Geriatrics Flashcards
What are the causes of acute confusion?
PINCH ME
Pain - severe Infection - UTI Nutrition Constipation hydration
Medication, Metabolic disorder - hypoglycaemia, hypercalcaemia
Environment
What are the drugs given for palliative end of life care?
- Morphine - for pain
- Antiemetic - for nausea and vomiting
- Hyoscine - for reducing secretions
- Midazolam (Benzo) - for agitation
What are the causes of pleural effusion?
- Pulmonary embolism
- Heart failure
- Infection
- Cancer - mostly unilateral
What are the 4 geriatric giants?
- Immobility
- Instability
- Incontinence
- Intellectual impairment
What is the a comprehensive geriatric assessment?
A process used by healthcare practitioners to assess the status of people who are frail & older in order to optimize their subsequent mx
Component:
1. Medical assessment - Doctor, Nurse, Pharmacist, Dietician, SaLT
- Functional assessment - OT, PT, SaLT
- Psychological Assessment - Doctor, Nurse, OT, Psychologist
- Social and environmental assessment - OT, SW
What is the responsibility of the lasting power of attorney?
People to make decisions on your behalf if you are unable to make decision (Lack capacity). Decisions made must be in the person’s best interests
o Cannot demand Rx
o Only to refuse / accept Rx
What are the alternatives if there is no lasting power of attorney?
- Check for court appointed deputy - For relatives to gain power over decisions when patient has no capacity & no LPA. Cannot demand Tx and can only accept or refuse it
- Independent mental capacity advocate - if the patient has no relatives or family -
What is an advanced decision?
A person over 18 can set out what types of treatment they would not want to have and in what circumstances, should they lack capacity to refuse consent in future
o Applies even in life. / death situations
o Must be valid (Not overridden by appointing an LPA)
What are part of basic care and cannot be stopped?
Oral food, fluids, warm, dry, clean, washing
What are part of basic medical care ?
Must be given if there is overall benefit to patient; can be stopped as it’s seen as not giving Rx :
Tube feeding, Parenteral fluids
What is the effect of BDZ and opioids in the elderly?
Can acutely cause confusion
What is the effect of anticholinergics in the elderly?
- Dry mouth
- Blurred vision
- Urinary retention
- Constipation
What is the effect of antihypertensives in the elderly?
Postural hypotension
What is the difference in pharmocokinetics of drug metabolism in the elderly?
Absorption:
- Delayed gastric emptying due to immobility, thus reduced intestinal blood flow
- Variable chg in 1st pass metabolism due to reduced hepatic blood flow
Distribution:
- Increased serum concentration of water soluble drugs due to reduced volume of distribution
- Increased half life of fat soluble drugs due to increased body fat
- Increased free serum, decrease in serum albumin
Elimination:
- eGFR < reliable with age
- Creatine clearance > accurate
What is the definition of malnutrition? and criteria for it?
A state in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on body’s form, function and clinical outcome
BMI <18.5 kg/m2
/Unintentional weight loss >10% in last 3-6 mths
/BMI <20kg/m2 + Unintentional weight loss >5% in last 3-6 mths
What are the broad causes of malnutrition?
- Starvation
- Increased nutritional requirements - sepsis
- Inability to use the nutrients ingested - malabsorption
How do you calculate Malnutrition universal screening tool scores when BMI or weight is not available?
Subjective data
OR
Can estimate height from ulna length
Can estimate BMI from mid upper arm circumference (MUAC)
How is a low risk MUST score managed?
• Provide green leaflet (‘Eating well’)
• Review/Re-screen:
o Care homes (Monthly)
o Community (Annually)
- Consider > frequent re-screening in high risk groups
- If BMI >30kg/m2 (Obese) = Rx according to local policy / National guidelines
How is a medium risk MUST score managed?
• Dietary advice to maximize nutritional intake; encourage:
o Small frequent meals & snacks
o With high energy & protein food and fluids
• Powdered nutritional supplements to be made up with water/milk are available
• Review progress/Repeat screening:
o After 1-3 mths (According to the clinical condition)
o /Sooner if the condition requires
- If improving = Continue until ‘Low risk’
- If deteriorating = Consider treating as ‘High risk’
How is a high risk MUST score managed?
- Provide dietary advice as ‘Medium risk’
- Prescribe oral nutritional supplements (ONS) & monitor (Consider local formularies)
- If improve = Consider Mx as ‘Medium risk’
• Refer to dietitian if:
o No improvement
o />Specialist support is required
How do you check if the NG tube is the right position?
1st line - Gastric aspirate pH <5.5
2nd line - CXR
What are the risk of NG tube and PEG tube?
NG tube: (short term)
- Tubes often easily displaced
- Risk of aspiration
- CI in Paralytic ileus
Percutaneous Endoscopic Gastrotomy tube: (long term)
- Bowel perforation
- Wound infection
- Peritonitis
- Aspiration
- Death
What are the indications of TPN?
• Non-functioning GI tracts; eg: Obstruction Perforation Ileus High output fistulas • Short bowel syndrome • Severe pancreatitis • Malabsorption
What are the complications of refeeding syndrome?
- Arrhythmias (Commonest cause of death)
- HF
- Seizures
- Cardiac arrest
- Delirum
What is the management of refeeding syndrome?
Before feeding & in the first 10d of refeeding; give:
o IV Pabrinex (Thiamine)
+ Vit B Compound Strong
- Start nutrition at 10kCal/kg for first 24h
- Monitor PO42-, K+, Mg2+ (PPM) daily & correct as appropriate
What are the drugs that can cause osteoporosis?
- Steroids
- Heparin
- Warfarin
- Phenytoin
- GnRH agonist
- PPI
What are the endocrine causes of osteoporosis?
• Hypogonadal states; eg: o Turner o Klinefelter o Testosterone deficiency o Premature ovarian failure
- Cushing’s syndrome
- Hyperparathyroidsm
- Hyper/Hypothryoidism
- T1DM
What are the GI and renal causes of osteoporosis?
GI - malabsorption disorders
Renal causes - Renal osteodystrophy (Impaired Vit D & Ca2+ metabolism)
What are the risk factors of osteoporosis?
Risk Factors: ‘SHATTERED’
Steroid use (>5mg/d Prednisolone)
Hyperthyroidism / Hyperparathyroidism / Hypercalciuria
Alcohol & Smoking
Thin (BMI <22) / T1DM
Testosterone ↓
Early menopause (Eg: Premature ovarian failure)
Renal / Liver failure
Erosive inflammatory bone disease (Eg: MM, RA)
Dietary Ca2+ ↓ / Malabsorption
What are the common areas of osteoporotic fractures?
• Distal radius (Colles’ fracture)
• Neck of femur fracture
• (Wedge) Fracture of thoracic vertebrae which may lead to:
o Loss of height
o Exaggerated dorsal kyphosis
o PainWhat is the DEXA score and what are the results important?
-1 to -2.5 = Osteopenia = Offer lifestyle advice
<2.5 = Osteoporosis = Offer Lifestyle Advice +Rx +Repeat DEXA in 2yrs
What is the medical management of osteoporosis?
1st line - Bisphosphonates - alendronate / if cannot be taken due to upper GI problems –> use risedronate or etidronate
2nd line - strontium ranelate or raloxifene (SERM)
3rd line - Denosumab
vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
What is the diagnostic investigation for lewy body dementia? What is the management?
Diagnosis:
- Usually clinical
- Single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan.
Management
- Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine
- Neuroleptic medication is to be avoided in LBD -a s tehy may develop irreversible parkinsonism
What antipsychotic is CI in parkinson’s disease?
Haloperidol
What is the diagnostic criteria for orthostatic hypotension?
a. A drop in systolic BP of 20mmHg or more (with or without symptoms)
b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
c. A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).
What are the medications associated with orthostatic hypotension?
- Nitrates
- Diuretics
- Anticholinergic medication
- Antidepressants
- Beta-blockers
- L-dopa
- ACE-inhibitors
What are the medications that can cause falls?
- Benzodiazepines
- Antipsychotics
- Opiates
- Anticonvulsants
- Codeine
- Digoxin
What is the NICE recommendation for falls?
- Identify all individuals who have fallen in the last 12 months
- For those with a falls history or at risk complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.
Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
- More than 2 falls in the last 12 months
- A fall that requires medical treatment
- Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
Individuals who fall but do not meet these criteria should be reviewed annually and given written information on falls.
What are the side effects of digoxin toxicity?
Digoxin has a narrow therapeutic index and toxicity can be potentiated by renal failure and hypokalaemia - can be triggered by infection
Symptoms of acute digoxin toxicity include gastrointestinal disturbance (nausea, vomiting, abdominal pain), dizziness, confusion, blurry or yellow vision, and arrhythmias.
What are the side effects of amitriptyline ?
Side-effects of an anticholinergic drug such as amitriptyline, including dry eyes, dry mouth, hypotension (often postural) and delirium. Amitriptyline is a commonly prescribed neuropathic painkiller.
Constipation, urinary retention, arrhythmias (including QT interval prolongation) and hypothermia.
What are the side effects of Indapamide ?
Indapamide and other thiazide diuretics can precipitate gout, and strong consideration should be made with regards to stopping the drug in patients with gout
What are the blood tests that are part of the confusion screen?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia)
Blood cultures (e.g. sepsis)
What is the score used to screen for pressure ulcers?
The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
What are the factors that predispose old people to pressure ulcers?
- Malnourishment
- Incontinence
- Lack of mobility
- Pain (leads to a reduction in mobility)
What is the management of pressure ulcers?
- A moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
- Wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
- Consider referral to the tissue viability nurse
- Surgical debridement may be beneficial for selected wounds
Why are tricyclic antidepressants to be stopped if dementia is suspected?
Risk of worsening cognitive impairment
When it needs to be stopped: wean off gradually over 4 weeks
How to differentiate delirium from dementia?
- Impairment of consciousness
- Fluctuation of symptoms: worse at night, periods of normality
- Abnormal perception (e.g. illusions and hallucinations)
- Agitation, fear
- Delusions
What are the features of Pick’s disease?
- Personality change
- Impaired social conduct.
- Hyperorality
- Disinhibition
- Increased appetite
- Perseveration behaviours.
What is the management of most dementia except FTD?
- Three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
- Memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, NICE recommend it is used in the following situation reserved for patients with:
→ moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors → as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's → monotherapy in severe Alzheimer's
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia
Who is donepezil CI in and what are its side effects?
CI in bradycardia
Adverse effects include insomnia
An elderly, frail woman is admitted to the ward following a fall at home. What is the most appropriate way to assess her risk of developing a pressure sore?
Waterlow score
What do you use to for a woman in delirium with a background of parkinsons disease?
Lorazepam
Haloperidol can make the parkinson’s worse
Which drugs can reduce the seziure threshold?
- Tramadol
- Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid
- Antipsychotics
- Antidepressents: Bupropion, Tricyclics, Venlafaxine
- Fentanyl
- Ketamine
- Lidocaine
- Lithium
- Antihistamines
A 77 year old man with a history of benign prostatic hyperplasia presents to clinic with nausea after eating some undercooked chicken last night. He is given some antiemetics but returns the next day with new symptoms of urinary retention. Which antiemetic could be responsible?
Cyclizine - has anticholinergic effects
Can enhance a high from opiates - especially with methadone so it is avoided in IVDU
Why are the adverse effects of ondensetron?
Often used to prevent nausea in chemotherapy
Can be given PO/IV and IM which makes it useful
Can increase the QT interval and can induce Torsades de pointes
What is the non-pharmacological management of postural hypotension?
- Modifying or removing medications that cause or worsen postural hypotension such as anti-hypertensives
- Encouraging fluid and salt intake
- Compression stockings and abdominal binders
What are the side effects of fludrocortisone?
Hypokalaemia, fluid retention and supine hypertension
A 72-year-old man with end stage renal disease on haemodialysis was admitted following a fracture of his left radius. In the ED he was given some painkillers. Which of medication would be appropriate to give him as a painkiller?
Tramadol - excreted during dialysis - elimination of tramadol is primarily by the hepatic route
If not use fenatanyl - stronger
Avoid morphine
A 67 year old man presents to your clinic after having his BP measured at a local health fair. His reading today is 164/84 which is similar to his previous records. His medical history is notable for angina, CKD stage 1 and T2DM (last HbA1c 8%). His only medication is occasional sublingual nitrate and metformin. What is your first line treatment for his newly diagnosed hypertension?
ACE-i
Improve heart failure and reduces the progression of renal disease and albuminuria
A 90 year old man with Parkinson’s disease comes into the A&E after suspected food poisoning. He feels sick and has vomited four times. His family have all had similar symptoms earlier today after eating a salad at the local takeaway. He is given something for his nausea when he arrived at triage. 3 hours his family are worried as he is not speaking as easily as he was before, looks more unsteady on his feet and is having difficulty moving. What treatment was he given at triage?
Metaclopramide - prokinetic and induces gastric contractions
In parkinson’s patients, it can make the symptoms worse
What medication is CI if sildenafil is being adminstered?
Nitrates
What are the medications that can cause acute confusion?
Benzodiazepines Opiates Antiparkinsonian agents Tricyclic antidepressants Digoxin Beta blockers Steroids Antihistamines such as Chlorphenamine
Which antibiotic used in UTI can transiently increase the creatinine levels?
Trimethoprim
What are the likely precipitators of postural hypotension?
Diuretics (46%)
Sedatives (17%)
Centrally acting adrenergic blockers (15%)
Peripheral acting adrenergic blockers (10%)
Vasodilators (9%)
β blockers (5%)
Nitrates (5%)
What are the reversible causes of dementia?
DEMENTIA: mnemonic
D- Drugs (barbiturates)
E - Eyes and Ears (visual/hearing impairment may be confused with dementia)
M - Metabolic (Cushing’s, hypothyroidism)
E - Emotional (depression can present as a pseudodementia),
N - Nutritional deficiencies/Normal pressure hydrocephalus,
T - Tumours/Trauma
I - Infections (e.g. encephalitis)
A - Alcoholism/Atherosclerosis (vascular).
