1
Q
Define Frailty
A
State of increased vulnerability from ageing, associated decline in reserve and function cross multiple physiological systems such that the ability to cope with every day or acute stressors is compromised
2
Q
Give the main features of frailty
A
- Poor function reserve
- Vulnerable to decompensation when facing illness, drug side effects, metabolic disturbance
- It is NOT inevitable
- Marker of mortality
3
Q
Give 2 ways to prevent frailty
A
- Good nutrition
- Physical activity
- Avoid social isolating
- Decrease alcohol intake
4
Q
Give 2 ways to assess frailty
A
- Clinical Frailty Score
- Walking speed = time to get up and walk 6m, good = <12s
- Grip strength
5
Q
What are the 5 geriatrics Ms and give an example of each?
A
- Mind –> dementia, delirium, depression
- Mobility –> impaired gait and balance, falls
- Medications –> polypharamcy, deprescribing/optimal prescribing, adverse effects, medication burden
- Multi-complexity –> multi morbidity, bio-psycho-social situations
- Matters most –> individual meaningful health outcomes and preferences
6
Q
What needs to be taken into consideration in a comprehensive assessment for discharge planning?
A
- Medical assessment –> diagnosis and treatment, co-morbidities, med review = Dr
- Functional assessment –> ADLs, gait, balance = OT, PT
- Psychological assessment –> cognition, mood
- Social assessment = care resources, finances = social worker
- Environmental assessment = home safety
7
Q
What are possible legal or ethical issue with geriatric patients?
A
- Care at the end of life
- Discharge destination
- Dementia and delirium
- Mental capacity act
8
Q
Define palliative care
A
Treatment that recognises the irreversible nature of the underlying disease –> holistic approach, symptom control
9
Q
What is Advanced Care Planning?
A
A process of discussion about goals of care and means of setting on record preferences for care of patients who may lose capacity or communicating ability in the future
10
Q
What can Advanced Care Planning include?
A
- Legal aspects
- Preferred place of care
- Treatment options acceptable to patient and suitable for patient
- DNACPR
- Specific plan for a complex situation
11
Q
Give 2 advantages of Advanced Care Planning
A
- Open ended
- Personalised care
- Avoids futile disease orientated treatment
- Patient centred goal
- Improves coordination of care
12
Q
Give 3 risk factors for falls
A
- Motor problems –> gait, balance
- Sensory impairment
- Cognitive/mood impairment –> dementia, delirium, depression
- Orthostatic hypotension
- Polypharmacy
- Alcohol, drugs
- Environmental hazards
- Incontinence
- Fear of falling
13
Q
Give 3 causes of falls
A
- Drugs –> sedative, alcohol
- MSK –> OA hip
- Syncope –> vasovagal, cariogenic, arrhythmias
- Stroke, TIA
- DM, hypoglycaemia
- Visual impairment
- Dementia
- Poor environment
14
Q
What is the management of falls?
A
- Strength and balance training
- Home hazard intervention
- Correct vision
- Review medication
- Integrated management of contributing morbidities
15
Q
Give 2 possible complications a long lie following a fall
A
- Rhabdomyolysis
- Pressure ulcers
- Dehydration
16
Q
What is Rhabdomyolysis?
A
Skeletal muscle breaks down due to traumatic, chemical or metabolic injury –> results from death of muscle fibres and release of their content (myoglobin, potassium, phosphate, creatine kinase) into the bloodstream
17
Q
Give 2 causes of Rhabdomyolysis
A
- Crush injuries
- Prolonged immobilisation following a fall
- prolonged seizure activity
- Hyperthermia
- Neuroleptic malignancy syndrome
18
Q
What is the clinical presentation of Rhabdomyolysis?
A
- Muscle aches and pain
- Oedema
- Fatigue
- Confusion
- Red-brown urine
19
Q
What investigations would you do and what would you see in someone with Rhabdomyolysis?
A
- Creatine Kinase –> very elevated
- Myoglobinurea –> red-brown urine
- U&Es –> AKI, hyperkalaemia
- ECG –> hyperkalaemia
20
Q
What is the management of Rhabdomyolysis?
A
Supportive –> fluids, electrolyte correction
Renal Replacement therapy
21
Q
Give 2 possible complications of Rhabdomyolysis?
A
- Kidney failure –> due to myoglobin
2. Cardiac arrhythmias –> cardiac arrest due to hyperkaleamia
22
Q
Give 3 signs of hyperkalaemia on an ECG
A
- Tall tented T waves
- Prolonged PR
- Loss of P wave
- Broad QRS
- ST elevation
- Sine wave pattern
23
Q
Define ulcer and pressure ulcer
A
Ulcer = break in the skin mucous membrane which fails to heal
Pressure ulcer = ulcer caused by pressure or shear force over a bony prominence
24
Q
Give 2 risk factors for pressure ulcers
A
- Immobility
- Poor nutrition
- Incontinence
- Multiple comorbidities
- Smoking
- Dehydration
25
What investigations would you do for someone with a possible pressure ulcer?
- Waterlow score = assesses risk of developing a pressure ulcer
- Admission with ulcer --> CRP, ESR, WCC, swabs, cultures, XR
26
What is the preventative management of pressure ulcers?
- Barrier creams
- Pressure redistribution
- Repositioning
- Regular skin assessment
27
What is the treatment of pressure ulcers?
Abx
Wound dressing
Pain relief
Debridement if grade 3 or 4
28
Define osteoporosis
Progressive deterioation of bone mass and microarchitecture
A systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture
Decreased bone mineral density due to imbalance between remodelling and resorption
29
Give 3 risk factors of osteoporosis
SHATTERED
1. Steroids
2. Hyperthyroidism, hyperparathyroidism, hypocalcaemia
3. Alcohol and smoking
4. Thin = BMI <18.5
5. Testosterone decreased
6. Early menopause = oestrogen deficiency
7. Renal/liver failure
8. Erosive/IBD
9. Dietary intake --> decreased Ca, malabsorption, T1DM
10. Previous fracture or FHx of osteoporosis or fracture
30
Give 3 possible cause of osteoporosis and briefly describe why
1. AI conditions (RA, IBD) --> inflammatory cytokine increases bone resorption
2. Hyperthyroidism/hyperparathyroisim --> increased bone turnover
3. Cushings --> cortical increases bone resorption and induces osteoblast apoptosis
4. Post menopausal --> less oestrogen so high bone turnover = resorption > formation
5. Low body weight and immobility --> reduced skeletal loading increases resorption
6. Medications --> glucocorticoids, Depo-povera, aromatase inhibitor, GnRH analogues, androgen deprivation
31
How does osteoporosis present?
Usually asymptomatic
| Fragile bones and pathological fractures (NOF, spine)
32
What investigations might you do in someone with suspected osteoporosis?
- Bone mineral density scan = DEXA scan
- Bone profile --> normal Ca, phosphate, alkP, can have low vit D
- FRAX
33
What does a DEXA scan show?
```
Looks at bone mineral density
Give a T score = standard deviation score which compares with gender matched young adult average:
>-1.0 = normal
-1 to -2.5 = osteopenia
< -2.5 = osteoporosis
```
34
What is FRAX and what does it take into consideration?
```
Predicts 10 year fracture change (primary prevention)
Looks at:
- Age
- Sex (female)
- Height and weight
- Previous fracture
- Parent fractured hip
- Current smoking
- Glucocorticoids
- RA
- Secondary osteoporosis
- Alcohol 3 or more units per day
- Femoral neck BMD
```
35
What is the non-pharmacological management of osteoporosis?
- Physio --> weight bearing exercise and falls prevention
- Smoking cessation
- Reduce alcohol
- Increase Ca and Vit D
36
What is the pharmacological management of osteoporosis?
Anti-resorptive = decrease osteoclast activity and bone turnover
- Bisphosphonates (inhibit cholesterol formation leading to osteoclast apoptosis) --> alendronate oral (upright for 30 mins and before eating)
- HRT
- Denosumab = monoclonal antibody to RANK ligand slowing osteoclast activity
Anabolic = increase osteoblast activity and bone formation
- Teriparatide (PTH analogue) --> increased bone density and improves trabecular strength
37
What are the determinants of bone strength?
1. Bone mineral density
2. Bone size
3. Geometry
4. Microarchitecture
5. Turnover
6. Mineralisation
38
Define osteopenia
Precursor to osteoporosis characterised by low bone density
| T score -1 to -2.5
39
Define osteomalacia
Poor bone mineralisation leading to soft bones due to lack of Ca2+, phosphate and vitamin D
40
Give 2 causes of Malnutrition
1. Decreased nutrient intake
2. Increased nutrition requirement --> sepsis, injury
3. Inability to utilise nutrients ingested --> malabsorption, severe diarrhoea, high output stoma
4. Combination of above
41
Give 3 possible consequences of Malnutrition
1. Decreased immunity
2. Muscle wasting --> falls, increased chest infections, decreased mobility
3. Impaired wound healing
4. Micronutrient deficiencies
5. Poor prognosis, reduced QOL
42
How is malnutrition assessed?
MUST = Malnutrition universal screening tool
| - BMI, History of weight loss, acute disease effect
43
What is the management of malnutrition?
- FOOD 1st --> snacks, nourishing drinks, food fortification
- Oral nutritional supplements --> liquid, powder, semi solid
- Enteral/parenteral feeding --> NG, gastrostomy, PEG
44
What is enteral feeding and name the types?
Direct feeding into the gut
- NG = feeds into stomach, short term (<30d), ward level insertion
- NJ = feeds into jejunum, short term (<60d), XR check
- PEG (percutaneous endoscopic gastrostomy)
45
Give 2 advantages and 2 disadvantages of enteral feeding
Advantages
1. Preserves gut mucosa and integrity
2. Improved nutritional status
3. Less invasive than parenteral
Disadvantages
1. Tolerance --> nausea, satiety, bowels
2. Uncomfortable to place
3. QOL
46
When is a PEG indicated?
1. Dysphagia --> storke, MND
2. Cystic fibrosis --> high nutritional requirements
3. Oral intake inadequate and likely long term
47
What is parenteral feeding?
Intravenously feeding when gut is inaccessible or unable to absorb sufficient nutrients to sustain nutritional status
48
What is refeeding syndrome?
Metabolic disturbance as a result of reinstating nutrition to patients who are starved/severely malnourished
49
Give 3 signs of refeeding syndrome
1. Hypophosphataemia
2. Hypokalaemia
3. Thiamine deficiency
4. Abnormal glucose metabolism
50
Give 2 possible complications of refeeding syndrome
1. Cardiac arrhythmias
2. Convulsions
3. Cardiac failure
51
Define polypharmacy
The concurrent use of multiple medications by 1 person (often stated as >5)
52
Define appropriate polypharmacy
Prescribing multiple medications for either complex conditions or multiple concurrent conditions where medicine use has been optimised
53
Define problematic polypharmacy
When multiple medicated are prescribed inappropriately, increasing the risk of side effects
54
Give 2 reasons polypharmacy occurs in the elderly
1. Multimorbidity
2. Incremental prescribing
3. EOL considerations
55
Give 2 problems with polypharamcy
1. Adverse reactions may go undetected, as linked with older age --> forgetfulness, weakness, tremor
2. Adverse reactions may be misinterpreted as a problem --> another prescription
3. Inappropriate drug uses --> patients doesn't understand, own interpretation of instruction
4. Medication nonadherance
56
What are common adverse drug reactions?
Falls --> postural hypotension
CONfusion --> sedation
Bowel problems --> diarrhoea or constipation
57
Define delirium
Clinical syndrome characterised by disturbed consciousness, cognitive function or perception
Acute confusional state that fluctuates in severity and is usually reversible
58
Give 3 risk factors for delirium
1. Older than 65
2. Significant comorbidities
3. hip fracture
4. Dementia
5. Cognitive impairment
6. Change of environment
59
Give 4 causes of delirium
PINCH ME
1. Pain
2. Infection
3. Nutrition
4. Constipation
5. Hydration
6. Metabolic/medications
7. Environment
Hypoxia, hypo/hyperthermia, organ dysfunction
60
Give 3 signs of a hyperactive delirium
1. Agitation
2. Aggression
3. Restlessness
4. readily distracted
5. Wandering
6. Hallucinations
61
Give 3 signs of a hypoactive delirium
1. Lethargy
2. Apathy
3. Excessive sleeping
4. Inattention
5. Motor retardation
6. Drowsy
7. Unarousable
62
What investigations might you do for a patient with suspected delirium
- Delirium screening bloods = FBC< U&Es, CRP, LFTs, Clotting, TFTs, Calcium, Haematinics, B12/folate
- Septic screen
- ABG
- Urinalysis
- Sputum sample
- CXR
- CURB65
63
What is urge incontinence?
Overactivity of detrusor muscle
| - Sudden feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs
64
What is stress incontinence?
Weak pelvic floor and sphincter muscles so urine leaks at times of increased pressure on the bladder
- Laughing, coughing, straining
65
What is overflow incontinence?
Chronic urinary retention due to obstruction to the outflow of urine resulting I overflow of urine and the incontinence occurs without urge to pass urine
66
Give 2 possible causes of overflow incontinence
1. Ach medications
2. Fibroids
3. Pelvic tumours
4. Constipation
5. Neurological conditions --> MS, diabetic neuropathy, spinal cord injuries
67
Give 3 risk factors for incontinence
1. Increased age
2. Postmenopausal status
3. INCreased BMI
4. Previous pregnancies and vaginal deliveries
5. Pelvic organ prolapse
6. Pelvic floor surgery
7. Neurological conditions --> MS
8. Cognitive impairment --> dementia
68
What investigations might you do for someone with incontinence?
- Good history (lifestyle factors) and examination
- Bladder diary
- Urine dipstick
- Post void residual bladder volume
- Urodynamic testing
69
What is the management for stress incontinence?
- Lifestyle = avoid caffeine, diuretics and overfilling bladder, weight loss, pelvic floor exercise
- Duloxetine
- Surgical = sling, colposuspension, artificial sphincter
70
What is the management for urge incontinence?
- Bladder training
- Anticholinergic medications = oxybutynin, tolterodine, solifenacin
- Mirabegron = B3 agonist
- Invasive = botox, sacral nerve stimulation, cystoplasty, urinary diversion
71
What is Heart Failure?
CO is inadequate for body requirements
Inability of the heart to deliver blood and thus O2 at a rate that is commensurate with the requirement of metabolising tissue of the body
72
Give 3 risk factors of heart failure
1. >65
2. African descent
3. Men
4. Obesity
5. Previous MI
73
What are the 3 cardinal symptoms of heart failure?
1. SOB
2. Fatigue
3. Peripheral oedema
74
Give 3 other symptoms of heart failure
1. Tachypnoea
2. Orthopnoea
3. Paroxysmal nocturnal dyspnoea
4. Pink frothy sputum
5. Cough
6. Weight loss
7. Cold peripheries
75
Give 3 signs of heart failure
1. Crackle in lungs
2. Heart murmurs
3. Oedema, ascites
4. Hypotension
5. Cyanosis
6. Displaced apex beat
7. Raised JVP
76
Describe the New York Heart Association Classification (NYHA)
- Class 1 = asymptomatic, no limitation
- Class 2 = Mild HF, slight limitation
- Class 3 = moderate HF, marked limitation
- Class 4 = severe HF, inability to carry out any physical activity without discomfort
77
Define systolic and diastolic heart failure
Systolic = inability of ventricle to contract normal --> decrease in CO
Diastolic = inability of ventricle to relax and fill properly --> decreased SV and CO
78
Give 3 causes of HF
1. Ischaemic heart disease
2. Cardiomyopathy
3. Valvular heart disease --> AS
4. Cor pulmonale
5. HTN
6. Alcohol excess
79
What is seen on a CXR of someone with HF
ABCDE
1. Alveolar Bat wing oedema a
2. Kerley B lines
3. Cardiomegaly
4. Dilated prominent upper lobe vessels
5. Pleural Effusion
80
What is the blood marker of HF?
Brain natriuretic peptide (BNP)
| - Secreted by ventricles in response to increased myocardial wall stress
81
How is acute HF managed?
LOON
- Loop diuretic = furosemide
- Oxygen
- Opioid = diamorphine
- Nitrates = GTN spray
82
What is the prevention of chronic HF?
Lifestyle modification = stop smoking, healthy eating, exercise, avoid large meals, vaccinations
Treat underlying cause --> dysrhythmias, valve disease
83
What is the management of chronic HF?
- Loop diuretic and thiazides --> fluid overload
- ACEi = ramipril
- BB = propranolol, atenolol
- Aldosterone antagonist = spirolactone
- Anticoagulation therapy and aspirin
- CCB = amlodipine
- ARB = losartan, candesartan (if ACEi ineffective)
- Digoxin
- Vasodilators = hydralazine
- Surgery --> revascularisation, transplant, resync, defib
My Phase 3a
flashcards
Decks in class (7)
# Cards
