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Medical Specialties > Elderly Care > Flashcards

Elderly Care Flashcards

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USMLE® Step 1 flashcards
1
Q

name a few reasons why people are getting older

A
  • better resources and care
  • better financial stability
  • screening programmes picking up disease sooner
  • diseases have better outcomes
  • better provisions for chronic diseases
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2
Q

name the three theories involved in ageing, and give a brief description of each

A
  • stochastic: accumulation of random changes that cause damage and ageing
  • programmed: specific sets of cells are programmed to stop working at a certain point in life
  • homeostatic failure: ageing caused by body’s loss of ability to maintain homeostasis
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3
Q

why are age and frailty not synonymous?

A

because ageing has lots of variability, an elderly person isn’t necessarily frail

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4
Q

why does eGFR in elderly people stay the same?

A

because even though creatinine clearance goes down, there is also less muscle mass so overall the eGFR remains unchanged

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5
Q

what are the main effects on the kidneys, heart and lungs as people age?

A

kidneys - reduced creatinine clearance
heart - increased blood pressure, reduced cardiac output
lungs - reduced vital capacity

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6
Q

what is the definition of frailty?

A

the body’s increasing inability to maintain homeostasis

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7
Q

what are the four “frailty syndromes”?

A
  • incontinence
  • confusion/delirium
  • falls
  • immobility
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8
Q

what is a consequence of reduced carotid baroreflex sensitivity in elderly patients?

A

inaccurate regulation of blood pressure

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9
Q

what is meant by social dyshomeostasis in elderly people?

A

inability to cope with changes in social circumstances or environmental inputs

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10
Q

define redundancy in the context of elderly medicine and frailty

A

redundancy is the ability to overcome a crisis, therefore elderly people tend to have lower redundancy

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11
Q

what are the 5 signs that make up the frailty phenotype?

A
  • unintentional weight loss
  • weak grip strength
  • exhaustion
  • low physical ability
  • slow walk
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12
Q

name all the possible health domains

A
  • psychological
  • physical
  • environmental
  • social
  • spiritual
  • medical
  • cognitive
  • financial
  • functional
  • behavioral
  • nutritional
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13
Q

how is frailty related to health domains?

A

frailty can be caused by a disruption of any of a patient’s health domains; disruption in one health domain can precipitate disruption in other health domains

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14
Q

what is the Comprehensive Geriatric Assessment?

A

it’s a process carried out to assess and manage illness in older people with frailty

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15
Q

who carries out the comprehensive geriatric assessment, and what are the main two aims?

A

carried out by MDT
main aims are:
- recognise medical problems
- recognise which health domains are affected
- decide which aspects can be reversed or improved

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16
Q

in terms of risk and benefit, what considerations should be made for elderly patients with regards to hospital admission? explain why

A
  • hospital admission is beneficial early on: it allows for accurate tests and resources
  • hospital admission becomes increasingly risky with time: infection, iatrogenic harm, confusion, muscle wasting
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17
Q

name a few extrinsic factors which may contribute to incontinence in elderly people

A
  • habits
  • drugs
  • social circumstances
  • environment
  • cognitive state
  • fluid intake
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18
Q

what are the main four intrinsic factors that contribute to incontinence?

A
  • bladder too weak
  • bladder too strong
  • outlet too weak
  • outlet too strong
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19
Q

what are the there main types of incontinence?

A
  • stress incontinence
  • urge incontinence
  • retention incontinence
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20
Q

what does an overactive bladder lead to?

A

urge incontinence

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21
Q

what does a weak bladder outlet lead to?

A

stress incontinence

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22
Q

what does a strictured bladder outlet lead to?

A

retention incontinence

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23
Q

what is the mainstay non-pharmacological treatment for stress incontinence?

A

pelvic floor (Kegel) exercises

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24
Q

what is the mainstay pharmacological treatment for urge incontinence? what is a downside of it?

A

anti-muscarinics; they have lots of side effects as they affect muscarinics receptors all over the body

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25
Q

what is the mainstay pharmacological treatment for retention incontinence? give examples

A 
alpha blockers (eg tamsulosin)
anti-aldosterone drugs (eg finasteride)
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26
Q

give an example of anti-muscarinic drugs used to treat urge incontinence

A

oxybutinin, solifenacin

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27
Q

name some of the side effects that come with anti-muscarinics used for urge incontinence

A

dry mouth
blurred vision
constipation
bradycardia

28
Q

name a possible cause of retention incontinence in males and females

A

males - BPH

females - fibrosis

29
Q

what is mirabegron and what is it used for?

A

adrenoceptor agonist

relaxes detrusor muscle, used for urge incontinence

30
Q

what are the four main types of drugs used to treat incontinence?

A
  • alpha-blockers (eg tamsulosin)
  • beta3 adrenoceptor-agonists (eg mirabegron)
  • anti-muscarinics (eg oxybutinin, solifenacin)
  • anti-aldosterone drugs (eg finasteride)
31
Q

Name a few steps to take in the investigation and management of urinary incontinence

A
  • Detailed history (esp drugs, extrinsic factors)
  • Examination (also PV and PR)
  • Residual bladder scan
  • MSSU and urinalysis
  • advice on lifestyle choices
  • Kegel exercises etc
  • referral if complicated cases
32
Q

name a few types of incontinence containment measures used to maintain an incontinent patient’s dignity

A
  • incontinence pads
  • urosheaths
  • catheterisation (intermittent, suprapubic)
33
Q

name some conditions which would require a patient with incontinence to be referred to specialists

A
  • vesico-vaginal fistula
  • palpable bladder after micturition
  • neurological disease
  • failure of initial incontinence treatment
  • patients with BPH or prostatic carcinoma
  • patients with Hx of continence surgery
34
Q

Name a few possible precipitants of delirium

A
  • pain
  • electrolyte imbalance
  • drugs
  • alcohol/drug withdrawal
  • hypoxia
  • lack of sleep
  • change in environment
  • constipation
  • urine retention
  • infection
  • dehydration
  • brain injury
35
Q

What percentage of hospital patients experience delirium during admission?

A

Up to 30% of admitted patients

36
Q

Name a few non-pharmacological ways to deal with delirium

A
  • calming the patient
  • restoring sleep pattern
  • reduce transfers and changes in environment
  • mobilise early
37
Q

What investigation is unsuitable for elderly patients with confusion, and why?

A

Urine dipstick - elderly patients often have asymptomatic bacteriuria, not necessarily have a UTI. Dipstick would be misleading

38
Q

Name some features of delirium

A
  • confusion
  • altered consciousness (hyper or hypo)
  • sensory changes (hallucinations)
  • cognitive changes (language, memory)
  • disturbed sleep pattern
  • altered physical function
39
Q

What is the screening tool called used to measure delirium?

A

4AT

40
Q

What 4 sections are included in the 4AT delirium screening tool?

A
  • alertness
  • AMT4
  • attention
  • acute/fluctuating onset
41
Q

List the steps you would take if a patient develops delirium

A
  • history
  • examination
  • calm patient
  • treat underlying cause/precipitant
  • try to avoid medications to stop the delirium
42
Q

When should medicines be considered to treat delirium?

A

If the patient becomes a danger to themselves or others by being in a delirium

43
Q

name a few symptoms of adverse drug reactions which in elderly people can mimic the symptoms of growing old

A
  • dizziness
  • delirium
  • incontinence
  • falls
  • depression
  • insomnia
  • fatigue
  • confusion
  • constipation
44
Q

why might using guidelines for specific conditions not be the best way to manage those conditions in elderly patients?

A

because guidelines only take into consideration that one disease, and don’t take into account the co-morbidities and polypharmacy normally found in elderly patients

45
Q

name a few of the biggest culprits for ADRs in elderly patients

A
  • NSAIDs
  • warfarin
  • diuretics
  • ACE inhibitors
  • beta-blockers
  • antidepressants
  • digoxin
  • opiates
  • prednisolone
46
Q

which two types of drugs are known to be the biggest causes of ADRs in elderly patients?

A

anticholinergics

sedatives

47
Q

with regards to pharmacokinetics, how is drug absorption affected by old age?

A

absorption rate slows down, but absorption extent remains the same

48
Q

with regards to pharmacokinetics, how do physiological changes in old age affect drug distribution?

A

reduced water content - reduced distribution of water soluble drugs –> higher serum concentration
increased fat content - increased distribution and storage of fat soluble drugs –> drug stays in system longer
reduced albumin –> more free drug, higher serum levels of active drug
BBB more permeable –> easier for drugs to cross into brain

49
Q

with regards to geriatric pharmacology, why should elderly patients get a smaller loading dose of a drug that distributes well in muscle (eg digoxin)?

A

because elderly patients have lower muscle mass, therefore the loading dose of drug should reflect that

50
Q

what happens to water soluble drugs in elderly patients, as a result of reduced body water content?

A

drug stays in circulation as it doesn’t distribute as well, leading to high serum concentration

51
Q

what happens to fat soluble drug in elderly patients, as a result of increased total body fat?

A

drug is distributed more widely and is stored in adipose tissue, increasing its half-life and taking longer to be metabolised

52
Q

with regards to elderly pharmacology, how does a reduction in albumin production affect drug distribution in elderly patients?

A

reduced albumin leads to reduced protein binding in the blood, so there is a higher volume of unbound drug in circulation resulting in higher serum concentration

53
Q

what are the four significant physiological changes in elderly patients which affect drug distribution?

A
  • reduced body water content
  • increased body fat content
  • decreased albumin production
  • increased BBB permeability
54
Q

with regards to pharmacokinetics, how does elderly age affect metabolism?

A

in old age drug metabolism is reduced, due to reduced liver mass and reduced liver blood flow

55
Q

with regards to pharmacokinetics, how does old age affect excretion?

A

in old age drug excretion is reduced, due to reduction in kidney function and reduced creatinine clearance

56
Q

which guidelines can be used for advice on geriatric drug prescriptions?

A
  • BNF
  • Beer’s criteria
  • START-STOPP criteria
  • Polypharmacy Guidance document
57
Q

name a few psychiatric drugs which may be problematic in elderly patients, and why

A

sedatives (eg benzo’s) - can cause confusion, falls
anti-psychotics - postural hypo, stroke, confusion, mobility problems
anti-depressants - less effective in elderly people

58
Q

name a few analgesic drugs which may be problematic in elderly patients, and why

A

opiates - elderly patients more sensitive to effects, but some are not as effective (eg tramadol)
NSAIDs - higher risk of bleeding, renal impairment

59
Q

name a few cardiology drugs which may be problematic in elderly patients, and why

A

diuretics - incontinence and mobility problems, not as effective, excreted slowly
digoxin - lower doses needed, toxicity risk
anti-hypertensives - postural hypotension, BP and HR affected differently, higher risk of falls, renal impairment
warfarin - risk of bleeding, renal impairment

60
Q

name a few antibiotics which may be problematic in elderly patients, and why

A

aminoglycosides - renal impairment
quinolones - delirium
co-trimoxasole and trimethoprim - blood abnormalities
all antibiotics carry risk of diarrhoea, c. diff infections and seizures in elderly patients

61
Q

in terms of falls, in which settings are elderly patients who fell more likely to be very unwell?

A

in hospital settings

62
Q

what are the two first things to find out if an elderly patient falls on a ward?

A

check for serious injury

investigate cause of fall

63
Q

what important consequences of falls in a ward should not be missed?

A 
subdural hematoma
head injury
fractured hip or limb
abdominal injury
spinal injury
seizure
64
Q

after an elderly inpatient fall, when should you CT immediately?

A

if GCS is low
if still confused a few hours later
if vomiting
if seizures

if skull fracture
if basal skull fracture signs

65
Q

after an elderly inpatient fall, when should you x-ray?

A

if pain on moving joint

if there is pain on weightbearing

Medical Specialties (4 decks)

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