THE GERIATRIC GIANTS

1. THE GERIATRIC GIANTS MEDICINE 400 Jane Courtney Hollywood Private Hospital 30th June 2008

2. Immobility Instability Incontinence Impaired intellect/memory

3. Impaired vision Impaired hearing Delirium Poly-pharmacy Care provision

4. Assessment Multi-disciplinary Functional - adl’s - iadl’s Problem oriented

5. FALLS

6. INCIDENCE • 30% community dwellers >65 years • 50% long term care • 60% fall in last year

7. CONSEQUENCES • 10 –15% fracture • Decrease in functional status • 2% injurious falls result in death

8. COSTS • 8% ED presentations >70 years • 33% of these admitted • Median stay 8 days

9. RISKS • Rarely single cause

10. 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

11. RISK FACTORS • Age • Female • Past fall • Cognitive impairment • Lower limb weakness • Balance disturbance

12. RISK FACTORS • Psychotropic meds • Arthritis • Past CVA • Orthostatic hypotension • Dizziness

13. AGE RELATED FUNCTIONAL DECLINE • Visual • Proprioceptive • Vestibular

14. ENVIRONMENT • FOOTWEAR • HOME MODIFICATIONS • BEHAVIOUR • SAFETY DEVICES • SOCIAL INTEGRATION

15. DISEASE RELATED FUNTIONAL DECLINE

16. neurological • CVA • Parkinsons • Cerebellar • Neuropathy • Dementia • Delerium • Epilepsy

17. cardiovascular • Arrythmia • Orthostatic hypotension • Anatomical • Vasomotor instability

18. GIT • Bleeding • D&V • Defecation syncope

19. metabolic • Hypothyroid • Hypoglycemia • Hypokalemia • hyponatremia

20. UGS • Micturition syncope • Nocturia • Incontinence

21. musculoskeletal • Arthritis • Myopathy • Deconditioning

22. Psychiatric • Anxiety • Depression

23. medications • Antihypertensives and cardiac • Antidepressants • Antipsychotics • Benzodiazepines • Levadopa • Narcotics

24. toxins • Alcohol

25. MECHANISM • SYNCOPE /HYPOTENSION • SEIZURE • DIZZINESS / BALANCE • GAIT DISTURBANCE • PAIN / WEAKNESS • MECHANICAL FALL

26. FUNCTIONAL IMPAIRMENT • BP regulation • Central processing • Gait • Neuromotor function • Postural control • Proprioception • Vestibular • vision

27. EVALUATION • History esp of fall • Examination esp BP, balance, vision, gait • Get up and go • Divided attention • Tests

28. PREVENTION • Strength and balance • Education • Medications • Environmental mods

29. PREVENT COMPLICATIONS

30. DEMENTIA

31. J-0 Causes of Cognitive Impairment

32. 1 Delirium • Sepsis • Hypoxia • Biochemical disturbances Calcium, sodium, glucose,urea,hepatic

33. DEFINITION • An acute organic mental syndrome characterized by: • Global cognitive impairment • Reduced consciousness • Disturbed attention • Psychomotor activity • Sleep-wake cycle disturbance

34. Neurological disease • Brain tumour • Stroke • Subdural

35. 3 Psychiatric Disease • Depression • Anxiety • Alcohol or other substance abuse

36. 4 Medications

37. 5 “Classics” • Thyroid • B12 • Folate

38. 6 Benign Forgetfulness

39. 7 Dementia

40. A-2 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 Reference: DSM-IV, pp 133-155.

41. CRITERIA FOR DIAGNOSIS • MEMORY IMPAIRMENT • OTHER COGNITIVE IMPAIRMENT • Language, motor skills, perception • ADL IMPAIRMENT • INSIDIOUS ONSET • DETERIORATING • NO OTHER CAUSE • Systemic,neurological, psychiatric

42. CRITERIA FOR DIAGNOSIS • PATHOLOGY- autopsy or brain biopsy

43. 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 Comparison delirium and dementia

44. 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

45. TYPES OF DEMENTIA • VASCULAR • Multi-infarct • Biswangers disease • INFECTIVE • Creutzfeld-jacob • AIDS • Neurosyphilis

46. TYPES OF DEMENTIA • TRAUMA • Sub dural • Dementia pugulistica • radiotherapy • NORMAL PRESSURE HYDROCEPHALUS

47. TYPES OF DEMENTIA • ASSOCIATED WITH OTHER DISEASES • Parkinson’s • Wilson’s • Multiple sclerosis • Tumours • Vasculitis

48. A-1 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

49. A-7 A • (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 B

50. A-9 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 Reference: Mayeux R, et al. N Engl J Med. 1999;341:1670-1679.