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Phase 4 > Geriatric medicine > Flashcards

Geriatric medicine Flashcards

1
Q

What can be seen microscopically on osteoporosis?

A

Reduced Tubercle
Thinning of cortical bone
Widening of harverian systems

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2
Q

Which areas are most at risk of developing pressure sores and must be regularly checked?

A 
Sacrum 
Iliac Crest 
Greater trochanter 
Heels 
Malleolus
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3
Q

What scoring systems can be used to assess pressure ulcers?

A

Norton Scale for pressure sores

Waterloo pressure score risk assessment

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4
Q

What is the first line treatment for alzheimer’s disease?

A

Acetylcholinesterase inhibitors

  • donepezil
  • galantamine
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5
Q

What are some of the deterioration seen in the gait of the elderly?

A

Difficulty rising

Unsteady on standing

Unsteady gait

Unsteady on turning

Unsteady sitting down

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6
Q

Define what is meant by disability, frailty and comorbidity

A

Disability indicates established loss of function

Frailty indicates increased vulnerability to loss of function / unable to withstand illness without loss of function

Comorbidity indicates multiple diagnoses

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7
Q

How can frailty be assessed?

A

By measuring the physiological function across a number of domains.

Fried Frailty score
Handgrip strength

Walking speed

Self reported exhaustion

Physically active

Loss of weight within 1 year

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8
Q

Name complications in diagnosis of disease in old age:

A
  • Present late
  • Present with atypical symptoms
  • Low functional status making seeing differences harder
  • Multiple pathologies

Late presentation
- patient often presume symptoms are part of getting old

Atypical presentation

  • pain receptors are blunted
  • M.Is often present differently
  • delirious presentation

Acute illness and changes of function are not as obvious

  • feel a bit off
  • pyrexia response if not the same

Multiple pathology
- the symptoms could be sourced to numerous different causes

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9
Q

What are some risk factors for falls?

A

History of falls

Muscle weakness

Gait or balance abnormalities

Visual disturbance

Cognitive impairment

  • delirium
  • dementia

Poor vision

Vertigo

Drugs

  • Sedatives
  • antipsychotics
  • antidepressants
  • anti - hypertension
  • more than 4 medications is a risk factor

Acute illness

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10
Q

If someone falls what management should be undertaken?

A

Following appropriate assessment and ABCDE:

  • Community Falls prevention programme
  • Environmental assessment by OT
  • Referral to falls clinic
  • ATAGO exercise programme
  • footwear/ footcare
  • specific managements
  • medications
  • postural hypotension
  • osteoporosis
  • visual optimisation
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11
Q

How can physiotherapists help against falls?

A

Strengthening exercises

Balance exercises

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12
Q

What can be measured to assess risk of falls?

A

Sitting to standing time

Rise out of chair

Timed up and go test

Grip strength

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13
Q

What are the super six exercises that done for falls prevention at community rehab centres?

A 
sit to stand 
heel raises 
toe raises 
one leg stands 
heel to toe 
heel to toe walking
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14
Q

How are the outcomes of community falls prevention services measured?

A

Tinetti Assessment

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15
Q

What are the interventions done to fall preventions in older people?

A

Individual or group strength and balance classes

Rationalism of medication

Correction of visual impairment

Home environmental hazard assessment

Calcium and Vitamin D supplementation

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16
Q

What are the types of urinary incontinence that can occur?

A

Functional Incontinence
- unable to make it to the toilet

Passive incontinence
- Decline in cognitive ability

Stress incontinence
- Weak sphincter vs intra abdominal pressures

Over active bladder

  • Psychological
  • Neurological conditions
  • Small bladder

Overflow Incontinence

  • prostate enlargement
  • pelvic mass
  • neurological conditions
  • in the absence of UTI
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17
Q

How is passive incontinence treated?

A

Physiotherapy
Walking aids - OT
Devices - Urisheaths
Urinary pads

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18
Q

How is Stress incontinence treated?

A

Conservative

  • reduced caffeine
  • Reduce BMI

Pelvic floor exercises
- 8 x 10secs contraction x 3 daily

Surgery

  • Colususpsion
  • mid Urethral sling
  • urethral bulking
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19
Q

How is a overactive bladder treated?

A

Bladder training

Anticholinergic/ Anti - musuranics

Beta 3 Agonists

Botox

Sacral Nerve stimulation

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20
Q

What are some causes to faecal incontinence?

A

Anal sphincter dysfunction

  • structural damage
  • surgery
  • birth
  • radiation
  • weak pelvic floor

Faecal overflow - long term constipation

  • opioids
  • neuropathic dysmotility

Loose stools
- infection

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21
Q

What are some ways of managing faecal incontinence?

A

Referral to incontinence nurse

Bowel training

Encouraging gastric colic reflexes

Incontinence control

Codiene/ phosphate enamea
- brake and accelerator approach

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22
Q

What are the grading scores for ulceration:

A

Stage 1: Non - blanching erythema

Stage 2: Shallow ulcer - epidermal layers

Stage 3: Deep ulcer involvement - thickness to dermis

Stage 4: Full thickness to bone

**grades 3-4 require to be reported to a serious incident

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23
Q

What is the definition of elderly abuse?

A

A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an elderly person

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24
Q

What are the five most common types of elderly abuse?

A

Physical

Psychological

Financial

Sexual

Neglect

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25
Q

What are some causes of malnutrition in the elderly?

A

Social isolation

Unable to access food

Decline in senses

  • taste
  • smell
  • no activation of hunger

Decreased compliance/ relaxation of stomach
- early satiety

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26
Q

What is a scoring system that can be carried out to assess the nutritional status of someone?

A

MUST score

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27
Q

How does frontotemporal dementia present?

A

Social disinhibition and family history

*Anti- ACh and Mematamine are not recommended

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28
Q

What are some investigations into sarcopenia?

A

Nutritional assessment
Cadence speed
Grip strength
Bioelectrical analysis of muscles

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29
Q

List some causes for sarcopenia:

A

Cancer/ Chronic disease

lack of physical activity

poorer nutritional intake

reduced motor units

Hypo-vitamin D

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30
Q

What are the risk factors for osteoporosis?

A 
Steroids 
Hyperparathyroidism/ Hypothyroidism 
Alcohol 
Low BMI 
Reduced Testosterone 
Menopause 
Renal Failure 
Erosive bone disease 
Dietary
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31
Q

What investigations can be done into Osteoporosis?

A

DEXA Scan

  • lumbar of spine
  • Proximal femur

Calcaneal Quantitative Ultrasound Scan

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32
Q

What is the management for osteoporosis?

A

Lifestyle measures

  • weight lifting
  • reduce smoking
  • reduce alcohol

Assessment for falls

Medications:

  • Bisphosphonates
  • hormone replacement
  • Denosumab - Anti RANKL
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33
Q

What are the common visual changes that occur in the elderly?

A

Visual Acuity changes

Cataracts

34
Q

What DEXA score would give a diagnosis of osteoporosis?

A

T

35
Q

Out with cognitive decline and memory, what other symptoms are associated with dementia?

A

Agitation
Aggression
apathy

36
Q

Out with dementia screening tools such as AMTs and MMSE, what other investigations should be done into dementia?

A

Look for reversible and organic causes:

  • TSH
  • B12 level/ Folate
  • Calcium level
  • Alcohol? - thiamine

Head MRI

  • vascular
  • encephalitis

EEG

37
Q

What are the subtypes of dementia?

A

Alzheimer’s disease

Vascular dementia
- sudden onset

Lewy Body Dementia

  • fluctuating cognitive impairment
  • progresses to Parkinson’s disease
  • characterised by eosinophilic cells on histology

Frontotemporal Dementia

  • Onset before 65
  • exudative dysfunction
  • personality changes
  • emotional unconcern
  • episodic memory etc is persevered until quite late on
38
Q

When should alzheimer’s be suspected?

A

> 40 years old +

  • progressive global cognitive impairment
  • reduced viso-spatial skill
  • memory
  • verbal abilities
  • executive functioning
39
Q

What are some risk factors for developing Alzheimer’s disease?

A

1st degree relative

Down’s syndrome

Apolipoprotein E/ ApoE

Reduced cognitive/ physical activity

Depression/ loneliness

Smoking

40
Q

What is the pharmacological management of dementia?

A

Acetylcholinesterase Inhibitors

  • Donepezil
  • Galantamine
  • Rivastigmine

Glutamate antagonists
- Memantine

Vitamine supplementation
- Vitamin E

41
Q

What are some side effects of Acetylcholinesterase inhibitors?

A

Peptic Ulcers

Heart Block

*bradycardia is contraindicated with actely-cholinsterase inhibitors

42
Q

What is the prognosis of Alzheimer’s disease?

A

7 year survival from diagnosis

43
Q

What are some other causes of depressive symptoms in elderly patients?

A

Grief
Hypothyroidism
Dementia
Dysthymia (persistent low mood)

44
Q

What is the definition of a fall?

A

An unexpected event which results in the patient coming to rest on the ground, floor or lower level. A fall doesn’t strictly have to be a collapse to the ground. It may be stumbling backwards into a chair or toilet.

45
Q

What screening tools can be used for delirium?

A

4AT

  • alertness
  • Orientation to time and place
  • Months backwards
  • fluctuation

AMT

46
Q

List some causes of false positives/ negatives for dementia/ delirium on screening tools:

A

False Positives:

  • language barrier
  • Nerves of patient
  • Feeling ill

False Negatives:

  • Previous heard answers
  • poor Testing technique
  • Education levels (someone well educated may pass certain tests, yet still had a significant reduction in their cognitive ability)
47
Q

What recommended screening tools can be used for dementia/ cognitive decline?

A

MMSE/ MSE

Addenbrooke’s Cognitive test

MOCA

48
Q

What investigations should be done when a patient presents after falling?

A

Beside tests:

  • basic observations
  • BM glucose
  • Blood pressure
  • Urine dip
  • ECG

Bloods:

  • FBC
  • U&Es
  • LFTs
  • Bone profile

Imaging

  • x-ray of injuries
  • CT of head if injured
  • Echo cardiogram
49
Q

What scoring system can be used to assess patients at risk of developing pressure sores?

A

Waterloo score

50
Q

Compare and contrast delirium vs dementia:

A

Delirium:

  • abrupt onset
  • Fluctuating course
  • Short duration - days/ weeks
  • Attention severely affected
  • Sleep wake cycle distributed
  • Incoherent speech (as opposed to impoverished)
51
Q

Which Type of dementia is most associated with visual hallucinations?

A

Lewy Body Dementia

52
Q

What are some physiological changes that occur in aging?

A

Reduced Respiratory Functioning

Reduction in renal function

Bone mass loss

25-50% loss of muscle

Visual deterioration

Brain atrophy

Neurosensory disturbance

53
Q

What is the best intervention for frailty in the elderly?

A

Comprehensive Geriatric assessment

54
Q

What is a comprehensive geriatric assessment?

A

Multidimensional interdisciplinary diagnostic approach to determine the physical, psychological and functional capacities of a frail elderly person - in order work out an integrated treatment with long term follow up.

55
Q

What are the 6 M’s?

A

Matter most to the patient
- DNACPR

Mind

  • delirium
  • depression
  • dementia
  • 4AT, AMT, further testing

Mobility
- Barthel Score

Medications
- Polypharmacy

Multi Comorbidities

Me and Mine
- who helps them?

56
Q

What does the 4AT consist of?

A

Alertness

AMT4

  • age
  • DOB
  • Place
  • Year

Attention
- months backwards

Acute or fluctuating consciousness

57
Q

Where do the majority of falls take place?

A

Outside

58
Q

What should the managed be for an elderly person who falls in the community?

A

Referral to Community falls prevent programme

Environmental assessment by and screening by OT

Referred to falls clinic

59
Q

What is the management for an elderly person who falls and attends hospital:

A

A&E referral to community falls prevent programme

All patients have a Falls risk assessment done within 24 hours

Falls policy for inpatients

60
Q

What are the best recommendations for falls prevention?

A

Adaptation and modification to home

Exercise training

  • strength
  • balance
  • Gait training

Withdrawal, minimisation of psychoactive medication

Withdrawal, minimisation of other medications

Management of postural hypotension

Management of foot problems

61
Q

What happens at a falls clinic?

A

Nurse assessment:

  • incontinence
  • AMT
  • visual acuity
  • ECG
  • Medication

Physio

  • Full neuromuscular exam
  • Tinetti - get up and go test

Medical

  • History
  • exam
  • Vertigo testing

Clinical psychology

MDT

  • list of problems and investigations needed
  • referral to Strength and balance classes
  • Community falls prevention class
62
Q

What are the implications of a fall?

A

Personal impact to patient

Prolonged hospitalisation

Increased mortality and morbidity

Litigation

63
Q

What equipment can be put in place at the hospital to help prevent falls?

A

Bed monitors

Chair monitors

Non slip mats/ one way glides

specialist seating

64
Q

Name a falls risk assessment:

A

Cannard Falls risk assessment

>18+ needs referral

65
Q

What are the causes for delirium and how is it managed?

A

MIST:

Metabolic abnormalities

  • hyponatremia
  • hypercalcaemia
  • Hypoglycemia

Infection

  • UTI
  • Malaria
  • Wounds

Surgical/ Stroke
- post Orthopaedic

Toxins/ Drugs

  • Dopamine agonists
  • Anticonvulsants

+

Constipation

Treatment:

  • reorientation
  • ensure glasses are being worn
  • clocks/ calendars in sight
  • Family members
  • Removal of indwelling devices

Medical treatment:
- Haloperidol

2nd line:
- benzodiazepines

66
Q

What investigations/ Management should be done into delirium?

A

4 AT

TIME check list:

T - Triggers (Causes)

I - Investigations

  • FBC
  • CRP
  • U&Es
  • Urine Dipstick
  • CXR?

M - Manage

E - Engage with families and friends

67
Q

Define delirium:

A

Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking, and altered levels of consciousness. with characteristics of:

  • hyperactivity
  • hypoactivity
  • mixed picture
  • hallucinations
68
Q

What are the differentials for delirium?

A

Dementia

Stroke

Metabolic disturbances
- hypoglycaemia

Status epilepticus

Hypoxia

69
Q

What are some risk factors for delirium?

A

> 65

Dementia

Recent surgery
- hip surgery

Acute illness

Psychological agitation

Polypharmacy

Renal impairment

70
Q

What are the giants of geriatrics?

A

Instability

Imbolility

Incontinence

Intellectual Impairment

71
Q

What is the diagnostic criteria for dementia?

A 
Impaired short and long term memory
\+ (at least two) 
- Poor judgement 
- dysphasia 
- Dyspraxia 
- Agnosia (poor recognition) 
- Personality change

Interference with work and social living

72
Q

What is the diagnostic criteria for delirium?

A

Acute change in mental status

Inability to maintain attention

Disorganised thinking

Altered level of consciousness

73
Q

What is the detrimental outcomes of delirium?

A

Increased hospital stay

increased mortality

Increased cost to NHS

Increased risk of dementia

74
Q

What initial things do you want to do when someone comes in with a fall?

A

ABCDE
- the D will probably be the major thing here.

  • Blood glucose
  • ECG
  • BP standing and sitting
  • CT head?
75
Q

What investigations should be done into urinary incontinence?

A

Urine dipstick

Review of drug history (ACE inhibitors can make stress incontinence worse)

Urinary diary

Urodynamic studies

76
Q

What is the exercise program for the elderly that is used?

A

OTAGO

77
Q

What is histologically seen with Lewy Body Dementia?

A

Eosinophilic Cytoplasmic inclusion bodies

78
Q

What proteins are seen in fronto-temporal dementia?

A

Tau proteins

79
Q

What non-pharmacological measures can be done for dementia patients?

A

Aromatherapy

Multisensory stimulation

Massage

Music

Animal assisted therapy

80
Q

What are some of the causes of dementia?

A

Degenerative

  • AD
  • Lewy body

Vascular

Metabolic

  • liver failure
  • uraemia

Infections

  • HIV
  • Neurosyphilus

Endocrine
- hypothyroidism

81
Q

Which type of dementia should not be treated with acetylcholinesterase inhibitors?

A

Vascular

Frontal temporal dementia

82
Q

What do you do when you suspect elderly mistreatment?

A

Interview patient alone
Seek senior help
Alert police or social worker

  • if they lack capacity then the relevant people must be contacted. This is under the:
  • Adult Support and Protection Act 2007

Phase 4 (49 decks)

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