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Geriatrics > Delirium, Immobility & Falls & Ageing & Frailty > Flashcards

Delirium, Immobility & Falls & Ageing & Frailty Flashcards

1
Q

What is delirium and what are the key features of it?

A

Delirium=acute change in your mental state

Key features:
Disturbed consciousness-Hypoactive/hyperactive/mixed

Change in cognition- Memory/perceptual/language/illusions/hallucinations

Acute onset and fluctuant

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2
Q

What are other common features of delirium?

A

Disturbance of sleep wake cycle

Disturbed psychomotor behaviour – DELIRIUM AFFECTS YOUR PHYSICAL FUNCTION

Emotional disturbance

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3
Q

Does anyone really know why delirium happens?

A

Not really

Maladaptive pro inflam state-as get older brain is a bit leakier and as you develop cognitive frailty brain gets even leakier again – much more likely to get delirium in response to some sort of external stimuli at advances of age and frailty than you are likely to have at younger ages

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4
Q

What precipitates delirium?

A

Infection (but not always a UTI!)
Dehydration
Biochemical disturbance
Pain
Drugs
Constipation/Urinary retention
Hypoxia
Alcohol/drug withdrawal
Sleep disturbance
Brain injury-Stroke/tumour/bleed etc
Changes in environment/emotional distress

Sometimes no idea and often multiple triggers!

Antidepressants are associated with falls

Dihydrocodeine for knee pain (flare of arthritis)-well recognised side effect is constipation

Urinary retention because of constipation, already has prostate problems – bit predisposed to bladder outflow problems

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5
Q

How common is delirium?

A

Commonest complication of hospitalisation

20-30% of all in-patients
Up to 50% of people post surgery
Up to 85% of people at end of their life

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6
Q

Why is delirium important?

A
  • Massive morbidity & mortality
  • Increased risk of death
  • Longer length of stay
  • Increased rates of institutionalisation
  • Persistent functional decline
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7
Q

How is delirium diagnosed?

A

4AT-Delirium Screening Tool

Everyone >65 when admitted to hosp should have one

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8
Q

What should be done when find delirium?

A

Treat the cause
- Full Hx and exam (incl. neuro)
- TIME bundle-helps to manage triggers

Explain the diagnosis!

Pharmacological measures
Non-pharmacological measures

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9
Q

What are the non-pharmacological treatments for delirium?

A

Re-orientate and reassure agitated patients- USE FAMILIES/CARERS

Encourage early mobility and self-care

Correction of sensory impairment

Normalise sleep-wake cycle

Ensure continuity of care
- Avoid hospitalisation if possible
- avoid frequent ward or room transfers

Avoid urinary catheterisation/venflons
Discharge people (if in hospital) ASAP

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10
Q

What pharmacological managements are appropriate for delirium?

A
  • Drug treatment for delirium usually not necessary
  • Stop bad drugs

Only if danger to themselves or others or distress which cannot be settled in any other way
Start low and go slow
12.5mg quetiapine orally
THIS SHOULD BE A CONSULTANT/REGISTRAR DECISION

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11
Q

Is delirium preventable?

A

Preventable in 30% of cases

Risk reduction for those at risk such as pain control, early mobilisation, maintaining hydration & nutrition etc

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12
Q

What does the delirium trajectory & follow up look like?

A
  • Usually settles quickly with management of underlying causes
  • May unmask previously undiagnosed cog impairment
  • More likely to go on & develop dementia
  • Risk factor for further episodes delirium/dementia/frailty syndromes so remember to record and communicate diagnosis and organise follow up

Recognise people at high risk-may influence what drugs are prescribed and what kind of community based models of care are offered to try and keep these people as fit & well and out of hospital

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13
Q

Is capacity decision specific?

A

Yes

  • Legally appointed proxy decision maker can be welfare POA or guardian
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14
Q

Is there association between delirium & falls?

A

4.5x more likely to fall if have delirium

Delirium prevention interventions also reduce falls

If stop people moving-much more likely to fall – promoting mobility is very important

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15
Q

Why are so many UTIs overdiagnosed?

A

High prevalence of asymptomatic bacteriuria in older adults

Asymptomatic bacteriuria-people who if you dip their urine will have leukocytes and nitrites or will grow bug in the lab-but these people do not have an active infection.

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16
Q

What should not be used to diagnoses UTI in older people?

A

Dipstick tests

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17
Q

How do drugs cause falls?

A

DECREASE:
- BP
- HR
- Awareness

INCREASE:
- Urine output
- Sedation
- Hallucinations
- qTC
- Dizziness

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18
Q

What are the culprit drugs that can be responsible for falls?

A

Antihypertensive
Beta blocker
Sedatives
Anticholinergics
Opioids
Alcohol

  • Lots of older people cure their own HT just by losing weight – frailty
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19
Q

How does where you are affect how you deal with a fall?

A

Falls clinic (full MDT)-Likely to be well patients, difficult and multifactorial falls

A+E - More likely to be acutely unwell. May not be possible to do it all

Assessing a hospital inpatient who has fallen - Very likely to be acutely unwell. Significant injury possible

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20
Q

What does syncope on exertion make you think of?

A

Aortic Stenosis

21
Q

What is important to cover in a systematic enquiry in addition to the usual things?

A

Memory – Ideally ask a relative too
Urinary symptoms (they won’t tell you if you don’t ask)
Has walking changed recently

Drugs
Especially over the counter antihistamine
Especially alcohol

22
Q

Falls examination: What is important to look for in head and arms?

A

Cerebellar signs

Bradykineasia, ridigidity – signs of PD

23
Q

What will happen to the centre of balance in Kyphosis?

A

Kyphosis-centre of balance will be effected – postural instability

24
Q

Falls examination: What to do with legs should be examined?

A
  • Peripheral neuropathy – vibration sense

Look at feet (footwear, toenails).
Check sensation, vibration sense, and proprioception – remember usually glove and stocking not dermatomal
Co-ordination

Put shoes and socks back on. (You may need a shoehorn)
Stand patient up.

Romberg’s
Assess gait

25
Q

What does each of these gaits mean in terms of a pathology…

1)Ataxic
2)Arthralgia
3)Hemiplegic
4)Small steps, shuffling
5)High stepping?

A

1)Cerebellar damage
2)Arthritis
3)Stroke
4)(Vascular) parkinsonism
5)Peripheral neuropathy

26
Q

Those non injured fallers what often happens?

A

Often left at home by paramedics and referred to community falls pathways- including falls clinic

27
Q

If a person who has fallen was lieing down for a long time what should be checked?

A

Long lie – check CK for rhabdomyolysis. Pneumonia and skin injury common as well.

28
Q

Does a head injury with no neurological signs need a CT head?

A

NO

Consider CT head if fall with head injury and neurological signs or anticoagulated

29
Q

What bloods should be checked in all falls patient?

A

B12, folate, CK, TFTs

ECG for all too

30
Q

How to assess a fallen patient?

A
  • ABCDE approach
  • Check glucose
  • Top to toe survey
31
Q

What should be included in the immediate assessment for serious injuries?

A
  • Head injury & extra dural
  • Seizure
  • C spine injury
  • Flail chest
  • Abdo injury
  • Flail chest
  • Pelvic injury
  • Limb fracture
32
Q

What are things not to miss after an inpatient falls?

A
  • SDH – fall may not have an obvious head injury and they may become confused a few days later
  • Fractured neck of femur – shortened and externally rotated
33
Q

When should you CT a head injury immediately?

A

Low GCS <13

Still confused after 2 hours (or not back to baseline cognitive state)

Focal neurology

Signs of skull fracture

Basal skull fracture – CSF leak, bruising around eyes,

Seizure

Vomiting

Anti-coagulation

34
Q

When should an xray be performed?

A

If pain on moving a joint have low threshold of x ray

If no deformity but pain on weight bearing have low threshold to x ray
- People can walk on fractured hips

35
Q

Septic patients get … blood sugar

A

LOW

36
Q

What are the nurses actions post-fall?

A

Repeat risk assessment
Datix
Call family
Try and prevent further fall-fall prevention care plan (ensure vision and mobility aids and call bed are in reach, consider bed rails, regular obs)

37
Q

Why is ageing beneficial, neutral and detrimental?

A

Beneficial
Increased experiential learning

Neutral
Grey hair
Pastime preference

Detrimental
Hypertension, decreased reaction time-comorbidities

38
Q

What are the theories of ageing?

A

Stochastic:
Cumulative damage (because of micro trauma and free radicals)
Random

Programmed:
Predetermined
Changes in gene expression during various stages

Homeostatic failure-less reserve to cope with any given environmental challenge so are less able to maintain homeostasis

39
Q

Describe the physiology of ageing?

A
  • Affects virtually every organ/system
  • Marked inter-individual variability in both development and magnitude of changes
  • Inter-individual variability INCREASES with age
  • Evidence very limited for 80+
40
Q

What happens to the kidneys as we age?

A
  • Poorer clearance in creatinine
  • Accompanied by reduction in muscle bulk
41
Q

What is dyshomeostasis and what is frailty according to this?

A

The point of physiology is to maintain a steady state-Impaired function of any organ system makes this more difficult

Frailty is effectively progressive dyshomeostasis

42
Q

What is frailty and what frailty syndromes can it result in?

A

A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge

This results in “Frailty Syndromes”:
Falls
Delirium
Immobility
Incontinence

43
Q

What do carotid sinuses detect changes in?

A

BP

44
Q

Who is more likely to present with HYPOTHERMIA & HEAT STROKE?

A

Those with FRAILTY

45
Q

What happens to measure of sway as we age?

A

Measure of sway when standing-older age groups sway more as less able to keep homeostasis in tight limits (cant correct as well for slight changes in weight when standing)

46
Q

What is ‘social’ dyshomeostasis?

A

Difficulty caused by environmental insults not only bio-medical

Ageing often associated with whole system dyshomeostasis

Different ability to compensate for e.g. death of spouse or daughter going on holiday

Humanity relies on the social structures around us to keep us well – tend to degrade as we get older

47
Q

How may Hyperthyroidism classically present compared to how it presents in a person with frailty?

A

Classic presentation:
Tremor
Anxiety
Weight loss
Diarrhoea

Person with frailty:
Depression
Cognitive impairment
Muscle weakness
Atrial fibrillation
Heart failure
Angina

48
Q

What are the practical implications of an increasingly ageing population?

A

Increasing number of older people with multiple co-existing medical conditions

Increased inter-individual variability in organ function and homeostatic reserve

Different presenting symptoms and signs
-Presentation of different “illnesses” can be v similar

Multimorbidity and frailty are different but are both issues for older people

49
Q

What are the practical implications of an increasingly ageing population?

A

Increasing number of older people with multiple co-existing medical conditions

Increased inter-individual variability in organ function and homeostatic reserve

Different presenting symptoms and signs
-Presentation of different “illnesses” can be v similar

Multimorbidity and frailty are different but are both issues for older people

Relatively little evidence of drug efficacy and safety for patients 80+
- Pre-marketing development still largely involving young and middle age pts with fewer co-morbidities

Multiple medications:
Drug-drug interactions
Adverse drug reactions

Geriatrics (4 decks)

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