Geriatrics

Question 1

Definition of hypoNa & physiological range

Answer 1

Serum sodium concentration below <135 mmol/L, normal range is between 130-145 mmol/L

Question 2

Aetiology of hypoNa

Answer 2

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

Question 3

Investigating hypoNa

Answer 3

Bloods - U&Es, Glucose, Lipids, TFTs, LFTs, early morning cortisol
Urinalysis - Urinary osmolality & Urinary sodium

Question 4

Signs of hypovolaemia (on examination)

Answer 4

Dry mucous membranes
Poor skin turgor ?>3
CRT >2
Postural hypotension
Tachycardia

Question 5

Signs of hypervolaemia (on examination)

Answer 5

''Puffy/swollen''
Peripheral oedema
Raised JVP
Bibasal crackles
Hypertension

Question 6

Basis of management of hypoNa

Answer 6

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.

Question 7

Definition of hyperNa

Answer 7

Serum sodium >145 mmol/L

Question 8

Causes of hyperNa

Answer 8

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

Question 9

Management of HyperNa

Answer 9

Treat any concurrent infections
Replace water losses
Encourage oral intake

Question 10

Definition of hyperkalaemia & severity

Answer 10

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

Question 11

Causes of hyperkalaemia

Answer 11

1. Impaired excretion (i.e. renal)
   
   • AKI & CKD
   • Mineralocorticoid deficiency (lack of aldosterone)
   • Drug effects e.g. spironolactone (inhibits aldosterone), ACEI
   • Renal tubular acidosis
2. 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).

Question 12

Main ECG changes in hyperK

Answer 12

Tall tented T waves

Question 13

Management of hyperK

Answer 13

Calcium gluconate & insulin - main stay of treatment for severe hyperK

Question 14

Definition of hypokalaemia & severity

Answer 14

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

Question 15

Causes of hypokalaemia

Answer 15

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

Question 16

ECG Changes of hypokalaemia

Answer 16

Flat T waves
ST depression
Prominent U waves
Prolonged PR

Question 17

Management of hypokalaemia

Answer 17

Oral (mild or moderate) or IV replacement (severe or symptomatic)

Question 18

Definition of Delirium

Answer 18

Acute confusional state with altered consciousness, alertness & cognition

Question 19

Causes of Delirium

Answer 19

'’PINCH ME’’

Pain, infection, nutritional compromise, constipation, hydration, metabolic/medication, environmental

Question 20

Risk factors for developing delirium

Answer 20

Advancing Age
Previous Episodes of delirium 
Cognitive impairment 
Sensory impairment 
Severity of injury/illness
Połypharmacy
Dependance syndromes - EtOH, drugs

Question 21

Clinical Features of Delirium

Answer 21

FLUCUATING

Hyperactive - aggression, confusion, hallucinations, agitation, wandering

Hypoactive - confusion, sleepy, drowsy, memory loss, lethargic

Question 22

Investigations - Delirium

Answer 22

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

Question 23

Assessment Tools for Delirium

Answer 23

AMT4 - age, DOB, place & time

4AT - alertness, AMT4, attention, acute change

Question 24

Management of Delirium

Answer 24

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