1 Geriatric Medicine (Elderly Medicine) Geriatric Medicine (Elderly Medicine) Key Topics FRAILTY AND SARCOPENIA (LO1) ................................................................................... 2 IMMOBILITY (LO1) .............................................................................................................. 4 ASSESSMENT OF COGNITION IN OLDER PEOPLE (LO2) ............................................... 6 DELIRIUM (LO2) .................................................................................................................. 9 DEMENTIA, WITH A FOCUS ON DEMENTIA IN HOSPITAL (LO2) .................................. 11 FALLS IN OLDER PEOPLE (LO3) ..................................................................................... 14 FALLS - ASSESSMENT OF BALANCE AND GAIT (LO3) ............................................... 17 STROKE & TIA (LO4) ........................................................................................................ 19 PRESCRIBING FOR OLDER PEOPLE (LO5) .................................................................... 22 PRESSURE ULCERS (LO6) .............................................................................................. 24 CGA, COMPREHENSIVE GERIATRIC ASSESSMENT (LO7) ........................................... 26 REHABILITATION OF OLDER PERSONS (LO8) .............................................................. 28 KEY TOPICS NOT COVERED BY THE LEARNING OBJECTIVE ..................................... 30 OTHER TOPICS - SENSORY IMPAIRMENTS IN OLD AGE ............................................. 31 OTHER TOPICS - THE LAW AND OLDER PEOPLE......................................................... 33 OTHER TOPICS - ASSESSMENT OF ACTIVITIES OF DAILY LIVING ............................. 36 OTHER TOPICS - ASSESSMENT FOR CARE IN THE COMMUNITY ............................... 38
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1 Geriatric Medicine (Elderly Medicine)
Geriatric Medicine (Elderly Medicine)
Key Topics
FRAILTY AND SARCOPENIA (LO1) ................................................................................... 2
REHABILITATION OF OLDER PERSONS (LO8) .............................................................. 28
KEY TOPICS NOT COVERED BY THE LEARNING OBJECTIVE ..................................... 30
OTHER TOPICS - SENSORY IMPAIRMENTS IN OLD AGE ............................................. 31
OTHER TOPICS - THE LAW AND OLDER PEOPLE ......................................................... 33
OTHER TOPICS - ASSESSMENT OF ACTIVITIES OF DAILY LIVING ............................. 36
OTHER TOPICS - ASSESSMENT FOR CARE IN THE COMMUNITY ............................... 38
2 Geriatric Medicine (Elderly Medicine)
Frailty and Sarcopenia (LO1)
Dr Daisy Wilson
What is frailty? Frailty is a medical syndrome with multiple causes and contributors that is characterized by
diminished strength, endurance, and reduced physiological function that increases an
individual’s vulnerability for developing increased dependency and/or death. Or put simply
an increased risk of adverse outcomes such as death or institutionalisation.
What is sarcopenia? Sarcopenia is the age related loss of muscle mass. It is different to cachexia which is a
metabolic condition resulting in weight loss as well as loss of muscle mass. Sarcopenia is
present if an individual has low muscle mass and either poor physical performance (timed
walk test/TGUG) or low muscle strength (hand grip strength). If all three criteria are present
the individual has severe sarcopenia and if just low muscle mass is present the individual
has pre-sarcopenia.
How are the two conditions linked? Sarcopenia is more common than frailty and is often thought of as either a pre-cursor
syndrome to frailty or the physical components of frailty. They have many of the same
causes and similar treatments appear to ameliorate their effects. However, we don’t yet
know the exact link and overlap between the two conditions so for the moment we should
consider them as separate conditions.
What causes frailty and sarcopenia? The pathophysiology of frailty and sarcopenia is fairly unexplored but the role of the immune
system, hormones, the endocrine and metabolic systems and lack of physical activity are
thought to be important.
How do you diagnose frailty? Frailty is most commonly diagnosed in clinical practice by instinct; this can be very subjective
and should be avoided. It is accepted that diagnosis of frailty following a comprehensive
geriatric assessment (CGA) is a robust method of diagnosis but without an appropriate prior
assessment the term frailty can be incorrectly applied. There are several methods of
diagnosis which can be utilised by the non-geriatrician who is not competent in CGA.
Electronic frailty index is a score computed by GP operating systems; it takes into
account 36 different criteria representing many different domains such as physical,
social and psychological.
Edmonton Frail Scale is used in many surgical settings to help diagnose frailty. It is a
short questionnaire along with a quick assessment of physical function (TGUG) and
cognition (clock drawing).
How do you diagnose sarcopenia? Sarcopenia is currently rarely diagnosed clinically likely due to the current lack of accepted
treatment. One of the easiest methods of diagnosis is to first measure an individual’s gait
speed. If this is less than 0.8m/s they should go on to have imaging (usually a DEXA) to
diagnose low muscle mass. If the gait speed is greater than 0.8m/s they should first have
their grip strength tested and only if this is low should they have imaging.
3 Geriatric Medicine (Elderly Medicine)
Why are frailty and sarcopenia important clinical conditions? These are both common conditions which contribute to a significant proportion of morbidity
and mortality in older adults. The direct cost of both these conditions is difficult to calculate
but it was estimated in the US in 2000 the direct healthcare cost of sarcopenia was $18.5
billion.
What can we do about it? Research has shown that both frailty and sarcopenia are reversible conditions. The evidence
base for management is currently small. These interventions have the best evidence and
geriatricians would be confident to recommend these as part of a management plan
especially as the potential negative effects are minimal.
Exercise intervention – particularly involving strength work
Nutrition – particularly involving protein or amino acid supplementation
Comprehensive geriatric assessment – has been demonstrated to reverse frailty
also associated with improved outcomes in hospital setting (see CGA section)
These interventions below have some or conflicting evidence and are not part of routine
practice.
ACE inhibitors – some evidence that this can improve strength and there is an
ongoing trial looking at ACEi and protein supplementation in sarcopenia
Vit D – conflicting evidence some studies have shown and improvement others
have shown negative effects.
Testosterone and DHEA (steroid precursor of testosterone) – variable results but
concerns with steroid replacement due to side effects (cardiovascular)
Reading: Fit for Frailty guidelines from BGS – http://www.bgs.org.uk/campaigns/fff/fff_full.pdf
European working group on sarcopenia in older people – nice background, definition and
Immobility is one of the most common presenting conditions in the frail elderly and along
with falls, confusion and incontinence is one of the so called geriatric giants. Unfortunately, it
is all too common to regard immobility or “off legs” as a diagnosis but remember that really it
is only a symptom for which a cause needs to be found. Unfortunately, the list of potential
causes is long and typically an individual patient may have several conditions contributing to
their mobility problems. Assessment should always begin with a careful history as this may
give a clue to underlying diagnosis. Conditions such as stroke or fractured neck of femur are
likely to lead to a sudden loss of mobility. The history is likely to be more progressive in
conditions such as arthritis or Parkinson’s disease.
Main causes of immobility in older adults
1. Following a fall -
Falls and immobility are closely linked. Adults who fall frequently often become
frightened to walk and may restrict their movements and in extreme cases take to
bed. Typically these patients resist standing and experience quite marked fall back
and anxiety when attempting to stand. An important consequence of falls is fractured
neck of femur and it is very important whenever there is a history of a recent fall to
exclude a fractured neck of femur in a patient who is unable to walk. The typical sign
of a painful externally rotated leg is not always present and x-ray maybe necessary to
confirm the diagnosis. Pain on weight bearing (even mild) is also a useful warning
sign.
2. Stroke -
Acute onset of a hemiparesis is usually accompanied by immobility to a greater or
lesser degree. Patients with more diffuse cerebrovascular disease often experience
gait abnormalities which can sometimes mimic Parkinson’s disease. Stroke is by
definition of sudden onset and again a clear history should help to make the
diagnosis. Sometimes the history is of a more insidious onset of arm or leg
weakness. In this case consider space occupying lesions such as primary or
secondary brain tumour or subdural haematoma.
3. Osteoarthritis -
Is extremely common in the ageing population particularly of the large weight bearing
joints of the hip and knee. The history is of pain in the effected joint often of months
or years and subject to periodic exacerbations. Degenerative disease of the lumbar
and cervical spine is also common and leads to pain and restricted mobility. Some
older adults have developed rheumatoid arthritis in middle age which they carry with
them into old age. The sudden onset of an acutely painful inflamed joint is an
important cause of loss of mobility and needs to be thoroughly investigated.
Common causes are septic arthritis, gout or pseudo gout but sometimes a flare up of
osteoarthritis can also cause similar appearances.
4. Parkinson’s Disease -
This condition, which mainly affects older adults, typically causes mobility problems
with tremor and bradykinesia. The onset is often rather insidious and consequently is
often missed. Medication can help symptoms but doesn’t slow disease progression.
5 Geriatric Medicine (Elderly Medicine)
Drug treatment (e.g. neuroleptics) is a frequent cause of potentially reversible
Parkinsonism in the elderly.
5. Chronic Cardiorespiratory Disease -
Chronic heart failure and COPD are extremely common. Mobility is often restricted by
breathlessness, poor stamina and lethargy.
6. Visual Impairment -
Commonly due to macular degeneration, patients may manage within their own
homes because of familiarity but outside the home or in an alien environment may
become immobile especially in hospital where the surroundings are often very
frightening and threatening.
7. Feet and Footwear -
An extremely common cause of mobility problems. Always look at the patients shoes
which you may find are either inappropriate or in poor condition. Remove the shoes
and socks and look at the feet. Painful calluses, overgrown toenails, bunions,
ischaemic ulcers, arthritis etc. are all cause of pain in the feet, which restricts
mobility.
8. Miscellaneous Condition -
There are a range of other things which can contribute to a patient’s poor mobility.
The depressed patient may become isolated and immobile. Patients with dementia
may have gait abnormalities which affect their mobility and in addition may have
become lost in an unfamiliar environment. Of course some patients with dementia
exhibit the reverse and have a tendency to wander whatever their surroundings. The
older patient in hospital often finds it particularly difficult to mobilise, urinary
catheterisation with a catheter bag trailing on the floor is equivalent to applying a ball
and chain to an older person who already has mobility difficulties. Provision of poorly
fitting clothes, trousers that won’t stay up and inadequate shoes often compounds
the problem.
Management
This is a multidisciplinary activity. The doctors job is to formulate an accurate diagnostic list,
which may be multiple and then to institute treatment with medication (sometimes removal
of) and/or surgery where appropriate. Physiotherapists clearly have a major role in
promoting mobility and will need to be involved immediately. Remember, they rely heavily on
the Clinician for an accurate diagnosis. Occupational Therapists have an important role
particularly in resettling the patient at home and providing aids and equipment to assist
mobility within hospital and around the home. Social Workers have a role in the provision of
home support and when necessary residential or nursing home care.
6 Geriatric Medicine (Elderly Medicine)
Assessment of cognition in older people (LO2)
Dr T Jackson
Impaired cognition is a frequent accompaniment to illness in old age. Usually it is transient
and precipitated by acute illness (i.e. delirium). Sometimes a person presents with a
background of longer term impaired cognition or dementia. Often the two can occur together.
The key is first to identify delirium. If it is delirium, then treat and manage as such. If not,
then it is likely to be chronic cognitive impairment. Sometimes teasing out the two is very
difficult, and requires excellent diagnostic skills and a collateral history.
In any case, we know that both delirium and dementia confers a greater risk of adverse
outcome during and after hospital admission (increased mortality and new care home
placement) so it is important to recognise and not see it as something that is not important.
So – what test should I use?
Well, there are many detailed and comprehensive tests of cognition available, but in clinical
practice such tests are often unworkable, particularly in the setting of an ill patient in a busy
ward or A&E department. At various times the NHS has mandated cognitive assessment of
inpatients linked to financial incentives (CQUINs)
Delirium screening should be done using the 4AT test –
4 or above: possible delirium +/- cognitive impairment
1-3: possible cognitive impairment
0: delirium or severe cognitive impairment unlikely (but delirium still possible if information
incomplete)
1 ALERTNESS - This includes patients who may be markedly drowsy (e.g. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4
2 AMT4 - Age, date of birth, place (name of the hospital or building), current year.
No mistakes 0
1 mistake 1
2 or more mistakes/untestable 2
3 ATTENTION - Months of the year backwards:
Ask the patient: “Please tell me the months of the year in backwards order, starting at
December.” To assist initial understanding one prompt of “what is the month before
December?” is permitted.
7 Geriatric Medicine (Elderly Medicine)
Achieves 7 months or more correctly 0
Starts but scores <7 months / refuses to start 1
Untestable (cannot start because unwell, drowsy, inattentive) 2
4 ACUTE CHANGE OR FLUCTUATING COURSE
Evidence of significant change or fluctuation in: alertness, cognition, other mental function
(e.g. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs
No 0
Yes 4
Cognitive impairment, if not delirium evident, can be screened for using the Abbreviated
Mental Test Score or AMTS – a cut off in hospital patients of <7 (i.e. 6/7 cut off) indicates
possible dementia
1. Time of day (to nearest hour)
2. Year
3. Place
4. Identify two people (i.e. nurse, doctor, relative)
5. Age
6. DOB
7. Address to be remembered (patient must repeat this to ensure registration and again
after 5 minutes – 42 West Street is the one used in the paper
8. Name of monarch
9. Year of start of First World War
10. Count backwards from 20 –1
Score one point for each correct answer
Clearly, these are screening tools, and further investigation of impaired cognition should then
be undertaken. Comprehensive cognitive tests such as Montreal Cognitive Assessment
(MOCA) or Addenbrooke’s Cognitive Assessment 3 (ACEiii) can then be used.
Informant tools such as the Informant Questionnaire of Cognitive Decline in the Elderly
(IQCODE) and Alzheimer’s disease * (AD8) can be very useful, and also help diagnose
dementia in the context of delirium
Issues are often present with respect to IQ, but also language and culture, when using these
tests and this should be taken into account. Also, remember that a test result like this does
not diagnose dementia – the doctor does!
The Mini Mental State Examination (MMSE) is a 30 question cognitive assessment which
was used routinely in clinical practice (normal 27+/30) however it is now copyrighted in a
classic example of ‘stealth patenting’ so should be avoided.
Consideration of depression should be made, and the 15 point Geriatric Depression Scale is
useful here
8 Geriatric Medicine (Elderly Medicine)
In departments of geriatric medicine, the Occupational Therapists have developed
considerable expertise in the administration of cognitive tests as well as its interpretation in
the context of a functional assessment of the patient’s capabilities
9 Geriatric Medicine (Elderly Medicine)
Delirium (LO2)
Dr T Jackson
Delirium is a common, severe neuropsychiatric syndrome that affects mainly older people in
hospital. Delirium occurs in up to 1 in 5 people in hospital and doubles the risk of mortality
in people who have it. It was thought of as a ‘normal’ response to illness in older people but
this is simply not the case. Delirium also accelerates cognitive decline in people with
dementia as well as being a risk factor for developing new dementia.
So not ‘what you expect’, but a medical emergency
Risks, precipitants and recognition
Delirium occurs as a result of an acute precipitant event – usually infection or surgery – and
occurs more frequently in people who are vulnerable to it. However, anyone can get delirium
if they are ill enough, and there are high rates of delirium in paediatric and adult intensive
care for example.
The most important vulnerability in older people is dementia – with up to two thirds of people
with delirium also having dementia (often mild and previously unnoticed). Other key
vulnerabilities are frailty, multimorbidity, sensory impairment, polypharmacy (especially anti
cholinergic drugs), and poor mobility.
Infection – though not always UTI! – and surgery are the most common precipitating events.
In fact delirium is the most common post-surgical complication seen in older people,
especially after hip fracture surgery and laparotomy. Other important precipitants not to miss
are pain, urinary retention, faecal impaction, drugs (especially opiates and anit-cholinergics)
Delirium is poorly recognised by medical staff, especially junior doctors – the reasons for this
are unknown and frankly a bit strange!
The key thing with recognising delirium is to suspect it - Think Delirium
The most important question to ask is – Is this new? – and will require you to get a good
collateral history from family, carers and healthcare staff.
People with delirium have reduced alertness and awareness – this is the key diagnostic
criteria, and may be described as ‘knocked off’. A drowsy or agitated patient is an unwell
patient and requires urgent assessment.
There will be cognitive change – ‘confusion’ – this may be memory loss, but more usually is
perceptual and orientation change. People think they are somewhere else and can have
very frightening hallucinations and thoughts.
The key cognitive deficit in delirium is attentional deficit. Patients will not follow the train of a
conversation, talk on about things of the point, or not make eye contact with you.
10 Geriatric Medicine (Elderly Medicine)
The 4AT test is the best screening and recognition tool at present and should be completed
on all acute admissions of older people to hospital and when you suspect delirium.
Right, I’ve recognised delirium – now what?
Management of delirium is centred on promptly recognising and treating the underlying
precipitant. As is often the case in geriatric medicine causes and usually multifactorial, and
examination and investigations will be opportunistic.
Examination should be comprehensive – ensure you make special reference to:
dysarthria, dysphasia (expressive and receptive) and difficulty performing tasks (apraxia).
The constellation of symptoms will depend upon the part of the brain involved.
Aetiology
There are two types of stroke – haemorrhagic and ischaemic. In the UK, about 10% are
haemorrhagic. Patients should have a CT head within one hour of arrival in hospital to
identify if there is intracerebral haemorrhage. The incidence of stroke increases with age but
it can affect people at any age.
Acute management
Ischaemic stroke
The key to acute management is to salvage the
“ischaemic penumbra” surrounding infarcted brain
tissue. The penumbra can remain viable for several
hours, but the earlier treatment is instituted the
better. Thrombolysis can be given up until 4.5
hours after symptom onset – this service is now
provided 24 hours/ day within the UK by a senior
clinician trained in giving thrombolysis.
In addition, thrombectomy is now recommended as
a treatment for patients with severe disabling
stroke and proximal intracranial large vessel
occlusion (initially identified on CT angiogram).
This treatment should be given in addition to thrombolysis (unless there are
contraindications) and within 5 hours of symptom onset.
Patients, in whom it is not possible to perform thrombolysis or thrombectomy, should be
given 300mg aspirin OD (oral/ rectal) for 2 weeks. Aspirin therapy is normally started 24
hours after thrombolysis, unless there are contraindications (e.g. secondary haemorrhage).
Figure 1 - The ischaemic penumbra, image via The Internet Stroke Center
20 Geriatric Medicine (Elderly Medicine)
Haemorrhagic stroke
There is currently no specific treatment for haemorrhagic stroke, but patients who are on
anticoagulants should be given immediate medication to reverse the effect. Blood pressure
control is also important. Individual hospitals will have their own local protocol; however, it is
recommended that patients who present within 6 hours with a systolic blood pressure (sBP)
above 150 mmHg should receive urgent treatment to maintain the sBP below 140 mmHg.
Rehabilitation
There is clear evidence that all patients benefit from early transfer to a stroke unit. This
means that they will receive early specialist input from nurses familiar with stroke medicine,
speech therapy, physiotherapy and occupational therapy, as appropriate.
Patients with stroke are at increased risk of venous thromboembolism – do not prescribe
enoxaparin to any stroke patients regardless of type. Intermittent pneumatic compression
stockings are being used in many hospitals and the key is commencing early rehabilitation.
Secondary prevention
Following identification of a stroke, it is important to identify possible risk factors that can be
addressed to prevent further strokes in the future. All patients with ischaemic stroke should
continue treatment with clopidogrel 75mg, unless they require anticoagulants. As a
minimum, most patients should have:
12 lead ECG to assess for AF (most will also need prolonged monitoring e.g. 24 hour
or longer) – Patients with AF will require anticoagulant therapy long-term
Cholesterol (target < 4.0)
HbA1c
Carotid dopplers to assess for carotid artery stenosis
Blood pressure management
Smoking cessation advice
Other investigations may be required depending on the clinical picture (e.g. younger patients
with no risk factors, history consistent with neck dissection)
Transient Ischaemic Attack (TIA)
Presentation
A TIA presents with symptoms similar to a stroke but with complete resolution within 24
hours. In reality, most TIAs are much shorter than this.
Investigations
If a patient presents after symptoms have fully resolved, there is normally no indication for
urgent brain imaging. Further investigations will be arranged in TIA clinic as necessary.
Management
Previously, TIAs were triaged by use of the ABCD2 score. However, the updated RCP stroke
guidelines advise that all patients with suspected TIA should be reviewed urgently within 24
hours, unless they present more than 7 days after the onset of symptoms (in which case
they should be seen as soon as possible within 7 days).
21 Geriatric Medicine (Elderly Medicine)
Suspected TIAs should be given 300mg aspirin and referred to their local TIA clinic. If a
diagnosis of TIA is confirmed, they will be given 75mg clopidogrel and screened for possible
predisposing factors as above in secondary prevention for stroke.
Further reading RCP National Clinical Guideline for Stroke – Fifth Edition 2016; Available via URL: https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx Thrombolysis video at AEME