Care of the Elderly Flashcards
1
Q
What is happening to fertility rate globally?
A
Decreasing
2
Q
What is happening to life expectancy globally?
A
Increasing
3
Q
List some reasons for increasing life expectancy?
A
Increased resource availability
Better economic conditions
Improved screening programs
Better outcomes following major events (MI, stroke, surgery)
4
Q
What is the consequence of increased life expectancy on presence of co-morbidities?
A
More people have several co-morbidities
5
Q
What is primary ageing?
A
The gradual ageing process
6
Q
What is secondary ageing?
A
The ageing process as a result of disease
7
Q
Name a benefit of ageing?
A
Increased experiential learning
8
Q
What are some neutral effects of ageing?
A
Grey hair
Pastime preference
9
Q
What are some detrimental effects of ageing?
A
Hypertension
Decreased reaction time
10
Q
What is the stochastic theory of ageing?
A
Ageing due to cumulative damage
Random changes over time, oxidative stress, microtrauma etc
11
Q
What is programmed theory of ageing?
A
Ageing that is predetermined
Caused by changes in gene expression during various stages
12
Q
What is the consequence to the body of stochastic and programmed theories of ageing?
A
Homeostatic failure
13
Q
What happens to inter-individual variability with age?
A
It increases
14
Q
What happens to creatinine clearance with age?
A
It decreases
15
Q
What happens to serum creatinine with age?
A
It stays roughly the same due to decreased muscle mass
16
Q
What happens to the gap between systole and diastole with age?
A
The gap increases with age
17
Q
What happens to cardiac output with age?
A
It decreases
18
Q
What happens to vital capacity with age?
A
It decreases
19
Q
How can you define frailty?
A
Progressive dyshomeostasis - susceptibility state that leads to a person being more likely to lose function in the face of an environmental challenge
20
Q
List examples of frailty syndromes
A
Falls Delirium Immobility Incontinence Functional loss
21
Q
What happens with baroreflex sensitivity with age?
A
Baroreflex sensitivity decreases
22
Q
What are the effects of heat and cold stress on age?
A
Increased chances of hypothermia and heat stroke (impaired homeostasis)
23
Q
What is ‘social homeostasis’?
A
Difficulty caused by environmental insults that can lead to frailty (eg death of a spouse etc)
24
Q
Do conditions present the same way in frailty?
A
No
25
Why is there an evidence gap for medications in older people?
Few trials of medications in older people
26
What happens to system redundancy with progressive accumulation of damage?
Redundancy is lost
27
What are the five 'Fried' criteria of frailty phenotype?
```
Unintentional weight loss
Exhaustion
Weak grip strength
Slow walking speed
Low physical activity
```
28
List some domains of health
```
Medical
Psychological
Functional
Behavioural
Nutritional
Spiritual
Environmental
Social
Societal
```
29
What is the comprehensive geriatric assessment?
A process to assess and manage illness in older people with frailty
30
What are the components of CGA?
- Determine what problems are
- Determine what can be reversed
- Produce a management plan
31
Is CGA goal centred or problem centred?
Goal-centred
| And person centred!
32
What are some components of the psychological domain of health in geriatrics?
Mood (Low mood, anxiety)
Confidence ('fear of falling syndrome')
Cognition (Delirium, dementia)
33
What are some components of the functional domain of health in geriatrics?
Mobility
Activities of daily living
Community living skills
34
What key professions are involved in geriatric inpatient care?
```
Geriatrician
OT
PT
Skilled nurses
(Others - GP, Social worker, Home care, Dietitian, SALT)
```
35
Where can CGA be applied?
Inpatient
Intermediate Care
Hospital at Home
36
What are some benefits of CGA?
- More likely to be alive and living at home
| - Less likely to be living in residential care
37
What are some of the benefits of being in hospital?
- Access to clinical expertise
- Access to complex tests and interventions
- Rapid access to supervised care support
38
What are some risks of being in hospital?
- Disorientation and delirium
- Learned dependency
- Deconditioning
- Iatrogenic harm
- Hospital Acquired Infection
39
When should you discharge elderly patients?
When goals are met, or risks outweigh benefits
40
How much more common is incontinence in women?
Three times more common in women
41
What are the categories of causes in urinary incontinence?
```
Extrinsic causes (Outwith urinary system)
Intrinsic causes (Problem w bladder/urinary outlet)
```
42
What are some extrinsic causes to urinary incontinence?
```
Physical state and comorbidities
Reduced mobility
Confusion (Delirium or dementia)
Drinking too much/wrong time
Medications (diuretics)
Constipation
Home circumstances
Social circumstances
```
43
How can you define frailty?
Progressive dyshomeostasis - susceptibility state that leads to a person being more likely to lose function in the face of an environmental challenge
44
List some reasons that ageing increases susceptibility to hypothermia and heat stroke?
- Reduced sweat gland output
- Reduced skin blood flow
- Smaller increase in cardiac output
- Less redistribution of blood flow fro kidneys
- Reduced metabolic heat production
- Reduced peripheral vasoconstriction
45
In what different ways may hyperthyroidism present in frailty?
```
Depression
Cognitive impairment
Muscle weakness
Atrial fibrillation
Heart failure
Angina
Also delirium, falls, immobility, loss of function!
```
46
What anatomical factors does continence depend on?
- Bladder and urethra
- Local innervation
- CNS connections
47
What are the functions of the bladder?
Urine storage
| Voluntary voiding
48
Which components of the bladder are made up of smooth muscle?
Detrusor muscle
| Internal urethral sphincter
49
Which component of the bladder is made up of striated muscle?
External urethral sphincter
50
What is involved in voluntary voiding of the bladder?
- Voluntary relaxation of external sphincter
| - Involuntary relaxation of internal sphincter + contraction of bladder
51
What is the parasympathetic supply to the bladder?
S2-S4
52
What is the sympathetic supply to the bladder?
T10-L2
B-adrenoreceptor - detrusor relaxation
A-Adrenoreceptor - contraction of neck of bladder + internal urethral sphincter
53
What is responsible for somatic control of pelvic floor muscle and external urethral sphincter?
S2-S4 nerves
| Pudendal nerve
54
What CNS centres are involved in micturition control?
Pontine micturition centre
Frontal cortex
Caudal part of spinal cord
55
What are the intrinsic factors that lead to incontinence?
Bladder/outlet too weak/strong
56
What drugs are used in incontinence to relax the detrusor muscle?
Antimuscarinics - eg oxybutinin, tolterodine, solifenacin, trospium
Beta-3 adrenoceptor agoists - mirabegron
57
What drugs are used in incontinence to relax the sphincter/bladder neck muscle?
Alpha Blockers - eg Tamsulosin, Tarazosin, Indoramin
58
What drugs are used in incontinence to shrink the prostate?
Anti-androgen drugs
| eg finasteride, dutaseride
59
What would be indications for referral to specialists in urinary incontinence?
-Failure of initial management (>3 months)
Or onset of
- Vesico-vaginal fistula
- Palpable bladder after micturition/confirmed large residual volume
- Disease of CNS
- Certain gynae conditions (fibroids, procidentia, rectocele, cystocele)
- Severe BPH/prostate cancer
- Previous surgery for contience
- No diagnosis
60
What would be indications for referral to specialists in faecal incontinence?
-Referral after failure of initial management
Or onset of
- Suspected sphincter damage
- Neurological disease
61
What options are available for incontinence if interventions fail?
- Incontinence pads
- Urosheaths
- Intermittent catheterisation
- Long term urinary catheterisation
- Suprapubic catheter
62
How common is delirium?
- 20-30% of all in-patients
- Up to 50% of people post surgery
- Up to 85% pf people at end of life
63
Why is reducing rates of delirium important?
- Massive morbidity and mortality
- Risk of death
- Longer hospital stay/increased institutionalisation
- Persistent functional decline
64
What disciplines may be involved in the management of delirium?
- Physios
- Nurses
- HCSW
- Occupational therapist
- Pharmacist
- Geriatricians
- Psychiatrists
- Social Work
65
What can be used in delirium prevention?
- Orientation and ensuring patients have hearing aids/glasses
- Promoting sleep hygeine
- Early mobilistion
- Pain control
- Prevention + Identifying Postop complications
- Maintaining hydration
- Regulation of bladder/bowel
- Provision of oxygen if appropriate
66
Should asymptomatic bacteruria be treated in older patients?
No
67
Should dipstick tests be used for the diagnosis of UTI in older people?
No.
68
What does tamsulosin (BPH drug) do to BP?
Decreases it
69
List some neurological causes of falls?
```
Stroke (Old, new)
Parkinsonism
Dementia
Deirium
Ataxia
```
70
List some cardiovascular causes of falls?
Postural hypotension
Arrythmia
Heart failure
Aortic Stenosis
71
List some musculoskeletal causes of falls?
Arthritis of weight bearing joints
Sarcopenia (Muscle wasting)
Deformities of feet
72
List some drug causes of falls?
```
Antihypertensives
Sedatives
Alcohol
Beta blocker
Anticholinergics
Opioids
```
73
In what ways do drugs cause falls?
Decreasing
- BP
- HR
- Awareness
Increasing
- Urine output
- Sedation
- Hallucinations
- qTC
- Dizziness
74
What may take place in a falls clinic?
- Eye tests, ECG, Lying and standing BP, Incontinence questionnaire.
- Full assessment of gait and balance
- Thorough history and examination
- Bone health and osteoporosis screening
- Treatment plan made
75
What systematic enquiry questions may be asked on falls history?
- Memory - ideally ask relative too
- Urinary symptoms
- Has walking changed recently
Drugs + Alcohol
76
What may be checked in a top to toe examination of falls?
```
Head and arms
-Cranial nerves (Glasses)
-Neglect
-Cerebellar signs
-Bradykinesia, Rigidity (PD signs)
Pulse (BP), Heart sounds
Kyphosis
Abdo exam (+PR)
Legs
-Loot at feet (Footwear, toenails)
-Check sensation, vibration, proprioception
-Co-ordination
-Romberg's
-Assess gait
```
77
How would you describe the gait of a patient with cerebellar damage?
Ataxic
78
How would you describe the gait of a patient with arthritis?
Arthralgic
| Hurts to walk, limping etc
79
How would you describe the gait of a patient with stroke?
Hemiplegic
80
How would you describe the gait of a patient peripheral neuropathy?
High stepping
81
How would you describe the gait of a patient with vascular parkinsonism?
Small steps, shuffling gait
| May do u turn when turning
82
What is involved in a falls assessment history in A+E?
- ABDCE assessment and assess and treat any injury.
- How did they fall? Did they trip over? What did they trip over?
- Long lie – check CK for rhabdomyolysis. Pneumonia and skin injury common as well.
- Any other falls.
- Any cognitive impairment
- Any incontinence
- Any syncope
- Any features of seizure (rare but happens)
- Are they drunk
- Look at ambulance sheet –
- Talk to relative
83
What examinations and investigations should be done for falls assessment in A+E?
- Acutely unwell? – do bloods
- Do a neuro examination as well as Chest / heart / abdomen (skip reflexes!)
- Look at legs and try and get them to walk (if you can)
- The best history you can get
- Full set of obs
- ECG for all
- Bloods for all* check B12, folate, CK, TFTs
- Check for delirium using 4AT
- Consider CT head if fall with head injury and neurological signs or anticoagulated
84
What is a major reversible cause of falls?
Drugs
85
What serious injuries are assessed for in falls?
- Head injury and extradural
- Seizure
- C spine injury
- Flail chest
- Abdominal injury
- Flail chest
- Pelvic injury
- Limb fracture
86
How would a broken hip present?
Externally rotated, shortened leg
87
What head injury may have a delayed presentation days later?
Subdural haemorrhage
88
In what falls head injury situations should a CT be undertaken?
```
Immediately if
Low GCS <13
Still confused after 2 hours (or not back to baseline cognitive state)
Focal neurology
Signs of skull fracture
Basal skull fracture – CSF leak, bruising around eyes,
Seizure
Vomiting
Anti-coagualtion
```
89
What actions that may undertaken by nurses following a fall?
- Repeated risk assessment
- Datix
- Call family
- Try and prevent further fall
90
What should be considered in a falls prevention care plan?
- Vision aids/mobility aids are in reach
- Consider bed rails
- Regular obs
- Communicate needs with staff
91
List some common iatrogenic drug problems
Anticholinergics - Confusion, dry mouth, constipation, blurred vision, urinary retention, orthostatic hypotension
Tricyclics - Confusion, Unsteady gait
Long acting benzodiazepines - CNS toxicity
Narcotics - confusion
Digoxin toxicity with normal serum concentrations
92
List some drugs commonly associated with admission due to adverse drug reactions (ADRs)?
- NSAIDs
- Diuretics
- Warfarin
- ACEIs
- Antidepressants
- Beta blockers
- Opiates etc
(Most adverse events from anticholinergics, sedatives)
93
List some examples of antimuscarinic drugs
- Oxybutynin (For overactive bladder)
- Amitriptyline (Tricyclic antidepressants)
- Chlorprozamine (Antipsychotic)
Nonclassical antimuscarinics
-Ranitidine, Phenytoin, Fluoxetine, Lithium etc
94
What changes occur in absorption of drugs in elderly patients?
Delay in rate of absorption
eg reduction of saliva production - reduce rate of absorption of bucally administered drugs eg GTN
95
What changes in the elderly patient effect the distribution of drugs in the body?
-Reduced muscle mass
-Increased adipose tissue
(^Duration of fat souble drug action eg diazepam)
-Reduced body water (^Serum levels of water soluble drugs eg digoxin)
Decreased albumin
(^serum levels acidic drugs eg furosemide)
Increased permeability across blood-brain barrier
96
What changes affect drug metabolism in the elderly?
- Decreased liver mass
- Decreased liver blood flow
Leads to
- toxicity due to reduced metabolism/excretion
- reduced first pass metabolism
97
What changes in excretion of drugs can be seen in elderly patients?
Renal function decreases - reduced clearance increases half life of drugs
98
What causes increased sensitivity to particular medicines in elderly patients?
- Change in receptor binding
- Decreased in receptor number
- Altered translation of a receptor initiated cellular response into a biochemical action
99
In general, are lower does or higher doses of medication needed in elderly patients?
Lower doses
100
What are some principles of prescribing in older patients?
- Be clear about diagnosis to avoid ADR
- Consider whether drug therapy needed
- Lower doses generally
- Think about particular problems in elderly with this drug
- Start low, go slow
- Review new drug
- Review all prescriptions regularly
- Try to keep regimens as simple as possible
- Consider compliance issues
- Bear in mind clinical trials are on young people!
101
What prescribing tools/guidance is available for prescribing for elderly patients?
- Beer's criteria
- START-STOPP criteria
- NHS Scotland Polypharmacy guidance
102
What are some adverse effects of antibiotic prescribing in the elderly?
- Diarrhoea and c. diff infection
- Blood dyscrasias (trimethoprim, co-trimoxazole)
- Delirium (quinolones)
- Seizures
- Renal impairment (aminoglycosides)
