Aged care Flashcards
Principals of treatment for osteoporosis
The general principles in treating osteoporosis are to prevent fractures by:
- restoring mobility and instituting measures to prevent falls
- excluding and treating underlying diseases that may be responsible for increased bone fragility
- establishing the severity of osteoporosis by bone densitometry (if this knowledge influences management)
- stratifying the fracture risk and choosing appropriate therapy (eg calcium and/or vitamin D supplements, specific osteoporosis therapy, oestrogen/progestin therapy)
- modifyingunderlying risk factorsfor fractures
considering weight-bearing exercise, under professional guidance (eg exercise physiologist, physiotherapist) to maximise its benefit and minimise its harm (eg people with osteoporosis should avoid sit-ups and other exercises resulting in spinal flexion).
Preventing osteoporosis:
Preventing osteoporosis
- Smoking, alcohol, BMI
- Weight bearing exercise to increase bone density
- Ensure adequate calcium; 3 serves of dairy a day. Daily intake should be >1300mg. First see if can give through diet if not put on 600mg of oral calcium supplement.
- Ensure adequate vit D; 7-40min of sun in winter, 6-7 in summer, and replace if deficient (a serum 25(OH)D of <50nmol/L including asymptomatic). Aim for >50 or >75 if diagnosed with OP.
- Oestrogen/progestin therapy; not used purely for osteo, if menopausal reasons then will also protect bones
Reduce glucocorticoid dose to lowest possible as causes reduced bone formation and increase resorption
What is a fall?
An event which results in a person coming to rest inadvertently on the ground or other lower level that is not a result of: - LOC/syncope - Violent blow - Sudden paralysis Seizure
History of a fall questions
History - Circumstances of the falls; • Activity • Location • Time of day (light) • Use of walking aid • Footwear • Eyewear • Warning symptoms; vertigo, palpitations • LOC • Ability to get up - Previous falls - Injuries and complicatons - Observer history - Fear of falling Impact on function and lifestyle e.g. wont go out alone
Exam in a fall
- Cognition; MMSE, AMTS
- Postural BP and HR lying and standing 1 and 3 minutes (HR wont go up if autonomic dysfunction)
- MSK exam; feet (corns, bunions shoes don’t fit), ROM decreased at MTP where push off, ankles, knees(OA) and hips for deformity, ROM, leg length discrepancy
- Neurological assessment
- CV exam esp. aortic stenosis causing syncope
- Vision acuity
- Hall-pike manoeuvre
- Gait and balance; rombergs, sternal push, heel to toe walking
- Examine footwear
GAIT AND BALANCE ASSESSMENT
- Timed up and go; stand up, walk 3m come back and sit come. Should be <12 seconds
- Dynamic balance • Functional reach; lean forward until feel like will fall over, measure how far • Step test • Turning 360 • Sternal push or shoulder tug
- Static balance • Romberg • Single limb stance • Tandem stance
Prevention of falls
- Exercise program; gait and balance
• Balance training decreases falls by 15-50% in community. Should consider most people with HX of falls, usually refer to physio to do so where challenged and supervision. If more stable then group programs like Tai Chi
• Strength and balance training also * decreases injuries
• Tai Chi (shown to reduce falls in randomised controlled trials in older people).
• Exercise to maintain mobility and strengthen quads- Home environment modification; OT assessment
- Medication review and minimization; (especially drugs causing sedation, altered gait or postural hypotension)
- Management of postural hypotension
- Foot wear; low heels, high surface contact, anti slip, management of foot problems
- improving vision when possible
- preventing or correcting vitamin D deficiency
- providing aids for daily living (eg appropriate walking aids, rails)
- minimising periods of immobilisation for medical/surgical purposes
- providing hip protectors, especially to osteoporotic patients at increased risk of falls (may decrease the risk of fractures after falling, but concordance is poor as very tight) * decreases injuries
- Treating osteoporosis *decreases injuries
What is a TBI
Traumatic brain injury (TBI) is an insult to the brain from an external mechanical force, potentially leading to an altered level of consciousness and permanent or temporary impairment of cognitive, physical, and psychosocial functions.
Types of TBI:
- Skull fracture
- Extradural
- Subdural
- SAH
- DAI
- Cerebral contusions
What are the 5 main cognitive issues in TBI?
- Slowed processing
- Impaired attention and concentration
- Cognitive fatigue and overload
- Impaired executive function; planning, problem solving, impulsive, no insight
What are the cognitive domains?
AVMEL
- Attention
- Visuospatial
- Memory
- EF
- Language
Screening tools for TBI
- NUCOG
- CLQT
- Cognistat
What two factors are best predictor of severity of TBI?
- length of LOC
- PTA duration
How does post traumatic amnesia present, what scale is used to monitor it and how to Mx
- Anterograde amnesia and features of a delirium
- Westmead PTA scale
- Rx like delirium
Signs of mood disorder in rehab
- Slow progress
- Refusal to engage
- anhedonia
- deteriorating
Some neuro and medical issues associated with TBI
- Mood disorders
- Epilepsy
- Visual changes
- Anosmia
- Balance/coordinaton
- Language
Acute and long term goals of TBI
Acute
- Monitor PTA, manage the effects
- Assess cognition post PTA
- Prevent and treat any medical complications; wound, DVT, mood etc.
Long term
- Remediate the patient’s disability and activity limitation
- Mx contractures
- Mx bowel and bladder
- Compensate for lost skills; alter env and teach new skills
- Vocational support
- social skill re-training
- support to return to work/study or find new vocation - Education for parents and carers on the deficits and ways to cope
- counselling
- financial support
- psyc - Ensure community support and ongoing follow up
7 steps in planning a rehab program
- Determine suitability
- Medically stable
- Cognitively adequate/or will be
- Supports
- Motivation
- Expectation of gains within timely manner - Where
- In patient or out patient - Timing
- What; intensity and content that is reviewed and includes meetings
- Why
- Goal setting
- SMART; specific, measurable (barthel, ICF), achievable, realistic and timely - Discharge planning inc post discharge therapy and supports
6 Common goals in rehab
- Optimise health
- Nutrition
- BP, lipids and sugars
- Infection
- Wound - Prevent complications
- DVT
- pressure areas
- mood
- early mobilise
- contractures
- secondary fracture complications
- further occurance eg stroke
- secondary infecton - promote return to pre-morbid function
- assess baseline and current function across all domains
- optimise current abilities and compensate for lost skills
- improve mobility; physio, nutrition
- ensure pain and mood not limiting - Maximise participation and facilitate integration into community
- Supports; social work and OT for support with social, education, financial, vocation
- skills retraining OT
- eduation
- driving - discharge planning and follow up
Acute mx and goals of spinal cord injury
- Prevent of secondary cord damage
- Careful movement and stabilising aids - Neurological assessment and classification to ASIA
- Optimise health and prevent complications associated with immobility
- DVT
- Wound
- Pressure
- Nutrition
- Bowel and bladder (IDC/SPC)
- BP (often labile)
- Analgesia esp for neuropathic pain; traditonal > TCA/anti-epileptics (pregabalin), SNRIs, opiods - Optimise psychosocial status and minimise secondary mood disorder
- psyc and social work
Medium-long term goals of spinal cord injury
- optimise bladder and bowel and reduce secondary complications
- education
- imaging; cystourethrogram (CUG)
- SPC/condom catheter/intermittant self catheter
- Fluid and fibre
- aperients (laxatives)
- consider ileostomy or colostomy for LMN bowels - manage ongoing pain
- psyc
- analgesia
- activity - optimise mobilisation
- orthosis
- gait retraining
- wheelchair
- commode chair for showering/bowels
- OT home modification - Ongoing skin mx
- regular checks for ulcers and ischaemia - optimise sexual function
- counselling
- education
- UMN may have erections but thats it
- support fertility - reduce complications associated with spasticity
- physio; movement of joints and stretching of muscles
- baclofen - promote return to independent function
- home modification
- educaiton to carer
- compensatory skills
- follow up and review - promote and support to return to work
- vocational skill training
- modifications to job/env or job
- support to maintain employer
- TAC and workcover re-entry support
Secondary prevention of stroke
- Assessment of cause and RF and prevent further strokes
- SNAP
- BP management: ACEi preferrable
- start a statin regardless of cholesterol
- Glycaemic control
- Antiplatelet; low dose aspirin (+/- dipyridamole if high risk) or clopidogrel
- Anticoagulation with DOAC or warfarin if AF
- Cease HRT
> emphasise adherance to meds
Secondary prevention of stroke
- Assessing RF and prevention of further strokes (secondary prevention)
- SNAP
- BP management: ACEi preferrable
- start a statin regardless of cholesterol
- Glycaemic control
- Antiplatelet; low dose aspirin (+/- dipyridamole if high risk) or clopidogrel
- Anticoagulation with DOAC or warfarin if AF
- Cease HRT
> emphasise adherance to meds
Acute medial and surgical management of stroke
Ø Go to stroke unit
- ABCs - Non contrast CT - Carotid imaging - FBE, UEC, lipids, CRP, glucose - ECG - Vasculitic screen; esp in young with no other RF for stroke - Prothrombotic screen - Thrombylisis within 4.5 hrs - Endovascular thrombectomy within 6 hours; can have thrombolysis in the mean time BP control - Monitor closely in first 48hrs - If >220/110, reduce slowly and monitor for neurological deterioration. Esp important for haemorrhagic as don’t want to bleed further. May need ICU support - If ICH maintain BP below 180 - Selected pts have decompressive hemicraniectomy for cerebral oedema - Dysphagia: Make nil by mouth as don’t know what affected and could aspirate. Swallowing assessed within 4 hours - Anti-platelet therapy; as soon as excluded haemorrhage, or if getting tPA then after 24hrs. Aspirin +/- dipyridamol or clopidogrel - Glycaemic therapy - Have glucose monitored for 72 hours Ø Assess rehabilitation needs within 24-48hours Also give access to palliative care
Stroke rehab goals and complication Mx
- Nutrition and swallow
- Vision
- Mobility
- ADLs
- Cardoresp
- Communiation
- Cognition
- Spasticity
- Shoulder sublaxation
- Mood
- Aphasia
- Fatigue
- Incontinence
Long term rehab/ DC planning
- Ongoing secondary prevention
- Ongoing medical management of complications
- Driving
- Vocation
- IP relationships/family
Sexuality
- Home assessment and modification
Symptoms and signs of thyrotoxicosis
nervousness heat intolerance palpitations fatigue weight loss (note: weight gain occurs in 10% of people)
Common examination findings include agitation, sinus tachycardia, fine tremor and hyper-reflexia.
Elderly patients often present with nonspecific symptoms. However, of the elderly patients with hyperthyroidism, up to 20% will have atrial fibrillation.
Causes of AF
P: pulmonary embolism, pulmonary disease, post-op
I: Ischemic heart disease, idiopathic
R: Rheumatic valvular disease (mitral stenosis or regurg)
A: Anaemia, alcohol, age, autonomic tone (vagal AF)
T: Thyroid disease (hyper)
E: Elevated BP
S: Sepsis, sleep apnoea, surgery
Symptoms and signs of bowel cancer
Left sided more likely:- Change in bowel habit
- Abdominal pain, left lower quadrant discomfort
- PR bleeding/mucus
- Mass PR
- Tenesmus (incomplete emptying)
- Bowel obstruction
Right sided
- Low Hb; Fatigue and weakness
- Weight loss
- Abdominal pain
Could also present with: - Obstruction - Perforation - Haemorrhage Fistula
Symptoms of acute and chronic mesenteric ischaemia
- Vascular disease risk factors
- Sources of emboli such as AF
- Often benign appearing abdomen but with severe pain that’s peritonitic; well localised and constant
- Sudden onset cramping
- Left lower abdominal pain
- Desire to defecate
PR bleeding - can be anaemic
chronic
- Gut claudication
- weight loss
- abdominal bruis
Symptoms and treatment of hypercalcaemia
- Bone pains
- Stones in kidney
- Throws; abdo pain
- Psychic moans
- • Constipation, anorexia, nausea
• Fatigue
Cognitive dysfunction; depression, anxiety, confusion
• Renal dysfunction; polyuria, stones, insufficiency
• Cardiac abnormalities
• Muscle weakness- Treatment
• Mild/asymptomatic; none needed, avoid aggravating such as volume depletion
Severe; volume expansion with saline, calcitonin
- Treatment
symptoms of parkinsons disease
Tremor
Bradykinesia; gait initiation
Rigidity; stooped posture
Postural instability; falls and bad balance
other
- dementia
- depression
- postural hypotension
- constipation
- hypersalivation
- anosmia
- sleep disturbance
Core features of LBD
- Fluctuating cognition; variation in alertness and attention ‘blank out’
- Visual hallucinations very detailed
- Parkinsonism
- Sleep impairment
- Autonomic dysfunction
- Visuospatial getting lost
