Slide 1

Slide 2 Providing optimal health outcomes (1) a team approach to care delivery either in a designated unit (2) targeted assessment techniques to prevent complications; (3) an increased emphasis on discharge planning and (4) enhanced communication between care providers across the care continuum. Slide 3 Medical Care Of The Aged 2 major issues in the aged: Physiological changes alter the course of disease Physiological changes alter the course of disease Disease is often associated with functional impairment Disease is often associated with functional impairment Slide 4 Disease in the aged is characterized by: Rapid deterioration Rapid deterioration Multiple diseases present Multiple diseases present Non-specific presentation Non-specific presentation Many complications Many complications Greater need for support after initial treatment Greater need for support after initial treatment Slide 5 Examples MI without pain MI without pain Pneumonia without fever Pneumonia without fever Bowel obstruction without pain Bowel obstruction without pain Therefore determining the degree of urgency is more difficult in the aged. Therefore determining the degree of urgency is more difficult in the aged. Slide 6 Medical Care Of The Aged 2 major issues in the aged: Physiological changes alter the course of disease Physiological changes alter the course of disease Disease is often associated with functional impairment Disease is often associated with functional impairment Slide 7 Functional decline is one of the commonest geriatric syndromes. Functional decline is rapidly evolving and dynamic, and can be reversed. Slide 8 risk factors risk factors active pathology active pathology impairment impairment functional limitation functional limitation disability disability death Slide 9 Function includes: Physical Physical Cognitive Cognitive Psychological Psychological Social Social Slide 10 Effects of disease: loss of independence and autonomy loss of independence and autonomy loss of mobility loss of mobility loss of social connections loss of social connections loss of dignity and privacy loss of dignity and privacy loss of confidence and self esteem loss of confidence and self esteem source of pain and suffering source of pain and suffering Slide 11 Social ParticipationCognitive Function Health and well-being Economic PhysicalEmotional Slide 12 As life span increases, an important question is emerging. Will the increased duration of life be associated with an increased period of infirmity and chronic disease (will there be compression of morbidity? Slide 13 Slide 14 Functional health is more important than biological health the primary aim of many aged people is to maintain an independent lifestyle. Functional health is more important than biological health the primary aim of many aged people is to maintain an independent lifestyle. Functional health measurements are more useful than objective indicators of health. Functional health measurements are more useful than objective indicators of health. Slide 15 A Definition Of Dysfunction We can define dysfunction as the incapacity of a system to perform at a certain level. We can define dysfunction as the incapacity of a system to perform at a certain level. Dysfunction then becomes a relative concept. Dysfunction then becomes a relative concept. We therefore need a benchmark to judge dysfunction against. We therefore need a benchmark to judge dysfunction against. Slide 16 A useful concept is Activities of Daily Living (ADLs). These cover the areas of: A useful concept is Activities of Daily Living (ADLs). These cover the areas of: work work recreation recreation self care self care A functional individual can perform activities in these three domains to a level which satisfies themselves. A functional individual can perform activities in these three domains to a level which satisfies themselves. Slide 17 Factors associated with functional disability Age Age Gender women suffer more disability Gender women suffer more disability Cognitive impairment Cognitive impairment Depression Depression Vision impairment Vision impairment Other illnesses Other illnesses Total disease burden Total disease burden Increased or decreased BMI Increased or decreased BMI Low physical activity Low physical activity Functional limitation in legs Functional limitation in legs Self perceived health Self perceived health Low levels of social contact Low levels of social contact Smoking Smoking Alcohol Alcohol Slide 18 The diseases which are most likely to lead to functional disability are: The diseases which are most likely to lead to functional disability are: cerebrovascular disease (which doubles the risk of functional dependence within four years); cerebrovascular disease (which doubles the risk of functional dependence within four years); arthritis (which increases the risk of functional dependence within four years 1.5 times); arthritis (which increases the risk of functional dependence within four years 1.5 times); coronary artery disease (increases the risk by 1.5). coronary artery disease (increases the risk by 1.5). Slide 19 The geriatric giants Functional disabilities resulting from pathology Immobility Immobility Instability Instability Incontinence Incontinence Intellectual impairment Intellectual impairment Slide 20 The giants of geriatrics result from multiple diseases in multiple organs All contributing Medical Medical Psychosocial and Psychosocial and Environmental Environmental factors should be taken into consideration Slide 21 Medical evaluation: Physical assessment Physical assessment Psychological assessment Psychological assessment Functional evaluation ADL ADL Environmental assessment Social Social Physical Physical Slide 22 Immobility Immobility is the inability to occupy space a contraction of the world in the person lives Slide 23 Causes of Immobility Physical barriers Physical symptoms Psychological barriers Social barriers Loss of capability Slide 24 Instability Instability is the lack of ability to correct displacement of the body during its movement through space due to problems in detecting problems in detecting problems in correcting problems in correctingmovement Slide 25 Balance involves Ocular mechanisms Ocular mechanisms Vestibular mechanisms Vestibular mechanisms Proprioceptive mechanisms Proprioceptive mechanisms Slide 26 Falls Approximately 25% of 70 year olds experience at least one fall per year rising to 35% in the over 75s. In the over 65s falls are the sixth commonest cause of, and account for 5% of all deaths. Slide 27 In 2008-9 rate of hospitalisation for falls in Australia exceeded 3,000 / 10,000 population In 2008-9 rate of hospitalisation for falls in Australia exceeded 3,000 / 10,000 population Rate of injury is steadily increasing Rate of injury is steadily increasing 33% of hospitalizations due to injuries to hip and thigh but hip fractures are decreasing 33% of hospitalizations due to injuries to hip and thigh but hip fractures are decreasing Head injuries are increasing Head injuries are increasing Slide 28 Causes of falls Impaired balance due to ageing ageing environmental factors environmental factors medical factors medical factors Age related changes: Poorer visual acuity and contrast sensitivity Poorer visual acuity and contrast sensitivity Poorer tactile sensitivity Poorer tactile sensitivity Poorer kinaesthetic sensitivity in limbs Poorer kinaesthetic sensitivity in limbs Less muscle power Less muscle power Slower muscle activation Slower muscle activation Slide 29 Falls are more common in Falls are more common in Females Females Those who have had falls Those who have had falls Those who are afraid of falling Those who are afraid of falling Slide 30 Incontinence Requires: Impaired function of bladder or bowel Impaired function of bladder or bowelPlus Extrinsic factors urinary tract disease urinary tract disease constipation constipation impaired mobility impaired mobility brain failure brain failure drug therapy drug therapy Slide 31 Intellectual Impairment Characterized by Impaired memory and withdrawal from familiar tasks Impaired memory and withdrawal from familiar tasks Failure to perform properly tasks which were previously undertaken Failure to perform properly tasks which were previously undertaken Disruptive/dangerous behaviour Disruptive/dangerous behaviour Slide 32 Frailty Frailty is a constellation of many conditions. Frailty is a constellation of many conditions. It can be described as excessive demand placed on reduced capacity. It can be described as excessive demand placed on reduced capacity. When determining if someone is frail, it may be useful to consider the account of assets and liabilities. When determining if someone is frail, it may be useful to consider the account of assets and liabilities. Slide 33 Assets are the things that help a person live in the community: Health Health Functional capacity Functional capacity Self reported health Self reported health Social and financial resources Social and financial resources The liabilities are:The liabilities are: Ill health Ill health Disability Disability Dependence on others Dependence on others Slide 34 Wasting of muscle and loss of strength Wasting of muscle and loss of strength Loss of endurance Loss of endurance Decreased balance and mobility Decreased balance and mobility Slowed performance Slowed performance Inactivity Inactivity Changes in cognitive function Changes in cognitive function Slide 35 Frailty is associated withFrailty is associated with Undernutrition Undernutrition Functional dependence Functional dependence Prolonged bed rest Prolonged bed rest Pressure sores Pressure sores Gait disorders Gait disorders Generalised weakness Generalised weakness Weight loss and anorexia Weight loss and anorexia Dementia & delirium Dementia & delirium Fear of falling Fear of falling Staying inside Staying inside Polypharmacy Polypharmacy Slide 36 Hospitalisation Presenting signs are often non-specific Presenting signs are often non-specific Delayed treatment Delayed treatment Increased length of stay Increased length of stay Increased morbidity and mortality Increased morbidity and mortality Slide 37 Pain Impacts on Impacts on Physical Physical Psychological Psychological Cognitive Cognitivefunction Slide 38 Hospitals are dangerous Making treatment decisions for the aged is difficult Making treatment decisions for the aged is difficult There is a fine balance between risk and benefit There is a fine balance between risk and benefit Slide 39 33% of people leave hospital with a new functional impairment 33% of people leave hospital with a new functional impairment Treatment in hospital must include measures to maintain functional status Treatment in hospital must include measures to maintain functional status Functional declines are usually unrelated to the reason for admission; they are effects of hospitalization itself Functional declines are usually unrelated to the reason for admission; they are effects of hospitalization itself The decrease occurs very early in the hospital stay. The decrease occurs very early in the hospital stay. Slide 40 23% of patients who declined in ADL function before admission failed to recover to previous function before discharge 23% of patients who declined in ADL function before admission failed to recover to previous function before discharge 12% of patients declined between hospital admission and discharge. 12% of patients declined between hospital admission and discharge. Covinsky et al. (2003) Journal of the American Geriatrics Society 51: 451458 Covinsky et al. (2003) Journal of the American Geriatrics Society 51: 451458 Slide 41 Activity % Independent at admission % Independent at discharge Bathing7160 Dressing7264 Transferring7061 Toileting8677 Eating8375 Covinsky et al. (2003) Covinsky et al. (2003) Journal of the American Geriatrics Society 51: 451458 Slide 42 Because of the temporary absence of the need or opportunity to perform ADLs during hospitalisation, the aged may not be aware of losses in functional capacity, and may overestimate their self-care skills. Because of the temporary absence of the need or opportunity to perform ADLs during hospitalisation, the aged may not be aware of losses in functional capacity, and may overestimate their self-care skills. Slide 43 Rehabilitation All sick elderly patients require active rehabilitation from day one of their acute illness. All sick elderly patients require active rehabilitation from day one of their acute illness. Slide 44 Rehabilitating elderly people Multiple pathologies - increases complexity Multiple pathologies - increases complexity Mental impairment - learning difficulties, inability to grasp new concepts or ways of doing things Mental impairment - learning difficulties, inability to grasp new concepts or ways of doing things Personality - a key factor in determining outcome. Personality - a key factor in determining outcome. Slide 45 Principles of Rehabilitation Objectives should be: Specific Specific Concrete Concrete Realistic Realistic Dated Dated And known to Patient Patient Relatives Relatives Staff Staff Slide 46 Therapeutic Interventions What would you do if a test was positive? What would you do if a test was positive? What would you do if a test was negative? What would you do if a test was negative? If the answer is the same then dont do the test. If the answer is the same then dont do the test. Slide 47 Pharmacology Appropriately used, drugs will increase quality of life. Appropriately used, drugs will increase quality of life. However, drugs can be responsible for serious side effects which may result in hospitalisation and even death However, drugs can be responsible for serious side effects which may result in hospitalisation and even death Slide 48 Pharmacokinetics The important factors to be considered in describing the movement of the drug through the body The important factors to be considered in describing the movement of the drug through the body Slide 49 Absorption A drug must be absorbed before it can have any effect A drug must be absorbed before it can have any effect Slide 50 Distribution The process by which drug is carried from its absorption site to its site of action. The process by which drug is carried from its absorption site to its site of action. Many drugs are transported in the blood bound to plasma proteins. Many drugs are transported in the blood bound to plasma proteins. Slide 51 Biotransformation Drugs with low water solubility are metabolised to make them more soluble The chemical reactions which make the drug more soluble decrease its pharmacological activity Drugs with low water solubility are metabolised to make them more soluble The chemical reactions which make the drug more soluble decrease its pharmacological activity Slide 52 Elimination Removal of the drug from the body. Mostly via the kidneys. Mostly via the kidneys. Slide 53 Measuring Drug Action Most common method is measuring half life. Most common method is measuring half life. The half life is the interval required for the elimination processes to reduce drug concentrations in the body by 50%. The half life is the interval required for the elimination processes to reduce drug concentrations in the body by 50%. Slide 54 For a drug to be effective, its concentration must exceed the Minimum Effective Concentration (MEC). For a drug to be effective, its concentration must exceed the Minimum Effective Concentration (MEC). The concentration of the drug must remain below the Minimum Toxic Concentration (MTC) The concentration of the drug must remain below the Minimum Toxic Concentration (MTC) The safety margin between the MAC and the MTC is the Therapeutic Index The safety margin between the MAC and the MTC is the Therapeutic Index Slide 55 For a drug to be effective, its concentration must exceed the Minimum Effective Concentration (MEC) must exceed the Minimum Effective Concentration (MEC) must remain below the Minimum Toxic Concentration (MTC) must remain below the Minimum Toxic Concentration (MTC) Slide 56 Pharmacology Of The Aged Absorption is affected by : changes in the motility of the stomach and intestines which occur as the subject ages. changes in the motility of the stomach and intestines which occur as the subject ages. diseases such as congestive heart failure diseases such as congestive heart failure Howeverabsorption becomes less important when drugs are taken chronically. Slide 57 Distribution is affected by increased body fat and decreased body water. Plasma protein levels in the blood fall due to age, immobility, and chronic disease. Slide 58 Metabolism is often slower in the aged as the result of decreased liver function. Metabolism is often slower in the aged as the result of decreased liver function. In general, the clearance rate of drugs in the aged is about 66% of that in younger people. In general, the clearance rate of drugs in the aged is about 66% of that in younger people. Slide 59 Excretion is the aspect of pharmacokinetics most affected by ageing. Excretion is the aspect of pharmacokinetics most affected by ageing. This is due to changes in kidney function. Renal blood flow falls with age - by 60 it is about 50% of the blood flow in a young adult. This is due to changes in kidney function. Renal blood flow falls with age - by 60 it is about 50% of the blood flow in a young adult. Slide 60 Changes In Pharmacokinetics procaine penicillin IM25 yo 10 h 77 yo 18 h doxycycline20 yo 11.9 h 42 yo 17.7 h diazepam (Valium)30 yo 30 h 65 yo 70 h propranolol (Inderal)29 yo 3.58 h 80 yo 3.56 h paracetamol24 yo 1.82 h 81 yo 3.03 h Slide 61 Adverse Reactions An adverse reaction is an undesired consequence of drug treatment. An adverse reaction is an undesired consequence of drug treatment. The incidence increases as people age. The incidence increases as people age. Patients aged between 60 and 70 years have twice the incidence of adverse reactions compared with people under 50. Patients aged between 60 and 70 years have twice the incidence of adverse reactions compared with people under 50. Slide 62 A previous history of an adverse reaction increases the risk of further reactions occurring. A previous history of an adverse reaction increases the risk of further reactions occurring. The second factor is the number of drugs being taken. The second factor is the number of drugs being taken. Over the counter preparations increase the risk of adverse reactions. Over the counter preparations increase the risk of adverse reactions. Slide 63 Drugs Likely To Cause Adverse Reactions benzodiazepines (eg valium) benzodiazepines (eg valium) non steroidal antiinflammatories (eg. aspirin, naproxen, ibuprofen) non steroidal antiinflammatories (eg. aspirin, naproxen, ibuprofen) opiate analgesics (eg codeine) opiate analgesics (eg codeine) major tranquillisers major tranquillisers diuretics diuretics Slide 64 The clearest indication that an adverse reaction has occurred is a temporal association between the onset of symptoms and the addition of a new drug or change in the dosing schedule. The clearest indication that an adverse reaction has occurred is a temporal association between the onset of symptoms and the addition of a new drug or change in the dosing schedule. Slide 65 Common ADRs CENTRAL NERVOUS SYSTEM mental compromise mental compromise depression depression excitation excitation cognitive defects cognitive defects amnesia amnesia ataxia ataxia Slide 66 CARDIOVASCULAR SYSTEM orthostatic hypotension orthostatic hypotension hypertension hypertension dysrhythmias dysrhythmias angina angina Slide 67 GASTROINTESINAL SYSTEM gastritis gastritis gastro oesophageal reflux gastro oesophageal reflux constipation constipation diarrhoea diarrhoea ulceration ulceration Slide 68 Overprescribing Overprescribing is one factor which may contribute to the incidence of adverse reactions. Overprescribing is one factor which may contribute to the incidence of adverse reactions. Slide 69 An elderly woman is living with her son, one of her seven children. Her daughter in law feels that her husband is unfairly burdened with responsibility for looking after his mother, and resents her presence in the house. The tension between the married couple is obvious, and a cause of great concern to the mother in law. Recently, the situation has been made worse by nocturnal incontinence suffered by the elderly woman. She has tried to conceal this from her son and daughter in law, but her attempts to change the bed in the middle of the night have disturbed the sleep of the family. Increasingly, the elderly woman is suffering from insomnia. This is yet another cause for concern, and she decides to consult with her doctor. On arrival at the practice, she finds the GP has taken a holiday, and employed a locum to cover her absence. The elderly woman discusses the problem of insomnia with the locum, and is prescribed valium to help her sleep. Three months later, she is admitted to a nursing home. Slide 70 Compliance Compliance refers to how well a patient follows the instructions relating to drug use. Compliance refers to how well a patient follows the instructions relating to drug use. The elderly have the best compliance of any age group. The elderly have the best compliance of any age group. Compliance decreases as the number of drugs being taken increases, and the duration of treatment increases. Compliance decreases as the number of drugs being taken increases, and the duration of treatment increases. The patient must be mentally and physically able to comply with the treatment programme. The patient must be mentally and physically able to comply with the treatment programme. The patient must want to comply. The patient must want to comply. Slide 71 Generally, patients will comply if they understand the treatment is beneficial, and if the benefits outweigh the costs and inconveniences. Generally, patients will comply if they understand the treatment is beneficial, and if the benefits outweigh the costs and inconveniences. The most common reason why a patient will stop taking drugs is that the drugs are having no beneficial effect. The most common reason why a patient will stop taking drugs is that the drugs are having no beneficial effect. Slide 72 World Health Organisation Recommendations 1. Drugs should not be used for longer than necessary and should be reviewed at periodic intervals. 2. Drug treatment should not be regarded as a substitute for advice or adjustments to daily living. 3. The margin between the therapeutic effect and the toxic dose is in many cases small, and drugs suitable for young people may not be suitable for aged people with the same condition. Slide 73 4. The smallest number of drugs should be used and the regime should be easy to follow. 5. Touch and colour vision are well preserved in the aged making size, shape and colour of the drugs very important. Liquid preparations are usually acceptable. Large tablets may be difficult to swallow. 6. Clear packaging which is easily opened is essential. Slide 74 7. The patient should be educated about their drugs. 8. A friend or relative may need to be involved to ensure compliance. 9. There must be regular reviews of treatment.