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

• Age

• Female

• Past fall

• Cognitive impairment

• Lower limb weakness

• Balance disturbance

RISK FACTORS

• Psychotropic meds

• Arthritis

• Past CVA

• Orthostatic hypotension

• Dizziness

AGE RELATED FUNCTIONAL DECLINE

• Visual

• Proprioceptive

• Vestibular

ENVIRONMENT

• FOOTWEAR

• HOME MODIFICATIONS

• BEHAVIOUR

• SAFETY DEVICES

• SOCIAL INTEGRATION

DISEASE RELATED FUNTIONAL DECLINE

neurological

• CVA

• Parkinsons

• Cerebellar

• Neuropathy

• Dementia

• Delerium

• Epilepsy

cardiovascular

• Arrythmia

• Orthostatic hypotension

• Anatomical

• Vasomotor instability

GIT

• Bleeding

• D&V

• Defecation syncope

metabolic

• Hypothyroid

• Hypoglycemia

• Hypokalemia

• hyponatremia

UGS

• Micturition syncope

• Nocturia

• Incontinence

musculoskeletal

• Arthritis

• Myopathy

• Deconditioning

Psychiatric

• Anxiety

• Depression

medications

• Antihypertensives and cardiac

• Antidepressants

• Antipsychotics

• Benzodiazepines

• Levadopa

• Narcotics

toxins

• Alcohol

MECHANISM

• SYNCOPE /HYPOTENSION

• SEIZURE

• DIZZINESS / BALANCE

• GAIT DISTURBANCE

• PAIN / WEAKNESS

• MECHANICAL FALL

FUNCTIONAL IMPAIRMENT

• BP regulation• Central processing• Gait• Neuromotor function• Postural control• Proprioception• Vestibular• vision

EVALUATION

• History esp of fall

• Examination esp BP, balance, vision, gait

• Get up and go

• Divided attention

• Tests

PREVENTION

• Strength and balance

• Education

• Medications

• Environmental mods

PREVENT COMPLICATIONS

DEMENTIA

Causes of Cognitive Impairment

J-0

1 Delirium

• Sepsis

• Hypoxia

• Biochemical disturbances

Calcium, sodium, glucose,urea,hepatic

DEFINITION

• An acute organic mental syndrome characterized by:

• 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

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 substance-induced 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

A-2

Reference: DSM-IV, pp 133-155.

CRITERIA FOR DIAGNOSIS

• MEMORY IMPAIRMENT• OTHER COGNITIVE IMPAIRMENT

– Language, motor skills, perception

• ADL IMPAIRMENT• INSIDIOUS ONSET• DETERIORATING• NO OTHER CAUSE

– Systemic,neurological, psychiatric

CRITERIA FOR DIAGNOSIS

• PATHOLOGY- autopsy or brain biopsy

Comparison delirium and dementia

• Sudden onset

• Usually reversible

• Short duration

• Fluctuations

• Altered consciousness

• Associated illness

• Inattention

• Always worse at night

• Impaired variable recall

• 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– Parkinson’s– Wilson’s– Multiple sclerosis– Tumours– Vasculitis

Alzheimer’s Disease Diagnosis• Acquired decline in cognitive function of an

insidious and progressive nature– Loss of memory – Impairment of at least one of;

• Language• Perception• Praxis• Problem solving, planning, organization• Judgement, insight or abstract thought

– Decline in ability to perform activities of daily living

A-1

• (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-7

A

B

Cholinergic Hypothesis• Role

– 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

A-9

Reference: Mayeux R, et al. N Engl J Med. 1999;341:1670-1679.

TREATMENT

Overall Management

• 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

• Sedatives

• Antidepressants

• Analgesics

• “SIADH”

• Antiepileptics

• Specials– Digoxin, cimetidine, lithium.

Treat Memory

• Cholinergics

• ?oestrogens

• Vitamin E

• Selegeline

Treat Symptoms

• Treat family

• Non pharmacological

• Antipsychotics

• Benzodiazepines

• ANTIDEPRESSANTS

Drug Utilization Trends in Dementia

T-5

Source: NDTI (Diagnosis codes: 3310, 2900, 2901, 2902, 2903, 2904), 1999.

Numberof Drug

Uses(000)

0

500

1000

1500

1995 1996 1997 1998 1999

Aricept

Risperdal

Haldol

Ativan

Vitamin E

Zoloft

Zyprexa

Feature ComparisonDose

Drug MoA Binding Escalation Dosing

Reminyl® AChEI, Competitive, 4-week steps bdnAChR reversible (od)

Aricept® AChEI Noncompetitive, 4/6-week steps odreversible

Exelon® AChEI Pseudo- 1-week steps bidirreversible

T-10

AD REM 8 59

Neuron and Acetylcholine

M-4

Postsynaptic nerve terminal

N receptor

Presynaptic nerve terminal

M receptor

ACh

Acetic acid Choline

AChE

AChE inhibitor

AD REM 8 60

Acetic acid Choline

Reminyl® Dual Mechanism of Action

M-6

Postsynaptic nerve terminal

Presynaptic nerve terminal

N receptor

M receptor

ACh

AChE

Reminyl binds to allosteric site on N receptor

Reminyl inhibits AChE

INCIDENCE

• 15% - 30% community-dwelling

• 30% hospitalized

• 50% long-term care

Predisposes to

• Rashes

• Pressure sores

• Urinary tract infections

• Falls

• Fractures

• Increased risk of institutional care

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

INCONTINENCE IS A SYMPTOM

• Transient or established.

• Urge, stress or overflow.

• Clinical.

Transient• D delirium• I infection• A atrophic vaginitis• P pharmaceuticals• P psychological (depression)• E excessive output• R restricted mobility• S stool impaction

pharmaceuticals• 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 non-neurogenic

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