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Medicine for the Elderly > General > Flashcards

General Flashcards

1
Q

Define ageing

A

Progressive, generalised impairment of function resulting in a loss of adaptive response to disease

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2
Q

Hw does ageing occur?

A

Random molecular damage during cell replication
Inactivity, poor diet, inflammation increase damage
Reduction in body’s adaptive reserve capacity

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3
Q

Describe the telomere ageing concept and hayflick limit

A

Progressively shortens with each cell replication, and eventually becomes too short to sustain cell replication
– this then leads to cell senescence

No times a normal cell can divide before division ceases

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4
Q

Defne sarcopenia

A

Age related loss of muscle mass, strength and muscle quality
- presence of low muscle quantity or quality, if also low performace = severe

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5
Q

Mechanisms of sarcopenia

A

Decr motor units
Decr no. msucle fibres
Incr mucle fibre atrophy

PLUS

Other factors incl:
Nutrition
Hormones
Metabolic/immune
RAAS

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6
Q

Management sarcopenia

A

Exercise
- improve muscle strength
Medications
- maybe ACEs, vit D, AA supplements
Nutrition
- promote protein synethesis

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7
Q

Define frailty

A

Loss of homeostasis and resilience
Increased vulnerability to decompensation after a stressor event

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8
Q

Define ageism

A

Ageism is unacceptable behaviour that occurs as a result of the belief that older people are of less value than younger people.

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9
Q

Medical component of CGA

A

Problem list
Co-morbid conditions and disease severity
Medication review
Nutritional status

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10
Q

Functioning component of CGA

A

Basic ADLs
Extended ADLs
Activity/exercise status
Gait and balance

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11
Q

Psychological component of CGA

A

Mental status/cognitive function
Mood/depression testing

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12
Q

Social/environment component of CGA

A

Informal needs and assets
Social circle
Care resource eligibility & resources
Safety

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13
Q

Main frailty syndromes

A

Off legs (poor mobility)
Falls
Confusion
Continence issues
Polypharmacy

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14
Q

What is a problem list?

A

Like differential diagnoses but lists problems important to pt e.g.
- falls
- confusion
- frailty

Uses syndromes rather than diseases
Delivered at MDT, v pt centred

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15
Q

How does acute illness present differently in older people?

A

Atypical/masked presentation
Delayed/wrong diagnosis
Pathophysio response varies
Poor immune response
Comorbidity increases
Inv/management tailored to individual
Med review med reviw med review!!!!!!

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16
Q

Pathophysiology presentation in older peopl

A

BP drops early
Absent tachycardia response
Temp low, not always high
CRP/WCC may not rise
Fluid balance difficult
Antibiotics prescribe as high risk C diff and resistance

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17
Q

How can you recognise a pt might be dying?

A

Prog weakness, usually bed bound
Progressive fatigue, eventual unconsciousness
Loss of interest in food/fluid, unable to take oral meds
Changes in breathing, apnoeic spells

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18
Q

LAST BREATH signs of active dying

A

Lethargy
Altered mental state
Skin changes
Tablets
Breathing changes

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19
Q

Treatable conditions that may look like dying

A

Opioid toxicity
Sepsis
Hypercalcaemia
Hypoglycaemia
Uraemia/AKI

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20
Q

Prioritising comfort in palliative pts

A

STOP
- unnecessary meds e.g. statins
- routine obs
- unused cannulas

START
- anticipatory medicatiosn for dying symptoms

DON’T FORGET
- plan for essential oral meds
- catheter to prevent urinary retention
- approp environment e.g. not ward bay
- holistic/spiritual support

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21
Q

PRN?

A

Pro re nata
- if required
- just in case subcut meds

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22
Q

Anticipatory meds in palliative care

A

Pain/SOB - morphine/opioid
Distress/agitation - midazolam
Nausea - levomepromazine
Resp secretions - hyoscine butylbromide

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23
Q

Things to think ab when prescribing opioids as anticipatory med for pain

A

Ensure they have preserved renal function
- high risk of opioid toxicity
Not opioid naive
Check if they’re on background opioid
- use same background as PRN
Switch oral pain meds to syringe driver
Subcut morphine is 2x stronger than oral morphine
- divide by 2 for syringe driver dosing

24
Q

Hydration/fluids at end of life

A

Fluid intake reduces, pts can’t tolerate oral fluids
Very few pts are thirsty at death
Ensure proper mouth care, dry mouth is really common
IV/subcut fluids not really used, risks more than benefits
Trial artificial hydration if distressed by thirst

25
Q

Clincial signs to confirm death

A

Absence of carotid pulse over 1 min
Absence of heart sounds over 1 min
Absence of resp sounds/efforts over 1 min
No response to painful stimuli e.g. trap squeeze
Fixed dilated pupil, no response to bright light

26
Q

Short term anticholinergic side effects

A

Confusion and hallucinations
Tachycardia
Blurred vision
Urinary retention
Constipation
Dizziness

27
Q

Long term anticholinergic side effects

A

Incr risk of dementia

28
Q

Easy drug STOPs in managing polypharmacy

A

Bleeding ulcer – stop NSAID
Kidney failure – stop ACE inhibitor
Severe hyponatraemia – stop antidepressant

29
Q

Caution for prescribing DOACs in elderly

A

Increased drug plasma level so advise dose reduction

30
Q

2 principles of drug absorption

A

Acidic (<7.35) drugs req acidic environment for absorption
- phenytoin, aspirin, penicillin
Basic drugs req basic environment for absorption
- diazepam, morphine, pethidine

31
Q

Changes affecting drug absorption in old peopl

A

Increased gastric pH, decrease small bowel
surface area
- basic drugs will absorb more
- important if prev GI surgery, NJ tube, transdermal patches
Think about method of delivery

32
Q

2 main transporter molecules

A

Albumin (Basic) binds to acidic drugs
Alpha-1 Acid Glycoprotein (acidic) binds to basic drugs

33
Q

Why is it important to think about distribution in older pts?

A

Elderly often low albumin but higher A-1 AG
- incr binding of basic drugs and incr basic environment as well
Incr fat compared to muscle
- incr vol distribution of lipophilic drugs

34
Q

Define volume of distribution

A

Theoretical volume into which all of drug is fully dissolved in plasma
Indicates lipophilicity of drug
- high Vd means stays in fatty tissues of body
e.g. if 100mg drug given at 0.1mg/L
0.1mg = 1L
100mg -> 1000L Vd

35
Q

Define half life

A

Time for drug concentration to fall to half of its
maximum concentration
- limited clearance by liver or renal system causes longer half-life, more common imapairment in older people

36
Q

Why is owe body water significant in older pt prescribing?

A

Lower VD of hydrophilic
drugs (e.g Lithium, Digoxin)

37
Q

Half life if lower Vd and CrCL

A

Unchanged esp in elderly
- caution in renal problems e.g. CKD/AKI

38
Q

How does liver function affect first pass metabolism?

A

Reduces liver function (due to size, blood flow, disease) causes reduced first pass metabolism (mainly phase 1)

Older pts rely on phase 2 metabolism, break down drug more slowly in liver, more likely hepatotoxicity

39
Q

General principle on dosing in elderly people

A

Lower doses achieve same effect
in the elderly (common e.g. alcohol)
Some effects e.g. beta blockers are decr (START LOW GO SLOW)

40
Q

Key drugs with narrow therapeutic index

A

Theophylline Vancomycin
Warfarin Phenytoin
Lithium Cyclosporin
Digoxin Carbamazepine
Gentamicin Levothyroxine

41
Q

Therapeutic window in elderly people

A

More narrow
- beware of drugs with narrow therapeutic index

42
Q

Managing common drug side effects (opiod, steroid, levothyroxine)

A

Opioid
- begin laxatives prophyllactically
Steroid
- bone protection, monitor blood sugars for diabetes
Levothyroxine
- no calcium, interferes with absorption

43
Q

Antibiotic prescribing in elderly people

A

Use as narrow-spectrum antibiotic as possible
Only use if confirmed infection/pos cultures
Risks of resistance and C.diff as a result of broad-spectrum wiping out microbiome
- low body water mass and reduced kidney injury in diarrhoea will cause crazy bad AKI

44
Q

Changes to bladder control in elderly

A

Decr in
- bladder capacity
- urethral closure pressure

Incr in
- post void residual vol
- detrusor overactivity

45
Q

Key transient causes of incontinence

A

Delirium
Infection – Urinary (symptomatic)
Atrophic urethritis/vaginitis
Pharmaceutical/Prostate
Psychological, especially depression
Endocrine (or excess fluid intake/output)
Restricted mobility
Stool impaction

46
Q

5 types of urinary incontinence

A

Stress
Urge
Mixed
Overflow
Functional

47
Q

Examinations in incontinent pt

A

General appearance – including BMI
General mobility
General Cognitive examination
Abdominal examination
Pelvic examination
Urinalysis?

48
Q

Investigations for urinary incontinence - after bladder diary

A

Post void bladder scan
Bladder Diaries
Consider PSA, U&Es, glucose
Urodynamic studies (conservative management first)

49
Q

Management stress vs urge incontinence

A

Stress
- pelvic floor exercise
Urge/mixed
- bladder training

50
Q

Pharm management urge incontinence

A

3 month trial conservative
1st line - tolteridine 2mg bd
2nd line - solifenacin 5mg once daily
3rd line - mirabegron 50mg once daily

51
Q

Management nocturia

A

Late afternoon diuretic
Desmopressin (not with HT, heart disease, watch sodium levels)

52
Q

When to refer to specialist in incontinence?

A

Symptomatic prolapse at or below introitus
Microscopic haematuria aged >50
Frank haematuria
Recurrent or persisting UTI
Suspected malignant mass
Chronic retention
Men with stress UI
Failure of conservative Rx

53
Q

Indications for catheters

A

Unable to manage self cath
Med management failed, surgery not appropriate
Skin wounds/pressure sores contaminated by urine
Pts distressed by changes of bed linen/clothing

54
Q

Exertional syncope preceding a fall?

A

Aortic stenosis
- ejection systolic (slow rising pulse, low cardiac output)

55
Q
A

Medicine for the Elderly (1 decks)

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