Practical Approach to Geriatric Syndromes: Falls and Polypharmacy
Undeniably, ageing, with ongoing diminishing of physical, mental abilities, is a natural occurrence and a biological process that occurs in every human being. The extent and speed of organ function decline can be significantly limited, by being aware of geriatric syndromes, that invariably arise in older people and seeking judicious attention for the same.
Geriatric syndromes are essentially multiple illnesses that develop in an older person, which simultaneously affect many organ systems within the body, owing to mainly ageing and loss of tissue function, which can be effectively treated and effectively managed.
Let us focus on a practical approach to assessing and managing two common geriatric syndromes i.e., Falls and Polypharmacy.
Due to either hazardous external environments or extreme muscle weakness, an elderly person succumbs to falls, where accidental circumstances result in them laying down on the ground or the lowest surface of a particular location. Problems with posture, skeletal stability, gait, remaining erect, as well as arthritis, osteoporosis and other bone, muscle, joint disorders trigger falls in the elderly.
Previous falls are strongly predictive of future falls. Older adults with a history of falls in the past year are 2.5 times more likely to fall again, in part because functional impairment from a fall often does not resolve. Many falls are potentially preventable by implementing interventions, especially those that target patients at higher risk. Fall assessment may help unearth opportunities for an intervention (e.g., dizziness, inappropriate medications, depressed mood, impaired gait and balance, weakness in lower extremity) and can help gauge the functional status of a patient. As such, fall risk in this population is not static and should be assessed on an ongoing basis. Simple gait and balance tests, using tools such as the Timed Up and Go test *or Gait Speed**, which take less than 2 minutes to complete and can be administered while walking patients from the waiting area to the examination room.
Those identified as at risk for falls, such as those who report falls or have abnormal gait and balance findings should be offered a multifactorial assessment and intervention. This includes an assessment of falls history (frequency, circumstances, symptoms, injuries, etc.), muscle strength, cardiovascular status, medications, visual acuity, positional blood pressure, feet and footwear, home environment, and mobility aids. Subsequent steps include a referral to a geriatrician, as well as promotion of moderate physical activity or an exercise program that incorporates gait, balance, and strength training to improve mobility, balance, and reaction time. Patients may also need specific advice concerning environmental or activity modifications, such as extra vigilance while negotiating sidewalk curbs, steps, and stairs. In-home safety evaluations should also be arranged for older patients. However, education alone is not sufficient for preventing falls and older patients must be encouraged to report issues related to gait and/or balance and falls during both routine appointments. Strategies with respect to how to fall safely once a fall is already underway are also beneficial.
Older adults are the largest consumers of medications. Polypharmacy refers to five or more daily medications. Clinical consequences of polypharmacy in older adults have been linked to adverse drug reactions, depression, disability, falls, frailty, health care use, postoperative complications, mortality, and caregiver burden.
Polypharmacy Challenges and Considerations
Age-related physiologic changes can affect the pharmacokinetics and pharmacodynamics of intensifying the prescribing challenges in older adults. Declining cell function in advanced age influences pharmacodynamics of medications and causes older adults to be more sensitive to medications. Other reasons include organ impairment, high pill burdens, and complex medication regimens. Prescribing cascades can occur when the effects of a medication are mistaken for and interpreted as a new medical symptom, leading to a new medication that itself causes additional adverse reactions. An increased risk of drug–drug interactions can result from these prescribing cascades as well as from fragmented care coordination, age-related physiologic changes, multimorbidity, and single disease state guidelines.
Screening tool include Beers criteria, the Medication Appropriate Index, the Screening tool of older persons' potentially inappropriate prescriptions (STOPP), and the Screening tool to alert doctors to right treatment (START) criteria, in addition to broad availability of medication alternatives. Each tool can be used in a complementary manner because of some of the variances between tools.
I prefer the brown bag medication review that involves the patient bringing in all medicines and supplements from home to the visit. If polypharmacy is identified one should evaluate each medication indication dosage, duration of use, duplications, DDIs, drug–disease interactions, and adverse drug reactions. A patient’s ability to read medication instructions and safely manage medications is also needed. If unnecessary and/or inappropriate polypharmacy is identified, de-prescribing should occur for those medications that are discontinued in the context of the patient’s goals, functional status, life expectancy, values, and preferences.
In summary, the presence of a geriatric syndrome/s may indicate a more limited reserve to tolerate additional stressors. Common geriatric syndromes include falls, cognitive impairment and delirium, depression, and polypharmacy; these conditions are highly relevant for older adults. The presence of these conditions may influence overall ability to tolerate stressors as well as quality of life and potentially survival.
*Begin by having the patient sit back in a standard chair and identify a line 3 meters, on the floor.
On the word “Go,” begin timing.
Stop timing after patient sits back down.
**Gait speed is: total distance / time. For example, if you did a 10 meter gait speed test and it took you 7 seconds, the equation would like: 10 meters / 7 seconds = 1.4 meters per second.
(gait speed < 1 m/second, which signifies significant risk)
Dr Tasneem Mayat
Southern Highlands Private Hospital Consulting Suites
93 - 95 Bowral Street
Bowral NSW 2576
P: 02 4862 9470
F: 02 4862 9471