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Geriatric Medicine
lmaan Zcra Khcrani aiul Saba Manzoor, chapter editors
Karolina Gacbe and Alyssa Li, associate editors
Wei hang Dai and Camilla Giovino, E8M editors
Dr. Jillian Alston, Dr. Vicky Chau, and Dr.Thiru Yogaparan,stall'
editors
Acronyms
Physiology and Pathology of Aging
Framework for the Approach to the Older Adult
Presentations in Older Adults
Constipation
Delirium
Elder Abuse
Falls
Frailty
Immobility
Incontinence
Malnutrition
Presbycusis
Presbyopia
Pressure Injuries
Driving Competency
Reporting Requirements
Conditions That May Impair Driving
Hazards of Hospitalization
Healthcare Institutions
Geriatric Pharmacology.
Pharmacokinetics
Pharmacodynamics
Polypharmacy
Inappropriate Prescribing inOlder Adults
Common Medications
Landmark Geriatric Medicine Trials
References
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GM18
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GMl Geriatric Medicine Toronto Notes 2023
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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
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Gastrointestinal Reduced Bl2, calcium andiron absorption Increased dysphagia,cancer.
diverticulitis,constipation, fecal
incontinence,hemorrhoids,intestinal
obstruction,malnutrition,weigh!loss +
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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
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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
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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.
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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)
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Perpetrator Characteristics
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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
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GM8 Geriatric Medicine Toronto Notes 2023
• home hazard assessment and modification with potential for collaboration with occupational therapy
(e.g. remove loose rugs and tripping hazards, add shower bars and stair railing, improve lighting)
• prescription of vitamin D 1000 1U daily if vitamin D stores are low
• optimization of calcium in diet with 1200 mg ofsupplemental calcium advised if osteoporosis is a risk
• tapering or gradual discontinuation of psychotropic medication
• postural hypotension, heart rate, and rhythm abnormalities management
• eyesight (cataract surgery) and footwear optimization
• compression socks if venousstasis edema
Will My Patient Fall ?
JAMA 2007;197:77-86
P urpoic Ip identify the prognostic Hint of mk
farlorslor future falls amoirqolder patients.
Study Selection: Meta anaiysisot prnspectnae cohort
studies of list factors lor falls.
Results It studieswere included. Clin calif
identiliable risk factors were identified across 6
domains:oitliostatic hypotenvon, visual impairment,
impairment of gait or balance,medication
use. limitations in DDLsor UDls.and cognitive
impairment.Ihe estimated pretest probebilitr ol
falling at least once in any g.ven yr lor individuals »
6b
yr was 2J% (95% Cl19-36% ).Patients who have fallen
m the past year are more likely to falI aga n (182.3•
2.8). Best predictors of future falls were dislorbances
n gait or balarce|lR 1.7-2.4).while visual
impairment impaired cognition,and medication were
not reliable predittors.
Conclusions Screening for nsk ot fallingdliragthe
cluneal examination begins with determining if the
patient hasfa lien in the past yr.For patentswho
have not previously fallen,screening consists of an
assessment of g ai t and balance. Patients who have
fallen or who have a gaitor balance problem are at
higher risk of future falls.
Frailty
Definition
• frailty:clinicallv-recognizable state of decreased reserve in older adults with increased vulnerability
to acute stressors resulting from functional decline across multiple physiologic systems
• functional decline: progressive limitation in the ability to carry out basic functional activities
• frailty is associated with higher risk of in-hospital death, adverse events, length of stay, hospital readmission, and newly dependent at discharge following critical illness
Dulhousie University Clinical Frailty Scale
Severe Frailty
Completely dependent on others
for personol cine,from whatever
cause Iphysical or cognitive I.
Even so.they seem stable and
not at high risk of dying (within
-6 mol
1 Very Fit
People who are robust, active,
enorgotlc.and inotnrotod.
They tend to exorclso regularly
and are among the fittest for
their ege.
4 Very Mild Fraility
Previously "vulnerable 'Eoily
transition from complete
Independence. While not dependent
on othersfor dally help,often
symptomslimit activities- A common
complaint is being "
slowed up"
onCkor bump bred during the day
i
Very Severe Frailly
Completely dependent for
personal cato and
approaching tho end of fafo.
Typically,they could not
recover even from a minor
Fit 5 Mild Frailty
A More evidentslowing and need
help with high ordoi lADLs
(finances, transportation, heavy
J
/A housework).Mild frailty
4 PfW^
ssivaly impairsshopping,
walking alone outside, moal prop. illness,
medications and bogins 1o restrict
light housework.
People who have no active
disoaso symptoms, but are lessfit
than category 1. Ofton, they
exercise or are very active
occasionally (e g. seasonally).
Moderate Frailty
Need help with all outsido activities
and housekeeping. Ofton have
problems with stairs,need help
bathing, and might need minimal
assistance with dressing (cuing.
Terminally III
Approaching tho end ol life
Poople w ill a life expectancy ol
<6 mo,who are not otherwise
living with severe frailty.(Many
terminally ill people can still
exorcise until very close to death).
(
Managing Well
Poople whoso medical problems
aie well controlled, ovoti if
occasionally symptomatic, but are
not regularly active beyond
routine walking
Scoring Frailty in People with Dementia
Degree of frailty generally correspondsto degree of dementia
Mild Dementia
Common symptoms include forgetting tho
details of a recent event,though still
remembering the event itself. Repeating the
samo question/story and social withdrawal
Severe Dementia
They cannot do personal caro without holp.
Very Severe Dementia
They are often bedfast Many are
virtually muto.
Moderate Dementia
Rocont memory is vary impair od. even
though they seemingly can remember
past life events well. Can do personal
care with prompting.
Figure 2. Rockwood Clinical Frailty Scale
Adapted from and reprinted with permission:Geriatric Medicine Research,Dalhousie University.Halifax,Canada. :2005-2020 Version 2.0.Allrights
reserved.
MODELS OF FRAILTY
Physical Frailty (PF) Phenotype (Fried et al.)
•Frail: >3 criteria; at-risk or pre-frail = 1 or 2 criteria
1. shrinking: unintentional weight loss (baseline:>10 lbs or 5% total body weight lost in prior
yr)
2. weakness: grip strength in lowest 20% (by gender, BMl)
3. poor endurance:as indicated by self-report of exhaustion
4. slowness:walking time/15 feet in slowest 20% (by gender,height)
5. low activity: keals/wk in lowest 20% (males: <383 keals/wk,females: <270 keals/wk)
Cumulative Deficit Approach (Rockwood et al.)
•balance between assets (e.g. health, attitudes, resources, caregiver) and deficits (e.g. illness, disability,
dependence, caregiver burden) that determines whether a person can maintain independence in the
community
•frailty index: number of deficits present/number of deficits possible
Etiology
•multifactorial:dvsregulated immune, endocrine,stress, and energy response systemslead to
development of clinical frailty
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Drugs/toxins
azathioprine, mercaptopurine, furosemide,estrogens, methyldopa, Ht-blockers, valproic acid,
ABx, acetaminophen,salicylates, methanol,organophosphates,steroids(controversial)
(£)
When thinking about the causes of
acute pancreatitis remember: I GET
SMASHED, but vast majority due to
gallstones or ethanol
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G'I9 Gastroenterology Toronto Notes 2023
Pathophysiology
• activation of proteolytic enzymes within pancreatic cells,starting with trypsin,leading to local and
systemic inflammatory response
• in gallstone pancreatitis,thisis due to mechanical obstruction of the pancreatic duct by stones
• in ethanol-related pancreatitis, pathogenesis is unknown
• in rare genetic diseases, mutations prevent the physiological breakdown of trypsin required normally
to stop proteolysis (e.g. mutant trypsin in hereditary pancreatitis or mutation in SPINK1 gene, which
normally inhibits activated trypsin); may be model for ethanol
-related pancreatitis
Pathology
• mild (interstitial)
peri-pancreatic fat necrosis
interstitial edema
• severe (necrotic)
• extensive peri-pancreatic and intra-pancreatic fat necrosis
parenchymal necrosis and hemorrhage -> infection in 60%
• release of toxic factors into systemic circulation and peritoneal space (causes multi-organ failure)
• severity of clinical features may not always correlate with pathology
• 3 phases
• local inflammation + necrosis -> hypovolemia
• systemic inflammation in multiple organs, especially in lungs, usually after IV fluids given ->
pulmonary edema
local complications >2 wk after presentation -> fluid collection (pseudocyst) or tissue collection
(necrosis),sterile or infected
Cullen
o's Sign
• Sensitive, not specific for acute
pancreatitis
Grey-Turner’sSign
. Flank ecchymosis
Signs and Symptoms
• pain:epigastric, noncolicky, constant
• can radiate to hack
• may improve when leaning forward (Ingleflnger'
ssign) • tetany:transient hypocalcemia
• tender rigid abdomen;guarding
. N/V
• abdominal distention from paralytic ileus
• fever:chemical, not due to infection
Investigations
• increased serum pancreatic enzymes: amylase, lipase (more specific)
• ALT >150 specific for biliary cause
• increased WBC, glucose, low calcium
• imaging:CT most useful for diagnosis and prognosis
• x-ray:
"sentinel loop" (dilated proximal jejunum), calcification, and “colon cut-off sign" (colonic
spasm)
• U/S:useful for evaluating biliary tree (67% sensitivity, 100% specificity)
CT scan with IV contrast:most useful when done >1 d after presentation, helpful for diagnosis
and prognosis because contrastseen only in viable pancreatic tissue, non-viable areas can be
biopsied percutaneously to differentiate sterile from infected necrosis
ERCP or MRCP if cause uncertain, assess for duct stone, pancreatic or ampullary tumour,
pancreas divisum
Classification
• interstitial edematous vs. necrotizing
• mild, moderate, severe
• jaundice: compression or obstruction of bile duct
• Cullen's/Grey-Turner’ssigns Increased Amylase
• Sensitive, not specific for acute
• hypovolemic shock: can lead to renal failure pancreatitis
• acute respiratory distresssyndrome
• coma Increased Lipase
• Highersensitivity and specificity
• Stays elevated longer
Prognosis
• usually a benign,self-limiting course,single or recurrent
• occasionally severe leading to:
• shock
• pulmonary edema
multi-organ dysfunction syndrome
• (il ulceration due to stress
• death
numerousscalesto describe severity: probably most useful is proportion of pancreas not
taking up contrast on CT done 48 h after presentation (necrotic pancreas does not take up the
contrast dye)
presence of organ failure, particularly organ failure that persists >48 h, is associated with
worse outcomes
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Table 25. Collections in Pancreatitis (Revised 2012 Atlanta Classification)
Liquid Solid +
Acute
Chronic
All of these collections ate classified asinlecled ot not infected
Acute petlpancrcalic fluid collection |APfC)
Pancreatic pseudocyst
Acute necrolic collection (ANC)
Walled-off necrosis (WON)
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G50 Gastroenterology Toronto Notes 2023
Treatment
• goals (only supportive therapy available)
1. hemodynamic stability
2. analgesia
3. oxygen
4.stop progression of damage (difficult)
5. treat local and systemic complications
• antibiotic use in infection (cephalosporins, imipenem), not indicated to prevent infection, although
without aspiration/biopsy can be difficult to distinguish infection from non-infected inflammation
• aspirate necrotic areas of pancreasto diagnose infection;drain if infected
• IV fluids (crystalloid or colloid)
beware third spacing of fluid, monitor urine output carefully
• NG suction (lets pancreas rest) if vomiting,stomach very dilated
• endoscopic sphincterotomy ifsevere gallstone pancreatitis (i.e. cholangitis or ongoing obstruction)
• nutritional support: N ) feeding tube or TPN if cannot tolerate enteric feeds
recent evidence supports NG enteral (or oral if feasible) feeds
• no benefit:glucagon, atropine, aprotinin, H’
-blockers, peritoneal lavage
• follow clinically and CT or U/S to exclude complications
• chief role of invasive intervention is to drain fluid collection, excise necrotic tissue (necrosectomy),
especially indicated if pseudocyst or walled-off necrosis is infected,
try to delay for >2 wk to allow demarcation between viable and necrotic tissue, better done
endoscopically or radiologically, rather than surgically if technically possible
Late Complications
• pseudocysts:follow if asymptomatic, drain ifsymptomatic or growing
drain preferably:endoscopic, percutaneous under radiological guidance,surgical if less invasive
methodsfail
• infected necrosis/abscesses: ABx + percutaneous drainage, endoscopic preferable to surgical
• bleeding: (1) gastric varices if splenic vein thrombosis, (2) pseudoaneurysm of vessels in areas of
necrosis, especially splenic artery,(3) duodenal ulcer related to compression of duodenum by enlarged
pancreas
• splenic and portal vein thrombosis: no effective therapy described, anticoagulation not proven,
hazardous
• rare:DM, pancreatic duct damage
Gallstones only cause acute pancreatitis
(not chronic pancreatitis)
Symptoms of Chronic Pancreatitis
• Abdominal pain
• Diabetes
• Steatorrhea
Etiology = Almost Ahways Alcohol
Chronic Pancreatitis Treatment
• EtOH abstinence
• Pancreatic enzyme replacement
• Analgesics
• Pancreatic resection if ductular
blockage
Definition
• irreversible damage to pancreas characterized by
1. pancreatic cell loss (from necrosis)
2. inflammation
3. fibrosis
Etiology/Pathophysiology
• Toxic-metabolic
EtOH (most common)
causes a larger proportion (>90%) of chronic pancreatitisthan acute pancreatitis
changes composition of pancreatic juice (e.g. increase viscosity)
decreases pancreatic secretion of pancreatic stone protein (lithostathine), which normally
solubilizes calcium salts
When toCallthe Surgeon In Acute Pancreatitis?
Endoscopic Transgastric vs. Surgical Necrosectomy ter
Infected Necrotizing Pancreatitis:A Random ired Trial
JAMA 2012:307:1053-1061
Once it was recognized thatsevere acute (necrotizing)
pancreatitis had a terrible prognosis because ol
an enubeiant inflammatory response leading to
multkirgai) failure, pancreatectocny was attempted.
However, contrary to the expected favourable
results, clinical eiperieuce hasshown thatsurgical
pancreatectomy is usually nol helpful, perhaps
because oncethe inflammatory coscadestirts. it
persists as a self-perpetuating cycle.Ihe problems
caused byacute pancreatitis can be thought of
as widespread burn initiated by inDarn matron in
the pancreas, hut haring little to do with ongoing
problems within the pancreasitself.Studiessuggest
that the only compellmg indication torsurgery is
infected necrotizing pancreatitis not responding to
ABi.As predicted,without removal ofsudi infected
pancreatic tissue,death is likely from sepsis.
In this recent randomized trial, transgastric
neaosectomy,an endoscopic lech nigue that also
removes infected necrotic pancreatic tissue,reduced
both a composite endpoint of major pancreatitis
complications(especially new onset organ failure)
and the pro-inflammatory response (as measured by
serum IL-S levels) to a greater extent than surgical
necrosectomy.Of course,not all necrotic collections
are in areasamenable to endoscopic intervention,
andthe advice olan eipeiienccd surgeon should
always he welcomed in severe acute pancreatitis,
hut the role olsurgery in this previously considered
surgical disease is rapidly diminishing.
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- precipitation of calcium within pancreatic duct results in duct and gland destruction
toxic effect on acinar and duct cells - directly or via increasing free radicals
« acinar cell injury leads to cytokine release, which stimulates pancreatic stellate cells to form
collagen (leading to fibrosis)
varying degrees of ductular dilatation,strictures, protein plugs, calcification
no satisfactory theory to explain why only a minority of individuals with EtOH use disorder
develop pancreatitis
• smoking
hypercalcemia
hypertriglyceridemia
• medications
• Idiopathic
• Genetic
• Autoimmune pancreatitis/steroid-responsive pancreatitis (e.g.IgG4-related disease)
• Recurrent acute pancreatitis/severe acute pancreatitis
• Obstructive (e.g. pancreas divisum, ampullary stenosis)
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Signs and Symptoms
• early stages
recurrent attacks of severe abdominal pain (upper abdomen and back)
chronic painless pancreatitis: 10%
• late stages: occurs in 15% of patients
steatorrhea (maldigestion) when >90% of function is lost
diabetes,calcification, jaundice, weight loss, pseudocyst,ascites, GI bleed
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G51 Gastroenterology Toronto Notes 2023
Investigations
• laboratory
• increase in serum glucose
increase in serum ALP,less commonly bilirubin (jaundice)
serum amylase and lipase usually normal
• stool elastase is low in steatorrhea
• abdominal x-ray: pancreatic calcifications
• U/S or CT:calcification,dilated pancreatic ducts, pseudocyst
• MRCP or ERCP:abnormalities of pancreatic ducts-narrowing and dilatation
• LUN: abnormalities of pancreatic parenchyma and pancreatic ducts, most sensitive test
• 72 h fecal fat test: measures exocrine function, fecal elastase preferable
• secretin test:gold standard, measures exocrine function but difficult to perform, unpleasant for
patient, expensive
Treatment
• most common problem is pain, difficult to control
• general management
• complete abstinence from EtOH
• enzyme replacement may help pain by resting pancreas via negative feedback
analgesics
celiac ganglion blocks
• time: pain decreases with time as pancreas "burns out"
• endoscopy:sphincterotomy,stent if duct is dilated, remove stones from pancreatic duct
• surgery:drain pancreatic duct (pancreaticojejunostomy) if duct is dilated (more effective than
endoscopy);resect pancreas if duct is contracted
• steatorrhea
pancreatic enzyme replacement
neither endoscopy nor surgery'can improve pancreatic function
Autoimmune Pancreatitis
•most commonly presents as a mimicker of pancreatic cancer (pancreatic mass detected because of
jaundice ± abdominal pain)
Investigations
•histology:lymphocyte and plasma cell infiltration of pancreas
•imaging:focal or diffuse enlargement of pancreas on CT or MRI,sausage-shaped, low density rim
around pancreas
•serology:increased serum lgG4 in type 1
•other organ involvement:sialadenitis, retroperitoneal fibrosis,biliary duct narrowing, nephritis
Treatment
•respondsto prednisone
•for refractory patients, consider immunomodulators (azathioprine, mycophenolate mofetil,
methotrexate) or rituximab
Clinical Nutrition
Determination of Nutritional Status
Challenging to Differentiate Markers of Malnutrition from Markers of Disease
• most important feature in assessing the need for nutritionalsupport is weight loss (expressed as
change in body massindex (kg/m-))
• Subjective Global Assessment divides nutritional statusinto A) adequately nourished, B) mild or
moderate malnutrition, and C) severe malnutrition in order to identify those who will benefit from
nutritionalsupport
• includes weight change in past 6 mo, weight change in past 2 wk,dietary intake change, current
dietary intake, G1 symptoms, functional capacity, effect of disease on nutritional requirements and
physical examination, including loss of subcutaneousfat/musdes wasting/edema/ascites
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Table 26. Small Bowel Nutrient Absorption
Fe»’ Proteins,Lipids Bile Acids
Na'
.HiO
CHO Vitamin Bn
Duodenum
Jejunum
Ileum
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G52 Gastroenterology Toronto Notes 2023
Determining Nutritional Requirements
• calories:total energy expenditure (THE)
= resting energy'expenditure (REE) x stressfactor (e.g. 1.7
for burns) usually works out to be 25-35 keal/kg depending on how disease affects metabolism, with
IV nutrition delivered as about 60% carbohydrate, 40% fat. Current trend is to provide fewer calories
(“permissive underfeeding"), especially in 1CU, to prevent hyperglycemia
• protein: 1-2 g/kg/d, depending on effect of disease on protein metabolism. In disease, a greater
proportion of energy expenditure comes from protein than in health
• electrolytes,minerals, and vitamins also required
Indications for Aggressive Nutritional Support:
• inability to meet nutritional needs;logical,but convincing evidence from literature not available for
1CU and other acute illnesses
• evidence that nutritional support improves outcome available for (I )short bowel syndrome (home
TEN), (2) before major abdominal or thoracic surgery if there is substantial malnutrition, (3) before
therapy for cancer of esophagus, head, and neck, (4) decompensated alcoholic liver disease, (5)
pancreatitis (acute and chronic). May be helpful for other indications also, but insufficient data
• nutritionalsupport at best prevents protein loss but usually no gain
Enteral Nutrition
Definition
• EN (tube feeding) is a way of providing food through a tube placed in the stomach or the small
intestine
• nasogastric (NG),or nasojejunal (N|) if nutritional support required for brief time; percutaneous
endoscopic gastrostomy (“G-tube” or “PEG tube")/percutaneous endoscopic jejunostomy (J-tube)
if nutritionalsupport required for more than 1 mo
• tubes can be placed endoscopically,radiologically,orsurgically
Indications
• oral feeding inadequate nr contraindicated
Feeds
• polymeric feeds contain whole protein, carbohydrates, fat as a liquid, and may or may not have fibre
added
• elemental feeds contain protein (as amino acids), carbohydrates (assimple sugars), and are low in fat
content (are therefore high in osmolarity)
• specific diets:low carbohydrate/high fat solution for ventilated patients(carbohydrate has a high
respiratory quotient so minimizes carbon dioxide production), high energy, low electrolyte solutions
for dialysis patients
Relative Contraindications
• non-functioning gut (e.g. intestinal obstruction, enteroenteral or enterocutaneous fistulae)
• uncontrolled diarrhea
• GI bleeding
Complications
• aspiration
• diarrhea
• refeeding syndrome (rare): carbohydrate can stimulate excessive insulin release, leading to cellular
uptake and low serum levels of phosphate, magnesium, potassium
• overfeeding syndrome (rare): hypertonic dehydration, hyperglycemia, hypercapnia, azotemia (from
excess protein)
Most Common Indications for Artificial
Nutrition Support
• Preexisting nutritional deprivation
• Anticipated or actual inadequate
energy intake by mouth
• Significant multiorgan system
disease
Whenever possible. EN is ALWAYS
preferable over PN
Parenteral Nutrition
Definition
• PN is the practice of feeding a person intravenously, bypassing the usual process of eating and
digestion
Indications
• short-term (<1 mo)
use whenever GI tract not functioning
only situations where PN has been well shown to increase survival are after bone marrow
transplant and in short bowel syndrome,some evidence for benefit in gastric cancer, but often
used in 1CU, perioperatively, and in difficult
-to-control sepsis
• preoperative: only useful in severely malnourished (e.g. loss of >15% ofpre-morbid weight,serum
albumin <28 g/L or <2.8 g/dL), and only if given for >2 wk
renal failure: PN shown to increase rate of recovery; no increase in survival
liver disease:branched chain amino acids may shorten duration of encephalopathy;no increase
in survival
IBD:PN closes fistulae and heals acute exacerbations of mucosal inflammation, but effect is
transient (EN is equally effective)
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• some evidence for efficacy, but convincing data not available for:
radiation/chemotherapy-induced enteritis
AIDS with wasting diarrhea
severe acute pancreatitis
•long-term (>1 mo):can be given at home
• severe untreatable small bowel disease (e.g. radiation enteritis, extensive GD, high output (istulae)
• following surgical resection of >70% of small bowel (e.g.small bowel infarction)
severe motility diseases (e.g.scleroderma affecting bowel)
Relative Contraindications
•functional G1 tract available for EN
•active infection; at least until appropriate antibiotic coverage
•inadequate venous access; triple-lumen central venous lines usually prevent this problem
Complications of PN
•sepsis: most serious of the common complications
•mechanical pneumothorax from insertion of central line, catheter migration and thrombosis, air
embolus
•metabolic: congestive heart failure, hyperglycemia, gallstones, cholestasis, electrolyte abnormalities,
micronutrient deficiency
Enteral Nutrition Preferable to Parenteral Nutrition
•fewer serious complications (especially sepsis)
•nutritional requirements better understood
•can supply gut-specific fuels such as glutamine and short chain fatty acids with EN
•nutrientsin the intestinal lumen have a trophic effect (prevent atrophy of the gut and pancreas)
•prevents gallstones by stimulating gallbladder motility
•much less expensive
Hypomagnesemia may be an initial sign
of short bowel syndrome in patients
who have undergone surgical bowel
resection
Enteral »s.Parenteral Nutritionlor Acute Pancreatitis
Cochrane DB Syst Ber 2010:1:C 0002837
Purpose: Compare EN vs. IPN m mortality,
morbidity,andhospital stay inpatientswith
pancreatitis.
Study Selection PCIsoflPNvs. EN in pancreatitis.
Results: E gut trials (n-348) were included. EH
decreases RR of death (0.50), multiple organ failure
(0.55),infection|0.39),and Otter local complications
(0.?0|. It also decreasedhospital stay by 2.3? d.
Conclusion: EN reducesmortality,organfiilure.
infections, and lengthol hospital stay m patients with
pancreatitis.
Common Medications
Table 27. Common Drugs Prescribed in Gastroenterology
Mechanism of
Action
Class Generic Drug Trade Name Dosing Contraindications Side Effects
Name
Indications
Proton Pump omeprazole
Inhibitors
(If /K- ATPasc
inhibitors)
Losec -
/
Prilosec '
20 mg PO once daily Inhibits gastric Duodenal ulcer,gastric
enzymes H'/K'
- ATPase ulcer, HSAIO associated
(proton pump) gastric and duodenal
ulcers,reflux esophagitis,
symptomatic OERO,
dyspepsia.ZollingerEllison syndrome,
eradication ofH. pylori
(combined with ABi)
Same as above
Hypersensitivity lodrug Dizziness,headache,
flatulence,abdominal
pain,nausea.rash,
increased risk of
osteoporotic fracture
(secondary to impaired
calcium absorption)
lansoprazole or Prevacid Same as above Same as above Same as above '
dexlansoprazole Dexilanl
Oral therapy:
lansoprazole
15-30 mg once daily
(before breakfast),
dexlansoprarole 30-60
mg once daily (does not
need to be taken before
breakfast)
40 mg PO once daily for
UGIB:80 mg IV
bolus then 8 mg/h
infusion
40 mg PO once daily
PantolocT
Protonix :
pantoprazole Same as above SameasaboveandUGIB Same as above Same as above
Pariet'
/
Aciphex '
Nexium '
rabeprarolc Same as above Same as above Same as above Same as above
csomepraiolc 20 -40 mgP0 once daily Same as above Same as above Same as above Same as above
Histamine
Hz Receptor
Antagonists
ranitidine*
'ranitidine drugs
recalled in 2019
due to impurity
concerns
Zantac - * 300 mg PO once daily or Inhibits gastric
1S0 mg 8ID
IV therapy:50 mg q3
Duodenal ulcer,gastric Hypersensitivity to drug
histamine H2 receptors ulcer, HSAID-associated
gastric and duodenal
ulcers, ulcer prophylaxis,
reflux esophagitis,
symptomatic GERD;not
useful lor acute Gl bleeds
Same as above
Confusion,dizziness,
headache,arrhythmias,
constipation,nausea,
agranulocytosis,
pancytopenia,
depression
h (but
tachyphylaxis a problem)
Pepcid! Oral therapy: duodenal/ Same as above
gastric
ulcers:40 mg qhs
GERD: 20 mg BIO
IV therapy: 20mg BID
famotidine Same as above Same as above
r -t
StoolSoftener docusate sodium Colace 100 400 mg PO once Promotes
daily,divided in1-4 doses incorporation of water
into stool
Rebel of constipation Presence of abdominal pain, throat irritation.
abdominal cramps,
rashes
lever.N/V
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G54 Gastroenterology Toronto Notes 2023
Table 27. Common Drugs Prescribed in Gastroenterology
Generic Drug Trade Name Dosing
Name
Mechanism of
Action
Class Indications Contraindications Side Effects
Osmotic
Laxatives
Constipation: 15 30 ml
POonce daily to BIO
Encephalopathy:
15-30mlBID to OID
Poorly absorbed in Chronic constipation,
Cl tradand is broken prevention, and treatment
down by colonic
bacteria into lactic
acid in the colon,
increases osmotic
colonic contents,
increases stool volume
Osmotic agent causes Relief of constipation
water retention in Colonoscopy prep
stool and promotes
frequency of stool
Osmotic retention of Relief of constipation
fluid which distends
the colon and
increases peristaltic
activity
lactulose lactulose
Constulose'
Patients who require a low
galactose diet
Flatulence,intestinal
cramps,nausea,
diarrhea if excessive
dosage
of portal-systemic
encephalopathy
PEG3350 lax-a-day 5
RestoralAX -
Golytelyr
Constipation:17 g
powder dissolved in 4-8
or liquidPOonce daily
Hypersensitivity to drug Abdominal distension,
pain,anal pain.thirst,
nausea,rigor,tonicclonic seizures (rare)
Renal impairment
Abdominal pain,
vomiting,diarrhea
Milk of
Magnesia/
Pedia -Lax!
Constipation (adult):
400 mg/5 mL:30-60 mL
POqhs
magnesium
hydroxide
Patients with myasthenia
gravis or other
neuromuscular disease
Stimulant
laxatives
Senokot 5 Tablets:1-4 POqhs
Syrup:10-15 mlPOqhs
Induce peristalsis in Constipation
lower colon
Patients with acute
abdomen
Abdominal cramps,
discolouration of breast
milk,urine,feces,
melanosis coli and atonic
colon from prolonged
use (controversial)
Abdominal colic,
abdominal discomfort,
proctitis (with
suppository use),
diarrhea
senna
bisacodyl Bisacodyl!
5-30 mg PO once daily Enteric nerve
(start at10 mg for bowel stimulation and local
contact-induced
secretory effects
Colonic movements
Constipation
Preparation of bowel for
procedure
G!obstruction
Gastroenteritis
preparation)
Bulk Laxatives psyllium Metamucil 5 Start at one heaping
tablespoon daily
Increases stool bulk Constipation
-•water retention
in stool
Hypersensitivity to drug
Gl obstruction
Gl obstruction,diarrhea,
constipation,abdominal
cramps
Guanylate
Cyclase C
Agonist
Constella1 75-145 pg once daily Opens water channels Chronic constipation
in bowel epithelial IBS-constipation
cells to add water
to stool
linadotide Children Diarrhea
Children «2 yr,known Abdominal pain or
hypersensitivity to discomfort,drowsiness
drug,acute dysentery or dizziness,tiredness,
characterized by blood in dry mouth,N/V,
stools and fever,acute UC or hypersensitivity reaction
pseudomembranous colitis
associated withbroadspectrum ABx
Hypersensitivity to
diphenoxylate or
atropine,jaundice,
pseudomembranous
enterocolitis,diarrhea
caused byenterotoxin
producing bacteria
Pancreatic disease,excess
EtOH, gallstonesor other
biliary disease
Antidiarrheal
Agents
loperamide Imodium® Acute diarrhea:4 mg PO
initially,followed by 2
mg after each unformed
stool
Acts as antidiarrheal
via cholinergic,
noncholingeric,
opiate,and non-opiate associated with IBD and
receptor-medicated
mechanisms;
decreases activity of
myenteric plexus
Inhibits Gl propulsion Adjunctive therapy for
via direct action diarrhea,as above
on smooth muscle,
resulting in a decrease
in peristaltic action
and increase in transit
lime
Bowel opioid
modulator
Adjunctive therapy
for acute non-specific
diarrhea,chronicdiarrhea
for reducing the volume of
discharge for ileostomies,
colostomies,and other
intestinalresections
diphenoxylate/
atropine
Lomotil - 5 mg PO TID to OID Dizziness,drowsiness,
insomnia,headache,
N/V,cramps,allergic
reaction
eluxadoline Viberzil - 75-100 mg BID IBS Pancreaticobiliary pain
including sphincter of
Oddi dysfunction
Diarrhea
Antiemetics dimenhydrinate Gravol - 25-50 mg PO/IV/IM
q4- 6 h PRN
Competitive Hr
receptor antagonist in sickness,postoperative
Gl tract,blood vessels, vomiting, and drugand respiratory tract, induced N/V
Blocks chemoreceptor
trigger zone
Diminishes vestibular
simulation and
disrupts labyrinthine
function through
central anticholinergic
action
01,DLeceptor
antagonist in
chemoreceptor trigger
zone and o-adrenergic
and anticholinergic
effects
Depresses reticular
activating system
(RAS) affecting emesis
Dopamine and 5-HI
receptor antagonist
in chemoreceptor
trigger zone.Enhances chemotherapy induced N/V, pheochromocytoma.
response to ACh migraines,constipation seizures,and EPS
inupper Gl tract,
enhancing motility
and gastric emptying.
Increases IES tone
Motion sickness,radiation Hypersensitivity to drug Xerostomia,sedation
prochlorperazine Stemetil 5 5-10 mg PO/IV/IM BID TID Postoperative N/V,
antipsychotic,anxiety
Hypersensitivity to drug Dystonia,
extrapyramidal
symptoms|EPS),seizure,
NMS (rarely)
PRN
metoclopramide Maxeran - 10 mg IV/TM q2-3 h pm,
10 -15 mg P0 OID (30 min
before meals and qhs)
GERO,diabetic
gastroparesis.
postoperative and
Restlessness,
drowsiness,dizziness,
fatigue, EPS,some
rareseriousside
effects include NMS,
agranulocytosis
Hypersensitivity to
drug.Gl obstruction,
perforation,hemorrhage. ri
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