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Ageing > Ageing > Flashcards

Ageing Flashcards

1
Q

how does an MI present in the elderly

A

No chest pain in 1/3

- Collapse
- Delirium
- Dizziness
- Breathlessness
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2
Q

what are the key features of delirium

A

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,

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3
Q

what are two types of delirium

A

agitated and restless
sleep and slow (worse mortality)
(can get mixed)

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4
Q

what medications can precipitate delirium

A

opiates, anticholingerics,

lorazepam (benzodiazepines)

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5
Q

what is the scoring system for delirium

A 
4AT tool 
slterness
AMT4
attention 
acute change or fluctuating course 
4+ highly suspicious

or

CAM (confusion assessment method)

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6
Q

what medications can be given for delirium and when

A

only if patient is a danger to themselves or others

  1. haloperidol (avoid in parkinsons)
  2. benzodiazepines (only if alcohol/ benzo withdrawal/ seizures/ haloperidol CI) use lorazepam
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7
Q

what is sarcopaenia

A

age related loss of muscle mass and function and low physical performance (loss of muscle mass with increased fat

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8
Q

what are the cardio/pulmonary affects of secondary mobility (bed rest)

A

decrease in blood volume (increased urine production)
cardiac deconditioning
postural hypotension
DVT
increased risk of pneumonia and infections

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9
Q

what are the MSK affects of bed rest

A

loss of strength (esp antigravity muscles)
increased non contractile tissues (collagen, stiffness)
contractures risk
loss of bone density

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10
Q

what are other consequences of bed rest

A 
renal calculi 
loss of urinary urgency 
pressure sores 
reduced appetite 
stomach transit time slower supine 
constipation
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11
Q

difference between pharmacokinetics and pharmodynamics

A 
kinetics= how drug works in body (absorption, distribution, metabolism, excretion) 
dynamics= how body reacts to drug (+ARDs)
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12
Q

how does pH affect drug absorption

A

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

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13
Q

which proteins bind to acidic/ basic drugs

A

albmin acidic
alpha-1 acid glycoprotein basic

elderly often have low albumin and higher A1AG

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14
Q

how is lipid binding affected in the elderly

A 
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

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15
Q

can you give propranolol in liver dysfunction

A

no

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16
Q

what happens to hepatic and renal metabolism in the elderly

A

reduced

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17
Q

think of 10 drugs with a low theraputic window

A 
Theophylline  
Warfarin  
Lithium  
Digoxin  
Gentamicin
Vancomycin  Phenytoin  
Cyclosporin  Carbamazepine  Levothyroxine
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18
Q

what is the general principle for pharmocodynamics in the elderly

A

lower doses achieve same affect but some effects are decreased (e.g. beta blockers and heart rate)

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19
Q

what happens to therapeutic window as age increases

A

decreases

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20
Q

what the four drugs most associated with ADRs in the elderly

A

warfarin, digoxin, insulin, benzodiazepines

also Diuretics
NSAIDS
Corticosteroids
Anti-hypertensive agents
Opioids
Theophylline
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21
Q

what preventative measures should be taken with these drugs in the elderly:
opioids

A

lactulose or senna prophylactically

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22
Q

what preventative measures should be taken with these drugs in the elderly:
steroids

A

osteoporosis prevention if long term

BG measurements regularly

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23
Q

what preventative measures should be taken with these drugs in the elderly:
levothyroxine

A

do not give at same time as calcium (different times of day)

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24
Q

what can be used instead of NSAIDs for mild OA

A

paracetamol

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25
Q

side effects of opioids and benzodiazepines

A

impaired pyschomotor function
falls
confusion

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26
Q

when would you stop:

beta blocker

A

in combination with verapamil (risk of symptomatic heart block )

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27
Q

when would you stop:

non cardio selective beta blocker

A

in COPD (bronchospasm)

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28
Q

when would you stop:

CCB

A

chronic constipation

diltiazem or verapamil with heart failure

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29
Q

what are the anti cholinergic side effects

A 
Confusion
Hallucinations
Tachycardia
Blurred vision
Urinary retention
Constipation
Dizziness
Falls
LONG TERM - Increased risk of developing dementia
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30
Q

give examples of drugs that can cause postural hypotension

A

alpha blocker for BPH

antihypertensives

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31
Q

what morbidity (conditions) are associated with immobilisation

A 
hypothermia
dehydration
pressure sores
rhabdomyolysis
venous thromboembolism
bronchopneumonia
muscular de conditioning
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32
Q

what types of chronic conditions increase the risk of falls

A 
Cardiovascular disease/syncope
Cognitive impairment 
Neurological
Vestibular disease
Vision problems
Musculoskeletal/gait
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33
Q

what are the common causes of syncope

A 
arrythmias
orthostatic hypotension
neurogenic (vasovagal)
carotid sinus hypersensitivity
valvular heart disease (aortic stenosis)
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34
Q

what neutological conditions cause falls

A 
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
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35
Q

what drugs commonly cause falls

A 
Benzodiazepines
Neuroleptics
Antihypertensives
Antidepressants
Anticholinergics
Class 1A antiarrthymics
36
Q

how do you take a lying and standing BP

A

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

37
Q

what interventions can be done to prevent falls

A

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

38
Q

how do you do a dix hall pike manoeuvre and what is a positive result

A

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

39
Q

what analgesic for MSK pain

A

NSAID

40
Q

what is the pain ladder

A

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

41
Q

what morphine preparations are used for different type of pain

A

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)

42
Q

how do you switch from max dose codeine to morphine

A

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

43
Q

what is opioid tolerance

A

will get withdrawal if morphine suddenly stopped

44
Q

what are the symptoms of opioid toxicity

A 
hallucinations 
vivid dreams 
confusion 
myoclonus 
sleepiness 
pin point pupils 
respiratory
45
Q

what are the symptoms of opioid toxicity

A 
hallucinations 
vivid dreams 
confusion 
myoclonus 
sleepiness 
pin point pupils 
respiratory depression
46
Q

what can reverse opioid toxicity

A

naloxone

47
Q

how do you recognise dying

A

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

48
Q

what conditions mimic dying

A 
opioid toxicity 
sepsis 
hypercalcaemia 
AKI
hypoglycaemia
49
Q

what is a syringe driver

A

continuous subcutaneous infusion

smoothest route for drugs when oral route not possible

50
Q

what is stronger oral or SCUT morphine

A

SCUT 2x stronger

51
Q

anticipatory prescription for pain/SOB

A

morphine

52
Q

anticipatory prescription for distress

A

midazolam

53
Q

anticipatory prescription for nausea

A

levomepromazine

54
Q

anticipatory prescription for secretions

A

buscopan

55
Q

how do you hydrate patients at end of lifw

A

too weak to swallow
avoid IV fluids
mouth care essential
artificial hydration if symptoms of thirst

56
Q

what is a telomere

A

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

57
Q

what is the hayflick limit

A

the number of times a cell can replicate before it can no longer divide anymore

58
Q

what is telomerase

A

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

59
Q

what causes damage to macromolecules (DNA mutations, lipid peroxidation, protein misfolding, aggregation, crosslinking)

A

ionising radiation, reactive oxygen species, (diet, radiation, inflammation)
extrinsic toxins

60
Q

what are the 4 main cellular responses to damage

A

repair
apoptosis
senescence
malignant transformation

61
Q

what is the disposable soma hypothesis

A

once reproductive age is over, damage is not repaired at the same rate as it accumulates

62
Q

what is frailty

A

loss of homeostasis and resilience- increased vulnerability to decompression after a stressor event

63
Q

how do you quantify frailty

A

deficit in body system accumulation
phenotypic
electronic frailty index

64
Q

what does frailty increase the risk of during/after hospitalisation

A

delirium, weight loss, immobility, pressure sores

65
Q

what is multimorbidity

A

multiple chronic conditions

66
Q

what three things predict survival in 75+s

A

not smoking
good social network
physical activity

67
Q

what are the key features of a stroke

A

acute onset
focal and at times global loss of brain function
symptoms lasting more than 24hrs/ leading t death with no apparent cause

68
Q

do you get pain in a stroke

A

not usually

69
Q

what can mimic a stroke

A

seizure, sepsis, toxic/ metabolic (hypo), space occupying lesion, pre syncope, acute confusion/ delirium, vestibular dysfunction (labrynthitis), functional disorder, dementia

70
Q

what are the types of stroke

A

haemorrhage- structural abnormality (AVM), hypertensive, amyloid angiopathy
subarachnoid haemorrhage
infarct- atheroembolic, small vessel, cardioembolic

71
Q

what scans are done for a stroke

A

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

72
Q

what is the management for a stroke

A

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

73
Q

what needs to be considered before thrombolysis in a stroke

A

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

74
Q

what antiplatelets therapy for a infarct stroke

A

aspirin 300mg ASAP (wait untill CT exclude bleed and 24hrs if have been thrombolysed)

75
Q

what is a TIA

A

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

76
Q

what medication to reduce risk of another stroke/ recurrant TIAs

A

aspirin

if high ABCD2 score dual antiplatelet therapy

77
Q

what secondary prevention for strokes

A 
Anticoagulants if cardioembolic/AF
Antiplatelets if not cardioembolic (first line  clopidogrel)
Stop smoking
Statins
Manage blood pressure
Diet and lifestyle advice
78
Q

do you treat a cardioembolic stroke with aspirin

A

no (use anticoagulants warfarin, heparin)

79
Q

what are the types of ischaemic stroke

A 
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)
80
Q

what is early community support

A

Role is to prevent hospital admissions by providing intensive community intervention for patients who are at increasing risk of admission

81
Q

what are the three national screening programmes

A 
AAA
bowel cancer (all men >65)
breast cancer (50-70)
82
Q

what vaccinations do the elderly get

A

flu annually
penumococcal >/= 65 one off
shingles 70 one off

83
Q

how much physical activity of recommended for the elderly

A

150 mins moderate or 75 mins vigorous intensity exercise per week
AND
strength exercises on ≥ 2 days per week

84
Q

what medication do you always give in a TIA

A

aspirin

85
Q

what is guardianship

A

when a court nominates people to look after someone’s affairs when no power of attorney can/ has been granted

86
Q

what are advanced directives

A

not legally binding but give an idea of what the patients would want in the future

87
Q

who is usually next of kin

A

Spouse/ long term partner first then parents/ children then other family/ friend

Ageing (2 decks)

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