B GERIATRICS TO DO Flashcards
DEMENTIA
What is dementia?
- Syndrome of acquired, chronic, global impairment of higher brain function in an alert patient, which interferes with ability to cope with daily living
DEMENTIA
How does subcortical dementia present?
Give some examples
- Psychomotor slowing, impaired memory retrieval, depression/apathy, executive dysfunction, personality change, language preserved
- PD, Huntington’s, alcohol-related + AIDS
DEMENTIA
What might a MMSE score indicate in dementia?
MMSE (/30) –
- 21–26 = mild, 14–20 = mod, 10–14 mod-severe, <10 = severe cognitive impairment
ALZHEIMER’S DISEASE
What is the clinical presentation of Alzheimer’s
4As of Alzheimer’s –
- Amnesia (recent memories poor, disorientation about time)
- Apraxia (unable to button clothes, use cutlery)
- Agnosia (unable to recognise body parts, objects, people)
- Aphasia (later feature, mixed receptive/expressive)
Insidious + progressive course of short-term memory loss Sx in early disease
FALLS
How may rhabdomyolysis present?
- Urine may be dark (‘Coca-Cola urine) + urinalysis +ve to Hb but without RBCs
MALNUTRITION
What are the components of MUST?
- BMI = 18.5-20 (1), <18.5 (2)
- Hx of weight loss = 5-10% (1) ≥10% (2)
- Acutely unwell or likely to have no intake >5d (2)
OSTEOPOROSIS
What are 2 important factors in osteoporosis development/primary causes?
- Increasing age
- Post-menopause as oestrogen is protective
OSTEOPOROSIS
What are the secondary causes/risk factors for osteoporosis?
SHATTERED
- Steroids
- Hyper/hypothyroid
- Alcohol/smoking
- Thin (low BMI)
- Testosterone low (F)
- Early menopause
- Renal/liver failure
- Relatives (FHx)
- Erosive bone disease (RA)
- Dietary Ca2+ low
OSTEOPOROSIS
What factors are assessed in the FRAX score?
- Personal = age, sex, weight, height
- PMH = RA, previous #, secondary osteoporosis (renal/liver disease, coeliac, thyroid issues)
- DH = glucocorticoids, lithium
- FHx = parental hip #
- Social = smoking, alcohol (≥3 drinks/day)
- Other = femoral neck BMD
OSTEOPOROSIS
What is an alternative to HRT?
- Selective oestrogen-receptor modulators (SERMs) like raloxifene
- Less breast cancer risk as stimulates oestrogen receptors just on bone
OSTEOPOROSIS
How do bisphosphonates, denosumab, HRT + SERMs compare to teriparatide?
- First lot are anti-resorptive meds which inhibits osteoclast activity + bone turnover
- Teriparatide is anabolic which increases osteoblast activity + bone formation
OSTEOPOROSIS
What are some adverse effects of bisphosphonates?
- Reflux + oesophagitis
- Osteonecrosis of jaw
- Atypical stress # (proximal femoral shaft)
PHARMACOLOGY
What is the mechanism of action of N-methyl D receptor antagonists (NMDA)?
- Protects brain cells from excess glutamate (excitatory neurotransmitter) released from cells affected by Alzheimer’s to prevent further damage, good for agitation + BPSD
URINARY RETENTION
What are some causes of urinary retention?
- BPH (#1 cause in men)
- Urethral strictures
- Anticholinergics
- Alcohol
- Constipation
- Infection
- Cancer
MILD COG IMPAIRMENT
How does it present?
- Reduced fluency + some short-term memory difficulties
FALLS
What markers are elevated in rhabdomyolysis?
Is that an issue?
- K+, phosphate, myoglobin + creatinine kinase
- Myoglobin is nephrotoxic as causes acute tubular necrosis
POSTURAL HYPOTENSION
What are some endocrine causes of postural hypotension?
DM, hypoadrenalism, hypothyroidism
PRESSURE ULCERS
What are some risk factors for pressure ulcers?
- Peripheral vascular disease (poor healing, reduced tissue perfusion)
- Immobility (#, pain)
- Dehydration + malnourishment
- Obesity
- Incontinence
PHARMACOLOGY
What are the side effects of acetylcholinesterase inhibitors?
- D+V,
- nausea,
- abdo pain (work systemically so GI upset)
- bradycardia
PHARMACOLOGY
When should NMDA be avoided?
Do not give in renal failure (low GFR) as nephrotoxic
PHARMACOLOGY
What are some side effects of NMDA?
- Confusion,
- hallucinations,
- agitation,
- paranoid delusions
BPPV
what are the causes?
50-70% = primary (idiopathic)
secondary
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines
HEART FAILURE
What are the compensatory mechanisms in heart failure?
- Sympathetic system
- RAAS
- Natriuretic peptides
- Ventricular dilation
- Ventricular hypertrophy
HEART FAILURE
Explain how the sympathetic system is compensatory in heart failure and give one disadvantage of sympathetic activation
Improves ventricular function by increasing HR and contractility = CO maintained
BUT it also causes arteriolar constriction which increases afterload and so myocardial work
HEART FAILURE
Explain how the RAAS system is compensatory in heart failure and give one disadvantage of RAAS activation
Reduced CO leads to reduced renal perfusion, this activates RAAS –> increased fluid retention so increased preload
BUT it also causes arteriolar constriction which increase afterload and so myocardial work
HEART FAILURE
what are the clinical signs of left heart failure?
- Pulmonary crackles
- S3 and S4 and murmurs
- Displaced apex beat
- Tachycardia
- fatigue
HEART FAILURE
what is the management for chronic HF?
1st line = ACEi, beta blocker
2nd = ARB + nitrate
3rd = cardiac resynchronization or digoxin
4th = diuretics (furosemide)
5th = aldosterone antagonist (spironolactone)
CONSTIPATION
what are the primary and secondary causes?
Primary
- disordered regulation of colonic and anorectal neuromuscular function
- IBS
Secondary
- metabolic - hypercalcaemia, hypothyroidism
- medicines - opiates, CCBs, antipsychotics
- neurological disorders - parkinsons, spinal cord lesions, DM
- bowel diseases - cancer, stricture, anal fissure
CONSTIPATION
what is the management?
- treatment of underlying cause
- increased dietary fibre
- increased fluid intake
- exercise
- bulk laxatives
- stool softeners
- osmotic laxatives - lactulose, macrogol
COTE ASSESSMENT
What is frailty?
- State of increased vulnerability resulting from ageing-associated decline in reserve + function across multiple physiological systems resulting in compromised ability to cope with everyday or acute stressors
COTE ASSESSMENT
What are the geriatric giants?
What do they represent?
4Is – - Instability (falls) - Immobility - Intellectual impairment (confusion) - Incontinence They are not diagnoses but more general things that COTE pts present with, often indicator of underlying problem
COTE ASSESSMENT
What are the geriatric 5Ms?
- Mind = dementia, delirium, depression
- Mobility = impaired gait + balance, falls
- Medications = polypharmacy, medication burden, adverse effects, de-prescribing/optimal prescribing
- Multi-complexity = multi-morbidity, biopsychosocial
- Matters most = individual meaningful health outcomes + preferences
POLYPHARMACY
What is pharmacodynamics?
How does this change for the elderly?
- What the DRUG does to the BODY
- In elderly, effects of similar drug conc. may be different to younger so prone to adverse drug reactions
POLYPHAMRACY
What is pharmacokinetics?
How does this change for the elderly?
- What the BODY does to the DRUG
- Changes in absorption, distribution, metabolism + excretion of drugs
- May mean drugs hang around longer or elderly pts may experience more toxicity from smaller dose
POLYPHARMACY
Give some specific pharmacokinetic issues in geriatrics.
- Hepatic first pass metabolism declines
- Reduced absorption as gastric pH increases due to atrophy
- Vascular system less responsive due to calcification of vessels
POLYPHARMACY
What are some common adverse drug reactions in geriatrics?
- Falls (postural hypotension with ACEi, beta-blockers)
- Confusion (sedation with anticholinergics)
- Bowel problems (opioids, PPIs)
MENTAL CAPACITY ACT
What is the purpose of the Mental Capacity Act, 2005?
- Empower + protect people >16y who lack capacity to make their own decisions about their care + treatment since 1/10/07
MENTAL CAPACITY ACT
What is the two-step test in MCA?
- Does the person have an impairment of their mind or brain? E.g. dementia, severe LD, brain injury, coma
- Is this impairment significant enough to deem them unable of making a particular decision?
MENTAL CAPACITY ACT
What are the 5 principles underpinning the MCA?
- Assume capacity until proven otherwise
- Maximise decision-making capacity (all practical support to help them make decision given)
- Freedom to make seemingly unwise choice (unwise decision ≠ incapacity)
- All decisions on behalf of patient in best interests
- Least restrictive option should be chosen
BEST INTERESTS
What are some important considerations when making best interest decisions?
- Encourage participation of the patient wherever possible
- Find out person’s views (past + present wishes, feelings, beliefs + values)
- Avoid discrimination (don’t make assumptions on any personal features)
- Regaining capacity (can the decision wait?)
- Identify all relevant circumstances to identify what they would have taken into account if they were making this decision
DOLS
What is the acid test for DoLS?
Must meet 3 criteria –
- Lack of capacity to consent to the arrangements or their care
- Subject to continuous supervision + control
- Not free to leave their care setting
MEDICO-LEGAL ASPECTS
What is an advanced refusal of treatments?
Is it legally binding?
- A living will
- Yes if:
– Adult ≥18y
– Was competent + fully informed when made decision
– Decision is clearly applicable to current circumstances
– No reason to believe changed mind
MEDICO-LEGAL ASPECTS
What is an advanced requests for treatment?
Is it legally binding?
- Patient’s wish for treatment
- Less legal binding but if it’s patient’s known wish to be kept alive then reasonable efforts (nutrition, hydration) should be considered
