Care of the elderly Flashcards
What increases the susceptibility of acquiring C. difficile?
- Antibiotic related: Fluoroquinolones (ciprofloxacin), cephalosporins (cefotaxime), penicillin and clindamycin
- In contact with another person who has C. diff
- PPIs
How is C. diff spread?
In bacterial spores within faeces
prevented by handwashing, room sterilisation, limited antibiotic use
What are the symptoms of a C. diff infection?
Watery diarrhoea
Fever
Nausea
Abdominal pain
How is c. diff diagnosed?
Blood culture: C diff toxin positive
Stool culture: c diff toxin positive
What is the management of C. diff?
- Stop offending antibiotics.
- infection control
- oral metronidazole
- if severe - vancomycin
What are some of the complications of c. diff
dehydration pseudomembranous colitis toxic megacolon perforation of the colon sepsis
How can c. diff be prevented?
- prevent cross infection
2. reducing antibiotic misuse
How likely is an elderly person going to fall within one year of having a fall?
66%
What are the risk factors for falling?
- Age >80
- Low weight
- Dependent on others for ADLs
- Previous fall (in the last 12 months)
- Fear of falling
- Balance problems
- Gait and motility problems ie parkisons
- Pain
- Drugs ie polypharmacy, antihypertensives
- Cardiovascular conditions
- Cognitive impairment
- Urinary incontinence (rushing to the toilet)
- Stroke
- Diabetes
What increases the risk of injury from falling?
- Weak bones (osteoporosis, osteomalacia, paget’s diseaese, bone mets)
- predisposition to falls
- poor self protection (lack of subcutaneous fat, loss of consciousness, neuropathy)
What questions should be asked when a patient presents with a fall?
- Is it an isolated event? is there a pattern to the falls?
- What causes the fall?
- What was the patient doing at the time?
- Was there a loss of consciousness?
- Was there any warning signs before the fall?
- What was there post-fall state like?
- Collateral history
- When was their last eyesight and optician review?
- Ask about past medical history
- Polypharmacy and drugs?
What examinations should be done in a person who has fallen?
Vital signs (postural hypotension) Cardiac examination Neurological examination Systemic examination Mini-mental state examination Blood glucose Visual impairment assessment 'Timed up and go test' 'Turn 180 degree test'
What is the management of a fall?
Treat any injuries Treat underlying causes Medication review Physiotherapy review OT review Optician review
How can falls be prevented?
- Group and home based exercise programmes
- Home safety interventions
- T’ai chi
- Risk assessment of environmental factors
- Treating underlying medical condition
- Alcohol reduction
- Vitamin D for ‘weak bones’
What is osteoporosis?
A progressive systemic skeletal disease characterised by reduced bone mass and micro-architectural deterioration of bone tissue
What is an osteoporotic fracture?
Fractures resulting from mechanical forces that wouldn’t ordinarily result in fracture
What does a T score of below -2.5 SD from normal indicate?
Osteoporosis
What is the epidemiology of osteoporosis?
Women are more likely to get it than men
Age related disease (bone mass declines with age, and is accelerated when women hit menopause)
What are the risk factors for fragility fractures?
REDUCED BMD Increasing age Female sex Low body mass (<19kg/m2) Parental history of a hip fracture Parental history of fragility fracture Corcticosteroid therapy Cushing’s syndrome Alcohol (>3 units a day) Smoking If increased risk of falling due to medical conditions
What are some of the secondary causes of osteoporosis (medical conditions)
Rheumatoid arthritis and other inflammatory arthropathies.
Prolonged immobilisation or a very sedentary lifestyle.
Primary hypogonadism (men and women).
Primary hyperparathyroidism.
Hyperthyroidism.
Post-transplantation.
Chronic kidney disease.
Gastrointestinal disease such as Crohn’s disease, ulcerative colitis and coeliac disease.
Untreated premature menopause (<45 years) or prolonged secondary amenorrhoea.
Type 1 diabetes mellitus.
Chronic liver disease
Chronic obstructive pulmonary disease
What is the presentation of osteoporosis?
Asymptomatic until patient has a fall resulting in a fragility fracture
Fractures are commonly at the spine, hi[ and wrist
What are the investigations for osteoporosis?
Xray
DEXA scan
Bloods (FBC, ESR, CRP, U&E, LFTS, TFTS, hormones, serum immunoglobulins and urinary bence Jones’ proteins)
What is the management of osteoporosis?
- Lifestyle advice
- Adequate calcium and vitamin D intake
- Bisphosphonates
- Denosumab
- Treatment of fractures
What is incontinence and what are the different types?
- An involuntary leakage of urine
1. Functional
2. Stress
3. Urge
4. Mixed
5. Overflow
6. True incontinence
What are the characteristics of functional incontinence?
- patient is unable to reach the toilet in time
- usually have poor mobility
- can be unfamiliar to surroundings
What are the characteristics of stress incontinence?
- Involuntary leakage during effort or exertion, coughing or sneezing.
- Due to an incompetent sphincter
- Can be associated with a genitourinary prolapse
What are the characteristics of urge incontinence?
- Involuntary urinary leakage accompanied by, or immediately preceded by urgency of micturition
- Detrusor instability or hyperreflexia = involuntary detrusor contraction
- Can be idiopathic or secondary to neuro problems
What are the characteristics of mixed incontinence?
Involuntary leakage or urine associated with urgency and exertion, effort, coughing or sneezing
What is the characteristics of overflow incontinence?
-Chronic bladder outflow obstruction. Often seen in prostatic disease in older men. Can lead to obstructive nephropathy
What is true incontinence?
Fistulous track between vagina and ureter or bladder or urethra causing continuous leakage or urine
What is the epidemiology of incontinence?
Prevalence increases with age
What are the risk factors for incontinence?
Women: pregnancy and vaginal delivery, Diabetes mellitus, high BMI, hysterectomy, UTIs, oral oestrogen therapy
Men: LUTS, infections, functional and cognitive impairment, euro disorders
Prostatectomy
What is the management for incontinence?
- Temporary containment pads
- pelvic floor exercises
- Stress: duloxetine or surgery
- Mixed: antimuscarinics (oxybutynin)
- intermittent self-catherterisation
- bladder training
- Botulinum toxin type A for neuro conditions
- urostomy
What are some neurological conditions that can result in incontinence?
- Stroke
- Parkinsons
- Multiple sclerosis
- Dementia
- Spinal cord injury
What is parkinsons?
Neurodegenerative disease
-decrease in dopamine due to depletion of the substantia nigra
What are the parkinsonian cardinal features?
- rigidity of movement
- hypertonia (resting tremor)
- bradykinesia
- postural instability
What is the aetiology of parkinsons?
UNKNOWN
- ?genetic factors
- ?synthetic opioid impurity
- ?pesticide exposure
What is found histiologically in Parkinsons?
Lewy bodies in the substantia nigra
What is the epidemiology of parkinsons?
Typically develops between 55-65
slightly more common in men
What are the clinical features of parkinsons?
- resting tremor - pill rolling of thumb and fingers, improved by voluntary movement
- rigidity - leadpipe/cogwheel rigidity
- bradykinesia - slowness of voluntary movement, difficulty initiating movement, monotonous speech, shuffling gait
-sleep disturbances, shuffling gait, reduced arm swing, depression and associated with lewy body dementia
What investigations are done in parkinsons?
- Clinical
2. Exclude other causes for parkinsonism ie CT for head injury, multi infarct dementia, medication review
Pharmacological management of parkinsons
- Levodopa with carbidopa
- Dopamine agonists (ropinirole)
- Catecholamine-O-Methyltransferase inhibitors (Entacapone)
- Monoamine-oxidase B inhibitors (Selegiline)
- Anti-cholinergic (Benztropine)
What’s the non-pharmacolgoical management of parkinsons?
- Physiotherapy
- Occupational therapy
- SALT
- Deep brain stimulation
What is drug induced parkinsonism and how is it treated?
Antipsychotics and antihypertensives are known to block dopaine receptors
When the drug is stopped, the symptoms stop
What is parkinsonian dementia?
- dementia with lewy bodies
- visual hallucinations, falls and memory loss
- changes in executive functioning ie planning the day, anticipating events, understanding jokes
What is a stroke?
- A clinical syndrome caused by a disruption of bloody supply to the brain causing a focal or global disturbance to cerebral functions
- > 24 hours
What are the 2 types of stroke?
- Ischaemic infarction (85%)
2. Haemorrhage (15%)
What are ischaemic infarctions caused by?
- thromboembolisms
- atheromas
- trauma
- infection
- malignancy
What are haemorrhagic stroke classical features?
- meningism
- severe headache
- coma within a few hours
What’s the aetiology of stroke?
- thrombosis in situ
- atherothrombolism
- heart emboli
- cns bleed (aneurysm rupture)
- vasculitis
- space occupying lesion
- venous sinus thrombosis
What’s the epidemiology of a stroke?
->65 years old
What are the risk factors for stroke?
- hypertension
- smoking
- diabetes mellitus
- heart disease (valvular, ischaemic, af)
- peripheral artery disease
- post-tia
- carotid artery occlusion
- combined oral contraceptive pill
- hyperlipidaemia
- excess alcohol
- clotting disorders
What’s the presentation of stroke?
SUDDEN ONSET
- cerebral hemisphere infarcts: contralateral hemiplegia, contralateral hemiplegia, homonymous hemianopia, dysphasia
- posterior circulation ischameia: ataxia, motor defecits and weakness, crossed syndrome, sensory defecit, diplopia, dysphagia, locked in syndrome
What are the investigations for a stroke?
CT SCAN: excludes haemorrhagic stroke for thrombolysis
BLOODS: FBC, ESR, hypoglycaemia, syphillis screen
Management of ischaemic stroke
aspirin 300mg
thrombolysis (once haemorrhagic stroke has been excluded as cause)
-long term antiplatelet therapy
-carotid endarectomy
Management of heamorrhagic stroke
surgery
What’s the MDT approach to treating a stroke?
- physio
- occupational therapy
- TREATMENT OF RISK FACTORS
What’s the ABCD2 score?
to determine the likelihood of having a stroke after having a TIA
- Age >60
- Blood pressure >140/90mmHg
- Clinical features (unilateral weakness, or speech disturbance without weakness)
- Duration of symptoms (>60 mins+ or 10-59mins)
- Diabetes
What is a subarachnoid haemorrhage?
Spontaneous arterial bleeding into the subarachnoid space
Caused by a rupture of ‘berry aneurysms’ or congenital arteriovenous malformations
What are the clinical features of a SAH?
- Sudden onset of severe (thunderclap headache)
- Absence of similar headaches in the past
- Nausea and vomiting
- Sometimes loss of consciousness
- meningeal irritation
- focal neurological signs
- papilloedema
What are the investigations for a SAH?
CT head
lumbar puncture
MR angiography (establishes fitness for surgery)
What’s the management for SAH?
- bed rest
- supportive measures
- nimodopine (reduces artery spasming)
- surgery
What is a subdural haematoma?
- an accumulation of blood in the subdural space
- usually caused by a rupture of bridging veins in the sagital sinus
Who are most at risk of having a subdural?
elderly or alcoholics
- due to atrophied brains
- increased likelihood to fall
what are the clinical symptoms of a subdural?
headache
drowsiness
fluctuating confusion
LATENT INTERVAL BETWEEN INJURY AND SYMPTOMS
How are subdurals diagnosed?
ct head
What is the management of a subdural?
surgical removal of the haematoma
What is an extradural haematoma?
-injuries that fracture the temporal bone and rupture the middle meningeal artery
what is the typical presentation of an extradural haematoma?
- history of head injury with brief loss of consiousness
- followed by lucid interval
- rapid deterioration with focal neurological sigsn
What’s the treatment for an extradural haematoma?
surgical drainage
What are pressure ulcers?
localised damage to the skin and/or underlying tissue that usually occur over a bony prominence resulting from pressure
What causes pressure ulcers?
- external pressure causes obstruction of the blood capillaries
- friction damages the superficial vessles
- shearing (separation of the skin from underlying tissues due to opposing forces)
- moisture
Where are common sites for pressure sores?
sacrum
coccyx
heels
hips
What are risk factors for pressure sores?
- immobile
- microclimates
- malnutrition
- low bmi
- arteriosclerosis
- neuropathies
- age >70
- dry skin
- malignancy
What are the stages of severity of pressure sores?
-Stage 1: intact skin, non-blanchable redness
-Stage 2: partial thickness loss of dermis: Shallow open ulcer with red pink wound bed
-Stage 3: full thickness tissue loss, subcutaneous fat may be visible
-Stage 4: full thickness tissue loss, with exposed bone, tendon, muscle. Slough may be present.
Deep tissue injury - A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue
What is the treatment for pressure sores?
- debridement
- dressings
- smoking cessation
- treatment of medical conditions which can slow down healing process ie infection
How can pressure sores be prevented?
- regular movement of the pt
- balanced diet with adequate protein and vit c
- support surfaces ie pressure sore mattresses
