Geriatrics Flashcards
How can pressure ulcers be prevented?
Support surface
Skin inspection
Movement
Manage incontinence
Nutrition
What is a pressure ulcer
An area of localised damage to the skin and underlying tissue caused by pressure
What factors are implicated in the formation of a pressure ulcer
Pressure
Shear
Friction
Moisture e.g. from incontinence
How does a pressure ulcer form
Decreased capillary flow due to pressure
Ischaemia, occlusion of lymphatic and capillary thrombosis
Pushes fluid out of capillaries
Oedema occurs and leads to cell and tissue death
How are pressure ulcers classified ?
Grade 1 - non-blanching erythema, warmth, hardness
Grade 2 - partial thickness skin loss. Looks like an abrasion or blister
Grade 3 - full thickness skin loss involving subcutaneous tissue
Grade 4 - extensive destruction, necrosis or damage to muscle, bone or supportive structures
Risk factors for pressure ulcers
Acute illness
Age
Level of consciousness
Cognition
Immobility
Sensory impairment
Chronic or terminal disease
Vascular disease
Malnutrition or dehydration
Incontinence
History of pressure damage
When should antibiotics be used in pressure ulcers
All pressure ulcers are colonised with bacteria
Antibiotics should only be used when clinical signs of infection are present and cu litres should be taken to confirm sensitivities
What changes to the bladder and it’s function occur with ageing
Bladder contraction frequency increases - increased urge to urinate
Bladder capacity reduces and residual volume increases
Increased urgency and fullness
Increased nocturia
What gender specific changes occur to bladder function
Females: reduced tone in sphincters
Urogenital atrophy Due to oestrogen decline
Males: increased frequency but reduced flow
Prostatic hypertrophy, increased urethral resistance and urethral obstruction to varying degrees
What factors can contribute to urinary incontinence
Usually multi factorial
- comorbidities
- polypharmacy
- physical and cognitive decline
- lower urinary tract dysfunction
What consequences of urinary incontinence can occur
Depress
Falls and fractures
UTIs
Social isolation
Deconditioning
What medication is first line for overactive bladder or mixed urinary incontinence
Oxybutynin
Only after bladder training course tried
What is assessed in a continuing care assessment
A continuing care assessment decides where/if a person should receive care after hospital
Assesses behaviour, continence, mobility, skin integrity
What are the types of urinary incontinence?
Overflow incontinence - involuntary leakage with constant dribbling or dribbling for some times after passing urine
Urge incontinence - involuntary leakage with or just after urgency
Overactive bladder syndrome - urgency with or without urge incontinence usually with frequency and nocturia
Mixed - leakage associated with urgency and also with exertion, effort or coughing
Stress - leakage on exertion, effort or coughing/sneezing
What is a CGA? What does it cover
A thorough MDT assessment and formation of a management / follow up plan
Covers:
1. Medical diagnosis and past diagnoses
2. Review of medications and concordance
3. Social circumstances
4. Mood and cognitive function
5. Functional ability
6. Environment
7. Economic circumstances
What is delirium
Clinical syndrome of disturbed consciousness, cognitive function or perception with an acute and fluctuating course
Causes of delirium
Pain
Infection
Nutrition
Constipation and urinary retention
Hydration
Medication (+ alcohol and withdrawal)
Environment
What tests can be used to assess for delirium
Confusion Assessment Method
4AT (short version of abbreviated mental test score AMTS)
How does CAM diagnose delirium
Needs both A & B
A: acute onset and fluctuating course
B: inattention
And either C or D
C: Disorganised thinking
D: altered level of consciousness
How does 4AT diagnose delirium
4 points or above diagnoses probable delirium
Clearly abnormal alertness 4 points
Age, DOB, current location, current year: 1 mistake 1 point, 2 or more 2 points
List months of year backwards: <7 correct 1 point, cannot assess 2 points
Acute change or fluctuating course 4 points
What is anticholinergic burden?
Cumulative effects of medications with anticholinergic effects
Dry mucous membranes, drowsiness, constipation, urinary retention
Increases cognitive impairment, falls risk and overall mortality
Grades medications 0 points to 3 points based on their burden
Score of 3 or more associated with adverse effects
What are the three main types of laxatives? And examples of each
Bulk forming - ispaghula husk, methyl cellulose
Osmotic laxatives - lactulose, macrogol
Stimulant laxatives - senna
What is frailty
Being vulnerable to poor resolution of homeostasis after a stressor event leading to cumulative decline
What is the phenotype model of frailty
Describes frailty as a syndrome with 5 variables
1. Unintentional weight loss
2. Self reported exhaustion
3. Low energy expenditure
4. Slow gait speed
5. Weak grip strength
3 or more frail
1-2 pre frail
0 not frail
What is the cumulative deficit model of frailty
Describes frailty as a state
92 baseline variables classed as present or absent
Can relate to clinical frailty scale
What is the clinical frailty scale
Scores frailty from 1-9
1 very fit
2 fit
3 managing well
4 living with very mild frailty
5 living with mild frailty
6 living with moderate frailty
7 living with severe frailty
8 living with very severe frailty
9 terminally ill
What signs can be picked up of frailty on physical examinations
Vital signs - lying standing blood pressure
Head and neck - cognitive assessment and visual examination
Cardio/respiratory/abdo - fluid overload, valve stenoses, vascular disease, bowels, bladder
Musculoskeletal - joints, muscle bulk, transferring
Skin
Neurological
How can factors for falls be assessed
Drugs
Ageing related
Medical causes
Environmental
What is BPPV
How is it diagnosed and treated
Benign paroxysmal positional vertigo
Vertigo that occurs in short spells and with head movements
Diagnosed using Dix-hallpike manoeuvre
Treated with Epley manoeuvre
What investigations should be done in a falls patient
FBC - anaemia and infection markers
Blood glucose
U&Es - electrolyte abnormalities
TFTs
B12 and folate
Bone profile
Vit D
ECG
What is a frax calculation
Works out the 10 year fracture risk
What is the first line treatment for osteoporosis
A bisphosphonate such as alendronic acid 70mg once weekly
Alongside calcium and vitamin D
What age related changes affect normal blood pressure regulation so can lead to syncope
Reduced baroreceptor sensitivity
RAAS system works less effectively
LV diastolic dysfunction - harder to increase stroke volume
Conduction system disease
Drugs can exacerbate this such as beta blockers, ACEi and diuretics
How is a stroke diagnosed
FAST test in the community
NIHSS scale to indicate severity
CT scan to decide ischaemic or haemorrhagic
What treatment is done once a haemorrhagic stroke is excluded
300mg aspirin
Thrombolysis with alteplase if within 4.5 hours of symptom onset and no exclusion criteria present
What are the main risks of thrombolysis
6% risk of haemorrhage (2-3% life threatening)
7% risk of angioedema
What is a lacunar stroke / lacunar syndrome ?
Subcritical stroke due to small vessel disease
Diagnosed by 1 of:
- unilateral weakness
- pure sensory stroke
- ataxic hemiparesis
What is posterior circulation syndrome?
Stroke in the posterior circulation
Diagnosed by 1 of
- cerebellar or brain stem syndrome
- loss of consciousness
- isolated homonymous hemianopia
What is a total anterior circulation stroke and partial anterior circulation stroke
Cortical strokes that occur in the MCA or ACA
Total or partial determined by 3 or 2 of the following symptoms
- unilateral weakness
- homonymous hemianopia
- higher cerebral dysfunction
How does a haemorrhagic stroke tend to present
Symptoms tend to progress rapidly (as oppose to very very sudden in ischaemic)
Can be younger patients
Headahce
Most commonly hypertensive either known or unknown
How can you differentiate a stroke in the anterior vs middle cerebral artery
Anterior tends to be lower extremity affected more
Middle tends to be upper limb affected more + aphasia more likely
What symptoms with posterior cerebral artery stroke
Contra lateral homonymous hemianopia with macular sparing
Visual agnosia
What is Weber’s syndrome
Midbrain stroke
Causes ipsilateral CNIII palsy
Contractural upper and lower limb weakness
How does a posterior inferior cerebellar artery stroke present
Ipsilateral facial pain and temp loss
Contra lateral limb and torso pain and temp loss
Ataxia and nystagmus
Anterior inferior cerebellar artery stroke
Ipsilateral facial paralysis and deafness
+ same as posterior inferior cerebellar stroke
Retinal/ophthalmic artery stroke
Amaurosis fugax - transient visual loss
Basilar artery stroke
Locked in syndrome
what are the core clinical features of Parkinson’s disease
bradykinesia
resting tremor
rigidity
what is the pathophysiology of PD
Lewy bodies causing loss of dopaminergic neurones in the basal ganglia, particularly the substantia nigra
diagnostic criteria for PD
- Bradykinesia + tremor or rigidity
- absence of red flags indicating another cause
- at least one of:
- response to dopaminergic therapy
- levodopa induced dyskinesia
- olfactory loss
what red flags indicate a diagnosis other than idiopathic Parkinson’s disease
symmetrical at onset
pyramidal tract signs
early falls
poor levodopa response
brisk reflexes and positive babinski
what are the main differential diagnoses of PD
vascular Parkinsonism
supra nuclear gaze palsy
multiple system atrophy
dementia with lewy bodies
Drug induced Parkinsonism
Normal pressure hydrocephalus
what are the non-motor features of PD
- mood disorders mainly depression
- constipation, urinary retention and erectile dysfunction
- cognitive impairment
- psychotic featyres
- olfactory deficit
- pain
- sleep disorders
where/how in the brain do different PD medications target?
dopaminergic therapies - replace loss of dopamine so more action at D1 and D2 receptors
NMDA receptor antagonists e.g. amantidine block excessive glutamate (inhibitory) action
deep brain stimulation its at the GPm and STN nuclei of the basal ganglia
what drugs for PD act in the peripheries enhance dopamines effects
decarboxylase inhibitors given with levodopa e.g co-careldopa reduce peripheral conversion to dopamine which can’t cross BBB
COMT inhibitors also increase delivery of L-DOPA e.g. entacapone
what drug acts centrally to enhance dopamines effect
MAO-B inhibitors reduce breakdown of dopamine in the CNS
e.g. selegiline
rasagiline
how does levodopa compare to direct dopamine agonists
levodopa (gold standard start first)
- better short term motor improvement
- reduced gait freezing
- more dyskinesia
dopamine agonists
- less efficacy but also less dyskinesia
- more impulse control disorders
what is dyskinesia? when does it occur
involuntary twisting writhing movements induced by dopamine, worse with prolonged treatment - increased dyskinesia and less levodopa effect
What is an essential tremor
A condition that’s usually familial
Produces a tremor worse on movement and that may be present in the legs and jaw
Beta blockers effective at reducing the tremor
How does drug induced Parkinsonism present
History of dopamine blocking drugs such an antipsychotics
Usually symmetrical rigidity and lack of facial expression
How does multiple systems atrophy present
Symmetrical Parkinsonism with early autonomic features such as hypotension and bladder instability
How does progressive supranuclear gaze palsy present
Falls, truncated rigidity, vertical gaze palsy and reduced midbrain volume on MRI
What is the triad of normal pressure hydrocephalus
How is it treated
Dementia, gait disorder and bladder instability
Diagnostic lumbar puncture and CSF removal then shunt
Examples of dopamine agonists
When can they be used
Ropinirole, pramipexole, rotigotine
Can be used first line
What are the 4 stages of Parkinson’s disease progression
- Pre diagnosis : nigrostriatal degeneration is occurring. Minimal motor symptoms, may have some subtle non motor symptoms
- Diagnosis and maintenance : drug treatment commenced with good response and no complications
- Complex : motor complications, neuropsychiatric issues
- Palliative : door drug response with multiple drugs, Parkinson’s dementia, swallowing and speech impairments. Discussions about end of life care needed
What is the Waterlow score
Identifies patients at risk of pressure ulcers
When should a FRAX calculation be done
assess fracture risk in
- anyone over 50 with a history of falls
- all women over 65
- all men over 75
treatment for osteoporosis
bisphosphonate (alendronic acid) + calcium + vit D
bisphosphonate contraindications
chronic kidney disease or pre-existing dysphagia or dyspepsia
drug induced Parkinsonism
Hx of dopamine blocking drugs
symmetrical rigidity and lack of facial expression
reduce of stop drug - need to liaise with psychiatry
areas assessed in NIHSS score
Consciousness
Pt knows month and age
Eye opening
Best gaze
Visual Fields
Facial Paresis
Right arm
Left arm
Right leg
Left leg
Limb ataxia
Sensation
Language
Dysarthria
Extinction + inattention
first line pharmacological treatment for delirium
0.5mg haloperidol
Contraindicated in Lewy body dementia and parkinsonsims
absolute thrombolysis contraindications
- previous intracranial haemorrhage
- seizure at onset of stroke
- intracranial neoplasm
- suspected SAH
- stroke of traumatic brain injury in previous 3 months
- LP is last 7 days
- GI haemorrhage in last 3 weeks
- active bleeding
- pregnancy
- oesophageal varices
- uncontrolled HTN >200/120mmHg
relative thrombolysis contraindications
concurrent anticoagulation INR (>1.7)
major surgery in previous 2 weeks
active diabetic haemorrhagic retinopathy
definition of postural hypotension
drop in BP of >20mmHg systolic and/or >10mmHg diastolic within 3 minutes of standing
causes of postural hypotension
Neurogenic
- T2DM (autonomic failure)
- Parkinson’s
- rapidly progressing; amyloid, SCLC
Non-neurogenic; hypovolaemia, cardiac failure or venous pooling
- cardiac impairment; MI, aortic stenosis, HF
- medications; antihypertensives, diuretics, beta-blockers, anti-adrenergic
- reduced intravascular volume; dehydration, adrenal insufficiency
- states that induce vasodilation e.g. fevers
postural hypotension non-pharmacological management
compression stockings
raise head of bed
increase water and salt intake
patient education and avoiding high risk situations
should always try before pharmacological methods
pharmacological management of postural hypotension
Fludrocortisone; mineralocorticoid that expands plasma volume
Midodrine; vasopressor useful in neurogenic PH
Pyridostigmine; has a vasopressor effect whilst standing
questions to ask in a nutritional assessment
- can the pt feed themselves; any assistance? cutlery?
- preparing own meals? cooking/microwave? if not who assists?
- doing shopping? who assists?
- any change in appetite or weight loss?
- any problems with dentition or chewing/swallowing?
- what is their normal intake like? no. of meals, portions etc
how is a MUST score calculated and used
- calculate BMI
- any recent weight loss and quantify as a % of body mass; weight loss score
- if pt acutely unwell and has their been little intake for >5days; acute disease effect score
- add up all scores from 1-3 to give MUST score
0 - routine care
1- monitor intake and aim to improve
2+ - refer to dietician and aim to improve intake
