Care of the Elderly Flashcards
Components of geriatric medicine?
slower treatment response, frailty, acute illness, different disease presentation patterns, co-morbidities, end of life, rehab, chronic illness
What is frailty?
increased vulnerability from ageing and decline in reserve and function in many systems so that ADLs and acute stressors are compromised
Risks for pneumonia?
smoking (lung cancer, COPD, peripheral vascular disease), diabetes, myeloma, dementia; all can lead to pneumonia
Most common presenting complaints in COTE?
falls most common (instability), confusion next (intellectual impairment), then off legs (immobility) and incontinence; last = social admission (acopia), chest pain, SOB, urinary symptoms
The 5Ms of geriatric medicine?
o Mind – dementia, delirium, depression
o Mobility – impaired gait and balance, falls
o Medications – polypharmacy, deprescribing/optimal prescribing, adverse effects, medication burden
o Multi-complexity – multi-morbidity, bio-psycho-social situations
o Matters most – individual meaningful health outcomes and preferences
What is acopia?
no acute medical problem, unable to cope with ADLs; usually underlying geriatric M causing
What aspects to consider when treating in COTE?
try to reduce meds on as can compromise them further and reduce organ function; multiple pathologies to balance; less relevant to have secondary prevention when very old; need to see if meds interact
What is deconditioning?
bedbound for 2+ days, confused, poor nutritional state; can’t look after self, fall and can’t walk
What is encompassed in a comprehensive geriatric assessment?
multidimensial, multidisciplinary diagnostic process; use medical, psych and functional capabilities; make co-ordinated integrated plan and long-term follow up; physical health, mental health, functional ability, social circumstances, environment
What is the goal of rehab?
restore patient’s max function; multi-discipline
What legal/ethical issues are there within COTE?
palliative care, discharge destination, dementia (MHA – safeguard; physical, neglect, physiological, financial, discriminatory, institutional, sexual abuse; must report it; don’t confront abuser; don’t ask too many questions)
What are common conditions in COTE?
delirium, dementia, depression, falls, syncope, PD, osteoporosis, incontinence, stroke, TIA, pressure ulcers, MCA
What is the 5 criteria of frailty?
slowness, weight loss, impaired strength, exhaustion, low physical activity
What is the frailty index and score?
number of deficit divided by number of deficits considered
What 2 types of ADLs are there?
basic (self-maintenance) or instrumental (independence in community)
What ADL assessment is used for dementia patients?
Lawton Brody
What ADL assessment is used for chronic disease and rehab patients?
Barthel index and functional independence measure
How is ADL decline prevented?
evaluation, management unit with MDT for therapy and review, home visits
Polypharmacy definition?
More than 5 meds
When is a medication review carried out?
when functional decline or development of syndromes; non-adherence think of depression/dementia
Risks in polypharmacy?
frailty, lack of communication, polypharmacy, change in pharmacokinetics, lack of evidence
What is involved in inappropriate prescribing?
CIs, wrong dose/duration, no affect on pt outcome, adversely affects prognosis
What should be done to safely prescribe?
benefits outweigh risks, cost effective, safe, tailored to individual
Why is resp disease more common in elderly?
More dead alveolar space
When should B2 agonists not be used?
MI
What is used for COPD depression?
paroxetine
What is used to treat CAP?
narrow-spectrum beta lactam and macrolide; for hospitalised use ceftriaxone with azithromycin; abx for 1wk
How is TB managed/treated?
CXR, tuberculin test; more likely to get miliary, meningitis, skeletal/GU if older; most from reactivation
What is obstructive sleep apnoea (OSA)?
repeated apnoea and hypopnoea in sleep which is common in older
RFs for OSA?
diabetes, obesity, renal failure, IHD, hypothyroidism, stroke
Complications from OSA?
drowsiness, fatigue, morning headache, difficulty conc, impaired ADL, cvd mortality
Management and treatment of OSA?
management = weight loss, no alcohol, thyroid replacement, avoid supine sleep; treat = CPAP; use overnight-attended polysomnography
Lung cancer RFs?
smoking, FH, occupational carcinogens, 2nd hand smoke, air pollution, underlying lung disease
Lunger cancer poor prognosis risks?
dementia, poor nutrition, no social support, bad stage, bad performance status, poor differentiation histology
Treatment an management of lung cancer?
surgery, chemo for advanced and radio; lots of cases in >60yrs
Age RFs for heart failure?
elevated left ventricular end diastolic pressure, increased arterial stiffness, impaired response to beta adrenergic stimulation, decline in sinus node function, renal and lung problems
Treatment for HF?
exercise, functional electrical stimulation, ACEi/ARBs, digoxin, bet blockers titrated to HR, cardiac resynchronisation therapy for those with LV fraction <35%, QRS >120 and advanced HF symptoms; most treatments do not reduce mortality but hospitalisations
What is delirium?
Acute disturbance of consciousness, change in cognition, reduced ability to focus, sustain and shift attention; can fluctuate
Causes of delirium?
condition (pneumonia, sepsis, meningitis), intoxication, med use (sedatives, narcotics, anticholinergics, psychotropics [benzodiazepines, anticonvulsants, Parkinson meds]), vascular disorders, metabolic disorders, vitamin deficiency, endocrinopathies, trauma, epilepsy, neoplasia
RFs for delirium?
sensory impairment, severe illness (infection/organ impairment), cognitive impairment, high urea/creatinine ratio, biochem disturbance, functional impairment, depression, alcohol/drug withdrawal; post-op risks = same as above plus old age, living sitch, abnormal preop bloods, surgery type
Delirium S+Ss?
acute, fluctuate, impaired consciousness, poor conc, memory deficit, abnormal sleep cycle, hallucinations, agitated, emotionally labile, neuro signs; hypoactive = apathy and quiet confusion; hyperactive = agitation, delusions, disorientated
Delirium investigations?
ABC, GCS, vitals, cap glucose, examination, bloods, urine, cultures, ECG, CXR, CT
Delirium diagnosis?
clinical; difficult in blind, >80yrs, dementia; DSM is gold standard; confusion assessment = acute onset, fluctuating course, inattention, disorganised thinking, altered consciousness level
Delirium prevention?
avoid risks and treat condition; insufficient evidence for pharma drugs
Delirium management and treatment?
calm and reassure, optimise vision and hearing, optimise sleep, meet needs, avoid sensory extremes, avoid speciality jargon, control environment of the room, antipsychotics if aggressive (haloperidol and olanzapine but in tremens use benzodiazepines)
Delirium complications?
acquired-infections, pressure sores, fx, cognitive impairment
Mild score on MMSE?
18-26
Moderate score on MMSE?
10-28
Severe score on MMSE?
less than 10
Management of dementia?
capacity assessment, driving and advance care planning
Risks of falling?
> 80yrs, female, low weight, hx falls, ADL dependency, orthostatic hypotension, meds (benzos, antidepressants, antipsychotics, anticonvulsants, antihypertensives), polypharmacy, alcohol misuse, DM, confusion, cognitive impairment, vision impairment, balance, gait, incontinence, wrong footwear, home hazards, depression, muscle weakness
Risk for fractures?
osteoporosis/malacia, Paget’s, bone mets, lack of SC fat, neuro problems, sensory/motor, joint problems
History for falls?
previous falls = pattern, pre/during/post, precipitants, LOC, chest pain, witnesses, sight; general health = appetite, functional status, cognition; exam = mental state, visual, CV, neuro, risk assess falling (timed up and go, turn 180 tests); establish cause
Tests for falls?
baseline bloods, ECG, lying/standing bp, urine dipstick
Management for falls?
group/home-based exercise, home safety (assessment and modify), review meds, cardiac pacing, get up slowly
What does a multfiactorial assessment consist of when related to falls?
cognition, continence, hx of falls, footwear, PMC, meds, postural instability, syncope syndrome, visual impairment
What are falls called when the cause is unknown?
Drop attacks
What is functional urinary incontinence?
can’t reach toilet on time from surroundings/immobility
What is stress urinary incontinence?
from exertion, sneezing etc (incompetent sphincter); hysterectomy
What is urge urinary incontinence?
urine leakage with urge of micturition first (detrusor instability and hyperreflexia, sometimes from infections/stones)
What is mixed urinary incontinence?
Urge and stress
What is overactive bladder syndrome?
urge without incontinence but frequency and nocturia (detrusor overactive)
What is overflow incontinence?
chronic bladder outflow obstruction (prostate) can lead to obstructive nephropathy
What is true incontinence?
from a fistula
Risk of incontinence in women?
pregnancy, DM, oral oestrogen, high BMI
Risk of incontinence in men?
LUTS, functional/cognitive impairment, neuro problems, prostatectomy
History for incontinence?
type, frequency, dribbling, loss of control, incomplete, dysuria, spasm, obstetric, bladder chart, sexual dysfunction, QOL, meds, bowels, treatment desire
Examination for incontinence?
DRE, pelvic floor digital, vaginal, abdo, pelvic, neuro
Investigations for incontinence?
urine dipstick, renal function, post void residual volume, urinary flow rate, kidney US; 2wk within if visible haematuria, microscopic haematuria >50, persistent UTI >40, suspected malignancy (women); refer if visible prolapse or palpable bladder after voiding; men referred = LUTS, complicated recurrent UTI, renal impairment, suspected malignancy
Management and treatment for incontinence?
pads given until plan; stress give pelvic floor exercises, 2nd line duloxetine but then use retropubic mid-urethral tape, open colposuspension, autologous rectal fascia sling; artificial sphincter 1st line in neuro disease and bladder training sometimes use Botox; pelvic floor for men after prostate surgery and artificial sphincters; mixed = pelvic floor, bladder training 1st, then oxybutynin and then darifenacin/solifenacin/tolterodine; overflow treat obstruction and intermittent self-catheterisation; augmentation cystoplasty in non-progressive neuro; ileal conduit diversion for neuro with intractable problems; desmopressin in women with nocturia
When are catheters used in incontinence?
for persistent urinary retention/renal impairment; indwelling if chronic and pt cannot self-catheterise
What is chronic constipation?
6 months; associated with haemorrhoids, anal fissure, colorectal cancer
History for constipation?
red flags, freq/nature/consistency stool, blood/mucus, diet, drugs, recent bowel change; exam abdo and DRE
Causes of constipation?
low fibre, low fluid, immobility, IBS, elderly, hosp, anorectal disease, intestinal obstruction, hypothyroidism, hypercalcaemia, hypokalaemia, opioids, anticholinergics, neuromuscular and chronic laxatives; if >40, recent bowel change and red flag invest
Investigations for constipation?
bloods, sigmoidoscopy, barium enema, anorecta physiology
Management and treatment for constipation?
treat cause, mobilise, increase fluids, fibre and drugs; bulk producers (stimulate peristalsis - methylcellulose); softeners (liquid paraffin); stimulants (bisacodyl, senna, docusate sodium, glycerol suppositories); osmotic agents (lactulose and magnesium salts), sodium phosphate enemas; prucalopride if 2 don’t work in woman in 6 months
Pressure ulcers S+Ss?
red, blistered, broken, necrotic skin and can extend to muscle/bone; from pressure and friction over bony prominence
Pressure ulcers risks?
AD, CVD, DM, COPD, hip fx, HF, DVT, limb paralysis, malignancy, PD, RA, UTI
Assessment tools for pressure ulcers?
Norton, Braden (sensory, moisture, activity, mobility, nutrition, friction), Waterlow; low score is high risk (1-4)
Hx for pressure ulcers?
comorbidities, nutrition, pain, continence, neuro, blood supply, infection, meds, previous, psych, social
Assessment for a pressure ulcer?
cause, site, dimensions, grade, exudate, type, infection, pain, appearance, skin, odour, fistula
Grading of pressure ulcers?
grade 1 = skin discolour and oedema, grade 2 = epidermis/dermis loss and superficial with blister, grade 3 = full skin loss and SC necrosis, grade 4 = extensive destruction and necrosis with damage to underlying structures (easier to infect)
Management and treatment of pressure ulcers?
3-4 referred to specialist; pressure, good nutrition, wound management (need to promote warm, moist healing), reposition pt, optimal conditions, pressure relieving support, pain relief, infection control (debridement/slough removal and cleansing); alginates for heavy exudate, cadexomer iodine for sloughy/infected, films for epithelializing, foams for granulating, hydrocolloids for low exudate and hydrogel for necrotic, superficial from autolytic debridement (occlusive dressings)
Prevention of pressure ulcers?
reduce moisture, risk factors, emollients if skin dry, foam mattress if high risk, polyurethane foam to bony prominences, barrier prep
End of life care MDT consist of?
key worker main point of pt contact; unscheduled care worker told about out of hours stuff
S+Ss for someone in palliative care?
weaker, incontinence (urinary then faecal), excessive sleep, lower appetite, weight loss, dense food = diarrhoea, anorexia, insomnia, constipation, sweating, nausea, dyspnoea, dysphasia, neuropsych, vomiting, dyspepsia, paresis, diarrhoea, pruritus
Management of someone in palliative care?
avoid injections, only prolong life if best interests, remember pillars and autonomy, carers need to know what pt wants, can give PD meds with a patch
When is an advance directive used?
pt can’t make decision themselves
What does an advance directive involve?
advance statements on medical treatment/social care in future, advance decision to refuse treatment (must be relevant to situation and valid)
What can an advance directive not do?
request treatment/something illegal/refuse treatment for mental health condition
What is an LPA?
nominate other person to make decisions for them when they lose capacity on property and affairs or health and welfare
How can an LPA be obtained?
Pt 18+ and has capacity
When can choose not to follow an advance directive?
validity questionable, not signed, not witnessed, not applicable to situation
What must be done when advanced planning?
document all conversations, reviewed regularly and on diagnosis/deterioration/personal change in circumstances
What does the Court of Protection do?
makes decisions and appoints deputies to act on behalf of people unable to make their own health/finance/welfare decisions; need to apply to the court to do become deputy; use this when person already lost capacity to get LPA
What is an independent mental capacity advocate?
safeguards people facing long-term move or about serious med treatment, lack capacity about decision at time it needs to be made, has no one to represent them other than paid staff
What is an enteral feeding tube?
tube gastrostomy, nasogastric, jejunostomy, oesophagostomy; palliative usually inserted at bedside/endoscopy
Forms of artificial fluid therapy?
IV, SC, rectal, enteral
Why is artificial nutrition used?
increase survival, stop aspiration, pressure sores, more comfort, decrease malnutrition and dehydration; usually for neuro and cancer
Risks from artificial nutrition?
peripheral and pulmonary oedema, circ overload, possible resp secretions; my require restraints
How to diagnose postural hypotension?
more than 20mmg/hg in standing and lying bp or anything less than 100 systolic
Postural hypotension treatment?
Fludrocortisone
Worst beta blocker to have in elderly?
atenolol
What kind of drugs increase risks of falls?
ach blockers
What is indicative of a pansystolic murmur?
Atrioventricular valve regurg, VSD etc
What is indicative of a ejection systolic murmur?
Aortic/pulmonary valve stenosis
What is indicative of a diastolic murmur?
Atrioventricular valve regurg
What is 1st and second heart sounds?
1st = aortic/pulmonary, 2nd = atrioventricular
Left sternal heave indicative of?
Right ventricular hypertrophy
What is consolidation lung sounds?
High vocal resonance, crackles, hyper resonant
Effusion lung sounds?
Stony dull percussion, reduced air entry and low vocal resonance (same with pneumothorax)
