6. Geriatric Syndromes – what are they and why are they ......Geriatric syndromes •...
Transcript of 6. Geriatric Syndromes – what are they and why are they ......Geriatric syndromes •...
GERIATRIC SYNDROMES- WHAT ARE THEY AND WHY ARE THEY IMPORTANT?
Dr Madeleine Cameron
Learning objectives
• Describe the term “geriatric syndromes”
• List conditions commonly recognised as “geriatric
syndromes”
• Explain the rationale behind Comprehensive Geriatric
Assessment
• Demonstrate an understanding of the complexity of
geriatric assessment ( i.e. with reference to geriatric
syndromes and medical and social complexity)
• Be able to explain frailty and give an example of a
model used to measure it
• Identify at least 2 of the challenges in translating
research in geriatrics into practice
• Demonstrate an appreciation of the need for a holistic
approach in management of the older person
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Geriatric syndromes
• “multifactorial health conditions that occur when the accumulated effects of impairments in
multiple systems render an older person vulnerable to situational challenges” (Tinetti et all)
• Usually united by issues related to cognitive impairment, functional impairment, older age and
impaired mobility
• Common risk factors and interrelated
• Complex multifactorial conditions
Geriatric syndromes (Won et al)
• Frailty
• Malnutrition
• Dementia
• Delirium
• Incontinence
• Falls
• Hearing impairment
• Visual impairment
• Sarcopaenia
• Immobility
• Gait disturbance
• Pressure ulcers
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Associations • Increased morbidity
• Increased mortality
• Increased health care utilisation and costs $$$
• Reduced quality of life
• Increased frequency with age
• Adverse impact on ADLs/function
Scope of the problem
• Ageing population
• Complex frail patients
• Cost $$$
• DRUGS
• Vulnerable population
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Epidemiology• By 2030, percentage of people over age 65 years will increase from 15% to 22%
• Population over age 80 fastest growing
• Increasing chronic disease and functional impairment
• 1.8million Disability adjusted life years (DALYs) lost in 2011 for >65yrs age group
• By 2028‐2029 ageing expected to reduce budget balance by around $36 billion
• Increased rates institutionalisation and hospital utilisation
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Challenges in assessment of the elderly
• Often the presenting problem does not represent the specific pathology underlying the change in
health status
• Atypical presentations
• Altered physiology of ageing
• Often conditions multifactorial
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How do we approach it?
• Comprehensive Geriatric Assessment (CGA)
‐ a multidisciplinary diagnostic and treatment
process that identifies medical, psychosocial, and
functional limitations of a frail older person in order to
develop a coordinated plan to maximize overall health
with aging
Comprehensive Geriatric Assessment• Model of assessment used by geriatricians to target interventions
• Assessment of medical issues, medications, social complexity, geriatric syndromes
• Identifies issues patients might not want to volunteer e.g. incontinence
• Allows tailoring of intervention to individual
• Evidence based for improving outcomes for care of elderly
• Efficacy varies according to setting it is utilised and way it is applied
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Evidence for CGA
• Improves diagnostic accuracy for care planning
• Prevents development of geriatric syndromes
• Increases chances of living at home after
hospitalisation‐by 25%
• Informs prognosis and life expectancy
• Tailoring diagnosis and therapy‐ can reduce in hospital
mortality
• Reduces re admission rates by 12%
• Helps preserve cognitive capacity
• Reduces institutionalisation
• Prevent functional decline
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Ageing physiology
• Normal physiology changes with age across all systems
• Variety of theories e.g. inflammatory, neuroendocrine,
telomere shortening
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Multimorbidity
• The National Quality Forum defines multiple chronic conditions as "two or more chronic
conditions that collectively have an adverse effect on health status, function, or quality of life
and that require complex healthcare management, decision‐making, or coordination"
• Increasing ageing population and better medical care
• More than 60% of patients >65 years
• Associations‐ poorer health status, QOL and health outcomes and higher use of care
• Increased risk of error and fragmentation
• Increased risk of interaction between diseases and polypharmacy
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Frailty • Syndrome of physiological decline marked by
increased vulnerability to stressors and vulnerability
to adverse health outcomes
• Separate to comorbidity
• Associated with poor health outcomes in its own right
• Multiple scoring systems‐ e.g. Fried, Rockwood,
Edmonton, CFS
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Functional impairment
• Definition: limitation in ability to carry out basic functional activities
• Negatively effects QOL and increases health care costs
• Increased likelihood of RACF admission, hospitalisation, death, dependence
• Can often be a symptom of other illness ‐>usually always multifactorial
• Increases need for carer support e.g. assistance with ADLs
• Contributing conditions e.g. CVA, Dementia
• Increasing health conditions‐> Increasing impairments
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Cognitive impairment- Delirium• Acute change in cognition due to another medical condition
• Hopefully reversible when underlying condition corrected
• Results in increased risk of falls, pressure injuries, prolonged hospitalisation, UTI, pneumonia,
admission to RACF on discharge, morbidity and mortality
• Often under recognised with significant burden of adverse effects
Cognitive impairment- Dementia
• Disorder of cognitive impairment in one or more domains (learning and memory, language,
executive function, complex attention, perceptual‐motor, social cognition) accompanied by
functional impairment ( i.e. difficulty managing daily tasks and loss of independence)
• Irreversible and degenerative neurocognitive decline
• Associated with functional decline, frailty, sarcopaenia, malnutrition etc
• Pseudodementia‐Anxiety and depression can mimic dementia and are common in the elderly
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Impact of dementia• Higher rates of polypharmacy and potentially inappropriate medications (PIMs)
• Higher risk of adverse effects
• Diagnosis should trigger medication review
• Higher morbidity and mortality, increased rates hospitalisation and emergency department
presentations
• Medication compliance can be an issue
• Availability of social support and other morbidity important
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Royal Commission into aged care• Began January 2019 following a number of reports from Media outlets
• Serious risk notices issued to aged care providers jumped 170% in the last year and significant
non compliance went up 292%
• Currently a lot of anxiety in RACFs
• Auditing of prescribing practices
• Often complexity of behavioural management in dementia underrated
• Often takes time to educate family or other decision makers further about dementia and
impact of polypharmacy.
Malnutrition• Condition resulting from diet which is deficient or excessive so that the diet causes health
problems. Often results from a diet which is deficient in calories, protein or nutrients
• Results in unintentional weight loss and sarcopaenia
• High prevalence of geriatric syndromes in malnourished elderly
• Contributes to progressive decline in health, reduced physical and cognitive functional status,
increased utilization of health care service, premature institutionalisation and increased mortality
• High prevalence rates in elderly and especially in aged care
• Social isolation also impacts
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Polypharmacy• Strong association with other geriatric syndromes‐ increases frailty, falls, cognitive impairment,
functional impairment
• Highly prevalent in aged care
• Increased risk of adverse effects, interactions, increased hospitalisation and presentations,
morbidity and mortality
• High risk due to increasing comorbidity, multiple healthcare providers
• Often poor communication in practice between hospitals and residential aged care facilities
• Also high rates poor adherence in older population in general
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Social context
• Huge impact of social isolation
• Social isolation‐Higher rates of depression and malnutrition
• “ Loneliness” as a predictive factor for health outcomes
• Formal and informal supports dictate outcomes in many situations
• Socioeconomic deprivation also impacts
• In cognitive impairment especially important
Focus on QOL/Patient centred care• Often older people value QOL over prolonged life
• Diagnosis of dementia should not exclude them
from “ the conversation”
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Deprescribing
• Coordinated effort between patient and clinician
• Need to consider complexity‐ social, medical, geriatric syndromes, economic, practicalities
• Involve family, GP, RACF and its staff, other specialists
Challenges- Why is translation of geriatric research into practice difficult? ( Inouye et al)
1) Lack of commonly accepted definitions for diagnosis recognition and coding of geriatric
syndromes
2) Lack of simple measurable interventions
3) Need for substantial provider time and longitudinal follow up to intervene and assess
effectiveness
4) Interventions often require new behaviours/attitude shift
5) Not enough champions for these interventions
6) Multi factorial nature of geriatric syndromes requiring coordinated multifaceted approach does
not adhere with traditional disease model
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Targeting interventions• Appropriateness of medical intervention
• Informed choices
• Opportunity for advanced care planning
• Deprescribing
• Ensuring appropriate patient and family/carer support
• Encouraging holistic view
• Maximising strengths/ supports
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Wong, C, 2017.
Case Example 1
• Mr FS‐ 88M advanced dementia
• Recent presentation to ED with fall and fractured ribs,
decline over preceding 3 months increasingly frail
• PMH: Advanced dementia, Renal cell carcinoma for
palliative treatment, PPM, IHD with stents, AF,
Dyslipidaemia, HTN, PVD, T2DM, PMR
• CFS8, Severe pain
• Wife (EPOA)“ I am not sure how much longer I can
watch him go on like this”
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Medication List
• Metoprolol 50mg BD
• Apixaban 5mg BD
• Digoxin 125mcg daily
• Frusemide 40mg BD
• Span K 2 tablets daily
• Atorvastatin 80mg
• Irbesartan 300mg daily
• Hydrochlorothiazide 12.5mg daily
• Risperidone 0.5mg BD
• Prednisone 5mg daily
• Pantoprazole 40mg daily
• Magnesium 2 tablets BD
Case Example 2
• Mr BG‐ 75M in RACF under public guardian
• Referred for disturbed behaviour
• PMH: Advanced dementia, IHD, COPD, HTN, GORD,
Depression, Dyslipidaemia
• Sarcopaenic, Frail, weight loss 10kg since admission,
dehydrated ++, depressed, poor sleep
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Medication List
• Isosorbide mononitrate 30mg SR daily
• Frusemide 40mg BD
• Span K 2 tablets daily
• Pantoprazole 40mg daily
• Magmin 2 tablets daily
• Aspirin 100mg daily
• Rosuvastatin 20mg daily
• Tiotropium 18mcg daily
• Salbutamol PRN
• Perindopril 5mg daily
• Amlodipine 5mg daily
Questions?
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References• Roller‐Wirnsberger R, Thurner B, Pucher C, Lindner S, Hubert Wirnsberger G, The clinical and therapeutic
challenge of treating older patients in clinical practice, British Journal of Pharmacology, June 2019, 1‐8.
• Inouye SK, Studenski S, Tinetti ME, Kuchel GA, Geriatric syndromes: Clinical, Research and Policy Implications of a Core Geriatric Concept, J Am Geriatr Soc 2007; 55 (5): 780‐791.
• Tinetti Me, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995; 273 (3) : 1348‐1353.
• Won CW, Yoo HJ, Yu SH, Kim CO, Dumlao LCI, Dewiasty E, 2013, Lists of geriatric syndromes in the Asian‐Pacific geriatric societies, Eur Geriatric Medicine, 4 (5): 335‐338.
• Older Australia at a Glance, Australian Institute of Health and welfare, 10.9.18.
• Australia’s Ageing Population, Australian Parliamentary Budget Office, Report No 2/2019.
• ANZCA Frailty education 2016.
• Pharmacokinetics and Pharmacodynamics in the Elderly, 2013, Midlov P.
• Fragala M.S. (2015) The Physiology of Aging and Exercise. In: Sullivan G., Pomidor A. (eds) Exercise for Aging Adults. Springer, Cham.
• Herr M, Robine JM, Pinot J, Arvieu JJ, Ankri J, Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people, Pharmacoepidemiol Drug Saf, 2015 Jun, 24 (6), 637‐46)
• Colon‐Emeric C, Whitson HE, Pavon J, Hoenig H, Functional decline in older adults, Am Fam Physician. 2013 Sep 15;88(6):388‐394.
• Queensland Brain Institute, Types of Dementia, 2020.
• Soundararajan AS, Mathew AN, Nanjuddan R, Ganesh A, 2017, Association of Geriatric Syndromes with Malnutrition Among Elderly, International Journal of Medical Research and Health Sciences, 6 (5): 14‐18.
• When I see an elderly person eating alone like this, Iwastesomuchtime.com, 2020.
• Porceddu SV, Haddad RI, Management of elderly patients with locoregionally confined head and neck cancer, 2017, The Lancet, Vol 18, Issue 5, P 274‐283.
• Wong, C. Ontario St Michael’s Hospital, 2017.
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