elderly medicine Flashcards
what is frailty?
state of increased vulnerability from ageing associated decline in reserve and function across multiple physiological systems
what are the most common presentations in geriatric medicine?
falls/instability
immobility
incontinence
intellectual impairment
what are the 5Ms of geriatric giants?
mind (dementia, delirium, depression)
Mobility (impaired gait & balance, falls)
medications (polypharmacy, adverse effects, medications burden)
multi-complexity (multi-morbidity, bio-psycho-social situations)
matter most: each individuals own meaningful health outcome goals and care preferences)
what is the CGA? and what are the domains of it and the members of the MDT that deal with each domain
comprehensive geriatric assessment. needs to be done as often there is non specific presentations 5 domains mental health (cognition/mood - psychologist/psychiatrist) physical health - problem list, co-morbid conditions, med review = doctor social aspects - care resources/finances = social worker functional aspect - ADL, gait, balance = physio/OT environment - home safety = OT
what happens after initial CGA?
Writing a problem list (covers all 5 domains)
Prioritisation (sequenced in order – should reflect pt preferences)
Management planning
Goal setting
Iteration (monitoring the progress)
what examinations should you consider in the elderly?
cognitive nutritional sensory MSK gair pressure and inspection postural BP
what scales can be used to assess activity/dependence ?
Barthel Index, Nottingham Extended Activities of Daily Living index
what scales can be used to assess cognition?
abbreviated mental test, MMSE, MOCA, Addenbrookes, CAM (confusion assessment method – for delirium)
what scale can be used to assess gait and balance?
berg balance scale
what scale can be used to measure psych and psychological morbidity in the elderly?
geriatric depression scale/ cohen-mansfield agitation inventory
what can help a patient return home after hospital admission?
care package
physios in community
active recovery
what is the definition of frailty?
medical syndrome with multiple causes and contributors that’s characterised by diminished strength and endurance and reduced physiological function which increases their dependency/risk of death
what is the classical frailty phenotype?
Frailty phenotype – Fried Model (measured to be robust – frail)
Presence of 3 or more characteristic of:
Unintentional weight loss
Weakness evidenced by poor grip strength
Self-reported exhaustion
Slow walking speed
Low level of physical activity
what can a lack of mobility lead to in the elderly ?
thromboembolic disease, chest infection, constipation, pressure ulceration
what mobility aids are there?
patient hoist, rotunda, walking frame, wheeled walkers, walking sticks
what are the roles of OT?
OT have role in discharge planning following acute admission (resulted in limitation of daily activities), help with a CGA, help with intervention (referral to intermediate care at home service) and discharge
OT aids commode, perching stool, urine bottle, toilet frame with seat, buckingham caddy
what are the sections of the MCA?
- Understand
- Retain
- Weigh up
- Communicate
capacity can be circumstantial
what are the points underpinning a MCA?
- Assume capacity unless proven otherwise
- Take all practical steps to help a person in decision making
- Person allowed to make unwise decision
- Always take or act on decisions for people without capacity in their best interests
- Consider whether outcome can be achieved in a less restrictive way
what is advanced care planning?
Advanced care planning enables people to make decisions and requests about their health and social care should they lose capacity.
Advanced care planning includes:
- Advance Statements
- Advance decision to refuse treatment
- Lasting power of attorney (LPA)
what are advanced statements in terms of advanced care planning?
Advance statements are not legally binding, but should be taken into account by healthcare providers when planning care. They serve as a guide to inform best interests decisions. An advance statement can cover any element of future care, ranging from how you would like your religious/spiritual beliefs reflected in your care, to how you like to do things (perhaps stating you would rather shower than bath) to what you might like to happen to your pets should you no longer be able to look after them. An advanced statement can be written or verbal and does not require witnesses or a signature (however these would assure people that the views expressed were genuinely your own.)
how is and advanced decision to refuse treatment used in advanced care planning?
An advanced decision to refuse treatment is legally binding. It enables an individual to refuse treatment, but not basic care such as offering food, water and measures to prevent pressure sores. It should be specific, referring to specific interventions and how different circumstances might alter your decision. An ADRT must be written down , signed by you & signed by a witness to be legitimate.
what do lasting power of attorneys have the power to do?
they can only refuse treatment not demand it
what are the different types of lasting power of attorney?
Health and welfare: they can may decisions about you daily routine, medical care treatment, moving into a care home, life-sustaining treatment
Property and affairs - can make decisions about managing back/building societies account, paying bills, collecting benefits or a pension, selling your home
what are the advantages of advanced care planning?
Motivates individuals to think about their future care.
Enables better informed best interests decisions.
Relatives are likely to be more comfortable with the care of an individual without capacity if that individual has formally expressed their wishes regarding health and social care.
what are the limitations of advanced care planning?
A patient cannot request specific care, they can only reject it.
An individual cannot reject basic care.
You cannot request assisted suicide. (or anything else illegal)
You cannot refuse treatment for a mental health condition.
A patient’s past preferences might not represent their current beliefs.
what is an IMCA?
(independent mental capacity advocacy)- An independent individual who has been specially trained to support people who cant make decisions alone with no fam/friends
what is the definition of polypharmacy?
= being prescribed more than 4 medications (increased side effects, increased drug interactions, therapeutic cascade (the adverse effects of a drug are misunderstood as new medical condition!), risk of medications not being reviewed properly)
what are the risks of osteoporosis?
Risks for osteoporosis = SHATTERED
Steroids, Hyperthyroidism, hyperparathyroidism(increases calcium by increased bone resorption (osteoclast activity), increase absorption from gut, decrease calcium excretion from kidneys), hypocalcaemia, Alcohol, Thin (BMI <22), Testosterone low (eg prostate cancer), early menopause – oestrogen deficiency, renal failure or liver, erosive/ IBD, dietary intake (reduced calcium)/ Drugs which can cause (PPIs – reduced acid – less calcium absorption)
what assessment can be used to find the 10 year probability of a fracture?
FRAX
what is osteomalacia?
softening of bones due to impaired bone metabolism from inadequate levels of calcium, phosphate
what advice and medical treatment would you give to someone with osteoporosis?
ADVICE: increase calcium intake, start on vitamin D, exercise -weight baring, stop smoking, fall prevention, home assessment
medical: bisphosphonates, strontium ranelate, raloxifene, calcitonin, denosumab
what is the best predicter of future falls?
> 2 falls in last year is best predictor of future falls risk
what is rhabdomyolysis?
can be caused by7 a long lie after a fall
classic triad of muscle pain (shoulders, thighs, lower back), muscle weakness, dark red/brown urine
often will present after a fall or epileptic seizure with acute renal failure
why do patients with rhabdomyolysis present with acute renal failure?
muscle breakdown causes increased potassium, phosphate raised (released from myocytes), myglobinuria, hypocalcaemia (myoglobin binds calcium) and CK raised– myoglobin causes acute tubular necrosis (AKI) – raised potassium causes arrhythmias)
what are the signs of hyperkalaemia on an ECG?
tall tented T waves and absent P waves
sinusoidal patteren
how do you manage rhabdomyolysis?
(IV calcium gluconate 10mls 10% (cardioprotective) bicarbonates, insulin, glucose 50% 50mls (drive K intracellularly), Kayexalate (binds K in GI tract), Diuretics OR Renal dialysis
what are the indications for dialysis in acute renal failure?
BLAST B - barbiturates L - lithium A- alcohol S - salicylates T - theophylline
what complications can a long lie after a fall cause?
Rhabdomyolysis
hypothermia
pressure sores
what are the risks for falls?
internal factors = neuro disease, cognitive decline, muscle weakness, visual deficit, incontinence, postural hypotension, dehydration, malnutrition
external risk factors - polypharmacy, walking aids, foot wear, hazards,
what medications can cause postural hypotension ?
ACE i diuretics nitrates bblockers alpha blocker
what investigations would you perform for someone who has had a fall?
ECG CK FBC bone biochemistry - serum calcium, phosphate and Vit D Lying/standing BP
what can cause syncope?
Cardiac arrhythmias (bradycardia, tachycardia, drug induced), structural heart disease (valves, cardiomyopathy, congenital, PE, aortic dissection)
Orthostatic htn see above for definitions! drug induced, primary autonomic failure (MSA, dementia with lewybodys), secondary autonomic failure (DM, spinal cord injuries), Volume depletion (haemorrhage, diarrhoea, vomiting)
Neuro epilepsy, NEAD etc (not really syncope! But appear like it)
Reflex vasovagal, situational, carotid sinus syndrome
what are the different types on incontinence in the elderly?
Urge (OAB) caused by infection, idiopathic, neurogenic. Lifestyle, bladder retraining, anticholinergics e.g. oxybutynin (increased risk of falls), mirabegron (B3 adrenoceptor agonist- better in elderly), vaginal oestrogen, botox, sacral nerve stimulation
Stress caused by instrumentation during childbirth, prolapse. Lifestyle, pelvic floor, duloxetine, TFVT/TOT
Mixed incontinence (combo of above 2)
Overflow (caused by BOO – bladder outlet obstruction – this also causes OAB due to irritant effect of urine). Target cause e.g. STDs, trauma, BPH, cancer of cervic, prostate, bladder
how would you investigate incontinence?
Do a systems review – neuro, cardio, abdo, mental state, pelvis. Ask about obstetric hx. Ask about medications!
IX urinanalysis, MSU (MC&S), post-void bladder scan, freq volume chart, more complex stuff later
what medications can influence urinary incontinence
Alcohol -polyuria, frequency, delirium
ACEi - cough and stress incontinence
Anticholinergic -urinary retention and overflow
Diuretic - polyuria, frequency, urgency
Opiate -delirium, sedation, constipation and urinary retention
TCA -urinary retention and overflow
what tests/screening tools would you do to assess someone with suspected delirium?
abbreviated mental test
then do a confusion assessment method (acute onset and fluctuating course, inattention, disorganised thinking, altered level of consciousness)
what are the common causes of delirium?
DELiRIUM D- drugs E - electrolyte imbalance L - lack of drugs - withdrawal or uncontrolled pain I - infection (UTI or pneumonia) R - reduced sensory input (vision, or hearing deficits) I - intracranial (CVA, subdural) U - urinary retention/faecal impaction M - myocardial - pulmonary
what does the delirium screen involve
FBC (WCC for infection, anaemia)
U&Es (urea, AKI (rhabdomyolysis), Na/K) – Na low, when Na is low do serum osmolality (low) but need to compare with urine osmolality, urine is conc and blood is dilute = SIADH caused by infection, brain damage, drugs (SSRIs), malignancy (Small cell)
LFT (liver failure)
TFTs (hypothyroid)
Blood glucose (hypoglycaemia)
Calcium raised (bone stones groans and psychic moans) (do parathyroid hormone test)- raised Ca consider bone mets (brain, bronchus, kidney, breast, prostate) hypercalceamia give FLUIDS and IV bisphosphonates - pamidronate
Heamantics (B12, folate)
INR (warfarin, bleeding risk) – do INR for subdural heamatoma, if fall want to know bleeding risk from fall
Septic screen (urine dip, cxr, blood cultures)
how is delirium managed?
treat underlying cause
manage environment - help with reorientation
pharmacological - haloperidol/lorazepam - if patient is agitated as a short term control of distress
what screening tool is used to assess dementia?
mini - mental state exam
it measures orientation, recall, language, registration, attention and calculation
what are the symptoms of Alzheimer’s?
Amnesia – memory loss
Aphasia – receptive or expressive
Apraxia – deficit in voluntary motor skills difficulty doing ADLs
Agnosia – difficulty recognising things or faces
Apathy – lack of motivation
what is the treatment for Alzheimer’s?
anticholinesterase inhibitiors (Donepezil, rivastigmine, galantamine) and NMDA antagonist (Memantine)
what is vascular dementia? what are the classical presentations?
step-wise deterioration, atherosclerotic risk factors, focal neurology, fits, nocturnal confusion
how does lewy body dementia usually present?
day to day fluctuating cognition, visual hallucinations, REM sleep disorder, recurrent falls, parkinsonism (do not prescribe antipsychotics in these e.g. haloperidol!)
how does fronto-temporal dementia usually present?
AKA picks disease
changes in behaviour, emotion and language, disinhibition
what is normal pressure hydrocephalus?
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis.
what are the symptoms of normal pressure hydrocephalus?
WET WACKY AND WOBBLY - urinary incontinence, dementia/ bradyphemia, gait abnormality - ataxia (can be similar to parkinsons!)
what would you see on the imaging of normal pressure hydrocephalus ?
hydrocephalus with an enlarged fourth ventricle
in addition to the ventriculomegaly there is typically an absence of substantial sulcal atrophy
how do you manage normal pressure hydrocephalus?
VP shunt - ventriculoperitoneal shunt
Acetazolamide -
how is an ischaemic stroke managed?
altepase if within 4.5 hours
how do you manage and intracerebral haemorrhage in someone on warfarin?
give vit k to reverse + prothrombin complex concentrate
what are the symptoms of Parkinson’s?
- Bradykinesia
- Rigidity
- Tremor
- Postural instability
- Mocrographia
- Abnormal shuffling gait
- Hypomimia
what are the causes of parkinsonism?
Idiopathic Parkinsons unilateral, upper limb mainly, treatment responsive, present with bradykinesia
Vascular parkinsons - lower limb, bilateral, falls and gait problems
Drug induced - hx of antipsychotics
Lewy Body Demetia cognitive impairment, present same time as parkinsonism or within few months, hallucinations, fluctuations in consciousness
Progressive supranuclear palsy - eye signs-vertical gaze palsy, cognitive impairment with frontal disinhibition, don’t respond to rx
MSA - prominent autonomic ft e.g. orthostatic htn, incontinence, impotence, cerebellar signs, not responsive to rx
what screening tool can be used for malnutrition?
MUST screening tool – (malnutrition universal screening tool) – identifies people who are risk of becoming malnourished e.g. 0 no risk, 1 medium risk, >2 high risk of malnourishment
what is refeeding syndrome?
- Metabolic disturbances as a result of reinstitution of nutrition to patients who are starved/severely malnourished – when given parenteral nutrition
- Prolonged starvation followed by provision of nutritional supplementation from any route
- Chronic malnutrition à insulin levels decreased, energy source switch to fats, normal serum phosphate levels, low intracellular phosphate levels
- Refeeding à insulin increased, movement of electrolytes into cell result in decreased serum electrolyte levels
what are the symptoms of refeeding syndrome?
abdominal pain
myalgia
nausea
seems delirious
what are the biochemical features of refeeding syndrome?
o Hypophosphatemia o Hypokalemia o Hypomagnesaemia o Abnormal fluid balance o Thiamine deficiency o Abnormal glucose metabolism (hyperglycaemia)
what are the complications of refeeding syndrome?
cardiac arrhythmias
coma
convulsions
cardiac failure
what are risk factors for pressure sores?
= immobility, surgery, smoking, incontinence, dehydration, poor nutrition, sensory impairment, Alzheimers/Parkinsons
Normally occur over bony prominence e.g. sacral bone
what risk tool can be used for pressure sores?
warterlow tool
braden tool
how can pressure sores be prevented?
Preventative = SSKIN
• Support surface – mattresses/cushions made of viscoelastic foam, gel, air
• Skin assessment - barrier creams, pressure redistribution, repositioning, regular skin assessment
• Keep moving
• Incontinence and moisture
• Nutrition and hydration
what are the four end of life care drugs?
Via syringe driver – subcut given
Hyoscine butyl bromide (Buscopan)/ glycopyronium (prevents upper airway secretions)
Haloperidol – for anxiety agitation
Morphine – calming pain and breathing rate
Cyclizine – nausea
what drugs cause delirium?
BAD HAT benzos analgesics - codeine Diuretic - furosemide antihistamines - chlorphenamine anti- arrhythmic - digoxin TCA - amitriptyline
what things effect the pharmokinetics of a drug?
absorption distribution higher fat content metabolism elimination
what is a best interest assessment?
- used to decide a persons best interest when they lack capacity for a particular decision
- if no fam or friends then they will need an independent mental capacity advocate
what are the complications of Rhabdomyolysis?
- AKI - myoglobin results in acute tubular necrosis
- hyperkalaemia - causes arrhythmias and cardiac arrest
- hypocalcaemia (myoglobin binds Ca2+)
- metabolic acidosis
what is osteoporosis?
- A systemic skeletal disease characterised by low bone mass and a micro
architectural deterioration of bone tissue, with a consequent increase in
bone fragility and susceptibility to fracture - Defined as bone mineral density (BMD) MORE than 2.5 standard
deviations BELOW the young adult mean value (T score < 2.5)
what is osteopenia?
- Pre-cursor to osteoporosis characterised by low bone density
- Defined as BMD between 1-2.5 standard deviations BELOW the young
adult mean value (-1< T score < 2.5)
what is osteomalacia?
Poor bone mineralisation leading to soft bone due to lack of Ca2+ (adults
form of Ricket’s)
what are the requirements for a DOLs application?
- going to care home/hosp
- not free to leave
- lacks capacity
what are DOLs?
deprivation of liberty safeguards:
- to provide the person with a representative – a person who is given certain rights and who should look out for and monitor the person receiving care
- to give the person (or their representative) the right to challenge a deprivation of liberty through the Court of Protection
- to provide a mechanism for a deprivation of liberty to be reviewed and monitored regularly
how long does a DOLs last?
12 months
