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AGEING  LECTURE  NOTES  
AGEING  AND  SOCIETY  
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People  are  living  longer  =>  ageing  population  
This  is  because  fewer  people  die  in  childhood,  but  also  because  fewer  people  die  in  middle  
age  
Mean   life   expectancy   is   increasing   by   2   years   per   decade   elapsed,   and   shows   no   sign   of  
lagging  
Increased  lifespan  has  led  to  a  change  in  population  structure  in  Western  countries  
Thus   an   increasing   number   of   older   people   are   accompanied   by   a   shrinking   number   of  
younger  people  
Is  this  a  good  thing  or  a  bad  thing?  
 
 

 
 

 

What  does  society  think  of  older  people?  
 
• Western  society  likes  the  new,  not  the  old  
• Older  people  are  frequently  portrayed  in  a  negative  light:  
! “Burden”  
! “Pensioner”  
! “Crock”  
! “Fossil”  
! “Crumble”  
 
Ageism  
 
• Definition:  Ageism  is  unacceptable  behaviour  that  occurs  as  a  result  of  the  belief  that  older  
people  are  of  less  value  than  younger  people  

  
•
•

May   be   manifest   by   the   media,   public   services,   employers,   relatives,   healthcare  
professionals  and  even  older  people  themselves  
Each  older  person  is  different,  indeed  heterogeneity  increases  with  age:  older  adults  are  a  
heterogeneous   group,   and   aging   occurs   at   different   rates   in   different   people
...
 
• Work  out  how  much  you  would  have  to  save  to  make  the  maths  work  (assume  you  retire  on  
50%  of  your  average  working  life  income,  and  that  the  stock  market  stays  flat!)  
• Answer:  25/35  x  0
...
g
...
     
• We   either   need   to   invest   more   into   pensions   or   work   for   longer   to   sustain   this   ageing  
population    
• Society  has  generally  negative  attitudes  to  older  people  and  ageism  is  rife  
• Older  people  are  heterogeneous,  and  examples  of  healthy,  productive  ageing  abound
...
   Biological  
ageing   occurs   at   very   different   rates   between   individuals   (biological   ageing   depends   on  
genetics  +  environmental  factors)
...
     
• Elder  abuse  is  common,  but  under-­‐recognised  
• Society  is  struggling  to  get  to  grips  with  how  to  pay  for  retirement  
• Society   is   completely   at   sea   when   thinking   about   how   to   look   after   older,   dependent   people  
in  the  future  
 
 
 
SARCOPENIA  AND  IMMOBILITY  
 
Disability  prevalence  
 
• 14%  of  population  over  16  yrs  
• 50-­‐60%  in  population  over  75  yrs  
• 80%  in  over  85’s  
• Commonest  type  of  disability:  problem  with  locomotion  (movement)  
• Commonest  cause  of  disability:  musculoskeletal  condition  e
...
 arthritis    
• Can  cause  problems  such  as:  
! Unable  to  go  outdoors  
! Unable  to  walk  400m  
! Difficulty  bending  down  
! Difficulty  getting  back  up  
! Unable  to  climb  stairs  
! Unable  to  maintain  balance  
• Appreciate  how  disability  can  have  a  major  impact  on  QoL  
 
 
 

  
Factors  contributing  to  immobility  
 
• Sarcopenia  
• Disuse  atrophy  e
...
 neurodegenerative  disorders  
• Intercurrent  illnesses  -­‐  particularly:  
! Arthritis  
! Stroke  
! Heart  disease  (especially  heart  failure)  
! COPD  /  chronic  lung  disease  
! Parkinsons  disease  
! Depression  
! Infections  (UTI,  Pneumonia)  
• Immobility  causes  further  progression  of  immobility  (vicious  cycle)    
 

 

 

Sarcopenia  
 
• Sarcopenia  =  age  related  loss  of  muscle  mass  (atrophy)  and  function  
• European  Working  Group  definition  (Criterion  1  +  Criterion  2  or  3):  
! 1
...
   Low  muscle  strength  (power)  
! 3
...
 
• In   fact,   elderly   people   who   have   sarcopenia/low   weight   produce   significantly   less   Cr   =>  
eGFR  may  overestimate  their  kidney  function    

  

 

 

 
Consequences  of  sarcopenia  
 
! Muscle  wasting  and  weakness  (loss  of  power)  
! Falls   and   fractures   –   remember   that   problems   with   MSK   system   and   locomotion   are   the  
commonest  contributing  factors  to  falls  
! Decreased  QOL  
! Bone  loss  (due  to  low  activity)  
! Obesity  
! Insulin  resistance  and  DM  (due  to  decreased  activity  levels  and  increased  fat  deposition)  
 

 
 
 
 

  
Mechanisms  of  sarcopenia  
 
• The  pathogenesis  of  sarcopenia  is  very  complex  and  multi-­‐factorial
...
 
• Impaired  regeneration  of  muscle  fibres  due  to  impaired  functioning  of  satellite  cells  
• Neuromuscular  changes:  Fibre  type  regrouping  e
...
 reinnervation  of  fast  twitch  muscles  with  
slow  motor  units  
• Protein   synthesis:   Rates   of   synthesis   reduced   especially   of   contractile   protein;   increased  
proteolysis  
• Nutrition:  Inadequate  intake  despite  reduced  BMR  (protein,  vitamins  and  micronutrients)  
• Muscle   perfusion:   Reduced   blood   flow;   endothelial   dysfunction;   asymptomatic   peripheral  
vascular  disease  
• Hormones  and  inflammatory  markers:  
! Reduced  GH/IGF-­‐I  
! High  IL-­‐6,  TNF-­‐α  
! Reduced  oestrogen  and  testosterone  
• Calcium  metabolism:  reduced  calcium  available  for  contraction    
• Early  life  influences:  low  birth  weight  linked  to  sarcopenia    
 
 
Sarcopenic  obesity  
 
• Loss  of  muscle  mass  with  increased  fat  (due  to  lack  of  activity)  
• Loss   of   muscle   mass   (atrophy   due   to   sarcopenia)   results   in   immobility
...
     
• Greater   risk   of   cardiometabolic   disorders:   insulin   resistance,   DM,   metabolic   syndrome,  
cardiovascular  disease  
 
 
Management  
 
• Exercise   (most   effective):   progressive   resistance   training   increases   strength   and  
endurance
...
   Resistance  training  to  increase  strength  
is  the  most  effective
...
g
...
g
...
   
Polypharmacy  and  CNS  acting  drugs  have  the  greatest  risk
...
  This   is   achieved   by   increasing   the   formation   of   adenosine   triphosphate  
(ATP)
...
    It   is  
possible  that  they  improved  cardiac  output,  and  hence,  muscle  blood  supply
...
5%  in  over  85’s  
 
 
Diagnosis  of  PD  
 
• Clinical  diagnosis  
• Bradykinesia  (slowness  of  movement),  plus  at  least  two  of:  
! Resting   tremor   (4-­‐6   Hz):   often   asymmetrical   e
...
  only   on   one   side,   or   worse   on  
one  side  
! Rigidity   (non   spastic   hypertonicity,   lead   pipe,   cog   wheel   due   to   superimposed   pill  
rolling  resting  tremor)  

•
•

•

! Impaired   righting   reflexes   (the   righting   reflex,   also   known   as   the   Labyrinthine  
righting   reflex,   is   a   reflex   that   corrects   the   orientation   of   the   body   when   it   is  
taken  out  of  its  normal  upright  position)  
Often  affects  arms  more  than  legs;  often  asymmetrical  
Idiopathic   PD   should   respond   to   a   trial   of   L-­‐dopa
...
    If   symptoms   rapidly  
improve  after  taking  levodopa  then  it  is  highly  likely  you  have  Parkinson’s  disease
...
   
Conventional   brain   imaging   scans   such   as   MRI   and   CT   scan   are   unable   to   diagnosis  
Parkinson’s   disease
...
  Lower   dopamine   transporter   levels   are   indicative   of   PD
...
 

 
 
Parkinsonism  
 
Parkinsonism  may  be  due  to:  
• Drugs  (e
...
 dopamine  blockers  such  as  metoclopramide  (anti-­‐emetic)  and  antipsychotics)  
• Stroke  disease  (if  basal  ganglia  is  damaged)  –  Vascular  Parkinson’s  
• Idiopathic  PD  (should  respond  to  a  trial  of  L-­‐dopa)  
• Parkinson  plus  syndromes    
! Progressive  supranuclear  palsy  PSP:    Parkinsonism  +  involvement  of  ocular  pathways  
(e
...
  supranuclear   ophthalmoplegia   =>   impaired   vertical   eye   movements,   diplopia)  
and   pseudobulbar   palsies   (e
...
  UMN   involvement   with   dysphagia   and   dysarthria   and  
brisk  bulbar  reflexes  with  spasticity)
...
     
! Multisystem   atrophy   MSA:     Parkinsonism   +   ANS   dysfunction   +   cerebellar  
dysfunction
...
     
• Can   be   confused   with   essential   tremor:     tremor   of   the   arms,   hands   or   fingers   but  
sometimes   involving   the   head   or   other   body   parts   during   voluntary   movements   such   as  
eating   and   writing;   kinetic/postural/action   tremor;   cause   unknown   but   often   familial   -­‐  
autosomal  dominant  AD  
 
Consequences  of  PD  
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•
•
•
•

Immobility  
Falls  
Impaired  confidence  
Incontinence  (cannot  reach  toilet  or  ANS  involvement)  
Dementia  (late  stages)  

 
 
PD  also  affects  other  parts  of  the  body    
 

Autonomic  dysfunction  (not  as  profound  as  MSA)  
! Constipation  
! Orthostatic  hypotension  
! Nocturia  (urinary  incontinence)    
• Inability  to  swallow  (dysphagia)  
• Mask  like  expressionless  face  
• Weight  loss  (poor  food  intake  plus  tremor)  
• Dementia  (occurs  >1  year  after  onset  of  movement  disorder,  otherwise  DLB)  
• Cognitive  impairment  and  dementia  (late)  with  an  approximately  20-­‐40%  prevalence  
• Fatigue  
• Pain  
• Sleep  disturbance  
• Ansomnia  (decreased  sense  of  smell)  may  be  an  early  sign    
 
 
 
 
Treatment  of  PD  
 
• Diagnosis  and  treatment  by  a  specialist  PD  service  
• Early  initiation  of  therapy  may  modify  disease  
• Aim  of  treatment  is  to  optimise  mobility  and  quality  of  life,  not  curative  
• Remember   medication   side   effects   –   anti-­‐Parkinsonism   drugs   can   produce   very   nasty   side  
effects  
• Review  diagnosis  at  each  stage  
 
 
Pharmacological  
 
• L-­‐dopa   (levodopa):   L-­‐dopa   crosses   the   protective   blood–brain   barrier,   whereas   dopamine  
itself  cannot
...
 
It   replaces   the   dopamine   that   is   lost   in   PD
...
     
• Dopamine  agonists  (e
...
 ropinirole  and  cabergoline  and  bromocriptine)  
• Dopa   decarboxylase   inhibitor   (e
...
  carbidopa):   inhibits   peripheral   metabolism   of   levodopa
...
    Also   reduces   systemic  
effects
...
g
...
  This   enzyme   is   involved   in   degrading  
neurotransmitters   such   as   DA   (dopamine)
...
     
• MAO-­‐B   inhibitor   (e
...
  selegiline,   rasagiline):   Monoamine   oxidase   inhibitors   (MAOIs)   are  
chemicals  which  inhibit  the  activity  of  the  monoamine  oxidase  enzyme  family
...
g
...
     
Apomorphine   does   not   actually   contain   morphine   or   its   skeleton,   or   bind   to   opioid  
receptors
...
g
...
   Strength  training  is  the  most  important  aspect  of  exercise-­‐based  rehabilitation
...
  For  
each  duplication  of  DNA  as  cells  divide,  there  is  a  little  bit  of  error  and  damage  introduced
...
 As  people  vary  in  lifestyle  and  genetics  this  means  that  inter-­‐individual  variability  increases  
with  age  (heterogeneity)
...
  At   the   same   time   there   is  
progressive   vulnerability   to   a   growing   range   of   health-­‐related   upsets   affecting   neurological   control  
mechanisms  like  hypoxia,  pyrexia,  and  the  effects  of  certain  drugs
...
g
...
   The  MTD  involves  geratricians,  specialist  nurses,  social  worker  and  OT  
 
The  GCA  compromises:  
 
• Medical:   Problem   list,   co-­‐morbid   conditions   and   disease   severity,   medication   review   (limit  
polypharmacy  and  optimise  medications)  and  nutritional  status  
• Psychological:   Mental   status/cognitive   function,   affective   disorders,   anxiety   disorders,  
psychosis,  testing,  behavioural  
• Functioning   and   QoL:     Basic   activities   of   daily   living   ADLs,   extended   ADLs,   activity/exercise  
status,  gait  and  balance,  QoL  
• Social/Environment:   Informal   needs   and   assets,   social   circle,   care   resource   eligibility   &  
resources,  safety,  home  environment,  mobility  around  house,  access  to  shops  etc  
 
Research  has  shown  that  CGA  in  a  dedicated  assessment  unit:  
 
• Reduces  mortality  at  6  months  
• Improves  function  
• Improves  cognition  
• Reduces  need  for  nursing  home  care    
• Reduces  subsequent  hospital  admission  
 
 
Common  issues  in  geriatric  patients  
 
• Dehydration  
• Self  Neglect  
• Malnourished  
• Anaemic  (mixed)  
• Postural  Instability  (loss  of  balance)  

•
•
•
•

Polypharmacy  and  multimorbidity  
Dementia  
Social  Isolation  
CV  and  cerebrovascular  disease  

 
 
Key  messages  
 
• Comprehensive  geriatric  assessment  is  the  founding  skills  of  geriatric  medicine  
• Ward   based   CGA   should   be   considered   the   evidence   based   standard   of   care   for   frail   older  
inpatients  
• Many  MDT  members  contribute  to  CGA  =>  communication  and  teamwork  are  essential  
 
 
 
Acute  illness  in  older  individuals    
 
• Older  people  do  not  always  present  as  per  the  textbook  
• Atypical  or  masked  presentations  may  delay  diagnosis  or  lead  to  the  wrong  diagnosis  
• This  is  part  of  the  challenge  of  looking  after  older  people!  
 
 
Why  are  older  people  different?  
 
• Frailty:     decline   in   function   across   multiple   body   systems   leading   to   loss   of   homeostatic  
reserve    
• May  mount  less  of  an  immune  response  
• Blunted  heart  rate  rise  
• Comorbid  disease  (e
...
 heart  failure,  renal  failure,  dementia)  
• Polypharmacy    
• Frailty    
 
 
MI  example  
 
• Young  people  =>    chest  pain  
• Older   people:   No   chest   pain   in   1/3   (particular   diabetics   and   other   pts   with   autonomic  
neuropathy)  
! Collapse  
! Delirium  
! Dizziness  
! Breathlessness  
• How  would  investigations  vary?  
• How  would  management  vary?  

  
 
Sepsis  example  
 
• BP   may   drop   early   (especially   in   those   on   anti-­‐hypertensives)   due   to   loss   of   homeostatic  
reserve  
• Temperature  often  low,  not  high  
• Tachycardic   response   may   be   absent   –   particularly   so   if   on   beta   blockers   or   other   ate  
limiting  drugs  (BCD  =  beta  blockers,  calcium  blockers  and  digoxin)  
• Delirium  may  be  a  prominent  feature  
• CRP  and  WCC  may  not  rise  (or  not  much)  
• Fluid  balance  may  be  hard  
• Antibiotics  should  be  targeted  
 
Key  points  
• In  older  people  we  must  have  a  low  index  of  clinical  suspicion  for  many  conditions  
• For  example,  perform  an  ECG  in  all  patients  with  confusion,  collapse,  dizziness  or  dyspnoea  
• Key  investigations  for  sick  elderly  patient  =  urinalysis  (as  UTIs  are  common),  ECG  (as  may  not  
present  typically  with  chest  pain),  FBC,  U&Es,  LFTs,  TFTs  
 
 
Outcomes  in  older  people  
 
• Acute  illness  carries  a  much  higher  mortality  rate  in  older  people  
• Older  people  have  less  homeostatic  reserve  (frailty)  
• They  therefore  tend  to  decompensate  faster  (due  to  frailty)  
• Prompt  diagnosis  and  treatment  are  therefore  critical  
• Even  minor  illnesses  (e
...
 flu)  can  cause  major  deterioration  in  physical  function  
• Each  illness  predisposes  to  further  illnesses  (e
...
 sepsis  increases  the  risk  of  MI;  MI  increases  
the   risk   of   pneumonia;   pneumonia   can   lead   to   stress   ulceration   and   GI   bleeding,   etc)   =>  
vicious  cycle  
 
 
The  dangers  of  iatrogenesis  
 
• Because  older  people  have  little  homeostatic  reserve,  they  are  often  delicately  balanced  
• Healthcare  interventions  therefore  cause  harm  in  many  cases  
• Timely  treatment  is  important,  but  needs  to  be  proportionate
...
 She  has  started  being  incontinent  
of  urine
...
 
Several  days  later,  she  is  still  confused,  and  now  has  diarrhoea
...
 
The   correct   underlying   diagnosis   in   this   case   was   constipation,   causing   acute   urinary  
retention  and  incontinence  
There  was  no  UTI  =>  unnecessary  administering  of  ABs  and  iatrogenic  C  diff  infection  
Both  constipation  and  retention  can  precipitate  delirium  in  frail  older  people  
 

 
Summary    
 
• Comprehensive  geriatric  assessment  (CGA)  is  the  founding  skills  of  geriatric  medicine  
• Ward   based   CGA   should   be   considered   the   evidence   based   standard   of   care   for   frail   older  
inpatients  
• Many  MDT  members  contribute  to  CGA  =>  communication  and  teamwork  are  key  
• Older  people  may  have  an  atypical  presentation  to  acute  illness  
• Older  people  are  prone  to  iatrogenic  disease  
• Rapid,  accurate  diagnosis  is  key  to  balancing  these  issues  
• Only  a  low  index  of  clinical  suspicion  is  needed  to  warrant  investigations  in  elderly    
 
 
 
 
Summary  of  components  of  Comprehensive  Geriatric  Assessment  (CGA)  
 
Medical  
• Co-­‐morbid  conditions  and  disease  severity  
• Medication  Review  (limitation  of  polypharmacy  and  optimise  medications)  
• Nutritional  status  
• Problem  list  
 
Psychological  
• Cognition  
• Mood  (affective  disorders)  
• Anxiety  
• Psychosis  
• Fears  
• Behaviour  
• Psychiatric  conditions  assessment  
 
Functional  capacity  (QoL)  
• Basic  activities  of  daily  living,  extended  activities  of  daily  living  

•
•
•
•

QoL  
Gait  and  balance  
Activity/exercise  status  
Instrumental  activities  of  daily  living  

 
Social  circumstances  
• Informal  support  available  from  family  or  friends  
• Social  network  such  a  visitors  or  daytime  activities  
• Eligibility  for  being  offered  care  resources  
• Social  groups    
 
Environment  
• Home  comfort,  facilities  and  safety  
• Use  or  potential  use  of  telehealth  technology  etc  
• Transport  facilities  
• Accessibility  to  local  resources  e
...
 shops  
 
 
 
AGEING  AND  END  OF  LIFE  PALLIATIVE  CARE  
 
• Palliative   care   is   an   approach   that   improves   the   quality   of   life   of   patients   and   their   families  
facing   the   problem   associated   with   life-­‐threatening   illness,   through   the   prevention   and  
relief  of  suffering  by  means  of  early  identification  and  impeccable  assessment  and  treatment  
of  pain  and  other  problems,  physical,  psychosocial  and  spiritual
...
   End  of  life  care  is  the  last  stages  of  palliative  care
...
   Opioid  sparing
...
     
• Regular  NSAID  e
...
 aspirin,  ibuprofen  or  diclofenac  (often  want  to  avoid  NSAIDS  in  elderly  
and  patients  with  renal/liver  disease)  
• +/-­‐  Adjuvant  analgesic  
• NB:  Adjuvant  analgesics  are  painkillers  whose  primary  indication  is  for  something  other  than  
pain   e
...
  anticonvulsants   (gabapentin)   and   antidepressants   (amitriptyline)
...
       Neuropathic  pain  is  common  in  cancer  e
...
 due  to  invasion  of  nerves
...
g
...
g
...
   Twice  daily  MST  is  the  preferred  option  as  
we  have  a  c=near  constant  therapeutic  level  of  morphine  in  the  body  for  most  of  the  day
...
     
• Ensure   there   is   always   “breakthrough”   oramorph   prescribed   PRN
...
   It  is  important  to  remember  that  1/6  is  just  an  approximation
...
   It  is  commonly  used  in  medicine  to  mean  as  needed  or  as  the  situation  arises  
 
 
 
 
Titrating  morphine  example  
 
• Day  1:  Oramorph  (liquid  morphine)  5mg  given  4  times  in  24  hours  (at  pts  request)  =  20mg  
total  daily  24  hour  dose  =>  Pain  control  was  achieved    
• Day  2:  Start  MST  10mg  twice  daily  (20mg  in  total)  +  breakthrough  Oramorph  (20/6=  3
...
e
...
     
Constipation  will  continue  throughout  use  of  opioid
...
g
...
   
However  the  laxative  should  be  given  continuously  as  constipation  is  an  ongoing  side  effect  
while  opioids  are  being  administered
...
Recognition  that  the  patient  is  dying  
2
...
Spiritual  care  
4
...
Review  of  clinical  interventions  should  be  in  the  patient’s  best  interests  
6
...
Nutritional  review,  including  commencement  or  cessation  
8
...
Regular  reassessment  of  the  patient  
10
...
g
...
5mg  (PRN)    [can  also  use  metoclopramide]  
• Respiratory  secretions  =>  SC  buscopan  (hyoscine  butylbromide)  20mg  (PRN)  
• Dyspnoea:  BDZ,  opioid,  fan  
 
Pain  control  at  end  of  life  
•

SC  morphine  is  twice  as  potent  as  oral  =>  SC  morphine  should  be  half  of  oral  dose  

•

Dose   of   PRN   SC   morphine   depends   on   24   hour   dose   of   morphine
...
g
...
5mg  PRN  2  hourly  (every  2  hours)  
• Buscopan  (hyoscine  butylbromide)  SC  20mg  PRN  2  hourly  (every  2  hours)  
 
 
Last  days:  
 
• Family  updated  
• Dies  peacefully  with  his  family  present  
 
 
 
FALLS  IN  THE  ELDERLY  
 
Who  falls?  
 
• Everyone  has  the  potential  
• 30%  over  65  years  per  year  
• Over  40%  over  75  years  per  year  
• Falls   in   elderly   are   much   more   serious   as   higher   risk   of   fracture,   fracture   complications,  
and  other  injuries  
• Elderly  individuals  also  take  much  longer  to  heal  
 
 
 
Consequences  of  falls  
 
• Injury  
! 10%  result  in  significant  injury  
! Trauma  e
...
 fractures  
! Hypothermia  
! Pressure  injury  (pressure  sore)  
! Infection  (hospital  acquired  or  complication  of  fracture  /  skin  laceration)  
 
• Psychological  and  social  

!
!
!
!
!
!

Restricted  activity  
Fear  and  anxiety  of  falling    
Depression  
Reduced  QOL  
Declining  function  
Impact  on  family  /  carers  

 
 
 
Why  do  people  fall?  
 
Lots  of  different  reasons  
 
• Locomotor  impairment  e
...
 MS  pathology  (commonest  cause)  
• Drugs:    polypharmacy,  CNS  acting  drugs  
• Neurological  deficit  
• Cognitive  impairment  
• Cardiovascular  disease  e
...
 as  a  result  of  syncope/pre-­‐syncope  
• Vestibular  problem  
• Visual  impairment  
• Environmental  factors  
 
Usually  a  combination  of  several  of  the  above  
 
 
Risk  Factors  and  RR  (relative  risk)-­‐OR  (odds  ratio)  
 
• Muscle  weakness  (e
...
 sarcopenia)  
4
...
0  
• Gait  deficit  
 
 
 
2
...
9  
• Use  assistive  device  
 
 
2
...
5  
• Arthritis  
 
 
 
2
...
3  
• Depression  
 
 
 
2
...
8  
• Age  >80  years    
 
 
1
...
7  
• Class  1a  antiarrhythmics  
 
1
...
2  
• Diuretics  
 
 
 
1
...
g
...
g
...
g
...
   Results  in  high  stepping  or  stamping  gait
...
g
...
g
...
g
...
    Also   perform   ECG   in  
any  patient  with  suspected  pre-­‐syncope,  palpitations,  or  dyspnoea
...
 
• Transient/sudden  reduction  in  blood  flow  to  brain  
• 3%  A&E  attendances  due  to  syncope  
• Must  get  collateral  history    
 
Syncope  can  be  broadly  divided  into:  
 
• Vasovagal  response:  increased  parasympathetic  nervous  system  (vagal)  tone  and  withdrawal  
of   sympathetic   nervous   system   tone   due   to   a   variety   of   triggers   e
...
  stress,   anxiety,   pain
...
     
• Cardiac    
! Arrhythmia  
! Obstructive  cardiac  lesion  (e
...
 aortic  stenosis)  
! Structural  cardiac  disease  (e
...
 hypertrophic  cardiomyopathy)  
! Aortic  dissection  
• Blood  pressure  
! Orthostatic  (postural)  hypotensive  faint  
! Hypovolaemia  
! Autonomic  neuropathy  
! Carotid  hypersensitivity    

•

Other   causes   e
...
  hypoglycaemia,   hypocapnia   (induces   cerebral   vasoconstriction),  
hypoxaemia,  and  anaemia  

 
 
Pathophysiological  mechanisms  of  syncope  include:  
 
• Impaired  baroreceptor  response:    carotid  hypersensitivty  
• Reduced  blood  volume  (hypovolaemia)  
• Altered  cerebral  autoregulation  e
...
g
...
g
...
g
...
 
! “Accidental”  
! Fall  versus  syncope  –  any  LOC?    Emotional  triggers?      Palpitations?    Chest  pain?    
Dyspnoea?    Pallor  or  light-­‐headedness  before  falling?    Recovery  time?  
! Postural  symptoms  –  dizziness  or  lightheadness  on  changing  posture  e
...
 standing  
up  or  turning  head  
! Vertigo  symptoms  –  room  spinning  or  oneself  spinning  around  room  
! May  be  an  overlap  
! Autobiographical  history  not  reliable  =>  witness  account  
• Frequency  –  has  fall  occurred  before?    How  many  times?    Circumstances  similar?  
• Indoors/outdoors  
• Can  they  get  up  
• Injuries  –  particularly  head  injury    
• ALWAYS  GET  A  COLLATERAL  HISTORY  IF  POSSIBLE  
 
PMH  
• Cardiovascular  disease  
• Neurological  disease  
! Stroke  
! PD  
! Neurodegenerative  conditions  
• Cognitive  impairment  
• Locomotor  
! OA  especially  lower  limbs  
! Spinal  problems  
• Diabetes  –  as  hypo  can  cause  falls  
• Visual  problems  –  cataracts,  glaucoma,  ARMD  
• Bone  health  –  osteoporosis    
 
DH  
• Cardiac  drugs  
• Neuroactive  drugs  
! PD  drugs  
! Antiepeleptics  
! Opiate  analgesia  
! Antipsychotics  
! Antidepressants  
! Sedatives  

•
•
•

Hypoglycaemics   e
...
  insulin   and   sulphonylureas   (e
...
  gliclazide,   glibenclamide   and  
tolbutamide)  
Anticoagulation  e
...
 warfarin  can  cause  ICH  or  hypovolaemia  due  to  internal  bleed  
Anti-­‐platelets  e
...
 aspirin  or  clopidogrel  

 
Social  history  
• Alcohol  and  illicit  drug  use  
• Walking  aids  
• Independence  for  ADLs  (activities  of  daily  living)  
• Home  environment  
• Carers  
 
Systematic  enquiry  
• Cardiac  
• Neurological  
• Locomotor  /  MS  
• Continence  
 
 
Examination    
• Mood  
• Cognitive  function  
• Neurological  
• Balance  
• Vision  
• Blood  pressure  (lying  and  standing)  
• Cardiovascular  
• Musculoskeletal  
• Gait  
 
 
Who  Should  Assess  Fallers?  
 
• Everyone  from  time-­‐to-­‐time  
! Ask  about  falls-­‐  often  unreported  
! “Get  up  and  go  test”  
 
• Geriatricians  and  MDT  
! Multiple  falls  
! Falls  requiring  hospital  attendance  
! Gait/balance  abnormalities  
 
 
The  MDT  

  
•
•
•
•
•
•
•
•
•

Doctors  
Physiotherapists  (Physios)  
Occupational  therapists  (OTs):  OTs  use  treatments  to  develop,  recover,  or  maintain  the  daily  
living  and  work  skills  of  people  with  a  physical,  mental  or  developmental  condition
...
g
...
g
...
35)   environment   for   absorption   e
...
  phenytoin  
(AED),  aspirin,  penicillins    

 
Basic   drugs   require   a   basic   (≈ph   >   7
...
g
...
   Gastrointestinal  absorption  is  affected  by  an  increase  in  gastric  pH  (less  acidic)  and  a  
decline   in   small   intestine   surface   area
...
   
They  may  have  an  impact  if  
 
Less  acidic  =>  acidic  drugs  absorption  is  decreased  and  basic  drugs  absorption  is  increased  
Less  surface  area  =>  less  absorption    
 
• Previous  GI  surgery  
• NG  tube  or  PEG  feed  
• Transdermal  patches  and  oedema  
 
Think  about  best  route  of  delivery:  
 
• Liquid/syrup  for  dysphagia  
• Can  tablets  be  crushed  for  PEG  or  NG  tube?  
• Confused  patients  refusing  tablets  /  acute  agitation  
• Nil  by  mouth  (NBM)  patients  for  surgery  or  investigations  
 
 
Drug  distribution  
 
• Far  greater  changes  and  impact  are  seen  with  body  distribution  changes
...
g
...
 
 
• There   is   an   increase   in   body   fat   tissue   (proportional   to   muscle   mass),   so   that   lipophilic  
drugs  (e
...
 diazepam,  anaesthetics)  have  a  larger  volume  of  distribution  (and  thus  a  longer  
half  life)  making  use  of  these  drugs  undesirable
...
g
...
   Albumin  is  basic  and  binds  to  acidic  drugs
...
g
...
g
...
g
...
g
...
   
• Elderly  patients  often  have  a  lower  GFR  (decreased:  size,  tubular  secretion,  renal  blood  flow)  
• Serum   creatinine   is   not   a   reliable   measure   of   renal   function   (elderly   produce   less  
creatinine  due  to  decreased  muscle  mass  =>  overestimates  GFR);  GFR  is  the  gold  standard  
indicator  of  renal  function  
• Creatinine  clearance  (CRCL)  is  used  to  estimate  GFR  
• A   commonly   used   surrogate   marker   for   estimate   of   creatinine   clearance   (CRCL)   is   the  
Cockcroft-­‐Gault   (CG)   formula,   which   in   turn   estimates   GFR   in   ml/min:   however   the   Cockroft  
and  Gault  Formula  may  overestimate  GFR  in  elderly  (as  elderly  produce  less  creatinine  due  
to  reduced  muscle  mass)  
• Cockroft   and   Gault   Formula   =>   [(140-­‐age)   x   mass   (kg)   x   (1
...
04   women)]/  
serum  Cr  (µmol/L)  
• The  most  recently  advocated  formula  for  calculating  the  eGFR  is  the  Modification  of  Diet  
in  Renal  Disease  (MDRD)  formula;  the  4-­‐variable  MDRD  estimates  GFR  using  four  variables  
-­‐    serum  creatinine,  age,  sex  and  ethnicity  [CASE]  
• Use  appendix  1  of  BNF  for  calculating  drug  doses  in  hepatic  and  renal  impairment  
 
CRCL  level  of  renal  impairment  
• Mild:  eGFR  50-­‐20ml/min  (stage  3  CKD)  
• Moderate:  20-­‐10ml/min  (stage  4  CKD)  
• Severe:  Less  than  10ml/min  or  anuric  (non  passage  of  urine)  –  Stage  5  CKD  
 
 

  
 
 
Pharmacodynamics  
 
• Pharmacodynamics=  drug  action  on  the  body  (+ADRs)  
• General  principle:  Lower  doses  achieve  same  effect  in  the  elderly  (common  e
...
 alcohol)  =>  
start  low  and  go  slow  
• However,   it   is   important   to   remember   that   some   effects   are   decreased   (e
...
e
...
     
! Vancomycin  
! Warfarin  
 
 
 
 
! Phenytoin  
! Lithium  
 
 
 
 
! Digoxin  
 
 
 
 
! Carbamazepine  

! Gentamicin    
! Levothyroxine  

 

 

 

 
 
Polypharmacy  +  OTC  preparations  
 
• Elderly  =  12%  of  population  but  32%  of  prescriptions  
• Average  use  for  person  >65  yrs  
! 4  prescription  drugs  
! 2
...
     
• Polypharmacy   is   often   associated   with   a   decreased   quality   of   life,   decreased   mobility   and  
cognition
...
g
...
   
This  may  lead  to  further  misdiagnoses  and  further  symptoms
...
g  prazosin)  
! Antipsychotic  =>  akithesia  =>  more  meds  

 
 
Adverse  drug  reaction  (ADRs)  
 
• The  elderly  are  at  high  risk  for  adverse  drug  reactions  (ADRs)
...
   
• As   the   number   of   medications   a   person   takes   increases,   the   risk   of   an   ADR   increases  
exponentially
...
  This   can  
result   in   additional   drugs   prescribed   in   response   to   treat   the   symptom   of   an   ADE,   instead   of  
stopping  the  offending  drug
...
 
• Prescribers  need  to  rely  on  careful  medication  history  taking  (including  OTC  preparations)  
in  order  to  diagnosis  ADR’s  that  present  in  atypical  ways
...
g
...
g
...
   NSAIDs  
• GI   hemorrhage   e
...
  due   to   peptic   ulcer   (as   a   result   of   decreased   mucosal   barrier   function  
due  to  decreased  PG  formation)  
• Decline  in  GFR  (due  to  renal  afferent  arteriole  vasoconstriction  as  a  result  of  decreased  PG  
formation)  =>  can  precipitate  toxicity  of  other  renally  excreted  drugs  i
...
 ones  with  narrow  
therapeutic  window    
• Caution  in  liver  cirrhosis  (due  to  risk  of  bleeding  and  heptorenal  syndrome)  
• Decreased  effectiveness  of  diuretics,  anti-­‐hypertensive  agents  
• Paracetamol  as  effective  as  NSAIDs  in  mild  OA  =>  paracetamol  is  first  line  for  many  types  
of  pain  (due  to  less  side  effects)  
 
 
 
 
2
...
   Antibiotics  
• AB  resistance  and  C
...
g
...
 
 

•

First,  start  low,  go  slow;  start  treatment  with  low  doses  due  to  lower  recommended  starting  
doses   in   elders   based   upon   pharmacokinetic   changes   with   aging   (e
...
  reduced   total   body  
water),  and  the  risk  of  an  ADR  often  being  dose  related
...
    Also   modify   the   dose   in   relation   to   degree   of   any   hepatic   and/or   renal  
impairment
...
    This   principle   teaches   avoiding   starting   drug   therapy  
until   the   diagnosis   of   the   condition   is   clearly   established
...
 

•

Third,  use  no  drug  beyond  its  time
...
   

•

Fourth,   avoid   the   use   of   new   drugs   until   their   safety   for   use   in   the   elderly   has   been  
established
...
 

•

Lastly,   the   primary   care   physician   (GP)   should   be   the   quarterback   of   all   medication  
prescribing
...
 Lack  of  oversight  in  this  setting  
can  often  result  in  duplication  of  therapy,  the  use  of  drugs  that  interact  with  each  other,  and  
the  use  of  drugs  that  are  inappropriate  for  the  elderly
...
 Regular  review  of  the  entire  medication  regimen  by  the  PCP  
can  be  accomplished  by  maintaining  an  active  drug  list,  and  review  of  all  current  medications  
by   specialists   by   having   the   patient   bring   all   medications   to   office   visits   (the   brown   bag  
review)
...
 

 

 

 

 

 

 
 
 
DELERIUM  
 
What  is  delirium?  
 
• An  ACUTE  transient,  usually  reversible,  global  cognitive  dysfunction  
• Hallmarks  are  (AAAA):    
! Acute  change  in  cognition  +/-­‐  fluctuating  (e
...
 sundowning)  
! Attention:    Decreased  attention:  test  with  digit  span  
! Alertness/activity:  Decreased  alertness,  hypoactive,  hyperactive  

•
•

! Assessment   of   orientation   and   4AT   tool:     time,   place,   and   person,   serial   7s,   digit  
span  
! Fluctuating  symptoms  (often  with  nocturnal  worsening  of  symptoms)  
Delirium   is   NOT   a   Dx;   delirium   occurs   secondary   to   some   other   cause(s)   of   systemic  
dysfunction  
The   principle   aim   of   management   is   to   identify   the   underlying   diagnoses   and   treat   them  
accordingly
...
g
...
g
...
 
• Diagnosis  is  missed  in  up  to  70%  of  cases  
• Associated   with   increased   mortality:   In   patients   who   are   admitted   with   delirium,   mortality  
rates  are  10-­‐26%  
• It  is  not  benign;  it  is  usually  a  marker  of  some  underlying  serious  pathology  
• It  is  very  distressing  for  patients,  relatives  and  carers
...
   
This  is  so  that  we  can  monitor  them  more  closely  and  aim  to  prevent  delirium  from  occurring
...
     
• Any   acute   factors   that   affect   neurotransmitter,   neuroendocrine   or   neuroinflammatory  
pathways  can  precipitate  an  episode  of  delirium  in  a  vulnerable  brain
...
 
• Some  of  the  most  common  precipitating  factors  are  listed  below  
• Young  people  can  get  delirium  as  well!!!  
 
 
       Metabolic  
• Malnutrition  
• Dehydration  
• Electrolyte  imbalance  
• Anaemia  
• Hypoxia  
• Hypercapnoea  
• Hypoglycaemia  
• Endocrine  disorders  (e
...
 SIADH,  Addison’s  disease,  hyperthyroidism,  hypercalcaemia)  
 
       Infection  
• Especially  respiratory  and  urinary  tract  infections  
 
       Medication  
• Anticholinergics  
• Dopaminergics  
• Opioids  
• Steroids  
• Polypharmacy  
         
Vascular  
•
•
•
•
•
•
•
•

•
•
•
•

Stroke/Transient  ischaemic  attack  
Myocardial  infarction  
Arrhythmias  
Decompensated  heart  failure  

         
Physical/psychological  stress  
• Pain  
• Iatrogenic  event  
• Chronic/terminal  illness  especially  cancer  
• Post-­‐traumatic  event  e
...
 fall  or  fracture  
• Immobilisation/restraint  
         
Other  
• Substance  withdrawal,  esp
...
 
 
 
Diagnosing  delirium  
 
• Step   1:   Is   there   an   acute   cognitive   impairment   /   change   in   cognition?     Often   best   to   ask   a  
family  member  or  carer  
• Single   question   in   delirium   (SQID):    ‘Do  you  feel   that  [patient’s  name]   has  been  more  con-­‐
fused  lately?’  
• Can  also  use  MMSE  or  alternative  cognitive  testing  tool  –  but  MUST  know  patients  baseline  
as  delirium  is  an  acute  change    
• If  yes  then  perform  the  confusion  assessment  method  (CAM)  
 
 
Confusion  assessment  method  (CAM)  
 
• Does  the  patient  have  symptoms  which  are  acute  and  fluctuating?  
• Attention:    Does  the  patient  have  inattention?  
• Activity:  altered  conscious  level  (hyper-­‐alert,  hypo-­‐alert  or  mixed  state)?  
• Does  the  patient  have  disorganised  thinking?  
• If  yes  to  the  above  =>  delirium  is  very  probable  
• Assess  with  the  4AT  tool:    
! Acute  and  fluctuating  symptoms  

! Attention  deficit  –  digit  span    
! Alertness:    altered  conscious  level  
! AMT4  score  (orientated  in  time,  place  and  person)  –  what  is  your  name?    Where  are  
you?    Do  you  know  what  day  it  is?  What  month  it  is?    What  year  it  is?  
 
 
 
Testing  inattention  
 
• Use  the  Digit  Span  test  
• Digit-­‐span  task  is  used  to  measure  working  memory's  (closely  linked  to  attention)   number  
storage  capacity
...
g
...
 If  they  do  this  successfully,  they  are  given  a  longer  list  (e
...
,  
'9,  2,  4,  0')
...
   
• This  test  assesses  not  only  memory  but  also  attention;  therefore  in  patients  with  memory  
impairment  may  not  be  a  reliable  indicator  of  attention    
 
 
Delirium  subtypes  
 
• Hyperactive:  Agitated,  aggressive,  wandering  
! Easy  to  diagnose  
• Hypoactive:  Withdrawn,  apathetic,  sleepy,  coma  
! Easily  missed  
! Hypoactive  delirium  has  twice  the  mortality  rate  of  hyperactive  delirium  
• Mixed  state  
 
 
The  4AT  tool  
 
• The  4  A's  Test  or  4AT  is  a  new  screening  tool  for  delirium  and  cognitive  impairment  
• The  4AT  is  designed  to  be  used  by  any  health  professional  at  first  contact  with  the  patient,  
and  at  other  times  when  delirium  is  suspected
...
g
...
g
...
Observe the patient if
Clearly abnormal
4
asleep, attempt to wake
...

AMT4 (age, D
...
B, place (hospital), current year)

Attention: Ask  the  patient:  “please  tell  me  the  months  of  
the  year  in  backwards  order,  starting  at  December
...
g
...


No mistakes
1 mistake
>2 mistakes/untestable
Achieves 7 months or more correctly
Starts but scores <7 months/refuses to start
Untestable (cannot start because unwell, drowsy,
inattentive)
No
Yes

0
1
2
0
1
2
0
4

 
More detailed cognitive assessment and
  If scored 4 or more this is possible
If scored 1-3 cognitive
informant history taking are required
impairment is suggested
  delirium +/- cognitive impairment
How  do  we  manage  delirium?  
Assessed/s
Results
Abnormality
TIME Initiate all elements within 2 hours (initial and write time of completion)
ent
seen
found
 
Think about possible triggers
Treatment  of  delirium  involves  two  main  strategies:    
SEWS (think sepsis)
• First,  
Blood glucose treatment  of  the  underlying  presumed  acute  cause  or  causes;    
Medication history (identify new medications/change offor   the   brain
...
  Detection  
and  management  o mental  stress  
Investigate and intervene to correctf  underlying causes is  also  very  important
...
 
Completed
Manage
  Initiate treatment of ALL underlying causes found above
Non-­‐pharmacological  treatments  are  the  first  measure  in  delirium,  unless  there  is  severe  agitation  
Explain
or  Document diagnosis ofplaces  the  person  at  risk  of  harming  oneself  or  others
...
Only use medication if
Ensure glasses and hearing aids are
Multifactorial  assessment  and  management   and
patient’s  symptoms  are  threatening  their  own  or  others  safety
...
Use:
unnecessary
Provide regular reassurance and
• Identify  and  reverse  any  underlying  causes   1
...
5-1mg orally or 0
...
Max
Urinary
Use family/familiar people toand  supportive  factors  
• Environmental   reassure and
5mg in 24 hours
...
Lorazepam 0
...
Remember benzodiazepines can
! “Continuity  of  
Reduce noise and visual overstimulationstaff”  Confrontation
worsen or prolong delirium
...
 
 
 
Pharmacological  management  of  delirium  
 
The   pharmacological   treatment   for   delirium   depends   on   its   cause
...
 Evidence  is  weaker  for  the  atypical  antipsychotics,  such  as  risperidone  and  olanzapine
...
    However,   if   delirium   is   due   to  
alcohol  withdrawal  or  benzodiazepine  withdrawal,  or,  if  antipsychotics  are  contraindicated  (e
...
 in  
Parkinson's  disease,  Parkinsonism,  DLB  or  neuroleptic  malignant  syndrome),  then  benzodiazepines  
are  recommended
...
 
 
Haloperidol  
• Usual  first  choice:  unless  CI  e
...
 Parkinsonism  or  heart  disease  
• Has  sedative  and  antipsychotic  properties  
• High  potency,  few  anticholinergic  side  effects,  no  active  metabolites  
• Start  with  low  dose  (0
...
5mg);  better  to  give  regularly  
• Oral  (avoid  IM  if  at  all  possible)  
• Max  5mg  in  24  hours  
• “Start  low  and  go  slow”  
• Get  senior  advice  before  giving  
 
 
Benzodiazepines  
• Use  if  alcohol  or  benzodiazepine  withdrawal  or  if  seizures  
• Use  in  dementia  with  Lewy  bodies  or  Parkinsonism    
• Use  lorazepam  (shorter  acting  and  fewer  active  metabolites)  
• Lorazepam   can   sometimes   worsen   delirium!!   (Hence   why   we   only   use   in   limited  
circumstances  e
...
 if  good  medical  nursing  care  fails,  and  haloperidol  is  CI)  
• Chlordiazepoxide  for  alcohol  withdrawal  
 
Important  points  
! Document  why  it  was  necessary  to  give  sedation
...
9%  vs  15%)  
• Reduced  number  of  days  with  delirium  (105  vs  161)  
• Reduced  number  of  delirium  episodes  (62  vs  90)  
 
Components  of  HELP  
• Cognition:  orientation  measures;  3x/day  cognitive  stimulation  
• Sleep  protocol  to  reduce  insomnia  and  sedative  use  
• Early  mobilisation:  3x/day  minimum  and  avoidance  of  restraints  
• Hearing  protocol:  hearing  aids,  wax  removal,  amplifying  devices    
• Visual  aids:  glasses,  large  print  
• Effective  hydration  
 
 
Summary  
• Get  proper  history  (from  patient  +/-­‐  collateral  history)  
• Recognise  delirium  
• Diagnose  delirium:    SQID,  CAM  tool,  4AT  tool  
• Delirium  is  not  benign  
• Delirium  often  has  more  than  one  cause:  once  you’ve  found  one  still  look  for  others  
• Only   give   sedation   (haloperidol   or   lorazepam)   if   absolutely   necessary   (e
...
  conservative  
methods  have  failed)  and  always  document  reason  why  given  
 
 

 

  
 
REHABILITATION    
 
• Rehabilitation   =   a   process   aiming   to   restore   personal   autonomy   and   participation   to  
activities   of   daily   life   considered   most   relevant   by   patients   or   service   users,   and   their   family  
carers    
• Restore  as  best  as  possible  
• Although   don’t   give   false   hopes   as   rehabilitation   will   likely   never   restore   back   to   pre-­‐morbid  
level  
 
 
Who  may  need  rehabilitation?  
 

 
 
 
Where  does  rehabilitation  occur?  
 
• Acute  Hospitals  
• Rehabilitation  units  
• Hospitals  
• Community:  in  peoples’  homes  
• Out-­‐patient  settings  e
...
 day  hospital  and  GP  or  community  hospital  settings  
 
 
Principles  of  Rehabilitation  
 
• Client  or  patient  centred:  ask  patient  “what  matters  most  to  you?”  
• Goal  -­‐directed:  identify  problems  and  then  set  realistic  goals  
• Co-­‐ordinated:  MDT  (complex  patient  needs  requires  specialist  input  from  several  disciplines)  
• Improve  outcomes  

  
 

 
 
Measuring  outcomes  
 
Impairment  or  activity  specific  
• Rivermead  Motor  Assessment  Scale  
• Chessington  Occupational  Therapy  Neurological  Assessment  Battery    
• Boston  Diagnostic  Aphasia  Examination  
 
Activities  of  Daily  Living  Scales  
• Barthel  Index  
• Functional  Independence  Measure  
• Measures  
! Feeding  
! Bathing  
! Grooming  
! Dressing  
! Bowels  
! Bladder  
! Toilet  Use  
! Transfers  (bed  to  chair,  and  back)  
! Mobility  (on  level  surfaces)  
! Stairs  
 
Other  Outcomes  
• Anxiety  and  depression  
• Quality  of  life  
• Cognitive  function  

 

•

•

Instrumental   ADL   (instrumental   activities   of   daily   living   (IADLs)   are   not   necessary   for  
fundamental  functioning,  but  they  let  an  individual  live  independently  in  a  community  e
...
 
housework,  managing  money,  use  of  telephone  or  other  form  of  communication  etc)  
Participation  measures  

 
 
Discharge  Planning  
 
• Housing  and  residential  care  
• Home  assessment  
• Home  alterations,  aids  appliances  
• Home  services  and  social  care  teams  
• Financial  issues  and  benefits  
• Transition  to  community  rehabilitation  
• Return  to  work,  leisure  and  other  life  roles  
 
 
 
AGEING:  SUMMARY  OF  COURSE    
•

We   live   in   an   ageing   population   and   there   is   going   to   be   even   more   older   people   in   the  
future  (and  less  younger  people  to  support  society  financially)  

•

This  will  cause  major  challenges  for  healthcare  providers  (as  well  as  society)  

•

Older   individuals   are   very   heterogeneous   across   any   measure   of   physiological   or   daily  
functions  (e
...
 spectrum  from  severely  frail  to  “fit  as  a  fiddle”)  

•

Many   older   individuals   have   a   loss   of   homeostatic   reserve   (frailty)   due   to   cumulative  
defects  across  multiple  body  systems  =>  small  insults  can  produce  major  problems  

•

Frailty   =   accumulated   deficits   across   multiple   systems   =>   loss   of   homeostatic   reserve  
(there  are  scales  to  quantify  frailty)  

•

It   is   NOT   being   old   which   causes   illness;   it   is   illness   which   causes   illness   e
...
  illness   causes  
frailty  (loss  of  homeostatic  reserve)  which  predisposes  to  more  illness  =>  vicious  cycle  

•

Although   getting   old   is   often   associated   with   the   accumulation   of   diseases,   it   is   not   an  
inevitable  part  of  aging  

•

The  comprehensive  geriatric  assessment  (CGA)  is  the  standard  of  care  for  older  people  -­‐  it  
is  an  evidence  based  method  for  looking  and  solving  problems  in  older  people
...
   If  
it   were   a   drug   it   would   be   the   best   drug   we   have!   The   number   needed   to   treat   is  
approximately  3
...
   Requires  MTD  assessment
...
    A   collateral   history   is   extremely   important
...
 The  big  5  modifications  which  can  be  used  
to   decrease   the   incidence   of   falls   are:   cataract   extraction,   strength   and   balance   training,  
calcium   and   vitamin   D   supplementation,   medication   review   (avoidance   of   polypharmacy  
and  CNS  acting  drugs  if  possible),  and  home  environment  modification
...
g
...
5  BMD)    

•

Delirium   is   common   in   hospital,   under-­‐diagnosed   and   doubles   mortality
...
   This  principle  is  
common  of  many  syndromes  in  geriatrics  =>  often  multiple  causes
...
   We  
must  manage  and  treat  the  multiple  causes  of  delirium
...
    Sarcopenia   (muscle   atrophy)   is   a   major   contributor   to  
reduced   muscle   strength   and   thus   immobility
...
   Treating  sarcopenia  is  key  to  increasing  health  and  
QoL
...
 

•

Rehabilitation  is  an  active  process  which  can  transform  the  lives  of  folder  people
...
   Polypharmacy  is  common
...
   Think  about  what  our  aims  are
...
  Use   kidney   function   and   liver   function   to  
influence  prescribing
...
   It  also  includes  the  time  building  up  to  end  of  life  
care

---