Ageing population

Question 1

Describe and explain the changes that occur to the aged respiratory system. (6)

Answer 1

Total lung capacity, forced vital capacity, FEV1 and vital capacity all reduce with age. This is because the amount of elastic support reduces, so lungs collapse more easily.

Question 2

Describe the differences between pneumothorax and atelectasis. (3)

Answer 2

Both forms of collapsed lung, but pneumothorax is due to air in the pleural space and a loss of the negative pressure keeping net lung tissue expanded, and atelectasis is due to loss of the elastic support in the lungs.

Question 3

Describe common complications of the changes to the respiratory system seen in age. (5)

Answer 3

Atelectasis, PE and Pneumonia occur commonly post-op due to the loss of elasticity (as well as smoking, malnutrition etc).
Loss of elastic tissue also causes collapse of the oropharynx which can lead to arterial desaturation and disrupted sleep.

Question 4

Describe the changes in pharmacokinetics in the elderly population. (4)

Answer 4

The elderly have an increased sensitivity to CNS depressants due to reduced hepatic and renal function. This leads to slower metabolism and elimination, so doses need to be lowered.

Question 5

Describe the changes that the elderly population experience in regards to their skin. (4)

Answer 5

Often have fragile skin prone to bruising (especially if on blood thinners), and fragile subcutaneous vessels leading to difficulty cannulating, and common extravasation.

Question 6

Describe the changes that occur to blood vessel in age, and the results of these changes. (4)

Answer 6

Large and medium vessels become less elastic and less compliant, meaning systemic vascular resistance raises, causing hypertension if associated with other factors eg smoking. This can lead to LV strain and hypertrophy.

Question 7

Describe why the elderly are more at risk of postural hypertension. (2)

Answer 7

Less elasticity and compliance of large and medium vessels, meaning postural hypertension occurs.

Question 8

Describe why the stroke volume decreases with age. (4)

Answer 8

Cardiac conduction cells decrease in number, increasing prevalence of heart blocks, ectopics, arrhythmias and AF.
Also reduction in stroke volume and ventricular contractility.

Question 9

Describe four things about pharmacology that need to be considered when prescribing to the aged. (8)

Answer 9

Reduced CO - delayed onset of IV anaesthesia.
Reduced body water and increased adipose - altered Vd of drugs.
Reduced plasma proteins - decrease in drug binding.
Polypharmacy encourages ADRs and DDIs.

Question 10

Describe the concept of “arm-brain time”. (3)

Answer 10

Time it takes for IV anaesthesia to kick in after being administered into the arm. Increased in old people, due to decreased CO.

Question 11

Describe the causes of reduced GFR in the elderly. (5)

Answer 11

Natural age-related decline
Fall in cardiac output
Atheromatous vascular disease
Nephrotoxic drugs - ACEi and NSAIDs.

Question 12

Describe the relationship with ageing and neurological disease. (3)

Answer 12

Cerebrovascular Disease is common secondarily to atherosclerosis and hypertension, which are both more common in age. Dementia is also associated with increased age.

Question 13

Describe the causes of a loss in thermoregulatory capabilities in the elderly, and explain why this is an issue. (4)

Answer 13

Nasal metabolic rate decreases with age, as does muscle mass.
This can become a problem if an elderly person can’t afford to heat their home.

Question 14

Describe why it is a problem that patients can leave hospital more malnourished than when they came in. (2)

Answer 14

Pressure sores can accumulate if the patient is especially thin and not very mobile.

Question 15

Describe how to take a history of a fall. (15)

Answer 15

Who - can we get a collateral history?
When - when did it occur? What were they doing?
Where - out? At home? Trip? Flashing lights?
What - before (symptoms prior to fall), during (LoC, incontinence, tongue biting, injuries) and after (confusion, regaining consciousness)
How - how long were they down? How many falls?

Question 16

Describe why LoC is the most important thing to investigate when taking a falls history. (2)

Answer 16

Need to know if the fall was due to syncope or whether the LoC was due to a head injury.

Question 17

Explain why syncopal LoC is normally self limiting. (1)

Answer 17

Normally due to low brain perfusion, which is fixed by being horizontal.

Question 18

List three pre-syncopal symptoms. (3)

Answer 18

Pallor
Light-headedness
Sweating

Question 19

If no collateral history can be gained, but a patient is found on the floor unable to be roused for hours, seeming exhausted, what could be one common differential? (3)

Answer 19

Elderly onset epilepsy, with tonic-clinic seizures. Patients are often so exhausted that they are unrousable.

Question 20

Describe reflex syncope. (6)

Answer 20

Disorder of the autonomic regulation of postural tone: can be vasovagal (normal faints), situational (coughing, straining), or due to carotid sinus massage.
Overactivation of the part of the medulla that controls CO and BP leading to a decrease in cerebral perfusion.

Question 21

Describe the presentation of orthostatic hypotension. (4)

Answer 21

Postural hypertension that occurs when changing from lying or sitting to standing. Normally defined as a drop of 20mmHg systolic or more about 3 minutes after standing with symptoms.

Question 22

Describe the MoA of orthostatic hypertension. (4)

Answer 22

Blood pooling in legs - reduces EDV (preload) - less stretch - reduced CO - reduced cerebral perfusion.

Question 23

Name the two things that commonly cause orthostatic hypertension. (2)

Answer 23

Anti-hypertensive medications

Dehydration

Question 24

Describe the common causes for non-syncopal falls. (4)

Answer 24

Often multi-factorial - osteoarthritis, diabetic neuropathy, infection, dehydration, trips.

Question 25

Classify a fall that results in a LoC due to a head injury. (1)

Answer 25

Non-syncopal.

Question 26

Describe the things that need to be considered when assessing the drug history of a patient with a history of falls. (3)

Answer 26

Polypharmacy - refer for medication review. Have they been started on any new medications that can cause falls indirectly?

Question 27

Describe the social history that needs to be considered when assessing a patient with a history of falls for discharge. (7)

Answer 27

Who is at home?
Who provides their care? Who pays for that?
What aids do they have, and from whom?
Alcohol? Smoking?

Question 28

Describe the examinations and investigations undertaken when a patient presents with a fall. (6)

Answer 28

Full neuro, cranial Nerve, CVS and resp exams.
Lying and standing BP, ECG, FBC, U+E, CK in a long lie situation.
CT, x-rays or echo if indicated.

Question 29

Describe the cause of rhabdomyalysis. (3)

Answer 29

Any traumatic injury to the sarcolemma leading to the release of intracellular ions, myoglobin, creatine kinase and urates into the circulation.

Question 30

Describe the consequences of rhabdomyalysis. (4)

Answer 30

Electrolyte disturbance, DIC, renal failure and multi-organ failure.

Question 31

Describe the diagnostic criteria for rhabdomyalysis. (2)

Answer 31

Serum CK levels must be 5 times the upper limit of normal to class as rhabdomyalysis.

Question 32

Define frailty. (3)

Answer 32

A condition characterised by loss of biological reserves and a vulnerability to adverse outcomes.

Question 33

Describe the frailty index score. (2)

Answer 33

Number of deficits in an individual / total number of deficits in the dataset.

Question 34

Name 6 different roles of healthcare workers that need to be involved in the care of a frail person. Explain their role. (12)

Answer 34

Doctors - need to adequately manage drugs and treatment plans.
Nurses - need to be extra reassuring.
OT - need to ensure the patient is safe at home.
PT - need to make sure the patient is as mobile as possible.
HCAs - need to ensure the patient is clean and comfy
Dieticians - need to ensure safe eating to avoid injury and malnutrition.

Question 35

Describe four common complications that are associated with frailty on a patients admission to a geriatric ward. (4)

Answer 35

Non-specific presentations
Homeostatic failure - immune, temp, bp, Na+
Multiple co-morbidities and polypharmacy.
Difficult social circumstances - poverty, loneliness.

Question 36

Define palliative care. (4)

Answer 36

Patient has a life threatening, progressive, incurable disease which is far advanced, with a limited prognosis. Focus of care becomes improving quality of life.

Question 37

Name some examples of what might be important to a patient when preparing for their own death in a palliative care situation. (6)

Answer 37

Truthfulness of the medical staff
Being able to chose their own care plan- informed consent
Being able to talk about it
Adequate symptom control
Avoiding medicalisation that prolongs life.
Being able to die with privacy and dignity.