Frailty Flashcards
(62 cards)
1
Q
What is frailty?
A
A clinically recognised state of increased vulnerability
2
Q
Patients who are frail are more susceptible to what?
A
Stressor events - ie the side effects from new medication, acute illnesses - frailty may lead to incomplete recovery
3
Q
What tool do we use to identify patients who might be frail?
A
Rockwood Frailty Score (Clinical Frailty Score)
4
Q
When should we assess a patient for frailty?
A
- if a px is 65+
5
Q
What does a score of UNDER 5 indicate on the Rockwood frailty score?
A
Low risk of frailty
6
Q
What does a score of 5+ indicate on the CFS?
A
5 - 6 - mild frailty - reversible
7, 8 or 9 - very frail - n
7
Q
If a patient presents to us as acutely ill, what should we base their frailty score on?
A
Their functionality two weeks ago - ie when they weren’t acutely ill
- this is more representative of how they usually function
8
Q
What is multi-morbidity?
A
The co - existence of 2+ chronic conditions where one is not necessarily more central than the other.
- they have cumulative effects for each individual
- eg a px with T2DM and HTN and CKD
9
Q
A
10
Q
What is a disability?
A
A physical or mental impairment that has negative effect on the ability to undertake daily activities
11
Q
Multimorbidities can be :
- clinically dominant
- synergistic
- coincedental
What does this mean?
A
- clinically dominant- where one condition overshadows the other (ie dementia overshadowing a <3 disease)
- synergistic - the morbidities are somewhat related - ie in relation to how they arise and how they are treated (heart and lung conditions - in similar area)
- coincidental - there is no obvious relationship - management of the condition are separate
12
Q
What are some typical symptoms and presentations of frailty?
A
- 😴 the patient may feel tired all the time
- 🩻 unintentional weight loss
- 💪 weakness
- 🦥 slowness
13
Q
What are some causes of frailty?
A
- 📉 reduced function
- 😵💫 delerium
- 💊 iatrogenesis - increased susceptibility to SE of medications/ treatments
- 💦 incontinence
14
Q
What are the 5 frailty syndromes?
(Ie common presentations of frailty)
A
- falls 🤕 - ie px may be found laying on the floor
- immobility ♿️ - sudden change to mobility
- incontinence 💦 - inability to pass urine or faeces
- delerium 😵💫 - acute confusion, very fast onset
- iatrogenesis - ie increased susceptiblty to SE of medications 💊
15
Q
After identifying a px over 65 for frailty, if they have a score of 5+ what else must we complete?
A
- a Comprehensive Geriatric Assessment
16
Q
What is a Comprehensive Geriatric Assessment?
A
An interdisciplinary diagnostic process to determine the medical and psychological and functional capacity of someone who is old and frail
17
Q
What two assessments are included in a Comprehensive Geriatric Assessment (CGA)?
A
- Rapid Clinical test for delirium (4A test)
- Rockwood CFS
18
Q
As pharmacists we must/must not conduct a medication review for ALL older people identified as frail (>/5 on the CFS)
A
We MUST
19
Q
What does a CGA involve?
A
- Assessing the patients physical, socioeconomics, environment, functional, balance/mobility level, psychological level and doing a medication review
- Creating a problem list
- Creating a personalised care plan
- Implementing the interventions
- Doing regular planned reviews
20
Q
Once the CGA has been completed, what are some interventions we can make to address a patients issues?
A
- 🦠 identify and reverse any medical diagnoses (ie that they were acutely admitted for)
- 💊 medication review and polypharmacy reduction
- 🏋️ excercise - very important to avoid the loss of muscle mass in sarcopenia
- 🍬 optimising long term conditions
- 🍎 nutritional support - ensuring the atient gets supplements they need
- 🏠 prioritising getting the patient home first
21
Q
What is the purpose of completing a CGA?
A
22
Q
What is the purpose and importance of a CGA?
A
They are used to assess the health needs and status of older patients (>65) and to create a coordinated, personalised management plan to help the px maintain independence and to prevent functional decline.
23
Q
What is polypharmacy?
A
The use of 5+ medications to manage a persons health
24
Q
What are some risks associated with polypharmacy, especially in the elderly?
A
- increased risk of ADRs
- px with frailty are 2x likely to suffer an ADR on polypharmacy
- increased risk of morbidity and mortality
25
If an elderly px presents with multiple ADRs ie its a recurrent reason for admission what do we need to consider/ do?
- consider frailty and thus doing CGA ( iatrogenesis/ susceptibility to SE of medications is a frailty syndrome!)
- a medication review
26
😢 What is problematic polyphamacy
This is when multiple medications are prescribed inappropriately or when the intended benefit of the medication is not realised
27
What are 5 main reasons for problematic polypharmacy?
- 🔬 There is no evidence based indication - the indication may have exired (consider diabetic px who was rx metformin in 50s - now 80 + very frail and underweight, - eating less and has probs reaped benefit of diabetic medication preventing micro/macrovascular effects - so not v necessary to be rx it any more)
- 💊 medications rx to treat the SE of other medicines (prescribing vortex/cascade)
- ❌ the medication fails to achieve the intended theraeutic objectives
- 🥵 the medicines caused unacceptale ADRs
😣 The demands ofthe medicine taking are unacceptable to the patient , or the patient is unable to maintain adherence to
-
28
What are some contributing factors to plpharmacy?
- 🤝 a lack of shared decision making
- 🦼 multi - morbidities
- 🏥—-> 🏠 transfer of care
- 💊 reflex prescribing (cascade / vortex)
29
What is “prescribing cascade”?
🩻 This is when an ADR is misinterpreted as a **new medical condition** and medications are prescribed inappropriately to treat this new condition
30
What is a prescribing vortex?
This is when each medication causes a side effect for which we prescribe a new medication to treat that side effect.
31
When deprescribing in polypharmacy, what are some examples of medications that we MUST continue the px on?
- any medication that is used to keep them ALIVE (immunosuppressants for organ transplant ie mycophenolate)
- any sort of HRT - ie levothyroxine,insulin, teraparatide, desmopressin,hyrocortisone/prednisolone, Erythropoietin
32
What is the meaning of anti cholinergic burden?
The XS side effects of anticholinergic medications - they can make an cognitively intelligent person seem demented !
33
What are the side effects of anticholinergic drugs?
- agitation 😡
- blurred vision 👓
- confusion 😵💫
- constipated 💩
- dry skin 🧴
- dry mouth 👄
- stasis of the urine 💦
- flushing skin 🥵
- headache, dizzyness , nausea
34
What is the harm of an high ACB score in a frail patient?
Px with high anticholinergic burdens are at an **increased risk of developing dementia**
35
Every ACB point above 4 increases the mortality risk by what (%)?
- 26%
36
what ACB score is associated with increased cognitive impairment and mortality?
- an ACB score of 3+
37
If a patient has an ACB score of 3+ what must we do?
Review the anticholinergic medications using the MAP mnenonic
- medication - is it essential?
- are there any alternatives with a lower ACB?
- monitor the px symptoms
38
Give some examples of drugs with high ACB scores?
- amitriptyline
- chloramphenamine
- solafenacin
- cetirizine
39
Give some examples of anticholinergic medications?
- amitriptyline
- chlorphenamine
- cetirizine
- promethazine
- atropine
- scopolamine
40
What are some deprescribing tools we can use ?
- ACB scores
- Impact tool
- Stop/start tool
41
What are the two **MAJOR** consequences of polypharmacy?
- 😵💫 Impaired cognition
- 🤕 falls
42
Cognitive impairment can present as dementia or delirium, what are some notable differences between the two?
- time course - delerium has a rapid onset (hrs - days) whilst dementia has a slower onset
- delirium can be reversed, dementia is tyically irreversible
- dementia symptoms tend to be consistent from day to day = in delerium, px symptoms change b/w hyperand hypoactive
- attn span is generally very well until end stage dementia, attn san in delerious px is very short
43
What is delirium?
Acute confusion
44
What are some symptoms of delirium?
- **easily distracted**
- **being not alert to things that are happening to them**
- **disorientation (time and location)**
- speaking less clearly
- **mood swings and behavioural changes**
- **hallucinations**
- **delusions or paranoia**
45
What are the causes of delirium? (PINCHME)?
- pain
- infection
- poor nutrition
- constipation or urinary retention
- hydration (poor), hypos and hyper electrolytes
- medication
- environment
-
Other causes include
- loe levels of blood oxygen
Abnormal metabolsm
Organ failrue
46
What is the name of the tool we use to screen delerium?
4AT test
47
What does the 4AT test used in dementia screen for?
- alertness - is the px drowsy or agitated
- awareness - is the patient aware of their age, DOB, location
- attention - their ability to stay focused on a mental task
- acute changes - if the symptoms come and go
48
A score of what on the 4AT test indicates possible delirium +/- cognitive impairment?
4+
49
What does a score of 1 -3 on the 4AT test indicate?
- possible cognitive impairment
50
What are the 3 types of delirium?
Hyperactive - px has heightened arousal, restlessness, agitation and they are more aggressive
Hypoactive - the px presents with apathy, quiet confusion, lethargy, drowsiness, difficulty waking (can be confused with depression)
Mixed - fluctuations between the two
51
What is a fall?
An **unintentional or unexpected loss of balance** resulting in the patient **coming to rest on the floor or ground or an object below knee level**
52
What are some risk factors for px to fall?
- previous falls
- visual impairment
- cognitive impairment - ie dementia
- physical frailty or mobility issues
- alcohol
- polypharmacy (ie meds that reduce BP!)
- fear of falling
- Footwear - ie tropping oer slippers
- clothing - too big trousers - may fall
- inappropriate walking aids (ie zimmer frame in dementia px)
- environment - stools, wet floors , clutter
53
What must we do if a px presents with a fall or reports recurrent falls in the past year or has an abnormality of gait and or balance?
- they should be considered fr a multifactorial falls risk assessment
This may include identification of falls hx, assessment of gait, balance, mobility, muscle weakness, OP risk ,
- assessment of cvd medications
- assessment of visual impairment
- measuring the px postural blood pressure
54
What is postural hypotension?
This is the fall in blood pressure when you stand up after lying or sitting down
55
How do we measure postural hypotension?
Ask px to lie down for 5 mins 🛌
Ask px to stand up after
Measure bp 1min and then 3 mins after
56
What decrease in BP indicates a px has postural hypotension?
- A drop in systolic BP > 20mmHg
Or
- a drop in diastolic BP >/ 10mmHg
Px experiencing lightheadedness and or dizziness that is abnormal
57
Give some examples of medications that may cause postural hypotension?
- anti - hypertensives
Diuretics
Nitrates
Sildenafil
Levodopa
TCAs
SSRIs
Antipsychotics
Anti muscarinics
58
How does frailty/ old age affect the **absorption** of drug?
Frail/ older px have :
- 👄 reduced saliva and thus may find it more difficult to swallow medications
- 🥛 increased gastric pH - may affect the drug release profile of enteric coated medications (early release)
- 🩸 decreased GI and regional blood supply (limits extent of absorption into circulation)
‼️ however there is little evidence that the dosage needs to be altered due to these absorption factors
59
How does frailty/ old age affect the **1st pass metabolism** of drugs?
- elderly px have reduced hepatic blood flow - thus reduced 1st pass met - thus >er drug effect and increased drug bioavailabilty
- risk of toxicity!
60
How does frailty/ old age affect the **distribution** of drug?
Distribution of water and fats is altered in older adults
- 🧈 >er proportion of fat - increasing Vd of lipid soluble drugs (ore drugs accumulate in peripheral tissues than target)
- this means that there is an prolonged half life, and slower elimination - there are also prolonged effects and a risk of accumulation with repeated dosing ———> dose adjustment is to lower the maintenance dose or to have longer dosing intervals to avoid accumulation and toxicity
- 💦 decrease in total body water (drier!) thus reduced Vd for water soluble drugs - less distribution - need lower doses of water soluble drugs bc the plasma conc would be higher.
- this means there are higher plasma concentrations after a standard dose - increased risk of toxicity ———> the loading and maintenance doses may need to be reduced to prevent adverse effects.
- 🩸 reduced plasma protein concentration - increasses free drug] - increased risk of toxicity
61
How does frailty/ old age affect the **metabolism** of drug?
Elderly adults have reduced metabolic clearance - increased levels or and duration of action of drugs that should be metabolised - risk of tox
- pro drugs may be LESS effective - not converted to active form!
62
How does frailty/ old age affect the **elimination** of drug?
Most elderly and frail px have reduced elimination of drugs - GFR falls with age
- may need lower doses to prevent tox
