COTE Flashcards
RF for pressure ulcers
- Age
- Immobility
- malnourishment
- Dehydration
- Sensory impairment
- obesity
- Urinary/feacal incompitence
- Reduced tissue perfusion
What are the geriatric giants?
Immobility (falls) Instability, Impotence (confusion) Incontinence, Impaired intellect Iatrogenesis
What are the causes for delirium?
Drugs Electrolyte imbalance Lack of drug Intracranial problems (stroke/TIA) Reduced sensory input Infections Urinary retnetion and fecal impaction Myocardial (MI/AF/arrhythmias)
What are the differences between dementia and delirium?
Dementia
- Has a longer time frame months/years
- Short term memory problems
- Can also have problems with languages, remembering words and speech issues
- Inattention
- No underlying medical cause
Delirium
- Shorter duration of symptoms days/weeks
- Acute confusion
- Altered levels of consciousness
- Can have delusions
- Due to another cause - infection usually
How could you try to prevent pressure ulcers?
- Trying to mobilise quickly
- Moving position regularly
- Pressure redistributing marrress
- Barrier creams
What treatments can you give to improve bone health?
- VD replacement
- Calcium supplements
- Bisphosphonates - alendronate
Give 6 causes of falls in elderly people?
- Postural hypotension (secondary to antihypertensives)
- Dementia
- Neuodegenerative diseases - Parkinsons and peripheral neuopathy
- Hypoglycaemia
- Poor environment - rugs/poo lighting
- Visual impairment
- Syncope (vasovagal, caridogenic and arrhythmias)
- MSK (OA of the hip)
- Medications (sedatives/alcohol)
- Stroke/TIA
List 3 features of the tremor in Parkinson’s disease
Slow (pin-rolling)
Worse at rest
Asymmetrical
reduced on distraction/movement
A 78 year old man presents having had an episode of left leg weakness this afternoon. He has had a TIA
What score system could you use to estimate his risk of stroke in the next few days?
ABCD2 Age >60 = 1 BP >140/90 = 1 Clinical features: - Unilateral weakness = 2 - Speech disturbance without weakness = 1 Duration of symptoms - >1 hr = 2 - 10-59m = 1 Diabetes = 1
Explain the scoring system on the ABCD2 score
> 6 = 8.1% risk of stroke within2 days - 33% in the next week
4-5 = 4.1% risk
4 points should be seen by a specialist in 2 days
All suspected TIAs should be seen within 7 days
What is the immediate management of a ?TIA
ABCD score and see a specialist accordingly
Aspirin 300mg daily with PPI if required
What is the long term plan/secondary prevention for a person with a TIA?
Lifestyle changes Clopidogrel 75mg daily Statin Antihypertensives if required Warfarin/NOACs if: AF, mitral stenosis, dilated cardiomyopathy or recent MI
Name 4 cardiac conditions that could cause an embolic CVA
Atrial fibrillation MI causing mural thrombus Infective endocarditis Aortic or mitral valve disease Patent foramen ovale
You do a CT head on a patient who has had a CVA. What colour would the following be?
A) heamorrhage
B) Vascular occlusion
A) Heamorrhage = white on CT
B) Vascular occlusion = darker on CT
A patient who has had a CVA has had an ECG and CT head - what other Ix would you request?
Clotting screen - indicates risk of thrombosis or haemorrhage
Syphilis screen
Echo - excludes cardiac sources of emboli
Carotid doppler - excludes internal carotid stenosis
Explain how a person with Bradykinesia due to Parkinson’s disease would present
Slow, shuffling gait
Reduced arm swing
Difficulty initiating movement
A 57 year old man presents with a ‘shaking hand’, he also says he feels a bit slow at times but he is still managing fine at his work in a shop. You suspect that he has parkinsons. How would you treat this patient?
He is young and his symptoms are not having a significant impact on his life yet - wouldn’t treat yet.
If he got worse - start
- Dopamine agonist = Ropinirole, Bromocriptine
What are the SE of dopamine agonists?
Postural hyoptension
Impulse control problems
Hallucinations
Bromocriptine and cabergolline can cause pulmonary, retroperitoneal and cardiac fibrosis so require echo, ESR, creatinine, & CXR before initiation
What medication is Levodopa prescribed with to prevent the peripheral SE of dopamine?
Dopa decarboxylase inhibitor
If someone had a thomobotic stroke - where could the thrombosis be?
Carotid arteries
What are the risk factors for a stroke?
Age, HTN
Smoking, DM
HLD, AF
List some of the causes of hyponatriamia
Sodium loss: D&V, DM, Diuretic excess, Addisons, severe burns
Dilution effect: HF, SIADH, NSAIDs (promote water retention), organic renal failure
Give symptoms of hypocalcaemia
Muscle cramps
Tetany
Carpopedal spasm (wrist flexion and fingers drawn together)
Paraesthesia (fingers/toes/around mouth)
Seizures
Long QT
(what would calcium do? - allows muscle relaxation)
Give symptoms of hypercalcaemia
BONES, STONES, MOANS, GROANS
Bone pain & fractures
Renal Stones - colic and impriment - polyuria, polydipsia, dehydration (nephrogenic diabetes insipidus)
Moans - drowsiness, delirium, impaired cognition
Groans - N&V&C, wt loss, abdo pain
Shot QT, HTN, Arrhythmias
Give examples of tests that can be used to screen for dementia
- Mini mental state exam (MMSE)
- General Practitioner assessment of cognition (GPCOG)
- 6 item cognitive impairment test (6CIT)
- Abbreviated mental test score (AMT)
- Montreal cognitive assessment (MoCA)
- Addenbrookes cognitive examination III (ACE-III)
What score of the MMSE would support a dementia diagnosis?
<25
How would a person with frontotemporal dementia present?
Personality change Socially inappropriate behaviour Poor judgement Apathy and decreased motivation Poor exectutive function Insidious onset - 50s-60s
What are the symptoms of a person with levy body dementia?
Fluctuation cognition Visual hallucinations Neuroleptic sensitivity Shuffling gait Increased tone Tremors Falls
What are the symptoms of Alzheimers?
Memory loss
Language deficits
Impaired visuospatial skills
Later behavioural symptoms
What bloods could you do to rule out organic causes of dementia?
TFT
Syphilis
LFT (hepatic encephalopathy and alcoholism)
VB12 and thiamine and folate levels
Give examples of acetylcholinesterase inhibitors
Donepezil
Rivastigmine
Galantamine
Give an alternate medication that can be used in Alzheimers
Memantine, a N-methyl-D-aspartate (NMDA)-receptor antagonist which blocks glutamate
What does a comprehensive medical assessment include?
Comprehensive Geriatric Assessment includes:
- Medical (problem list, comorbidities, medication review and nutritional screen)
- Mental (cognition, mood & anxiety, fears)
- Functional (ADL, gait & balance, activity/exercise)
- Social and environmental (support from family/friends, social network, care resource eligibility, home safety and facilities, transport facilities)
What is delirium?
Acute fluctuating syndrome of disturbed consciousness, attention, cognition and perception
What are the two different types of delirium?
Hyperactive agitation, inappropriate behaviour, hallucinations
Hypoactive lethargy, reduced concentration
O/E what are you looking for in a person with dementia?
Clinical examination
- Respiratory conditions,for example chest infection, pulmonary embolus, heart failure, or chronic obstructive pulmonary disease.
- Cardiovascular conditions,for example myocardial infarction and heart failure.
- Abdominal conditions,for example acute abdomen, constipation, faecal loading (carry out a rectal exam if possible if impaction is suspected), urinary retention, and urinary tract infection.
- Musculoskeletal conditions,for example hip fracture.
- Neurological conditions,for example stroke, subdural haematoma, epilepsy, encephalitis, or drug intoxication.
- Skin conditions,for example infection, pressure sores, or ulcers.
- Electrolyte imbalancesuch as dehydration, acute kidney injury, hypercalcaemia,or hyponatraemia.
- Endocrine and metabolic disorderssuch as cachexia, thiamine deficiency, or thyroid dysfunction.
- Sensory impairment,for example impacted ear wax, ill-fitting or non-functioning hearing aids, and spectacles.
- Pain— look for non-verbal signs of pain, particularly in people with communication difficulties.
Describe a comprehensive geriatric assessment
An interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old
The aim is to develop a coordinated, integrated plan for treatment and long-term support
What would make some one high risk for a fracture?
Glucocorticoid therapy Age >75 Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score
How do bisphosphonates work?
MAO of bisphophonates:
Incorporated into the bone matrix and accumulate in osteoclasts when they resorb bone. This inhibits the osteoclasts and causes apoptosis - protects bones by reducing the amount of bone resorption
Osteoclasts: bone resorption
Osteoblasts: bone formation
What are the long term SE of bisphosphonates?
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
Explain the femoral neck T score
T score -1 to +1 = healthy -2.5 to -1 = osteopenia >-2.5 = osteoporosis >-2.5 + fracture = severe osteoporosis
What are the consequences of malnutrition?
Impaired immunity imparied wound healing muscle mass loss Impaired skin integrity Prolonged hospital stays
What does the assumptions and requirements does the mental capacity act have?
Assume capacity – person assumed to have capacity until proven otherwise
Maximise decision-making capacity – all practical support to help a person make a decision should be given
Freedom to make seemingly unwise decisions – an apparently unwise decision in itself does not prove incapacity
Best interests – all decisions taken on behalf of the person must be in their best interests
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.
Assessment, 28 days, not renewable
an Approved Mental Health Professional (AMHP) + 2 Dr’s
One of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act + 1 Dr who knows the patient (GP)
a) Section 4
b) Section 5(2)
c) Section 5(4)
d) Section 2
e) Section 3
Assessment, 28 days, not renewable
an Approved Mental Health Professional (AMHP) + 2 Dr’s
One of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act + 1 Dr who knows the patient (GP)
= section 2
Similar to another section, allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
a) Section 4
b) Section 5(2)
c) Section 5(4)
d) Section 2
e) Section 3
Section 5(4) similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
72-hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a) Section 4
b) Section 5(2)
c) Section 5(4)
d) Section 2
e) Section 3
72-hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a) Section 4
Treatment for up to 6 months, can be renewed
a) Section 4
b) Section 5(2)
c) Section 5(4)
d) Section 2
e) Section 3
Section 3
A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
a) Section 4
b) Section 5(2)
c) Section 5(4)
d) Section 2
e) Section 3
Section 5
A court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety
a) Section 135
b) Section 136
a) section 135
Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
a) Section 135
b) Section 136
b) section 136
What should be considered when making a decision in someones 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
What is DOL?
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
What is lasting power of attorney?
“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
What is a Independent mental capacity advocate (IMCA)?
What is their role?
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.
Give examples of drugs that can cause delirium
BDZ NSAIDs Lithium TCA H2 blockers - ranitidine
