Ageing Flashcards
how does an MI present in the elderly
No chest pain in 1/3
- Collapse - Delirium - Dizziness - Breathlessness
what are the key features of delirium
disturbance in attention, change in cognition, inattention, altered level of conscious, disorganised thinking,
develops acutely, fluctuates, has a cause (usually more than one), lasts hours to less than a month,
what are two types of delirium
agitated and restless
sleep and slow (worse mortality)
(can get mixed)
what medications can precipitate delirium
opiates, anticholingerics,
lorazepam (benzodiazepines)
what is the scoring system for delirium
4AT tool slterness AMT4 attention acute change or fluctuating course 4+ highly suspicious
or
CAM (confusion assessment method)
what medications can be given for delirium and when
only if patient is a danger to themselves or others
- haloperidol (avoid in parkinsons)
- benzodiazepines (only if alcohol/ benzo withdrawal/ seizures/ haloperidol CI) use lorazepam
what is sarcopaenia
age related loss of muscle mass and function and low physical performance (loss of muscle mass with increased fat
what are the cardio/pulmonary affects of secondary mobility (bed rest)
decrease in blood volume (increased urine production)
cardiac deconditioning
postural hypotension
DVT
increased risk of pneumonia and infections
what are the MSK affects of bed rest
loss of strength (esp antigravity muscles)
increased non contractile tissues (collagen, stiffness)
contractures risk
loss of bone density
what are other consequences of bed rest
renal calculi loss of urinary urgency pressure sores reduced appetite stomach transit time slower supine constipation
difference between pharmacokinetics and pharmodynamics
kinetics= how drug works in body (absorption, distribution, metabolism, excretion) dynamics= how body reacts to drug (+ARDs)
how does pH affect drug absorption
acidic drugs absorbed best in acidic environment (aspirin, penicillin)
basic drugs require basic environments (morphine, diazepam)
older patients have less acidic stomachs (less parietal cells and lower small bowel SA), + remember PPIs
which proteins bind to acidic/ basic drugs
albmin acidic
alpha-1 acid glycoprotein basic
elderly often have low albumin and higher A1AG
how is lipid binding affected in the elderly
increased fat (increases binding of lipophillic drugs) during weight loss (cachexia) these drug will be released into plasma
also decreased body water so decreased hydophilic drug binding
can you give propranolol in liver dysfunction
no
what happens to hepatic and renal metabolism in the elderly
reduced
think of 10 drugs with a low theraputic window
Theophylline Warfarin Lithium Digoxin Gentamicin Vancomycin Phenytoin Cyclosporin Carbamazepine Levothyroxine
what is the general principle for pharmocodynamics in the elderly
lower doses achieve same affect but some effects are decreased (e.g. beta blockers and heart rate)
what happens to therapeutic window as age increases
decreases
what the four drugs most associated with ADRs in the elderly
warfarin, digoxin, insulin, benzodiazepines
also Diuretics NSAIDS Corticosteroids Anti-hypertensive agents Opioids Theophylline
what preventative measures should be taken with these drugs in the elderly:
opioids
lactulose or senna prophylactically
what preventative measures should be taken with these drugs in the elderly:
steroids
osteoporosis prevention if long term
BG measurements regularly
what preventative measures should be taken with these drugs in the elderly:
levothyroxine
do not give at same time as calcium (different times of day)
what can be used instead of NSAIDs for mild OA
paracetamol
side effects of opioids and benzodiazepines
impaired pyschomotor function
falls
confusion
when would you stop:
beta blocker
in combination with verapamil (risk of symptomatic heart block )
when would you stop:
non cardio selective beta blocker
in COPD (bronchospasm)
when would you stop:
CCB
chronic constipation
diltiazem or verapamil with heart failure
what are the anti cholinergic side effects
Confusion Hallucinations Tachycardia Blurred vision Urinary retention Constipation Dizziness Falls LONG TERM - Increased risk of developing dementia
give examples of drugs that can cause postural hypotension
alpha blocker for BPH
antihypertensives
what morbidity (conditions) are associated with immobilisation
hypothermia dehydration pressure sores rhabdomyolysis venous thromboembolism bronchopneumonia muscular de conditioning
what types of chronic conditions increase the risk of falls
Cardiovascular disease/syncope Cognitive impairment Neurological Vestibular disease Vision problems Musculoskeletal/gait
what are the common causes of syncope
arrythmias orthostatic hypotension neurogenic (vasovagal) carotid sinus hypersensitivity valvular heart disease (aortic stenosis)
what neutological conditions cause falls
carvical myelopathy (high stepping gate, rombergs positive) peripheral neuropathy (altered sensation, gait wide based) lumbar stenosis (pain/paraesthesia legs, wide based gait) cerebellar ataxia (wide based gait) parkinsons (shuffling gait, tremor, rigidity, bradykinesia, orthostatic hypotension) stroke disease
what drugs commonly cause falls
Benzodiazepines Neuroleptics Antihypertensives Antidepressants Anticholinergics Class 1A antiarrthymics
how do you take a lying and standing BP
1st BP: taken after lying for at least five minutes.
2nd BP: taken after standing in the first minute
3rd BP: taken after standing for three minutes
what interventions can be done to prevent falls
Strength and balance training (strongest evidence)
Must be 3x week for minimum 12 weeks
Otago exercise programme
FaME: Falls Management Exercise
Some forms of Tai Chi
Environmental modifications
Footwear and foot care
Vision optimization
Patient education and treatment
Medication review
STOP
>4 medications = independent risk factor for falls
Psychoactive medication priority & best evidence
START
Consider Calcium/Vitamin D
Best evidence in longterm care setting/proven vitamin D deficiency
Fracture risk assessment/osteoporosis treatment
Management of postural hypotension
Cardiac pacing if indicated
how do you do a dix hall pike manoeuvre and what is a positive result
Patient sits upright
Rotate head to 45 degrees
Lie flat quickly and extend head to 20degrees
Observe eyes 45 seconds
Positive result:
Latency of onset
Rotational nystagmus – fast phase to affected side
what analgesic for MSK pain
NSAID
what is the pain ladder
Step 1; mild pain
Paracetamol 1g 4x daily
and/or NSAID eg naproxen 500mg 2x daily
and/or other adjuvant
Step 2; moderate pain
Codeine 30-60mg 4x daily (or can use codeine combined with paracetamol = cocodomol 30/500, 2 tabs x4 daily)
and/or adjuvant
Step 3; severe pain
Stop codeine and switch to strong opioid – usually morphine
Can use in conjunction with paracetamol/NSAID/adjuvants
what morphine preparations are used for different type of pain
modified release for background pain (MST/ zoromorph) twice daily tablet
immediate release for breakthrough pain (PRN tablet of sevredol or oromorph) (approx 1/6th of total background dose) (last 4 hours)
how do you switch from max dose codeine to morphine
Stop codeine
Switch to morphine sulfate M/R 10 to 15mg twice daily with morphine sulfate I/R 5mg ‘PRN’ 4 hourly
Gradually titrate up background M/R morphine dose depending on the amount of ‘PRN’ I/R morphine used.
No maximum dose but monitor pain to make sure morphine is helping and that there are no unwanted side effects
what is opioid tolerance
will get withdrawal if morphine suddenly stopped
what are the symptoms of opioid toxicity
hallucinations vivid dreams confusion myoclonus sleepiness pin point pupils respiratory
what are the symptoms of opioid toxicity
hallucinations vivid dreams confusion myoclonus sleepiness pin point pupils respiratory depression
what can reverse opioid toxicity
naloxone
how do you recognise dying
Worsening weakness and performance status
Worsening physiological status with no reversibility
Struggling to manage oral medicines
Losing interest in food and fluid
Sleeping more, eventual unconsciousness
what conditions mimic dying
opioid toxicity sepsis hypercalcaemia AKI hypoglycaemia
what is a syringe driver
continuous subcutaneous infusion
smoothest route for drugs when oral route not possible
what is stronger oral or SCUT morphine
SCUT 2x stronger
anticipatory prescription for pain/SOB
morphine
anticipatory prescription for distress
midazolam
anticipatory prescription for nausea
levomepromazine
anticipatory prescription for secretions
buscopan
how do you hydrate patients at end of lifw
too weak to swallow
avoid IV fluids
mouth care essential
artificial hydration if symptoms of thirst
what is a telomere
the each of each chromosome (multiple repeats of a single motif (TTAGGG in humans) which form a DNA loop) which shortens with each cell replication leading to cell senescence
what is the hayflick limit
the number of times a cell can replicate before it can no longer divide anymore
what is telomerase
An ribonucleoprotein complex can re-extend the shortened telomeres. The complex is active in some cells (e.g. immune cells, stem cells) which need to divide many times
what causes damage to macromolecules (DNA mutations, lipid peroxidation, protein misfolding, aggregation, crosslinking)
ionising radiation, reactive oxygen species, (diet, radiation, inflammation)
extrinsic toxins
what are the 4 main cellular responses to damage
repair
apoptosis
senescence
malignant transformation
what is the disposable soma hypothesis
once reproductive age is over, damage is not repaired at the same rate as it accumulates
what is frailty
loss of homeostasis and resilience- increased vulnerability to decompression after a stressor event
how do you quantify frailty
deficit in body system accumulation
phenotypic
electronic frailty index
what does frailty increase the risk of during/after hospitalisation
delirium, weight loss, immobility, pressure sores
what is multimorbidity
multiple chronic conditions
what three things predict survival in 75+s
not smoking
good social network
physical activity
what are the key features of a stroke
acute onset
focal and at times global loss of brain function
symptoms lasting more than 24hrs/ leading t death with no apparent cause
do you get pain in a stroke
not usually
what can mimic a stroke
seizure, sepsis, toxic/ metabolic (hypo), space occupying lesion, pre syncope, acute confusion/ delirium, vestibular dysfunction (labrynthitis), functional disorder, dementia
what are the types of stroke
haemorrhage- structural abnormality (AVM), hypertensive, amyloid angiopathy
subarachnoid haemorrhage
infarct- atheroembolic, small vessel, cardioembolic
what scans are done for a stroke
CT- very sensitive to blood (will show up white), mass effect will cause brain to bulge across midline. in an infarct will be a slightly darker area (oedema) and will loose sulci. (if done within first few hours of infarct might not see anything). not sensitivie for blood after a week- do MRI (will show us as scarring)
MRI can be a lot more sensitive. infarcts will show up as a white area on MRI
carotid imaging looking for stenosis
what is the management for a stroke
thrombolysis (IV TPA- less than 4.5 hours after onset
)/ thrombectomy (physically removing proximal clot)
(BP control and reversal of anticoagulation if haemorrhagic)
imaging
swallow assessment (to prevent aspiration)
nutrition and hydration
antiplatelets
stroke unit care
DVT prevention
what needs to be considered before thrombolysis in a stroke
age, time since onset (longer you wait from onset of symptoms the less benefit you get from thrombolysis), previous intracerebral haemorrhage/ infarct, atrophic changes (increased risk of bleeding), blood pressure, diabetes (also increases risk of bleed), potential benefit to be gained from thrombolysis
what antiplatelets therapy for a infarct stroke
aspirin 300mg ASAP (wait untill CT exclude bleed and 24hrs if have been thrombolysed)
what is a TIA
brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction
NOT BENIGN
what medication to reduce risk of another stroke/ recurrant TIAs
aspirin
if high ABCD2 score dual antiplatelet therapy
what secondary prevention for strokes
Anticoagulants if cardioembolic/AF Antiplatelets if not cardioembolic (first line clopidogrel) Stop smoking Statins Manage blood pressure Diet and lifestyle advice
do you treat a cardioembolic stroke with aspirin
no (use anticoagulants warfarin, heparin)
what are the types of ischaemic stroke
Cardioembolic Fibrin dependent “red thrombus” Atheroembolic Platelet dependent “white thrombus” – Cf Acute Coronary Syndrome Small vessel disease Arteriosclerosis Microatheroma of the ostium, Embolism (athero and cardioembolism)
what is early community support
Role is to prevent hospital admissions by providing intensive community intervention for patients who are at increasing risk of admission
what are the three national screening programmes
AAA bowel cancer (all men >65) breast cancer (50-70)
what vaccinations do the elderly get
flu annually
penumococcal >/= 65 one off
shingles 70 one off
how much physical activity of recommended for the elderly
150 mins moderate or 75 mins vigorous intensity exercise per week
AND
strength exercises on ≥ 2 days per week
what medication do you always give in a TIA
aspirin
what is guardianship
when a court nominates people to look after someone’s affairs when no power of attorney can/ has been granted
what are advanced directives
not legally binding but give an idea of what the patients would want in the future
who is usually next of kin
Spouse/ long term partner first then parents/ children then other family/ friend
