ACUTE GERIATRICS

Dr Natalie King FRCP

Clinical lead for Acute Medicine

Surrey and Sussex Healthcare NHS Trust

Head of KSS School of Pas

FPARCP board

What is acute geriatrics?

Understanding the concept of Frailty

Clinical case

OVERVIEW

What is Acute Geriatrics?

Provision of care at or before presentation to ED

GP screening and pre-optimisation

Multidisciplinary care

Why do we need Acute Geriatric care?

Demographic changes

Heterogeneity of older people

Atypical presentation

Complex patients are

-more likely to need admission

-less likely to be discharged from AMU

-have longer LOS

-higher readmission rates

CGA

Comprehensive Geriatric Assessment (CGA) provides an evidence-based model for the provision of the co-ordinated multi-disciplinary care that these patients need

How do we target those in need?

• Age versus needs based services

• Front door geriatric MDTs/acute geriatric units

To identify those at risk or in need you need to understand a little about frailty….

Frailty-distinct clinical entity from normal ageing

Consisting of • Multisystem dysregulation

Leading to • Loss of physiological reserve

Leading to

• A state of increased vulnerability to stressors

Frailty

• Affects 10% of those over 65yrs

• Rises to 25%-50% of those over 85yrs

Frailty

Disability Long term conditions

Theories

Phenotype-Fried

• Five predefined physical frailty criteria

• Not frail 0

• Pre-frail 1-2

• Frail 3-5

Accumulation of deficits- Rockwood

• Deficits across various domains (eg cognition, physical functioning, self related health, smoking, history and lab results)

Recognising frailty in an individual

• Validated assessment tools:

Walking speed

Timed get up and go test

GP assessment

Polypharmacy (>5 medications)

Self reported health <6/10

The Groningen questionnaire (postal)

PRISMA 7 questionnaire

PRISMA 7

1. Are you more than 85 years? 2. Male? 3. In general do you have any health problems that

require you to limit your activities? 4. Do you need someone to help you on a regular basis? 5. In general do you have any health problems that

require you to stay at home? 6. In case of need can you count on someone close to you? 7. Do you regularly use a stick, walker or wheelchair to get

about?

• Over 3 is considered to identify frailty

Frailty Index (Rockwood)

The 5 frailty syndromes

Geriatric Giants

Falls

Immobility

Delirium Incontinence

Iatrogenic (medications)

Clinical case

Mrs J

86yrs lives alone

Widowed

2am- goes to bathroom at home

Unable to get off the toilet

Calls lifeline

No formal care

PMH- HTN, Osteoporosis, previous Colles fracture

Drugs

• Adcal D3

• Alendronate weekly

• Bendrofluazide

• Amlodipine

• Aspirin

• Co-codamol 8/500

Examination

BP 105/70

HR 60 Reg

HS normal

JVP normal

Chest bibasal crackles

Mild ankle oedema

Abdo SNT

Neuro- “moving all 4 limbs”

Investigations

Na 130

K 4.2

Urea 8.2

Creat 72

ALT 42, ALP 168

CRP 14

WC 9.4

Hb 113

Plt 180

Urine- leuc 1, Nit +

CXR- “Clear”

ECG- SR, nil acute

Trop 28

What was the working diagnosis?

www.freeimages.co.uk

What was the working diagnosis?

“Off legs”

UTI

? “Acopia”

Started on trimethoprim

Geriatrician’s lens

Seen by Medical team on call

PTWR by Geriatrics

So lets review the case again…

www.freeimages.co.uk

Mrs J

2am- goes to bathroom at home

Unable to get off the toilet

Calls lifeline

No formal care

ED arrival 3.10am

PMH- HTN, Osteoporosis, previous colles fracture

Drugs

• Adcal D3

• Alendronate weekly

• Bendrofluazide

• Amlodipine

• Aspirin

• Cocodamol 8/500

Examination

BP 105/70

HR 60 Reg

HS normal

JVP normal

Mild ankle swelling

Chest bibasal crackles

Abdo SNT

Neuro- “moving all 4 limbs”- more!

The missing pieces

General inspection

Check for sensory deficits

Check mouth

Skin and joints

Cognitive assessment

Functional assessment

Na 130

K 4.2

Urea 9.0

Creat 72

ALT 42, ALP 168

CRP 14

WC 9.4

Hb 113

Plt 180

Urine- leuc 1, Nit +

CXR- bibasal atelactasis

ECG- SR poor R wave progression

Trop 28

Problem list

Decline in physical and functional ability

Hyponatraemia

Signs of cognitive decline on screening

High ALP - ?2nd osteomalacia ? Liver congestion

UTI possible given history of UI

FRAILTY

Decline in physical and functional ability

Frailty can lead to decline

Functional decline

“the inability to perform usual activities of daily living due to weakness, reduced muscle strength, and reduced exercise capacity”

Can occur due to deconditioning and acute illness during hospitalization

“Off legs” in the elderly

Ageing causes:

Reduced muscle strength

Reduced aerobic capacity

Vasomotor instability

Baroreceptor insensitivity

Reduced sensory capacity

Chronic illness and comorbidity can heighten these

Usually as a result of acute illness and reduced functional

reserve

Functional decline

• 8% of those >65yr need help with >1 ADL rising to 30% men and 50% of women over 85

• Preadmission health and functional status can predict risk of decline

The effects of bed rest

System Effect

Cardiovascular ↓ Stroke volume, ↓ cardiac output, orthostatic hypotension

Respiratory ↓ Respiratory excursion, ↓ oxygen uptake, ↑ potential for atelectasis

Muscles ↓ Muscle strength, ↓ muscle blood flow

Bone ↑ Bone loss, ↓ bone density

GI Malnutrition, anorexia, constipation

GU Incontinence

Skin Sheering force, potential for skin breakdown

Psychological Social isolation, anxiety, depression, disorientation

“Acopia”

Pejorative term used to describe inability to perform ADL, no acute medical problems or inappropriate admission

Studies have shown many with “acopia” have complex comorbidities needing specialist input

One study of 93 acopia admissions – Over half presented with a geriatric syndrome

– Only 5 had no acute medical issues

– 22% died

Kee and Rippingale Age and Ageing 2009 38(1):103-105

Hyponatraemia

Hyponatraemia in the elderly

The most common electrolyte abnormality in the elderly

• Associated with increased mortality

• Asymptomatic hyponatraemia may contribute to cognitive disorders, posture and gait impairment

• Independent risk factor for falls and osteoporosis

• In up to 50% of presumed SIADH- no cause found

High ALP ?Osteomalacia

Osteomalacia

Calcium- low/normal

Phosphate- low/normal

ALP raised PTH raised

Slide 34

Poor bone mineralisation Body aches, muscle weakness and bone fragility Commonest cause in Elderly Vitamin D deficiency Insufficient <50nmol/l Deficient <25nmol/l Established risk factor for falls, Osteoporosis and fractures

Replacing Vitamin D <25nmol/l

Loading first

First line-1st line: Colecalciferol 20,000 IU capsule: 5 capsules a day for 3 days

2nd line: Colecalciferol 20,000 IU capsule: 3 capsules (60,000 IU) for 8-12 weeks

Then

Maintenance of 800-1000IU/dayOTC high strength vitamin D preparation providing 800-2,000 IU/day + Lifestyle advice

OR

Adcal D3 - 2 daily (containing 400 IU colecalciferol per tablet)

UTI

A note on UTI in the elderly

Studies suggest UTI misdiagnosed in 40% of hospitalised elderly *

UTI is however more common and carries 5% 28 day mortality

Urine dip is NOT a diagnostic tool

Prevalence of asymptomatic bacteriuria with age

Asymptomatic bacteriuria should not be treated (NNH 3)

Woodford HJ, George J J Am Geriatr Soc 2009;57:107-14

So how to apply this to elderly?

A very hard diagnosis

• 1/3 do not have fever

• Bacteriuria doesn’t represent disease

• Leucocytes may be present with or without bacteria

• Complicated UTI implies functional or structural abnormality-male/older female

Full assessment

Presence of symptoms

Expert consensus

Abx treatment of bacteruria if:

Acute dysuria alone OR

Fever plus at least one of • New or worsening urgency

• Frequency

• Suprapubic pain

• Gross haematuria

• Costovertebral tenderness

• Urinary incontinence

Loeb et al. Infection control and hospital epidemiology 2001;22:120-124

Elderly and catheters

Dipstick testing has no value *

Only send catheter samples if **

– Fever

– Localising signs

– Systemic features

– Exclusion of other sources first

Change the catheter before antibiotic treatment ( if catheter has been in for >7days)**

* Tambyah PA, Maki DG. Archives of Internal Medicine. 2000;160:673-77 **Tenke et al. Int Journal of Antimicrobial Agents 2008;31S:S68-78

Cognitive decline

Progressive decline in memory plus one or more of: aphasia

apraxia

agnosia

disturbed executive function

Abrupt onset

Fluctuant

Hypoactive/hyperactive

Slide 42

Dementia Delirium

Causes

D Dementia E Electrolyte disorders L Lung, liver, heart, kidney, brain I Infection R Rx Drugs I Injury, Pain, Stress U Unfamiliar environment M Metabolic

Confusion Assessment Model

Needs 1+2 +3 or 4

1. Acute onset and fluctuating course

2. Inattention

3. Disorganised thinking

4. Altered level of consciousness

Delirium

• Prevent

Assess for delirium within 24hrs of admission

Avoid ward/bed moves

Correct ward first time

Avoid psychoactive drugs, in fact all drugs!

Orientation (day/night/clocks)

Back to Mrs J

• Stop BFZ

• Stop co-codamol and objectively measure pain

• PT /OT assessment of functional ability

• Cognitive assessment

• Check Ca/Vit D level

• Stop antibiotics unless febrile/symptoms

• Repeat ECG but if no changes not for repeat troponin

Hospital stay

Collateral history

Cognition assessment

Nutritional assessment

Full functional assessment

Therapies

Medication review

Discharge planning

Medications implicated in frailty

Hypnotics

falls

Benzodiazepines

falls

Sulphonylureas

falls

Opiate based analgesics

delirium

Antimuscarinics

Cognitive impairment

NSAIDs

Renal failure

Before going home

• Reablement package

• Voluntary services

• Communication with GP

• Communication with family/carers

• Communication with patient

Key recommendations for managing frailty

• Detailed physical, functional, social and physiological

needs assessment (MDT)

• Identify and manage reversible causes

• Refer to geriatric medicine where frailty is associated with significant complexity, diagnostic uncertainty or challenging symptom control

• Review medication using STOPP-START criteria

Key recommendations for managing frailty

• Use clinical judgement and patient goals when applying disease based evidenced treatments

• Create a personal care plan for each patient which might include ACP/EOLC planning

• Communicate across the healthcare economy

www.surreyandsussex.nhs.uk/our-services/a-z-of-services/post-graduate-education-centre/kent-surrey-and-sussex-school-of-physician-associates/