Geriatrics Flashcards
humans have high redundancy and little need for repair, give some examples of this (3)
- 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
define ageing and frailty
ageing: accumulation of microdamage to the organ system –> less ability to overcome environmental stress
frailty: this susceptibility to dyshomeostasis + impaired organ function
frailty assessment (5) - 3 of these must be fulfilled before the person is considered frail
- unintentional weightloss
- exhaustion
- slow walking, reduced mobility
- low physical activity
- weak grip strength
decompensated frailty syndrome (4) - how is this important in geriatric medicine?
- falls
- immobility
- delirium
- functional decline
this is how elderly ppl are going to present instead of the classic disease symptoms
what is the best time to discharge patients?
list some benefits (3) and risks (5) of hospitalization
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
decline of the renal system in the elderly
decreased renal function –> increased creatinine (but also less muscle mass –> less creatinine, therefore not much change in creatinine level)
decline of the CVS system in the elderly
- 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
decline of the respiratory system in the elderly
- total lung capacity remains the same but functional residual volume decreases
decline of mobility in the elderly
decreased ability to control posture in restricted time window –> sway when standing and walking
mental decline in the elderly
decreased cognitive capability to cope with physical or mental stress
hyperthyroidism (classic (4) vs elderly presentation (5))
classic:
- irritability, anxiety
- tremors
- weight loss
- diarrhea
elderly:
- depression
- cognitive impairment
- muscle weakness
- AF
- HF, angina
decline of thermoregualtion in the elderly
- 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
indication for normal referral for urinary and fecal incontinence
failure of 3 months of initial management
diarrhea/constipation with intact sphincter for fecal incontinence
indication for urgent referral for urinary incontinence (6)
- 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)
indications for urgent referral for fecal incontinence (2)
- neurological damage
- sphincter damage
what are the 3 different types of catheterization and how are they different?
- self-administered catheter - for those who are dextrous enough
- long term catheter - for those not dextrous enough
- suprapubic catheters - for overflow incontinence or underactive bladder, reversible
the main 3 presentation of delirium
- 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
other presentations of delirium (3)
- disturbed sleep/wake cycle
- emotional disturbance: low mood, depression, apathy
- disturbed psychomotor symptoms: walking gait, falls, decreased functionality
complications of delirium (4)
- longer hospital stay
- increased risk of institutionalization
- increased mortality and morbidity
- persistent funcitonal decline
who are at risk of getting delirium? (5)
- frailty
- extremes of age
- 85% of end of life ppl
- 50% post op ppl
- 20-30% of hospitalized ppl
causes of delirium (10) - almost everything in the elderly
- 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
4AT score description: what score is considered delirious?
- alertness:
- 0: normal, or initially drowsy for < 10 secs before responding as normal
- 4: clearly abnormal - AMT4 - LADY (location, age, DOB, year)
- 0: no mistakes
- 1: 1 mistake
- 2: >= 2 mistakes - attention - saying months backwards
- 0: >= 7 months correct
- 1: < 7 months correct or refusing to start
- 2: unable to start - 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
3 main management of delirium - which of these is the main one?
- TIME bundle
- non-pharma management + prevention (MAIN)
- pharma management
what is the TIME bundle management?
Think about the cause
Investigation + intervention
Management plan
Explore, engage, explain
what are some of the non-pharma management of delirium? (5)
- reassure and reorientate agitated patients
- encourage early mobility and self care
- ensure continuity of care, maintain environment, discharge ASAP
- correct sensory impairment
- AVOID catheterization
what are some of the pharma management of delirum? (2)
- stop causative medications
- quetiapine (atypical antipsychotics) 12.5mg orally and slowly go up as needed
outcomes of delirium (4)
- most will recover quickly
- however, most don’t return to normal afterwards
- increased risk of dementia
- increased risk of further delirium episodes
what is a prescribing cascade?
prescribing more medications to deal with side effects caused by existing medications
changes in pharmacokinetics of the elderly: absorption (1), distribution (3), metabolism (1), excretion (1) - and the example of medications for each
- 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)
- 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
- 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)
- excretion: decreased renal clearance –> increased half life + toxicity
changes in pharmacodynamics in the elderly (3) - with this explain why diazepam and warfarin have enhanced effect in the elderly
- 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
side effects of anticholinergics - divide this into central and peripheral
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
side effects of tricyclic antidepressants
confusion, unsteady gait
side effects of digoxin - why is it more toxic?
lower dose needed - more toxic due to less water in the body of elderly, which means faster distribution of this water-soluble drug
side effects of benzodiazepines (sedatives)
drowsiness, confusion, falls
side effects of narcotics
confusion
side effects of antipsychotics (4)
- confusion
- stroke
- movement disorders
- postural hypotension
side effects of NSAIDs (3)
- renal impairment, AKI
- GI bleeds
- bronchospasm
side effects of warfarin (2)
- GI bleeds
- falls
side effects of beta blockers
decreased HR + bp –> postural hypotension –> falls
side effects of opioids (4)
- CNS effects
- nausea
- constipation
- respiratory depression (in strong opioids)
side effects of donepezil (cholinesterase inhibitor)
decreased HR –> falls
side effects of misonidazole (antifungal)
potent P450 inhibitor in the liver –> reduced metabolism of prodrugs like warfarin –> ineffective (coagulation)
top 5 drugs that cause the most common ADRs and what they are
- NSAIDs
- diuretics
- warfarin
- ACEI
- others: antidepressants, beta blockers, digoxin, prednisolone, clopidogrel
principles of prescribing for the elderly (4)
- 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
what are some side effects of specific abx? (5)
- diarhea, C-diff infections
- seizures
- trimethroprim, co-trimoxazole: blood dyscrasia
- quinolones: delirium
- aminoglycoside: renal impairment
causes of falls in different organ systems (7)
- 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.
causes of falls in inpatients (5), which of these is the main one?
- Delirium (MAIN)
- exacerbation of their illness
- starting/stopping their antihypertensives –> postural hypotension –> fall
- low BG
- simply an accident (slipping, falling out of bed)
different levels of urgency of falls and where patients are treated (3)
- falls clinic: usually not an emergency and has been assessed for cause of fall before referral here.
- emergency department: an emergency, cause of fall might be multifactorial
- inpatient falls: likely to be acutely unwell, might lead to death
what are the 2 things that you must check and rule out in inpatient falls
- subdural haemorrhage: may not be immediately symptomatic
- fractured femur: shorter + externally rotated leg
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?
rhabdomyolysis: breakdown of muscles –> increased creatinine kinase –> renal injury
- treated with IV fluids
what are the 5 different gait abnormalities and what sort of pathology do they associate with?
- ataxic (unsteady, staggering) - cerebellar damage
- arthralgia (painful) - arthritis
- shuffling, small steps - vascular/idiopathic PKD
- hemiplegic (unilateral) - stroke
- high-stepping (foot drop) - peripheral nerve injury (common fibular n.)
