Elderly Flashcards
Define geriatric giants/frailty syndromes
- Falls (instability).
- Immobility
- Incontinence
- Cognitive impairment
- Iatrogenesis e.g. increased susceptibility to the side effects of medication
- Inanition (state of malnutrition, physical and mental exhaustion)
Define polypharmacy
When a patient takes 4 or more medications regularly.
What is the strongest risk factor for frailty?
Age
List the risk factors for frailty
- Age
- Female
- Sarcopenia
What is the FRAX score?
Fracture risk assessment tool - helps to identify people who may be at risk of developing osteoporosis.
Outline the impact of falls
- Injury
- Fear of falling
- Social isolation
- Deconditioning
- Discharged to care home —> loss of independence
Outline the components of a comprehensive geriatric assessment
- Recognition of frailty.
- Holistic medical review (biopsychosocial) including: identification/optimisation of medical illnesses, goal setting, drug review and anticipatory care planning.
- Individualised care and support plan.
Give examples of when you would assume frailty
- Dementia and/or delirium
- Living in nursing home or residential care
- Parkinson’s disease
- Falls (not always)
Sheltered accommodation vs residential homes vs nursing homes
- Sheltered accommodation: resident lives in their own flat, but there may be communal areas (independent living/warden controlled).
- Residential homes: staffed by carers.
- Nursing home: staffed by nurses and carers, residents are more dependent and have higher, complex care needs.
Test for delirium?
4 A’s test
What questions would you ask in an elderly social history?
- Do they live alone?
- Stairs in the house?
- Use of walking aids?
- Carers (if so, what for?)
- Family support?
- ADLs? - independent?
- Lifeline (safety necklace button)?
- Aids/safety equipment in the house (e.g. handrails, wet rooms, stair lifts etc)?
Management of frailty
- Vitamin D
- Diet/nutrition
- Exercise
- Medications
Outline the issues associated with polypharmacy
- Associated with falls
- Increased risk of drug interactions
- Increased risk of adverse effects
Describe the common drugs that have adverse effects on the elderly
- Anticholinergics: dry mouth, urinary retention, constipation, confusion (increased risk of delirium), dizziness, blurred vision, falls.
- Diuretics: postural hypotension, AKI.
- Antihypertensives: postural hypotension, AKI.
- Hypnotics: drowsiness, confusion, unsteadiness.
- NSAIDs: AKI, GI bleeding.
- Antibiotics.
- Amitriptyline: anticholinergic effects - blurred vision, dry mouth, and constipation etc.
- Opioids: constipation, sedation.
- Beta blockers: bradycardia.
Outline the types of falls
- Simple ‘one off’ fall.
- Recurrent falls
- Syncope and pre-syncope.
Outline the limitations to successful falls rehabilitation
- Injury - long rehab process, limits activities.
- Dementia - confusion, non compliance.
- Fear of falling.
- Osteoporosis.
Define syncope
Transient LOC due to cerebral hypoperfusion.
Define mild cognitive impairment
Problems with memory or higher cortical thinking, not severe enough to interfere with everyday life.
What is the abbreviated mental test score (AMTS)?
10-point assessment to rapidly assess/screen elderly patients for the possibility of dementia and delirium.
< 6 suggests dementia or delirium.
Which drugs can precipitate delirium?
Opiates, anticholinergics and benzodiazepines.
List the differentials of dementia
- Ageing
- Mild cognitive impairment
- Delirium
- Depression
- Amnesic syndrome
- SOL
- Alcohol abuse
- Thyroid problems
- NPH
- Folate or B12 deficiency
Outline the investigations for suspected dementia
- MSE and cognitive assessment.
- Bloods: FBC, U&Es, LFTs, TFTs, CRP, glucose, B12, folate, bone profile.
- MSU.
- CXR.
- ECG.
- CT head.
Describe the features of delirium
- Disturbance in attention.
- Disturbance in consciousness.
- Change in cognition.
- Disorganised thinking.
- Altered perception.
- Altered social behaviour.
- Occurs over a short period of time (<24 hrs) - acute onset.
- Reversible and fluctuating.
- Disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication, or substance withdrawal.
Describe the physiology of ageing
- Increased body fat percentage and decreased total body water.
- Decreased bone and muscle mass.
- Reduced immune system function.
- Decreased elastin, increased collagen and increased calcium deposits in heart and blood vessels, stiffen cardiac muscle, decreasing contractility and CO, and reducing ventricular relaxing and filling.
- Hypertension due to vessel wall stiffness.
- Calcification of heart valves.
- Reduced elastic recoil, reduced chest wall compliance and decreased strength of respiratory muscles —> increased residual volume and decreased vital capacity.
- Reduced cilia function —> chest infections.
- Reduced renal blood flow, decreasing eGFR.
- Decreased peristalsis causing constipation.
- Decreased oestrogen and testosterone —> osteoporosis.
- Increased insulin resistance.
- Neuronal loss.
Important examinations in the elderly
- Cognitive assessment
- Nutritional assessment
- Hydration assessment
- Sensory assessment
- Neurological assessment
- MSK and gait assessment
- Pressure sores inspection
- L/S BP
What system is used to assess a patients risk of pressure sores?
Waterlow score
What are the predisposing factors for delirium?
- Age > 65 years
- Background of dementia
- Significant injury e.g. hip fracture
- Frailty or multimorbidity
- Polypharmacy
- Previous delirium
Name 3 precipitating factors for delirium
- Infection
- Change of environment
- Constipation
Outline the management for delirium
- Treat underlying cause
- Modification of environment
- Haloperidol
Describe the pathophysiology of shingles
Primary varicella zoster virus lays dormant in dorsal root ganglia, then it reactivates following immunosuppression.
Describe the clinical features of shingles
- Prodromal phase: paraesthesia and pain (throbbing, burning, stabbing) in the affected dermatome.
- Unilateral, erythematous, vesicular rash in a dermatomal distribution.
- Systemic features: headache, fever, malaise, fatigue.
Which dermatomes are most commonly affected with shingles?
Lumbar or thoracic
Which cranial nerve is affected in Herpes zoster ophthalmicus?
Trigeminal nerve
Define Hutchinson’s sign
- The presence of vesicular lesions on the side or tip of the nose that represents the dermatome of the nasociliary nerve (branch of the Ophthalmic division of the trigeminal nerve).
- This sign correlates highly with subsequent eye involvement.
Which condition describes reactivation of herpes zoster in the geniculate ganglion of the facial nerve?
Ramsay hunt syndrome
Management of shingles?
- Oral anti-viral therapy (e.g. aciclovir), within 72 hours of rash onset.
- Analgesia.
What is the most common complication of shingles?
Post-herpetic neuralgia - pain that is persistent, or appears more than, 90 days after the rash onset.
Outline the causes of delirium
- Infection.
- Withdrawal (alcohol, drugs).
- Acute metabolic.
- Trauma.
- Constipation.
- Hypoxia/hypercapnia.
- Deficiencies.
- Endocrine (thyroid, glucose, cortisol).
- Acute vascular.
- Toxins (metals).
- Dehydration.
- Pain.
- Environment.
- Polypharmacy.
Diagnostic tools for delirium
- AMT
- 4 ATs
- CAM criteria
Predisposing factors for pressure ulcers
- Malnutrition
- Incontinence: both urinary and faecal
- Immobility
- Pain (which can lead to decreased mobility)
Dementia with fluctuating cognition and hallucinations
Lewy body dementia
