GMl Geriatric Medicine Toronto Notes 2023

Activate Windows

Go to Settings to activate Windows,

GM2 Geriatric Medicine Toronto Notes 2023

Acronyms

ACEl angiotensin converting enzyme ESAS

inhibitor

activities of daily living

adverse drug reaction

benign prostatic hypertrophy GCA

blood urea nitrogen

cognitive behavioural therapy GFR

comprehensive geriatric

assessment

chronic kidney disease

central nervous system

cardiac output

creatinine clearance

Edmonton Symptom Assessment MMSE Mini Mental Status Examination PPS

MS multiple sclerosis

musculoskeletal

NE norepinephrine

Palliative Performance Scale

per rectal

parathyroid hormone

personal support worker

peptic ulcer disease

peripheral vascular disease

rheumatoid arthritis

serotonin-norepinephrine

reuptake inhibitor

selective serotonin reuptake

inhibitor

transient ischemic attack

tricyclic antidepressant

urinary incontinence

Scale PR

ADL ESR erythrocyte sedimentation rate MSK

gamma-aminobutryic acid

giant cell arteritis

PTH

ADR GABA PSW

BPH NP nurse practitioner

gastroesophageal reflux disease NPIAP National Pressure Injury

Advisory Panel

NSTEMI non SI elevation myocardial

infarction

PUD

BUN GtIJU PVD

CBT glomerular filtration rate

instrumental activities of daily

living

inflammatory bowel disease NYD

irritable bov/el syndrome

international normalized ratio PCI

RA

CGA IAUL SNRI

CKD IBD not yet diagnosed SSRI

over the counter

percutaneous coronary

intervention

power of attorney

CNS IBS OTC

CO INR TIA

CrCI LOC level of consciousness

left ventricle

TCA

LV POA Ul

Physiology and Pathology of Aging

Holistic Considerations for Aging

• aging is a loss of homeostasis relating to a breakdown in maintenance of specific molecular and

cellular structures and pathways

• some of these changes are specific to the tissues of certain organs, whereas others occur over a number

of organ systems

• normal age-related changes represent biologic processes common to everyone asthey age; however,

the rate and extent is extremely heterogeneous; thus, for the same chronological age, individuals may

present with a different biological age or frailty level

• major categories of impairment develop with old age and affect the physical, mental, and social

domains of older adults, usually due to many predisposing and precipitating factors rather than a

single cause

The table below outlines the physiological changes that occur with aging and their organ specific

impacts. In addition, it outlines pathological conditions occurring in greater frequency in older adults.

Physiological changes may predispose older adults to pathological conditions; however, unlike normal

changes of aging, not all older adults will develop pathological changes associated with aging

Functional Assessment

(ADLs and lADLs)

ADls: ABODE TT lADls:SHAFT TT

Ambulating

Bathing

Continence

Shopping

H ousework

Accounting.'Managing

finances

Foodpiepaiation

Tianspwtation

Telephone

Taking medications

Diessmg

Eating

Tansfenmg

Toileting

Can use lorrn.ilassessment took such as

the Lavrton-Brody Instrumental Activities ot

Daily Living Scale to assess functioning

Table 1. A Systems-Based Analysis of Potential Changes That Can Occur with Aging

System Physiological Changes Impact of Physiologic Changes Pathological Changes

Occurring Frequently with

Older Adults

Comprehensive Geriatric Assessment foi Older

Adults Admitted toHospital

Cochrane OB Syst Rev 2017;CD0062t1

Purpose fo deteimire whether CGA uo improve cue

provided toolder adults admittedlo hospital.

Results Conclusions Inpatient CGA increases

kkefihood that patientswill be alive in then own

homes at 3-12 mo follow-up frisk ratio (KB)1.06.95%

Cl1.01-1.10|.decreases the likelihood that patients

willbe admitted to a nursing home at 3-12 mo (BB

0.80.95% Cl 0.72-0.89),and resultsisktlle oino

difference in dependence (BB 0.97.95% Cl0.89101),

Evidence lor cost reflectiveness of performing a CGA in

older adults admitted to hospitalIs inconclusive due

to imprecision and inconsistency among studies.

Neurologic Mild Impact on woiking memory and

processing speed

Deduced sleep lime

Reduced fine-motor control

Reducedreflex response

Eyes:thickened lenses,reduced pupil Eyes:reduced visual acuity,dark

diameter.Increased lipidinfillrates, adaptation

decreased lacrimal gland secretion ENI:teduced sense of smell and lasle.

ENT:reduced saliva,atrophied hair

cells,reduced cochlear and inner

ear neurons,reduced ossicular

articulation

Increased left ventricular thickness

and stiffness

Increased vascular resistance

Reduced pacemaker cells

Decreased barorcllex and autonomic

reflexes

Decreased vessel elasticity,

cardiac myocyte size and number,

8-adrenergic responsiveness

Increased tracheal cartilage

calcification,mucous gland

hypertrophy

Decreased elastic recoil,increased

residual volume,reduced vital

capacity,forced expiratory volume

Reduced chest wall compliance

Increased Intestinal villous atrophy

Decreased esophageal peristalsis,

gastric acid secretion, liver mass,

hepatic blood flow,calcium, and iron

absorption

Decreased brain mass and cerebral

blood flow

Increased white mailer changes

Reduced number of neuions

Reduced action potential speed

Increased insomnia,

neurodegcneiative disease (e.g.

Vascular dementia.Alzheimer's

disease),stroke

Increased glaucoma,cataracts,

macular degeneration,presbycusis,

presbyopia, tinnitus, vertigo, oral

dryness

Senses

reduced detection olhigher frequency

sounds, reduced vestibular function

Cardiovascular Increased sBP,decreased dBP.HR,CO,

wide pulse pressure

Heart and blood vessels less responsive

to physiological stress

Increased atherosclerosis.CAD. Ml,

CHT.HTN,arrhythmias,orthostatic

hypotension

Comprehensive Geriatric Assessment loi

Community-Dwelling,High-Risk.And frail Older

People

Cochrane D8 Syst Rev 2022:000012705

Purpose: Appraisal of the effectiveness olusing

the CGA for community-dwelling,high-risk, and frail

older adults.

Results Conclusions CGA resultednnodiflerenre

m mortality duringmedian follow -upat 12 months

(BB 0.88 95% Cl 0.76-1.02),and concurrently no

difference innursing home admission|RB 0.93,

95% Cl 0.76to1.14|.CGA may decrease therisk of

unplanned hospital admission overUmonths of

Mow-up (Rfi 0.83 95% Cl 0.70 to 0.99).

Increased COPD.pneumonia,

pulmonary embolism

Respiratory Decreased arterial partial pressure ol

oxygen,decreased exercise tolerance,

decreased pulmonary reserve

r n

L J

Gastrointestinal Reduced Bl2, calcium andiron absorption Increased dysphagia,cancer.

diverticulitis,constipation, fecal

incontinence,hemorrhoids,intestinal

obstruction,malnutrition,weigh!loss +

Activate Windows

Go to Settings to activate Windows,

CM3 Geriatric Medicine Toronto Notes 2023

Table 1. A Systems-Based Analysis of Potential Changes That Can Occur with Aging

System Physiological Changes Impact of Physiologic Changes Pathological Changes

Occurring Frequently with

Older Adults

Renal and Urologic Decreased renal mass and number of Decreased cGFR and concentration ability Increased urinary incontinence

renal tubules andglomcruli, reduced ol kidney

renal blood flow

and urgency, nocturia , BPH.

proslate cancel, pyelonephritis,

nephrolithiasis. Utl. testicular atrophy,

proslate enlargement

Increased urine pH

Reduce nerve density and diminished Reduced hydroiylation ol vitamin D

detrusor function in bladder Proteinuria

Reduced diurnal anlidiurelic hormone Urinary frequency and urgency

Hocturia

Reproductive Decreased androgen,estrogen,

sperm count,vaginal secretion

Decreased ovary, uterus, vagina, and

breast sire

Increased Nt. PIN. insulin,

vasopressin

Decreased thyroid and adrenal

corticosteroid secretion

Increased breast and endometrial

cancer, cystocele, rectocele.atrophic

vaginitis

Endocrine Impaired stress response Increased DM. hypothyroidism

MSK Increased calcium lossfrom bone Decreased strength (note:reduced motor Increased arthritis, bursitis.

Decreased muscle massisaicopenia, strength on neurological examination is osteoporosis,muscle weakness with

cartilage,synovial fluid lubrication not expected) gait abnormalities, polymyalgia

Jointstiffness and reduced joint capsule rheumatica

flexibility

Atrophy of sebaceous and sweat

glands

Decreased epidermal and dermal

thickness, dermal vascularity,

melanocytes, collagen synthesis,

elaslin synthesis

Increased skin laxity,wrinkles, and

skin stiffness

Integumentary Increased skin laxity,wrinkles, and skin Increased lentigo, cherry

stiffness, and easy bruising hemangiomas, pruritus,seborrheic

keratosis, herpes roster, decubitus

ulcers,skin cancer, easy bruising,

onychomycosis.senile purpura.

xerosis cutis

Decreased antigen-antibody affinity, Reduced response to new pathogens. Increased susceptibility to

decreased efficacy of neutrophils and reduced response to immunizations and malignancies, infections, and

macrophages,decreased numbers need for boosters autoimmune conditions

of B and T cells (excluding memory B Blunted fever response and atypical

presentation of infections which may

lead to delayed care

Immunologic

and memory I cells)

Psychiatric Decreased processing speed,

cognitive flexibility.visuospalial

perception , working memory.and

divided attention

loss of synaptic plasticity

Increased depression,dementia,

delirium,suicidahty, anxiety,sleep

disruption

Framework for the Approach to the Older Adult

History: A Brief Geriatric Screen Using “The 5 M’s Framework”

• mind: consider mentation, dementia, delirium, and depression

• consider more validated screening when concerns are raised from family members

• consider asking if patients suffer from chronic pain

• mobility: observe for impaired gait and balance and consider fall injury prevention strategies

consider evidenced-based ways to reduce injuries: exercise, vision evaluation and treatment,

home safety assessment, occupational therapy support, calcium and vitamin D supplementation

• medications: monitor for polypharmacy, consider de-prescribing where possible, check adherence,

check medication understanding from patient perspective, be cautious of adverse medication effects

• multimorbidity: use a bio-psycho-social approach to assess a patient’

s comorbidities

• matters most: explore values and priorities (maintaining independence, preventing adverse events,

optimizing comfort, prioritizing prolonged life)

Focused Geriatric Physical Exam

• general and vital signs: weight (signs of cachexia, unintentional weight loss), height (reduction may

indicate vertebral compression fractures or osteoporosis), blood pressure, and orthostatic vitals

• head and neck: test visual acuity, in-office hearing screen (whisper test), dentition, denture fit,

lymphadenopathv, and neck masses

• cardiac: auscultate for arrhythmias, murmurs, extra heart sounds

• respiratory: auscultate, observe for SOB

• peripheral vascular exam: assess for arterial or venous insufficiency, inspect for edema and ulcers,

palpate for diminished peripheral pulses

• dermatologic: look for premalignant/malignant lesions especially on sun-exposed areas, examine for

pressure sores in patients with diabetes, especially those who are immobile, examine for unexplained

bruises or signs of elder abuse

• MSK:determine range of motion of all joints, based on history and focused joint exam for arthritic

features

• gait: check footwear and fit of gait aids, assess gait, Romberg for balance, and 30 ssit-to-stand test

• neurologic: examine cranial nerves, examine tone, reflexes, sensation, upper motor signs, and power

in upper and lower extremities

r n

L

+

Activate Windows

Go to Settings to activate Windows.

GM l Geriatric Medicine Toronto Notes 2023

Presentations in Older Adults

Constipation

•see Gastroenterology, G27

Definition

•Rome IV Diagnostic Criteria (£2 must be present in 1/4 of bowel movements for S3 mo with

symptom onset 6 mo prior):

straining

« hard stools

sensation of incomplete evacuation

use of manual maneuvers to facilitate defecation

sensation of anorectal obstruction/blockage

<3 bowel movements per wk

• patients must meet both of the following criteria:

loose stool rarely present without the use of laxatives

does not meet Rome IV criteria for IBS

Epidemiology

•chronic constipation increases with age (up to 1/3of patients >65 yr experience constipation and 1/2

of patients >80 yr)

•in the elderly, chronic constipation may present as fecal impaction and overflow diarrhea

Etiology

•neurological:dementia

•metabolic: hypercalcemia, hypothyroidism, hypokalemia

•nutritional:low dietary fibre, dehydration

•drugs association with constipation:

• OiC

opioids

psychotropics (e.g.antipsychotics,TCAs)

anticholinergics (e.g.dimenhydrinate, diphenhydramine,TCAs, antimuscarinicsfor urinary

incontinence)

calcium channel blockers

diuretics

supplements(e.g. iron, calcium)

Pathophysiology

•impaired rectal sensation (increased rectal distention required to stimulate the urge to defecate)

•colorectal dysmotility

Alarm Symptoms

•fever

•blood in stool

•severe nausea/vomiting,severe abdominal pain

•abdominal/rectal mass

•unintentional weight loss

•obstipation

•new changes in bowel habits when age >50 yr

•unexplained anemia or iron deficiency on blood work

Treatment

•non-pharmacological

bowel training

» increase fibre intake (note:bulking agents, e.g. psyllium,Metamucil*, may worsen constipation in

some)

• ensure adequate fluid intake

• increase physical activity

•pharmacological

• see figure I

• discourage chronic laxative use

review medication regime, reduce dosages orsubstitute

•see Common Medications,GM17

+

Activate Windows

Go to Settings to activate Windows.

GM5 Geriatric Medicine Toronto Notes 2023

Chronic Constipation j

A Double-Blind. Placebo-Controlled Study of

Prucaloprido inildorlyPatientswithChronic

Constipation

Neurogastioenteiol Hotil 2010:22(91991 98

Purpose:loassess the efficacy, safety,and

tolerability of prucalopride in chronically constipated

elder ty patients.

lesults/Conclusions Ireprucalopnde dose range

tested(1-4 mg duly)is effective at promoting bowel

movements,nunmiiiingconstipation- associated

symptoms,and nptonng quality of life.It Is safe

and well-tolerated in elderly patients wtb chronic

constipation.

NO { Fecal Impaction YES

4

Remove constipating medications (if possible)

Increase fluid intake

Increase activity or exercise

Increase fibre intake (20-30 gfd)

Start Urned toilet training

Perform manual disimpaction

Use enemas and/or suppositories

Start bowel regimen to prevent

recurrence

4

Milk of magnesia

Lactulose

Peg-Lyte

Senna compounds

Bisacodyl

YES Effective NO theEffect of Probiotics as a Treatment for

Constipation in the Elderly:ASystematic Review

Arch GerontolGeriatr 2017:71:142 49

Purpose:Evaluate the effectiveness of probiotxs

m treating elderly constipation,as an alternative to

traditional dug based tieatments.

Results Conclusions Analysis of placebo controlled

RCIs suggested that administration ol probiotics

significantly impioved constipation in the elderly

by 10 AO1icompared toplacebo,further trialsare

requited to elucidate optimalprotocols of probiotic

treatment regimens.

i i

Continue regimen polyethylene glycol (PEG3350 high dose)

j

YES Effective NO

4

^

Continue regimen j

n

’

I

Lubiprotone Biofeedback therapy

Idyssynergic defecation)

Alvimopan

Methylnaltrexone

opioid-induced constipahon)

Figure 1.Treatment algorithm for the management of chronic constipation in older adults

Adapted from:ClinInterv Aging 2010:5:163-171

Delirium

•see Psychiatry. PS23 and Neurology. N21

Definition

•acute and potentially reversible disturbance in cognition, attention, or level of consciousness

Epidemiology

•delirium is especially common among patients in the 1CU setting, postsurgical setting, and general

medicalsetting

• up to 25% of patients after elective surgery

50% of patients after high-risk procedures(e.g. cardiac surgery, hip-fracture repair)

up to 75% of mechanically ventilated patients in the 1CU

•can affect all ages but is especially common in hospitalized older adults

one-third of general medical patients >70 yr have delirium

Screening/Diagnostic Tools

•screened using the Confusion Assessment Method: delirium likely if 1 + 2 and either 3 or 4 are present

1. acute onset and fluctuating course

2. inattention

3. disorganized thinking

4. altered level of consciousness

•classified as: hyperactive,hvpoactive, or mixed

Differential Diagnosis

•3Ds (dementia, delirium, depression) can present with overlapping cognitive changes

An Approach to Delirium: “DIMS-R”

•D: drugs (consider prescribed,over the counter, overdose, intoxication, and withdrawal)

•I:infection (consider urinary tract, lungs, skin, bacteremia)

•M: metabolic disturbances (consider fluid imbalances, electrolyte abnormalities, nutritional

deficiencies)

•S: structural insults (cardiovascular, CNS,pulmonary, Gl)

•R: retention (urinary retention,constipation)

Work-Up

•work-up is not universal and depends on possible causes based on history and physical exam:

drugs, toxins, withdrawal: medication review, substance use history

• infection, infarction,inflammation: CBC, urinalysis,urine culture,blood culture,CXR,EGG,

troponin, creatinine kinase

Delirium inOlder Persons:Advances inDiagnosis

and treatment

JAMA 2017:318(12):1161-74

Purpose:To provide overview of current state of

diagnosis andtreatment of delirium andidentify

prom sing areas for future research

Methods:Controlled vocabulary and keyword terms

were seaabedin Ovid MEDLINE Embase and the

Cochrane Library with focus cn studies conductedIn

elderly populations.

Results:127articles met inclusion criteria.High

sensitnrity and specificity brief screening tools and

measures of delirium sererity contribute to ability

foifagnose.Heat risk stratify,and prognosticate

patents.Honphatmacologic approaches are

effective for delirium preventionand retommeeded

for dehriumtreatment. Pharmacologic treatment

(antipsycbotics.other sedatives) for agitation

should only be used if the patient is at safety risk

fo thniselns oiothers or isimpeding medical

treatment oltbe underlying cause.

Condusioa:Better screening and diagnosis

of dehrium leads to bettei nsk stratification.

Nonphamucotogic approaches of delirium prevention

are effect.re.whereas pharmacological management

o!delmum is controversial.

+

Activate Windows

Go to Settings to activate Windows.

GM6 Geriatric Medicine Toronto Notes 2023

metabolic: basic and extended electrolytes, vitamin Bt ’, TSH, LI T, toxicology screen, glucose,

arterial blood gas/venous blood gas, creatinine

structural: neurologic exam, CT head Antipsychotics for Treating Delirium in

HospitalizedAdults:A Systematic Review

A nn Intern Med 2019:1)1:435-95

Purpose Eviluilewillicurrent literature the

risks and benefits of antipsyctiotics in delirium

management hosp.tal zed adults.

Study Selection: KIs of antipsychoticvs. placebo

01 another antipsychotic,iswellas prospective

observational studies that report barms, ate selected

through searches on PuSMed.Embase,CENlltAl,

CINAHL. and PsytIHFO from inceptron to July 2019.

the review selected 16 RCtsard 10 observat onal

studies ofhospitalired adults.

Data Synthesis: No significant difference m sedation,

delirium,hospital length-of-stay.or mortality

between haloperidol and second-generation

antipsychotics vs.placebo. No difference Inmodality

m direct comparisonsbetween second-generation

antipsychotics.While shortterm use ofantipsychotics

lor delirium managementdoes not appear to pose

neiiiotogicalhatm, it posesa risk of 01protongalion.

Conclusion. Ire current evidence does not suppoit

the routine use ol haloper dot or second-generation

antipsychotics in delirium management for adult

inpatients.

Delirium Prevention in Older Adults

•ensure optimal vision and hearing to support orientation (e.g. appropriate eyewear and hearing aids)

•frequent reorientation techniques

•family visitation

•maintaining a routine in prolonged hospital stays

•ensure adequate dentition

•adequate pain management

•provide adequate nutrition and hydration (up in chair to eat and drink whenever feasible)

•encourage regular mobilization to build and maintain strength, balance, and endurance

•avoid unnecessary medications and monitor for drug interactions

•avoid bladder catheterization

•ensure adequate sleep at night and wakefulness during the day

Table 2. Differentiating the Three Ds of Cognitive Impairment

Dementia Delirium Depression

Gradual or step-wise decline

Months to years

Progressive, usually irreversible

Aculc (hours todays)

Days to weeks

Fluctuating, reversible

High morbidily/morlalityin

very old

Fluctuating

Impaired,difficulty concentrating

Impaired, fluctuating

Severe agitation/retardation

Subacule (weeks to months)

Variable

Recurrent,usually reversible

Onset

Duration

Natural History

Level of Consciousness Normal Normal

Intact initially

Intact initially

Oisinhibition.loss of ADlitADLs.

personality change

Normal

Fragmented sleep at night

Labile,flattened, apathetic

Chronic,gradually progressive

decline in cognilion

Domains impacted depend on

dementia subtype

Short termmemory impairment

is predominate in Alzheimer's

dementia

Attention

Orientation tldcr Abuse Prevalence inCommunity Settings: A

SystematicReview and Meta-Analysis

lancet Glob Health 2017:5:117-56

Purpose: Snce quantitative syntheses of elder abuse

prevalence are raie. the study aimed to quantity

and understand prevalence variation at global and

regional levels.

Methods: A comprehensive search strategy from

M databases was employed to identity elder abuse

prevalence studies in the community, published from

inception toJune 2015.Subgroupanalysis and metaregression were used to eiptore heterogeneity.

Results: 52 of the 38544 in t ally identified studies

were eligble loiinclusion,all of which were

geographically diverse (28 countries). The pooled

prevalence estimates werelt.6% for psychological

abuse. 6.8% for financial abuse. 4.2% lor neglect.

2.6% lor physical abose. and 0.9% lorseiual abuse.

Significant heterogeneity was found in associations

with overall prevalence estimates, including sample

size, income classification,and method of data

collection,but not with gender.

Conclusion tldei abuse isa neglected pubk health

priority,especially compared with other types of

violence.Elcder abuse seems to affect1in 6older

adults worldwide,a figure totaling 141million people.

Intact

Behaviour Importuning,self-harm/suicide

Slowing

Early morning awakening

Depressed. stable

Impdired concentration

Psychomotor

Sleep-Wake Cycle

Mood and Affect

Cognition

Fluctuates between eitremcs

Reversed sleep-wake cycle

Anxious,irritable,fluctuating

Fluctuation precededby mood

changes

Inattention

May have impaired short- term

memory

Possible impairment in episodic

memory

Memory Loss

Evidence on Management of Delirium:

• see “Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review”

• see “Delirium in Older Persons: Advances in Diagnosis and Treatment"

Elder Abuse

Definition

• includes physical abuse,sexual abuse, emotional/psychological abuse, financial exploitation, and

neglect

• elder abuse is a criminal offence under the Criminal Code of Canada and in most EJ .S. states

Elder Abuse Screening tools: A Systematic Review

J Adult Prot 2017:19:368 )9

C ontext andPurpose: Wrth high rates of morbidity

and mortality,along with deleterbos psychological

harms,elder abuse is often difficult to detect,this

study seeks to review currently available elder abuse

screening tools.

Results:11of 34 full text studiesmet inclusion

criteria and weie included «the final analysis.

01these,three studies reported sensitivity and

specificity while the remainder reported validty and

reliability testing.Ultimately,the dinical environment

will dictate the choice ol screening tool,

limitations Ydiiatior.s n tool qualitiesand

characteristics led to challenges in data synthesis.

A further challenge was the lack of a gold standard

screening tool(or elder abuse,for evaluation of

heterogeneity.

Conclusion Research on screening tools remains

hard-pressed in distinguishing those assessing

suspected or actual elder abuseard those assessing

risk lactorsfor abuse. Allhough screening tools cany

inherent Imitations,they can be used to guide luithei

assessments lor an object,-

*

diagnosis.

Epidemiology

• in Canada in 2019, almost 4518 seniors were victims of police-reported family violence

• the perpetrators of family violence against seniors were identified to be their grown child (34% of

cases) and their spouses ( 26% of the cases)

• in older adults >60 yr, elder abuse is estimated to occur in 10% of patients

• insufficient evidence to include/exclude screening in the Periodic Health Exam

Risk Factors

Table 3. Risk Factors for Elder Abuse

Situational Factors

Victim Characteristics

Social

Physical or emotional dependenceon caregiver

lack of close familylies

History olfamily violence

Dementia or recent deterioration in health

Related to victim

Dependency on older adult (e.g. financial dependency)

+

Perpetrator Characteristics

Activate Windows

Go to Settings to activate Windows.

GM7 Geriatric Medicine Toronto Notes 2023

Screening Tools

• Elder Abuse Suspicion Index© (EASI©): a six-item questionnaire to raise a physicians level of

suspicion for elder abuse and promote referral of possible victimsfor further assessment by social

services

EASI

For each of the 6 Items below,indicate

“yes.

"“no.

" or “did not answer.

" A response

of “yes"on1+ of questions 2-6 is concerning

for elder abuse

010.S asked of patient;0.6 answered by

doctor (Within the last 12 months)

Management

• assess patient’s decision-making capacity regarding any proposed intervention

• address imminent safety

• consider referral to local resources ( home care, respite agencies,shelters, legal services, police

services,government-supported elder abuse consultants)

• create emergency safety plan

• offer assistance with reporting abuse

• in Ontario, reporting elder abuse is mandatory when an older adult resides in a Long-term Care Home

or a Retirement Home

1Have you relied on people for any of the

following:bathing, dressing,shopping,

banking, or meals?

2 Has anyone prevented you from getting

food, clothes, medication,glasses,

hearing aids or medical care,or from

being with people you wanted to be with?

3 Have you been upset because someone

talked to you in a way that made you feel

shamed or threatened?

4 Has anyone tried to force you to sign

papers or to use your money against your

will?

6 Has anyone made you afraid, touched

you in ways that you did not

you physically?

6 Doctor;Elder abuse may be associated

with findingssuch as:poor eye contact,

withdrawn nature,malnourishment.

hygiene issues, cuts, bruises,

inappropriate clothing,or medication

compliance issues. Did you notice any of

these today or in the last 12 months?

MkHJ.NlunC.URiwick M.eU.fcwkprent and

nMdioo ola tool toassist ptry*

cats'ajenbliuljon ol elder

abuse TieElder torse Suspicion tnta(EIS! ;

|.J Elder Abuse

«ed»O8:2O(3i

:276 3O0.

Mips '«ww.rricgill.tJiTjmlyir«

'

4re»

*

ch,

projettslelder

Falls

Definition

• an event resulting in a person coming to rest inadvertently on a lower level, other than as a

consequence of sudden paralysis, epileptic seizure,or overwhelming external force

Epidemiology

• approximately 20-30% of older adults >65 yr fall each year in Canada, prevalence increases with age

falls resulting in injury (e.g. broken/fractured bones,sprain/strain, concussion) were more likely

to occur in women than men

25% associated with serious and 1/3 of hospitalizations were associated with hip fractures

more than 1/3 of older adults are admitted to long-term care after hospitalization

Etiology

• intrinsic factors

age-related changes and diseases associated with aging: MSK (arthritis, muscle weakness),

sensory (visual, proprioceptive, vestibular), cognitive (depression, dementia, delirium, anxiety),

cardiovascular (CAD,arrhythmia, Ml,low BP), neurologic (stroke, decreased LOC,gait

disturbances/ataxia), and metabolic (glucose, electrolytes)

orthostatic/syncopal

acute illness, exacerbation of chronic illness

• extrinsic factors

environmental (e.g. home layout,slippery surfaces, overcrowding, new environments)

side effects of medications, polypharmacy (>4 medications), and substance misuse (e.g. alcohol

misuse)

• situational factors

activities (e.g. rushing to the toilet, walking while distracted)

want,or hurt

Additional

o

Canadian Resourcesfor

Management of Suspected Elder Abuse

Older A dultsSafety Line:24/7

confidential phone line providing

Information and referralsfor older adults

experiencing abuse

Advocacy Centre for the Elderly

Canadian Network for Prevention of

Elder Abuse

History and Physical Exam

• falls history:pre-fall symptoms (chest pain,syncope, presyncope, palpitations),infectious symptoms,

mechanisms,loss of consciousness, head trauma, neck/cervicalspine trauma, post-fall (how long were

Key Clinical History Findings in Falls

Evaluation

they on the ground, who helped them up, post-fall confusion or amnesia)

• extended history: previous falls and/or gait instability, intrinsic, extrinsic and situational factors,

associated symptoms, medication and alcohol use, change in medications

• have a witness present, if possible, for interview

• physical exam:orthostatic BP,injury screen,cardiac, visual acuity,examination of feet and footwear,

gait assessment, Timed Up-and-Go Test, MSK,neurologic

SPLATT

Symptoms

Previous falls

Location of falls

Activity at the time of fal I

Time of fall

Trauma

Investigations

• CGA to identify potential causes

• investigations should be tailored based on history and physical examination. Ihey might consist of:

CBC, electrolytes, BUN,creatinine,glucose, Ca 2+, TSH, vitamin B12, urinalysis, cardiac enzymes,

ECG,CT head (as directed by history and physical), coagulation profile

• bone densitometry (dual-energy X-ray absorptiometry) for osteoporosis screening in all women and

men >65 yr

Interventions

• interventions depend on the identified intrinsic and extrinsic risk factors.First address any acute

illness that precipitated the fall and treat any injuries or complications

• muscle strengthening, balance retraining (e.g.Tai Chi) with appropriate assistive devices, and group

exercise programs

• hip protectors

• fitted gait aid

• multidisciplinary, multifactorial, health and environmental risk factor assessment, and intervention

programs in the community

Impact of Medication Classes on Falls

Risk in Geriatrics(Odds Ratios)

• Antidepressants (1.68)

• Neuroleptics/antipsychotics(1.59)

• Benzodiazepines(1.57)

• Sedatives/hypnotics(1.47)

. Antihypertensive agents(1.24)

. NSAIDs (1.21)

. Diuretics(1.07)

. fl-blockers (1.01)

MeManalpkol the impact <49oaSutrai

clamonMltineWerly persons.IntiMemMed

20O9:l69f2t):t952-1960

n

LJ

+