General Geriatrics Flashcards
Common causes of constipation in the elderly?
Dehydration
Diabetes
Low fibre intake
Immobility
IBS
Hypothyroidism
Hypercalcemia
Neurological- Stroke, Parkinson’s
Colorectal cancer
Rectal prolapse
How is constipation diagnosed?
ROME IV Criteria
How should hard v soft stool impaction be managed?
hard- stool softeners, osmotic laxatives (e.g. lactulose/movicol), enemas
soft- stimulant laxatives e.g. senna
Faecal incontinence in the elderly is always abnormal and usually curable. What is it most commonly caused by?
faecal impaction with overflow diarrhoea. This accounts for 50% of faecal incontinence. The second most common cause is neurogenic dysfunction
What increases risk of incontinence?
Older female
Obesity
Previous pregnancy
Prolapse
Smoking - chronic cough = strain
Constipation = strain
Neurological dysfunction
Medications
What are the key components of a continence exam?
Review of bladder and bowel diary
Urine dipstick and MSU
A post micturition bladder scan
Abdominal examination and PR exam
External genitalia review particularly looking for atrophic vaginitis in females
Non pharmacological interventions for incontinence?
Switch to decaff drinks
Improve bowel habit
Regular toileting
Pelvic floor exercises
Common drugs for treating overactive bladder?
Mirabegron
Oxybutinin
Tolterodine
The MUST score is used to assess patients at risk of malnutrition. What are its 3 components?
current BMI,
history of unintentional weight loss,
likelihood of future weight loss
what does NICE recommend for the management of malnutrition?
dietician support if the patient is at high-risk
a food-first approach with clear instructions rather than simply prescribing oral nutritional supplements
if supplements are used they should be taken between meals rather than instead of meals
what are the 4 stages of wound healing?
hemostasis,
inflammation,
proliferation,
remodelling
Define ‘feed at risk’
What discussions should be had about this?
When a patient can choose to continue eating and drinking despite known risk of aspiration
Discuss signs of aspiration and what to do in case of aspiration with family
Give choking advice
What is the evidence for enteral feeding in dementia?
Only to be used in acute illness
No evidence of increased life span and increased risk of aspiration and infection
Define delirium.
How do you assess for it?
Acute and fluctuating changes to consciousness, cognition or perception
4AT score
What percentage of elderly patients, admitted to hospital, are affected by acute confusional state (delirium)?
up to 30%
What are the risk factors for developing delirium (or acute confusional state) ?
age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy
How can delirium be categorised?
hyperactive (agitated and confused), hypoactive
(withdrawn and drowsy) or mixed.
What are the main causes of delirium?
PINCH ME
Pain
Infection: esp UTIs
Nutrition: hypo/hyperglycaemia, consider metabolic issues e..g hypercalcaemia
Constipation : consider constipating medications e.g. codeine and ondansetron
Hydration: dehydration, alcohol withdrawal
Medication
Environment: change of environment
What factors favour delirium over dementia as a diagnosis?
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. hallucinations and delusions)
agitation, fear
Examinations in acute confusion?
Check for signs of hypoxia
Fluid balance
Mini mental state examination
How do you carry out a fluid balance assessment?
Fluid intake and urine output
Cap refill
Pulses and JVP
BP
Skin turgor
Check mucous membranes
Investigations in acute confusion ?
Confusion screen bloods
Urine dip (infection)
ECG
CT head
What is involved in a ‘confusion screen’ bloods and why?
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
How is delirium managed?
Tx underlying cause, modify environment, try haloperidol 0.5 mg
(unless pt has Parkinsonism in which case lorazepam 0.5mg )
What non pharmacological interventions can help with delirium?
Reassurance
Consistency
Orientation – clock, pictures, talking, stimulate, family
Avoid transfer between wards / less moves
Minimise sensory deprivation/overload – ear wax, hearing aids
Safe wandering
Sleep hygiene – scheduled med rounds, overnight interventions
What are the complications associated with delirium?
increased mortality, prolonged hospital admission, higher complication rates, institutionalisation and increased risk of developing dementia
What is the GPCOG test?
a test designed as a GP screening tool for dementia
Give some risk factors for multi-morbidity
increasing age
Female sex
Low socioeconomic status
Tobacco and alcohol usage
Lack of physical activity
Poor nutrition and obesity
What is the most common comorbid condition?
Hypertension
Define fraility.
How should it be assessed?
Frailty is defined as a state of impaired homeostasis leading to increased vulnerability to minor stressor events.
through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire
What topics are covered in the PRISMA-7 questionnaire?
age,
sex,
health problems,
help at home,
mobility,
social support
Give some physical manifestations of frailty
Sarcopenia- loss of skeletal muscle, fat mass may be preserved
Unintentional weight loss- disease, ill fitting dentures, inability to make or eat meals
Fatigue
What is the clinical frailty scale? How is it helpful?
Set of 9 phenotypes ranging from very fit to terminally ill which can be used to summarise the older patient’s overall level of fitness or frailty and predict outcomes of survival/prognosticate
What is a CGA?
comprehensive geriatric assessment —> Multidimensional, interdisciplinary diagnostic processes to determine the medical, psychological and functional capabilities of frail older people to develop a coordinated & integrated plan for treatment and long-term follow up
What are the domains of a CGA? (7)
Problem list – current and past
Medication review
Nutritional status
Mental health – cognition, mood and anxiety, fears
Functional capacity - basic activities of daily living , gait and balance, exercise status
Social circumstances
Environment - home environment, facilities and safety within the home, accessibility to local resources
What are some tools that can be used to see how well a patient is coping with their ADLs?
- Barthel Index
- Nottingham Extended activities of daily living
What are the “geriatric giants”?
Immobility
Instability/falls
Incontinence
Impaired memory (dementia, delirium)
Iatrogenesis
What is the Waterlow score?
Used to identify patients at risk of pressure sores
what factors increase the risk of pressure ulcers?
malnourishment,
incontinence,
lack of mobility,
pain
Outline grades 1-4 of pressure sores
Outline the management of pressure ulcers
hydrocolloid dressings and hydrogel to provide a moist wound environment to encourage healing
wound swabs taken routinely
consider referral to the tissue viability nurse
surgical debridement for selected wounds
Which tool is used to assess the risk of stroke in the short term post TIA?
The ABCD2 score
The ABCD2 score is calculated by summing up the points for five different factors including age, blood pressure, clinical features, duration of symptoms and the presence of diabetes. ABCD2>=4 indicates a higher risk.
Give some indications that a patient is reaching the end of life
Bed bound.
Semi-comatose.
Only able to take sips of fluid.
Unable to take medicine orally
4 medications used in palliative care?
opioid e.g. morphine
anti-emetic
anti-secretory - glycopyrronium
sedation - benzodiazepine
Outline the concept of polypharmacy and how to approach prescribing in the elderly
Polypharmacy is the concurrent use of multiple medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. It is associated with increased hospitalizations and higher costs of care.
Reduce dose- often start at 50% of the adult dose
Review regularly (can use STOPP START)
Give clear instructions
What can Trimethoprim do to the kidneys in the elderly population?
False AKI
Transient rise in creatinine levels by reducing the creatinine excretion of the kidneys. This does NOT reflect the actual GFR and therefore this phenomenon is not reflective of an Acute kidney injury but rather the calculated eGFR
A patient is struggling after constantly worrying about their spouse with dementia. What is this often called?
How should it be managed?
Carer strain
Refer to social services
What are the symptoms of carer strain?
Frustration,
Self neglect,
Isolation from other relationships
What percent of carers in England have suffered from carer strain?
75%
Give an example of a sequence task that an occupational therapist may assess
Washing and dressing oneself
What does the term safeguarding describe?
Measures to protect the health, well-being and human rights of individuals which allow people to live free from abuse, harm and neglect
