Week 5: Geriatric patients (Part 1)

What is frailty?

Medical syndrome characterised by dysregulation of multiple organ systems.

Diminished strength, reduced function, increased vulnerability.

What are the additional challenges in managing frail patients?

Multiple diagnoses

Non-specific S&S.

Underlying pathology not always obvious

Increased mental, cognitive and social issues

Polypharmacy

Increase vulnerability

What are the cardiovascular changes that occur for geriatrics?

Reduced vessel wall compliance. (Reduced elastin, increased collagen and calcium).

Endothelium is less responsive.

Impaired diastolic relaxation.

Decreased baroreceptor sensitivty.

Heart valve undergoes sclerosis

What are the respiratory changes that occur for geriatrics?

- Reduced lung compliance.

- Reduced diffusion capacity (effects gas exchange).

- Reduced elastic recoil

- Decrease resp muscle strength

- Increase chest wall stiffening

- Decreased cough/gag reflex.

- Loss of cilia.

What are the haematological changes that occur for geriatrics?

Decreased immune function.

- B-cell presevered but decreased specific antibody and increased autoantibody production.

- T-Cell numbers decreased. Reduced activation.

- Decreased seroconversion and seroprotection rates.

- 20-30% have decreased febrile response to infection.

What are the endocrine changes that occur for geriatrics?

Increased fat composition

Development of T2Dm common

Impaired thermoregulation due to change in hypothalamic function.

What are the musculoskeletal changes that occur for geriatrics?

Decreased bone and muscle mass.

Due to atrophy (decrease, waste, shrinkage of cells), neuronal degeneration, impaired protein synthesis.

What are the genitourinary changes that occur for geriatrics?

Reduced renal function

Loss of nephrons

Thickened basement membrane.

Increased renal artery resistance, meaning reduced kidney blood flow.

What are the GI changes that occur for geriatrics?

Reduced oesophageal motility meaning impaired swallowing and GORD.

Weakened connective tissue causing diverticula.

What are the CNS changes that occur for geriatrics?

Reduced neural transmission. Altered in concentration.

Development of hearing impairment.

Development of vision impairment. (Loss on the ability to focus on nearby objects. Changes in lens nucleus and decreased ciliary muscle contractility.

What are the integumentary changes that occur for geriatrics?

Skin becomes thinner, less elastic, drier, wrinkled

Bruise easier, tearing more easily, impaired skin repair.

What are the pharmacodynamic changes that occur for geriatrics?

Decreased hepatic metabolism, increased toxicity risk.

Decreased GFR, decreased excretion, increased toxicity risk.

Increased total body fat, increased distribution of fat soluble drugs.

Decreased total body water, decreased distribution of water soluble drugs.

Decreased serum albumin, increased effect of albumin bound drugs like warfarin.

What are some examples of fat soluble drugs

Midazolam

Fentanyl

Ketamine

Amiodarone

Diazepam

What are some common conditions affecting geriatric patients?

Syncope, metabolic disorders

Gait disturbance, stroke, inner ear disorder

headache, TIA,

Confusion, UTI,diabetes,

Diarrhoea, infections, diverticulitis, hyperthyroidism, bowel cancer.

Chest pain.

What considerations should be made regarding medication history of geriatric patients?

Polypharmacy.

Inappropriate prescribing.

Risk of side effects

Missed doses.

What considerations should be made regarding general history of geriatric patients?

Medical records, webster packs, use family members.

Use environment and care-giver. Is there signs of abuse?

Cognitive state of patient.

What considerations should be made regarding general examination of geriatric patients?

Ensure to acquire a postural BP.

Pacemaker, defib, scars, medical buzzer or medi alert.

Signs of neglect.

Signs of malnutrition

Pressure sores

Mobility assessment

What is dementia?

acquired neurological syndrome characterized by progressive deterioration in intellectual functions, judgment, thinking, visuospatial skills, constructional abilities, language, memory, emotions and behavior.

What are the risk factors of dementia?

Aging, family history, diabetes, obesity, smoking, cardiac dysrhythmias (e.g. cardiac dysrhythmias), female, lower education, previous head injury.

What are the classifications of dementia?

Alzheimers Disease

Vascular Dementia

Mixed dementia

Lewy body dementia

Frontotemporal dementia

Huntingdon's disease

Alcohol-related dementia

Progressive supranuclear palsy.

What is Alzheimer's Disease

Most common

Memory is affected.

May also impair function, language, visuospatial skills.

Agitation and/or behavioural changes.

What is Vascular Dementia?

Second most common

Acute onset

Symptoms depend on the location of the stroke/s

Can see cerebrobascular disease.

What is Mixed Dementia?

Mixed features of both alzheimers and vascular dementia.

What is Lewy body dementia?

Progressive decline

Visual hallucinations

Parkinosonian signs

Alterations of alertness and attention

Fluctuating cognitive decline.

What is frontotemporal dementia?

Rarer

Occurs secondary to degeneration of the frontal lobe and temporal lobe.

What are other types of dementia? (More rare)

Huntingdon's disease

Alcohol-related dementia

Progressive supranuclear palsy.

What is delirium?

State of mental confusion that develops quickly, usually fluctuates in intensity.

Thought that acetylcholine inhibition or pro-inflammatory cytokines may play a role.

How does delirium present?

Disturbance in consciousness

Changes in cognition or development of percepual distrubance.

Hx supports underlying condition, medication withdrawal.

May be agitated and restless. OR quiet and withdrawn.

What are the causes of delirium?

Hypoxia, hypercarbia, hypo/hyperglycaemia, hyponatremia

Infections

Decreased CO

Drugs/intox

Medications

Faecal impaction

Urinary retention

What is the prognosis of delirium?

Reversible with proper and timely treatment

How is a cognitive impairment assessed?

- Mini-mental sate exam: Series of questions scored out of 30.

- Clock drawing

- Confusion assessment method (CAM)