AGEING WEEK FORMWATIVE ASSESSMENT

Question 1

A 92 year old woman presents with a three day history of confusion and falls. She has a fever of 38.2oC, is breathless with a cough, is disoriented, and is not focusing on the conversation that you are trying to have with her. She keeps falling asleep. Select one: a. Dementia b. Stroke c. Delirium d. Psychosis e. Deafness Which is it characterisitc of?

Answer 1

This is most likely to be delirium

Question 2

A 92 year old woman presents with a three day history of confusion and falls. She has a fever of 38.2oC, is breathless with a cough, is disoriented, and is not focusing on the conversation that you are trying to have with her. She keeps falling asleep. What features of the presentation make delirium likely? What type of delirium is it likely to be?

Answer 2

The woman has confusion and inattention with acute onset therefore making delirium likely Likely to be hypoactive delirium as she keeps falling asleep

Question 3

What is it likely that the patient has ?

Answer 3

It is likely this patient has syncope - can tell by the paleness, sweatiness and then blacking out for a few seconds An implantable loop recorder would probably be best here

Question 4

What is the likely cause of this patients syncope?

Answer 4

Likely cause of the syncope would be AF hence why the implantable loop recorder would be ideal for diagnosis

Question 5

Give an explanation for the drug choice?

Answer 5

Mini-mental state exam - looks for cognitive impairment level (usually due to dementia) SHe should continue to take paracetamol Calcium and vitD are of no use as she is bed bound Simvastatin and aspirin arent worth taing as they are seccondary prevention when she doesnt have long left Zopiclone -increases the risk of falls and worsens cognition

Question 6

An 85 year old woman presents having fallen at home. On examination, she displays inattention, disorientation and is aggressive when you approach her. She denies chest pain, cough or breathlessness. On examination her pulse is 110/min, BP 90/50, oxygen saturations 85% on air, temperature 36.2oC. Her chest is clear to auscultation and her ECG shows sinus tachycardia. The most likely diagnosis is: a. Urinary tract infection , b. Pneumonia , c. Stroke , d. Subdural haematoma, e. PE

Answer 6

Appears to have delirium due to a PE PE usually causes hypotension and presents with chest pain and breathlessness in the young but may not have these two symptoms in the elderly

Question 7

Older people can atypically present with a PE without complaining of pain or breathlessness as in the previous question What other coniditon is it common for pain and breathlessness but old people dont always complain of?

Answer 7

Myocardial infarction

Question 8

Which type of stroke commonly occurs due to falls in the elderly and those with drinking problem? Which type of stroke commonly occurs due to burst aneurysms?

Answer 8

Falls in the elderly and those with drinking problems - subdural haematoma commonly occurs due to aneurysms - subarachnoid haemorrhage

Question 9

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Answer 9

d - referral to community geriatrics team She has multiple problems, including at least two ‘geriatric giants’. The diagnosis is unclear – she might have depression, dementia, or the side-effects of physical illness. As such, a comprehensive geriatric assessment approach is required, and this is best delivered by the community geriatrics team. She does not require admission (either to hospital or a care home); she can be supported at home if additional help is put in. Psychiatry help may be required, but this addresses only one problem, as does falls clinic.

Question 10

An 82 year old woman comes to see you in clinic. She has lost 8 Kg in weight over the last 12 months, and her appetite is poor. She often complains of nausea and an “upset stomach”. She has a past history of osteoporosis, oesophagitis, depression and hypertension. Which drug that an 82 year old woman may be taking can cause GI upset? (most women take these supplements)

Answer 10

Calcium Calcium causes nausea or GI upset in 25% of users. She does need vitamin D as a adjunct for her denosumab therapy (which she needs to treat osteoporosis) but she could switch to vitamin D alone. Amlodipine is unlikely to be affecting her appetite; mirtazapine is needed to treat her depression (which might be contributing to her weight loss), and omeprazole is needed for her oesophagitis – without this the oesophagitis might in fact get worse, further worsening her food intake.

Question 11

What are the 4 main side effects of hypercalcaemia?

Answer 11

Painful bones Abdominal groan - GI upset Renal stones Psychic moans - persistently elevated calcium can cause depression

Question 12

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Answer 12

Evidence of sarcopenia due to reduced grip strength and muscle wasting Resistance training is the most likely to increase her strength

Question 13

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Answer 13

d - Nurse her in a side room Dont want to sedate her as pharamcological managements are only if she is a danger to others or herself

Question 14

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Answer 14

d. Apply to the court to appoint a guardian With his severe cognitive impairment and lack of ability to remember information, it is highly likely that he lacks capacity to make a decision on his place of residence (although a full assessment of capacity is needed). In this case, because no power of attorney was in place before he lost capacity, guardianship will be required – once appointed by the Courts, the guardian can make decisions on behalf of the patient. Until this occurs though, you cannot transfer him against his will to a care home.

Question 15

Why can we not arrange for the relative to gain power of attorney in thiscase?

Answer 15

A power of attornery has to be put in place before patient loses capacity And once the courts appoint a guardian he can be transferred to a care home as it cant be done against someones will

Question 16

You are at a board meeting of your local NHS organisation, who are looking to allocate £500,000 to a new community-based falls reduction service, targeted at older people who have had at least one fall in the last year. There are five proposals being presented, and only one can be funded. Select one: a. Slipper exchange programme to improve footwear b. Funding for Tai Chi classes , c. Community walking programme, d. Free eye test vouchers, e. Enhanced pavement gritting service for sheltered housing complexes

Answer 16

b - funding tai chi classes Tai chi is proven to improve balance in the elderly

Question 17

How long must strength and balance training be resumed for when intervening for falls in the elderly?

Answer 17

Strength and balance training for 3x per week for 12 weeks minimum

Question 18

In an elderly member of the community with COPD who is nearing death, how does the disease projectory usually occur?

Answer 18

Difficult to prognosticate with a slow decline usually punctuated by exacerbation with uncertainty as to which should cause death

Question 19

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Answer 19

b. - his condition is difficult to prognosticate in, but the family can expect a slow decline over time punctuated by further exacerbations - any one of which may be the episode in which he dies

Question 20

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Answer 20

Pain and breathlessness - Morphine (opiate) 2mg subcutaneous injection 1hourly as required Anxiety/agitation/distress - Midazolam (benzodiazepine) 2mg subcutaneous injection 1hourly as required Respiratory secretions - Buscopan (hyoscine butylbromide - anti-muscarinic) - 20mg subcutaneous injection 1hourly as required Nausea/vomiting - Levomepromaine (broad spectrum anti-emetic) - 2.5mg subcutaneous injection 8hourly as required

Question 21

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Answer 21

Review his current medication - man has severe polympharamcy with some of the drugs having quite a few side effects Take some baseline bloods - checks for AKI or liver failure sodium levels

Question 22

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Answer 22

Perform a PR rectal examination - likely he has constipation causing urinary retention Ask the nurse to perform a bladder scan - urinary retention is not uncommon in the elderly

Question 23

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Answer 23

Ask the nursing staff to insert a urinary catheter Perform a rectal PR exam

Question 24

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Answer 24

To be discharged home with extra support in place in the form of ESDS (early supported discharge services with a package of care and community review by the physiotherapist and occupational therapist) To be transferred to a non-acute ward nearer his home for further rehabilitation whilst his delirium resolves