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Geriatric Syndromes Flashcards

1
Q

What are the tools used to identify frailty?

A

FRAIL Scale
Clinical Frailty Scale

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2
Q

Components of FRAIL scale?

A

Fatigue
Resistance
Ambulation
Illness
Loss of weight

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3
Q

Goals of therapy for frailty

A
  1. What matter most to the patient
  2. Establish goals prior to deciding interventions
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4
Q

Intervention of frailty (1)

A

Physical/occupational exercises

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5
Q

Intervention of frailty (2)

A

Nutritional intake with oral nutritional supplement

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6
Q

Intervention of frailty (3)

A

Medication review
a. DRPs affecting 1st and 2nd intervention
b. Vitamin D supplementation

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7
Q

Fall risk identification

A

Fall history
Mobility
Sensory function
Activities of daily living
Cognitive function
Autonomic function
Disease history
Medication history
Nutrition history
Environment hazard

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8
Q

Stratification based on future fall risk

A

Fall past 12 months?
Gait and balance impaired?

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9
Q

FRIDs mechanism of harm

A
  1. Sedation
  2. Orthostatic hypotension
  3. Anticholinergics
  4. Hypoglycaemia
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10
Q

STOPPPFall consensus round 1

A

BZD
Antipsychotic
BZD-related drugs
Opioids
Antidepressants
Anticholinergics
Antiepileptics
Diuretics
Alpha blocker as anti-HTN

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11
Q

STOPPPFall consensus round 2

A

Alpha blocker for prostate hyperplasia
Centrally-acting antihypertensives
Antihistamines
Vasodilators used in cardiac diseases

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12
Q

STOPPPFall consensus round 3

A

Overactive bladder and urge incontinence medications

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13
Q

What are the 4 types of dizziness?

A

Vertigo
Pre-syncopal dizziness
Dysequilibrium
Unspecified dizziness

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14
Q

Evaluation of dizziness

A

TiTraTE
- Timing
- Triggers
- Targetted examination

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15
Q

7 types of dizziness that we can aim to treat underlying cause

A

BPPV
Orthostatic hypotension
Meniere’s Disease
Vestibular Migraine
Psychogenic dizziness
Drug-induced dizziness
Vestibular neuronitis

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16
Q

Pharmacotherapy for vestibular symptoms (only for prolonged >30mins)

A
  1. Antihistamines – diphenhydramine, dimenhydrinate, meclizine
  2. Phenothiazines – prochlorperazine, promethazine
  3. Anticholinergics – hyoscine hydrobromide
  4. BZDs – lorazepam, diazepam, clonazepam
  5. Antidopaminergic – metoclopramide
  6. calcium channel antagonist – cinnarizine
  7. Histamine analogues – betahistine
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17
Q

Side effects of anticholinergics

A

Dry mouth
Urinary retention
Tachycardia
Risk of increasing BP

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18
Q

Phenothiazines

A

Additional antidopaminergic effects
Contraindicated in Parkinsonism (as it may worsen movement disorders)

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19
Q

BZDs

A

More sedating
Increases fall risk
Only for short term use for a few days
Cognitive impairment, depression

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20
Q

Calcium channel antagonist

A

Sedating
Weight gain
Has antihistaminergic effect
Caution in Parkinsonism

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21
Q

Histamine analogues

A

Use with caution in asthma
Contraindicated if active/history of PUD

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22
Q

Delirium subtypes

A

Hyperactive
Hypoactive

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23
Q

Risk factors for delirium

A

65 years or older
Cognitive impairment and/or dementia
Current hip fracture
Severe illness

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24
Q

Detection of delirium

A

Confusion assessment method (CAM)
4AT

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25
Q

Components of 4AT

A

Level of alertness
- State name and address
Abbreviated mental test 4 (AMT4)
- Age, date of birth, place, current year
Attention
- List months in reverse order
Acuity
- Significant mental change or fluctuation the last 2 weeks and persisting in last 24 hours

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26
Q

Diagnosis of delirium

A

Physical examination
- Vital signs, hydration status, skin conditions, potential infection foci
History
Labs/imaging studies

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27
Q

Causes of delirium

A

I WATCH DEATH

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28
Q

I WATCH DEATH

A

Infectious
Withdrawal
Acute metabolic disorder
Trauma
CNS pathology
Hypoxia
Deficiencies
Endocrinopathies
Acute vascular
Toxins, substance use, medication
Heavy metals

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29
Q

Drugs believed to increase risk of delirium (4)

A

Strong anticholinergic
BZD – not to cease chronic BZD abruptly especially if used for seizure, REM, sleep behaviour disorders, anxiety
Z-drugs
Opioids – especially Pethidine
H2RA – if delirious use PPI, if not possible, use famotidine at really adjusted dose

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30
Q

Drugs believed to cause/prolonged delirium (14)

A

Analgesics – opioids especially pethidine
Antimicrobials – fluroquinolone, cefepime
Anticholinergics
Corticosteroids
Dopamine agonists
GI agents
Herbs – atropa belladonna extract
Hypoglycaemics
Hypnotics/sedatives
Anticonvulsants
Antidepressants
CV drugs – digoxin
Muscle relaxants
Other psychoactive agents – lithium

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31
Q

Prevention of delirium (a)

A

Sensory function optimisation
– hearing/visual aids

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32
Q

Prevention of delirium (b)

A

Hydration/nutrition

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33
Q

Prevention of delirium (c)

A

Bowel movement/urination

34
Q

Prevention of delirium (d)

A

Early mobility

35
Q

Prevention of delirium (e)

A

Pain control

36
Q

Prevention of delirium (f)

A

Medication review

37
Q

Prevention of delirium (g)

A

Social interaction with loved ones

38
Q

Prevention of delirium (h)

A

Reorientation with clock/calendar/proper lighting
- Introducing cognitively stimulating activities

39
Q

Prevention of delirium (i)

A

Conducive environment

40
Q

Prevention of delirium (j)

A

Promote good sleep

41
Q

Prevention of delirium (k)

A

Address infection/hypoxia

42
Q

First line for agitation in delirium

A

Non-pharmacological interventions

43
Q

Pharmacotherapy for agitation in delirium?

A

Antipsychotics
Benzodiazepines

44
Q

Antipsychotics of choice in agitation

A

(non-ICU) SC/IM/PO Haloperidol 0.3-1mg BD, put to 5mg/day
Atypical antipsychotics
- PO only quetiapine 6.25-12.5mg BD, up to 100mg/day
- (safest QTc?) PO Olaznapine 1.25mg-2.5mg up to 10mg/day

45
Q

Caution/consideration for antipsychotic use in agitation

A

Only short term use due to higher risk of mortality and possibly stroke when used in patients with dementia

46
Q

Benzodiazepines of choice in agitation

A

PO/IV/SC Lorazepam 0.5-1mg

47
Q

Physiology of lower urinary tract

A

Bladder filling phase
- Activation of sympathetic, blockade of parasympathetic
- Bladder activation when b3 adrenergic receptor is activated
- Tightening of bladder outlet/urethra when a1 adrenergic receptor is activated
Bladder voiding phase

48
Q

Types of UI

A

Stress
Urge
Overflow
Functional

49
Q

Stress UI

A

Involuntary loss of urine in small amount with increasing intra abdominal pressure

50
Q

Urge UI

A

Leakage of urine because of inability to delay voiding after sensation of bladder fullness is perceived

51
Q

Functional UI

A

Urinary accidents associated with the inability to toilet because of impairment of cognitive and/or physical functioning, psychological unwillingness, environmental barriers

52
Q

How to determine UI types?

A
  1. During past 3 months have you leaked urine (even a small amount)?
  2. During the past 3 months, did you leak urine while
    a. performing some physical activity like coughing, sneezing, lifting, exercising
    b. cannot get to toilet fast enough
    c. without physical activity and without sense of urgency
  3. …. did you leak urine most often: a, b, c, d equally as often with physical activity as with a sense of urgency
53
Q

Differential diagnosis of transient cause of UI

54
Q

D in DIAPPERS

55
Q

I in DIAPPERS

A

Infection (acute UTI)

56
Q

A in DIAPPERS

A

Atrophic vaginitis

57
Q

P1 in DIAPPERS

A

Pharmaceuticals

58
Q

P2 in DIAPPERS

A

Psychological disorders

59
Q

E in DIAPPERS

A

Excessive urine output (hyperglycaemia)

60
Q

R in DIAPPERS

A

Reduced mobility or reversible (drug induced) urinary retention

61
Q

S in DIAPPERS

A

Stool impaction

62
Q

How does antihistamines/anticholinergics affect bladder function?

A

Decreased contractility via anticholinergic effects

63
Q

How does cholinesterase inhibitors (PD/AD) affect bladder function?

A

UI, interactions with anti-muscarinics

64
Q

How do decongestants affect bladder function?

A

Increased urethral sphincter tone

65
Q

How do BZDs affect bladder function?

A

Impaired micturition via muscle relaxant effect

66
Q

How do opioids affect bladder function?

A

Decreased sensation of fullness and increased sphincter tone

67
Q

How do GABAnergic agents (Gabapentin, Pregabalin) affect bladder function?

A

Edema causing nocturne and nighttime incontinence

68
Q

How do ACEi affect bladder function?

A

Decreased contractility, chronic coughing

69
Q

How do a-agonists (midodrine, phenylephrine) affect bladder function?

A

Increased urethral sphincter

70
Q

How do a1-blocker (BPH medicines) affect bladder function?

A

Decreased urethral sphincter tone

71
Q

How do anti-arrythmics affect bladder function?

A

Decreased contractility via local anaesthetic effect on bladder mucosa or anticholinergic effect

72
Q

How do CCBs affect bladder function?

A

Impaired detrusor contractility and retention, DHP agents can cause pedal edema leading to nocturnal emptying

73
Q

How does diuretic affect bladder function?

A

Increase urine production, contractility or rate of emptying

74
Q

How do thiazolidinediones affect bladder function?

A

Pedal edema causing nocturnal polyuria

75
Q

How do TCAs/SNRIs affect bladder function?

A

Decreased contractility via anticholinergic effects

76
Q

How does duloxetine affect bladder function?

A

Increased urethral sphincter tone

77
Q

How do antipsychotics (e.g. chlorpromazine) affect bladder function?

A

Decreased contractility via anticholinergic effect, increased malnutrition and stress UI via simulation of a1 receptors and/or central dopaminergic receptors

78
Q

How do oestrogen affect bladder function?

A

Increased urinary incontinence

79
Q

Non-pharmacological management of UI

A
  • Address underlying cause
  • Lifestyle modifications (weight loss, normal bowel habits, reduce bladder irritants, water hygiene
  • Bladder retraining
  • Kegel’s pelvic floor muscle exercise
  • Timed voiding
  • Continent products
80
Q

Pharmacological management for Stress UI

A
  • Kepel’s exercise
  • Topical oestrogen (may take up to 3 months)
  • Duloxetine (unless CrCl<30)

Multi-morbid (5 decks)

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