FM Flashcards
RAPRIOP
- Reassurance and explanation, address ICE
- Advice and counselling
- Prescribing
- Referral
- Ix
- Observation and FU
- Prevention
HASBLED score
for 1y major bleeding risk of AF; for Warfarin; now also for NOAC
HT Abnormal L/RFT Stroke hx Bleeding tendency / predisposition (e.g. anemia) Labile INR Elderly (>65) Drugs (Aspirin, NSAID, alcohol)
BPPV presentation
JC WCS
Benign paroxysmal positional vertigo
- No hearing symptom
- Usually last for about 3wk
- Recurrence common
- Provoke by turning over to particular position in bed or when reaching up
- Wakes in sleep
Tx of BPPV
JC WCS
- Epley’s maneuver (Therapeutic)
- Reassurance
- Waiting + vestibular sedatives
- Avoid driving
- 45o prop up or 2 high pillows
- Don’t sleep on side of bad ear
- Keep head still at vertical position (i.e. not bend -
forward/backward) - Repositioning maneuvers
- Surgery (High risk of severe sensorineural hearing loss)
- Posterior ampullary nerve section
- Posterior canal obliteration
Nutritional needs for elderly
Geri
Fat/Carb/Dietary fiber same as young ppl
Per week
- 2x portion of fish (1=oily fish with omega-3 FA and vit D)
- Fruits, vegetables (with a variety of vitamins and minerals)
- Fiber, probiotics (preserved food, yogurt - gut health)
- Additional vit D supplement for older
- Protein intake (more than young adults; at least 1-1.2g/kg/day)
*use Dietary reference intakes (DRI) calculator
Causes of Dysphagia
Geri
Oro-pharyngeal vs Esophageal dysphagia
Oro: Difficulty initiating swallowing +/- chocking or aspiration
Eso: Food sticking after swallowing +/- regurgitation
Oro: Stroke, dementia, PD, bulbar/pseudobulbar palsy, MG
VFSS, Neuro Ix
3 phases of swallowing
- Oral
- Pharyngeal
- Esophageal
Bedside swallowing test
Geri
- Screening
- Give 1 tea spoon of water + feel throat (x3 attempt)
- Give 60-90ml of water + feel throat
All safe then Diet as tolerated (DAT)
Any problem –> refer SLT (Speech and language therapist), keep NPO
Clinical signs of aspiration
Geri
- Wet/gurgly/abnormal voice quality
- Coughing/Choking
- Tachypnea
- Eyes watering
- Repeated throat clearing
- O2 desaturation >=2%
- Pneumonia
Mx for Dysphagia
Geri
- Optimize eating/drinking position (seated at a table, propped up in bed, sit up 90o, chin down)
- Altered consistency of food/drinks
- NG feeding (does not reduce risk of aspiration, uncomfortable, restrain, low QOL)
- PEG feeding (can still aspirate stomach content, more invasive, more comfortable in long term, PEJ to reduce risk of aspiration)
Causes of Fall
Geri
- LOC – syncope or pre-syncope
- Loss of strength, balance or coordination
- External force (pushed over)
- Sudden uncontrolled symptom – chest pain, seizure
- Undetermined, e.g. rolled out of bed (reason could be REM sleep disorders, postural hypotension when getting up for toilet)
Ix for Fall
Geri
Neuro
- CT brain
- MRI brain
- Carotid sinus massage (rub 1 at a time to see which side has problem; massage + ECG at same time)
- Dix-Hallpike test
CVS
- ECG
- 24h Holter / 7d Holter
- Echo
- Erect/Supine BP
- Tilt table test
Others
- CBC
- Thyroid function
- Biochem
- DH
- BP diary
Timed up and go test
Geri
<10s = Normal
>14s = ↑Fall risk
<20s = Can still go out alone
>30s = ADL dependent
- With or without armrest (w/o is more difficult)
- Walking aids allowed
- No personal assistance
Step 1: Begin the test with the patient sitting in the chair with his/her hips all the way to the back of the seat
Step 2: Start timer on the word Go. Patient walks 3 meters and turns around
Step 3: Stop the timer when patient sits down
Medical interventions to prevent falls
Geri
- Treat underlying conditions, e.g. cardiac arrhythmia
- Treat postural hypotension, e.g.
- Fludrocortisone 100-400mcg OD [Monitor RFT, may ↑Na, ↓K]
- Use Midodrine (AB) if Fludro doesn’t work
- Compression stockings - Treat sarcopenia, e.g. Protein supplements
- Modification of RFs, e.g. BMD, weight
- Vit D can reduce fall risk for OAH residents (cuz Vit D + protein = muscles)
- Med adjustment, e.g. night sedation
**Fall is not absolute CI for NOAC or Warfarin
Therapy to prevent falls
Geri
- PT = Group + home based therapy
- Strength + balance + flexibility exercises, e.g. Tai Chi - OT = Environmental adaptation, e.g. safety rails in showers
- Footwear, sight correction, hip protector
- Home installed alarm system - Refer to Day hospital, Elderly centers, NGOs
- Community services
- MSW for home care, financial help
- Comprehensive geriatric assessment (CGA)
Counsel for Fall
Geri
- Find out everything you need to assess fall risk
- Find out caring issues, living environment
- Find out effect on basic & instrumental ADLs
- Explore physical consequences, e.g. fractures, head injury
- Explore psychological effects, e.g. fear of going out
- Explore carer burden
- Explain level of risk
- Explain medical & therapy tx options
- Empower by educating and teaching how to self-help
- Reassure and manage expectations by patient & family
Major RF for stroke (similar for ischemic/hemorrhagic)
Geri
Modifiable
- HT / DM / HL
- Smoking / Alcohol abuse
- AF
- Carotid stenosis
- Physical inactivity
- Obesity
Non-modifiable
- Age
- Sex
- Race/ethnicity
- Heredity
Unclear: Hyperhomocysteinemia, other cardiac disease, HRT
Major preventive strategies for stroke (RF control)
Geri
- Lifestyle modifications: Diet, exercise, weight, smoking
- BP: aim 130/80 (start tx if 150/90)
- DM: aim A1c <7%
- Lipid: aim LDL <2 (start tx at 2.5/2.69)
- Carotid stenosis: Carotid endarterectomy or stenting
- AF: anticoagulation
- Antiplatelet: Aspirin/Clopidogrel/Aspirin+Dipyridamole/Cilostazol (wiki: for Intermittent claudication)
CHA2DS2VASc score
(for non-valvular AF)
Geri
- CHF
- HT
- Age >75
- DM
- Stroke
- Vascular disease (MI, PVD)
- Age 65-74
- Sex category: Female
1: consider anticoagulation; >=2 anticoagulation indicated
CI to oral AC –> LAAO (Left atrial appendage occlusion)
RF for Dementia
Geri
- Traumatic brain injury
- Mid-life obesity
- Mid-life HT
- Current smoking
- DM
- ?Hx of Depression
- ?Sleep disturbances
- ?HL
Decreased risk for Dementia
Geri
- Years of formal education
- Physical activity
- Mediterranean diet
- Cognitive training (controversial)
- ?Moderate alcohol consumption
- ?Social engagement
SCD vs MCI vs Dementia
Geri
Preclinical (Subjective cognitive decline SCD) “Patient knows, doctor doesn’t”
- Silent phase: brain changes w/o measurable Sx
- Patient may notice changes, but not detectable on tests
MCI (Mild cognitive impairment)
- Cognitive changes of concern to patient/family
- > =1 cognitive domains impaired significantly
- Preserved ADL
Dementia
- Cognitive impairment severe enough to interfere with everyday abilities
MoCA domains
(VNM ALA DO)
Geri
Montreal cognitive assessment
- Visuospatial/Executive
- Naming
- Memory
- Attention
- Language
- Abstraction
- Delayed recall
- Orientation
MoCA scores
Geri
<= 2 centile (2 SD from mean) = Dementia, i.e. Major NCD (neuro-cognitive disorder)
<= 7 centile (1.5 SD) = MCI
<= 16 centile (1 SD) = Mild NCD
**2-16 is mild NCD; <2 is major
AMT domains
Geri
Abbreviated mental test
- Personal recall
- Orientation
- New learning
- Orientation
- Personal recall
- Memory
- Concentration
- New memory recall
BPSD symptoms
Geri
Behavioral and psychological symptoms of Dementia
Apathy
- Withdrawn
- Lacks interest
- Amotivation
Aggression
- Physical/Verbal aggression
- Aggressive resistance to care
Depression
- Sad
- Tearful
- Hopeless
- Guilty
- Anxious
- Irritable/screaming
- Suicidal
Mania
- Euphoria
- Pressured speech
- Irritable
Agitation
- Pacing
- Repetitive actions
- Dressing/undressing
- Restless, anxious
Psychosis
- Hallucinations
- Delusions
- Misidentification
- Suspicious
Counsel on Dementia
Geri
- Find out everything about the memory deficit
- Find out caring issues, living environment
- Effects on basic and instrumental ADLs
- Explore physical consequences, e.g. incontinence, falls
- Explore BPSD, e.g. mood, delusions, hallucinations, sleep
- Explore carer burden
- Explain common DDx
- Explain Dx may include normal aging (if very mild)
- Explain drug options, SEs
- Manage expectations: Tx not a cure, just delay deterioration
- Educate, classes, exercises, cognitive stimulation, NGOs
Instrumental ADL
Geri
(PS CHL GMM)
Photoshop CH Lai with GM $
- Phone (Ability to use telephone)
- Shopping
- Cooking (Food preparation)
- Housekeeping
- Laundry
- Go out (Mode of transportation)
- Med (Responsibility for own medications)
- Money (Ability to handle finances)
Mini nutritional assessment
Geri
Total 30 points
- Screening max 14
- Assessment max 16
24-30 = Normal 17-23.5 = At risk of malnutrition <17 = Malnourished
Basic ADL
衣2 食 住2 行
(x6)
- Grooming
- Dressing
- Self-feeding
- Bathing
- Toileting
- Transferring
Bathel Index of ADL
- Bowels
- Bladder
- Grooming
- Toilet use
- Feeding
- Transfer
- Mobility
- Dressing
- Stairs
- Bathing
Impairments by stroke
Cognitive functions
(1) Arousal and orientation
(2) Attention
(3) Memory
(4) Frontal executive function, reasoning, judgement
(5) Visuospatial perception, e.g. visual neglect, semi-neglect, agnosia
- -> Cognitive training, compensatory strategies by OT and CP
(6) Language –> assessment, training by OT
Impairments by stroke
Sensory functions
(1) Vision
- Ophthalmologist
- Visual scanning to compensate for visual field loss by OT
(2) Hearing
- Prescriptions of hearing aids
(3) Body sensation (diminished or exaggerated (central pain))
–> Sensory re-education; Compensatory strategy
Medications and physical modality (e.g. TENS) to control central pain
Impairments by stroke
Neuromusculoskeletal
(1) Mobility of joint, e.g. stiffness, contracture
- -> Stretching program by PT; Splintage by OT
(2) Abnormal tone, e.g. spasticity
–> Treat only if pain, interfere hygiene, or limit function
PT: ROM exercise, stretching and heat
OT: Proper positioning, splint, cast
Drugs: Baclofen, Tolperisone, Dantrolene
Botulinum toxin injection
Pheno/Alcohol nerve block or motor-point block
Surgery: +/- tendon release/transfer
(3) Hemiparesis/Hemiplegia
- Strength training, electrical stimulation (PT)
(4) Balance, coordination
- Balance, coordination training in parallel bars, balance board, use of Balance Master machine (PT)
Impairments by stroke
Swallowing dysfunction
(1) Dysphagia
- Managed by ST
- NG rube / PEG if oral feeding not safe
- Control volume and consistency of food
- Proper head posture etc.
Impairments by stroke
Voice and speech
Dysphonia and Dysarthria
- ST, +/- ENT
Impairments by stroke
UG, Reproductive function
(1) Impairment of bladder control
(Urinary incontinence, ROU etc.)
(due to hyper-reflexic / hypocontractile bladder or impaired ability to transfer to toilet)
Tx
- Timed void schedule, regulation of fluid intake, transfer and dressing skill training
- Med: Anti-cholinergics for hyper-reflexic bladder
- Catheterization for ROU
- Use of external collecting device / diapers etc.
(2) Sexual dysfunction
- Counselling, skill training / positioning, drugs
Impairments by stroke
Digestive system
(1) Impairment of bowl control (incontinence, bowel impaction)
- Timed toilet schedule
- Dietary fiber
- Training in toilet transfer
- Judicious use of laxatives
Impairments by stroke
Emotional function
(1) Post-stroke depression - around 30-40%
- Counselling / psychotherapy (nurse, CP), antidepressants
Activity limitation and Participation restriction by stroke
Communication
Verbal and non-verbal
- Dysarthria/Dysphasia training by ST
- Strategies for communication, e.g. use of communication broad
BATHE model
To enable patient to share illness experience
Background Affect Trouble Handling Empathy
4P approach
To explore psychosocial factors
Predisposing
Precipitating
Perpetuating
Protective
Satir model
Behavior, action, story Coping Feelings Feelings about feelings Perceptions Expectations Yearnings Self
Non-drug interventions for common mental health disorders
- CIPS
- Active listening
- BATHE technique - Psychoeducation
- iCBT - Relaxation exercises
- Slow breathing exercises
- Progressive muscle relaxation - Behavioral activation
- Activity scheduling
- Exercise prescription - Training manuals and guidelines
- Thinking healthy (for PN depression)
- Problem management plus (for adversity)
- Interpersonal therapy (for depression)
