Geriatric Medicine – an
overview for final year medical
studnets
David J Stott
David Cargill Professor of Geriatric Medicine
Aims and objectives
• Knowledge
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Presentation of disease in later life
Pragmatic approach to care
Comprehensive Geriatric Assessment
Rehabilitation
• Skills
– Diagnosis
• Attitudes
– Ethical approach
– Positive / realistic attitude outcomes healthcare for
older people
Geriatric Giants – non-specific
presentation of disease / frailty
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Instability (falls)
Immobility (‘off feet’)
Incontinence
Intellectual impairment
(delirium and dementia)
Case presentation, 85yrs female
• Cognitively slow
– responds simple motor
commands
– 2/4 on AMT4
• Surrogate history (daughter)
– 1 week deterioration mobility,
assistance to transfer / walk,
confusion
– Fall out of bed
– Urinary incontinence
• PMH
– MI, # femur, depression
– Deaf, hearing aids
– Short-sighted, glasses
• Drugs
– 10 on prescription
• FH/SH
– Lives alone, home help daily
Observations / basic
investigations
• Thin
• Temp 38.5oC
• Lying / standing BP
112/70, 90/68 mmHg
• Crackles R lung base
• Na 118 mmol/L
• Urea 15.2 mmol/L
• WBC 24.9 109/L
• CRP 250
Construct a problem list
• Brainstorming
– Long list
• Organising
– Key domains
• Prioritising
– What needs sorted first
Key concepts in geriatric
medicine
• Non-specific
presentation of disease
• Frailty
• Multiple diseases
• Iatrogenesis
– adverse drug reactions
• Reduced homeostatic
reserve
• Multiple problems
• Complex solutions
Testing comprehension
• Single stage motor
commands
– Show me your tongue
• 2 or 3-stage motor
commands
– Take this paper in your left
hand, fold it in half, and
hand it back to me (put it on
the floor/table)
Causes of impairment
• Reduced conscious level
• Deafness
• Depression
• Dysphasia
• Resistive / non-cooperative
• Severe delirium / dementia
• Motor deficit
– (weakness, pain)
Is this older person confused?
Diagnosis
Recognition
Dementia
Delirium
Treatment
Prevention
4-point Abbreviated Mental Test
(AMT4)
1.
2.
3.
4.
what year are we in?
what do we call this place you are in?
how old are you?
what is your date of birth?
Reasons older people score badly on
formal cognitive testing
• Cognitive impairment
– Delirium, Dementia
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Deafness, visual impairment
Motor deficit
Dysphasia
Reduced conscious level
Resistiveness
Distracted (pain, emotional distress, depression)
Diagnostic criteria for dementia
(DSM IV-R)
• Impaired short and long-term memory
• At least two of; impaired abstract thinking,
poor judgement, dysphasia / dyspraxia /
agnosia, personality change
• Interferes with work or social activities
• No delirium
• Identified organic cause / no non-organic
mental disorder
Prevalence of dementia (%) by age
(yrs)
Mild cognitive impairment (MCI) and
dementia, age > 65
MCI
16.8%
Dementia
8.0%
MCI + dementia
24.8%
Graham, Lancet 1997;349:1793
Cognitive decline in older people
– the interaction of Alzheimer
pathology and vascular disease
Neurofibrillary
tangles
Small vessel
ischaemia - deep
white matter
Beta-amyloid
Confusion assessment method
(CAM) criteria for delirium
1.
2.
3.
4.
Acute change in mental status
Inattention (fluctuation)
Disorganised thinking
Altered level of consciousness
Delirium requires 1 + 2 + (3 or 4)
Cumulative incidence of delirium
in hospitalised patients
Age > 65 years
15-20%
‘Frail’ elderly
40-60%
Prior chronic
30-45%
cognitive impairment
Cochrane Database of Systematic
Reviews
Outcome of delirium
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Prolonged hospital stay
Increased mortality
Increased costs of health care
Residual cognitive impairment
Increased risk of progression to dementia
Causes of delirium
Disturbance
Infection
Cardio-respiratory
Fluid / electrolyte
Metabolic
Intracranial
Drug
toxicity/withdrawal
% of cases
35
32
30
13
12
20
O'Keefe & Lavan, Age Ageing
1999;28: 115
Basic protocols of care for frail older
people reduce the risk of delirium
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Orientation / cognitive stimulation
Non-pharmacological sleep protocol
Early mobilisation
Visual aids / adaptations
Hearing aids etc
Active rehydration
Inouye NEJM 1999; 340: 669
Incidence of delirium
Assessing mobility
• History (patient / surrogate) – current and usual status
– Bed / chair transfers, walking
– Independent / personal assistance (eg 1 or 2 people)
– Aids (Zimmer, stick etc)
• Examination
– Transfers (bed / chair, gait)
• Timed up-and-go test
– Usual walking aid
History taking and falls risk
assessment for older people
• All older individuals should be asked whether they
have fallen (in the past year)
• An older person who reports a fall should be asked
about the frequency and circumstances of the
fall(s)
• Older individuals should be asked if they
experience difficulties with walking or balance
• Contributory medicines
A fall is a symptom not a diagnosis
Common causes to consider • Postural hypotension
• Paroxysmal cardiac arrhythmias
• Epilepsy
• Neurological disease
– (eg stroke, Parkinson’s, cervical myelopathy)
• Sarcopaenia
– (eg undernutrition)
• Poor judgement of capabilities
– (eg dementia)
Summary – history taking in older patient
Things to do
• Test comprehension / cognition
– Simple motor commands
– AMT4
– Surrogate history if problem
• Identify geriatric giants
• Determine mobility aids and needs
for personal assistance
• Recognise communication barriers
– Sensory impairment
• Hearing aid, Spectacles
– Distracted patient
• Pain, emotional distress
• Recognise iatrogenesis
• Patient / carer wishes / fears
Things to avoid
• Trying to take detailed
history from patient with
communication impairment
• Planning care without
taking into account patient
and carer views
Key concept - multidisciplinary
care for the frail older person
• Rehabilitation
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Assessment
Nursing
Medical treatment
Goal-setting
Physical therapy
Aids and adaptations
Education
Psychological support
Evaluation / follow-up
Patient and carers
Comprehensive geriatric assessment
for older adults admitted to hospital
• 22 trials, 6 countries, 10315 elderly participants
• Patients given CGA were – More likely to end up alive and in their own homes
(6 months OR 1.25, 95% CI 1.11 to 1.42, P = 0.0002)
– Less likely to be institutionalised
(OR 0.79, 95% CI 0.69 to 0.88, P < 0.0001)
– More likely to have improved cognition
(OR 1.11, 95% CI 0.20 to 2.01, P = 0.02).
• Compared to general medical care
Ellis CDSR 2011
The importance of the multi- or
inter-disciplinary case conference
• Key component of
proven systems of
CGA in hospital
• Medical
involvement
• Minimum weekly
face-face meetings
Community-based
multidisciplinary care
• Randomised controlled trials of communitybased multifactorial interventions
• 89 trials including 97984 elderly people
• Reduced nursing home admissions
RR=0·87 (95%CI 0·83,0·90)
• Death RR=1·00 (95%CI 0·97,1·02)
Beswick, Lancet 2008; 371: 725
Conclusion – comprehensive
multidisciplinary assessment and
rehabilitation for frail older people
In hospital
• Reduces disability
• Reduces risk of cognitive decline
• Increases chances of survival
In community
• Increases chances of independent living
Thank-you for your attention!