Polypharmacy definition, prevalence, management
> 5 meds
36% of >70yo
No mortality in RCTs but has been shown to do so in some small trials - personalised seems to carry benefit
Common drugs that pose risk in older patients (6)
- NSAIDs - bleed, AKI, HTN
- Benzo - fall
- Anticholinergic - retention, cog impairment
- TCA - hypotension, sedation
- SU - hypoglycaemia
- Prazosin - hypotension, dry mouth, urinary issues
Delirium definition and prevalence in gen med, ED, ICU
disturbance in attention and awareness that occurs acutely and fluctuates
with an additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception)
Gen med 1/4 (same for stroke, post-cabg)
ED 15%
ICU 50-70%
Pall care 59-88%
Risk factors (6) and causes for delirium
Risk:
1. EtOH abuse 5.7x
2. Age 4x
3. Functional disability 4x
4. Malnutrition 4x
5. Dementia 3x
6. Visual and hearing impairment 3x
Causes:
Acute illness/ infection
Medications
Electrolytes
IDC
Delirium outcomes (5)
36% delirium at discharge
- Mortality 2-4x (in-hospital and 39 vs 23% @ 2yrs)
- Length of stay 2x
- Cognitive decline - 10x risk of dementia, 3x worse rate
- Complications 3x
- Nursing home 3x
Delirium prevention, detection, treatment
Prevention - multicomponent interventions OR 0.47
Detection - 4AT (88% pooled sensitivity & specificity)
EEG - 100% sensitivity (less so with dementia)
Melatonin 49% risk reduction
Survorexant (orexin antagonist - inhibits arousal and promotes sleep) 70% reduction in ICU
(50% when combined with melatonin)
other drugs do not reduce severity, duration, symptoms, length of stay, mortality
Dementia prevelance
4th leading cause of death
Doubles every 5 years past 60yo
Higher in Aboriginal Australians
Alzheimer’s diseases pathologies
- Plaques and tangles
- Microvascular lesions
- Atrophy
- Hippocampal sclerosis
- Cortical Lewy bodies
Causes of dementia in order of prevalence
- Alzheimer
- Vascular (up to 75% will have some evidence of it)
- Limbic predominant age-related TDP-43 encephalopathy neuropathological change (LATE-NC)
- Levy body (alpha synucleinopathy)
Frontotemporal dementia types
- Behaviour = personality - apathy + inappropriate; cognitive - executive dysfunction + memory
- Primary progressive aphasia = impairment in language: logopenic, semantic, agrammatic
- Motoric = impairment in attention, executive functioning and visuospatial»_space; may accompany PSP, corticobasal degeneration, MND
cholinesterase inhibitors
symptomatic (no disease modifications)
some evidence of improvement in carer rated quality of life
not indicated in mild cognitive impairment
Memantine
NMDA receptor antagonist
Small benefit on cognitive function and functional decline
Mod-severe Alzheimer
Aducanumab
anti amyloid beta ab
Controversial - surrogate improvement in plaque, NO improvement clinically and serious cerebral oedema and hemorrhage
Dementia symptom management
Citalopram (SSRI) for agitation
Severe symptoms - offer risperidone or olanzapine
Dementia prevention
Cardiovascular health
Exercise
Avoid EtOH and smoking
Reduce depression + maintain social contact
Education
Treat hearing impairment
Synucleinopathies and tauopathies - 3 each
Synucleinopathies
- Parkinson
- Lewy body Dementia
- MSA
Tauopathies
- Alzheimer
- PSP
- Corticobasal degeneration
