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Geriatric Syndromes Flashcards

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1
Q

What are the tools used to identify frailty?

A

FRAIL Scale
Clinical Frailty Scale

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2
Q

Components of FRAIL scale?

A

Fatigue
Resistance
Ambulation
Illness
Loss of weight

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3
Q

Goals of therapy for frailty

A
  1. What matter most to the patient
  2. Establish goals prior to deciding interventions
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4
Q

Intervention of frailty (1)

A

Physical/occupational exercises

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5
Q

Intervention of frailty (2)

A

Nutritional intake with oral nutritional supplement

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6
Q

Intervention of frailty (3)

A

Medication review
a. DRPs affecting 1st and 2nd intervention
b. Vitamin D supplementation

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7
Q

Fall risk identification

A

Fall history
Mobility
Sensory function
Activities of daily living
Cognitive function
Autonomic function
Disease history
Medication history
Nutrition history
Environment hazard

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8
Q

Stratification based on future fall risk

A

Fall past 12 months?
Gait and balance impaired?

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9
Q

FRIDs mechanism of harm

A
  1. Sedation
  2. Orthostatic hypotension
  3. Anticholinergics
  4. Hypoglycaemia
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10
Q

STOPPPFall consensus round 1

A

BZD
Antipsychotic
BZD-related drugs
Opioids
Antidepressants
Anticholinergics
Antiepileptics
Diuretics
Alpha blocker as anti-HTN

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11
Q

STOPPPFall consensus round 2

A

Alpha blocker for prostate hyperplasia
Centrally-acting antihypertensives
Antihistamines
Vasodilators used in cardiac diseases

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12
Q

STOPPPFall consensus round 3

A

Overactive bladder and urge incontinence medications

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13
Q

What are the 4 types of dizziness?

A

Vertigo
Pre-syncopal dizziness
Dysequilibrium
Unspecified dizziness

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14
Q

Evaluation of dizziness

A

TiTraTE
- Timing
- Triggers
- Targetted examination

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15
Q

7 types of dizziness that we can aim to treat underlying cause

A

BPPV
Orthostatic hypotension
Meniere’s Disease
Vestibular Migraine
Psychogenic dizziness
Drug-induced dizziness
Vestibular neuronitis

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16
Q

Pharmacotherapy for vestibular symptoms (only for prolonged >30mins)

A
  1. Antihistamines – diphenhydramine, dimenhydrinate, meclizine
  2. Phenothiazines – prochlorperazine, promethazine
  3. Anticholinergics – hyoscine hydrobromide
  4. BZDs – lorazepam, diazepam, clonazepam
  5. Antidopaminergic – metoclopramide
  6. calcium channel antagonist – cinnarizine
  7. Histamine analogues – betahistine
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17
Q

Side effects of anticholinergics

A

Dry mouth
Urinary retention
Tachycardia
Risk of increasing BP

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18
Q

Phenothiazines

A

Additional antidopaminergic effects
Contraindicated in Parkinsonism (as it may worsen movement disorders)

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19
Q

BZDs

A

More sedating
Increases fall risk
Only for short term use for a few days
Cognitive impairment, depression

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20
Q

Calcium channel antagonist

A

Sedating
Weight gain
Has antihistaminergic effect
Caution in Parkinsonism

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21
Q

Histamine analogues

A

Use with caution in asthma
Contraindicated if active/history of PUD

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22
Q

Delirium subtypes

A

Hyperactive
Hypoactive

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23
Q

Risk factors for delirium

A

65 years or older
Cognitive impairment and/or dementia
Current hip fracture
Severe illness

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24
Q

Detection of delirium

A

Confusion assessment method (CAM)
4AT

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25
Components of 4AT
Level of alertness - State name and address Abbreviated mental test 4 (AMT4) - Age, date of birth, place, current year Attention - List months in reverse order Acuity - Significant mental change or fluctuation the last 2 weeks and persisting in last 24 hours
26
Diagnosis of delirium
Physical examination - Vital signs, hydration status, skin conditions, potential infection foci History Labs/imaging studies
27
Causes of delirium
I WATCH DEATH
28
I WATCH DEATH
Infectious Withdrawal Acute metabolic disorder Trauma CNS pathology Hypoxia Deficiencies Endocrinopathies Acute vascular Toxins, substance use, medication Heavy metals
29
Drugs believed to increase risk of delirium (4)
Strong anticholinergic BZD – not to cease chronic BZD abruptly especially if used for seizure, REM, sleep behaviour disorders, anxiety Z-drugs Opioids – especially Pethidine H2RA – if delirious use PPI, if not possible, use famotidine at really adjusted dose
30
Drugs believed to cause/prolonged delirium (14)
Analgesics – opioids especially pethidine Antimicrobials – fluroquinolone, cefepime Anticholinergics Corticosteroids Dopamine agonists GI agents Herbs – atropa belladonna extract Hypoglycaemics Hypnotics/sedatives Anticonvulsants Antidepressants CV drugs – digoxin Muscle relaxants Other psychoactive agents – lithium
31
Prevention of delirium (a)
Sensory function optimisation – hearing/visual aids
32
Prevention of delirium (b)
Hydration/nutrition
33
Prevention of delirium (c)
Bowel movement/urination
34
Prevention of delirium (d)
Early mobility
35
Prevention of delirium (e)
Pain control
36
Prevention of delirium (f)
Medication review
37
Prevention of delirium (g)
Social interaction with loved ones
38
Prevention of delirium (h)
Reorientation with clock/calendar/proper lighting - Introducing cognitively stimulating activities
39
Prevention of delirium (i)
Conducive environment
40
Prevention of delirium (j)
Promote good sleep
41
Prevention of delirium (k)
Address infection/hypoxia
42
First line for agitation in delirium
Non-pharmacological interventions
43
Pharmacotherapy for agitation in delirium?
Antipsychotics Benzodiazepines
44
Antipsychotics of choice in agitation
(non-ICU) SC/IM/PO Haloperidol 0.3-1mg BD, put to 5mg/day Atypical antipsychotics - PO only quetiapine 6.25-12.5mg BD, up to 100mg/day - (safest QTc?) PO Olaznapine 1.25mg-2.5mg up to 10mg/day
45
Caution/consideration for antipsychotic use in agitation
Only short term use due to higher risk of mortality and possibly stroke when used in patients with dementia
46
Benzodiazepines of choice in agitation
PO/IV/SC Lorazepam 0.5-1mg
47
Physiology of lower urinary tract
Bladder filling phase - Activation of sympathetic, blockade of parasympathetic - Bladder activation when b3 adrenergic receptor is activated - Tightening of bladder outlet/urethra when a1 adrenergic receptor is activated Bladder voiding phase
48
Types of UI
Stress Urge Overflow Functional
49
Stress UI
Involuntary loss of urine in small amount with increasing intra abdominal pressure
50
Urge UI
Leakage of urine because of inability to delay voiding after sensation of bladder fullness is perceived
51
Functional UI
Urinary accidents associated with the inability to toilet because of impairment of cognitive and/or physical functioning, psychological unwillingness, environmental barriers
52
How to determine UI types?
1. During past 3 months have you leaked urine (even a small amount)? 2. During the past 3 months, did you leak urine while a. performing some physical activity like coughing, sneezing, lifting, exercising b. cannot get to toilet fast enough c. without physical activity and without sense of urgency 3. .... did you leak urine most often: a, b, c, d equally as often with physical activity as with a sense of urgency
53
Differential diagnosis of transient cause of UI
DIAPPERS
54
D in DIAPPERS
Delirium
55
I in DIAPPERS
Infection (acute UTI)
56
A in DIAPPERS
Atrophic vaginitis
57
P1 in DIAPPERS
Pharmaceuticals
58
P2 in DIAPPERS
Psychological disorders
59
E in DIAPPERS
Excessive urine output (hyperglycaemia)
60
R in DIAPPERS
Reduced mobility or reversible (drug induced) urinary retention
61
S in DIAPPERS
Stool impaction
62
How does antihistamines/anticholinergics affect bladder function?
Decreased contractility via anticholinergic effects
63
How does cholinesterase inhibitors (PD/AD) affect bladder function?
UI, interactions with anti-muscarinics
64
How do decongestants affect bladder function?
Increased urethral sphincter tone
65
How do BZDs affect bladder function?
Impaired micturition via muscle relaxant effect
66
How do opioids affect bladder function?
Decreased sensation of fullness and increased sphincter tone
67
How do GABAnergic agents (Gabapentin, Pregabalin) affect bladder function?
Edema causing nocturne and nighttime incontinence
68
How do ACEi affect bladder function?
Decreased contractility, chronic coughing
69
How do a-agonists (midodrine, phenylephrine) affect bladder function?
Increased urethral sphincter
70
How do a1-blocker (BPH medicines) affect bladder function?
Decreased urethral sphincter tone
71
How do anti-arrythmics affect bladder function?
Decreased contractility via local anaesthetic effect on bladder mucosa or anticholinergic effect
72
How do CCBs affect bladder function?
Impaired detrusor contractility and retention, DHP agents can cause pedal edema leading to nocturnal emptying
73
How does diuretic affect bladder function?
Increase urine production, contractility or rate of emptying
74
How do thiazolidinediones affect bladder function?
Pedal edema causing nocturnal polyuria
75
How do TCAs/SNRIs affect bladder function?
Decreased contractility via anticholinergic effects
76
How does duloxetine affect bladder function?
Increased urethral sphincter tone
77
How do antipsychotics (e.g. chlorpromazine) affect bladder function?
Decreased contractility via anticholinergic effect, increased malnutrition and stress UI via simulation of a1 receptors and/or central dopaminergic receptors
78
How do oestrogen affect bladder function?
Increased urinary incontinence
79
Non-pharmacological management of UI
- Address underlying cause - Lifestyle modifications (weight loss, normal bowel habits, reduce bladder irritants, water hygiene - Bladder retraining - Kegel's pelvic floor muscle exercise - Timed voiding - Continent products
80
Pharmacological management for Stress UI
- Kepel's exercise - Topical oestrogen (may take up to 3 months) - Duloxetine (unless CrCl<30)
81

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