Geri 3a Flashcards
Causes of acute delirium
Pain
Infection
Constipation
Urinary retention
Metabolic: hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
Medications: e.g. opioids
Hypoxia
change of environemtn
alcohol withdrawal
Give haroperidol as firast line to calm
most common causes of vertigo encountered
Benign Paroxysma; Positional Vertigo (BPPV)
vertigo: sensation that u or the environment around is moving r spinning
It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.
- Calcium debris in semicircular canal usually idiopathic, mayb preceded by head trauma.
- vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
- may be associated with nausea
- each episode typically lasts 10-20 seconds
- positive Dix-Hallpike manoeuvre, indicated by:
- patient experiences vertigo
- rotatory nystagmus
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:
* Epley manoeuvre (successful in around 80% of cases)
Delirium V Dementia
- Factors favouring delirium over dementia
- impairment of consciousness
- fluctuation of symptoms: worse at night, periods of normality
- abnormal perception (e.g. illusions and hallucinations)
- agitation, fear
- delusions
VitD replacement can help prevent falls.
Falls in the elderly
associated with significant mortality and morbidity in the elderly
Normal Gait: Neuro(basal ganglia + corticol basal ganglia loop) MSK (appropriate tone + strength) Fine touch + proprioception
Medical probelms affecting stated systems can cause falls in elderly.
RF: Lower limb weakness, vision proble, pollypharmacy, gait disturbace conditions, postural Hypotension, arthritis
- impact patients confidence and independence.
- Rx Risk of falling: benzos, antipsychotics, opiates,anticonvulsants, codeine, digoxin
- RX causes posturan hypoTN: nitrates, ACEi, Antcholinergics, antidepressants,BBlockers, Ldopa, Diuretics
Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
* >2 falls in the last 12 months
* A fall that requires medical treatment
* Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
FRAX or QFracture to assess the 10-year risk
Osteoporosis managemet
BMD of < 2.5 standard deviations (SD) below the young adult mean density
- it increases the risk of fragility
- . Certain fragility fractures such as fractured neck of femur are associated with significant morbidity and mortality
RF - corticosteroid use
- smoking
- alcohol
- low body mass index
- family history
- VitD and calcium supplementation
- aldendronate 1st line or etidronate (if GI symptoms)
- 2nd line Raloxifene - selective oestrogen receptor modulator (SERM)
in fall always get a hip fracture anterposterior and lateral
all hip fractures need surgical intervention.
Constipation
Delayed alimentay tract transit time.
- harde faces
- soft faces throught bowels which are unable to be evacuated
- high impaction due to cancer or diverticular disease.
- Constipation can be acute cause of delirium
- can lead to sepsis or renal failure
Causes
* Reduced motility due to opiates, iron, anticholinergics, antidepressants, CCB
* neuromuscualr: parkinsons, diabetic neuropathy
* carcinoma of bowel.
Stimulant laxatives: senna, avoid in hard stools - use osmotic laxative like lactulose. long term laxaive use linked to bowel neuronal damafe.
Acute Cardiac Failure
Refer to paper notes
Malnutrition in elderly
Around 10% of patients aged over 65 years are malnourished, the vast majority of those living independently, i.e. not in hospital or care/nursing homes.
Screening for malnutrition if mostly done using MUST (Malnutrition Universal Screen Tool). A link is provided to a copy of the MUST score algorithm.
* it should be done on admission to care/nursing homes and hospital, or if there is concern. For example an elderly, thin patient with pressure sores
* it takes into account BMI, recent weight change and the presence of acute disease
* categorises patients into low, medium and high risk
Management of malnutrition is difficult. NICE recommend the following points:
1. dietician support if the patient is high-risk
1. a ‘food-first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’), rather than just prescribing oral nutritional supplements (ONS) such as Ensure
1. if ONS are used they should be taken between meals, rather than instead of meals
1.
Hypothermia
Core temperature <35°C, but <35.5°C is probably abnormal
Causes
Often multifactorial.
* Illness (drugs, fall, pneumonia)
* Defective homeostasis (failure of autonomic nervous system-induced
shivering and vasoconstriction; decreased muscle mass)
* Cold exposure (clothing, defective temperature discrimination, climate, poeverty)
- Rectal temperature is the gold standard but well-taken oral or tympanic temperature will suffice.
- cold to touch, bradycardia
- Signs can mimic stroke with falls, unsteadiness,
weakness, - Hypomotility may lead to ileus, gastric dilation and
vomiting. - Disseminated intravascular coagulation (DIC), pressure injuries, and rhabdomyolysis
- Regular BP, pulse, temperature, respiratory rate, oxygen sats, glucose; continuous ECG; consider urinary catheter. Consider ITU.
Hypothermia is a common presentation of sepsis in hospital older ppl
- Mild hypothermia should be managed with gentle warming and close monitoring
- The features of severe hypothermia may mimic those of death. Beginresuscitation whilst gathering information that permits a decision as to whether further intervention is likely to be futile or else not in thepatient’s interests
Drug treatment
Consider: - Empirical antibiotics (most have evidence of infection on careful serial
assessment) - Adrenal insufficiency (treatment: hydrocortisone 100mg qds)
- Hypothyroidism (treatment: liothyronine 50micrograms then
25micrograms tds iv, always with hydrocortisone) - Thiamine deficiency (malnourished or alcoholic) (treatment: B vitamins
oral or iv) (as Pabrinex®)
Polypharmacy
Polypharmacy can cause problems, but is sometimes appropriate—
depriving patients of beneficial treatments because they are old, or already on multiple other medications, can also be wrong. In a recent study of medication changes during a geriatric admission, the total number of drugs was the same at admission and discharge, but they had often been changed. In other words, there was active evaluation of medication going on—the goal being not just to limit the number of drugs, but also to
optimize and individually tailor treatment
Do not deny older patients disease modifying treatments simply to avoid polypharmacy
Pressure Ulcers
RF: malnourishment, incontinence, lack of mobility, pain
Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age. They typically develop over bony prominences such as the sacrum or heel. The following factors predispose to the development of pressure
Grade 1 Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade 2 Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister
Grade 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss - Rhabdomyolysis
Rhabdomyolysis = AKI too
Managed: IV fluids to maintain good urine output
urinary alkalinization is sometimes used
Waterlow score to screen patients who r at risk of developing v these
Management
* a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
* wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
* consider referral to the tissue viability nurse
* surgical debridement may be beneficial for selected wounds
Multimorbidity
Hypertension is most common alongside another disease.
The presence of two or more long-term health conditions, including: Defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse
- Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire:
- Consider a ‘bisphosphonate holiday’ in those taking bisphosphonates for longer than three years as there is no consistent evidence of continued benefits after this point. Discuss stopping bisphosphonates after 3 years and include patient choice, fracture risk and life expectancy in the discussion.
- Consider the use of screening tools such as STOPP/ START in older people to recognise medicine safety concerns: STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions and START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
What tool is used to identify unecessary medications for elderly patients
- STOPP (Screening Tool of Older Persons’ Prescriptions)
- Checklist includes a list of common medications and drug classes that may be problematic for older adults due to factors such as increased sensitivity to side effects, potential interactions, or the presence of specific medical conditions.
STOPP identifies medications where risk outweighs therapeutic benefits
What tool is used to identify beneficial medications for elderly patients
- START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
