Transcript Geriatric Medicine teaching slides

Geriatric Medicine
Why is Geriatric Medicine a specialty?
• Sick old people present differently
• They can be clinically complex
• Atypical presentations such as (new) reduced
mobility are not ‘social problems’ – they are medical
problems in disguise
• Comprehensive Geriatric Assessment (GCA) and
rehabilitation have a strong evidence base
• Acute specialist (geriatric/MDT) care in several
different settings improves outcomes
Geriatric Medicine topics
• Physiology of ageing (including side effects of medication)
• Falls and fragility fractures
• Syncope
• Dizziness
• Funny turns (TIA/seizure)
• Delirium
• Dementia
• Incontinence
• Rehabilitation
*including any relevant legal aspects (England)
Physiology
• Impaired immunity
– Elderly patients commonly do not get a fever or a
raised white cell count in sepsis
– An ‘acute abdomen’ is usually soft
• Reduced homeostasis/physiological reserve
• Reduced renal function despite a ‘normal’
creatinine
• Some clinical findings are not necessarily
pathological…
Atypical presentations – ‘medical problems in
disguise’
‘At the core of geriatric medicine as a specialty is the recognition
that older people with serious medical problems do not
present in a textbook fashion, but with falls, confusion,
immobility, incontinence, yet are perceived as a failure to
cope or in need of social care. This misconception that an
older person’s health needs are social leads to a prosthetic
approach, replacing those things they cannot do themselves,
rather than making a medical diagnosis. Thus the opportunity
for treatment and rehabilitation is lost. Old age medicine is
complex and failure to attempt to assess people’s problems as
medical is unacceptable.’
RCP / BGS statement 2001
Question 1
A 75-year-old woman was admitted following a fall.
During an assessment of her fall she complained of recent
balance problems and brief vertigo whenever she looked
up.
Her past medical history comprised hypertension, mild
angina and diet controlled diabetes for which she was
taking aspirin 75mg daily and amlodipine 10mg daily. On
examination, her gait and balance was normal, and there
were no focal neurological signs or injuries.
What is the most likely reason for her fall?
A
B
C
D
E
Acoustic neuroma
Benign positional vertigo
Cervical spondylosis
Mechanical fall
Vertebrobasilar insufficiency
Falls in older people
• NICE Clinical Guideline 161: assessment and
prevention of falls in older people (Jul 2013)
• NICE Clinical Guideline 146: osteoporosis:
assessing risk of fragility fractures (Aug 2012)
• Assess fracture risk in:
– Previous fragility fracture
– History of falls
– (Guideline lists others as well)
• FRAX or Qfracture plus other risks +/- DXA scan
There is no such thing as a
‘mechanical fall’ in older people
(and always think about bones!)
Question 2
An 80-year-old man was admitted after an episode of transient
loss of consciousness. He did not injure himself and recovered
quickly. This has happened 6 times in the last 18 months, always
while standing or walking.
His past medical history included type 2 diabetes, hypertension
and benign prostatic hypertrophy for which he was taking
metformin, ramipril, bendroflumethiazide and tamsulosin. On
examination, there was nothing abnormal to find. Postural BP,
blood results and 12-lead ECG were normal.
What is the next best step in management?
A
B
C
D
E
Ambulatory blood pressure monitoring
Ambulatory ECG
Capillary glucose measurement during symptoms
Carotid sinus massage
Tilt test
Collapse ?cause
transient loss of consciousness
Due to acute
illness
1.
2.
3.
4.
Syncope
Neurally-mediated
Orthostatic hypotension
Cardiac arrhythmia
Structural
Seizure
Hypoglycaemia
Intoxication
etc
TLOC alone is
never a TIA
Question 3
An 80-year-old man with dementia was admitted with
increased confusion thought to be due to a recent change
in medication. His wife was no longer able to look after
him at home. He had been wandering up and down the
ward and occasionally attempting to leave. He was
amenable to distraction from the nursing staff most of
the time but became aggressive if he was contradicted or
manhandled.
There was no evidence of physical illness and his blood
results, 12-lead ECG and CT of the head were all normal.
Delirium
• NICE Clinical Guideline 103 – delirium:
prevention, diagnosis and management (Jul
2010)
• A clinician’s brief guide to the Mental Capacity
Act 2nd Ed. Brindle et al. RCPsych Publications,
2015.
Case histories
NICE Clinical Guideline 103
Admission to hospital
Risk factors? Age >65; cognitive impairment/dementia; hip fracture; severe illness
YES
At risk
NO
YES
Are there any indicators of delirium? – NB
carers or relatives may report these:
RECENT changes in cognitive function,
behaviour, perception or physical function?
Change in risk factors?
NO
Daily observations for
indicators of delirium PLUS
delirium prevention strategies
YES
Clinical assessment: short CAM and AMT
Delirium diagnosed?*
YES
Not at risk
Record in hospital and
primary care notes.
TREATMENT
Delirium in older people
Definition:
• An acute decline in cognition and attention
• (‘acute confusional state’)*
Characteristics:
1. A common problem
2. Often unrecognised
3. With serious complications
4. Multi-factorial aetiology
5. Preventable
Delirium is an acute medical
problem, not a psychiatric
disorder!
(and a serious medical condition)
Diagnostic criteria for delirium
(DSM IV)
• Acute onset (hours or days)
• Disturbance of consciousness with reduced ability to focus,
sustain or shift attention
• Change in cognition or development of a perceptual
disturbance
• These disturbances fluctuate over the course of a day
• An organic (i.e. acute medical or surgical) not a psychiatric
cause – e.g. medication, illness etc.
• Often multi-factorial
Diagnostic criteria for delirium
(DSM IV)
• Acute onset (hours or days)
• Disturbance of consciousness with reduced ability to focus,
sustain or shift attention
• Change in cognition or development of a perceptual
disturbance
• These disturbances fluctuate over the course of a day
• An organic (i.e. acute medical or surgical) not a psychiatric
cause – e.g. medication, illness etc.
• Often multi-factorial
3 sub-types of delirium
• Hyperactive (meerkat-like)
• Hypoactive (in bed; carphology)
• Mixed
• Hypoactive delirium more likely to go
unrecognised and thus has a worse outcome
21/110 patients with delirium. The sensitivity and specificity of carphology
and/or floccillation for the diagnosis of delirium were 14 and 98%
respectively; positive likelihood ratio 6.8.
Associated with hyperactive and hypoactive delirium subtypes, and occurred
early during incident delirium.
In-patient mortality rates in patients with carphology/floccillation was double
the rate in patients without the behaviours.
Bottom line: uncommon physical signs, but presence highly suggests delirium.
Simplified diagnostic criteria: the short Confusion
Assessment Method (CAM)
Criteria
Present?
1. Acute onset and fluctuating course
Y/N
(Is there an acute change in mental state? Did this
fluctuate during the past day?)
2. Inattention
Y/N
(Is the patient easily distracted or does he have difficulty
keeping track of what is being said?)
Inattention can also be detected by asking for the days of
the week to be recited backwards
3. Disorganised thinking
Y/N
(Is the patient’s speech disorganised, incoherent, rambling,
irrelevant, unclear/illogical or unpredictable switching
between subjects?)
4. Altered level of consciousness
Y/N
(Is the patient vigilant (hyper-alert) or lethargic/drowsy?)
1 + 2 + either 3 or 4 must be present to diagnose delirium.
Delirium rates in studies
Hospital:
• Prevalence (on admission)
• Incidence (while in hospital)
Postoperative:
Intensive care unit:
Nursing home/post-acute care:
Inouye. NEJM 2006; 354: 1157-65
10-40%
15-60%
15-53%
70-87%
20-60%
Delirium is often unrecognised
• Previous studies: 32-66% cases unrecognised by
physicians
• Yale-New Haven Hospital study (1988-1989):
– 65% (15/23) unrecognised by physicians
– 43% (10/23) unrecognised by nurses
Delirium has serious complications
Studies show delirium is associated
with poor outcomes. People who
develop delirium are more likely to:
• Stay in hospital or critical care for
longer
• Have an increased incidence of
dementia
• Have more hospital-acquired
complications eg falls, pressure
ulcers
• Be admitted to long term care
• Die*
(mortality among hospitalised patients is 2276%, as high as MI or sepsis. One-year mortality
35-40%)
Delirium has a multi-factorial aetiology
The overlap between delirium
and dementia
• Strong inter-relationship both
patho-physiologically and
clinically
• Dementia increases the risk of
getting delirium
• Delirium increases the risk of
getting dementia
Underlying mechanism?
• Patho-physiology is poorly
understood
• Good evidence for neurotransmitter disturbances: ACh
deficiency and dopamine excess
• Diffuse slowing of cortical
background activity on EEG
• Generalised disruption of higher
cortical function on neuropsychological and imaging studies
Who gets delirium? - predisposing risk factors
•
•
•
•
•
•
•
•
Old
Cognitive impairment
Poor functional status
Sensory impairment (ie blind, deaf)
Reduced oral intake (dehydrated, malnourished)
Psycho-active drugs
Polypharmacy
Medical co-morbidities (acute and chronic)
What causes delirium? - precipitating factors
• Intercurrent illness
• Drugs
– Esp opioids, sedatives, drugs with anti-cholinergic side effects
•
•
•
•
•
•
Pain
Surgery
Environmental (eg urinary catheter use)
Sleep deprivation
Dehydration
Primary neurological disease (e.g. non-dominant hemisphere
stroke)
Multi-factorial aetiology
Complex inter-relationship between a vulnerable patient (with predisposing risk
factors) and precipitating factors. Thus in highly vulnerable patients, something like
one dose of a sleeping tablet could cause delirium; whereas in a relatively fit and well
patient, delirium may only develop after general anaesthesia or admission to ICU.
Delirium is preventable
• Several studies have shown
significant reductions in the
incidence and/or severity of
delirium using multi-factorial
interventions
• In contrast, dissemination of good
practice alone is only weakly
effective
• The Yale Delirium Prevention
Model – 1) Reality orientation, 2)
Promotion of sleep, 3) Early
mobilisation, 4) Avoid sensory
deprivation, 5) Avoid dehydration
The Yale Delirium Prevention Model
• Designed to counteract the iatrogenic risk factors leading to delirium in
hospital
• Targets 6 areas:
–
–
–
–
–
–
Cognitive impairment: reality orientation
Sleep deprivation: non-pharmacologic sleep protocol
Immobilisation: early mobilisation protocol
Vision impairment: vision aids
Hearing impairment: hearing aids / amplification devices
Dehydration: early recognition and treatment
• Significant reduction in risk of delirium and total delirium days, without
significant effect on delirium severity or recurrence
• Effectiveness and cost-effectiveness of the programme has been
demonstrated in multiple studies
• Primary prevention of delirium likely to be most effective treatment
strategy
• Incident delirium significantly reduced –
(13.3 to 4.6%; P = 0.006)
• Delirium severity and duration also significantly reduced
• Mortality, LoS, ADLs at discharge, going in to care same
both groups*
Some commonly used drugs (in older people)
with anti-cholinergic side effects
•
•
•
•
•
•
•
Anti-histamines
Anti-spasmodics eg hyoscine
Amitriptyline
Codeine
Cyclizine
Anti-Parkinson’s medications
Oxybutynin and other bladder
stabilisers
• Theophylline
Never assume delirium is due to a UTI
• Bacteruria (bugs in the
urine), manifest as nitrites
and leucocytes in the urine,
is a common normal finding
in old ladies (50% NH
residents), and some old
men
• Therefore UTI cannot be
diagnosed on the basis of a
through test of urine
(dipstick) alone in older
people.
The doctor is also confused
• In up to one-fifth of cases, a cause for delirium cannot be
found. In most, this is because delirium can persist long after
the precipitating factor has resolved
– Eg following a partial seizure
– Or a single dose of a psycho-active medicine
• If one possible cause of delirium is found, do not stop looking.
In older people there is often more than one cause.
Question 4
Which of the following best defines ‘acopia’?
A. An inability to cope with activities of daily living
B. A town in Peru
C. An inability to cope with a stressful situation usually
leading to a nervous breakdown
D. The fastest way to get a Geriatrician fuming when
presenting a patient on the post-take ward round
E. A lack of Policemen
Question 5
Which of the following best defines ‘medically fit
for discharge’?
A. No medical cause for the patient’s symptoms has been
identified
B. The patient is back at their baseline (or best) physical
and cognitive state
C. A term used inappropriately by doctors who have no
training in, or dislike, Geriatric Medicine
D. The patient has no rehabilitation needs
E. The patient is on a surgical ward and does not need an
operation
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Edited by Nicola Cooper, Consultant in Acute Medicine and Geriatrics,
Leeds General Infirmary, Leeds, UK, Kirsty Forrest, Consultant in
Anaesthesia and Education, Leeds General Infir mary, Leeds, UK, and
Graham Mulley, Professor of Elderly Medicine and Pr esident of the
British Geriatrics Society, St James's University Hospital, Leeds, UK
of
Geriatric Medicine
About the ABC of Geriatric Medicine
ABC Geriatric Medicine
ABC
Demographic trends confirm what clinicians already know – they are spending
increasing amounts of time dealing with older people. This new ABC pr ovides an
introduction to the new and increasing challenges of treating older patients in a
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ABC of Geriatric Medicine provides an overview of geriatric medicine in
practice. Chapters are written by experts, and are based on the specialty
geriatric medicine curriculum in the UK.
ABC of Geriatric Medicine is a highly illustrated, informative, and practical source
of knowledge, with links to further infor mation and resources. It is an essential
guide where management of the ageing population is a major health issue – for
hospital and family doctors, students, nurses and other members of the multidisciplinary team.
About the ABC series
Edited by Nicola Cooper, Kirsty Forrest and Graham Mulley
Cooper | Forrest | Mulley
Questions
ABC
Geriatric Medicine
of
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