Geriatrics Flashcards
Define frailty
State of increased vulnerability resulting from ageing-associated decline in physiological reserve and function across multiple systems
Results in adverse outcomes following minor stressors
Give an example of linked comorbidities seen in geriatrics
Smoking and COPD and lung cancer
Give an example of unlinked comorbidities seen in geriatrics
Diabetes, dementia and myeloma
Name the geriatric giants (4 Is)
Instability, intellectual impairment, incontinence, immobility
Name the geriatric giants
5 Ms
Mind, mobility, medications, multi-complexity, matters most
What is deconditioning?
Geriatric patients bedbound for days/weeks. See confusion, poor nutritional state (even prior to admission) and made worse by acute illness.
Ie old people have a series of physiological changes after prolonged periods of being in bed
Describe the clinical frailty score
Score of 1-9 with 1=very fit 2=well 3=managing well 4=vulnerable 5=mildly frail 6=moderately frail 7=severely frail 8=very severely frail 9=terminally ill
What comes under best practice for orthogeriatrics?
Prompt surgery within 36 hours, prompt orthogeriatric assessment within 72 hours, pre-op cognitive testing, delirium assessment after op, prompt mobilisation after surgery, fracture prevention assessment, nutritional assessment
Ways of assessing frailty?
CFS, walking speed, grip strength
If someone has fallen from standing height and broken their hip what must you consider?
BONES! probably got osteoporosis so need to be thinking about bisphosphonates, calcium and vitamin d replacement
Options for bisphosphonates
Oral alendronic acid/alendronate
IV zoledronic acid
Pros and cons of oral bisphosphonates
Pros: don’t need to be stabbed, can leave the patient to it
Cons: need to take it on a completely empty stomach, 30mins-2 hour before food or other fluids, take with a large gulp of water, need to remain sat upright for at 30 mins after taking it, can’t take with other medication
Pros and cons of IV zol
Pros: one injection lasts a whole year
Cons: a needle, have to give it over 15 mins, need to come in to have it
Name the rapid test for delirium
4AT : alertness, AMT4, attention, acute change/fluctuating course
Define delirium
acute confusional state that fluctuates in severity and is usually reversible
Usually the result of other organic processes
Define dementia
syndrome of acquired chronic global impairment of higher brain function, in an alert patient, which interferes with ability to cope with daily living
What are BPSDs?
Behavioural and psychological symptoms of dementia
Non cognitive symptoms eg agitation, depression, irritability, disinhibition, hallucinations
What do you see in hyperactive delirium?
Agitation, delusions, hallucinations, wandering, aggression
What are potential causes of delirium?
PINCH ME
Pain, infection, nutrition, constipation, hydration, medication, environment
In what proportion of patients is delirium preventable
1 in 3
What do you see in hypoactive delirium?
Can be confused with depression: lethargy, slowness, excessive sleeping, inattention
Give some examples of reversible dementias?
Around 10%
Depression, B12/folate, hypothyroid, normal pressure hydrocephalus
Describe the FRIED criteria
Frailty=clinical syndrome if at least 3 of:
Unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity
2 criteria=pre-frail
What are causes of malnutrition?
Decreased nutrient intake (starvation), increased nutrient requirements (sepsis, injury), inability to utilise nutrients ingested (malabsorption), combination of different reasons
Consequences of malnutrition?
Reduced ability to fight infection, muscle wasting, impaired wound healing, micronutrient deficiencies
leading to…
poorer prognosis/reduced quality of life/increased length of stay/more complications/more readmissions/greater community health needs
What is the MUST score?
Malnutrition universal screening tool
Based on BMI, height, weight loss, acute disease effect
Escalation of treatment of malnutrition?
Food first
ONS (oral nutritional supplement)
Enteral/parenteral nutrition
Pros and cons of enteral feeding
Pros: direct feeding into GI tract, preserves gut mucosa integrity, improves nutritional status, inexpensive vs parenteral
Cons: tolerance (nausea, satiety, bowels), tube can be uncomfortable to place, quality of life and personal appearance affected
Short term options for enteral feeding?
Nasogastric tube
For less than 30 days, check pH aspirate to confirm position, can be inserted at ward level
Long term options for enteral feeding?
PEG-percutaneous endoscopic gastrostomy
Indications= dysphagia, CF
Post pyloric/PEJ: percutaneous endoscopic jejunostomy
Indications= delayed gastric emptying, upper GI/pancreatic surgery, high risk aspiration, severe acute pancreatitis
When would you use parenteral feeding?
When gut inaccessible or unable to absorb sufficient nutrients to sustain nutritional status
Name a few indications for parenteral feeding?
Short bowel syndrome, GI fistula, bowel obstruction, prolonged bowel rest, severe malnutrition/sig weight loss/hypoproteinaemia
Options for parenteral feeding? Pros and cons?
PICC line or central line
Positives=can meet nutritional requirements, easily tolerated
Cons=costly, risk of line infection, more invasive procedure, gut atrophy
What is refeeding syndrome?
Group of clinical signs and symptoms that can occur in malnourished/starved patient when reintroducing nutrition
Pathophysiology of refeeding syndrome?
There is a shift in use of energy stores from fat metabolism to carb metabolism
Leads to increase in insulin and cellular uptake of potassium, phosphate and magnesium
Also a shift in fluid.
Can lead to fluid retention, cardiac arrhythmias,resp insufficiency and even death
How to manage refeeding syndrome?
Prevent=slow and gradual increase in carbs
Management: IV pabrinex or thiamine and vitamin B prior to feeding and for first 10 days. Slow reintroduction of nutrition over 4-7 days. Daily monitoring of refeeding bloods including U+Es, phosphate and magnesium
Correct until stable
Principles of UTI management in elderly?
Never dipstick urine in over 70s- naturally have white cells and bacteria in urine
Send off for MSU if symptomatic and treat the symptoms- nitro/trimethoprim are first line
