Transcript Falls -Prevention and Management

The Geriatric Giants
Dr Hannah Seymour
Consultant Geriatrician
RPH
Aknowledge slides from
• Dr Kate Ingram
• Dr Mark Donaldson
• Dr Chris Beer
• Dr Sean Maher
GIANTS OF GERIATRICS (Isaacs 1970)
• Immobility
• Instability
• Intellectual Impairment
• Incontinence
• Iatrogenesis
I’m going to talk about
• Cognition – Forgetfulness vs Delirium vs Dementia
• Falls – Reversible causes in the community
• Immobility – How to avoid and manage it
• Incontinence – Especially reversible causes
• Iatrogenic Conditions – Especially Polypharmcy &
Malnutrition
Cognition
Cognitive Screening Tests
• Screening
Detection amongst “healthy” community members of
(unsuspected) disorders or risk factors
• Case Finding
Detection of cognitive impairment where high
probability of disease in particular population or
setting
Cognitive Screening Tests
• Normal ageing vs MCI vs early dementia?
• No perfect test for early detection
• Case for detection of mild cognitive impairment unclear
Risks vs benefits, costs, no effective therapies
May change with new therapies
• Emphasis on detection of dementia
Benefit from interventions
• Should always be done if memory complaints or history
suggestive of dementia
Cognitive Screening Tests
• Detect cognitive impairment from any cause
• Don’t diagnose dementia!
• Generally test orientation, recall of short and long term
memory, personal information, attention and other
domains eg visuospatial
Cognitive Screening Tests: MMSE
•Standardised MMSE Molloy
et al 1991
•Floor and ceiling effects
•Western background,
education, language
•No test of executive
function
•Orientation
•Registration, Recall
•Attention
•Calculation
•Language
•Visual construction
Cognitive Screening Tests: Geriatric
Depression Scale (GDS) Yesavage 1983
•30 Questions
Cut off 11
Sens 84%
Spec 95%
Cut off 14
Sens 80%
Spec 100%
•15 Question version
•4 & 10 Question versions
•Yes or No responses to questions
about depression symptoms
•Depression an important cause
of cognitive impairment
Dementia
• Global cognitive impairment
• Irreversible
• Clear sensorium
• Usually progressive
Dementia: Causes
•Alzheimer’s
•Lewy Body
•Frontotemporal
•Parkinson’s
•Other extrapyramidal
syndromes
•Huntington’s
•Vascular
•Cushing’s, Addison’s, Thyroid,
parathyroid, diabetes
•Vitamin B12, thiamine, nicotine
deficiency
•Normal pressure hydrocephalus,
Head injury, space occupying
lesion, multiple sclerosis
•Syphilis, HIV, encephalitis, CJD
Stroke
Small vessel ischaemia
Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, O’Brien & Ames
Dementia: Some “Reversible or
partly reversible” Causes
•Drugs
•Liver disease
•Depression
•Normal pressure hydrocephalus
•Metabolic causes
•Subdural haematoma
•Thyroid Disease
•Neoplasm
•Vitamin B12 deficiency
•Hypercalcaemia
Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, O’Brien & Ames
Dementia: Diagnostic features
•development of multiple
cognitive deficits
•impairment in
occupational or social
functioning
•decline from a previously
higher level of functioning
•memory impairment
•And at least one of:
aphasia
apraxia
agnosia
disturbance in executive
functioning.
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Memory
•Memory impairment needed for diagnosis
•early prominent symptom
•new learning impaired
•forgets previously learned material
•loses valuables, forget food cooking, lost in
unfamiliar territory, poor medication compliance
•forgets personal details eg family, occupation,
address, own name
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Aphasia
•Language difficulty
•Loss of complexity
•Naming people or objects
•Repetition
•Comprehension (verbal and
written)
•eventually mute
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Apraxia
•Difficulty performing motor task despite intact
comprehension
power
Sensation
•Trouble with everyday tasks eg cleaning teeth,
washing
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Agnosia
•Difficulty recognising objects or people
•Trouble recognising ordinary objects, family
members, even themselves in photographs or mirrors
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Executive
Functioning
•ability to think abstractly
•judgement, reasoning, insight
•plan, initiate, sequence, monitor, and stop complex behaviour
•difficulty coping with novel tasks or complexity
•poor choices
•financial problems
•at risk behaviour due to lack of insight
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association
Diagnostic features: Behaviour
•Delusions, especially paranoia
•Social withdrawal
•Hallucinations, especially visual
•Neglect of personal care, home,
nutrition
•Irritability, aggression (verbal
and physical)
•Resistiveness
•Agitation, wandering, getting
lost
•Apathy
•Sleep disturbance
•Mood disturbance
Anxiety
Depression
•Demanding, attention seeking,
repetitive
Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Assessment
• History – most important
• Examination
• Neuropsychometric testing
• Laboratory tests
FBP, U&E, TFT, B12, folate, BSL, syphilis serology, ESR,
Urinalysis, calcium +/- lumbar puncture, EEG
• Imaging
CT, MRI
SPECT, PET
Dementia: Alzheimer’s Disease
• Accounts for 60% of Dementia in Australia
• Neuronal degeneration with plaques of beta amyloid
and neurofibrillary tangles
• Early onset forms due to gene mutations
• Main feature is memory loss, plus other domains,
gradually progressive
• Treatment with cholinesterase inhibitors (donepezil,
galantamine, rivastigmine) or memantine
• New therapies seem promising
Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Alzheimer’s Disease: Natural
History
Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Lewy Body Disease
• Lewy bodies = neuronal inclusions of neurofilament protein
ubiquitin
• Found in basal ganglia in PD, diffusely through cerebral cortex in
DLB - spectrum of same disease?
• Classic features of cognitive impairment plus
Fluctuation in cognition, alertness, attention
Visual hallucinations
Parkinsonism
• Respond to cholinesterase inhibitors
• Very sensitive to antipsychotics => rigidity
Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Vascular Dementia
• Cognitive impairment due cerebrovascular disease
Small vessel ischaemic changes - gradual decline
Recurrent stroke - stepwise deterioration
• Evidence of vascular changes on CT/MRI
• Vascular risk factors - HTN, cholesterol, diabetes, smoking, existing
cardiac disease
• Often early onset gait disturbance (balance and/or gait dyspraxia),
falls, urinary incontinence
• Often frontal lobe features, emotional lability, pseudobulbar palsy
with speech/swallowing problems
Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Frontotemporal
Dementia
• Probably represents several diseases
• Early loss of personal and social awareness
• Disinhibition often prominent
• Mental rigidity, inflexibility, “concrete”
• Depression and anxiety prominent
• Speech and language disturbance
Reduced in complexity
Echolalia, stereotypy
• Early primitive reflexes and urinary incontinence
• Late rigidity, tremor
Adapted from Hecker J., Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Management
• Treat reversible causes!
• Education
• Cholinesterase inhibitors (AD, LBD)
• Control of vascular risk factors
• Maintain cognitive and physical activity
• Treat depression
Dementia: Practical Issues
•Education
•Memory aids
•Counselling
•Home safety
•Community Resources
•Driving
Alzheimer’s Assoc
Respite in home, day centres &
residential
•Enduring Power of attorney
•Testamentary capacity
•Advanced directives
Crisis Care
•Continence
Care packages
•Residential Care
•Strategies for managing behaviour
Adapted from Hecker J Dementia and Alzheimer’s Disease in A Practical Guide to Geriatric Medicine. Ratnaike R
Dementia: Take home messages
• Cognitive screening tools only detect cognitive impairment they don’t diagnose
• History suggestive of dementia or abnormal cognitive test
result should result in suggestion for further evaluation
• A diagnosis of dementia requires decline in occupational
and social functioning, at least one other cognitive domain
impaired (aphasia, agnosia, apraxia, executive
dysfunction), as well memory
• Interventions usually beneficial
• Carer support vital to management
Delirium in Older People
Delirium: Definition
• de lira “to wander”
• Clinical syndrome characterised by
rapid onset of altered consciousness
and cognition
that fluctuates
Delirium: Epidemiology
• Prevalence in elderly hospital admissions
10 - 24%
• Incidence during hospital stay
6 - 56%
• Post operative incidence
10 - 61%
Delirium: Aetiology
• Geriatric syndrome
• Multiple factors acting in concert
• Patient vulnerability
• Predisposing factors
• Precipitating factors
Delirium: Predisposing factors
•Dementia
•Advanced age
•Multiple medications
•Neurological damage
•Visual and hearing
impairment
•Functional disability
•Severe/multiple chronic
medical conditions
•Dehydration
•Alcohol abuse
•Depression
•Chronic renal impairment
Delirium: Clinical Features
• Prodrome sometimes recognised
irritable, angry, evasive, bewildered
• Develops over hours to days
• Fluctuates
lucid periods during day
maximal disturbance at night
Delirium: Clinical Features
• Inattention
• Disorientation
• Short term memory impairment
• Thinking is disordered
• Speech rambling and incoherent
• Delusions, misperceptions and visual hallucinations
• Distress
Delirium: Clinical Features
• Disturbance of consciousness
• Hyperactive delirium
Repetitive behaviours e.g. plucking at sheets,
wandering, verbal and physical aggression
• Hypoactive delirium
quiet, withdrawn patient, often mistaken for
depression
• Mixed pattern
Delirium: Detection
• Delirium often missed
• 32 – 67% of delirious patients are not diagnosed
• Cognitive assessment should be standard
MMSE or AMTS
• Serial testing to monitor progress and to detect delirium
arising during an admission
• Mental status = a “vital sign”
Delirium: Detection
Confusion Assessment Method
(Inouye et al Ann Int Med 1990;113:234-42)
1 Acute onset and fluctuation of cognition
AND
2 Inattention
with EITHER
3 Disorganised thinking
OR
4 Altered level of consciousness
Delirium: Management
• Treat underlying causes
• Correct dehydration
• Review medications
• Non Pharmacological
• Pharmacological
• Monitor progress
Delirium: Outcomes
Duration
• More persistent than previously realised
• up to one week in 60%
• two weeks in 20%
• four weeks in 15%
• more than four weeks in 5%
• Others report delirium still present at 6 months
O'Keeffe S The prognostic significance of delirium in older hospital patients J of the
Am Geriatr Soc 1997;45(2):174-8
Delirium: Outcomes
Cognitive decline
• Early cognitive impairment unmasked by acute illness
• May be acute and permanent deficits due to ischaemia,
hypoxia or mediated by glucocorticoids or cytokines
Francis J Prognosis after hospital discharge of older medical patients with
delirium. J Am Geriatr Soc 1992;40(6):601-6
Delirium: Take Home Messages
• Common
• Distressing
• Often Missed
• Cognitive testing should be routine
• Complex Geriatric Syndrome
• Preventable
• Predicts adverse outcomes
Falls -Prevention and
Management
Definition
• “A fall occurs when environmental hazards or demands
exceed an individual’s ability to maintain postural
stability”
Mary Tinetti ASGM ASM 2001
Enormity of the Problem
• 33% over 65yrs fall annually
• 50% of these have repeat falls
• In nursing homes 50-65% fall annually
• 10-15% of falls result in serious injury
• 1% hip fracture rate
Breakdown of Discussion
• Falls in community dwelling elderly
• Compliance problems
• Unanswered questions
Modifiable Risk Factors for Falls
in the Community
•Psychotropic drugs – especially benzodiazepines
•Multiple drugs
•Postural Hypotension
•Environmental hazards
•Vision
•Poor balance or gait
•Poor functioning with ADLs
•Footwear
Preventing Falls in the
Community
• Independence model of care
• Screening of home environment by OT / health worker
• Psychotropic medication withdrawal
• Medication review/ minimization
• Appropriate vision aids & footwear
• Balance and exercise program
• Avoiding Injury - Treating Osteoporosis
Falls Clinic Process
Multidisciplinary- everyone assessed by the following:
• Geriatrician- full history, examination, investigation, including
osteoporosis workup
• Nurse-lying and standing BP, vision, continence, community
supports
• Physiotherapist- administers Fallscreen, ?need for walking aid,
teaches patient to get up off floor, strength and balance
exercise program, sets home program, general footwear advice
• OT- ADL assessment, 50% get home visit, group education
sessions
+/- social work assessment for package of care, hostel/ N/H
+/- clinical psychologist to address fear of falling or podiatry
Falls Clinic Process
Contd.
• All new patients discussed at a multidisciplinary meeting at the
end of the clinic, and management plan formulated
• Length of time attending the clinic approx 6-10 weeks.
• On discharge, given home exercise program
• Followed up 4 months following discharge
What about in the Kimberley
• No research in remote or Indigenous settings
• Moving to single multiskilled professional in metro areas
• Can do great functional assessments and improve
reversible risk factors
• Independence model of care very important
Who Should Have a Comprehensive Falls
Assessment?
• All older persons to be asked once a year about falls
• If 1 fall -GP assessment, and observe the ‘Get up and
go” test
• Triggers for further assessment
>1 fall in last year
A fall resulting in injuries
Abnormalities in gait or balance
Symptoms of dizziness
Evidence of a fear of falling
Hip Protectors
• Reduce hip fracture rate (by 50%) for those in nursing
homes with a high risk of falling
• Compliance is problematic- 38 –57% in various studies
Vitamin D Deficiency and Falls
• Causes muscle weakness and probably falls
• Leads to osteoporosis and increased risk of fracture
• Very common in elderly, community dwelling population
(? Indigenous)
• Almost universal in residential care
• Replacement with calcium reduces fractures in
residential care and in those who are deficient in the
community
Patient Compliance with Fall Initiatives
• Survey in Aust (Whitehead, 2003)
72% reluctant to do exercises
57% reluctant to stop sleeping tablets
43% reluctant to have a home assessment
• Campbell, JAGS, 1999
Study demonstrated reduced falls with psychotropic
withdrawal program and home based exercises
47% had restarted their psychotropics within 1 mth
Patient Compliance with Fall Initiatives
• Simpson
UK study investigated barriers to a falls program
The elderly patients involved had reduced
understanding of the benefits of exercise
Home visits were considered intrusive, and felt that
there was inadequate negotiation about the
necessary changes resulting in resentment
Summary
• Falls are a hallmark of the frail elderly
• Falls are usually multifactorial in origin
• DON’T be pessimistic- multidisciplinary
treatment can prevent up to 60% of falls
• The elderly have the most to gain by treating
their osteoporosis
Immobility
How to avoid it?
• Encourage functional mobility
• Educate family and carers
• Early rehabilitation
• Appropriate use and maintenance of mobility aids
• Physiotherapy if possible
Management of the Immobile Patient
• Ensure no reversible causes can be identified
• Encourage Independence within limits of mobility
Avoiding Pressure Ulcers
• Regular assessment of bony prominences
• Regular turning to relieve pressure – ideally 2 hourly
• Use pillows if no air mattresses available
• Avoid friction and shearing forces (safe manual
handling)
• Skin Hygeine and Moisture
• Leave blisters intact
• Get help early – for example Donna Angel at RPH will
advise
Urinary Incontinence in
the Elderly
Incontinence in the Elderly
• Prevalence in community dwelling elderly
-women 30%
-men 15%
• 60% of nursing home residents
• Risks
-parity (association is weak in women over
65yrs)
-hysterectomy
-obesity
Continence requires:
• Adequate mobility
• Mentation
• Motivation
• Manual dexterity
• Intact lower urinary tract function
Medical Complications
• Rashes
• Pressure ulcers
• UTI
• Falls
• Fractures
Psychosocial complications
• Embarrassment
• Stigmatisation
• Isolation
• Depression
• Institutionalisation risk
A Normal Bladder
• First urge to void occurs when bladder volume is 150 –
300mls
• Normal bladder volume 300 – 600mls
• Bladder capacity declines with age and post void
bladder volumes increases (up to 50 – 100 mls)
• Involuntary bladder contractions also increase with age
• Lose the ability to concentrate urine at night (ADH
secretion) with nocturia 1 – 2 x)
Causes of Transient Incontinence
• Delirium
• Infection (symptomatic UTI)
• Atrophic vaginitis/ urethritis
• Pharmaceuticals
• Psychological
• Excessive urine output
• Restricted mobility
• Stool impaction
Drugs Affecting Continence
• Diuretics
• Anticholinergics
• Psychotropics
• ACE inhibitors (cough)
• Narcotics
• Alpha blockers (urethral relaxation)
• B agonists (retention)
• Calcium channel blockers (retention)
Persistent Incontinence
-Stress
• Involuntary loss of urine (usually small amounts) with
increases in intra- abdominal pressure (coughing,
sneezing, laughing, exercising)
• In women, causes include lack of oestrogen, obesity,
previous vaginal deliveries, previous surgery
• In men (rare) causes include radiotherapy and
prostatectomy.
Persistent Incontinence
-Urge
• Leakage of urine (larger volumes) due to inability to
delay voiding after sensation of bladder fullness is felt
• Associated symptoms include nocturia, urinary
frequency
• Causes
Ideopathic (Detrusor overactivity)
Local pathology- tumour, stone, diverticuli, outflow
obstruction
CNS disorders- stroke
Detrusor hyperactivity with Impaired
Contractility (DHIC)
• A subset of patients will have this, emptying less than
1/3 of bladder volume
• Are predisposed to urinary retention
Persistent Incontinence
-Overflow
• Leakage of urine (small amounts) resulting from
mechanical forces on an overdistended bladder
• Causes
Anatomical obstruction by prostate, stricture,
cystocoele
Acontractile bladder associated with diabetes or spinal
cord injury
Medication related
Assessment
• History
Characteristics of incontinence
Medical problems, medications, bothersomeness
• Bladder chart
• Examination
General- esp CCF, venous insufficiency
Abdominal
PR
lumbosacral innervation
In women- inspect for prolapse, cough test,
atrophic vaginitis
Assessment of mental state and mobility
Assessment
• Urinalysis
the relationship of asymptomatic bactiuria with
incontinence is controversial.
No benefit from treating the nursing home
population
? Eradicate bactiuria once and assess it effect on
incontinence
• Post Void Residual Volume – Important to rule out
significant retention
<100 mls normal
>200 mls abnormal
Assessment- selected patients
• Urine culture, cytology
• Blood glucose, calcium, renal function
• Abdominal ultrasound
• Urodynamics
Recent data suggest that it has little clinical
utility in urge incontinence
Management
• Supportive measures
• Education
• Environmental changes eg toilet light on
• Use of toilet substitutes eg bottle, commode
• Modification of fluid intake patterns
• Alcohol, caffeine avoidance
• Management of constipation
• Smoking cessation, treatment of cough
Management- Behavoural
• Pelvic floor exercises- useful for urge
and stress incontinence
• Bladder Retraining
Urge incontinence
Progressive lengthening of intervoiding interval
Management- Behavoural
Institutionalised patients
• Scheduled toiletting- 2 hrly during day, 4 hrly at
night
• Habit training- variable schedule depending on
patients voiding patterns
• Prompted toiletting- prompted to toilet 2 hrly, only
toiletted on request, positive reinforcement (25 40% of nursing home residents respond)
Management Urge Incontinence- Drugs
• Anticholinergics eg. Oxybutinin 2.5- 5 mg tds
have 60 – 70% reduction in frequency of incontinence
episodes
Probably work via afferent pathways
S/Es: dry mouth, constipation, confusion, urinary
retention
• Oestrogen vaginal cream 0.5-1g nightly for 1 month,
then 2-3x/ week (NB oral oestrogens worsened
incontinence in the WHI study)
Management Stress Incontinence- Drugs
Little role for medications
Imipramine 25-50 mg tds (anticholinergic as well, so
there is an argument for using it for mixed urge/
stress incontinence) Efficacy date is lacking, though
and has side effects ++ in elderly
Duloxitene- serotonin and noradrenaline reuptake
inhibitor (results in 50-54% reduction in frequency of
incontinence). Causes initial nausea
Management of Overflow Incontinence
Catheter if significant retention then:
Refer to urology who may advise medication and or
surgery
Drugs - Prazosin, Tamsulosin, Terazosin
Management- other strategies
• Surgery
- TURP
- Bladder neck elevation, peri-urethral
collagen injections
• Catheters- IMCs, IDCs
• Botulinum toxin injection into detrusor muscle or
bladder neck
• Continence pessaries- for women with large prolapses
when surgery is contraindicated
• Desmopressin for large volume nocturia
Iatrogenic Problems
Polypharmacy
Objectives
• Understand why Polypharmacy is common in older
people
• Identify the problems caused by polypharmacy in older
people
• Monitor and manage Polypharmacy
• Understand inappropriate versus appropriate
Polypharmacy
The Challenge of Geriatric Clinical
Pharmacology
‘to balance an incomplete evidence base for efficacy
in frail, older people against the problems related to
adverse drug reactions without denying older people
potentially valuable pharmacotherapeutic
interventions’
Le Couter et al
Polypharmacy
• 5 or more drugs
• 20-40% of older people
Causes of Polypharmacy
•Comorbidities
•Age
•Prescriber (what influences prescribers?)
•Reluctance to cease another prescriber’s prescription
•‘Rational Polypharmacy’
Risks of Polypharmacy
• Adverse drug reactions common cause of
hospital admission
morbidity and mortality
• Falling, delirium and the other geriatric syndromes may
be drug-related
• Medication errors
polypharmacy, per se, appears to be a risk factor for
adverse outcomes
What are the goals of care?
• Often different in frail person
• Risks of polypharmacy higher in frail person with limited
homeostatic reserve
Eg antihypertensives
Weigh risks and benefits
•Efficacy
•Risk of ADR
•Pt wishes
Common difficult areas
• Include Benzodiazepine and psychotropic polypharmacy
• Antihypertensives
Medication Withdrawal Can be Achieved
Is Discontinuation Safe?
•Psychotropic withdrawal
reactions
•Anti anginals
•Anticonvulsant medications
Other Difficult Areas - Under
treatment
• Analgesics
• Osteoporosis therapy
(Anticoagulants)
(ACE-inhibitors and B-blockers)
Under treatment Continued
•Ca and Vit D (v bisphosphonates)
Reviewing Medications
• View and Record all medications, including OTC’s,
herbs, dietary supplements
• Ask about other prescribers
• Cautious medication withdrawal where indicated
Use aids
•Simplify regimens
•Medication cards
•Dosette Boxes
•‘Webster Pack’
•Supervised medications
•Involving caregivers
Conclusions
• Avoid polypharmacy
• Weigh risks and benefits
• Scrutinise all medication prescriptions critically
• Monitor therapy carefully in elderly patients
Malnutrition
Prevalence
• Increases with frailty and physical dependance
• Estimated 4.8% recipients of domiciliary aged care
clients
• 27.7% Sub-acute crae
Consequences
• More GP consultations
• More prescriptions
• Higher hospital admission rate
• Increased risk of:
Falls
Prolonged hospitalisation
Institutionalisation
Infections
Pressure Ulcers
Death
Nutritional Frailty
• Disability due to unintentional loss of body weight and
sarcopenia
• Search for medical causes
• Low Socioeconomic status significant risk factor
• As are poor health, polypharmacy, low mood, low
cognition.
Non Physiological Causes
• Social Factors – Poverty, Inability to shop, cook or feed
• Psychological Factors – Alcohol, Depression, Dementia
• Medical Factors – Cancer, Chronic Disease
• Medications – Side Effects common
Screening
• Two Question Rapid Screen
Positive if :
Body Mass Index <22kg/m2
Weight loss > 7.5% over 3 months
Management
• Treat/Manage reversible causes
• Educate individual and family –
www.nhmrc.gov.au/publications/synopses/n23syn.htm
• Oral supplements with macronutrients
• Lack of evidence for most vitamin supplements
• Ref : Malnutrition in older people - Australian Family Physician Vol 33, No 10
October 2004