16.3 (16.3) palliative medicine and care of the elderly Flashcards
List the 5 most common causes of death in people over the age of 65
stroke
Alzheimer’s disease
heart disease
chronic lower respiratory diseases
cancer
List 5 major geriatric syndromes
memory problems
Depression
vision and hearing loss
incontinence
Falls
FS: mem-dep-LIF
List 5 triggers for considering a transition to a palliative approach to care for the elderly
-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
List 3 goals of a palliative care needs assessment*
-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
What are 3 goals of heart failure clinics?
- reduce mortality
- reduce rehospitalization rates
- improve QOL through individualized patient care
How do heart failure clinics aim to reduced mortality and improve QOL - list 4?
- management of underlying heart failure
- implantable cardiac device evaluation
- optimize med adherence and appropriate deprescribing
- Assess function, nutrition, and QOL
- longitudinal follow up (esp after hospital)
- shared decision making, providing info, ACP
- Education for heart failure clinicians & others
- Ongoing quality assessment of model of care
FS: 1, 2, 4, 6
List four focus of rehab medicine in elderly
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
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?
- less breathlessness
- less fatigue
- improved overall well being
List four categories of rehabilitative interventions that can help the elderly (not in 6th edition)
physical modalities to manage pain
provision of adaptive and assistive EQUIPMENT
ENVIRONMENTAL modifications
EXERCISE programmes
ENERGY conservation strategies
List 4 elements of transitional care (between settings - hospital to subacute to nursing facility/home) for the elderly
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
What are three predictive factors for successful ability to have a home death for an older person
intensity of available home support
living with relatives
family support
List 3 ways to address the needs of older people (and their caregiver) at EOL*
- Timely access to specialist palliative care
- Case management, coordination, communication across care settings
- After-hours care, including practitioner access
- Target services to specific population needs, i.e. cultural needs
- Adressing workforce issues
Name 5 possible adverse outcomes for caregivers?
- social, financial, employment implications
- health implications
- depression/anxiety, may worsen closer to pt’s EOL
- feeling sadness, anger, resentment, isolation, and inadequacy
- complicated grief, esp if pt has unrelieved symptoms
FS: depression/anxiety, complex grief, health, social isolation, financial
Identify three challenges in caring patients with dementia
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*
List five predictors of mortality in patients with dementia
-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)
Name 3 tools for predicting survival in patients with dementia
- Functional assessment staging tool (FAST)
- Karnofsky Performance Status
- Advanced Dementia Prognostic Tool (ADEPT) by Mitchell
List 4 complications of a PEG tube in someone with advanced dementia.
What does evidence show in regards to survival benefit?
pain
GI bleeding
use of restraints
fecal incontinence
aspiration
higher incidence of pneumonia
NO SURVIVAL BENEFIT
List at least 4 non-pharm approaches to reducing behavioural and psychological symptoms of dementia
- clear communication*
- understanding triggers* (ABC)
- social interaction
- environment*
- adapt treatment to patient’s interests
- consistency, avoid punishment*
- r/o constipation/delirium/depression/anxiety
- dementia care mapping
ABC = activating event, behaviour, consequence
FS: similar to delirium - orientation, aids, hydration, pee, poop + clear communication + understanding triggers
List five cognitive domains that can be impacted by delirium
Attention
Orientation
Language
Sleep wake cycle
thought process
visuospatial ability
List the criteria for diagnosing delirium
- disturbance in attention, cognition, and consciousness
- acute onset and fluctuating course
- occurs in context of underlying medical condition
List 4 important risk factors for delirium*
- increasing age*
- dementia and cognitive impairment*
- visual impairment
- admission to hospital for fracture
- severe medical illness*
- medications*
FS: DIMS-O
List four strategies to prevent delirium in hospitalized patients
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
How does evidence for non-pharm vs pharm measures compare for management of delirium?
- systematic reviews of non-pharm measures show significant reductions in delirium incidence
- Studies so far do not show impact of anti-psychotics on delirium incidence, duration, severity, or hospital LOS
List atleast 5 barriers to managing pain in older adults*
- underassessment of pain
- adjusting RX due to pharmacokinetic/dynamic changes
- polypharmacy
- multimorbidity
- cognitive impairment
- gait disorders
- Older adult beliefs about pain and its treatment
- Access to pain services
List three medical conditions and 3 medications that can be associated with constipation in the elderly
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
List five main causes that can contribute to falls in the elderly
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
List at least 5 classes of medications that can increase falls risk
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
List three interventions for fall prevention in the elderly (besides reducing contributing meds)
Reducing environmental hazards*
Gait retraining
Assistive devices (eg gait aid)*
Appropriate footwear*
Define frailty and at least 3 features of it*
- 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
Frailty requires at least 3 of what five findings
unintentional weight loss
low physical activity levels
slow walking speed
poor grip strength
self reported exhaustion
List 4 prevention strategies for frailty
- Primary:
- adress cormobid illness (i.e. HTN)
- chronic disease management*
- exercise* - Secondary:
- nutrition* - Tertiary:
- maintaining and improving function
- control of symptoms
- maintain psychological well being*
- prevent hospitalization when possibly
What type of assessment strategy is effective for frailty?
Geriatric interdisciplinary assessment (MD, RN, OT/PT, SWK)
List four risk factors for depression in the elderly
unmarried status
living alone
lack of social support*
negative life events such as bereavement*
low SES*
comorbid psych/medical illness*
List two scales that have been validated to assess for depression in the elderly
Beck Depression Inventory
Hamilton Depression Scale
Geriatric Depression Scale
Cornell Scale for Depression in Dementia
List 3 neuropsychological domains affected by depression in older adults
- processing SPEED
- verbal and non-verbal MEMORY
- EXECUTIVE functioning
FS: MES
List three indications to refer an older adult to specialist psychiatric services for depression
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
List 3 pathomechanisms of presbycusis
- Deterioration of auditory sensitivity
- Loss of auditory sensory cells
- Loss of central processing functions
List 3 common causes of vision impairment in the older adult
- Age-related macular degeneration
- Glaucoma
- Cataracts
- Diabetic retinopathy
Is xerostomia a normal part of aging? List three complications of xerostomia
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
List 4 medical conditions that may cause xerostomia
- Dehydration
- Sjogren’s syndrome
- diabetes
- Alzheimer’s disease
List 5 classes of medications that can cause xerostomia
- antidepressants
- sedatives/tranquilizers
- anti-histamines
- antihypertensives (alpha/beta blockers, diuretics, CCB, ACEi)
- cytotoxic agents
- anti-parkinsonism meds
- antiepileptics
FS:
Diuretics
Anti-cholinergic
Anti-histamine
Opioid
Benzo
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.
- skin atrophy
- Decreased ability to retain water
- Decreased cell replacement
- Decreased sweat production
- 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
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
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)
List four factors that contribute to frailty*
ageing
comorbid disease
nutritional inadequacy
environmental impacts
genetic factors
lifestyle factors
