Elderly - general principles

Question 1

How much more likely is a person to fall in an institution compared to at home?

Answer 1

3x

Question 2

What is the most common cause if injury in older people?

Answer 2

Falls

1-2% result in hip fractures

Question 3

What % of falls result in major injury?

Answer 3

10%

Question 4

How do bisphosphonates work?

Answer 4

e.g. alendronic acid, causes death of osteoclasts

Question 5

What is teriparatide?

Answer 5

Form of PTH, promote the function of osteoblasts

Question 6

What is denosumab?

Answer 6

Blocks RANKL and thus inhibits osteoclast function

Question 7

What is benign paroxysmal positional vertigo?

Answer 7

• Calcium carbonate crystals dislodge from otolith organs and disrupt flow of endolymph in semicircular canals
• sudden dizziness on moving head in particular direction, nausea and vomiting
• Epley/Selmont maneuver to reposition crystals – head tilted in various ways to promote crystal exiting the canals

Question 8

What % of hospital patients have dementia?

Answer 8

20%

Question 9

What are the 4 As of Alzheimers?

Answer 9

Apraxia: difficulty planning and performing motor tasks

Amnesia

Aphasia

Agnosia: inability to interpret sensations e.g. inability to recognise things

Question 10

Where is especially prone to atrophy in Alzheimers?

Answer 10

Earliest sign is medial temporal lobe atrophy

Medial temporal and parieto-temporal lobes

• Relative sparing of primary sensory/ motor/ visual cortex
• Dilated ventricles

Question 11

Discuss the pathophysiology of Alzheimers

Answer 11

Clusters of amyloid plaques: causes calcium influx and glutamate excitotoxicity = cell death

Hyperphosphorylated tau eads to neurofibrillary tangles and loss of structural integrity

Question 12

What is donepezil?

Answer 12

Acetylcholinesterase inhibitor - used to treat Alzheimers as Alzheimers causes loss of cholinergic neurons

Also galantamine and rivastigmine

Question 13

What treatments are available for vascular dementia?

Answer 13

Clopidogrel, aspirin and warfarin to prevent clotting

Lifetstyle changes e.g. stopping smoking, improving diet and exercising

Acetylcholinesterase inhibitors and NMDA antagonists aren’t used to treat pure vascular dementia

Question 14

What is dementia with lewy bodies?

Answer 14

Deposits of alpha synuclein (lewy bodies) gather in neurons and cause neuronal death

Falls, syncope, neuroleptic sensitivity (sensitivity to antipsychotics), hallucinations and dellusions

Atrophy in midbrain, temporal lobe, pariteal lobe and cingulate gyrus

Question 15

Discuss fronto-temporal dementia

Answer 15

Mainly early onset

10% familial

Mutation in tau gene

1. dementia of frontal type
2. progressive non-fluent aphasia
3. semantic dementia

Question 16

What is an antalgic gait?

Answer 16

Gait to avoid pain

Question 17

Discuss the sub. nigra

Answer 17

2 areas: pars compacta and pars reticulata

The pars compacta serves mainly as an output to the basal ganglia circuit, supplying the striatum with dopamine.

The pars reticulata, though, serves mainly as an input, conveying signals from the basal ganglia to numerous other brain structure

Question 18

System changes in the elderly

Answer 18

Neuro: slow and less regular gait, slowed cognition

MSK: sarcopenia, osteopenia, pain

CV: loss of myocytes and reduced heart compliance, calcification

Resp: reduced gas exchange efficiency, impaired mucocilliary escalator

GI: impaired peristalsis, reduced bowel motilitym reduced rectal wall elasticity, weight loss

Genitourinary: renal function declines, kidneys shrink, CK reduces with loss of muscle bulk so can give false negatives, prostate enlargement, ability to concentrate urine decreases

Eyes: increased risk of retinal detachment, presbyopia (deterioration of sight with age due to lens stiffness)

Ears: wax more viscious, presbycusis, balance imapired due to loss of ear hair cells

Skin: thin, less elastic, prone to damage, dry, less subcut fat (reduced ability to stay warm), slower repair

Question 19

Important to consider when assessing discharge of patient

Answer 19

Pre-admission status, where they came from, can they use stairs, toilet

Patient ability: ADLs, washing, cooking, getting to bed, toilet, stairs, dressing (asked by OT)

Once a patients baseline and current status is ascertained, a problem list is made and SMART goals outlined

Question 20

Where do patients go following discharge?

Answer 20

Home: if functionally suitable and appropriate support

Inpatient rehab: to allow patient to achieve their potential function, indicated if their pre-admission function was high but they currently require a lot of support

Residential home: respite, medically fit but needs time to recover, allows for thorough assessment of need

Nursing home: temporary if extra support needed in short term, permanent if not safe to return home, lacks rehab potential and care needs cannot be met elsewhere

Palliative fast track: within last 6 weeks, allows for funding to be sought so patient can have a say in where they spend their last days

Question 21

Input of social services in discharge planning

Answer 21

Social services input is needed to organise packages of care

Referral to integrated complex discharge hub is made - this team aid staff to progress discharges

Notification of assessment is submitted 1st: requests social worker to be allocated

Notification of discharge: informs social services that the patient is medically and therapy fit for discharge that day and social serves input is the only cause of delay