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FRAILTY Flashcards

1
Q

What is frailty?

A

A medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance and reduced physiological functions that increases individuals vulnerability for developing dependency and/or death
Multiple body systems gradually lose their in-built reserves due to ageing
A state of increased vulnerability to poor resolution of homeostasis after a stressor event

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2
Q

How common is frailty?

A

10% of people aged >65 years have frailty and between 25-50% of those aged over 85

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3
Q

What is multimorbidity?

A

The presence of 2 or more complex conditions

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4
Q

What is polypharmacy?

A

When a pt is prescribed 4 or more drugs

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5
Q

What is sarcopenia?

A

A degenerative loss of skeletal muscle mass, quality and strength associated with ageing
Other contributory factors - diet, vit D deficiency, obesity, cognitive/psych/social

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6
Q

How is frailty measured?

A

Phenotype model - fried
Cumulative deficit model - rock wood
Electronic frailty index (EFI) - for GPs

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7
Q

What are the geriatric giants?

A

Immobility - “gone off legs”
Instability - falls
Incontinence
Impaired intellect/memory - dementia + delirium
Iatrogenic - more at risk of SE from drugs

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8
Q

Why is it important to recognise frailty?

A

Issues with polypharmacy
Higher risk of harm from hospitalisation
Frail people can become very sick from seemingly minor insults
Higher risk of mortality from surgery or other procedures
Higher risk of iatrogenic haem e.g. drug interactions

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9
Q

Consequences of immobility?

A

Deconditoning
Venous thromboembolism
Infections
Pressure sores
Decompensation of other medical conditions
Psychosocial - low mood, isolation, reliance on other people, institutionalisation

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10
Q

Symptoms to ask about for incontinence?

A

Leaking when coughing or sneezing
Immobility
Bowel symptoms e.g. constipation
Meds - diuretics, Anticholinergics, opioids

Voiding: hesitancy, poor/intermittent stream, straining, incomplete emptying, terminal dribbling
Storage: urgency, frequency, Nocturia, urinary incontinence
Post-micturition: dribbling, sensation of incomplete emptying

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11
Q

3 categories of urinary incontinence?

A

Stress - due to weak pelvic floor
Urge - overactive bladder
Retention with overflow - atonic bladder that leaks or bladder outflow obstruction

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12
Q

Investigtaions for urinary incontinence?

A

Urine dip
Post void bladder scan (post void residual 100ml norm, residual >350ml = retention)
Urodynamics if mixed picture of cause unsure
May refer to urogynaecology

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13
Q

General advice for urinary incontinence?

A

Drink plenty during day
Last drink no less than 2 hours before bed
Spend longer on toilet
Regular toileting
Avoid getting constipated
Avoid caffeine
Pelvi flooor exercises
Meds - Anticholinergics (suspectibe to SE such as retention, constipation and delirium) and mirabegron
Catheterisation for retention

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14
Q

Faecal incontinence causes?

A

Diarrhoea
Inability to get to toilet on time
Constipation with overflow
A consequence of advancing dementia and inability to recognise they need to pass stool

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15
Q

Management of stress incontinence?

A

1 - 3 months of pelvic floor exercises
2 - surgery
3 - duloxetine

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16
Q

Management of urge incontinence?

A

1 - 6 weeks of bladder retraining
2 - antimuscarunics e.g. oxybutinin
3 - Beta 3 adrenergic receptor agonist e.g. mirabegron

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17
Q

Assessments important in geriatrics?

A

Nutrition assessment
Swallow assessment
VTE risk assessment
Skin assessment
MSK and gait assessment
Sensory and neurology assessment
Cognition e.g. MMSE< AMT
Hydration assessment
Postural BP assessment

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18
Q

What is the MUST score?

A

Malnutrition Universal screening tool

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19
Q

Issues with polypharmacy?

A

Drug-drug interactions
Increased risk of side effects
Medication non-adherence and reduced compliance
Inappropriate prescribing

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20
Q

How does drug absorption, distribution, metabolism, and excretion change as you age?

A

Absorption stays the same
Distribution changes - total body fat increases as you age so fat-soluble drugs have an increased volume of sirtibution whilst total body water decreases so water-soluble drugs decrease their distribution. Serum albumin also decreases so albumin-bound drugs increase
Metabolism is affected as decreased liver volume and enzyme activity = decreased metabolism
Excretion is affected as decreased kidney function

All of this increases the drug in the circulation

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21
Q

What are the 2 ways in which we can combat the increase in drug in circulation that inevitably occurs in the elderly?

A

Decrease the dose
Increase the interval time

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22
Q

Physiology of ageing: cardiac

A

Decreased elastic, increased collagen, increased calcium deposition in cardiac muscle and vessels = stiffening of cardiac muscle = decreased diastolic relaxation and filling = CO decreases
BP increases
Reduced maximum heart rate
Dilattaion of aorta
Reduced number of pacing myocytes in SAN
Arteriosclerosis develops
Degeneration and calcification of heart valves
F

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23
Q

Challenges of geriatric medicine?

A

Multiple diagnoses and possibility of acute-on-chronic presentations
Non-specific presentations
Complex histories and examination
Polypharmacy
Increased prevalence of mental and social issues
Increased vulnerability to stressor events
Poor recovery from stressor events
High prevalence of cognitive dysfunction
Ethical considerations - autonomy, beneficence vs non-maleficience

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24
Q

Physiology of ageing: body fat and water

A

Increased body fat
Decreased total body water

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25
Q

Physiology of ageing: bone and muscle

A

Decreased bone density
Decreased muscle mass

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26
Q

Physiology of ageing: immune system

A

Reduced T cells
Reduced activation to new and recognised antigens
Reduced antibody production

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27
Q

Physiology of ageing: respiratory

A

Reduced elastic recoil
Reduced chest compliance/increased chest wall rigidity
Increased V/Q mismatch
Decreased strength of muscles of respiration
Increased residual volume and reduced vital capacity
Reduced cough and ciliary action

28
Q

Physiology of ageing: renal

A

Reduced cortica renal mass and nephrons
Thickened basement membranes
Increased renal artery resistance meaning reduce blood flow to kidneys
Reduced GFR

29
Q

Physiology of ageing: gastrointestinal

A

Decreased peristalsis -> constipation
Increased colon wall strength
Increased pressure in the lumen

30
Q

Physiology of ageing: endocrine

A

Increased insulin resistance due to deterioration in pancreatic beta cell function
Decreased testosterone and oestrogen

31
Q

Outline the abbreviated mental test?

A

Out of 10

  1. What is your name?
  2. What is your DOB?
  3. Ask pt to remmeber an address, repeat back to you and ask them again at the end?
  4. Current year
  5. Approx time
  6. Where are they?
  7. Identify roles of 2 people
  8. Year WW2 ended (1945)
  9. Current monarch or president
  10. Count backwards from 20
32
Q

What is sheltered accommodation?

A

Aka warden controlled or independant living
Where the resident will live in their own flat but there may be communal areas
They sometimes have onsite carers, an onsite warden or no staff but pull cords with a responder system

33
Q

What are residential homes?

A

Homes staffed by carers
Residents needs are usually required to be met with the assistance of 1 person

34
Q

What are nursing home?

A

Homes staffed by nurses and carers
Residents are usually dependant and have higher care needs than those in a residential home

35
Q

What are SMART goals?

A

Goals that are specific measurable achievable realistic and timely

36
Q

Aim of rehabilitation?

A

To return a person to their previous level of function

37
Q

Reasons a pt may move to a temporary residential home placement?

A

Respite to allow a family member or carer a break
Step down whilst awaiting on a care package
Respite to allow for ongoing assessment of needs e.g. medically fit for discharge but needs longer to allow delirium to go

If the pt has further needs they may need a temporary or permenant nursing home placement

38
Q

What is fast track?

A

When a pt is likely to be in their last 6 weeks of life a medical decision can be made to deem them FastTrack
Once these forms are completed, funding can be applied for which allows for a prompter discharge to the pt’s preferred place of death
Packages of care can be sought for or 24 hour placements paid for if the needs of the pt cannot be met at home or they do not wish to return home
Discharge to the local hospice may be an option for symptom control or EOL care. The palliative care team within the hopsital are the access point for this

39
Q

What is a NOA?

A

A notification of assessment
This requests a social worker to be allocated

40
Q

What is a NOD?

A

Can only be submitted after a NOA and must be done within 72 hours
It informs social services that the pt is medically and therapy fit for discharge that day and social services input is the only factor delaying the discharge

41
Q

What is the phenotype model for frailty?

A

This describes a group of patient characteristics which if present can predict poorer outcomes
E.g. unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion, low energy expenditure

42
Q

What is the cumulative deficit model of frailty?

A

It assumes an accumulation of deficits which can occur with ageing combine to increase the frailty index and in turn increase the risk of an adverse outcome
E.g. loss of hearing, low mood, tremor

43
Q

Some methods for identifying frailty?

A

PRISMA 7 questionnaire
Walking speed
Timed up and go test
Self-reported health
Gp assessment
Grip strength

44
Q

What is the British Geriatrics Society?

A

A society for everyone working with older people
They develop guidance on the recognition and management of older people with frailty in community and outpatient - “Fit for Frailty”

45
Q

What is deprescribing

A

the process of withdrawal of an inappropriate medication, supervised by a healthcare professional with the goal of managing polypharmacy and improving outcomes

46
Q

Why do we do deprescribing for the elderly?

A

Evidence of reduced drug efficacy due to physiological changes
Increased risk of harm

47
Q

What is STOPP/START?

A

A screening tool…
STOPP - identifies medications where risk outweighs therapeutic benefit in certain conditions
START - suggests medications that may provide addditional benefits e.g. PPI for gastroprotection in pt on meds increasing bleeding risk

48
Q

Most common comorbid conditions?

A

Hypertension
Depression and anxiety
Chronic pain
Prostate disorders
Thyroid disorders
Coronary artery disease

49
Q

Risk factors for multimorbidity?

A

Increasing age
Female sex
Low socioeconomic status
Tobacco and alcohol usage
Lack of physical activity
Poor nutrition and obesity

50
Q

Complications of multimorbidity?

A

Decreased quality of life and life expectancy
Increased treatment burden: Difficulties in understanding and self-managing condition as well as adherence to lifestyle changes
Mental health issues: Those with cognitive impairment are particularly vulnerable
Polypharmacy: Adverse drug events increase in prevalence as the number of chronic conditions increases
Negative impact on carers welfare

51
Q

What is article 5 of the Human Rights Act?

A

That a person should not have interference by the state in a person’s freedom - right to liberty
This is a qualified right i..e there are circumstances where the state can take this right away

52
Q

What are deprivation of Liberty Safegaurds?

A

Safegaurds to protect those deprived of their liberty i.e. when their freedom is limited in some way such as being under continous supervision and not free to leave and person lacks capacity to consent
DoLS are administer by the local authority
Mental disorder, mental capacity and best interests will be assessed - this ensures the persons liberty is done in the least restrictive way and in the pt best interests
The person being cared for will be given a representative who can be a paid representative or a relative/friend - gives them certain rights

53
Q

why is creatinine often normal in the elderly even when they have renal impairment?

A

Because they have a lower muscle mass as a physiological process
This results in lower creatinine prediction
There is also a decline in GFR

54
Q

Most common medication causes of adverse drug reactions?

A

NSAIDs
Diuretics
Warfarin
ACEi ARBs
Antidepressants
Beta blockers
Opiates
Digoxin
Pred
Clopidogrel

55
Q

What is the anticholinergic burden?

A

the cumulative effect on an individual of taking one or more medications with anticholinergic activity.
A high score may increase risks of cognitive impairment, functional impairment, falls and mortality in adults over 65

56
Q

By the age of 70 what % of renal function do most have?

A

50%

57
Q

What can cause a reduced food intake in the elderly?

A

A decline in the ability to ingest adequate amount of food = anorexia
Decline in sensory functioning i.e. impaired gustatory and olfactory function alters perception of food
Impaired response to CCK resulting in early satiety, low ghrelin, increased leptin and low insulin levels
Abnormalities in gastric motility, chronic gastritis, slow bowel motility, decreased gastric secretions etc
Depression, mood, social isolation, poverty

58
Q

Protein consumption requirements as you get older?

A

Older adults require up to 50% more protein than a younger adult to preserve muscle mass and strength i.e. to reduce Sarcopenia

59
Q

how can nutritional intake be support in the elderly

A

‘Food first’ advice - advise to eat little and often, fortify full fat milk, increase amounts of high energy food and choose foods that are enjoyed the most
OTC supplements
Oral nutrition prescriptions e.g. ensure shake, fortisip etc
Enteral tube feeding e.g. NGT
Parenteral nutrition - IV administration

60
Q

What are pressure ulcers?

A

Ulcers that develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age
They typically develop over bony prominences e.g. sacrum or heel

61
Q

Factors that predispose to the development of pressure ulcers?

A

Malnourishment
Incontinence - urinary and faecal
Lack of mobility
Pain which leads to reduction in mobility

62
Q

What score is used to screen patients at risk of developing pressure ulcers?

A

Waterlow score - includes BMI, nutritional status, skin type, mobility and continence

63
Q

Grading of pressure ulcers?

A

Grade 1 - non-blanchable erythema of intact skin - basically just skin colour change
Grade 2 - partial thickness skin loss (epidermis or dermis, or both). Ulcer is superficial and presents as an abrasion or blister
Grade 3 - full thickness skin loss involving damage/necrosis to subcutaneous tissue that may extend down to the underlyign fascia
Grade 4 - extensive destruction, tissue necrosis or damage to muscle/bone/supporting structures with or without full thickness skin loss

64
Q

Management of pressure ulcers?

A

Moist wound environment e.g. hydrocolloid dressings and hydrogels
Dont use soaps as this is drying
Consider systemic antibiotics e.g. if evidence of surrounding cellulitis
Consider referral to tissue viability nurse
Surgical debridement may be beneficial

65
Q

Preventing UTIs in patients with long term catheterisation?

A

Aseptic catheter insertion technique
Replace catheters about every 4 weeks
Silicone catheters are better
Do not offer antibiotic prophylaxis unless immunocompromised

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