Ageing

Question 1

Describe the ageing trends in the population

Answer 1

Life expectancy is increasing

Older population is becoming the largest group in society

Question 2

Why are people living longer

Answer 2

Fewer die in childhood
More survive health events in middle age - MI
Sanitation, food hygiene and medical advancements all contribute

Question 3

Likelihood of having a disability increases with age - true or false

Answer 3

TRUE

Question 4

What are the biggest causes of disability in the elderly

Answer 4

CVD - stroke and heart disease
Cancer
COPD etc
MSK - arthritis

Question 5

What are the financial issues with the population shift

Answer 5

Many more people in retirement and fewer working to support the pension schemes etc

Question 6

What is the aim of palliative care

Answer 6

Holistic care that considers the whole person and making them more comfortable – e.g. reducing nausea, pain, fatigue
Emotional and psychological support

Question 7

How do we plan palliative care

Answer 7

Advance Care Plans (ACP’s) or Key Information Summary (KIS)

This plan is shared among the entire healthcare team

Question 8

What is the illness trajectory of organ failure

Answer 8

Regular dips in function as the condition is exacerbated

Don’t quite get back to original function

Question 9

What is the illness trajectory of frailty

Answer 9

Very low baseline function so can be hard to pick up deterioration

Question 10

Describe the WHO pain ladder

Answer 10

Step 1 - Mild pain
Paracetamol 1g 4x daily
and/or NSAID
and/or adjuvant

Step 2 - Moderate pain
Codeine (30-60mg 4x daily)
and/or adjuvant

Step 3 severe pain
Strong opioid - usually morphine
Can use with para/NSAID/adjuvants

Question 11

What are the adjuvants that can be used in pain management

Answer 11

Extra drugs that can be added depending on th e type of pain
NSAID, gabapentin, pregabalin

Question 12

Describe the use of morphine in palliative care

Answer 12

Prescribe modified release to cover the background pain

Then offer an immediate release PRN to cover flares

Question 13

Describe modified release (MR) morphine

Answer 13

12 hourly preparation that is given in morning and at bedtime (2x daily)
Manages the background/continuous pain
In form of MST or zomorph

Question 14

Describe immediate release (IR) morphine

Answer 14

Used to manage the flare up PRN – lasts for around 4 hours
Should be around 1/6 of background dose
Given as Sevradol (tablet) or oramorph (liquid)

Question 15

How do you decide on the dosage of morphine

Answer 15

Start on 10-15mg MR 2x daily with 5mg PRN
Gradually titrate the background MR morphine if needed until you get full benefit
Monitor for side effects

Question 16

What are the signs of morphine toxicity

Answer 16

Myoclonus – sudden jerking movements
Hallucinations
Drowsiness
Respiratory distress is a severe case

Question 17

What should you do if someone shows signs of morphine toxicity

Answer 17

SENIOR ADVICE Dose adjustment
Switch to another opioid
Small diluted doses of naloxone

Question 18

Why might impaired renal function affect morphine levels

Answer 18

Morphine is excreted by the kidneys so if function is lowered the morphine will accumulate
Can lead to risk of toxicity

Question 19

Why should you not use naloxone on someone on long term opioids

Answer 19

It will completely reverse the affects and cause a huge amount of distress and pain

Question 20

You can stay at the same dose when switching from one strong opioid to another - true or false

Answer 20

FALSE
The doses are very different so you must convert them
Get senior advice

Question 21

Which treatable conditions can mimic dying

Answer 21

Opioid/drug toxicity
Sepsis
Hypercalcaemia
AKI
Hypoglycaemia

Question 22

How do you maintain comfort at end of life

Answer 22

Only continue essential medication
Switch oral meds to another route if struggling to swallow
Treat common symptoms
Stop routine monitoring and remove unneeded equipment
Ensure its a comfy/safe environment

Question 23

What is the function of a syringe driver

Answer 23

Allows for continuous subcutaneous infusion of medication
Up to 3 meds can be infused at once
Portable

Question 24

Which is stronger, subcut or oral morphine

Answer 24

SCUT is 2x stronger

Need to alter dose when switching to a syringe driver

Question 25

Which symptoms might you need to prescribe for pre-emptively in end of life care

Answer 25

Pain
Distress
Nausea

Question 26

How do you verify a death

Answer 26

Check for spontaneous movement (inc. respiratory effort) 
Check for reaction to voice and pain 
Palpate at least 2 major pulse for 1min 
Inspect eyes
Auscultate heart and lung for 2 mins

Question 27

Why must you record the presence of pacemakers etc in the deceased

Answer 27

Need to notify the undertaker as it will explode if they are cremated

Question 28

Which socio-economic group is more likely to develop multiple morbidities

Answer 28

The more deprived

Question 29

Which climate factors affect the health of the elderly

Answer 29

Migration - can survive the long journey
Frailty
Heat waves and natural disaster
Air pollution

Question 30

Which national screening programmes are available for the elderly

Answer 30

AAA - men over 65
Bowel cancer
Breast cancer

Question 31

What is the function of screening programmes

Answer 31

Pick up health conditions early in order to alter the natural history of a disease

Question 32

What are the conditions of a successful screening programme

Answer 32

Significant condition 
Able to detect when early stage or latent
Test is acceptable to public 
Test is sensitive and specific 
Able to intervene if positive 
Acceptable cost

Question 33

which vaccines are given to the elderly

Answer 33

Flu - over 65s
Pneumococcal - over 65s
Shingles - 70