Geriatrics Flashcards
Name four things in a Falls History you would want to know about pre-fall
Any dizziness/light headedness
Any cardiac symptoms
Any weakness
Any previous near misses
Name four examinations you could do in a falls patient
Functional assessment of mobility (how do they mobilise etc)
CVS exam (inc lying and standing BP immediately, at 3 minutes and at 5 minutes)
Neurological Exam
Musculoskeletal Exam
Name two specific tests involved in falls risk assessments
Timed Up and Go
Turn 180
What is the Timed Up and Go test?
Time the person getting up from their chair without using their arms, walking three metres, turning around and returning to seat
Can use a walking stick if they normally mobilise with one
> 15 seconds is deemed to be a high falls risk
What is the Turn 180 test?
Asked to stand and turn 180
> 4 steps taken requires further assessment
Falls risk assessments should be carried out via Nerve Centre within 6 hours of admission. Who gets a standard falls risk assessment?
Over 65
Under 65 with clinically judged falls risk
Falls risk assessments should be carried out via Nerve Centre within 6 hours of admission. Who gets an enhanced falls risk assessment?
Admitted following a fall
2 or more falls in past 12 months
Previous inpatient fall at UHL
Name five causes of Syncopal Falls
Vasovagal Situational Postural Hypotension Autonomic Failure Carotid Sinus Hypersensitivity
Name three causes of Non Syncopal Falls
Poor Vision
Muscle Weakness
Labyrinthitis
Other than the two specific tests in a falls risk assessment, what else does it comprise of?
Comprehensive History and Exam
Medication Review
Psychological (fear of falling)
FRAX is a tool used to estimate the ten year fracture probability risk. Who qualifies to be evaluated?
All women >65 and all men >75
If other risk factors can consider in <65
Name some of the parameters of the FRAX tool
Sex Weight Height Previous # Smoking Alcohol Steroids Parenteral Nutrition T and Z Score
Define Osteoporosis
Low bone mass and deterioration of architecture leading to reduced bone strength and increased fracture risk
Describe the mnemonic ‘SHATTERED’ for Osteoporosis
Steroids Hyperthyroidism Alcohol Tobacco Thin Early Menopause Renal Failure Erosive Bone Disease Dietary Insufficiency
Using a DEXA scan, two scores can be produced: Z score and T Score. What is the T Score?
Number of standard deviations from the mean bone density of a healthy person (30y old and same sex)
> -1.5 - normal
Using a DEXA scan, two scores can be produced: Z score and T Score. What is the Z Score?
Number of standard deviations from the mean bone density of same age and sex
Name three conservative managements for Osteoporosis
Quit Smoking
Increase weight bearing exercises
Calcium and Vitamin D Rich Diet
What is the first line medical management for Osteoporosis?
Bisphosphonates (Alendronic Acid)
What should you inform patients about Bisphosphonates
Stay upright and wait 30 minutes before food after taking one
Side effects include GI Upset and Jaw Osteonecrosis
Name four contraindications to Bisphosphonate therapy
Achalasia
Stomach Ulcers
eGFR<30
Cognitive Impairment (won’t follow instructions)
If wanting to give a patient Bisphosphonates but unable to take orally, what could you prescribe?
IV Zolendronate
Yearly infusion
Requires good Creatinine Clearance
Name two other medical management options for Osteoporosis
Teriparatide (Recombinant PTH)
Denosumab (MAB reducing bone reabsorption - subcutaneous biannually)
Name two side effects of Teriparitide
Dizziness
Tachycardia
Name two side effects of Denosumab
Red/Dry/Itchy Skin
Blisters
What is classed as Polypharmacy?
Taking 5 or more medications at any one time
What is the STOPP tool?
Screening Tool for Older Persons Prescription
Aims to reduce incidence of medicine related adverse events
Can be in relation to single drugs or classes (check in BNF ‘caution’ boxes)
What is the START tool?
Screening Tool to Alert the Right Treatment
Prevents omissions of indicated appropriate medications
Name 6 other pharmacy considerations in older people’s prescriptions
Forms of Medicine (is a liquid form more appropriate?)
Are some symptoms just manifestations of ageing (dont require treatment?)
Patients are more sensitive to medications
Pharmacokinetics (clearance ability)
Review regularly
Simplify regimes
What are the four components of an incontinence history
- Defining the type of incontinence
- Defining the causes and precipitants
- Excluding other pathology
- Assessing the severity and impact on patient’s life
How could you determine the type of incontinence?
Any triggers?
Constant vs Intermittent Leakage
Amount of Urine Lost
What information can help determine the cause of incontinence?
Exclude UTIs/Calculi
Whether frequency is worse during day or at night
Factors worsening urge
Reversible causes (eg look at medication list)
Risk factors for stress (high parity, large babies etc)
What factors in an incontinence history would lead you to think of other pathological causes?
Haematuria Pain Acute Onset Obstructive symptoms Neurological symptoms
How can you assess the impact of incontinence on a patient?
- Standardised Pad Test (better than subjective for measuring volume)
- What lifestyle changes/restrictions the patient now has
- Urogenital Distress Inventory
- Incontinence Impact Questionnaire
What features of incontinence are you looking for on an ABDO exam?
Palpable bladder after voiding
What features of incontinence are you looking for on an PELVIC exam?
- Atrophic Vaginal Mucosa
- Stress/Cough Test
- Organ Prolapse
- Pelvic Floor Contraction (rated out of 5 using Oxford System)
- Pelvic Mass/Tenderness
What features of incontinence are you looking for on a RECTAL exam?
Constipation and Tone
What features of incontinence are you looking for on a NEUROLOGICAL exam?
Change in Perineal Sensation/Anal Tone
Lower limb neuro exam
What features of incontinence are you looking for on a CARDIAC exam?
Volume Status
Signs of Heart Failure
Describe the normal parameters of voiding
- Number of day time voids - 3 to 5 hourly
- Total urine - 1500 to 2000mls
- Largest single void - 300 to 600mls
How can you interpret a bladder diary/frequency volume chart?
Frequent small volume - OABS, Detrusor Overactivity
Frequent large volume - Polyuria
Frequent small volume with low urine output - fluid restriction
Nocturnal - Ageing, OSA, Cardiac Failure
Describe the procedure of a bladder scan
- Patient is asked to void (volume measured)
- Probe placed 3cm above pubic symphysis
Volume <100ml is normal
Volume >200ml requires further investigations
Volume >500ml requires urgent discussion
Describe the Bristol Stool Chart
1 - Hard Lumps like nuts 2 - Sausage shaped but lumpy 3 - Sausage shaped with cracks on 4 - Smooth Sausage shaped 5 - Soft blobs with clear cut edges 6 - Fluffy with ragged edges 7 - Watery
What has to be present in a urine dip for UTI to be a possibility?
Leukocyte Esterase
Nitrates
Give three risk factors for Stress Incontinence
Pelvic Surgery
Child Birth
Oestrogen Deficient States
Define Stress Incontinence
Involuntary urination upon increase in intra-abdominal pressure due to weak pelvic floor
Describe the conservative management of Stress Incontinence
Lose Weight
Pelvic Floor (8 contractions tds)
Stop Smoking
Reduce Caffiene
How can Stress Incontinence be investigated?
Exclude infection
Frequency Volume Chart (normal)
Urodynamics
Describe the medical management of Stress Incontinence
Serotonin and Noradrenaline Reuptake Inhibitor - Duloxetine (increases pudendal nerve activity and sphincter pressure)
Describe the surgical management of Stress Incontinence
Burch Colposuspension (sutures between coopers and paravaginal)
Periurethral Bulking
TVT
Define Urge Incontinence
Presence of urgency in the absence of other pathology
Normally due to Detrusor Overactivity and associated with Nocturia/Frequency
Name three risk factors for Urge Incontinence
MS
Spina Bifida
Pelvic Surgery
Name three investigations of Urge Incontinence
Exclude infection
Frequency Volume (increased)
Urodynamic (Detrusor Overactivity)
Describe the conservative management of Urge Incontinence
Avoid Caffiene and Alcohol
Bladder Retraining
Describe the medical management of Urge Incontinence
- Oxybutinin (Antimuscarinic preventing bladder contraction)
- Solifenacin (Antimuscarinic)
- Mirabegron (B3 Agonist promoting relaxation)
- Tamsulosin/Doxazosin (Promotes prostate relaxation and bladder emptying)
Name two contraindications to Antimuscarinic medication for Urge Incontinence
Myasthenia Gravis
Closed Angle Glaucoma
Name four containment products for Incontinence
- Absorbent Pads
- Absorbent Bed/Chair Pads
- Penile Sheaths
- Catheterisation (short term, long term, suprapubic, intermittent)
Define Functional Incontinence
Unable to reach the toilet in time due to cognitive/physical problems
Name three causes of Faecal Incontinence
Faecal Impaction (and overflow diarrhoea)
Sphincter dysfunction (haemorrhoids, obstetric tears)
Impaired sensation
What is Faecal loading?
Smearing
Small amounts of type 1 stool or copious amounts of 6/7
Name two complications of Faecal Loading
Urinary Retention
Stercoral Perforation
How is Faecal Incontinence Managed?
Enemas, Stool Softeners, Stimulants
Manual Evacuation (perforation risk vs benefit)
Always coprescribe constipating drugs with laxatives
How would you investigate Chronic Diarrhoea?
Bowel Imaging
Stool Culture
Exclude Impaction/Causative Medication
Dietary Review
How would you manage Chronic Diarrhoea?
Consider low dose loperamide (if not then break and accelerate)
What are Pressure Sores?
Persistently red/blistered/necrotic skin that can lead to exposure of underlying structures, caused by shear pressure/forces over bony prominence (most common in immobility)
Name the 5 most common areas for Pressure Sores
Occiput Heel Malleolus Ischium Greater Trochanter
Name four risk factors for Pressure Sores
Alzheimers
Diabetes
Hip Fractures
Parkinsons
What is the Braden Score for Pressure Sores?
Each item is scored between 1 and 4
The lower the score the greater their risk
Sensory perception, Moisture, Activity, Mobility, Nutrition, Fraction/Shear
What is the Waterlow Score for Pressure Sores?
Scoring system for risk of Pressure Sores
BMI, Continence Level, Skin Appearance, Mobility, Sex, Age, Tissue Malnutrition, Neurological Deficit, Major Surgery
10+ at risk
15+ high risk
20+ very high risk
How are Pressure Sores assessed?
Using medical photography and ruler measurements
Cause of Ulcer
Site/Location
Dimensions
Describe Stage 1 Pressure Sores
Non blanchable erythema of intact skin
May appear blue/purple on darker skin
Describe Stage 2 Pressure Sores
Partial thickness, loss of epidermis/dermis/both
Normally an Abrasion/Blister
Describe Stage 3 Pressure Sores
Full thickness skin loss which may extend down to underlying fascia
Describe Stage 4 Pressure Sores
Extensive destruction/Tissue Necrosis/Damage to muscle or bone
Extremely difficult to heal, high infection risk
Describe Stage 5 Pressure Sores
Unstageable
Base of ulcer is covered by slough so depth is undetermined
When do Pressure Sores require specialist services?
Extensive Superficial Ulcers
Grade 3/Grade 4 pressure ulcers
Deteriorating
Name 6 mainstays of Pressure Sore management
Repositioning Managing other conditions which may delay healing Pressure relieving support Wound dressing Pain relief Infection Control
Why might Debridement help tissue healing?
Devitalised tissue slows tissue healing
Can be autolytic/mechanical/surgical
What is a Comprehensive Geriatric Assessment?
Holistic approach to the elderly patient
Encompasses physical/functional/social/environmental/psychological and medication review
Name 6 things examined in the Physical Assessment of the Elderly patient
Sensory Loss Feet and Footwear Gait and Balance Lying and Standing BP Joints Weight and Nutrition
What is assessed in a Psychological Assessment of the Elderly Patient?
Mood and Cognition
What is assessed in the Functional Assessment of the Elderly Patient?
1) What can and what does the person actually do
2) How recently has it changed
Nottingham Extended ADLs
Timed Up and Go
Assess timescale of change
How is a Medication Review carried out?
Full drug history
For each drug: Are you good at remembering to take? Can you swallow okay? What are you most concerned about with tablets? Do you think it works? Any SE?
STOPP-START
Name four side effects of Parkinson’s medication
Impulse control disorders
Excess Daytime Sleepiness
Excess Drooling
If not taken - Neuroleptic Malignant Syndrome
What should you base the Clinical Frailty Scale on?
What their level of function was two weeks ago
Define Postural Hypotension
Systolic drop >20mmHg on standing (or drop below 90mmHg)
Give four causes of Postural Hypotension
Diabetes
Dehydration
Drugs
MSA
How is Postural Hypotension measured?
Lying Down and Measured
Standing immediately, after one minute and after three minutes
What is the Falls Prevention Programme?
Combination of therapy and education to help prevent and limit damage caused by falls
When should Osteoporosis be managed?
If score is <= -2.5 then treat
If not, modify risk factors, treat underlying conditions and review in 2 years
What is Shared Decision Making?
Integrates patient and clinical choice
Seek Participation Explore and compare treatment options Assess values and preferences Reach a decision together Evaluate decision
What are the four questions of Shared Decision making?
What are the benefits?
What are the risks?
What are the alternatives?
What if we do nothing?
BRAN
What is an Advanced Directive?
Legal document written at time when patient is of sound mind
Refers to specific treatments
Must be witnessed
Can refuse medication but can’t request
According to the Mental Capacity Act, when can Advance Directives be overruled?
- If they are withdrawn when patient is of sound mind
- If three is strong belief that current situation would’ve changed wishes
- Overruled by LPA
What happens if someone loses capacity but doesn’t have a Lasting Power of Attorney?
- Referred to the court of protection and assigned one for welfare and one for finances
Can an LPA overrule an advanced directive?
If the Advanced Directive was made after someone was appointed LPA - no
If the Advanced Directive was made before someone was appointed LPA - yes
What are the four sections from Gold Standard Framework for Advanced Care Planning?
- What is important to you in your life at the moment
- What WOULD you like to happen to you if you became unwell
- What WOULDN’T you like to happen if you became unwell
- Who would you like (if you would like) someone to speak on your behalf
