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Care of the elderly ppt - PowerP

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									Care of Elderly
 Nambi Ramamoorthy
     ST1 GPR
          Who are they?
• Above 65?
  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
•   ?
• 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
•   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
    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

•   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
• Hip protectors (equivocal results in trials)
• 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
  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
•   Acute or chronic?
•   How to assess?
•   How to confirm?
•   What to do?
• 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
        Primary degenerations

• Alzheimer's disease (65% of cases)

• Dementia with Lewy bodies (DLB)
• Pick's disease
• Frontal lobe dementia
• Parkinson's disease

• Huntington's chorea
• Progressive supranuclear palsy

• Spinocerebellar degenerations

• Progressive myoclonic epilepsy
• Alzheimer's disease (AD) - the cause of most
  cases of dementia, accounting for about 60%

• its a degenerative cerebral disease, with
  insidious onset, which is characterised by a slow
  progressive decline in cognition and ability to
• 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
• other degenerative diseases - Huntington‟s
• prion diseases - Creutzfeldt-Jakob Disease
• reversible causes
  – psychiatric disorders - „pseudodementia‟ of
  – 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
    – 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
• 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
• General Practitioner Assessment of
  Cognition (GPCOG)
• Attention and
  concentration ability
• Orientation - time, place,
• Memory - both short- and
• Praxis - can they get
  dressed, lay a table, etc.
• Language function
  (usually evident during
• Executive function -
  problem-solving, etc.
Holistic Assessment
•   Full blood count
•   Erythrocyte sedimentation rate
•   Urea and electrolytes
•   Glucose
•   Liver function tests (including gamma glutamyl transferase) and
•   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).
• 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.
• 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
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
• 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

  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
• 'Listen to the patient. He (or she) is telling
  you the diagnosis.'
• Define exactly what is meant by tired or
• 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
 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
• 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
• 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,
• Examination
• Differential diagnoses

 Anaemia; iron deficiency; cancer; renal disease; liver disease; heart
  failure; thyroid disease; diabetes; autoimmune
• 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

• 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

 E. A high-protein diet is required in patients with proteinuria to replace urinary

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
• http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=1
• http://lutonicsbutnotlunatics.blogspot.com/2009/02/akt-exam-
• http://www.passmedicine.com/

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