Geriatric syndromes

D. Greyling

Geriatric syndromes

• 1. Frailty• 2. Delirium• 3. Falls• 4. Sleep disorders• 5.Dizziness• 6. Syncope• 7. Pressure sores• 8. Incontinence• 9. Elder mistreatment• 10.Dementia• 11. Parkinson's

Frailty

• A clinical syndrome of increased vulnerability and decreased ability to maintain homeostasis that is age related and centrally characterized by decline in functional reserves across multiple physiological systems

Frailty

• Suspect if :• 1. Unintentional weight loss of more than 4,5

kg in the past year• 2. Feeling exhausted• 3.Weakness ( Poor grip strength )• 4. Slow walking speed• 5. Low physical activity

Frailty

• Associated with a high risk of falls, dependency disability, institutionalization, hospitalization, risk of iatrogenesis and side effects of medical interventions and death.

• Frailty is part of a single or multiple clinical syndromes

Delirium

• CAM( Confusion Assessment Method):• 1. Acute onset and fluctuating course• 2.Inattention• 3.Disorganized thinking• 4.Altered level of consciousness: From

lethargic, stupor to coma.

Clinical

• History: Precipitating factors• Ask and determine:• 1. Level of consciousness• 2.Orientation• 3.Memory• 4.Attention• 5.Perceptual problems : delusions• 6. Pschycomotor behavior• 7.Sleep –wake cycle

Precipitating factors

• D – Drugs• I – Infections• M- Metabolic ( electolytes,glucose,acid base)

• T- Toxins• O – Oxygen deficiency• P – Psychiatric ( Bereavement, Emotional

stress)

Falls• 35 - 40 % of persons over 65 fall in a given year and increases with

age.

• Risk factors for falls: • 1. Muscle weakness• 2. Gait Deficit• 3.Balance deficit• 4.Use of assistive device• 5.Visual deficit• 6.Impaired Daily Activity of living• 7.Cognitive impairment• 8.Age more than 80

Assessment

• 1. History• 2.Medications• 3.Vision• 4.Gait and Balance : Standing on one leg for 5 sec• Bending • 5.Lower limb joints• 6.Neurological• 7.Cardiovascular: Orthostatic hypotension• Pulse rate and rhythm

Sleep disorders• 50 % of elderly persons complain of sleep difficulty

• 1. Sleep disordered breathing• Hypopneas or apneas during sleep

• 2. Restless legs syndrome : Cluster of repeated leg jerks every 20 – 40 seconds during sleep

• 3. Circadian rhythm sleep disorders: Sleep wake cycle• - sleepy early in the evening and waking up early

• 4. Insomnia : low quantity and or quality of sleep

• 5. Rapid eye movement sleep behavior disorders :• A dissociated state during which complex motoric behaviors occur

Dizziness

• A broad term to describe various abnormal sensations arising from perceptions of the bodies relationship to space and of unsteadiness.

• Older than 65 years 10 % in crease for every 5 years

Causes

• 1. Vestibular causes• 2.Central nervous system causes( TIA / Stroke)• 3.Psychiatric disorders( Depression/ Anxiety)• 4.Cervical spine( Vertebral artery occlusion)• 5.Systemic causes( DM, HT, CAD, Low Hb,

Hypothyroidism,CCF)• 6.Orthostatic hypotension• 7. Post prandial hypotension• 8 Drugs

Syncope

• Rapid onset of transient loss of consciousness and spontaneous complete recovery

• Caused by blunted baroreceptor sensitivity

Evaluation

• Three questions:• 1. ? Loss of consciousness attributable to the

syncope(Trauma, Epilepsy , Vascular, Conversion)

• 2. ? Heart disease• 3. Are there important clinical features that

suggest the etiology ?

Syncope examination

• Orthostatic hypotension• Use of devices for mobilty• Vision• 5 item recall• Gait• Balance• Neuromuscular: Quadriceps strenght• Rigidity,Tremor, Bradikinesai

Pressure ulcers

• Areas of local tissue trauma developing where soft tissue are compressed between bony prominences and any external surface for long periods of time.

• Most common : Sacrum, Ischial tuberosities , throchanters and heels

Stage 1

• Skin intact with redness over a bony prominence

Stage 2 : Loss of the dermis with a shallow ulcer

Stage 3: Full tissue loss

Stage 4: Full thickness with exposed tendon/muscle/bone

Incontinence

• Any involuntary leakage of urine.• “DRIIIPP”• D – Delirium• R- Restricted mobility• I – Infection ( UTI) ,Inflammation ( Atrophic

vaginitis), Impaction of feaces• P- Pharmaceuticals

Types of incontinence

• Stress: Loss of urine with increase of intra – abdominal pressure

• Urge : Inability to delay voiding after sensation of bladder fullness is perceived

• Mixed: Combination of above• Overflow: Due to mechanical forces on an

over distended bladder( Urinary retention/ Abnormal bladder and sphincter function)

Elderly mistreatment

• The willful infliction of pain, injury or causing mental anguish to an elder person.

• Very common – Physical abuse• Neglect• Financial or material abuse• Psychological and verbal abuse• Violation of a trusting

relationship

Risk factors for elderly abuse

• Disability• Cognitive impairment• Abusers likely to abuse alcohol/drugs• Abuser dependency• Living arrangement• External stress• Social isolation• History of violence of the abuser

Dementia

Dementia

• Progressive cognitive and behavioral deficits accompanied by structural abnormalities of the brain.

• DSM IV criteria:• 1. Memory impairment• 2. One of the following disturbances:• - Language disturbance• -Impaired ability to carry out motoric activities• - Failure to identify objects• - Disturbance in executive functioning• 3.Significant impairment in social and occupational functioning• 4.Do not occur during the course of delirium

Mild cognitive impairment

• Memory complaint• Memory impairment for age and education• Preserved general cognitive function• Intact social and occupational function

Parkinson’s Disease

• Any combination of six independent motoric features:

• 1.Rest tremor• 2.Bradykinesia• 3.Rigidity• 4.Loss of postural reflexes• 5.Flexed posture• 6.Freezing phenomenon( Feet glued to the

ground)