IC 3 (geriatric syndromes) Flashcards
what is geriatric syndrome
- prevalent in elderly pts (eg frail)
- impairment in multiple organ system
- neg impact on FUNCTIONAL, QOL, MORTALITY
frailty definition
- Increases vulnerability to stressors (acute illness, surgery etc) lead to poorer health outcomes
- Age is no longer considered a defining characteristics.
- Youth can be frail too
- Is a syndrome: group of s&sx that aggregate in hierarchical order, may trigger a cascade of alterations across other systems.
physical characteristics (Fried Frailty Tool)
clinical use (need pt participation & specialised equip)
- Weak (poor hand grip strength, difficulty walking up 1 flight staris)
- Slow walking (>6-7s for 10 feet)
- Low physical activity
- Weight loss (≥5% weight loss in last year)
- Exhaustion (fatigued when performing daily activities)
□ Pre-frail: 1-2
□ Frail: >3
frailty associated with
- Longer hosp stay, more post-op complication, greater likelihood of discharge institutionalization (if require surgery)
- Associated with other comorb and conditions
□ Polypharmacy
□ Osteoarthritis
□ Analgesic use
□ Heart failure and CVD
□ Risk of falling
□ Depressive sx
□ Cognitive dysfunction
hypothesis model of frailty and adverse health outcomes
triggers:
- oxidative stress, mitochondrial dysfunction, DNA damage, cell senescence
- gene variation + environ
- INFLAM DISEASE
–> inflam, neuroendocrine dysregulation
Markers of frailty:
- (incr) CRP, IL-6, Cortisol
- (decr) IGF-1 insulin growth factor, DHEA-S dehydroepiandrosterone sulfate
—> clinical frailty (slow, weak, weight loss, low activity, fatigue)
clinical manifestation of frailty (that leads to clinical frailty sx)
Negative energy balance
Sarcopenia
immune function decline
cognitive impairment
incr clotting
decr glucose metabolism
clinical frailty scale (SG)
1-9
CFS 4 = pre-frail (mild frailty), functionally Independent, but symptoms of chronic illnesses are affecting activity tolerance
CFS 5 = Need assistance for all or some of the iADLs
CFS 6 = Need assistance for all outside activities and some of the bADLs (e.g. dressing ,bathing)
CFS 7 = Clinically stable but FULLY dependent for personal care
CFS 8 = Nearing end of life and FULLY dependent for personal care
CFS 9 = Terminally ill (<6 months) but not severely frail
FRAIL scale (US)
fatigue
resistance (climb 1 flight of stairs)
ambulation (walk 80m)
illness (HTN, DM, cancer, chronic lung disease, asthma, HA, CHF, angina, stroke, arthritis, CKD) > 5 =1point
loss of weight (>5% in past year)
Pre-frail: 1-2
Frail: >3
management of frailty
- establish goals ( assessing indiv pt physical, psychological, social and environmental needs)
- physical exercise/ OT
- nutritional intake
- med review
possible cuases of low nutritional intake in frail pts
- Medication side effects
○ Suppress appetite, anticholinergics (dry mouth, decr saliva prod – affect swallowing and taste), sense of taste, sedation - Depression
- Access to food
○ Financial, physical restriction - Require assistance
- Chewing/ swallowing
○ Consistency of food - Unnecessary dietary restriction
○ Not impt to restrict for frail pts, need energy
med review for frail pts
- DRPs affecting ability to take part in PT/OT and adequate nutritional intake
- Vit D suppl (bone, muscle, immune system)
- Explicit criterias (BEERS, STOPP)
fall definition
At unexpected event in which a person comes to rest on the ground, floor or a lower surface
- Mostly multifactorial cases
- Adverse patient outcomes
- Pain, fracture, traumatic brain injury
- Concern about falling (vs fear of falling)
- Reduced QOL/ functional dependency
routine checkup with HCP
3 key qns
1) fall past 12mnth
2) Do you feel steady when you stand/ walk?
3) Any concerns of falling?
yes to any –> further evaluation
when presenting to HCP w/ fall or related injury/ Yes to key qn
assess fall severity
- injury
- ≥2 fall last yr
- frailty
- lie on floor unable to get up
- loss of consciousness/ suscepted syncope
if yes: HIGH RISK
not high risk –> refer for gait, balance test
- Test:
□ Timed up and go (>15s)
□ gait speed ≤ 0.8m/s
□ Berg balance scale (retrieve object from floor)
□ Performance-orientated mobility assessment - Recommended for:
□ Persons who report single fall in past 12mnths (early detection of any deficits) to identify indiv who may need multifactorial assessment*
yes = intermediate risk
low fall risk intervention
educate on fall prevention
advise on physical activity exercise
f/u 1yr
intermediate fall risk
2nd prevention to improve MAJOR RISK FACTOR
* tailored exercise: balance, gait, strength
* educate on fall prevention
f/u 1yr
high fall risk
2nd prevention and treatment
- multifactorial fall risk assessment
- individualised tailored interventiion…
f/u 30-90d
multifactorial fall risk assessment
- Medication history
○ Acute, chronic medical prob (osteoporosis/ UI/ CVD) - Disease history
○ Cardiovascular disorder
○ Contributing disease/ atypical disease presentation
○ Depressive disorders - Mobility
○ Balance, gait, walking air/ footwear/ foot prob
○ muscle strength - Neurological function (cognitive function, lower extremity peri nerves, proprioception, reflex, test of cortical, extrapyramidal and cerebellar function)
○ Cognition, Delirium, Behaviour - Sensory function
○ Dizzy, vision, hearing - Activities of daily living
○ Functional ability - Autonomic function
○ orthostatic hypotension
○ Urinary incontinence - Nutrition history
○ Nutritional status
○ Vit D - Functional assessment
○ Indiv perceived functional ability and fear related to falling
○ Any concerns/ activities that contribute to deconditioning
○ ADL skills (use of adaptive equip, mobility aids) - Environment
intrinsic factors for fall risk
lower extremity weakness, previous fall, gait and balance, visual impair, dep, functional and cog impairment, dizzy, low BMI, UI, OH, female, >80yo
extrinsic factors for fall risk
polypharm, psychotropic meds, environ hazard, lack safety equip
Identify Falls Risk Increasing Drugs (FRIDS) by mechanism:
Sedation
Orthostatic hypotension
Anticholinergics – slow down reaction time, drowsy, blurred vision, confusion
Hypoglycemia
explicit criteria for FRIDS: STOPPFall drug classes
- OH induction: a-blockers, central antihypertensives, vasodilators, diuretics
- Opioids
- Psychotropics: antidep, antipsychotics, BZP/ Z-drugs
- Anticonvulsants
- Anticholinergics: 1st gen antihistamines, muscle relaxants
dizziness definition
Dizziness important geriatric syndrome as it can result in
* Potentially serious etiologies (stroke, MI, traumatic brain injury) * Incr risk of fall * Incr risk of deconditioning (period of inactivity, reduced muscle strength) * Reduced QOL
4 types of dizziness
- Vertigo
○ Object spinning/ they are moving
○ Benign paroxysmal positional vertigo - Pre-syncopal dizziness
○ Change in body posture pOH (dizziness goes away when u sit/ lie) - Disequilibrium
○ Central etiologies - Unspecified dizziness
○ Older adults can have more than 1 type of dizziness
○ Not enough to determine cause
differential dx of dizziness and vertigo
peripheral: BPPV, vestibular neuritis, Meniere disease, otosclerosis
central causes: vestibular migraine, CVB, meningiomas
others: psych, med induced, CVS/ metabolic/ OH
20% med related
TiTraTe approach to evaluate dizziness
Ti : Timing – Continuous or Episodic (Onset, Freq, Duration)
Tr : Triggers – head movement, posture change, spontaneous, intermittent
TE: Targeted Examination
Episodic Triggered: Dix-Hallpike maneuver
Positive: Benign Paroxysmal Positional Vertigo
Negativedap-like maneuver trigger: Orthostatic Hypotension
Episodic Spontaneous: further history
Unilateral hearing loss/sensation of ear fullness: Meniere Disease
Migraine Headache: Vestibular Migraine
Psychiatric symptoms: Panic attack, etc
