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COTE Flashcards

1
Q

What are the 4 geriatric giants?

A
  1. instability (falls)
  2. Immobility
  3. Intellectual impairment
  4. Incontinence
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2
Q

What are the four key domains of a comprehensive geriatric assessment?

A
  1. Medical Assessment
  2. Functional Assessment
  3. Psychological assessment
  4. Social/environmental assessment
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3
Q

Who is involved in a medical assessment?

What do they do?

A
  • Doctor
  • nurse
  • pharmacist
  • dietician
  • SaLT

Role:

  • problem list
  • manage comobidiies
  • medication review
  • nutritional status
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4
Q

Who is involved in Functional Assessment and what do they do?

A
  • OT
  • PT
  • SaLT

Role:
assess activities of daily living, activity and exercise status and gait and balance

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5
Q

Who is involved in a psychological assessment and what do they do?

A
  • Doctor
  • OT
  • Nurse
  • Psychologist

Role

  • do cognitive status testing
  • Mood/Depression screening
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6
Q

Social/Environmental Assessment?

A
  • OT
  • SW

Role

  • home safety
  • care resource eligibility
  • support needs
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7
Q

What is Pharmacodynamics

How is this taken into account in the elderly?

A

pharmacodynamics - the affect of the drug and their mechanism

Dose is lower in the elderly

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8
Q

Give examples of each of these drug classes

Explain how the elderly are more impacted by them

  1. Benzodiazapines and opioids
  2. Anticholinergics
  3. Anti-hypertensives
A
  1. Benzodiazapines and opioids
    elderly more prone to CNS effects - e.g confusion and sedation
  2. Anticholinergics
    e. g TCA, urinary anti muscarinics e.g oxybutynin, Anti psychotics
    - more sensitive to SE e.g - dry mouth, constipation, blurred vision, urinary retention
  3. Anti-hypertensives
    esp. alpha blockers Doxazosin:
    - elderly more prone to postural HTN
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9
Q

Define pharmacokinetics?

What are the components?

A

What the body does to the drug

  • Absorption
  • Distribution
  • metabolism
  • elimination
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10
Q

How does ageing affect the Absorption stage of of pharmacokinetics

A

Absorption: not highly impacted by ageing

  • delayed gastric emptying due to reduced mobility and intestinal blood flow
  • variable change in 1st pass metabolism due to variable hepatic blood flow
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11
Q

How does ageing affect the Distribution stage of pharmacokinetics

water solube drugs
fat soluble drugs
albumin binding drugs

A
  • there is reduced total body weight and increased total body fat.

So:

Water soluble drugs e.g lithium, alcohol, digoxin, aminoglycosides: have a higher serum concentration

Fat soluble drugs e.g diazapam, trazadone: have a higher half life due to increased body fat

Albumin binding drugs e.g phenytoin, warfarin, cimetidine - higher free serum due to lower serum albumin

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12
Q

How does ageing affect the elimination stage of of pharmacokinetics?

which measuring tool should you use?

A

there is variable reduction in renal function - important to adjust dosage

eGFR less reliable as weight, age, sex dependent

creatinine clearance more accurate

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13
Q

What is Polypharmacy?

What does it lead to?

What is an important step to take?

A

multiple pathologies leading to multiple drug therapy.

leads to:

  1. increased healthcare costs
  2. Adverse drug interactions
  3. inappropriate drug use
  4. medication non adherence
  5. drug interactions

important to review meds regularly

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14
Q

What are 3 common adverse drug reactions in the elderly ?

What causes 2/3rds of ADRs?

A
  1. Falls - postural hypotension, sedation
  2. Confusion (sedation)
  3. GI upset (diarrhoea and constipation)

2/3rds of all drugs reactions caused by: CV drugs, CNS drugs, Opioids, anticholinergics, NSAIDs

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15
Q

How should you manage/ avoid possible drug interactions?

what are common interactions?

A
  1. check drugs - stop and reduce doses where possible

common examples:

  • statins and macrolides
  • Amlodipine and simvastin
  • Warfarin and a lot
  1. Always ASK what theyre taking -
    gingko extract/warfarin (bleeding risk)
    st johns wart and serotonin - risk of serotonin syndrome
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16
Q

How should you manage swallowing difficulties

A
  • Give alternative formulas e.g - patch, solution, sublingual
  • consider crushing/dispersing tablets/capsules
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17
Q

How should you manage weight dependant medication?

A

Always endorse weight on drug chart - important for many meds

e. g
- paracetamol
- delteparin

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18
Q

Define urinary incontinence

Who is more prevalent in?

A

Urinary incontinence is the involuntary leaking of urine that is sufficient enough in frequency and amount to cause physical or emotional distress

More common in women, increases in severity with age

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19
Q

What are the examinations/ history you would do for urinary incontinence?

A

General: delirum, reduced mobility, sedation, BMI

Urogynaecological: look for:

  • atrophic urethritis
  • vulvar excoriation
  • ask patient to cough/valsalva manoeuvre whilst standing to induce leakage

Neuro exam: if neurological symptoms

DRE:

  • rectal sphincter tone
  • faecal impaction
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20
Q

What are the investigations you would do for urinary incontinence? What do each of them look for?

A
  1. Urinanalysis + MSU urine culture: rule out metablic/UTI
  2. Cather: post void residual urine volume urine specimen:
    - exclude urinary retention with overflow or infection. normal = <100mL
  3. frequency volume bladder chart (diary)
    - >7 voids daily is frequent, but dependant on habit intake
  4. urodynamic assesment: exclude destursor overactivity and sphincter dyssynergia
Simple cystometry: determine stress 
1. incontinence, 
2. detrusor overactivity, 
3. measures 1st void sensation, 
4. measures bladder capacity
(normal sensation to void occurs at 150mL, bladder capacity = 400-600mL)

Uroflowmetry - measuring urine flow and flow times to screen for outflow obstruction and abnormal detrusor contractility
- normally in women peak flow is 15-20mL/s with total void volume of 150-200mL

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21
Q

What are the four types of urinary incontinence?

What is overactive bladder syndrome

A
  1. stress urinary incontinence
    - involuntary leaking from an incompetent sphincter when intra-abdominal pressure and therefore pressure on bladder is too great.
  2. Urge urinary incontinence
    - the urge to urinate quickly followed by uncontrollable leakage due to inappropriate contraction of the detrusor muscle. urgency/leakage may be associated with latchkey incontinence
  • commonly co-exists with frequency and nocturia to form overactive bladder syndrome
  1. Mixed urinary incontinence
    - combination of sress and urge - usually one predominates
  2. Overflow incontinence
    - usually due to injury or insult - e.g postpartum
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22
Q

Which are the two main types of urinary incontinence that are managed in the elderly?

A
  • stress urinary incontinence

- urge urinary incontinence

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23
Q

What is stress urinary incontinence?

Stress urinary incontinence is caused by pelvic floor weakness and urethral sphincter incompetence, what causes these?

A
  • involuntary leaking from an incompetent sphincter when intra-abdominal pressure and therefore pressure on bladder is too great.

causes

  1. Physical changes from pregnancy/childbirth (also multiparity)
  2. menopausal changes (less oestorogen = weaking of pelvic muscle)
  3. chronic increased intra abdominal pressure - obesity, coughing (copd, straining)
  4. damage from surgery - hysterectomy, turp
  5. urogenital prolapse
  6. neuro conditions e.g - parkinsons, MS
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24
Q

How do you diagnose stress urinary incontinence?

A
  1. history
  2. physical examination and +ve stress test

urinanalsysis / PVR normal

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25
Q

What is the management for stress urinary incontinence?

A
  1. Pelvic floor exrcises - 8 contractions 3x daily for 3 months. incontinence pads
  2. Pharmacological - Duolexetine
  3. Surgical - Gold standard last resort is Tension free tansvaginal Tape (or transobturator tape)
    - replaces deficient pelvic floow muscle and provides support under the urethra
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26
Q

What is urge urinary incontinence?

Urge urinary incontinence is caused by detrusor overactivity. What are possible causes for this? (6)

A
  • the urge to urinate quickly followed by uncontrollable leakage due to inappropriate contraction of the detrusor muscle. urgency/leakage may be associated with latchkey incontinence
  1. excessive alcohol/caffeine intake
  2. Poor fluid intake (strong conc. urine irritating bladder)
  3. conditions of LUTS - UTI/bladder tumour, atrophic vaginitis, BPH
  4. neurological conditions e.g DM - autonomic neuropathy
  5. medications e.g diuretics
  6. constipation/BPH/Bladder injury/SC injury (overflow incontinence)
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27
Q

How do you diagnose urge urinary incontinence?

A
  • urodynamic studies
  • Exlcude UTI (urinalysis MSU)
  • neuro exam (organic brain damage e.g PD, stroke, dementia)
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28
Q

What is the management for urge urinary incontinence? (6)

A
  1. Conservative - behavioural modification (bladder retraining), weight loss, quit smoking, caffeine nd drinking before bed
  2. Pharmacological
    - 1st line: anticholinergicse.g oxybutynin, tolteridone - SE - dry eyes, blurred vision, constipation, urinary retention
    - beta adrenergic agonost - mirabegron - SE tachychardia - use when anticholinergics CI or SE’s too much
  3. intravaginal oestrogen cream for vaginal atrophy
  4. Intravaginal botulinum toxin
  5. Neuromodulation using TENS - inhibits reflex involuntary detrusor contractions
  6. surgery last resort
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29
Q

What is Osteoporosis?

A

Reduced bone mass density and micro-achitectural deterioration which leads to increased bone fragility and increased risk of fractures.

30
Q

What is osteopenia

A

A condition where BMD is lower than normal but less sere than osteoporosis

31
Q

What is the pathophysiology of osteoporosis?

A

Imbalance between osteoclastic resorption and osteoblastic new bone formation

32
Q

What is the aetiology of osteoporosis?

primary? Secondary? (6)

A

Really Really Mad Dentists Eat Nachos

Renal failure/CKD
Rheumatological disorders
Malnutrition, malabsorption and parenteral nutrition (any GIT or cirrhosis)
Drugs (steroids, heparin, warfarin, phenytoin)
Early menopause (POF), also late menarche or long term hx of oligomenorrhia (athletes, anorexia)
Neoplasia

33
Q

What are the clinical features of osteoporosis? most common sites?

A 
hallmark = fragility fractures 
Trabecular and long bones affected
Most common sites 
1. Distal radius (colles fracture)
2. Neck of femur 
3. Wedge fracture of thoracic fracture causing loss of heigh, exaggerated dorsal kyphosis and pain
34
Q

What investigations would you do for Osteoporosis?

A
  1. DEXA scan (dual X-ray Absorptiometry scan) - measures BMD
  2. X-ray - low sensitivity, specificty, often only done in hindsight
  3. Bloods: Calcium, Phosphate, ALP ????
35
Q

WHO DEXA Tscore criteria for osteoporosis and osteopenia? What should you do for osteoporosis?

A

Osteopoenia: -1 to -2.5

Osteoporosis: > -2.5

Offer lifestyle advice and bone protection treatment, repeat DEXA in 2 years

36
Q

What is the management of osteopenia

A

offer lifestyle advice

37
Q

What osteoporosis risk assessment can you use? What does it measure? Who is it aimed at?

A

FRAX - 10 year risk of fragility fracture

Women >65
men >75

38
Q

What are the things taken into account in FRAX? (11)

A
  1. Age
  2. Sex
  3. Weight
  4. Height
  5. Previous fracture
  6. Parental fracture
  7. Current smoker
  8. glucocorticoids
  9. Alcohol intake
  10. RA
  11. Secondary osteoporosis
39
Q

What do you do for people who are low risk, medium risk and high risk according to the FRAX assessment?

A

Low Risk: reassure, lifestyle modification
Medium risk: BMD
High risk: offer bone protection treatment

40
Q

How do you manage Osteoporosis?

A
  1. Lifestyle measures - quit smoking, reduce alcohol, weight bearing exercise, calcium and vitamin d rick diets, home based fall intervention
  2. Pharmacological
  • 1st line bisphosphonate e.g Aledronate - used for prophylaxis in long term steroid use. S.E - photosensitivity, GI upset, Oesophageal ulcers
  • Calcium and vitamin d Adcal D3 - target serum levels of 1,25 hydroxyl vit D >75mmol/l
  • Strontium renelate (intolerant to bisphosphonate)
  • HRT (prevention, relative risk of breast cancer, increased CV risk)
  • Raloxifene (selective oestrogen receptor modulator - less breast ca risk than HRT)
  • Teriparatide - recombinant PTH - stimulates osteoblast formation
  • Denosumab - monolocal Ab to RANKL - reduced bone resorption
41
Q

What is the underlying cause of a pressure ulcer? What does it lead to?

A

Due to uninterrupted pressure on the skin, shear forces, friction, moisture or varying combination of these things causing ulcers which can lead to extensive painful sc destruction

42
Q

Where are the most common site?

A
  1. sacrum and heel
  2. greater trochanter
  3. shoulder
  4. head
43
Q

What are the risk factors for pressure ulcers?

A
  1. Extremes of age
  2. Reduced mobility and/or sensation e.g hip fracture/surgery, limb paralysis)
  3. Vascular disease e.g DVT
  4. Chronic or terminal illness
44
Q

How do you asses a pressure ulcer?

A
  1. reasses ulcer at least weekly
  2. Ulcer -
    - cause of ulcer and grade
    - site location and dimesnions
    - wound appearance and appearence of surrounding skin
    - exudate amount, type and odour
    - local signs of infection
    - undermining/tracking (sinus or fistula)
    - Pain
  3. general physical condition
    - comobrbidities
    - nutrition
    - pain
    - continence
    - neuro (sensory impairment, loc, cognitive status)
    - blood supply
    - mobility
    - signs of local/systemic infection
45
Q

What is the classification of pressure ulcers?

Stage 1

A

Stage 1- non blanching erythema of intact skin

46
Q

Stage 2 pressure ulcer?

A

Partial thickness skin loss, superficial presenting as abrasion or blister.

47
Q

Stage 3 pressure ulcer?

A

Full thickness skin loss, necrosis may extend to fat but does not go beyond the fascia. undermining and tunneling may be seen

48
Q

Stage 4 pressure ulcer? What does it predispose to?

A

Extensive destruction including damage to bone muscle or tendons. predisposes to fatal infections. undermining and tunneling.

49
Q

What is the management of pressure ulcers?

5

A

Extensive superficial ulcers, stage 3/4 or those deteriorating need referral to specialist.

  1. Repositioning frequently to redistribute pressure
  2. Pressure relieving systems e.g beds, mattresses, overlays, cushions
  3. Treatment of cocurrent conditions which may delay healing e.g - DM, Immunocompromised
  4. Local wound management (dressings)
  5. Pain relief
50
Q

What is malnutrition defined as

A
  1. BMI <18.5kgm2
    or
  2. Unintentional weight loss > 10% in last 3-6 months
    or
    (3) BMI < 20 kg/m2​ ​ + Unintentional weight loss > 5% in last 3-6 months
51
Q

What are 3 causes of malnutrition

A
  1. Decreased Nutritional Intake (STARVATION)​ – environment, feeding problems, appetite, apathy
  2. Increased Nutritional Requirements (Sepsis/Injury)​ – inflammatory conditions, acute infection/ pyrexia, surgery,
    wound healing, trauma, liver disease, malignant, chronic inflammation eg. cancer
  3. Inability to utilize nutrients ingested/Increased Loss (MALABSORPTION)​ – diarrhoea, vomiting, bowel surgery, pancreatic insufficiency, IBD, losses from drains & wound
52
Q

What is the consequence of malnutrition?

A
  1. Impaired immunity/wound healing
  2. ↓ muscle mass/resp. & cardiac function
  3. physical strength/skin integrity, Impaired recovery, worsening prognosis,
  4. ↓ QoL,
  5. prolonged hospital stay, more admissions
53
Q

What is the screening/assessment tool used for malnutrition?

A

MUST - malnutrition universal screening tool

54
Q

What are the three main routes of artificial nutrition?

A
  1. Oral supplements (e.g fortisip)
  2. Enteral interventions
    - Nasogastric (NG)
    - Percutaenous endocopic gastrostomy (PEG)
    - Post-pyloric feeding: ND/NJ or jejunostomy
  3. total parenteral nutrition (TPN)
55
Q

What is the benefit of oral supplementation

A

improves outcome (weight gain, decrease mortality and length of stay)

56
Q

What are the three types of enteral interventions?

A
  • nasogastric NG (short term)
    percutaneous edoscopic
  • gastrostomy (PEG)
  • Post-pyloric feeding ND/NJ or jejunostomy
57
Q

What can you do to check and NG tube is in the correct position?

A

1st line - check PH with gastric aspirate - <5.5

2nd line - CXR: correctly positioned one should be located below the diaphragm

58
Q

What are the pros and cons to an NG tube

A 
\+ = preserved intestinal mucosa, inexpensive, less serious complications
- = paralytic ileus, risk of aspiration, tubes easily displaced
59
Q

what is the downside of percutaneous endoscopic gastrostomy (PEG)

A

increased risk of procedure
(bowel perforation, infection, aspiration, death)

dementia patients - neither prolongs nor improves quality of life

60
Q

When is a ND/NJ tube or jejunostomy indicated

A

indicated in delayed gastric emptying
upper GI surgery
high risk of aspiration
acute pancreatis

61
Q

What are the pros and cons of ND/NJ tube or jejunostomy

A

+ = more physiologica, cheaper than PN, lower risk of sepsis

  • difficult to position, uncomfortable
62
Q

When is Total parenteral nutrition indicated (TPN) (2)

A

when GIT is inaccesible or unable to absorb sufficient nutrients (obstruction, perforation, ileus, high output fistula)

Short bowel syndrome, severe pancreatitis/malabsorption

63
Q

What are the pros and cons of total parenteral nutrition

A

+ provides nutrition when GIT not available. well tolerated, completely absorbed

-: expensive, not physiology (risk of GI tract mucosa atrophy, increased risk of infection, hyperglycaemia)

64
Q

What is refeeding syndrome?

A

metabolic derangements which is characterised by a group of symptoms which start on the re-introduction of nutrition in severely malnourished/starved individual

65
Q

What is the pathophysiology of refeeding syndrome?

A
  1. prolonged fasting/starving state leading to low insulin, raised glucagon, raised cortisol
  2. other sources of energy used - glyconeogenesis, gluconeogensis, protein catabolism
  3. leads to intracellular depletion of electrolytes, proteitns, fats, minerals vitamins
  4. refeeding leads to requirement of phosphate, magneiusm, potassium, thiamine, intracellularly = rapid depletion serum levels
66
Q

What are the clinical features of refeeding syndrome?

A
  1. N+V
  2. Constipation
  3. diarrhoea
  4. muscle twitching
  5. weakness (due to hypokalaemia and low magnesium levels)
67
Q

What imbalances are seen in refeeding syndrome

A

K+
Magnesium
Phosphate
Thiamine

also
oedema seen

68
Q

What are the possible complications of refeeding syndrome?

A 
arrthythmia (most common)
heart failure
seizures
cardiac arrest
delirium
69
Q

What is the management of refeeding syndrome?

A
  1. IV pabrinex
  2. Vitamin B compound tablets (prior to refeeding and for 1st 10 days)
  3. start nutrition at 10kcals/kg for 1st 24hrs
  4. monitor PPM daily
70
Q

What must you continue to monitor?

A 
monitor
Potassium
Phosphate
Magnesium 
daily
71
Q

What are the 5 steps in the MUST screening tool?

A

step 1 - BMI scoring
18.5-20 = 1
<18.5 = 2

step 2 - unplanned weight loss in past 3-6 months
% score
5-10%= 1

step 3 - acutely unwell patient unlikely to have no nutritional intake >5 days = 5

step 4 = combine scores

72
Q

What should you do with someone low risk on the Must score?

Medium Risk?

High risk?

A

low =0
ensure appropriate feeds, repeat screen 3-6 months, document

Medium =1: follow MUST1 care pathway

High =2

  1. follow action plan for medium
  2. refer to dietician
  3. document

COTE, Sexual health (2 decks)

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