COTE Flashcards
What are risk factors for falls?
- Motor problems: gait/balance
- Sensory impairment
- Cognitive/mood impairment: dementia, delirium
- Orthostatic hypotension
- Polypharmacy
- Drugs (sedatives, alcohol))
- Environmental hazards: poor lighting
- Incontinence
- Fear of falling
Causes of falling in the elderly
- Drugs (sedative, alcohol)
- MSK eg OA of the hip
- Syncope (vasovagal, cardiogenic, arrhythmias)
- Stroke/TIA
- Hypoglycaemia
- Visual impairment
- Dementia
- Poor environment
What is hyperactive delirium?
Characterised by being highly alert and uncooperative
What is hypoactive delirium?
More common, you sleep more and become inattentive and disorganised with daily task you might miss meals or appointments
Clinical features of delirium
- Globally impaired cognition, perception and consciousness which develops over hours/days
- Marked memory deficit
- Disordered or disorientated thinking
- Reversal of the sleep-wake cycle
- Tactile or visual hallucinations
Risk factors of delirium
> 65
- Dementia/previous cognitive
- Impairment
- Hip fracture
- Acute illness
- Psychological agitation (eg pain)
Causes of delirium
PINCH ME Pain Infection (systemic or intracranial) Nutrition (thiamine, nicotinic acid or B12 def) Constipation> Retention Hydration Metabolism/medication (uraemia, liver failure, Na, glucose) (withdrawal) Environment Surgery/post GA Vascular (stroke, MI) Hypoxia (resp or cardiac failure)
What tests do you do with someone you suspect to be delirius?
Look for cause (eg UTI, pneumonia, MI)
- FBC, U&E, LFT, glucose, ABG, septic screen (urine dipstick, CXR, blood cultures), malaria film, ECg, CT, EEG
- Look for increased calcium
- Haemantics (B12 and folate)
- INR
Management of delirium
- Treat underlying cause
- Reorientate patient
- Encourage visits from family and friends
- Try no tot move around wards much
- Monitor fluid
- Mobilise and encourage activity
- Practice sleep regime
- Avoid or remove catheteres, IV cannula
- Watch out for infection
- Review medication
- Avoid medication if possible, IM haloperidol, BDZ if needed
What are the 3 main features of Parkinson’s?
- Resting tremor
- Bradykinesia
- Rigidity (cog-wheel)
What is the tremor like in Parkinson’s?
- Pill rolling (slow)
- Worse at rest
- Asymmetrical
- Reduced on distraction
- Reduced on movement
Underlying pathophysiology of Parkinson’s
Loss of dopaminergic neurones in substantia nigra
What class of drugs is normally combined with L-Dopa to prevent peripheral side effects?
- L-dopa carboxylase inhibitor (carbidopa or benzeraide)
Complications of L-dopa therapy
- Postural hypotension on starting treatment
- Confusion
- hallucinations
- L-dopa induced dyskinesias
- On-off effect: fluctuations in motor performance between normal function (on) and restricted mobility (off)
- Shortening duration of action of each dose (ie end dose deterioration, where dyskinesias become more prominent at the end of the duration of action
Define dementia
A chronic progressive illness, which is irreversible. There is preserved attention and consciousness with no underlying medical cause.
Describe delirium
Acute onset, fluctuating course, inattention, altered level of consciousness, usually reversible, associated with underlying medi al condition
Vascular Dementia
- Step wise progression
- Caused by problems with the blood supply to the brain
Alzheimer’s Dementia
- Most common type, progressive
- Loss of ability to learn, process and retain new information
- Looks atrophic on CT/MRI
- 5 ‘a’s- amnesia
aphasia, apraxia, agnosia, apathy
Pathophysiology of Alzheimer’s Dementia
- Neurofibrillary tangle
- Loss of neurones
- Aggregation of beta-amyloid plaques
Management of Alzheimer’s
- CT/MRI- atrophic
- Supportive
- AChE inhibitors (Donepezil, Rivastigmine, Galatine)
- Memantine
What is a ‘Comprehensive Geriatric Assessment’ designed to do?
- Identify health problems and establish a management plan in older patient with frailty
What domains are taken into account in the CGA?
- Physical health
- Mental health
- Social aspects
- Functional aspects
- Environment
Who are involved in the CGA?
- Geriatrician
- Nurses
- Pharmacist
- OT
- Physio
- SALT
- Dietician
- Social worker
etc
Complications of a long lie following a fall?
- Pressure ulcers
- Dehydration
- Rhabdomyolysis - results from death of muscle fibres and release contents into blood stream- leads to kidney failure
Investigations to do if you see a pressure ulcer
- Risk score to assess risk of developing = Waterlow score
- CRP, ESR
- WCC
- Swabs
- Blood cultures
- Xray for bone involvement
Management of pressure ulcer
- Antibiotics
- Wound dressing
- Pain relief
- Debridement if grade 3/4
Define ‘osteoporosis’
Decreased bone mineral density due to imbalance between remodelling and resorption
T score less than -2.5
Risk factors for osteoporosis
- Smoking
- Early menopause
- Steroid use
- Underweight
- Inactivity
- Alcohol
- ALL ELDERLY PEOPLE
Most common fractures in those with osteoporosis
- Hip
- Spinal
- NOF
How is osteoporosis diagnosed?
DEXA scan
What does the FRAX score assess
The risk of a 10 yr fragility fracture
How is osteoporosis managed?
Bisphosphonates
Presentation of Vit C deficiency
- Bleeding from gums
- Extensive bruising on legs (unrelated to falls)
Management of Vit C
- Correct the def > MDT approach to malnourishment
How is Nutritional Status assessed?
- Using the ‘MUST’ screening tool > Malnutrition Universal Screening Tool
What is Refeeding Syndrome?
- Metabolic disturbances as a result of reinstating nutrition to patients who are starved/severely malnourished
Biochemical features of refeeding syndrome
- Hypophosphataemia
- Hypokalaemia
- Thiamine deficiency
- Abnormal glucose metabolism
Complications of Refeeding syndrome
- Cardiac arrhythmias
- Convulsions
- Cardiac failure
How should you manage Refeeding Syndrome
- Monitor blood biochemistry
- Commence re-feeding with guidelines
What are the four ‘I’s of Geriatrics Giants
- Immobility
- Incontinence
- Incompetence
- Impaired homeostasis
What is receptive aphasia
Difficulty comprehending
- Wernicke’s area
Expressive Aphasia
- Difficulty producing language
- Broca’s area
Lewy body dementia
- Day-to-day fluctuating cognition
- Visual hallucinations
- Sleep disturbance
- Recurrent falls
- Parkinsons
DON’T PRESCRIBE NEUROEPILEPTIC DRUG AS MAKES PATIENT WORSE
Vascular dementia
- No atherosclerotic risk factors; multiple cerebral infarcts
- Step wise deterioration in cognition
- Can get focal neurology
- Fits
- Nocturnal confusion
What is Pick’s disease and what are the symptoms
- A type of front-temporal dementia
- Disinhibition
- Antisocial behaviour
- Personality changes
- Knife-blade atrophy
Symptoms of Normal Pressure Hydrocephalus
- Wet, whacky, wobbly
- Urinary incontinence
- Dementia
- Gait disturbance
- Due to increased CSF, b ut ventricles dilate
Name some cognitive assessment tools
- MMSE
- Addenbrooke’s cognitive examination tool III (ACE-III)
- Montreal cognitive assessment (MOCA)
- Abbreviated mental test score (AMT)
- 6-item cognitive impairment test (6-CIT)
- General practitioner assessment of cognition (GP COG)
What is involved in a septic screen
- Urine dipstick
- CXR
- Blood cultures
- ABG- lactate
- Bloods- infection?
- Lumbar puncture
- ECG
What is involved in a CGA for discharge planning
Medical assessment: diagnosis and treatment, co-morbid conditions and disease severity review- doctor/consultant
Functional assessment: ADL, gait, balance- OT, physio
Physiological assessment: cognition, mood- nurse, psychiatrist
Social assessment: care resources, finances- social workers
Environmental assessment:- home safety team
What is the bone profile in osteoporosis
- Normal
- Calcium, phosphate, and alk phos are all normal
- Bloods can help identify cause/risk factors for osteoporosis
Define osteopenia
- Precursor to osteoporosis
- T score -1 to -2.5
What is osteomalacia
- Softening of bones due to impaired bone metabolism from inadequate levels of calcium, phosphate and vit D
What does parathyroid hormone do?
- Increases osteoclast activity- release calcium and phosphate from bones
- Increases calcium reabsorption but decreases phosphate reabsorption from the kidneys
- Active vit D production is increased- increases calcium absorption from the gut and decreases phosphate
What is the role of vit D
- increases calcium absorption from the gut
Metabolite changes in muscle breakdown cause what?
Increased: potassium, phosphate, myoglobin, creatinine kinase
Myoglobin is harmful to kidneys as it causes acute tubular necrosis
Increased potassium- increased risk of arrhythmias- do an ECG
What is Rhabdomyolysis
Skeletal muscle breaks down due to traumatic, chemical or metabolic injury
What causes Rhabdomyolysis
- Crush injuries
- Prolonged immobilisation following a fall
- Prolonged seizure activity
- Hyperthermia
- Neuroepileptic malignancy syndrome
Management of Rhabdomyolysis
- Supportive
- IV fluids
- Correction of electrolytes
- Renal replacement therapy
What does hyperkalaemia look like on an ECG
- Peaked T waves
- Prolonged PR segment
- Loss of P waves
- ST elevation
- Broad QRS
- ST elevation
- Sine wave pattern
- Ventricular fibrillation
Management of hyperkalaemia
- Calcium glutinate (cardioprotective)
- Bicarbonates
- Insulin
- Glucose (drives potassium into cells)
- Kalayexalate ( bind K+ in the GI tract)
- Diuretics- dialysis if kidneys are not okay
Depression in the elderly
- Some physical illness can give similar symptoms
- Depression can make you think your long term illnesses are worsening even if they aren’t
- Depression can affect your memory
- Antidepressants in older people can lower amount of salt in blood- can make feel weak and unsteady
What is the biggest cause of hypercalcaemia in older people
Hyperparathyroidism
How do diuretics work in heart failure
- In heart failure there is an increased preload and therefore decreased flow to kidneys
- If you start on diuretics it will start looking like its damaging the kidneys as its dehydrating them
- But really it is reducing the preload which then will increase the output and therefore in the long run increases the flow to the kidneys (Stalin model)
