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Geriatric Medicine 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 outcomes 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) 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… 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 2001 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? A B C D E Acoustic neuroma Benign positional vertigo Cervical spondylosis Mechanical fall Vertebrobasilar insufficiency 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 scan There is no such thing as a ‘mechanical fall’ in older people (and always think about bones!) 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? A B C D E Ambulatory blood pressure monitoring Ambulatory ECG Capillary glucose measurement during symptoms Carotid sinus massage Tilt test Collapse ?cause transient loss of consciousness Due to acute illness 1. 2. 3. 4. Syncope Neurally-mediated Orthostatic hypotension Cardiac arrhythmia Structural Seizure Hypoglycaemia Intoxication etc TLOC alone is never a TIA 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. Delirium • NICE Clinical Guideline 103 – delirium: prevention, diagnosis and management (Jul 2010) • A clinician’s brief guide to the Mental Capacity Act 2nd Ed. Brindle et al. RCPsych Publications, 2015. Case histories NICE Clinical Guideline 103 Admission to hospital Risk factors? Age >65; cognitive impairment/dementia; hip fracture; severe illness YES At risk NO YES Are there any indicators of delirium? – NB carers or relatives may report these: RECENT changes in cognitive function, behaviour, perception or physical function? Change in risk factors? NO Daily observations for indicators of delirium PLUS delirium prevention strategies YES Clinical assessment: short CAM and AMT Delirium diagnosed?* YES Not at risk Record in hospital and primary care notes. TREATMENT Delirium in older people Definition: • An acute decline in cognition and attention • (‘acute confusional state’)* Characteristics: 1. A common problem 2. Often unrecognised 3. With serious complications 4. Multi-factorial aetiology 5. Preventable Delirium is an acute medical problem, not a psychiatric disorder! (and a serious medical condition) 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-factorial 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-factorial 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 outcome 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. Simplified diagnostic criteria: the short Confusion Assessment Method (CAM) Criteria Present? 1. Acute onset and fluctuating course Y/N (Is there an acute change in mental state? Did this fluctuate during the past day?) 2. Inattention Y/N (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 3. Disorganised thinking Y/N (Is the patient’s speech disorganised, incoherent, rambling, irrelevant, unclear/illogical or unpredictable switching between subjects?) 4. Altered level of consciousness Y/N (Is the patient vigilant (hyper-alert) or lethargic/drowsy?) 1 + 2 + either 3 or 4 must be present to diagnose delirium. Delirium rates in studies Hospital: • Prevalence (on admission) • Incidence (while in hospital) Postoperative: Intensive care unit: Nursing home/post-acute care: Inouye. NEJM 2006; 354: 1157-65 10-40% 15-60% 15-53% 70-87% 20-60% 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 nurses Delirium has serious complications Studies show delirium is associated with poor outcomes. People 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 2276%, as high as MI or sepsis. One-year mortality 35-40%) 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 neurotransmitter disturbances: ACh deficiency and dopamine excess • Diffuse slowing of cortical background activity on EEG • Generalised disruption of higher cortical function on neuropsychological and imaging studies Who gets delirium? - predisposing 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) What causes delirium? - precipitating 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) 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. 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 dehydration 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 strategy • 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* 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 • Theophylline 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. 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. Question 4 Which of the following best defines ‘acopia’? A. An inability to cope with activities of daily living B. A town in Peru C. An inability to cope with a stressful situation usually leading to a nervous breakdown D. The fastest way to get a Geriatrician fuming when presenting a patient on the post-take ward round E. A lack of Policemen Question 5 Which of the following best defines ‘medically fit for discharge’? A. No medical cause for the patient’s symptoms has been identified B. The patient is back at their baseline (or best) physical and cognitive state C. A term used inappropriately by doctors who have no training in, or dislike, Geriatric Medicine D. The patient has no rehabilitation needs E. The patient is on a surgical ward and does not need an operation 9781405169424_cooper_pb.qxd 10/10/08 12:52 Page 1 of Edited by Nicola Cooper, Consultant in Acute Medicine and Geriatrics, Leeds General Infirmary, Leeds, UK, Kirsty Forrest, Consultant in Anaesthesia and Education, Leeds General Infir mary, Leeds, UK, and Graham Mulley, Professor of Elderly Medicine and Pr esident of the British Geriatrics Society, St James's University Hospital, Leeds, UK of Geriatric Medicine About the ABC of Geriatric Medicine ABC Geriatric Medicine ABC Demographic trends confirm what clinicians already know – they are spending increasing amounts of time dealing with older people. This new ABC pr ovides an introduction to the new and increasing challenges of treating older patients in a variety of settings. ABC of Geriatric Medicine provides an overview of geriatric medicine in practice. Chapters are written by experts, and are based on the specialty geriatric medicine curriculum in the UK. ABC of Geriatric Medicine is a highly illustrated, informative, and practical source of knowledge, with links to further infor mation and resources. It is an essential guide where management of the ageing population is a major health issue – for hospital and family doctors, students, nurses and other members of the multidisciplinary team. About the ABC series Edited by Nicola Cooper, Kirsty Forrest and Graham Mulley Cooper | Forrest | Mulley Questions ABC Geriatric Medicine of The new ABC series has been thor oughly updated, offering a fresh look, layout and features throughout, helping you to access infor mation and deliver the best patient care. The newly designed books r emain an essential reference tool for GPs, GP registrars, junior doctors and those in primary car e, designed to address the concerns of general practitioners and pr ovide effective study aids for doctors in training. Now offering over 40 titles, this extensive series pr ovides you with a quick and dependable reference on a range of topics in all the major specialities. Each book in the new series now of fers links to further infor mation and articles, and a new dedicated website provides you with even mor e support. The ABC series is the essential and dependable sour ce of up-to-date infor mation for all practitioners and students in general practice. www.abcbookseries.com www.abcbookseries.com