Elderly medicine Flashcards
Give 3 infective and pharmacological causes of a delirium?
- UTIs, pneumonia, sepsis, viral infections, meningitis, encephalitis, malaria
- benzos, analgesics (morphine), anticholinergics, anticonvulsants, steroids, GTN spray, warfarin, statins, digoxin, B blockers
Give 5 common non infective, non pharmacological causes of a delerium?
- post op
- constipation, incontinance
- trauma (head injury)
- neoplasms (paraneoplastci syndromes/ brain mets)
- toxins (alcohol, CO)
- vascular (ischaemia, infarction)
- metabolic (hypoxia, electrolyte imbalance)
- vit deficiency (B12, thiamine)
- endocrine disorders (thyroid, hypopituitaryism, cushings)
What are the components of the CAM score?
- acute/ fluctuating change in mental status AND inattention (can go 20-1) AND altered level of consciousness OR disorganised thinking
How may you investigate delirium?
- ABCDE
- urine dip, PR, blood glucose, blood cultures depending on suspected problem
- FBC, U&E, LFT. TFT, calcium, Mg, cardiac enzymes, haematinics,, PSA
- ECG
- CXR
- CT of brain (rarely useful)
How would you manage a delirium?
- TREAT CAUSE
- support symptoms
- make surrounds familiar (photos, encourage fam visits, early discharge)
- allow supervised wandering- think about why wandering (need toilet?)
- anti psychotics (haloperidol) used in aggressive pts who dont respond to de- escalation techniques
How is delirium tremens treated?
benzodiazepams
Give 6 causes of constipation
- low fluid intake
- low fibre diet
- immobility
- polypharmacy
- post op pain
- IBS
- endocrine/ metabolic disturbance
- idiopathic slow transit
- usually multifactoral
Name 4 drugs which could cause constipation
- antidepressants
- anti psychotics
- CCBs
- diuretics
- opiates
- antacids
- iron supplements
- NSAIDs
Give 3 metabolic/ endocrine conditions which could cause constipation?
- hypothyroid
- hypercalcaemia
- hypokalaemia
- lead poisoning
- diabetic neuropathy
How do you investigate constipation?
- abdo exam and PR
- FBC, U&E,TFTs
- sigmoidoscopy and biopsy of normal mucosa if unknown cause
- barium enema if suspected colorectal malignancy
What drugs are used for soft faecal impaction only? (1 type 2 examples)
stimulants (senna, biscodyl)
What drugs are used for hard faecal impaction only? (2 types, 2 of each))
Softeners (arachnid oil, ducosate sodium) Osmotic agents (macrogol then lactulose)
Which drugs can be used for soft or hard impaction?
Bulk forming laxatives (isphagula)- use first before stimulants/ osmotic agents/ softeners
What are the 4 types of incontinence?
- stress (small volumes leak on coughing/ laughing)
- urge (frequent voiding, usually seen in destrusor overactivity)
- overflow (due to urinary retention, often seen in obstructions and BPH)
- functional (often due to cognitive or physical impairment)
How should urinary incontinence be investigated?
- review or bladder and bowel diary
- abdo exam
- urine dip and MSU
- PR exam inc prostate in male
- external genitalia review esp looking for atrophic vaginitis in females
- post void bladder USS
How is incontinance managed?
- stress= pelvic floor exercises
- urge= bladder training
- urge = reduce cafffine, treat cause etc
- functional= improve ability to toilet
- pads and long term catheters
- pharmacological used last (oxybutanine- anticholinergics, anti- muscarinics etc)
What do you need to be able to do t have capacity?
- understand information
- retain information
- weigh up information relating to a decision
- communicate a decision
What is a DOLs form?
deprivation of liberty- used in delirium for drs to make best interest decisions for pt
Give 5 signs that a pt is approaching end of life?
- bed bound
- semi comatose
- only able to sip flui
- cannot take oral meds
- frequent infections
- treatment failure
What end of life symptoms may palliative care staff want to help reduce?
- N+V
- Dyspnoea
- agitation
- confusion
- terminal secretions
- constipation
- anorexia
What drugs are commonly used in palliative care and why? (6)
- morphine (pain, dyspnoea)
- haloperidol (delirium)
- dexamethasone (anorexia)
- midazolam (agitation)
- metoclopamide (N+V)
- amitriptyline (neuropathic pain)
- hyoscine (terminal secretions)
- ducosate/ senna (constipation)
What are the two broad categories of falls?
syncopal falls (Loss of consciousness with low BP) non syncopal falls (with or without LOC)
Give 5 causes of syncope
- orthostatic hypotension
- carotid sinus hypersensitivity
- arrhythmias
- aortic stenosis and other cardiac structural abnormalities
- PE
- cerebrovascular disease
- subclavian steal syndrome
- vasovagal
Give 2 causes of non syncopal falls with and without LOC
without LOC- MSK or accidental falls
with LOC- seizures, psychogenic, intoxication, hypoglycaemia, TIA and stroke
How should a fall be investigated?
- lying and standing BP
- CVS and resp exam
- ECG
- neuro and msk exam
- bloods
- further investigations as required eg xray, CTPA, EEG, head CT etc
- look for cause and consequence
What may cause orthostatic hypotension? (postural drop >20/10 mmHg)
Hypotensive drugs (BB and CCB esp), addisons, AS, Heart failure, antipsychotics, baroreceptor desensitivity with age.
How should strokes be managed?
- urgent CT or MRI head to determine haemorrhagic or ischaemic
- if embolic: alteplase if present within 4 hrs and no contraindications, then aspirin for 2 weeks and decide on new antiplatelet later
- if ischaemic: BP lowering drugs and surgery
- DVT prophylaxis
- CVS risk reduction
- carotid doppler
- PT, OT and SALT input
How are TIA managed?
- aspirin 300mg daily
- high risk= urgent TIA clinic
- lifestyle mod
- CVS risk reduction
- carotid doppler and intervention if appropriate
- no driving for 1 month
What causes faecal incontinence?
- 50% due to overflow diarrhoea + anal sphincter gaping and reduced tone with age
- rest is due to neurogenic dysfunction (will have significantly reduced anal tone and sensation)
