1
Q
changes in ADME in older people
A
drug stays in body longer so can be toxic (S/E) at lower doses
- reduced first pass metabolism
- reduced hepatic metabolism
- reduced renal excretion
- increased distribution of lipophilic drugs (due to increased body fat concentraion and decreased body water concentration) –> stays in body longer
2
Q
propanolol in older people
A
first pass metabolism declines
so more in system/ toxic at lower doses
Fatigue
Hypotension
Dizziness
3
Q
hepatic metabolism decreased by
A
HF
smoking
ageing
4
Q
digoxin in older people
A
reduced renal excretion so more in system/toxic at lower doses
nausea and vomiting abdominal pain Arrhythmias Yellow discoloration of vision Hyperkalemia ECG reverse kick sign
5
Q
lipophilic drugs in older people
A
- increased distribution of lipophilic drugs
- due to increased body fat concentraion and decreased body water concentration
- diazepam
- Chlordiazepoxide
6
Q
diazepam in older people
A
Increased distribution of lipophilic drugs due to increased body fat concentraion and decreased
Drowsy
Confused
7
Q
when cutting down polypharmacy, which are often booted out (8)
A
- secondary prevention drugs (bisphosphonates, statins)
- antihypertensives if patient experiencing postural hypotension
- quinine (Prescribed for night leg cramps but doesn’t work)
- Tricyclics, amitriptyline, anti-constipation (bad for cognition)
- st johns wart
- weak painkillers when on stronger ones
- dual antiplatlet therapy if MI over 1y ago
- high risk of toxic effects (diazepam, propanolol, warfarin, nitrates, digoxin,…)
8
Q
define fragility fracture
A
fall from standing height or less that results in broken bone
9
Q
things that improve orthogeriatric outcomes
A
Prompt orthogeriatric assessment -- 72h Prompt surgery -- 36h Pre-surgical cognitive testing Prompt mobilisation after surgery -- day on / after surgery Not delirious in post-surgery assessment Returned to original residence by 120 days Nutrition assessment Fracture prevention assessment
10
Q
frailty =
A
Related to age but not essential with ageing
Multiple body systems
Less ability to withstand an insult
- More at risk of adverse outcomes - hospital admission, reduced mobility, loss of independance, reduced ADL function, death
11
Q
frailty prevention
A
Good nutrition
Physical activity
Avoid social isolation
Limited alcohol intake
12
Q
frailty assessment
A
Clinical frailty scale (CFS) aka Rockwood
- 1-9
- quick and easy
- not valid for measuring improvement after acute illness or if patient younger than 65
Fried criteria (phenotype) 3 or more of: - Unintentional weight loss - Self-reported exhaustion - Weakness - grip strength - Slow walking speed - Low physical activity 2 = “pre-frail”
e-FI electronic frailty index
36 possible deficits
- Comorbidities - DM, HTN, Renal disease
- Polypharmacy / multimorbidity
- Sensory impairment
- Self-reported symptoms (Dizziness, Sleep disturbance)
- Social factors (Social isolation, Living alone)
presence/ absence of deficits as a proportion of the 36
Walking speed
Grip strength
Up and go time
- Time to stand up walk 6m (or 3m, turn and back) and sit again
- Should be 10s or less
PRISMA 7
- 7 item questionnaire
- 3 or more is :/
Groningen questionnaire
- 15 items
- 4 or more is :/
13
Q
first line bisphosphonate
A
alendronic acid
14
Q
difficulty with taking alendronic acid
alternative
A
need to take 1st thing in morning and remain upright for 30 mins
this is hard when cognitive impairment is involved
zolendronic acid IV - sometimes just one dose for a few months-years
15
Q
end of life indicators
A
Weight loss Recurrent unplanned admissions Delirium Frailty rising Frailty plus dementia Comorbidities Recurrent and persistent infections Not responding to medication
16
Q
when is there increased nutrition requirements
A
injury
sepsis
17
Q
consequences of malnutrition
A
Weakened immune system - Prone to infection Muscle wasting - Arms and legs especially visible - Falls, mobility problems - Increased chest infections Impaired wound healing - Longer hospital stay Micronutrient deficiency
18
Q
MUST tool =
A
malnutrition universal screening tool
- BMI (weight, height)
- weight loss
- acute disease effect (Yes/no) = Patient nil by mouth or likely not to eat at all for 5 days or more (past or future)
19
Q
malnutrition treatment
A
- food - snacks, nourishing drinks, food fortification
- oral nutrional supplements (ONS) - improve micro/macro intake: juice/ milkshake/ soup/ powder/ semisolid
- enteral feeding
- parentral feeding
20
Q
enteral feeding types
A
straight into gut:
NG nasogastric tube
nasojejunal tube
PEG tube (percutaneous endoscopic gastrostomy )
PEJ percutaneous endoscopic jejunostomy
21
Q
parental feeding =
A
fed via IV- PICC / central line
when gut is inaccessible or unable to absorb sufficiently
22
Q
TPN =
A
TPN = total parenteral nutrition
IV feeding via central/PICC line
23
Q
parental feeding pros and cons
A
Advantages - Meet nutritional requirements - Easily tolerated Disadvantages - More costly - Risk of line infection ---- Unlikely but serious risk if occurs - More invasive - Gut atrophy - villi flatten ---Reduced absorption when go back to gut feeding
24
Q
indications for parental feeding
A
Inadequate absorption -- Short - bowel syndrome -- Due to surgery Gastrointestinal fistulae Bowel obstruction Prolonged bowel rest -- Severe IBS sometimes want to rest the gut Severe malnutrition, significant weight loss and/or hypoproteinemia when enteral feeding isnt an option
25
enteral feeding pros and cons
```
Advantages
- Preserves gut mucosa and integrity
- Improves nutritional status
- Inexpensive (compared to parenteral nutrition)
Disadvantages
- Tolerance issues
--- Nausea
--- Satiety
--- Bowels
--- But may be something else so need to check first eg Medication esp if changed recently
- Discomfort of tube placement
- Quality of life, dignity, confidence (aesthetic displeasing appearance for patients)
```
26
NG tube
- how is it inserted
- check its position how
- maximum duration of tube presence
inserted on ward - slide tube in with lube, swallowing helps
Check it is in the right place using aspirate pH (gold standard) -- <5.5
X Ray confirmation is second line position check
<30days (consider PEG after)
27
nasojejunal feeding
- how is it inserted
- maximum duration of tube presence
Needs to X Ray guided, not on ward
Unable to use aspirate to check if it is in the right place
<60days
28
PEG tube indications
- Consider if NG tube in for 30days
- Dysphagia (stroke, head injury, neck surgery) Not improving
- Cystic fibrosis -- High nutritional requirements
- Oral intake inadequate and this is likely to be the case long term
29
PEJ indications
Not tolerating PEG feeding
Delayed gastric emptying
Upper GI/ pancreatic surgery (bypass pancreas)
High risk of aspiration
Severe acute pancreatitis (bypass pancreas)
30
refeeding syndrome
- what is this
- risks
- actions
When malnutrition/ starved patient when reintroducing nutrition - Due to energy stores shift from fat metabolism to carbohydrate metabolism. This promotes insulin secretion and therefore cellular uptake of potassium, phosphate and magnesium
- electrolytes drop
- Fluid retention
- Cardiac arrhythmias
- Respiratory insufficiency
- Death (Rarely)
- refeeding bloods monitoring to check for electrolytes
- Slow introduction of nutrition - esp carbs
- in high risk patients : IV (if unable to take tablets) pabrinex or thiamine + vitamin B co-strong PRIOR to feeding and 10 days into feeding
31
falls risk factors (12)
- previous fall
- fear of falling
- balance problems (ataxia, vertigo, cerebellar stroke, inner ear infection)
- gait problems (PD, OA)
- pain
- drugs
- CVD (heart block, syncope (AF), stroke, antihypertensive medication)
- cognitive impairment
- urinary incontinence (catheter connections tripped over, urge - rushes , UTI - confusion)
- stroke
- DM (hyper, hypo, diabetic retinopathy- vision, diabetic neuropathy - sensation)
- sensory impairment
32
how can drugs increase risk of falls
antihypertensives (b blockers, diuretics) and tamsulosin (alpha blocker) - postural hypotension
amitriptyline and tricyclics - bad for cognition
benzodiazepines - confusion
33
possible causes of falls
- syncope
- postural hypotension
- delirium (can be caused by electrolyte imbalance)
- hypo/hyperglycemia
- reduced mobility, frail
- medications
- mechanical
- sensory impairment eg glasses not currently being worn
- UTI
- osteoarthritis
34
postural hypotension =
systolic drops 20, diastolic drops 10
35
lifestyle changes for syncope/ postural hypotension
get up slowly
pedal feet before standing
compression stockings
recognise symptoms and sit down or whatever
36
deconditioning
unable to do things previously done due to immobility
| improved with rehab
37
time up and go test should be less than how many seconds
10
38
frailty measured by Phenotype (observable characteristics)-- Fried criteria
- what are the markers
- how many for frail/prefrail
3 or more = frail:
2 = “pre-frail”
- Unintentional weight loss
- Self-reported exhaustion
- Weakness - grip strength
- Slow walking speed
- Low physical activity
39
Cumulative deficit
e-FI electronic frailty index
- how many defecits possible
- some examples
```
36
Comorbidities
- DM
- HTN
- Renal disease
Polypharmacy / multimorbidity
Sensory impairment
Self-reported symptoms
- Dizziness
- Sleep disturbance
Social factors
- Social isolation
- Living alone
```
presence/ absence of deficits as a proportion of the 36
40
when is end of life care considered
definite or at risk of dying in next 12 months
41
which is more common hyper or hypoactive delerium
hyper
42
hyperactive delerium characteristics
```
Agitation
Delusions
Hallucinations
Wandering
Aggressions
```
43
delerium definition
an acute confusional state that fluctuates in severity and is usually reversible. It is usually the result of another organic process
44
confusion = ??? until proven otherwise
delerium
45
hyperactive delerium management
Non pharmacological first line
- Calm and defuse, cup of tea
- Orientation
- Reassurance
- Continuity of staff and environment
- Quiet environment
- Provide hearing aids / glasses (if they have impairment)
- Potential for 1:1 supervision
- Family members come and help settle them down
- Check obs and reexamined
- Review of drugs
- Control pain
- Avoid catheters and drips unless necessary
Pharmacological
- Sedation
- - If risk to patient or other people
- - Use lowest dose possible
- - haloperidol best
- - (lorazepam included in geriatrics, but advised to avoid in psych as can increase confusion and sedation)
46
delerium investigations
check obs and reexamined
review of drugs
Order confusion bloods (set of bloods that look for common reversible causes of delirium: B12 deficiency, folate deficiency, hypercalcaemia, ferritin, TSH etc)
47
hypoactive delerium characteristics
```
Easier to miss
May be mistaken for depression
Lethargy
Slowness with tasks
Excessive sleeping
Inattention
Confused, unable to follow conversation
Less willing to engage
```
48
delerium risk factors
```
Old age
Dementia
Past hospital admission,
past delirium
Significant comorbidities
Sensory impairment
Change of environment
Polypharmacy
Sleep deprivation
Pain
```
lower threshold for delerium
49
delerium causes
```
Infections (eg pneumonia)
Drugs
- Staring, stopping
Metabolic (Eg constipation)
Neurological (eg SAH)
```
50
delerium precipitating factors
```
Change of environments
Sleep deprivation
Pain
Attachments - drips, catheters
Lack of mobilising
```
51
dementia definition and charachteristics
a syndrome of acquired, chronic, global impairment of higher brain function, in an alert patient, which interferes with the ability to cope with daily living.
decline in memory and at least 1 funtion:
- Skilled movements
- Language
- Executive function
- -- Working memory
- -- Monitoring and regulating behaviours, actions, alertness and emotions
- -- Cognitive flexibility
- -- Attention
- -- Organizing
- -- Sustained effort
- Impair social or occupational functioning
progressive
52
dementia assessment
MOCA screens then assessed by a doctor
53
BPSD=
BPSD = behavioural and psychological symptoms of dementia. This is a heterogenous group of non-cognitive symptoms and behaviours
```
Agitation
Irritability
Depression, apathy
Disinhibition- sexual, social
Hallucinations, delusions
Aggression
Anxiety
```
occur in most dementia patients
(treatment? = pain relief and non-pharmalogical intervantions 1st line)
54
alzheimers symptoms
```
Memory and language affected first
- Short term memory
- Disorientation
Then personality changes
Visual spatial disorientation
Dysphasia
Dyscalculia
Dyspraxia
- Motor problems
Lack of physical motor signs
- Few UMN signs initially
- End stage - rigidity / spasticity , And myoclonus and visual hallucinations, language
```
55
where in brain most affected in alzheimers
Posterior cortical affected most
| Atrophy
56
vascular dementia symptoms
stepwise presentation- sudden/ abrupt presentation
Mental slowing
Poor attention and retrieval
Reduced mental manipulation
Mood disturbance
Apathy
Physical signs - apraxic gait, urinary incontience, pyramidal signs
Lack of cortical signs (if pure)
Good on multiple choice prompt for memory withdrawal
57
vascular dementia risk factors
alcohol
| smoking
58
lewy body dementia pathophysiology as in where
cortical
59
vascular dementia pathophysiology inc as in where
subcortical
multi-infarct
cerebreal small vessel disease
post stroke/ tia - usually within 3m
60
lewy body dementia symptoms
```
Visual hallucinations
- Earlier than in alzheimers
delusions
Parkinsonism (usually before PD)
Cognition may be fluctuating even though it is progressive
Perceptual-spatial deficits
Myoclonus
- Earlier than in alzheimers
transient loss of concsiousness
```
61
frontotemporal dementia pathophysiology as in where
fronto cortical
| frontal and temporal neocortical
62
semantic dementia
type of frontotemporal dementia
| Fluent speech but lose picture meaning
63
Primary progressive aphasia dementia
type of frontotemporal dementia
| non-fluent aphasia
64
frontotemporal symptoms
Change in behaviour - social breakdown
- Withdrawal and lost interest in hobbies
- Disinhibition
--- Eg urinating in living room, naked
--- Unhygienic
- Altered eating patterns
---- Eg Now like sweet food more
- Behaviour stereotypes - repeated behaviours
---- eg singing a certain melody
---- Eg want to take certain chains of buses regularly (But able to pay and plan and get on bus etc)
- Apathetic
- Frontal cognitive function - in executive function = dysexecutive syndrome (if tested)
No motor signs initially (some none)
Long disease course
65
pseudodementia
- what is affected
- what is the cause
Memory loss, attention impairment - so harder to retain
Often secondary to mental health
- Most commonly depression
66
Paraphasic errors
mispronounce words
67
primitive reflexes (dementia)
Pout reflex
-- After stroking upper lip / tapping lips
Palmomental reflex
-- Scratch palm, chin crinkles
68
dementia treatment
| - including egs and s/e and when to use what
Acetylcholinesterase inhibitors (for mild/moderate)
- Rivastigmine
- Donepazil
- Galantamine
- S/E - bradycardia, diarrhea, vomiting, headache
NMDA (N-methyl-D-aspartate) antagonist (if above is contraindicated/ SEs)
- Memantine
- alzheimers or agressive
- If severe impairment of AChE i not working (can be switched or can be used together)
- S/E - dizzy, confusion, hallucinations, seizure
cognitive social and physical stimulation
- Cognitive reorientation
- -- Life stories and reminiscence work (Talk about memories, create photo album, listen to old music etc)
- Reassure
- Psychoeducation
- Cognitive stimulation therapy
- -- Group activities
- --Exercise
- --Socialising
- --Improves memory, language, problem solving skills - benefits mild and moderate dementia
- Cognitive rehabilitation
- ---Learn a skill eg mobile phone
69
which dementia is most common
alzheimers
70
"normal" score on adenbrookes cognitive exam (ACE).
why is normal in """""
Scores out of 100. “Normal” - 82-88. (one specific one sensitive)
Normal doesn't exclude dementia (premorbid IQ (judged by profession- so high IQ person getting 85 may be bad whereas may be normal for someone else)
71
adenbrooks domains and what is affected in dementia
```
Attention
Memory
Fluency
Language
Visuospatial
```
Dementia - 2 or more demain deficits normally
72
mild cognitive impairment
- charachterisitcs
- diagnosis
Cognitive impairment with no functional impairment
| Diagnosis from cognitive testing (like dementia)
73
additional treatment for vascular dementia
vascular risk factors - prevent on stroke
74
dementia vs delerium
- dementia : progressive, slow long onset, delerium: acute, sudden, short lasting
- delerium: variation in intensity - worse in evenings
- delerium: attention affected, dementia : memory
- delerium: often reversible, dementia: irreversible mainly
- hallucinations (Esp visual and tactile) are more common in delerium than dementia (although lewy body experiences these)
75
"worried well" = ?
memory loss without pathology, due to stress
76
amnesia
Attention good
| Prompting memory recall does not help poor memory
phase 3a mine
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