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BDS2; CHHD > Care of the elderly > Flashcards

Care of the elderly Flashcards

1
Q

What age group does geriatric medicine deal with in the UK

A

> 75

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2
Q

What age related differences of medical importance are present in geriatric medicine

A

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

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3
Q

Why is it important to not stop at one diagnosis with elderly patients

A

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

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4
Q

What are the common presentations seen in geriatric patients

A
  • 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
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5
Q

What are the geriatric ‘giants’

A
  1. Incontinence
  2. Immobility
  3. Instability (falls and syncope)
  4. Intellectual impairment (delirium and dementia)
  5. Iatrogenic disease = medication related
  6. Infection (chest, urine, biliary tract)
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6
Q

What reduced homeostatic reserves are associated with aging

A
  • 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
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7
Q

Describe how geriatric patients have impaired immunity

A
  • 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
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8
Q

What are the common sites of presentation of shingles

A

Affects single dermatomes; thoracic

  • chest and trigeminal nerve are predisposed
  • unilateral presentation
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9
Q

What are the key activities of daily living (ADL)

A
  1. Mobility including aids and appliances
  2. Washing and dressing
  3. Continence
  4. Eating and drinking
  5. Shopping, cooking and cleaning
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10
Q

What is a fragility fracture

A

Fracture sustained when falling from standing height or less

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11
Q

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

A

D

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12
Q

What is osteoporosis and list the common fracture sites

A

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

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13
Q

Outline aetiology of osteoporosis

A

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

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14
Q

What are the non-modifiable risk factors for osteoporosis

A
  1. Female
  2. Family history of osteoporosis
  3. Caucasian or asian ethnicity
  4. Age > 65
  5. Previous fragility fracture
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15
Q

What are the modifiable risk factors of osteoporosis

A
  • Low BMI
  • Smoking
  • XS alcohol
  • Low calcium intake and vit D deficiency
  • Inactivity
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16
Q

What are the hormonal and drug risk factors of osteoporosis

A 
Hormonal = menopause before 45, male hypogonadism 
Drugs = glucocorticoids, anticonvulsants, cytotoxic therapy
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17
Q

What are the secondary causes of osteoporosis

A
  • Rheumatoid arthritis
  • Hyperthyroidism
  • Malabsorption (partial coeliac disease)
  • Chronic liver disease
  • Primary hyperparathyroidism
  • Prolonged immobilisation
  • Anorexia nervosa
18
Q

How is osteoporosis diagnosed

A
  • 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)
19
Q

Describe how vitamin D is essential for bone health

A

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

20
Q

How is vitamin D obtained

A

Majority = produced through action of sunlight on skin to give D3

Some = D3 from meat and D2 from vegetables

21
Q

Outline treatment for osteoporosis (lifestyle changes)

A
  • 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
22
Q

Outline pharmacological treatments for osteoporosis

A
  1. Calcium and vitamin D supplements
  2. 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
  3. Raloxifene
  4. Teriparatide
  5. Calcitonin
  6. Strontium renelate
23
Q

Why are hormone replacement therapies no longer recommended for the treatment of osteoporosis

A

Because of the increased risk of breast cancer and CVD

24
Q

Outline potential indications for bisphosphonates

A
  1. Prevention and treatment of osteoporosis in postmenopausal women
  2. Prophylaxis of corticosteroid-associated osteoporosis
  3. Treatment of hypercalcaemia of malignancy
  4. Management of bone metastases e.g. breast cancer
  5. Management of osteolytic lesions in multiple myeloma
  6. Management of Paget’s disease
25
Q

What are the clinical presentations of B/MRONJ

A
  • Delayed healing following dental extraction/ oral surgery
  • Pain, soft tissue infection and swelling
  • Numbness, paraesthesia
  • Exposed bone
  • Nonexposed variant
26
Q

How is B/MRONJ managed

A
  • 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
27
Q

Describe the pathophysiology of strokes

A

It is caused by sudden disruption to blood supply of brain

  1. 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)
  2. Intracerebral haemorrhage = rupture of blood vessels in brain tissue causing direct neuronal injury and cerebral oedema
28
Q

Outline risk factors for cerebrovascular accidents

A
  • Hypertension, heart disease, PVD, TIA/stokes, carotid bruit
  • Smoking, diabetes, OCP, alcoholism
  • Polycythaemia, increased clotting
  • Hyperlipidaemia
29
Q

What differentiates TIAs from strokes

A

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

30
Q

What are the general clinical features of strokes and TIAs

A
  • 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
31
Q

What are the clinical features fo stoke/TIAs with anterior (carotid) circulation territory

A
  1. Cortical dysfunction = dysphasia, sensory/visual inattention, hemianopia
  2. Monoccular blindness
  3. Unilateral weakness
  4. Unilateral sensory disturbance
  5. Dysarthria
  6. Neuromuscular dysphagia
32
Q

What are the clinical features fo stoke/TIAs with posterior (vertebrobasilar) circulation territory

A
  1. Cranial nerve palsy
  2. Ataxia / incoordination / disequilibrium
  3. Diplopia
  4. Bilateral visual loss
  5. Unilateral/ bilateral weakness or sensory disturbance
  6. Dysarthria
  7. Neuromuscular dysphagia
33
Q

Outline acute management of strokes/ TIAs

A
  • 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
34
Q

Outline secondary prevention for stroke/TIAs

A
  1. Antiplatelet agents = aspirin, clopidogrel, dipyridamole
  2. Anticoagulation = atrial fibrillation; warfarin
  3. Risk factor management = hypertension, lipids, smoking, dietary advice, salt restriction
35
Q

What is dementia

A

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

36
Q

What high cognitive functions are disturbed in dementia

A
  • Memory
  • Thoughts
  • Orientation
  • Comprehension
  • Calculation
  • Learning capacity
  • Language
  • Judgement
37
Q

Outline presentation of dementia

A

Initially = memory loss

Late stage = non-cognitive symptoms e.g. agitation, aggression or apathy

  • Wandering, hallucinations, slow repetitive speech, mood disturbance
38
Q

What are the different types of dementia

A
  1. Alzheimer’s disease
  2. Vascular dementia ( acute onset, multi-infarct, subcortical)
  3. Dementia with Lewy bodies
  4. Fronto-temporal dementia syndrome (Pick’s disease)
39
Q

What are the rarer causes of dementia

A
  • Hypothyroidism
  • Reduced vitamin B12, folate, thiamine (alcoholism)
  • Depression
  • Syphilis, HIV
  • Tumors
  • Subdural haematoma
  • Parkinson’s
  • Normal pressure hydrocephalus
  • Pellagra
  • Whipples disease
40
Q

What is Alzheimer’s disease

A

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

41
Q

What is the cause of Alzheimer’s

A

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

42
Q

How is Alzheimer’s managed

A
  1. Develop routines
  2. Acetylchoninesterase inhibitors: Donepezill, Ricastigmine, Galantamine
  3. BP control
  4. Depression treatment
  5. Avoid drugs causing cognitive impairment
  6. Support for carers

BDS2; CHHD (32 decks)

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