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Clinical Year 4 > Care of the Elderly & Dementia > Flashcards

Care of the Elderly & Dementia Flashcards

1
Q

What is dementia?

A

Dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function.

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2
Q

Mini Mental State Examination

A

Mini Mental State Examination (out of 30)

Normal: 26-30
Mild dementia : 21-25
Moderate dementia: 10-20
Severe dementia: 0-9

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3
Q

What is a mild cognitive impairment?

A

Syndrome defined as cognitive decline greater than expected for an individual’s age and education level but that does not interfere notably with activities of daily life. (10% per year develop A.D.)

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4
Q

Which drugs can contribute to cognitive impairment?

A

Anti-cholinergics – e.g. Oxybutynin

Anti-psychotics – e.g. Chlorpromazine

Anti-histamines

Anxiolytics – e.g. Benzodiazepines

Antidepressants – e.g. TCA’s, SSRI’s

Anticonvulsants – e.g. Phenytoin

Opiates

PD drugs

Lithium

Steroids

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5
Q

Is drug induced cognitive impairment reversible?

A

Yes

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6
Q

What are the main symptoms of Alzheimer’s Disease?

A

Memory loss, personality changes, global cognitive dysfunction and functional impairments

Visual spatial disturbances (early finding)

Apraxia (loss of the ability to perform activities that a person is physically able and willing to do)

Language disturbances

Personality changes

Delusions/hallucinations (usually later in course)

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7
Q

What drugs are normally used to treat Alzheimer’s Disease?

A

Cholinesterase inhibitors

  • (Donepezil, Rivastigmine & Galantamine)
  • Low levels of acetylcholine in A.D.

Mild to Moderate disease

Initiate under specialist care

Continue only if worthwhile effect

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8
Q

What is Mermantine and when should it be used?

A

NMDA receptor antagonist (blocks action of glutamate)
- Excess glutamate in mid-late stage interferes with neurotransmission & contributes to neurone loss.

Used in:

  • Moderate disease (if intolerant of or contraindication to acetylcholinesterase inhibitors)
  • Severe disease
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9
Q

Who needs to go to a falls clinic?

A

Recurrent fallers – no cause identified

Poor balance

Undiagnosed “dizziness”

Syncope – unknown cause

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10
Q

What needs to be tested when a patient falls?

A

Full examination

  • GAIT
  • Pulse, heart murmurs
  • Cerebellar testing
  • Joints
  • Proprioception & sensation in feet

Blood tests (including Vitamin D)

Lying & standing BP

ECG

Tilt table test

CT brain

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11
Q

Postural Hypotension

A

Fall of 20 mmHg in SBP or 10 mmHg in DBP on assuming upright position

Prevalence 30% in over 75 yo

Increased all-cause mortality

Impaired capacity to increase vascular resistance on standing

Mostly treatable but easily missed

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12
Q

What are common symptoms of postural hypotension?

A

Postural dizziness or pre-syncope
Falls
Syncope
Visual disturbance

Weakness, lethary
“Coathanger” ache

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13
Q

What are common causes of postural hypotension?

A

Medication

  • Antihypertensives: esp. diuretics & Doxazosin
  • TCA’s, PD meds, antipsychotics

Intercurrent illness

Bed rest

Autonomic dysfunction
- DM, PD, paraneoplastic, Addison’s, post infective autonomic dysfunction, alcohol

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14
Q

What can be used to treat postural hypotension?

A

MEDICATION REVIEW

Conservative measures

  • Increase fluid input
  • AEDs
  • Advice

Medication

  • Fludrocortisone
  • Midodrine
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15
Q

What factors can affect digoxin levels?

A

Renal function

Frailty

Hypokalaemia
- Use K+ sparing diuretics with loop diuretics

Other drugs (see next)

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16
Q

What are the symptoms of Digoxin toxicity?

A

Systemic

  • Anorexia, n/v, diarrhoea
  • Lethargy/fatigue
  • Confusion
  • Blurred vision – yellow/green halos

Cardiac
- Bradycardia

17
Q

How do you manage digoxin toxicity?

A

Mild:

  • Stop digoxin for 2-3 days
  • Replace K+
  • Repeat level and start at lower dose

Severe:
- Digibind (iv)

18
Q

Why is prescribing more difficult in older people?

A

Multiple pathology

Polypharmacy

  • Increased drug interactions, side effects
  • Decreased adherence

Difficulties with adherence

Altered drug handling

  • Physical changes
  • Pharmacokinetics
  • Pharmacodynamics
19
Q

What are some unintentional reasons for non-adherence in the elderly?

A

Difficulty with packaging or devices

Difficulty swallowing

Confusion/memory problems

Poor communication/misunderstanding

Polypharmacy/complicated regimen

20
Q

What are some intentional reasons for non-adherence in the elderly?

A
  • Deliberate adjustments
  • Lack of confidence in medicines or prescriber
  • Side effects or concerns about these
  • Polypharmacy/complicated regimen
  • Poor communication/lack of information
21
Q

How can you improve adherence in elderly patients?

A

Assess use of medicines

Large print labels and leaflets

Plain tops on bottles

Medication reminder cards

Multi-compartment compliance aids (MCAs)

22
Q

How is ABSORPTION affected in elderly patients?

A

Reduced rate of absorption but extent of absorption unchanged

  • Reduced salivary flow, emptying time, surface area and blood flow
  • Increased gastric pH

Exceptions

  • Decreased absorption of vitamins
  • Increased absorption of levodopa
23
Q

How is DISTRIBUTION affected in elderly patients?

A

Reduced perfusion
- slow distribution throughout the body

Reduced body water
- increased plasma conc of water-soluble drugs

Increased body fat
- prolonged effects of fat soluble drugs

Reduced albumin

Reduced muscle

24
Q

How is METABOLISM affected in elderly patients?

A

Reduced hepatic perfusion

Reduced first pass metabolism

Reduced hepatic enzymes

BUT - large reserve, so ? clinical significance

25
Q

How is ELIMINATION affected in elderly patients?

A

Rredictable age-related DECLINE IN RENAL FUNCTION
- worsened by dehydration, cardiac failure, diabetes, infection etc

THE MOST IMPORTANT PHARMACOKINETIC CHANGE IN THE ELDERLY!

26
Q

How is PHARMACODYNAMICS affected in elderly patients?

A

“What the drug does to the body”

Changes in target receptor sensitivity

  • Increased effects of CNS-acting drugs
  • Decreased efficacy of beta blockers

Changes in target organ responsiveness

Loss of homeostatic mechanisms

Result = altered sensistivy to drugs

27
Q

What are the main principles of safe prescribing in the elderly?

A

Start low and go slow

Simple regimens

Monitor for efficacy

Watch for side effects and interactions

Set clear therapeutic goals

28
Q

Examples of STOPP drugs in the elderly

A

Long term digoxin over 125mcg with impaired renal function

Neuroleptics as long term hypnotics

Metoclopramide in Parkinson’s disease

NSAID in heart failure

29
Q

Examples of STARTT drugs in the edlerly

A

Warfarin in chronic AF

ACE-I in chronic heart failure

Bisphosphonates in patients on maintenance corticosteroids

30
Q

What are the types of drugs that can be classified as problem drugs in the elderly?

A

Diuretics (especially bendroflumethiazide)
- hyponatraemia, dehyration, renal impairment, postural hypotension

Antihypertensives
- dehydration, renal impairment, postural hypotension

CNS acting agents
- postural sway, confusion, falls, sedation

Opioids
- hypotension, constipation and CNS effects

NSAIDs
- fluid retention, GI and renal toxicity

Anticholinergics (e.g. TCAs, oxybutynin)
- Blurred vision, constipation, confusion, urinary retention

31
Q

What are the main monitoring parameters in elderly patients?

A

Haematology
- FBC

Biochemistry

  • LFTs
  • U&Es
  • Blood sugar
  • TFTs
  • Blood lipids

Body mass index or equivalent

Drug therapeutic target ranges

32
Q

What are common signs of danger in the elderly?

A

Hyponatraemia
- Muscle cramps, slurred speech, confusion etc.

Hypoglyceamia
- Nausea, sweating, weakness or fainting, confusion, headache, cold sweat, bizarre behaviour etc.

Anaemia
- Tiredness, palpitations, SOB, dizziness etc.

Hypokalaemia
- Muscle weakness, intestinal atony, increased sensitivity to digoxin, polyuria, polydypsia etc.

33
Q

What is the abbey pain score?

A

Used to measure pain in people with dementia who cannot verbalise

0-2 = No pain
3-7 = Mild
8-13 = Moderate
14+ = Severe

Clinical Year 4 (12 decks)

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