How is frailty defined?
“a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, which increases the risk of adverse outcomes, including falls, delirium, and disability”
- In a frail person, an apparently small insult e.g. new drug, minor infection or small surgery –> causes disproportionate change in health state:
- Independent –> to dependent
- Mobile –> to immobile
- Postural stability –> to fall prone
- Lucid –> delirious
Image - green = fit elderly person, red = frail elderly person
What are some common clinical presentations of frailty?
- Falls - balance and gait impairment = major features of frailty
- Hot-fall = related to a minor illness that ↓ postural balance below threshold needed to maintain proper gait
- Spontaneous fall = more severe frailty, postural systems (e.g. vision, balance, strength) aren’t sufficient to navigate undemanding environments
- Delirium (acute confusion) - characterised by rapid onset of fluctuating confusion and impaired awareness
- ~30% of elderly persons admitted to hospital develop delirium
- Fluctuating disability - day-to-day instability giving pts ‘good’ days and ‘bad’ days
- Sarcopenia (loss of muscle mass + strength due to ageing)
- Osteoporosis
- Non-specific: extreme fatigue, unexplained weight-loss, frequent infections
What 7 aspects are assessed as part of a ‘comprehensive geriatric assessment’
- Medical diagnoses
- Review of medication
- Social circumstances
- Assessment of cognition and mood
- Functional ability - deficits in intrumental activitys of daily living (IADLs: banking, transportation, cooking, cleaning, shopping) or basic activites of daily living (BADLs: feeding, bathing, dressing, toileting)
- Environmental assessment
- Economic circumstances
What is the predicitive value of urine dipsticks in elderly pts?
Positive predictive value of dipstick = rubbish (“might as well toss a coin”)
- Asymptomatic bacteriuria is common in older people
- Only a -ve result is considered useful as it eliminates UTI
- Give antibiotics for UTI in elderly if:
- Pts have acute urinary symptoms or have bacteriuria and evidence of systemic inflammation (fever / ↑ inflammatory markers) without another more likely source of infection
In elderly pts who can provide a history, what is required to diagnose UTI?
- NOT a urine dipstick!
- Only diagnose in the presence of at least 3 acute urinary symptoms:
- Dysuria
- Urgency
- Frequency
- Suprapubic tenderness
If an elderly patient “sounds chesty” frequently and has recurrent pneumonia, what pathological mechnaism should you consider and what action should you take?
Consider recurrent aspiration (causing pneumonia)
Refer for SALT review
What are the two stages of testing Capacity, both of which must be satisfied?
- The patient cannot make a decision due to ‘a condition of mind or brain’
- For elderly persons this is most often dementia or delirium, but can be due to learning disability or severe depression
- It therefore follows that if a person does NOT have a condition of mind or brain, capacity should be assumed present
- The person cannot: Understand, Retain, Weigh up, Communicate information relevant to the decision in question
- Evidence of inability to do this relevant to the decision must be recorded
What are the 5 symptoms in Fried’s frailty phenotype (3 or more of which have to present for someone to be labelled ‘frail’)?
3 or more of the following:
- Walking speed - appear in slowest 20% by gender and height
- Measure: timed 15 foot (5 metre) walk
- Grip strength - weakest 20% by gender and BMI
- Measure: dynanometer
- Weight loss - loss of 10 lbs (4.5kg) in the past year
- Measure: self report
- Fatigue - self reported “trouble getting going”
- Activity level - lowest 20% (males: 383 kcals/week, females: 270 kcals/week)
- Measure: self report no. of calories expended
What are the 6 categories of Elder Abuse?
- Financial abuse
- Neglect
- Sexual abuse
- Psychological abuse
- Physical abuse
- Racial / cultural abuse
What are the 4 categories of Risk Factors for Elder Abuse?
What is in each category?
- Factors relating to the older (abused) person
- Cognitive impairment
- Shared living
- Functional dependency
- Low income
- Factors relating to the perpetrator
- Psychiatric illness (including dementia)
- Drug and alcohol dependency
- Caregiver burden and stress
- Relationship factors between perpetrator and abused
- Family disharmony
- Conflicted relationships
- Environmental factors
- Low social support
- Shared living
