old age conditions (falls)

Question 1

define ageing

Answer 1

progressive, generalised impairment of function resulting in a loss of adaptive response to disease

• random molecular damage during cell replication
• reduction in bodys adaptive reserve capacity (resilence)

Question 2

ageing hypotheses

Answer 2

• DNA damage affecting cell repair
• mitochondria produce free radicals which produce oxidative stress which accumulates with age
• tips of telomeres shorten with cell division over time leads to cell senescence
• loss of elasticity in tendons, skins, blood vessels

hayflick limit = no. times a human cells can divide before division ceases

Question 3

sarcopenia

Answer 3

age related loss of muscle mass, stength + muscle quality leading to decline in physical function, falls, frailty

-> reduction in type II, fast twitch, muscle fibres

Question 4

diagnosis + management of frailty

Answer 4

diagnosis = presence of low muscle mass + either low muscle strength (hand grip) or low physical performance

Mx
- exercise - resistance training
- medication - no approved, some benefits with: growth hormone, vit D, amino acid suplements
- nutrition - promotes protein synthesis

Question 5

frailty scoring

Answer 5

Rockwood frailty scale

• low of homeostasis + resilience
• increased vulnerability to decompensation after a STRESSOR EVENT
• minor illnesses can cause profound deterioration

Question 6

elder abuse

Answer 6

• Some frail older adults are vulnerable to abuse
• Usually from close relative
• Financial, verbal, physical, sexual
• Scale underestimated
• 3% of over 65s report it

Question 7

what does the comprehensive geriatric assessment comprise?

Answer 7

medical - problem list, conditions + disease severity, medication, nutrition

functioning - daily activity levels/status, gait + balance

psychological - mental status, cognitive function, mood/depression

social/environment - informal needs + assets, social circle, care resource eligibility

Question 8

most emphasised point of comphrehensive geriatric assessment

Answer 8

problem list !!

not list of differential but most symptomatic, includes non medical issues
- weight loss, falls, confusion, polypharmacy

Question 9

how does an MI presentation in an older person differ?

Answer 9

young -> chest pain

older
- no chest pain in 1/3
- collapse, delirium
- dizziness, breathlessness

Question 10

how does a sepsis presentation in an older person differ?

Answer 10

BP may drop early – esp those on vasodilating antihypertensives

Tachycardiac response may be absent

Temperature often low, not high

CRP + WCC may not rise (or not much) – WCC made in bone, frail

Fluid balance may be hard – problem if low BP, or kidney problems
- Frail older people have less homeostatic reserve, they are often delicately balanced

Antibiotics should be targeted as higher risk C.Diff + antibiotic resistance

Question 11

delirium

Answer 11

acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs

disturbance in attention
change in cognition
short onset (hrs-days)
tends to FLUCTUATE

Question 12

subtypes of delirium

Answer 12

hyperactive - agitated, agressive, wandering -> easy to diagnose

hypoactive -> withdrawn, apathetic, sleepy, coma -> easily missed, 2x the mortality rate

(be wary of drowsy “quiet” patient)

Question 13

causes of delirium

Answer 13

DELIRIUM

Drugs/medication
Electrolyte disturbances – hyponatraemia
Lack of drugs – withdrawal
Infection
Reduced sensory input, pain
Intracranial – stroke/subdural
Urinary retention/constipation
Metabolic – AKI, hypoglycaemia, hypothyroid, B12/folate

Question 14

delirium pathophysio

Answer 14

not well understood

• Variable derangement of multiple neurotransmitters (particularly ACh)
• Direct toxic insults to brain also contribute – drugs, hypoxia, low sodium, low glucose
• Irregular stress responses probably also contribute – cortisol, prostaglandins, cytokine release

Question 15

how does delirium differ from dementia + depression

Answer 15

sudden onset
short, flutuating course
usually reversible
agitated, restless / sleepy slow (hyper/hypoactive)
alertness FLUCTUATES
impaired attention

disorganised thinking
distorted perception (hallucinations)

Question 16

delirium screening

Answer 16

all patients >65yrs on admission to hospital should be screened - even if asymptomatic

confusion assessment method
4-AT score

Question 17

confusion assessment method

Answer 17

requires features of 1 + 2 and either 3 or 4

1. acute onset + fluctuating course
2. inattention
3. disorganised thinking
4. altered level of consciousness

Question 18

4-AT score

Answer 18

> =4 = possible delirium
89.7% sensitivity + 84% specificity for delirium

tests
- alertness
- AMT4 (age, DOB, current location, current year)
- attention
- acute change or fluctuating course

Question 19

delirium investigations

Answer 19

History – often collateral from fam
Full examination, neurological, MSK – may be difficult due to agitation/confusion

Blood sugar – elderly at big risk of blood sugar problems
- Medication review
- Triage any patients with high NEWS

Tests
o Bloods – FBC, U&Es, LFTs, CRP, calcium, B12/folate, TSH, Mg, glucose
o Blood cultures if septic
o ECG
o Imaging – will depend on presentation
o Bladder scan
o CT head if indicated – focal neurolgy/head injury

Question 20

common medication culprits for delirium

Answer 20

Opioids – tramadol, codeine
Anticholinergics – amitriptyline, oxybutynin
Sedatives – benzos, sleep tablets, anti-histamines
Psychotropic – lithium, anti-psychotics, anti-depressants

Anti-epileptics – phenytoin, carbamezapine
Cardiac medications – digoxin, anti-hyptensives
Steroids, NSAIDs

Withdrawal of medications/alcohol/nicotine
Parkinsons medications – NEVER stop these acutely with d/w PD specialist

Question 21

non-pharmacological management of distress/agitation in delirium

Answer 21

encourage mobilisation
optimise chronic disease
activity charts - useful if prolonged
sensory input important - glasses, hearing aids ok
fluid chart - dehydration will exacerbate

Question 22

capacity considerations in delirium

Answer 22

may have capacity for personal care but not medication decisions
adults with incapacity (AWI) form should be completed if appropriate
- review regularly, can be revoked post-delirium

initiate TIME bundle
- Think + exclude possible triggers
- Investigate _ intervene to correct underlying cause
- Management plan
- Engage + explore

Question 23

pharmacological management of distress/agitation in delirium

Answer 23

1st line = haloperidol 500mg - IM if unable to take orally
DO NOT USE IN PARKINSONS OR LEWY BODY DEMENTIA
-> in these patients use lorazepam 500mg

if requiring ongoing antipsychotic then early referral to POA is v important

(reserved when non-pharma failed + symptoms threaten safety or to others - significantly distressing psychotic symptoms)

Question 24

preventing delirium

Answer 24

• Minimal moves in hospital, regular orientation, glasses + hearing aids
• Maintaining oral hygiene, nutrition/hydration
• Medication should be reviewed on admission
• Pain control post-op + early recognition of post-op complications
• Early mobilisations
• Regular review of bladder/bowel function

Question 25

falls

Answer 25

Prevalence increases with age, 50% of over 80s fall at least one a year o 3 fold higher incidence in care-home residents Majority of falls are multifactorial - Significant burden to patient + NHS Assessment + management of a patient presenting with falls needs to be multifactorial

Question 26

falls

Answer 26

Prevalence increases with age, 50% of over 80s fall at least one a year o 3 fold higher incidence in care-home residents Majority of falls are multifactorial - Significant burden to patient + NHS Assessment + management of a patient presenting with falls needs to be multifactorial

Question 27

implication of falls

Answer 27

40-60% suffer injury 5% result in fracture or hospitalisation - (hip fracture mortality 1yr post op = 15-36% loss of confidencce -> social isolation -> functional decline costs NHS 2.3billion a year 40% of hospital admissions

Question 28

why are old people more likely to fall?

Answer 28

motor coordination central processing + cognition - decrease reaction time sarcopenia decreased cardioresp fitness vision - smaller pupils lens thickening (decrease light) decrease peripheral sensation + proprioception - increase postural sway fear of falling increases risk of falls - restricts physical activity -> unconditioned balance skills

Question 29

intrinsic factors contributing to falls

Answer 29

age related changes in gait, postural reflexes, muscle strength cognition impaired vision + hearing medical conditions - diabetes -> diabetic neuropathy -> altered proprioception + poor vision - arthritis, parkinsons, stroke -> altered gait pattern - incontinence -> increase need to rush, mobilised at night - acute illness -> almost anything

Question 30

extrinsic factors contributing to falls

Answer 30

medications - diuretics, antihypertensives, sedatives, anticholinergics, hypoglycaemic agents environmental - rugs, stairs inadequate lighting inappropriate footwear inappropriate use of walking aids

Question 31

vision problems associated with falls

Answer 31

Early cataract surgery reduces falls Bifocal + varifocal glasses are assoc with INCREASED falls risk Recent optician visit/new prescription glasses INCREASE fall risk *ask about vision distortion – age-related macular degeneration -> “misjudging curb…”, central vision distortion of doorframes + curbs

Question 32

when is rombergs test positive

Answer 32

in proprioceptive + vestibular disorders loss of balance when eyes shut (feet together)

Question 33

functionally significant peripheral neuropathy

Answer 33

loss of heel reflexes decreased vibratory sense that improves proximally impaired sense at great toe inability to maintain unipedal stance for 10secs in 3 attempts (possible causes - diabetes, alcohol, vit B12 deficiency)

Question 34

"drop attack"

Answer 34

an event whereby the person suddenly collapses without any preceding symptoms + without apparent loss of consciousness -> Account for 20% of elderly patients presenting to falls services

Question 35

orthostatic hypotension diagnosis

Answer 35

based largerly off history of symptoms + a drop >20/10mmHg within 3 mins of standing

Question 36

causes of orthostatic hypotension

Answer 36

baroreflex dysfunction - loss of baroceptor sensitivity + vasoconstriction associated with ageing (+vascular disease) medication or other circumstances - volume depletion, immobility, alpha-blockers (BPH) conditions that cause peripheral neuropathy can cause autonomic neuropathy + orthostatic hypotension parkinsons + LBD

Question 37

management of orthostatic hypotension

Answer 37

stop culprit drugs - alpha-blockers (doxasin+tamsulosin), antihypertensives, diuretics, pregabilin, antidepressants avoid sudden changes in movement increase salt in diet compression stocking elevate legs calf muscle exercises ** when failed -> fludrocortinsone, midodrine **

Question 38

psychotropic drugs that contribute to fall risk

Answer 38

taking doubles fall risk, stopping reduces fall risk some cause orthostatic hypotension - venlafaxine, duloxetine, risperidone, haloperidol phenytoin may cause permanent cerbellar damage + unsteadinessin long term use at therapeutic dose

Question 39

cardiac medications which contribute to fall risk

Answer 39

alpha-blockers - used for prostatism - doxazosin, indoramin, tamsulosin, prazosin ACEi + betablockers should be maintained whenever poss NICE = - stop nitrates, CCB or other vasodilators - always check BP - if no evidence of congestion - reduce diuretics

Question 40

what BP in old is assoc with increased fall risk?

Answer 40

BP of 120 or below

Question 41

target BPs in over/under 80s

Answer 41

over 80 = <150/90 under 80 = <140/90