Geriatric Syndromes

Common problems that affect older adults
o Frailty
o Delirium
o Falls
o Sleep disorders
o Dizziness
o Syncope
o Dysphagia
o Pressure ulcers
o Elder mistreatment
o Urinary Incontinence
Osteoporosis

Falls, disability, hospitalization and death

- Unintentional weight loss (> 10 lbs over a year)
- Self-reported exhaustion
- Weakness (grip strength)
- Slow walking speed
- Low physical activity

- Mildly frail = Limited dependence on others for instrumental activities of daily living
- Moderately frail = Help is needed with both instrumental and non-instrumental activities of daily living
- Severely frail = Completely dependent on others for the activities of daily living, or terminally ill

Basic self-care activities:
- Dressing
- Eating
- Ambulating
- Transfers
- Toileting/continence
- Hygiene

Needed to function independently in the community;
require physical + cognitive function
- Shopping
- Housework
- Accounting
- Food preparation
- Transportation
- Telephone use

Delirium

A) A disturbance in attention and awareness
- Reduced ability to direct, focus, sustain, and shift attention
- Reduced orientation to the environment
B) The disturbance:
- Occurs over a short period of time (usually hours to a few days)
- Represents a change from baseline attention and awareness, and
- Tends to fluctuate in severity during the course of a day.
C) An additional disturbance in cognition
- e.g., memory deficit, disorientation, language, visuospatial ability, or perception

Disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

· Hypoxia
· Dehydration
· Electrolyte disturbances
· Pain
· Medications

- Anticholinergics
- Benzodiazepines
- Opioids

*Treat delirium by finding and reversing the underlying cause = NO treatment*

TRUE

- Non-Syncopal: Unintentional events where the person comes to rest on the floor or ground that are NOT caused by loss of consciousness, stroke, seizure, or overwhelming force
- Syncopal: Fall caused by a transient, self-limited loss of consciousness

Transient, self-limited loss of consciousness usually leading to falling
- Rapid onset
- Spontaneous, complete, and prompt recovery

Caused by transient and sudden drop of cerebral oxygen delivery
- Due to altered cerebral autoregulation

- Reflex syncopal syndromes = Vasovagal faint
- Orthostatic hypotension = **Medications**
- Cardiac arrhythmias
- Structural cardiac disease
- Cerebrovascular

TRUE

- Psychoactive medication use
- Use of 4+ medications

When they cause an injury (mostly fractures)

· Any psychotropic
· Antipsychotic
· Sedatives/hypnotics
· Any benzodiazepine
· TCAs
· Type 1a anti-arrhythmic
· Digoxin

- Adapt or modify home
- Withdraw or minimize harmful medications: Sedative/hypnotics, anxiolytics, antidepressants, antipsychotics
- Reduce the total number of medications (4+)
- Manage postural hypotension
- Treat foot problems
- Wear appropriate shoes
- Regular exercise
- Correct known vision problems
- Vitamin D supplement ≥ 800 units/day

SBP > 20 mmHg or DBP > 10 mmHg

Dizziness / Postural unsteadiness / Syncope / Falls

- Volume depletion
- Baroreflex dysfunction
- Autonomic insufficiency
- Venodilators: α-blockers / α-β blockers

- Rise slowly from sitting or supine position
- Cross legs while standing and contract muscles for 30 seconds
- Raise head of bed by 20-30 degrees
- Use waist high compression stockings
- Increase sodium and water intake (except in HF patients)
** Goal of non-pharm therapy is to increase venous return to the heart**

- Discontinue causative medications
- Fludricortisone: 0.1 mg daily starting dose / 0.3 mg daily maximum
- Midodrine: 2.5 mg TID starting dose / 10 mg TID maximum

- Take longer to fall asleep
- Have lower sleep efficiency
- Have more nighttime awakenings
- Wake up earlier than they would like
- Require more daytime naps

Low quantity and/or poor quality of sleep resulting in a sense of non-restorative sleep

Sleep hygiene
- Check effect of medications on sedation/wakefulness
- Avoid caffeine, alcohol, and cigarettes after lunch
- Limit liquids in the evening
- Keep a regular bedtime/wake schedule
- Avoid naps or limit to one per day, no longer than 30 minutes

- Always be accompanied by behavioral interventions
- Prescribe the lowest effective dose
- Use hypnotics with shorter half-lives

5 mg IR or 6.25 mg CR

- Have patient swallow medications while fully upright if possible
- Change medications to liquids or powders which can be taken on top of food
- Be knowledgeable about which medications can be crushed

Pressure Ulcers

Prevention is the best treatment!
- Reposition every two hours
- Manage incontinence
Debridement: Necessary for Stage III-IV ulcers
Occlusive, moisture-retaining dressing: Key for Stage I-II ulcers
Appropriate analgesia for dressing changes
Maximize nutrition