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 ID: 548761
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Slide1
Geriatric MedicineSlide2
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 outcomesSlide3
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)Slide4
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
…Slide5
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 2001Slide6
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?Slide7
A Acoustic neuroma
B Benign
positional vertigo
C
Cervical spondylosis
D
Mechanical fall
E
Vertebrobasilar insufficiencySlide8
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 scanSlide9Slide10
There is no such thing as
a
‘
mechanical fall
’
in older people
(and always think about bones!)Slide11
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?Slide12
A Ambulatory blood pressure monitoring
B Ambulatory ECG
C
Capillary glucose measurement
during symptoms
D Carotid sinus massage
E Tilt testSlide13
Collapse ?cause
transient loss of consciousness
Due to acute illness
Syncope
Seizure
Hypoglycaemia
Intoxication
etc
Neurally
-
mediated
Orthostatic hypotension
Cardiac arrhythmia
Structural
TLOC alone is never a TIASlide14
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.Slide15
Delirium
NICE Clinical Guideline
103
– delirium: prevention, diagnosis and management (
Jul
2010)
A clinician’s brief guide to the Mental Capacity Act 2
nd
Ed. Brindle et al. RCPsych Publications, 2015.Slide16
Case historiesSlide17
NICE Clinical Guideline
103
Admission to hospital
Risk factors? Age >65; cognitive impairment/dementia; hip fracture; severe illness
YES
At risk
NO
Not at risk
Change in risk factors?
YES
Are there any indicators of delirium? – NB carers or relatives may report these: RECENT changes in cognitive function, behaviour, perception or physical function?
YES
Clinical assessment: short CAM and AMT
Delirium diagnosed?*
NO
Daily observations for indicators of delirium
PLUS
delirium prevention strategies
YES
Record in hospital and primary care notes.
TREATMENTSlide18Slide19
Delirium in older people
Definition:
An acute decline in cognition
and attention
(
‘
acute confusional state
’
)*
Characteristics:
A common problem
Often unrecognised
With serious complications
Multi-factorial aetiology
PreventableSlide20
Delirium is an acute medical problem, not a psychiatric disorder!
(and a serious medical condition)Slide21
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-factorialSlide22
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-factorialSlide23
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 outcomeSlide24
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.Slide25
Simplified diagnostic criteria: the short Confusion Assessment Method (CAM)
Criteria
Present?
Acute onset and fluctuating course
(Is there an acute change in mental state? Did this fluctuate during the past day?)
Y / N
2. Inattention
(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
Y / N
3. Disorganised thinking
(Is the patient’s speech disorganised, incoherent, rambling, irrelevant, unclear/illogical or unpredictable switching between subjects?)
Y / N
4. Altered level of consciousness
(Is the patient vigilant (hyper-alert) or lethargic/drowsy?)
Y / N
1 + 2 + either 3 or 4 must be present to diagnose delirium.Slide26
Delirium rates in studies
Hospital:
Prevalence (on admission) 10-40%
Incidence (while in hospital) 15-60%
Postoperative:
15
-53%
Intensive care unit:
70
-87%
Nursing home/post-acute care: 20-60%
Inouye. NEJM 2006; 354: 1157-65Slide27
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 nursesSlide28
Delirium has serious complications
S
tudies show delirium is associated with poor outcomes.
P
eople 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 22- 76%, as high as MI or
sepsis. One-year mortality 35-40%)Slide29
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 neuro-transmitter disturbances: ACh deficiency and dopamine excess
Diffuse slowing of cortical background activity on EEG
Generalised disruption of higher cortical function on neuro-psychological and imaging studiesSlide30
Who gets delirium? - p
redisposing
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)Slide31
What causes delirium? - p
recipitating
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)Slide32
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.Slide33
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 dehydrationSlide34
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 strategySlide35
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*Slide36
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
TheophyllineSlide37
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.Slide38
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.Slide39
Question 4
Which of the following best defines ‘acopia
’
?
An
inability to cope with activities of daily
living
A
town in
Peru
An
inability to cope with a stressful situation usually leading to
a nervous breakdown
The
fastest way to get
a Geriatrician fuming
when presenting a patient
on
the
post
-
take
ward
round
A lack of PolicemenSlide40
Question 5
Which of the following best defines
‘medically fit for discharge’?
No medical cause for the patient’s symptoms has been identified
The patient is back at their baseline (or best) physical and cognitive state
A term used inappropriately by doctors who have no training in, or dislike, Geriatric Medicine
The patient has no rehabilitation needs
The patient is on a surgical ward and does not need an operationSlide41
Questions