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Medical Specialties > Geriatrics > Flashcards

Geriatrics Flashcards

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USMLE® Step 1 flashcards
1
Q

humans have high redundancy and little need for repair, give some examples of this (3)

A
  • there are 2 kidneys, but only 5% of its function is needed
  • only 20% of the liver’s function is needed
  • heart continues to work after multiple heart attacks
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2
Q

define ageing and frailty

A

ageing: accumulation of microdamage to the organ system –> less ability to overcome environmental stress
frailty: this susceptibility to dyshomeostasis + impaired organ function

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3
Q

frailty assessment (5) - 3 of these must be fulfilled before the person is considered frail

A
  1. unintentional weightloss
  2. exhaustion
  3. slow walking, reduced mobility
  4. low physical activity
  5. weak grip strength
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4
Q

decompensated frailty syndrome (4) - how is this important in geriatric medicine?

A
  1. falls
  2. immobility
  3. delirium
  4. functional decline
    this is how elderly ppl are going to present instead of the classic disease symptoms
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5
Q

what is the best time to discharge patients?

list some benefits (3) and risks (5) of hospitalization

A

discharge when risks > benefits (different for different ppl)

benefits:
- access to clinical expertise
- immediate and continuous care and support
- access to complex procedures
risks:
- delirium/disorientation (unfamiliar environment)
- learned dependency
- deconditioning
- iatrogenic harm (more doctors = more drugs)
- hospital acquired infections

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6
Q

decline of the renal system in the elderly

A

decreased renal function –> increased creatinine (but also less muscle mass –> less creatinine, therefore not much change in creatinine level)

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7
Q

decline of the CVS system in the elderly

A
  • increased systolic bp with age, but > 60 yrs diastolic bp falls too (antihypertensives dangerous in elderly)
  • decreased cardiac output, less ability to respond to SNS stimulation from baroreflex
  • decreased baroreflex sensitivity –> postural hypotension and falls
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8
Q

decline of the respiratory system in the elderly

A
  • total lung capacity remains the same but functional residual volume decreases
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9
Q

decline of mobility in the elderly

A

decreased ability to control posture in restricted time window –> sway when standing and walking

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10
Q

mental decline in the elderly

A

decreased cognitive capability to cope with physical or mental stress

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11
Q

hyperthyroidism (classic (4) vs elderly presentation (5))

A

classic:
- irritability, anxiety
- tremors
- weight loss
- diarrhea
elderly:
- depression
- cognitive impairment
- muscle weakness
- AF
- HF, angina

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12
Q

decline of thermoregualtion in the elderly

A
  • no change in basal body temperature
  • cold stress: decreased ability to vasoconstrict + decreased metabolic heat generation –> hypothermia
  • heat stress: decreased sweat gland output + decreased CO + decreased skin blood flow + decreased fluid redistribution –> heat stroke
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13
Q

indication for normal referral for urinary and fecal incontinence

A

failure of 3 months of initial management

diarrhea/constipation with intact sphincter for fecal incontinence

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14
Q

indication for urgent referral for urinary incontinence (6)

A
  • unknown cause (refer to urodynamics)
  • vesico-vaginal fistula formation
  • neurological damage
  • palpable bladder and residual volume after voiding
  • severe BPH or prostate cancer
  • previous surgery for incontinence issues that have recurred (more likely to have complications)
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15
Q

indications for urgent referral for fecal incontinence (2)

A
  • neurological damage

- sphincter damage

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16
Q

what are the 3 different types of catheterization and how are they different?

A
  1. self-administered catheter - for those who are dextrous enough
  2. long term catheter - for those not dextrous enough
  3. suprapubic catheters - for overflow incontinence or underactive bladder, reversible
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17
Q

the main 3 presentation of delirium

A
  • disturbed consciousness: 1. hyperactive (agitated, restless), 2. hypoactive (lethargy, stupor), 3. mixed (MAIN)
  • cognitive decline: hallucinations, memory, attention, perception - worse at night
  • acute and fluctuant
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18
Q

other presentations of delirium (3)

A
  • disturbed sleep/wake cycle
  • emotional disturbance: low mood, depression, apathy
  • disturbed psychomotor symptoms: walking gait, falls, decreased functionality
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19
Q

complications of delirium (4)

A
  • longer hospital stay
  • increased risk of institutionalization
  • increased mortality and morbidity
  • persistent funcitonal decline
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20
Q

who are at risk of getting delirium? (5)

A
  • frailty
  • extremes of age
  • 85% of end of life ppl
  • 50% post op ppl
  • 20-30% of hospitalized ppl
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21
Q

causes of delirium (10) - almost everything in the elderly

A
  • infection (UTI over diagnosed)
  • constipation, urinary retention
  • mental stress, change of surroundings
  • pain
  • biochemical and electrolyte imbalances
  • dehydration
  • sleep disturbance
  • hypoxia
  • medications, drugs and alcohol withdrawal
  • idiopathic
22
Q

4AT score description: what score is considered delirious?

A
  1. alertness:
    - 0: normal, or initially drowsy for < 10 secs before responding as normal
    - 4: clearly abnormal
  2. AMT4 - LADY (location, age, DOB, year)
    - 0: no mistakes
    - 1: 1 mistake
    - 2: >= 2 mistakes
  3. attention - saying months backwards
    - 0: >= 7 months correct
    - 1: < 7 months correct or refusing to start
    - 2: unable to start
  4. acute change in cognition in the past 2 week which is still evident in the past 24 hrs
    - 0: no
    - 4: yes

score of 4: potential delirium +/- cognitive impairment
score of 1-3: potential cognitive impairment
score of 0: delirium or cognitive impairment unlikely

23
Q

3 main management of delirium - which of these is the main one?

A
  • TIME bundle
  • non-pharma management + prevention (MAIN)
  • pharma management
24
Q

what is the TIME bundle management?

A

Think about the cause
Investigation + intervention
Management plan
Explore, engage, explain

25
Q

what are some of the non-pharma management of delirium? (5)

A
  • reassure and reorientate agitated patients
  • encourage early mobility and self care
  • ensure continuity of care, maintain environment, discharge ASAP
  • correct sensory impairment
  • AVOID catheterization
26
Q

what are some of the pharma management of delirum? (2)

A
  • stop causative medications

- quetiapine (atypical antipsychotics) 12.5mg orally and slowly go up as needed

27
Q

outcomes of delirium (4)

A
  • most will recover quickly
  • however, most don’t return to normal afterwards
  • increased risk of dementia
  • increased risk of further delirium episodes
28
Q

what is a prescribing cascade?

A

prescribing more medications to deal with side effects caused by existing medications

29
Q

changes in pharmacokinetics of the elderly: absorption (1), distribution (3), metabolism (1), excretion (1) - and the example of medications for each

A
  1. absorption: decreased gut transit time
    • decreased absorption with decreased saliva production: GTN which is absorbed buccally
    • increased absorption with decreased saliva production: PK disease which relies on DOPA (normally broken down by decarboxylase in the saliva)
  2. distribution:
    - altered body constitution
    • less muscle
    • more fat: increased distribution for fat soluble drugs (benzodiazepines, diazepam)
    • less body water: decreased distribution for water soluble drugs (digoxin, forusemide)
      - less protein binding (decreased albumin production from liver): increased free drugs in serum –> increased acidity in acidic drugs (forusemide)
      - increased BBB permeability
  3. metabolism: decreased liver mass + decreased liver blood flow –> decreased liver metabolism
    • decreased drug metabolism in the liver –> increased bioavailibility and serum concentration
    • decreased bioavailability of prodrugs that must be first metabolised by liver into active form (enalapril, ACEI)
  4. excretion: decreased renal clearance –> increased half life + toxicity
30
Q

changes in pharmacodynamics in the elderly (3) - with this explain why diazepam and warfarin have enhanced effect in the elderly

A
  • altered receptor binding
  • less receptor number
    • increased effectiveness: diazepam binds to less receptors in the brain –> less drug needed for sedation
    • increased effectiveness: less clotting factors produced in the liver –> less warfarin needed for anticoagulation
  • altered translation of receptor-mediated intracellular signals into a biochemical signal
31
Q

side effects of anticholinergics - divide this into central and peripheral

A

decreased PNS stimulation of cholinergic receptors all over the body

peripheral: blurred vision, dried mouth, constipation, urinary retention, postural hypotension, tachycardia
central: confusion, memory impairment, falls, delirium, agitations, hallucinations

32
Q

side effects of tricyclic antidepressants

A

confusion, unsteady gait

33
Q

side effects of digoxin - why is it more toxic?

A

lower dose needed - more toxic due to less water in the body of elderly, which means faster distribution of this water-soluble drug

34
Q

side effects of benzodiazepines (sedatives)

A

drowsiness, confusion, falls

35
Q

side effects of narcotics

A

confusion

36
Q

side effects of antipsychotics (4)

A
  • confusion
  • stroke
  • movement disorders
  • postural hypotension
37
Q

side effects of NSAIDs (3)

A
  • renal impairment, AKI
  • GI bleeds
  • bronchospasm
38
Q

side effects of warfarin (2)

A
  • GI bleeds

- falls

39
Q

side effects of beta blockers

A

decreased HR + bp –> postural hypotension –> falls

40
Q

side effects of opioids (4)

A
  • CNS effects
  • nausea
  • constipation
  • respiratory depression (in strong opioids)
41
Q

side effects of donepezil (cholinesterase inhibitor)

A

decreased HR –> falls

42
Q

side effects of misonidazole (antifungal)

A

potent P450 inhibitor in the liver –> reduced metabolism of prodrugs like warfarin –> ineffective (coagulation)

43
Q

top 5 drugs that cause the most common ADRs and what they are

A
  1. ​NSAIDs
  2. diuretics
  3. warfarin
  4. ACEI
  5. others: antidepressants, beta blockers, digoxin, prednisolone, clopidogrel
44
Q

principles of prescribing for the elderly (4)

A
  • pharmacokinetics and dynamics different in the elderly than the normal population
  • avoid prescribing more medications, unless necessary, and start at the lowest dose possible
  • stop medications that are no longer needed
  • consider complications of polypharmacy
45
Q

what are some side effects of specific abx? (5)

A
  • diarhea, C-diff infections
  • seizures
  • trimethroprim, co-trimoxazole: blood dyscrasia
  • quinolones: delirium
  • aminoglycoside: renal impairment
46
Q

causes of falls in different organ systems (7)

A
  • generally unwell: infections
  • MSK: arthritis, sarcopenia (thigh muscle wasting), deformities
  • CVS: postural hypotension, HT, arrhythmia, aortic stenosis
  • neurological: stroke, ataxia, dementia, PKD
  • sensory: visual impairment, hearing loss
  • incontinence: rushing to the bathroom
  • drugs: alcohol, antihypertensives, warfarin, benzodiazepines, anticholinergics, etc.
47
Q

causes of falls in inpatients (5), which of these is the main one?

A
  • Delirium (MAIN)
  • exacerbation of their illness
  • starting/stopping their antihypertensives –> postural hypotension –> fall
  • low BG
  • simply an accident (slipping, falling out of bed)
48
Q

different levels of urgency of falls and where patients are treated (3)

A
  1. falls clinic: usually not an emergency and has been assessed for cause of fall before referral here.
  2. emergency department: an emergency, cause of fall might be multifactorial
  3. inpatient falls: likely to be acutely unwell, might lead to death
49
Q

what are the 2 things that you must check and rule out in inpatient falls

A
  • subdural haemorrhage: may not be immediately symptomatic

- fractured femur: shorter + externally rotated leg

50
Q

what is one of the main concerns for falls in the elderly, especially if they have been lying for a long time before someone found them? How can this be treated?

A

rhabdomyolysis: breakdown of muscles –> increased creatinine kinase –> renal injury
- treated with IV fluids

51
Q

what are the 5 different gait abnormalities and what sort of pathology do they associate with?

A
  1. ataxic (unsteady, staggering) - cerebellar damage
  2. arthralgia (painful) - arthritis
  3. shuffling, small steps - vascular/idiopathic PKD
  4. hemiplegic (unilateral) - stroke
  5. high-stepping (foot drop) - peripheral nerve injury (common fibular n.)

Medical Specialties (4 decks)

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