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GM4 Geriatric Medicine
Differential Diagnoses of Common Presentations
Toronto Notes 2019
Delirium, Dementia, and Depression
• seePsychiatry,PS19,PS21,PS10andNeurology,N20 Definition
• alloftheabovemaypresentwithpathologicdecreaseinmemory,language,orexecutivefunction
Differential Diagnosis
• these conditions may occur simultaneously (e.g. dementia is a risk factor for delirium)
Delirium Prevention in Elderly
• ensureoptimalvisionandhearingtosupportorientation(e.g.appropriateeyewearandhearingaids) • provideadequatenutritionandhydration(upinchairtoeatanddrinkwheneverfeasible)
• encourageregularmobilizationtobuildandmaintainstrength,balance,andendurance
• avoidunnecessarymedicationsandmonitorfordruginteractions
Antipsychotics for Delirium
Cochrane DB Syst Rev 2009;CD005594 Objectives: To compare the efficacy and incidence of adverse effects of haloperidol with risperidone, olanzapine, and quetiapine in the treatment of delirium.
Selection Criteria: Types of studies included, unconfounded, randomized trials with concealed allocation of subjects.
Results: Three studies were included, comparing haloperidol with risperidone, olanzapine, and placebo in the management of delirium and in the incidence of adverse drug reactions. Decreases
in delirium scores were not significantly different when comparing the effect of low dose haloperidol (<3.0 mg/d) with olanzapine and risperidone (odds ratio 0.63; 95% CI 10.29-1.38; p=0.25). High dose haloperidol (>4.5 mg/d) was associated with an increased incidence of extrapyramidal adverse effects compared with olanzapine. Low dose haloperidol decreased the severity and duration of delirium in post-operative patients, although not the incidence of delirium compared to placebo. Conclusions: There is no evidence that haloperidol in low dosage has different efficacy in comparison with the atypical antipsychotics olanzapine and risperidone in the management of delirium or has
a greater frequency of adverse drug effects than these drugs. High dose haloperidol was associated with a greater incidence of side effects. Low dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients, compared with placebo. However, all studies were small and should be repeated.
Falls
Definition
• avoidbladdercatheterizationifpossible • ensureadequatesleep
Table 3. Differentiating the Three Ds of Cognitive Impairment
Onset
Duration Natural History
Level of Consciousness Attention
Orientation
Behaviour
Psychomotor Sleep-Wake Cycle Mood and Affect Cognition
Memory Loss
Dementia
Gradual or step-wise decline Months to years
Progressive, usually irreversible
Normal
Intact initially
Intact initially
Disinhibition, loss of ADL/ IADLs, personality change
Normal
Fragmented sleep at night
Labile but not usually anxious
Decreased executive function, paucity of thought
Short-term
Delirium
Acute (hours to days) Days to weeks
Fluctuating, reversible
High morbidity/mortality in very old
Fluctuating
Impaired, difficulty concentrating Impaired, fluctuates
Severe agitation/retardation
Fluctuates between extremes
Reversed sleep-wake cycle
Anxious, irritable, fluctuating
Fluctuation preceded by mood changes
Marked short-term
Depression
Subacute Variable
Recurrent Usually reversible
Normal
Intact
Importuning, self-harm/suicide
Slowing
Early morning awakening Depressed, stable Concentration impaired
Short-term
Key Physical Findings in the Elderly Patient Who Falls or Nearly Falls
I HATE FALLING
Inflammation of joints
Hypotension (orthostatic changes) Auditory and visual abnormalities Tremor
Equilibrium (balance) problem Foot Problems
Arrhythmia, heart block or valvular
disease
Leg-length discrepancy
Lack of conditioning (generalized weakness) Illness
Nutrition
Gait disturbance
Am Fam Phys 2001;61:2159-2172
Falls Evaluation - SPLATT: Symptoms
Previous falls
Location of falls
Activity at the time of fall Time of fall
Trauma
• aneventwhichresultsinapersoncomingtorestinadvertentlyonthegroundorfloororotherlower level, other than as a consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force
Epidemiology
• 30-40%ofpeople>65yroldand~50%ofpeople>80yroldfalleachyear
■ equally common between men and women, but more likely to result in injury in women and death
in men
■ falls are the leading cause of death from injury in persons ≥65 yr
■ 25% associated with serious injuries (e.g. hip fracture, head injury, bruises, laceration) ■ between 25-75% do not recover to previous level of ADL function after injurious falls
Etiology
• intrinsicfactors
■ age-related changes and diseases associated with aging: musculoskeletal (arthritis, muscle
weakness), sensory (visual, proprioceptive, vestibular), cognitive (depression, dementia, delirium, anxiety), cardiovascular (CAD, arrhythmia, MI, low BP), neurologic (stroke, decreased LOC, gait disturbances/ataxia), metabolic (glucose, electrolytes)
■ orthostatic/syncopal
■ side effects of medications, polypharmacy (>4 medications), and substance abuse (e.g. alcohol) ■ acute illness, exacerbation of chronic illness
• extrinsicfactors
■ environmental (e.g. home layout, slippery surfaces, overcrowding, new environments)
• situationalfactors
■ activities (e.g. rushing to the toilet, walking while distracted)