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Geriatric Syndromes PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Geriatric syndromes” by Shane O’Hanlon & Giuseppe Colloca.

This medical PowerPoint presentation is about Geriatric syndromes, a group of health conditions that are commonly experienced by older adults, and are typically characterized by multifactorial causes and complex interactions among multiple physiological and psychosocial systems.

Some common geriatric syndromes include Falls, Frailty, Cognitive impairment, Delirium, Incontinence, and Malnutrition etc.

Tags : Geriatric syndromes, Falls, Frailty, Cognitive impairment, Delirium, Incontinence, Malnutrition, Geriatrics, Geriatric Medicine, Geriatrics PowerPoint presentation

Published on : May 02, 2023 | Views : 1822 | Downloads : 0

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Slide 1-

Shane O’Hanlon & Giuseppe Colloca Geriatric syndromes Treviso, Italy
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Disclosure Nothing to disclose
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Case: Anna is an 84 year old lady with a new diagnosis of breast cancer Past history: hypertension, wrist fracture. Pneumonia & acute confusion 2 months ago didn’t recover to functional/cognitive baseline. Medications: alendronic acid, solifenacin, aspirin atorvastatin, bisoprolol, amlodipine, calcium +Vit D. She lives alone, walks with a zimmer frame, has a carer twice a day. Finds it difficult to climb stairs. Exam: BMI 16. Muscle wasting.
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Geriatric Syndromes Cognitive impairment Malnutrition Mobility impairment & falls Osteoporosis Functional impairment Incontinence Sarcopenia Frailty Polypharmacy
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"a number of symptoms occurring together" συνδρομή, συν δρόμος
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Using the term syndrome is somewhat misleading since this term is normally used to describe a pattern of symptoms and signs that have a single underlying cause. Geriatric syndromes, by contrast, refer to "multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational challenges.”
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The term geriatric syndrome is used to capture clinical conditions that are frequently encountered in older persons, have a deleterious effect on function and quality of life, have multifactorial pathophysiology, often involving systems unrelated to the apparent chief complaint, and are manifested by stereotypical clinical presentations.
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Geriatric syndromes reflect the complex interactions between an individual's vulnerabilities and exposure to stressors or challenges.
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Geriatric Syndromes Cognitive impairment Malnutrition Mobility impairment & falls Osteoporosis Functional impairment Incontinence Sarcopenia Frailty Polypharmacy
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Geriatric Syndromes Older adults with cancer have more geriatric syndromes than older adults without cancer Association of Cancer With Geriatric Syndromes in Older Medicare Beneficiaries. Mohile et al (2011) JCO.
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Cognitive impairment Mild Cognitive Impairment Dementia Delirium
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Domains of cognition Memory – long term vs short term Executive function – planning/problem solving Language – object naming, word finding, speech Visuospatial – to acquire and retain visual info Orientation – time, person and place Attention – maintain a response during an activity
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Assessment of cognition
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Mild Cognitive Impairment A slight but noticeable and measurable decline in cognitive abilities, including memory and thinking skills. Not severe enough to interfere with daily function A person with MCI is at an increased risk of developing Alzheimer's or another dementia.
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Memory work-up Thorough history AND collateral history Assessment of function Neuro exam Evaluation of mood Lab tests and brain imaging (CT or MRI) Most of these are to rule out other causes
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Dementia Not one specific disease – a group term for many Decline in memory or other thinking skills At least two of these Severe enough to reduce a person’s ability to perform everyday activities Usually progressive – starts slowly, gets worse Often ignored, or thought part of ageing, by family Patients sometimes not aware
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Alzheimer’s dementia Most common type of dementia (60-80%) Age is greatest risk factor Usually gradual onset and progression Short term memory loss Average prognosis usually 4-8 years after diagnosis, but can be up to 20 years So some people can be very slowly progressive Do not use dementia as a reason for changing treatment without evaluating it!
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PET scans
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Vascular dementia Dementia caused by cerebrovascular disease 2nd most common, about 10% of dementia Can happen suddenly after stroke, or gradually as more blood supply is affected Impaired planning and judgement, word-finding difficulty, memory affected later Behaviour can change: irritable Some seem like they don’t have dementia at all! Link to vascular gait apraxia – lower limb Parkinson’s
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Brain imaging: ischaemic changes
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Signs of late dementia Deepening confusion Not recognising family members Behaviour changes Paranoid suspicions Difficulty speaking, swallowing and walking
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Can you treat it? Some causes of memory loss are treatable Hypothyroidism, depression, thiamine deficiency.. Dementia itself – no cure or treatment Medications that can temporarily improve symptoms Acetylcholinesterase inhibitors (e.g. donepezil) NMDA receptor agonist (e.g. memantine) Also memory rehabilitation
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Why diagnose it? Trial of medication Identification of risk factors that might be modified Support Advance care planning / prognosis
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Modifying risk factors Cardiovascular risk factors: blood pressure, cholesterol, diabetes, smoking, weight Exercise: regular exercise lower the risk Diet: Mediterranean diet Little meat Whole grains, fish, fruit and vegetables, nuts, olive oil
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Decision-making capacity Important to think about this in anyone with cognitive changes of any sort Can they Understand… Analyse… Remember… Communicate the information about the decision Remember it can fluctuate!
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Delirium Sudden onset confusion (or worsening) Fluctuating course Poor attention Most common in people who have some type of cognitive impairment A medical emergency!
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Screening or diagnosis We miss up to 70% of delirium So routine screening recommended, e.g. 4AT Diagnostic tool: CAM
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Consequences x2-3 times higher mortality Greater functional decline & more likely to need a nursing home More likely to be diagnosed with dementia after an episode (if no previous dementia)
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Delirium and cancer Check for dehydration Check for high calcium Check for infection Are they on steroids? Brain mets are quite rare as a cause of delirium https://academic.oup.com/annonc/article/29/Supplement_4/iv143/5046944
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Other things to check Urinary retention Constipation Opioid toxicity Sedative medications (started or stopped), or other new meds Change in environment? Any previous episodes of delirium (likely to recur)
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Malnutrition Prevalence 2-10% of older population in the community 30-60% of older people in hospital 40-85% nursing home residents 20-70% patients with cancer
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A vicious circle Malnutrition Poor appetite Reduced mobility Reduced feeding capacity Apathy, depression, poor concentration Loss of muscle strength
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Causes “Meals on wheels” Medications Emotional (depression) Alcoholism, abuse Late life paranoia Swallowing problems Oral problems Nosocomial infections Wandering/dementia Hyperthyroidism, hypercalcemia, hypoadrenalism Enteric problems (malabsoption) Eating problems (e.g. tremor) Low salt, low cholesterol diet Shopping and meal preparation problems
Slide 37-

Consequences of malnutrition for older people with cancer Loss of weight and muscle Reduced immune competence, more infections Psychosocial stress Lower quality of life Treatment toxicity Greater mortality
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ESPEN Guidelines Screen each patient's nutritional status early in the course of his or her cancer treatment. Identify signs or symptoms of anorexia, cachexia, and sarcopenia as early as possible. Measure muscle mass precisely by sensitive imaging technologies (e.g. CT) for early detection of malnutrition/sarcopenia. Use specific biomarkers to assess severity of cancer related systemic inflammation, e.g. CRP and albumin. Use indirect calorimetry to estimate resting energy expenditure (REE) in order to personalize energy and protein needs. Use nutrition and metabolic support as a vital part of cancer care Assess physical function routinely to monitor and guide physical rehabilitation. https://www.espen.org/files/ESPEN-Guidelines/PIIS0261561417302285.pdf
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Mobility impairment and falls
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Mobility impairment Loss of symmetry of movement (PD, pain, stroke) Difficulty initiating or maintaining gait (PD or vascular gait apraxia) Retropulsion (PD) Foot-drop (peripheral neuropathy, trauma) Short step length (fear of falling, arthritis, PD, vascular gait apraxia) Broad based gait (cerebellar problems, alcohol, bilateral kne or hip problems) Stops walking when talking (cognitive) Poor safety awareness (cognitive)
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Gait speed J Geriatr Phys Ther. 2003;26(3):14-22. 0.82 m/s BMJ2011;343:d7679
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Falls Yearly, 1 in 3 adults over 65 years falls In nursing homes, 1 in 2 In 40% to 60% of older people, a fall results in physical damage, of which 10-15% serious damage
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Medical risk factors Impaired musculoskeletal function, osteoporosis, gait abnormality Cardiac arrythmias, blood pressure fluctuation Depression, dementia Arthritis, hip weakness and imbalance Neurologic disorders Vision or hearing loss Side effect of medications
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Other risk factors Lack of activity Intoxication Dehydration Malnutrition Shoes and walking aids Risk factors at home
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How to assess falls History gives diagnosis in most cases Was there a prodrome (dizziness, chest pain)? Did you lose consciousness? Were there any injuries? Can you get up by yourself? Have you fallen before?
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Common causes in older people Orthostatic hypotension (too many blood pressure meds? Dehydration? Recent illness? Parkinson’s?) Also check for aortic stenosis Osteoarthritis – stiffness, pain in joints affecting mobility Medications – almost every one increases risk! Cognition – poor safety awareness Less common: arrhythmia, seizure, Parkinson’s, stroke
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How to reduce falls Multicomponent intervention Otago exercise programme (reduces risk of falls & fall-related injuries and death, improves QOL – but not bone mineral density)
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Osteoporosis A systemic disorder of the skeleton characterised by a loss of bone strength and increased risk of fractures
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Epidemiology Worldwide: 200 million people European Union: 22 million women and 5.5 million men United States: 8 million women and 2 million men Effect: 1:3 women and 1:5 over the age of 50 years will have one or more osteoporotic fractures in their lifetime
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Osteoporosis risk
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Diagnosis of osteoporosis DEXA scan But if fragility fracture in older adult, treat as osteoporosis Can also use FRAX score as a risk assessment tool – gives estimated risk of osteoporosis related fracture in the next 10 years
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Causes of osteoporosis Decreased mechanical stress Weight loss Catabolic state Chronic inflammation Medication
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Cancer related causes Steroid therapy Aromatase inhibitors Androgen deprivation therapy Chemotherapy – impact on ovaries Oophorectomy Primary bone cancer or mets increase fracture risk
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Sequelae of a hip fracture 25-33% mortality after 1 year In those >75 years: 50% mortality 25% permanent immobility Only 14-21% full recover of ADL capacity
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Vertebral fractures Finding vertebral fractures is a chance to prevent a future hip fracture Treatment (e.g. bisphosphonates or denosumab) is very good at lowering risk
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Functional impairments Limitations in IADL 40% Limitations in ADL 28% Impaired mobility 34%
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Functional impairment + cancer Very little research Huge variation across cancer types, whether treated, whether during treatment or after Many treatments will affect function, and it may be a reason to stop treatment Functional impairment may be worse than shorter survival with good QOL
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Ageing and disability
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Incontinence Prevalence in women 20-39 years 7% 40-59 years 17% 60-79 years 23% ≥80 years 32% Nursing homes 60-80% Prevalence in men: approximately 1/3 in early years, equal over 80 years
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Aetiology Changes in the lower urinary tract and innervation Patient level Comorbidities Medication: diuretics, antihypertensives Functional and mobility impairments NOBODY ever asks patients about this! But it has a huge impact on QoL
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Management Find out the cause: stress vs urge Reduce caffeine, regular toileting Ensure no constipation Medications: anticholinergics (but can cause confusion, dry mouth, constipation…) Incontinence-wear if necessary Sometimes a catheter Surgery
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Consequences Impact on self-esteem Social withdrawal Falls risk Caregiver burden
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Care giver burden 44% care givers for older cancer patients say that the burden of care is too great In many cases, the caregiver is required to make oncologic treatment feasible!
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Musculoskeletal Aging, Sarcopenia
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Body composition Demling RH. Eplasty. 2009 Fat Mass Lean Body Mass (LBM) – Muscle – Visceral tissue – Connective tissue – Other 5% 60% 20% 15% 25% 75% % Body composition(by weight) Protein 20% Minerals 10% Water 70% Muscle is a major component of LBM and plays a vital role in maintaining health1 Strength Energy Mobility Skeletal support and balance Wound healing Immune function Digestive function Skin health
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1. Grimby G, Saltin B. Clin Physiol. 1983;3:209–218. 2. Flakoll P, et al. Nutrition. 2004;20:445–451.3. Baier S, et al. JPEN J Parenter Enteral Nutr. 2009;33:71–82. 4. Janssen I, et al. J Appl Physiol. 2000;89:81–88. Loss of muscle mass and strength, a natural part of aging After age 40, healthy adults can lose 8% of muscle every 10 years Between 40 to 70 years old, healthy adults lose an average of 24% of muscle % peak muscle mass Loss each decade after age 70 15% 24% loss from age 40–70 100 90 80 70 60 50 25 30 40 50 60 70
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Aging and muscle Consequences of losing LBM/Muscle Demling RH. Eplasty. 2009;9:65–94
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Goodpaster BH, et al. J Gerontol A Biol Sci Med Sci. 2006;61:1059-1064. Older men and women lost strength over time; men lost almost twice as much strength as women Men Women Lean Mass Strength Strength Lean Mass P <.001 P <.301 P <.001 P <.016 Changes from baseline (%) -2 -6 -10 -14 -12 -8 -4 0 Declines in leg lean mass and muscle strength over 3 years Health ABC Study: muscle strength declines more than muscle mass Weight loser (< 3%) Stable weight Weight gainer (> 3%) 2 -16
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Stable body weight masks age-related changes in body composition Gallagher D, et al. Am J Physiol Endocrinol Metab. 2000;279:E366-375. The 0.5 kg decrease in body weight resulted mainly from a combined • decrease in fat-free body mass (– 1.4 kg) and increase in fat mass (+ 1.2 kg) ∆ Kilograms Weight Fat Mass Fat-Free Skeletal Total Appendicular Mass Leg Skeletal Mass Arm Skeletal Mass Bone Mineral ↓ ↑↑ ↓↓ ↓ ↓ ↓  -2.0 0 0.5 1.0 1.5 -1.5 -1.0 -0.5 2.0 Changes in body composition after age 60 in healthy older men: longitudinal study with follow-up time 4.7 ± 2.3 years
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Health ABC Study: inter- and intra-muscular fat increase even with stable body weight Delmonico MJ, et al. Am J Clin Nutr. 2009;90:1579-1585. Thigh cross-section view (magnetic resonance) Thigh cross-section view (computed tomography)
Slide 71-

Sarcopenia AGING “Sarcopenia is a (geriatric) syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength (and/or function) with a risk of adverse outcomes such as physical disability, poor quality of life and death”
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European consensus definition of sarcopenia(EWGSOP*) *European Working Group on Sarcopenia in Older Persons Age Ageing. 2010;39:412-423. A syndrome characterized by progressive and generalized loss of skeletal muscle mass and function with a risk of adverse outcomes, such as physical disability, poor quality of life, and death Criteria for the diagnosis of sarcopenia 1. LOW MUSCLE MASS 3. LOW PHYSICAL PERFORMANCE 2. LOW MUSCLE STRENGTH OR SARCOPENIA
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Sarcopenia increases likelihood of poor physical function and increased disability Janssen I, et al. J Am Geriatr Soc. 2002;50:889-896. Likelihood of not being able to:
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Primary versus secondary sarcopenia Curr Opin Clin Nutr Metab Care. 2010;13:1-7. *European Working Group on Sarcopenia in Older Persons definition
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The etiology of sarcopenia Thomas DR. Clin Nutr. 2007;26:389-399. Ryall JG, et al. Biogerontology. 2008;9:213-228. Cruz-Jentoft AJ, et al. Curr Opin Clin Nutr Metab Care. 2010;13:1-7. (Growth hormone/IGF-1, testosterone, DHEA, estrogens)
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Association between sarcopenia and all-cause mortality during hospitalization and after one year No Sarcopenia p=0.004 p=0.003 770 in-hospital patients Sarcopenia and mortality in hospital J Gerontology, 2014
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Comparing sarcopenia and cachexia Thomas DR. Clin Nutr. 2007;26:389-399. Morley JE, et al. Nutrition. 2008;24:815-819.
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Sarcopenia and frailty overlap Fried LP, et al. J Gerontol A Biol Sci Med Sci. 2001;56:M146-156. Cruz-Jentoft AJ, et al. Age Ageing. 2010;39:412-423. Bauer JM, et al. Exp Gerontol. 2008;43:674-678.
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Tools for measuring sarcopenia parameters Cruz-Jentoft AJ, et al. Age Ageing. 2010;39:412-423. www.grc.nia.nih.gov/branches/leps/sppb/
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Image – based muscle quantification on axial CT images 3rd lumbar vertebra Shen W et al J Appl Physiol 2004, 97:2333-8
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SARCOPENIA CUTOFF VALUES BASED ON CT SCAN ASSESSMENT MUSCLE MASS AT THE LEVEL OF L3 Skeletal Muscle Index (SMI) at the level of L3 Males: <55 cm2/m2 Females: <39 cm2/m2 Prado C. Lancet Oncol 2008; 9: 629–35 Clinical Nutrition . 2014; 33: 737-748
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Chemotherapy is reduced >20% or terminated in sarcopenic patients, due to excess toxicity Dose-limiting toxicity, % Clin Cancer Res. 2009 15:2920-6; Clin Cancer Res 2007;13:3264-8; Ann Oncol. 2010; 21:1594-8; Br J Cancer. 2013; 108:1034-41; PLoS One. 2012;7(5):e37563; Clin Endocrinol Metab. 2013;98:2401-8, Inv New Drugs, 2013; PLoS One. 2012;7(1):e29330
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Take home message Many geriatric syndromes interact and amplify each other Geriatric syndromes and functional impairments are highly prevalent and easily missed if not specifically looked for The presence of geriatric syndromes reflects a patient’s fitness/vulnerability which has significant consequences for oncologic treatment