Geriatric Syndromes

FRAILTY – someone who is skinny, weak and vulnerable (cannot be diagnosed based on appearance)
- No universally accepted definition of frailty
- Represent variety of illness, condition or physical state
- We cannot simply say that a person is beginning to be frail or is already in the end stage of
frailty which is the FTT (Failure to thrive)
- Phenotype= encompasses specific patient criteria; operationally useful definition of frailty

 Fried et al found that frailty could be operationally defined as a clinical syndrome in

which three or more of the following criteria were present

1. Unintentional weight loss (10 lbs) ( > 5 percent of BW in past year)

2. Self-reported exhaustion
3. Weakness (Grip strength = lowest 20th percentile)
4. Slow walking speed (15 ft; lowest 20th percentile)
5. Low physical activity Kcals spent per week: males expending <383 kcals and female <
270 kcals)

NOTE: Patients meeting no criterial were non-frail

 Study of osteoporotic fractures (SOF) index used a reduced set of criteria and is more
clinically performable

1. Weight loss 5 % over the past year

2. Inability to rise from chair five times in succession (w/o use of arms)
3. Responding, “no”, to the question: “Do you feel full of energy?”

 Once frail a pt is frail it is very uncommon to transition back into non-frail

- Frailty progress to FTT and ultimately to death
- Health care professional : prevent progression to FTT
- Disability can contribute to frailty and vice versa, but the two conditions are not
the same
- Disability : Impairment in the ability to perform basic ADLs, but does not have
the affectation of the multiple organ system compared to frailty

 Epidemiology
- A Canadian study: among community-dwelling adults living in one of 10
provinces (65-102) 22.7% were frail and among those 85 or older nearly 40%
were frail
- More common:
 Women than in men
 African Americans and Asians than in Hispanic or Caucasians
 Single than married men
- Frailty is associated with lower income as well
 Etiology
- Causes of Frailty are complex

 Frailty in Elderly (AG-LED) (W-WELS)

 Outcomes
- Variety of outcomes are associated
- Higher risk of falling, developing decreased mobility, declining in performance of
ADLs, being institutionalized
- Less responsive to influenza vaccination and have worse outcomes with renal
transplantation and in some general surgical situations
  Treatment
- Reversing or treating frailty is problematic
- There may be some possibility in reversing the pre-frail stage, but once full frailty
is established it is generally considered irreversible
- Programs involving stretching, resistance training, and tai-chi have been shown to
benefit.
- Treating the chronic condition that contributed to their frailty symptoms
- Exercise activity has even been shown to be beneficial in a program involving as
little as 2 days per week about 30 to 60 min

 Prevention
- Exercise is probably the best measure that can be utilized besides treating
optimizing and other chronic conditions
- The benefits that have been shown in older pts with exercise include increased
mobility, enhanced performance of ADLs, improved gait, decreased falls,
improved bone mineral density, and increased general well-being

DELIRIUM
- Acute mental status chance that is characterized by a disorder of attention and cognitive
function that is typically a consequence of a medical condition
- Once delirium occurs we must recognize it so that we will be able to evaluate and
eventually treat

 Epidemiology
- Prevalence : ranges from 14% to 24% on hospital admission and the incidence of
delirium arising during hospitalization is 6% - 56% among general hospital
population
- Rate are higher for older adults as well as pts with more severe illness
- The rate of delirium is highest in patients in intensive care units ICU, which can
range 70% to 87%
- Delirium is associated with worsening outcomes, and so prevention is vitally
important
- Delirium is associated with 3- fold increased risk of death up to 6 months after
hospital discharge

 Diagnosis

 DSM – 4 Diagnosis criteria

- American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorder
(4th edition, DSM-IV) four key feature that can characterize delirium:

1. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention

2. A change in cognition of the development of a perceptual disturbance that is not better
accounted for by a preexisting, established, or evolving dementia
 3. The disturbance develops over a short period of time and tends to fluctuate during the
course of the day
4. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is caused by a medical condition, substance intoxication, or medication side
effect.

o Additional features
1. Psychomotor behavioral disturbances such as hypo activity, hyperactivity with increased
sympathetic activity, and impairment in sleep duration and architecture
2. Variable emotional disturbances, including fear, depression, euphoria, or perplexity

Note: 1 of the listed criteria must be present

 DSM- 5 Diagnostic criteria

Note: 2 of the listed criteria must be present

 CAM = Confusion assessment method

1. Acute onset and fluctuating course

2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
 Clinical MANIFESTATIONS
1. Acute onset/Fluctuations = unpredictable symptoms, may disappear and worsen
in a small amount of time
2. Attention deficit = true hallmark of delirium, easily distracted, calm environment
less distraction
3. Confusion/Disorganized thinking = can’t think straight, thoughts have no sense
4. Altered level of Consciousness and psychomotor activity = Decrease arousal and
sometimes too much energy, its either too energetic (masyadong makulit si pt) or
lacks energy (pt will sleep during Tx)
5. Perceptual and emotional disturbances = Hallucination , fear, sadness and
depression
6. Sleep/wake cycle disturbances = worsening of the condition occur during the
night (sun downing) they find it difficult to sleep. Result in day time drowsiness
7. Memory impairment/ disorientation = Person, place and time(disorientation) ,
question about self (memory)

 Classification

1. Hyperactive = easy to identify, shows restlessness and sometimes hallucinate

2. Hypoactive = “Quiet delirium” , greater risk due to lack of identification which may
lead to lack of appropriate Tx
3. Mixed = both

CAR

DUS

 Risk Factors (DAD- PAP- MD)

Age >70 Dehydration

Dementia/cognitive impairment Impaired ADLs/ functional dependence
Depression Malnutrition
 Past CVA Polypharmacy
Alcohol abuse Vision Impairment
Psychoactive medications Hearing Impairment
Multiple medical comorbidities Severe or terminal illness

 Causes
  Pathophysiology
- Incompletely understood but it is
unlikely that a single mechanism is fully responsible
- Delirium represents a final common pathway of many physiologic disturbances
with multiple “causes”
- Disturbance in the balance of neurotransmitters is one of the more widely
accepted explanation (ACh and dopamine)

 Patient evaluation
- Two important aspects

1. One must recognize the condition exists

2. One must diligently evaluate for the underlying medical illness or illnesses
that have caused delirium

 Differential diagnosis

 Management
- Mainstays of therapy: 4 components

1. Identify and treat the underlying condition

2. Avoid additional insults that can prolong or worsen the condition
3. Provide supportive and restorative care that will allow the patient time to recover safely
4. Treatment may need to be initiated to manage harmful or dangerous behaviors that maybe
present and may interfere with the first three component of management. Treatment can
be both pharmacologic and nonpharmacological
 Note: there are no proven Tx or models of care that successfully reduce the duration of
delirium once its developed

 Prevention
- Avoidance of immobility and sensory deprivation
- Provision of glasses, assistive hearing devices, appropriate orienting stimuli (clock,
calendar, and natural lighting)
- Regular review of medication and minimization of psychoactive medication and
discontinuation of unnecessary drugs
- The use of staff or family members who can provide interpersonal contact with
use of reorientation strategies and encouragement for increasing activity and
increased oral intake
- Avoid use of restraints as well as unneeded “tethers” such as urinary catheters or
telemetry monitors
- Allowance for uninterrupted sleep with appropriate night-time lightning and noise
should be provided
- Natural lighting and encouragement for activity during daytime can also be helpful

 Prognosis
- Duration and prognosis is quite variable
- Condition may only last for a day or two, but it often lasts much longer with some
studies demonstrating delirium symptoms up to 12 months after diagnosis
- Marker for severe illness but is also independently associated with poor outcomes
- It is associated with increased mortality and institutional placement

URINARY INCONTINENCE

 Epidemiology
- Consistently increase with age and is overall higher for women
- Prevalence: 30 – 50% of women and 17-24% of men older than age 60
- Rate as high as 85% have been reported for those individuals living in long-term care facilities

 The Type of Urinary incontinence

CLASSIFICATION
Common causes of Transient incontinence:
- Delirium
- Infection
- Atrophic Urethritis
- Pharmaceuticals
- Psychologic
- Excess Urine Output
- Restricted Mobility
- Stool Impaction

 Different
1. Overactive bladder OAB is characterized by symptoms of urinary urgency (compelling urge to
void) with or without the presence of incontinence
2. Neurogenic bladder is bladder dysfunction secondary to acquired or traumatic neurologic
damage of the CNS ,PNS or both
  Impact

Physical health
- As a medical practitioner you have to check for
pressure sores or moist areas
- Since there are increased risk for pressure sores
- UTI is also common
- Some patients have increased risk for fall/ because of
the urge to urinate
- especially the elders if they rush going to the
bathroom
- Decreased in sexual activity

Psychological well-being
- Embarrassed since personal hygiene is dependent in
others
- Can cause depression and anxiety

Social Balance
- Development of anxiety from having no available bathroom when the pt is in the need to void, it
may contribute to social isolation
- Would lead to decreased community and social involvement

Financial condition
- Expenses
- Laboratory exams , evaluation and referrals to other healthcare practitioner

Quality of life
- Pt with urinary incontinence has a decreased quality of life compared to those without

 Anatomy of Urinary system

1. Kidney is the one that forms the urine

2. Ureter connects the kidney to the bladder
3. Bladder which store the urine
4. Urethra serves as the channel to which the urine is eliminated

During micturition reflex

1. Urethral sphincter will relax
2. Detrusor muscle contract
3. Rugae increases the surface area of the bladder (folds), only stretched when there is urine
4. Ureteral orifices and Internal Urethral sphincter, form the trigone

 Pathophysiology
- Recognized physiologic changes that occur with aging include decreased bladder
capacity, decreased elasticity of bladder, increased frequency of detrusor
contractions, decreased ability to postpone micturition(more frequent voids),
decreased detrusor muscle strength and contractility, incomplete bladder
emptying, and decreased urethral closing pressure(leakage of urine)

 Etiology
- Remains unknown
- Essentially, the detrusor muscle develops involuntary overactivity or uninhibited
contractions during the filling phase, which forces urine through urethra.
- It is often seen in association with SCI, MS and stroke

1. Stress urinary incontinence

- is either hypermobility of the urethra, when normal muscle supports at the
urethral junction fail or due to intrinsic sphincter deficits
- If either is present then the total bladder pressure maybe higher that the
urethral closing pressure this produces the incontinence
- Decreased estrogen levels or history of prostate surgery may cause
hypermobility of urethra
- A factor for causing intrinsic sphincter deficits may be presence of prostate
cancer
2. Mixed urinary incontinence
- A combination of stress and urge incontinence pathologies.
3. Overflow incontinence
- Caused by an atonic and over-distended bladder, urethral obstruction, or
detrusor sphincter dyssynergia.
4. Transient urinary incontinence
- The result of external factors that negatively affect the urinary tract. The
pneumonic DIAPPERS has been used to list potential causes for transient UI.
5. Functional urinary incontinence
 - Caused by conditions external to the urinary system and is considered to be a
form of transient UI.

 Risk Factor

Modifiable Risk Factors Non-modifiable Risk Factors

Tobacco Age
Alcohol  Caucasian race
Caffeine Menopause
Obesity  Parity
Cognitive impairment  Impaired mobility Asthma
Physical inactivity 
Constipation  
Medications

 Evaluation
 History
 Physical Examination
 Diagnostic studies
  The following are key components of urodynamic studies (UDS).

1. Uroflowmetry:
- A noninvasive measure of urine flow rate over time. The hydrostatic pressure from
urine accumulation is measured via gravimetric meter. A rate less than 12 mL/s is
suggestive, but not diagnostic of obstruction
2. Multichannel urodynamics: Includes cystometry (CMG) and electromyography (EMG).
 CMG—a measure of the change in bladder pressure during filling and voiding. It
is used to evaluate involuntary detrusor contractions, sensation, compliance, and
bladder capacity during filling.
 EMG—provides a continuous measure of pelvic floor muscle contraction and a
comparison to detrusor contraction through use of patch or needle electrodes. It
allows for evaluation of synergy of muscle contractions.
3. Pressure flow studies (PFS): An invasive measure of urine ow and detrusor pressure. It
evaluates bladder contractility and outlet obstruction.
4. Videourodynamics: Combines genitourinary fluoroscopy with multichannel UDS. It is
used when anatomy and function must be further investigated to obtain a definitive
diagnosis.
5. Abdominal leak point pressure (ALPP) and Valsalva leak point (VLP): Interchangeable
terms for the lowest abdomen-generated pressure, in absence of detrusor contraction that
causes UI. The patient completes a Valsalva maneuver and cough at different urine
volumes.
6. Detrusor leak point pressure: Lowest detrusor pressure able to cause incontinence. A
phasic rise in detrusor pressure during filling is a sign of overactivity that has potential to
result in leakage of urine.
7. Urethral point pressure: The urethral pressure is measured at different anatomical points
using a transducer catheter. This is an important part of the SUI evaluation because it
provides part of the maximal urethral closure pressure measurement.

 Treatment
Behavioral Therapy:
1. Timed Voiding
2. Bladder-training therapies
3. Pelvic floor muscle therapy (PFMT), also known as Kegel exercises
 4. Electrical Stimulation
5. Weighted cones

Lifestyle Adjustments
1. Weight loss
2. Remove potential irritants such as alcohol, caffeine or tobacco
3. Limit fluid intake especially during night to avoid nocturnal UI.
4. Reduction of polypharmacy
5. Wear non-restrictive clothing
6. Low bed level
7. Bedside commode