Dr Carol ChongGeriatrician and Supervisor of Intern Training

The Northern HospitalOctober 19th 2012

You need to be aware of aged care issues. Older patients are everywhere!

• Dementia• Delirium (… wait for Dr Holbeach’s talk!)• Falls in hospital• Functional decline• Polypharmacy• Incontinence• Aged Care Services (and all the acronyms!)

1) Look out for patients with dementia 2) Liaise with families whenever possible 3) Know the patient’s premorbid functional

status 4) If someone has fallen, you need to work

out why 5) Beware the confused patient, they can do

badly

Know which patients have cognitive impairment or dementia

You’ll have to liaise more closely with family members eg. for consent, letting them know what’s happening

Prone to delirium and other complications

Will save a lot of heartache later… Should liase with the family asap (particularly

if patient has memory problems)◦ - you are available and care

Speaking to the family will help you gather important info, gain rapport and save you time later.

Communication breakdown is a major cause of complaints. Your consultant will love you if you are a communicator!

Impairment of memory +

Another cognitive domain (aphasia, apraxia, agnosia, executive dysfunction)

+ **Functional impairment (decline from previous

level of function, severe enough to interfere with daily function (versus mild cognitive impairment)

Not reversible, not due to psych illness.

Often diagnosed as an outpatient. Need to exclude delirium.

Alzheimer’s 60-80% Lewy Body 10-20% Vascular 10-20% Mixed Alzheimer’s and Vascular Dementia Fronto-temporal

Other – Alcohol related, CJD, Huntington’s etc

“Reversible” dementia ◦ pseudodementia Depression◦ Alcohol related (intoxication, withdrawal)◦ Normal pressure hydrocephalus◦ Medication related (opiates, sedatives,

antipsychotics)◦ Metabolic disorders◦ CNS: tumors, subdurals etc.

Mild Cognitive Impairment

Current Spectrum of DementiaFrontotemporal

Dementia4%

Hippocampal Sclerosis

1%

Dementia With Lewy Bodies

8%Pure Vascular

Dementia3%

Mixed Dementia42%

Alzheimer's Disease

42%

Barker WW, et al. Alzheimer Dis Assoc Disord. 2002;16:203-212.

N = 382

Barker WW, et al. Alzheimer Dis Assoc Disord. 2002;16:203-212.

Commonest dementia Median survival from time to diagnosis in one

study 4.2 years for men, 5.7 years for women A clinical diagnosis

Gold standard– pathological correlation of senile plaques and neurofibrillary tangles. AUTOPSY (but not practical!)

Clinical – early and accurate diagnosis is important so patients and families can plan for the future.

Insidious onset, gradual decline Symptoms: forgetful, repetitive, misplace

things Collateral history is important. Patient’s

often feel their memory is okay. Family notice STM loss.

Rule out reversible causes. FBE, U+E, LFTS, Ca, PO4, B12, folate, TFTS.

CT or MRI Brain – shrunken hippocampi

MMSE – A must! - short term memory usually impaired first. If not consider differentials.

Neuropsychological tests if diagnosis uncertain.

Other Ix – SPECT scan, PET scan, in research Amyloid scans.

Cholinesterase Inhibitors for mild-moderate AD◦ Small degree of benefit◦ Cost-benefit ratio remains controversial

Donepezil (Aricept), Galantamine (Reminyl) , Rivastigmine (Exelon)

In Australia PBS indication – MMSE between 10 – 24 or can start at higher MMSE scores now. 2 point improvement within 6 months for continuation.

Small improvements on cognitive and global function.

Loss of cholinergic neurons Reduced cerebral production of choline

acetyl transferase decreased acetylcholine

Cholinesterase inhibitors delay breakdown of acetylcholine relased into synaptic clefts and enhance cholinergic neurotransmission

Treatment for periods of 6M to 1 year produced improvements in cognitive function 1.37 points (95%CI 1.13-1.61) in MMSE

Benefits on measurements of ADLS, behaviour and global clinical state but benefits are not large.

Efficacious for mild-mod dementia Cochrane review 2006 (13 trials)

80 year old lady commenced donepezil 5mg o daily 2 days ago for Alzheimer’s Disease – presents to ED with vomiting and diarrhoea?

Can donepezil cause these symptoms?

80 year old man commenced donepezil 5mg o daily yesterday, presents with collapse

o/e b.p 90/60 pulse 40

Can donepezil cause this problem?

Usually mild and transient S.E (20%), generally well tolerated but can cause…

Nausea and vomiting (start low dose) Anorexia Diarrhoea Bradycardia (If bradycardic on examination

– check ECG and ensure no heart block) Urinary incontinence Confusion

Less GI side effects Minimal skin irritation Convenient to patients and caregivers

Start with the Exelon 5 patch, increase to the Exelon 10 patch in a month if tolerated

Case Scenario – Pt goes back to Geriatrician since donepezil is stopped and is commenced on memantine instead…

But comes into ED 3 days later complaining of dizziness.

Can this be from menantine?

Memantine (Ebixa) – for moderate to severe AD. MMSE score between 10-14 for PBS approval◦ NMDA receptor antagnoist◦ NMDA receptor involved in learning and memory ◦ Postulated to inhibit cytotoxic overstimulation of

glutamatergic neurons.◦ Neuroprotective

S.E: generally well tolerated. Dizziness most common SE. Worsening delusions and hallucinations in some.

Vitamin E (antioxidant)–No evidence from RCTsincreased mortality at high dose

SelegilineEstrogenNSAIDS and COX2 inhibitors– side effects

+CV mortalityGingko biloba – questionable efficacyPrevention: Lifestyle factors unproven but

useful to try.

50 year old man presents to ED after crashing his car into a tree. Police find him confused and disorientated. Family rush to the scene and say his personality has changed over 6 months. Very aggressive verbally, dishevelled, impulsive and does things without thinking…

Characterised by frontotemporal lobar degeneration.

In individuals aged less than 65, FTD is 2nd most common after AD

Mean age of onset 58.5 years. Family history in 20-40%, assoc with tau

gene mutation.

Presentation: behavioural problems, language difficulties (NB only a small % have memory problems initially)

Changes in personality or social conduct (90%), memory impairment (57%), language problems (56%), dysexecutive symptoms (54%)

Often mistaken as a psychiatric illness

At least 6 month history of change in personality and behaviour sufficient to interfere with interpersonal relationships◦ Disinhibition, Impulsivity, Social withdrawal,

emotional lability, apathy, reduced concern for others, poor personal hygeine,

LOSS OF INSIGHT O/E Look for frontal signs Ix: MMSE – not great at picking up frontal

impairment. Frontal Assessment Battery

Radiology – Frontal and temporal lobe atrophy may be present.

Treatment: Supportive. Patient’s often admitted to a secure ward

due to behavioural disturbance.

Associated with parkinsonism. 2nd most common neurodegenerative dementia.

CORE features Gradually progressive dementia Fluctuating cognition Visual hallucinations Motor features of parkinsonism

Supportive feature Repeated falls Syncopy Sensitivity to neuroleptics REM sleep disorder

Beware of these patients. Can’t give regular antipsychotics for

behavioural disturbance

Parkinsonism◦ Avoid antipsychotics (except can trial quetiapine)◦ *Consider benzodiazepines to treat behavioural

disturbance◦ *Avoid Metoclopramide for vomiting

Give domperidone instead

Pathology= presence of lewy bodies in brainstem and cortex

Treatment: Cholinesterase inhibitors (some evidence that cholinergic deficit is greater than in Alzheimer’s)

Rivastigmine found to be of benefit in 1 multicentre trial.

Beware of neuroleptic sensitivity – difficulty in avoiding in patients with psychosis

Post-stroke cognitive deficits Stepwise deterioration, less predictable

course Diverse manifestations

◦ Cognitive deficits depending on which part of the brain is affected.

◦ MMSE variable 0/E neurological deficits Imaging shows infarcts Treatment: Stroke risk factors.

Antiplatelet agent. No conclusive evidence for cholinesterase inhibitors

Very useful Should be first line before anti-psychotics. Activity groups Carer’s groups

For behavioural and psychological symptoms of dementia where non-pharmacological measures have not worked.

Judicious use, short term use.

Risperidone (Riserdal) * only one on PBS for BPSD. S

Olanzapine (Zyprexia) Quetiapine (Seroquel)

Side effects: Somnolence, Parkinsonism, gait disturbance, postural hypotenstion

Med Reg asks you to admit an 88 year old lady with pneumonia. Has multiple other medical problems including IHD, CCF, AF.

Not sure of home situation…

It’s up to you to take a history

This helps with discharge planning! Where do they live?

◦ Home alone vs with family vs residential care Ask about ADLs

◦ Personal ADLs◦ Domestic ADLs◦ Community ALDLs◦ Cognition◦ Mobility, gait aids

Allied health team can help you gather info◦Your best friends!

Physiotherapist – premorbid mobility is important◦Use of a gait aid, frame, steps in and out

the house

Occupational therapist- home set up, daily activities

Social worker – what’s really happening, can the patient manage at home?

Speech Pathologist – swallowing or speech difficulties

Dietician – supplements are usefulPodiatrist – ulcers, diabetic feet etc

Low or high level?

D/c planning is often easier Aged care unit often looks after these

patients

In general, need to be able to walk 50 metres independently (can use an aid eg. frame)

Be able to self toilet or manage continence aid

Will get assistance with showering/dressing and medication management

Dementia specific hostels – secure ward

Full nursing care Assistance with showering, dressing,

toileting, feeding, walking

Thinking of sending someone to GEM or Rehab or placement (hostel or nursing home)

Help to liaise with allied health and nursing staff

HLC – LLC – ACAS – PAG – HH – MOW – PCA – CAPS – EACH –

HLC – High level care LLC – Low level care ACAS – Aged Care Assessment Service – for level of

care paperwork,respite case management PAG – planned activity group HH – Home help usually fortnightly MOW – Meals on wheals PCA – Personal care assistance CAPS – Community Aged Care Package EACH – Extended Aged Care at Home Package

A common cause of admission into hospital

Older people who fall are more likely to fall again

Be more detailed than just saying a “mechanical fall” – this phrase has little meaning.◦ Eg. tripped, slipped, lost balance

Think of the cause of the fall◦ Intrinsic vs Extrinsic causes

Impaired balance, reduced mobility, muscle weakness and lack of exercise

Cognitive impairment Continence Feet and footwear Syncope and dizziness Medications Vision

Hospitals are foreign places! Common places where falls occur in

hospital◦ Near the bed – getting out of bed◦ In the bathroom

Try to prevent falls where possible If your patient has fallen or is at high

risk – you can ◦ Ask for a high-low bed◦ Chair alarms◦ 1:1 nursing for agitated patients◦ Do a thorough medical review to look for a

cause

Need to document the fall in the history Circumstances surrounding the fall Mechanism of fall – eg. slipped in the

bathroom. Any injuries sustained –minor, major

◦ Document any bruising, sites of pain so this can be followed up.

If there is pain – low threshold for ordering x-rays◦ Osteoporosis is common in the elderly◦ Minimal trauma fractures can occur◦ CT Brain – if head strike particularly if on warfarin

Work with nursing and allied health staff on a plan to prevent further falls

Engage the team, be a leader!

Dr Holbeach will tell you more….

Delirium is common Often distressing to family members Recognition is important

Be aware of aged care issues You can help the older patient in

hospital by being proactive, speak to families early and engage the allied health team

Aged care is rewarding, as small things can make a big difference!!