general older medicine Flashcards
what are some risk factors for falls ?
previous falls
lower limb weakness
balance /gait disturbance
polypharmacy ( +4)
incontinence
over 65
depression
postural hypotension
what are some key questions to ask someone who has fallen ?
where was it the patient fell ?
when did they fall ?
did anyone else see the person fall ( collateral )
what happened ? associated features
why do they think they fell ?
have they fallen before ?
PMH
SH
systems review
what are some medications that cause postural hypotension and therefore lead to falls ?
nitrates
diuretics
anticholinergic
antidepressants
beta blockers
L-DOPA
ACEi
what are some medications associated with falls that don’t cause postural hypotension ?
benzodiazepines
antipsychotics
opiates
anticonvulsants
codeine
digoxin
what approach should be used in a falls patient ?
A to E assessment
what are some investigations for a falls patient ?
bedside - basic obs, BP, blood glucose, urine dip, ECG
bloods - FBC, U&E’s, LFTs, bone profile
imaging - CXR, limbs, CT head and cardiac echo
what are some risk factors for urinary incontinence ?
advancing age
previous pregnancy and childbirth
high BMI
hysterectomy
FH
who is the most affected by urinary incontinence ?
elderly females
what is urge incontinence ?
the urge to urinate is quickly followed by uncontrollable leakage due to detrusor over activity
what is stress incontinence ?
leaking small amounts of urine when straining like coughing or laughing
what is the pathophysiology of stress incontinence ?
weakness of the pelvic floor and sphincter muscles. this allows urine to leak at times of increased pressure on the bladder
what is mixed incontinence ?
a combination of urge and stress incontinence
what is overflow incontinence ?
occurs when there is chronic urinary retention due to an obstruction to the outflow of urine. this results in an overflow of urine and incontinence occurs without the urge to pass urine.
what can cause overflow incontinence ?
anticholinergic medications
fibroids
pelvic tumours
neurological conditions - MS, diabetic neuropathy and spinal cord injuries
who is mostly affected by overflow incontinence ?
elderly men
what is functional incontinence ?
comorbid physical conditions impair the patient’s ability to get to a bathroom in time
what are some causes of functional incontinence ?
dementia
sedating medication
injury / illness resulting in decreased ambulation
what are some risk factors for urinary incontinence ?
increased age
postmenopausal status
increased BMI
previous pregnancies and vaginal deliveries
pelvic organ prolapse
pelvic floor surgery
neurological conditions - MS
cognitive impairment and dementia
what are some modifiable lifestyle factors that contribute to urinary incontinence ?
caffeine consumption
alcohol consumption
medications
BMI
what are some investigations for urinary incontinence ?
bladder diary
urine dip
post-void residual bladder volume
urodynamic testing
what medications should be stopped before performing urodynamic testing ?
anticholinergics
bladder related medications
around 5 days before the tests
how are urodynamic tests performed ?
a thin catheter is inserted into the bladder and another into the rectum.
these 2 catheters can measure the pressures in the bladder and rectum for comparison. the bladder is filled with liquid and various measurements are taken.
what are some of the measurements taken from a urodynamic test ?
cystometry - measures the detrusor muscle contraction and pressure
uroflowmetry - flow rate
leak point pressure - the point at which the bladder pressure results in leakage of urine - assesses stress incontinence
post-void residual bladder volume
video urodynamic testing
what is the management of stress incontinence ?
avoid caffeine, diuretics and overfilling the bladder
weight loss if appropriate
supervised pelvic floor exercises
surgery
duloxetine - second line if surgery not prefered
what are some surgical options for stress incontinence ?
tension-free vaginal tape - mesh sling
autologous sling procedure - strip of fascia
colposuspension - stitches to connect the anterior vaginal walla and pubic symphysis
intramural urethral bulking
what is the management of urge incontinence ?
bladder retraining
anticholinergic medication - oxybutynin
mirabegron
invasive procedures - where medical treatment has failed
what are some side effects of anticholinergics ?
dry mouth
dry eyes
urinary retention
constipation
postural hypotension
what is mirabegron contraindicated in ?
uncontrolled hypertension
what does mirabegron act on ?
beta 3 agonist stimulating the sympathetic NS
what are some invasive options for managing urge incontinence in medical management has failed ?
botulinum toxin type A injection into the bladder wall
percutaneous sacral nerve stimulation
augmentation cystoplasty
urinary diversion
what is the difference between osteoporosis and osteopenia ?
osteoporosis - significant reduction in bone density
osteopenia - less severe decrease in bone density
on a DEXA scan what t score is considered normal ?
more than -1
on a DEXA scan what t score is considered as osteopenia ?
-1 to - 2.5
on a DEXA scan what t score is considered as osteoporosis ?
less than - 2.5
on a DEXA scan what t score is considered as severe osteoporosis ?
less than -2.5 plus a fracture
how is bone mineral density measured ?
using a DEXA scan
what is a DEXA scan ?
a type of x ray that measures how much radiation is absorbed by the bones indicating how dense the bone is
what is a z score in bone density ?
the number of standard deviations the patient is from the average for their age, sex and ethnicity
what is the T score in relation to bone density ?
the number of standard deviations the patient is from an average healthy young adult.
what are some risk factors for osteoporosis ?
older age
post-menopausal women
reduced mobility and activity
low BMI
low calcium or vitamin D intake
alcohol and smoking
chronic diseases - hyperthyroid, CKD
long term corticosteroids
certain medications
what is the management of osteoporosis ?
address reversible risk factors
address insufficient intake of calcium and vitamin D
bisphosphonates
how do bisphosphonates work in osteoporosis ?
interfere with the way osteoclasts attach to bone, reducing their activity ad the reabsorption of bone.
what are some important side effects of bisphosphonates ?
reflux and oesophageal erosions
Atypical fractures
osteonecrosis of the jaw and external auditory canal
how should bisphosphonates be taken ?
orally on an empty stomach with a full glass of water.
afterwards the patient should sit upright for 30 minutes before moving or eating
what are some other specialist options for treating osteoporosis ?
denosumab - monoclonal antibody that targets osteoclasts
how do pressure ulcers occur ?
in patients with reduced mobility where there has been prolonged pressure on particular areas leading to the skin breaking down.
how should pressure ulcers be prevented ?
individual risk assessments
regular repositioning
special inflating mattresses
regular skin checks
protective dressings and creams
what is the assessment tool for estimating the risk of pressure ulcers ?
waterflow score
what are the 2 types of cerebrovascular accidents ?
ischaemia or infarction of the brain - ischaemic stroke
intracranial haemorrhage - haemorrhagic stroke
what is ischaemia and infarction ?
ischaemia - inadequate blood supply
infarction - tissue death due to ischaemia
how can blood supply to the brain be disrupted ?
a thrombus or embolus
atherosclerosis
shock
vasculitis
what is a TIA ?
temporary neurological dysfunction ( lasting less than 24 hours ) caused by ischaemia but without infarction.
how does a stroke present ?
asymmetrical -
limb weakness
facial weakness
dysphasia
visual field defects
sensory loss
ataxia and vertigo
what is a risk factor for strokes ?
previous stroke or TIA
AF
carotid artery stenosis
HTN
DM
raised cholesterol
FH
smoking
obesity
vasculitis
COCP
what is the initial management of a TIA ?
aspirin 300mg daily
referral for specialist assessment within 24 hours
diffusion weighted MRI scan
what is the immediate management of a stroke ?
exclude hypoglycaemia
immediate CT brain ( to exclude haemorrhage )
aspirin 300 mg daily for 2 weeks
what is the definitive management of a stroke ?
thrombolysis with alteplase when haemorrhage is excluded
thrombectomy ( 24 hours )
what is alteplase ?
a tissue plasminogen activator that rapidly breaks down clots.
given within 4.5 hours of symptom onset
what is the management of carotid artert stenosis ?
carotid endarterectomy
angioplasty and stenting
what is the secondary prevention for a stroke ?
clopidogrel 75mg
atorvastatin 20-80mg
blood pressure and diabetic control
address modifiable risk factors - smoking, obesity and exercise
what is the criteria for determining the type of stroke in the oxford stroke classification ?
unilateral hemiparesis and/or hemisensory loss of face, arm and leg
homonymous hemianopia
higher cognitive dysfunction - dysphasia
what arteries are affected in a TACs infarct ?
middle and anterior cerebral arteries
what criteria needs to be met for a TACs stroke ?
all 3 of the oxford classification
- unilateral hemiparesis and/or hemisensory loss
- homonymous hemianopia
- higher cognitive dysfunction
what arteries are involved in a PACs infarct ?
smaller arteries of the anterior circulation
- upper or lower division of the middle cerebral artery
what criteria needs to be met in a PACs infarct ?
2 of the following from the oxford stroke classification :
- unilateral hemiparesis and/or hemisensory loss
- homonymous hemianopia
- higher cognitive dysfunction
what arteries are involved in a lacunar infarct ?
perforating arteries around the internal capsule, thalamus and basal ganglia
how does a lacunar infarct present ?
presents with one of the following :
- unilateral weakness ( and / or sensory deficit )
- pure sensory stroke
- ataxic hemiparesis
what arteries are affected in a POCs infarct ?
vertebrobasilar arteries
how does a POCs infarct present ?
cerebellar or brainstem syndrome
loss of consciousness
isolated homonymous hemianopia
how does a retinal / ophthalmic artery occlusion present ?
amaurosis fugax
how does a basilar artery occlusion present ?
locked in syndrome
what is the most common cause of faecal incontinence ?
faecal impaction
what should be performed in a patient with faecal incontinence ?
PR - rectum, prostate, anal tone and sensation
what is the management of chronic diarrhoea ?
regular toileting and dietary review
low dose loperamide can be trialled
what is malnutrition ?
- BMI less than 18.5
- unintentional weight loss greater than 10 % within the last 3-6 months
- BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
what is the screening tool for malnutrition ?
MUST
what is the management of malnutrition ?
dietician support if high risk on MUST
food first approach rather than prescribing oral nutritional supplements
what are some cases of malnutrition ?
reduced dietary intake
malabsorption
increases losses or altered requirements
energy expenditure
what are some consequences of malnutrition ?
altered muscle function
altered cardio-resp function
altered GI function
poor immunity and wound healing
psychosocial effects
what are the 4 stages of wound stages ?
haemostasis
inflammation
proliferation
remodelling
what are some local factors that effect wound healing ?
infection
oxygenation
foreign body
venous insufficiency
what are some systemic factors that effect wound healing ?
age
gender
stress
ischaemia
DM
obesity
medications such as steroids, NSAIDs, chemotherapy
immunocompromised
nutrition
What is a residential home ?
They provide accommodation and personal care such as help with washing and dressing, taking medications and going to the toilet.
What is a nursing home ?
They provide personal care but there is always 1 or more qualified nurses on duty
