Geri 3a

Question 1

Causes of acute delirium

Answer 1

Pain
Infection
Constipation
Urinary retention
Metabolic: hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
Medications: e.g. opioids
Hypoxia
change of environemtn
alcohol withdrawal

Give haroperidol as firast line to calm

Question 2

most common causes of vertigo encountered

Benign Paroxysma; Positional Vertigo (BPPV)

vertigo: sensation that u or the environment around is moving r spinning

It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.
- Calcium debris in semicircular canal usually idiopathic, mayb preceded by head trauma.

Answer 2

• vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
• may be associated with nausea
• each episode typically lasts 10-20 seconds
• positive Dix-Hallpike manoeuvre, indicated by:
• patient experiences vertigo
• rotatory nystagmus

BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:
* Epley manoeuvre (successful in around 80% of cases)

Question 3

Delirium V Dementia

Answer 3

• Factors favouring delirium over dementia
• impairment of consciousness
• fluctuation of symptoms: worse at night, periods of normality
• abnormal perception (e.g. illusions and hallucinations)
• agitation, fear
• delusions

Question 4

VitD replacement can help prevent falls.

Falls in the elderly

associated with significant mortality and morbidity in the elderly

Normal Gait: Neuro(basal ganglia + corticol basal ganglia loop) MSK (appropriate tone + strength) Fine touch + proprioception
Medical probelms affecting stated systems can cause falls in elderly.
RF: Lower limb weakness, vision proble, pollypharmacy, gait disturbace conditions, postural Hypotension, arthritis

Answer 4

• impact patients confidence and independence.
• Rx Risk of falling: benzos, antipsychotics, opiates,anticonvulsants, codeine, digoxin
• RX causes posturan hypoTN: nitrates, ACEi, Antcholinergics, antidepressants,BBlockers, Ldopa, Diuretics

Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
* >2 falls in the last 12 months
* A fall that requires medical treatment
* Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’

Question 5

FRAX or QFracture to assess the 10-year risk

Osteoporosis managemet

BMD of < 2.5 standard deviations (SD) below the young adult mean density

• it increases the risk of fragility
• . Certain fragility fractures such as fractured neck of femur are associated with significant morbidity and mortality
  RF
• corticosteroid use
• smoking
• alcohol
• low body mass index
• family history

Answer 5

• VitD and calcium supplementation
• aldendronate 1st line or etidronate (if GI symptoms)
• 2nd line Raloxifene - selective oestrogen receptor modulator (SERM)

in fall always get a hip fracture anterposterior and lateral
all hip fractures need surgical intervention.

Question 6

Constipation

Delayed alimentay tract transit time.

1. harde faces
2. soft faces throught bowels which are unable to be evacuated
3. high impaction due to cancer or diverticular disease.

Answer 6

• Constipation can be acute cause of delirium
• can lead to sepsis or renal failure

Causes
* Reduced motility due to opiates, iron, anticholinergics, antidepressants, CCB
* neuromuscualr: parkinsons, diabetic neuropathy
* carcinoma of bowel.

Stimulant laxatives: senna, avoid in hard stools - use osmotic laxative like lactulose. long term laxaive use linked to bowel neuronal damafe.

Question 7

Acute Cardiac Failure

Answer 7

Refer to paper notes

Question 8

Malnutrition in elderly

Around 10% of patients aged over 65 years are malnourished, the vast majority of those living independently, i.e. not in hospital or care/nursing homes.

Answer 8

Screening for malnutrition if mostly done using MUST (Malnutrition Universal Screen Tool). A link is provided to a copy of the MUST score algorithm.
* it should be done on admission to care/nursing homes and hospital, or if there is concern. For example an elderly, thin patient with pressure sores
* it takes into account BMI, recent weight change and the presence of acute disease
* categorises patients into low, medium and high risk

Management of malnutrition is difficult. NICE recommend the following points:
1. dietician support if the patient is high-risk
1. a ‘food-first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’), rather than just prescribing oral nutritional supplements (ONS) such as Ensure
1. if ONS are used they should be taken between meals, rather than instead of meals
1.

Question 9

Hypothermia

Core temperature <35°C, but <35.5°C is probably abnormal

Causes
Often multifactorial.
* Illness (drugs, fall, pneumonia)
* Defective homeostasis (failure of autonomic nervous system-induced
shivering and vasoconstriction; decreased muscle mass)
* Cold exposure (clothing, defective temperature discrimination, climate, poeverty)

Answer 9

• Rectal temperature is the gold standard but well-taken oral or tympanic temperature will suffice.
• cold to touch, bradycardia
• Signs can mimic stroke with falls, unsteadiness,
  weakness,
• Hypomotility may lead to ileus, gastric dilation and
  vomiting.
• Disseminated intravascular coagulation (DIC), pressure injuries, and rhabdomyolysis
• Regular BP, pulse, temperature, respiratory rate, oxygen sats, glucose; continuous ECG; consider urinary catheter. Consider ITU.

Hypothermia is a common presentation of sepsis in hospital older ppl

• Mild hypothermia should be managed with gentle warming and close monitoring
• The features of severe hypothermia may mimic those of death. Beginresuscitation whilst gathering information that permits a decision as to whether further intervention is likely to be futile or else not in thepatient’s interests
  Drug treatment
  Consider:
• Empirical antibiotics (most have evidence of infection on careful serial
  assessment)
• Adrenal insufficiency (treatment: hydrocortisone 100mg qds)
• Hypothyroidism (treatment: liothyronine 50micrograms then
  25micrograms tds iv, always with hydrocortisone)
• Thiamine deficiency (malnourished or alcoholic) (treatment: B vitamins
  oral or iv) (as Pabrinex®)

Question 10

Polypharmacy

Polypharmacy can cause problems, but is sometimes appropriate—
depriving patients of beneficial treatments because they are old, or already on multiple other medications, can also be wrong. In a recent study of medication changes during a geriatric admission, the total number of drugs was the same at admission and discharge, but they had often been changed. In other words, there was active evaluation of medication going on—the goal being not just to limit the number of drugs, but also to
optimize and individually tailor treatment

Answer 10

Do not deny older patients disease modifying treatments simply to avoid polypharmacy

Question 11

Pressure Ulcers

RF: malnourishment, incontinence, lack of mobility, pain

Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age. They typically develop over bony prominences such as the sacrum or heel. The following factors predispose to the development of pressure

Answer 11

Grade 1 Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade 2 Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister
Grade 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss - Rhabdomyolysis

Rhabdomyolysis = AKI too
Managed: IV fluids to maintain good urine output
urinary alkalinization is sometimes used

Waterlow score to screen patients who r at risk of developing v these

Management
* a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
* wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
* consider referral to the tissue viability nurse
* surgical debridement may be beneficial for selected wounds

Question 12

Multimorbidity

Hypertension is most common alongside another disease.

The presence of two or more long-term health conditions, including: Defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse

Answer 12

• Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire:
• Consider a ‘bisphosphonate holiday’ in those taking bisphosphonates for longer than three years as there is no consistent evidence of continued benefits after this point. Discuss stopping bisphosphonates after 3 years and include patient choice, fracture risk and life expectancy in the discussion.
• Consider the use of screening tools such as STOPP/ START in older people to recognise medicine safety concerns: STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions and START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk

Question 13

What tool is used to identify unecessary medications for elderly patients

Answer 13

• STOPP (Screening Tool of Older Persons’ Prescriptions)
• Checklist includes a list of common medications and drug classes that may be problematic for older adults due to factors such as increased sensitivity to side effects, potential interactions, or the presence of specific medical conditions.

STOPP identifies medications where risk outweighs therapeutic benefits

Question 14

What tool is used to identify beneficial medications for elderly patients

Answer 14

• START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk