23 - Older Person's Medicine Flashcards
1
Q
What are some important points in a geriatric history you need to cover in addition to a normal history?
A
- 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
2
Q
Who is in involved in a Comprehensive Geriatric Assessment (CGA) and what is the aim of this assessment?
A
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
3
Q
What is involved in a Comprehensive Geriatric Assessment?
A
- Problem list (current and past)
- Medication review
- Nutritional status
- Mental health
- Functional assessment: basic ADL, gait, functional ADLs
- Social circumstances
- Environment
4
Q
What is defined as polypharmacy?
A
When a patient is taking 6 or more drugs at once
5
Q
What is the STOPPSTART tool?
A
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
6
Q
What do you need to remember when writing a prescription?
A
- 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
7
Q
What are the aims of discharge planning for older patients?
A
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
8
Q
What is a section 2 and section 5 when organising discharge from hospital for an older patient?
A
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
9
Q
What do you need to sort out before a patient can be discharged?
A
- TTO (medication to take home)
- Transport
- Therapy assessment (physio and OT)
- Outpatient appointments
- Restarting package of care
- Transfer back letter for residential residents
10
Q
Why do some discharges fail?
A
- 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
11
Q
If an elderly patient lacks the capacity to consent for a procedure, what should you do?
A
- Liase with relatives to see what the patient would wish for
- Act in their best interest
- Involve a IMCA
12
Q
What is frailty and some examples of frailty syndromes?
A
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
13
Q
How are falls classified into categories?
A
- Syncopal
- Non-syncopal
14
Q
What are some causes of falls in the elderly?
A
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
15
Q
What is the definition of syncope?
A
Transient LOC that is spontaneous and rapid onset with prompt full recovery
16
Q
What are some causes of cardiac syncope?
A
17
Q
What is the definition of postural hypotension?
A
In first 3 min of standing:
- Systolic BP fall > 20 mmHg or
- Diastolic BP fall > 10 mmHg
18
Q
What are some causes of postural (orthostatic) hypotension?
A
- Hypovolaemia (Dehydration, Haemorrhage, Addison’s)
- Autonomic failure (Diabetes)
- Prolonged bed rest
- Drugs eg antihypertensives, anti-anginals, antidepressants,
- Alcohol
19
Q
What is a vaso-vagal syncope?
A
Do tilt table testing
20
Q
When an elderly patient presents with a fall, what are some important questions to ask in the history?
A
- 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?
21
Q
How should you examine an elderly patient that has presented with a fall to try to find the cause?
A
- 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
22
Q
Some patients with falls are referred to a Falls Prevention Programme, what does this involve?
A
- 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
23
Q
What is delirium and what are some causes of this?
A
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
24
Q
What are the different types of delirium?
A
25
How is delirium screened for?
- AMT4 (age, d.o.b, place, current year)
- AMT10
- CAM (confusion assessment method)
**- 4AT**
>4 suggests delirium.
26
What investigations should you do if you suspect a patient to have delirium?
27
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
28
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
29
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.
Haloperidol is contraindicated in Parkinson’s.
**Prevention for those at risk!!!!**
30
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
31
What are the different types of dementia and how does their presentation vary?
**Alzheimer's (most common):** Insidious onset 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
32
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**
33
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
34
How can you tell the difference between dementia and deliurum?
Collateral history is very important!
- Dementia is slow onset, delirium is sudden onset
35
What are the different types of urinary incontinence in the elderly?
Often multifactorial
- Stress
- Urge
- Nocturnal
- Overflow due to retention
- Functional
36
What questions should you ask in a urinary continence history?
- How people void
- Frequency
- Symptoms
- Oral intake and what drinks
- Bowel habit (stool type, frequency)
- Drug history
37
What examinations should you perform for a patient presenting with urinary incontinence?
- Abdo exam
- PR exam
- External genitalia
- Urine dipsick and MSU
- Post micturition bladder scan
- Review of bladder and bowel diary
38
What is the management for urinary incontinence in general terms?
**_1st Line - Conservative_**
- Drink more as dilute urine not irritant to bladder so bladder can hold on to it
- Decaff drinks
- Good bowel habit
- Regular toileting
- Bladder retraining
- Pelvic floor exercises
**_2nd Line - Pharmacology_**
- Do not give oxybutynin (anticholinergic) to elderly due to risk of postural hypotension and falls
**_3rd Line - Surgery_**
39
What are some of the causes of faecal incontinence in the elderly?
**- Faecal impaction** with overflow diarrhoea
**- Neurogenic dysfunction**
**- Gaping anal sphincter** due to haemorrhoids or chronic constipation
40
How can you tell if faecal incontinence is due to spinal cord pathology?
Reduced anal sphincter tone and sensation
41
How do you examine someone with faecal incontinence?
PR looking at:
- Anal tone
- Sensation
- Prostate
- Visual inspection of anus
- Stool type if any in rectum
42
What should raise your suspicion of faecal impaction? (rectum full of soft or hard stool)
- Smearing
- Small amount of type 1 stool
- Lots of type 6/7 stool
- Mass palpated on abdominal exam
- Urinary retention (must always due PR with this to check for impacted rectum and large prostate)
43
Why is chronic constipation and faecal impaction so dangerous?
Stercoral perforation and ischaemic bowel which can lead to shock and death
44
How is faecal impaction managed?
**Hard stool:** Give stool softener like *macrogol* then a few days later give *stimulant like glycerol* or use *enema docusate sodium.*
Can also give Ispaghula Husk if cannot increase fibre in diet
**_Soft Stool:_** *Give stimulant or enema*
**_Difficult cases:_** *manual evacuation* (risk of perforation outweighed by benefits of improving patient's symptoms and wellbeing)
Give ***laxatives prophylactically*** if elderly and taking another drug that has constipation as a side effect. Always encourage fluids, fibre and exercise!
45
How is chronic diarrhoea treated?
- Bowel imaging and stool culture to rule out underlying causes
- Stop any causative medications
- Rule out faecal impaction
**_Treatment:_**
- Regular toileting
- Dietary review
- Low dose loperamide with enema regimes
46
What is the ABCD2 score?
A tool used to calculate the **short term risk of a stroke after a TIA**
Calculate by summing up and if **4 or more indicates a high risk:**
- Age
- Blood pressure
- Clinical features
- Duration of symptoms
- Presence of diabetes
47
How should you investigate someone with a suspected TIA?
- Immediate 300mg aspirin then take daily
- If high risk of stroke (ABCD2 4 or more) then prioritised to be seen in TIA clinic straight away
**_Ix_**: carotid doppler, CT or MRI of brain
48
How is a TIA managed?
- Lifestyle modifications
- Treat hypercholesterolaemia and hypertension
- Carotidendartectomy
- Antiplatelets
49
Apart from having a ABCD2 score of 4 or more, who is at high risk of a stroke after a TIA?
Crescendo TIA of two or more TIAs in one week
50
How do we define a stroke?
Sudden onset focal neurological deficit that lasts more than 24 hours or imaging evidence of infarction or haemorraghe
51
How are strokes classified?
**Bamford Classification:** which vascular territory involved
**TOAST classification:** underlying aetiology
**Bleeds:** Primary (hypertension) or Secondary (trauma, anticoagulation associated)
52
What are the different types of strokes according to the Bamford Classification and how do they present?
- TACS
- PACS
- LAC
- POCS
TACs has worst prognosis
53
What are the screening tools for the rapid assessment of a patient presenting with a suspected stroke?
**FAST:**
- Facial drooping
- Arm weakness
- Speech slurred
- Time to call 999
**ROSIER:**
- Determines difference between stroke and stroke mimic in A and E
54
What is the NIHSS scale?
Evaluates the neurological status in acute stroke patients to measure stroke severity. Looks at 15 components:
- Level of consciousness
- Language
- Neglect
etc etc
55
How is a ischaemic stroke managed in general terms?
- Stop/reverse any anticoagulants
- Send for CT
- Once confirmed ischaemic give **alteplase if \<4.5 hours since onset**
**- Also give 300mg aspirin (orally or rectally) and continue this for 2 weeks after stroke,** then long term anticoagulation
- Rehabilitation
- Modify stroke risk factors
56
Can you drive after having a TIA or a stroke?
- Not allowed to drive for **one month** after a stroke or TIA. After this you can drive if no permanent neurological deficit
- If recurrent TIAs cannot drive for 3 months
57
If a patient has a TIA or stroke, when should they be referred for a carotid endarterectomy?
If **carotid stenosis 50-99%** should be assessed and referred within a week of TIA/stroke
Should then have surgery within 2 weeks of onset of stroke/TIA
58
What is malignant MCA syndrome and how is this treated?
**Rapid neurological deterioration** due to the effects of **space occupying cerebral oedema** following MCA stroke
Need a **decompressive hemicraniectomy** if they have a decrease in consciousnes
Treated within 48 hours, must be under 60 and have an infarct \<50% of MCA and a NIHSS \>15
59
What are some examples of stroke mimics?
- Seizures
- Space occupying lesions
- Hemiplegic migraine
- MS
- Sepsis
- Hypoglycaemia
60
What are some complex decisions that may need to be made after a patient has a stroke?
- DNACPR
- Enteral feeding due to risk of aspiration
61
What does the CHADVASC score calculate?
The risk of someone with AF developing a stroke
62
What is the priority of care during palliation?
**- Dignity**
**- Comfort** e.g stop observations
**- Follow advanced directives** that state their wishes if they are unable to communicate anymore
63
What are some milestones that can help you to recognise a patient is becoming end of life?
- Bed bound
- Semicomatose
- Only able to sip fluid
- Unable to take oral medication
64
What are some symptoms that a palliative care patient might experience?
65
What are some anticipatory medications that may be used in palliative care?
Prescribed S/C or syringe driver for those who are expected to deteriorate rapidly
66
How do you confirm that a patient is dead?
- Check pupils are fixed and dilated
- Check no response to pain
- Check no breath or heart sounds after 1 minute of auscultation
67
How is a death certificate filled out in a patient who has died in hospital?
Doctor who has cared for the patient in the last 14 days goes to the morturary
1a - Cause of death
1b - Condition leading to cause of death
1c - Additional condition leading to 1b
2 - Any contributing factors or conditions
68
How is cremation paperwork carried out?
Completed by 2 independent doctors with 1 of them having cared for the patient and the other being 2 years post-registration seeking confirmation of cause of death from variety of sources
Need to remove pacemakers and radioactive implants before cremation
69
When should a death be reported by a doctor to the coroner?
- Death a result of poisoning or controlled drug
- Death as a result of trauma
- Related to any medical treatment
- Ocurrred due to self harm
- Death occurred in custody or DOLS
- No practioner attended the deceased within 14 days before death
- Identity of deceased unknown
70
What are the 5 principles of capacity?
71
How is mental capacity assessed?
Capacity assessments are time and decision specific, ALWAYS REASSES
**_Step 1:_**
- Does the person have an impairment of their mind or brain e.g alcohol or drug use, stroke, dementia, severe LD
**_Step 2:_**
- Does the impairment mean the person is unable to make a specific decision when they need to?
- Need to fill criteria on image (understanding, retain, weigh up, communicate)
72
What is the mechanism of action for each class of laxatives?
73
What are some causes of constipation in the elderly?
- Drugs e.g opioids
- Poor water intake
- Poor fibre intake
- Immobility
- Electrolyte imbalances
- Hypothyroidism
74
What are some drugs that can cause constipation?
- Opioids
- TCA
- CCBs
- Anti-Parkinson's (dopaminergic)
75
An 88 year old has surgery for a fractured neck of femur. After this he is unable to pass a stool for a week. What investigations should you do?
- Abdo and PR exam
- AXR to check for faecal impaction
- Bladder scan to check if urinary retention is a cause
- U+Es, Mg, Ca to see if electrolyte imbalance
76
What laxatives should be given to someone with the following types of constipation:
- Short duration
- Chronic
- Opioid induced
**Short (not responded to increased fibre):** Bulk forming laxative with adeqaute fluid intake. If still hard give osmotic laxative. If soft just give stimulant
**Chronic:** Same as above then slowly withdraw when regular bowel habits. If using 2 then withdraw stimulant first. If 2 laxatives still not working at highest dose for 6 months, give prucalopride, reassess if not working after 4 weeks
**Opioid induced:** Osmotic and Stimulant. AVOID bulk forming
77
What are some medications that can contribute to urinary incontinence and urinary retention?
**Urinary retention**: alpha agonists, CCBs, TCA, antipsychotics, benzodiazepines, opioids, NSAIDs
**Urinary incontinence:** diuretics, alpha blockers, any drugs causing retention as will cause overflow
78
What are some drugs used to treat an overactive bladder?
**Antimuscarinics:** oxybutynin, tolterodine
**B3 agonist:** Mirabegron
79
Why may someone with dementia in a nursing home have poor oral intake?
- Difficulty chewing and swallowing
- Constipated
- Drug side effects
- Anorexia from dementia
- Not physically active
80
What types of fluid and food consistencies can the SALT team recommend for patients with swallowing difficulties e.g dementia?
**_Fluids:_** thickened fluids to either syrup, custard or pudding consistency
**_Foods:_**
**- Blended diet:** B is thin blended like soup, C is thick blended and can be moulded/holds own shape
**- Mashed diet:** D still has some lumps in as not pureed/sieved
**- Soft diet:** just avoiding high risk foods for aspiration
**- Normal diet**
81
Should dementia patients be fed with enteral feeding e.g NG/PEG?
**No**
- Higher risk of aspiration with NG than swallow in dementia
- Does not improve nutrition and survival
- Unpleasant procedure and patient may try to pull it out
82
What does feeding at risk mean and what do you have to tell the patient's family with this?
Patient continues to eat and drink despite a significant risk of aspiration/choking
Tell family it helps them to maintain quality of life, that other options (e.g NG) may also not reduce risk of aspiration, ask them how they want to treat further aspiration pneumonias e.g ?no hospitalisation
83
What is a best interest decision and when is it made?
A decision made for a person who lacks capacity to make their own decision
84
What is an advanced care plan?
A conversation between a patient and their family/carers/GP outlining their future wishes and priorities for care/treatment
This is made whilst the patient still has capacity
85
What is a ReSPECT form?
**Personalised recommendations for a person’s clinical care and treatment in a future emergency** in which they are unable to make or express choices
Can be reviewed and is not legally binding
Only legally binding if ADRT is signed
86
What are some medications that increase the risk of falls in the elderly?
87
What are some causes of acute confusion in the elderly?
- Infection
- Stroke/TIA
- Hypoglycaemia
- Head injury
- Alcohol
- CO poisoning
88
What examination and investigations should you order for a patient who is acutely confused?
##Footnote
Can also do the following:
- CT scan (eg. if focal neurologic signs, head injury or fall, raised intracranial pressure signs)
- Serum B12 and folate
- ABG
- Specific cultures (MSU, sputum)
- Lumbar Puncture (if meningism or headache and fever)
89
How should you manage a patient with acute confusion?
- Withdraw or reduce any drugs causing confusion
- Correct biochemical derangements
- If high likelihood of infection treat promptly with antibiotics
- Relieve exacerbating symptoms (pain, urinary retention, constipation, thirst)
- Avoid major tranquillisers where possible
- Monitor AMTS
- Communicate with the relatives
