General Flashcards
Define ageing
Progressive, generalised impairment of function resulting in a loss of adaptive response to disease
Hw does ageing occur?
Random molecular damage during cell replication
Inactivity, poor diet, inflammation increase damage
Reduction in body’s adaptive reserve capacity
Describe the telomere ageing concept and hayflick limit
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
Defne sarcopenia
Age related loss of muscle mass, strength and muscle quality
- presence of low muscle quantity or quality, if also low performace = severe
Mechanisms of sarcopenia
Decr motor units
Decr no. msucle fibres
Incr mucle fibre atrophy
PLUS
Other factors incl:
Nutrition
Hormones
Metabolic/immune
RAAS
Management sarcopenia
Exercise
- improve muscle strength
Medications
- maybe ACEs, vit D, AA supplements
Nutrition
- promote protein synethesis
Define frailty
Loss of homeostasis and resilience
Increased vulnerability to decompensation after a stressor event
Define ageism
Ageism is unacceptable behaviour that occurs as a result of the belief that older people are of less value than younger people.
Medical component of CGA
Problem list
Co-morbid conditions and disease severity
Medication review
Nutritional status
Functioning component of CGA
Basic ADLs
Extended ADLs
Activity/exercise status
Gait and balance
Psychological component of CGA
Mental status/cognitive function
Mood/depression testing
Social/environment component of CGA
Informal needs and assets
Social circle
Care resource eligibility & resources
Safety
Main frailty syndromes
Off legs (poor mobility)
Falls
Confusion
Continence issues
Polypharmacy
What is a problem list?
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
How does acute illness present differently in older people?
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!!!!!!
Pathophysiology presentation in older peopl
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
How can you recognise a pt might be dying?
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
LAST BREATH signs of active dying
Lethargy
Altered mental state
Skin changes
Tablets
Breathing changes
Treatable conditions that may look like dying
Opioid toxicity
Sepsis
Hypercalcaemia
Hypoglycaemia
Uraemia/AKI
Prioritising comfort in palliative pts
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
PRN?
Pro re nata
- if required
- just in case subcut meds
Anticipatory meds in palliative care
Pain/SOB - morphine/opioid
Distress/agitation - midazolam
Nausea - levomepromazine
Resp secretions - hyoscine butylbromide
Things to think ab when prescribing opioids as anticipatory med for pain
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
Hydration/fluids at end of life
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
Clincial signs to confirm death
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
Short term anticholinergic side effects
Confusion and hallucinations
Tachycardia
Blurred vision
Urinary retention
Constipation
Dizziness
Long term anticholinergic side effects
Incr risk of dementia
Easy drug STOPs in managing polypharmacy
Bleeding ulcer – stop NSAID
Kidney failure – stop ACE inhibitor
Severe hyponatraemia – stop antidepressant
Caution for prescribing DOACs in elderly
Increased drug plasma level so advise dose reduction
2 principles of drug absorption
Acidic (<7.35) drugs req acidic environment for absorption
- phenytoin, aspirin, penicillin
Basic drugs req basic environment for absorption
- diazepam, morphine, pethidine
Changes affecting drug absorption in old peopl
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
2 main transporter molecules
Albumin (Basic) binds to acidic drugs
Alpha-1 Acid Glycoprotein (acidic) binds to basic drugs
Why is it important to think about distribution in older pts?
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
Define volume of distribution
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
Define half life
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
Why is owe body water significant in older pt prescribing?
Lower VD of hydrophilic
drugs (e.g Lithium, Digoxin)
Half life if lower Vd and CrCL
Unchanged esp in elderly
- caution in renal problems e.g. CKD/AKI
How does liver function affect first pass metabolism?
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
General principle on dosing in elderly people
Lower doses achieve same effect
in the elderly (common e.g. alcohol)
Some effects e.g. beta blockers are decr (START LOW GO SLOW)
Key drugs with narrow therapeutic index
Theophylline Vancomycin
Warfarin Phenytoin
Lithium Cyclosporin
Digoxin Carbamazepine
Gentamicin Levothyroxine
Therapeutic window in elderly people
More narrow
- beware of drugs with narrow therapeutic index
Managing common drug side effects (opiod, steroid, levothyroxine)
Opioid
- begin laxatives prophyllactically
Steroid
- bone protection, monitor blood sugars for diabetes
Levothyroxine
- no calcium, interferes with absorption
Antibiotic prescribing in elderly people
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
Changes to bladder control in elderly
Decr in
- bladder capacity
- urethral closure pressure
Incr in
- post void residual vol
- detrusor overactivity
Key transient causes of incontinence
Delirium
Infection – Urinary (symptomatic)
Atrophic urethritis/vaginitis
Pharmaceutical/Prostate
Psychological, especially depression
Endocrine (or excess fluid intake/output)
Restricted mobility
Stool impaction
5 types of urinary incontinence
Stress
Urge
Mixed
Overflow
Functional
Examinations in incontinent pt
General appearance – including BMI
General mobility
General Cognitive examination
Abdominal examination
Pelvic examination
Urinalysis?
Investigations for urinary incontinence - after bladder diary
Post void bladder scan
Bladder Diaries
Consider PSA, U&Es, glucose
Urodynamic studies (conservative management first)
Management stress vs urge incontinence
Stress
- pelvic floor exercise
Urge/mixed
- bladder training
Pharm management urge incontinence
3 month trial conservative
1st line - tolteridine 2mg bd
2nd line - solifenacin 5mg once daily
3rd line - mirabegron 50mg once daily
Management nocturia
Late afternoon diuretic
Desmopressin (not with HT, heart disease, watch sodium levels)
When to refer to specialist in incontinence?
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
Indications for catheters
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
Exertional syncope preceding a fall?
Aortic stenosis
- ejection systolic (slow rising pulse, low cardiac output)
