Care of the elderly Flashcards
What age group does geriatric medicine deal with in the UK
> 75
What age related differences of medical importance are present in geriatric medicine
Differences in physiology and presentation of disease, which influences assessment, investigation and management
Can affect pharmacokinetics: reduced volume distribution, reduced liver metabolism, reduced renal blood flow, reduced clearance of water soluble drugs
Can affect pharmacodynamics: increased sensitivity of body to drugs, lower dosage needed
Why is it important to not stop at one diagnosis with elderly patients
Due to patients commonly presenting > 1 problem = multiple pathologies and this is complicated by poly pharmacy and pre-existing disease which can predispose the drugs given to adverse effects and drug interactions
What are the common presentations seen in geriatric patients
- General deterioration and functional decline
- Confusion, falls, reduced mobility (medical problems in disguise)
- Fractured neck of femur
- Acute disease may be hidden and precipitate impairment of other systems
What are the geriatric ‘giants’
- Incontinence
- Immobility
- Instability (falls and syncope)
- Intellectual impairment (delirium and dementia)
- Iatrogenic disease = medication related
- Infection (chest, urine, biliary tract)
What reduced homeostatic reserves are associated with aging
- Reduction in organ function and reduced compensation
- CVS reduced responsiveness in severe illness
- Renal function decline and renal failure due to medication and illness
- Thermoregulation impairment
Describe how geriatric patients have impaired immunity
- More likely to get shingles with reactivation of HZV
- May not have increased WBC count or pyrexia with infection - instead hypothermia
- Tend not to get rigid abdomen in peritonitis: tender and soft
What are the common sites of presentation of shingles
Affects single dermatomes; thoracic
- chest and trigeminal nerve are predisposed
- unilateral presentation
What are the key activities of daily living (ADL)
- Mobility including aids and appliances
- Washing and dressing
- Continence
- Eating and drinking
- Shopping, cooking and cleaning
What is a fragility fracture
Fracture sustained when falling from standing height or less
Which one of the following skeletal sites is most commonly involved in osteoporotic bone fractures:
a. Mandible
b. Radius
c. Sacrum
d. Spine
e. Tibia
D
What is osteoporosis and list the common fracture sites
A progressive systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone and tissue with a consequent increase in bone fragility and susceptibility to fracture
= asymptomatic until fracture occurs: common in spine, wrist, hip
Osteoporosis results in chronic pain, disability, loss of independence and premature death
Outline aetiology of osteoporosis
Commonly postmenopausal women as a result of oestrogen deficiency (1 in 3)
50% of male cases are associated with hypogonadism (treatment for reduced function of sexual glands causes osteoporosis), corticosteroid treatment and XS alcohol
What are the non-modifiable risk factors for osteoporosis
- Female
- Family history of osteoporosis
- Caucasian or asian ethnicity
- Age > 65
- Previous fragility fracture
What are the modifiable risk factors of osteoporosis
- Low BMI
- Smoking
- XS alcohol
- Low calcium intake and vit D deficiency
- Inactivity
What are the hormonal and drug risk factors of osteoporosis
Hormonal = menopause before 45, male hypogonadism Drugs = glucocorticoids, anticonvulsants, cytotoxic therapy
What are the secondary causes of osteoporosis
- Rheumatoid arthritis
- Hyperthyroidism
- Malabsorption (partial coeliac disease)
- Chronic liver disease
- Primary hyperparathyroidism
- Prolonged immobilisation
- Anorexia nervosa
How is osteoporosis diagnosed
- Marked osteopenia on plain x-ray
- Previous fragility fracture
- Identification of risk for osteoporosis
- Bone mineral density by facial dural energy x-ray absorptiometry (DEXA scan)
Describe how vitamin D is essential for bone health
It regulates calcium and phosphate absorption and metabolism - deficiency is common in elderly and can be asymptomatic or cause muscular aches, bone pains, osteomalacia (bone softening), and can exacerbate bone loss in osteoporosis
How is vitamin D obtained
Majority = produced through action of sunlight on skin to give D3
Some = D3 from meat and D2 from vegetables
Outline treatment for osteoporosis (lifestyle changes)
- Smoking cessation, alcohol moderation
- Healthy balanced diet, good calcium intake, low salt
- Appropriate sun exposure
- If oral corticosteroids are required, low dose and use steroid sparing agents
- Regular weight bearing exercise
Outline pharmacological treatments for osteoporosis
- Calcium and vitamin D supplements
- Bisphosphonates = reduce rate of bone turnover but can cause medicine-related osteonecrosis of the jaw
- alendronate (can cause oesophagitis and oral ulcers)
- ettidronate
- risedronate
- zoledronate - Raloxifene
- Teriparatide
- Calcitonin
- Strontium renelate
Why are hormone replacement therapies no longer recommended for the treatment of osteoporosis
Because of the increased risk of breast cancer and CVD
Outline potential indications for bisphosphonates
- Prevention and treatment of osteoporosis in postmenopausal women
- Prophylaxis of corticosteroid-associated osteoporosis
- Treatment of hypercalcaemia of malignancy
- Management of bone metastases e.g. breast cancer
- Management of osteolytic lesions in multiple myeloma
- Management of Paget’s disease
What are the clinical presentations of B/MRONJ
- Delayed healing following dental extraction/ oral surgery
- Pain, soft tissue infection and swelling
- Numbness, paraesthesia
- Exposed bone
- Nonexposed variant
How is B/MRONJ managed
- Identify patients at risk and educate
- If surgical intervention is needed use atraumatic technique
- Potential prophylactic antibiotics given
- Stop bisphosphonate treatment, nutritional supplements, hyperbaric oxygen, chlorhexidine, systematic antibiotics
Describe the pathophysiology of strokes
It is caused by sudden disruption to blood supply of brain
- Cerebral infarction = blockage of arterial blood supply by small vessel occlusion, atherothromboembolism or embolisation: results in disturbance of neuronal electrical activity (reversible) and cellular membrane integrity (irreversible)
- Intracerebral haemorrhage = rupture of blood vessels in brain tissue causing direct neuronal injury and cerebral oedema
Outline risk factors for cerebrovascular accidents
- Hypertension, heart disease, PVD, TIA/stokes, carotid bruit
- Smoking, diabetes, OCP, alcoholism
- Polycythaemia, increased clotting
- Hyperlipidaemia
What differentiates TIAs from strokes
Neurological sings and symptoms resolve within 24 hrs and most last for an hour (those involving eye last a few minutes) - embolic
Many TIAs lasting several hours are infarcts
What are the general clinical features of strokes and TIAs
- Sudden onset of focal neurological deficit
- Ensuing disability relating to distribution of affected artery but collateral supplies make this less clear
- Difficult to distinguish clinically between ischaemic and haemorrhagic strokes
- Haemorrhagic stoke may have associated meningism, severe headache and coma within hours
What are the clinical features fo stoke/TIAs with anterior (carotid) circulation territory
- Cortical dysfunction = dysphasia, sensory/visual inattention, hemianopia
- Monoccular blindness
- Unilateral weakness
- Unilateral sensory disturbance
- Dysarthria
- Neuromuscular dysphagia
What are the clinical features fo stoke/TIAs with posterior (vertebrobasilar) circulation territory
- Cranial nerve palsy
- Ataxia / incoordination / disequilibrium
- Diplopia
- Bilateral visual loss
- Unilateral/ bilateral weakness or sensory disturbance
- Dysarthria
- Neuromuscular dysphagia
Outline acute management of strokes/ TIAs
- Maintain patients airways, avoid hypoxia/aspiration
- Monitor blood glucose (keep between 4-11)
- Monitor BP
- Urgent CT/MRI
- Thrombolysis if aged 18-80 and <4.5 hours ago
- NBM until swallowing assessed
- Antiplatelet agents once haemorrhagic stroke excluded (aspirin 300mg/d 2 weeks reduced to 75mg/d)
- Admission to specialist stroke unit
Outline secondary prevention for stroke/TIAs
- Antiplatelet agents = aspirin, clopidogrel, dipyridamole
- Anticoagulation = atrial fibrillation; warfarin
- Risk factor management = hypertension, lipids, smoking, dietary advice, salt restriction
What is dementia
Syndrome due to disease of the brain, chronic and progressive in nature where there is an absence of clouding of consciousness and disturbance of multiple higher cognitive thoughts
What high cognitive functions are disturbed in dementia
- Memory
- Thoughts
- Orientation
- Comprehension
- Calculation
- Learning capacity
- Language
- Judgement
Outline presentation of dementia
Initially = memory loss
Late stage = non-cognitive symptoms e.g. agitation, aggression or apathy
- Wandering, hallucinations, slow repetitive speech, mood disturbance
What are the different types of dementia
- Alzheimer’s disease
- Vascular dementia ( acute onset, multi-infarct, subcortical)
- Dementia with Lewy bodies
- Fronto-temporal dementia syndrome (Pick’s disease)
What are the rarer causes of dementia
- Hypothyroidism
- Reduced vitamin B12, folate, thiamine (alcoholism)
- Depression
- Syphilis, HIV
- Tumors
- Subdural haematoma
- Parkinson’s
- Normal pressure hydrocephalus
- Pellagra
- Whipples disease
What is Alzheimer’s disease
Leading cause of dementia with progressive and global cognitive impairment: impaired visuospatial skills, memory, verbal ability, planning and lack of insight
Later causing irritability, mood disturbance, behavioural change, psychosis, agnosia
Become sedentary and take no interest
What is the cause of Alzheimer’s
Accumulation of beta-amyloid peptide (degradation product of amyloid precursor protein) which results in progressive neuronal damage, neurofibrillary triangles, amyloid plaques, loss of neurotransmitter acetylcholine
How is Alzheimer’s managed
- Develop routines
- Acetylchoninesterase inhibitors: Donepezill, Ricastigmine, Galantamine
- BP control
- Depression treatment
- Avoid drugs causing cognitive impairment
- Support for carers
