Phase 3A medicine > key gerries notes > Flashcards

key gerries notes Flashcards

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1
Q

what is frailty

A

an increase in vulnerability and decline (age related) in functional and psychological reserve leading to acopia with everyday stressors

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2
Q

what are the GIANTS of geriatrics

A

Describe the significant health chalenneged faced by the elderlt:

immobility
instability
impaired consciousness/intellectual impairment
incontinence
inanition
iatrogenesis

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3
Q

what are the 5 M’s of geriatrics

A

guide how to provide comprehensive care to older adults:

mind
mobility
medications
multicomplexity
matters most

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4
Q

who are included in COTE MDTs

A

medical - doctor, nurse, pharmacist, dietician => PMHx, DHx, nutrition
functional - OT, PT, SALT => ADLs, frailty
Psychological - doctor, psychiatry, nurse => GCS, 4AT (AMS), PHQ-9
social - OT, social worker => reintegration post discharge
Environmental - community nurse, NHS appointed house assessor - social worker

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5
Q

what is polypharmacy

A

> /= 5 medication concurrently

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6
Q

what is appropriate medication

A

less than/= to 5 medications + needed (e.g. MI prophylaxis)

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7
Q

what is inappropriate medications

A

increase medications unnecessarily - seperate prescibing, increased comorbidites, pain managemet

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8
Q

what is anticholinergic burden score

A

the cumulative effect of taking multiple medications with anticholinergic properties

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9
Q

risk of

A
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10
Q

what is the conseuqence of an anticholinergic burden score of >3

A

increased risk of falls, cognitive impairment, morbidity, adverse effect

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11
Q

examples of medications that can increase the anticholinergic burden

A

paroxetine
amitriptyline
oxybutinin
clozapinne
promethazine
quetiapine

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12
Q

what are the symptoms of anticholinergic syndrome

A

PNS - can’t see, pee, spit, shit + flushing
CNS - agitation, low GCS, altered mental state, ataxic

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13
Q

what is pharmacokinetics

A

how the body acts on the drug

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14
Q

what is pharmacodynamics

A

how the drug acts on the body

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15
Q

how does warfarin and NSAIDs/macrolides interact

A

increased bleeding risk

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16
Q

how does omperzole interact with clopidogrel

A

lower clopigrel effect

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17
Q

how do SSRIs and NSAIDs interact

A

increased GI bleed risk

co-prescribe PPI

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18
Q

how do ACE-i and spironolactone interact

A

increased AKI risk + increase potassium

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19
Q

how does methotrexate interact with trimethoprim

A

myelosuppression

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20
Q

how do statins interact with macrolides/grapefruit juice

A

increase statin bioavailability

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21
Q

how does iron interact with tetracycine

A

decrease tetracyline effect

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22
Q

what does the Mental capacity act 2005 help

A

empowers decision making in those aged more than 16 years in lacked capacity

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23
Q

what are the principles of the MCA 2005

A

best interests
assume capacity till proved otherwise
reduce harm principle
give all the information
least restrictive option

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24
Q

what is an independent mental capacity advocate

A

NHS appointed for non-lasting power of attonery patient
they can inquire medical decisions but cannot make decision on patients behalf

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25
what is a lasting power of attonery
appointed by patient to make decisions on behalf if the patient is lacking capacity can be financial and/or health - registed with office of public guard
26
what is an advanced directive
written statement by older/= to 18 year old detailing treatment preferences should they lack capacity in the future applicable to the situation, can't determine treatment (only refuse), can't refuse basic treatment (food, hydration)
27
what to do when there is no LPA and there is a dispute over best interests
apply to court for temporary decision maker
28
what are DOLs
deprivation of libertie safeguard - patient unfree to leave - 24hr supervised residence for less than 7 days if urgent and temporarry with a maximum of 12 months when authorised - if pose risk to self/others, least restrictive option, patient lacks capacity
29
what does a patient need if they want to self-discharge
DHx update OT PT GP follow up letter to GP
30
what is delirium
a transient (<6m) acute change in consciousness and cognition due to an underlying pathology which is reversible
31
what are the causes of delirium
PINCH ME pain infection - UTI/URTI nutrition - decreased constipation hydration/hypoxia - decreased metabolic/medication environment/endocrine/electrolyte
32
what are some risk factors for delirium
increased age PHx delirium having dementia
33
symptoms of delirium
clouded consciousness reduced cognition inattention fluctuations disturbed wake-sleep cycles disordered thinking visual hallucinations
34
what are the type of delirium
hyperactive - agitation, persecutory delusion, hallucination hypoactive - withdrawn, lower GCS mixed
35
what medications can trigger delirium
TCA opiates beta-blockers steroids L-dopa benzos
36
how to diagnose delirium
confusion bloods ECG +/- CXR/urine dip/CT head/MSU screen with 4AT (alertness + AMT4 - age, DOB, time, place + attention (months backwards) + acute course/fluctuation) confirmed with SHORT CAM
37
what are included in confusion bloods
FBC UE calcium B12/folate TSH glucose coag blood cultures / ESR + CRP
38
treatment for delirium
orient - decrease noise, same staff, clocks on walls, sleep-wake cycle hygiene, family time agitation - 1) calm verbally, 2) PO/IM haloperidol (PARKINSONS USE BENZO - LORAZ)
39
what is dementia
a progressive decline in cognitive function in altert patient for >6months with brain pathology which is irreversible
40
what are the cortical causes of dementia
Alzheimers frontotemporal dementia vascular dementia LBD
41
what are some subcortical causes for dementia
Parkinsons Huntigntons alcohol AIDS
42
what is alzheimers
widespread deposits of beta-amyloid plaques in the cortex with axon damage and decreased acetylcholine
43
risk factors for alzheimers disease
CVD Fhx genetics - T.21 female
44
symptoms of alzheimers
aphasia agnosia - can't recognise familiar objects/voices apraxia amnesia all gradual decline
45
what is vascular dementia
CVA results in cortical infarct
46
risk factors for vascular dementia
CVAs other - IHD
47
symptoms of vascular dementia
4 A's more severe in stepwise decline
48
what is lewy body dementia
deposits of ubiquitin and alpha synuclein in basal ganglia and cortex
49
risk factors for LBD
parkinsons FHx increased age
50
symptoms of LBD
triad - cognitive fluctuation + parkinsonism + hallucinations REM sleep disorder most rapidly declining dementia
51
what is frontotemporal dementia
pick bodies (tau + ubiquitin) in fronto/temporal lobes
52
risk factors for frontotemporal dementia
FHx affects 50-60 TDP43
53
symptoms of frontotemporal dementia
frontal - apathy, mood disorder, decreased executive function, hyperphagia, somnia, crying temporal - trouble with grammar disinhibited
54
diagnosis of dementia
confusion bloods + syphillis/HIV? addenbrookes (higher = better, 83-87 suggest mild) CT - r/o SOL,NPH MRI - head Others - SPECT, DaT (LBD 2 dots instead of commas)
55
what would be seen on an MRI for the dementias
AD - diffuse cortical and hippocampal atrophy, succal widening, ventricles increased - micro (tau, beta-amyloid, decrease Ach axons) FTD - F + T deposits - micro pick bodies (U + Tau) VD - >1 white cortical infarcts LBD - cortical deposit / basal ganglia deposit / normal - micro (U + alpha-synuclein)
56
treatment generally of dementia
PT, OT, SALT, neuro, GP
57
treatment for alzheimer's
1) Acetylcholinesterase inhibitor - donpezil, rivastigmine, galantamine 2) NMDA inhibitor - memantine
58
treatment for FTD
SSRI Antipsychotic NO ACETYLCHOLINESTERASE - worsen symptoms
59
how is vascular dementia managed
reduce risk factors - aspirin + statins
60
what medication should be avoided in LBD
antipsychotics (benzo instead)
61
what are some other dementias
prion - creutzfedlt-jakub. - rapid, bovine vaccines HIV associated neurological disorder normal pressure hydrocephalus alcohol wilsons disease - Keiser Fleischer rings (penicillamine) pseudodemential - IDK answers, normal MMSE - depression neurosyphilis - tertiary
62
causes of falls
MSK - fracture, osteoporosis iatrogenic - increased anticholinergic burden, low BP (ACE-i, beta-blocker, CCB), benzos neuro - TIA/stroke, seizure, parkinsons, cerebellar CV - syncope, postural hypotension environment - poor footwear, rugs endo - hypoglycaemia
63
How to assess a fall
circumstances - pre/during/post ADLS - Barthel index - dressing, bathing, toileting, dressing frailty - Rockwood frailty score (0-9) higher = more frail fall risk - FRAT tool
64
investigations after a fall
bloods - FBC, UE, eGFR, CK, bone profile, B12/folate, Vit D lying/standing BP + ECG CXR + CT head (r/o pneumothorax and head injury) urine dip MMSE Dexa
65
complications of a fall
SDH - haematoma pneumothorax fractures rhabdomyolysis
66
treatment after a fall
exercises home assessment for hazards OT PT meds review eye check
67
risk factors for rhabdomyolysis
long lie >1 hour NMS anabolic steroids hyperthermia
68
symptoms, diagnosis and trearment of rhabdo
coca cola urine + muscle pain CK levels increase, myoglobin increased (cocal cola urine) IV fluids, IV Na2CO3 (prevent AKI)
69
what is postural hypotension
>20mmHg systolic or >10 mmHg dias drop in BP after standing from sitting, not resolved <3 mins
70
risk factors for postural hypotension
increased age CVD
71
pathophysiology of postural hypotension
impaired neuro-cardiac baroreceptor reflex
72
symptoms of postural hypotension
lightheaded (+syncope) after standing from sitting +/- dizzy, palpitations
73
causes of postural hypotension
CV - HF, MI, AF neuro - parkinsons iatrogenic - meds to lower BP other - addison's
74
diagnosis of postural hypotension
L/S BP ECG
75
treatment for postural hypotension
conservative - increase water, stand slowly meds (off licence) midodrine (retention) + fludro (oedema)
76
where are pressure sores common
sacrum bony prominence - greater trochanter, ischium
77
what causes pressure sores
increased PRESSURE/friction/shearing/ moisture => ischaemia => if >2 hours = necrosis
78
risk factors for pressure sores
immobility older age vascular disease - including DM confusion poor nutrition/dehydration
79
what score assesses the risk of developing pressure sores
Waterlow score
80
how are pressure scores graded
1) non blanching erythema, no mucosal tear 2) mucosal breach 3) full thickness skin involvement 4) bone/joint involvement
81
investigations of pressure sores
Bloods MC+S site swab safe guard?
82
treatment for pressure sores
prevention - reposition, barrier cream grades 1-2 = pain ladder, +/- IV fluclox if cellulitis suspected grades 3-4 = wound dressing + surgical debridement + treatment above
83
what is malnutrition
nutritional deficit with functional effects
84
when is malnutrition common
older age eating disorder malabsorption - coeliac poor diet dysphagia cancer
85
what tool can be used to screen for malnutrition
MUST
86
what is accounted for in the MUST tool
BMI (<18.5 =2, 18.2 - 20 = 1) unintentional weight loss (5-10% =1) not ate properly in 5 days (=2) - acute illness
87
results of the MUST score
0 = mild-none, advice, no action 1 = mod, observe >2 = severe, dietician input
88
symptoms of malnutrition
anaemia symptoms - fatigue, angular stomatitis, glossitis poor wound healing dehydration low libido constipation decreased urine output
89
invetsigations of malnutrition
bloods LSBP ECG (low K+)
90
treatment for malnutrition
conservative - increase calorie intake, fortisips dietician - assess swalllow, monitor electrolyte if refeeding, advice on diet, advise feeding method
91
alternative feeding options
NG + NJ tube - shorter term 30-60 days PEG - dementia + risk of aspiration pneumonia, MND PEJ - upper GI surgery, pancreatitis PICC feed - GI obstruction
92
how to treat aspiration pneumonia
IV cephalosporin or IV metronidazole
93
complications of malnutrition
osteoporosis falls + frailty refeeding syndrome CV - bradycardia ECG changes postural hypotension
94
what is osteoporosis
a decrease in bone mineral density of less than -2.5 standard deviations below the young adult mean T-score <-2.5 selective destruction of horizontal trabecullae
95
what are the causes/risk factors of osteoporosis
SHATTERED steroids hyperthyroid alcohol thin testosterone decreased estrogen decreased renal/liver failure erosive bone disease - RA drugs - methotrexate, lithium, warfarin, DMT1
96
symptoms of oesteoporosis
pathological fractures: colles - outstrecthed hand NOF - externally rotated shortened leg vertebral crush - widow stoop hip fracture SAND - spine, arm proper (humerus), NOF, distal radius
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investigations for osteoporosis
bloods - Hb, UE, bone profile, LFT XR -fracture DEXA scan - compared BMD to healthy 30 year old (-1 - -2.5 = osteopenia)
98
what is a z-score
compares BMD to average of someone same demographic
99
what is the FRAX score
10 year risk in 40-90y based on certain factors - PMHx, FHx, sex + age <10% = low - 5 year f/u 10-19% = mod - DEXA + consider Tx >20% = high risk - do DEXA and give Tx
100
what is the conservative treatment for osteoporosis
increase dietary calcium sunlight exposure -vit D calcium supplement -AdCal3
101
what is the medical management for osteoporosis
bisphosphonates - inhibit osteoclasts - take on empty stomach first thing, stay upright for 30 mins after and take with a full glass of water (S/E GORD + oesophagitis) medication related osteonecrosis of the jaw denosumab - inhibit Rank-L - 2 yearly SC raloxifene - oestrogen modulator = agonises bone and inhibit at endometrium teradaratinide = recombinant PTH HRT
102
risk factors for incontinence
female multiparity increased age abdo surgery BPH spinal trauma
103
causes of overflow incontinence
post-retention in BPH and prostate cancer
104
causes of neurogenic incontinenece
cauda equina
105
diagnosis of incontinence
bladder diary urine dip urodynamic studies MRI spine CT cystourogram
106
treatment for incontinence - urge, stress and neurogenic
urge = bladder retrain, oxybutynin stress = pelvic floor exercise, duloxetine neurogenic = perm catheter
107
what are the causes of urinary retention
BPH prostate cancer anticholinergics faecal impaction
108
diagnosis of urinary retention
PR exam urodynamic studies +/- CT abdo
109
treatment for urinary retention
analgesia acutely catheterise
110
complications of retention
hydronephrosis pyelonephritis AKI
111
aim of palliation
care for <3 months to live max QOL, set affairs in order, maximise spiritual outcome improve family coping
112
meds for palliation - pain, secretions, N+V, dyspnoea, agitation
pain = morphine secretion = hyoscine butylbromide N+V = metoclopramide dyspnoea = midazolam + O2 agitation = haloperidol if can't take PO - give via syringe driver mixed with 0.9% saline
113
114
what is hypothermia
Core body temp <35 with rectal
115
symptoms of hypothermia
shivering pilorection (goose bumps) autonomic change - tachy, HTN initially then brady and hypotension)
116
diagnosis and treatment of hypothermia
temp and ECG (osborne J wave - extra QRS deflection/VF/tachy) external rewarm, A-E
117
what is hyperthermia
CBT >40 with CNS dysfunction older = increased heat younger = due to increased exertion
118
symptoms of hyperthermia
hot flushed skin hypotensive altered mental state
119
diagnosis and treatment of hyperthermia
temp, ECG, BP A-E IV fluid + cooling
120
symptoms of nocturnal cramps and treatment
exclusively geriatric with night leg cramps abnormal posturing + posterior calf tightening quinine water intake increase and exercise S/E - ECG QRS prolong, hypotensive, metabolic acidosis, tinnitus
121
complications of hyperthermia
DIC rhabdomyolysis = AKI
122
what can be included in an NHS care package
home adaptation - hand rail, ramps allowances - PIP (personal independence payment), attendance allowance help after discharge from hospital - paid carer - dress, cook, clean, toilet NHS continueing healthcare - fully paid for disabled/severe illness patient care - palliative cases normally
123
what is heart failire
Cardiac output insufficient to meet the metabolic need of the body
124
how is heart failure quantified
Hf with reduced ejection fraction <50% (% blood in LV squeezed out with each contraction) HF with preserved ejection fraction >50% - clinical Sx problem with filling in diastole
125
causes of HF
IHD HTN valvular heart disease - aortic stenosis arrhythmia cardiomyopathy
126
symptoms of HF
breathless worse with exertion orthopnoea paroxysmal nocturnal dyspnoea cough - pink/white frothy sputum peripheral oedema fatigue
127
examination findings
bilateral bibasal crackles tachypnoea/cardia HTN 3rd heart sound increased JVP peripheral oedema
128
diagnosis of heart failure
NT-ProBNP ECG ECHO clinical Sx +/-CXR
129
what classification system is used for HF
new york heart association classification
130
what are the NYAC of HF
1) no limitiations on daily activity 2) comfortable at rest, sx with moderate/ordinary activities - slight ADL struggle 3) comfortable at rest, sx with any/mild activities - sig ADL struggle 4) symptoms at rest
131
general treatment of HF
ECHO flu/covid/pneumococal imms stop smoking care plan cardiac rehab optimise comorbid Tx
132
medical management of HF
ABAS ACE-i beta blocker aldosterone antagonist (when A and B not tolerated
133
specialist management of HF
sacubitril with valsartan ivabradine hydralazine with nitratre digoxin
134
surgical management of HF
valvular replace implantable cardio defib cardiac resync therapy <35% EF - RA/RV/LV pacemaker heart transplant
135
what palliation can be used for hiccups
chlorpromazine
Phase 3A medicine
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