1 - Older Person's Medicine Flashcards
How do you take a collateral history for dementia/delirium?
What tool is being used to replace the HASBLED tool to quantify the risk of bleeding with anticoagulation in AF? Also, how do you use this tool?
ORBIT!
How do you perform a mental state exam?
ASEPTIC
How do you do an MMSE and how would you interpret the result?
How do you test someone for postural hypotension?
- Lie for 5 minutes
- Stand and take BP at 1 min, 3 min and 5 mins
What document needs to be signed to make a DNACPR decision legally binding?
ADRT
Advanced Decision to Refuse Treatment
What assessment should you do for a holistic view of an elderly patient?
Comprehensive Geriatric Assessment
What are some tools that can be used to see how well a patient is coping with their ADLs?
- Barthel Index
- Nottingham Extended activities of daily living
What is the clinical frailty scale?
Become ‘frail’ from 5/6
What is frailty?
Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserve
Patient’s are unable to bounce back from minor infections quickly and likely to have long term impacts from simple things such as UTI
What is the PRISMA-7 tool?
If 3 or more ‘yes’ then need to consider frailty so further clinical review!
How is constipation diagnosed?
ROME IV Criteria
What are some causes of constipation in the elderly?
Primary: no organic cause, dysregulation of colon or anorectal muscles
Secondary: diet, drugs, metabolic, endocrine or neurological disorder or obstruction
What type of stool is present in constipation?
Type 1 or 2
Type 7 if overflow
What are some red flags with constipation?
May indicate GI malignancy if:
- Weight loss
- Loss of appetite
- Abdominal mass
- Dark stool
What are some treatment options for constipation?
- Exclude underlying causes including colorectal cancer
- Lifestyle modification e.g. dietary improvements, increase exercise
- Enemas if impaction present e.g. sodium citrate
- Suppositories e.g. glycerol
- Bulk laxatives e.g. ispaghula husk, methylcellulose
- Stool softeners e.g. docusate sodium
- Osmotic laxative e.g. lactulose, macrogol
- Stimulant laxatives e.g. senna, bisacodyl
What opioids should you use in CKD and why?
Buprenorphine or Alfentanil as Morphine is renally excreted so risk of opioid toxicity
Tramadol is hepatically and renal excreted so can use this too
What are some causes of postural hypotension?
- Drugs: particularly vasodilators, diuretics, negative inotropes, antidepressants, opiates
- Chronic hypertension: due to loss of baroreceptor reflexes
- Dehydration
- Sepsis
- Autonomic nervous dysfunction: e.g. Parkinson’s
- Adrenal insufficiency
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How is postural hypotension managed?
- Hydration
- Review polypharmacy
- Reduce adverse outcomes from falls (e.g. fall alarm, soft flooring)
- Behavioural changes (e.g. rising from sitting slowly)
- Compression stocking
- Fludrocortisone (poor evidence base) or Midodrine
What are some drugs that can lower the seizure threshold?
- Antibiotics: penicillins, cephalosporins, metronidazole, isoniazid
- Antipsychotics
- Antidepressents: Bupropion, Tricyclics, Venlafaxine
- Tramadol
- Fentanyl
- Ketamine
- Lidocaine
- Lithium
- Antihistamines
What are some risk factors for a subdural haemorrhage?
What can Trimethoprim do to the kidneys in the elderly population?
False AKI
Transient rise in creatinine levels by reducing the creatinine excretion of the kidneys. This does NOT reflect the actual GFR and therefore this phenomenon is not reflective of an Acute kidney injury but rather the calculated eGFR
How does viagra work and what are some side effects of this?
- PDE5 inhibitor: enhances effect of nitric oxide causing smooth muscle relaxation and subsequent penile erection due to inflow of blood
- Contra-indicated in patients taking nitrates
- Side effects: flushing, headache, dyspepsia, nasal congestion, dizziness, diarrhoea, rashes and UTIs
What are the six domains of cognition?
- executive function
- learning and memory
- perceptual-motor function
- language
- complex attention
- social cognition
What are some examples of BPSD in dementia?
- Affective: agitation, hoarding, wandering, screaming, crying, depression
- Psychotic: delusions and hallucinations
- Hyperactive: aggressive, disinhibition, refusing care
- Apathetic: indifference, appetite issues
What are the most common types of hallucination in dementia?
- Visual
- Tactile
What are the four different parts of memory clinic?
- History and Collateral History
- Physical and Mental State Examination inc Risk Assessment
- Cognitive Assessment e.g ACE-III, MOCA
- Investigations
What are some questions to ask in the history in the memory clinic?
- What is the course of symptoms over time?
- Any impact on day to day life?
- Why have they come now?
- Any changes in general health?
What physical exams may you consider at memory clinic?
- Neurological
- CVS
What investigations may you do at memory clinic?
- Bloods
- ECG (look for contraindications)
- CT head/MRI brain to assist dementia subtype
In which dementia patients should you not use anti-dementia medication in?
- Vascular UNLESS mixed dementia suspected
- Frontotemporal
- Cognitive impairment secondary to MS
What are different levels of mental health observations?
Level 1 - Hourly
Level 2 - Could be 2:15, 2:30
Level 3 - Within eye’s sight at all times
Level 4 - Within arm’s reach at all times
What are different levels of mental health observations?
Level 1 - Hourly
Level 2 - Could be 2:15, 2:30
Level 3 - Within eye’s sight at all times
Level 4 - Within arm’s reach at all times
What are some different types of memory in memory clinic that you need to assess?
- Procedural
- Episodic
- Short
- Long
- Faces
- Names
- Words
Depression can lead to memory problems and mimic dementia in the elderly. What symptoms should you ask about to rule out depression?
- 3 core symptoms: low mood, lack of motivation, lack of interest/enjoyment
- Other symptoms: poor sleep, poor appetite, loss of libido, anxiety
What things do we need to risk assess in memory clinic?
- Self neglect
- Vulnerability e.g locking doors, finances
- Driving
- Medications
- Self harm and Suicide
- Falls
- Risk to others e.g irritable, aggressive
How would you describe dementia to a patient in clinic OR OSCE?
(image important)
Umbrella term for damage to the brain. What causes the damage determines what type of dementia it is
Cannot get diagnosis from CT, can only get post-mortem by taking a brain sample, however CT can show patterns that point towards one disease process over the other
It is irreversible but we can do A, B, C to support
We can also refer you to the (e.g OT, physio, social services) who can help you with A, B, C
Assess carer strain!!
What cognition tests can be done in memory clinic?
- ACE-III
- Mini-ACE
- MoCA
- MMSE
- AMTS (OSCE - MEMORISE THIS!!!)
- 6CIT
What is the inverse care law?
What are the main differences between acute confusion, dementia and delirium?
What are some adaptations you can make when taking a history from a patient with cognitive impairment?
What is a CGA and what are the advantages and disadvantages of using this?
A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up
What medications in particular should be used with caution in the elderly?
Nephrotoxic drugs e.g ACEi, Aminoglycides as already have reduced renal function
Low therapeutic index drugs e.g Digoxin
What are three classes of drugs that increase falls in the elderly?
- Benzodiazepines
- Anti-psychotics
- Anti-depressants
Fill in the following table.
What are the 5 domains of a falls risk assessment?
- *1) History and examination**
- *2) Drug review**
- *3) Specific review of medical risk factors**
- *4) Functional and Mobility assessment**
- *5) Psychological effects of fall** (may reduce mobility to prevent falls but this in turn causes muscle weakness)
What are the 4 main questions in an Advance Care Plan?
- At this time in your life, what is important to you?
- What elements of care are important to you and what WOULD you like to happen in future?
- What would you NOT want to happen?
- Who would speak for you?
What are 3 barriers to carers accessing support?
- A lack of information
- Reluctance to use services because of a sense of duty
- Restrictions in service use due to cost or lack of availability
What are some questions you can ask in a spiritual history?
What support do you have?
Do you have people you can talk to?
What is your greatest worry?
What is the most important issue in your life?
What would be the most helpful thing for you?
What do we need to know about you to give you the best care?
What gives your life meaning?
Where do you get your strength from?
Is religion or faith important to you?
What are some non-pharmacological management options for constipation?
- Increase fibre intake
- Sorbitol e.g prunes, raisins
- Mobility
- Regular toileting
- Increase fluid intake
What are some different pharmacological options for constipation?
What are some non-pharmacological management options for BPSD symptoms in dementia?
- ABC charts- identify patterns
- Distraction/re-direction
- Activity scheduling, daily structure, day centre attendance- increased socialisation
- Environmental interventions- natural light, calendar, clocks
- Compensate for sensory impairments, hearing aids/glasses
- Reminiscence therapy/ life story books
- Adequate nutrition/general health/continence issues
- Physical presence/ Therapeutic touch- dolls to hold, keep hands busy
- Complimentary therapies e.g. hand massage, aromatherapy
What antipsychotic is used in BPSD in dementia and what are the side effects?
Must document risk/benefit discussion, including S.E. with patient/carers
- Extrapyramidal symptoms
- Over-sedation
- Falls
- Prolonged QTc interval
- CVA- especially with atypicals
What antipsychotic is used in BPSD in dementia and what are the side effects?
Must document risk/benefit discussion, including S.E. with patient/carers
- Extrapyramidal symptoms
- Over-sedation
- Falls
- Prolonged QTc interval
- CVA- especially with atypicals
What is the most common inherited learning disability?
Fragile X
How can we improve the uptake of COVID vaccines?
What is the definition of mild cognitive impairment?
What issues do we need to think about when feeding in dementia?
What are the different types of imaging you can do if you are suspecting a certain type of dementia?
What investigations needs to be done before starting anti-dementia medication?
Memantine used when severe Alzheimer’s!!!!
What are some non-pharmacological management options for postural hypotension?
- Withdraw offending medication
- Rise slowly from supine to sitting to standing position
- Avoid straining, coughing, and prolonged standing in hot
weather - Cross legs while standing
- Raise head of bed 10 to 20 degrees
- Small meals and coffee in the morning
- Elastic waist high stocking
- Increase salt and water intake
- Exercise, eg, swimming, recumbent biking, and rowing
Why is midrodine the last line option for postural hypotension?
Serious cardiac side effects
Why should you not do rapid rewarming in elderly patients with hypothermia?
May cause vasodilation leading to shock and death
