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Phase 3 > Elderly Care > Flashcards

Elderly Care Flashcards

1
Q

What features are looked for in the confusion assessment method? What is the criteria for diagnosing delirium from this?

A
  1. Acute onset and fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered level of consciousness
    Diagnosis of delirium requires presence of 1 and 2 and either 3 or 4
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2
Q

What are the different classes of compression stockings?

A

Class 1: applies 14-17mmHg. Used for tired legs, varicose veins and mild oedema
Class 2: applies 18-24mmHg. Used for severe varicose veins, prevention of ulcers, reduction of severe oedema, reduce risk of ulcer recurrence
Class 3: applies 25-35mmHg. Used for lymphoedema, prevention of venous ulcers, very severe varicose veins, post phlebitis/cellulitis

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3
Q

What are multi layer compression bandaging systems used for?

A

Alternative to high compression bandages for treatment of venous leg ulcers
Compression achieved by combined effects of two or three extensible bandages applied over layer of orthopaedic wadding and wound contact dressing

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4
Q

From this medication list, suggest which could be responsible for causing falls and state what side effect could cause the fall.
Metformin, gliclazide, amlodipine, ramipril, furosemide, aspirin, bisoprolol, atorvastatin

A

Gliclazide - hypoglycaemia
Amlodipine, ramipril, furosemide, bisoprolol - hypotension
Furosemide - dehydration, hyponatraemia, urgency, nocturia
Bisoprolol - bradycardia
Ramipril - electrolyte imbalance, hyperkalaemia, hyponatraemia

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5
Q

Apart from blood tests, suggest investigations that are appropriate in the initial assessment of a patient with falls and confusion along with a rationale for each

A

CXR - rule out infection
Urine dip/MSU - rule out infection
CT head - rule out subdural/stroke
Lying/ standing BP - postural hypotension
ECG - identify arrhythmia
Visual fields - field loss (indicating stroke)

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6
Q

After a 3 day inpatient stay due to a fall, an 85 year old gentleman is medically fit for discharge. State other allied health professionals/services that should be involved in the patient’s care prior to discharge and the reason for referral to each

A

Physiotherapy - check falls risk and improve mobility
Occupational therapy - check home is set up safely/ hand rails/ mobility aids
Social services - setting up package of care/meals on wheels
Dietician - ensure nutritional needs are being met
Old age psychiatry/memory clinic - detailed cognitive assessment
Pharmacist - provision of dosette box / compliance aids
Diabetic specialist nurse - optimise medication to reduce risk of hypoglycaemic episodes

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7
Q

What are the components of the 6CIT?

A 
What year is it?
What month is it?
Address with 5 components to remember
What time is it? (Within 1 hour)
Count backwards from 20-1
Months of year in reverse
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8
Q

What score on the 6CIT is significant?

A

8 or more

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9
Q

What are the features of delirium?

A

Disturbance of consciousness – Hypoactive, Hyperactive or Mixed
Change in cognition
Acute onset
Fluctuates

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10
Q

What tool can be used to aid a diagnosis of delirium?

A

Confusion assessment method

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11
Q

What are the top 4 causes of delirium?

A

Infection
Polypharmacy
Electrolyte disturbance
Constipation

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12
Q

What are some less common but important causes of delirium?

A 
Withdrawal from alcohol or other drugs
Organ failure
Endocrine
Epileptic
Pain
Intracranial pathology
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13
Q

What baseline investigations should you do in a patient with delirium?

A 
FBC, ESR 
U and Es
Glucose
LFTS and amylase
TFTs
CRP
Calcium and phosphate
CXR
ECG
Urinalysis and M, C and S
Blood culture
Blood gases
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14
Q

What non drug treatments can be used in delirium?

A 
Quiet environment
Spectacles and hearing aids 
Reassure and reorientate
Don’t argue or correct delusions
Educate visitors , staff and relatives
Enlist relatives help
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15
Q

What drug treatments can be used for delirium?

A

Lorazepam

Haloperidol

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16
Q

What is the most common psychiatric illness in elderly people?

A

Depression

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17
Q

What are risk factors for depression in elderly people?

A

Disability and illness (pain, sensory and cognitive impairment)
Loss of independence
Co-existing diseases such as Parkinson’s and Dementia
Social Isolation
Bereavement
Reduced sense of purpose
Fears around death and dying
Substance abuse (alcohol and over counter prescriptions)

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18
Q

What are clinical features of depression?

A 
Sadness
Anorexia and weight loss
Sleep disturbance
Disturbance of behaviour
Cognitive impairment
Suicidal ideation 
Physical slowness
Somatisation
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19
Q

What symptoms of depression may be more present in elderly people?

A

Early Morning Wakening
Depressive cognition
Anhedonia
Diurnal Mood Variation

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20
Q

What scales are used to assess depression in elderly people?

A

Hospital anxiety and depression scale

Geriatric depression scale

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21
Q

What is non drug management for depression in elderly people?

A

Supportive treatment
Psychotherapy
Electroconvulsive therapy
The Silver Line

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22
Q

What are drug treatments for depression?

A

Selective serotonin reuptake inhibitors (citalopram, sertraline)
Tricyclic antidepressants (amitriptyline)
Serotonin and Noradrenaline reuptake inhibitors (venlafaxine)
Serotonin antagonist (mirtzapine)

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23
Q

What is dementia?

A

Acquired decline in memory and other cognitive functions in an alert (not delirious) person enough to affect daily life (home, social function) for 12 months

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24
Q

What cognitive tests can be done to test for dementia?

A 
AMT
MMSE
MOCA
6-CIT 
AD-8
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25
Q

What is the general management of dementia?

A

Modify reversible aggravating factors
Assess for and treat depression appropriately
Social considerations
Practical considerations - deprivation of liberty?
Risk management

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26
Q

What is drug management of dementia?

A

Acetylcholinesterase inhibitors
Memantine
Aspirin and Statins

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27
Q

What is a chronic disease?

A

Long-term conditions or chronic diseases are conditions for which there is currently no cure which are managed with drugs and other treatment

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28
Q

What are patient aims of chronic disease management?

A

Reduce morbidity
Improve quality of life
Increase longevity

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29
Q

What are societal aims of chronic disease management?

A

Increase ability to work
Reduce costs
Reduce demands on health services
Reduce demands on social services

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30
Q

What is a comprehensive geriatric assessment?

A

Multidimensional holistic assessment of an older person considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person and their family and carers when relevant

31
Q

What are the domains of a comprehensive geriatric assessment?

A 
Medical 
Psychological 
Social 
Functional 
Environmental
32
Q

What is a STOPP START criteria?

A

STOPP: screening tool of older persons prescriptions
START: screening tool to alert doctors to right treatment

33
Q

What is a Barthel scale?

A 
Measure performance in activities of daily living - 10 variables
Faecal incontinence
Urinary incontinence
Grooming
Toilet use
Transfers
Walking
Dressing
Climbing stairs
Bathing
34
Q

What is a timed up and go test?

A

Time taken to stand up from a chair, walk 3 meters, turn around, walk back and sit down again
Assess person’s mobility
Score 10 seconds or less - normal
11-20 - normal for frail elderly and disabled
Greater than 20 seconds - need assistance outside and further intervention required
Greater than 30 seconds - falls prone

35
Q

Who may need to be in the MDT to do a comprehensive geriatric assessment?

A 
Doctor
Nurse
Physiotherapist
Occupational therapist
Dietician
Social worker
Community matron
District nurse
Specialist nurse
36
Q

When does a comprehensive geriatric assessment need doing?

A

Complex admissions to hospital
Planning for transfer of care for rehabilitation/re-enablement
Continuing Care assessment
An older person having multiple falls
A frail patient prior to surgery
A person receiving intermediate care or other community based rehabilitation

37
Q

What is the outcome of a comprehensive geriatric assessment?

A

Problem List

Plan of action for each problem

38
Q

What is frailty?

A

Multiple body systems gradually lose their built-in reserve poor functional reserve

39
Q

Why is it important to be aware of frailty?

A

Poor physiological reserve
Risk of adverse outcome after apparently minor event eg infection/new medication
Dramatic change in their physical and mental well being
Poor outcome after operation
Frailty is not an inevitable part of ageing, it is a long-term condition
Frailty is not static, it can be improved with intervention or worsened

40
Q

How can frailty be identified?

A

PRISMA 7 questionnaire; more than 3
Walking speed; taking more than 5 sec to walk 4 m
Timed up and go test; 3 meter in 10 sec
Grip strength; hand held dynamometer when patient can’t walk
Out-patient surgical setting; Edmonton frail scale;cognition/nutrition

41
Q

What factors are associated with frailty?

A 
Age
Multi-morbidity
Disability
Polypharmacy
Smoking
Alcohol excess
Poor diet (obesity / low protein)
Inactivity
Immune-endocrine axis
Vitamin D deficiency
Psychological factors
Social factors
42
Q

What are the geriatric giants which raise suspicion of frailty?

A 
Falls
Immobility
Delirium
Incontinence
Susceptibility to medication side-effects
43
Q

What is the definition of polypharmacy?

A

4 or more medications

44
Q

What is the phenotype model of frailty?

A 
Unintentional weight loss
Reduced muscle strength
Reduced gait speed
Self-reported exhaustion
Low energy expenditure
≥3 features suggests Frailty
45
Q

What is the deficit model of frailty?

A 
Symptoms: sensory loss
Signs: tremor
Diseases / diagnoses: dementia
Deficits combine to increase “frailty index”
Accumulate with age
46
Q

What proportion of over 65s are frail?

A

10%

47
Q

What proportion of 80-90 year olds are frail?

A

30%

48
Q

What is the PRISMA 7 questionnaire?

A

WAre you more than 85 years old?
Male?
Do you have any health problems that limit your activities?
Do you need someone to help you on a regular basis?
Do you have any health problems that require you to stay at home?
In case of need, can you count on someone close to you?
Do you regularly use a stick, walker or wheelchair to get about?
>3 suggests frailty

49
Q

What is a timed up and go test?

A 
Stand up from a standard chair (with arms)
Walk 3m
Turn around
Walk back to the chair
Sit down
>10 seconds suggests possible frailty
50
Q

When should frailty be looked for?

A

Routine OPD appt: med, surgical,memory
Primary care review for older people
Social service assessment for care and support
Review by community care team/home carers in community
Ambulance crew called out
Planning for any intervention
New medication/operation

51
Q

What can be done to manage frailty?

A

Comprehensive geriatric assessment
Consider and address reversible conditions
Consider specialist input (geriatrician, old-age psychiatrist)
Consider other MDT input (community matron)
Medication reviews
Personalised care planning
Influenza and pneumococcal vaccinations
Primary prevention: weight management programmes, smoking cessation, detection and brief advice for excessive alcohol consumption, hypertension
Secondary prevention programmes – chronic disease clinics
Secondary prevention of osteoporosis after fragility fracture using bisphosphonates
Targeted assessment and support for people older people: community matron and/or specialist nursing services
Named GP for patients >75 years old

52
Q

What is a good intervention to reduce the risk of falls and/or injury in a frail person?

A

Individualised strength and balance training

53
Q

What should be involved in an individualised care and support plan for a frail patient?

A

Personal goals
Medical management goals
Escalation and emergency plans
Advance care plans – for some

54
Q

What is the DoTS classification of adverse drug reactions?

A

Dose: toxic reaction, collateral reaction, hypersusceptibility reaction
Time-course: first dose, early, intermediate, late, withdrawal, delayed
Susceptibility: Genetic, Age, Sex, pregnancy, hepatic /renal impairment, other drugs (interactions), diet

55
Q

What is ageing?

A

Gradual loss of function of cells and organs, with the eventual outcome of death

56
Q

What are factors which contribute to why elderly patients are more susceptible to adverse drug reactions?

A 
Receptor responses – decreased beta adrenoceptor sensitivity
Altered coagulation factor synthesis
CNS becomes more sensitive to psychotropics/hypnotics
Baroreceptor response less sensitive
Renal clearance reduced
Thirst response blunted
Thermoregulation blunted
Altered immune response
Slower gastric emptying
Reduced plasma albumin
Increased ratio of adipose to lean tissue
Altered liver metabolism
57
Q

What strategies can be used to improve drug concordance in elderly patients?

A

Simplify: once-daily dosing, try to prescribe medicines to be taken at same time of day, try to use medications with dual indications (beta blockers), Consider daily dose reminder system (Dosette box)
Educate: Explain reasons for medication and how to take it, Warn of predictable side effects, Enlist support of family and carers in monitoring
Monitor: Check tablet boxes and use of medications, Monitor requests for prescriptions, Serum monitoring if needed

58
Q

When should medication reviews be performed in elderly patients?

A

All patients aged >75 years should have an annual review of their repeat medication
Those taking 4 or more medicines should be reviewed every 6
months
May be completed by any suitably qualified health professional

59
Q

Which scoring system is used to detect risk of pressure sore development?

A

Waterlow score

BMI, nutritional status, skin type, mobility, continence

60
Q

What are the geriatric giants?

A 
Immobility 
Instability 
Incontinence 
Intellectual Impairment 
Iatrogenic
61
Q

What percent of geriatric patients presenting with a fall will die in a year?

A

25%

62
Q

What are causes of syncope?

A

Cardiac: Arrhythmias, Aortic stenosis
Orthostatic hypotension: drugs, autonomic dysfunction, hypovolaemia, hypoadrenalism
Neuro: vasovagal, seizure, hypoglycaemia

63
Q

What examinations should be performed on an elderly patient who has fallen?

A

ABCDE if acutely unwell
Cardiovascular (BP, postural drop, dehydration, murmurs)
Neurological (GCS / AVPU score, focal neurology)
MSK (evidence of trauma / injuries resulting from fall)

64
Q

What investigations should be done for an elderly patient who has fallen?

A 
FBC, U&Es, bone profile, glucose 
ECG 
Lying / standing BP 
Urinalysis 
Consider: CT head (Head injury with new confusion, on warfarin, new neurology), Xrays, CK, 24 hour tape +/- ECHO, Tilt-table testing
65
Q

What features make up a diagnosis of delirium?

A

Acute onset
Fluctuating course
Inattention
Disorganised thinking or loss of consciousness

66
Q

What is a PRISMA 7 score?

A

Used to identify potential frailty/need for further clinical review if score of 3 or more
Are you more than 85 years?
Male?
In general do you have any health problems that require you to limit your activities?
Do you need someone to help you on a regular basis?
In general do you have any health problems that require you to stay at
home?
In case of need can you count on someone close to you?
Do you regularly use a stick, walker or wheelchair to get about?

67
Q

Which criteria can be used to assess for polypharmacy?

A

STOPP-START criteria
Screening Tool of Older People’s potentially inappropriate
Prescriptions
Screening Tool to Alert doctors to Right (appropriate, indicated) Treatments

68
Q

Why can polypharmacy be a problem?

A

Loss of patient compliance
Prescription errors
Increased Adverse Drug Reactions and Interactions
Inappropriate prescribing

69
Q

When is inappropriate polypharmacy present?

A

There is no evidence based indication, the indication has expired orthe dose is unnecessarily high
One or more medicines fail to achieve the therapeutic objectives
they are intended to achieve
One, or the combination of several drugs cause unacceptable
adverse drug reactions (ADRs), or put the patient at an unacceptably high risk of such ADRs
Patient is not willing or able to take one or more medicines as
intended

70
Q

In which 2 cardiovascular problems should NSAIDs not be used?

A

HTN

Heart failure

71
Q

What are 7 steps for managing polypharmacy in the elderly according to sign criteria?

A

Identify objectives of drug therapy
Identify essential drug therapy
Does the patient take unnecessary drug therapy
Are therapeutic objectives being achieved?
Does the patient have ADR or is at risk of ADR?
Is drug therapy cost effective?
Is the patient willing and able to take the drug therapy as intended?

72
Q

What are some drugs that have a severe anticholinergic burden?

A 
Amitriptylline
Atropine
Chlorpheniramine
Chlorpromazine
Clomipramine
Clozapine
Diphenhydramine (in some antihistamines, some Nytol andother sleep remedies) 
Imipramine 
Nortriptyline 
Oxybutinin
Paroxetine 
Procyclidine
Promethazine 
Tolterodine
73
Q

What is the management of patients at risk of corticosteroid induced osteoporosis?

A

Patients over 65 or have had previous fragility fracture should be offered bone protection
Patients under 65 offer dexa. Score between 0 and -1.5, repeat scan in 1-3 years. Score less than -1.5 offer bone protection

Phase 3 (23 decks)

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