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Falls in Elderly Flashcards

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1
Q

What are the common causes of provoked falls?

A

Pushed
Syncope
Seizure related
Icy walkway

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2
Q

What are the unintentional falls

A

Loss of balance

Weakness

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3
Q

What are the risk factors of falls?

A

Advanced age

Medications

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4
Q

What medications are associated with falls?

A

Drugs that cause:
Sedation
CNS/cognitive effects
Psychoactive medications

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5
Q

What number of medications is independently associated with falls

A

4 or more

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6
Q

What is the definition of dizziness?

A

Spinning/light-headedness, w/o loss of consciousness, and may or may not be associated with falls

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7
Q

What are the different classifications of dizziness?

A

Vertigo - sensation of movement
Light headedness - common in COPD/hypoxia
Disequilibrium - lower extremities or trunk
Presyncope - associated with nausea, sweating, or weakness

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8
Q

What is the definition of syncope?

A

“Transient loss of consciousness almost always associated with falls” associated with central hypoperfusion

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9
Q

What is syncope associated with?

A 
Seizures
TIAs
Metabolic disorders
Intoxication
Orthostatic hypotension
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10
Q

What are the most common causes of dizziness/syncope are attributed to?

A

CV or neurological conditions

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11
Q

What is the definition of orthostatic hypotension?

A

Symptomatic decline in BP after standing

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12
Q

For orthostatic hypotension, how is SBP and DBP reduced?

A

greater than or equal to 20 SBP or greater than or equal to 10 DBP within 3 minutes of standing

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13
Q

How much blood is in the lower extremities when standing during orthostatic hypotension?

A

500-1000ml

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14
Q

How does the body return blood to the heart and maintain blood pressure?

A

CNS increases sympathetic and decreases parasympathetic outflow

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15
Q

Why is orthostatic hypotension more common in the elderly?

A

Blunted baroreceptor response

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16
Q

What are sx of orthostatic hypotension?

A 
Weakness
Dizziness
Light-headedness
Blurred vision
Possible syncope
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17
Q

What are other etiologies for orthostatic hypotension?

A

Autonomic failure (Lewy bodies, neuropathies)
Volume depletion
Reflex syncope

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18
Q

Which medications can cause orthostatic hypotension?

A 
Antihypertensive agents (BB, diuretics, CCBs, vasodilators, alpha blockers)
Sedative hypnotics
Antidepressants
PDE-5 inhibitors
Antipsychotic agents
Muscle relaxants
Narcotic analgesics
Antiparkinsons agents --> but also Parkinson's disease
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19
Q

What are some management strategies for orthostatic hypotension?

A 
Hydration
Reduction of medication offenders
Elastic stocking/ab binders
Exercise
Medications
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20
Q

When are medications used for orthostatic hypotension?

A

Last line
Typically someone would not be on any antihypertensive agents at this point but would still not be able to maintain adequate blood pressures

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21
Q

When are medications more commonly used for patients with orthostatic hypotension?

A

Pts w/autonomic dysfunction or neuropathy

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22
Q

What are the commonly used agents for orthostatic hypotension?

A

Fludricortisone

Midodrine

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23
Q

What is fludrocortisone?

A

Synthetic adrenocrotical steroid with potent mineralcorticoid activity

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24
Q

What is the MOA of fludricortisone?

A

Mimics aldosterone
An endogenous mineralcorticoid
Promotes resorption at the distal renal tubule

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25
What do larger doses of fludricortisone do in the body?
Endogenous adrenal cortical secretion Thymic activity Pituitary corticotropin execretion
26
What is the dose of fludrocortisone in orthostatic hypotension?
0.1-0.2 mg PO once daily | Max 0.2mg daily, no dosage adjustments are needed for renal or hepatic impairment
27
What are the AEs of fludricortisone in orthostatic hypotension?
``` Edema Electrolyte abnormalities (K wasting, hyperglycemia) Ab distension PUD Myopathy HA Vertigo ```
28
What is midodrine?
Prodrug hydrolyzed to desglymidodrine
29
What is midodrine's MOA?
Binds to alpha-1 receptors on arteries and veins to increase vascular tone and elevate blood rpessure
30
Can midodrine pass the BBB?
Limited which means no central action
31
What is the dose of midodrine?
``` 10mg TID (4 hours between doses; no later than 6pm) Max daily 30mg ```
32
What are the dose adjustments in midodrine?
No adjustment for hepatic impairment | In renal impairment, start with 2.5mg per dose TID
33
What are the AEs for midodrine?
``` Pruritus Shivering Parasthesias Dysuria HTN Bradyarrhythmia ```
34
What is the new orphan drug for orthostatic hypotension?
Droxidopa (Northera)
35
What is the MOA of droxidopa?
Synthetic precursor to NE, use results in peripheral vasoconstriction
36
What is droxidopa indicated for?
Neurogenic orthostasis (Parkinson's disease)
37
What is the dose for droxidopa?
100mg TID | Titrate by 100mg TID every 24-48 hours until 1800 mg/day max
38
Is there efficacy beyond using droxidopa for 2 weeks?
Nope
39
What are the AEs for droxidopa?
``` HTN Nausea HA Dizziness Neuroleptic malignant syndrome ```
40
What drugs are considered to be added if the first line therapies are not effective in orthostatic hypotension?
``` Pyridostigimine NSAIDs Caffeine Erythropoietin Dihydroergotamine DA (metoclopramide, domeperidone) Amulatiory NE infusions ```
41
If the patient is in an urgent, emergent or critical settings, what medications are used for orthostatic hypotension?
Vasopressors | IV fluids
42
What are sources of vitamin D?
Sunlight (cholecalciferol) Diet Supplementation
43
What parts of the diet contain cholecalciferol?
Oily fish Eggs Fortified dairy
44
What parts of the diet contain ergocalciferol?
Fungi | Eggs
45
Why is vit D deficiency common in older adults?
Inadequate dietary intake Low sun exposure Northern hemisphere residence Age related changes of the liver and kidney
46
What are s/sx of vit D deficiency?
Muscle weakness Bone impairment Potentially neuromuscular impairment
47
What is the normal and goal 25(OH) vitamin D level?
greater than or equal to 30
48
What is the level for 25(OH) vitamin D insufficiency?
21-29
49
What is the level for 25(OH) vitamin D deficiency?
less than or equal to 20
50
How long should clinicians wait to check the patient has reached appropriate levels?
4 months
51
What is the order for most to least common fractures in elderly?
Vertebral > wrist > hip
52
How does WHO classify Osteoporosis?
BMD T-score
53
What are the classifications for BMD T-score?
Normal T > -1 Osteopenia T= -1 to -2.5 Osteoporosis T= -2.5 or worse
54
How do hip fractures affect the elderly?
Increase in anxiety and depression Decrease independence/confidence Increase mortality - 25% 1 year mortality
55
How do falls affect the elderly?
Increase hospital stays and increase chance of being institutionalized Hasten functional decline
56
How often is the human skeleton replaced?
Every 7-10 years
57
What are the steps in remodeling of bone?
Resorption Reversal Formation Quiescence
58
What is predmoninant mineral in the bone?
Hydroxyapatite
59
What do osteoblasts do?
Bone formation
60
What do osteoclasts do?
Bone resorption
61
What are basic multicellular units (BMU) made of?
Team of osteoclasts and osteoblasts
62
What do BMUs perform?
Performs the remodeling process
63
What are the four largest predictors of fracture risk?
Low BMD Prior fragility fracture Age FH of osteoporosis
64
What are factors associated with low bone mass?
``` Famle Caucasian/asian Sedentary lifestyle Immobility Low body weight (<125lbs) Low Ca intake Smoking Excessive alcohol Low sun exposure Medications ```
65
What medications can cause low bone mass?
``` Usually chronic meds Glucocorticoids at 7.5 mg prednisone for 3 months Heparin (15,000 units/d for 3-6 months) Phenytoin Phenobarbital Thyroid supplements Aluminum Lithium Loops ```
66
What are osteoporosis risk factor classifications?
Modifiable | Nonmodifiable
67
What are nonmodifiable RFs for osteoporosis?
``` Age Race Sex FH Early menopause/oophoerctomy ```
68
What are modifiable RFs for osteoporosis?
Sex hormone deficiency Ca and Vit D intake Physical activity Cigarette smoking
69
What is the pathophysiology of osteoporosis?
Characterized by low bone mass and microarchitectural deterioration of bone tissue
70
What are non pharmacologic interventions for falls and fractures
Exercise programs - tai chi is well studied and recommended Evaluations and modifications of environment Visual correction procedures Medication reduction/withdrawal Adequate calcium and Vit D intake to develop and maintain healthy bones Smoking cessation, moderation of EtOH and caffeine
71
What is the recommended dietary allowance of calcium?
1000-1200 mg daily
72
What is the recommended dietary allowance of vitamin D?
600-800 units daily, some recommend 800-1000 units daily
73
What are the side effects of calcium supplementation?
Constipation, gas, upset stomach Kidney stones (uncommon) Food sources of calcium may be better tolerated
74
What are the available calcium products?
Calcium carbonate Calcium citrate Calcium phosphate tribasic
75
What are the Calcium carbonate supplements?
Tums Caltrate w/vit D, OsCal w/vit D OsCal +/- vit D
76
What are the calcium citrate supplements?
Citracal +/- vitamin D | Cal-Citrate
77
What is the calcium phosphate tribasic supplement?
Posture
78
What is the calcium supplement daily dose for men 50-70 years?
1000mg daily
79
What is the calcium supplement daily dose for women 50+ and men 71+?
1200mg daily
80
What is the max intake of calcium per the IOM?
2000mg daily
81
What is the max intake of calcium per the NOF?
1500mg daily
82
What are DDIs with calcium?
PPIs (decrease Ca absorption) Ca decreases absorption of iron, tetracycline, quinolones, bisphosphonates when given concominantly Fiber laxatives decrease Ca absorption if given concomitantly
83
What are the side effects of Vitamin D?
Hypercalcemia (weakness, HA, somnolence, Nausea, cardiac rhythm disturbance) Hypercalcuria Kidney stones, especially when combined with Ca Toxicity is very rare
84
What are the available Vitamin D products?
D3 (cholecalciferol) | D2 (ergocalciferol)
85
Which vitamin D is more potent and has better bioavailability?
D3 - 3 times more potent than D2
86
Which vitamin D is available OTC?
D3
87
In a patient with regular absorptive capacity, 100IU will increase 1,25 (OH) vitamin D level by how much?
0.6 - 1.0 ng/ml
88
What is the dosing of ergocalciferol?
50,000 IU capsules | 8,000 IU/mL liquid
89
What are the repletion dosing for patients with Vit D insufficiency/deficiency?
50,000 IU weekly 4000-6000 units daily Obese patients 6000-10000 units daily
90
How long is a patient on repletion dosing for VitD insufficiency/deficiency?
6-12 weeks, then the patient is converted to the maintenance dose
91
What are the maintenance doses for vitamin D insufficiency/deficiency?
800-1000 IU daily or 50,000 monthly in those w/o deficiency 1500-2000 units daily in those with a h/o deficiency Obese patients 3000-6000 units daily with a h/o deficiency
92
Who is calcitriol reserved for?
Patients with late stage kidney disease or who aren't having adequate results from D3/D2
93
What form of Vit D is calcitriol?
Active vitamin D
94
When do we use vitamin D analogs?
Primarily in patients with advanced kidney disease for vitamin D replacement and hyperparathyroidism
95
What does the use of cod liver oil to treat vitamin D deficiency expose patients to?
Vitamin A that results in greater osteoporosis, hip fracture, and malignancy risk
96
Why are combination Ca and Vit D products not recommended for primary supplementation of vit D?
Relatively low doses (of vit D) Multiple daily doses required Low adherence with Ca supplements
97
Vitamin D should not be given at the same time as what products?
Binding resins High-fiber cereals Fiber stool softeners d/t poor absorption
98
What does the USPTF say about the routine supplementation of vitamin D?
No longer recommends supplementation for community dwelling elders 65 or older
99
According to the AGS, what vitamin D dose does not prevent falls in those 65+ yo?
< 600 IU
100
What does the AGS recommend for vitamin D daily dose?
4000 IU
101
Which drugs are used for prevention of osteoporosis?
``` Alendronate Ibandronate Risedronate Zoledronic acid Conjugated estrogens Raloxifene ```
102
What are the preventative doses for alendronate?
5mg daily | 35mg weekly
103
What is the preventative dose for ibandronate?
2.5mg daily | 150mg monthly
104
What is the preventative dose for risedronate?
5mg daily
105
What is the preventative dose for zoledronic acid?
5mg IV Q24mo
106
What is the conjugated estrogens dos?
0.625mg daily
107
What is raloxifene's dose?
60mg daily

Geriatrics (15 decks)

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