Elderly care Flashcards
1
Q
What is included in the comprehensive geriatric assessment for discharge planning?
A
- MEDICAL ASSESSMENT - by the doctor - problem list (diagnosis and treatment), comorbid conditions, medication review
- FUNCTIONAL ASSESSMENT- by OT/PT - assess ADL and gait, balance
- PSYCHOLOGICAL ASSESSMENT- by nurse/psychiatrist - cognition, mood
- SOCIAL ASSESSMENT- by social worker - care resources, finances
- ENVIRONMENTAL ASSESSMENT- home safety
2
Q
How is osteoporosis caused?
A
= reduction in bone mineral density and disruption of bone architecture
due to imbalance in bone remodelling - there is increased resorption by osteoclasts than deposition by osteoblasts
3
Q
What is osteopenia?
A
precursor to osteoporosis
4
Q
What is osteomalacia?
A
softening of bones, due to impaired metabolism from inadequate levels of calcium, phosphate and vitamin D
5
Q
What is the role of parathyroid hormone?
A
- increase calcium reabsorption
- increase osteoclast activity causing release of calcium and phosphate from the bones
- active vitamin D production increased
OVERALL EFFECT= INCREASE CONC OF CALCIUM IN THE BLOOD
6
Q
list the risk factors for osteoporosis
A
S- steroids H- hyperthyroidism, hyperparathyroidism A- alcohol, tobacco T- thin (BMI <22) T- testosterone decrease E- early menopause R- renal/liver failure E- erosive inflammatory bowel disease D- dietary intake (decrease Ca, malabsorption)
7
Q
How does osteoporosis present?
A
fragility fractures!!! e.g. wrist, femoral neck
8
Q
What is the gold standard investigation to diagnose osteoporosis?
A
Dual x-ray absorptiometry (DEXA scan)
WHO T score
9
Q
Which other investigations might you do in osteoporosis?
A
- x-ray - spinal x-ray see vertebral fractures and show bone density
- FBC, bone and liver tests - bone profile normal
- vitamin D levels - low
10
Q
Outline the management of osteoporosis?
A
- conservative
- oral calcium and vitamin D
- 1st line = bisphosphonates
- 2nd line = strontium ranelate
11
Q
Name examples of bisphosponates and when are they recommended?
A
alendronate, risedronate
NICE recommends women >75 y/o following fragility fracture
12
Q
Define fall
A
an event in which results in a person coming to rest inadvertently on the ground or floor or other level
13
Q
Define syncope
A
temporary loss of consciousness, characterised by fast onset, short duration and spontaneous recovery
14
Q
List the risk factors for recurrent falls
A
Motor problems - gait/balance impairment, muscle weakness, parkinsons
Sensory impairment - vision problems, peripheral neuropathy, vestibular dysfunction
Cognitive impairment - dementia, delirium, depression
Environment - poor lighting, poorly fitted slippers, rugs/obstacles
medical problems - hypoglycaemia, stroke, dehydration
Polypharmacy
Syncope - vasovagal, postural hypotension, vertigo
15
Q
What are the physical complications that can result from falls?
A
pressure ulcers infection - pneumonia fractures rhabdomyolysis hypothermia
16
Q
How can falls be prevented?
A
- strength and balance training - physiotherapist makes assessment and prescribes tailored therapy
- environmental assessment- reduce stressors, OT assess home situation, walking aids/grab rails/ raised toilet seats
- medical assessment- reduce polypharmacy, drug review, bone health assessment
17
Q
which drugs can contribute to falls?
A
- beta blockers
- nitrates
- benzodiazepines - cause drowsiness
- diuretic
- antipsychotics - drowsiness, induce parkinsons
- steroids - cause proximal weakness
- TCA - dizziness
- anti histamines
- multiple anti hypertensives - cause hypotension!
18
Q
Which drugs can help to minimise the risk of falls?
A
- fludrocortisone - increases circulating volume to increase blood pressure
- calcium - improves muscle strength
- vitamin D - improves muscle strength and improves function of stretch receptors
19
Q
Which cognitive assessment tools are used to assess dementia?
A
- addenbrookes cognitive examination
- Montreal cognitive assessment
- abbreviated mental test score
- mini mental state examination
- 6 item cognitive impairment test
- GP assessment of cognition
20
Q
Describe the pathology behind Alzheimers disease
A
atrophy of the brain tissue and enlarged ventricles
beta amyloid plaques and neurofibrillary tangles (made of tau) cause nerve degeneration
21
Q
List the risk factors of Alzheimers disease
A
ApoE gene genetic downs syndrome female hypothyroidism
22
Q
How does Alzheimers disease present?
A
Amnesia Apathy Agnosia Apraxia Aphasia
+ gradual progressive, global memory disorder
23
Q
How is alzheimers treated?
A
anti-cholinesterase inhibitors e.g. donepezil, rivastigmine
OR
NMDA receptor blockers e.g. memantine
24
Q
What are the risk factors for vascular disease?
A
CAUSED BY MULTIPLE MINI INFARCTS: hypertension diabetes smoking stroke/TIA sedentary life style high cholesterol
25
How does vascular disease present?
sudden onset
behavioural change
rapid decline
26
How is vascular disease managed?
reduce risk factors!
| aspirin, statin, anti hypertensives
27
How is FTD caused?
atrophy of the frontal and temporal lobes
28
How does FTD present?
younger age onset
aggressive disease- rapid decline
behaviour change e.g. disinhibition, emotionally blunt, change in appetite
29
How is lewy body dementia caused?
lewy bodies (made of alpha synuclein proteins) are deposited in the basal ganglia and cerebral cortex
30
How does lewy body dementia present? (4)
1. rapid decline
2. visual hallucinations
3. fluctuating cognition and alertness
4. parkinsonism
31
How is lewy body dementia diagnosed and treated?
dopamine transporter scan
rivastigmine
32
Define delirium
acute transient, reversible state of fluctuating impairment of consciousness, cognition and perception
33
What are the 2 presentations of delirium?
1. hypoactive - quiet, lethargy, withdrawn, picking at clothes
2. hyperactive - aggressive, violent, shouting, hallucinations, agitated, inappropriate behaviour
34
How can delirium be caused?
D- drugs e.g. benzo, steroids, opioids
E- electrolyte disturbance e.g. hypoglycaemia, hypercalcaemia, increased urea
L- lack of drug (withdrawal) e.g. alcohol
I- infection e.g. UTI, pneumonia
R- reduced sensory input e.g. deaf, blind
I- intracranial problems e.g. stroke, post ictal, subdural haematoma, trauma, head injury
U- urinary retention, constipation
M- malnutrition e.g. thiamine, B12 deficiency, nicotinic acid
35
What is the ICD-10 diagnostic criteria for delirium? (5)
1. impaired consciousness
2. cognitive disturbance
3. due to a physical cause
4. delusional perception
5. fluctuating and over a short period of time
36
What is included in the delirium screen?
1. FBC
2. U&Es
3. LFT
4. blood glucose
5. TFTs
6. calcium
7. INR
8. MSU
9. septic screen
37
Outline what is involved in supportive management for patients with delirium
```
clocks and calendars
continuity of care
adequate lighting
good sleep hygiene
access of hearing aids/ glasses
side room
mobilise
```
38
When is medication given for delirious patients?
only given if patient causing harm to themselves or others- last resort!
IM lorazepam or IM haloperidol
39
Define pressure sore
an area of skin necrosis due to pressure induced ischaemia found on the sacrum, heels, over greater trochanters and shoulders
40
List the risk factors for a pressure sore
```
diabetes
immobility - bed bound
poor nutrition
incontinence
smoking
multiple comorbidities
dehydration
obesity
vascular disease
```
41
what are the 4 mechanisms that can result in a pressure sore
1. pressure
2. shear
3. friction
4. moisture
42
How are pressure sores graded?
```
0 = skin hyperaemia
1= non blanching erythema
2= brown skin or blistering
3= ulcer down to subcut fat
4= ulcer down to bone, joint or tendon
```
43
Which score is used to assess the risk of developing a pressure ulcer?
waterlow score
44
How can pressure sores be prevented?
1. barrier creams
2. pressure redistribution and friction reduction e.g. air mattresses, heel support, cushions
3. repositioning - every 4 hours if at risk
4. regular skin assessments - skin integrity, flour change, pain
5. promote healing environment - good nutrition, good glycemic control in diabetics, manage incontinence
45
Which score is used to assess malnutrition?
MUST score - Malnutrition universal screening tool
```
0= low risk and reassess in a week
1= medium risk, put on food chart
2= high risk, refer to dietician
```
46
define incontinence
involuntary leakage of urine
47
List the possible causes of incontinence
1. overactive bladder syndrome
2. stress urinary incontinence syndrome
3. fistula
4. neurological e.g. MS
5. overflow
6. age related causes e.g. diminished total bladder capacity and bladder contractile function
7. UTI
8. delirium
9. drugs e.g. diuretics, anti cholinergic
10. prolapse
11. polyuria e.g. diabetes, hypercalcaemia
48
Outline the symptoms of overactive bladder syndrome and how is this caused?
= involuntary bladder detrusor muscle contractions
urgency incontinence
nocturnal enuresis
increased frequency
49
Outline the cause and symptoms of stress urinary incontinence syndrome
= sphincter weakness and pelvic muscle weakness following childbirth
involuntary leakage by laughing, coughing, lifting, exercise
50
How can urinary symptoms be classified?
1. URGENCY
frequency (>8 times a day), strong urge, nocturnal incontinence
2. STRESS
involuntary small volume leaks when laughing, coughing, moving
3. OBSTRUCTIVE = MEN!
decreased force of stream, hesitancy, intermittent flow
51
List the investigations carried out in urinary incontinence
1. BLADDER DIARY - note voided volume, frequency of voiding and leakage, fluid intake, diurnal variation
2. MSU urinalysis
3. residual urine measurement
e. g. in and out catheter and bladder scanner
4. questionnaire - electronic personal assessment questionnaire
5. vaginal examination - exclude prolapse
52
How is overactive bladder syndrome diagnosed?
urodynamic studies
53
Which lifestyle adaptations can help with incontinence?
weight loss
smoking cessation
reduced caffeine intake
regular toileting
54
how is overactive bladder syndrome managed?
1. bladder retraining
2. anti- cholinergic drugs e.g. oxybutynin, tolterodine
3. botulinum toxin
55
How is stress incontinence syndrome managed?
1. pelvic floor exercises / vaginal cones
| 2. surgery - tension free vaginal tape or colposuspension
56
What is the difference between pharmacokinetics and pharmacodynamics?
pharmacokinetics = how body gets rid of drug and metabolises it
pharmacodynamics = how drug affects the body
57
How might pharmacokinetics change in the elderly?
1. absorption = delayed gastric emptying due to decreased mobility and decreased intestinal blood flow
2. distribution = less total body water, higher fat content (fat soluble drugs stored longer)
3. elimination = renal function decreases with age
58
How might pharmacodynamics change in the elderly?
elderly more sensitive to drugs so should be started at lower doses
59
What are the problems with polypharmacy?
```
cost of drugs
adverse drug reactions
medication non adherence
drug-drug interactions
prescribing cascade
associated with falls
```
60
How can we help patients take their medication if they have swallowing difficulties?
offer different formulations e.g. patches, sublingual
medication from same class
minimise number of drugs
61
What are the side effects of bisphosphonates?
```
oesophageal ulcer
oesophagitis
nausea, vomiting, diarrhoea
alopecia
dizziness
flu like illness
```
62
how are bisphosphonates recommended to be taken?
1. sit up for 30 mins
2. drink lots of fluid with them
3. don't eat or take any other tablets for 30 mins
63
What are the psychological complications of falls?
fear of falling limits ADLs
social isolation
depression and anxiety
64
What is carotid sinus hypersensitivity?
exaggerated carotid sinus baroreceptor response causing neurogenic syncope -
dizziness when shaving, head turning or tight collars
65
Which investigations might you do for a patient presenting with falls?
```
FBC - anaemia, WCC
U&E - dehydration
CRP
blood glucose
urine dip
ECG
CT head
lying and standing BP
```
66
What is rhabdomyolysis and what might you find on investigation?
breakdown of muscle
increases creatinine kinase levels and potassium
67
What are the 5 geriatric giants?
1. MIND - dementia, delirium, dementia
2. MOBILITY - impaired gait and balance, falls
3. MEDICATIONS- polypharmacy, adverse effects, medication burden
4. MULTI COMPLEXITY - multi morbidity
5. MATTERS MOST- individual meaningful health outcomes and preferences
68
what are 2 non painful diagnoses in the elderly that are normally painful?
silent MI
| peptic ulcer perforation
69
Which 2 medication review toolkits are used in geriatrics?
STOPP
| START
70
What are the 4 key components of frailty syndrome?
1. reduced strength and endurance
2. decreased physiological function
3. metabolic disturbances
4. vulnerability and dependency
71
What is the marker used to score frailty?
Rockwood frailty index
72
if cannot calculate BMI, how could you approximate it?
ulnar length = height
| mid upper arm circumference = weight
73
what are the 3 types of feed?
1. polymeric (osmolite)
2. elemental (individual nutrients)
3. diet specific (coeliac)
74
Define refeeding syndrome
metabolic disturbance due to rapid reinstitution of nutrients in a severely malnourished patient
75
What are the 3 key electrolyte imbalance in refeeding syndrome?
low phosphate
low magnesium
low potassium
76
What do the refeeding syndrome electrolyte disturbances increase the risk of?
cardiac arrhythmias
77
What is the physiology of refeeding syndrome?
1. increase carbohydrate load
2. increase insulin
3. increase phosphate uptake into cells
4. hypophosphataemia
78
How can refeeding syndrome be prevented?
1. identify high risk patients e.g. alcoholics, anorexics, post GI surgery, cancer
2. administer thiamine before and during
3. slow feeding over 4-7 days
4. monitor electrolytes closely (every day)
5. regular clinical assessment and observation
79
Define polypharmacy
>4 medications prescribed
80
How do you determine a patients mental capacity?
TWO STAGE CAPACITY TEST
1. do they have an impairment of their brain function?
2. does this impairment constitute a loss of capacity? (4 criteria)
81
What are the 4 principles underpinning the MCA?
1. assume capacity until proven otherwise
2. help the person in their decision making
3. a person is allowed to make unwise decisions
4. decisions made for a person who lacks capacity must be in their best interest
82
What is an example of medical and basic care in terms of feeding?
basic care = oral fluids and food - always offered
medical treatment = PEG/ PRN feeding - only if offers overall benefit to patient
83
What are the indications for a catheter?
symptomatic urinary retention
bladder outflow obstruction
AKI
intensive care
84
Define lasting power of attorney
= legal document
| lets a person appoint people "attorneys" to make decisions on your behalf so it can be used if cannot make own decisions
85
Define court of protection
makes decisions and appoints deputies to act on behalf of people who are unable to make decisions about their personal health, finance or welfare
86
Define Independent Mental capacity Advocate (IMCA)
An IMCA safeguards the rights of people who:
1. face a decision about long term move or serious medical treatment
2. lack capacity to make decision
3. have nobody else who is willing and able to represent them or be consulted in the process of working out their best interests
87
Which drug is used to clear respiratory secretions?
hyoscine butyl bromide
88
Which 4 drugs are given in end of life?
1. analgesia e.g. morphine
2. anti emetic e.g. haloperidol
3. for secretions e.g. hyoscine butyl bromide
4. sedation e.g. benzodiazepines
89
What is involved in advanced care planning?
1. advanced directive
2. DNA CPR
3. lasting power of attorney
