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Care of Elderly Nambi Ramamoorthy ST1 GPR Who are they? • Above 65? 70? 75? National Service Framework for Older People (2001) • Care near home Best when care is provided in their own homes • Person-centred care Patients should be treated as individuals and empowered to make choices about their own care • Age discrimination Patients should be treated according to clinical need rather than age • Intermediate care The aim here is to relieve pressure on acute hospital beds and provide care in a more community- based setting • The NHS is also to take action on stroke prevention, in the promotion of health and active life and a reduction in the number of falls for older people What common problems • Falls • House Bound • Confusion • Depression • Capacity • Not coping • Tiredness • Hearing and vision • ? Falls • 30% of those over 65 years old and over 40% for those over 75 have had a fall in the past 12 months. • is the commonest cause of accidental deaths in elders over 75 years • It cost 1.7 million every year for NHS Etiology • Accident and environmental hazards (31%) • Gait and balance disorders or weakness (17%) • Dizziness and vertigo (13%) • Drop attack (9%) • Confusion (5%) • Postural hypotension (3%) • Visual disorder (2%) • Syncope (0.3%) The causes of postural hypotension may be divided into • venous pooling of blood: • hypovolaemia: – severe varicose veins – dehydration – prolonged standing – exsanguination e.g. gastrointestinal bleed • impaired vasomotor tone: • drugs: – diabetic autonomic – hypotensive agents neuropathy – tranquilisers – Shy-Drager syndrome – phenothiazines – levodopa • reduced muscle tone: • Addisonian disease: – prolonged bed rest – Addison's disease – hypopituitarism – abrupt cessation of steroid therapy Drugs which may cause orthostatic hypotension include: • beta blockers • diuretics • ACE inhibitors • phenothiazines • tranquilisers • L-dop Examination can be tailored to the history but will usefully include: • Cardiovascular assessment • Selective neurological assessment • Functional assessment (of for example gait and transferring) • MMSE score • Vision testing NICE recommends pragmatic tests • Timed Up & Go Test: request that the patient rise from a chair without the support of their arms, walk 3 metres, turn round and sit down again. A walking aid can be used if required. Completion of the test without unsteadiness or difficulty suggests a low risk of falling. • Turn 180° Test: request that the patient stand up and step around until they are facing the opposite direction. If more than four steps are required to do this, further assessment is indicated. Investigation for falls • Basic blood tests including: • ECG to confirm or suggest: • Full blood count (macrocytosis Atrial fibrillation, Conduction may indicate alcohol abuse) defects where there is a • Urea and electrolytes prolonged PR interval, inferior • Liver function tests (LFTs) - ischaemia or bundle branch abnormal LFTs may indicate block alcohol abuse, especially Ambulatory ECG may be required gamma GT to discover episodes of • Thyroid function tests bradycardia with possible heart block or even tachyarrhythmia • Vitamin B12 • Echocardiography • Random blood glucose • Visual assessment • Urinalysis may reveal • Syncope or TIAs require unsuspected diabetes to additional investigations account for vascular disease, including neuroimaging neuropathy and poor vision NICE has identified four interventions with evidence-based effectiveness: • Strength and balance training • Home hazard intervention and follow-up • Medication review • Cardiac pacing where indicated Methods deemed ineffective or with an equivocal evidence base include • Brisk walking (may be hazardous in postmenopausal women) • Low-intensity exercise combined with continence training • Cognitive and behavioural interventions • Referral for visual disturbance (but should not be discouraged on grounds of good practice) • Vitamin D (may help to improve bone strength but there is no evidence that it reduces fall frequency) • Hip protectors (equivocal results in trials) AKT • A 70 year old man presents to you as a new patient. He informs you that since a stroke two years ago he has suffered from dizziness and increasing difficulty mobilising. Initial recovery was good. His repeat prescriptions (from previous GP) are:- Ramipril 10mg daily; Indapamide 1.5mg daily; Aspirin 75mg daily; Atorvastatin 40mg daily; Furosemide 40mg daily; Prochlorperazine 5mg daily. Which focussed examinations below are most likely to lead to a management plan? A. Cranial nerves and cerebellum B. Mental state and reflexes C. Muscle power and blood pressure D. Postural blood pressure and gait E. Pyramidal tracts and joint position sense • Answer: d Postural blood pressure and gait. Regrettably this is not an uncommon scenario – inappropriate drug regimes find their way on to repeat prescribing systems (in this case a thiazide and loop diuretic which have synergistic actions) Consequences are treated symptomatically (in this case with a phenothiazine) which can itself cause Parkinsonism Confusion • Acute or chronic? • How to assess? • How to confirm? • What to do? Dementia • Defined as a progressive and largely irreversible global deterioration in intellectual function, behaviour and personality in the presence of normal consciousness and perception. • young-onset dementia – formerly known as “pre-senile dementia”, refers to patients who develop dementia before the age of 65 years • late-onset dementia – previously known as “senile dementia”, refers to patients who develop dementia after the age of 65 years Primary degenerations • Alzheimer's disease (65% of cases) • Dementia with Lewy bodies (DLB) http://www.youtube.com/watch?v=s0_7sojlQms • Pick's disease http://www.youtube.com/watch?v=8L7EseDwYxQ&feature=related • Frontal lobe dementia http://www.youtube.com/watch?v=EHSdNjhkvE8&feature=channel • Parkinson's disease • Huntington's chorea http://www.nhs.uk/conditions/Huntingtons-disease/Pages/Introduction.aspx • Progressive supranuclear palsy • Spinocerebellar degenerations • Progressive myoclonic epilepsy • Alzheimer's disease (AD) - the cause of most cases of dementia, accounting for about 60% http://www.5min.com/Video/Alzheimers-Disease--Signs-231184329 • its a degenerative cerebral disease, with insidious onset, which is characterised by a slow progressive decline in cognition and ability to function • vascular dementia (VaD) and dementia with Lewy bodies (DLB) are responsible for most other cases of dementia (15 to 20% of cases in each) (1) – vascular dementia usually arises from multiple infarcts or generalised small vessel disease - has a more sudden onset than Alzheimer's disease. – DLB is slowly progressive - DLB shares many of the features of Alzheimer's disease and Parkinson's disease • other degenerative diseases - Huntington‟s disease • prion diseases - Creutzfeldt-Jakob Disease • reversible causes – psychiatric disorders - „pseudodementia‟ of depression – space-occupying lesions – toxic and metabolic disorders - alcohol-related dementia, vitamin B12 or folate deficiency – endocrine abnormalities – hypothyroidism (1) • Several risk non modifiable risk factors – age – advancing age is the most important risk factor in developing dementia – learning disabilities – in people with Down‟s syndrome, dementia develops 30–40 years earlier than in a normal person – gender – rate of dementia is higher in women than in men (specially for Alzheimers disease) – genetic factors • modifiable risk factors – alcohol consumption – smoking – particulary for Alzheimers – obesity – hypertension – hypercholesterolaemia – head injury • education and mental stimulation Assessment • MMSE total score 30 Scores of 25-30 out of 30 are considered normal; NICE classify 21-24 as mild, 10-20 as moderate and <10 as severe impairment • AMT • General Practitioner Assessment of Cognition (GPCOG) Assessment • Attention and concentration ability • Orientation - time, place, person • Memory - both short- and long-term • Praxis - can they get dressed, lay a table, etc. • Language function (usually evident during questioning) • Executive function - problem-solving, etc. Holistic Assessment Investigation • Full blood count • Erythrocyte sedimentation rate • Urea and electrolytes • Glucose • Liver function tests (including gamma glutamyl transferase) and calcium • Thyroid function tests • MSU (if delirium is a possibility) • B12 and folate (red cell folate) • Consider also doing the following in relevant groups of patients: • HIV, syphilis screen, drug screen, monitor blood levels of certain drugs (e.g. anticonvulsants or digoxin). • Consider blood cultures and CT/MRI scan (to exclude subdural or space occupying lesion). Management • Who to refer Patients with positive MMSE • Why to refer Early intervention with measures as simple as patient support and counselling may delay admission to residential care by up to 1 year. This effect is not seen where a delay of as little as 6 months between identification and treatment exists. • Where to refer Psychogeriatrician or memory clinic. AKT • 8. A 67 year old woman, who is well known to you, has been diagnosed with Alzheimer‟s disease and is in a care home. You are asked to see her because she has become aggressive and violent towards carers and other residents. Carers have followed NICE guidance on the management of aggression with no success. You manage to examine her and can find no obvious cause for her deterioration. You decide that she will need admission for further assessment in order to exclude other remediable causes for her agitation, and that it is justifiable to sedate her at this point. Which the single most appropriate drug for this purpose? a ) IM haloperidol b ) Oral diazepam c ) Oral chlorpromazine d ) IM lorazepam e ) Oral lorazepam • Answer: E Agitation and aggression should be managed by non- pharmacological methods where possible. The use of drugs is often unnecessary, and they can increase the risk of cerebrovascular events. If the risks have been considered and are justified, oral drugs are preferable to parenteral routes. Oral lorazepam, haloperidol or olanzapine in the lowest effective dose are the preferred drugs. Careful patient monitoring after sedation is mandatory. The Mental Capacity Act 2005 has the following principles • Adults must be assumed to have capacity to make decisions about their care unless proved otherwise. • Individuals should be given all available support to help them come to a decision. • Individuals should retain the right to make what others might consider eccentric or unwise decisions. • Anything done on behalf of an individual without capacity must be in that person's best interests. • The rights and basic freedoms of an individual without capacity should be restricted as little as possible. • With the patient's consent, relatives and carers should be involved in management decisions. Depression • Depression assessments such as the 4 item Geriatric Depression Scale are easy and quick to perform with a high sensitivity and specificity. Patients who screen positive for depression should be considered for antidepressants and be reassessed cognitively when their depression has lifted. • Care must be taken as dementia and depression often co-exist Geriatric Depression Scale (GDS) 1.Are you basically satisfied with your life? 2.Do you feel that your life is empty? 3.Are you afraid that something bad is going to happen to you? 4.Do you feel happy most of the time? 4 Item GDS score /4, Score 1 for answers in block capitals: 2- 4=Depressed, 1=uncertain, 0=Not depressed TATTS, tired all the time syndrome • 20 to 30% of cases will have a discernible physical disease. Up to 50% of cases have a mainly psychological cause, with tiredness as a cardinal feature of depression. • 'Listen to the patient. He (or she) is telling you the diagnosis.' • Define exactly what is meant by tired or fatigue • Note the duration of the problem apparent precipitating factor? • previous levels of energy and how these compare with the present 'What do you expect at your age?' The active elderly person who suddenly loses energy and becomes easily fatigued has serious illness. • Has the patient noticed any other changes?: This may be change in weight or appetite, polyuria and thirst or sleep disturbance. Perhaps the ankles are swollen at the end of the day and nocturia more pronounced • Has there been a recent start or change in medication?: Treatments for hypertension, especially betablockers, can cause lethargy. • Is weight going up or down? How is appetite • Is there polyuria or nocturia? Diabetes mellitus is not the only condition to be considered. Chronic renal failure may present with lethargy and polyuria from failure to concentrate urine. • Has the bowel habit changed? Bowels are often sluggish in depression or a change of bowel habit may indicate malignancy and, with it, anaemia. • Examination • Differential diagnoses Depression Anaemia; iron deficiency; cancer; renal disease; liver disease; heart failure; thyroid disease; diabetes; autoimmune Cancer • Man • Woman Lung Bowel Bowel Lung prostate Breast/ovary Which of the following statements about screening for colorectal cancer are true? Select three options only. A. The presence of a latent phase with precancerous lesions makes colorectal cancer ideal for screening B. Colonoscopy is the only screening method proven to reduce mortality C. Of patients with colorectal cancer 90% have symptoms of rectal bleeding D. Proposed national screening for colorectal cancer will target those aged 50-74 years E. Flexible sigmoidoscopy in women of average risk picks up only 35% of cancers F. Of patients with iron-deficient anaemia in general practice 11% were found to have gastrointestinal cancer • Answer: A,E, F fecal occult blood testing is the only screening method proven to cut death rates. the proposed screening programme will start in 2010 and scren the age group 60-69 years. the CONCeRN study showed low sensitivity for colonoscopy in women of average risk. rectal bleeding occurs in less than 50% of colorectal cancer. Guideline on management • Physical problems such as diabetes, heart failure or serious systemic disease need appropriate management. Anaemia should be corrected. it would be wrong to assume that iron deficiency is only a problem when anaemia occurs. • Psychological distress is common with lethargy and fatigue and it is difficult to ascertain if this is the primary cause of the complaint or the result of it. question of who benefits from antidepressants? Antidepressants, especially selective serotonin re-uptake inhibitors (SSRIs), should be used with great care, • Fatigue and somnolence -respiratory failure and carbon dioxide retention. Obstructive sleep apnoea is associated with somnolence, lethargy and poor concentration. Loss of weight is beneficial. • The doctor may help the patient to identify social and lifestyle issues that are responsible in part or in whole. The patient may be in a position to address them but, even if they are unavoidable, the mere fact that someone has discussed them and lent an empathetic ear can be therapeutic. • Drug or alcohol abuse may need to be addressed. As part of their annual review for hypertension, your patients have urea and electrolytes measured. Significant numbers are now coming back with evidence of chronic renal impairment. Which of the following statements about this condition are true? Select three statements only. A. Most laboratories now provide a measurement of the patient’s true glomerular filtration rate (GFR) which is a definitive guide to renal function B.Patients with eGFR > 60 ml/min per 1.73 m2 do not have renal impairment C.An eGFR < 15 is the cut-off for stage 5 chronic renalimpairment, at which point patients should be considered for dialysis D. A blood pressure treatment goal of < 125/75 is indicatedfor patients with proteinuria E. A high-protein diet is required in patients with proteinuria to replace urinary losses F. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with only one kidney G. Patients with moderate-to-severe chronic renal impairment should follow a diet restricted in potassium • Answer: C,D,G The result measured by laboratories is an estimated GFR (or eGFR), which assumes standard body surface area and race. Patients who have, for instance, had an amputation may receive erroneous results. An eGFR between 60 and 89 correlates with mild renal impairment. Stage 5 chronic kidney disease is defined as eGFR < 15. Low protein diet has been shown to reduce death rate in chronic renal disease. Patients with only one kidney are prone to renal impairment and should all be considered for ACE inhibitors. Further reading • http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi cationsPolicyAndGuidance/DH_4003066 • http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=1 0956 • http://lutonicsbutnotlunatics.blogspot.com/2009/02/akt-exam- questions.html • http://www.passmedicine.com/
"Care of the elderly ppt - PowerP"