COTE Flashcards
Define frailty
State of increased vulnerability resulting from age-associated decline in functional reserve
across multiple systems
resulting in compromised ability to cope with everyday or acute stressors
What are the 4 geriatric giants?
- instability (falls)
- immobility
- intellectual impairment
- incontinence
What is a comprehensive geriatric assessment?
MDT diagnostic process
Identifies health problems and establishes management plans in older patients with frailty
What are the 4 components of the comprehensive geriatric assessment?
- medical assessment
- functional assessment
- psychological assessment
- social and environmental assessment
How do the onset, features and causes of delirium and dementia differ?
acute onset + fluctuating course
inattention + altered level of consciousness
usually reversible
associated with underlying medical cause
chronic illness + progressive course
no clouding of consciousness
no underlying/reversible cause
What assessment tool is used for delirium?
4-AT
What causes delirium?
Drugs - changing dose/introducing new ones/polypharmacy
Electrolyte imbalances
Lack of drugs - withdrawal
Infection
Reduced sensory input - blind, deaf, changing environment
IC problems - stroke, seizures, haemorrhage
Urinary retention + faecal impaction
Myocardial problems - MI, arrhythmia
dehydration, B12
How is delirium managed?
treat underlying cause
manage the environment
Name some ways in which the environment can be altered to help delirium
Clocks and calendars to maximise orientation
Ensure hearing aids/glasses are worn
Photos of family members
Consistency of staff members
Quiet bay/side room
Sleep hygiene
How is confusion investigated?
bloods (FBC, U&Es, LFTs, TFTs, CRP/ESR, folate/B12, HbA1C) - possible causes of infection/delirium
ECG - exclude MI
urine dipstick - exclude UTI
CXR - exclude pneumonia
sputum culture
stool chart - constipation?
nutrition/hydration
maximise orientation
What are the complications of a long lie following a fall?
pressure ulcers
dehydration
rhabdomyolysis
hypothermia
How do you investigate pressure ulcers?
CRP, ESR
WCC
swabs
blood cultures
x-ray for bone involvement
How are pressure ulcers managed?
antibiotics
wound dressing
pain relief
debridement if grade 3/4
What is osteoporosis?
decreased bone mineral density due to imbalance between remodelling and resorption
> increases bone fragility and susceptibility to fracture
T score
Most common fracture sites?
spine
hip
NOF
RFs for osteoporosis?
SHATTERED
Steroids
Hyperthyroidism
Alcohol/smoking
Thin (BMI<22)
Testosterone deficiency
Early menopause
Renal/liver failure
Erosive or inflammatory bone disease (RA, Ank spond)
Dietary Ca2+ deficiency
all elderly!
How is osteoporosis managed?
bisphosphonates - zoledronate, alendronate
can be given IV once/yr or oral once/wk
What are the issues with real bisphosphonates? What is there a risk of?
have to have them on an empty stomach (first thing in morning) and stay upright for half an hr after taking them
due to risk of oesophagitis
What tool is used to assess nutritional status?
MUST (malnutrition universal screening tool)
What is re-feeding syndrome?
Metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished
What are the biochemical consequences of re-feeding syndrome?
hypophosphataemia
hypokalaemia
thiamine deficiency
abnormal glucose metabolism
What are the potential consequences of re-feeding syndrome?
4C’s:
cardiac arrhythmias
coma
convulsions
cardiac failure
How is re-feeding syndrome treated?
monitor electrolytes/glucose
commence re-feeding with guidelines
RFs for pressure ulcers?
age
immobility for long periods e.g. fracture, hospital stay
peripheral vascular diseases
dehydration
malnourishment
obesity
How can pressure ulcers be prevented?
mobilise
change position
pressure redistributing mattresses
barrier creams
regular skin assessment
Name 3 treatments to improve bone health?
bisphosphonates
vitamin D + Ca supplements
exercise - impact e.g. walking, not swimming
Causes of falls in elderly people?
- Drugs - medications, alcohol
- MSK - OA, MS, previous fall and decreased confidence, muscle weakness due to inactivity
- CVS - syncope (vasovagal, situational), postural hypotension, MI, arrhythmia, dehydration
- Neurological - stroke, PD, gait disturbance, visual impairment, peripheral neuropathy, myopathy, vertigo
- Infection/sepsis
- Hypoglycaemia
- Dementia/delirium
- Incontinence
- Poor environment
What medications can increase the risk of falls in the elderly?
benzos (sedative), ADs, antipsychotics
anti-hypertensives - ACEi, CCB, beta-blockers + diuretics
polypharmacy
3 main features of Parkinson’s?
bradykinesia
rigidity - lead-pipe, cog-wheel
resting tremor
Differentiating features of a parkinsonian tremor?
Pill rolling
Worse at rest but reduced on distraction or movement
Worse on one side (asymmetrical)
What is the underlying pathophysiology of Parkinson’s?
Loss of dopaminergic neurones in the substantia nigra
What class of drug is normally combined with L-dopa therapy to prevent peripheral side-effects in Parkinson’s?
Carbidopa – a dopa-decarboxylase inhibitor
Complications of L-dopa therapy?
Dyskinesia
End-dose deterioration
What cardiac conditions can cause an embolic CVA?
AF
IE
atrial-septal defect/patent foramen ovale
aortic/mitral valve disease, valve replacement
How does an ischaemic stroke compare to a haemorrhage stroke on CT?
ischaemic = black
haemorrhage = white
How is a CVA investigated?
ECG + CT head
consider:
carotid artery doppler
lipid profile
clotting screen
echo
What ABCD2 score is considered “high risk” for a stroke and what should be done?
4+ = high risk
Aspirin – 300mg daily – started immediately
Specialist referral within 24 hours of onset of symptoms
Secondary prevention measures (statins, antihypertensives)
What are crescendo TIAs? How should they be treated?
2+ episodes in a week
treated as high risk regardless of ABCD2 score
What should be done for someone with an ABCD2 score of ≤ 3?
Specialist referral within 1 week of symptom onset, including decision or brain imaging
What are the components of the GCS?
best eye opening response
best verbal response
best motor repose - how well they localise pain
Causes of hyponatraemia?
Dilutional effect – HF, SIADH, hypervolaemia, NSAIDS, oliguria, renal failure
Sodium loss – Addison’s disease, D&V, osmotic diuresis (DM, diuretic excess), severe burns, diuretic stage of acute renal failure
Sx of hypocalcaemia?
Muscle cramps/spasms
Tetany - carpopedal spasm, laryngospasm, bronchospasm
Seizures
Parasthesia
Sx of hypercalcaemia?
BONES - bone pain, fractures, muscle weakness
STONES - renal stones/colic, polyuria, polydipsia, dehydration
PSYCHIATRIC MOANS - depression, drowsiness/coma
ABDOMINAL GROANS - N&V, weight loss, anorexia, constipation, abdominal pain
What cognitive assessments are often used?
GP-COG
Addenbrooke’s
6-CIT
AMT
MOCA
Name the 4 types of dementia and their key features?
Alzheimer’s - agnosia, apraxia, amnesia, aphasia
vascular - stepwise progression following ischaemic brain injury
LBD - sleep disorder, falls, impaired consciousness, visual hallucinations, parkinonism
Frontotemporal – memory fairly preserved, extreme personality changes and disinhibition
What are the key blood test to exclude treatable causes of dementia?
vitamin B12, thiamine, folate
TFTs
FBC - anaemia
syphilis serology
LFTs - hepatic encephalopathy, alcoholism
How is Alzheimer’s treated?
AChEi - donepezil, rivastigmine, galatamine
= only for alzheimer’s
alternative: NMDA-receptor antagonist (blocks glutamate) > memantine
2 subtypes of delirium?
Hyperactive > agitated, inappropriate behaviour, hallucinations
Hypoactive > lethargy, reduced concentration = often missed
RFs for delirium?
old age
CI, sensory impairment
frailty, multiple comorbities
significant injuries e.g. hip #
functional impairment
terminal phase of illness
hx of alcohol excess
poor nutrition
lack of stimulation
How does delirium present?
Acute behavioural change
Disorganised thinking/altered perception
Altered level of consciousness
Falling
Loss of appetite
What factors indicate a patient is at high risk of # and need to be treated with bisphosphonates?
on steroids
age >75
previous hip/vertebral fractures
further fractures on treatment
high risk on FRAX score
DEXA scan T score
What is the action of bisphosphonates?
inhibition of osteoclasts
3 adverse affects of bisphosphonates?
Oesophagitis
Osteonecrosis of the jaw
Increased risk of atypical stress fractures of the proximal femoral shaft (alendronate)
How are DEXA scan scores interpreted?
-1 to +1 = healthy
- 1 to -2.5 = osteopenia
≤ -2.5 = osteoporosis
≤ 2.5 and a current fragility fracture = severe osteoporosis
What are the components of the FRAX scoring system?
Parent hip fracture
Height and weight (BMI)
Smoking
Alcohol >3 units a day
Steroids
Previous hip fracture
Femoral neck bone mineral density
Female gender
Age
RA
Secondary osteoporosis
How is malnutrition diagnosed?
BMI < 18.5 kg/m2
Unintentional weight loss >10% in the last 3-6 months
BMI < 20kg/m2 plus unintentional weight loss >5% within the last 3-6months
Causes of malnutrition?
Inadequate nutritional intake (starvation)
Increased nutrient requirements (cancer, sepsis, injury)
Inability to utilise ingested nutrients (malabsorption)
Increased loss (vomiting, diarrhoea)
What tests should be done before commencing feeds in a patient who is malnourished?
U&Es, LFTs
ECG
Clinical features of re-feeding syndrome?
CVS – arrythymias
GI – abdo pain, constipation, vomiting, anorexia
MSK – weakness, myalgia, rhabdomyelosis, osteomalacia
Resp - SOB, ventilator dependence, respiratory muscle weakness
Neuro – weakness, paraesthesia, ataxia
Metabolic – infections, thrombocytopenia, haemolysis, anaemia
Other – liver failure, Wernicke’s encephalopathy
When looking at best interests in a pt without capacity, what needs to be considered?
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 and values of the person and any other relevant factors
Views of other relevant people (family members etc.)
What is the role of an advanced directive?
Allows people who understand the implications of their choices to state their treatment wishes in advance
They can authorise specific procedures or refuse treatment in a predefined future situation
What makes an advanced refusal of treatment legally binding?
The person is an adult
The person was competent and fully informed when making the decision
The decision is clearly applicable to current circumstances
There is no reason to believe that they have since changed their mind
What factors make an advanced directive less legally binding?
an advanced REQUEST for treatment - does not have same legal binding as a refusal
but if it’s pt’s known wishes to be kept alive then reasonable efforts should be made
What is deprivation of liberty?
Occurs when a person does not consent to care or treatment
e.g. pt with dementia who is not free to leave a care home and lacks capacity to consent to this
What is a LPoA?
A document which a person can use to nominate someone else to make certain decisions on their behalf when they are unable to do so themselves
Can be financial/about estate, or medical/health decisions
To be valid – needs to be registered with the Office of the Public Guardian
What is the role of an independent mental capacity advocate?
Commissioned from independent organisations by the NHS/local authorities to ensure the MCA is being followed
Support/represent its who lack capacity and do not have anyone else to represent them in decisions
Definition of postural hypotension?
A drop of >20/10 mmHg within 3 minutes of standing
Causes of postural hypotension?
Medications – diuretics, antihypertensives, antidepressants, polypharmacy
Cardiac – aortic stenosis, arrythmias, MI, cardiomyopathy, CHF, anaemia
Endocrine – diabetes insipidus, hypoadrenalism, hypothyroid, hypo anything..
Neuro – PD and PD+ syndromes
Blood loss, dehydration, shock
How does postural hypotension present?
Asymptomatic
Falls/syncope
Dizziness, light-headedness
Blurred vision
Weakness, fatigue
Palpitations
Headache
How is postural hypotension investigated?
Lying and standing blood pressure
Investigate for medical causes – medication review, blood tests
How is postural hypotension managed?
drink lots of water, avoid large meals and alcohol
exercises
stand slowly, sleep with head raised
fludrocortisone, midodrine (autonomic dysfunction only)
How are pressure ulcers classified?
Grade 1 – non-blanching erythema with intact skin
Grade 2 – partial thickness skin loss involving epidermis, dermis or both (abrasion/blister)
Grade 3 – full-thickness skin loss involving damage/necrosis of sub-cut tissue
Grade 4 – extensive loss, destruction/necrosis of muscle, bone or support structures
Unstageable – depth unknown, base of ulcer covered by debris
What are the 2 major metabolic components of Ca homeostasis?
vitamin D
PTH
What is the role of vit D?
increased Ca absorption in the gut
increase Ca release from bone
Where is PTH realised and by what trigger?
Secreted from the chief cells of the PT gland
In response to low serum Ca2+ levels (detected by calcium sensor cells in the PT glands)
What are the actions of PTH?
= increases Ca levels
increases osteoclast activity
increases intestinal Ca absorption
increases vit D activation
increases renal tubule re-absorption of Ca
4 common sites for osteoporosis related fractures?
thoracic vertebrae > kyphosis, loss of height
lumbar vertebrae
proximal femur
distal radius - Colle’s fracture
How would you investigate someone with suspected osteoporosis?
DEXA scan: T value
Why does urinary incontinence happen in old age?
urethral atrophy
pelvic floor atrophy
prostatic hypertrophy
What are the reversible and treatable causes of urinary incontinence?
reversible:
- UTI
- delirium
- DMT2
- diuretics
Treatable:
- BPH
- overactive bladder
- stress incontinence
How should urinary incontinence be managed?
Depends on cause
- overactive bladder > antimuscarinics + bladder retraining
- dementia > regular toileting
- stress incont. > pelvic floor exercises
- BPH > antiandrogens, surgery
- hypotonic bladder - intermittent catheter
catheters
What can be given to treat nocturia?
desmopressin (careful in >65 > hypoNa+)
drainage sheath
How should faecal incontinence caused by constipation/bowel obstruction be managed?
rehydration
small + regular meals
enema 2x daily until empty
colonic washout
laxatives - lactulose, senn, movicol
How is neurogenic faecal incontinence managed?
planned evacuation - loperamide then phosphate enema 2x/wk
regular toileting + suppository
What is Paget’s disease? What is the pathophysiology?
excessive bone turnover due to excessive activity of osteoblasts + clasts
> patchy areas of high density (sclerosis) and low density (lysis) > enlarged and misshapen bones with structural problems mostly in axial skeleton
How does Paget’s disease present?
bone pain + deformity
fractures
hearing loss
How does Paget’s present on x-ray?
bone enlargement and deformity
OP circumscripta - osteolytic lesions that appear less dense
cotton wool appearance of skull - patchy areas of sclerosis and lysis
v shaped defects in long bones - v shaped osteolytic bone lesions within healthy bone
How is Paget’s detected on blood results?
raised ALP
but normal LFTs
normal Ca + P
How is Paget’s managed?
bisphosphonates
NSAIDs
Ca + Vit D
What are the 2 key complications of paget’s?
osteogenic sarcoma
spinal stenosis + spinal cord compression - deformity in spine leads to narrowing + presses on nerves
Which tool can be used to assess frailty status?
PRISMA-7
