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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
Q

What treatment might you give for mood effects of dementia? How effective are these?

A

Antidepressants - SSRI, SNRI

Not very effective as mood effects often due to brain matter loss

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26
Q

Why might you be careful about treatment of behavioural and psychological symptoms in LBD and PDD?

A

Caution or don’t use anti-dopaminergics (ie antipsychotics) - might make PD worse
Balance control of behavioural symptoms and parkinsonian symptoms

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27
Q

How might you be able to prevent delirium through the environment?

A 
Quiet spaces, calming music
Bright colours
Big clear signs
Continuity of staff
Talking to patients
Use people's names and introduce yourself
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28
Q

What is delirium?

A

Acute confusional state - fluctuating disturbance in level of consciousness, attention and global cognition

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29
Q

What are the risk factors for developing delirium?

A

Cognitive impairment, frailty, older age, previous delirium episode, sensory impairment, comorbidities, polypharmacy, change of environment

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30
Q

What is the 4As test?

A
  1. Alertness
  2. AMT4
  3. Attention
  4. Acute change or fluctuating course

Higher score means more likely to be delirium

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31
Q

What are 3 different types of delirium?

A

Hyperactive
Hypoactive
Mixed

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32
Q

How do you test for normal pressure hydrocephalus?

A

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

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33
Q

What are the 4 questions in the AMT4?

A

Age
Date of birth
Place
Year

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34
Q

What are the 3 Ds of old age psychiatry?

A

Depression
Delirium
Dementia

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35
Q

Describe dementia

A

Progressive neurological disorder impacting cognition, causes functional impairment

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36
Q

Give the different types of dementia in order or commonest to least common

A 
Alzheimers
Vascular
Lewy Body Dementia
Mixed (mostly AD and vascular)
Frontotemporal
PDD
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37
Q

Give some differentials of dementia

A 
Stroke
Head injury
Space-occupying lesion
Alcohol
Depression
Pseudo-dementia
38
Q

What investigations might you do for someone presenting with dementia?

A

Neurological examination
Cognitive assessment = ACE-III, MoCA
Bloods
Imaging - CT/MRI/DaT/SPECT

39
Q

What might you see on imaging for Alzheimer’s?

A

Atrophy and enlargement of ventricles, hippocampal atrophy

SPECT - fusion of brain

40
Q

What are the 5 domains of the ACE-III?

A
  1. Attention
  2. Memory
  3. Fluency
  4. Language
  5. Visuospatial function
41
Q

What is pseudo-dementia?

A

Mild cognitive impairment secondary to mental illness e.g. depression
Refuse to answer, impairs function and attention, frontal lobe and white matter changes

42
Q

When are NMDA antagonists more indicated for treatment of AD and LBD?

A

More for mental illness and calming effects

43
Q

Give some common general causes of delirium

A 
PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication (e.g. benzos, pregabalin, gabapentin)
Environment
44
Q

What is Charles Bonnet Syndrome?

A

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
Q

Why does first pass metabolism decrease in the elderly?

A

Atrophy of parietal cells so gastric pH increases - less acidic

46
Q

Why are salbutamol and anti-hypertensives less effective in the elderly?

A

Calcification of blood vessels

47
Q

Why might Digoxin levels be too high in the elderly? What are the risks of this?

A

Renal excretion decreases, increasing Digoxin blood concentrations
SE: yellow tinge to vision, ST depression, hyperkalaemia, arrhythmias

48
Q

Why might anti-cholinergic effects be more pronounced in the elderly?

A

Anti-muscarinic receptors change (up-regulated) so drugs can have more potent effect

49
Q

What might drugs like diazepam have longer half-lives in the elderly?

A

Body fat concentration increases

Therefore half-life of lipophillic drugs e.g. diazepam, increase

50
Q

What percentage of hospital admissions are due to adverse drug reactions? What are the most common reasons for admission?

A

60% admissions
Commonest = Falls
Then constipation or confusion

51
Q

Is paracetamol OK in the elderly?

A

Yes mostly unless liver disease

Can be used as adjunctive painkiller therapy

52
Q

What type of prevention should aspirin be used for?

A

Secondary prevention - not primary!

53
Q

Why might SSRIs and NSAIDs together be harmful?

A

Increased risk of GI bleed

may prescribe PPI or H2 antagonist

54
Q

What are the risks of taking PPIs short and long-term?

A 
Commonly cause nausea, vomiting - may switch to H2 antagonist
Increased risk osteoporosis
Nephrotoxic - renal impairment
Confusion
Increased risk infection
55
Q

What percentage of those aged over 65 fall each year?

A

28-35% (1/3)

56
Q

What percentage of falls in the elderly result in serious injury?

A

40-60%

57
Q

Following an initial fall, what is the risk of a subsequent fall within a year?

A

66% (2/3)

58
Q

Give some common risk factors for falls

A 
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
Q

Give some examples of medications which may increase falls risk

A

Benzodiazepines
Anti-hypertensives
Diuretics - hypovolaemia, hypokalaemia - cardiac problems
Opioids

60
Q

What is considered a high risk FRAX score?

A

> 20% 10 year risk of major osteoporotic fracture

>3% 10 year risk of hip fracture

61
Q

What is a DEXA scan? When is it indicated?

A

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
Q

What are the different T-score classifications for bone health?

A

Above -1 SD = NORMAL
Between -1 and -2.5 SD = Osteopenia
Less than -2.5 SD = Osteoporosis

63
Q

Give 3 general mechanisms which can caue malnutrition

A

Decreased intake
Increased nutrient requirements
Inability to use nutrients ingested - malabsorption

64
Q

Give some consequences of malnutrition

A

Decreased immunity, increased risk infection
Muscle wasting - falls, immobility/inactivity, increased risk chest infections, DVT/PE
Impaired wound healing
Micronutrient deficiencies

65
Q

What screening tool can be used to recognise malnutrition?

A

Malnutrition Universal Screening Tool

MUST

66
Q

What 3 factors does MUST use to assess nutrition?

A

BMI
History of weight loss
Acute Disease effect

67
Q

What score counts as high risk for malnutrition using MUST?

A

> 2 = high risk score

Monitor feeding, weight (be aware weight may be due to fluid overload)

68
Q

What is the order for types of intervention used for malnutrition?

A
  1. FOOD, fortification
  2. Oral nutritional supplements
  3. Enteral/parenteral
69
Q

What is enteral nutrition?

A

Direct feeding into the gut e.g. stomach, duodenum, jejunum

70
Q

Why is enteral nutrition chosen over parenteral if possible?

A

Preserves gut mucosa and integrity

Less expensive than parenteral

71
Q

What are the disadvantages of enteral nutrition?

A

Tolerance - nausea, satiety, constipation, diarrhoea
Tube can be uncomfortable
Decreased QoL, appearance

72
Q

What might you do to check the position of a NG tube?

A
  1. Check pH aspirate to confirm position (<5.5)

2. X-ray confirmation if not able to get pH

73
Q

How long might an NG tube be used for?

A

Short-term, usually <30 days

74
Q

How might you check the position of an NJ tube?

A

X-ray guided only

75
Q

How long might an NJ tube be used for?

A

Short-term, usually <60 days

76
Q

Give 2 examples of long-term enteral feeding options

A

Percutaneous endoscopic gastrostomy - PEG

Percutaneous endososcopic jejunostomy - PEJ

77
Q

What are the indications for PEG feeding?

A

Dysphagia - stroke, head and neck surgery, neuro
Cystic fibrosis - high nutritional requirements
Oral nutritional intake inadequate long-term

78
Q

What are the indications for PEJ feeding?

A

Delayed gastric emptying
Upper GI/pancreatic surgery
High risk of aspiration
Severe acute pancreatitis

79
Q

When might parenteral nutrition be used?

A

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
Q

How is parenteral nutrition commonly delivered

A

IV access through PICC line or central line

81
Q

What are the disadvantages of parenteral nutrition?

A

Risk of line infection
More expensive
Invasive

82
Q

What is refeeding syndrome?

A

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
Q

How do you manage refeeding syndrome?

A

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
Q

Give the 3 criteria for AKIs

A
  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
Q

How would you manage an AKI?

A

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
Q

What would negative or positive urinalysis suggest for investigating an AKI?

A 
Negative = Pre-renal causes  of AKI
Positive = Renal or post-renal (glomerular disease, UTI, nephritis, catheter trauma)
87
Q

What patient criteria would there be for ACE-inhibitor or angiotensin-receptor blocker to be used as 1st line management of hypertension?

A

Under 55
Not black of African-Caribbean
OR anyone with diabetes

88
Q

What patient criteria would there be for Calcium channel blockers to be 1st line management of hypertension?

A

Over 55
Black of African-Caribbean
No diabetes

89
Q

What is Step 2 of hypertension management?

A

2 of the following drugs

ACE-I/ARB, CCB, thiazide-like diuretic

90
Q

What is Step 3 of hypertension management?

A

All 3 of ACE-I/ARB, CCB, thiazide-like diuretic

91
Q

What is Step 4 of hypertension management?

A

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
Q

What is CURB65?

A

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

Phase 3a (8 decks)

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