Geriatrics Flashcards
Definition of hypoNa & physiological range
Serum sodium concentration below <135 mmol/L, normal range is between 130-145 mmol/L
Aetiology of hypoNa
Hypovolemia; GI losses (V&D), Renal losses (diuretics), Skin losses (burns), Other (sepsis, Addison’s)
Euvovolemic; (SIADH, hypothyroidism, high water, low solute intake e.g. 1o polydipsia, anorexia nervosa)
Hypervolemic; heart failure, CKD, liver failure, nephrotic syndrome
Investigating hypoNa
Bloods - U&Es, Glucose, Lipids, TFTs, LFTs, early morning cortisol
Urinalysis - Urinary osmolality & Urinary sodium
Signs of hypovolaemia (on examination)
Dry mucous membranes Poor skin turgor ?>3 CRT >2 Postural hypotension Tachycardia
Signs of hypervolaemia (on examination)
''Puffy/swollen'' Peripheral oedema Raised JVP Bibasal crackles Hypertension
Basis of management of hypoNa
Hypovolaemia - check causes e.g. medication review, fluid replacement should normalise sodium
Euvolaemic - most common caused by SIADH therefore fluid restrict, may need some ADH inhibitors
Hypervolaemic - Patients with hypervolaemic hyponatraemia require treatment of the underlying cause. As a general rule, these patients are managed with fluid and salt restriction and the use of diuretics, especially in heart failure.
Definition of hyperNa
Serum sodium >145 mmol/L
Causes of hyperNa
Unreplaced water losses in the elderly (most commonly); from skin (sweat), GI (D&V), urinary - a/w concurrent infections
Excess salt intake - dietary, oral (poisoning), IV (hypertonic saline)
Water loss into cells - usually temporary event that occurs after extreme exercise or seizure
Management of HyperNa
Treat any concurrent infections
Replace water losses
Encourage oral intake
Definition of hyperkalaemia & severity
Serum potassium >5.5 mmol/L
Mild: 5.5-5.9 mmol/L
Moderate: 6.0-6.4 mmol/L
Severe: >6.5 mmol/L
Causes of hyperkalaemia
- Impaired excretion (i.e. renal)
- AKI & CKD
- Mineralocorticoid deficiency (lack of aldosterone)
- Drug effects e.g. spironolactone (inhibits aldosterone), ACEI
- Renal tubular acidosis
- Increased uptake
○ IV therapy or increased dietary uptake
3. Extracellular shift in potassium ○ Acidosis e.g. DKA ○ Tumour lysis syndrome ○ Rhabdomyolysis ○ Digoxin ○ Burns ○ Trauma
4. Pseudohyperkalaemia ○ Tourniquet ○ Haemolysed sample ○ Marked leucocytosis (high white cell count) or thrombocytosis (high platelet count).
Main ECG changes in hyperK
Tall tented T waves
Management of hyperK
Calcium gluconate & insulin - main stay of treatment for severe hyperK
Definition of hypokalaemia & severity
Serum potassium of <3.5 mmol/L; normal range of 3.5-5.5 mmol/L
Mild: 3.0-3.4 mmol/L
Moderate: 2.5-2.9 mmol/L
Severe: <2.5mmol/L or symptomatic
Causes of hypokalaemia
Increased excretion • Drugs e.g. thiazide diuretics • Renal disease • GI loss e.g. D&V, laxative abuse • Skin; burns, • Increased aldosterone
Reduced intake
• Dietary deficiency
• Inappropriate replacement
• Eating disorders; bulimia, anorexia nervosa, alcoholism
Transcellular shift in potassium
• Alkalosis
• Insulin
• Activation of beta-adrenergic receptors e.g. salbutamol
ECG Changes of hypokalaemia
Flat T waves
ST depression
Prominent U waves
Prolonged PR
Management of hypokalaemia
Oral (mild or moderate) or IV replacement (severe or symptomatic)
Definition of Delirium
Acute confusional state with altered consciousness, alertness & cognition
Causes of Delirium
'’PINCH ME’’
Pain, infection, nutritional compromise, constipation, hydration, metabolic/medication, environmental
Risk factors for developing delirium
Advancing Age Previous Episodes of delirium Cognitive impairment Sensory impairment Severity of injury/illness Połypharmacy Dependance syndromes - EtOH, drugs
Clinical Features of Delirium
FLUCUATING
Hyperactive - aggression, confusion, hallucinations, agitation, wandering
Hypoactive - confusion, sleepy, drowsy, memory loss, lethargic
Investigations - Delirium
Bedside - observations inc temp, general examination, urinalysis & cultures
Bloods - FBC (Hb, WCC), CRP/ESR, U&Es, LFTs, Bone profile - Ca, B12& folate, TFTs, cultures if temp
Imaging - consider CT to r/o stroke/bleed
Assessment tools - 4AT, AMT4
Assessment Tools for Delirium
AMT4 - age, DOB, place & time
4AT - alertness, AMT4, attention, acute change
Management of Delirium
Management:
First step is prevention e.g. not moving wards, clocks/calanders/memories, friends & family visiting, avoid polypharmacy, laxatives with analgesia
* Notice & reverse causes * Preventative steps * IF patient becomes a threat to themselves or others can consider 0.5mg of haloperidol IM
