general medicine and care of older people Flashcards
how many people have long term conditions in England?
- 15 million people have long term conditions
how are long term conditions managed?
- managed with drugs and treatments
what percentage of over 60s have long term conditions?
- 58%
what other group (other than elder) have a higher prevalence and severity of long term conditions?
- more deprived groups have a higher prevalence
- 60% higher in the poorest social class and
how much of health and social care is used on people with long term conditions?
- 70% of health and social care expenditure is used for treating and caring for people with long- term conditions
what is increasing over time?
- number of people with multiple long term conditions is increasing
what is comorbidity?
- co- existence of other conditions with a specific index condition (presence of additional diseases in relation to an index disease in one individual)
what is multimorbidity?
- co- existence of multiple conditions without a specific index condition
- presence of multiple diseases in one individual
who is multimorbidity more commonly seen in? what is this possibly due to?
- seen more frequently in older adults
- possibly due to ageing population
what type of status makes you more likely to experience multimorbidity?
- lower socioeconomic status
what is multimorbidity influenced by?
- various factors e.g., sex, ethnicity and various health- related behaviours that may increase the risk of chronic conditions
what can patients with multimorbidity experience?
- experience different combinations of conditions
- making it a highly diverse condition
what do chronic physical conditions often coexist with?
- usually coexist with mental health conditions
what can some types of multimorbidity increase? (2)
- increased disability and functional decline
what can some types of multimorbidity reduce? (2)
- reduced well- being and quality of life
is there data on all types of multimorbidity?
- no, information on some types of multimorbidity is limited
what factors are unclear in multimorbidity research?
- unclear which factors predict the risk of developing different types of multimorbidity
what is there no data on? what does this make harder?
- no data on factors that increase the risk of multimorbidity independently of its component conditions
- makes it hard to develop prevention strategies
what are there very few trials of?
- few trials of interventions to manage multimorbidity
what is the evidence base heavily skewed towards?
- skewed towards older populations and HICs
what is morbidity burden?
- overall impact of the different diseases in an individual taking into account their severity
what is patient’s complexity?
- overall impact of the different diseases in an individual taking into account their severity and other health- related attributes
what do the conditions of multimorbidity include? (5)
- defined physical and mental health conditions - - - learning disabilities
- symptom complexes (frailty or chronic pain)
- sensory impairment (sight, hearing loss)
- alcohol and substance abuse
what does WHO define multimorbidity as?
- being affected by two or more chronic health conditions in the same individual
what may patients with multiple health conditions not always require?
- may not always require an approach to care beyond managing their individual conditions in isolation
what management is needed as the severity and complexity of the condition increases?
- need for a management strategy that considers multimorbidity becomes more likely
what is management that considers multimorbidity especially needed?
- in cases where clusters of conditions have different management strategies and where a patient has both mental and physical conditions
what may not be the best option for multimorbidity patients?
- uncoordinated and fragmented care from healthcare systems that focus on single conditions may not be the best
what is multimorbidity associated with an increase of in older adults regardless of income level?
- associated with increased occurrence of hospitalisation and readmission
what does multimorbidity increase in the UK? (2)
- healthcare utilisation
- costs of primary, secondary and dental care
what two combinations of conditions represented a significant share of secondary care costs?
- chronic kidney disease and hypertension
- diabetes and hypertension
what conditions were the highest preventable emergency admission costs found? (3)
- combinations of chronic heart failure, chronic kidney disease and hypertension
what approach should be taken due to the fact there is no clear/ discrete disease combinations to target interventions?
- implies a generalist/ multidisciplinary team approach which will remain important rather than pathways based on a few specific disease clusters
when should you think multimorbidity? (7)
- identified by a person
- struggle with treatment/ daily activities
- receive support from multiple services
- have physical and mental health conditions
- signs of frailty or frequent falls
- frequently seek unplanned or emergency care
- take regular medicines (polypharmacy)
what is frailty?
- clinical syndrome caused by age- related biological changes that lead to negative outcomes
what does frailty indicate?
- indicates increased vulnerability
what are the two main consequences that frailty leads to?
- functional impairment
- adverse health outcomes
what are the three things that frailty contribute to?
- falls
- multimorbidity
- mortality
what does frailty lower? (2)
- quality of life
- life expectancy
what state can frailty be? what can it coexist with?
- can be a pre- disability state
- or can coexist with disability
is frailty reversible?
- yes
what is the frailty phenotype?
- describes a group of patient characteristics (unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy expenditure) which, if present, can predict poorer outcomes
what is the Rockwood frailty scale often used for?
- initial screening for patients
what is the Rockwood frailty scale?
- assumes an accumulation of deficits which can occur with ageing and which combine to increase the ‘frailty index’ which in turn will increase the risk of an adverse outcome
what is the cumulative deficits model closely associated with?
- associated with comprehensive geriatric assessment
what was developed based on Rockwood and comprehensive assessment?
- electronic frailty scale
what does the eFI do?
- searches primary care records for 36 variables, including diagnosis, symptoms, sensory impairments and disabilities
what are the variables used to identify in the eFI? (3)
- identifies risk of hospital admission, care home admission or even death
what are the five frailty symptoms by the British Geriatric Society?
- falls
- immobility
- delirium
- incontinence
- susceptibility to side effects of medication
how is frailty diagnosed when using the phenotype model to look at walking speed?
- more than 5 seconds to walk 4 metres indicates frailty
how is frailty diagnosed when using the phenotype model to look at timed up and go test?
- mean time of more than 12 seconds indicates frailty
what are the 3 other indications of frailty diagnosis using the phenotype model?
- low grip strength
- immune deficits
- reduced ability to withstand an ‘insult’
what self- reported physical activity score indicates frailty for men?
- scores of 56 or less for men
what self- reported physical activity score indicates frailty for women?
- scores of 59 or less for women
what is the ISAR screening?
- self report screening tool composed of six simple ‘yes/no’ items
what is ISAR screening related to? (5)
- related to functional dependence, recent hospitalisation, impaired memory and vision and polypharmacy
what does a comprehensive geriatric assessment involve? (6)
- assessment
- problem list
- goals
- personalised care planning
- intervention
- review
what are the 8 aspects of assessment in the comprehensive geriatric assessment?
- medical
- functional
- psychological
- social
- environmental
- advance care planning
- spirituality
- sexuality and intimacy
what three aspects of the comprehensive geriatric assessment do physiotherapists focus on?
- functional
- social
- environmental
what does the comprehensive geriatric assessment help to plan?
- helps to plan a standardised plan for treatment of patients
what is sarcopenia?
- progressive and generalised skeletal muscle disorder that is associated with the increased likelihood of adverse outcomes
what are the four adverse outcomes that sarcopenia increases the likelihood of?
- falls
- fractures
- physical disability
- mortality
what are quick screening tools for sarcopenia?
- MRSA and SARC-F
what score on MRSA-7 indicates a risk of sarcopenia?
- <30 indicates a risk of sarcopenia
what score on MRSA-5 indicates sarcopenia risk?
- <45 indicates sarcopenia risk
what are the SARC-F test 5 components?
- strength
- assistance in walking
- rise from a chair
- climb stairs
- falls
what does the SARC-F screening tool highlight?
- highlights key issues/ weaknesses of patients
what outcome measures may be used for muscle strength, quality and performance? (5)
- grip strength
- chair stand > 30 second
- GST-4
- 4 stage balance test
- TUG test
what do older people with sarcopenia have a higher risk of?
- higher risk of hospitalisation
what are the 11 risk factors associated with sarcopenia in hospitalised older people?
- longer days of bed rest
- cognitive impairment
- low body mass index
- dependency with ADLs
- age
- diabetes
- depression
- osteoporosis
- falls
- physical inactivity
- polypharmacy
what are the 3 elements that present across most tests that define sarcopenia?
- muscle mass
- grip strength
- gait speed
what does acute sarcopenia lead to? (9)
- delirium
- cognitive impairment
- malnutrition
- insomnia
- chronic disease
- bedrest and disuse
- depression
- acute medical illness
- acute psychological stress
what are the two stages of acute sarcopenia?
- pre- sarcopenia
- chronic sarcopenia
what are the two treatment options for sarcopenia?
- medication e.g., steroids
- surgical procedures
what is hospital- acquired deconditioning?
- state of poor functional performance after an acute hospitalisation
what is HAD a strong risk factor for in the following year? (3)
- mortality
- re-hospitalisation
- institutionalisation
what is HAD associated with?
- associated with high costs
what are the predictive tools for HAD relating to subject characteristics? (6)
- sex
- age
- education
- skin integrity
- limb circumference
- incontinence
what pre- hospitalisation status are red flags for HAD? (6)
- previous need for assistance in ADLs
- previous need for assistance travelling
- use of walking device
- functional balance
- mobility
- gait speed
what hospitalisation events are predictive tools for HAD? (5)
- diagnosis
- function at discharge
- symptom severity
- depressive symptoms
- steps per day
what are the two biological markers predictive of HAD?
- creatine levels
- dipstick proteinuria
what are the three suggestions in preventing deconditioning for older people?
- sit up
- get dressed
- keep moving
what is the most effective non- pharmacological intervention for reducing frailty?
- physical activity
what is the most effective type of physical activity for older patients?
- resistance training
what are the next most effective physical activity types most effective for older people? (3)
- mind body exercise
- mixed physical training
- aerobic training
what should multicomponent intervention for frailty involve? (4)
- physical, nutritional, cognitive components and polypharmacy
what exercise can have significant benefits on depressive symptoms of frail individuals? why?
- group based physical exercises
- because it makes the exercise more fun, relatable and achievable
what is crucial in the management of frailty? why?
- preventative screening
- because it helps with early identification and intervention
- significantly improves health outcomes
what is delirium?
- acute, fluctuating syndrome of encephalopathy
- confusional state
what does delirium cause? (4)
- disturbed consciousness, attention, cognition and perception
what is the duration in which delirium is usually developed?
- developed over hours to days
what contribute to the pathogenesis of delirium?
- several neurobiological processes contribute
what are some neurobiological processes that contribute to delirium? (5)
- neuroinflammation
- brain vascular dysfunction
- altered brain metabolism
- neurotransmitter imbalance
- impaired neuronal network connectivity
what three changes may occur due to delirium?
- behavioural disturbances
- personality changes
- psychotic features
who does delirium typically occur in?
- typically occur in people with predisposing factors when new precipitating factors are added
what are the three subtypes of delirium based on the person’s symptoms?
- hyperactive delirium
- hypoactive delirium
- mixed delirium
what does hyperactive delirium present with? (5)
- inappropriate behaviour
- hallucinations
- agitation
- restlessness
- wandering
what does hypoactive delirium present with? (5)
- lethargy
- reduced concentration
- reduced appetite
- quiet
- withdrawn
what does mixed delirium present with?
- present with signs and symptoms of both hyperactive and hypoactive subtypes
what are the predisposing factors of delirium? (11)
- older age (over 65)
- cognitive impairment e.g., dementia
- frailty/ multi comorbidities e.g., stroke or heart failure
- significant injuries e.g., hip fracture
- functional impairments e.g., immobility or use of physical restraints
- Iatrogenic events
- alcohol excess
- sensory impairment
- poor nutrition
- lack of stimulation
- terminal phase of illness
what are the precipitating factors of delirium? (11)
- infections
- metabolic disorders
- cardiovascular disorders
- respiratory disorders
- neurological disorders
- endocrine disorders
- urological disorders
- gastrointestinal disorders
- severe uncontrolled pain
- alcohol intoxication or withdrawal
- medication
what are the complications of delirium? (11)
- increased mortality
- increased length of stay in hospital
- nosocomial infections
- increased risk of admission to long- term care
- increased incidence of dementia
- falls
- pressure sores
- continence problems
- malnutrition
- functional impairment
- distress for the person, their family and/ or careers
what are the three ways of managing delirium in primary acute care settings?
- correcting precipitating factors
- optimising treatment for comorbidities
- advising family and carers on management strategies
what reorientation strategies did the NICE guidelines put forward? (4)
- regular cues
- easily visible and accurate clocks/ calendars
- continuity of care from carers and nursing staff
- encouraging visits from family/ friends
what were the two ways that the NICE guidelines put forward to maintain safe mobility of delirious patients?
- avoid physical restraints e.g., cot sides
- encourage walking at least three times a day (or active ROM)
how did NICE guidelines put forward normalising the sleep cycle of delirious patients?
- discourage napping and encourage bright light exposure in the daytime
- encourage uninterrupted sleep at night with a quiet room and low- level lighting
what are the two causes of cognitive impairment among older adults? what relationship do they have?
- delirium and dementia
- have a distinct, complex + interconnected relationship
how do you distinguish between delirium and dementia?
- recognise the presence of an abrupt change in mental state from the normal condition or improvement in symptoms upon addressing the underlying causes e.g., infection, medication
what does Alzheimer’s cause?
- causes a slow decline in memory and cognitive ability over months to years while consciousness stays in take
what are the 4 screening methods for delirium?
- confusion assessment method
- mini mental state examination
- 4 A’s test
- montreal cognitive assessment
what is CAM? what does it evaluate?
- confusion assessment method
- widely used tool
- evaluates sudden onset, inattention, disorganised thinking and altered consciousness
when is delirium confirmed in the confusion assessment method?
- confirmed if the first and second features are present, along with either the third or fourth
what is the MMSE used for?
- mini- mental state examination
- used to assess cognitive impairment and evaluate cognitive aspects of delirium
what is the 4 A’s test? what does it assess?
- rapid screening tool for delirium and cognitive impairment
- assesses alertness, AMT4, attention and acute change or fluctuating course
what does the MoCA assess?
- montreal cognitive assessment
- assesses different cognitive domains affected by delirium
what can tailored exercises at moderate exercise intensity improve? (4)
- motor skills
- cognitive function
- autonomy
- quality of life
what does early mobilisation reduce? (4)
- readmission
- falls
- sores
- respiratory events
what does early mobilisation increase?
- increases independence
what does occupational therapy improve and reduce?
- improves function
- reduces delirium and behavioural disorders
what does occupational therapy facilitate?
- facilitates home discharge
how can preventing delirium in hospitalised patients be effectively achieved?
- achieved by implementing multicomponent nonpharmacological approaches e.g., medical management, social and cognitive engagement and promotion of functional mobility
what specific interventions can be used in preventing and treating delirium? (4)
- adequate hydration and nutrition
- early mobilisation
- infection control
- frequent orientation
