Care Of The Elderly Flashcards
Three broad classifications of syncope?
Reflex syncope
Orthostatic hypotension
Cardiac syncope
Causes of reflex syncope?
Vasovagal
Carotid sinus syncope
Situations (cough, mictuition)
Causes of cardiac syncope?
Arrhythmia
Drug induced
Structural heart disease
Causes of orthostatic (postural) hypotension?
1st degree autonomic failure????
2nd degree failure- e.g. Parkinson’s, diabetes
Drug induced volume depletion e.g. Dehydration
Features in history suggesting cardiac syncope?
Can occurs when supine During exertion Preceded by palpitations Presence of severe heart disease ECG changes
What is sick sinus syndrome?
Degeneration of sinus node e.g fibrosis- can cause arrhythmia.
Treatment depends on arrhythmia
????
What is carotid sinus syndrome?
Affects baroreceptors, more sensitive in elderly so can pass out. They become deformed with atheroma etc.
Diagnosis by carotid sinus massage??
What is a stokes Adams attack?
Transient arrhythmia (e.g bradycardia due to complete heart block) causing decreased cardiac output and LOC.
What is cough syncope?
Weakness and LOC after paroxysm of coughing
What is effort syncope?
Syncope on exercise; cardiac origin e.g aortic stenosis, hypertrophic cardiomyopathy
What is mictuition syncope?
Mostly affects men at night
What is carotid sinus syncope?
Carotid sinus hypersensitivity (on turning head or shaving neck)
What is vasal vagal syncope?
Provoked by emotion, pain, fear or standing long.
Due to reflex bradycardia +/- peripheral vasodilation.
Preceded by nausea, pallor, swearing and closing visual field (pre-syncope)
What is Acute Kidney Injury (AKI)?
Abrupt decline in renal function over hours or days.
Defined by acute rise in serum creatinine and/or reduction in urine output.
Modifiable risk factors of dementia
Smoking Atherosclerosis Alcohol High cholesterol Obesity Low standard education
Non modifiable risk factors of dementia?
Genetics
Age
Mild cognitive impairment
What is the management/ treatment of delirium?
Treat underlying cause:
Poly pharmacy- drug review Pain- simple analgesia Constipation- laxatives Infection- antibiotics Correct electrolytes
What are precipitating factors of delirium?
Drug initiation Medical illness Systemic infection Metabolic derangement Surgery Pain Brain disorders (eg. Stroke, seizures) Systemic organ failure
What are the at risk groups for delirium?
Dementia Multiple comorbidities Physical frailty Older age Sensory impairments (e.g visual)
Differential diagnosis of delirium?
Dementia
Focal neurological syndromes e.g wernickes encephalopathy, frontal lobe lesions
Non convulsive status epilepticus
Primary psychiatric illness eg. Depression, manic, schizophrenia
PEG feeding risks and dementia?
Risks: bowel perforation, wound infection, peritonitis, aspiration, death
Evidence: artificial nutrition in patients with advanced dementia neither prolongs nor improves QOL.
Autonomy?
The right for an individual to make his or her own choice
Justice?
A concept that emphasizes fairness and equality among individuals
Beneficence?
The principle of acting with the best interest of the other in mind
Non-Maleficence?
The principle that ‘’above all, do no harm’’, as stated in the Hippocratic Oath
LPA (lasting power of attorney)?
A legal document that lets you (the ‘donor’) appoint people (known as ‘attorneys’) to make decisions on your behalf. It could be used if you became unable to make your own decisions.
There are 2 types: health and welfare, property and financial affairs
Court protection?
Makes decisions and appoints deputies to act on behalf of people who are unable to make decisions about their personal health, finance or welfare
IMCA (independent Mental Capacity Advocate)?
Safeguards the rights of people who:
• are facing a decision about a long-term move or about serious medical treatment;
• lack capacity to make a specified decision at the time it needs to be made; and
• have nobody else who is willing and able to represent them or be consulted in the process of working out their best interests, other than paid staff.
What is frailty?
- Poor functional reserve.
- Failure to integrate responses in the face of stress.
- Vulnerable to decompensation when faced with illness, drug side-effects, metabolic disturbance.
What is delirium and its presentation?
Acquired syndrome, acute onset, impaired consciousness ‘clouding’, cognitive impairment, inattention, disturbed sleep/wake cycle, emotional disturbance, fluctuating course, hallucinations, disinhibtion, worse at night, agitated/ aggressive. disorientated
Risk factors for delirium?
increasing age, underlying dementia, sensory impairment
Causes of delirium?
medications- anticholinergics, PD meds, benzos,
Infection (chest, UTI, cellulitis etc)
Substance misuse and withdrawal
Brain insult (brain injury, space occupying esion, seizures)
Constipation, Urinary retention
Metabolic (diabetes, thyroid, dehydration, b12, folate, thiamine)
How would you approach a patient with delirium?
ABCDE (not forgetting glucose)
medical history (+collateral)
CLinical investigations
MMSE (out of 30)/ Abbreviated mental state score (out of ten)
Investigations in suspected delirium/ confusion?
- Bloods: U&E, LFT, FBC, CRP, haemantinics (iron, B12, folate), TFT’s, calcium, phosphate, magnesium, glucose, cultures if sepsis
- Urine dip/ MC&S
- If clinical suspicion: CXR, AXR, ECG, ABG, serology
- No cause found/ neurology. History of head injury on warfarin- CT head
Management of delirium?
- Treat underlying cause
- Supportive measures- same nurses, avoid moving patient etc
- Treat pain
- Hearing aids, glasses etc
- For agitation: 0.5mg lorazepam oral or 0.5 haloperidol oral (unless parkinsons or Lewy body dementia)
What is dementia?
An acquired global impairment of higher mental functions without impaired consciousness.
What is the ICD-10 criteria of dementia?
ICD 10 criteria- evidence of impairment in:
• Memory (at least 6 months)
• Other cognitive abilities- speech and and language, planning and organisation, judgement, thinking, apraxia and agnosia
• Emotional changes – lability, irritability, apathy, coarsened social behaviour
• AND- absence of clouding of consciousness
How would you assess someone with suspected dementia?
- History and examination
- Cognitive testing
- Bloods-confusion screen (as with delirium)
- Imaging
What screening tests would you use for dementia?
- AMTS
- Clock-drawing
- Mini-mental state examination
- Montreal cognitive assessment (MoCA)
- Consider frontal lobe testing
What cognitive tests do you use in Dementia?
- Addenbrookes Cognitive Assessment Revised (ACE-R)
* Cambridge Assessment of Memory and Cognition
Would you use CT/MRI scans on suspected dementia?
o All patients- rule out other pathology
o Alzheimer’s disease- thinning of medial temporal lobes and hippocampi
What is a SPECT scan used to differentiate between?
Differentiate between AD and FTD and vascular dementia
What is a DaTSCAN?
Used as part of SPECT imaging
Shows decreased uptake in DLB (lewy body)
General management of patients with Dementia?
Memory enhancement strategies Promote independence where possible Occupational therapy Familiar environment and regular routine Home care progressing to 24 hour care Forward planning Mental capacity and mental health acts may be needed Notify DVLA Pharmacological agents
What pharmacological agents can be used in Dementia and for what types of Dementia?
• Cholinesterase inhibitors (mild to moderately severe AD)
o Donepezil
o Galantamine
o Rivastigmine (also licenced for PDD and NICE recommended for DLB)
• NMDA receptor partial antagonists (moderate to severe AD)
o Memantine
What are some behavioural and psychiatric symptoms of dementia (BPSD’s)?
- Agitation and aggression
- Anxiety
- Delusions and hallucinations
- Depression
- Disinhibition
- Elation or apathy
- Irritability
- Paranoia
- Screaming
- Psychosis
- Poor appetite
- Repetitive behaviour
- Sleep disturbance
- Wandering
What is the management of BPSD’s?
• Exclude super-imposed delirium/ pain
Antipsychotics:
o Increased cerebrovasucalr risk so only indicated for severe BPSDs (only rispirdone liscenced)
o Neuroleptic sensitivity in DLW (lewy body)
• Benzodiazepines (evidence limited):
o Diazepam regular
o Lorazepam 0.5mg PRN for acute agitation (or haloperidol 0.5mg PRN)
What are risk factors for Alzheimer’s?
- Increasing age
- Family history
- Female
- Down’s syndrome
- Hypercholesterolaemia
- Diabetes
- Lymphoma
What are the genetics involved in Alhzeimers?
- Risk factor for late onset disease (Apolipoprotein E4)
* Early-onset, autosomal dominant: Amyloid beta precursor protein (chromosome 21), Presenilin (PSEN) 1 and 2
What is the pathophysiology of Alhziemers?
loss of neurons and the presence of two main microscopic neuropathological hallmarks: extracellular amyloid plaques and intracellular neurofibrillary tangles
Clinical features of ALhzeimers?
- Progressive memory problems
- Word-finding difficulties and dysphasia
- Problems with planning and decision-making
- Disorientation in place and time
- Wandering
- Apathy, lability in mood, depression
- Difficulty in ADLs
- Hallucinations, delusions, paranoia
- Disinhibition, aggression, agitation
Risk factors for vascular dementia?
- Male
- Increasing age
- Hypertension, atherolsclerosis
- High cholesterol
- Diabetes
- Arrythmias
- Heart failure
- Genetics (CADSIL)- cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
What are the types of vascular dementia?
- Multi-infarct dementia- accumulation of small strokes
- Acute onset- succession of strokes or single large stroke
- Other less common forms
What are the clinical features of vascular dementia?
- Dementia with “stepwise deterioration”
- Correlation between vascular events and dementia
- May have focal neurology
- Early gait disturbance
- Emotional lability
- Nocturnal confusion
- Psychomotor retardation
- Low mood and depression
What is the pathophysiology of Lewy body dementia?
- Formation of Lewy bodies (intracytoplasmic inclusion bodies containing ubiquitin and tau protein)
- Widespread through brain compared to PD
What are the clinical features of Lewy body dementia?
- fluctuating dementia
- Parkinsonian features
- Visual hallucinations
- Fainting spells
- Sleep disorder
- Neuroleptic sensitivity- acute worsening/ PArkinsonian symptoms symptoms on starting antipsychotics.
What are the risk factors of frontotemporal dementia?
- Female
- One of most common causes of dementia in under 65’s
- Genetic risk factors
- Associated with MND
What is the pathology of frontotemporal dementia?
- Asymmetrical degeneration of frontal and temporal lobes with thinning of gyri “knife-blade atrophy”
- Pick’s disease just one form - Pick bodies – tau-containing intracytoplasmic inclusion bodies
What are the features of fronto-temporal dementia?
PERSONALITY CHANGE
difficulties planning, echolalia, perseveration, reduced speech, loss of literacy skills, disinhibition, antisocial acts, inattention, compulsions, lack of insight, reduced self care, mood disorder, loss of empathy, memory loss, withdrawal, rigidity, akinesia
What are the five key principles of the mental health act?
•Everyone should presumed to have capacity
•effort must be made to support patients to make the decision (maximise capacity)
•People are allowed to make unwise decisions
•Anything done on behalf of someone who lacks capacity should be done in their best interests
•That decision should be the least restrictive option
(Capacity is decision specific)
How do you assess capacity?
- Can the patient understand the information necessary to make the decision?
- Can they retain that information long enough to…
- Weigh-up the decision?
- Can they communicate that decision?
(If the answer to any of above is no, then the person lacks capacity to make the decision)
What is a Deprivation of Liberty Safeguard (DOLS)?
A DoLS is used to keep a person who lacks capacity to consent to their care in hospital (or a care home) in their best interests
E.g. patients with dementia asking to leave. May be requiring physical or chemical restraint to stay
Who can authorise a DOLS and for how long?
Authorised by the local authority. Takes up to 28 days. Patient needs a representative (friend, family, carer, IMCA) to advocate on their behalf.
Hospital can detain for up to 7 days in an urgent situation – an urgent authorisation. Must liaise with family, friends and carers first
What are the criteria of the patient for DOLS?
1.Be 18 or over
2,Have a mental condition
3,Lack capacity to consent to their care
4.Needs to have restrictions in place in their best interests
4.Proposed restrictions would deprive them of their liberty
5.Not have an advance decision to refuse treatment that the DoLS would contradict
6.Not be better detained under the Mental Health Act
