Transcript Geriatric_Giants_Jane_Courtney - E-Ageing: E

THE GERIATRIC
GIANTS
MEDICINE 400
Jane Courtney
Hollywood Private Hospital
30th June 2008
Immobility
Instability
Incontinence
Impaired intellect/memory
Impaired vision
Impaired hearing
Delirium
Poly-pharmacy
Care provision
Assessment
Multi-disciplinary
Functional - adl’s
- iadl’s
Problem oriented
FALLS
INCIDENCE
– 30% community dwellers >65 years
– 50% long term care
– 60% fall in last year
CONSEQUENCES
• 10 –15% fracture
• Decrease in functional status
• 2% injurious falls result in death
COSTS
• 8% ED presentations >70 years
• 33% of these admitted
• Median stay 8 days
RISKS
• Rarely single cause
Falls usually occur when a threat to the
normal homeostatic mechanisms that
maintain postural stability is superimposed on
age-related declines in balance,ambulation
and cardiovascular function.
Threat
•Acute illness
•Environmental stress
•Unsafe walking surface
RISK FACTORS
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Age
Female
Past fall
Cognitive impairment
Lower limb weakness
Balance disturbance
RISK FACTORS
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Psychotropic meds
Arthritis
Past CVA
Orthostatic hypotension
Dizziness
AGE RELATED FUNCTIONAL
DECLINE
• Visual
• Proprioceptive
• Vestibular
ENVIRONMENT
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FOOTWEAR
HOME MODIFICATIONS
BEHAVIOUR
SAFETY DEVICES
SOCIAL INTEGRATION
DISEASE RELATED
FUNTIONAL DECLINE
neurological
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CVA
Parkinsons
Cerebellar
Neuropathy
Dementia
Delerium
Epilepsy
cardiovascular
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Arrythmia
Orthostatic hypotension
Anatomical
Vasomotor instability
GIT
• Bleeding
• D&V
• Defecation syncope
metabolic
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Hypothyroid
Hypoglycemia
Hypokalemia
hyponatremia
UGS
• Micturition syncope
• Nocturia
• Incontinence
musculoskeletal
• Arthritis
• Myopathy
• Deconditioning
Psychiatric
• Anxiety
• Depression
medications
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Antihypertensives and cardiac
Antidepressants
Antipsychotics
Benzodiazepines
Levadopa
Narcotics
toxins
• Alcohol
MECHANISM
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SYNCOPE /HYPOTENSION
SEIZURE
DIZZINESS / BALANCE
GAIT DISTURBANCE
PAIN / WEAKNESS
MECHANICAL FALL
FUNCTIONAL IMPAIRMENT
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BP regulation
Central processing
Gait
Neuromotor function
Postural control
Proprioception
Vestibular
vision
EVALUATION
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History esp of fall
Examination esp BP, balance, vision, gait
Get up and go
Divided attention
Tests
PREVENTION
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Strength and balance
Education
Medications
Environmental mods
PREVENT COMPLICATIONS
DEMENTIA
J-0
Causes of Cognitive Impairment
1 Delirium
• Sepsis
• Hypoxia
• Biochemical disturbances
Calcium, sodium, glucose,urea,hepatic
DEFINITION
• An acute organic mental syndrome
characterized by:
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Global cognitive impairment
Reduced consciousness
Disturbed attention
Psychomotor activity
Sleep-wake cycle disturbance
2 Neurological disease
• Brain tumour
• Stroke
• Subdural
3 Psychiatric Disease
• Depression
• Anxiety
• Alcohol or other substance abuse
4 Medications
5 “Classics”
• Thyroid
• B12
• Folate
6 Benign Forgetfulness
7 Dementia
A-2
Definition of Dementia
• The development of multiple cognitive deficits manifested by both
memory impairment and one or more of the following
– Aphasia -Apraxia -Agnosia
– Disturbance in executive functioning
• These cognitive deficits cause significant impairment in social or
occupational functioning
• The course is characterized by gradual onset and continuing cognitive
decline
• The cognitive deficits are not due to other CNS, systemic, or substanceinduced conditions
• The deficits do not occur exclusively during the course of a delirium
• The disturbance is not better accounted for by another Axis I disorder
Reference: DSM-IV, pp 133-155.
CRITERIA FOR DIAGNOSIS
• MEMORY IMPAIRMENT
• OTHER COGNITIVE IMPAIRMENT
– Language, motor skills, perception
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ADL IMPAIRMENT
INSIDIOUS ONSET
DETERIORATING
NO OTHER CAUSE
– Systemic,neurological, psychiatric
CRITERIA FOR DIAGNOSIS
• PATHOLOGY- autopsy or brain biopsy
Comparison
delirium and dementia
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Sudden onset
Usually reversible
Short duration
Fluctuations
Altered consciousness
Associated illness
Inattention
Always worse at night
Impaired variable recall
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Insidious onset
Slowly progressive
Long duration
Relatively stable
Normal consciousness
Not associated
Attention not sustained
Can be worse at night
Memory loss
TYPES OF DEMENTIA
• PRIMARY NEURODEGENERATIVE
– CORTICAL
• Alzheimer’s disease
• Fronto-temporal dementias (Pick’s disease)
– SUBCORTICAL
• Progressive supra nuclear palsy
• Huntington’s
• Lewy Body Disease
TYPES OF DEMENTIA
• VASCULAR
– Multi-infarct
– Biswangers disease
• INFECTIVE
– Creutzfeld-jacob
– AIDS
– Neurosyphilis
TYPES OF DEMENTIA
• TRAUMA
– Sub dural
– Dementia pugulistica
– radiotherapy
• NORMAL PRESSURE
HYDROCEPHALUS
TYPES OF DEMENTIA
• ASSOCIATED WITH OTHER DISEASES
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Parkinson’s
Wilson’s
Multiple sclerosis
Tumours
Vasculitis
A-1
Alzheimer’s Disease Diagnosis
• Acquired decline in cognitive function of an
insidious and progressive nature
– Loss of memory
– Impairment of at least one of;
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Language
Perception
Praxis
Problem solving, planning, organization
Judgement, insight or abstract thought
– Decline in ability to perform activities
of daily living
A-7
A
B
• (A) Immunocytochemical
staining of NFTs in the
isocortex of human AD
brain with the anti-tau
antibody AT8
• (B) Immunocytochemical
staining of senile plaques in
the isocortex of human AD
brain with the anti-amyloid
antibody 4G8
A-9
• Role
Cholinergic Hypothesis
– Acetylcholine (ACh) is an important neurotransmitter in
areas of the brain involved in memory formation (eg.
hippocampus, cerebral cortex, and amygdala)
• Impact
– Loss of ACh occurs early in AD and correlates with the
impairment of memory
• Treatment approach
– Enhancement or restoration of cholinergic function may
significantly reduce the severity of
cognitive loss
Reference: Mayeux R, et al. N Engl J Med. 1999;341:1670-1679.
TREATMENT
Overall Management
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Is it Alzheimers? OR what?
Are there any reversible components?
Any specific treatments?
Educate and support carer/family.
Treat symptoms as they arise.
Treat intercurrent problems.
Medications
• Can cause cognitive impairment
• Can treat memory loss (Alzheimer’s, DLB)
• Can treat symptoms
• Can prevent (vascular)
Cause Cognitive Impairment
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Sedatives
Antidepressants
Analgesics
“SIADH”
Antiepileptics
Specials
– Digoxin, cimetidine, lithium.
Treat Memory
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Cholinergics
?oestrogens
Vitamin E
Selegeline
Treat Symptoms
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Treat family
Non pharmacological
Antipsychotics
Benzodiazepines
ANTIDEPRESSANTS
T-5
Drug Utilization Trends in
Dementia
1500
Aricept
Risperdal
Haldol
Ativan
1000
Vitamin E
Zoloft
Zyprexa
Number
of Drug
Uses
(000)
500
0
1995
1996
1997
Source: NDTI (Diagnosis codes: 3310, 2900, 2901, 2902, 2903, 2904), 1999.
1998
1999
T-10
Feature Comparison
Dose
Escalation
Drug
MoA
Binding
Reminyl®
Aricept®
AChEI,
nAChR
AChEI
Exelon®
AChEI
Competitive,
4-week steps
reversible
Noncompetitive, 4/6-week steps
reversible
Pseudo1-week steps
irreversible
Dosing
bd
(od)
od
bid
M-4
Neuron and Acetylcholine
Presynaptic
nerve terminal
M receptor
Postsynaptic
nerve terminal
AD REM 8
59
M-6
Reminyl® Dual Mechanism of Action
Presynaptic
nerve terminal
M receptor
Postsynaptic
nerve terminal
AD REM 8
60
INCIDENCE
• 15% - 30% community-dwelling
• 30% hospitalized
• 50% long-term care
Predisposes to
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Rashes
Pressure sores
Urinary tract infections
Falls
Fractures
Increased risk of institutional care
INCONTINENCE IS A SYMPTOM
Incontinence is abnormal at any age.
Prevalence increases with age.
At no age does it affect the majority of
individuals.
Even with severe dementia not all people
are incontinent
NEW INCONTINENCE MUST BE INVESTIGATED
• Transient or established.
• Urge, stress or overflow.
• Clinical.
Transient
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D
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P
P
E
R
S
delirium
infection
atrophic vaginitis
pharmaceuticals
psychological (depression)
excessive output
restricted mobility
stool impaction
pharmaceuticals
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Anticholinergics
Alpha agonists (men)
Alpha antagonists (women)
Calcium channel blockers
ACE inhibitors (cough)
Diruretics
Sedatives (and alcohol)
Established
Patho-physiological mechanisms
detrusor overactivity
detrusor underactivity
obstruction
outlet incontinence
Each can be either neurogenic or nonneurogenic
WHAT DO WE DO?
HISTORY
EXAMINATION
INVESTIGATIONS.
TYPE
FREQUENCY
PATTERN
MEDICAL
MEDICATIONS
FUNCTION
FULL PHYSICAL….GUIDED
PELVIC
RECTAL
NEUROLOGICAL
STRESS
VOIDING CHART
U&E, CALCIUM, GLUCOSE
URINALYSIS+/- MSU
RESIDUAL VOLUME
ULTRASOUND
URODYNAMICS
CYSTOSCOPY
TREATMENT
FIRST THE CAUSE IN TRANSIENT
STRESS- PELVIC FLOOR EXERCISES
- WEIGHT LOSS
- OESTROGEN
- SURGERY
OBSTRUCTION - ALPHA ANTAGONIST
- SURGERY
DO - ANTICHOLINERGIC
DU - CATHETER
PADS, BOTTLES, COMMODES
A LAST WORD ABOUT
POLYPHARMACY
THE GERIATRICIAN’S PEN
v’s A BALANCING ACT