16.3 (16.3) palliative medicine and care of the elderly

Question 1

List the 5 most common causes of death in people over the age of 65

Answer 1

stroke
Alzheimer’s disease
heart disease
chronic lower respiratory diseases
cancer

Question 2

List 5 major geriatric syndromes

Answer 2

memory problems
Depression
vision and hearing loss
incontinence
Falls

FS: mem-dep-LIF

Question 3

List 5 triggers for considering a transition to a palliative approach to care for the elderly

Answer 3

-you answer yes to the surprise question

-new life limiting illness dx*
-worsening Dx prognostication markers*
-worsening tx response
-multiple hospital admissions*
-admission to nursing home*
-spouse/partner death*

WP: yes to surprise is SQ neg; reviewed Downer 2017 source, didn’t say this per se

Question 4

List 3 goals of a palliative care needs assessment*

Answer 4

-match type and level of need experienced by people with progressive illness and their caregivers with appropriate services/people

-health professionals in general and specialist practice determine which needs may be met in that setting and which are better managed by specialists

-facilitate communication between primary and specialist care providers about patients and caregiver needs and actions taken to address these

Question 5

What are 3 goals of heart failure clinics?

Answer 5

1. reduce mortality
2. reduce rehospitalization rates
3. improve QOL through individualized patient care

Question 6

How do heart failure clinics aim to reduced mortality and improve QOL - list 4?

Answer 6

1. management of underlying heart failure
2. implantable cardiac device evaluation
3. optimize med adherence and appropriate deprescribing
4. Assess function, nutrition, and QOL
5. longitudinal follow up (esp after hospital)
6. shared decision making, providing info, ACP
7. Education for heart failure clinicians & others
8. Ongoing quality assessment of model of care

FS: 1, 2, 4, 6

Question 7

List four focus of rehab medicine in elderly

Answer 7

preventative strategies to minimize complications from primary disease

restorative strategies that help regain function and loss of strength from tx/dz

supportive strategies to maintain function at new baseline

palliative strategies that reduce burden of care and maximize QOL

FS: Prevent, restore, maintain, palliate

Question 8

Advanced age is not an exclusion criteria for pulmonary rehab. If older people are well enough to participate, what 3 symptom benefits are they likely to derive?

Answer 8

1. less breathlessness
2. less fatigue
3. improved overall well being

Question 9

List four categories of rehabilitative interventions that can help the elderly (not in 6th edition)

Answer 9

physical modalities to manage pain

provision of adaptive and assistive EQUIPMENT

ENVIRONMENTAL modifications

EXERCISE programmes

ENERGY conservation strategies

Question 10

List 4 elements of transitional care (between settings - hospital to subacute to nursing facility/home) for the elderly

Answer 10

education of pt and family

coordination among health professionals involved in transition (comprehensive d/c planning, med rec, community follow up)

logistical arrangements

effective communication

Question 11

What are three predictive factors for successful ability to have a home death for an older person

Answer 11

intensity of available home support

living with relatives

family support

Question 12

List 3 ways to address the needs of older people (and their caregiver) at EOL*

Answer 12

1. Timely access to specialist palliative care
2. Case management, coordination, communication across care settings
3. After-hours care, including practitioner access
4. Target services to specific population needs, i.e. cultural needs
5. Adressing workforce issues

Question 13

Name 5 possible adverse outcomes for caregivers?

Answer 13

1. social, financial, employment implications
2. health implications
3. depression/anxiety, may worsen closer to pt’s EOL
4. feeling sadness, anger, resentment, isolation, and inadequacy
5. complicated grief, esp if pt has unrelieved symptoms

FS: depression/anxiety, complex grief, health, social isolation, financial

Question 14

Identify three challenges in caring patients with dementia

Answer 14

difficulties in identifying a well defined terminal phase

more protracted duration of end stage illness (weeks to months)*

issues related to communication and decision making*

challenges in pain assessment in cognitively impaired

Behavioural disturbances*

Question 15

List five predictors of mortality in patients with dementia

Answer 15

-limitation of physical function
-malnutrition
-pressure sores
-delirium
-comorbidities - resp disease, cardiovascular dz, DM
-urinary incontinence
-physical restraint use

FS: (head to toe)
- Function
- Intake (malnutrition)
- Aspiration
- Pressure ulcer
- Other comorbidities (including delirium)

Question 16

Name 3 tools for predicting survival in patients with dementia

Answer 16

1. Functional assessment staging tool (FAST)
2. Karnofsky Performance Status
3. Advanced Dementia Prognostic Tool (ADEPT) by Mitchell

Question 17

List 4 complications of a PEG tube in someone with advanced dementia.

What does evidence show in regards to survival benefit?

Answer 17

pain
GI bleeding
use of restraints
fecal incontinence
aspiration
higher incidence of pneumonia

NO SURVIVAL BENEFIT

Question 18

List at least 4 non-pharm approaches to reducing behavioural and psychological symptoms of dementia

Answer 18

1. clear communication*
2. understanding triggers* (ABC)
3. social interaction
4. environment*
5. adapt treatment to patient’s interests
6. consistency, avoid punishment*
7. r/o constipation/delirium/depression/anxiety
8. dementia care mapping

ABC = activating event, behaviour, consequence

FS: similar to delirium - orientation, aids, hydration, pee, poop + clear communication + understanding triggers

Question 19

List five cognitive domains that can be impacted by delirium

Answer 19

Attention
Orientation
Language
Sleep wake cycle
thought process
visuospatial ability

Question 20

List the criteria for diagnosing delirium

Answer 20

1. disturbance in attention, cognition, and consciousness
2. acute onset and fluctuating course
3. occurs in context of underlying medical condition

Question 21

List 4 important risk factors for delirium*

Answer 21

1. increasing age*
2. dementia and cognitive impairment*
3. visual impairment
4. admission to hospital for fracture
5. severe medical illness*
6. medications*

FS: DIMS-O

Question 22

List four strategies to prevent delirium in hospitalized patients

Answer 22

Orienting approaches*
managing dehydration *
managing constipation*
avoiding unnecessary catheterization*
optimizing O2 saturation
Encouraging mobility
resolving reversible causes of sensory impairment by providing visual and hearing aids*

FS: orientation, aids, hydration, poop, pee

Question 23

How does evidence for non-pharm vs pharm measures compare for management of delirium?

Answer 23

1. systematic reviews of non-pharm measures show significant reductions in delirium incidence
2. Studies so far do not show impact of anti-psychotics on delirium incidence, duration, severity, or hospital LOS

Question 24

List atleast 5 barriers to managing pain in older adults*

Answer 24

1. underassessment of pain
2. adjusting RX due to pharmacokinetic/dynamic changes
3. polypharmacy
4. multimorbidity
5. cognitive impairment
6. gait disorders
7. Older adult beliefs about pain and its treatment
8. Access to pain services

Question 25

List three medical conditions and 3 medications that can be associated with constipation in the elderly

Answer 25

medical conditions - parkinsons, diverticular disease, hypothyroidism, dementia, stroke

medications - iron, calcium tablets, calcium channel blockers, NSAIDs, TCAs, opioids

Others: age related change in colonic physiology, immobility, reduced oral fluid/fibre intake

Question 26

List five main causes that can contribute to falls in the elderly

Answer 26

COGNITIVE and mood impairments

MOTOR problems (gait, balance, muscle weakness)

SENSORY impairment (vestibular, vision, peripheral neuropathy)

CARDIAC (postural hypotension)

MEDS

environmental hazards
fear of falling

Question 27

List at least 5 classes of medications that can increase falls risk

Answer 27

Hypotensive:
1. cardiac meds (digoxin, type 1a antiarrhythmics, diuretics)

Psychoactive:
2. benzodiazepenes*
3. antidepressants
4. antiepileptics
5. antipsychotics
6. antiparkinson drugs
7. opioids*
8. urological spasmolytics

FS: nausea drugs***
Anti H
Anti cholinergic
Anti D
Anti 5HT3

Question 28

List three interventions for fall prevention in the elderly (besides reducing contributing meds)

Answer 28

Reducing environmental hazards*
Gait retraining
Assistive devices (eg gait aid)*
Appropriate footwear*

Question 29

Define frailty and at least 3 features of it*

Answer 29

1. diminished capacity to withstand stress or increased vulnerability to adverse outcomes along with:
   - physical disability
   - impaired ADLs
   - social withdrawal
   - slow motor processing
   - cognitive changes
   - weight loss
   - negative energy balance

Question 30

Frailty requires at least 3 of what five findings

Answer 30

unintentional weight loss
low physical activity levels
slow walking speed
poor grip strength
self reported exhaustion

Question 31

List 4 prevention strategies for frailty

Answer 31

1. Primary:
   - adress cormobid illness (i.e. HTN)
   - chronic disease management*
   - exercise*
2. Secondary:
   - nutrition*
3. Tertiary:
   - maintaining and improving function
   - control of symptoms
   - maintain psychological well being*
   - prevent hospitalization when possibly

Question 32

What type of assessment strategy is effective for frailty?

Answer 32

Geriatric interdisciplinary assessment (MD, RN, OT/PT, SWK)

Question 33

List four risk factors for depression in the elderly

Answer 33

unmarried status
living alone
lack of social support*
negative life events such as bereavement*
low SES*
comorbid psych/medical illness*

Question 34

List two scales that have been validated to assess for depression in the elderly

Answer 34

Beck Depression Inventory
Hamilton Depression Scale
Geriatric Depression Scale
Cornell Scale for Depression in Dementia

Question 35

List 3 neuropsychological domains affected by depression in older adults

Answer 35

1. processing SPEED
2. verbal and non-verbal MEMORY
3. EXECUTIVE functioning

FS: MES

Question 36

List three indications to refer an older adult to specialist psychiatric services for depression

Answer 36

failure of adequate trial of treatment
need ECT
those at risk of self harm and suicide
abuse alcohol and drugs
comorbid psychiatric conditions
comorbid dementia

Question 37

List 3 pathomechanisms of presbycusis

Answer 37

1. Deterioration of auditory sensitivity
2. Loss of auditory sensory cells
3. Loss of central processing functions

Question 38

List 3 common causes of vision impairment in the older adult

Answer 38

1. Age-related macular degeneration
2. Glaucoma
3. Cataracts
4. Diabetic retinopathy

Question 39

Is xerostomia a normal part of aging? List three complications of xerostomia

Answer 39

Some studies have shown age related changes to salivary glands but others have not. Xerostomia should not just be attributed to age.

complications: altered taste, difficulty chewing and swallowing, mucosal breakdown, candidiasis, dental problems, increased susceptibility to asp pna

FS:
Tongue - altered taste
Cheek - candida
Teeth - dental issues
Throat - dysphagia

Question 40

List 4 medical conditions that may cause xerostomia

Answer 40

1. Dehydration
2. Sjogren’s syndrome
3. diabetes
4. Alzheimer’s disease

Question 41

List 5 classes of medications that can cause xerostomia

Answer 41

1. antidepressants
2. sedatives/tranquilizers
3. anti-histamines
4. antihypertensives (alpha/beta blockers, diuretics, CCB, ACEi)
5. cytotoxic agents
6. anti-parkinsonism meds
7. antiepileptics

FS:
Diuretics
Anti-cholinergic
Anti-histamine
Opioid
Benzo

Question 42

List 3 age related changes to the structure or function of the skin in older adults

List 3 implications of these changes for older adults.

Answer 42

1. skin atrophy
2. Decreased ability to retain water
3. Decreased cell replacement
4. Decreased sweat production
5. Decreased Langerhans cells (immune responsiveness)

Implications:
1. Reduced skin barrier function
2. Decreased wound healing
3. Risk of pressure ulceration
4. Altered absorption transdermal meds

Question 43

How are the following affected by aging?
a. Drug absorption
b. hepatic first pass metabolism and drug bioavailability
c. volume of distribution
d. Cytochrome P450 activity
e. homeostatic mechanisms

Answer 43

a. Drug absorption - may be changed (changes in gastric motility, gastric pH, reduced bile salts synthesis, altered buffer capacity of GI fluids, mucosal enzymes, intestinal epithelial drug transporters)

b. hepatic first pass metabolism - decreased; drug bioavailability - increased (reduced liver mass, perfusion, enzymes)

c. volume of distribution - decreased in hydrophilic drugs (due to decreasing total body water => decrease half life), increased in lipophilic drugs (due to increasing body fat => longer half life of lipophilic drugs)

d. Cytochrome P450 activity - unchanged (no changes in induction/inhibition of hepatic enzymes)

e. homeostatic ability declines (increased risk of med side effects - hypotention/electrolyte changes)

Question 44

List four factors that contribute to frailty*

Answer 44

ageing
comorbid disease
nutritional inadequacy
environmental impacts
genetic factors
lifestyle factors