general

Question 1

define frailty

Answer 1

distinct clinical state that is related to ageing but results in increased vulnerability from a decline in physiological and psychological reserve. therefore, a minor insult can lead to a significant functional decline and disability. it is an independent predictor of mortality

Question 2

what are the 2 main models that define frailty?

Answer 2

(1) phenotype model:
- uses a a core group of 5 clinical core presentations:
1. unintentional weight loss
2. reduced muscle strength
3. reduced gait speed
4. self-reported exhaustion
5. low energy expenditure
- three or more identifies adverse outcomes associated with frailty

(2) cumulative more:
- raised the concept of frailty index based on the assumption that an accumulation of deficits results in an increase in adverse outcomes
- the clinical frailty scale was based on the work by the same team: 1->9 ( vert fit -> terminally ill)

Question 3

previously known as ‘Geriatric Giants’, frailty syndromes can be used to identify those that may have frailty. what are frailty syndromes?

Answer 3

clincians should have high suspicion in individuals who present with either:
falls
immobility
delerium
incontinence
susceptibility to SEs of medication
as these can mask a more serious medical problem

Question 4

what should we note about disease in the elderly?

Answer 4

• can present atypically and cause grater mortality and morbidity
• they have an increased susceptibility to infection die to changes in their immune system. the number of T cells are reduced which results in lower reactivity to antigens and reduced immunological memory
• there is a diminished fever response in 20-30% of older patients who present with an infection this could be partly explained by their decreased immune response however a lower basal temp and thermal homeostasis is likely to play a part

Question 5

what options are available for looking after older people in the community?

Answer 5

rapid response team :
- can assess a pt within 24hours and provide urgent help at home. they can support individuals at home, help prevent unnecessary hospital admission and maximise independence through reablement and rehabilitation

hospital at home:

• a step up from the rapid response team
• multidisciplinary care team
• provide hospital care at home including point of care Ix such as bloods, ECGs and bladder scans
• Tx could include IV meds with closer monitoring of the pt’s response and potential SEs
• the consultant geriatrician will visit the pt at home to complete the holistic assessment and help formulate an individual management plan

community hospitals:
- can be a halfway point between home and an acute hospital

Question 6

how might initial assessment in acute hospital, differ for pt’s with frailty?

Answer 6

a broader approach is needed as pt’s with frailty may well have multiple complex co-morbidities and co-pathology and combined with atypical presentation can make diagnosis challenging

Question 7

what is meant by ‘comprehensive geriatric assessment’?

Answer 7

both a diagnostic and therapeutic process that aims to assess a patient holistically and develop an individualised management plan. it is multidimensional and interdisciplinary requiting more than one profession to contribute. there is good evidence that individuals who have a CGA are more likely to be alive and less likely to be in institutional care at 1-yr post-intervention when compared to standard medical care

the domains that are included in a CGA are:

• physical
• socioeconomic/environmental
• functional capacity
• mobility/balance
• psychological/mental health
• medication review

Question 8

what is NHS Scotlands guidance on polypharmacy (>5meds)?

Answer 8

7 steps to appropriate polypharmacy:

1. right medicine?
2. stop unnecessary medicine
3. effective medicine?
4. harmful medicine
5. cost effective medicine
6. agree and share medicine plan
7. what matters to the pt?

Question 9

discuss the theory of ageing process

Answer 9

multifactoral:

• genetic/cellular
• environmental
• evolutionary theory

theory of ageing - molecular:

• age related ‘programmed’ regulation of gene expression at different stages in life
• certain genes are turned on and off
• epigenetic modifications e.g. DNA methylation: addition of methyl group to cytosine has the effect of making the gene less active; global reduction in methylation in ageing, but more active in a poorly controlled way, focal increase near
• can predict age on the amount of genes that are methylated
• histone modification: histone package and order DNA; activity and function can be modified by acetylation and methylation; changes can affect gene regulation and DNA repair

theory of ageing - cellular:
- telomere shortening:
progressive loss of chromosome ‘‘caps’’; free radical damage in oxdidative metabolism –> get shorter and shorter; expose protein called shelterin, once activated and exposed can trigger apoptosis +/or stop replication

theory of ageing - environmental and evolutionary:

• ‘wear and tear’ i.e. inability to regenerate damage tissue over time
• cumulative DNA damaging including UV and ionising radiation
• ‘whole body metabolism and energy expenditure theory’ (can only consume/burn certain amount of calories before we die - applies to mouse/rat models)
• ‘disposable soma’ i.e. no evolutionary advantage in survival beyond reproduction and rearing children

Question 10

outline some of the decline in organ function associated with the ageing process

Answer 10

• > decline in maximal energy output with age
• > almost any organ tends to decline in function with age:
• kidney function is relatively stationary up to about 50, then relative decline with age
• rapid upturn in CO from birth to 10y/o, then from teenage and beyond there is a decline in CO (at rest). purely due to age, not coronary condition
• these declines are not life-limiting but decline reserves. e.g. if get chest infection and lung function declines further - they won’t have same outcome as someone younger

Question 11

discuss the change in population structure

Answer 11

older population increasing

Question 12

have some understanding of the challenges of health care in old age

Answer 12

• most health issues are more common with increasing age
• health and social costs rise with increasing age
• burden on disease links to deprivation index (smoking, alcohol, diet and obesity, housing)

Question 13

discuss realistic medicine in older patients

Answer 13

is about:

• holistic approach (physical, psychological, social and functional well being)
• involving the pt in decisions
• health literacy e.g. risks/benefits
• decision making
• potential for harm in over or under- investigation and treatment

Question 14

what factors would make someone more at risk of a fall

Answer 14

environment
balance
postural HT
medication
cerebellar things
inner ear control
proproception
sarcopenia

Question 15

outline how the ageing process can affect the pharmacokinetics and pharmacodynamic handling go medicines

Answer 15

reduced renal clearance:

• > nephrotoxic drugs enhanced
• > acute illness, especially with dehydration, likely to develop AKI and rapid drop in renal function
• > care with NSAIDs, aminoglycosides like gentamicin, digoxin, ACEi

reduced liver size and blood flow, reduced enzyme activity:
-> bioavailability might be increased for drugs that are extensively metabolised by the liver e.g. propranolol and verapamil and many psychotropics due to loss of first pass metabolism

increased sensitivity to certain medicines:

• CNS, CV function, gastro-intestinal SEs, haematology
• more susceptible to hypersensitive SEs of drugs e.g. anti-hypotensive, opioids, levodopa
• more prone to constipation from drugs

thermoregulation may be impaired:
- increasing risk of hypothermia. i.e. if on sedating drugs, may not be aware of body temp, increasing the risk

Question 16

discuss the process of accurate medicines reconciliation

Answer 16

• more than 50% of errors happen at transitions of care - admission, transfers, discharge
• medicines reconciliation = a complete list of medications, accurately communicated
• use structured template if available
• resolve any discrepancies
• include OTC and complementary meds
• use >1 information source:
  > pt’s/families/carers
  > a list of actual medications (green bag scheme)
  > GP letter/printout
  > previous hospital notes/letters
  > repeat prescription slips
  > phone GP surgery
  > phone the community pharmacy
  >emergency care summery (ECS) or Key information summary (KIS)
  -take the time:
  > improves safety
  > improves efficiency
  > improves therapeutic outcomes
  > reduces medication errors/ near misses/ missed doses
  > reduces delays to treatment
  > savings to NHS from prevented errors

Question 17

discuss the concept of polypharmacy

Answer 17

• the concurrent use of multiple medications by a pt
• most common in the elderly
• 50% of hospital admissions due to adverse drug events are preventable… 70% of these are in pt’s over 65 years of age and on 5 or more medicines
• huge treatment burden which many can struggle with

appropriate polypharmacy = medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed by the pt; therapeutic objectives are achieved/achievable’ therapy has been optimised to minimise ADRs; pt is motivated and able to take medicines as intended

Question 18

describe the steps involved in undertaking a medicine review

Answer 18

target certain pt’s:

• high degree of frailty
• on high risk medication based on SE profiles
• prescribed 10 or more medicines
• palliative care pt’s
• acute admissions

step1:
what matters to the pt
step2:
identify any essential drug therapies
step3:
does the pt take any uncessesary drug therapies?
step 4:
are therapeutic objectives being achieved?
step 5:
is the pt at risk of ADRs or suffers ADRs?
step 6:
is the drug therapy cost effective?
step 7:
is the pt willing and able to take the drug therapy as intended?

Question 19

identify medicines which are poorly tolerated in the elderly/ frail adults

Answer 19

• antipsychotics (can cause drowsiness, extra-pyramidal SEs and HTN)
• NSAIDs (can cause GI bleed and AKI)
• digoxin (can cause renal impairment especially in higher doses)
• benzodiazepines (prone to falls)
• opiates/ combined analgesics (CNS and hypersensitive SEs increasing risk of falls)
• anticholinergics (toxicity: dry mouth, hyperthermia, vision loss, dilated pupils, urinary retention, tachycardia, absent bowel sounds)

Question 20

explain general principles of realistic prescribing in the elderly

Answer 20

• limit range
• consider risk/benefit (is it necessary? improve QoL?)
• reduce the dose
• start slow, go slow
• regular review
• simplify regimens
• explain clearly
• check concordance problems
• be alert during acute illnesses (can increase the risk from meds)
• medicine reconciliation before changing meds

Question 21

describe the definition and diagnosis of sarcopenia

Answer 21

• a progressive and generalised skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality
• primary = age is the only factor
  secondary = factors other than age. systemic disease
  frailty = geriatric syndrome (characterised by a decline in multi organ physiological systems over time)
• acute = <6mnths, chronic = >6months (associated with increased mortality)

1. identify individuals at risk:
   - SARC-F questionnaire (strength, assistance with walking, rise from chair, climb stairs, falls). >4 is predictive of sarcopenia and poor outcomes
   - clinical suspicion (always)
2. assess:
   - low muscle strength indicates that sarcopenia is probable
   - use grip-strength with specific cut-off points (M <27kg, W <16kg)
   - or chair stand test >15s for five rises
   - assess causes (e.g. inflammatory response + disease related malnutrition, clinical conditions like cancer, sepsis, neurodegenerative disease, CKD, COPD)
3. make diagnosis:
   - low muscle quantity or quality
   - dual energy X-ray Absorptiometry (DXA). appendicular skeletal muscle mass (M<20kg, W<15kg)
   - sarcopenia confirmed
4. check severity:
   - low physical performance . gait speed (4m usual walking) <0.8metres/second
   - sarcopenia severe

Question 22

compare the differences in metabolic response and substrate utilisation during starvation and inflammatory disease

Answer 22

acute starvation (<72hrs):
- increased glycogenolysis,
increased glycogen oxidation
- increased net protein catabolism
- increased lipolysis,
ketogenesis in the liver
-increased energy expenditure

prolonged starvation (>72hrs):

• depleted glycogen stores, decreased glycogen oxidation
• increased lipolysis, ketogenesis in liver
• decrease energy expenditure
• increase net protein catabolism
• > metabolic response =
  1. the production of ketones from fatty acids, mobilised from the fat stores, spare the muscle protein from being used for glucose production and provide the necessary fuel to brain and muscles
  2. the sharp decrease in insulin production and an increase in glucagon release which stimulates lipolysis, i.e. fatty acids release from fat cells, and ketogenesis
  3. the basal/resting metabolic rate decreases due to decreases in circulating T3 thyroid hormones and glucocorticoids

inflammatory response:
- increase glycogenolysis, increase glycogen oxidation

• > metabolic response =
  1. RMR increases proportion to the degree of inflammatory insult
  2. body gives higher priority to wound repair and host defence than tissue preservation
  3. fat mobilisation occurs, but contribution is less significant than long-term starvation
  4. ketogenesis is diminished during inflammatory disease which encourages further gluconeogenesis from protein stores and muscle wasting
  5. body protein is catabolised to contribute to gluconeogenesis for 1) glucose to used by the brain and 2) amino acids used for production of cytokines and other inflammatory response proteins
• promotes muscle wastage further. disease and inflammation have detrimental impact on muscle and proteins sarcopenia by preferentially attacking the muscle for amino acid supply

Question 23

describe the nutritional consequences of common drug treatments

Answer 23

affect the nutritional status in 4 main ways:

1. food intake:
   - anorexia with N+V are common symptoms of ABs
   - NSAIDs and ABs can care GIT effects like indigestion/ heartburn/ gastritis/ bloating/ early satiety/ abdominal pain/ diarrhoea
   - antipsychotics can cause taste changes or dry mouth making it difficult to chew and swallow food
2. nutrition absorption:
   - antacids (-P), penicilamin (-Zn) can form insoluble complexes with molecules inhibiting their absorption in the bowel
   - aspirin (-vit c), sulphasalazine (-folate) competition for common binding sites increases need for greater intake
   - chemo drugs can cause damage to the absorptive surface of the intestinal mucosa
3. nutrient secretion:
   - diuretics can promote urinary losses (e.g. Na, P, Ca, Mg, Zn)
4. nutrient metabolism:
   - corticosteroids and oral contraceptives have been lined with glucose intolerance as they affect CHO metabolism

Question 24

what are the guidelines for protein intake and exercise for optimal muscle function?

Answer 24

optimal dietary protein intake >65y/o:

• healthy = 1-1.2g/kg body weight/day
• with acute or chronic illnesses = 1.2-1.5g protein

optimal exercise for all older adults:

• daily PA, if possible
• resistance training as part of an overall fitness regimen
• key at all stages of life for the prevention and management of muscle wasting and sarcopenia

Question 25

in Scotland, anyone over the age of 16 is to be regarded as competent/ have capacity to make decisions for themselves unless proven otherwise. in capacity means incapable to…?

Answer 25

a) acting; or
b) making decisions; or
c) communicating decisions; or
d) understanding decisions; or
e) retaining the memory of decisions

Question 26

what are some of the ethical and legal issues at end of life care

Answer 26

1. ageism:
   - treatment rates drop disproportionately for people over 70-75yrs in areas such as surgery, chemo and talking therapies
   - unfair allocation of treatment implies that people >70 are not given the right information to make decision for themselves
   - decisions not being made on the person, but on one characteristic
   - all adults have autonomy, and it denies their basic human dignity to remove this without good reason - it is a moral wrong and also unlawful
2. competence and refusal of treatment:
   - healthcare staff tend to assume that an older person refusing treatment ‘irrationally’ or without giving a reason is incompetent simply because they are making this decision
   - this is wrong - incompetence is a legal term with specific criteria to be met
3. autonomy:
   - any competent adult has the right to make any decisions regarding their health, including refusing treatment
   - consent is vital in providing medical treatment, and it is a criminal offence to treat a competent person in the absence of consent
4. dignity:
   - making decisions about treatment, especially those that might extend or shorten life, is tied very close to dignity
5. doctrine of double effect:
   - no discussion about end of life can happen without the doctrine of double effect. it will happen
6. assisted suicide:
   - argued in terms of dignity (pro-choice - pro-life)
   - illegal

Question 27

describe the role of lasting power of attorney and advance decisions in healthcare

Answer 27

advance directives:

• adults with incapacity act 2000 says that healthcare professionals must take into account the past and present wishes of the person
• AD constitutes indication of past wishes of the person
• a way for a person to state, while they are competent, what treatments they would or would not want in the event that they become incompetent to make or unable to communicate treatment decisions (e.g. dementia, coma)

welfare POA:

• rather than have a single document that might not fully reflect the person’s wishes as time goes on, some choose to appoint a welfare attorney
• they can make decisions on behalf of the person int he event of incapacity/loss of communication

Question 28

how can frailty impact on health?

Answer 28

• adverse outcomes for frail pt’s
• have longer stays in hospital
• lose muscle in hospital (10days in hospital = 10 years muscle wastage in>80s)
• more susceptible to complications of admission (delirium, nutritional problems, dehydration, pressure sores, falls)
• high mortality rate
• higher rates of admission to residential care

Question 29

explain the important of recognising frailty

Answer 29

• asses, plan and implement interventions
• prevent the insult that leads to disability

initiate frailty pathways that benefit the pt (reduction in hospital stays, more support at home, improved experience etc) and hospitals (reduction in avoidable admissions, increased bed capacity, cost benefit etc)

Question 30

outline CGA and its benefits

Answer 30

• multidisciplinary diagnostic process
• considers medical, social and psychological issues
• consider co-existing conditions
• requires specialist team with specialist skills
• generate personalised care plan
• personalised application of clinical guidelines
• advanced care planning
• share knowledge and planning amongst patient, carers and teams

benefits:
- rapid identification of frail elderly and initiation of CGA leads to improved outcomes

Question 31

describe frailty syndromes

Answer 31

• markers of a frail patient
• can mask serious underlying illness and the response to a crisis call from an older person with frailty should reflect the potential underlying illness and not the symptom itself

1. delirium:
   - acute change in mental state (hyper vs hypoactive)
   - predictor of worse outcomes during admission: increase falls, pressure sires, admission to long term care, mortality
   - RFS = old age, polypharmacy, dementia, infection, dehydration, severe illness, surgery, hip fracture, sensory impairment, constipation, retention
   - assess: 4AT
   - initiate TIME bundle
2. urinary/faecal incontinence:
   - can be ‘deal-breaker’ for independent living/living at home
   - stress, urge, obstructive, neurological
   - examine: neurological, cognition, abdo, PR
   - Ix: fluid charts, urinanalysis, FBC, CRP, post-void bladder scan
   - Tx: treat reversible facors, lifestyle changes, topical oestrogen, medications, bladder retraining
3. falls:
   - Hx
   - examine: CVS, neurological, msk, visual
   - environment and bone protection
4. medication SEs:
   - Tx should be individualised
5. immobility

Question 32

list 3 causes of non-specific raised troponin?

Answer 32

• sepsis
• CKD
• HF

Question 33

what changes are there in older adults physiology?

Answer 33

CV:

• reduced vascular compliance –> systolic HTN, LVH, aortic sclerosis
• reduced cardiac reserve
• increased risk of arrhythmias
• increased risk of postural HTN (from medications or diseases more common in the elderly e.g. Parkinsons)

Resp:

• reduced lung compliance
• reduced immune function
• reduced cough reflex (can’t clear things out)
• increased risk of infection and bronchospasm

Renal:

• kidneys get smaller so reduced mass and blood flow - reduced GFR
• reduced bladder capacity
• prostatic enlargement
• increased risk of AKI, adverse drug reactions, bladder dysfunction, UTI, nocturia

GI:

• reduced gastric motility
• malabsorption (B12, vit D, folic acid, calcium)
• dental problems
• reduced liver function (decreased drug metabolism)

msk:

• sarcopenia
• bone loss
• increase risk of osteoporosis, OA, instability, falls

Nervous system:

• decrease no. of neurones and NTs
• compromised thermoregulation
• risk of reduced cognitive function, delirium, altered response to infection, sleep disorders

immune system:
- increased susceptibility to infection, reduced efficacy of vaccination

Question 34

what non-physiological changes are there in older adults?

Answer 34

social changes:
- loss of spouses/nearby relatives… family moved away, socially isolated. medication/ shopping/ appointments missed

financial changes:
- impact on heating, hot water, food, access to other activities and services

cultural/generational change:
- ‘stigma’ attached to illness, psychological illness, some infections

Question 35

discuss atypical presentation in older adults

Answer 35

atypical presentation results in large presentation, increased morbidity and mortality, increased unscheduled admissions

increased risk of atypical presentation:

• over 85s
• multiple comorbidity
• polypharmacy
• cognitive impairment
• functional impairment

atypical presentations:

• frailty syndromes
• low mood vs cognitive impairment
• infection without fever or raised inflammatory markers
• silent MI (fatigue or general weakness)
• pulmonary oedema without SOB (fatigue and reduced exercise tolerance)
• paradoxical presentation of thyroid disease

Question 36

outline important considerations for older adults in hospital

Answer 36

• more susceptible to HAI, delirium, poor nutrition/dehydration, pressure ulcers
• more likely to have adverse outcomes e.g. longer stays, readmissions, mortality, transfer to residential care
• medication lists
• ACP/POA paperwork
• personal belongings (dentures, glasses, hearing/mobility aids)
• red bag scheme
• prevent adverse events: delirium screening (4AT) and prevention (identify risks, orientation, appropriate environment, social stimulation, increase mobility, avoid dehydration, adequate nutrition, pain management)

Question 37

consider safe discharge planning for older adults

Answer 37

• pt well enough to be at home
• medications (including aids - rosette box, prompts etc)
• physical environment
• social support (friends, family, local services, third sector)
• carer support (formal carers, informal carers)
• support for carers
• smart technology (e.g door sensors, med reminders)

Question 38

what is the difference between guardianship and PoA?

Answer 38

guardianship -> court appointed person who act and maker decisions on behalf of an adult with incapacity

PoA -> the adult has chosen that person before they lack capacity. approven by the court