Geriatric Medicine - PowerPoint Presentation

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 scanSlide9
Slide10

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.

TREATMENTSlide18
Slide19

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