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Specialties > Care of the Elderly > Flashcards

Care of the Elderly Flashcards

1
Q

What is happening to fertility rate globally?

A

Decreasing

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2
Q

What is happening to life expectancy globally?

A

Increasing

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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)

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4
Q

What is the consequence of increased life expectancy on presence of co-morbidities?

A

More people have several co-morbidities

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5
Q

What is primary ageing?

A

The gradual ageing process

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6
Q

What is secondary ageing?

A

The ageing process as a result of disease

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7
Q

Name a benefit of ageing?

A

Increased experiential learning

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8
Q

What are some neutral effects of ageing?

A

Grey hair

Pastime preference

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9
Q

What are some detrimental effects of ageing?

A

Hypertension

Decreased reaction time

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10
Q

What is the stochastic theory of ageing?

A

Ageing due to cumulative damage

Random changes over time, oxidative stress, microtrauma etc

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11
Q

What is programmed theory of ageing?

A

Ageing that is predetermined

Caused by changes in gene expression during various stages

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12
Q

What is the consequence to the body of stochastic and programmed theories of ageing?

A

Homeostatic failure

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13
Q

What happens to inter-individual variability with age?

A

It increases

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14
Q

What happens to creatinine clearance with age?

A

It decreases

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15
Q

What happens to serum creatinine with age?

A

It stays roughly the same due to decreased muscle mass

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16
Q

What happens to the gap between systole and diastole with age?

A

The gap increases with age

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17
Q

What happens to cardiac output with age?

A

It decreases

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18
Q

What happens to vital capacity with age?

A

It decreases

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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

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20
Q

List examples of frailty syndromes

A 
Falls
Delirium
Immobility
Incontinence
Functional loss
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21
Q

What happens with baroreflex sensitivity with age?

A

Baroreflex sensitivity decreases

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22
Q

What are the effects of heat and cold stress on age?

A

Increased chances of hypothermia and heat stroke (impaired homeostasis)

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23
Q

What is ‘social homeostasis’?

A

Difficulty caused by environmental insults that can lead to frailty (eg death of a spouse etc)

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24
Q

Do conditions present the same way in frailty?

A

No

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25
Q

Why is there an evidence gap for medications in older people?

A

Few trials of medications in older people

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26
Q

What happens to system redundancy with progressive accumulation of damage?

A

Redundancy is lost

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27
Q

What are the five ‘Fried’ criteria of frailty phenotype?

A 
Unintentional weight loss
Exhaustion
Weak grip strength
Slow walking speed
Low physical activity
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28
Q

List some domains of health

A 
Medical
Psychological
Functional
Behavioural
Nutritional
Spiritual
Environmental
Social
Societal
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29
Q

What is the comprehensive geriatric assessment?

A

A process to assess and manage illness in older people with frailty

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30
Q

What are the components of CGA?

A
  • Determine what problems are
  • Determine what can be reversed
  • Produce a management plan
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31
Q

Is CGA goal centred or problem centred?

A

Goal-centred

And person centred!

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32
Q

What are some components of the psychological domain of health in geriatrics?

A

Mood (Low mood, anxiety)
Confidence (‘fear of falling syndrome’)
Cognition (Delirium, dementia)

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33
Q

What are some components of the functional domain of health in geriatrics?

A

Mobility
Activities of daily living
Community living skills

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34
Q

What key professions are involved in geriatric inpatient care?

A 
Geriatrician
OT
PT
Skilled nurses
(Others - GP, Social worker, Home care, Dietitian, SALT)
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35
Q

Where can CGA be applied?

A

Inpatient
Intermediate Care
Hospital at Home

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36
Q

What are some benefits of CGA?

A
  • More likely to be alive and living at home

- Less likely to be living in residential care

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37
Q

What are some of the benefits of being in hospital?

A
  • Access to clinical expertise
  • Access to complex tests and interventions
  • Rapid access to supervised care support
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38
Q

What are some risks of being in hospital?

A
  • Disorientation and delirium
  • Learned dependency
  • Deconditioning
  • Iatrogenic harm
  • Hospital Acquired Infection
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39
Q

When should you discharge elderly patients?

A

When goals are met, or risks outweigh benefits

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40
Q

How much more common is incontinence in women?

A

Three times more common in women

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41
Q

What are the categories of causes in urinary incontinence?

A 
Extrinsic causes (Outwith urinary system)
Intrinsic causes (Problem w bladder/urinary outlet)
42
Q

What are some extrinsic causes to urinary incontinence?

A 
Physical state and comorbidities 
Reduced mobility
Confusion (Delirium or dementia)
Drinking too much/wrong time
Medications (diuretics)
Constipation
Home circumstances
Social circumstances
43
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

44
Q

List some reasons that ageing increases susceptibility to hypothermia and heat stroke?

A
  • 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
Q

In what different ways may hyperthyroidism present in frailty?

A 
Depression
Cognitive impairment
Muscle weakness
Atrial fibrillation
Heart failure
Angina
Also delirium, falls, immobility, loss of function!
46
Q

What anatomical factors does continence depend on?

A
  • Bladder and urethra
  • Local innervation
  • CNS connections
47
Q

What are the functions of the bladder?

A

Urine storage

Voluntary voiding

48
Q

Which components of the bladder are made up of smooth muscle?

A

Detrusor muscle

Internal urethral sphincter

49
Q

Which component of the bladder is made up of striated muscle?

A

External urethral sphincter

50
Q

What is involved in voluntary voiding of the bladder?

A
  • Voluntary relaxation of external sphincter

- Involuntary relaxation of internal sphincter + contraction of bladder

51
Q

What is the parasympathetic supply to the bladder?

A

S2-S4

52
Q

What is the sympathetic supply to the bladder?

A

T10-L2

B-adrenoreceptor - detrusor relaxation
A-Adrenoreceptor - contraction of neck of bladder + internal urethral sphincter

53
Q

What is responsible for somatic control of pelvic floor muscle and external urethral sphincter?

A

S2-S4 nerves

Pudendal nerve

54
Q

What CNS centres are involved in micturition control?

A

Pontine micturition centre
Frontal cortex
Caudal part of spinal cord

55
Q

What are the intrinsic factors that lead to incontinence?

A

Bladder/outlet too weak/strong

56
Q

What drugs are used in incontinence to relax the detrusor muscle?

A

Antimuscarinics - eg oxybutinin, tolterodine, solifenacin, trospium

Beta-3 adrenoceptor agoists - mirabegron

57
Q

What drugs are used in incontinence to relax the sphincter/bladder neck muscle?

A

Alpha Blockers - eg Tamsulosin, Tarazosin, Indoramin

58
Q

What drugs are used in incontinence to shrink the prostate?

A

Anti-androgen drugs

eg finasteride, dutaseride

59
Q

What would be indications for referral to specialists in urinary incontinence?

A

-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
Q

What would be indications for referral to specialists in faecal incontinence?

A

-Referral after failure of initial management

Or onset of

  • Suspected sphincter damage
  • Neurological disease
61
Q

What options are available for incontinence if interventions fail?

A
  • Incontinence pads
  • Urosheaths
  • Intermittent catheterisation
  • Long term urinary catheterisation
  • Suprapubic catheter
62
Q

How common is delirium?

A
  • 20-30% of all in-patients
  • Up to 50% of people post surgery
  • Up to 85% pf people at end of life
63
Q

Why is reducing rates of delirium important?

A
  • Massive morbidity and mortality
  • Risk of death
  • Longer hospital stay/increased institutionalisation
  • Persistent functional decline
64
Q

What disciplines may be involved in the management of delirium?

A
  • Physios
  • Nurses
  • HCSW
  • Occupational therapist
  • Pharmacist
  • Geriatricians
  • Psychiatrists
  • Social Work
65
Q

What can be used in delirium prevention?

A
  • 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
Q

Should asymptomatic bacteruria be treated in older patients?

A

No

67
Q

Should dipstick tests be used for the diagnosis of UTI in older people?

A

No.

68
Q

What does tamsulosin (BPH drug) do to BP?

A

Decreases it

69
Q

List some neurological causes of falls?

A 
Stroke (Old, new)
Parkinsonism
Dementia
Deirium
Ataxia
70
Q

List some cardiovascular causes of falls?

A

Postural hypotension
Arrythmia
Heart failure
Aortic Stenosis

71
Q

List some musculoskeletal causes of falls?

A

Arthritis of weight bearing joints
Sarcopenia (Muscle wasting)
Deformities of feet

72
Q

List some drug causes of falls?

A 
Antihypertensives
Sedatives
Alcohol
Beta blocker
Anticholinergics
Opioids
73
Q

In what ways do drugs cause falls?

A

Decreasing

  • BP
  • HR
  • Awareness

Increasing

  • Urine output
  • Sedation
  • Hallucinations
  • qTC
  • Dizziness
74
Q

What may take place in a falls clinic?

A
  • 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
Q

What systematic enquiry questions may be asked on falls history?

A
  • Memory - ideally ask relative too
  • Urinary symptoms
  • Has walking changed recently

Drugs + Alcohol

76
Q

What may be checked in a top to toe examination of falls?

A 
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
Q

How would you describe the gait of a patient with cerebellar damage?

A

Ataxic

78
Q

How would you describe the gait of a patient with arthritis?

A

Arthralgic

Hurts to walk, limping etc

79
Q

How would you describe the gait of a patient with stroke?

A

Hemiplegic

80
Q

How would you describe the gait of a patient peripheral neuropathy?

A

High stepping

81
Q

How would you describe the gait of a patient with vascular parkinsonism?

A

Small steps, shuffling gait

May do u turn when turning

82
Q

What is involved in a falls assessment history in A+E?

A
  • 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
Q

What examinations and investigations should be done for falls assessment in A+E?

A
  • 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
Q

What is a major reversible cause of falls?

A

Drugs

85
Q

What serious injuries are assessed for in falls?

A
  • Head injury and extradural
  • Seizure
  • C spine injury
  • Flail chest
  • Abdominal injury
  • Flail chest
  • Pelvic injury
  • Limb fracture
86
Q

How would a broken hip present?

A

Externally rotated, shortened leg

87
Q

What head injury may have a delayed presentation days later?

A

Subdural haemorrhage

88
Q

In what falls head injury situations should a CT be undertaken?

A 
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
Q

What actions that may undertaken by nurses following a fall?

A
  • Repeated risk assessment
  • Datix
  • Call family
  • Try and prevent further fall
90
Q

What should be considered in a falls prevention care plan?

A
  • Vision aids/mobility aids are in reach
  • Consider bed rails
  • Regular obs
  • Communicate needs with staff
91
Q

List some common iatrogenic drug problems

A

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
Q

List some drugs commonly associated with admission due to adverse drug reactions (ADRs)?

A
  • NSAIDs
  • Diuretics
  • Warfarin
  • ACEIs
  • Antidepressants
  • Beta blockers
  • Opiates etc

(Most adverse events from anticholinergics, sedatives)

93
Q

List some examples of antimuscarinic drugs

A
  • Oxybutynin (For overactive bladder)
  • Amitriptyline (Tricyclic antidepressants)
  • Chlorprozamine (Antipsychotic)

Nonclassical antimuscarinics
-Ranitidine, Phenytoin, Fluoxetine, Lithium etc

94
Q

What changes occur in absorption of drugs in elderly patients?

A

Delay in rate of absorption

eg reduction of saliva production - reduce rate of absorption of bucally administered drugs eg GTN

95
Q

What changes in the elderly patient effect the distribution of drugs in the body?

A

-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
Q

What changes affect drug metabolism in the elderly?

A
  • Decreased liver mass
  • Decreased liver blood flow

Leads to

  • toxicity due to reduced metabolism/excretion
  • reduced first pass metabolism
97
Q

What changes in excretion of drugs can be seen in elderly patients?

A

Renal function decreases - reduced clearance increases half life of drugs

98
Q

What causes increased sensitivity to particular medicines in elderly patients?

A
  • Change in receptor binding
  • Decreased in receptor number
  • Altered translation of a receptor initiated cellular response into a biochemical action
99
Q

In general, are lower does or higher doses of medication needed in elderly patients?

A

Lower doses

100
Q

What are some principles of prescribing in older patients?

A
  • 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
Q

What prescribing tools/guidance is available for prescribing for elderly patients?

A
  • Beer’s criteria
  • START-STOPP criteria
  • NHS Scotland Polypharmacy guidance
102
Q

What are some adverse effects of antibiotic prescribing in the elderly?

A
  • Diarrhoea and c. diff infection
  • Blood dyscrasias (trimethoprim, co-trimoxazole)
  • Delirium (quinolones)
  • Seizures
  • Renal impairment (aminoglycosides)

Specialties (5 decks)

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