Geriatrics, Oncology and Palliative Care Notes PDF

Neal Aquilina 2023/24 Geriatrics, Oncology and Palliative Care Notes (MDS4015) The goal of these notes was to create one note that covers completely everything that is needed for the exam. To compile these notes I went throug...

Neal Aquilina 2023/24 Geriatrics, Oncology and Palliative Care Notes (MDS4015) The goal of these notes was to create one note that covers completely everything that is needed for the exam. To compile these notes I went through lectures, tutorials and various books, and even added things found in past papers. I believe them to be the only resource needed for the exam and it is all I used for the exam right after completing them. If you have any questions about the contents please feel free to message me. Note: Lecturer names are not mentioned as there was a lot of overlap so I compiled the similar notes to avoid repetition. Geriatrics Clinical Presentation and Assessment in Geriatrics (AV) + Frailty (PF) Clinical Presentation - Clinically we may de ne frailty as a de nable clinical state involving multiple signs and symptoms. Using this approach, its syndromatic character (mentioned later) is brought out. This allows for heterogeneity of expression, however we are uncertain whether heterogenous phenotypic expressions in frailty share common or di erent pathways and so it is unclear whether frailty is a syndrome or several syndromes. - Those that are most likely to potentially be frail are those that are 80 or older. However, even those in their 60s and 70s may be frail, and those in their 80s are not necessarily frail. - In the Fried model of frailty, frailty is physically characterised by: Low exercise tolerance and consequential low physical activity Slow gait speed Involuntary weight loss Muscle weakness due to sarcopenia (muscle loss that occurs with ageing) Easily exhausted Sedentary behaviour MMSA - SCOME Notes Database Page 1 of 105 fi fi ff  Neal Aquilina 2023/24 - There is also a multidimensional de nition of frailty where it is de ned as a heterogenous state that includes physical, cognitive and psychosocial domains. Therefore, in frailty, the whole health of the patient is a ected. - The nal de nition of frailty is its functional de nition where it is present in terms of losses in human functioning, alterations in several domains of function and reduction of activities. Therefore it is understood to be a diminished ability to carry out life functions, both of a personal and of a social nature. - However, the most acceptable de nition of frailty is that of the WHO, that says that frailty is a progressive age-related decline in physiological systems that results in decreased reserves of intrinsic capacity, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcomes. - Those that are frail tend to present with some signs that are not as common in those that are not frail. They present: With geriatric giants Atypically Non-speci cally With multiple problems With functional problems With a cascade of problems With quick complications - The 5 geriatric giants are: Immobility Instability Incontinence Intellectual impairment Iatrogenic illness - The geriatric giants are not diagnoses but are ways in which common problems in frail individuals present or common complications of illness. We must then identify their cause/s. - For the atypical presentation, this may mean a non- textbook presentation, such as a faint heart attack or one that presents with confusion. However, we must remember that these presentations are typical for frail older patients. - The non-speci c presentation is when there is a syndrome presenting in an older person with insidious and progressive physical deterioration, diminishing initiative, drive and concentration, increasing dependence, and diminished appetite and weight loss. Those that present like this are at danger of their symptoms being labelled as just old age, but these are indicators of fraility, and may also indicate unrecognised diseases, such as malignancy, hypothyroidism, chronic infections and possibly also dementia. - Some of the most common chronic problems found in older patients include: Heart disease OA Visual and hearing loss Parkinson’s disease Previous fracture of the femur DM MMSA - SCOME Notes Database Page 2 of 105 fi fi fi fi fi fi fi ff fi Neal Aquilina 2023/24 Cognitive problems Depression - The functional problems mainly include problems with mobility and their performing of ADLs, basic ones and instrumental ones. This leads to them becoming dependent on others. - With the cascade of problems we can see how a focal disease may cause a global impact in a frail and older patient. - They are also at risk of developing complications very quickly, such as a UTI that is quickly complicated by septicaemia, or a chest infection complicated by cardiac failure. Clinical Assessment - They require a proper assessment with a good systemic inquiry, this will require time and patience. It must be comprehensive. - The comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capabilities. This basically means that we must not only assess their diseases and comorbidities, but must also assess their function and ability, mental health and cognition, and their need for support networks. - The CGA involves assessment of: Medical evaluation Functional assessment Cognitive assessment Psychosocial assessment - The comprehensive assessment must always be followed by a management plan that includes rehabilitation and a team. - The CGA is carried out by a MDT that may include the responsible geriatrician, nurses, physical and occupational therapists, social workers, speech/language therapists, nutritionists and pharmacists. - The comprehensive assessment does not only look at the presenting symptoms, but must include a detailed systemic inquiry, while looking at the functional and social circumstances. To see which patients require this, we may use certain screening tools, such as the Barthel ADL index. - We may also conduct follow-up Barthel score assessments to see if we have managed to improve their function. - The comprehensive geriatric assessment (CGA), together with its associated interventions, is the gold standard for the diagnosis and management of frailty. - Other screening tools that may be used to look for frailty include the: Clinical frailty scale Edmonton frailty scale (FRAIL Index) Frailty phenotype Inter-frail Prisma-7 Sherbrooke postal questionnaire Short physical performance battery (SPPB) Study of osteoporotic fractures index (SOF) Assessment of gait speed, possibly using the get up and go test. MMSA - SCOME Notes Database Page 3 of 105 Neal Aquilina 2023/24 - If screening turns out to be positive, we may then recommend performing a CGA to have a more global assessment of the person and we may then diagnose frailty by using validated scales that are derived from the CGA, these include the frailty index of accumulative de cits and the frailty trait scale. - Some other screening tools include the assessment of polypharmacy present and frequent falls indicators. These two are easily administered for screening of possible frailty in Malta and they are e ective as was proved by a study conducted at Karin Grech by comparing those with many falls and more than 5 medications with their respective clinical frailty scale index scores. However, it was found that the number of falls alone was predictive of frailty, but the number of medications alone was not found to be predictive of frailty, but the sum of medications and falls was found to be predictive of frailty, therefore the number of falls may be a better indicator of frailty than the degree of polypharmacy. - It was therefore determined for the above study that, the screening of the general population may be done using the two levelled simple screening tool as it rendered good sensitivity (70%) and speci city (71%) against the commonly used clinical frailty scale. However, the above is only true for when assessing those with more than one fall during the past 6 months and are currently taking 4 or more medications (2 falls and 4 medications is therefore the cut-o for referral), and so these patients should be referred for formal frailty assessment. - This study also therefore shows that multi morbidity is associated with frailty and so they would require a more comprehensive and integrated approach to treatment of their condition/s. - When taking our history we must keep in mind that our patients may have communication and memory problems and may either not care or be afraid. - During our systemic inquiry we must ensure to ask about: Continence Depression Falls Nutrition Hearing Vision Medications Smoking Alcohol - We may use the abbreviated mental test to assess wether the patient has a cognitive problem. During it we ask 4 questions about the patient’s age, date of brith, current year and current place. If this is indicated, we may then conduct the MMSE. - During our examination we should assess wether patients are dehydrated, we may assess this by pinching their skin in the abdomen usually. This is important since frail older patients may become dehydrated quickly as a rapid complication of illness. - We should also assess the classical pressure areas for pressure sores. This is especially important if they are bed-bound. - We should also examine the mouth for candida as they are prone to infections. - It is also important to examine their feet, especially in MMSA - SCOME Notes Database Page 4 of 105 fi ff fi ff Neal Aquilina 2023/24 diabetics. - We must also assess their footwear due to their high risk of falling. - To summarise, during our examination we should examine all organ systems in detail, but we should pay special attention to: Hygiene The skin, for pressure sore areas and dehydration The mouth, to assess oral hygiene and look out for candida Feet and footwear Nutritional status, by assessing their weight Gait and balance - To assess their gait and balance we may use the Get up and Go test where they have to stand up from a chair, walk a certain distance (usually 3m), turn around it and then walk back and sit down again. This activity should be timed. This test provides a lot of information. - To try and prevent frailty we may try monitor frailty indicators, especially in those at risk, in order to target disability prevention programmes and help reduce the burden that frailty places on individuals and society. - Some risk factors for frailty are: Age Female gender Low income Sedentary lifestyle Comorbidity Obesity Depressive symptoms Poor hearing Previous falls Lack of social support Environment, such as living in an urban population - To aid in the prevention we must increase awareness about frailty and help remove the stigma with being frail that is found amongst older individuals. NICE also recommends health promotion activities in mid-life to encourage healthy behaviours, such as reducing smoking and alcohol consumption, increasing physical activity, and improving diet to achieve and maintain a healthy weight to improve health and reduce the risk of frailty in later life. - The management of frailty involves 3 principal points: Screening frail older adults in clinical practice Assessing them by looking after the causes of their frailty (and so di erent patients will have di erent managements due to the di erent causes of frailty that there may be in each patient) Proposing strong and long-term useful interventions - A recent study revealed that the following interventions where found to be e ective in preventing or reducing frailty: Exercise Nutrition Cognitive training Comprehensive geriatric assessment and management Rehabilitation - To analyse which geriatric patients are at risk for malnutrition, it is strongly recommended to use the validated Mini Nutrition Assessment (MNA). This is especially important since higher BMI, especially in sarcopenic patients, aggravates the risk of mobility limitations and development or aggravation of frailty. MMSA - SCOME Notes Database Page 5 of 105 ff ff ff ff Neal Aquilina 2023/24 - If the frail older patient is obese we may recommend 0.5-1kg of weight loss per week, while maintaining at least 1g of protein per kg body weight per day in their diet, to help prevent further sarcopenia. We may even increase the protein intake slightly more, but this in combination with exercise was found to give the best results in helping to regain muscle mass and decrease frailty. - The risk of frailty may also be reduced by adhering to a Mediterranean diet. - In frail elderly patients that tend to be at a high risk for falls and fractures, we must ensure that they have a minimum level of 30ng/mL of 25-OH vit D. To ensure this, we give doses of 20-25ug/day of vit D supplements. - For exercise, multicomponent exercise programs performed with low intensity, in 30-45 minute sessions, 3 times a week were found to have a bene cial e ect on the functional ability and overall health of frail patients. This was found to be especially so for resistance training, that when done alone was found to be the most e ective at reducing physical and psychosocial deterioration. - Exercise mainly seems to be e ective in the earlier stages of frailty. - Strength and balance training are also bene cial in preventing falls. - We must also try and avoid polypharmacy (the use of at least 5 medications) and, especially, hyperpolyphamacy (the use of at least 10 medications). However, we must note that around 50% of individuals older than 65 receive polypharmacy and so we should focus on tackling inappropriate polypharmacy. - Some tools that we may utilise in order to manage inappropriate prescribing and so help reduce poly pharmacy, are the Beers criteria, STOPP-START technique and the Laroche criteria. - To help promote social interaction in the elderly, we may educate them on electronic technologies that have been developed with the purpose of promoting social interaction and communication, physical activity and exercise, and better dietary habits, or those that support other activities of daily life of the elderly. - When managing frail older patients, we must remember that they can be helped, especially if they are experiencing acute events together with their progressive decline, as by treating these acute events we will slow their progression and help maintain a good quality of life for longer. We may do this by: Treating the acute event properly Avoiding complications Slowing the progression of the disease Maintaining functional abilities Maintaining a good quality of life MMSA - SCOME Notes Database Page 6 of 105 ff fi fi ff ff  Neal Aquilina 2023/24 Urinary Incontinence (AV) - Incontinence is one of the 5 geriatric giants and it is a very common problem in the older person, with a prevalence of 70-80%. - It especially a ects older persons with comorbidities, polypharmacy and both physical and cognitive functional impairment. - The main types of UI are: Stress UI - This type of incontinence occurs when there's pressure or stress on the bladder. Activities like coughing, sneezing, laughing, lifting heavy objects, or exercising can cause leakage due to weakened pelvic oor muscles or a weakened sphincter. SUI results from weakened support to the bladder and urethra, leading to leakage with increased abdominal pressure. Urgency UI or overactive bladder (OAB) - UUI or OAB involves a sudden and intense urge to urinate, often resulting in involuntary leakage before reaching the toilet. It happens due to involuntary bladder contractions or spasms. Individuals with UUI often experience a strong and sudden need to urinate, sometimes even waking up multiple times during the night to go to the bathroom. Over ow UI - This occurs when the bladder doesn't completely empty during urination, due to blockage, weak bladder muscles or nerve damage leading to continuous dribbling or leakage. Mixed UI - As the name suggests, mixed incontinence involves a combination of di erent types of urinary incontinence, most commonly a mix of SUI and UUI. Individuals with mixed incontinence experience symptoms of both stress-related leakage and sudden, strong urges to urinate. Functional UI - This occurs when physical or mental limitations prevent an individual from reaching the bathroom in time. It's not necessarily due to bladder dysfunction but rather external factors like mobility issues, cognitive impairment, or environmental barriers. The person may have normal bladder control but cannot reach the toilet due to external limitations. Transient UI - Temporary incontinence that's often due to a temporary condition or situation such as a urinary tract infection (UTI), medications, constipation, or certain foods or drinks. Transient incontinence is temporary and resolves once the underlying cause is addressed or treated. - Stress and urge UI are the most common in the elderly, together with the possibility for a mix between the two. - Despite its very negative e ects on quality life, urinary incontinence (UI) is still largely undetected and underrated due to many di erent reasons, including the fact that: Older persons are less likely to discuss incontinence with their physician. Only about half of those with incontinence seek help for their symptoms The percentage of older persons that receive e ective treatment is about 30-50%, despite the valid management options available. - The pathophysiology behind UI in women is related to age-related anatomical changes in the lower UT, including: Weakening of the structures in the pelvic oor Shortening of the urethra Urogenital atrophy due to lack of oestrogen Increasing risk of pelvic oor prolapse - The pathophysiology behind UI in men is also related to age-related anatomical changes in the lower UT, mainly including benign prostatic enlargement due to BPH, that is the most common age-related change and may lead to out ow obstruction of MMSA - SCOME Notes Database Page 7 of 105 ff fl ff fl ff fl ff ff fl fl Neal Aquilina 2023/24 the urinary tract, causing an increased risk for urinary retention and over ow UI (this is the most common type of UI in elderly men). - Some more functional age-related lower UT changes that contribute to the pathophysiology in both genders include: Involuntary bladder contraction becomes more common Decreased bladder contractility, leading to detrusor under activity Increased post-void residual volume (PVR), hence increasing the risk of over ow UI Sphincteric muscle becomes more weak Decreased urethral closure pressure Diurnal urine output shifted to later in the day Nocturnal polyuria, which accounts for 30% of urination in older individuals, predisposes to nocturia and nighttime UI - Some predisposing and causative factors for UI include: Disorders of the CNS, such as cerebrovascular disease, dementia, Parkinon’s disease and normal pressure hydrocephalus Degenerative back diseases T2DM, mainly due to autonomic and peripheral neuropathy Heart failure, sleep apnoea and COPD Depression and delirium Bowel condition, with both constipation and faecal incontinence being associated Acute UTIs Functional and mobility disabilities Neoplasms, benign or malignant, but this is less commonly associated - Some medications may also be linked to the pathophysiology of UI. These are found in the table below. - UI predisposes to many problems that may be: Medical problems, including: - Falls - Insomnia - UTIs - Skin consequences MMSA - SCOME Notes Database Page 8 of 105 fl fl  Neal Aquilina 2023/24 - Pressure sores Psychological problems, including fear, sadness, anxiety and depression Social problems, including: - Loneliness - Social isolation - Need for increased resources - Precipitation to nursing home admission - Decreased coping with instrumental ADLs (iADLs) - Patients may not report their UI due to: Embarrassment Lack of knowledge about treatment options The belief that UI is an inevitable part of ageing The notion that symptoms are unimportant, especially if they are mild The fact that physicians are unlikely to inquire about it without prompting by the older client The fact that the response of some professionals to UI is limited to passing a remark on the inevitability of this pathological condition and giving very conservative therapeutic recommendations, such as just using incontinence pads - Although there are no speci c screening recommendations for UI, screening is likely to be of maximum bene t for those older adults whose QoL could possibly be a ected, it has been suggested to either screen all older adults, or all frail older adults. - To improve the detection of UI we should: Ensure ease of access by establishment of referral pathways for detection through appropriate assessment and treatment Develop and use a standard screening questionnaire to create uniformity Develop basic screening in primary care through trained nurses or other health workers Ensure that specialists are integrated in this care pathway Establish accredited programs of training for nurses and other health or social care professionals - The best methods used to assess continence are with the use of: The comprehensive geriatric assessment Brief clinical questions, such as: - Do you have any problem or trouble from your bladder? - Do you have any complaint about your bladder or urine? - Do you lose urine when you don’t want to? A speci c clinical questionnaire, such as the international consultation on incontinence questionnaire UI (ICIQ-UI-SF), that is used to screen all older and frail adults - As part of our basic evaluation for UI we should conduct: History of comorbid conditions Detailed review of patient’s medications Assessment for other lower UT symptoms (LUTS) Functional evaluation of ADLs and iADLs Complete physical examination, including a DRE Dipstick urinalysis, plus a urine culture if suspecting a UTI Assessment of PVR urine Voiding diaries Clinical questionnaires, mainly the ICIQ-UI (SF) Pad-testing MMSA - SCOME Notes Database Page 9 of 105 fi fi fi ff  Neal Aquilina 2023/24 - The goals of this basic evaluation are to identify conditions contributing to the UI, identify patients that require further evaluation and identify patients for whom treatment may be initiated without further testing. - The patients that will be deemed to require further evaluation are those that satisfy one or more of the following criteria: Uncertain diagnosis and inability to develop a reasonable management plan based on the basic evaluation Failure to respond to an adequate therapeutic trial Abnormal PVR urine (>200mL) Haematuria without a known cause Neurogenic bladder Negative stress test with stress UI symptoms When surgical intervention for UI is being considered Symptomatic pelvic prolapse Suspected stula History of anti-incontinence surgery, radical pelvic surgery or pelvic radiotherapy Presence of other comorbid conditions, such as UTI, persistent di culty with bladder emptying, prostate nodule, asymmetry or other indicators of prostate cancer, or other neurologic conditions, such as MS, SCI, stroke or PD. - Treatment options include conservative options with lifestyle interventions and behavioural interventions, or the non-conservative ones, with pharmacological treatment, devices and absorbent aids, and surgical intervention. - The conservative treatment is the mainstay of UI management and it must involve an individualised treatment plan to address speci c needs. - Lifestyle interventions are mainly considered in urgency, stress or mixed UI. They may include: Patient education Weight loss, as there is a known association between obesity and stress UI, but we must recommend it carefully at advanced age in order to ensure that we are minimising muscle and bone mass loss Modi cation of uid intake with ca eine reduction, especially in women with urgency UI, and reduction of carbonated beverages, mostly for stress UI Addressing of chronic constipation, as it is a likely risk factor for an overactive bladder and urgency UI due to associated straining Stopping smoking as it is associated with urgency UI in older people - Modi cation of uid intake in general should only be advised if intake is either excessive or poor. - We may address chronic constipation by recommending them to promptly respond to the urge to defecate, by exercising, and by increasing dietary bre. - Lifestyle interventions are mainly targeted for ambulatory, cognitively-intact older patients and their goal is to decrease the incontinence episodes without SEs. - For behavioural intervention, signi cant motivation is required from the patient and caregiver, and therapeutic measures must be individually tailored while considering the patient’s cognitive and functional capabilities. - The recommended behavioural interventions include: Timed voiding using a xed and pre-determined time interval between toileting that may even be implemented in the cognitively impaired. We should make no attempts at patient education, enforcement of behaviours or re-establishing of voiding patterns Pelvic oor muscle training (PFMT) that is the rst-line treatment for stress UI in women, but has a smaller therapeutic e ect for urgency and mixed UIs. It should be implemented for at least 3 months with continuous exercise required to MMSA - SCOME Notes Database Page 10 of 105 fi fi fl fi fl fl fi fi ff ff fi fi fi ffi  Neal Aquilina 2023/24 maintain the gained bene t as it helps by improving pelvic oor function that may help inhibit bladder contraction in an overactive bladder (OAB). Bladder training involves development of a progressive voiding schedule in combination with relaxation and distraction techniques. It is the rst-line treatment in any type of UI for at least a short period of time, and before considering other treatment options, a minimum of 6 weeks of training are advised in women with urgency or mixed UI. For this, patient motivation and learning abilities are important. Prompted voiding has the goal of increasing the patient’s demand to use the toilet, and decreasing the number of UI episodes. It works by positive reinforcement through verbal prompts by a caregiver and is most useful in care dependent people in whom it is the gold-standard. - We may only start to consider pharmacological treatment for UI after adequate non- pharmacological therapy has been attempted for at least 3 months, except for those patients with a transient UI in whom immediate medical treatment may be indicated. - We should continue the non-pharmacological treatment after initiation of the pharmacological treatment. - Most pharmacological interventions are e ective on urge incontinence and an OAB, while few agents have been studied for stress incontinence. - Antimuscarinic drugs are the rst-line therapy for urge incontinence and OAB. They have systemic SEs including dry mouth, constipation, blurred vision, somnolence, orthostatic hypotension and dizziness, with signi cant impact on persistence of treatment. - The long term e cacy of antimuscarinics has not been established yet and so their use in frail individuals is not evidence-based. - Oxybutinin (an antimuscarinic) may a ect cognition, while the a ects of other drugs have not yet been studied, but we should always perform a cognitive evaluation at baseline, so we may detect any changes if they develop over time. Fesoterodine is best in older patients. - It is recommended to avoid the use of antimuscarinics in cases of moderate- severe cognitive impairment and we must be cautious for potential pharmacodynamic interactions due to how common polypharmacy is in this population. - It is also important to note that anitmuscarinics are incompatible with anti cholinesterase inhibitors. - B3-agonists are second-line for urge incontinence or OAB. - The main B3-agonist used is Mirabegron, and it seems to have a better tolerability pro le in the older patient compared to antimuscarinic drugs. But, there is very little data on its e ectiveness and safety in older patients. - Duloxetine (SNRI) is primarily used for stress incontinence, but it is also used for urge incontinence, but there is no clear evidence of its e ectiveness in either type of UI. It has signi cant SEs that include nausea, dry mouth, constipation, insomnia and dizziness. - Topical oestrogens are also primarily used for stress incontinence, but are also used for urge incontinence. They are well tolerated and safe and may be used as a rst option in MMSA - SCOME Notes Database Page 11 of 105 fi fi ff ffi fi fi ff ff fi ff fl ff fi fi  Neal Aquilina 2023/24 postmenopausal women, but we should be careful in women with a history of ER +ve breast cancer as they may have systemic absorption. - We usually manage over ow UI with bladder drainage with intermittent catheterisation or a temporary indwelling catheter for 1-2 weeks. Men may also bene t from treatment with a-blockers. - Urological interventions are however usually needed in men with urinary obstruction due to prostate problems. - For over ow UI in older women, they may need surgical treatment for large pelvic oor prolapses, underlying urinary retention and over ow. - When managing over ow UI we must ensure to manage constipation to avoid faecal impaction and we should also discontinue or reduce medications that impair detrusor contractility. - If the above options were insu cient we may consider the internal devices and absorbent aids. - Women with good manual dexterity are candidates for intravaginal support devices (pessaries) or urethral occlusion inserts. These o er the option of temporary or occasional use and are suitable for patients with exercise induced SUI. - Pessaries may also bene t women whose stress or urge incontinence is exacerbated by bladder or uterine prolapse. They are inserted by a health care provider and the pessary may be removed for cleaning and reinserted every 4-6 weeks. - When using pessaries, we must monitor for vaginal infections and ulcerations. - The use of absorbent continence aids is extensive and they should be used in combination with a holistic continence management plan. - If all the above has not worked, surgical management of UI may be considered. - The decision to perform surgery should be made after a comprehensive clinical evaluation with an objective con rmation of: The diagnosis and severity of the urinary loss A correlation of the anatomic and physiologic ndings with the surgical plan Estimation of the surgical risk and its the impact on quality of life Patient preference - Patients may then weigh the potential risks and bene ts provided by this evaluation. But, we must keep in mind that most interventions are not suitable for fail older individuals or those with many comorbidities, but some minimally invasive procedures are available for a select group of older people. - The surgical management for an OAB may involve: Intravesical botulinum toxin injections that result in variable continence rates with a durability of 6-12 months. Modulation of the bladder re ex pathways via percutaneous tibial nerve stimulation (PTNS) or implanted sacral nerve stimulation (SNS). This is 4th-line for patients with refractory OAB. Augmentation cystoplasty, but this is rarely used in older patients. - The surgical management of stress incontinence involves tension-free vaginal tape procedures, but these may cause post-operative problems in bladder emptying in older patients. Another option is periurethral injection of bulking agents, but this only o ers a short term improvement in stress incontinence symptoms. MMSA - SCOME Notes Database Page 12 of 105 fl fl fl fi fl ffi fi fi fl ff fi fi ff fl  Neal Aquilina 2023/24 Acute Confusional State (SA) - The acute confusional state is aka delirium, organic brain syndrome, acute cerebral insu ciency, metabolic encephalopathy, acute brain failure or post-op psychosis. - In DSM-5, delirium is de ned as a transient, usually reversible, cause of cerebral dysfunction and it manifests clinically with a wide range of neuropsychiatric abnormalities. It is commonly characterised by disturbed consciousness, cognitive function or perception. - It may occur at any age, but it is more common in the elderly and those that have a compromised mental status. - Its diagnosis is clinical and no laboratory test can diagnose delirium. - According to DSM-5, the following criteria must be satis ed to diagnose delirium: Disturbance in attention and awareness, with reduced ability to direct, focus, sustain and shift attention. Change in cognition that is not better accounted for by a pre-existing, established or evolving dementia. This change in cognition may present as a memory de cit, disorientation, language disturbance or perceptual disturbance. The disturbance must develop over a short period of time, usually hours to days, and tends to uctuate during the course of the day. There is evidence that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. This may take a while to develop, and so we may need to re-assess. - Delirium may present with an acute onset of an impairment of cognitive function that a ects orientation, attention, memory, and planning and organisation skills together with a disturbance of consciousness, with a uctuating course. - Some other symptoms they may experience include: Clouding of consciousness Fluctuating levels of consciousness Di culty maintaining or shifting attention Disorientation Illusions or hallucinations Dysphasia or dysarthria Tremor Motor abnormalities - Susceptible patients presenting to hospital or being admitted to nursing homes must be assessed for delirium. - It a ects around 80% of ITU pts and 15-25% of hospital admissions. - Risk factors for delirium include: Age 65 and older Cognitive impairment, dementia or both Current hip fracture Severe medical illness, including HIV - Delirium has a very high mortality if untreated and those a ected by it are more likely to require longer hospital stays or critical care. They are also at an increased risk of developing dementia and of needing long- term care. MMSA - SCOME Notes Database Page 13 of 105 ff ffi ff ffi ff fl fi fl fi fi Neal Aquilina 2023/24 - Some common medical causes of delirium include: Infection, mainly pneumonias and UTIs Cardiological illness Respiratory disorders Neurological problems Electrolyte imbalances Endocrine and metabolic disorder Drugs, particularly those with anticholinergic SEs, like the tricyclic antidepressants, anti-parkinsonian drugs, opiates, analgesics and steroids Drugs of abuse, especially benzodiazepine, and alcohol withdrawal Urinary retention Faecal impaction Severe pain Multiple contributing causes - Most of the patients will be unable to provide an accurate history and so a collateral history is vital in such cases that this is suspected. It is important to nd the details of the symptoms leading up to the delirium that may help suggest the underlying cause. - In the history we should pay special attention to: The past medical history for previous similar episodes and comorbid illnesses Drug history to see if there was any use of anticholinergic drugs or benzodiazepines, or if it is possible for there to be withdrawal from benzodiazepines Social history to ask about alcohol, smoking and diet, and food intake history Their pre-morbid functional level - During our examination we should: Check for pyrexia Search for any signs of infection and exclude urinary retention Check for evidence of alcohol and/or drug abuse or withdrawal Conduct cognitive functional assessment using a standardised screening tool, such as the MMSE Conduct a neurological examination, including assessment of speech Conduct an abdominal examination for distended bladder, including DRE if faecal impaction is suspected. - For patients in hospital setting, drowsiness is pathognomic of delirium. - However, it may be hard to recognise delirium early on as it may present as: A hyperactive patient (least common), that is restless, agitated and/or aggressive A hypoactive patient, that is withdrawn, quiet and sleepy Mixed (most common) - To help screen for delirium we should conduct cognitive testing on all new admissions to hospitals and nursing homes together with serial testing for patients at risk. We should also obtain history from an informant to establish onset and course of confusion. - A useful screening tool is the confusion assessment method (CAM) that is a 5 minute test with 95% sensitivity and 90% speci city. There is also the short CAM (CAM-S) and the 4-AT test. - To have a positive CAM result, the patient MMSA - SCOME Notes Database Page 14 of 105 fi fi  Neal Aquilina 2023/24 must have an acute onset and uctuating course of inattention and either of disorganised thinking, with disorganised or incoherent speech, or an altered level of consciousness, in which case the patient may appear lethargic or stuporous. - CAM identi es delirium, but does not assess its severity. - We may assess for inattention by asking the patient to count back from 20-1 and if there is inattention they will have reduced ability to maintain attention on this task or shift attention to another one. - The 4-AT is a website test that was developed to increase the local rates of detection of delirium in an acute general hospital setting. It gives a score of 0-12 based on alertness, attention, the presence of an acute change or uctuating course, and the AMT-4, that asks about age, DOB, place, and current year. - Those with a 4-AT score of 4 or more may possibly have delirium and/or cognitive impairment, those with a score of 1-3 may possibly have cognitive impairment, and those with a score of 0 are unlikely to have delirium or severe cognitive impairment. It does not diagnose delirium, but it suggests its presence, it only takes 2 minutes to perform. - Therefore, with both the CAM-S and the 4-AT scores, the lower the scores the less likely there is to be delirium. - When investigating these patients we should conduct: Assessment of parameters, including temperate, pulse, BP, RR and pulse oximetry FBC and CRP U&E and calcium LFTs Glucose ECG Urinalysis TFTs Assessment of B12 and folate - We may also consider some other investigations, such as: CXR CT head if there are focal neurological signs, depressed consciousness or delirium remains unexplained by initial investigations EEG ABGs Blood cultures Speci c cultures, such as those of urine or sputum, especially if suspecting infection Lumbar puncture - To help prevent delirium we should ensure that those at risk of developing it are cared for by a team of healthcare workers that are familiar with the person at risk. We should MMSA - SCOME Notes Database Page 15 of 105 fi fi fl fl Neal Aquilina 2023/24 therefore avoid inter- and intra-ward transfers unless absolutely necessary for these patients. - The initial management of delirium involves identifying and managing the possible underlying cause or combination of causes. We should also ensure e ective communication and reorientation and provide reassurance and a suitable care environment. For those that are distressed or are at risk to themselves or others, we should initially use both verbal and nonverbal de-escalation techniques. - Then, to help address the cognitive impairment and/or disorientation we should: Ensure that there is appropriate lighting and clear signage with a clock and calendar being clearly visible to the patient Talk to the patient to reorientate them by explaining where they are, who they are and what their role is Introduce cognitively stimulating activities, such as reminiscence Facilitate regular visits for family and friends - While addressing the above, we should also implement some general interventions for delirium, including: Addressing dehydration and/or constipation Assessing for hypoxia and optimising their oxygen saturation Treating them for any underlying infections Avoiding using physical restraints Avoiding urinary catheterisation Addressing immobility or limited mobility Addressing pain Addressing sensory impairment Promoting good sleep patterns and sleep hygiene - When managing the patients we should ensure that there is minimal use of sedatives and tranquillisers, such as haloperidol (65), stress, depression, htn and AF. Migraines and varicella zoster virus may also be stroke RFs. - All antipsychotics increase the risk of stoke, atypicals more than typicals. And the risk is even higher if the pt su ers from dementia. - In general, strokes on the dominant side may a ect speech and language abilities more prominently, while strokes on the non-dominant side may cause spatial neglect or lack of awareness of the a ected side. - Strokes on the dominant side are also more likely to lead to more signi cant functional impairments as ex: hand movements with right hand will no longer be easy so more functional impairment in right-handed individuals. - To prevent stroke we treat and modify any RFs, we encourage a healthy diet and exercise, we treat htn, DM and lipid abnormalities, encourage smoking cessation, and avoid risky drugs. - We may also use NOACs or warfarin and add a high-dose statin for those with a h/o stroke or TIA. We mainly use atrovostatin. MMSA - SCOME Notes Database Page 26 of 105 fi ff ff ff ff fi ff ff  Neal Aquilina 2023/24 - We may also add DAPT with aspirin and clopidogrel or dipyridamole. However, aspirin or clopidogrel alone are safer to reduce bleeding risk and so we only use DAPT in those that are higher risk. - TIA is a very mild subtype of stroke. TIAs are transient, brief episodes, typically lasting a few minutes to up to 24 hours. They are often short-lived, and symptoms resolve without causing permanent damage. - Having a past TIA increases your risk for stoke by 7 times. - When someone presents with TIA we should immediately start aspirin 300mg daily and we then assess their stroke risk and address any risk factors. - We can use the ABCD score to assess the prognosis of those who su er from a TIA. They are considered to be at a high risk of stroke if they have an ABCD score of 4 or more. These high risk patients need specialist assessment within 24h, while those with an ABCD score of 3 and below can have specialist assessment within a week. - We can use a cranial CT (CCT) to distinguish reliably between haemorrhagic and ischaemic stroke and we may detect signs of ischaemia as early as 2 hours after stroke onset and of haemorrhage almost immediately. - MRI identi es ischaemic lesions in the posterior fossa reliably and MR angiography gives info on the vascular status, including the venous system and it may identify aneurysms larger than 3mm in diameter. It is better for ischaemic lesions, but since it take long we usually always do a CT as 1st-line. - If someone presents with stroke we maintain O2 sat above 95% and glucose between 4-11mmol/L. We also need BP control and should consider BP reduction to 185/110mmHg for those who are candidates for thrombolysis. We also need an urgent CT. - Alteplase is a thrombolytic agent and it is considered for the treatment of acute ischaemic stroke if ICH has been excluded, it has been less than 4.5h (for when alteplase is given) from symptom onset, and BP is less than 185/110mmHg. - After a patient has been given alteplase, we may consider conducting cerebral angioplasty and stenting with physical removal of large blood clots. But this must be done within 6h of stroke symptom onset, and may only be done after the patient has been given alteplase. - Rehabilitation also forms an essential part of stroke management. Consider possible bene t from assisted walking devices. - Stroke may cause the complications of: Bladder dysfunction, that a ects more than 1/3 of pts and mostly involves UI. It usually resolves within a month. MMSA - SCOME Notes Database Page 27 of 105 fi fi ff ff Neal Aquilina 2023/24 UTIs, this is the most frequent infective complication in stroke patients. It is mostly iatrogenic due to catheterisation. Bronchopneumonia, this is the second most common infective complication in stroke pts. We may prevent it with early mobilisation, swallowing training and by avoiding inhalation during enteral nutrition. Decubitus (lying down) ulceration, that we may help prevent by using an air mattress, keeping the pt’s skin dry and turning them frequently. If severe, they may require antibiotics and possibly even surgical debridement. Seizures (common) and epilepsy (less common (3-4%)), that are more likely with haemorhagic stroke, large infarcts with cortical involvement and embolic stroke. If they develop early-on (within 2-4 weeks) they have a lower risk of recurrence and are likely to be due to metabolic changes of the acute phase, but late seizures (after 6-12 months) are more likely to recur and are thought to occur due to consequent post-stroke loss and re-organisation of axonal connections. However, prophylactic anti-epileptic therapy is not recommended in stroke patients. We only give anti epileptic therapy if there are recurrent seizures. Depression, that a ects 1/3 of pts, tends to be e ectively treated with antidepressants acutely. Psychological therapy is also bene cial. Complications of Immobility - The main complications of immobility are musculoskeletal, but there are also GI, psychological (due to social isolation), skin, respiratory and cardiovascular complications. - The musculoskeletal complications include: Muscle atrophy Loss of muscle strength and endurance Osteoporosis Joint contractures Problems with balance and co-ordination Sarcopenia - The GI complications include: Constipation, that may cause abdominal discomfort, decreased appetite and delirium Faecal impaction - The skin complications mainly include pressure ulcers that predispose to infection and cause pain. - The respiratory complications are pneumonia and atelectasis. - The cardiovascular complications are DVT, PE and orthostasis. - They may also develop functional decline that is aka deconditioning and is the loss of the ability to perform basic activities of daily living. - To address the musculoskeletal complications of immobility, we refer them to the physio- and occupational therapists for muscle strengthening exercises, mobilisation, prevention of contractures and more. - For the GI complications we should ensure there are regular bowel movements, consider osmotic laxatives like lactulose, reduce treatments that promote constipation if possible and promote uid intake. - For the skin complication (pressure sores) we should ensure regular turning in bed if bed bound, at least every 2 hours, or every 4 hours if they have an air mattress. We should also conduct regular assessment of pressure areas and should treat any MMSA - SCOME Notes Database Page 28 of 105 ff fl ff fi  Neal Aquilina 2023/24 pressure sores with the TVN, we must also ensure adequate nutrition and if chair bound should still ensure frequent change in position. - For the respiratory complications we should avoid sedating drugs and ensure proper feeding if they are in bed to prevent aspiration. - In those that are acutely ill and immobile, we should give LMWH as to prevent the CV complications such as DVT and PE. We should also ensure adequate hydration and elevation of the head of the bed to avoid orthostatic hypotension in patients who have been immobile in bed for some time and are going to be mobilised. - To help with the social isolation we should provide the proper walking aids to promote mobility and should also apply for community services to keep social contact with the patient. Sarcopenia - The International Working Group on Sarcopenia (IWGS) de ned sarcopenia as a combination of low muscle mass and low muscle function, another de nition is that it is a syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength with a risk of adverse outcomes, such as physical disability, poor quality of life and death by the European Working Group on Sarcopenia in Older People (EWGSOP). - However, it is recommended to assess for the presence of both low muscle mass and low muscle function for the diagnosis of sarcopenia. - It is important to asses both since muscle strength/function declines more rapidly than muscle mass during ageing, especially in those older than 80. - The new operational de nition of sarcopenia, given by EWGSOP2 is low muscle strength, low muscle quantity/quality (muscle mass) and low physical performance. If all 3 are present it is severe sarcopenia, if just the rst two are present it is de nite sarcopenia, and if there is just low muscle strength it is probably sarcopenia. - To assess muscle strength we assess hand grip strength and use the chair stand test. - We can assess the hand grip strength using the Jamar hand-held dynamometer. We use this test as poor hand-grip strength represents a predictor of functional disability and mortality. The cut-o is less than 16kg for women and less than 27kg for men. - To assess for low muscle mass we use a DEXA scan or possibly CT or MRI. - To assess for low physical performance we may use gait speed, SPPB, TUG and a 400m walk. - We should remember that hand-grip strength and physical performance are better predictors of clinical outcome than low muscle mass is. - Sarcopenia may be present in as many as 50% of those older than 80, but this depends on the literature de nition being applied. However, even with conservative estimates sarcopenia a ects more than 50 million people today and will a ect more than 200 million in the next 40 years. - Primary sarcopenia is progressive and is associated with the impact of ageing, but has no speci c aetiological cause. It may be contributed to by a reduction in motor neurones, alterations in skeletal muscle tissue, including mitochondrial dysfunction and reduced protein synthesis, and changes in the hormonal milieu. MMSA - SCOME Notes Database Page 29 of 105 fi fi fi ff fi ff fi fi ff fi  Neal Aquilina 2023/24 - However, there may be secondary sarcopenia that may be due to or aggravated by a lack of physical activity, malnutrition with reduced protein intake, chronic in ammation and comorbidity. - With a lack of physical activity, for each hour increase in sedentary time, the risk of sarcopenia increases by 33%. - The use of physical restraints and side- rails may also increase immobility. - Physical restraints include any manual method attached to or adjacent to the individual that cannot be easily removed and restricts the freedom of movement or normal access to one’s body. - Physical restraints and side-rails may be used to avoid falls, due to impaired cognition or as a nursing aid. However, studies have shown that they actually increase the incidence of falls and their associated injuries. - Common complications of restraints and side-rails include: Immobility Hyperthermia Rhabdomyolysis Brachial plexus injury Axillary vein thrombosis Compressive neuropathy Hess’ sign Stress-induced cardiac arrhythmias - Less commonly, restraints and side-rails, may cause strangulation and asphyxia. - The prevention of immobility requires multiple interventions that rely on co-ordination via interdisciplinary dialogues and action, together with a CGA, individualised intervention plans targeting risk factors and promotion of mobility. - To promote mobility we should avoid ordering bed rest and if bed resting we should ensure that they are able to move around in bed and transfer and ambulate safely, as this reduces the risks of falls. We should also assess their ability to perform the skills necessary for safe mobility and transfer, and we should encourage and assist patients with bed mobility, transferring and ambulating. - To help prevent immobility we must also: Facilitate observation by placing patients at risk of falls closer to nurses, encouraging friends and family to visit and allowing easy access to true-call systems. O er activities, such as recreational or therapeutic ones. We should also encourage family members and friends to engage them in approved activities. Maintain continence by avoiding the use of diapers, ensuring adequate toilet height and if gait is not steady we should provide the use of commodes or urinals. Promote comfort by managing any pain and moving and turning them around in bed often, to reduce the risk of pressure sores. We should be aware that those with dementia are less likely to be treated for their pain as they are not able to report or describe the pain well. MMSA - SCOME Notes Database Page 30 of 105 ff fl Neal Aquilina 2023/24 Iatrogenic Illness (GB) - This is an inadvertent adverse e ect or complication that results from medical treatment or advice. This is not restricted to conventional medicine. - It is amongst the geriatric giants. - Iatrogenesis is a major phenomenon and a severe risk to patients and may cause around 250,000 deaths per year in the US, the majority of which are due to nosocomial infections in hospitals and non-error, negative e ects of drugs. - The risk of iatrogenesis is increased by: Increasing age of patient Multiple chronic disease comorbidities Liver impairment Renal impairment Polypharmacy Many physicians caring for the same patient Poor record keeping Hospitalisation Increasing length of hospital stay - The risk of iatrogenesis may be decreased by: Geriatric multidisciplinary care Acute geriatric units Pharmacist’s input Advanced directives - Some examples of iatrogenic e ects include: ADRs of prescription drugs Over-use of drugs Prescription drug interaction Allergic reactions to drugs Wrong prescription, perhaps due to illegible handwriting or typos on computer Unavoidable iatrogenic consequences, such as those caused by amputations or organ removal Negligence Nosocomial infections and antibiotic abuse Iatrogenic poverty Over-diagnosis - Some of the ADRs of prescription drugs include: HF and GI bleeding caused by NSAIDs Dehydration and gout caused by diuretics Osteonecrosis of the jaw caused by bisphosphonates Asthma and peripheral circulatory problems caused by B-blockers GI upset and weight loss caused by biguanides Falls and confusion in the elderly caused by sedatives Chorea-like movements caused by levodopa A dry and non-productive cough caused by ACE-Is Increased susceptibility to fractures if a hyperthyroid state occurs with thyroxine - The over use of drugs may occur due to high doses, prolonged use or antibiotic resistance with antibiotic abuse. - Prescription drug interactions are a very common iatrogenic e ect. These may be synergistic, such as with the potentiation of warfarin when taken together with amiodarone or NSAIDs (both highly protein bound), or antagonistic, such as with the reduction in the e ect of warfarin if taken with vit K supplements. MMSA - SCOME Notes Database Page 31 of 105 ff ff ff ff ff  Neal Aquilina 2023/24 - The unavoidable iatrogenic consequences involve things like the SEs of radiation or the loss of function resulting from the removal of a diseased organ, such as iatrogenic diabetes from the removal of the pancreas. - Iatrogenic poverty is actually the leading cause of bankruptcy in the US. It is therefore important for us doctors to balance the e ectiveness of treatment and its nancial cost. - An extreme example of negligence would include operating on the wrong side of the body. - Over-diagnosis may be causing harm to heathy people due to earlier detection and wider de nition of diseases, this is contributed to by screening programmes. Patients may even be being over-dosed and over-treated as a result of this. - One problem that is occurring with over-diagnosis includes the detection of early cancer through screening programmes that would never cause symptoms or death. - The problem of over-diagnosis is also contributed to by the widening of disease de nitions, meaning even those at very low risk will receive permanent medical labels and lifelong treatment that will fail to bene t many of them. There are also the negative e ects of labelling with depression and intractable anxiety, the harm of unneeded tests and therapies, and the cost of wasted resources that could have been better used. - Research is needed, into how we may discriminate between benign abnormalities and those that will go on to cause harm, to help prevent over-diagnosis. - Iatrogenic diseases may also have a signi cant psychomotor impact and devastating social consequences. - Iatrogenic illness has signi cant impact in the elderly as they tend to posses more risk factors. MMSA - SCOME Notes Database Page 32 of 105 ff fi fi fi ff fi fi fi  Neal Aquilina 2023/24 Medicines Optimisation in Older Persons (MG) - Some problems associated with medications in older persons are: The presence of multiple disorders The presence of multiple medications Age-related body changes Medicine administration issues - Some important age-related body changes are those a ecting pharmacokinetics and pharmacodynamics. - For the pharmacokinetic changes, these a ect absorption, distribution, metabolism and excretion. - The changes in absorption include: Decreased absorption due to increased gastric pH and decreased gastric blood ow Decreased rst pass metabolism due to decreased hepatic blood ow Deceased absorption rate due to decreased motility - The changes in distribution include: An increase in volume of distribution (VoD) for lipid-soluble drugs due to the increase in body fat A decrease in the VoD for water-soluble drugs due to the decrease in total body water Increased free drug concentration due to decreased albumin levels Increased cerebral drug concentrations due to a decreased P-glycoprotein - Metabolism will be slower due to a decrease in hepatic blood ow and metabolic activity. - Excretion will be reduced or occur at a slower rate since there is decreased renal blood ow and clearance. The eGFR is a commonly used estimate that is used to assess the rate of excretion, however it is better to use creatinine clearance or the absolute GFR in cases of patients at the extremes of weight, nephrotoxic drugs or drugs with a narrow therapeutic index. - To calculate creatinine clearance we use the Cockroft and Gault Equation and for the absolute GFR we use the Modi ed Diet in Renal Disease (MDRD) equation. - The pharmacodynamic changes include: Increased sensitivity to certain medications, particularly with opiates, benzodiazepines and warfarin Decreased sensitivity to certain other medications, particularly with B-blockers and B-agonsits Compromised homeostatic mechanisms, such as those causing postural hypotension and decreased balance - This is why we must always start low and go slow with medications in the elderly. - Some useful prescribing tools to nd the best medications for use in the elderly include STOPP/START, STOPPFrail, STOPPFall, Beers criteria and the ACB score. - The BEERS criteria will give a list of drugs that should be avoided in older patients. It need not be applied to all older patients but we use it for guidance. It has a drug and disease category. It is the US system. - The STOPP/START criteria are used more since they are European. They provide lists of drugs that should be avoided or used in older patients. Ex: loop diuretics should not MMSA - SCOME Notes Database Page 33 of 105 fl fl fi fl fi ff ff fi fl Neal Aquilina 2023/24 be used for dependent ankle oedema without evidence of CHF, liver failure, renal failure or nephrotic syndrome. EX: we should use vit K antagonists (warfarin) or direct thrombin inhibitors in the presence of chronic atrial brillation. - However, for the START STOP criteria there are prescribing emissions (do not apply to all older patients), including how we should not use: Statins post haemorrhagic stroke DOACs in AF with mechanical valves B-blockers in certain cases of HFrEF - We should always conduct risk assessment and re-evaluation of treatment goals through out the course of treatment so to ensure wether there is a need for de- prescribing. This is most important for drugs like PPIs, statins and bisphosphonates as patients tend to stay on them for longer than they are needed. - De-prescribing is very important in frailty as there are higher risks associated with medications in these patients. - When prescribing we should always be aware of some common ADRs, including: Anticholinergic symptoms Mental status change Orthostatic hypotension GIT disturbances Urinary incontinence - Most ADRs are dose-dependant and so we should ensure we are using the best recommended dose for that patient. - We must also consider any relevant co-morbidities. This is especially important in the elderly as they may even have new co-morbidities from when the drug was rst prescribed and the drugs they are taking may target or a ect more than one of their conditions. - We must also assess for the need of monitoring as this helps prevent ADRs, such as with monitoring of: LFTs and eGFR for simvastatin LFTs and TFTs for amiodarone eGFR and potassium for ACE-Is eGFR, potassium and sodium for diuretics - We must also monitor clinical parameters such as: HR with medications like digoxin, atenolol, amiodarone and donepezil (used for dementia) BP with medications like ACE-Is and nitrates - We must also avoid as much as possible the use of drugs to treat the SEs of other drugs as this tends to lead to a prescribing cascade. Ex: we use levodopa to treat a patient with Parkinson’s, but it causes hallucinations and confusion, so we give risperidone, but it causes extrapyramidal SEs, so we give ropinirole. This may be better managed by reducing the dose slightly of levodopa. - We must also be cautious about drug interactions. Most cannot be avoided, but we should consider the most signi cant ones including: Simvastatin with carbamazepine Amiodarone with haloperidol Digoxin with loop diuretics (cause hypokalaemia and so potentiate digoxin) Warfarin with NSAIDs - We do not always need to avoid drug interactions, but we should adjust for it, such as by monitoring certain clinical parameters. - We must always consider OTC medications when it comes to drug interactions, especially with herbal medications. MMSA - SCOME Notes Database Page 34 of 105 fi fi ff fi Neal Aquilina 2023/24 - Medication reviews should be continuously conducted in all patients, but they are especially important for those with: New medications Hospital admission Multiple medications Actual ADR experienced New diagnosis Multiple co-morbidities Non-adherence - Medication reviews must always be patient-oriented and we must listen to the patient, even in the elderly. - Refer to ppt as some slides were confusing, not sure how important this lecture is honestly. MMSA - SCOME Notes Database Page 35 of 105  Neal Aquilina 2023/24 Rehabilitation in Older People (PF) - Rehabilitation is not a cure, but is a means of enabling a person to circumvent persistent impairments in order to minimise their disability. - It aims to restore personal autonomy in those aspects of daily living considered most relevant by patients or service users and their family carers. - It is also considered as a complex process that usually involves several professional disciplines and is aimed at improving the QoL of older patients facing living di culties caused by chronic disease/s. - The di erences of older age that must be considered in rehabilitation are: Reduced physical capacity Short-life expectancy Multiple pathologies Policies to keep older people out of institutional care Low expectations by professionals and patients Carers and elderly abuse Interruptions by acute illness - A pathology is an abnormality of structure or function that a ects an organ or organ system, such as a stroke is due to cerebrovascular disease. - Impairment is damage of an organ or part of the body, such as how a stroke causes hemiplegia. - Disability is the ways in which the impairment a ects the function of the individual, such as how hemiplegia leads to di culty dressing. - Handicap is the way in which the impairment and disability in uence the patient’s resettlement in the community. - It was found that the majority of older adults in Malta do not have a disability, but from those with a disability, a physical disability is the most common. However, in those older than 80, half are disabled. - The most common disabling conditions are: Stroke Arthritis Cardiorespiratory diseases Neck of femur fractures Peripheral vascular disease - Some myths about rehabilitation are that: It is time limited and has an end-point, usually when the patient leaves hospital The patient is a passive recipient of the treatment It is done only by therapists It can only be done in a hospital setting It is only appropriate for patients with mobility problems It is too expensive, it is expensive, but it is well worth it It does not work - During rehabilitation we assess and attempt to improve all 4 of physical, social, spiritual and psychological function. - The possible interventions of rehabilitation may be split into the soft and hard ones. - Soft forms of rehabilitation include: Advising Educating Counselling Encouraging Listening MMSA - SCOME Notes Database Page 36 of 105 ff ffi ff ff fl ffi  Neal Aquilina 2023/24 - While the hard forms of rehabilitation include: Drugs Physio Occupational therapy (OT) Speech and language therapy (SLT) Appliances Adaptations Aids for ADLs - Successful rehabilitation requires: Positive attitude and approach Individual assessment of the patient and carer Involvement of the patient and carer Team-work Promotion of independence by special and general therapeutic techniques Optimisation of the environment - Some barriers to rehabilitation are: Unidenti ed medical problems Multiple pathologies Occult depression Occult dementia Communication problems - There are some scales we may use during the rehabilitation process to assess the patients physical and mental functions, these include the simple Barthel’s scale, geriatric depression scale (GDS), MMSE, Waterlow and mini- nutritional assessment (MNA). - The simple Barthel’s scale is a 20 point scale that shows us the grade of physical disability in the person’s ADLs. - Waterlow’s scale is main only used by nurses to assess the patients’ skin health, mainly for pressure sores. - Goal setting is central in the management of disabled older people. These goals should be meaningful to the patient, clearly communicated, ideally written down, and realistic, but still challenging. - Those that are most likely to require rehabilitation are those that experience: Disability with uncertain cause New impairment, disability or handicap Deterioration in existing impairment, disability or handicap Caregiver strain Barely coping at home New referral to home care services - Inpatient rehabilitation is required when: Patients are highly dependent or have high care needs, especially if there is night- time care Patients have complex or multiple disabilities A rapid response is required Patients have poor housing or unsuitable domestic circumstances There are no community rehabilitation services available - Outpatient rehabilitation is ideal when: Patients are of low or modest dependency Patients have less complex or a single disability A slower response would be acceptable MMSA - SCOME Notes Database Page 37 of 105 fi Neal Aquilina 2023/24 There are appropriate housing and domestic circumstances - For example, in the rehabilitation package of stroke we: Provide direct treatment of the damaged organ, such as with Bobath therapy, and anti-spastic agents Prevent damage to other organs, by caring for the skin for example Prevent psychological damage through counselling Assess impact of the stroke on their physical, cognitive, emotional and social function Re-train them in their ADLs Provide aids and appliances, if necessary Modify their home environment Mobilise a social support netwok Educate the patient and their carers Provide counselling and support for the patient and their carers - Orthogeriatric care is the medical care of older patients with orthopaedic disorders, the most common one being hip fractures. However, some other bone fragility fractures include those of the pelvis, vertebrae, ankle, humerus and forearm. - If not operated on, hip fractures have a 70% 1-year mortality and there is an 80% prevalence of severe disability in those that survive. But if we operate, these numbers decrease to 30% and 40% respectively. - The fractures may be: Subcaptial undisplaced fractures, that accounts for 10% of cases, and are best treated with pins or screws and a plate. Sub capital displaced fractures, that account for 35% of cases, and are best treated with hemiarthroplasty for older and frailer patients or total arthroplasty if younger. Trochanteric two-part fractures, that account for 20% of cases, and are best treated with screws and a plate. Trochanteric multi-part fractures, that account for 30% of cases, and are best treated with screws and a plate. - It is recommended that at least one general ward in an acute hospital should be developed as a centre of excellence for orthogeriatric practice. - There are 5 di erent models for orthogeriatric care. These are: The traditional model, where it is dealt with as part of a general geriatric service and any medical queries dealt with by a consultative service. The older fractures are initially managed on the trauma ward, followed by rehabilitation. Variation on the traditional model that involves regular input from geriatricians together with MDT ward rounds involving both geriatricians and orthopaedic surgeons 1-2 times weekly. The patient will be under the orthopaedic team. Transfer to geriatric rehabilitation where the pre-op management is done by the orthopaedic team and then there is early post-op transfer to the geriatric rehabilitation unit. Here the patient is under the geriatric care team and there may or may not be combined orthopaedic and geriatric ward rounds. Combined orthogeriatric care where older fracture patients are admitted to specialised orhtogeriatric unit under joint care of a geriatrician and an orthopaedic surgeon, who should agree on a treatment plan together. They are then assessed by the geriatric team both pre- and post-op. They then undergo ongoing rehabilitation in this unit or in a step-down rehabilitation unit. Community rehabilitation is where optimally selected able patients are chosen by a geriatrician and undergo rehabilitation in the community following discharge directly home from the orthopaedic ward. MMSA - SCOME Notes Database Page 38 of 105 ff Neal Aquilina 2023/24 - The majority of the following points mainly apply to hip fractures as they are the most common. - Following X-ray con rmation of the suspected diagnosis, if there are no medical or anaesthetic complications, which is the case 95% of the time, we should operate within 24h. - Prior to the operation it is important to assess cognition, nutrition, function, social function and comorbidities. - While awaiting operation we must care for any pressure areas, especially those of the heel on the fractured side. We must also prevent deterioration while awaiting surgery and this may involve proteins and energy supplements, as they have been shown to improve outcome in those that are undernourished. - Post-op, we should: Avoid urinary catheterisation. Avoid urinary retention. Use low dose heparin, LMWH or aspirin to reduce the risk of DVT and PE. Consider the need for intra- or post-op blood transfusion, as it is needed in around 50% of patients with hip fractures, mostly for those with trochanteric fractures or who have had total arthroplasty. Consider giving iron supplements as we tend to do this, but it is not evidence based. Add regular analgesics, usually paracetamol, but we should take particular care of pts with delirium and dementia as they tend to be under-treated for their pain. If opioids are necessary we should do our best to prevent constipation. Mobilise within 48h post-op, unless they had an unstable trochanteric fracture. Avoid excess adduction and exion at the injured hip to avoid dislocation following arthroplasty. This should be explained to the patient and their relatives. Communicate between MDT, patient and their family. Start physiotherapy and OT for rehabilitation. - The goal of physio is to achieve independent mobility, self-care and continence post- op. It should be started with a forearm-support frame, then a pick-up or wheeled frame and eventually crutches. However, there is no EBM guidance for the best therapy regime. - For OT, their ADLs should be assed on the ward and during a home visit and we should add adaptive equipment, such as a toilet surround, toilet raiser or shower chair, as needed. MMSA - SCOME Notes Database Page 39 of 105 fi fl Neal Aquilina 2023/24 Falls (JC) - Falls are common in the elderly, hence why they are considered to be a geriatric giant. - They cause high morbidity, mortality and service use. - However, they are potentially preventable with 30% being considered to be preventable. - Up to 35% of those older than 65 in the community fall at least once in one year, and this percentage keeps on increasing at older ages and is even higher for those in institutional care and those that su er with dementia. - 50% of fallers fall repeatedly. - 75% of deaths due to falls a ect those older than 65 and men are more likely to die from a fall. Those that are older and so tend to be more frail have an even higher mortality from falls. - 40-60% of falls lead to injuries, but the majority are minor, and the rest are usually fractures. 1% from these injuries are neck of femur fractures. The injury rates are even higher in institutionalised patients. - Falls are also the most common cause of traumatic brain injury. - 5% of falls require hospitalisation and they have some other severe complications including dehydration, hypothermia, rhabdomyolysis (that may then cause kidney failure), pneumonia and pressure injuries. We must also not forget their psychological impact as 50% of fallers are left with a fear of falling, that further increases their risk of falling again. - Those older than 75 are 4 times more likely to be admitted to a long-term care facility for a year or more following a fall, than those aged 65-74. - Some of the reasons why falls are more common in the elderly are due to: Gait changes Postural instability, possibly due to losses in proprioception Sensory impairments Memory impairments Lack of exercise Decreased muscle mass and strength Slower reaction time Impaired protective responses Comorbidities, such as osteoporosis - There are more than 400 causes/risk factors for falls, but those that increase risk the most include muscle weakness, a history of falls, gait de cit, balance de cit, and the use of assistive devices. - Our clinical approach to any fall should be as follows: Assess and treat any injury Determine the probable cause and identify risk factors, through history, examination and targeted investigations. Prevent recurrence with: - Treatment of the underlying illness - Reducing risk factors - Reducing environmental hazards - Employing adaptive and assertive behaviour - Dizziness is a sensation of spinning (vertigo), light- headedness or impending faintness (syncope) accompanied by unsteadiness or imbalance MMSA - SCOME Notes Database Page 40 of 105 ff ff fi fi Neal Aquilina 2023/24 (disequilibrium). Its incidence is multifactorial. - When checking for vertigo we should use the Ha