Geriatrics Flashcards
What is a key tool in geriatric history/exam?
collateral history…paramedics, carers, family, GP
What are key aspects of social history that you must inquire about in geriatric history?
social support- carers, family support?
activities of daily living- requires assistance or independent?
continence
cognition
mobility- falls, walking aids, mobility around house
exercise tolerance
What aspects of physical examination are important in a geriatric exam?
vision and hearing
swallow, nutrition, hydration
bladder and bowel
injury
skin
Name two other allied professionals who are involved in the care of geriatric patients?
occupational therapist- improving every day life, prevent falls, memory rehab, home modifications, help with vision loss
Social worker- connecting to appropriate services, community resources
dietitian
speech and language therapist
physio
What criteria is used to assess frailty?
fried frailty criteria
Name two components of the fried frailty criteria
weight loss, exhaustion, low physical activity, slowness and weakness (measured by grip strength)
A patient has a score of 3 on fried frailty criteria. Are they frail?
> 3 = frail
1-2= pre-frail
Name one frailty index/scoring system
ROckwood’s frailty index- the more things you have wrong the more likely you are going to be frail
fried frailty criteria
Edmonton frail scale
List three common problems in frailty
falls
cognitive impairment
continence
mobility
nutrition
polypharmacy
mood
loneliness
alcohol
vision
hearing
Which is the most helpful tool for frailty for medical students?
Health improvement Scotland frailty score
Name one key thing that can be done to improve health outcomes for frail people when they first begin to show evidence of physical and mental decline
comprehensive geriatric assessment CGA- specialist care
What is a bedside frailty score?
FRAIL acronym
Functional decline- self care
Residential care
Acute or chronic confusion
Immobility
Living with support at home
Which tests should you do to rule out delirium and depression?
4AT
GDS- geriatric depression scale
How does pharmacokinetics change with age?
absorption- low HCL secretions
Less body water and more body fat- impact on half life
Elimination- high first pass metabolism, reduction in doses e.g. morphine
Reduction in creatinine- impairment of renal excretion
How does pharmacodynamics change with age?
increased sensitivity to medication due to changes in receptor numbers and response
What is risperidone?
antipsychotic
What is the impact of risperidone on dementia?
increased risk of stroke and roles, caution in elderly
List two contributing factors to polypharmacy
seeing multiple doctors
failure to review
severe chronic disease
care home
admission
failure to recognise non concordance= not actually taking the medications
What is number needed to treat?
The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.). For example, if a drug has an NNT of 5, it means you have to treat 5 people with the drug to prevent one additional bad outcome.
The lower the number the better
List three classes of drugs that should be stopped in person who is unwell
ACEi
ARBs
NSAIDs
Diuretics
Metformin
How do water and fat content change with increasing age?
increase in total body fat
decrease in total body water
List three causes of weight loss?
poor dentition
swallowing difficulties
cognitive impairment
access/environment
poor appetite
low mood
chronic disease
acute illness/injury –> inflammation
List two risk factors for pressure ulcers
sarcopenia
malnutrition
immobility
neurological damage
medical conditions
incontinence
List two medical conditions that increase the risk of pressure sores
COPD
dementia
CVA
fracture/surgery
malignancy
List the grades of pressure ulcers
Grade 1- non blanching erythema
Grade 2- Partial thickness skin loss
Grade 3- Full thickness skin loss
Grade 4- Full thickness tissue loss
List two strategies to improve outcome of skin ulcers
keep repositioning
incontinence and moisture
skin inspection
surface- redistribute body weight
nutrition and hydration
List three types of incontinence
Passive/functional
Overactive bladder/urge
Stress incontinence
Overflow
Two causes of stress incontinence?
child birth
chronic cough
obesity
Management of stress UI?
lifestyle advice
pelvic floor exercises
pads
surgery
Two causes of urge incontinence
neurological conditions- MS, dementia, PD
small capacity bladder
UTI
Management of urge incontinence?
pelvic floor exercises
bladder retraining
anticholinergics
B3 agonist
Botox into bladder wall
Two causes of overflow UI?
enlarged prostate
constipation
pelvic mass
neurological conditions
List two components of an examination to assess urinary incontinence?
PR
Skin
Stand patient up/cough
Vaginal exam
Cognitive assessment
Check skin if concern for dementia/immobility
Red flags for urinary incontinence?
pelvic pain
haematuria
back pain
loss of senstion/tone
Investigations for urinary incontinence?
urine dip/culture
frequency volume diaries
post voidal bladder scan
blood tests- WCC/CRP, Hb- new anaemia, PSA- prostate
List two hallmarks of diagnostic features of delerium
- Cognitive impairment
- Fluctuation in levels of consciousness/drowsy
- Inability to focus/inattentive
List three causes of delerium
infection
drugs
constipation
pain
urinary retention
dehydration
Does syncope increase mortality?
no
List two characters of syncope
loss of postural tone
transient global cerebral hypoperfusion characterised by rapid onset, short duration and spontaneous recovery
Name three causes of syncope
reflex- (trigger) vasovagal, carotid sinus, situational (cough, laugh)
Orthostatic hypotension= postural hypotension
Cardiac
List two causes of postural hypotension/orthostatic hypotension
medications
hypovolaemia/dehydration
hypoadrenalism- short synacthen test
Primary autonomic dysfunction e.g. idiopathic parkinson’s disease
secondary autonomic dysfunction e.g. diabetes, lambert eaton syndrome, infections e.g. HIV
Specific questions to ask about syncope in relation to orthostatic hypotension?
prodromal symptoms
diet/fluid intake
alcohol??
eyewitness account
recovery period
standing sitting
hot bath?
DRIVING
Management of orthostatic hypotension?
identify triggers
improve hydration
medication review
24 hour BP monitor
List three differentials for delerium
dementia
deaf/blind
depression
dysphasia
different language
alcohol- withdrawal
List three differences between delirium and dementia
Onset- acute vs insidious
Course- fluctuating versus progessive
Conscious- clouded vs clear
Hallucinations vs absent
Delusions vs absent
Hyper/hypo activity vs normal
List a screening test for delerium
4AT
CAM- confusion assessment method
Difference between 4AT and AMT4?
AMT4- abbreviated mental test: age, DoB, place, year, indicates cognition while 4AT is delirium tool
List two personal factors that increase risk of delirium
male
older age
dementia
depression
alcohol
sensory impairment
List two environmental factors that precipitate delerium
severe medical illness
polypharmacy
surgery
dehydration
malnutrition
sleep deprivation
List three complications of delerium
increases risk of future dementia
increased mortality
increased hospital stay
PTSD
pressure sores
falls
pneumonia
increased readmission rates
What is the management of delirium?
target risk factors- dehydration, sensory loss, immobility, polypharmacy
TIME burdle
re-orientation
address pain
antipsychotics
List three domains that dementia affects
memory
orientation
comprehension
learning capacity
calculation
language
judgement
Three differentials for dementia?
delirium
depression
iatrogenic- anticholinergic medications
physical illness- anaemia, thyroid dysfunction
List one cognitive test you would use to assess dementia?
MMSE
Montreal cognitive assessment MoCA
Addenbrookes cognitive exam
List three components of dementia screening bloods?
FBC
U+E
LFT
CRP
Bone profile
Haematinics
TFT
Discuss the pathophysiology of dementia
amyloid plaques and neurofibrillary tangles (tau hyperphosphorylation) causing atrophy
Which regions of the brain are affected most in alzheimer’s disease
mediotemporal e.g. hippocampus
List one genetic risk for dementia
presenellin 1 and 2
amyloid precursor protein APP
In which type of dementia should you be cautious with antipsychotics?
lewy body dementia
List two classes of drugs used in the treatment of dementia
acetylcholinesterase inhibitors e.g. rivastigmine
NMDA antagonist e.g. memantine
Name one contraindication for acetylcholinesterase inhibitors?
bradycardia or 2nd degree heart block
List two psychological treatments for dementia
cognitive stimulation therapy grou
memory management group
patient and carer education
List two aspects of social treatment for dementia
power of attorney/guardianship
Home care, help with shopping etc
OT assessment (kitchen, baths)
Managing risk (smoke detectors, telecare, alarms, locked meds box)
List four aspects of memory/dementia history you would take
daily tasks- cooking/dressing/cleaning
mobility
paying bills
Word finding
Mood/interests/attention
Using gadgets- tv remote, phone
falls
black outs
hallucinations
empathy?
taking medications?
What is the difference between parkinson’s disease dementia and lewy body dementia?
If symptoms start >1 year after motor syx= PDD
If symptoms dementia start <1 year after or before motor symptoms= Lewy body dementia
What are the key features of sporadic creutzfeldt jakob disease?
rapidly progressive dementia- memory, language, behaviour changes
Motor symptoms- ataxia, myoclonus, rigidity
Later stages- bed bound….
4 month prognosis from onset of symptoms!!
List three ways in which distress can manifest in behaviour
physical aggression
verbal aggression
self harm
shouting
lack of self care
stripping
sleep problems
inappropriate sexual behaviors
spitting
List two biological causes of physical aggression
alcohol withdrawal
Pain
Drug induced
Frontal lobe deficit
List two psychological causes of aggression
frustration from being:
misunderstood
inability to communicate well
inability to understand
embarrassed during personal care
List two social causes of aggression
does not like being touched
prevented from leaving building
not liking carer e.g. due to age, sex
Two causes of excessive walking
distraction from pain
drug induced
boredom
sense of control
hungry
Patient is sleepy and is picking at the air and at their clothes. What is this a classic sign of?
delirium!!
Which anti psychotic can be used to calm/sedate distressed patient?
risperidone, in small doses
