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My Phase 3a > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Define Frailty

A

State of increased vulnerability from ageing, associated decline in reserve and function cross multiple physiological systems such that the ability to cope with every day or acute stressors is compromised

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2
Q

Give the main features of frailty

A
  • Poor function reserve
  • Vulnerable to decompensation when facing illness, drug side effects, metabolic disturbance
  • It is NOT inevitable
  • Marker of mortality
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3
Q

Give 2 ways to prevent frailty

A
  1. Good nutrition
  2. Physical activity
  3. Avoid social isolating
  4. Decrease alcohol intake
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4
Q

Give 2 ways to assess frailty

A
  1. Clinical Frailty Score
  2. Walking speed = time to get up and walk 6m, good = <12s
  3. Grip strength
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5
Q

What are the 5 geriatrics Ms and give an example of each?

A
  1. Mind –> dementia, delirium, depression
  2. Mobility –> impaired gait and balance, falls
  3. Medications –> polypharamcy, deprescribing/optimal prescribing, adverse effects, medication burden
  4. Multi-complexity –> multi morbidity, bio-psycho-social situations
  5. Matters most –> individual meaningful health outcomes and preferences
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6
Q

What needs to be taken into consideration in a comprehensive assessment for discharge planning?

A
  1. Medical assessment –> diagnosis and treatment, co-morbidities, med review = Dr
  2. Functional assessment –> ADLs, gait, balance = OT, PT
  3. Psychological assessment –> cognition, mood
  4. Social assessment = care resources, finances = social worker
  5. Environmental assessment = home safety
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7
Q

What are possible legal or ethical issue with geriatric patients?

A
  • Care at the end of life
  • Discharge destination
  • Dementia and delirium
  • Mental capacity act
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8
Q

Define palliative care

A

Treatment that recognises the irreversible nature of the underlying disease –> holistic approach, symptom control

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9
Q

What is Advanced Care Planning?

A

A process of discussion about goals of care and means of setting on record preferences for care of patients who may lose capacity or communicating ability in the future

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10
Q

What can Advanced Care Planning include?

A
  • Legal aspects
  • Preferred place of care
  • Treatment options acceptable to patient and suitable for patient
  • DNACPR
  • Specific plan for a complex situation
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11
Q

Give 2 advantages of Advanced Care Planning

A
  1. Open ended
  2. Personalised care
  3. Avoids futile disease orientated treatment
  4. Patient centred goal
  5. Improves coordination of care
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12
Q

Give 3 risk factors for falls

A
  1. Motor problems –> gait, balance
  2. Sensory impairment
  3. Cognitive/mood impairment –> dementia, delirium, depression
  4. Orthostatic hypotension
  5. Polypharmacy
  6. Alcohol, drugs
  7. Environmental hazards
  8. Incontinence
  9. Fear of falling
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13
Q

Give 3 causes of falls

A
  1. Drugs –> sedative, alcohol
  2. MSK –> OA hip
  3. Syncope –> vasovagal, cariogenic, arrhythmias
  4. Stroke, TIA
  5. DM, hypoglycaemia
  6. Visual impairment
  7. Dementia
  8. Poor environment
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14
Q

What is the management of falls?

A
  • Strength and balance training
  • Home hazard intervention
  • Correct vision
  • Review medication
  • Integrated management of contributing morbidities
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15
Q

Give 2 possible complications a long lie following a fall

A
  1. Rhabdomyolysis
  2. Pressure ulcers
  3. Dehydration
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16
Q

What is Rhabdomyolysis?

A

Skeletal muscle breaks down due to traumatic, chemical or metabolic injury –> results from death of muscle fibres and release of their content (myoglobin, potassium, phosphate, creatine kinase) into the bloodstream

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17
Q

Give 2 causes of Rhabdomyolysis

A
  1. Crush injuries
  2. Prolonged immobilisation following a fall
  3. prolonged seizure activity
  4. Hyperthermia
  5. Neuroleptic malignancy syndrome
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18
Q

What is the clinical presentation of Rhabdomyolysis?

A
  • Muscle aches and pain
  • Oedema
  • Fatigue
  • Confusion
  • Red-brown urine
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19
Q

What investigations would you do and what would you see in someone with Rhabdomyolysis?

A
  • Creatine Kinase –> very elevated
  • Myoglobinurea –> red-brown urine
  • U&Es –> AKI, hyperkalaemia
  • ECG –> hyperkalaemia
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20
Q

What is the management of Rhabdomyolysis?

A

Supportive –> fluids, electrolyte correction

Renal Replacement therapy

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21
Q

Give 2 possible complications of Rhabdomyolysis?

A
  1. Kidney failure –> due to myoglobin

2. Cardiac arrhythmias –> cardiac arrest due to hyperkaleamia

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22
Q

Give 3 signs of hyperkalaemia on an ECG

A
  1. Tall tented T waves
  2. Prolonged PR
  3. Loss of P wave
  4. Broad QRS
  5. ST elevation
  6. Sine wave pattern
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23
Q

Define ulcer and pressure ulcer

A

Ulcer = break in the skin mucous membrane which fails to heal

Pressure ulcer = ulcer caused by pressure or shear force over a bony prominence

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24
Q

Give 2 risk factors for pressure ulcers

A
  1. Immobility
  2. Poor nutrition
  3. Incontinence
  4. Multiple comorbidities
  5. Smoking
  6. Dehydration
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25
Q

What investigations would you do for someone with a possible pressure ulcer?

A
  • Waterlow score = assesses risk of developing a pressure ulcer
  • Admission with ulcer –> CRP, ESR, WCC, swabs, cultures, XR
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26
Q

What is the preventative management of pressure ulcers?

A
  • Barrier creams
  • Pressure redistribution
  • Repositioning
  • Regular skin assessment
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27
Q

What is the treatment of pressure ulcers?

A

Abx
Wound dressing
Pain relief
Debridement if grade 3 or 4

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28
Q

Define osteoporosis

A

Progressive deterioation of bone mass and microarchitecture

A systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture

Decreased bone mineral density due to imbalance between remodelling and resorption

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29
Q

Give 3 risk factors of osteoporosis

A

SHATTERED

  1. Steroids
  2. Hyperthyroidism, hyperparathyroidism, hypocalcaemia
  3. Alcohol and smoking
  4. Thin = BMI <18.5
  5. Testosterone decreased
  6. Early menopause = oestrogen deficiency
  7. Renal/liver failure
  8. Erosive/IBD
  9. Dietary intake –> decreased Ca, malabsorption, T1DM
  10. Previous fracture or FHx of osteoporosis or fracture
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30
Q

Give 3 possible cause of osteoporosis and briefly describe why

A
  1. AI conditions (RA, IBD) –> inflammatory cytokine increases bone resorption
  2. Hyperthyroidism/hyperparathyroisim –> increased bone turnover
  3. Cushings –> cortical increases bone resorption and induces osteoblast apoptosis
  4. Post menopausal –> less oestrogen so high bone turnover = resorption > formation
  5. Low body weight and immobility –> reduced skeletal loading increases resorption
  6. Medications –> glucocorticoids, Depo-povera, aromatase inhibitor, GnRH analogues, androgen deprivation
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31
Q

How does osteoporosis present?

A

Usually asymptomatic

Fragile bones and pathological fractures (NOF, spine)

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32
Q

What investigations might you do in someone with suspected osteoporosis?

A
  • Bone mineral density scan = DEXA scan
  • Bone profile –> normal Ca, phosphate, alkP, can have low vit D
  • FRAX
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33
Q

What does a DEXA scan show?

A 
Looks at bone mineral density
Give a T score = standard deviation score which compares with gender matched young adult average: 
>-1.0 = normal 
-1 to -2.5 = osteopenia
< -2.5 = osteoporosis
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34
Q

What is FRAX and what does it take into consideration?

A 
Predicts 10 year fracture change (primary prevention) 
Looks at:
- Age 
- Sex (female) 
- Height and weight 
- Previous fracture 
- Parent fractured hip 
- Current smoking 
- Glucocorticoids 
- RA 
- Secondary osteoporosis 
- Alcohol 3 or more units per day 
- Femoral neck BMD
35
Q

What is the non-pharmacological management of osteoporosis?

A
  • Physio –> weight bearing exercise and falls prevention
  • Smoking cessation
  • Reduce alcohol
  • Increase Ca and Vit D
36
Q

What is the pharmacological management of osteoporosis?

A

Anti-resorptive = decrease osteoclast activity and bone turnover

  • Bisphosphonates (inhibit cholesterol formation leading to osteoclast apoptosis) –> alendronate oral (upright for 30 mins and before eating)
  • HRT
  • Denosumab = monoclonal antibody to RANK ligand slowing osteoclast activity

Anabolic = increase osteoblast activity and bone formation
- Teriparatide (PTH analogue) –> increased bone density and improves trabecular strength

37
Q

What are the determinants of bone strength?

A
  1. Bone mineral density
  2. Bone size
  3. Geometry
  4. Microarchitecture
  5. Turnover
  6. Mineralisation
38
Q

Define osteopenia

A

Precursor to osteoporosis characterised by low bone density

T score -1 to -2.5

39
Q

Define osteomalacia

A

Poor bone mineralisation leading to soft bones due to lack of Ca2+, phosphate and vitamin D

40
Q

Give 2 causes of Malnutrition

A
  1. Decreased nutrient intake
  2. Increased nutrition requirement –> sepsis, injury
  3. Inability to utilise nutrients ingested –> malabsorption, severe diarrhoea, high output stoma
  4. Combination of above
41
Q

Give 3 possible consequences of Malnutrition

A
  1. Decreased immunity
  2. Muscle wasting –> falls, increased chest infections, decreased mobility
  3. Impaired wound healing
  4. Micronutrient deficiencies
  5. Poor prognosis, reduced QOL
42
Q

How is malnutrition assessed?

A

MUST = Malnutrition universal screening tool

- BMI, History of weight loss, acute disease effect

43
Q

What is the management of malnutrition?

A
  • FOOD 1st –> snacks, nourishing drinks, food fortification
  • Oral nutritional supplements –> liquid, powder, semi solid
  • Enteral/parenteral feeding –> NG, gastrostomy, PEG
44
Q

What is enteral feeding and name the types?

A

Direct feeding into the gut

  • NG = feeds into stomach, short term (<30d), ward level insertion
  • NJ = feeds into jejunum, short term (<60d), XR check
  • PEG (percutaneous endoscopic gastrostomy)
45
Q

Give 2 advantages and 2 disadvantages of enteral feeding

A

Advantages

  1. Preserves gut mucosa and integrity
  2. Improved nutritional status
  3. Less invasive than parenteral

Disadvantages

  1. Tolerance –> nausea, satiety, bowels
  2. Uncomfortable to place
  3. QOL
46
Q

When is a PEG indicated?

A
  1. Dysphagia –> storke, MND
  2. Cystic fibrosis –> high nutritional requirements
  3. Oral intake inadequate and likely long term
47
Q

What is parenteral feeding?

A

Intravenously feeding when gut is inaccessible or unable to absorb sufficient nutrients to sustain nutritional status

48
Q

What is refeeding syndrome?

A

Metabolic disturbance as a result of reinstating nutrition to patients who are starved/severely malnourished

49
Q

Give 3 signs of refeeding syndrome

A
  1. Hypophosphataemia
  2. Hypokalaemia
  3. Thiamine deficiency
  4. Abnormal glucose metabolism
50
Q

Give 2 possible complications of refeeding syndrome

A
  1. Cardiac arrhythmias
  2. Convulsions
  3. Cardiac failure
51
Q

Define polypharmacy

A

The concurrent use of multiple medications by 1 person (often stated as >5)

52
Q

Define appropriate polypharmacy

A

Prescribing multiple medications for either complex conditions or multiple concurrent conditions where medicine use has been optimised

53
Q

Define problematic polypharmacy

A

When multiple medicated are prescribed inappropriately, increasing the risk of side effects

54
Q

Give 2 reasons polypharmacy occurs in the elderly

A
  1. Multimorbidity
  2. Incremental prescribing
  3. EOL considerations
55
Q

Give 2 problems with polypharamcy

A
  1. Adverse reactions may go undetected, as linked with older age –> forgetfulness, weakness, tremor
  2. Adverse reactions may be misinterpreted as a problem –> another prescription
  3. Inappropriate drug uses –> patients doesn’t understand, own interpretation of instruction
  4. Medication nonadherance
56
Q

What are common adverse drug reactions?

A

Falls –> postural hypotension
CONfusion –> sedation
Bowel problems –> diarrhoea or constipation

57
Q

Define delirium

A

Clinical syndrome characterised by disturbed consciousness, cognitive function or perception
Acute confusional state that fluctuates in severity and is usually reversible

58
Q

Give 3 risk factors for delirium

A
  1. Older than 65
  2. Significant comorbidities
  3. hip fracture
  4. Dementia
  5. Cognitive impairment
  6. Change of environment
59
Q

Give 4 causes of delirium

A

PINCH ME

  1. Pain
  2. Infection
  3. Nutrition
  4. Constipation
  5. Hydration
  6. Metabolic/medications
  7. Environment

Hypoxia, hypo/hyperthermia, organ dysfunction

60
Q

Give 3 signs of a hyperactive delirium

A
  1. Agitation
  2. Aggression
  3. Restlessness
  4. readily distracted
  5. Wandering
  6. Hallucinations
61
Q

Give 3 signs of a hypoactive delirium

A
  1. Lethargy
  2. Apathy
  3. Excessive sleeping
  4. Inattention
  5. Motor retardation
  6. Drowsy
  7. Unarousable
62
Q

What investigations might you do for a patient with suspected delirium

A
  • Delirium screening bloods = FBC< U&Es, CRP, LFTs, Clotting, TFTs, Calcium, Haematinics, B12/folate
  • Septic screen
  • ABG
  • Urinalysis
  • Sputum sample
  • CXR
  • CURB65
63
Q

What is urge incontinence?

A

Overactivity of detrusor muscle

- Sudden feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs

64
Q

What is stress incontinence?

A

Weak pelvic floor and sphincter muscles so urine leaks at times of increased pressure on the bladder
- Laughing, coughing, straining

65
Q

What is overflow incontinence?

A

Chronic urinary retention due to obstruction to the outflow of urine resulting I overflow of urine and the incontinence occurs without urge to pass urine

66
Q

Give 2 possible causes of overflow incontinence

A
  1. Ach medications
  2. Fibroids
  3. Pelvic tumours
  4. Constipation
  5. Neurological conditions –> MS, diabetic neuropathy, spinal cord injuries
67
Q

Give 3 risk factors for incontinence

A
  1. Increased age
  2. Postmenopausal status
  3. INCreased BMI
  4. Previous pregnancies and vaginal deliveries
  5. Pelvic organ prolapse
  6. Pelvic floor surgery
  7. Neurological conditions –> MS
  8. Cognitive impairment –> dementia
68
Q

What investigations might you do for someone with incontinence?

A
  • Good history (lifestyle factors) and examination
  • Bladder diary
  • Urine dipstick
  • Post void residual bladder volume
  • Urodynamic testing
69
Q

What is the management for stress incontinence?

A
  • Lifestyle = avoid caffeine, diuretics and overfilling bladder, weight loss, pelvic floor exercise
  • Duloxetine
  • Surgical = sling, colposuspension, artificial sphincter
70
Q

What is the management for urge incontinence?

A
  • Bladder training
  • Anticholinergic medications = oxybutynin, tolterodine, solifenacin
  • Mirabegron = B3 agonist
  • Invasive = botox, sacral nerve stimulation, cystoplasty, urinary diversion
71
Q

What is Heart Failure?

A

CO is inadequate for body requirements
Inability of the heart to deliver blood and thus O2 at a rate that is commensurate with the requirement of metabolising tissue of the body

72
Q

Give 3 risk factors of heart failure

A
  1. > 65
  2. African descent
  3. Men
  4. Obesity
  5. Previous MI
73
Q

What are the 3 cardinal symptoms of heart failure?

A
  1. SOB
  2. Fatigue
  3. Peripheral oedema
74
Q

Give 3 other symptoms of heart failure

A
  1. Tachypnoea
  2. Orthopnoea
  3. Paroxysmal nocturnal dyspnoea
  4. Pink frothy sputum
  5. Cough
  6. Weight loss
  7. Cold peripheries
75
Q

Give 3 signs of heart failure

A
  1. Crackle in lungs
  2. Heart murmurs
  3. Oedema, ascites
  4. Hypotension
  5. Cyanosis
  6. Displaced apex beat
  7. Raised JVP
76
Q

Describe the New York Heart Association Classification (NYHA)

A
  • Class 1 = asymptomatic, no limitation
  • Class 2 = Mild HF, slight limitation
  • Class 3 = moderate HF, marked limitation
  • Class 4 = severe HF, inability to carry out any physical activity without discomfort
77
Q

Define systolic and diastolic heart failure

A

Systolic = inability of ventricle to contract normal –> decrease in CO

Diastolic = inability of ventricle to relax and fill properly –> decreased SV and CO

78
Q

Give 3 causes of HF

A
  1. Ischaemic heart disease
  2. Cardiomyopathy
  3. Valvular heart disease –> AS
  4. Cor pulmonale
  5. HTN
  6. Alcohol excess
79
Q

What is seen on a CXR of someone with HF

A

ABCDE

  1. Alveolar Bat wing oedema a
  2. Kerley B lines
  3. Cardiomegaly
  4. Dilated prominent upper lobe vessels
  5. Pleural Effusion
80
Q

What is the blood marker of HF?

A

Brain natriuretic peptide (BNP)

- Secreted by ventricles in response to increased myocardial wall stress

81
Q

How is acute HF managed?

A

LOON

  • Loop diuretic = furosemide
  • Oxygen
  • Opioid = diamorphine
  • Nitrates = GTN spray
82
Q

What is the prevention of chronic HF?

A

Lifestyle modification = stop smoking, healthy eating, exercise, avoid large meals, vaccinations
Treat underlying cause –> dysrhythmias, valve disease

83
Q

What is the management of chronic HF?

A
  • Loop diuretic and thiazides –> fluid overload
  • ACEi = ramipril
  • BB = propranolol, atenolol
  • Aldosterone antagonist = spirolactone
  • Anticoagulation therapy and aspirin
  • CCB = amlodipine
  • ARB = losartan, candesartan (if ACEi ineffective)
  • Digoxin
  • Vasodilators = hydralazine
  • Surgery –> revascularisation, transplant, resync, defib

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