Frail patients

Hyperosmolar hyperglycaemia (HH) is generally the fulminant result of poorly treated type 2 diabetes or delayed diagnosis of previously unknown type 2 diabetes. HH is less frequent than DKA, but mortality is higher and remains close to 15% in many centres [1,20]. As implied hyperosmolality is the primary clinical problem and there will be hyperglycaemia of >35 0 mmol/L and an effective seram osmolality of >320 mOsm/kg (Table 1). HH most often occurs in frail patients in combination with other potentially fatal conditions. Strict differentiation between DKA and HH can be difficult, because some degree of ketosis may be present in HH and because, for example, lactic acidosis, respiratory and renal failure may also be present. In practise this dilemma is mainly ornamental, since diagnostic and therapeutic efforts follow the same principles. 

Table 74.2 RT options in fit adults tsee What if... for elderly/l,D/fraill Table 74.3 RT in elderly/l,D/frail patients Table 74.4 Managing aggression on psychiatric wards/CMHTs Chapter 77 Delirium tremens...

Agitation (restraint and rapid tranquilisation are risky in elderly or frail patients)... 

Having more than one prescriber increases the risk of inappropriate drug use (Piecoro et al. 2000, Dhalla et al. 2002). Thus, it is important that frail elderly have a physician that has knowledge of the patient s entire pharmacotherapy. It also emphasises the need for communication between different care givers. 

Delirium often has a multifactorial cause (Box 6.1). Elderly patients with severe illness or who are already cognitively impaired are vulnerable to delirium. Malnutrition or dehydration may further enhance the risk. The most common causes for delirium are drugs and diseases. Frail elderly who are vulnerable to delirium may be pushed into delirium by one dose of an inappropriate drug or by e.g. urinary retention whereas younger individuals are far more resistant. 

The prevalence rates of schizophrenia are lower in old age than in younger age groups (Copeland et al. 1998). The incidence of Alzheimer s disease with psychosis is much more frequent than the incidence of schizophrenia in old age (Jeste and Finkel 2000). For the frail Alzheimer s patients, medications may induce or aggravate the symptoms. 

Part of this relates to the problem of polypharmacy. Some patients take 9 medications and they need every one of those 9. But the worrisome kind of polypharmacy is the unbridled, undisciplined use of a large number of drugs, especially in a frail older... 

The results of Lerer et al. [1995] are consistent with clinical experience. When there is a need for rapid response with ECT (e.g., food refusal], treatment three times per week is indicated. On the other hand, if a patient appears to be at risk for cognitive side effects (e.g., frail elderly], reducing the frequency of treatment to two times per week is justified. 

The typically advanced age of patients with AD and their often frail health state, setting strict limits to clinical experimentation. 

Sodium phosphate is available as a nonprescription liquid formulation and by prescription as a tablet formulation. When taking these agents, it is very important that patients maintain adequate hydration by taking increased oral liquids to compensate for fecal fluid loss. Sodium phosphate frequently causes hyperphosphatemia, hypocalcemia, hypernatremia, and hypokalemia. Although these electrolyte abnormalities are clinically insignificant in most patients, they may lead to cardiac arrhythmias or acute renal failure due to tubular deposition of calcium phosphate (nephrocalcinosis). Sodium phosphate preparations should not be used in patients who are frail or elderly, have renal insufficiency, have significant cardiac disease, or are unable to maintain adequate hydration during bowel preparation. 

Old age increases sensitivity to sulfonylureas and the frail elderly are at greatest risk (142). Chlorpropamide is no longer recommended for treatment of type 2 diabetes. However, in 1993 and 1994, of 3050 older Mexican Americans, 365 used inappropriate medicines, of whom 36 used chlorpropamide (143). In a comparable study of 5734 patients over 65 years old, hospitalized in 81 geriatric... 

Rarely, patients may complain of visual frails or after-images on nefazodone... 

The word geriatric refers to individuals who are over age 65 years. This has been described as the most heterogeneous population because it constitutes fit, physiologically healthy patients to extremely frail, debilitated patients in long-term care facilities (LTCF). 

Extrapyramidal symptoms have been reported in a few frail elderly women (SEDA-13, 169). A few cases of myoclonic encephalopathy have been observed at therapeutic dosages old people, patients of low body weight, and patients with renal insufficiency due to dehydration appear to be especially vulnerable (SEDA-9, 189) (SEDA-10,172) (SEDA-11, 179). 

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