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Phase 3a > Care of the Elderly > Flashcards

Care of the Elderly Flashcards

1
Q

What are the 5 Is of geriatric medicine?

A
  1. Immobility
  2. Infection
  3. Incontinence
  4. Impaired intellect
  5. (frailty)
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2
Q

What has the 5 Is been changed to recently?

A

5Ms

  1. Mind
  2. Mobility
  3. Medications
  4. Multi-complexity
  5. Matters most - holistic approach
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3
Q

Give some geriatric principles

A
  1. Address issues irrespective of reason for attending
  2. Take responsibility for all comorbidities
  3. Stop medications instead of start them
  4. Any intervention should increase length and quality or life
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4
Q

What is the purpose of statins? What may be reasonable in elderly population?

A

To reduce cholesterol to reduce 10 year risk of CVD event (stroke/MI). Consider stopping in elderly population as benefit is likely to be zero

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5
Q

What are some common side effects of statins?

A

Headaches
Dizziness
Nausea
Digestive problems e.g. vomiting, diarrhoea, constipation, indigestion, farting
MUSCLE PAIN - myopathy, myositis, rhabdo - rare
Sleep problems
Low blood count

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6
Q

What are the risks of taking anti-hypertensives in the elderly?

A

Falls risk - dizziness, light-headedness
Postural hypotension
Reduced energy
Reduced mobility

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7
Q

Are beta blockers recommended in the elderly for treatment of hypertension?

A

No - not as effective in those over 60, and its comorbid effects are unattractive. Only given if heart failure or ischaemic heart disease

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8
Q

Why might control of hyperglycaemia not be so critical in the elderly?

A

Less time to develop diabetic complications, and risk of hypoglycaemia is greater than hyperglycaemia

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9
Q

Why is renal impairment significant in elderly pharmacology?

A

Nephrotoxic drugs
Reduced clearance of medications
Check are medications safe to use if renally impaired

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10
Q

Give some anticholinergic side effects

A 
Dry mouth + eyes
Constipation
Sedation, drowsy
Tachycardia
Urinary retention/incontinence
Blurred vision
Dizziness
Confusion
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11
Q

Describe the anti-cholinergic scoring system and why it is done

A

Done as a predictor of frailty
= ACB Score
Score of 3+ associated with increased cognitive impairment and mortality
1 = atenolol, codeine, diazepam, digoxin, furosemide
2 = amantidine, carbamazepine
3 = antidepressants, antipsychotics, antimuscarinics

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12
Q

Name some medications used for urinary incontinence. What type of medication are these and what are alternatives?

A

Darifenacin, Trospium, Oxybutinin
Anti-muscarinics - increase progression dementia
Better alternative - solifenacin or trospium (not cross BBB)

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13
Q

Give some indications for beta blockers

A 
AF/cardiac arrhythmias - cardioselective
Heart failure - cardioselective
Anxiety - propanolol
Migraine prophylaxis - propanolol
Essential tremor - propanolol/primidone
Hypertension - 6th line
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14
Q

Why is atenolol not a great beta blocker? What might be used instead?

A

Not cardioselective - can worsen asthma, postural hypotension
Is indicated for HTN but 6th line
Use cardioselective - bisoprolol, metoprolol, cardevilol

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15
Q

List the different types of dementia

A 
Alzheimers
Unclassified
Mixed
Vascular
Lewy Body Dementia
Parkinson's Disease Dementia
Frontotemporal
others - amyloid angiopathy, korsakoff's dementia
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16
Q

Give some characteristic features of Alzheimers

A

Gradual onset and progression
Short-term memory worse
Physical health not affected directly

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17
Q

Give some characteristics of vascular dementia

A

Acute or step-wise progression
Focal neurological signs
Vascular disease/risk factors

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18
Q

Give some characteristics of Lewy Body Dementia

A 
Fluctuating cognition
Visual hallucinations
Parkinsonian symptoms
Cognitive symptoms at same time or before parkinson symptoms
Generalised atrophy on CT
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19
Q

Give some characteristics of Parkinson’s Disease Dementia

A

Fluctuating cognition
Visual hallucinations
Parkinsonian symptoms (>2 years before cognitive decline)
Prognosis better than LBD

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20
Q

Give characteristics of Frontotemporal dementia

A

Insidious onset - 50s-60s
Personality and behavioural changes
Apathy and social disinhibition

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21
Q

Give characteristics of Amyloid Angiopathy dementia

A

Presentation similar to vascular dementia

amyloid plaques - risk of haemorrhagic stroke especially if anticoagulated as plaques can bleed

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22
Q

Give characteristics of Korsakoff’s dementia

A

Due to alcohol excess
Cerebral atrophy on CT
Confabulation common

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23
Q

What cognitive enhancers are there?

A

Anti-cholinergics - donepezil, rivastigmine

NMDA antagonist - memantine - neuroprotective effect

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24
Q

When might you use antipsychotics in dementia treatment? Which ones can you use?

A

Used for behavioiural and psychological symptoms

Haloperidol (caution in PDD), Risperidone (AD), Quetiapine

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25
What treatment might you give for mood effects of dementia? How effective are these?
Antidepressants - SSRI, SNRI | Not very effective as mood effects often due to brain matter loss
26
Why might you be careful about treatment of behavioural and psychological symptoms in LBD and PDD?
Caution or don't use anti-dopaminergics (ie antipsychotics) - might make PD worse Balance control of behavioural symptoms and parkinsonian symptoms
27
How might you be able to prevent delirium through the environment?
``` Quiet spaces, calming music Bright colours Big clear signs Continuity of staff Talking to patients Use people's names and introduce yourself ```
28
What is delirium?
Acute confusional state - fluctuating disturbance in level of consciousness, attention and global cognition
29
What are the risk factors for developing delirium?
Cognitive impairment, frailty, older age, previous delirium episode, sensory impairment, comorbidities, polypharmacy, change of environment
30
What is the 4As test?
1. Alertness 2. AMT4 3. Attention 4. Acute change or fluctuating course Higher score means more likely to be delirium
31
What are 3 different types of delirium?
Hyperactive Hypoactive Mixed
32
How do you test for normal pressure hydrocephalus?
Get them to get up, walk, and sit - time it! Then do LP Repeat 1st step and time it. If faster 2nd time, then may benefit from LP or lumbar drainage
33
What are the 4 questions in the AMT4?
Age Date of birth Place Year
34
What are the 3 Ds of old age psychiatry?
Depression Delirium Dementia
35
Describe dementia
Progressive neurological disorder impacting cognition, causes functional impairment
36
Give the different types of dementia in order or commonest to least common
``` Alzheimers Vascular Lewy Body Dementia Mixed (mostly AD and vascular) Frontotemporal PDD ```
37
Give some differentials of dementia
``` Stroke Head injury Space-occupying lesion Alcohol Depression Pseudo-dementia ```
38
What investigations might you do for someone presenting with dementia?
Neurological examination Cognitive assessment = ACE-III, MoCA Bloods Imaging - CT/MRI/DaT/SPECT
39
What might you see on imaging for Alzheimer's?
Atrophy and enlargement of ventricles, hippocampal atrophy | SPECT - fusion of brain
40
What are the 5 domains of the ACE-III?
1. Attention 2. Memory 3. Fluency 4. Language 5. Visuospatial function
41
What is pseudo-dementia?
Mild cognitive impairment secondary to mental illness e.g. depression Refuse to answer, impairs function and attention, frontal lobe and white matter changes
42
When are NMDA antagonists more indicated for treatment of AD and LBD?
More for mental illness and calming effects
43
Give some common general causes of delirium
``` PINCH ME Pain Infection Nutrition Constipation Hydration Medication (e.g. benzos, pregabalin, gabapentin) Environment ```
44
What is Charles Bonnet Syndrome?
Visual hallucinations due to brain's adjustment to significant vision loss - check vision, age-related macular degeneration Only use antipsychotics if distressing as can increase risk of CVD/stroke Often resolves on its own
45
Why does first pass metabolism decrease in the elderly?
Atrophy of parietal cells so gastric pH increases - less acidic
46
Why are salbutamol and anti-hypertensives less effective in the elderly?
Calcification of blood vessels
47
Why might Digoxin levels be too high in the elderly? What are the risks of this?
Renal excretion decreases, increasing Digoxin blood concentrations SE: yellow tinge to vision, ST depression, hyperkalaemia, arrhythmias
48
Why might anti-cholinergic effects be more pronounced in the elderly?
Anti-muscarinic receptors change (up-regulated) so drugs can have more potent effect
49
What might drugs like diazepam have longer half-lives in the elderly?
Body fat concentration increases | Therefore half-life of lipophillic drugs e.g. diazepam, increase
50
What percentage of hospital admissions are due to adverse drug reactions? What are the most common reasons for admission?
60% admissions Commonest = Falls Then constipation or confusion
51
Is paracetamol OK in the elderly?
Yes mostly unless liver disease | Can be used as adjunctive painkiller therapy
52
What type of prevention should aspirin be used for?
Secondary prevention - not primary!
53
Why might SSRIs and NSAIDs together be harmful?
Increased risk of GI bleed | may prescribe PPI or H2 antagonist
54
What are the risks of taking PPIs short and long-term?
``` Commonly cause nausea, vomiting - may switch to H2 antagonist Increased risk osteoporosis Nephrotoxic - renal impairment Confusion Increased risk infection ```
55
What percentage of those aged over 65 fall each year?
28-35% (1/3)
56
What percentage of falls in the elderly result in serious injury?
40-60%
57
Following an initial fall, what is the risk of a subsequent fall within a year?
66% (2/3)
58
Give some common risk factors for falls
``` Previous falls Fear of falling Balance problems Gait and mobility problems Vision loss Pain Drugs Cardiovascular conditions e.g. aortic stenosis Cognitive impairment Urinary incontinence Stroke Diabetes ```
59
Give some examples of medications which may increase falls risk
Benzodiazepines Anti-hypertensives Diuretics - hypovolaemia, hypokalaemia - cardiac problems Opioids
60
What is considered a high risk FRAX score?
>20% 10 year risk of major osteoporotic fracture | >3% 10 year risk of hip fracture
61
What is a DEXA scan? When is it indicated?
Dual Energy X-ray Absorptiometry = bone density scan To diagnose osteoporosis, risk of fractures, measure amount of bone, fat and muscle in body Uses low dose radiation Gives T score to give diagnosis/fracture risk
62
What are the different T-score classifications for bone health?
Above -1 SD = NORMAL Between -1 and -2.5 SD = Osteopenia Less than -2.5 SD = Osteoporosis
63
Give 3 general mechanisms which can caue malnutrition
Decreased intake Increased nutrient requirements Inability to use nutrients ingested - malabsorption
64
Give some consequences of malnutrition
Decreased immunity, increased risk infection Muscle wasting - falls, immobility/inactivity, increased risk chest infections, DVT/PE Impaired wound healing Micronutrient deficiencies
65
What screening tool can be used to recognise malnutrition?
Malnutrition Universal Screening Tool | MUST
66
What 3 factors does MUST use to assess nutrition?
BMI History of weight loss Acute Disease effect
67
What score counts as high risk for malnutrition using MUST?
>2 = high risk score | Monitor feeding, weight (be aware weight may be due to fluid overload)
68
What is the order for types of intervention used for malnutrition?
1. FOOD, fortification 2. Oral nutritional supplements 3. Enteral/parenteral
69
What is enteral nutrition?
Direct feeding into the gut e.g. stomach, duodenum, jejunum
70
Why is enteral nutrition chosen over parenteral if possible?
Preserves gut mucosa and integrity | Less expensive than parenteral
71
What are the disadvantages of enteral nutrition?
Tolerance - nausea, satiety, constipation, diarrhoea Tube can be uncomfortable Decreased QoL, appearance
72
What might you do to check the position of a NG tube?
1. Check pH aspirate to confirm position (<5.5) | 2. X-ray confirmation if not able to get pH
73
How long might an NG tube be used for?
Short-term, usually <30 days
74
How might you check the position of an NJ tube?
X-ray guided only
75
How long might an NJ tube be used for?
Short-term, usually <60 days
76
Give 2 examples of long-term enteral feeding options
Percutaneous endoscopic gastrostomy - PEG | Percutaneous endososcopic jejunostomy - PEJ
77
What are the indications for PEG feeding?
Dysphagia - stroke, head and neck surgery, neuro Cystic fibrosis - high nutritional requirements Oral nutritional intake inadequate long-term
78
What are the indications for PEJ feeding?
Delayed gastric emptying Upper GI/pancreatic surgery High risk of aspiration Severe acute pancreatitis
79
When might parenteral nutrition be used?
When gut is inaccessible or unable to absorb sufficient nutrients e.g. inadequate absorption, fistulas, bowel obstruction, prolonged bowel rest, severe malnutrition (when enteral not possible)
80
How is parenteral nutrition commonly delivered
IV access through PICC line or central line
81
What are the disadvantages of parenteral nutrition?
Risk of line infection More expensive Invasive
82
What is refeeding syndrome?
Occurs when introducing nutrition for malnourished person. Shift from fat metabolism to carb metabolism. Insulin surge increases celllular uptake of K, phosphate, Mg causing shift in fluids and electrolytes. Fluid retention/cardiac arrhythmias, respiratory insufficiency, death
83
How do you manage refeeding syndrome?
IV Pabrinex//thiamine, Vit B PRIOR to feeding and for first 10 days Slow introduction of nutrition Daily monitoring U+Es, phosphate, Mg, K, BM, LFTs, CRP, triglycerides, zinc, selenium, copper, manganese Stool chart monitoring Fluid balance monitoring
84
Give the 3 criteria for AKIs
1. serum creatinine rise of >26 in 48hrs 2. >50% increase in baseline serum creatinine in past 7 days 3. urine output <0.5ml/kg/hr for 6 hours
85
How would you manage an AKI?
Check volume status - if dehydrated give fluids Check renal function and serum potassium levels (exclude hyperkalaemia) Consider CVD, obstruction, inflammatory process, drugs, rhabdomylosis, catheter infection Urinalysis Stage the AKI
86
What would negative or positive urinalysis suggest for investigating an AKI?
``` Negative = Pre-renal causes of AKI Positive = Renal or post-renal (glomerular disease, UTI, nephritis, catheter trauma) ```
87
What patient criteria would there be for ACE-inhibitor or angiotensin-receptor blocker to be used as 1st line management of hypertension?
Under 55 Not black of African-Caribbean OR anyone with diabetes
88
What patient criteria would there be for Calcium channel blockers to be 1st line management of hypertension?
Over 55 Black of African-Caribbean No diabetes
89
What is Step 2 of hypertension management?
2 of the following drugs | ACE-I/ARB, CCB, thiazide-like diuretic
90
What is Step 3 of hypertension management?
All 3 of ACE-I/ARB, CCB, thiazide-like diuretic
91
What is Step 4 of hypertension management?
Confirm resistant hypertension: ABPM, HBPM, postural hypotension If K<4.5 = low dose spironolactone If K>4.5 = alpha or beta blocker Seek expert advice
92
What is CURB65?
Tool to measure severity of pneumonia Based on confusion, respiratory rate, blood pressure, age and blood urea nitrogen Score 0-1 - consider outpatient treatment Score 2 - consider inpatient treatment Score 3+ - inpatient treatment with possible intensive care admission

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