23 - Older Person's Medicine Flashcards
What are some important points in a geriatric history you need to cover in addition to a normal history?
- Falls history
- Assessment of cognition (check with collaterals if change)
- Continence assessment
- Social and functional history (where do they live, do they have carers, do they have adaptations in home)
- Further systemic enquiry
- Advanced care planning
Who is in involved in a Comprehensive Geriatric Assessment (CGA) and what is the aim of this assessment?
Team: Geriatrician, Nurse Specialist, OT, Physio, Pharmacist, S+L, Dietician
They aim for better outcomes such as reduced readmission, reduced long-term care, greater patient satisfaction and lower costs
What is involved in a Comprehensive Geriatric Assessment?
- Problem list (current and past)
- Medication review
- Nutritional status
- Mental health
- Functional assessment: basic ADL, gait, functional ADLs
- Social circumstances
- Environment
What is defined as polypharmacy?
When a patient is taking 6 or more drugs at once
What is the STOPPSTART tool?
Tool used to optimise prescribing in the elderly to prevent adverse effects and reduce drug costs/drug wastage
Stops inappropriate prescribing
Identify medications where the risks outweigh the benefits
What do you need to remember when writing a prescription?
- Check drug allergies
- Check drug interactions
- Write full drug name and UNITS not IU
- Include start date/end date or review date
- Print name and sign
What are the aims of discharge planning for older patients?
Healthcare professionals work with patient and their family/carers to agree care pathway. Must be ‘person-centred’, maximise QoL and maximise independence
Aims: reduce length of stay in hospital, prevent unplanned readmission, improve the way community services coordinate
What is a section 2 and section 5 when organising discharge from hospital for an older patient?
Section 2: Referral to social services if patient is likely to need comunity care once discharge. to assess for funding e.g care home, carers. Patient is then allocated a social worker who is responsible for their package of care
Section 5: Nursing staff alert social services when patient is medically fit for discharge so social services need to start decisive action towards discharge
What do you need to sort out before a patient can be discharged?
- TTO (medication to take home)
- Transport
- Therapy assessment (physio and OT)
- Outpatient appointments
- Restarting package of care
- Transfer back letter for residential residents
Why do some discharges fail?
- One of the requirements for discharge may not be complete e.g starting package of care
- Patient health complicatins
- Communication breakdown between healthcare and social services
- Family decisions
- Decisions around funding
If an elderly patient lacks the capacity to consent for a procedure, what should you do?
- Liase with relatives to see what the patient would wish for
- Act in their best interest
- Involve a IMCA
What is frailty and some examples of frailty syndromes?
Distinctive health state related to the aging process inwhich multiple body systems gradually lose their inbuilt reserve
Use Rockwood clinical frailty score
Frailty syndromes: falls, immobility, delirium, incontinence, susceptibility to side effects of medications
How are falls classified into categories?
- Syncopal
- Non-syncopal
What are some causes of falls in the elderly?
Non-Syncopal
- Impaired vision
- Home hazards
- Drug side effects affecting balance and BP
- Dizziness
Syncopal
- Cardiac syncope: ACS, Aortic stenosis, Dysarrhythmias
- Postural Hypotension
- Neurally mediated: vasovagal
What is the definition of syncope?
Transient LOC that is spontaneous and rapid onset with prompt full recovery
What are some causes of cardiac syncope?
What is the definition of postural hypotension?
In first 3 min of standing:
- Systolic BP fall > 20 mmHg or
- Diastolic BP fall > 10 mmHg
What are some causes of postural (orthostatic) hypotension?
- Hypovolaemia (Dehydration, Haemorrhage, Addison’s)
- Autonomic failure (Diabetes)
- Prolonged bed rest
- Drugs eg antihypertensives, anti-anginals, antidepressants,
- Alcohol
What is a vaso-vagal syncope?
Do tilt table testing
When an elderly patient presents with a fall, what are some important questions to ask in the history?
- What were they doing?
- How did the fall happen?
- How did they feel before the fall?
- Any cardiac symptoms?
- Any loss of consciousness?
- What medication do they take?
How should you examine an elderly patient that has presented with a fall to try to find the cause?
- MSK exam: check joints
- Neurological exam
- CVS exam: including ECG and lying/standing BP immediately and then at 3 and 5 minutes
- Functional assessment of mobility: what is their gait like, how do they mobilise
- Osteoporosis risk assessment: start bone protection straight away if >75 and fracture
Some patients with falls are referred to a Falls Prevention Programme, what does this involve?
- Exercises to improve flexibility, strength and balance
- Teaching backwards chaining to prevent long-lie after fall
- Education about how to have a healthly lifestyle and make home changes to precent falls
What is delirium and what are some causes of this?
Acute confusion state with sudden onset over 1-2 days and fluctuating course. It has a change in consciousness and hyper or hypoalert.
Causes: infections, substance intoxication, substance withdrawal, electrolyte imbalance, hypoxia, constipation, urinary retention
What are the different types of delirium?
How is delirium screened for?
- AMT4
- AMT10
- CAM (confusion assessment method)
- 4AT
What investigations should you do if you suspect a patient to have delirium?
What patients are at increased risk of developing delirium and what are the complications of delirium?
Increased risk: cognitive impairment, sensory impairment, surgical patients, hip fracture patients as risk of infection, dementia
Complications: increased mortality, prolonged hospital admission, increased risk of developing dementia
How long does delirium take to resolve?
Can take up to 3 months to get back to previous levels of functioning or may never return to baseline
How is delirium managed?
Supportive care: treat underlying cause, orientate patient to time and place
Pharmacological treatment (Lorazepam and Haloperidol): only if patient is a harm to themselves or others.
Prevention for those at risk!!!!
What is the definition of dementia?
Progressive decline in cognitive function over several months
Affects many areas of function e.g retaining new information, managing complex tasks, langage difficulty, ability to self-care
What are the different types of dementia and how does their presentation vary?
Alzheimer’s (most common): Insidious onsret with slow progression, behaviour problems common
Vascular (second most common): Step wise progression with vascular risk factors
Lewy Body Dementia: Gradually progressive with auditory and visual hallucinations. Parkinsonism commonly present
Parkinson’s with Dementia: Features of Parkinson’s with confusion at least a year after parkinson’s diagnosis
Frontotemporal: Early onset with complex behavioural problems and language issues
Mixed: Vascular and Alzheimer’s
How do you assess for dementia?
- Collateral history from relatives
- Clear history of declining memory over several months
- Exclude delirium and depression
- Exclude reversible causes
- Screening tools e.g AMT, MMSE, MOCA
- Brain imaging e.g hippocampul atrophy
- Refer to memory clinic
What treatment is offered to patients with dementia?
- Cholinestase inhibitors e.g donepezil, rivastigmin
- If vascular dementia can only modify risk factors
- Inevitable progressive decline so advanced care planning and supportive care
How can you tell the difference between dementia and deliurum?
Collateral history is very important!
- Dementia is slow onset, delirium is sudden onset
What are the different types of urinary incontinence in the elderly?
Often multifactorial
- Stress
- Urge
- Nocturnal
- Overflow due to retention
- Functional