Ageing And Complex Health Flashcards
What is included in a comprehensive geriatric assessment
Medical diagnoses Review of meds Social circumstances Assessment of cognition and mood Functional ability Environmental assessment
Fried’s phenotype of frailty
Grip strength Activity levels Weight loss Fatigue Walking speed
Frailty is associated with death, institutionalisation, adverse outcomes and falls
Falls history
Before the fall- what were they doing, what was the time of day, symptoms before the fall, why do they think they fell
During- LOC, bite tongue, incontience, injured themselves
After the fall- how did they get help, could they get up, complications such as long lie, fracture, head injury
Vision, cognition, other PMH, osteoporotic risk factors
DAME! Drugs, ageing, medical conditions, environment
Drug causes of falls
Polypharmacy Anti hypertensives Sedatives Opioids Psychotropics Glicliazide- hypoglycaemia
Age related causes of falls
Vision changes Cognitive decline Gait abnormalities Osteoarthritis Postural instability Sarcopenia Reduction in baroreceptor sensitivity
Medical causes
Cardiac - hypotension, arrhythmia
Neuro disease eg Parkinson’s, stroke, neuropathy
Cataracts
Environmental causes of fall
Walking aids
Inappropriate footwear
Carpets
Home hazards
What is vertigo
Sensation of room spinning.
Causes include BPPV, Menieres disease, vestibular neuritis, acoustic neuroma
Central causes migraine, brain stem ischaemia, cerebellum stroke, MS
Short spells of vertigo (up to one minute), settles spontaneously, occurs on movement of head eg in and out of bed or looking up or turning quickly
Diagnosis BPPV
Diagnosed by Dix Hallpike manoeuvre
Treat with Epley
Patient feels lightheaded, associated with pallor, sweating, often when pt is standing
Pre syncopal.
Suggest a cerebral hypoperfusion due to hypotension. Often postural hypotension
Do lying and standing BP. Check meds
Examine patient presenting with dizziness
Neuro
Eye sight
BP
Cardio resp- pulse, JVP, heart sounds, peripheral oedema, chest sounds
MSK- examine hands, hip exam, knee exam, ankle, gait
Tests after a fall
FBC TFTs, B12 HbA1c Bone profile Urea and electrolytes ECG- arrhythmia CK- only if there way long lie and query rhabdomyolysis Urine dip if urinary symptoms CT brain if head injury and LOC, anti coag use or neuro deficit Echo is HF symptoms Tilt table only if syncope CXR if chest symptoms
Assess osteoporosis risk
FRAX tool. Assesses ten year fracture risk.
First line osteoporosis treatment
Bisphosphonates, calcium, vit D supplements
Alendronic acid 70mg weekly.
Confusion assessment tools
AMTS10 quick cognitive assessment
Addenbrookes - dementia tool
MOCA good sensitivity but time consuming
MMSE
Things that can lead to confusion
Change in environment Subdural haematoma or intracranial bleeds Hip fracture Constipation! Pain Low BP Dehydration Previous delirium Recent surgery Poor sleep Any infection
Tests and tools assessing confusion and delirium
Confusion assessment method (acute onset, fluctuating course, imattention, disorganised thoughts, altered consciousness)
4AT- alterness, attention, acute, AMT4
Things to review if patient delirious
FNC UE review for sepsis- do obs Fluid intake Constipation MSU ECG CXR calcium Blood cultures if think sepsis
How to treat delirium
Identify and manage underlying cause
Ensure effective communication
De-escalate if distressed- use familiar staff or family. Do not move
Consider short term haloperidol or olanzapine if patient is at risk or risk of hurting others
Ask about alcohol intake
Prognosis of delirium
Two thirds recover (1/3 quickly, 1/3 slowly)
One third do not recover completely
It is associated with with numerous negative outcomes- longer hospital stays, increased incidence of dementia, increased complications such as falls and pressure ulcers, increased rate of admission to long term care, more likely to die
Prevention of delirium
Good lighting, clear signage, reorientation, reduce chance of dehydration and constipation, hypoxia, try to make person mobile ASAP, infection, meds review, assess pain, ensure good nutrition, heating and visual aids, try encourage good sleep
Steps of a medication review
Identify objectives of drug therapy Identify which drugs are essential Does the patient have any unnecessary drugs Are all objectives being achieved Are there any ADR or at risks ADRs Drug cost effective Is the patient taking the meds
What are the features of Parkinsonism
Bradykinesia- slowness of initiating voluntary movements. Difficulty in sustaining repetitive movements
Rigidity - involuntary increase in muscle tone. Present through range of movement
Tremor- rhythmic involuntary movements eg pill rolling
Postural instability
Causes of parkinonism
Idiopathic
Drug induced- cyclizine, haloperidol, prochlorperazine, metoclopramide
Vascular Parkinson’s - small strokes in basal ganglia
Features of drug induced Parkinsonism
Usually symmetrical onset
Treatment- stop or reduce meds. Liase with psych
Features of vascular Parkinsonism
Extreme shuffling gait but preserved arm swing
Tremor less common
Approx 50% levodopa
Features of idiopathic Parkinson’s
Gradual onset Unilateral initially and one side always worse Unilateral and fine tremor Hypophonia Micrographia Freezing gait
Treatment- levodopa or dopamine agonist and physical activity and therapy
Essential tremor
On action Symmetrical Alcohol improves it FH Coarse tremor Jaw tremor Leg tremor No evidence of bradykinesia or gait disturbance Non specific beta blockers eg propanolol can be effective in reducing tremor
Scans done to determine whether essential tremor or PD
DAT scan can show decreased dopamine uptake
Not often indicated unless trouble distinguishing between essential tremor and PD
Tremor worse on movement
Essential tremor Dystonic tremor Exaggerated physiological tremor Hyperthyroidism Dystonic tremors
Intention tremor
Cerebellum disorders.
Dementia with Lewy Bodies
Triad of dementia, Parkinsonism, visual hallucinations
Fluctuations in alertness
Shared care with psychiatry, neurology and geriatrics
Progressive supranuclear palsy
Early falls, truncate rigidity, vertical gaze palsy
Reduction in midbrain volume on MRI
Requires early speech and language review
Normal pressure hydrocephalus
Triad of dementia, gait disorder and bladder instability
Diagnostic lumbar puncture and CSF removal then ventriculoperitoneal shunt
Three steps to diagnosing Parkinson’s disease
1- diagnosis of a parkinsonian syndrome
2- exclusion criteria
3- supporting evidence eg unilateral tenor, preofessige, persistent asymmetry, good response to levodopa
If wanting second opinion, do not try levodopa as this could mask symptoms
Treatment of Parkinson’s disease
Co beneldopa
Levodopa with benserazide which acts as a dopa decarboylase inhviitor so stops the additional creation of dopamine outside of the brain therefore more dopamine for the brain and less systemic side effects eg nausea
Second line is dopamine agonist. These are not desirable as can cause hallucinations and behavioural problems eg gambling, overeating, hyper sexuality
What is the MUST score
Malnutrition universal screening tool
Five step screening tool to identify adults who are malnourished, at risk of malnutrition or are obese
- Measure height and weight to get BMI
- Note percentage unplanned weight loss and score using tables
- Establish acute disease effect and score
- Add scores from steps 1- 3 to obtain risk of malnutrition
- Use management guidelines and or local policy to develop care plan
Grading of ulcers
1 non blanchable erythema. Skin intact
- Partial thickness loss- abrasion or clear blister
- Full thickness skin loss. Sub cut fat may be visible
- Muscle or bone or tendons exposed
How to prevent pressure ulcers
SKINS
support surface needs to be adequate Keep or moving Incontinence (manage) Nutrition and hydration Skin inspection to Detect early signs
How to identify stroke, in community and in A&E
Community - FAST
A&E- Rosier score
If stroke suspected, what should you do
CT ASAP to look fo signs of haemorrhage. CT angiography can also help.
Take full history
Thrombolysis alteplase if under 4.5 hours
Thrombolysis check list
Symptoms of acute stroke
Onset in last 4.5 hours
Measurable deficit on NIHSS
Absence of haemorrhage on scan
Follow up after thrombolysis
CT scan after 24 hours to check that there has been no haemorrhage following thrombolysis
Do NIHSS again to see if there is an improvement
Refer to physio and OT
Unilateral weakness of face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction - dysphasia
Total anterior circulation stroke
Two of :
unilateral weakness of face, arm leg
Homonymous hemianopia
Higher cerebral dysfunction
Partial anterior circulation syndrome
One of:
Unilateral weakness of face, arm leg
Pure sensory stroke
Ataxic hemiparesis
And no evidence of higher cerebral dysfunction
Lacunae syndrome
One of
Cerebellum or brainstem syndromes
Loss of consciousness
Isolated homonymous hemianopia
Posterior circulation syndrome
Risk factors for haemorrhagic stroke
Hypertension Cerebral amyloid angiopathy Aneurysms eg with poly cystic kidney disease Cerebral arteriovenous malformations Brain tumours
If TIA, what tool should be used to assess stroke risk
ABCD2
Age over 60
Blood pressure >140/90
Clinical features max 2 points (2 for unilateral weakness, 1 speech difficulty)
Duration (2 for over 60, 1 for 10-59, 0 for less than 10)
Diabetes 1
Max 7 points
4 or Above is high risk of stroke
Following TIA, what makes a stroke highly likely
ABCD2 score of over 4
AF
Multiple TIAs
DVLA And TIA
If normal driver
Stop driving immediately
No driving for four weeks
No need to inform DVLA
DVLA and stroke
No driving for four weeks and must tell DVLA. after the four weeks, need reassessing
Differential for TIA
Syncope Atypical seizure Migraine Temporal arteritis Retinal haemorrhage or detachment Hypoglycaemia Labyrinthine disorders
Test ps after TIA diagnosis
ECG to check for AF
carotid Doppler, do carotid endarterectomy is over 70% occluded leading to symptoms
FBC, UE, LFT, lipids, blood glucose, BMI
If AF present with TIA..
Do CHADS2VASC and HASBLED to assess clot and bleeding risk
Headache, weakness in left side developed over 30 mins. Drowsy. FAST positive
Likely to be a haemorrhage. Still get CT
Risk factors for stroke
a HTN, peripheral vascular disease, ischaemia heart disease, smoking, diabetes , AF, combined pill, clotting disorders, vasculitis, carotid stenosis
