Elderly Medicine Flashcards
1
Q
What should be included in a medical history?
A
- Current reason for his admission
- Falls history
- Assessment of cognition
- Continence assesment - bladder and bowels assessment
- PMH and disease severity
- Current medication list and complicance
- Drug allergies
- Social and functional history - who do they live with. How are they supported and by whom. Mobilising. Shopping cleaning
- Alcohol and smoking
- Systemic enquiry
- Wishes and advanced decisions
2
Q
What should be used when assessing old people?
A
Comprehensive Geriatric Assessment
3
Q
What does Comprehensive Geriatric Assessment look at?
A
- Problem list
- Medication review
- Nutritional status
- Mental health
- Functional capacity
- Social circumstances
- Environment
4
Q
What is poly pharmacy?
A
Looking at 6 or more drugs being prescribed at any one time.
5
Q
What should you do whenever you prescribe a drug?
A
- Check the correct agent is prescrined
- Drug allergies
- Interactions with other drugs
- Use genetic drug names and write them down in capitals
- Don’t use abbreviations
- Dose, frequency and times and route of administration are clearly identified. Include a start date
- Be cautious using decimal points
- Units rather than u
- Print name as well as signing if on a paper chart
- Review medications daily
- Stop those not needed
6
Q
What is the importance of discharge planning?
A
- Agree care pathways of the older persons
- Give a patient centred perspective approach
- Discharge arrangements should maximise the quality of life and promote independence
7
Q
What is section 2?
A
- Section 2 - referral is made to social services to assess funding. e.g a care home or direct payments.
- Social worker is then allocated to the patient/ service user and will be responsible for putting together an appropriate packet of care
8
Q
What is section 5?
A
- Sent by nursing staff to social services alerting them to the fact that the patients has been declared as ‘medically stable for discharge’
- Once recieved the designated socail worker is expected to take decisive action towards discharge
9
Q
What do discharges involve?
A
- Medication to take home
- Transport
- Therapy assessment - OT, physio
- Restarting package of care
- Outpatient/ user appointment
- District nurse referral if required/ palliative or community led referral if warranted
- Transfer back letter for residential nursing home
10
Q
Why do discharges fail?
A
- Patient/ user health complications
- Communication breakdown
- Family decisions
- Decisions around funding
11
Q
What are the geriatric giants?
A
- Falls
- Incontinence
- Dementia/ delirium
- immobility
12
Q
How are falls usually classed?
A
- Syncopal
- Non syncopal
13
Q
What questions should be asked in a falls history?
A
- What were they doing?
- How did the fall happen?
- How did you feel before the fall?
- Dizziness or lightheadedness
- Loss of consciousness?
- cardiac sx?
- Did they have weakness anywhere? DId you lose control of your waterworks?
- Has this happened before?
- Have they had any near misses before?
- What medication are they on? sedatives, hypoglycaemic, opiates, opiates, cardiac medicatiom/
- How do they normally mobilise?
14
Q
What should a falls examination focus on?
A
- Mobility assessment - mobilise, with what and gait
- Cardiovascular examination - ECG/ lying and standing BP
- Neurological examination
- MSK examinartion - joint function
- Assess osteoporosis risk!
15
Q
What is delirium?
A
- Acute confusional state, with sudden onset and fluctuating course
- Develops over 1-2 days and is recognised by a change in consciousness
- Can be caused by an underlying medical problem, substance intoxication and substance withdrawal
- Common in older persons, with sensory and cognitive impairment
- It can be:
- Hyperactive: restlessness, mood lability, agitation, or aggression
- Hypoactive: slow and withdrawn
16
Q
What are the clinical features of delirium?
A
- Globally impaired cognition, perception, and consciousness which develops over hours/days
- Marked memory deficit, disordered or disorientated thinking, and reversal of the sleep–wake cycle.
- Some patients experience tactile or visual hallucinations.
17
Q
What are some of the causes of delirium?
A
- Surgery
- Systemic infection: pneumonia, uti, malaria, wounds, iv lines.
- Intracranial infection or head injury.
- Drugs/drug withdrawal: opiates, levodopa, sedatives, recreational.
- Alcohol withdrawal (2–5d post-admission; ↑lfts, ↑mcv; history of alcohol abuse).
- Metabolic: uraemia, liver failure, Na+ or ↑↓glucose, ↓Hb, malnutrition (beriberi, p[link]).
- Hypoxia: respiratory or cardiac failure.
- Vascular: stroke, myocardial infarction.
- Nutritional: thiamine, nicotinic acid, or b12 deficiency.
18
Q
What are some of the risks associated with delirium
A
- Increased mortality
- Prolonged hospital admission
- Higher complication rates
- Institutionalisation
- Increased risk of developing dementia
19
Q
What are the 8 signs of delirium?
A
- Disordered thinking
- Euphoric, fearful, depressed or angry
- Language impaired
- Illusions, delusions, hallucinations
- Reversal of sleep awake cycle
- Inattention
- Unaware/ disorientated
- Memory deficits
20
Q
How is delirium investigated?
A
- Look for the cause (eg UTI, pneumonia, MI)
- Bloods: FBC, UE, LFT, blood glucose, ABG, septic screen (urine dipstick, cxr, blood cultures)
- Further investigations: ECG, malaria films, LP, EEG, CT
21
Q
What are some of the RFs for delirium?
A
- >65y
- Dementia/previous cognitive impairment
- Hip fracture
- Acute illness
- Psychological agitation (eg pain)
22
Q
How is delirium managed clinically?
A
- Reorientate the patient: explain where they are, who you are at each encounter; hearing aids/glasses. Visible clocks/calendars
- Visits from friends and family
- Monitor fluid balance and encourage oral intake
- Look for constipation.
- Mobilize and encourage physical activity.
- Practise sleep hygeine: restrict daytime napping, minimize night-time disturbance.
- Avoid or remove catheters, iv cannulae, monitoring leads and other devices (Î infection risk and may get pulled out).
- Watch out for infection and physical discomfort/distress.
- Review medication and discontinue any unnecessary agents.
-
Pharmacological: Sedation: only if the patient is a risk to their own/other patients’ safety (never use physical restraints).
- Haloperidol 0.5–2mg,
- Chlorpromazine 50–100mg po if poss: avoid in elderly and alcohol withdrawal
- Avoid antipsychotics with Parkinson’s disease or Lewy body dementia
23
Q
What is dementia?
A
- A neurodegenerative syndrome with progressive decline in several cognitive domains
- Occurs over several months
- Affects many different areas of function: retaining new information, managing complex tasks, language and word finding, behaviour, orientatio, recognition, ability to self care and reasoning
24
Q
What are the types of dementia?
A
- Alzheimers Disease - Most common (75%)
- Vascular dementia (25%)
- Lewy body dementia (15-25%)
- Parkinson’s disease with dementia
- Frontotemporal dementia
25
Q
How is dementia diagnosed?
A
-
History from the patient with a thorough collateral narrative:
- Timeline of decline and domains affected
- Activities of daily living
-
Cognitive assessment:
- Validated dementia screen: AMTS
- Mental state examination: anxiety, depression, or hallucinations
-
Investigations: ↑tsh/↓b12/↓folate, ↓thiamine (eg alcohol), ↓Ca2+.
- MSU, FBC, ESR, UE, LFT, glucose
- MRI: subdural haematoma, normal-pressure hydrocephalus11), vascular damage or structural pathology.
- Functional imaging (FDG, PET, SPECT)
- Consider EEG: suspected delirium, frontotemporal dementia, cjd, or a seizure disorder.
26
Q
What is Alzheimers disease?
Who does it affect?
How does it present?
A
- Most common dementia form
- Insidious onset with slow progression
- Adults: >40
- CT Brain imaging may show hippocampal/ cortical atrophy
- Plaques and neurofibriliary tangles
Presentation
- Behavioural problems
- Progressive, and global cognitive impairment: visuo-spatial skill, memory, verbal abilities, and executive function (planning)
- Anosognosia—a lack of insight into the problems engendered by the disease, eg missed appointments, mishandling of money.
- Later: irritability; mood disturbance (depression or euphoria)
- Behavioural change: aggression, wandering, disinhibition)
- Psychosis (hallucinations or delusions)
- Agnosia (may not recognize self in the mirror).
27
Q
What is the cause or pathophysiology of Alzheimers?
A
APP (amyloid precursor protein) degradation
↓
B amyloid peptide accumulation in neurones
↓
Neuronal damage + neurofibrillary tangles
↓
↓ ACh neurotransmitter ↓
28
Q
What are the sx of Alzheimers?
A
- Progressive, and global cognitive impairment
- Visuo-spatial skill, memory, verbal abilities, and executive function (planning)
- Anosognosia —a lack of insight into the problems engendered by the disease
- Irritability and mood disturbance (depression or euphoria)
- Behavioural change (aggression, wandering, disinhibition)
- Psychosis (hallucinations or delusions)
- Agnosia (may not recognize self in the mirror).
29
Q
What are the RFs for Alzheimers?
A
- 1st-degree relative with AD
- Down’s syndrome
- Vascular risk factors: ↑bp, diabetes, dyslipidaemia, ↑homocysteine, af
- ↓physical/cognitive activity; depression; loneliness
- Genetics: apoe4 allele on chromosome 19
30
Q
How is Alzheimers managed?
A
- Mild: Refer to a specialist memory service, group cognitive stimulation therapy
-
1st: Acetylcholinesterase inhibitors:
- Donepezil
-
SE: peptic ulcer disease + heart block - check sx + perform ECG
- Rivastigmine
- Galantamine
- 2nd: memantine (NMDA-r antagonist)
- BP control: HF 2x ↑risk
- Anti psychotics: only if pt are a risk, severe agitation etc.
31
Q
What is vascular dementia?
A
- Second most common
- Chronic progressive disease causing cognitive impairment.
- Cumulative effect of many small strokes: sudden onset and stepwise deterioration
- Affects executive functions of the brain such as planning more than memory.
- Early changes: Motor and mood changes
- Look for evidence of arteriopathy
-
Vascular RFs: >60, obesity, hx of stroke, smoking, hypertension
- Others: DM, high cholesterol, alcohol
- CT/ MRI Imaging: suggests vascular disease - shows cerebrovascular lesion
- Treatment:
-
Modify RFs
-
Statins, diabetes control, HT control, anti platelet
- Do not use acetylcholinesterase inhibitors or memantine in these patients.
-
Statins, diabetes control, HT control, anti platelet
-
Modify RFs
32
Q
What is Lewy Body dementia ?
A
- Gradually progressive
- Presents:
- Auditory and visual hallucinations.
- Delusions are well formed and persistent.
- Cognitive fluctuations in cognition, attention, and arousal
- Motor sx: bradykinesia +/- rest tremor, rigidity, or both
- Dementia first, parkinsonism later (Parkinsons is the other way round)
- Histology: Lewy bodies (alpha synuclein) in substantia nigra in brainstem and neocortex.
-
Management:
- Avoid using antipsychotics in Lewy body dementia (↑↑risk of SE) - e.g. haloperidol
- Short acting benzodiapines: lorazepam
- Anti cholinesterase inhibitors: donepazil
- Atypical anti psychotics: quitiepine
- If w depression: give SSRI: sertraline
- Motor sx: carbidopa/levodopa
33
Q
What is frontotemporal dementia?
A
- Early onset
- Presentation:
- Complex behaviour, language dysfunction possible
- Coarsening of personality, social behaviour, and habits
- Behavioural/personality change; disinhibition; hyperorality, stereotyped behaviour, and emotional unconcern.
- Progressive loss of language fluency or comprehension
- Development of memory impairment, disorientation, or apraxias
-
Diagnostic fx:
- Age of onset: peak mid 50s
- FH of FTD
- Altered eating habits
-
Imaging: Frontal and temporal atrophy: loss of >70% of spindle neurons.
- Pick inclusion bodies on histology
- Management:
- Supportive
- If irritable: Anti psychotics: 1: lorazepam, 2, haloperidol
- SSRIs: sertraline
*
34
Q
What are the types of incontinence?
A
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- Functional incontinence
- Mixed incontinence
35
Q
What is stress incontinence?
A
- RFs: Increasing age, obesity, women
- Small volumes leak out during increased intra abdominal pressure
- Common in pregnancy and following birth
- Examine for pelvic floor weakness/prolapse/pelvic masses
- Management:
- Pelvic floor exercises, exercise, weight loss
- Duloxetine
- Tension free vag tape
36
Q
What is urge incontinence?
A
- Frequent voiding
- Cannot hold urine
- Urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts
- Nocturnal incontinence common
- Overactive bladder: Detrusor overactivity
- Management:
- Conservative: bladder retraining, fluid moderation, avoid caffeine
- Pharm: Antimuscarinics:
- 1st: oxybutinin, tolterodine sr 4mg/24h;
- 2nd: solifenacil
- Surgery: neuromodulation, sacral stimulation
37
Q
What is over flow incontinence?
A
- Due to urinary retention
- Obstructive symptoms
- Often found in men with enlarged prostate
38
Q
What is functional incontinence?
A
- When physiological factors are relatively unimportant.
- The patient is ‘caught short’ and too slow in finding the toilet because of (for example) immobility, or unfamiliar surroundings.
39
Q
What should a continence history focus on?
A
- How people void
- Frequency
- Symptoms
- Oral intake
- Types of drinks consumed
- Bowel habit - stool type + frequency
- Drug history
40
Q
What is covered in a continence history?
A
- Review of bladder and bowel diary
- Abdo exam
- Urine dipstick + MSU
- PR examination - prostate exam in male
- External genitalia - atrophic vaginitis in women
- Post micturition bladder scan
41
Q
How is urge incontinence managed?
A
- Conservative: Avoid caffeine, good bowel habit, Improving oral intake, regular toileting and pelvic floor exercise, bladder retraining
-
Pharmacological: Anticholinergics
- Oxybutinin - young people
- Tolteridine - not for old ppl -> causes postural hypotension or solefenacil
- Surgery: botox/ neuromodulator or sacral stimulation
42
Q
How do you manage bladder incontinence?
A
- Stress incontinence: duloxetine 40mg / 12hr PO (se: nausea)
-
Urge: Anticholinergics -
- Oxybutinin - young people
- Tolterdine - not for old ppl -> causes postural hypotension or solefenacil
43
Q
Why are the elderly prone to faecal incontinence?
A
- Rectum becomes more vacous as we age
- External anal sphincter can gape (haeamarrhoids, constipation)
- Old people cannot exert the same intra abdominal pressure and muscle tension required to defaecate
44
Q
What should you be concerned about with faecal incontinence?
A
Spinal cord pathology - urgent management required
45
Q
What is the most common cause of faecal incontinence?
A
- Faecal impaction with out flow diarrhoea (50%)
- 2nd: neurological dysfunction
46
Q
How is faecal incontinence diagnosed?
A
PR exam
47
Q
What should we assess in the PR exam?
A
- Rectum
- Prostate (men)
- Anal tone
- Sensation
- Visual inspection around anus
- Stool type (soft, hard)
48
Q
If you find faecal/ urinary incontinence what must you do?
A
Check for the other
If you find urinary, check for faecal etc
49
Q
What are some of the more extreme complications of faecal impaction?
A
- Stercoral perforation
- Ischaemic bowel
50
Q
How are hard impacted stools managed?
A
- Enemas: some may not work if the rectum is loaded with hard stool and will fall out
- Stool softeners
- Stimulants
- Extreme cases: manual evacuation (risk of perforation)
- In older pt make sure any drug that causes constipation as a SE is prescribed with a laxative?
51
Q
How is chronic diarrhoea managed in the elderly?
A
- Treat underlying causes: bowel imaging, stool culture
- Remove causative medications
- Regular toileting
- Low dose loperamide
- Eneme regimines
52
Q
What is a TIA?
A
- Focal neurological deficits due to a blockage of a blood supply to a part of the brain
- Symptoms lasting <24h
53
Q
What are some of the signs of TIA?
A
- Specific to the arterial territory involved
- Amaurosis fugax - when retinal artery is occluded
- Global events (eg syncope, dizziness) are not typical
54
Q
What are some of the causes of TIAs?
A
- Atherothromboembolism from the carotid: listen for bruits
- Cardioembolism: mural thrombus post-mi or in af, valve disease, prosthetic valve
- Hyperviscosity: eg polycythaemia, sickle-cell anaemia, myeloma.
55
Q
What investigations are required for TIA diagnosis?
A
- fbc, esr, u&es, glucose, lipids, cxr, ecg,
- Carotid Doppler ± angiography
- CT/ MRI
- Echocardiogram.
56
Q
What are some of the sx of stroke?
A
- Unilateral weakness or parlaysis
- Aphasia
- Ataxia
- Dysphagia
- Diplopia
- Vision loss
57
Q
What treatment is given for TIAs?
A
- Control cardiovascular risk factors: bp; hyperlipidaemia, stop smoking
- Antiplatelet drugs: aspirin 300mg od for 2wks, then switch to clopidogrel 75mg od
- Carotid endarterectomy: Perform within 2wks of first presentation if 70–99% stenosis
- Give anticoagulants if cardiac emboli caused it
58
Q
What is used to predict the short term risk of TIA -> progressing to stroke?
A
- ABCD2
- Look at the following factors: age, BP, clinical features, duration of sx, diabetes)
- =>4 - Higher risk
- =>6 - Strongly predicts stroke
59
Q
What is a stroke?
A
- Infarction or bleeding into the brain manifests with sudden-onset neurological deficit
- Sx >24 hours
60
Q
How are strokes broadly caused?
A
- Infarct
- Haemmorhage
61
Q
How are strokes classified?
A
- Bamford Classification - Haemmorhagic - Classifies vascular territory involved
-
TOAST classification - Ischaemic - aetiology of infarcts
*
62
Q
What are the causes of stroke?
A
- Small vessel occlusion/cerebral microangiopathy or thrombosis in situ.
- Cardiac emboli
- Atherothromboembolism (eg from carotids)
- CNS bleeds: ↑bp, trauma, aneurysm rupture, anticoagulation, thrombolysis
63
Q
What are the modifiable RFs of stroke?
A
↑bp, smoking, dm, heart disease (valvular, ischaemic, af), peripheral vascular disease, ↑pcv, carotid bruit, combined ocp, ↑lipids, ↑alcohol use, ↑clotting (eg ↑plasma fibrinogen, ↑antithrombin iii, p[link]), ↑homocysteine, syphilis.
64
Q
How are strokes acutely treated pharmacologically?
A
- Thrombolysis: As soon as haemorrhage has been excluded, symptoms must be ≤4.5h ago: Alteplase
- CT 24h post-lysis to identify bleeds
- Anticoagulants: aspirin 300mg (for 2 wks, then switch to long-term antithrombotic treatment,
65
Q
How else do you manage a stroke (think non pharmacologically)?
A
Protect the airway:
Maintain homeostasis:
- Blood glucose: 4–11 mmol/L.
- Blood pressure: only treat if there is a hypertensive emergency (eg encephalopathy or aortic dissection)
- Screen swallow: ‘Nil by mouth’ until this is done (but keep hydrated).
- CT/MRI within 1h: Essential if: thrombolysis considered, high risk of haemorrhage (↓GCS, signs of ↑ICP, severe headache, meningism, progressive symptoms, bleeding tendency or anticoagulated), or unusual presentation (eg fluctuating consciousness, fever).
- Diffusion-weighted MRI is most sensitive for an acute infarct, but ct helps rule out primary haemorrhage
• Haemorrhoagic stroke: Antiplatelet agents: aspirin 300mg (continue for 2 weeks, then switch to long-term antithrombotic treatment)
- Orally - is not dysphagic, enterally if yes
• Ischaemic stroke: Thrombolysis: sx ≤4.5h ago.2 Alteplase. CT 24h post-lysis to identify bleeds
66
Q
What are the different types of stroke?
A
- TACS - Total anterior circulation stroke - worst prognosis
- PACS - Partial anterior circulation stroke
- LAC - Lacunar stroke
- POCS - Posterior circulation stroke
67
Q
What assessment tools are used for the rapid assessment of a pt with suspected stroke?
A
- FAST - Face (drooping), Arms (weakness), Speech (slurred), Time (time to call 999)
- ROSIER - Used to help medical staff distinguish between a stroke and a stroke mimic.
- NIH stroke sale - clinical stroke assessment - measures stroke severity. Scores on all levels of consciousnes, language, neglect, visual field loss. extra ocular movement, motor strength, ataxia, dysarthria, sensory loss.
68
Q
What is the criteria for carotid endoarterectomy?
A
- Carotid artery stenosis: 50-99% with stable neurological symptoms from stroke / TIA
- Refer within 1 week of stroke or TIA symptoms sx
- Assess fitness for surgery (risk of stroke in surgery)
69
Q
What is one of the risks of severe MCA infarction?
A
Malignant MCA syndrome
- Consider for decompressive hemicraniectomy
- Referred within 24 hrs of sx onset and treated withn 48hrs
- <60 yo, CT infarct of at least 50% MCA territory and NIHSS > 15 hours
70
Q
What are some of the stroke mimics?
A
- Seizures
- Space occupying lesions
- Hemiplegic migraine
- Multiple Sclerosis
- Sepsis
- Pre neurological weakness
71
Q
How do you decide if someone is suitable for anti coagulation?
A
- CHAD-VASC - determining if someone is suitable for anticoagulation - AF + risk of stoke
- HASBLED
Warfarin vs DOAC
72
Q
Post stroke, what other complex decisions need to be decided?
A
- DNAR
- NG and PEG
- Enteral feed - without risk
- Aspirational threat
73
Q
How is palliative care now provided?
A
- Previously Liverpool Care Pathway but this is no longer used
- Care is now individualised for each patient.
74
Q
How can end of life phases be recognised:
A
- Bed bound
- Semi comatose
- Only takes sips of fluid
- Unable to take mediine orally
- Sx: pain, nausea. vomiting, dyspneao, agitation, confusion, constpitation, anorexia, terminal secretion
75
Q
What should we continue to provide for end of life care
A
- Personal care
- Obs stopped
- Dental and mouth care
- Macmillan nurses and palliative care team
76
Q
When is a death certificate given?
A
- To be completed by doctor that has cared for pt in last 14 days to complete death certificate
- Pupils: fixed and dilated
- No response to pain
- No breath/ heart sounds after 1 min of auscultation
- Pt transported tm mortuary and bereavement
77
Q
Who is cremation paperwork completed by ?
A
- Two doctors
- Part 1 - Completed by a doctor who knows the pt
- Part 2 - Independent doctor. 2 years post reg. Seeking confirmation of the cause of death from a variety of course
- Remember: pacemarkers and radiactive implants must be removed before cremation
78
Q
When should a death be reported to a coroner?
A
- Occurs as a result of poisoning
- Trauma, violence and physical injury
- Related to treatment or procedure
- Injury or disease received during or attributed to persons work
- Notifiable accident, poisoning or disease
- Neglect or failure
- Unnatural death
- Death occured in custody
- No attending practitioner attended decreased within 14days prior
- Unknown identify
