Geriatrics

Question 1

Define frailty

Answer 1

State of increased vulnerability resulting from ageing-associated decline in physiological reserve and function across multiple systems
Results in adverse outcomes following minor stressors

Question 2

Give an example of linked comorbidities seen in geriatrics

Answer 2

Smoking and COPD and lung cancer

Question 3

Give an example of unlinked comorbidities seen in geriatrics

Answer 3

Diabetes, dementia and myeloma

Question 4

Name the geriatric giants (4 Is)

Answer 4

Instability, intellectual impairment, incontinence, immobility

Question 5

Name the geriatric giants

5 Ms

Answer 5

Mind, mobility, medications, multi-complexity, matters most

Question 6

What is deconditioning?

Answer 6

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

Question 7

Describe the clinical frailty score

Answer 7

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

Question 8

What comes under best practice for orthogeriatrics?

Answer 8

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

Question 9

Ways of assessing frailty?

Answer 9

CFS, walking speed, grip strength

Question 10

If someone has fallen from standing height and broken their hip what must you consider?

Answer 10

BONES! probably got osteoporosis so need to be thinking about bisphosphonates, calcium and vitamin d replacement

Question 11

Options for bisphosphonates

Answer 11

Oral alendronic acid/alendronate

IV zoledronic acid

Question 12

Pros and cons of oral bisphosphonates

Answer 12

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

Question 13

Pros and cons of IV zol

Answer 13

Pros: one injection lasts a whole year
Cons: a needle, have to give it over 15 mins, need to come in to have it

Question 14

Name the rapid test for delirium

Answer 14

4AT : alertness, AMT4, attention, acute change/fluctuating course

Question 15

Define delirium

Answer 15

acute confusional state that fluctuates in severity and is usually reversible
Usually the result of other organic processes

Question 16

Define dementia

Answer 16

syndrome of acquired chronic global impairment of higher brain function, in an alert patient, which interferes with ability to cope with daily living

Question 17

What are BPSDs?

Answer 17

Behavioural and psychological symptoms of dementia

Non cognitive symptoms eg agitation, depression, irritability, disinhibition, hallucinations

Question 18

What do you see in hyperactive delirium?

Answer 18

Agitation, delusions, hallucinations, wandering, aggression

Question 19

What are potential causes of delirium?

Answer 19

PINCH ME

Pain, infection, nutrition, constipation, hydration, medication, environment

Question 20

In what proportion of patients is delirium preventable

Answer 20

1 in 3

Question 21

What do you see in hypoactive delirium?

Answer 21

Can be confused with depression: lethargy, slowness, excessive sleeping, inattention

Question 22

Give some examples of reversible dementias?

Answer 22

Around 10%

Depression, B12/folate, hypothyroid, normal pressure hydrocephalus

Question 23

Describe the FRIED criteria

Answer 23

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

Question 24

What are causes of malnutrition?

Answer 24

Decreased nutrient intake (starvation), increased nutrient requirements (sepsis, injury), inability to utilise nutrients ingested (malabsorption), combination of different reasons

Question 25

Consequences of malnutrition?

Answer 25

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

Question 26

What is the MUST score?

Answer 26

Malnutrition universal screening tool

Based on BMI, height, weight loss, acute disease effect

Question 27

Escalation of treatment of malnutrition?

Answer 27

Food first
ONS (oral nutritional supplement)
Enteral/parenteral nutrition

Question 28

Pros and cons of enteral feeding

Answer 28

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

Question 29

Short term options for enteral feeding?

Answer 29

Nasogastric tube

For less than 30 days, check pH aspirate to confirm position, can be inserted at ward level

Question 30

Long term options for enteral feeding?

Answer 30

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

Question 31

When would you use parenteral feeding?

Answer 31

When gut inaccessible or unable to absorb sufficient nutrients to sustain nutritional status

Question 32

Name a few indications for parenteral feeding?

Answer 32

Short bowel syndrome, GI fistula, bowel obstruction, prolonged bowel rest, severe malnutrition/sig weight loss/hypoproteinaemia

Question 33

Options for parenteral feeding? Pros and cons?

Answer 33

PICC line or central line
Positives=can meet nutritional requirements, easily tolerated
Cons=costly, risk of line infection, more invasive procedure, gut atrophy

Question 34

What is refeeding syndrome?

Answer 34

Group of clinical signs and symptoms that can occur in malnourished/starved patient when reintroducing nutrition

Question 35

Pathophysiology of refeeding syndrome?

Answer 35

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

Question 36

How to manage refeeding syndrome?

Answer 36

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

Question 37

Principles of UTI management in elderly?

Answer 37

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