Frailty Flashcards
Osteomalacia
Def, cause, sx, ix, mx
refers to a metabolic bone disease that features osteopenia and disordered bone calcification, resulting in an excess of osteoid, or unmineralized, mainly collagenous, tissue. This process occurs after the closure of the epiphyses, distinguishing it from rickets, a similar disorder occurring before epiphyseal closure.
The primary cause of osteomalacia is vitamin D deficiency, which can arise from:
• Inadequate dietary intake of vitamin D
• Insufficient sunlight exposure
• Malabsorption disorders such as celiac disease or inflammatory bowel disease
• The presence of melanin in darker skin types, which lowers the skin’s ability to produce vitamin D from sunlight
• Increased demand, such as during pregnancy or breastfeeding
Sx:
• Pain in the lower back, hips, and pelvis
• Pseudofractures, or Looser’s zones, which are areas of incomplete stress fractures
• Bone tenderness
• Muscle weakness
Ix:
• Blood tests to check for low levels of vitamin D, calcium, and phosphate, and to assess kidney function
• Bone biopsy, considered the gold standard for diagnosis
• Imaging studies such as X-rays to identify pseudofractures or other bone abnormalities. DEXA scan shows low bone mineral density
Mx:
- colecalciferol
Osteomyelitis
Def, cause, rf, sx, ix, mx
Osteomyelitis refers to inflammation in a bone and bone marrow, usually caused by bacterial infection.
Haematogenous osteomyelitis refers to when a pathogen is carried through the blood and seeded in the bone. This is the most common mode of infection. Alternatively, osteomyelitis can occur due to direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation.
Cause:
Staphylococcus aureus causes most cases of osteomyelitis.
Rf:
Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression
Sx:
Fever
Pain and tenderness
Erythema
Swelling
Ix:
MRI (gold standard)
Bloods- raised WBC, CRP, ESR
Blood culture
X-ray (not always useful)- periosteal reaction, loacalised osteopenia, destruction to bone
Mx:
Surgical debridement
Abx- flucoxacillin primary (clindamycin if allergic, vancomycin if MRSA)
Osteoporosis
Def, sx, ix, mx
Osteoporosis is a systemic skeletal disease characterized by reduced bone mass and altered microarchitecture of the bone tissue, leading to increased bone fragility and a consequent increase in fracture risk. It is typically defined by a DEXA scan T-score of -2.5 or lower.
Sx:
• Back pain, caused by a fractured or collapsed vertebra
• Loss of height over time
• A stooped posture
• A bone fracture that occurs much more easily than expected
Ix:
• DEXA scan (Gold standard) with a T-score of -2.5 or lower indicating osteoporosis
• X-rays for suspected fractures
• MRI of the spine to assess vertebral fractures
• Blood tests to exclude metabolic bone diseases and assess vitamin D, calcium, and hormone levels
- FRAX Score
The FRAX (Fracture Risk Assessment Tool) score is used to estimate the 10-year probability of a major osteoporotic fracture. Interpretation of FRAX scores:
• Normal: 10-year probability <10%
• Osteopenia (low bone density): 10-year probability 10-20%
• Osteoporosis: 10-year probability >20%
Mx:
- first line is bisphosphonates eg. Alendronate, risendronate and zolendronic acid
- if bisphosphonates not suitable then denosumab and others can be used
Venous vs arterial ulcers
Site, rf, sx, description
Urinary incontinence
Causes, types, sx, ix, mx
Causes:
- urge: idiopathic, neuro conditions, inflammation and bladder irritants
- stress: urethral hypermobility and intrinsic sphincter deficiency
- overflow: enlarged prostate (bph, cancer and inflammation), diabetes, obstructing masses, fistulas, spinal cord injuries and anticholinergic meds
Transcient causes:
• D – elirium
• I – nfection
• A – thropy
• P – harmaceuticals
• E – xcess excretion
• R – estricted mobility
• S – tool impaction
Ix:
- bladder diary
- urinary stress test
- urinanalysis
- renal function tests
- PSA
- post void residual bladder scan
- renal Uss
- MRI
Mx:
• Self-monitoring
• Bladder training - Kegles
• Lifestyle changes
- Absorbent materials, urine bottles, vaginal pessaries
- Caffeine reduction
- Weight loss
• Medical equipment
• Surgery
• Drug review
• Medication -Antimuscarinics, topical oestrogen, alpha-adrenergic antagonists (selective vs non-selective), 5-alpha reductase inhibitors
Mitral valve stenosis
Def, sx, causes, ix, mx, comp
Def:
Mid-diastolic, low-pitched “rumbling”. Loud S1
due to thick valves, Opening snap after S2.
Sx:
Palpable tapping apex beat, prominent S1. Malar flush. Afib
- No symptoms until orifices <2cm2
- Symptoms due to pulmonary hypertension:
dyspnoea, haemoptysis, recurrent bronchitis
- Eventually right HF symptoms: fatigue, leg
swelling
- Due to large left atrium -> AFib: palpitations,
systemic embol
- Face : Mitral facies / malar flush (due to
↓CO)
- Pulse : AFib
- RV : heaving, sustained
- Apex: localised, tapping
- HS: Loud S1, loud P2(pulmonary HTN),
opening snap
- Murmurs: mid diastolic murmur rumbling
at apex
Causes:
• Rheumatic heart disease
• Infective endocarditis
• Calcification/fibrosis in elderly
Ix:
- CXR: Small heart with enlarged left atrium, Calcified mitral valve, Sign of pulmonary oedema
- ECG: AF, Bifid P wave/P mitrale, Right axis deviation/ tall R waves in lead V1 (Right ventricle
hypertrophy)
- Echocardiogram
- Cardiac catheterisation (indicated in): Previous valvotomy, sign of other valve disease, angina, severe, pulmonary hypertension, calcified mitral valve
Mx:
- AF: digoxin and anticoagulation
- Pulmonary oedema : diuretics
- Trans-septal balloon valvotomy (pliable, non-
calcified valve)
- Closed valvotomy
- Open valvotomy
- Mitral valve replacement
Complications:
- Results in right-sided heart failure
- To maintain CO, left atrial pressure↑»left atrial hypertrophy and dilatation»_space;pulmonary venous, arterial and right heart pressure ↑»_space; pulmonary oedema»_space;pulmonary HTN»_space; right ventricular hypertrophy, dilatation failure and subsequent tricuspid regurgitation
Mitral valve regurgitation
Def, types, sx, causes, ix, mx, comp
Def:
Regurgitation refers to a ‘leaking’ of blood through the valve during ventricular systole. It can be classified as primary or secondary:
• Primary: refers to pathology affecting components of the valve itself. Degenerative disease is the most common cause.
• Secondary: refers to regurgitation due to changes to left ventricle
Sx:
- Pan-systolic, high-pitched “whistling” murmur.
Radiates to left axilla. +/- S3.
- Pulse : sinus rhythm or AF
- Apex : forceful, displaced, systolic thrill
- Sounds: Soft S1, split S2, loud P2 . maybe a mid-systolic click (sudden prolapse of the valve)
- Mitral area thrill. Heart failure and pulmonary oedema. Afib.
- Causes:
• Idiopathic weakening of the valve with age
• Ischaemic heart disease
• Infective endocarditis
• Rheumatic heart disease
• Connective tissue disorders, such as Ehlers-
Danlos syndrome or Marfan syndrome
Ix:
- CXR: Left atrial and left ventricular enlargement, Increased cardiac thoracic ratio, Valve calcification
- ECG: Bifid P wave, Left ventricular hypertrophy (tall R wave in leads 1, V6 and deep S wave is V1 and V2), AF might be present
- Exercise testing – to assess a patients overall functional capacity.
- Echocardiogram + Doppler
- Cardiac catheterization: often for surgical planning or assess pulmonary hypertension
Mx:
- Prophylaxis against Infective endocarditis
- If fast AF : rate control (beta-blockers)+ anticoagulated
- Pulmonary oedema / HF; diuretic (spironolactone)
- ACE inhibitor
- Surgery
Comp:
- Results in Congestive HF and left sided heart failure
• Mitral valve regurgitation > left atrial dilatation. Stroke volume ↓ due to regurgitation, thus LV hypertrophy to increase stroke volume and hence CO.
• Later = R sided HF
Pressure sores
Def, path, sx, ix, mx
Pressure sores are localised areas of tissue damage caused by prolonged pressure or friction, typically occurring over bony prominences. They can range from superficial skin damage to deep tissue injury and are often associated with
immobility and prolonged pressure on specific body areas.
Path:
1. Pressure and Tissue Ischemia: Continuous pressure or friction reduces blood flow to affected areas, leading to tissue ischemia (lack of oxygen and nutrients.
2. Cellular Damage: Lack of oxygen and nutrients causes cellular damage, primarily affecting skin and underlying tissues.
3. Inflammation: Injured tissues trigger an inflammatory response, which can further exacerbate tissue damage.
4. Necrosis and Ulceration: Severe tissue damage may lead to tissue necrosis, ultimately resulting in an open wound or ulcer.
Sx:
• Skin changes, ranging from redness to skin breakdown and ulceration.
• Pain or discomfort at the affected site.
• Warmth or coolness over the affected area.
• Swelling or induration (hardening) of the surrounding tissue.
• Open sores or wounds with varying degrees of tissue involvement
Ix:
Pressure sores are diagnosed clinically in correlation to their appearance, however additional investigations which may form part of their management include:
• Imaging studies (e.g. X-rays, MRI) to assess underlying tissue involvement
• Blood tests (e.g. full blood count, serum albumin) to assess overall health and nutritional status
• Wounds should only be swabbed if infection is suspected
Mx:
1. Pressure Relief: Minimising pressure on affected areas through repositioning, specialised mattresses, and cushions.
2. Wound Care: Appropriate wound cleaning, debridement, and dressing changes. Regular review of wounds to monitor any changes in size and appearance.
3. Nutritional Support: Ensuring adequate nutrition and hydration, addressing deficiencies.
4. Pain Management: Managing pain associated with pressure sores.
5. Infection Control: Preventing and treating wound infections.
6. Surgical Interventions: In some cases, surgical procedures (e.g. flap reconstruction) may be necessary.
Neuropathic ulcers
Def, rf, sx, description, ix, mx
A neuropathic ulcer is due to peripheral neuropathy
There is a loss of protective sensation. which leads to
repetitive stress and unnoticed injuries forming,
resulting in painless ulcers forming on the pressure
points on the limb. Concurrent vascular disease will
often contribute to their formation and reducing healing potential.
Risk Factors:
Neuropathic ulcers can develop from any peripheral
neuropathy condition, the most common being
diabetes mellitus and B12 deficiency.
Ulcer risk is further compounded by any foot
deformity or concurrent peripheral vascular disease
Sx:
• Warm feet and pulses still present (unless element of concurrent arterial disease).
• Burning/tingling in legs (paraesthesia - painful neuropathy)
• Occur most commonly on sites increased pressure points on the bottom of the feet. (e.g. metatarsal
heads or heels).
• Signs of peripheral neuropathy (classically in a ‘glove and stocking’ distribution
Appearance:
• Ulcers are variable in size and depth, with a “punched out appearance”. These ulcers are often
neglected because they don’t cause pain.
• May appear pink/red or brown/black while the borders look like a deep punched out.
• The surrounding skin is often calloused and dry and cracked.
• The wound is red and warm in the early stages, may progress to eschar and gangrene in later stage
Ix:
• Blood glucose (random or HbA1c %)
• Serum B12 levels
• Look for signs of concurrent arterial disease and assess with ABPI +/- doppler duplex.
• Wound swab if deep infection deep infection (e.g. visible bone or ulcers extending into joints),
• may warrant an X-ray to assess for osteomyelitis.
• Peripheral neural examination
• Assess the extent of peripheral neuropathy which can be done using the 10g monofilament or
Ipswich touch test, along with testing vibration sensation with a 128Hz tuning fork.
Mx:
• Referral to diabetic foot clinics for patients with neuropathic ulcers, where they are managed via a
full multidisciplinary (MDT) team.
• Diabetic control should be optimised, targeting HbA1c <7%.
• Improved diet and increased exercise and any cardiovascular risk factors present managed
accordingly.
• Regular chiropody to maintain good foot hygiene and appropriate footwear provided (e.g. non-
weight bearing shoes).
• Antibiotics based on wound swab culture and sensitivity result (e.g. flucloxacillin)
• Ischaemic or necrotic tissue may require surgical debridement or amputation
Adverse drug effects
Most likely meds to cause ADRs:
- antiplatelets
- diuretics
- anticoagulants
- NSAIDs
- steroids
- anti-depressants
Most associated with anticholinergic activity:
• Antidepressants
• Antipsychotics
• Antiemetics
• Urinary antispasmodics
• Sedatives
• Antiallergics (antihistamines)
• H2 receptor blockers
• Antiparkinson
