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3a 2023 > Care of the Elderly > Flashcards

Care of the Elderly Flashcards

1
Q

define frailty

A

state of increased vulnerability resulting from ageing associated decline in reserve and function across multiple physiological systems such that ability to cope with everyday or acute stressors is compromised

key bits is they have a poor functional reserve, so they’re really vulnerable to decompensation when faced with illness, drug side-effects or metabolic disturbances

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2
Q

what are some common co-morbidities seen in the elderly?

A 
linked - lung cancer, COPD, peripheral vascular disease (smoking causes all)
unlinked:
- diabetes
- dementia
- myeloma

PNEUMONIA - often seen on top of all of these!

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3
Q

what are the most common causes of geriatric admission?

A 
falls
confusion
incontinence
'off legs'
social admission
chest pain, SOB, urinary symptoms
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4
Q

what are the 4 geriatric giants (Is)?

A

Instability (falls)
Immobility (off legs)
Intellectual impairment (confusion)
Incontinence

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5
Q

what are the 5 Ms of geriatrics?

Really important imo about what affects elderly people

A 
Mind:
  - dementia
  - delirium
  - depression
Mobility:
  - impaired gait and balance
  - falls
Medications:
  - polypharmacy
  - deprescribing/optimal prescribing
  - adverse effects
  - medication burden
Multi-complexity
  - mutli-morbidity
  - biopsychosocial situations
Matters most
  - individual meaningful health outcomes and preferences
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6
Q

what is acopia?

A

term for “social admission” - negative connotations - DON’T use.
used to describe pts unable to cope with ADLs.

beware serious underlying pathologies that can easily be missed.

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7
Q

what is deconditioning?

A

occurs after a patient has been bedbound for days/weeks when admitted to hospital
they’re confused.
poor nutritional state (often present even prior to admission), made worse by acute illness.
can’t walk, falls, can’t look after themselves.
need a lot more than just meds!

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8
Q

what is involved in a comprehensive geriatric assessment?

A

it’s a multidimensional, multidisciplinary diagnostic process
determines frail older person’s medical, psychological and functional capacity.
tries to develop coordinated, integrated plan for treatment and long term follow up.

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9
Q

what are the four areas of a comprehensive geriatric assessment (CGA)? who might contribute to assessment of each category?

A

medical assessment - drs, nurse, pharmacist, dietician, SaLT
functional assessment - OT, PT, SaLT
psychological assessment - dr, nurse, OT, psychologist
social and environmental assessment - OT, social worker

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10
Q

what is included in the medical assessment as part of the CGA?

A

problem list
co-morbid conditions and disease severity
medication review
nutritional status

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11
Q

what is included in the functional assessment as part of the CGA?

A

ADLs
activity/exercise status
gait and balance

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12
Q

what is included in the psychological assessment as part of the CGA?

A

cognitive status testing

depression/mood screening

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13
Q

what is included in the social/environmental assessment as part of the CGA?

A

informal support needs and assets
eligibility/need for carers
home safety

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14
Q

what are the activities of daily living (ADLs)?

A
  • mobility - ask about aids, appliances etc, stairs?
  • washing and dressing
  • continence
  • eating and drinking
  • shopping, cooking and cleaning
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15
Q

list some drugs that can cause confusion/affect memory when prescribed in older people

A 
antipsychotics
benzodiazepines
antimuscarinics
opioid analgesics
some anticonvulsants
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16
Q

list some drugs that have a narrow therapeutic window when prescribed in older people

A 
digoxin
lithium
warfarin
phenytoin
theophyllines
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17
Q

list some drugs with a long half-life when prescribed in older people

A

long-acting benzodiazepines (diazepam, nitrazepam)
fluoxetine (SSRI)
glibeclamide

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18
Q

list some drugs that can cause hypothermia when prescribed in older people

A

antipsychotics

TCAs

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19
Q

list some drugs that can cause Parkinsonism/movement disorders when prescribed in older people

A

metoclopramide
antipsychotics
stemetil

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20
Q

list some drugs that can cause bleeding when prescribed in older people

A

NSAIDs

warfarin

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21
Q

list some drugs that can predispose to falls when prescribed in older people

A 
antipsychotics
sedatives
antihypertensives (esp. alpha blockers, nitrates, ACE inhibitors)
diuretics
antidepressants
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22
Q

what is polypharmacy?

A

when a patient is taking a large number of different prescription medications (some define this as 4+), often some which aren’t needed.

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23
Q

list some potential reasons for polypharmacy in older people

A
  • multiple chronic disease processes requiring specific drug treatments
  • multiple physicians involved in care (for different diseases)
  • admission to residential/nursing home
  • failure to review medication and repeat prescriptions
  • failure to discontinue unnecessary medication
  • failure of dr to recognise poor therapeutic response as non-compliance
  • prescribing cascade - more and more drugs added on in attempt to treat what are actually side effects of the original drugs
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24
Q

list possible causes of falls in the elderly

A
  • drugs e.g. sedatives, alcohol
  • MSK e.g. OA of hip
  • syncope e.g. vasovagal, cardiogenic, arrhythmias
  • stroke/TIA
  • postural hypotension - secondary to antiHTNs, hypovolaemia, dopaminergic drugs
  • neurological - peripheral neuropathy, Parkinson’s
  • hypoglycaemia
  • visual impairment
  • vertigo e.g. BPV, meiere’s disease
  • poor environment (e.g. dim light, loose rugs)
  • dementia
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25
Q

what are the three main features of Parkinson’s?

A

1) tremor
2) bradykinesia
3) rigidity - lead-pipe, cogwheel

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26
Q

list 3 differentiating features of a parkinsonian tremor

A
  • slow, pill-rolling
  • worse at rest
  • asymmetrical
  • reduced on distraction
  • reduced on movement
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27
Q

what is the underlying pathophysiology of Parkinson’s?

A

loss of dopaminergic neurons in substantia nigra

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28
Q

what class of drug is normally combined with L-dopa to prevent peripheral side effects?

A

dopa decarboxylase inhibitor e.g. carbidopa or benserazide

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29
Q

list some potential complications of L-dopa therapy

A
  • postural hypotension on starting treatment
  • confusion, hallucinations
  • L-dopa induced dyskinesias
  • On-off effect - fluctuations in motor performance between normal function (on) and restricted mobility (off)
  • shortening duration of action of each dose (i.e. end dose deterioration where dyskinesias become more prominent at the end of the duration of action)
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30
Q

how do immediately manage a TIA?

A

ABCDE assessment
aspirin 300mg daily started immediately (+PPI if needed)
specialist assessment within 24hrs of onset of symptoms - or within a week if the suspected TIA was more than a week ago

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31
Q

what are the components of secondary prevention post TIA?

A 
lifestyle modification
clopidogrel 75mg daily
statins
antihypertensives if necessary
warfarin/NOAC if AF, mitral stenosis, dilated cardiomyopathy, recent big septal MI
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32
Q

list some risk factors for pressure ulcers

A
  • age >70yrs
  • being bedridden
  • paralysis (complete or partial)
  • obesity
  • urinary or bowel incontinence
  • poor nutrition
  • medical conditions affecting blood supply e.g. diabetes, peripheral arterial disease, renal failure, heart failure
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33
Q

what is the name of the scoring system used to asses pressure ulcer risk?

A

Waterlow scoring system

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34
Q

how can pressure sores be prevented?

A

1) barrier creams
2) pressure redistribution and friction reduction - foam mattresses, heel support, cushions
3) repositioning - every 6hrs if normal risk, every 4hrs if high risk
4) regular skin assessment

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35
Q

what should you look for when assessing skin for risk of pressure sores?

A
  • areas of pain/discomfort
  • skin integrity at pressure areas
  • colour changes
  • variations in heart, firmness and moisture
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36
Q

how often should a patient at normal vs high risk be ‘turned’/repositioned to prevent pressure sores?

A

every 6 hrs in normal risk

every 4hrs in high risk

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37
Q

list cardiac conditions that could cause an embolic CVA

A
  • AF
  • MI causing mural thrombus
  • infective endocarditis
  • aortic/mitral valve disease
  • patent foramen ovale
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38
Q

describe the bradykinesic features of Parkinson’s disease

A
  • slow, shuffling steps
  • reduced arm swinging
  • difficulty in initiating movement
  • mask-like face
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39
Q

what drugs used in Parkinon’s have been associated with pulmonary/retroperitoneal/cardiac fibrosis?

A

ergot-derived dopamine receptor agonists (bromocriptine, cabergoline)

should do echo, ESR, creatinine and CXR before treatment and monitor closely

(called ergot since first produced from a type of fungus called ergot)

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40
Q

what possible side effects might you see in a patient on a dopamine receptor agonist?
(e.g. bromocriptine, ropinirole, cabergoline, apomorphine)

A
  1. impulse control disorders
  2. excessive daytime somnolence
  3. hallucinations in older people

(also: nasal congestion, postural hypotension)

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41
Q

give three adverse effects due to the difficulty in achieving steady dose of levodopa for Parkinson’s

A
  1. combined with decarboxylase inhibitor (e.g. carbidopa)
  2. dyskinesia at peak dose (writhing movements),
  3. on-off effect, large variation in motor performance
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42
Q

Common adverse effects of Levodopa

A
  1. dry mouth,
  2. anorexia,
  3. palpitations,
  4. postural hypotension,
  5. psychosis,
  6. drowsiness
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43
Q

list some alternative drugs (i.e. not L dopa) for Parkinson’s treatment

A
  1. MAO-B inhibitors (stops MAO from recycling old dopamine)
  2. COMT Inhibitors (similarly needed like decarboxylase inhibs to prevent peripheral breakdown)
  3. Dopamine agonists
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44
Q

give some RFs for a CVA

A 
age
HTN
smoking
hyperlipidaemia
DM
AF
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45
Q

what sort of features would you see in a cerebral hemisphere infarct?

A
  • contralateral hemiplegia (flaccid then spastic)
  • contralateral sensory loss
  • homonymous hemianopia
  • dysphasia
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46
Q

what sort of features would you see in a brainstem infarct?

A

more severe symptoms - quadriplegia, locked in syndrome

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47
Q

what sort of features would you see in a lacunar infarct?

A

small infarcts around basal ganglia, internal capsule, thalamus and pons

can result in pure motor, pure sensory, mixed sensorimotor signs or ataxia

48
Q

describe immediate management of a stroke

A
  • ABCDE assessment
  • urgent neuroimaging to rule out haemorrhagic
  • thrombolysis (E.g. alteplase) within 4.5 hours of symptom onset if no prev intracranial haemorrhage, uncontrolled HTN, pregnancy etc
  • aspirin 300mg ASAP
49
Q

what scoring system is used to determine stroke risk after TIA? how do the scores impact management?

A

TIA ABCD2 ≥ 4 (High Risk):

  • Aspirin (300 mg daily) started immediately
  • Specialist referral within 24 hours of onset of symptoms.
  • Secondary prevention measures.

TIA ABCD2 ≤ 3:

  • Specialist referral within 1 week of symptom onset, including decision on brain imaging
  • If vascular territory or pathology is uncertain, refer for brain imaging

Crescendo TIAs (two or more episodes in a week) should be treated as being at high risk, regardless of ABCD2 score.

50
Q

list some possible causes of delirium

A
  • Infection (commonly UTI and pneumonia)
  • Metabolic (hypoglycaemia, renal failure, liver failure, electrolyte imbalance e.g. hyponatriaemia, hypocalcaemia.)
  • Drugs: benzodiazepines, opiates, alcohol
  • Hypoxia
  • Nutritional deficiency (vitamin B12, thiamine) (mentioned in placement)
  • MI
  • Intracranial lesion (incl. space-occupying, epilepsy, CVA, head injury)
51
Q

list some causes of hyponatraemia

A

Dilutional effect:

  • heart failure
  • hypoproteinaemia
  • SIADH
  • hypervolaemia/fluid excess
  • NSAIDs (promote water retention)
  • oliguric renal failure

Sodium loss:

  • addison’s disease (aldostesrone insufficiency)
  • D&V
  • osmotic diuresis e.g. DM, diuretic excess, severe burns, diuretic stage of acute renal failure
52
Q

list some features of hypocalcaemia

A

Paraesthesia (usually fingers, toes and around mouth).
Tetany.
Carpopedal spasm (wrist flexion and fingers drawn together).
Prolonged QT
Muscle cramps
Seizures.
Laryngospasm; bronchospasm

53
Q

list some features of hypercalcaemia

A

bones, stones, moans and groans:
Bone pain, fractures (hyperPTH or malignancy)
Renal stones (renal colic); renal impairment (renal calcinosis);
Polyuria, polydipsia, dehydration (nephrogenic diabetes insipidus)
Drowsiness, delirium, muscle weakness, impaired cognition, depression, coma
Nausea, vomiting, constipation, abdominal pain, weight loss, anorexia
HTN, shortened QT, arrhythmias.

54
Q

what MMSE scores supports dementia?

A

<25

<10 = severe
10-20 = moderate
21-25 = mild

25-27 = borderline

55
Q

list some tools used to assess cognition

A
  • addenbrookes cognitive examination-III (ACE-III)
  • montreal cognitive assessment (MoCA)
  • abbreviated mental test score (AMT)
  • 6 item cognitive impairment test (6CIT)
  • GP assessment of cogntition (GPCOG)
56
Q

list some blood tests you would order to exclude treatable causes of dementia

A
  • TFTs
  • syphilis serology
  • LFTs - hepatic encephalopathy, alcoholism
  • Vit B12, thiamine (B1), folate levels
57
Q

what type of drug is donepezil, and what is it used to treat? give examples of others in the same class

A

acetylcholinesterase inhibitor
only used in Alzheimer’s disease

others = rivastigmine, galantamine

58
Q

give an alternative drug to ACh-ase inhibitors for use in moderate to severe Alzheimer’s

A

memantine - N-methyl-D-aspartate (NMDA) antagonist, blocks glutamate

59
Q

learn the 4 types of dementia and their features

A

you have other cards on this I cba to type it out again

60
Q

what is delirium? what are the two main types?

A

“acute fluctuating syndrome of disturbed consciousness, attention, cognition and perception”

hyperactive –> agitation, inappropriate behaviour, hallucinations

hypoactive –> lethargy, reduce concentration

61
Q

list some risk factors for delirium

A
  • Older age
  • Cognitive impairment
  • Frailty/multiple comorbidities
  • Significant injuries
  • Functional impairment
  • Hx of alcohol excess
  • Sensory impairment
  • Poor nutrition
  • Lack of stimulation
  • Terminal phase of illness
62
Q

list some bedside tests you would perform if you suspected a patient had developed delirium

A 
O2 sats
BP
temperature
ABG/VBG
urinalysis
63
Q

list some investigations you would perform if you suspected a patient had developed delirium

A
  • FBC, LFT, U&E
  • CRP/ESR
  • Sputum culture
  • Folate, B12
  • HbA1C
  • TFT
  • CXR, ECG, urinalysis (MSU if abnormal)
64
Q

list some differentials for delirium

A
  • depression
  • dementia
  • mental illness
  • anxiety
  • thyroid disease
  • temporal lobe epilepsy
  • Charles Bonnet syndrome
65
Q

list some reorientation measures you can use for someone with delirium

A
  • easily visible and accurate clocks and calendars
  • continuity of care from carers/nursing staff - try and keep nursing to one nurse
  • discourage napping, encourage bright light exposure in daytime - put near window!
  • regular cues e.g. explaining who and where they are
  • encourage friends/family to visit and exposure to familiar objects
  • maintain safe mobility - avoid restraints e.g. cot sides, encourage walking >3 times per day
66
Q

summarise medical management of delirium

A

treat underlying cause
medication review, treat infection, pain relief needed?

low dose haloperidol/lorazepam

67
Q

list some contra-indications to use of haloperidol in management delirium

A

Lewy body dementia
Parkinsonism
prolonged QT interval

68
Q

list some non-medical management options for dementia

A 
aromatherapy
music and dance, physical activity
contact with pets and animals
massage
re-orientation - clocks, diaries, calendars
69
Q

how do bisphophonates work?

A

analogues of pyrophosphate, a molecule which decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis.

70
Q

list some clinical uses of bisphosphonates

A

Prevention and treatment of osteoporosis
Hypercalcaemia
Paget’s disease
Pain from bone metatases

71
Q

list some adverse effects of bisphosphonates

A
  • Oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
  • Osteonecrosis of the jaw
  • Increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
72
Q

what advice should you give a patient regarding how to take bisphosphonates?

A

Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet

73
Q

define malnutrition

A

State in which a deficiency of energy, protein, and/or other nutrients causes measurable adverse effects on the body’s form, composition, function and clinical outcome. (NICE 2006)

74
Q

list some causes of malnutrition

A

1) Decreased nutrient intake (starvation)
2) Increased nutrient requirements (sepsis or injury)
3) Inability to utilise ingested nutrients (malabsorption)
4) Or combination of above

75
Q

what tool is used to diagnose malnutrition?

A

MUST score

NB - serum albumin often used as marker, but can be inaccurate

76
Q

how does NICE define malnutrition?

A

a Body Mass Index (BMI) of less than 18.5; or
unintentional weight loss greater than 10% within the last 3-6 months; or
a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months

77
Q

what factors can indicate a patient is at risk of malnutrition?

A
  • Eaten little or nothing for >5 days (or likely to do so)
  • Poor absorptive capacity
  • High nutrient losses
  • Increased nutritional needs from causes such as catabolism
78
Q

list some factors affecting food intake that could lead to malnutrition

A 
Environment
Meal times
Food temp, smell, sounds
Feeding problems
Unfamiliar foods
Appetite, apathy, anxiety
Pain
Surgery
Medication
Radiotherapy
79
Q

list some factors increasing calorie/nutrient requirements that could lead to malnutrition

A 
Acute infection/pyrexia
Inflammatory condition
Trauma
Liver disease
Wound healing
Surgery
Malignancy
Chronic infection (e.g. HIV)
80
Q

list some factors increasing loss that could lead to malnutrition

A 
Diarrhoea
Vomiting
Bowel surgery
Pancreatic insufficiency
Inflammatory bowel disease
Losses from drains and wounds
81
Q

list some possible consequences of malnutrition

A
  • Impaired immunity
  • Impaired wound healing
  • Muscle mass loss
  • Respiratory function loss
  • Cardiac function loss
  • Impaired skin integrity
  • Impaired recovery from illness
  • Worsening prognosis
  • Low quality of life
  • Prolonged hospital stay
  • More hospital admissions
  • Greater healthcare needs
82
Q

describe pathogenesis of refeeding syndrome

A

Prolonged starvation followed by provision of nutritional supplementation from any route

Chronic malnutrition –> insulin levels decreased, energy source switch to fats, normal serum phosphate levels, low intracellular phosphate levels

Refeeding –> insulin increased, movement of electrolytes into cell result in decreased serum electrolyte levels

83
Q

give some clinical features of refeeding syndrome

A

CVS: arrhythmia, HT, CHF
GI: abdo pain, constipation, vomiting, anorexia
MUSC: weakness, myalgias, rhabdomyolysis, osteomalacia
RESP: SOB, ventilator dependence, respiratory muscle weakness
NEURO: weakness, paraesthesia, ataxia
METABOLIC: infections, thrombocytopaenia, haemolysis, anaemia
OTHER: ATN, Wernicke’s encephalopathy, liver failure

84
Q

list some test you would want to do before beginning feeding

A

U&E
LFT
ECGs

85
Q

what blood results would you see in refeeding syndrome?

A 
hypophosphataemia
hypokalaemia
hypomagnesaemia
hyperglycaemia
thiamine deficiency (erythryocyte transketolase or thiamine level)
trace elements deficiencies
86
Q

what is syncope? what three ‘areas’ should you consider in thinking about differentials?

A

transient, self-limited LOD with an inability to maintain postural tone, followed by spontaneous recovery

think about Head, Heart and Vessels

87
Q

list some ‘head’ causes of syncope

A

Hypoxia
Epilepsy
Anxiety & hyperventilation
Dysfunctional brain stem

88
Q

list some ‘heart’ causes of syncope

A 
MI, ACS
PE
Aortic obstruction (AS, IHSS, myxmoma)
Arrhythmias
Long/short QT syndrome
Brugada syndrome, WPW
Cardiomyopathy
89
Q

list some ‘vessel’ causes of syncope

A

Vasovagal (emotional reaction)
Valsalva (micturition, cough, straining, sneeze)
Carotid sinus syncope
Situational (GI stimulation, post-exercise, post-prandial, weight lifting, wind instruments)
ENT (glossopharyngeal neuralgia)
Low systemic vascular resistance
Autonomic dysfunction: Addison’s, diabetic vascular neuropathy
Drugs such as CCBs, beta-blockers, anti-hypertensives

90
Q

list some red flags in a syncope history and what they’d make you consider

A
  • Exertional onset: aortic stenosis, cardiomyopathy, coronary artery disease
  • Chest pain: MI, PE
  • Dyspnoea: aortic stenosis, MI, PE
  • Low back pain: AAA rupture
  • Palpitations: arrhythmias
  • Severe headaches: cranial haemorrhage
91
Q

what four things do you assess when assessing capacity?

A

Understand the information relevant to the decision
Retain the information
Weigh up the information
Communicate the decision

92
Q

what are the five key aspects of the MCA?

A

1) Assume capacity – person assumed to have capacity until proven otherwise
2) Maximise decision-making capacity – all practical support to help a person make a decision should be given
3) Freedom to make seemingly unwise decisions – an apparently unwise decision in itself does not prove incapacity
4) Best interests – all decisions taken on behalf of the person must be in their best interests
5) Least restrictive option – when making a decision on another person’s behalf, the alternative that achieves the necessary goal and interferes the least with the person’s rights and freedom of action must be chosen.

93
Q

explain what should be considered when making a best interests decision

A
  • Whether the person is likely to regain capacity and can the decision wait
  • How to encourage and optimise the participation of the person in the decision
  • The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
  • Views of other relevant people
94
Q

what do advanced directions allow?

A

Allow people who understand the implications of their choices to state their treatment wishes in advance.
They can be used to:
- Authorise or request specific procedures
- Refuse treatment in a predefined future situation (advance directive)

95
Q

when is an advanced refusal of treatment legally binding?

A

if:

1) The person is an adult, and
2) Was competent and fully informed when making the decision, and
3) The decision is clearly applicable to current circumstances, and
4) There is no reason to believe that they have since changed their mind

96
Q

when are advance requests for treatment legally binding?

A

they aren’t! should be considered when assessing best interests, but legally a patient may not demand specific treatment.

there is a duty to take reasonable steps e.g. artificial nutrition and hydration to keep the person alive if that is patient’s known wish

97
Q

explain what a lasting power of attorney is

A

“A document which a person can nominate someone else to make certain decision on their behalf (for example on finances, health and personal welfare) when they are unable to do so themselves”.
To be valid, it needs to be registered with the Office of the Public Guardian

98
Q

what is an IMCA?

A

Independent mental capacity advocate (IMCA)

  • Commissioned from independent organisations by the NHS and local authorities to ensure that MCA is being followed
  • Role of IMCA: support and represent people who lack capacity and they do not have anyone else to represent them in decisions about changes in long-term accommodation or serious medical treatment. They can also be present for decisions regarding care reviews or adult protection.
99
Q

when is a DoLS required?

A
  • Mental Capacity Act allows restraint and restrictions to be used – but only if they are in a person’s best interests.
  • Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are called the Deprivation of Liberty Safeguards.
  • DoL = any time a patient is subject to continuous supervision or control, and/or is not free to leave the care home/hospital - and lacks capacity to consent to any of this.
100
Q

what is the process for getting a DoLS?

A
  • care homes or hospitals must ask local authority if they can deprive a person of their liberty. This is called requesting a standard authorisation.
  • There are six assessments which have to take place before a standard authorisation can be given.
  • If a standard authorisation is given, one key safeguard is that the person has someone appointed with legal powers to represent them. This is called the relevant person’s representative and will usually be a family member or friend, but might be an IMCA.
101
Q

what conditions need to be met before a standard authorisation (under DoLS) can be granted?

A
  • person is 18 or over (different safeguards apply for children).
  • person is suffering from a mental disorder.
  • person lacks capacity to decide for themselves about the restrictions which are proposed so they can receive the necessary care and treatment.
  • restrictions would deprive the person of their liberty.
  • proposed restrictions would be in the person’s best interests.
  • should the person instead be considered for detention under the Mental Health Act?
  • there is no valid advance decision to refuse treatment or support that would be overridden by any DoLS process.

if any of these not met, authorisation not granted - so care home/hospital has to adjust care plan to be less restrictive.

102
Q

who conducts a DoLS assessment?

A

two independent professionals - one a mental health assessor, one a best interests assessor - need to have had specific training.

nearest relative or IMCA also consulted.

103
Q

what are the six assessments that are done as part of DoLS assessment?

A

1) age assessment (must be <18yrs)
2) no refusals assessment - would proposed care go against any advanced refusals in place or decision of someone with LPA?
3) mental capacity assessment - as per MCA to assess whether capacity to decide on these deprivations of liberty
4) mental health assessment - can only be authorised if they have a ‘mental disorder’ as defined in MHA
5) eligibility assessment - not eligible for DoLS if under MHA sections
6) best interests assessment - performed by best interests assessor, taking into account views of close family/relatives, anyone with LPA, IMCA etc

104
Q

in a DoLS assessment, who can act as best interests assessor?

A

an approved mental health professional, social worker, nurse, occupational therapist or psychologist, with the required training and experience.
can be employed by the supervisory body or the managing authority, but must not be involved in decisions about your care or treatment.

105
Q

list some social and demographic risk factors for falls

A

advanced age
living alone
previous falls
limited ADLs

106
Q

list some age-related changes RFs for falls

A

reduced ability to discriminate edges e.g. stairs
reduced peripheral sensation
slower reaction times
muscle weakness

also - poor gait and balance / postural instability (not necessarily age related)

107
Q

list some medical problems that are risk factors for falls

A 
cognitive impairment
Parkinson's disease
cerebrovascular disease
eyes diseases reducing acuity e.g. glaucoma, cataracts, age-related macular degeneration
arthritis
foot problems
peripheral neuropathy
incontinence
108
Q

list some medicals that are risk factors for falls

A

psychiatric meds e.g. antidepressants
cardiovascular meds e.g. antihypertensives
being on 4+ medications

109
Q

list some environmental risk factors for falls

A

ill-fitting footwear e.g. loose slippers
wearing varifocal glasses
loose rugs
dim lighting

110
Q

what are the main components of a multifactorial falls risk assessment for a patient with recurrent falls?

A
  • history
  • medication review
  • abbreviated mental test score
  • vision assessment - cataracts, acuity, visual fields
  • lying and standing BP
  • CVS examination
  • ECG
  • get-up-and-go test (rise from chair, without using their arms if poss, walk 3m, turn and return to sit in the chair)
  • neuro exam
111
Q

when might you refer a falls patient to a geriatrician specialising in falls?

A
  • abnormal gait/balance requiring diagnosis
  • possible LOC
  • if dizziness is a precipitating factor
  • when medical conditions contributing to falls could be optimised (e.g. postural hypotension, Parkinson’s)
  • recurrent unexplained falls
112
Q

how is postural hypotension tested for/diagnosed?

A

lying-standing BP
lie supine for 5 mins
take BP lying, 1 min after standing, 3 and 10 mins after as well.
diagnose if >20 mmHg drop systolic (or >10 diastolic)

113
Q

what investigations would you order for a suspected fragility fracture/osteoporosis?

A
  • FBC
  • ESR
  • U&Es and creatinine
  • calcium, alk phos, phosphate
  • TFTs
  • LFTs
  • serum electrophoresis and urinary Bence-Jones protein
114
Q

explain the changes that occur in the urinary tract with ageing

A
  • shortening of the urethra
  • post-menopausal atrophy of urothelium
  • reduced bladder sensation
  • reduced detrusor muscle function
  • increased residual bladder volume
  • less effective urethral closure
115
Q

list some drugs that can worsen/precipitate incontinence

A
  • diuretics
  • sedatives
  • alpha blockers
  • any drugs with cholinergic properties
116
Q

what are the 5 main types of incontinence in older people?

A
  • urge incontinence/OAB
  • stress incontinence
  • mixed (urge and stress)
  • voiding problems e.g. obstruction, neurogenic bladder
  • functional incontinence - unable to get to toilet or confused

3a 2023 (19 decks)

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