COTE FC from ppt Flashcards
define frailty
-state of increased vulnerability resulting from ageing-associated decline in functional reserve
-across multiple physiological systems
-resulting in compromised ability to cope with everyday or acute stressors
what is the impact of frailty on elderly people and how does it change how they need to be cared for
different type of doctor - geriatricians are experts in frailty
poor functional reserve - trivial insult to a younger person has a large impact on an older person
failure to intergrate responses in the face of stress
vulnerable to decompensation when faced with illness, drug side effects and metabolic disturbance
what are the most common presenting complaints in geriatric medicine
- falls
- confusion
- fever/infection
- new incontinence
- ‘off legs’ - used to be able to walk and now can’t
- ‘failed DRT (discharge response team)
- chest pain/SOB
- urinary symptoms - pain, changes, incontinence
- off food, generally unwell
what are the geriatric giants
4 I’s
1. instability (falls)
2. immobility
3. intellectual impairment (confusion)
4. incontinence
not diagnoses - more general/vague - normally indicative of underlying problems
what is the comprehensive geriatric assessment
not a form to fill in/booklet - process of what is done in geriatrics
multidimensional, MDT diagnostic process
focussed on determining a frail older person medical, psychological and functional capability
development of a co-ordinate, intergrated plan for treatment and long term follow up
what are the 4 components of the comprehensive geriatric assessment
- medical assessment
- functional assessment
- psychological
- social and environmental assessment
what is the medical assessment made up of
doctor, nurse, pharmacist, dietician, SALT
problem list, comorbs, medicaton review, nutritional statuses
what makes up the functional assessment
OT, PT, SALT
assesses ADLs, activity, exercise status, gait, balance
what is the psychological assessment comprised of
doctor, nurse, OT, psychologist
cognitive status testing, mood/depression testing (PHQ-9 questionnaire)
what is the social and environmental assessment comprised of
OT and social worker if needed
informal support needs and assets, care resource eligibility, home safety
what are the features of delirium
acute onset
fluctuating course
inattention
altered level of unconsciousness
usually reversible
associated with underlying medical cause
what are the features of dementia
chronic illness
progressive course
no clouding of consciousness
no underlying/reversible cause
name an assessment tool used for delirium
4-AT
what causes delirium
infection
drug use - withdrawal or new medications interaction
reduced sensory input - blind, deaf, changing environment
intracranial problems - stroke, seizures, haemorrhages
electrolyte imbalances
constipation
urinary retention
heart problems - MI, arrhythmia
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 membrers
consistency of staff members
quiet bay/side room is possible
sleep hygiene (promote night sleep, not daytime)
what is the role of the comprehensive geriatric assessment
identifies health problems and establishes management plans in older patients wit frailty
who makes up the comprehensive geriaric assessment team
geriatrician
social worker
physiotherapist
occupational therapist
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
ABx
wound dressing
pain relief
debridement if grade 3/4
what is osteoporosis
decreased bone mineral density due to imbalance between remodelling and resorption
increases risk for fractures - particularly spine, hip and NOF
what are some risk factors for osteoporosis
smoking
early menopause
steroid use
underweight
inactivity
alcohol
ALL ELDERLY PEOPLE
how is osteoporosis managed
bisphosphonates (zoledronate, alendronate)
IV once a year or oral once a week - (empty stomach, stay upright for half an hour as may = oesophagitis)
what is a tool used for assess nutritional status
MUST screening tool (malnutritional 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 features of refeeding syndrome
hypophosphataemia
hypokalaemia
thiamine deficiency
abnormal glucose metabolism
what are some complications of re-feeding syndrome
cardiac arrythmias
coma
convulsions
cardiac failure
how is re-feeding syndrome treated
monitor blood biochem
commence re-feeding with guidelines
recognise electrolytes (phosphate, K+, Mg)
monitor glucose and Na levels
supportve care
refer to nutritional support team/dietician
what are some risk factors for pressure ulcers
age
peripheral vascular disease
immobile a long time
dehydration
obesity
malnourishment
how can you prevent pressure ulcers
keep patient mobile
change bed positon
special mattress - pressure re-distributing mattress
barrier creams
regular skin assessment
name 2 treatmen that will improve bone health
bisphosphonates
vitamin D and calcium supplements
(exercise - impact like walking, not swimming)
what are some environmental causes of falls in elderly people
loose rugs
pets
furniture
unstable footwear
what are some power/balance causes of falls in elderly people
inactivity leading to - muscle weakness
dizziness/loss of balance/loss of proprioception (vertigo)
pain/MS - osteoarthritis
previous fall leading to decreased confidence
what are some cardiovascular causes of falls in elderly people
vasovagal syncope (faint)
situational syncope - micturition (old men, night time)
postural hypotension
MI
arrhythmia
dehydration/shock
what are some neurological causes of falls in elderly people
stroke
PD
gait disturbance
visual impairment
peripheral neuropathy
myopathy (statin or steroid myopaty)
what are some medications that increase risk of falls in elderly people
benzodiazepines - sedatve so impair coordination
diuretics
anti-Hypertensive - ACEi, CCB, Beta-blocker
antidepressant
antipsychotic
polypharmacy
what are some other causes of falls in elderly people
infection/sepsis
delirium
hypoglycaemia
incontnence
alcohol - intoxication, neuropathy, Korsakoff’s/wernicke’s
what are the three main features of Parkinson’s
- bradykinesia
- rigidity (lead-pipe, cog-wheel)
- tremor
list three differentiating features of a Parkinsonian tremor
pill rolling
worse at rest
reduced on distraction
reduced on 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
carbidopa - a dopa decarboxylase inhibitor
name 3 complications of L-dopa therapy
development of choreiform movements (L-dopa induced dyskinesia)
become tolerant to the medication - even if the dose is increased the effect will become less
confusion
hallucinations
postural hypotension on starting treatment
name 4 cardiac conditions that may cause an embolic CVA
- AF
- infective endocarditis
- atrial septal defect / patent foramen ovale
- mitral regurg
- aortic or mitral valve disease
- valve replacement
Other than an ECG and CT head in stroke, what 3 other investigations might you consider and why
carotid artery doppler - carotid artery stenosis could = stroke and should be treated promptly
lipid profile - could be hypercholesterolaemia as a RF for stroke
clotting screen - may indicate increased risk of thrombosis or haemorrhage
ECHO - exclude cardiac sources of emboli
what ABCDs score is considered ‘high risk’ for a stroke and what should be done
> 4 = high rsik
- aspirin - 100mg daily - immediately
- specialist referral within 24 hours of system inset
- secondary prevention measures (statins, antihypertensive)
crescendo TIAs (two or more episodes in a week) should be treated as high risk, regardless of ABCDs score
what should be done for someone with an ABCDs score of <3
specialist referral within 1 week of symptoms onset, including decision of brain imagening
if vascular territory or pathology is uncertain - refer to brain imaging
what are he components of the GCS
- best eye opening response
- best verbal response
- best motor response (how well they localise pain)
list 6 causes of delirium
infection
polypharmacy
urinary retention
constipation
dehydration
electrolyte imbalance
medication withdrawal
stroke
MI
B12 deficiency
list 3 non-invasive investigations you would do for someone with suspected delirium
FBC
ECG to exclude MI
U&E
urine dip to exclude UTI
CXR - exlcude pneumonia
list 4 causes of hyponatraemia
dilutional effect - SIADH, hypervolaemia/failure excess, NSAIDS (promote water retention), oliguria renal failure (dilution)
sodium loss - Addison’s disease, diarrhoea and vomiting, osmotic diurese (DM, diuretic excess), severe burns, diuretic stage of acute renal failure
name 4 symptoms of hypocalacaemia
muscle cramps/spasms
tetany
seizures
parathesia
cardopedal spasm
laryngospasm, bronchospasm
name 4 symptoms of hypercalacemia
BONES, STONES, MOANS, GROANS
bone pain, fractures
renal stones (renal colic), polyuria, polydipsia, dehydration
drowsiness/coma
muscle weakness
depression
N+V, weight loss, anorexia
constipation, abdo pain
what MMSE supports a diagnosis of dementia
<25 supports dementia
what other cognitive assessments tools may be used
GP-COG
Addenbrooke’s
6-CIT
AMT
MOCA
name 4 different types of dementia and their key features
Alzheimers - agnosia, apraxia, amnesia, aphasia
vascular dementia - stepwise progression of symptoms following ischaemic brain injury
lew body dementia - sleep behaviour, falls, impaired consciousness, visual hallucinations, Parkinsonism
frontotemporal dementia - memory fairly preserved, extreme personality changes and disinhibition
list 4 blood tests you would do to exclude treatable causes of dementia
Vit B12, thiamine, folate
TFT
FBC looking for anaemia
syphilis serology (neurosyphilis)
LFT (hepatic encephalopathy, alcoholism)
what is donepezil and what types of dementia can it be treated
acetylcholinesterase inhibitor (others are rivastigmine and galatamine)
can only be used to treat Alzheimer’s
alternative medication - NMDA-receptor antagonist - blocks glutamate (memantine)
what are 2 types of subtypes of delirium
hyperactive => agitates, inappropriate behaviour, hallucinations
hypoactive => lethargy, reduced concentration
what are some risk factors for delirium
old age
cognitive impairment
frailt/multiple comorbidities
significant injuries (e.g hip)
functional impairment
history of alcohol excess
sensory impairment (deaf, blind)
poor nutrition
lack of stimulation
terminal phase of illness
how does delirium present
acute behavioural change
diorganised thinking/altered perception
altered level of consciousness
falling
loss of appetite
what bedside tests would you do for someone with delirium
O2 sats
BP
Temp
ABG/VBG
what investigations would you do for someone with delirium
FBC, LFT, U&E
CRP/ESR
sputum culture
Folate, B12
HbA1C
TFT
CXR, ECG, urinalysis
how regularly should bisphosphonates be checkes
after 5 years - treatment reassessed, update FRAX score and DEXA scan
what are the reasons to keep treating with bisphosphonates
on steroids
age > 75
previous hip/vertebral fractures
further fractures on treatment
high risk on FRAX score
DEXA scan T-score <-2.5 after treatment
how do bisphosphonates work
inhibition of osteoclasts
list 3 adverse effects of bisphosphonates
oesophagits
osteonecrosis of the jaw
increased risk of atpical stress fractures of the proximal femoral shaft in patients taking 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 weigth (BMI)
smoking
alcohol >3 units/day
steroids
previous hip fracture
femoral neck bone mineral densit
female gender
age
RA
secondary osteoporosis
how is malnutrition diagnosed
BMI <18.5 Kg/m^2
unintentional weight loss >10% in last 3-6 months
BMI <20Kg/M^2 plus unintentional weight loss >5% within the last 3-6months
what are some causes of malnutrition
inadequate nutritional intake (starvation)
increased nutrient requirements (cancer, sepsis, injury)
inability to utilise ingested nutrients (malabsorptions)
increased loss (vomiting, diarrhoea)
combination of all of them
what tests are important to be done before commencing feeds
U&Es
LFTs
ECG
what are some clinical features of re-feeding syndrome
CVS - arrhythmia
GI - abdo pain, constipation, vomiting, anorexia
MSK - weakness, myalgia, rhabdomyolysis, osteomalacia
resp - SOB, ventilator dependence, resp muscle weakness
neuro - weakness, paraesthesia, ataxia
metabolic - infections, thrombocytopenia, haemolysis, anaemia
other - liver failure, Wernicke’s encephalopathy
what needs to be considered in a best interests decision
whether person is likely to regain capacit and decision can wait
how to encourage and optimise the participaton of the person in the decision
past and present wishes, feelings, belief and values of the person and other relevant factors
views of other relevant people (family 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
they can refuse treatment in a predefined future situation
what factors would mean the advanced directive had less of a legal binding
if there is an advanced request for treatment
this does not have the same legal binding as a refusal of treatment
but if it’s the patient’s known wish to be kept alive then reasonable efforts (nutrition, hydration) should be made
what is deprivation of liberty
occurs when a person does not consent to care or treatment
- cannot consent to treatment/care but they are having it anyway
for example a person with dementa who is not free to leave a care home and lacks capacity to consent to this
what is a lasting power of attorney
a document which a person can use to nominate someone else to make certain decision on their behalf when they are unable to do so themselves
it 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 (IMCA)
commisioned from independent organisations by the NHS and local authorties to ensure the MSA is being followed
Role = support and represent the people who lack capacity and do not have anyone else to represent them in decisions (i.e long term accomodation or serious medical treatment)
what is the definition of postural hypotension
a drop of >20/10 mmHg w/in 3 mins of standing
occurs in 30% of patients over 70
what are some causes of postural hypotension
medications - diuretics, antihypertensives, antidepressants, polypharmacy
cardiac - aortic stenosis, arrhythmias, 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-headiness
blurred vision
weakness
fatigue
palpitations
headaches
how is postural hypotension investigated
lying and standing blood pressure
investigate for medical causes - medication review, blood test
how is postural hypotension managed
drink lots of water
avoid large meals and alcohol
exercise
stand slowly
sleep with head raised
pharmacological - 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 calcium homeostatis
vit D
PTH
what is the role of vitamin D
increased Ca2+ absorption in gut
increased Ca2+ release from the bone
where is PTH released from and what triggers its release
secreted from the chief cells of the parathyroid gland
in response to low serum Ca2+ levels (detected by calcium sensor cells in the parathyroid glands)
what is the role/actions of parathyroid hormone
acts to increase Ca2+ levels
causes increase osteoclast activity
increases intestinal Ca2+ absorption
increased vit D activation
increased renal tubule re-absorption of Ca2+
how is osteoporosis defined
reduction in bone mineral density
and micro-architectural deterioration of bone tissue
with a consequent increase in bone fragility and suceptibility to fracture
BMD>2.5 SDs below the mean is diagnostic
T-score <-2.5
what are the 4 common sites of osteoporosis related fractures
- thoracic vertebra - may lead to kyphosis and loss of height
- lumbar vertebra
- proximal femure
- distal radius (Colles’ fracture)
what T score would be seen in someone with osteopenia
-1 to -2.5
if > -1 then normal
