CARE OF THE ELDERLY Flashcards
What are 5 challenges faced in geriatric patients?
Frailty Co-morbidity/polypharmacy Atypical disease presentation Slower response to treatment Need for social support
What is frailty?
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
What are the 7 most common presenting complaints in geriatrics?
Falls Confusion Incontinence Off legs Social admission Chest pain SOB
What are the 5 Ms of geriatrics?
Mind (dementia, depression) Mobility (falls) Medications (polypharmacy) Multi-complexity (multi-morbidity) Matters most - meaningful health outcomes
What are the geriatric giants?
Instability
Intellectual impairment
Immobility
Incontinence
What is acopia?
Inability to cope with activities of daily living, mean age 85 years
High mortality rate
Can have serious underlying pathology
Treatment problems in older people? (5)
More prone to side effects Drug interactions Reduced organ function Relevance of secondary prevention Polypharmacy
What is deconditioning?
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
What are the 4 parts to a comprehensive geriatric assessment?
Medical
Functional
Psychological
Social/environmental
What is rehabilitation?
Process of restoring a patient to maximum function
4 legal/ethical issues in geriatrics?
End of life care
Discharge destination
Safeguarding vulnerability
Mental capacity - dementia
Types of abuse older people may undergo?
Neglect Financial abuse Discrimination Institutional abuse Psychological abuse
What is the age range for geriatrics?
Over 65
What is the prevalence of falls?
30% community over 65
40% community over 75
Higher in care homes
What are the leading 5 causes of death in older people?
CV disease Cancer Stroke Pulmonary disease Falls
Impact of falls? (7)
Morbidity e.g. hip fracture
Mortality
Functional decline - hospitalisation, institutionalisation
Long lie - hypothermia, dehydration, pressure sores, death
Depression
Social isolation
Loss of confidence
Cause of falls? (14)
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
Management of falls? (9)
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
What % of falls is due to syncope?
20% of UNEXPLAINED falls - majority of patients with syncope will suffer a fall
Causes of syncope? (5)
Arrythmias Orthostatic hypotension Neurocardiogenic (vasovagal) Carotid sinus syndrome Valvular heart disease
What is osteoporosis?
Commonest bone disease in adults, characterised by a reduction in bone density, disruption of bone architecture and risk of fracture after low impact trauma
Presentation of osteoporosis?
Usually with fragility fracture - hip, vertebra, pelvis, radius/ulna, humerus
Definition of fragility fracture?
Associated with low trauma - fall from a height equal to or less than that of a chair
Risk factor for osteoporosis and fractures?
Age - post menopause Female gender Parental history of fracture Previous fracture Low BMI Low bone mineral density Smoking, alcohol Drugs
What drugs predispose to osteoporosis and fractures? (4)
Steroids
Anticonvulsants
Heparin
Aromatase inhibitors
Investigations for osteoporosis? (7)
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
Treatment for osteoporosis? (5)
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)
Medications that may cause dizziness –> falls?
ACEis, beta blockers, diuretics, benzos, anticholinergics
Medications that may cause hypotension –> falls?
Beta blockers, vasodilators (nitrates/calcium blockers), viagra, opioids
Cause of hip fractures?
Frailty and falls risk
What are the types of hip fracture?
Intracapsular and extracapsular
Symptoms of hip fractures? (4)
Pain in hip
Inability to walk
Fall
Shortened and externally rotated limb
Investigations of hip fractures? (10)
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
Management of hip fracture? (5)
Analgesia and fluids Pressure area care Early surgery within 48 hours - screw fixation Antibiotic prophylaxis Thromboprophylaxis
When are hip fractures managed conservatively? (4)
Short life expectancy
Late presentation - partially healed
Immobility
High risk surgery
What are other common fragility fractures?
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
How are vertebral fractures managed? (6)
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
What is a pressure ulcer?
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
Risk factors for pressure ulcers? (9)
Age >70 Bedridden and immobile Obese Incontinent Decreased consciousness Malnutrition/dehydration Diabetes Peripheral arterial disease Severe chronic disease
Investigations for pressure ulcer? (5)
Assessment of risk - Waterlow scoring CRP/ESR, WCC Swabs for infection Blood cultures X ray for bone involvement
Common sites for pressure ulcers?
Sacrum Occiput Heels Elbows Shoulder Inner knees
Grading of pressure ulcers?
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
Prevention of pressure ulcers? (5)
Barrier creams Foam mattress Heel supports Repositioning every 4-6 hours Regular skin assessment
Management of a pressure ulcer? (5)
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
Most common causes of delirium in the elderly?
Infection
Medications - dopamine agonists, anticonvulsants, opioids, benzos
Dehydration/electrolyte disturbance
Treatment of delirium in the elderly?
Remove cause
Continuity of care
Easy orientation i.e. big clock
What is malnutrition?
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
Causes of malnutrition?
Decreased nutrient intake
Increased nutrient requirements
Inability to use ingested nutrients
What is the MUST tool?
Malnutrition universal screening tool
Components of the MUST tool
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
Management of high risk malnutrition?
Refer to dietitian
Reweigh weekly
Optimise fluids etc
Give some factors affecting intake?
Meal times, unfamiliar foods, lack of appetite, pain, anxiety, medications
Give some factors increasing requirements?
Infection, inflammation, trauma, liver disease, wound healing, surgery, malignancy, chronic infection
Give some factors increasing loss?
Diarrhoea, vomiting, bowel surgery, pancreatic insufficiency, IBD
Consequences of malnutrition?
Impaired immunity Impaired wound healing Loss of muscle mass Loss of cardiac function Impaired skin integrity - pressure ulcers Prolonged hospital stay
What is refeeding syndrome?
Prolonged starvation followed by provision of nutritional supplementation
Potentially fatal shift in fluids and electrolytes
Symptoms of refeeding syndrome? (10)
Arrhythmia Hypertension Abdo pain Vomiting Constipation Rhabdomyolysis Weakness SoB Infections Anaemia
What is shown on bloods in refeeding syndrome? (5)
Hypophosphataemia Hypokalaemia Hypomagnesaemia Hyperglycaemia Thiamine deficiency
Treatment of refeeding syndrome?
Replace electrolytes - phosphate, potassium, magnesium
Monitor sodium and glucose
Vitamin B6, B12, folate
Advice for meals in the elderly?
Small and frequent high calorie (i.e. fortisip)
What is parenteral nutrition?
IV administration of nutrients, use central catheter (into vein i.e. subclavian, internal jugular, femoral) if longer than 2 weeks
Indications for total parenteral nutrition? (5)
Short bowel syndrome GI fistula Severe malnutrition IBD Multi organ failure
What is enteral feeding?
Delivery of nutritionally complete feed directly into stomach, duodenum or jejunum
How is enteral feeding done?
NG/NJ tube, PEG (percutaneous endoscopic gastrostomy) tube after 1 month
Indications for a PEG tube?
Stroke
Parkinsons
MND
Oesophageal cancer
What are the types of incontinence?
Urinary and faecal, can be double
Mechanisms of incontinence?
Stress - weakness of urinary outlet
Urge - detrusor overactivity
Overflow - urethral stricture, detrusor weakness - BLADDER OUTLET OBSTRUCTION
Functional
Complications of incontinence?
Depression
Pressure ulcers/skin infection
Care home admission
Impaired QoL
Causes of stress incontinence?
RISE IN ABDO PRESSURE, WEAK SPHINCTER
Age
Obesity
Pelvic floor damage - childbirth, trauma, prostatectomy
Causes of urge incontinence?
DETRUSOR OVERACTIVITY
Detrusor instability - infection/inflammation
Brain damage - Stroke, Parkinsons, Dementia
Diabetes
Diuretics
Investigation of incontinence?
Fluid diary Urinalysis (diabetes, UTI) FBC, U+E, glucose, Ca Post void bladder scan Uroflowmetry, cystometry, ambulatory urodynamics
Reversible/transient causes of incontinence?
Delirium Infection Atrophy (vaginal) Pharmacological Psychological Excess urine output Restricted mobility Stool impaction
Medications causing/exacerbating urinary incontinence?
Antipsychotics Diuretics Cholinesterase inhibitors ACEis CCBs Opioids Alpha adrenoreceptor blockers
Red flags in incontinence? (4)
Pain on micturition
Haematuria
Prolapse beyond introitus
Suspicion of prostate cancer
Management of stress incontinence? (5)
Stop smoking, lose weight, reduce alcohol/caffeine Pelvic floor exercises, vaginal cones Duloxetine Pudendal nerve stimulation Surgery - mid-urethral sling
Management of urge incontinence/overactive bladder?
Reduce fluid intake, caffeine/alcohol, lose weight Oestrogen for atrophic vaginitis Bladder training Antimuscarinics Botulinum toxin Surgery - sacral nerve stimulation
Name antimuscarinics used in urge incontinence?
Oxybutinin
Tolteradine
Why is inappropriate prescribing more common in older people?
Higher prevalence of chronic disease
Higher levels of polypharmacy
Age related physiological changes
Complications of polypharmacy?
Reduced compliance
Increased drug interactions
Side effects
Prolonged hospital stay
Changes in metabolism in drugs in older people? (4)
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
What is polypharmacy?
Increase in the number of medications/the use of more medications than are medically necessary
Major is >5 drugs
What is appropriate polypharmacy?
All drugs prescribed for the purpose of achieving specific therapeutic objectives
Therapeutic objectives are being achieved
Minimised risk of ADRs
Motivated patient
5 steps of deprescribing protocol?
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
What is compliance and concordance?
Compliance - degree to which patient correctly follows medical advice or treatment
Concordance - consultation process, agreement between patient and doctor
Reasons for non compliance?
Problems swallowing
Side effects
Difficulty obtaining medications
Difficulty remembering doses/times
How can compliance be helped?
Carers
Pre filled pill organisers/dosette boxes
What is pneumonia?
Acute lower respiratory tract illness characterised by inflammation and infiltration of neutrophils
Risk factors for pneumonia? (7)
Very young or very old Smoking Viral infection COPD, lung tumour, bronchiectasis Immunosuppression esp. p.jirovecii Hospitalisation Aspiration - after stroke, Parkinsons
Classification of pneumonia?
Community acquired
Hospital acquired
Aspiration
Immunocompromised
Commonest cause of community acquired pneumonia?
1 - Streptococcus pneumoniae
2 - Haemophilus influenzae, Mycoplasma pneumoniae
3 - Staphylococcus aureus, Legionella
15% viral
Commonest cause of hospital acquired pneumonia?
Gram negative enterobacteria or Staphylococcus aureus
2 - Pseudomonas, Klebsiella
Organism associated with immunocompromised pneumonia?
Pneumocystis jiroveci (P.carinii)
Symptoms of pneumonia?
Fever Rigors, malaise Anorexia Dyspnoea Cough Purulent sputum Haemoptysis Pleuritic chest pain
How may the elderly present with pneumonia?
Systemically - malaise, fatigue, anorexia, myalgia, confused
Signs of pneumonia? (8)
Pyrexia Cyanosis Confusion Tachypnoea Tachycardia Hypotension Consolidation Pleural rub
Signs of consolidation? (4)
Diminished expansion
Dull percussion
Increased vocal resonance
Bronchial breathing
What is the CURB-65 score?
Confusion Urea >7mmol/L Resp rate >30/min BP <90 /60 65 or over in age
2 = hospital, 3 = severe, may need ITU
Tests for pneumonia? (5)
CXR Oxygen saturation (then ABG if <92%) BP Bloods - FBC, U+E, CRP, LFT, cultures Sputum MC+S
What is seen on CXR in pneumonia? (3)
Lobar/multilobar infiltrates
Cavitation
Pleural effusion
Additional tests in severe/possibly atypical pneumonia?
Urine antigens - legionella, pneumococcal
Atypical organism/viral serology - PCR sputum, paired serology
Pleural fluid aspiration and culture
Bronchoscopy/bronchoalveolar lavage if immunocompromised/ITU
Management of pneumonia? (6)
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
Complications of pneumonia?
Pleural effusion Empyema Lung abscess Respiratory failure Sepsis
How is low severity community acquired pneumonia treated?
Amoxicillin - 5 days (or clarithromycin) oral, extend if not improving after 3 days
How is moderate CAP treated?
Amoxicillin AND clarithromycin 7-10 days
Oral or IV
How is severe CAP treated?
Co-amoxiclav AND amoxicillin IV
What should be used is staphylococcus or MRSA suspected in pneumonia?
Add flucloxacillin if staphylococcal
Vancomycin if MRSA
Treat for 10 days at least
How are atypical Legionella and P.jirovecii pneumonias treated?
Legionella - ciprofloxacin with clarithromycin
P.jirovecii - co-trimoxazole
How is hospital acquired pneumonia treated?
Piperacillin-tazobactam IV 7 days
Who should get the pneumococcal vaccine?
> 65s
Chronic heart, liver, renal, lung conditions
Diabetics
Immunosuppressed
What is an advanced care directive?
Advance decisions allow a patient to express their wishes to refuse medical treatment in the future
When does an advance decision come into practice?
When patient loses capacity to make/communicate decisions
What criteria must an advance decision fulfil? (4)
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.
How is an advance decision made?
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’
What can be included in an advance care directive? (5)
Where - home, hospital What medical treatment they do/don't want Dietary requirements Environment - TV, music, bedtime habits Religious beliefs Visitors
What CAN’T a patient refuse in an advance directive?
Basic care i.e. warmth, shelter, food and water
Treatment for mental health if detained under the mental health act
When can an advance care directive be withdrawn?
If the person still has capacity
Any actions suggesting they changed their mind
What is a power of attorney?
Legal document allowing someone else to make decisions on your behalf if you are no longer able to/no longer want to
Difference between ordinary and lasting power of attorney?
Ordinary - covers decisions about financial affairs, valid with capacity
Lasting - covers finances, or health, if you lose mental capacity for the future
When can lasting power of attorneys be used?
Financial - while you still have capacity or when you lose it
Health - only when you lose capacity
Can LPA overrule advance directives?
Yes if the LPA states they can in the document
Can advance directives overrule LPA?
Yes if the advance directive is made after LPA
Are advance decisions and LPAs legally binding?
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)
What are the 5 principles of the mental capacity act?
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
When are independent mental capacity advocates (IMCA) used?
For people who lack capacity and face serious decisions with noone to be an advocate for them
Causes of incapacity?
Dementia Psychotic illness Learning disability Traumatic brain injury Stroke
What 4 things must a person be able to do to have capacity?
Understand information
Retain it
Weigh up options
Communicate it back
If making a decision in best interests, what must be considered?
Is there an advance directive or LPA?
Patient wishes and beliefs
Consult with family
Consider if they will regain capacity
What is an advance statement?
NOT legally binding, just a guide of how they would like future care
What is dols?
Deprivation of liberty safeguards - amendment to mental capacity act, allowing restraint to be used/restriction of liberty if it is in best interests
Who does dols apply to? (3)
Mental disorder
Lacks capacity
Deprivation of liberty is in best interests
Where do dols apply?
Care homes, hospitals
Examples of why dols is needed?
i.e. in dementia, can decide on their routine, stop them wandering at night, prevent them leaving hospital, continuous supervision
Who carries out dols?
Best interest assessor
Mental health assessor - doctor
What is the relevant person’s representative?
Rep for the patient if dols granted, usually family member
If no family, IMCA
How long does dols last?
12 months - but with regular checks to see if needed
Who is the supervisory body for DOLS in the care home? Hospital?
Care home - local authority
Hospital - CCG
What does a dols ensure
That people who are deprived of their liberty are protected from harm, and it is appropriate and in their best interests
What is the court of protection?
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.
What is a court appointed deputy?
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.
