Aged Care Flashcards
Risk factors/predisposing factors for delirium
- Elderly/frail patients
- Pre-existing cognitive defects (dementia, past brain trauma, PD, stroke, tumour, MS)
- Meds: Polypharmacy or rapid escalation of opiod dose
- Sensory impairment/deprivation and immobility
- Multiple chronic medical conditions (cancer, organ failure, recurrent infx, neuropathic pain)
- Previous delirium
- Dehydration, malnutrition and sleep deprivation
Precipitating factors for developing delirium
- MEDS (anticholinergic and polypharmacy! change in meds)
- Intoxication, substance withdrawal (alch, benzos)
- Severe/multiple medical problems
(INFX/SEPSIS, fever/hypothermia, metabolic encephalopathies, DEHYDRATION/poor nutrition, ELECTROLYTE imbalance, organ failure, hypoxia), hypotension, constipation, retention, hyper/hypoglycaemia, cancer, FRACTURES, AMI - SURGERY and anaesthetics (esp emerg, lengthy and ortho procedures)
- Acute brain pathology (STROKE, abi, trauma)
- Environment (sleep, urinary catheter, pain and discomfort, unfamiliar environment, immobility, restraints, absence of sensory aids)
DDX disturbed behaviour
Delirium
Dementia
Depression or mania (mood disorders w psychotic SX)
Primary psychotic disorders (Schizophrenia/delusional disorder, schizoaffective disorder, schizophreniform psychosis, brief psychotic disorders)
Drug-induced (intoxication or withdrawal)
Organic psychoses
Diagnosis of delirium
Confusion assessment method (CAM)
Presence of both:
- Acute onset and fluctuating course
- Inattention
Plus one of the following:
- Disorganised thinking (speech, memory, hallucinations, delusions etc)
- Altered conscious state
Diagnosis of dementia
Other screening tests
Via MMSE
Score <24 indicates cognitive impairment
Other:
- MoCA
- RUDAS
- ACE-R
- Clock-drawing test
- Neuropsych assessment
What are the limitations of the MMSE
Doesn’t test executive function
Depends on patient’s education, culture, language, sensory abilities etc
DSM5 Criteria for dementia
A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains*:
- Learning and memory
- Language
- Executive function
- Complex attention
- Perceptual-motor
- Social cognition
B. The cognitive deficits interfere with independence in everyday activities.
C. The cognitive deficits do not occur exclusively in the context of a delirium
D. The cognitive deficits are not better explained by another mental disorder (eg, major depressive disorder, schizophrenia)
Auditory Agnosia
Inability to understand/comprehend speech despite intact hearing, speech production and reading abilities
Apraxia
Inability to coordinate muscles to produce speech due to loss of motor cortex function
Causes of dementia in order of occurrence
- Alzheimer’s disease (70%)
- Vascular dementia (15%)
- Fronto-temporal dementia (10%)
- Lewy-body/Parkinson’s dementia
Diagnosing geriatric depression
+ SX
Geriatric depression survey (GDS)
SX
- decr mood and anhedonia
- insomnia
- decr appetite
- psychomotor sx
- mood congruent delusions/hallucinations
- self-harm
- COGNITIVE/MEM IMPAIRMENT (subjective = pseudodementia)
- SOMATIC complaints and HYPOCHONDRIASIS
What is fronto-temporal dementia characterised by?
Problems w
- social behaviour
- impulse control (disinhibition, suddenly have an uncontrollable sweet tooth)
- personality
- inappropriate behaviour
- planning and sequencing
Fronto-temporal dementia:
Ave age onset
Pace of onset
Progression/Prognosis
Onset <70yo
Quick onset over 6mo
Quick progression/decline (~7 years)
Baseline inx for dementia
Imaging-CTB Bloods - FBE CRP UEC CMP LFT TFT B12, folate, thiamine
Urine dipstick and MSU and ACR
Baseline inx for delirium
CXR
MSU
Bloods: FBE, CRP UEC, CMP (Ca) LFT PO4 BSL saO2
Drugs more likely to cause delirim
Steroids
Digoxins
Anticholinergics (TCAs, oxybutinin, anti PD, antihistamines)
Benzos
Opiods
How to manage sleep in delirious patients
□ Non-pharmacological techniques (re-orientation and gentle nursing etc)
□ Soft low-level light
□ Medications for those who do not settle w gentle/conservative measures
® Low-dose Quietapine can help them sleep (Only available in tablet form)
® Olanzapine can be given as SC injection or wafer which can be advantageous
Simple management measures to help with delirium whilst waiting for inx. results
§ Withdrawal: Nicotine patch
§ Treat constipation - laxatives, fibre, fluids
§ Optimise diabetic control
§ Review medications - reduce opiods if pain is under control
§ Ensure adequate sleep
§ Ensure they have hearing aids in
When conservative mx fails:
§ Medication (quetiapine, olazapine, haloperidol)
Types of delirium
Hyperactive
Hypoactive
Mixed types (fluctuates between hypo and hyperactive states)
What patients are at risk of hypercalcaemia and what does this predispose them to?
- SCC of lung, breast, renal cell, prostate, head and neck
- Bony mets
Risk of developing delirium
Managing delirium in terminal phase - terminal restlessness
Bladder scan to check full bladder/bowel (IDC if necessary)
Control pain/consider reducing opiod dose or opiod rotation if well-controlled
Sedation
Sedative agents used in terminal restlessness
BENZOS 1st line
LEVOMEPROMAZINE is 2nd line
PHENOBARBITONE if all else fails
What benzos are used for terminal restlessness?
Midazolam first line, or clonazepam (both available as SC injections or SC continuous infusions via syringe driver)
Can use lorazepam as S/L form
RFs for stress incontinence
Women (pregnancy)
Men who have had prostate/rectal surgery
Obesity
Chronic sneezing, coughing, running, lifting
Stress incontinence picture:
- leakages
- bladder diary
Small vol leaks with rise in IAP
Normal bladder diary
Management stress incontinence
Pelvic floor exercises and assessment of technique by continence physio (trial for 3 months)
Topical estrogen if post-menopausal (cream, tablet, pessary)
Surgery (trans-vaginal tape)
Overactive bladder - causes
Idiopathic is most common cause
MS (disrupts message to inhibit reflex)
Post-stroke
PD
SX of overactive bladder
Freq
Urgency with triggers - Water, key in door, laugh, cold
Nocturia
sensation of large vol leaks
Bladder diary with overactive bladder
Frequency
Small volume voids
Nocturia
Management of overactive bladder
Bladder retraining (trial 6weeks-8mo)
- Deferment
Or Timed toileting
Pelvic floor exercises
Avoid/reduce caffeine and alcohol Increase fluids (maintain ~1500ml)
Use pads (confidence in social situations)
Medication if conservative MX fails
- Oxybutynin (anticholinergic) - Beta3 agonist - Botulinum toxin
Side effects of anticholinergics
Dry mouth
Retention
Components of a geriatric psych assessment
- Physical
- Sensory impairments and aids
- Frailty: mobility, comorbidities and gait/abnormal movements - Mental
- Psychiatric and psychological
- Cognitive - Social
- Family, friends, supports
- Living condition
- Finances
- Hobbies, religiosity
- Culture and language
- Stigma - Risk assessment
- Assess competence (appoint an enduring power of attorney)
- Driving
- Finances and legal matters
- Lifestyle and accom
- Medical tx
Domains of cognition
Attention Visuospatial Language Memory Executive function
Assessment of attention
Serial 7s
World backwards
Days of week or months of year backwards
Orientation to TPP
Assessment of visuospatial
Drawing reproduction
Clock drawing
Memory assessment
Recall 3 objects
Items starting with P and/or animals in 1min
Produce drawing after delay
Exec function assessment
Proverbs (no ifs, ands or buts)
3 step command (motor sequencing)
Categorical fluency (naming animals)
Clock drawing
Language
Reading and comprehension (close your eyes)
Write a sentence
Word finding
Components of a cognitive assessment
Hx - req collateral history
- what is their baseline, age and education?
- time course
- rule out medical causes for decr cognition and delirium
Functional assessment
- PADLs, DADLs, IADLs
- Mobility
- Frailty
- Supports
- Work/job
- Finances
- Driving
O/E +/- OT (home) assessment and
Inx
tests (MMSE, CAM, GDS etc)
Driving assessment
SX of BPSD
Agitation and aggression and irritability
Repetitive and inappropriate vocalisations
Sexual disinhibition
Wandering
MOOD - Depression, anxiety, apathy
Delusions and hallucinations and paranoia
Restlessness and overactivity
Aetiology of BPSD (list 5 in each category)
Biological
- Meds
- Pain
- Constipation
- Urinary retention
- Sensory impairment
- Tiredness
- Hunger, thirst
- Delirium/acute medical illness
Psychological
- Previous psychological lines (depression and anxiety)
- Premorbid personality
- Frustration
- Boredom
- Fear
Environmental
- overstimulation
- understimulation (boredom)
- Overcrowding
- consistent caregiving/ high staff changes
- provocation by others
Non pharmacological MX of BPSD
- Clarify the problem (behavioural chart - what/when/where/why, identify the behaviours you want to treat, any triggers and/or reasons for behaviour)
- Correct reversible factors - Treat medical problems and causes of disability (mobility, vision, hearing) and PAIN
- Environment - low stimulus, privacy, adequate space, staff trained in behave. mx
- Interpersonal - staff education/support/training, patient-cantered care, behavioural mx techniques, psychoeducation for staff
- Therapeutic - relaxation and behavioural mx techniques
Pharmacological MX of BPSD (mention any SEs)
Antipsychotics for aggression and delusions (risperidone, haloperidol, quetiapine, olanzapine)
SE: incr risk CV events and death
Benzos to decrease agitation
SE: incr risk falls, sedation, decr cognition
reversible causes of BPSD to consider
Drugs and alcohol + withdrawal Eyes and ears Metabolic (thyroid, Ca, Na, BSL) Emotional/psych Nutritional Trauma and tumours (subdural haem, brain tumour) Infx (HIV, neurosyphilis) Atheroma (vasc dementia)
DDX memory loss
Age associated memory decline
Mild cognitive impairment
Dementia
- AD/VD/LB/PD/FTD
Delirium
Depression
Medical problem
- thyroid
- HyperCa
- HypoNa
- Hypoglycaemia
- Brain tumour
- Infx (meningitis, enceph, neurosyphilis, HIV)
- Low B12, folate
- Low thiamine
- Medication SEs
- Drugs and alcohol
- Intoxication
- Subdural haemmhorage
- head trauma
Why is polypharmacy bad?
Drug interactions
Drug side effects
Pill burden - missed doses, wrong drug, cost
Delirium
Mortality and morbidity incr (hospital admission and prescribing errors)
Falls - hypotension (antiHTN) and benzos
Common causes of malignant bowel obstruction
Colorectal and ovarian cancers are the most common intra-abdominal cancers assoc w MBO
Breast cancer and melanoma are the most common extra-abdominal causes.
Investigations for suspected bowel obstruction
The abdominal X-ray is used to look for dilated loops of bowel, air fluid levels, or both.
The abdominal CT is useful in making the diagnosis of bowel obstruction, evaluating for complications, and staging and choosing surgical or endoscopic intervention.
+/- Endoscopy
Treatment of MBO
- Surgical (debulking, diverting colostomy, intestinal bypass, and resection)
- Resection should be considered in patients with good performance status and localised disease - Nasogastric tubes are often placed in initial treatment for decompression if symptom relief does not occur with medications. OR percutaneous gastrostomy tube OR metallic stents
- Medical therapy and palliation
- IV fluids and electrolyte replacement initially, then consider TPN
- Opioids
- Antiemetics (metaclopramide)
- Antisecretory agents (octreotide, a somatostatin analogue)
- Dexamethasone
Key physical findings in the elderly who falls
I HATE FALLING
Inflammation or deformity of joints Hypertension Auditory/visual problems Tremor (PD etc) Equilibrium Foot problems Arrhythmia, heart block or valvular disease Leg length discrepancy Lack of conditioning Illness (acute or chronic) Nutrition Gait disturbance
Common causes of falls
Intrinsic MSK - gait disturbance - pain - joint/balance disorders - muscle weakness
CVS
- Postural hypotension
- Arrhythmia
- Valvular
- IHD/MI
CNS
- CNS disorder, syncope, epilepsy
- stroke/TIA
- sensory (Visual impairment and hearing impairment, peripheral neuropathy)
OTHER
- Acute illness
- Hypoglycaemia
- psychological (fear, anxiety)
- decr cognition
Extrinsic
- environmental hazards (loose rugs, cords, uneven floor, clutter, lighting)
- footwear
Behaviour (risk activities - ladder, standing on chair etc)
Meds and other substances
- withdrawal
- intoxication
- medications
- polypharmacy
Medications that can cause falls
Sedatives (opioids, bentos) Anxiolytics TCAs Antihypertensives (digoxin) Cardiac meds C/S NSAIDs Anticholinergics Hypoglycaemics
Physical exam for falls evaluation
Vitals and orthostatic BP
Vision and hearing
Gait and balance
- one-leg balance
- timed up and go
- chair stand (arms crossed)
- Romberg’s test
- walking on heels/toes
- sternal push or shoulder tug
Neuro
Functional evaluation
- write a sentence
- lift a book
- put on and take off a jacket
- pick up a penny
- turn 360 deg and walk 15m
Falls prevention strategies
INTRINSIC Optimise medical conditions - Appropriate sensory aids - BP - foot and joint conditions - inx and mx syncope - CV PT - gait and balance training and resistance exercises
EXTRINSIC Gait aids OT home assessment w appropriate changes Low bed Proper foot wear Improve home supports
DRUGS
Vit D 1000iu daily
Medication R/V - tapering and discontinuation of sedatives, avoidance of polypharmacy
BEHAVIOUR
Advice re: reducing falls and risky behaviour
Clinical psych r/v for severe fear of falling
INJURY PREVENTION
Hip protectors
Crash pads
Education re: how to get up from fall
Management of dementia
- Multidisciplinary! (OT, PT, Speech, language therapy)
- Family meetings important
- Orientation cues
- Psych: CBT, reminiscence work, validation therapy
- Optimise vision and hearing
- Optimise other medical problems (treat RFs, chronic and acute medical problems)
- Treat BPSD SX
- Education and support for patients and carers
- Legal advice - Power of attorney
- Advice Re driving
- OT home assessment and modifications
- Community support services (district nursing, meals on wheels, house keeping tc)
- Training for staff in care homes
- Pall care in terminal stages
Medications used only for
- sec prevention (in VD)
- treat aggression or specific SX of BPSD
- Enhance cholinergic transmission in AD (cholinesterase inhibitors or NMDA antagonists)
Features of vasc dementia
Step-wise deterioration CV risk factors SX - Focal neurology - Gait disturbance - Early incontinence - Falls - Cognition (exec function, encoding) affected but memory intact - Psychological SX (depression and apathy, hallucinations, emotional lability)
Imaging will show evidence of infarct
Features LBD
Marked and varied FLUCTUATIONS Rapid progression Cognitive SX PRECEDE physical SX by >= 1 year (if physical sx come first, think PD w dementia) SX of - AD - PD - neuropsych (visual hallucinations) - Postural instability (FALLS!)
Features FTD
Often genetic predisposition
MMSE often normal early on
Impaired exec function (planning, sequencing, prioritising, multitasking, behavioural monitoring)
- Behaviour: Social disinhibition, Loss of empathy, Compulsive eating
- Language: Aphasia, dysarthria
- Motor: dystonia, gait disorder, tremor, clumsiness
Role of medications in AD
Medications can slow the progression and/or improve SX temporarily
Mild-mod AD - anti cholinesterase inhibitors
(donezepil, rivastigmine, galantamine)
Mod-severe - NMDA antagonists (memantine)
Features AD
Slow progressive decline in cognition
first affects STM and episodic memory and visuospatial cognition
Steps to breaking bad news
SPIKES model Setting/situation • Private, quiet space • No interruptions • Turn phone off or onto silence
Perception -assess patient’s current understanding
Invitation - what information would they like to know?
Knowledge - give info to patient
Emotion - address patients emotion and give Empathetic response
Strategy and summary
- tell them what happens next
- identify Supports
- organise referrals and reviews
- Discuss your role in the treatment from heronin
- May need second consultation to discuss everything
DDX constipation
Lifestyle • Diet • Lack of hydration Medication Thyroid Hypokalaemia, hypercalcaemia Pain - Haemmharoids and fissures MS IBS Obstruction • Functional
* Bowel cancer * Lymphoma * Rectal cancer * Strictures * Diverticulitis * Adhesions * Faecal loading * volvulus
• Pelvic masses (ovarian cancer) Depression Diabetes Eating disorder - anorexia, bulimia SCZ Drug abuse
Why might PSA be elevated?
Recent vigorous exercise within 48hr or ejaculation within 2-3 days, infection (prostatitis), BPH can cause a rise in PSA, incr age, UTI, catheter or DRE
Rehab issues list for Spinal cord injury
Psychosocial (OT, PT, psych to monitor for depression)
Bladder - need for IDC or SPC may be temporary or permanent
- monitor for UTIs
Skin - daily skin checks and pressure relief for risk of pressure wounds
Bowels - UMN empties reflexively vs LMN empties w IAP
Sexuality
Spasticity and contractures
Autonomic dysfunction - BP instability common w high SCI >T6
Pain - MSK or neuropathic (req psych, PT, gabapentin, pregabalin or TCA)
Gait - req gait retraining and orthotics (low and incomplete SCI may be able to walk again)
Resp function - high para and quad patients @ risk of URTIs progressing to LRTIs (inability to cough)
- req early PT, abx and yearly flu vaccine
Equipment - wheelchair and cushion, +/- commode for showing and toiling +/- urinary/bowel equipment etc
Home modification - OT
Long term complications of SCI
Severe form of osteoporosis
Post traumatic syrinx - when SC heals w a small cyst at site of damage which can (2% cases) expand and cause further neurological damage
Para or quadriplegia
Depression, PTSD
Bladder and bowel dysfunction Sexual dysfunction Pain Susceptibility to RTI Spasticity and contractors
How do you classify extent of SCI?
ASIA classification system
A-E
A: complete (no sensory or motor in S4-S5)
B - incomplete (sensory not motor preserved below level, extending through S4-S5)
C - incomplete (motor preserved below level w power<3)
D- incomplete (motor preserved below level w power >=3)
E- normal
What are the assessment tools used to measure patient functional performance and level of care called
a) in rehab
b) in GEM
a) Rehab = FIM (functional independence measure)
b) GEM = Barthel Scale
Suitability criteria for entering a rehab program
- Medical stability
- Reasonable cognition (or expectation that it will recover i.e. some stroke and TBA patients)
- Motivation
- Psychologically stable
- Performance gains expected
- Availability of supportive family/carers in circumstances where level of residual impairment/limitation is significant
examples of neuropathic pain
Diabetic peripheral neuropathy
MS
Post herpetic neuralgia
Central post-stroke pain
Pain scales used in people w dementia who cannot communicate
PAINAID
Abbey Pain scale
Assess vocalisation/noises, facial expression, body language, behavioural change, physiological change, physical changes
Characteristics and RFs of late onset schizophreia
Onset >40yo (>60yo is very late onset)
More common in women Higher rates positive symptoms (persecutory delusions and multimodal hallucinations); less neg symptoms and thought disorder fFamily HX Premorbid paranoid personality Socially isolated
What tends to happen in old age with people that suffer from early onset SCZ?
Positive SX don’t worsen but negative SX do (apathy, affect blunting, withdrawal, amotivation, cognitive defects)
Highly prone to: substance abuse, physical illness, social isolation and self-neglect, Tardive dyskinesia and incr family burden
ACA stroke presentation
Contralateral hemiplegia and sensory changes (legs)
Grasp reflex
Paranoia (inability to reflex)
MCA stroke presentation
Contralateral hemiplegia and sensory changes (arms and face) + dysphagia
Contralateral homonymous hemianopia
Dominant (L hem) -> dysphasia, apraxia
Non-dominant -> affective agnosia, prosody, visuospatial defect, neglect
PCA stroke presentation
Contralateral hemianopia
Visual agnosia
Prosopagnosia
Can write but not read
Brainstem infarct presentation
Contralateral BODY pain and temp loss
Ipsilateral FACIAL pain and temp loss; hornet’s syndrome; nystagmus; hemiataxia
Dysphagia
Dysphonia
Causes of acute onset/transient incontinence
DIAPERS
Delirium/dementia/stroke/PD/cord compression Infection Atrophic vaginitis Pharmaceuticals Endocrine (hyperCa or DM, CRF) Restricted mobility Stool impact (constipation)
History associated features to ask about with incontinence
fever weight loss, night sweats polydipsia and polyuria decr perineal sensation change in sensation or weakness in lower limbs chronic cough, heavy lifting HX trauma Bowels
Mobility aids Medications Childbirth Smoking and alcohol obesity
Causes of overflow incontinence
BPH, prostate cancer Tumour Cystocoeal or prolapse Urethral stricture Iatrogenic
Causes of constipation in aged/pall care
Medication: opioids, antacids, diuretics, iron, 5HT3 antagonists
Secondary effects of illness (dehydration, immobility, poor diet, anorexia)
Tumour in, or compressing, bowel wall
Damage to lumbosacral spinal cord, cauda equina or pelvic nerves
Hypercalcaemia
Concurrent disease such as diabetes, hypothyroidism, diverticular disease, anal fissure, haemorrhoids, Parkinson’s disease, MS, MND, hypokalaemia, hyperCa
Management of constipation in Aged care
Good oral fluid intake (2 litres per day if able)
Review dietary intake
Ensure privacy and access to toilet facilities
Good toiling posture - access to footstool to elevate knees
Encourage mobility where possible
Address any reversible factors causing the constipation.
Medication
- Doses should be titrated according to individual response)
- Use oral laxatives if possible in preference to alternative routes of administration
Rectal intervention may be needed for significant faecal impaction (esp if immobile or bed bound) or with SCI
MONITOR
Choices of laxatives for constipation in pal care
Option A (softener ± stimulant) Coloxyl/lactulose (softener) +/- Senna (stimulant)
Option B (osmotic laxative) Movicol sachets
+/- Option C (Rectal treatment)
- Soft loading: Dulcolax/fleet suppository
- Hard loading: glycerol suppository as lubricant or stimulant; then treat as per soft
- V hard: Phosphate or oil enema
Paraplegic or bedbound patient
- Use rectal intervention every 1 to 3 days to avoid possible impaction resulting in faecal incontinence, anal fissures or both.
Antiemetics and their respective uses
Prochlorperazine=Stemetil (vestibular)
Metaclopramide (GIT and CTZ)
Haloperidol (CTZ)
2nd line
- Ondansetron (exxy!) - CTZ, gut obstruction
Non-Pharm Symptomatic treatment of SOB in pall care
Non-pharm
- CBT
- Education and explanation
- position (sit upright, loose clothing)
- Fan/open window -> airflow across face
- distraction
- relaxation, controlled breathing
- environmental (eliminate irritants, don’t overheat room, humidify dry air)
- consider Pulmonary rehab
- CAM
Principles of management of SOB w opiods
use if SOB on minimal exertion or at rest
Start with Morphine, hydromorph (5 stronger than morph), oxycodone (fast-acting, 1.5x stronger than morpine)
- titrate UP to effective dose
- convert to slow release
Convert to slow release forms if it becomes an ongoing requirement (MS contin, oxycontin, Targin etc)
If already on opioids for pain, incr dose by 25-50%
Pharm Symptomatic treatment of SOB in pall care
Pharm
- OPIODS FIRST LINE
- Corticosteroids (dex) - specificifically for airway/SVC obstruction, pulmonary fibrosis, radiation pneumonitis, asthma, COPD
- Benzos 1st line if major anxiety component
- O2 for chronic lung disease w paO2<55mmHg
Factors to consider to prevent delirium on the medical wards
Cognitive impairment Sleep Immobility Visual and hearing impairment Dehydration
Factors to consider to prevent delirium on the surgical wards
Early surgery Analgesia O2 delivery Fluid MX Medication RV Bowel and bladder MX Nutrition Early mobilisation Prevent and treat post op complications (DVT, PE, infx etc)
WHO LADDER for managing acute pain
- Mild pain
- Non-pharm mx and paracetamol - Moderate pain
- Add NSAID and/or oral opiod (codeine or oxycodone) for shortest possible period - Severe pain
- IV or SC opiod (morphine, hydromorphine)
Opiod side effects
Constipation in all (ALWAYS co-prescribe a laxative)
Sedation, drowsiness
N and V (coprescibe an antiemetic)
Resp depression, cough suppression
Physical tolerance, dependence and withdrawal
Psychological dependence
CI for NSAIDs
Renal failure Gastric ulcers/bleeding Past TIA/STROKE or MI Uncontrolled HTN CCF IBD
Adjuvant analgesics
Antidepressants (TCA, SSRI, SNRI) Anticonvulsants (Gabapentin, pregabalin, Carbamazepine) Corticosteroids Local anaesthetics (lignocaine) NMDA antagonists (ketamine) Calcitonin Bisphosphonates
Non-pharmacological management of pain
PHYSICAL Exercise, stretching, PT Heat/cold Massage Acupuncture
PSYCHOLOGICAL
Relaxation and stress MX
CBT
CAM
Tens
Opioids for acute pain vs chronic pain
ACUTE
Oral: codeine, oxycodone
IV: Morphine, hydromorphine
SC/subling: Fentanyl (shortest acting)
CHRONIC
Oral: tramadol and tapentadol
Methadone
Bupronorphine
PADLs vs IADLs
PADLs bathing dressing toiling continence grooming feeding transferring
IADLs shopping cooking housework home maintenance driving finances medications
What type of NOF is susceptible to AVN?
intracapsular is susceptible to AVN of head of femur
Components of pre-op (NOF) assessment
Basic bloods (FBE, UEC, coags, group and hold) Radiology - hip, pelvis, chest x ray ECG bowel and bladder mx (IDC) fluid status and MX (IVC) diabetic control (BSL) Medication RV (stop anticoags)
Peri-op management of NOF
ANALGESIA bladder and bowel mx diabetic mx fluid status monitor for post-op anaemia wound mx weight bearing status and hip precautions prevention of post op complications (VTE, pressure wounds, delirium, functional decline, incontinence, withdrawal)
MOBILISE ASAP
Falls and fracture risk assessment and prevention
Goal setting and DC planning
Gait and balance assessment tasks
- one-leg balance
- timed up and go
- chair stand (arms crossed)
- Romberg’s test
- walking on heels/toes
- sternal push or shoulder tug
what does Romberg’s test assess?
Vision
Proprioception
Vestibular function/balance
Prevention of delirium
Careful prescribing Optimising medical conditions treat pain glasses and hearing aids orientation - clocks and calendars minimise noise hydration and nutrition infection control minimise sedation
Questions to ask on cognitive assessment
Driving still?
Medical compliance
Safety at home
Living arrangements and support
Financial abilities - still managing own bills etc
Enduring power of attorney and advanced directives
ADLs:
pADLs - dressing, showing, toiling
dADLs - cooking, cleaning, paying bills
cADLs - shopping, driving
Mx of Alzheimer’s x
Organise community health services ACAS referral CADMS referral +/- neuropsychologist Assess competence and capacity Contact family and discuss Establish EPOA Inform VicRoads Cholinesterase inhibitors
BASIC ASSESSMENT of incontinence
Urine dipstick +/- MSU DRE +/- AXR post void residual medication RV UEC BSL CMP Bladder Diary
More:
- urodynamics
- urine flow rates
Impairment
Disability
Handicap
Impairment - at level of organ or system function
Disability - limitation in FUNCTIONAL performance or activity
Handicap - reflection of the interaction between person and the adaptability to the surrounding environment
Recognising a dying patients
Sleeping more
Eating/driinking less - decr urine
Change in cognition/conscious status
Late signs
- Chainstoke breathing
- Change colour - become grey/blue
- terminal delirium
Symptoms treated PRN in pall care
Terminal agitation - benzos or haloperidol
Breathing - opiates
Secretions - glycopyrulate
N&V - metacloprimide/maxilon
Pain - morphine
USE SYRINGE DRIVER:
haloperidol, midaz, morphine, metacloprimide
SPIKES model
Setting/surrounding Perception - assess the patient's Invitation - obtain patient's Knowledge - provide Emotions - address patient's emotions using empathic responses Summarise
Confirming death
Response to voice
Response to Pain
heart sounds
Chest
Pupils
Diff types of opiods
Morphine 1st line
Hydromorphine (5x stronger than morph)- used in kidney impairment; CI in liver failure
Oxycodone (1.5x stronger than morphine) - used when neuro effects of morphine too great
Targin (slow release oxycodone + naloxone)
Fentanyl - ok w kidney impairment; least constipation; patch, not orally available
Buprenorphine - only given in chronic and stable pain
when to increase baseline pain relief and by how mcuh
If they have >3 breakthrough doses required in 24 hours, then increase baseline dose by 10%
Dose ratio for conversion of oral morphine to oxycodone
1: 1.5
Dose ratio for conversion of oral morphine to hydromorphine
1:5
Dose ratio for conversion of oral morphine to IV morphine
1:3
Dose ratio for conversion of oral oxycodone to IV morphine
1:2
Causes N&V
Medications
- abx
- chemo
- opiates
- new medication
GI (often relieved by vomiting, aggr by eating)
- infection
- obstruction
- altered peristalsis
- PUD
Metabolic
- renal and liver failure
- hyperCa
CNS (aggr by sight/smell, often dry wrenthing)
- vestibular
- raised ICP
Causes of constipation
Medications
- opioids
- ca channel blockers
- TCA
Lifestyle
- decr mobility
- poor fluid intake and diet
Obstruction (bowel cancer or ovarian leading to peritonitis disease) - AXR, CTAbdo
HyperCa
Mx constipation
Non pharmacological #1
- fibre, fluid, weight bearing exercises
Pharmacological
- Bulking agent - colony
- Stimulating agent - senna, movicol
- softening - lactulose
- may need enema to clear out impaction
Mx of constipation cause by hypercalcaemia
Normal saline + bisphosphonate
Mx of constipation caused by opiates
Swap to Targin
or IM methyl-naltrexone
Also prescribe laxative +/- antiemetic
antidepressant useful in elderly patinets
mirtazepine
SE include eating more and sleeping more which can be beneficial!
Problem w antipsychotics in LBD
Can worsen parkinsonisms and potentially be irreversible
Can use very low dose Seroquil/quetiapine
Acute and chronic stressors that can lead to depression in elderly
Acute
- grief, separation
- acute physical illness or recent diagnosis (esp stroke, PD)
- sudden change in living circumstances
Chronic
- decr health and mobility
- carer burden
- sensory loss
- cognitive decline
- social isolation
BIOLOGICAL mx of depression in elderly
Obviously always have social and psychological mx to start with
SSRIs or SNRIs (be wary of SiADH), or Mirtazepine or moclobemide
+/- antipsychotics for augmentation and/or depression w psychotic features
+/- Li for augmentation
+/- Benzos, zopiclone for SX relief (insomnia, agitation)
+/- ECT for severe depression w or w/out catatonia or treatment resistance
Risk assessment in elderly
HTS
- Accidental (Malnutrition, dehydration (?catatonia), medication noncompliance for diabetes etc)
- Deliberate (Self harm and Suicide - need to assess RFs for suicide)
- Substance abuse
HTO - command hallucinations? past violence, involvement w police?
Protective factors (family, supports, GP, income, housing)
Vulnerability ◦ History of drug abuse ◦ History of physical abuse ◦ Living alone? ◦ Family support and home environment
Compliance to tx, medications
Absconding risk
Non response to treatment for psychiatric conditions - what is your approach>
Review medications - any interactions? cease or decr dose of unnecessary ones
Treat comorbidities esp HTN, DM
Reduce possible effects of handicaps caused by chronic disease, sensory impairment, poor mobility, malnutrition
Address social and psychological factors
Compliance?
Adjunct treatment and ECT
Pathophysiology of TBI
what do we aim to prevent w treatment?
Primary injury
- focal injury assoc w contact (fractures, lacerations, contusions, hematoma)
- diffuse injury assoc w acceleration/deceleration injuries (diffuse axonal injuries ex from MVA)
Secondary injury (aim to prevent this!) - raised ICP, local oedema, hypoxic damage, neurochemical changes
What factors determine severity and outcome of TBI?
GCS (mlid if >= 13; severe if <=8)
Duration of LOC (mild if <30min; severe if >24h)
Post traumatic amnesia (mild if <1 day; severe if >1week)
Complications of TBI
Neurological
- visual changes (diplopia, CN 6 palsy, blurred vision, hemianopia and VF loss)
- loss of taste and smell
- vertigo, dizziness
- dysphagia, dysarthria
- weakness
- sensory impairment
- apraxia
- neglect
Medical
- spasticity
- epilepsy
- hydrocephalus
- endocrine - siADH, DI
- psych (depression, PTSD)
Cognitive
- dysexecutive syndrome from frontal lobe damage
- memory deficits (PTA)
- attention and focus (PTA)
- Slowed processing
- cognitive and physical fatigue
Management of spasticity
PT
+/- serial casting and splinting
+/- meds (PO baclofen, botulinum toxin injections)
Features of PTA
Memory impairment following TBI Disorientation Poor attention disrupted sleep-wake cycle fatigue irritability, aggression Overstimulation
Essentially the same as delirium except for context
Rehabilitation post TBI
Monitor and manage any PTA
- assess cognition/function after emergence and rehab
Prevent and treat complications of TBI
PT and OT to optimise mobility and function
Education for PT and carers
Follow up +/- OP rehab
Long term: OT driving assessment and return to work (SW)
Mx of sports related concussion
Rule out structural damage w CT and confirm diagnosis
Neuropsuch (SCAT) to estimate recovery and return to play (graded return)
What is post concussion syndrome?
Small group of patients develop persistent Sx (>3mo duration) following a minor TBI
GP to monitor for this
SX include
- physical (fatigue, headaches, blurred vision, dizziness)
- cognitive (concentration, attention, memory)
- behavioural (irritation, depression, poor socialisation)
Complications following stroke
Secondary stroke/TIA/haemmhoragic transformation so need secondary prevention ASAP
Spasticity Pain Depression, cognition Falls Bladder/bowel incontinence or constipation UTIs Sexual dysfunction Sleep apnoea (central) Fatigue Malnutrition and dehydration Complications of immobility (pressure wounds, pneumonia, orthostatic hypotension, dependent oedema, reconditioning, DVT/PE, contractors, osteoporosis)
Stroke prognosis
1/3 die
1/3 recover completely
1/3 persistent impairment
Components of inpatient rehab for stroke
Prevent and manage complications - nutrition and swallowing; contractures, spasticity, bladder, depression etc
Incr independence in PADLs - compensatory techniques +/- equipment
Incr independence in mobility - gait aids, gait/transfer retraining
Communication, cognition, behaviour -assess for deficits, educate and manage
Home assessment,
Home services application
Education and support counselling for pts and family (fam meetings, driving, return to work, sexual and interpersonal, carer education)
DC planning
Rehab interventions for weakness
Limb positioning, Splinting, Passive ROM exercises, resistance exercises to AVOID CONTRACTURS
Practice functional tasks
Compensatory tasks (PT, OT)
Spasticity MX (stretching, positioning, splinting, baclofen, bot toxin injections etc)
When should you expect most recovery to occur in rehab post-stroke?
Most rapid recovery in first 3 months post-stroke
Completes around 6 months
Indicators of poor prognosis post stroke
Large stroke size Old age MAny comorbidities Stroke mechanism and location Dense clinical findings Complications Functional status prior to stroke Poor family and social support Poor motivation and cognitive impairment
