THE GERIATRIC GIANTS MEDICINE 400 Jane Courtney Hollywood

THE GERIATRIC GIANTS MEDICINE 400 Jane Courtney Hollywood Private Hospital 30 th 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

J-0 Causes of Cognitive Impairment

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 • B 12 • Folate

6 Benign Forgetfulness

7 Dementia

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 substanceinduced 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.

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

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

A-7 A B • (A) Immunocytochemical staining of NFTs in the isocortex of human AD brain with the anti-tau antibody AT 8 • (B) Immunocytochemical staining of senile plaques in the isocortex of human AD brain with the anti-amyloid antibody 4 G 8

A-9 • Role Cholinergic Hypothesis – 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.

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

T-5 Drug Utilization Trends in Dementia 1500 Aricept Risperdal Haldol Ativan 1000 Vitamin E Zoloft Zyprexa Number of Drug Uses (000) 500 0 1995 1996 1997 Source: NDTI (Diagnosis codes: 3310, 2901, 2902, 2903, 2904), 1999. 1998 1999

T-10 Feature Comparison Dose Escalation Drug Mo. A Binding Reminyl® Aricept® ACh. EI, n. ACh. R ACh. EI Exelon® ACh. EI Competitive, 4 -week steps reversible Noncompetitive, 4/6 -week steps reversible Pseudo 1 -week steps irreversible Dosing bd (od) od bid

M-4 Neuron and Acetylcholine ACh. E inhibitor Acetic acid Choline Presynaptic nerve terminal M receptor Postsynaptic nerve terminal N receptor ACh. E ACh AD REM 8 59

M-6 Reminyl® Dual Mechanism of Action Reminyl inhibits ACh. E Reminyl binds to allosteric site on N receptor Acetic acid Choline Presynaptic nerve terminal M receptor ACh Postsynaptic nerve terminal N receptor ACh. E AD REM 8 60

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 A SYMPTOM 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

• Transient or established. • Urge, stress or overflow. • Clinical.

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

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