--- module: 043-02 language: en chapter: 43 title: "Ageing, Frailty, Polypharmacy, and Geriatric Assessment" module_title: "Physiological reserve, medication burden, function, and goal-concordant ageing care" source_sha256: 5ad9f95c96b9591d3ef18920f29e2510fb8f11de82a6efa6b1609a30c335576d --- # Reserve, medication burden, function, and goals ## Narrowed reserve and presentation ### Normal resting values, narrowed reserve #### Acute illness crosses several thresholds ### Falls, confusion, immobility, new dependence ### Baseline function as a diagnostic vital sign ## Frailty and function ### Reduced reserve and impaired recovery #### Distinct from age, comorbidity, disability ### Scores estimate population risk only ### Contributors are modifiable ### Minor insult triggers dependence cascade #### Prevent with early mobilisation from day one ### Ask specifically, not just "independent" ### Destination follows trajectory and goals ## Sarcopenia ### Low strength with reduced quantity or quality ### Grip, chair rise, gait speed reveal more ### Progressively loaded resistance exercise ### Protein cannot rebuild without mechanical load ## Cardiovascular ageing and orthostasis ### Stiffness, afterload, diastolic filling ### Reduced beta response limits compensation ### Many factors combine into orthostatic hypotension ### Measure after rest, several minutes standing ### Heart-rate response separates causes #### Neurogenic: small heart-rate rise #### Volume depletion: larger rise ### Symptom diary matches treatment to conditions ## Kidney and drug handling ### Low muscle mass overestimates filtration #### Trends, cystatin, measured clearance ### Less reserve for water, sodium, potassium ### Water-soluble loading dose gives higher level ### Pharmacodynamics often outweigh kinetics #### Delirium, falls, hypoglycaemia, bleeding ## Reconciliation and deprescribing ### Ask what is actually taken ### Cascade: new drug treats earlier adverse effect ### Deprescribing as a monitored therapeutic trial #### Prioritise duplicates, toxicity, no indication #### Judge prevention by absolute benefit and time ### Abrupt cessation risks withdrawal or rebound ### Change in stages with baseline values ### Success measured by function, not count ## Falls as events with mechanisms ### Ask before, during, and after ### Causes can coexist ### Treat identified contributors ### Inability to rise predicts harm #### Pressure injury, rhabdomyolysis, hypothermia ### Walking does not exclude fracture ### Not simply a mechanical fall ### Graded return avoids disuse ## Delirium and comprehensive assessment ### Acute network dysfunction in vulnerable host #### Dementia does not explain acute decline #### Quiet patient may have hypoactive delirium ### Remove causes, rebuild orientation and cues ### Assessment converts problems into one plan #### Effective only when implemented and owned ## Nutrition and continence ### Weight loss as disease and function ### Texture modification can reduce intake ### Albumin reflects inflammation and illness ### Continence depends on access and assistance ### Anticholinergics worsen cognition and falls ### Catheters need indication and removal plan ## Capacity and goal-concordant care ### Specific decision at a specific time ### Barriers can falsely appear as incapacity ### Record decision, options, own-words understanding ### Capacity is not all or nothing ### Substitute acts on the person's values ### Best, worst, most likely functional outcomes ### Proportionate care, not less care ### Plan ranks priority goal and reassessment #### Palliation and rehabilitation used together