Geriatric medicine Flashcards
What can be seen microscopically on osteoporosis?
Reduced Tubercle
Thinning of cortical bone
Widening of harverian systems
Which areas are most at risk of developing pressure sores and must be regularly checked?
Sacrum Iliac Crest Greater trochanter Heels Malleolus
What scoring systems can be used to assess pressure ulcers?
Norton Scale for pressure sores
Waterloo pressure score risk assessment
What is the first line treatment for alzheimer’s disease?
Acetylcholinesterase inhibitors
- donepezil
- galantamine
What are some of the deterioration seen in the gait of the elderly?
Difficulty rising
Unsteady on standing
Unsteady gait
Unsteady on turning
Unsteady sitting down
Define what is meant by disability, frailty and comorbidity
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
How can frailty be assessed?
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
Name complications in diagnosis of disease in old age:
- 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
What are some risk factors for falls?
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
If someone falls what management should be undertaken?
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
How can physiotherapists help against falls?
Strengthening exercises
Balance exercises
What can be measured to assess risk of falls?
Sitting to standing time
Rise out of chair
Timed up and go test
Grip strength
What are the super six exercises that done for falls prevention at community rehab centres?
sit to stand heel raises toe raises one leg stands heel to toe heel to toe walking
How are the outcomes of community falls prevention services measured?
Tinetti Assessment
What are the interventions done to fall preventions in older people?
Individual or group strength and balance classes
Rationalism of medication
Correction of visual impairment
Home environmental hazard assessment
Calcium and Vitamin D supplementation
What are the types of urinary incontinence that can occur?
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
How is passive incontinence treated?
Physiotherapy
Walking aids - OT
Devices - Urisheaths
Urinary pads
How is Stress incontinence treated?
Conservative
- reduced caffeine
- Reduce BMI
Pelvic floor exercises
- 8 x 10secs contraction x 3 daily
Surgery
- Colususpsion
- mid Urethral sling
- urethral bulking
How is a overactive bladder treated?
Bladder training
Anticholinergic/ Anti - musuranics
Beta 3 Agonists
Botox
Sacral Nerve stimulation
What are some causes to faecal incontinence?
Anal sphincter dysfunction
- structural damage
- surgery
- birth
- radiation
- weak pelvic floor
Faecal overflow - long term constipation
- opioids
- neuropathic dysmotility
Loose stools
- infection
What are some ways of managing faecal incontinence?
Referral to incontinence nurse
Bowel training
Encouraging gastric colic reflexes
Incontinence control
Codiene/ phosphate enamea
- brake and accelerator approach
What are the grading scores for ulceration:
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
What is the definition of elderly abuse?
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
What are the five most common types of elderly abuse?
Physical
Psychological
Financial
Sexual
Neglect
What are some causes of malnutrition in the elderly?
Social isolation
Unable to access food
Decline in senses
- taste
- smell
- no activation of hunger
Decreased compliance/ relaxation of stomach
- early satiety
What is a scoring system that can be carried out to assess the nutritional status of someone?
MUST score
How does frontotemporal dementia present?
Social disinhibition and family history
*Anti- ACh and Mematamine are not recommended
What are some investigations into sarcopenia?
Nutritional assessment
Cadence speed
Grip strength
Bioelectrical analysis of muscles
List some causes for sarcopenia:
Cancer/ Chronic disease
lack of physical activity
poorer nutritional intake
reduced motor units
Hypo-vitamin D
What are the risk factors for osteoporosis?
Steroids Hyperparathyroidism/ Hypothyroidism Alcohol Low BMI Reduced Testosterone Menopause Renal Failure Erosive bone disease Dietary
What investigations can be done into Osteoporosis?
DEXA Scan
- lumbar of spine
- Proximal femur
Calcaneal Quantitative Ultrasound Scan
What is the management for osteoporosis?
Lifestyle measures
- weight lifting
- reduce smoking
- reduce alcohol
Assessment for falls
Medications:
- Bisphosphonates
- hormone replacement
- Denosumab - Anti RANKL
What are the common visual changes that occur in the elderly?
Visual Acuity changes
Cataracts
What DEXA score would give a diagnosis of osteoporosis?
T
Out with cognitive decline and memory, what other symptoms are associated with dementia?
Agitation
Aggression
apathy
Out with dementia screening tools such as AMTs and MMSE, what other investigations should be done into dementia?
Look for reversible and organic causes:
- TSH
- B12 level/ Folate
- Calcium level
- Alcohol? - thiamine
Head MRI
- vascular
- encephalitis
EEG
What are the subtypes of dementia?
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
When should alzheimer’s be suspected?
> 40 years old +
- progressive global cognitive impairment
- reduced viso-spatial skill
- memory
- verbal abilities
- executive functioning
What are some risk factors for developing Alzheimer’s disease?
1st degree relative
Down’s syndrome
Apolipoprotein E/ ApoE
Reduced cognitive/ physical activity
Depression/ loneliness
Smoking
What is the pharmacological management of dementia?
Acetylcholinesterase Inhibitors
- Donepezil
- Galantamine
- Rivastigmine
Glutamate antagonists
- Memantine
Vitamine supplementation
- Vitamin E
What are some side effects of Acetylcholinesterase inhibitors?
Peptic Ulcers
Heart Block
*bradycardia is contraindicated with actely-cholinsterase inhibitors
What is the prognosis of Alzheimer’s disease?
7 year survival from diagnosis
What are some other causes of depressive symptoms in elderly patients?
Grief
Hypothyroidism
Dementia
Dysthymia (persistent low mood)
What is the definition of a fall?
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.
What screening tools can be used for delirium?
4AT
- alertness
- Orientation to time and place
- Months backwards
- fluctuation
AMT
List some causes of false positives/ negatives for dementia/ delirium on screening tools:
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)
What recommended screening tools can be used for dementia/ cognitive decline?
MMSE/ MSE
Addenbrooke’s Cognitive test
MOCA
What investigations should be done when a patient presents after falling?
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
What scoring system can be used to assess patients at risk of developing pressure sores?
Waterloo score
Compare and contrast delirium vs dementia:
Delirium:
- abrupt onset
- Fluctuating course
- Short duration - days/ weeks
- Attention severely affected
- Sleep wake cycle distributed
- Incoherent speech (as opposed to impoverished)
Which Type of dementia is most associated with visual hallucinations?
Lewy Body Dementia
What are some physiological changes that occur in aging?
Reduced Respiratory Functioning
Reduction in renal function
Bone mass loss
25-50% loss of muscle
Visual deterioration
Brain atrophy
Neurosensory disturbance
What is the best intervention for frailty in the elderly?
Comprehensive Geriatric assessment
What is a comprehensive geriatric assessment?
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.
What are the 6 M’s?
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?
What does the 4AT consist of?
Alertness
AMT4
- age
- DOB
- Place
- Year
Attention
- months backwards
Acute or fluctuating consciousness
Where do the majority of falls take place?
Outside
What should the managed be for an elderly person who falls in the community?
Referral to Community falls prevent programme
Environmental assessment by and screening by OT
Referred to falls clinic
What is the management for an elderly person who falls and attends hospital:
A&E referral to community falls prevent programme
All patients have a Falls risk assessment done within 24 hours
Falls policy for inpatients
What are the best recommendations for falls prevention?
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
What happens at a falls clinic?
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
What are the implications of a fall?
Personal impact to patient
Prolonged hospitalisation
Increased mortality and morbidity
Litigation
What equipment can be put in place at the hospital to help prevent falls?
Bed monitors
Chair monitors
Non slip mats/ one way glides
specialist seating
Name a falls risk assessment:
Cannard Falls risk assessment
>18+ needs referral
What are the causes for delirium and how is it managed?
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
What investigations/ Management should be done into delirium?
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
Define delirium:
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
What are the differentials for delirium?
Dementia
Stroke
Metabolic disturbances
- hypoglycaemia
Status epilepticus
Hypoxia
What are some risk factors for delirium?
> 65
Dementia
Recent surgery
- hip surgery
Acute illness
Psychological agitation
Polypharmacy
Renal impairment
What are the giants of geriatrics?
Instability
Imbolility
Incontinence
Intellectual Impairment
What is the diagnostic criteria for dementia?
Impaired short and long term memory \+ (at least two) - Poor judgement - dysphasia - Dyspraxia - Agnosia (poor recognition) - Personality change
Interference with work and social living
What is the diagnostic criteria for delirium?
Acute change in mental status
Inability to maintain attention
Disorganised thinking
Altered level of consciousness
What is the detrimental outcomes of delirium?
Increased hospital stay
increased mortality
Increased cost to NHS
Increased risk of dementia
What initial things do you want to do when someone comes in with a fall?
ABCDE
- the D will probably be the major thing here.
- Blood glucose
- ECG
- BP standing and sitting
- CT head?
What investigations should be done into urinary incontinence?
Urine dipstick
Review of drug history (ACE inhibitors can make stress incontinence worse)
Urinary diary
Urodynamic studies
What is the exercise program for the elderly that is used?
OTAGO
What is histologically seen with Lewy Body Dementia?
Eosinophilic Cytoplasmic inclusion bodies
What proteins are seen in fronto-temporal dementia?
Tau proteins
What non-pharmacological measures can be done for dementia patients?
Aromatherapy
Multisensory stimulation
Massage
Music
Animal assisted therapy
What are some of the causes of dementia?
Degenerative
- AD
- Lewy body
Vascular
Metabolic
- liver failure
- uraemia
Infections
- HIV
- Neurosyphilus
Endocrine
- hypothyroidism
Which type of dementia should not be treated with acetylcholinesterase inhibitors?
Vascular
Frontal temporal dementia
What do you do when you suspect elderly mistreatment?
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
