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Phase 3A medicine > COTE FC from ppt > Flashcards

COTE FC from ppt Flashcards

1
Q

define frailty

A

-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

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2
Q

what is the impact of frailty on elderly people and how does it change how they need to be cared for

A

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

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3
Q

what are the most common presenting complaints in geriatric medicine

A
  1. falls
  2. confusion
  3. fever/infection
  4. new incontinence
  5. ‘off legs’ - used to be able to walk and now can’t
  6. ‘failed DRT (discharge response team)
  7. chest pain/SOB
  8. urinary symptoms - pain, changes, incontinence
  9. off food, generally unwell
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4
Q

what are the geriatric giants

A

4 I’s
1. instability (falls)
2. immobility
3. intellectual impairment (confusion)
4. incontinence

not diagnoses - more general/vague - normally indicative of underlying problems

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5
Q

what is the comprehensive geriatric assessment

A

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

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6
Q

what are the 4 components of the comprehensive geriatric assessment

A
  1. medical assessment
  2. functional assessment
  3. psychological
  4. social and environmental assessment
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7
Q

what is the medical assessment made up of

A

doctor, nurse, pharmacist, dietician, SALT

problem list, comorbs, medicaton review, nutritional statuses

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8
Q

what makes up the functional assessment

A

OT, PT, SALT

assesses ADLs, activity, exercise status, gait, balance

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9
Q

what is the psychological assessment comprised of

A

doctor, nurse, OT, psychologist

cognitive status testing, mood/depression testing (PHQ-9 questionnaire)

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10
Q

what is the social and environmental assessment comprised of

A

OT and social worker if needed

informal support needs and assets, care resource eligibility, home safety

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11
Q

what are the features of delirium

A

acute onset
fluctuating course
inattention
altered level of unconsciousness
usually reversible
associated with underlying medical cause

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12
Q

what are the features of dementia

A

chronic illness
progressive course
no clouding of consciousness
no underlying/reversible cause

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13
Q

name an assessment tool used for delirium

A

4-AT

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14
Q

what causes delirium

A

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

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15
Q

how is delirium managed

A

treat underlying cause

manage the environment

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16
Q

name some ways in which the environment can be altered to help delirium

A

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)

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17
Q

what is the role of the comprehensive geriatric assessment

A

identifies health problems and establishes management plans in older patients wit frailty

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18
Q

who makes up the comprehensive geriaric assessment team

A

geriatrician
social worker
physiotherapist
occupational therapist

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19
Q

what are the complications of a long lie following a fall

A
  1. pressure ulcers
  2. dehydration
  3. rhabdomyolysis
  4. hypothermia
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20
Q

how do you investigate pressure ulcers

A

CRP, ESR
WCC
swabs
blood cultures
X-ray for bone involvement

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21
Q

how are pressure ulcers managed

A

ABx
wound dressing
pain relief
debridement if grade 3/4

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22
Q

what is osteoporosis

A

decreased bone mineral density due to imbalance between remodelling and resorption

increases risk for fractures - particularly spine, hip and NOF

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23
Q

what are some risk factors for osteoporosis

A

smoking
early menopause
steroid use
underweight
inactivity
alcohol
ALL ELDERLY PEOPLE

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24
Q

how is osteoporosis managed

A

bisphosphonates (zoledronate, alendronate)

IV once a year or oral once a week - (empty stomach, stay upright for half an hour as may = oesophagitis)

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25
Q

what is a tool used for assess nutritional status

A

MUST screening tool (malnutritional universal screening tool)

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26
Q

what is re-feeding syndrome

A

metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished

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27
Q

what are the biochemical features of refeeding syndrome

A

hypophosphataemia
hypokalaemia
thiamine deficiency
abnormal glucose metabolism

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28
Q

what are some complications of re-feeding syndrome

A

cardiac arrythmias
coma
convulsions
cardiac failure

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29
Q

how is re-feeding syndrome treated

A

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

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30
Q

what are some risk factors for pressure ulcers

A

age
peripheral vascular disease
immobile a long time
dehydration
obesity
malnourishment

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31
Q

how can you prevent pressure ulcers

A

keep patient mobile
change bed positon
special mattress - pressure re-distributing mattress
barrier creams
regular skin assessment

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32
Q

name 2 treatmen that will improve bone health

A

bisphosphonates

vitamin D and calcium supplements

(exercise - impact like walking, not swimming)

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33
Q

what are some environmental causes of falls in elderly people

A

loose rugs
pets
furniture
unstable footwear

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34
Q

what are some power/balance causes of falls in elderly people

A

inactivity leading to - muscle weakness

dizziness/loss of balance/loss of proprioception (vertigo)

pain/MS - osteoarthritis

previous fall leading to decreased confidence

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35
Q

what are some cardiovascular causes of falls in elderly people

A

vasovagal syncope (faint)
situational syncope - micturition (old men, night time)
postural hypotension
MI
arrhythmia
dehydration/shock

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36
Q

what are some neurological causes of falls in elderly people

A

stroke
PD
gait disturbance
visual impairment
peripheral neuropathy
myopathy (statin or steroid myopaty)

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37
Q

what are some medications that increase risk of falls in elderly people

A

benzodiazepines - sedatve so impair coordination
diuretics
anti-Hypertensive - ACEi, CCB, Beta-blocker
antidepressant
antipsychotic
polypharmacy

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38
Q

what are some other causes of falls in elderly people

A

infection/sepsis
delirium
hypoglycaemia
incontnence
alcohol - intoxication, neuropathy, Korsakoff’s/wernicke’s

39
Q

what are the three main features of Parkinson’s

A
  1. bradykinesia
  2. rigidity (lead-pipe, cog-wheel)
  3. tremor
40
Q

list three differentiating features of a Parkinsonian tremor

A

pill rolling
worse at rest
reduced on distraction
reduced on movement
worse on one side (asymmetrical)

41
Q

what is the underlying pathophysiology of Parkinson’s

A

loss of dopaminergic neurones in the substantia nigra

42
Q

what class of drug is normally combined with L-dopa therapy to prevent peripheral side-effects

A

carbidopa - a dopa decarboxylase inhibitor

43
Q

name 3 complications of L-dopa therapy

A

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

44
Q

name 4 cardiac conditions that may cause an embolic CVA

A
  1. AF
  2. infective endocarditis
  3. atrial septal defect / patent foramen ovale
  4. mitral regurg
  5. aortic or mitral valve disease
  6. valve replacement
45
Q

Other than an ECG and CT head in stroke, what 3 other investigations might you consider and why

A

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

46
Q

what ABCDs score is considered ‘high risk’ for a stroke and what should be done

A

> 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

47
Q

what should be done for someone with an ABCDs score of <3

A

specialist referral within 1 week of symptoms onset, including decision of brain imagening

if vascular territory or pathology is uncertain - refer to brain imaging

48
Q

what are he components of the GCS

A
  1. best eye opening response
  2. best verbal response
  3. best motor response (how well they localise pain)
49
Q

list 6 causes of delirium

A

infection
polypharmacy
urinary retention
constipation
dehydration
electrolyte imbalance
medication withdrawal
stroke
MI
B12 deficiency

50
Q

list 3 non-invasive investigations you would do for someone with suspected delirium

A

FBC
ECG to exclude MI
U&E
urine dip to exclude UTI
CXR - exlcude pneumonia

51
Q

list 4 causes of hyponatraemia

A

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

52
Q

name 4 symptoms of hypocalacaemia

A

muscle cramps/spasms
tetany
seizures
parathesia
cardopedal spasm
laryngospasm, bronchospasm

53
Q

name 4 symptoms of hypercalacemia

A

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

54
Q

what MMSE supports a diagnosis of dementia

A

<25 supports dementia

55
Q

what other cognitive assessments tools may be used

A

GP-COG
Addenbrooke’s
6-CIT
AMT
MOCA

56
Q

name 4 different types of dementia and their key features

A

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

57
Q

list 4 blood tests you would do to exclude treatable causes of dementia

A

Vit B12, thiamine, folate
TFT
FBC looking for anaemia
syphilis serology (neurosyphilis)
LFT (hepatic encephalopathy, alcoholism)

58
Q

what is donepezil and what types of dementia can it be treated

A

acetylcholinesterase inhibitor (others are rivastigmine and galatamine)

can only be used to treat Alzheimer’s

alternative medication - NMDA-receptor antagonist - blocks glutamate (memantine)

59
Q

what are 2 types of subtypes of delirium

A

hyperactive => agitates, inappropriate behaviour, hallucinations

hypoactive => lethargy, reduced concentration

60
Q

what are some risk factors for delirium

A

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

61
Q

how does delirium present

A

acute behavioural change
diorganised thinking/altered perception
altered level of consciousness
falling
loss of appetite

62
Q

what bedside tests would you do for someone with delirium

A

O2 sats
BP
Temp
ABG/VBG

63
Q

what investigations would you do for someone with delirium

A

FBC, LFT, U&E
CRP/ESR
sputum culture
Folate, B12
HbA1C
TFT
CXR, ECG, urinalysis

64
Q

how regularly should bisphosphonates be checkes

A

after 5 years - treatment reassessed, update FRAX score and DEXA scan

65
Q

what are the reasons to keep treating with bisphosphonates

A

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

66
Q

how do bisphosphonates work

A

inhibition of osteoclasts

67
Q

list 3 adverse effects of bisphosphonates

A

oesophagits
osteonecrosis of the jaw
increased risk of atpical stress fractures of the proximal femoral shaft in patients taking alendronate

68
Q

how are DEXA scan scores interpreted

A

-1 to + 1 = healthy
-1 to -2.5 = osteopenia
<-2.5 = osteoporosis
<2.5 and a current fragility fracture = severe osteoporosis

69
Q

what are the components of the FRAX scoring system

A

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

70
Q

how is malnutrition diagnosed

A

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

71
Q

what are some causes of malnutrition

A

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

72
Q

what tests are important to be done before commencing feeds

A

U&Es
LFTs
ECG

73
Q

what are some clinical features of re-feeding syndrome

A

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

74
Q

what needs to be considered in a best interests decision

A

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)

75
Q

what is the role of an advanced directive

A

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

76
Q
A
77
Q

what factors would mean the advanced directive had less of a legal binding

A

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

78
Q

what is deprivation of liberty

A

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

79
Q

what is a lasting power of attorney

A

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

80
Q

what is the role of an independent mental capacity advocate (IMCA)

A

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)

81
Q

what is the definition of postural hypotension

A

a drop of >20/10 mmHg w/in 3 mins of standing

occurs in 30% of patients over 70

82
Q

what are some causes of postural hypotension

A

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

83
Q

how does postural hypotension present

A

asymptomatic
falls/syncope
dizziness
light-headiness
blurred vision
weakness
fatigue
palpitations
headaches

84
Q

how is postural hypotension investigated

A

lying and standing blood pressure
investigate for medical causes - medication review, blood test

85
Q

how is postural hypotension managed

A

drink lots of water
avoid large meals and alcohol
exercise
stand slowly
sleep with head raised
pharmacological - fludrocortisone, midodrine (autonomic dysfunction only)

86
Q

how are pressure ulcers classified

A

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

87
Q

what are the 2 major metabolic components of calcium homeostatis

A

vit D

PTH

88
Q

what is the role of vitamin D

A

increased Ca2+ absorption in gut

increased Ca2+ release from the bone

89
Q

where is PTH released from and what triggers its release

A

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)

90
Q

what is the role/actions of parathyroid hormone

A

acts to increase Ca2+ levels

causes increase osteoclast activity
increases intestinal Ca2+ absorption
increased vit D activation
increased renal tubule re-absorption of Ca2+

91
Q

how is osteoporosis defined

A

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

92
Q

what are the 4 common sites of osteoporosis related fractures

A
  1. thoracic vertebra - may lead to kyphosis and loss of height
  2. lumbar vertebra
  3. proximal femure
  4. distal radius (Colles’ fracture)
93
Q

what T score would be seen in someone with osteopenia

A

-1 to -2.5

if > -1 then normal

Phase 3A medicine (5 decks)

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