Care of the Elderly ILA Flashcards
1
Q
What are the risks of PEG feeding?
A
Risks include bowel perforation, wound infection, peritonitis, aspiration, death.
2
Q
What is autonomy?
A
The right for an individual to make his or her own choice.
3
Q
What is justice?
A
A concept that emphasizes fairness and equality among individuals.
4
Q
What is beneficence?
A
The principle of acting with the best interest of the other in mind.
5
Q
What is non-maleficence?
A
The principle that “above all, do no harm,” as stated in the Hippocratic Oath.
6
Q
What is lasting power of attorney?
A
A lasting power of attorney is a legal document that lets you (the ‘donor’) appoint people (known as ‘attorneys’) to make decisions on your behalf. It could be used if you became unable to make your own decisions.
There are 2 types of lasting power of attorney:
• health and welfare
• property and financial affairs
7
Q
What is the Court of Protection?
A
The Court of Protection makes decisions and appoints deputies to act on behalf of people who are unable to make decisions about their personal health, finance or welfare.
8
Q
Who is a court appointed deputy?
A
You need to apply to the Court of Protection to act as someone’s deputy and make decisions on their behalf. You would use this if the person in question has already lost capacity to grant a LPA.
9
Q
What is an IMCA?
A
Independent Mental Capacity Advocate
An IMCA safeguards the rights of people who:
• are facing a decision about a long-term move or about serious medical treatment;
• lack capacity to make a specified decision at the time it needs to be made; and
• have nobody else who is willing and able to represent them or be consulted in the process of working out their best interests, other than paid staff.
10
Q
When withdrawing treatment, basic care must always still be provided. What does this include?
A
Oral food/fluid is basic care.
Tube feeding/parenteral fluids is medical treatment.
Basic care must always be offered.
Medical treatment must if offered if it will be of ‘overall benefit’ to the patient.
11
Q
What is frailty?
A
State of increased vulnerability resulting from ageing associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised.
It is not inevitable, not simply due to multiple long term conditions and not irreversible
12
Q
What are the 5 M’s of geriatric giants?
A
Mind- dementia ,delirium, depression
Mobility- falls
Medications- polypharmacy, AEs
Multi-complexity- biopsychosocial situations
Matters most- individual meaningful health outcomes and preferences
13
Q
What is a comprehensive geriatric assessment?
A
Medical assessment- doctor, nurse, pharmacist, dietician, SaLT
Functional assessment-OT,PT,SaLT
Psychological assessment
Doctor, nurse, OT, psychologist
Social and environmental assessment
OT, SW
14
Q
What is the role of the medical assessment?
A
Problem list
Co-morbid conditions and disease severity
Medication review
Nutritional status
15
Q
What is the role of the functional assessment?
A
Activities of daily living
Activity/exercise status
Gait and balance
16
Q
What is the role of the psychological assessment?
A
Cognitive status testing
Mood/depression testing
17
Q
What is the role of the social and environmental assessment?
A
Informal support needs and assets
Eligibility/need for carers
Home safety
18
Q
Following an initial fall, what is the risk of having another one within a year?
A
66%
19
Q
What percentage of over 65s fall each year?
A
28-35%
20
Q
What are the common risk factors for falls?
A
Previous falls Fear of falling Balance problems Gait and mobility problems Pain Drugs- GTN, BBs, diuretics, a-blockers, sedatives, SSRIs Cardiovascular conditions Cognitive impairment Urinary incontinence Stroke Diabetes
21
Q
What is Alzheimer’s disease? (pathophysiology)
A
- Global atrophy
- Intracellular neurofibrillary tangles made from tau protein-> disrupt the microtubules in nerves
- Extra-cellular beta-amyloid plaques -> disrupt nerve communication at synapses -> causes nerve degeneration
22
Q
What are the 5 A’s of Alzheimer’s?
A
- Amnesia
- Aphasia
- Apraxia- deficit in voluntary motor skills (ADLs)
- Agnosia- difficulty recognising things or faces
- Apathy- lack of motivation
23
Q
What is the treatment for Alzheimer’s?
A
Anticholinesterase inhibitors e.g. donepezil, rivastigmine, galantine
24
Q
What are the characteristic features for Lewy Body Dementia?
A
Day-to-day fluctuating cognition, visual hallucinations, sleep disturbance, recurrent falls, parkinsonism (TRAP)
25
What are the characteristic features of vascular dementia?
Step-wise deterioration in cognition (but can be generalised decline), sundowning, mood plays a bigger role, inappropriate behaviour, can get focal neurology, fits, nocturnal confusion
26
What medications should you not give in LBD?
Typical anti-psychotics
| Anti-cholinergics (can worsen cognition)
27
What is Picks disease?
A type of frontotemporal dementia- disinhibition, antisocial behaviour, personality changes, knife-blade atrophy
Tends to affect younger people
28
What is normal pressure hydrocephalus?
A triad of ‘wet, wacky, wobbly’ – urinary incontinence, dementia, gait disturbance. Due to ↑CSF, but ventricles dilate
29
Name 3 cognitive assessment tools, other than MMSE?
Addenbrookes cognitive examination-III (ACE-III)
Montreal cognitive assessment (MoCA)
Abbreviated mental test score (AMT)
6-Item cognitive impairment test (6CIT)
General practitioner assessment of cognition (GPCOG)
30
What is mild cognitive impairment?
Cognitive impairment but minimal impairment of ADL’s
31
Define delirium. Name the 2 types?
Delirium = acute, transient, reversible state of fluctuating impairment of consciousness, cognition, and perception
1. Hyperactive = agitation, inappropriate behaviour, hallucinations
2. Hypoactive = lethargy, reduced concentration
32
Name 5 causes of delirium?
Drug use, e.g. anticholinergics, opioids, steroids, benzodiazipines
Electrolyte abnormalities, e.g. ↓/↑ Na+, ↑Ca2+,↓Glucose, ↑urea
Lack of drug (withdrawal),
Infection, e.g. UTI or pneumonia
Reduced sensory input (blind, deaf)
Intracranial problems (stroke, post-Ictal, meningitis, subdural haematoma)
Urinary retention and constipation
Malnutrition, e.g. thiamine, nicotinic acid, B12 deficiency
33
Name 5 investigations which are part of the delirium screen?
Bloods:
FBC (WCC for infection, anaemia, MCV), U&Es (urea, AKI or Na+, K+), LFT (liver failure, or alcohol abuse)
blood glucose, TFTs (hypothyroid), ↑Ca2+ (bones stones, groans, psychic moans)
haematinics (B12 and folate), INR (Warfarin, bleeding risk)
Septic Screen
urine dipstick
chest X-ray
blood cultures
```
ECG
Malaria films
Lumbar Puncture
EEG
CT / MRI
```
34
Name 3 supportive methods of management for delirium?
Supportive management: alter environment → help with reorientation
- Clocks and calendars
- Side room
- Sleep hygiene – discourage napping
- Adequate lighting
- Continuity of care
- Access to hearing aids / glasses
35
What medical treatment can be used to manage delirium?
```
Medical treatment: (Try to Avoid)
IM haloperidol (antipsychotic)
benzodiazepines
```
36
The patient recovers and is medically fit. What are the next steps in management? Who is involved?
Complete a full Comprehensive Geriatric Assessment for Discharge Planning?
Medical Assessment – Problem list (diagnosis and treatment), co-morbid conditions & disease severity, Medication review- doctor / consultant
Functional Assessment – ADL, gait, balance- occupational therapist, physiotherapist
Psychological Assessment – cognition, mood- nurse, psychiatrist
Social assessment – care resources, finances- social worker
Environmental assessment – home safety
37
What is osteoporosis?
↓bone mineral density (BMD), ↑ bone fragility → fractures
38
What is osteopenia?
precursor to osteoporosis
39
What is osteomalacia?
softening of bones, due to impaired bone metabolism from inadequate levels of Ca2+, PO43- and Vitamin D
40
What investigation is most useful to assess the extent of osteoporosis?
What is the diagnostic criteria for osteoporosis?
DEXA = Dual-Energy X-ray Absorptiometry
WHO osteoporosis criteria (T score)
>1 BMD is better than reference
0 to -1 = normal
-1 to -2.5 = osteopenia – give lifestyle measures
≤ -2.5 SDs= osteoporosis
41
What is the T score?
The number of standard deviations the patients’ bone mineral density differs from the population average for a young healthy adult.
42
What is assessed in bone profile in bloods in osteoporosis?
Ca2+, PO43-, Alk Phosphate
43
Name 5 risk factors for osteoporosis (SHATTERED)
```
Steroids (>5mg/day)
Hyperthyroidism, hyperparathyroidism, hypocalcaemia
Alcohol / tobacco
Thin (BMI < 22)
Testosterone ↓ (antiandrogens)
Early menopause – oestrogen deficiency
Renal or liver failure
Erosive / Inflammatory bowel disease
Dietary intake (↓Ca2+, malabsorption, diabetes type I)
```
44
Name another drug can cause osteoporosis?
PPI omeprazole – reduce stomach acid and reduce ca absorption from the stomach
45
How does the parathyroid gland work?
Low conc Ca in blood -> release of PTH ->
1. Increases Ca resorption from bone
2. Increases bone reabsorbtion from kidney
3. Increases Ca absorption into blood (with the help of vitamin D from the kidney- also decreases phosphate)
Increases Ca conc
46
How is vitamin D synthesised?
UV sunlight + dietary Vit D -> 1,25 hydroxy vitamin D (1,25-(OH)2D) → ↑ Ca2+ absorption from gut
47
What is conservative treatment in osteoporosis?
- ↓ risk factors
- weight
-bearing exercises
- fall prevention
– balance exercises
- home assessment
48
What is medical treatment in osteoporosis?
- Bisphosphonates e.g. Alendronate – Instructions to patient? Side effects?
- Strontium Ranelate – similar Ca2+ structure – forms bone- -Raloxifene (SERM) – agonist in bone, antagonist in breast
- Calcitonin – reduce pain after fractures- -Denosumab – Monoclonal to RANK Ligand, SC twice yearly
49
Define syncope?
Syncope = temporary loss of consciousness, characterised by
- fast onset
- short duration
- spontaneous recovery(due to hypo perfusion of the brain)
50
Name some causes of collapse?
Neuro- hypoxia, epilepsy, anxiety
CVS- MI, ACS, PE, aortic obstruction, arrhythmias
Drugs- CCBs, BBs, anti-hypertensives
Other- vasovagal, valsalva
51
An 81 year old woman was found collapsed at home following a fall. She is shown to have a raised urea, creatinine and potassium. Her urine is dark red in colour. It has been estimated that she was lying on the floor for at least 24 hours before being found?
What is the most likely cause of the patients acute kidney injury (AKI)?
What causes the urine to be dark red?
Rhabdomyolysis – skeletal muscle breaks down due to traumatic, chemical or metabolic injury.
Common causes = crush injuries, prolonged immobilisation following a fall, prolonged seizure activity, hyperthermia, neuroleptic malignant syndrome.
Muscle breakdown causes – ↑ potassium, phosphate, myoglobin and creatine kinase
Myoglobin is harmful to kidneys → acute tubular necrosis
Raised potassium – increases risk of arrhythmias → Do ECG
52
What are the signs of hyperkalaemia on ECG?
Peaked T waves
Loss of P waves
Sine wave pattern
53
What is the management of hyperkalaemia?
C BIG K DRop
Calcium gluconate- cardioprotective
Bicarbonates
Insulin
Glucose (all drive K intracellularly)
Kayexalate- binds K in the GI tract
Diuretics- if kidneys good
Renal- dialysis in kidneys bad
54
Define ulcer?
A break in the skin or mucous membrane which fails to heal
55
Name 3 risk factors for a Pressure Ulcer?
Pressure Ulcer = caused by pressure or shear force over bony prominence
```
Risk Factors:
IMMOBILITY – bed bound
Poor nutrition
Incontinence
Multiple comorbidities
Smoking
Dehydration
```
56
What score is used to assess the risk of developing a pressure ulcer?
Waterlow score – assess risk of developing a pressure ulcer
57
Name 3 ways of preventing a pressure ulcer?
Barrier creams
Pressure redistribution - special foam mattresses
Repositioning
Regular skin assessment
58
What are the complications of a long lie following a fall?
1. Pressure ulcers
2. Dehydration
3. Rhabdomyelosis
59
What are the investigations for a pressure ulcer?
```
CRP, ESR
WCC
Swabs
Blood cultures
X-ray for bone involvement
```
60
What is the management of pressure ulcers?
Antibiotics
Wound dressing
Pain relief
Debridement if grade 3/4
61
What is refeeding syndrome?
Metabolic disturbances as a result of reinstitution of nutrition to patients who are starved/severely malnourished
Biochemical features:
Hypophosphatemia
Hypokalemia
Thiamine deficiency
Abnormal glucose metabolism
Complications: cardiac arrhythmias, coma, convulsions, cardiac failure
Treatment: monitor blood biochem, commence refeeding with guidelines
62
What are the 4 I geriatric giants?
Immobility
Incontinence
Incompetence
Impaired homeostasis
63
List 4 causes of hyponatraemia?
Hyponatriaemia Causes
- Dilutional effect: Heart failure, hypoproteinaemia, SIADH, hypervolaemia/fluid excess, NSAIDs (promote water retention), oliguric renal failure (dilution)
- Sodium loss: Addison’s disease (aldosterone insufficiency), diarrhoea & vomiting, osmotic diuresis (e.g. Diabetes mellitus, diuretic excess), severe burns, diuretic stage of acute renal failure.
64
Name 4 symptoms of hypocalcaemia and another 4 for hypercalcaemia?
Hypercalcaemia- bones, stones, groans and psychiatric moans
```
Bone pain, fractures (hyperPTH or malignancy)
Renal stones (renal colic); renal impairment (renal calcinosis); polyuria, polydipsia, dehydration (nephrogenic diabetes insipidus)
Drowsiness, delirium, coma, muscle weakness, impaired cognition, depression
Nausea, vomiting, weight loss, anorexia, constipation, abdominal pain.
HTN, shortened QT, arrhythmias.
```
Hypocalcaemia:
- Paraesthesia (usually fingers, toes and around mouth).
- Tetany.
- Carpopedal spasm (wrist flexion and fingers drawn together).
- Muscle cramps
- Seizures.
- Prolonged QT
- Laryngospasm; bronchospasm
65
What MMSE score supports a diagnosis of dementia?
MMSE <25 supports dementia. 25-27 is borderline. <10 severe; 10-20 moderate; 21-24 mild.
66
What blood tests would you do to exclude organic causes of dementia?
```
Thyroid function tests
Syphilis serology (neurosyphilis)
Liver function tests (hepatic encephalopathy; alcoholism)
Vitamin B12, thiamine (B1) and folate levels
```
67
What is Donepezil and what types of dementia can it be used to treat?
Donepezil is an acetylcholinesterase inhibitor; used only in Alzheimer’s disease.
68
What are clinical symptoms of delirium?
Acute behavioural change (hours to days)
Altered social behaviour
Altered level of consciousness
Falling and loss of appetite
69
What are some differential diagnoses for delirium?
Depression
Dementia
Mental illness
Anxiety
Thyroid disease
Temporal lobe epilepsy
Charles Bonnet syndrome
70
What is malnutrition?
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)
71
What are causes of malnutrition?
Decreased nutrient intake (starvation)
Increased nutrient requirements (sepsis or injury)
Inability to utilise ingested nutrients (malabsorption)
Or combination of above
72
How is malnutrition diagnosed?
BMI <18.5kg/m2
Unintentional weight loss >10% last 3-6mths
BMI <20kg/m2 AND unintentional weight loss >5% within last 3-6mths
73
Who is at risk of malnutrition?
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
74
What factors affect intake for malnutrition?
```
Environment
Meal times
Food temp, smell, sounds
Feeding problems
Unfamiliar foods
Appetite, apathy, anxiety
Pain
Surgery
Medication
Radiotherapy
```
75
What factors increase requirements for malnutrition?
```
Acute infection/pyrexia
Inflammatory condition
Trauma
Liver disease
Wound healing
Surgery
Malignancy
Chronic infection (e.g. HIV)
```
76
What factors increase loss in malnutrition?
```
Diarrhoea
Vomiting
Bowel surgery
Pancreatic insufficiency
Inflammatory bowel disease
Losses from drains and wounds
```
77
What are consequences of malnutrition?
```
Impaired immunity
Impaired wound healing
Muscle mass lost
Resp function loss
Cardiac function loss
Impaired skin integrity
Worsening prognosis
Low QOL
Prolonged hosp stay
```
78
What are the 5 principles of the Mental Capacity Act?
```
Assume capacity
Maximise decision-making quality
Freedom to make seemingly unwise decisions
Best interests
Least restrictive options
```
79
Who is the MHA for?
anyone above 16 years of age who will not be admitted voluntarily. Patients under the influence of alcohol or drugs are specifically excluded.
80
What should be considered for best interests?
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
81
What is advanced directives?
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)
Advance refusals of treatment are legally binding if:
- The person is an adult, and
- Was competent and fully informed when making the decision, and
- The decision is clearly applicable to current circumstances, and
- There is no reason to believe that they have since changed their mind
Advance requests for treatment do not have the same legal binding status but should be considered when assessing best interest
-There is a duty to take reasonable steps (eg artificial nutrition and hydration) to keep the person alive if that is the patient’s known wish
82
When is a DOLS used?
“DoL occurs when a person does not consent to care or treatment, for example, a person with dementia who is not free to leave a care home and lacks capacity to consent to this”
83
When is a LPA used?
“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
84
What is the role of the independent mental capacity advocate?
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.
85
What are the 3 variants in fronto-temporal dementia?
1) Behavioural variant (Picks disease)
2) Semantic- can speak, receptive aphasia
3) Progressive non-fluent aphasia- expressive aphasia
