What is a Geriatric Syndrome?

Definition:

Four Parts:

1.

2.

3.

4.

Geriatric Syndrome: Groups of s/s that are frequently seen in the elderly that are associated with mortality and morbidity.

1. C/C often unrelated to underlying pathology

2. Multi-factorial pathophys

3. Multiple Risk Factors

4. Impacts function and QOL

Common Physical Geriatric Syndromes

1.                            2.

3.                            4.

5.                            6.

7.                            8.

9.

Common Social Issues:

1.                             2.

Common Physical Geriatric Syndromes

1. Dementia/Delerium                2. Polypharmacy

3. Depression                            4. Falls

5. Nutritional Deficits                 6. Urinary Incontinence

7. Sleep Disorders                     8. Pain

9. Sensory Deficits

Common Social Issues:  Elder Abuse & Caregiver Burden

Geriatric Age Groups

1. Young Old:

2. Old, Old:

3. Very Old:

Important to note of the Very Old:

1. Young Old 65-74 y/o

2. Old, Old 75-84 y/o

3. Very Old 85+

Fastest growing segment of the population and highest rate of chronic disease and disability

Life Expectancy

How many more years a person can expect to live

Complicating Factors of Assessment

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1. Differentiating normal age-related changes from the effects of disease

2. The presence of multiple diseases

3. Under-reporting of illnesses

4. Atypical or altered presentations of diseases

Atypical Presentation of Hyperthyroidism

Symptoms:

Suspect in:

Typical Presentation:

Apathetic Hyperthyroidism- lethargy and intellectual blunting

Suspect in unexplained HF, tachycardia, new onset psych sx

Typical Presentation: Palpitations, weight loss, hyperactivity

Atypical Hypothyroidism

Presentation:

1.

2.

3.

4.

1. Weight loss rather than gain

2. Cognitive changes

3. Depression

4. Nonspecific deterioration in health

Hypothyroidism

10% of the population >60 y/o have:

In 20-50%, what happens?

Those that have overt hypothyroidism are usually r/t:

10% of the population >60 y/o have subclinical hypothyroidism

In 20-50%, the TSH returns to normal and in others remains the same

r/t goiter or have thyroid antibodies

Hypothyroidism

Screening TSH Normal :

If TSH is elevated, then obtain:

Normal Range:

If TSH is elevated and free T4 is low:

Normal TSH: 0.3-5.0 mU/L

If TSH is elevated then obtain a free T4

Normal: 0.8-1.8 ng/dl

If TSH is elevated and free T4 is low- Primary Hypothyroidism

Hypothyroidism Treatment

Start with:

Wait:

Elderly patients:

Side Effects:

1.

2.

Start with low levothyroxine- 25 mcg daily

Wait 6 weeks and repeat labs before increasing

Elderly patients may not have an obvious benefit to normalization of TSH

1. Excessive suppression of TSH leading to a fib, CHF

2. Increases risk of osteoporosis

Pneumonia Atypical Presentation

1.

2.

3.

1. Malaise

2. Anorexia

3. Mental Status Changes

Heart Failure Atypical Presentation

1.

2.

3.

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5.

1. Incontinence/Nocturia

2. Confusion

3. Insomnia

4. Fatigue

5. Lethargy

UTI Atypical Presentation

1.

2.

3.

1. Nocturia

2. New or worsening incontinence

3. Mental Status Change

Appendicitis Atypical Presentation

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2.

3.

4.

1. Diffuse pain rather than RLQ pain

2. Signs of peritonitis may be attenuated (less guarding)

3. Febrile response may be less

4. Less vigorous WBC response

GI Bleed Atypical Presentation

1.

MI Atypical Presentation

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2.

3.

4.

5.

6.

1. Dyspnea

2. n/v

3. More likely to be silent

4. Less likely to present with CP

5. Dyspnea more common

6. May also present as confusion

Depression Atypical Presentation

1.

2.

3.

4.

1. Constitutional Symptoms

2. Failure to thrive

3. Memory complaints

4. Irritability

Differential Diagnosis of Sudden Confusion

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6.

7.

1. Infection (UTI, PNA)

2. HF

3. MI

4. Adverse Drug Reaction

5. Stroke

6. Metabolic Disorder (hyper/hypoglycemia, azotemia, electrolyte imbalance)

7. Fecal Impaction

Differential Diagnosis of Failure to Thrive

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10.

1. Sensory impairment

2. Endocrine d/o (DM, hypothyroid)

3. CA

4. Infections

5. HF

6. Depression

7. Delerium/dementia

8. Parkinson's Disease

9. Isolation/neglect

10. Medication effects

Differential Diagnosis of Fatigue

1.

2.

3.

4.

1. Depression

2. Heart Failure

3. Anemia

4. Hypothyroidism

Differential Diagnosis of Insomnia

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3.

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6.

7.

8.

1. Age related sleep changes

2. Anxiety, worry, fear, depression

3. HF

4. Sleep apnea

5. Nocturia, overactive bladder

6. Restless leg syndrome

7. GI Issues- GERD

8. Environmental- noise, temp, food, etoh, caffeine

Age Related Sleep Changes

1.

2.

3.

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5.

1. Sleep quality decreased but quantity is unchanged

2. Increased stage 1 and 2 sleep

3. Decreased stage 3 and 4 sleep

4. Frequent nighttime arousals and awakenings

5. Daytime naps common

Differential Diagnosis of New Onset Urinary Incontinence:

1.

2.

3.

4.

5.

6.

1. Uncontrolled DM

2. Delerium

3. Adverse drug reaction

4. UTI

5. Fecal impaction

6. Immobility

Health in the elderly is best measured in terms of:

What is functional status?

Function

Ability to function independently in physical, mental, and social activities of daily life

Obtaining a Medical History in the Geriatric Patient

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1. Format unchanged

2. Family history often of less importance

3. PMH

4. Careful med history

5. Immunizations

Medical History- Pay special attention to:

1.

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6.

7.

1. Health status rating

2. Energy level

3. Mood

4. Activity level

5. Nutrition

6. Sleep

7. Pain

PMH- Special Attention to:

1. Respiratory: (2)

2. Cardiovascular: (7)

1. increasing dyspnea, cough

2. Orthopnea, edema, angina, claudication, palpitations, dizziness, syncope

PMH- Special Attention to:

1. GI: (4)

2. GU: (4)

3. MS: (3)

1. GI: difficulty chewing, dysphagia, abdominal pain, change in bowel habits

2. GU: LUTS, incontinence, hematuria, vaginal bleeding

3. MS: painful joints, deformities, swelling

PMH- Special Attention to:

1. Neuro: (8)

2. Psychological: (4)

3. Nutrition: (3)

1. Neuro: unsteady gait, falls, transient weakness, numbness, tingling, HA, syncope, dizziness

2. Phychological: memory loss, depression, anxiety, agitation

3. Nutrition: Weight loss/gain, belt and clothing size, problems obtaining and preparing food

PMH: Special Attention to:

1. Mobility

       Assess:

       How?

       Inability suggests:

        Then:

        Notice:

1. Mobility

       Assess transfer ability, gait, and balance

       How: Stand from seated position in hard backed chair

                without using arms

       Inability suggests weakness and is predictive of

       future disability

Then have patient walk across the room and back using usual assistive device

Notice abnormalities: path deviation, diminished step height and/or length, trips, slips, near falls or difficulty turning

Another mobility assessment tool:

How:

What it means:

Timed get up and go test

Get up from chair, walk 10 feet, turn around and return to sitting

People who take longer than 10 seconds are at increased risk for falls

Pain

Prevalance increases with:

Poorly controlled pain increases risk for:

       
1.

2.

3.

4.

Prevalence increases with each decade of life

1. Impaired cognitive function

2. Sleep disturbances

3. Depression

4. Impaired ADLs

Weight Loss Red Flags

Community Dwelling:

Nursing Home:

Community Dwelling: Involuntary and >10 lbs in 6 months of >4% in 1 year in community dwelling

Nursing Home: Weight loss of ?5% in past 30 days; >10% in past 180 days, dietary intake of <75% of most meals

Nutritional Changes

1. Decrease in food intake r/t:

2. Changes in:

1. Decrease in food intake r/t less activity, decrease in energy demands and decreased lean body mass

2. Change sin taste, decreased sense of smell and higher threshold for taste recognition such as salt

Nutritional Changes

1. Early satiety r/t:

2. Impaired regulation of food intake:

     a.

     b.

3. Decreased:

1. Early satiety r/t decrease in stomach compliance- delayed gastric emptying

2. Impaired regulation of food intake:

    a. gastric hormone changes, peripheral staiety signals

        not well detected by the brain

    b. Decreased stimulatory effects of neurotransmitters

        involved in appetite (opioids, neuropeptide Y,

        orexins, ghrelins)

Differential Diagnosis for Weight Loss

1.

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4.

5.

6.

7.

8.

1. Cancer

2. Medication s/e: abx, theophylline, dig, SSRIs, opioids

3. Depression

4. Infections and acute illness

5. Inability to obtain and prepare food

6. Thyroid disease

7. Chewing/dentures/oral infections

8. Dysphagia

Weight Loss Diagnostic Testing

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1. CBC

2. Sed rate

3. CMP

4. UA

5. CXR

6. TSH to r/o underlying disease

7. Serum albumin level </= 3.5 g/dl

8. Pre-albumin level

9. Cholesterol level <160 mg/dl

Pre-Albumin

1. What is it?

2. Definition

3. Correlates with:

4. What is the major source of production:

1. Hepatic Protein

2. Sensitive, cost effective in determining malnutrition in both critically and chronically ill

3. Correlates with patient outcomes and recovery

4. Liver is the major source

Normal pre-albumin levels:

Poor Prognosis Level:

Begin interventions for patients with what level:

Treat with:

Normal: 15.0-35.0 mg/dl

Poor Prog: <5.0 mg/dl

Begin interventions at <15.0 mg/dl

Treat with: supplements, monitoring and nutritional consultation

Weight Loss- Interventions (Non pharmacologic)

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4.

1. Liberalize diet

2. Start supplements early

3. Supplements: Ensure, boost, glucerna

4. Multivitamin with minerals

Weight Loss Pharmacologic Interventions

1.

2.

3.

Drawbacks:

1. Dronabinol (Marinol)

2. Megesterol Acetate (Megace)

3. Mirazepine (Remeron)

No FDA approved drugs for the elderly, s/e to the medications, expensive and not covered by Medicare D

Dronabinol (Marinol)

Has shown some effect in:

Side Effects:

Has shown effects in improving appetite in AIDS patients

S/E: Significant CNS Effects

Megesterol Acetate (Megace)

Studies Show:

No Impact on:

Side Effects:

2 small RCTs in malnourished elderly indicated slight improvements in appetite and weight gain that was not sustained

No impact on QOL or improved m/m

s/e: edema, CHF, DVT, impaired corticoadrenal function

Mirtazepine (Remeron)

Function:

Well studied in elderly?

Helps to improve appetite and weight gain

Not well studied in elderly

What is sarcopenia?

Causes:

Sarcopenia: syndrome characterized by loss of muscle mass and strength

Causes:

1. Decrease in activity

2. Reduction in testosterone and estrogen

3. Inadequate protein intake

4. Insulin resistance increases with aging= muscle breakdown

Symptoms of:

1. Vitamin B12 Deficiency:

2. Vitamin D Deficiency:

3. Inadequate Ca intake:

1. B12: results in neuro, psychological or hematologic disease

    If borderline, obtain a methyl malonic acid level

    Elevated level confirms B12 deficiency

2. Vitamin D: muscle weakness, depression, falls, fx

3. fx

Alchol

Blood alcohol levels as compared with the young:

Sensitivity:

BAC levels higher than younger adults for the same amount consumed

Sensitivity may increase

C Have you ever tried to Cut down on your drinking?

A Have you ever gotten Annoyed at someone who

   critisized your drinking?

G Do you ever feel Guilty about your drinking?

E Have you ever had an Eye opener to steady your nerves

   or get rid of a hangover?

Physical Exam:

1. VS

2.

3. HEENT (4)

1. VS- ht/wt/bmi

2. Skin

3. HEENT: visual acuity, hearing, cerumen, mouth/dentition

Physical Assessment

1. CV: (2)

2. Neuro: (3)

3. Rectal Exam: (3)

1. CV: Orthostatic BP, Peripheral Vascular system

2. Neuro: Cognitive function, gait/balance, muscle tone/strength/tremors

3. Rectal Exam: Masses, prostate, stool for occult blood

Physical Exam:

1. Pelvic Exam: (3)

Initial Screening Labs/Studies

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1. CBC & Diff

2. CMP

3. UA

4. TSH

5. B12, Folic acid level

6. Lipid profile

7. EKG for baseline

8. CXR

9. Other labs and studies based on history

Functional Assessment

1.

2.

3.

4.

5.

1. Cognitive Function

2. Mobility

3. ADLs

4. Depression

5. Caregiver burden

Cognitive Status

The prevalence of cognitive decline:

Associated with:

Doubles every 5 years after 65

Associated with increased risk of accidents, delerium, nonadhearance and disability even in the absence of dementia

Folstein Mini Mental State Exam

Assesses:

1.

2.

3.

4.

5.

1. Orientation

2. Registration and recall

3. Attention and calculation

4. Language

5. Visual-spatial skills

Folstein MMSE:

1. Max Score:

2. Do not penalize for:

3. Suspect dementia if:

1. Max score is 30

2. Do not penalize for items that can not be completed for non cognitive reasons

3. Suspect dementia if score is   <24

What is often the first manifestation of cognitive delcine?

Associated with:

Executive function

Microvascular disease

What does the clock drawing test assess?

1.

2.

An abnormal clock suggests:

1. executive function

2. visual spatial skills

dementia

Cognitive Test: Naming

Tests:

1

2

3

Example:

Concern if:

1. Verbal fluency

2. general fund of knowledge

3. executive function

Name all the 4 legged animals that you can recall in 1 minute

Concern if less than 8-10

Cognitive Tests: Trails

Test:

1

2

Can be:

Example:

1. Executive function

2. ability to sequence info

Written or oral

Ex: Ask patient to recite alphabet and numbers then match letter to corresponding number (A-1, B-2)

Cognitive Tests: Montreal Cognitive Assessment (MoCA)

Can be used to screen for:

1.

2.

3.

1. Vascular dementia

2. Mild cognitive impairment

3. Alzheimers

MoCA

Assesses:

1.

2.

3.

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6.

7.

8.

1. Attention and concentration

2. Executive function

3. Memory

4. Language

5. Visual-spatial skills

6. Conceptual thinking

7. calculation

8. Orientation

MoCA

Total possible score:

Normal Score:

30

26+

Delerium

What is it?

What fraction of hospitalized patients experience?

Strongly and independently associated with:

Acute confusional state

1/3

Poor outcome

Delirium

Develops over:

During the day it can:

Short period of time- hours to days

Fluctuate

Delirium Causes (Theories)

1.

2.

3.

1. Cholinergic Deficiency

2. Dopaminergic Excess

3. Cytokines

1. Cholinergic Deficiency

Associated with:

Dopaminergic Excess

Associated with:

Cytokines

What may play a role?

Why?

-IL-1, IL-2, IL-6, TNF and interferon

Increases blood brain barrier permeability = alterations in neurotransmitters

Basline Factors- Risk Factors for Delirium:

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7.

1. Advanced age

2. pre-existing functional impairment

3. Dementia

4. High level of comorbid conditions

5. Male

6. Sensory impairments

7. Alcohol abuse

Precipitating Risk Factors for Delirium

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3.

4.

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6.

7.

1. Hospitalizations/Surgery

2. Pain

3. Meds

4. Low Hct

5. Bedrest

6. Catheters

7. Restraints

Evaluation of Delirium

History:

Physical Exam

Labs:

Other Data:

Not useful: Brain imaging

1. History: Time course of the onset, medications

2. PE

3. CBC, lytes, renal function, UA

4. SpO2, CXR, EKG

Brain Imaging

Management of Delirium

1.

2.

3.

1. Identify and treat contributors

2. Anticipate and prevent complications

3. Restore activity ASAP

What tool can assess for Delirium?

Diagnosis Requires presence of 1 and 2 and either 3 or 4

1.

2.

3.

4.

Confusion Assessment Moden (CAM)

1. Acute onset or fluctuating course

2. Inattention

3. Disorganized thinking

4. ALOC