Care of the Elderly Flashcards
1
Q
5 elements assessed in a comprehensive geriatric assessment
A
physical health
mental health
social aspects
functional aspects
environment
2
Q
steps of a comprehensive geriatric assessment
A
- Assessment
- Stratified problem list
- Management plan
- Goals – then review
3
Q
tools used for assessing ADL’s
A
- Barthel index - 10 basic ADLs (Disabilities, bladder/bowels, grooming, toilet use, feeding, transfer, mobility, dressing, stairs, bathing)
- Nottingham extended ADL scale - assesses instrumental ADLs (22 item)
4
Q
inappropriate prescribing
A
Drugs which are contraindicated
Inappropriate dose/duration
Adversely affect prognosis
Not prescribing drug which is indicated
5
Q
Risks of prescribing in older people
A
- changes in pharmacokinetics and dynamics
- polypharmacy and co-morbidity
- frailty
- cognitive/communication difficulties
- lack of testing/evidence in older people
6
Q
Physiological changes to pharmacokinetics/dynamics with aging
A
- absorption (GI changes)
- distribution - increased fat and decreased water (fat soluble drugs well distributed), low albumin
- hepatic metabolism (reduced hepatic volume and enzymes)
- renal elimination - reduced GFR
TOXICITY
7
Q
Geriatric Giants (6 I’s)
A
Incontinence, immobility, intellectual impairment, iatrogenesis, inanition, instability
8
Q
Frailty diagnostic models
A
- frailty phenotype Fried model (inintensional weight loss, weakness, exhaustion, slow walking, low level of activity
- clinical frailty scale Rockwood (1 very fit - 9 end of life)
9
Q
Physiological markers of frailty
A
- Increased inflammation, insulin, glucose, and d-dimer
- Decreased albumin and vitamin D
10
Q
What is osteoporosis
A
- progressive loss of bone mass
- microarchitectural changes - reduced cross linking in trabecular bone with cortical thinning
11
Q
Bone remodelling steps
A
- osteoclast activation (RANK-l bind with precursor cells)
- aggregation onto trabecular plate
- breakdown of bone
- simultaneous osteoblastic deposition of osteoid
- mineralisation with Ca and Pi
12
Q
FRAX score
A
- 10y risk of fracture (>10% need DEXA scan)
13
Q
DEXA scan values
A
T-score (SD above/below BMD of average 25y/o)
< -2.5 osteoporosis
<-1 osteopenia
14
Q
Management of osteoporosis
A
- vit D and Ca
- weight bearing exercise
- HRT in early menopause
- bisphosphonates (alendronate 10mg for 3-5y, anti-resorptive)
15
Q
SE and measures taken when on bisphosphonates
A
- oesophageal irritation - sit up for 30mins after and have water
- osteonecrosis of the jaw - good dental hygiene
16
Q
assessment for falls
A
- > 2 in a year is significant
- Assess cognition, vision, vestibular system, postural BP, CV system, proprioception, MSK, neuro and gait, footwear/walking aids
17
Q
Investigations for falls
A
ECG, lying and standing BP
consider bloods including CK (from long lie muscle breakdown)
18
Q
Complications from a long lie
A
pressure sores, rhabdomyolysis, dehydration, hypothermia, pneumonia
19
Q
classification of dizziness
A
- vertigo (spinning, vestibulo-labyrinthine system)
- presyncope
- unsteady (imbalance, abnormal sensory input)
- psychogenic
- mixed (frailty, multi-sensory dizziness syndrome)
20
Q
Peripheral and central causes of vertigo
A
- Peripheral causes = benign paroxysmal positional vertigo (BPPV), Meniere’s disease, vestibular neuritis, otitis media, aminoglycoside toxicity, acoustic neuroma
- Central causes = migraine, brainstem ischaemia, cerebellar stroke, MS
21
Q
manoeuvre for testing vertigo
A
Dix-Hallpike manoeuvre - causes ore severe vertigo and nystagmus
22
Q
Benign paroxysmal positional vertigo
A
recurrent short episodes of vertigo
displacement of Ca crystals (otoliths) from inner ear to semi-circular canals
23
Q
Meniere’s disease
A
30-50 y/o
recurrent vertigo lasting hours, tinnitus and fluctuations in hearing, progressive hearing loss
excess secretion of endolymph in canals
24
Q
vestibular neuritis
A
sudden onset severe vertigo 2-3 days, nausea, spontaneous nystagmus
recent viral infection
25
causes of syncope (COR)
- cardiac (arrhythmias, structural heart disease)
- orthostatic hypotension (drug induced, primary autonomic failure (parkinsons etc), secondary autonomic failure (DM, spinal injuries etc), volume depletion)
- reflex syncope (vasovagal, situational, carotid sinus syndrome)
26
Investigations for syncope
bloods, ECG, 24h tape, l&s BP
27
treatment of syncope
C - med review, cardiac pacing, surgery
O - med review, increase fluids, counter manoeuvres, compression stockings, fludrocortisone (mineralocorticoid to increase plasma volume)
R- counter manoeuvres
28
stress incontinence (causes and management)
- weakness of urinary outlet
- caused by pelvic muscle damage
- lifestyle measures (stop smoking, weight loss, less caffeine), Kegels, duloxetine, surgery
29
Urge incontinence (causes and management)
- failure to store urine dur to high bladder pressure
- overactive bladder - urgency and urge
- lifestyle changes, bladder training, kegels, anticholinergic (tolteridone), B3 adrenoceptor agonist (mirabegron), vaginal oestrogens, intradetrusor botox, sacral nerve stimulation
30
Overflow incontinence
chronic urinary retention
31
mixed incontinence
stress and urge
32
Investigations for incontinence
urinalysis, mid-stream urine microscopy/culture/sensitivity, post-void bladder scan, bladder diary
33
types of constipation
1. High impaction caused by obstructive lesion
2. Whole distal colon loaded with soft puffy like faeces
3. Hard stool in rectum – faecal impaction may cause overflow diarrhoea
34
Treatment of constipation
- rehydration, mobilisation, high fibre diet, med review
- stimulant laxatives - senna
- softening laxatives - lactulose (need adequate fluid intake)
- bulking laxatives - fybogel - fibre, can cause obstruction
- enema or suppositories for rectal constipation
35
Features of delirium
– acute onset, fluctuating, inattention, altered consciousness, medical cause
36
types of delirium
* Hypoactive – inactivity, abnormal drowsiness
* Hyperactive – restlessness, mood changes, hallucinations
* Mixed – switches back and forth
37
pathogenesis of delirium
- acetylcholine inhibition or pro-inflammatory cytokines
- metabolic disturbance (hypoxia, hypoglycaemia)
38
Causes/precipitating factors of delirium (DELIRIUM)
D – drugs
E – electrolyte imbalance
L – liver failure/ low oxygen
I – infection
R – retention (urinary/ faecal)
I – intracranial
U – uraemia
M- metabolic
39
assessment of delirium
abbreviated mental test then confusion assessment method if <8/10
40
investigations for delirium
* First line – WCC, CRP, electrolytes, LFT, TFT, glucose, CXR, urinalysis, ECG
* Second line – Ca, B12, folate, ABG, specimen cultures, CT head, toxicology screen, bladder scan, lumbar puncture
41
management/prevention of delirium
- treat cause
- manage environment (orientation, good sleep)
- monitor
- haloperidol/lorazepam in severe distress in Lewy body dementia and parkinsons)
42
Alzheimer's disease
- accumulation of Aβ amyloid and tau protein cause neuronal damage, neurofibrillary tangles, amyloid plaques, and loss of acetylcholine
- particularly in hippocampus, amygdala, temporal neocortex and subcortical nuclei
- AD genetic mutations for early onset
43
Vascular dementia
- caused by atherosclerosis or stroke in brain
- subdivided into cortical vascular, subcortical vascular, post-stroke
44
Mixed dementia
AD and VaD
45
Lewy Body Dementia
- Fluctuations in cognition, early visual hallucinations, and Parkinsonism (cognitive dysfunction presents within 2 years of motor features)
- Lewy bodies build up in cortex and basal ganglia causing cellular loss
46
frontotemporal dementia
- changes in behaviour, emotion and language before memory is affected
47
Examination for dementia
CV and neuro, MMSE
48
Management of dementia
- MDT, supportive care
- Cognitive AD – acetylcholine esterase inhibitor (rivastigmine), anti-glutamate/NDMA antagonist (memantine)
49
Total/partial anterior circulation stroke criteria
- all 3 total, 2/3 partial: unilateral weakness, homonymous hemianopia, higher cerebral dysfunction
50
lacunar syndrome stroke criteria
1 of: pure sensory, pure motor, sensori-motor, ataxic hemiparesis
51
posterior circulation syndrome stroke classification
1 of: CN palsy with contralateral motor/sensory deficit, bilateral motor/sensory deficit, conjugate eye movement disorder (gaze palsy), cerebella dysfunction, isolated homonymous hemianopia
52
investigations for stroke
* FAST
* Screen swallow (nil by mouth until this is done)
* CT head
* Bloods – FBC, U&E, ESR, TFT, glucose, clotting screen
* ECG
* Carotid doppler
53
management of stroke
* Protect airway and maintain homeostasis
* Ischaemic stroke – IV alteplase within 4.5h of onset, aspirin 300mg 2 weeks then clopidogrel 75mg
* Haemorrhagic – control BP to 140/90 (beta blocker), surgery (clot evasion)
* Rehab – physio, OT
54
features of parkinsonism
* Bradykinesia – slow movements (finger to thumb test)
* Rigidity – increased tone on movement, superimposed tremor (cog wheeling)
* Tremor – resting, high amplitude, low frequency (pill rolling)
* Postural instability
* Micrographia
* Abnormal gait – slow, shuffling, short steps, gets faster with momentum (festination)
* Hypomimia – expressionless face
55
types of parkinsonism
* Parkinson’s disease – unilateral onset, upper limb predominance, treatment responsive, present with bradykinesia
* Vascular parkinsonism – lower limb, bilateral onset, falls and gait problems
* Drug-induced parkinsonism – antipsychotics
* Lewy Body dementia – cognitive impairment with parkinsonism, hallucinations
* Progressive supranuclear palsy – eye signs (vertical gaze palsy), cognitive impairment, no response to dopaminergic treatment
* Multi-system atrophy – autonomic features (postural hypotension, incontinence, difficulty regulating temp), cerebellar signs, no response to treatment
56
Parkinson's disease
neurodegenerative disease, dopaminergic neuron loss and Lewy bodies concentrated in the substantia nigra – causes lack of dopamine
57
treatment of Parkinson's disease
- dopaminergic drugs - co-careldopa first line (levodopa and carbidopa) - levodopa long term use causes dyskinesias
- anticholinergic amantadine used to reduce tremor and dyskinesia
- dopamine receptor agonist - pramiprexole
58
clinical signs of poor nutrition and the specific deficiencies
* Wernicke’s (vitamin B1/thiamine) – ataxia, confusion, coma, nystagmus
* Anaemia (Fe, B12, folate)
* Gingivitis (vit C)
* Angular stomatitis, glossitis (vitamin B)
* Koilonychia (Fe)
* Bruising (vit C and K)
* Proximal myopathy, bone pain, fractures (vit D)
* Oedema (protein)
* Muscle wasting (protein, calorie)
* Polyneuropathy (vit B12, B1)
59
malnutrition universal screening tool (MUST) steps
1. Calculate BMI
2. Note percentage of unplanned weight loss
3. Establish acute disease effect and score
4. Add scores from step 1-3
5. Develop care plan (score >1 is high risk and need intervention)
60
refeeding syndrome
- fatal shifts in fluids/electrolytes with hormonal and metabolic changes when artificial feeding
- hypophosphatemia (abnormal fluid balance, changes in metabolism, thiamine def, hypokalaemia, hypomagnesaemia)
- at risk if without food for >5d
61
treatment/prevention of refeeding syndrome
* Give thiamine, vit B and multivitamin then start feeding, gradually increasing over 4-7 days, monitor fluids and electrolytes/vitamins closely and supplement if needed
62
stages of pressure ulcers
1. Non-blanching erythema – localised area over a bony prominence
2. Partial thickness – loss of dermis, shallow open ulcer
3. Full thickness – loss of subcut fat (bone, tendon, or muscle not visible)
4. Full thickness – exposed bone, tendon, or muscle
63
prevention of pressure ulcers (SSKIN)
S- support surface (beds/pressure mats)
S- skin assessment
K- keep moving
I- incontinence and moisture – assessments and management
N- nutrition and hydration
64
advance statements
not legally binding but considered carefully
65
lasting power of attorney
giving someone legal authority the make decisions about health, property and finances
66
advanced decisions (living will)
legally binding, decisions to refuse specific medical treatment
