Phase 3a > Geriatrics > Flashcards

Geriatrics Flashcards

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1
Q

What is included in a Comprehensive Geriatric Assessment?

A
  • MEDICAL:
    - problems list / Co-morbidities + Disease SEVERITY
    - MEDICATION review
    - NUTRITIONAL status
  • MENTAL HEALTH:
    - COGNITION
    - Mood + anxiety + Fears
  • FUNCTIONAL CAPACITY:
    - Daily living
    - Gait + BALANCE
    - Activity status
  • SOCIAL / ENVIRONMENTAL ASSESSMENT
    - Social support (family + friends)
    - Social network (visitors + activities)
    - CARE RESOURCE ELIGIBILITY
    - Home safety + FACILITIES
    - TRANSPORT
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2
Q

4 As of Alzheimer’s

A
  • Amnesia (short term memory loss is usually 1st presenting feature)
  • Aphasia (language impairment)
  • Apraxia (inability to do task despite physically having the faculties to do it and understanding what must be done)
  • Agnosia (Inability to identify objects despite knowing what the object/thing/person is)
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3
Q

Main diffrences in Px of diff types of dementia

A
  • Alzheimer’s is mc - typically in elderly
    - starts with short term memory loss - memory loss is defining feature
  • Vascular
    - step wise / sudden deterioration after cva
    - change in behaviour / impaired memory
  • Frontotemporal - oft HEREDITARY and earlier onset (between 40s-65 ish)
    - Personality + Behavioural change is key factor - stereotypical, repetitive + compulsive actions; emotional blunting; abnormal eating + sleeping; Language problems
    - Memory is preserved more comparatively
  • Lewy body (memory loss for at least 12 months before parknisonism movement issues start
    - cognitive impairment is FLUCTUATING
    - HALLUCINATIONS + Sleep disturbance
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4
Q

Key diff in pathophys of diff dementia’s

A
  • Alzheimers
    - abnormal phosphorylation of tau protein -> deposits -> B-amyloid plaques in brain + blood vessels (neuritic plaques + amyloid angiopathy)
    - Neurofibrillory tangles -> neuronal NECROSIS
    - Acetylcholine deficiency
  • Vascular = CVD
  • Frontotemporal
    - Frontotemporal atrophy
    - Pick’s bodies - mutated tau gene -> abnormal swelling of neurones
  • Lewy body
    - Lewy bodies = ALPHA-SYNEUCLIN protein deposits in brain stem + neocortex -> reduce Acetylcholine + dopamine
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5
Q

Dementia Tx

A

ACETYLCHOILEESTERASE INHIB ie Donepezil = 1st for Alzheimer’s + Lewy body dementia
- NB: DO NOT use in Frontotemporal (can make worse); little effect for vascular

  • Rivastigmine = good for hallucinations
  • MEMANTINE (N-Methyl-D-Aspartate (NMDA) receptor ANTagonists) = good for any dementia (tho only officially recommended for alzheimers)

NB - vascular dementia can’t really be treated with dementia meds - need to Tx underlying

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6
Q

Pseudodementia

A

Cognitive impairment secondary to mental illness
- oft respond with “don’t know”

  • Impaired EXECUTIVE FUNCTION + ATTENTION

May see frontal lobe changes + white matter hyperintensity on MRI

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7
Q

What is included in a Confusion screen

A
  • FBC
  • U+E
  • LFTs
  • TFT’s
  • Coag / INR
  • CALCIUM
  • B12 + FOLATE
  • GLUCOSE
  • CULTURES

Should also do urinalysis + consider imaging depending on Sx + suspected pathology

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8
Q

Benign Paroxysmal Positional Vertigo + Px

A

MC of vertigo - average age of onset 55

  • Vertigo triggered by change in head position (rolling over, gazing upwards)
  • Potentially associated nausea
  • Each episode typically lasts 10-20 seconds
  • DIX-HALLPIKE manouver +ve (get patient to lie down, head hanging over side, with ear pointed to ground for 1-2 min) -> Vertigo + ROTATORY NYSTAGMUS
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9
Q

Mx of benign paroxysmal positional vertigo

A

Sx releif only

  • Epley manouver
  • Vestibular rehabilitation exercises (patient can learn themselves) e.g. Brandt-Daroff exercises
  • Medication oft prescribed but limited effect
    • BETAHISTINE

~50% get recurrance of Sx 3-5yrs post-diagnosis

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10
Q

RFx for Falls

A
  • Previous fall / fear of falling
  • Muscle weakness / Balance/gait disturbances / Arthritis
  • Vision problems
  • Postural hypotension
  • Depression / Cognitive impairment
  • POLYPHARMACY (4+) or any PSYCHOACTIVE DRUGS
  • Incontinence
  • (Age > 65)
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11
Q

Examples of drugs which can contribute to falls

A

Postural hypotension (bascially all HTN meds in this catagory):

  • Nitrates
  • DIURETICS
  • ANTICHOLINERGIC
  • Antidepressants
  • BET-BLOCKERS
  • L-DOPA
  • ACE-I

Also (all the usual stuff with big side effects):

  • BENZODIAZEPINES
  • Antipsychotics
  • Opiates
  • Anticonvulsants
  • Codeine
  • Digoxin
  • Sedatives
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12
Q

Tests for underlying cause of falls

A
  • Turn 180 / Timed up and go test
  • Muscle TONE
  • INjuries / deformaties
  • VISION ASSESSMENT
  • Dementia screen

+ general bloods / urinalysis if confusion etc

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13
Q

Frailty definition

A

State of increased VULNERABILITY due to AGEING-ASSOCIATED decline in FUNCTIONAL RESERVE, Across MULTIPLE PHYSIOLOGICAL systems, Resulting in COMPROMISED ability to COPE with everyday activites / acute stressors

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14
Q

Frailty assessment

A
  • GAIT speed
  • Self-reported health status
  • PRISMA 7 questionnaire (7 Qs)
    - > 85 y/o; male; limited activity; regular support; house-bound; social support; walking aid
    - 1 point for each ‘yes’
    - 3 or more = risk of frailty
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15
Q

Common causes of urinary incontinence

A

Age-related:

  • Reduced bladder capacity / contractility
  • Reduced ability to post-pone voiding
  • Loss of pelvic floor + urethral sphincter musculature
  • Atrophy of vagina / urethra
  • Prostate hypertrophy

Co-morbs:

  • Reduced mobility / Impaired COGNITION
  • MEDS
  • Constipation

Reversible:

  • UTI / urethral irritability
  • DELERIUM / DRUGS
  • CONSTIPATION
  • Polyuria
  • Prolapse
  • Bladder stones / tumours

Environment:

  • Toilet too far/hard to access
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16
Q

Urinary incontinence Ix

A
  • LUTS + bladder diary
  • Examination: Vaginal, rectal, neuro (as suspected)
  • Urinalysis + midstream urine

(surely a bladder scan would be useful??)

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17
Q

Urinary Incontinence Mx

A

Depends on cause:

  • Bladder retraining
  • Regular toileting
  • Pelvic floor exercises

Stress:

  • Transvaginal pessaries if prolapse; COLPOSUSPENSION / FASCIAL SLINGS; Mid-urethral slings
  • bulking agents to bladder neck if surgery too much for patient
  • DULOEXETINE if nowt else works

Urge:

  • Avoid caffine + sugary drinks + excessive fluids
  • OXYBUTININ / TOLTERODINE for OVERACTIVITY (anticholinergic)
  • Consider MIRABEGRON (Beta-3 agonist) in elderly but caution if HTN
  • Botox
  • Sacral neuromodulation

Overflow:

  • FINASTERIDE / TAMSULOSIN for BPH
  • Prostatectomy
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18
Q

When are catheters indicated?

A
  • Urinary RETENTION
  • Obstructed outflow + DETERIORATING RENAL FUNCTION
  • Acute RENAL FAILURE
  • If in intensive care
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19
Q

Complications of catheterisation

A
  • Blockage
  • Bypassing
  • Infection
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20
Q

What mechanisms maintain fecal continence?

A
  • Sigmo-rectal sphincter
  • Ano-rectal angle + anal sphincters
  • Ano-rectal sensation
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21
Q

Causes for fecal incontinence

A
  • Fecal impaction (so constipated the more liquidy stuff is just leaking out)
  • Neurogenic (loss of sphincter control)
  • Haemorrhoids
  • Rectal prolapse
  • Tumours
  • IBD
  • Drugs
    - esp ACETYLCHOLINESTERASE INHIBITORS (Rivastigmine, Donepezil) e.g. for dementia / parkinson’s
  • Functional incontinence (can’t make it to toilet; too cognitively impaired etc)
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22
Q

Fecal incontinence Mx

A

Neuro:

  • Planned evacuation at appropriate time (e.g. with LOPERAMIDE)

Overflow from impaction:

  • REHYDRATE
  • ENEMA (Phosphate agent)
  • Complete colonic washout
  • Manual evacuation
  • Laxatives

Prevention:

  • Once / Twice weekly enema

+ Tx underlying cause of CONSTIPATION obvs

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23
Q

Constipation

A

Typically Type 1 and 2 on Bristol stool chart (rabbit droppings/clumped together)
- Type 7 if over flow (liquid)

Primary = no organic cause - probs due to colon / anorectal muscle function dysregulation

Secondary = due to other underlying cause

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24
Q

RFx for constipation

A
  • Increased AGE
  • Inactivity
  • Low calorie intake
  • Low fibre diet
  • MEDS
    - OPIATES, antidepressants, antacids, antihistamines, iron supplements
  • FEMALE SEX
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25
Px of constipation
- Infrequent bowel movement - < 3 /wk - Difficulty passing bowel movements / excessive straining - TENESMUS - Abdo distension / mass felt at lower quadrant - Rectal bleeding - Anal fissures - Haemorrhoids - Presence of hard stool / impaction on PR exam
26
Rome IV criteria for constipation
- Fewer than three bowel movements per week - Hard stool in >25% of bowel movements - Tenesmus (sense of incomplete evacuation) in >25% of bowel movements - Excessive straining in >25% of bowel movements - A need for digital evacuation of bowel movements Don't need all to Dx
27
Causes of constipation
- Dietary (inadequate fibre / fluid) - Behavioural (inactivity / avoidance of defecation) - Electrolyte disturbance (HYPERcalcaemia) - Drugs - Opiates - CCB - some Antipsychotics - Neuro disorder - Spinal cord lesions; Parkinson's; Diabetic neuropathy - Endocrine (HYPOTHYROID) - Colon (stricture / malig) - Anal disease (Fissure; proctitis)
28
Constipation Mx
Depends on underlying cause - Life style changes (fibre, fluids, activity) - Bulkening agents - Ispaghula husk - Methylcellulose - Stool softners - Docusate sodium - Osmotic laxatives - LACTULOSE - Macrogol - Stimulant laxatives - SENNA - Bisacodyl - Enemas if impaction (sodium citrate) - Suppositories (glycerol) Refer to specialist for gut motility evaluation if not resolved by laxatives
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Alarm features which may indicate GI malig
- Weight loss - Loss of appetite - Abdo mass - DARK stool
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Ix for constipation
- Bloods: - FBC, Electolytes, TFTs, GLUCOSE - Abdo x-ray if suspect 2ndary cause e.g. obsttruction - Barium enema (if suspect impaction / RECTAL mass) - Colonoscopy (if suspect MALIG)
31
Malnutrition
State in which deficiency of energy, protein and/or other NUTRIENTS causes MEASURABLE ADVERSE EFFECTS on body's FORM, COMPOSITION, FUNCTION + CLINICAL OUTCOME
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Causes of malnutrition
- Decreased intake - Increased nutrient requirements (SEPSIS / INJURY) - Malabsorption / impaired metabolisation
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Dx of Malnutrition
Any of following: - **BMI < 18.5kg/m^2** - **Weight loss > 10%** of weight in **last 3-6 months** - BMI < 20 kg/m2 AND weight loss >5% in last 3-6 months
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Features of malnutrition
Reduced electrolytes (Hypophosphataemia, Hypokalaemia) - Thiamine def - Abnormal glucose metabolism
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Complications of malnutrition
- Cardiac arrhythmias - Cardiac failure (also a risk of refeeding as contractility reduces while malnourished) - Coma - Convulsions
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Mx of malnutrition
- Monitor bloods (biochem) - esp GLucose, Na, K+, Mg, Phosphate - Refeed within guidelines - Nutritional team / dietitian support - Supportive care
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RFx for pressure sores
- Lack of mobility (e.g. due to Pain) - Malnutrition - Incontinence
38
Assessing risk of pressure sores
Waterlow score: - BMI - Nutritional status - Skin type - Mobility - Continence - Sex / Age - Neurological deficit - Surgery - Medication (steroids, cytotoxics + high dose anti-inflam) **Score of >=10** = at RISK - >= 15 = HIGH risk - >= 20 = very High
39
Prevention of pressure sores
- Barrier creams (esp for incontinence) - Pressure redistribution + Repositioning (for mechanical causes) REGULARLY assess skin
40
Mx of pressure sores
- Hydrocoloid dressings (moist wound environment -> ulcer healing) - be mind full of what dressings are used - strong adhesive may tear skin more - SURGICAL DEBRIDEMENT (tho sometimes better to leave hard necrotic cap in place to allow healing/prevent) Abx only given if signs of infection
41
Classification / Stages of pressure ulcers
1. Non-blanching localised erythema (skin intact) 2. PARTIAL THICKNESS skin loss involving dermis, epidermis or both 3. Full thickness skin loss (Damage / NECROSIS of SUB-CUT tissue) 4. Extensive loss, destruction / necrosis of Muscle, BONE or SUPPORT structures Unstagable = depth unknown as base covered in debris / necrosis
42
START and STOPP
Tools to help optimize medications - START suggests meds which may provide ADDITIONAL benefits - STOPP assess which drugs could be DISCONTINUED NB polypharmacy = **4 or more meds**
43
Summary of Parkinson's
- Pathophys = Progressive reduction of dopamine in basal ganglia - Classic triad = resting tremor (oft unilateral); cogwheel rigidity; BRADYKINESIA - Also: - SLEEP DISTURBANCE; - mask-like face; - POSTURAL insability / POSTURAL HYPOTENSION / - shuffling gait + reduced arm swing; - Depression; - Anosmia; - Cognitive impairment / memory problems - Mx: - **LEVODOPA** (less effective over time, SE = dyskinesia) - COMT inhibitors = **Entacapone / Tolcapone** - Dopamine agonists = **Bromocryptine** - SE = Pulm fibrosis
44
Parkinson's plus syndrome
- Progressive supranuclear palsey (vertical gaze palsey) - Multiple system atrophy - Early autonnomic features - **Postural hypotension**; Incontinence; Impotence - Cortico-basal degeneration - **Spontaneous activity** in affected limb OR **Akinetic rigidity** - Lewy body dementia (notably cognitive impairment + visual HALLUCINATIONS)
45
What are the 5 key principles of the MCA 2005
- Assume capacity - Maxise / enable decision-making capacity - Freedom to make seemingly unwise decisions - All decisions must be taken in BEST interests - Choose least restrictive option
46
What is necessary for an individual to have capacity?
Depends on their ability to: - Understand relevant information - Retain information - Weigh up information - Communicate decision
47
Which article is relevant to deprivation of liberty
**Article 5 of Human Rights Act** - 'everyone has the right to liberty and security of person. No one shall be deprived of his or her liberty [unless] in accordance with a procedure prescribed in law' Deprivation of LIberty occurs when: - Person is subject to CONTINUOUS SUPERVISION / control AND person is NOT FREE to leave
48
What conditions must be met for a DoLs to be legal?
- Only for ADULTS (>18) - Suffering from mental disorder - Must be PATIENT / Care home resident - LACKS CAPACITY - Restrictions deprive liberty BUT are in person's BEST INTERESTS - No valid advance decision to refuse Tx /support that would be overridden by a DoLs (Advance directive would take precidence) Consider whether person should be sectiond under Mental Health Act instead
49
Independant Mental Capacity Advocate job role
- represents individual who lacks capacity but has no one else to represent them - present for decisions regarding: - changes in Long-term accomodation - Serious medical decision - Care reviews - Adult protection
50
What to consider when making a best interests decision
- is individual likely to regain capacity and can decision wait - How to encourage / optimise patient involvement in decision making - Past + present wishes, feelings, beliefs + values of person (+ any other relevant factors) - Views of other relevant people (e.g. patient's family)
51
RFx for osteoporosis
SHATTERED - Steroids - Hyperthyroid / Hyperparathyroid - Alcohol + SMOKING - Thin (BMI < 22) - Testosterone def - Early menopause - Renal / LIVER FAILURE - EROSIVE / Inflam BONE DISEASE (rheumatoid) - DIABETES + FHx
52
DDx for increased fracture risk
- Metabolic bone disease (osteomalacia + hyperparathyroid) - 1ry Osteoporosis - 2ndry oseoporosis - Cushing's syndrome - Hyperthyroid (high bone turnover) - Meds e.g. Glucocorticoids, anticonvulsants - MALIGNANCIES: - Multiple myeloma / METS
53
FRAX Score
Fracture Risk Assessment Tool - estimates **10-year probability** of MAJOR OSTEOPOROTIC FRACTURE - Normal = <10% - Osteopenia = 10-20% - Osteoporosis = >20%
54
DEXA scan
looks at bone density and generates: - T score (bone density against agaverage bone density of healthy group) - >-1.0 = normal - -1.0 to -2.5 = Osteopenia - <-2.5 = Osteoporisis - Z score (bone density against average bone density in your age group)
55
Lifestyle modifications for osteoporosis
- Diet (+ consider vit supps) - stop smoking - WEIGHT bearing exercise - DIABETIC CONTROL - Hip protectors in nursing home patients
56
Bisphosphonates Indications, SE + How to take
1st line for osteoporosis (DEXA <-2.5 OR DEXA < -1 AND FRAX >20%) SE: GI (dyspepsia; Oesophagitis) - MSK pain - Sometimes: Osteonecrosis of jaw + atypical femoral fractures Take: - On EMPTY stomach - Full glass of water - Upright for 30 mins after
57
2nd line Tx for osteoporosis
- Denosumab - Raloxifene - HRT - Teriparatide - Strontium ranelate
58
Advanced statement vs advanced decision
- Decision is referring to future decision to deny some kind of treatment (e.g. DNAR) so must be written down + signed with witnesses - Legally binding (except they can't refuse psych Tx) - Statement is a statement of people personal preferances which must be legally taken into consideration when making a best intersts decision but is not a legally binding document itself - can be made verbally but better to write down
59
What information can be included in an advanced statement
- Religious or spiritual views, and those that might relate to care ​ - Food preferences ​- Information about your daily routine​ Where you would like to be cared for (in hospital, at home, in a care home etc.) -​ Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)
60
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