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3A REVISION > CARE OF THE ELDERLY > Flashcards

CARE OF THE ELDERLY Flashcards

1
Q

What are 5 challenges faced in geriatric patients?

A 
Frailty
Co-morbidity/polypharmacy
Atypical disease presentation
Slower response to treatment
Need for social support
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2
Q

What is frailty?

A

State of increased vulnerability resulting from ageing associated decline in reserve and function, across multiple physiologic systems so that the ability to cope with everyday or acute stressors is compromised

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3
Q

What are the 7 most common presenting complaints in geriatrics?

A 
Falls
Confusion
Incontinence
Off legs
Social admission
Chest pain
SOB
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4
Q

What are the 5 Ms of geriatrics?

A 
Mind (dementia, depression)
Mobility (falls)
Medications (polypharmacy)
Multi-complexity (multi-morbidity)
Matters most - meaningful health outcomes
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5
Q

What are the geriatric giants?

A

Instability
Intellectual impairment
Immobility
Incontinence

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6
Q

What is acopia?

A

Inability to cope with activities of daily living, mean age 85 years
High mortality rate
Can have serious underlying pathology

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7
Q

Treatment problems in older people? (5)

A 
More prone to side effects
Drug interactions
Reduced organ function
Relevance of secondary prevention
Polypharmacy
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8
Q

What is deconditioning?

A

Deconditioning is a complex process of physiological change following a period of inactivity, bedrest or sedentary lifestyle. It results in functional losses in such areas as mental status, degree of continence and ability to accomplish activities of daily living

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9
Q

What are the 4 parts to a comprehensive geriatric assessment?

A

Medical
Functional
Psychological
Social/environmental

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10
Q

What is rehabilitation?

A

Process of restoring a patient to maximum function

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11
Q

4 legal/ethical issues in geriatrics?

A

End of life care
Discharge destination
Safeguarding vulnerability
Mental capacity - dementia

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12
Q

Types of abuse older people may undergo?

A 
Neglect
Financial abuse
Discrimination
Institutional abuse
Psychological abuse
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13
Q

What is the age range for geriatrics?

A

Over 65

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14
Q

What is the prevalence of falls?

A

30% community over 65
40% community over 75
Higher in care homes

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15
Q

What are the leading 5 causes of death in older people?

A 
CV disease
Cancer
Stroke
Pulmonary disease
Falls
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16
Q

Impact of falls? (7)

A

Morbidity e.g. hip fracture
Mortality
Functional decline - hospitalisation, institutionalisation
Long lie - hypothermia, dehydration, pressure sores, death
Depression
Social isolation
Loss of confidence

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17
Q

Cause of falls? (14)

A 
Parkinsons disease/motor disorders
Cognitive impairment - dementia
Stroke
Weak muscles
Neuropathy
Arthritis
Decreased visual acuity
Dizziness/hypotension
Syncope
Arrhythmias
Nutritional deficiency
Medication 
Alcohol
Obstacles/poor lighting
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18
Q

Management of falls? (9)

A 
Screening - ask about previous falls, problems with walking or balance
Treat underlying disease
Home modification
Modify other risk factors
Strength and balance training
Footwear/foot care
Vision optimisation
Medication optimisation
Fracture risk assessment - osteoporosis treatment
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19
Q

What % of falls is due to syncope?

A

20% of UNEXPLAINED falls - majority of patients with syncope will suffer a fall

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20
Q

Causes of syncope? (5)

A 
Arrythmias
Orthostatic hypotension
Neurocardiogenic (vasovagal)
Carotid sinus syndrome
Valvular heart disease
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21
Q

What is osteoporosis?

A

Commonest bone disease in adults, characterised by a reduction in bone density, disruption of bone architecture and risk of fracture after low impact trauma

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22
Q

Presentation of osteoporosis?

A

Usually with fragility fracture - hip, vertebra, pelvis, radius/ulna, humerus

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23
Q

Definition of fragility fracture?

A

Associated with low trauma - fall from a height equal to or less than that of a chair

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24
Q

Risk factor for osteoporosis and fractures?

A 
Age - post menopause
Female gender
Parental history of fracture
Previous fracture
Low BMI
Low bone mineral density
Smoking, alcohol
Drugs
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25
Q

What drugs predispose to osteoporosis and fractures? (4)

A

Steroids
Anticonvulsants
Heparin
Aromatase inhibitors

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26
Q

Investigations for osteoporosis? (7)

A

DEXA scan - measures bone mineral density, osteoporosis = T score -2.5 SDs from baseline
FBC and ESR
Serum electrophoresis and urine (myeloma)
Bone profile - raised alkaline phosphatase
LFTs U+Es
Parathyroid hormone/vitamin D
Calcium measurements

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27
Q

Treatment for osteoporosis? (5)

A

Calcium and vitamin D supplements, NUTRITION AND EXERCISE
Bisphosphonates - alendronate
Raloxifene - selective oestrogen receptor modulator
Strontium ranelate if high risk
Denosumab
Teraparatide if high risk (PTH)

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28
Q

Medications that may cause dizziness –> falls?

A

ACEis, beta blockers, diuretics, benzos, anticholinergics

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29
Q

Medications that may cause hypotension –> falls?

A

Beta blockers, vasodilators (nitrates/calcium blockers), viagra, opioids

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30
Q

Cause of hip fractures?

A

Frailty and falls risk

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31
Q

What are the types of hip fracture?

A

Intracapsular and extracapsular

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32
Q

Symptoms of hip fractures? (4)

A

Pain in hip
Inability to walk
Fall
Shortened and externally rotated limb

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33
Q

Investigations of hip fractures? (10)

A 
Hip x ray
CXR, ECG
FBC for anaemia, ESR
INR before surgery, blood grouping
Serum electrophoresis and urine (myeloma)
Bone profile - raised alkaline phosphatase
LFTs U+Es
Parathyroid hormone/vitamin D
Calcium measurements
MSU
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34
Q

Management of hip fracture? (5)

A 
Analgesia and fluids
Pressure area care
Early surgery within 48 hours - screw fixation
Antibiotic prophylaxis
Thromboprophylaxis
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35
Q

When are hip fractures managed conservatively? (4)

A

Short life expectancy
Late presentation - partially healed
Immobility
High risk surgery

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36
Q

What are other common fragility fractures?

A

Vertebral fractures - can occur on bending, standing, coughing, many are asymptomatic and just get loss of height
Wrist fractures - falling onto outstretched hand
Pelvic fractures

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37
Q

How are vertebral fractures managed? (6)

A 
Analgesia (calcitonin if severe pain)
Back brace and limit activity 
Physiotherapy
Bisphosphonates
Vertebroplasty - inject filler into the vertebrae for height and strength
Surgery with spinal fusion last resort
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38
Q

What is a pressure ulcer?

A

Area of localised damage to the skin and underlying tissue caused by the extrinsic factors of pressure (perpendicular load), shear (parallel load), friction
Exacerbated by moisture

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39
Q

Risk factors for pressure ulcers? (9)

A 
Age >70
Bedridden and immobile
Obese
Incontinent
Decreased consciousness
Malnutrition/dehydration 
Diabetes
Peripheral arterial disease
Severe chronic disease
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40
Q

Investigations for pressure ulcer? (5)

A 
Assessment of risk - Waterlow scoring
CRP/ESR, WCC
Swabs for infection
Blood cultures
X ray for bone involvement
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41
Q

Common sites for pressure ulcers?

A 
Sacrum
Occiput 
Heels
Elbows
Shoulder
Inner knees
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42
Q

Grading of pressure ulcers?

A

1 erythema of skin
2 partial thickness loss (blister, abrasion)
3 full thickness skin loss and damage to SC tissue
4 necrosis or muscle/bone damage
5 depth unknown

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43
Q

Prevention of pressure ulcers? (5)

A 
Barrier creams
Foam mattress
Heel supports
Repositioning every 4-6 hours
Regular skin assessment
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44
Q

Management of a pressure ulcer? (5)

A

Good nutrition/hydration
Foam mattress if not already/dynamic support surface
Wound dressings - modern occlusive dressings promoting moist healing
Debridement of necrosis
Antibiotics if infection

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45
Q

Most common causes of delirium in the elderly?

A

Infection
Medications - dopamine agonists, anticonvulsants, opioids, benzos
Dehydration/electrolyte disturbance

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46
Q

Treatment of delirium in the elderly?

A

Remove cause
Continuity of care
Easy orientation i.e. big clock

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47
Q

What is malnutrition?

A

State in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on the body’s form, composition, function and clinical outcome

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48
Q

Causes of malnutrition?

A

Decreased nutrient intake
Increased nutrient requirements
Inability to use ingested nutrients

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49
Q

What is the MUST tool?

A

Malnutrition universal screening tool

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50
Q

Components of the MUST tool

A

BMI (<18.5)
Unplanned weight loss in past 3-6 months
Acute illness and likely no nutritional intake for >5days
Score 1 med risk, 2 or more high risk

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51
Q

Management of high risk malnutrition?

A

Refer to dietitian
Reweigh weekly
Optimise fluids etc

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52
Q

Give some factors affecting intake?

A

Meal times, unfamiliar foods, lack of appetite, pain, anxiety, medications

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53
Q

Give some factors increasing requirements?

A

Infection, inflammation, trauma, liver disease, wound healing, surgery, malignancy, chronic infection

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54
Q

Give some factors increasing loss?

A

Diarrhoea, vomiting, bowel surgery, pancreatic insufficiency, IBD

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55
Q

Consequences of malnutrition?

A 
Impaired immunity
Impaired wound healing
Loss of muscle mass
Loss of cardiac function
Impaired skin integrity - pressure ulcers
Prolonged hospital stay
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56
Q

What is refeeding syndrome?

A

Prolonged starvation followed by provision of nutritional supplementation
Potentially fatal shift in fluids and electrolytes

57
Q

Symptoms of refeeding syndrome? (10)

A 
Arrhythmia
Hypertension
Abdo pain
Vomiting
Constipation
Rhabdomyolysis
Weakness
SoB
Infections
Anaemia
58
Q

What is shown on bloods in refeeding syndrome? (5)

A 
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Hyperglycaemia
Thiamine deficiency
59
Q

Treatment of refeeding syndrome?

A

Replace electrolytes - phosphate, potassium, magnesium
Monitor sodium and glucose
Vitamin B6, B12, folate

60
Q

Advice for meals in the elderly?

A

Small and frequent high calorie (i.e. fortisip)

61
Q

What is parenteral nutrition?

A

IV administration of nutrients, use central catheter (into vein i.e. subclavian, internal jugular, femoral) if longer than 2 weeks

62
Q

Indications for total parenteral nutrition? (5)

A 
Short bowel syndrome
GI fistula
Severe malnutrition
IBD
Multi organ failure
63
Q

What is enteral feeding?

A

Delivery of nutritionally complete feed directly into stomach, duodenum or jejunum

64
Q

How is enteral feeding done?

A

NG/NJ tube, PEG (percutaneous endoscopic gastrostomy) tube after 1 month

65
Q

Indications for a PEG tube?

A

Stroke
Parkinsons
MND
Oesophageal cancer

66
Q

What are the types of incontinence?

A

Urinary and faecal, can be double

67
Q

Mechanisms of incontinence?

A

Stress - weakness of urinary outlet
Urge - detrusor overactivity
Overflow - urethral stricture, detrusor weakness - BLADDER OUTLET OBSTRUCTION
Functional

68
Q

Complications of incontinence?

A

Depression
Pressure ulcers/skin infection
Care home admission
Impaired QoL

69
Q

Causes of stress incontinence?

A

RISE IN ABDO PRESSURE, WEAK SPHINCTER
Age
Obesity
Pelvic floor damage - childbirth, trauma, prostatectomy

70
Q

Causes of urge incontinence?

A

DETRUSOR OVERACTIVITY
Detrusor instability - infection/inflammation
Brain damage - Stroke, Parkinsons, Dementia
Diabetes
Diuretics

71
Q

Investigation of incontinence?

A 
Fluid diary
Urinalysis (diabetes, UTI)
FBC, U+E, glucose, Ca
Post void bladder scan
Uroflowmetry, cystometry, ambulatory urodynamics
72
Q

Reversible/transient causes of incontinence?

A 
Delirium
Infection
Atrophy (vaginal)
Pharmacological
Psychological
Excess urine output
Restricted mobility
Stool impaction
73
Q

Medications causing/exacerbating urinary incontinence?

A 
Antipsychotics
Diuretics
Cholinesterase inhibitors
ACEis
CCBs
Opioids
Alpha adrenoreceptor blockers
74
Q

Red flags in incontinence? (4)

A

Pain on micturition
Haematuria
Prolapse beyond introitus
Suspicion of prostate cancer

75
Q

Management of stress incontinence? (5)

A 
Stop smoking, lose weight, reduce alcohol/caffeine
Pelvic floor exercises, vaginal cones
Duloxetine
Pudendal nerve stimulation
Surgery - mid-urethral sling
76
Q

Management of urge incontinence/overactive bladder?

A 
Reduce fluid intake, caffeine/alcohol, lose weight
Oestrogen for atrophic vaginitis
Bladder training
Antimuscarinics
Botulinum toxin
Surgery - sacral nerve stimulation
77
Q

Name antimuscarinics used in urge incontinence?

A

Oxybutinin

Tolteradine

78
Q

Why is inappropriate prescribing more common in older people?

A

Higher prevalence of chronic disease
Higher levels of polypharmacy
Age related physiological changes

79
Q

Complications of polypharmacy?

A

Reduced compliance
Increased drug interactions
Side effects
Prolonged hospital stay

80
Q

Changes in metabolism in drugs in older people? (4)

A

Fat distribution increases - fat soluble drugs
Decrease in water - water soluble drugs
Hepatic metabolism - reduced liver volume and enzyme activity so reduced liver metabolism
Renal elimination - reduction in GFR so decreased excretion

81
Q

What is polypharmacy?

A

Increase in the number of medications/the use of more medications than are medically necessary
Major is >5 drugs

82
Q

What is appropriate polypharmacy?

A

All drugs prescribed for the purpose of achieving specific therapeutic objectives
Therapeutic objectives are being achieved
Minimised risk of ADRs
Motivated patient

83
Q

5 steps of deprescribing protocol?

A

Ascertain reasons for all drugs
Consider overall risk of drug induced harm
Assess each drug pros and cons
Prioritize drugs for disontinuation with lowest benefit:harm ratio, lowest risk of withdrawal
Monitor for improvement or worsening of symptoms

84
Q

What is compliance and concordance?

A

Compliance - degree to which patient correctly follows medical advice or treatment
Concordance - consultation process, agreement between patient and doctor

85
Q

Reasons for non compliance?

A

Problems swallowing
Side effects
Difficulty obtaining medications
Difficulty remembering doses/times

86
Q

How can compliance be helped?

A

Carers

Pre filled pill organisers/dosette boxes

87
Q

What is pneumonia?

A

Acute lower respiratory tract illness characterised by inflammation and infiltration of neutrophils

88
Q

Risk factors for pneumonia? (7)

A 
Very young or very old
Smoking
Viral infection
COPD, lung tumour, bronchiectasis
Immunosuppression esp. p.jirovecii
Hospitalisation
Aspiration - after stroke, Parkinsons
89
Q

Classification of pneumonia?

A

Community acquired
Hospital acquired
Aspiration
Immunocompromised

90
Q

Commonest cause of community acquired pneumonia?

A

1 - Streptococcus pneumoniae
2 - Haemophilus influenzae, Mycoplasma pneumoniae
3 - Staphylococcus aureus, Legionella
15% viral

91
Q

Commonest cause of hospital acquired pneumonia?

A

Gram negative enterobacteria or Staphylococcus aureus

2 - Pseudomonas, Klebsiella

92
Q

Organism associated with immunocompromised pneumonia?

A

Pneumocystis jiroveci (P.carinii)

93
Q

Symptoms of pneumonia?

A 
Fever
Rigors, malaise
Anorexia
Dyspnoea
Cough
Purulent sputum
Haemoptysis
Pleuritic chest pain
94
Q

How may the elderly present with pneumonia?

A

Systemically - malaise, fatigue, anorexia, myalgia, confused

95
Q

Signs of pneumonia? (8)

A 
Pyrexia
Cyanosis
Confusion
Tachypnoea
Tachycardia
Hypotension
Consolidation
Pleural rub
96
Q

Signs of consolidation? (4)

A

Diminished expansion
Dull percussion
Increased vocal resonance
Bronchial breathing

97
Q

What is the CURB-65 score?

A 
Confusion
Urea >7mmol/L
Resp rate >30/min
BP <90 /60
65 or over in age

2 = hospital, 3 = severe, may need ITU

98
Q

Tests for pneumonia? (5)

A 
CXR
Oxygen saturation (then ABG if <92%)
BP
Bloods - FBC, U+E, CRP, LFT, cultures
Sputum MC+S
99
Q

What is seen on CXR in pneumonia? (3)

A

Lobar/multilobar infiltrates
Cavitation
Pleural effusion

100
Q

Additional tests in severe/possibly atypical pneumonia?

A

Urine antigens - legionella, pneumococcal
Atypical organism/viral serology - PCR sputum, paired serology
Pleural fluid aspiration and culture
Bronchoscopy/bronchoalveolar lavage if immunocompromised/ITU

101
Q

Management of pneumonia? (6)

A

Antibiotics - oral if not severe, IV if severe/vomiting
Oxygen to keep sats >94%
IV fluids
VTE prophylaxis
Analgesia if needed
Repeat CXR if not improving/for 6 wk follow up

102
Q

Complications of pneumonia?

A 
Pleural effusion
Empyema
Lung abscess
Respiratory failure
Sepsis
103
Q

How is low severity community acquired pneumonia treated?

A

Amoxicillin - 5 days (or clarithromycin) oral, extend if not improving after 3 days

104
Q

How is moderate CAP treated?

A

Amoxicillin AND clarithromycin 7-10 days

Oral or IV

105
Q

How is severe CAP treated?

A

Co-amoxiclav AND amoxicillin IV

106
Q

What should be used is staphylococcus or MRSA suspected in pneumonia?

A

Add flucloxacillin if staphylococcal
Vancomycin if MRSA
Treat for 10 days at least

107
Q

How are atypical Legionella and P.jirovecii pneumonias treated?

A

Legionella - ciprofloxacin with clarithromycin

P.jirovecii - co-trimoxazole

108
Q

How is hospital acquired pneumonia treated?

A

Piperacillin-tazobactam IV 7 days

109
Q

Who should get the pneumococcal vaccine?

A

> 65s
Chronic heart, liver, renal, lung conditions
Diabetics
Immunosuppressed

110
Q

What is an advanced care directive?

A

Advance decisions allow a patient to express their wishes to refuse medical treatment in the future

111
Q

When does an advance decision come into practice?

A

When patient loses capacity to make/communicate decisions

112
Q

What criteria must an advance decision fulfil? (4)

A

Must be clear about the circumstances under which you would not want to receive the specified treatment
Should specify whether you want to receive the specific treatment, even if this could lead to your death
Can’t be used to request certain treatment
Can’t be used to ask for your life to be ended.

113
Q

How is an advance decision made?

A

Tell GP and medical team to put in notes - record, date, sign

IF it is to refuse life saving treatment it must be in writing and include ‘even if life is at risk as a result’

114
Q

What can be included in an advance care directive? (5)

A 
Where - home, hospital
What medical treatment they do/don't want
Dietary requirements
Environment - TV, music, bedtime habits
Religious beliefs
Visitors
115
Q

What CAN’T a patient refuse in an advance directive?

A

Basic care i.e. warmth, shelter, food and water

Treatment for mental health if detained under the mental health act

116
Q

When can an advance care directive be withdrawn?

A

If the person still has capacity

Any actions suggesting they changed their mind

117
Q

What is a power of attorney?

A

Legal document allowing someone else to make decisions on your behalf if you are no longer able to/no longer want to

118
Q

Difference between ordinary and lasting power of attorney?

A

Ordinary - covers decisions about financial affairs, valid with capacity
Lasting - covers finances, or health, if you lose mental capacity for the future

119
Q

When can lasting power of attorneys be used?

A

Financial - while you still have capacity or when you lose it
Health - only when you lose capacity

120
Q

Can LPA overrule advance directives?

A

Yes if the LPA states they can in the document

121
Q

Can advance directives overrule LPA?

A

Yes if the advance directive is made after LPA

122
Q

Are advance decisions and LPAs legally binding?

A

Yes if it is valid and applicable - advance decisions to refuse treatment straight away, LPA when registered with office of the public guardian (can take 3 months)

123
Q

What are the 5 principles of the mental capacity act?

A

1) presumption of capacity
2) right for individuals to be supported to make their own decisions
3) retain the right to make what might be seen as eccentric or unwise decisions 4) anything done for or on behalf of people without capacity must be in their best interest
5) anything done for or on behalf of people without capacity should be the least restrictive of their basic rights and freedoms

124
Q

When are independent mental capacity advocates (IMCA) used?

A

For people who lack capacity and face serious decisions with noone to be an advocate for them

125
Q

Causes of incapacity?

A 
Dementia
Psychotic illness
Learning disability
Traumatic brain injury
Stroke
126
Q

What 4 things must a person be able to do to have capacity?

A

Understand information
Retain it
Weigh up options
Communicate it back

127
Q

If making a decision in best interests, what must be considered?

A

Is there an advance directive or LPA?
Patient wishes and beliefs
Consult with family
Consider if they will regain capacity

128
Q

What is an advance statement?

A

NOT legally binding, just a guide of how they would like future care

129
Q

What is dols?

A

Deprivation of liberty safeguards - amendment to mental capacity act, allowing restraint to be used/restriction of liberty if it is in best interests

130
Q

Who does dols apply to? (3)

A

Mental disorder
Lacks capacity
Deprivation of liberty is in best interests

131
Q

Where do dols apply?

A

Care homes, hospitals

132
Q

Examples of why dols is needed?

A

i.e. in dementia, can decide on their routine, stop them wandering at night, prevent them leaving hospital, continuous supervision

133
Q

Who carries out dols?

A

Best interest assessor

Mental health assessor - doctor

134
Q

What is the relevant person’s representative?

A

Rep for the patient if dols granted, usually family member

If no family, IMCA

135
Q

How long does dols last?

A

12 months - but with regular checks to see if needed

136
Q

Who is the supervisory body for DOLS in the care home? Hospital?

A

Care home - local authority

Hospital - CCG

137
Q

What does a dols ensure

A

That people who are deprived of their liberty are protected from harm, and it is appropriate and in their best interests

138
Q

What is the court of protection?

A

The Court of 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.

139
Q

What is a court appointed deputy?

A

You need to apply to the Court of Protection to act as someone’s deputy and make decisions on their behalf. You would use this if the person in question has already lost capacity to grant a LPA.

3A REVISION (17 decks)

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