduce or eliminate nitrates, BZD, neuroleptics, antihypertensives if possible
  4. 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
  1. Seniors Affordable Housing: live independently & manage own care, but prefer to live near other seniors
  2. Retirement / Nursing Home: Fairly independent & require minimal support with ADLs and IADLs
  3. Supportive Housing: Min to moderate assistance with daily activities while living independently; may offer PT & rehab services
  4. 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
  5. 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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Posted in 35 Elderly, 99 Priority Topics, FM 99 priority topics, Geri

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