The Geriatric Giants

Dr Hannah Seymour Consultant Geriatrician RPH

Aknowledge slides from

Dr Kate Ingram Dr Mark Donaldson Dr Chris Beer Dr Sean Maher

GIANTS OF GERIATRICS (Isaacs 1970)

Immobility Instability Intellectual Impairment Incontinence Iatrogenesis

Im going to talk about

Cognition Forgetfulness vs Delirium vs Dementia Falls Reversible causes in the community Immobility How to avoid and manage it Incontinence Especially reversible causes Iatrogenic Conditions Especially Polypharmcy & Malnutrition

Cognition

Cognitive Screening Tests

Screening Detection amongst healthy community members of (unsuspected) disorders or risk factors

Case Finding Detection of cognitive impairment where high probability of disease in particular population or setting

Cognitive Screening Tests

Normal ageing vs MCI vs early dementia? No perfect test for early detection Case for detection of mild cognitive impairment unclear Risks vs benefits, costs, no effective therapies May change with new therapies Emphasis on detection of dementia Benefit from interventions Should always be done if memory complaints or history suggestive of dementia

Cognitive Screening Tests

Detect cognitive impairment from any cause Dont diagnose dementia! Generally test orientation, recall of short and long term memory, personal information, attention and other domains eg visuospatial

Cognitive Screening Tests: MMSE

Standardised MMSE Molloy et al 1991 Floor and ceiling effects Western background, education, language No test of executive function Orientation Registration, Recall Attention Calculation Language Visual construction

Cognitive Screening Tests: Geriatric Depression Scale (GDS) Yesavage 1983

30 Questions Cut off 11 Sens 84% Spec 95% Cut off 14 Sens 80% Spec 100% 15 Question version 4 & 10 Question versions Yes or No responses to questions about depression symptoms Depression an important cause of cognitive impairment

Dementia
Global cognitive impairment Irreversible Clear sensorium Usually progressive

Dementia: Causes
Alzheimers Lewy Body Frontotemporal Parkinsons Other extrapyramidal syndromes Huntingtons Vascular Stroke Small vessel ischaemia
Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, OBrien & Ames

Cushings, Addisons, Thyroid, parathyroid, diabetes Vitamin B12, thiamine, nicotine deficiency Normal pressure hydrocephalus, Head injury, space occupying lesion, multiple sclerosis Syphilis, HIV, encephalitis, CJD

Dementia: Some Reversible or partly reversible Causes

Drugs Depression Metabolic causes Thyroid Disease Vitamin B12 deficiency Hypercalcaemia Liver disease Normal pressure hydrocephalus Subdural haematoma Neoplasm

Adapted from Eastley R., Assessment of Dementia, in Dementia, Eds Burns, OBrien & Ames

Dementia: Diagnostic features

development of multiple cognitive deficits impairment in occupational or social functioning decline from a previously higher level of functioning memory impairment And at least one of: aphasia apraxia agnosia disturbance in executive functioning.
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Memory

Memory impairment needed for diagnosis early prominent symptom new learning impaired forgets previously learned material loses valuables, forget food cooking, lost in unfamiliar territory, poor medication compliance forgets personal details eg family, occupation, address, own name
Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Aphasia

Language difficulty
Loss of complexity Naming people or objects Repetition Comprehension (verbal and written) eventually mute

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Apraxia

Difficulty performing motor task despite intact comprehension power Sensation Trouble with everyday tasks eg cleaning teeth, washing

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Agnosia

Difficulty recognising objects or people

Trouble recognising ordinary objects, family members, even themselves in photographs or mirrors

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Executive Functioning

ability to think abstractly judgement, reasoning, insight plan, initiate, sequence, monitor, and stop complex behaviour difficulty coping with novel tasks or complexity poor choices financial problems at risk behaviour due to lack of insight

Adapted from Diagnostic and Statistical Manual of mental disorders IV edition revised 2000, American Psychiatric Association

Diagnostic features: Behaviour

Delusions, especially paranoia Hallucinations, especially visual Irritability, aggression (verbal and physical) Resistiveness Agitation, wandering, getting lost Social withdrawal Neglect of personal care, home, nutrition Apathy Sleep disturbance Mood disturbance Anxiety Depression Demanding, attention seeking, repetitive
Adapted from Hecker J., Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Assessment
History most important Examination Neuropsychometric testing Laboratory tests FBP, U&E, TFT, B12, folate, BSL, syphilis serology, ESR, Urinalysis, calcium +/- lumbar puncture, EEG Imaging CT, MRI SPECT, PET

Dementia: Alzheimers Disease

Accounts for 60% of Dementia in Australia Neuronal degeneration with plaques of beta amyloid and neurofibrillary tangles Early onset forms due to gene mutations Main feature is memory loss, plus other domains, gradually progressive Treatment with cholinesterase inhibitors (donepezil, galantamine, rivastigmine) or memantine New therapies seem promising

Adapted from Hecker J., Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Alzheimers Disease: Natural History

Adapted from Hecker J., Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Lewy Body Disease

Lewy bodies = neuronal inclusions of neurofilament protein ubiquitin Found in basal ganglia in PD, diffusely through cerebral cortex in DLB - spectrum of same disease? Classic features of cognitive impairment plus Fluctuation in cognition, alertness, attention Visual hallucinations Parkinsonism Respond to cholinesterase inhibitors Very sensitive to antipsychotics => rigidity
Adapted from Hecker J., Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Vascular Dementia

Cognitive impairment due cerebrovascular disease Small vessel ischaemic changes - gradual decline Recurrent stroke - stepwise deterioration Evidence of vascular changes on CT/MRI Vascular risk factors - HTN, cholesterol, diabetes, smoking, existing cardiac disease Often early onset gait disturbance (balance and/or gait dyspraxia), falls, urinary incontinence Often frontal lobe features, emotional lability, pseudobulbar palsy with speech/swallowing problems

Adapted from Hecker J., Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Frontotemporal Dementia

Probably represents several diseases Early loss of personal and social awareness Disinhibition often prominent Mental rigidity, inflexibility, concrete Depression and anxiety prominent Speech and language disturbance Reduced in complexity Echolalia, stereotypy Early primitive reflexes and urinary incontinence Late rigidity, tremor
Adapted from Hecker J., Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Management
Treat reversible causes! Education Cholinesterase inhibitors (AD, LBD) Control of vascular risk factors Maintain cognitive and physical activity Treat depression

Dementia: Practical Issues

Education Counselling Community Resources Alzheimers Assoc Respite in home, day centres & residential Crisis Care Care packages Strategies for managing behaviour Memory aids Home safety Driving Enduring Power of attorney Testamentary capacity Advanced directives Continence Residential Care

Adapted from Hecker J Dementia and Alzheimers Disease in A Practical Guide to Geriatric Medicine. Ratnaike R

Dementia: Take home messages

Cognitive screening tools only detect cognitive impairment they dont diagnose History suggestive of dementia or abnormal cognitive test result should result in suggestion for further evaluation A diagnosis of dementia requires decline in occupational and social functioning, at least one other cognitive domain impaired (aphasia, agnosia, apraxia, executive dysfunction), as well memory Interventions usually beneficial Carer support vital to management

Delirium in Older People

Delirium: Definition
de lira to wander Clinical syndrome characterised by rapid onset of altered consciousness and cognition that fluctuates

Delirium: Epidemiology
Prevalence in elderly hospital admissions

10 - 24%
Incidence during hospital stay

6 - 56%
Post operative incidence

10 - 61%

Delirium: Aetiology
Geriatric syndrome Multiple factors acting in concert Patient vulnerability Predisposing factors Precipitating factors

Delirium: Predisposing factors

Dementia Multiple medications Visual and hearing impairment Severe/multiple chronic medical conditions Dehydration Advanced age Neurological damage Functional disability Alcohol abuse Depression Chronic renal impairment

Delirium: Clinical Features

Prodrome sometimes recognised irritable, angry, evasive, bewildered Develops over hours to days Fluctuates lucid periods during day maximal disturbance at night

Delirium: Clinical Features

Inattention Disorientation Short term memory impairment Thinking is disordered Speech rambling and incoherent Delusions, misperceptions and visual hallucinations Distress

Delirium: Clinical Features

Disturbance of consciousness Hyperactive delirium Repetitive behaviours e.g. plucking at sheets, wandering, verbal and physical aggression Hypoactive delirium quiet, withdrawn patient, often mistaken for depression Mixed pattern

Delirium: Detection
Delirium often missed 32 67% of delirious patients are not diagnosed Cognitive assessment should be standard MMSE or AMTS Serial testing to monitor progress and to detect delirium arising during an admission Mental status = a vital sign

Delirium: Detection
Confusion Assessment Method (Inouye et al Ann Int Med 1990;113:234-42) 1 Acute onset and fluctuation of cognition AND 2 Inattention with EITHER 3 Disorganised thinking OR 4 Altered level of consciousness

Delirium: Management
Treat underlying causes Correct dehydration Review medications Non Pharmacological Pharmacological Monitor progress

Delirium: Outcomes Duration

More persistent than previously realised up to one week in 60% two weeks in 20% four weeks in 15% more than four weeks in 5% Others report delirium still present at 6 months
O'Keeffe S The prognostic significance of delirium in older hospital patients J of the Am Geriatr Soc 1997;45(2):174-8

Delirium: Outcomes Cognitive decline

Early cognitive impairment unmasked by acute illness

May be acute and permanent deficits due to ischaemia, hypoxia or mediated by glucocorticoids or cytokines
Francis J Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc 1992;40(6):601-6

Delirium: Take Home Messages

Common Distressing Often Missed Cognitive testing should be routine Complex Geriatric Syndrome Preventable Predicts adverse outcomes

Falls -Prevention and Management

Definition

A fall occurs when environmental hazards or demands exceed an individuals ability to maintain postural stability
Mary Tinetti ASGM ASM 2001

Enormity of the Problem

33% over 65yrs fall annually 50% of these have repeat falls In nursing homes 50-65% fall annually 10-15% of falls result in serious injury 1% hip fracture rate

Breakdown of Discussion
Falls in community dwelling elderly

Compliance problems

Unanswered questions

Modifiable Risk Factors for Falls in the Community

Psychotropic drugs especially benzodiazepines Multiple drugs Postural Hypotension Environmental hazards Vision Poor balance or gait Poor functioning with ADLs Footwear

Preventing Falls in the Community

Independence model of care Screening of home environment by OT / health worker Psychotropic medication withdrawal Medication review/ minimization Appropriate vision aids & footwear Balance and exercise program Avoiding Injury - Treating Osteoporosis

Falls Clinic Process

Multidisciplinary- everyone assessed by the following: Geriatrician- full history, examination, investigation, including osteoporosis workup Nurse-lying and standing BP, vision, continence, community supports Physiotherapist- administers Fallscreen, ?need for walking aid, teaches patient to get up off floor, strength and balance exercise program, sets home program, general footwear advice OT- ADL assessment, 50% get home visit, group education sessions +/- social work assessment for package of care, hostel/ N/H +/- clinical psychologist to address fear of falling or podiatry

Falls Clinic Process

Contd.

All new patients discussed at a multidisciplinary meeting at the end of the clinic, and management plan formulated

Length of time attending the clinic approx 6-10 weeks.

On discharge, given home exercise program

Followed up 4 months following discharge

What about in the Kimberley

No research in remote or Indigenous settings Moving to single multiskilled professional in metro areas Can do great functional assessments and improve reversible risk factors Independence model of care very important

Who Should Have a Comprehensive Falls Assessment?

All older persons to be asked once a year about falls If 1 fall -GP assessment, and observe the Get up and go test Triggers for further assessment >1 fall in last year A fall resulting in injuries Abnormalities in gait or balance Symptoms of dizziness Evidence of a fear of falling

Hip Protectors
Reduce hip fracture rate (by 50%) for those in nursing homes with a high risk of falling Compliance is problematic- 38 57% in various studies

Vitamin D Deficiency and Falls

Causes muscle weakness and probably falls Leads to osteoporosis and increased risk of fracture Very common in elderly, community dwelling population (? Indigenous) Almost universal in residential care Replacement with calcium reduces fractures in residential care and in those who are deficient in the community

Patient Compliance with Fall Initiatives

Survey in Aust (Whitehead, 2003) 72% reluctant to do exercises 57% reluctant to stop sleeping tablets 43% reluctant to have a home assessment

Campbell, JAGS, 1999 Study demonstrated reduced falls with psychotropic withdrawal program and home based exercises 47% had restarted their psychotropics within 1 mth

Patient Compliance with Fall Initiatives

Simpson UK study investigated barriers to a falls program The elderly patients involved had reduced understanding of the benefits of exercise Home visits were considered intrusive, and felt that there was inadequate negotiation about the necessary changes resulting in resentment

Summary
Falls are a hallmark of the frail elderly Falls are usually multifactorial in origin DONT be pessimistic- multidisciplinary treatment can prevent up to 60% of falls The elderly have the most to gain by treating their osteoporosis

Immobility

How to avoid it?

Encourage functional mobility Educate family and carers Early rehabilitation Appropriate use and maintenance of mobility aids Physiotherapy if possible

Management of the Immobile Patient

Ensure no reversible causes can be identified

Encourage Independence within limits of mobility

Avoiding Pressure Ulcers

Regular assessment of bony prominences Regular turning to relieve pressure ideally 2 hourly Use pillows if no air mattresses available Avoid friction and shearing forces (safe manual handling) Skin Hygeine and Moisture Leave blisters intact Get help early for example Donna Angel at RPH will advise

Urinary Incontinence in the Elderly

Incontinence in the Elderly

Prevalence in community dwelling elderly -women 30% -men 15% 60% of nursing home residents Risks -parity (association is weak in women over 65yrs) -hysterectomy -obesity

Continence requires:

Adequate mobility Mentation Motivation Manual dexterity Intact lower urinary tract function

Medical Complications

Rashes Pressure ulcers UTI Falls Fractures

Psychosocial complications

Embarrassment Stigmatisation Isolation Depression Institutionalisation risk

A Normal Bladder
First urge to void occurs when bladder volume is 150 300mls Normal bladder volume 300 600mls Bladder capacity declines with age and post void bladder volumes increases (up to 50 100 mls) Involuntary bladder contractions also increase with age Lose the ability to concentrate urine at night (ADH secretion) with nocturia 1 2 x)

Causes of Transient Incontinence

Delirium Infection (symptomatic UTI) Atrophic vaginitis/ urethritis Pharmaceuticals Psychological Excessive urine output Restricted mobility Stool impaction

Drugs Affecting Continence

Diuretics Anticholinergics Psychotropics ACE inhibitors (cough) Narcotics Alpha blockers (urethral relaxation) B agonists (retention) Calcium channel blockers (retention)

Persistent Incontinence -Stress

Involuntary loss of urine (usually small amounts) with increases in intra- abdominal pressure (coughing, sneezing, laughing, exercising)

In women, causes include lack of oestrogen, obesity, previous vaginal deliveries, previous surgery

In men (rare) causes include radiotherapy and prostatectomy.

Persistent Incontinence -Urge

Leakage of urine (larger volumes) due to inability to delay voiding after sensation of bladder fullness is felt Associated symptoms include nocturia, urinary frequency Causes Ideopathic (Detrusor overactivity) Local pathology- tumour, stone, diverticuli, outflow obstruction CNS disorders- stroke

Detrusor hyperactivity with Impaired Contractility (DHIC)

A subset of patients will have this, emptying less than 1/3 of bladder volume

Are predisposed to urinary retention

Persistent Incontinence -Overflow

Leakage of urine (small amounts) resulting from mechanical forces on an overdistended bladder Causes Anatomical obstruction by prostate, stricture, cystocoele Acontractile bladder associated with diabetes or spinal cord injury Medication related

Assessment
History Characteristics of incontinence Medical problems, medications, bothersomeness Bladder chart Examination General- esp CCF, venous insufficiency Abdominal PR lumbosacral innervation In women- inspect for prolapse, cough test, atrophic vaginitis Assessment of mental state and mobility

Assessment
Urinalysis the relationship of asymptomatic bactiuria with incontinence is controversial. No benefit from treating the nursing home population ? Eradicate bactiuria once and assess it effect on incontinence Post Void Residual Volume Important to rule out significant retention <100 mls normal >200 mls abnormal

Assessment- selected patients

Urine culture, cytology Blood glucose, calcium, renal function Abdominal ultrasound Urodynamics Recent data suggest that it has little clinical utility in urge incontinence

Management
Supportive measures Education Environmental changes eg toilet light on Use of toilet substitutes eg bottle, commode Modification of fluid intake patterns Alcohol, caffeine avoidance Management of constipation Smoking cessation, treatment of cough

Management- Behavoural
Pelvic floor exercises- useful for urge and stress incontinence Bladder Retraining Urge incontinence Progressive lengthening of intervoiding interval

Management- Behavoural
Institutionalised patients Scheduled toiletting- 2 hrly during day, 4 hrly at night Habit training- variable schedule depending on patients voiding patterns Prompted toiletting- prompted to toilet 2 hrly, only toiletted on request, positive reinforcement (25 -40% of nursing home residents respond)

Management Urge Incontinence- Drugs

Anticholinergics eg. Oxybutinin 2.5- 5 mg tds have 60 70% reduction in frequency of incontinence episodes Probably work via afferent pathways S/Es: dry mouth, constipation, confusion, urinary retention Oestrogen vaginal cream 0.5-1g nightly for 1 month, then 2-3x/ week (NB oral oestrogens worsened incontinence in the WHI study)

Management Stress Incontinence- Drugs

Little role for medications Imipramine 25-50 mg tds (anticholinergic as well, so there is an argument for using it for mixed urge/ stress incontinence) Efficacy date is lacking, though and has side effects ++ in elderly Duloxitene- serotonin and noradrenaline reuptake inhibitor (results in 50-54% reduction in frequency of incontinence). Causes initial nausea

Management of Overflow Incontinence

Catheter if significant retention then: Refer to urology who may advise medication and or surgery Drugs - Prazosin, Tamsulosin, Terazosin

Management- other strategies

Surgery - TURP - Bladder neck elevation, peri-urethral collagen injections

Catheters- IMCs, IDCs Botulinum toxin injection into detrusor muscle or bladder neck Continence pessaries- for women with large prolapses when surgery is contraindicated Desmopressin for large volume nocturia

Iatrogenic Problems

Polypharmacy

Objectives
Understand why Polypharmacy is common in older people Identify the problems caused by polypharmacy in older people Monitor and manage Polypharmacy Understand inappropriate versus appropriate Polypharmacy

The Challenge of Geriatric Clinical Pharmacology

to balance an incomplete evidence base for efficacy in frail, older people against the problems related to adverse drug reactions without denying older people potentially valuable pharmacotherapeutic interventions Le Couter et al

Polypharmacy

5 or more drugs

20-40% of older people

Causes of Polypharmacy
Comorbidities Age Prescriber (what influences prescribers?) Reluctance to cease another prescribers prescription Rational Polypharmacy

Risks of Polypharmacy
Adverse drug reactions common cause of hospital admission morbidity and mortality Falling, delirium and the other geriatric syndromes may be drug-related Medication errors polypharmacy, per se, appears to be a risk factor for adverse outcomes

What are the goals of care?

Often different in frail person

Risks of polypharmacy higher in frail person with limited homeostatic reserve Eg antihypertensives

Weigh risks and benefits

Efficacy Risk of ADR Pt wishes

Common difficult areas

Include Benzodiazepine and psychotropic polypharmacy Antihypertensives Medication Withdrawal Can be Achieved

Is Discontinuation Safe?

Psychotropic withdrawal reactions Anti anginals Anticonvulsant medications

Other Difficult Areas - Under treatment

Analgesics Osteoporosis therapy

(Anticoagulants) (ACE-inhibitors and B-blockers)

Under treatment Continued

Ca and Vit D (v bisphosphonates)

Reviewing Medications

View and Record all medications, including OTCs, herbs, dietary supplements Ask about other prescribers Cautious medication withdrawal where indicated

Use aids
Simplify regimens Medication cards Dosette Boxes Webster Pack Supervised medications Involving caregivers

Conclusions
Avoid polypharmacy Weigh risks and benefits Scrutinise all medication prescriptions critically Monitor therapy carefully in elderly patients

Malnutrition

Prevalence
Increases with frailty and physical dependance Estimated 4.8% recipients of domiciliary aged care clients 27.7% Sub-acute crae

Consequences
More GP consultations More prescriptions Higher hospital admission rate Increased risk of: Falls Prolonged hospitalisation Institutionalisation Infections Pressure Ulcers Death

Nutritional Frailty
Disability due to unintentional loss of body weight and sarcopenia Search for medical causes Low Socioeconomic status significant risk factor As are poor health, polypharmacy, low mood, low cognition.

Non Physiological Causes

Social Factors Poverty, Inability to shop, cook or feed Psychological Factors Alcohol, Depression, Dementia Medical Factors Cancer, Chronic Disease Medications Side Effects common

Screening
Two Question Rapid Screen Positive if : Body Mass Index <22kg/m2 Weight loss > 7.5% over 3 months

Management
Treat/Manage reversible causes Educate individual and family www.nhmrc.gov.au/publications/synopses/n23syn.htm Oral supplements with macronutrients Lack of evidence for most vitamin supplements

Ref : Malnutrition in older people - Australian Family Physician Vol 33, No 10 October 2004