GERIATRICS

ROLE OF BEDREST IN THE ELDERLY

- little data

Lancet 1999
Dangers of bed rest include: DVT; osteoporosis; bedsores; pneurmonia; muscle
deconditioning.

39 trials : conclusion: there is little evidence for the efficacy of bed rest as a form
of therapy - & the effects are possibly harmful

Review – 24 trials on bed rest after prodedures showed that 7 measured

outcomes ( ex nausea, headache, dizziness, bleeding etc) – were better with bed
rest, but none significantly so, 26 measured outcomes were worse with bed rest &
9 measured outcomes were significantly worsened with bedrest.

Based on these trials- prolonged bedrest should not be offered for acute lower
back pain, MI , pTB & infectious hepatitis; in case of Acute MI – should not exceed
3 days
? I thought bedrest was beneficial for hep A

If a person is in bed for 10 days – the recovery time = 1 /12

COMPLIANCE ISSUES –
a. The typical patient who may not accept the treatment prescribed
b. Ways to get elderly to accept Rx and comply

The typical patient who has difficulties with compliance and why
- Psychiatric comorbidities – especially depression; personality disorders;
substance abuse; schitzophrenia; mental retardation
- Cognitive impairement & dementia
- Inadequate follow-up and discharge planning
- SEs of medications
- Patient’s lack of belief in medication – and lack of insight
- Socioeconomic problems
- Chronic conditions
- Stigmata associated with the disease – supposedly of the young – ex HIV
- Complexity of medication – especially polypharmacy
- Abuse by caregiver
- Bad arthritis – unable to open

Managing poor compliance

- look for markers of non-compliance – missed appointments; lack of response
to medication
- patient and carer education
- Provide good communication between patient/ family and physician
- Simple; clear instructions
- Pill packs
- Customise the medication to the patient
- Obtain help from family members
- Depo medications
- Directly observe therapy

FALLS IN THE ELDERLY – including GAIT assessment + see handout in

notes “ FALLS AND GAIT DISORDERS IN THE ELDERLY
Important points

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 > 1/3rd of persons 65yrs + fall each yr; ½ of these falls are recurrent
 5% OF FALLERS SUSTAIN A FRACTURE – while a further 5 – 10% sustain other
significant injuries
 Fractures especially (hip) in the elderly are associated with a high morbidity
and mortality & are also costly to the health budget
 20% of hip surgery patients die at 90 days

Mechanism of falls
A few falls have a single cause. More typically they result from the interaction of
multiple and diverse sometimes correctable risk factors and situations

Screen for those at risk of falling:

 Arthritis
 Depressive symptoms
 Postural hypotension
 Impairment in cognition, vision or balance
 Impairment in gait, balance or muscle strength
 Certain drugs are associated with an  risk of falling : esp SSRIs; Tricyclics,
neuroleptic agents – generally all of these are due to increased risk of postural
hypotension, benzos, anticonvulsants, and class IA antiarrhythmic
 Poly pharmacy : four or more prescription medications.
 Other “periods” of high risk: episodes of acute illness or exacerbations of
chronic illness or 1/12 after discharge from hospital ( acute illness accounts
for about 10% of falls in older adults)
 + the risk of falling consistently  as the no of these risk factors 
 Vertigo and dizziness

OTs can assist with accident and environmental causes for falls

Physio can assess for balance and gait

Complications of falls -: injury, fear of falling, social isolation, depression &

increased dependency ( functional decline) & increased risk of nursing home
placement

Recurrent fallers = 2 or more falls in 12 months

Screen for those at risk of fracture : Low BMD, previous fragility fracture or
propensity for falling

Who requires a falls assessment:

1. 1 x fall with an injury

2. 2 x falls in the prior 12 months
3. 1 x fall and an abnormal gait

For our patient : include a description of circumstances surrounding the fall and
any associated symptoms, a detailed review of medications, assessment for acute
and chronic physical problems, mobility level and function and cognitive status

Investigation -

 Clinical exam: Brief screening test for balance and gait: “get up and go test”
; looking for unsteadiness as the pt gets up from a chair without using his or

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 her arms, walks 3 meters, and returns ( should take < 10 sec) ; if > 14sec 
there is a high risk of falling
 Neurological exam for focal signs, screen for peripheral neuropathy,
proprioceptive impairment
 Lower extremity strength and joint function
 Postural changes in pulse and BP, presence of arrhythmias, visual problems,
 If postural BP, need strategies to prevent falls ; ex. Get up slowly and sit prior
to standing;
 Targeted cardiovascular assessments (Syncope / Arrhythmia) + persons who
have fallen should be asked about LOC

Lab test : FBC, U&E, Glucose , B12 , Osteoporosis related: corrected calcium ,
PTH, ALP, TSH, 25 Hydroxyvit D,

Other tests depends on abnormality of history and physical exam

 CT or MRI : if head injury or new, focal, neurologic findings on the physical

examination
 EEG is rarely helpful (? If thought seizure activity = cause)
 Evaluation of an arrhythmia is warranted if there is clinical evidence, ex known
history of cardiac events or an abnormal ECG.
 DEXA scan; ? mass screening…is it effective. Probably only for those at risk of
osteoporosis or those at risk of falls

Those at risk of osteoporosis include: Genetic: family history; Females > males,
advanced age, low calcium diet and high caffeine intake, Late menarche and early
menopause ( short oestrogen window) , Smoking, alcohol abuse, sedentary
lifestyle. Other; low BMI, nulliparity, small statue

Management
Pharmacological therapy
 Calcium and Vit D
 Other: Bisphosphonates, SERMS “raloxifene”
Non- Pharmacological
 Weight bearing exercise
 Balance and gait training
 Refraining from smoking
 Refraining from ethanol abuse
 Home hazard modifications
 Assistive devices for mobilisation

Prevention of falls and thus subsequent fractures

 Review and possible  or elimination of medications; the goal: maximize the

overall health & functional benefits of the medications while minimizing their
adverse effects. (try to limit to 4 or fewer)
 Balance and gait training, muscle-strengthening exercise; - Physio
 Home-hazard modifications after hospital discharge (perhaps by OT) eg
removal of rugs, a change to safer footwear, the use of nonslip bathmats,
lighting at night, and the addition of stair rails
 Appropriate assistive device, such as a cane or walker.
 Hip protectors for those are risk of fracture and falls

- OT
- PHYSIO -: GAIT & BALANCE TRAINING

Educate person at risk + family members about the multifactorial nature of most
falls, and the specific risk factors for falling & possible interventions. Those living

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alone: personal emergency-response system or a telephone that is accessible
from the floor.

SEE DIAGRAM ON THE PHYSIOLOGIC CHANGES INFLUENCING GAIT ;

INSTABILITY AND FALLS- handout

HYPERTENSION IN THE OCTOGENARIAN

 Common

Isolated systolic hypertension

 ~ 60% of cases of hypertension in the elderly
 Systolic pressure  and diastolic pressure  after 60yrs
 Mainly due to diminished arterial compliance/ arterial wall stiffness

Who should be treated

- benefits of treating hpt in the elderly are well documented ( CVA & CV
disease_
- Regardless of age, as long as patient has reasonable life expectancy  treat if
SBP > 160 ( +/- diastolic BP)
- If at high risk of Cardiovascular events – ex diabetes, smokers – Rx if systolic
BP > 140
- Nb- trials have included the relatively fit – caution with frail elderly & very old

Why is treatment difficult

1. May already be polypharmacy – be aware of drug interactions
2. Postural hypotension ( may be precipitated by other drugs:
TCAs/phenothiazines; Vasodilators – Nitrates, CCB) opiates and alcohol
3. postprandial hypotension- 75min after meal – pooling of blood in splanchnic
circulation
Why is 2 and 3 so common : sluggish baroreceptor and SNS responsiveness -
+ may have autonomic dysfunction – ex Lewy Body disease, multiple strokes
4. Impaired cerebral autoregulation – so low dose Rx -  gradually
5. More at risk of electrolyte disturbances

Lifestyle modification for Rx of Hypertension in elderly

- never too late; studies have shown that lifestyle changes lower BP in the
elderly ( especially Na+ and weight reduction)
- Address other risk factors for cardiovascular disease also (  wt, stop smoking,
diet,  cholesterol
- TONE study – Na+ and weight reduction in 60 -80yrs olds  need for
antihypertensive Rx
- WRT Na+ : the pressor effect of sodium excess and antihypertensive effect of
Na+ restriction progressively increases with age
- DASH + Exercize can decrease BP  8 – 10 mmHg

DRUG THERAPY
- Start if lifestyle changes are not good enough
- Start with ½ dose of younger patients – to reduce SEs
- Reduce BP slowly to minimise risk of ischaemic symptoms- particularly in
patients with postural hypotension

WHAT IS THE GOAL

- Systolic BPO < 140
- Diastolic < 90
BUT -: ADVERVSE OUTCOMES IF DIASTOLIC PRESSURE IS TOO LOW ie < 65-
low DBP may reflect less aortic compliance due to atherosclerosis

Draw graph – hypertension in the elderly trial

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 WHICH DRUG
ALLHAT – 2002 ( HPT + one other risk factor for coronary heart disease)
- For > 65 yrs – thiazide had best stroke and HF protection cf
amlodipine & lisinopril ( doxasosin arm stopped early – due to high
rate of heart failure)

ANBP2 trial – 2nd Australian National BP trial – 2003

- the presence of another risk factor was not required
- HCTZ vs ACE inhibitor
- ACE inhibitor group had a lower incidence of cardiovascular events – no
difference in mortality – benefit limited to men

SO WHICH DRUG?

: ACE inhibitors * also a Q

- no good head to head trials
comparing ACE inhibitors
Thiazides - Plasma concentrations higher
-  Ca 2+; uric acid in the elderly – start low dose
- if K+  3.5 mortality  and increase slowly
- Can see 1st dose hypotension
- Adv – cheap; reduce
- ? dose effect rather than drug
urinary Ca+ excretion ? effect
prevent bone loss - BAD if dehydrated
- Dis: gout, electrolyte - If RAS – can crash kidneys
abn, more common in - Can see Increased K+
- Cough –
elderly ;low K+ & low
- Cough worsens stress
Na+ incontinence
- Angiooedema

BBs Antihypertensives
- poorly tolerated in the elderly
- Uncertainty
whether they do Alpha blockers
improve - Postural hypotension common
outcome in the
elderly- diuretic
superior CCB
-elderly need lower dose
– as reduced hepatic
blood flow and drug
clearance
- Postural hypotension 5
SO which drug
According to BRENT

If postural hypotension – in order

1. ARB
2. ACE
3. BB
4. CCB

 The worst drugs for postural hypotension- in order

1. Prasosin
2. Diuretic
3. Hydralazine

If CVA
1. CCB
2. ACE inhibitor or ARB

** recall – want to lower BP but not too low as lowers cerebral perfusion

How do you measure hypertension in AF: take the highest reading

Must measure BP standing up if possible when adjusting medication –

titrate dose to standing BP

See a reflexive tachycardia with prazaine and hydrallazine

Brain and kidney perfusion during systole

According to JAMA and Up to date

- start with HCTZ – but not if postural BP; watch K+ ( consider adding K+
sparing agent
- If inadequate – add ACE inhibitor or CCB ( better if CVA)
- If other co-existing conditions – ex angina ; HF – use specific antihypertensives
to also benefit these conditions

URINARY INCONTINENCE IN THE ELDERLY

BRENT’S “ DIAPERS “

1. Delirium
2. Infection
3. Atrophic urethritis and vaginitis
4. Pharmacological
5. Excess fluid intake or output ( diuretic, Ca+, DI)

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 6. Restricted mobility – Functional
7. Stool impaction – ie the stool distends the rectum which inhibits
the reflex arc for micturition + constipated people get UTIs more
commonly

 Embarrassing + increased morbidity

Should screen those > 65yrs
- ask about symptoms of urgency and stress incontinence

2 problems but often combination of both – ie mixed

A. Urge incontinence : associated with detrouser instability

- abrupt onset of or associated with an overwhelming desire to void  associated
with leakage ( precipitants include: running water, out in cold
- with small volumes start getting contractions

Rx- anticholinergics –** however these can cause delirium

B. Stress incontinence – ( cough/laugh and wet) ( ie associated with manoeuvres

that  abdominal pressure)
- problem is with the pelvic floor muscles – Normally intrabdominal pressure
exerts pressure equally on the bladder and urethra  if urethra slips lower into
the pelvic floor this doesn’t occur and bladder pressure > urethral pressure 
urination occurs
- can be contributed to by (post menopausal lack of oestrogen)

- important to establish whether leakage occurs coincident with or after a several

– second delay following the maneuver. Immediated leakage suggests stress
while delayed suggests stress maneuver-induced urinary incontinence

Rx – usually gynaes
- bladder slings
- Ring pessaries
- Collagen injection
- Pelvic muscle exercises
- Oestrogen creams

C – Mixed Stress/ urge – can try oxybutinin

FUNCTIONAL INCONTINENCE

1. Parkinson’s disease
2. Dementia

Other
- Overflow : continual urine dripping or small amounts of leakage with minimal
increases in intraabdominal pressure may indicate overflow urinary
incontinence or sphincter impairment
- Overactive bladder ( symptom syndrome) – urgency, frequency & nocturia
with or without urge incontinence – may be due to example high intake of
caffeinated beverages

FUNCT

OE
- alertness and functional status
- Postural BP – orthostatic symptoms can cause patients to self restrict mobility
- Neuro exam –

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 cervical spondylosis or stenosis with secondary interruption of inhibitory tracts
to the detrouser – thus causing detrouser overactivity
evaluation of scaral root integrity – test perineal sensation and resting anal
tone

- CVS – volume overload/ diuretics

- Musculoskeletal – joint mobility
- PV – assess degree of vaginal atrophy + assess adequacy of pelvic support -
simms speculum
- Rectal masses and faecal impaction

Investigations
- renal function
- glucose
- calcium
- B12
- Urine – MC & S

List of drugs causing urinary incontinence

- Caffeine and ethanol
- diuretics
- Lithium – DI
- Anticholinergics causing urinary retention – can cause overflow incontinence
-  adrenergic blockers – causes urethral relaxation
- adrenergic agonists – can cause urinary retention & overflow
- ( other drugs causing urinary retention – BB, CCB)

CLINICAL APPROACH TO A PROGRESSIVE DECLINE IN COGNITIVE FUNCTION IN THE

ELDERLY:

Other questions in past exam papers involving geriatrics

- The reason for making the wrong diagnosis of acute MI in the elderly
- History –
 may be silent MI in the elderly especially if diabetic
 May be confusion / delirium
 May have multiple co-morbidities
 Mixed cardiac disease – vavlular lesions / especially AS

Exam

Tests

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