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Phase 3A Quiz > COTE > Flashcards

COTE Flashcards

1
Q

Define Geriatric giants?

A

Major categories of impairment that appear in elderly people.

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2
Q

What are the 5 Geriatric giants (Bernard Isaacs)?

5I’s

A 
Immobility 
Instability 
Incontinence
Intellectual impairment 
Iatrogenic Illness
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3
Q

What are the conversion factors for

  1. Oral Morphine -> Oral Oxycodone?
  2. Oral Codeine -> Oral Morphine
  3. Oral Tramadol -> Oral Morphine
  4. Oral Morphine -> Subcut Morphine
  5. Oral Morphine -> Subcut Diamorphine
  6. Oral Oxycodone -> Subcut Diamorphine
  7. Oral Morphine -> Transdermal Fentanyl
A
  1. 1.5 (Usually said that Oxycodone is nice as strong)
  2. Divide 10
  3. Divide 10
  4. Divide by 2
  5. Divide by 3
  6. Divide by 1.5
  7. Conversion of 1:100 (X100)
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4
Q

Advantages of oxycodone VS morphine in elderly/palliative care?

A

Less sedation
Vomiting
Pruritus

Although greater constipation

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5
Q

What is a syringe driver?

A

Continuous subcutaneous infusion.

Usually considered in palliative care as an alternative to oral route consumption difficulties and those patients that aren’t active and mobile.

Green - mm per 24hr (delivery rate given)
Blue - mm per hr (delivery rate given)

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6
Q

What are the primary side effects of opioids?

A

Nausea
Drowsiness
Constipation

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7
Q

What is usually a good adjunct to prescribe alongside opioids?

A

Laxatives

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8
Q

Which opioids are preferred in elderly/palliative care and why?

A

Buprenorphine
Fentanyl

Less nephrotoxic as they’re not renally excreted so is a good choice for those with severe renal impairment. Undergo hepatic metabolism.

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9
Q

NICE Guidelines on Palliative care prescribing for pain relief [6 Points]

A
  1. When starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine for breakthrough pain
  2. If no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain.
  3. Oral MR release morphine > Transdermal patches
  4. Prescribe laxatives for all patients after starting strong opioids.
  5. Drowsiness is transient if no settling adjust dosage. Consider adding antiemetic if nausea persists.
  6. For cancer patients - Breakthrough dose of morphine is 1/6 of the daily morphine dose
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10
Q

Name medications used in syringe drivers for Palliative care patients:

  1. Nausea and vomiting (4)
  2. Respiratory secretions (1)
  3. Bowel colic (1)
  4. Agitation/restlessness (3)
  5. Pain (1)
A

Nausea/Vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide

Respiratory secretions: hyoscine hydrobromide

Bowel Colic: hyoscine butylbromide

Agitation: Midazolam, Haloperidol, Levomepromazine

Pain: Diamorphine (Able to mix with a number of drugs, more soluble than morphine, easier to administer in higher doses)

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11
Q

Headache cause by raised ICP due to Brain mets/cancer

What would you GIVE?

A

Dexamethasone

  • Reduce oedema around brain
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12
Q

GMC - Stance on life prolonging treatment in terminal ill px

[3 Points]

A

Must not be motivated by a desire to bring about a patient’s death.

You must always start with a presumption in favour of prolonging life and you

Must take all reasonable steps to prolong life.

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13
Q

What are the 5 Main Pre-emptive medications prescribed for EOL? Indications?

A

Morphine/Oxycodone - Pain & Breathlessness

Midazolam - Agitation, Anxiety
Haloperidol- Nausea, Agitation, delirium
Hyoscine Butylbromide l- Respiratory secretions

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14
Q

What are the 9 Scores of the Clinical Frailty Scale (Rockwood Clinical frailty score)

A 
1 - Very Fit
2 - Well
3 - Managing Well
4 - Vunerable
5 - Mildly Frail
6 - Mod Frail
7 - Sev Frail
8 - Very Sev Frail
9 - Terminally Ill
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15
Q

What 3 questions should you be asking someone WHO HAS HAD A FALL?

A
  1. Why did they fall?
  2. How did they fall?
  3. Did they injure themselves?
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16
Q

Why should anticholinergic drugs be avoided in the elderly population?

A

More suscepible to the neurological toxicity of anticholinergic drugs because of: physiological and pathological modifications related to aging.

Increase in the blood–brain barrier permeability
Lower ability of the liver and kidney to break down and excrete medications
Substantial decrease in cholinergic neurons/receptors in the brain

Can easily cause confusion or delirium
Drowsiness/sedation

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17
Q

What 5 areas are anticholinergic drugs used for?

A

Antimuscarinics (Urinary Incontinence)
Anti-psychotics/Anti-Depressants
Antihistamines
Antispasmodics

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18
Q

Risk factors of long-lie fall

A
  1. Rhabdomyeolysis
  2. Pressure sores
  3. Dehyrdration
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19
Q

Define Comprehensive Geriatric Assessment?

A

An interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old”

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20
Q

What does IMCA stand for?

Role of IMCA?

A

Independent mental capacity advocate

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.

Commissoned by NHS and local authorities.

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21
Q

List 5 Causes for Falls?

Total 7

A

Visual impairment
Dementia
Drugs
Hypoglycaemia
Poor environment - Lighting, surrounding (loose furniture - rugs)
Neurological - Stroke/ Parkinson’s, peripheral neuropathy
Syncope - Vasovagal, cariogenic, arrhythmias

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22
Q

Complications of L-Dopa Therapy?

A

Postural Hypotension

On-off effect - Fluctuations in motor performance between normal function and restricted mobility.

Dyskinesias with long term use (Shortening duration of action of each dose)

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23
Q

Why is Carbidopa combined with L-dopa?

Class of drug?

A

Carbidopa prevents the breakdown of levodopa prematurely in the bloodstream so more levodopa can enter the brain.

Decarboxylase dopamine inhibitor

Also aid in reducing N/V

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24
Q

Cardiac Conditions can cause embolic CVA ?

Hint: 5

A 
AF
Infective Endocarditis
MI causing mural thrombus
Aortic / Mitral valve disease 
Patent foramen ovale
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25
Interventions in hospital for Px to PREVENT PRESSURE SORES?
Regular Skin Assessments - Pain, Colour changes, Skin integrity at pressure areas, Temperature, Firmness, Moisture Repositioning Pressure redistrubition - Foam mattresses, cushions, heel support Barrier creams
26
Name 2 Dopamine Agoists for Parkinsons?
Bromocriptine | Ropinirole
27
What 4 Areas (Domains) does a Comprehensive Geriatric Assessment Address?
Medical - Medication Review, Nutritional status, Problem list/co-morbidities, Disease severity [Doc, Nurse, Dietician, SALT] Mental Health - Cognition, Mood/Anxiety, Fears [Psychologist, Doc, Nurse, OT] Functional Capacity - ADLs, Gait & Balance, Physical, Acitivity/Exercise status [OT, PT, SALT] Social/Environmental - Transport, Home safety, Social network support, Care resources eligibility [OT, Social Worker] Result - Personalised Care Plan + Intervention + Regular Review
28
Treatment for Dementia - Pharmalogical/ Non-Pharma?
``` Non-Medical Contact with animals Music and dance Aromatherapy Massage ``` Pharmacological AD - Ach-Inhibtors/Antiglutaminergic (NMDA-Agonists) Vascular - Management of vascular risk factors Lewy Body - Rivastigmine, Clozapine FTD - Supportive
29
Name 2 AcH-Inhibitors for Alzheimers Dementia
Donepenzil | Rivastigmine
30
Define Malnutrition
State in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on the body's - Form - Composition - Function - Clinical Outcome
31
Causes of malnutrition?
Starvation - Decreased nutrient intake Malabsorption - Inability to utilise ingested nutrients Increased nutrient requirement (infection/sepsis)
32
Diagnostic Criteria for malnutrition
BMI <18.5 kg/m2 unintentional weight loss greater than 10% within the last 3–6 months BMI <20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
33
What factors make a person AT RISK of Malnutrition?
Eaten little or nothing >5Days Poor absorptive capacity High nutrient losses Increased nutritional needs from causes such as catabolism.
34
Name some consequences of malnutrition?
Impaired immunity Impaired wound healing and general recovery Muscle mass loss Cardiorespiratory function loss
35
Factors that increase loss of nutrients
``` Diarrhoea Vomiting IBD Pancreatic insufficiency Surgery, Drains ```
36
Factors that increased nutritional requirements
``` Trauma Acute infection Chronic infection Surgery Malignancy ```
37
Factors that affect intake of nutrients
``` Pain Medication Environment Meal times Anxiety/Mood Appetite Food temperarture ```
38
Define Refeeding syndrome
Metabolic changes that occur on the reintroduction of nutrition to in those who are malnourished or in the starved state
39
What electrolyte abnormalities occur as a result of refeeding syndrome
``` Hypophosphataemia Hypomagnesaemia Hypokalaemia Thiamine deficiency Fluid retention and Volume overload (Na & H20) Hyperglycaemia ```
40
Explain the Pathophysiological steps of Refeeding syndrome?
1. Refeeding stimulates insulin secretion (Increased insulin) 2. Movement of electrolytes into cell 3. Decreased serum electrolytes
41
What checks should be done prior to refeeding?
Electrolyte checks -U/E, | ECG, LFTs, Blood glucose levels
42
Treatment for refeeding syndrome?
Electrolyte replacement (Po4, K, Mg) Vitamins (B6, B12, Folate) Dietician referral Slow and gradual increase in caloric and fluid intake.
43
Pathophysiology of chronic malnutrition
1. Insulin levels decrease 2. Energy source switch (Glycogneolysism Gluconeogensis, Protein catabolism) 3. Normal serum phosphate levels 4. Low intracellular phosphate levels
44
What does insulin trigger?
Uptake of glucose, phosphate, potassium by cells which causes a depletion of serum levels. Increase kidney sodium retention.j
45
What are the consequences of low phosphate levels
Reduced levels of ATP metabolism Tissue hypoxia
46
Clinical Features of refeeding syndrome
CVS - Arrhytmia, HTN, CHF RESP - SOB, Respiratory muscle weakness Neuro - Weakness, Paresthesia, Ataxia Metabolic - Anaemia, Infections, Wernicke's encephalopathy GI - Abdo pain, consipation, vomiting, anorexia MSK- Myalgia, weakness, rhabdomyolysis, Osteomalacia
47
Define Osteoporosis?
Loss in bone density and greater fracture risk due to increased turnover of bone breakdown compared to bone formation.
48
What cells are responsible for breakdown bone?
Osteoclasts
49
What cells are responsible for bone formation?
Osteoblasts
50
Define Osteomalacia?
Lack of mineralisation and softening of the bones. Usually due to Vit D/Ca deficiency
51
Which organ secretes calcitonin?
Thyroid gland In response to high serum calcium. Opposes PTH promoting bone formation > resorption
52
What promotes CA2+ absorption in the GUT
Vit D
53
How do bisphosphonates work?
Analogues of phosphate. They help to decrease lecule which decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis.
54
Uses and Side effects of Bisphophonates
``` USES prevention and treatment of osteoporosis hypercalcaemia Paget's disease pain from bone metatases ``` ``` S/E Oesophageal ulcers Oesphagitis Osteonecrosi of the jaw Risk of atypical stress fractures (proximal femoral shaft - Alendronate) ```
55
What areas cover the medical assessment of CGA?
Medication review Nutritional Status Co-morbitities + Disease severity Problem list
56
What areas cover the medical assessment of CGA?
ADLs Activity/exercise status Gait and balance
57
What areas cover the psychological assessment of CGA?
Cognitive status testing | Mood/depression testing
58
What areas cover the social and environment assessment of CGA?
Home safety Eligibility/need for carers informal support needs and assets
59
Most common cause of acute confusional state in the elderly? What clinical marker would increase?
Infection - Chest/UTI CRP
60
What investigations would you run for acute confusional state?
``` Bloods - FBC, U+E, LFT, Glucose, Bone profile B12, Folate, CRP Cognitive test - AMT Imaging - CXR, CT Head? Urinalysis PR ```
61
Who needs and AMT assessment?
Everyone >60
62
Causes of Delirium?
``` D - Drugs E - Electrolyte imbalance L - Level of pain (High/Post-op) I - Infection R -Respiratory - Hypoxia/Hypercapnia I - Impaction of faeces U - Urinary retention M - Metabolic disorder ```
63
Patient Present with Falls? ACTIONS - INVESTIGATION TO TREATEMENT
Obtain Hx / Collateral Hx [Assess what 'PATIENT USUAL NORMAL'] EXAMINATION - Beside tests - Vital Obs, Glucose, Urine dip, ECG Bloods - FBC, U+E, LFT, Bone profile Imaging - CXR, XR, CT head, echo Rule out focal neurological signs/ bone deformity
64
Risk Factors for falls?
``` Prev Falls in 12M Balance issues - vertigo Gait&Mobility problems - Parkinsons, prev fractures/joint replacement Fear of falling Drugs - Antihypertensives/psychotics/depressants CVS - Arrythmisa, postural htn Urinary incontinence Stroke Cognitive impairment - dementia/delirum Diabetes - Peripheral neuropathy Environmental - Living area, loose carpets Alcohol ```
65
Geriatric syndromes?
5M's Mind - 3Ds (Depression, Dementia, Delirium) Mobility - Impaired gait and balance Medications - Polypharmacy, Adverse effects, Optimal prescribing Multi-complexity - Multimorbidity, Biopsychosocial Matters most - Individuals preferences and meanigful health outcomes
66
Define Frailty?
State of increased vulnerability resulting from ageing associated decline in reserve and function across multiple physiological systems that the ability to cope with everyday is compromised
67
Explain the Confusion Assessment Method Screen?
1. Acute onset and fluctuating course 2. Inattention (20 - 1 test with reduced capacity to shift attention/keep attention focused) 3. Disorganised thinking (Disorganised/incoherent speech) 4. Change level of consciousness (Letheragic/state of stupor)
68
Name the basic ADLs? DEATH Pneumonic?
``` D - Dress E - Eating A - Ambulation T - Toileting/Transfers H - Hygiene (Bathing & Dressing) ```
69
Name the IADLS? (Instrumental ADLs) ? SHAFT Pneumonic?
``` S - Shopping H - Housework/Hobbies A - Accounting - Banking, Bills, Taxes F - Food Preparation T - Transportation, Telephoning, Tools ```
70
4 Grades of Pressure Sores?
Grade 1 - Non- Blanchable erythema of intact skin, discolouration of skin Grade 2 - Partial thickness skin loss Grade 3 - Full thickness skin loss, Damage to/necrosis of subset tissue that extends down but not through underlying fascia Grade 4 - Extensive destruction, Tissue necrosis, damage to muscle, bone or supporting structures with or without full thickness skin loss.
71
What screening tool is used for Malnutrition?
MUST (Malnutrition Universal Screening Tool) | -BMI , Hx of WL, Acute Illness
72
What screening tool is used to assess risk of developing a pressure sore?
Waterlow Score | -BMI, Nutritional status, skin type, mobility, continence
73
What screening tool is used to assess the progress of wound healing
BWAT (Bates Jensen wound assessment tool) | Formerly PSST-6 Score (Pressure sore status tool)
74
Define Acopia
Patient’s inability to cope with activities of daily living. No acute medical problem AKA Social admission
75
What are the 5 Principles of Mental Capacity Act?
1. Presumption of capacity - A person is assumed to have capacity unless established that capacity is lacked. 2. Individual supported to make their own decisions - All practicable steps have been taken to be allow patient to make a decision without success. 3. Unwise decisions - Just because a person makes an unwise decision doesn't mean they lack capacity 4. Best Interests - Any decisions/act done must be done in the patient's best interests 5. Less Restrictive option - Decisions made doesn't stop patient's freedom more than needed.
76
What is DOLS?
Deprivation of liberty safeguards (MCA Act 2005) The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements”. Person has someone appointed to represent them. Should be used for the minimum amount of time possible Person has a legal right of appeal over the arrangements.
77
What test is done to see if someone is Deprived of their liberties? 3 questions asked?
Acid Test 1. Person subject to continuous supervision and control? 2. Person free to leave? 3. Does the person act the capacity to consent to their care and treatment in those circumstances. DOLS - Used only if the person will be deprived of their liberty in a care home or hospital and patient lacks capacity Safeguards that aim to make sure people in care homes + hospitals are looked after in a way that doesn't restrict their freedom and is in their best interests.
78
How long can an emergency DOLS last for?
7 Days Authoisation - Emergency authorisations
79
What environments are DOLS only allowed to be implemented in?
Care home/admitted in hospital, >18 | DoLS can't be done if a patient resides in their home

Phase 3A Quiz (7 decks)

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