Geriatrics Flashcards
MUST score
Screening tool to identify adults, who are malnourished, at risk of malnutrition
Score 0,1,2
BMI >20, 18.5-20, <18.5
Weight loss in past 3-6mo <5%, 5-10%, >10%
If ill and no nut intake for 5 days = add 2
score 0 - normal
score 1 - track intake for 3 days then screen at time intervals from then
score 2 - make a plan eg dietician etc
Define acute kidney injury
Rise in serum creatinine of 26 micromol/L or greater within 48 hours.
A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days.
A fall in urine output to less than 0.5mL/kg/hour for more than 6 hours.
What is uraemia pericarditis
pericarditis caused by build up of toxins as not being excreted eg aki/ckd
ECG pericarditis
Widespread concave ST elevation and PR depression
Reciprocal ST depression and PR elevation in lead aVR (± V1)
sinus tachy
Causes aki
Pre-renal (70%):
- hypovolaemia eg sepsis, dehydration
- renal artery stenosis
- Heart failure
Renal:
- glomerulonephritis
- acute tubular necrosis
- rhabdomyolysis
Post-renal:
- kidney stone
- prostatic hyperplasia
- urinary tract obstruction
Complication of pre-renal aki
acute tubular necrosis
urine sodium levels pre-renal aki
low as kidneys holding onto sodium to preserve volume
Invetsigation pre-renal aki
- hydration assessment
- renal artery doppler if suspect renovascular disease
When to suspect acute tubular necrosis
when there is renal hypoperfusion or a tubular nephrotoxin
Invetsigations for renal aki
Urine dip:
blood and protein suggest glomerulonephritis
normal may suggest ATN
Urine protein:creatinine ratio
nephritic screen
myeloma screen
CK if rhabdomyolysis
normal urine protein:creatinine ratio?
nephrotic?
<15mg/mmol =normal
> 300mg/mmol = nephrotic
Investigations post-renal aki
Bladder scan
Renal tract USS
Drugs that should be stopped in AKI as may worsen renal function
NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
Aminoglycosides
ACE inhibitors
Angiotensin II receptor antagonists
Diuretics
Drugs that may have to be stopped in AKI as increased risk of toxicity (but doesn’t usually worsen AKI itself)
- Metformin
- Lithium
- Digoxin
Management hyperkalaemia
- IV calcium gluconate to stabilise cardiac membrane
- Combined insulin/dextrose infusion, Nebulised salbutamol
- Removal of K from body: Calcium resonium (orally or enema), Loop diuretics, Dialysis
does aki cause alkalosis or acidosis
acidosis
Define CKD
Presence of marker of kidney damage (e.g. proteinuria) or decreased GFR for > 3 months
Causes of CKD from most to least common
Diabetes (secondary glomerular disease)
Chronic hypertension
Chronic glomerulonephritis
Polycystic kidney disease
Invetsigations CKD
History
Urine dipstick
Renal USS
Renal biopsy if required
When is dialysis indicated CKD
when GFR is <15ml/minute, and there are symptoms or complications of kidney disease
Complications aki
Hyperkalaemia
Fluid overload, heart failure and pulmonary oedema
Metabolic acidosis
Uraemia (high urea) can lead to encephalopathy or pericarditis
Acute tubular necrosis, blood and urine test results
normal serum urea:creatinine ratio would be expected.
On urine tests, sodium levels higher than 40 mmol/, low osmolality, and muddy brown casts would be expected
CKD stages
The G score is based on the eGFR:
G1 = eGFR >90
G2 = eGFR 60-89
G3a = eGFR 45-59
G3b = eGFR 30-44
G4 = eGFR 15-29
G5 = eGFR <15 (known as “end-stage renal failure”)
The A score is based on the albumin:creatinine ratio:
A1 = < 3mg/mmol
A2 = 3 – 30mg/mmol
A3 = > 30mg/mmol
The patient does not have CKD if they have a score of A1 combined with G1 or G2. They need at least an eGFR of < 60 or proteinuria for a diagnosis of CKD.
When to refer CKD to specialist
eGFR < 30
ACR ≥ 70 mg/mmol
Accelerated progression defined as a decrease in eGFR of 15 or 25% or 15 ml/min in 1 year
Uncontrolled hypertension despite ≥ 4 antihypertensives
First line drug CKD
ACE inhibitors If:
Diabetes plus ACR > 3mg/mmol
Hypertension plus ACR > 30mg/mmol
All patients with ACR > 70mg/mmol
Aim to keep blood pressure <140/90 (or < 130/80 if ACR > 70mg/mmol).
How does CKD cause anaemia?
damaged kidneys –> less EPO –> less production of RBC
What is renal bone disease
- High serum phosphate due to reduced excretion
- Low vitamin D due to kidneys not converting to active form
- Low serum calcium as there isn’t vit D to help absorb it
–> hyperparathyroidism –> PTH –> increased osteoclast activity –> resorption of calcium form bones
management of renal bone disease
Active forms of vitamin D (alfacalcidol and calcitriol)
Low phosphate diet
Bisphosphonates can be used to treat osteoporosis
Define postural hypotension
a fall of systolic blood pressure > 20 mmHg on standing
Causes postural hypotension
hypovolaemia
autonomic dysfunction: diabetes, Parkinson’s
drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives, bendoflurothiazide
Alcohol
Chronic hypertension: due to loss of baroreceptor reflexes
How to know if there is autonomic dysfunction associated with the postural hypotension
if Autonomic dysfunction - heart rate won’t increase to compensate
A 44 year old man comes to clinic complaining of episodes of a 2 week history of dizziness. These episodes come on suddenly. He feels like the room is spinning around, but does not experience any loss of hearing or tinnitus. His past medical history is relevant for an upper respiratory infection a few weeks ago
Vestibular neuronitis
Vertigo
Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected
Viral labyrinthitis
vertigo Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
management?
MEnieres disease
antihistamines and bed rest
FRAX tool categories
low risk: reassure and give lifestyle advice
intermediate risk: offer BMD test
high risk: offer bone protection treatment
T score scoring
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
Risk factors osteoporosis
SHATTERED
Steroid use >5mg/day prednisolone
Hyperthyroidism; hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI <22)
Testosterone low (e.g. anti androgen in cancer of prostate)
Early menopause
Renal or liver failure
Erosive/inflammatory bone disease (e.g. RA or myeloma)
Dietary Ca low/malabsorption or Diabetes mellitus type 1
Family history
Secondary prevention of osteoporotic fractures in post menopausal women
Indicated when:
- Fragility fracture and DEXA scan < 2.5
- over 75 doesn’t require scan if unfeasible
- alendronate (+ calcium +vit D)
- risedronate or etidronate if can’t tolerate SE of alendronate
- strontium ranelate and raloxifene
- Denosumab
SE alendronate
upper GI SE such as reflux in 25% of people
When should patients taking steroids be given bone protection
- > 65 with history of fracture
- < 65 with T score < -1.5
- alendronate (+ calcium +vit D)
Dressings for pressure ulcers
Hydrocolloid dressings
What tool is used to screen for pressure ulcer risk
Waterlow score
It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
Garden system for grading hip fractures
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
Blood supply disruption is most common following Types III and IV
What type of bacteria is c.diff
Gram positive anaerobic bacilli
features c.diff
diarrhoea
abdominal pain
a raised white blood cell count (WCC) is characteristic
if severe toxic megacolon may develop
Pathophysiology c.diff
Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile.
produces an exotoxin which causes intestinal damage
Diagnosis c.diff
stool sample Clostridium difficile toxin (CDT)
Management c.diff
- vancomycin 10 days
- oral fidaxomicin
- oral vancomycin +/- IV metronidazole
If recurrent:
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
Management life threatening c.diff eg toxic megacolon, hypotension
oral vancomycin AND IV metronidazole
MMSE scoring
20-26 = mild cognitive impairment
10-20 = moderate impairment
less than 10 indicates severe impairment.
MMSE <25 supports dementia. 25-27 is borderline.
What is FRAX tool
a fracture risk calculator that estimates an individual’s 10-year probability of incurring a hip or other major osteoporotic fracture.
What is ABCD2 tool?
risk of stroke after TIA
4 components of comprehensive geriatric assessment
Medical assessment
Functional assessment
Psychological assessment
Social and environmental assessment
How long should you continue bisphosphonates
After a 5year period for oral bisphosphonates (3years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan.
side effects bisphosphonates
oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
symptoms of digoxin toxicity
gastrointestinal disturbance (nausea, vomiting, abdominal pain), dizziness, confusion, blurry or yellow vision, and arrhythmias.
Drugs which contribute to falls
Via postural hypotension:
diuretics
antihypertensives,
L-dopa
phenothiazines
antidepressants
sedatives
bendoflurothiazide
Via other mechanisms:
digoxin
antpsychotics
opiods
benzo
codeine
anti-convulsants
tests for postural instability
‘Turn 180° test’ or the ‘Timed up and Go test’.
initial step when someone prevents with altered cognition
- confusion screen
FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels
Bone Profile (Calcium): hypercalcaemia can cause confusion
symptoms hypercalcaemia
‘painful bones, renal stones, abdominal groans, and psychic moans’
what drugs should you stop in dementia
TCAs
STOPP-START
PRISMA-7
to assess frailty
> 3 suggests an increased risk of frailty and the need for further clinical review
define frailty
Frailty is defined as a state of impaired homeostasis leading to increased vulnerability to minor stressor events.
GPCOG
GP screening tool for dementia.
NYHA
scale to classify the severity of heart failure
HAS-BLED
score given to assess the risk of major bleeding in patients who are taking anticoagulants.
changed to orbit
STOPP-START
what drugs to stop and start in a med review for someone who is 65 years or older.
BPPV invetsigation and management
positive Dix-Hallpike manoeuvre
epley maneouvre
1st line pain management EoL
morphine
pain management EoL if renal failure
Alfentanyl
Useful for patients with renal failure who cannot take morphine
medications EoL N&V
Levomepromazine
Cyclizine
Haloperidol
Metoclopramide
medications secretions EoL
Hyoscine hydrobromide
Hyoscine butylbromide
Glycopyrronium
What is an advanced statement?
An Advance Statement is sometimes called a “Statement of Wishes and Care Preferences”. It allows an individual to make general statements about their wishes, beliefs, feelings and values and how these influence their preferences for their future care and treatment.
An Advance Statement is not by itself legally binding, but legally must be taken into consideration when making a “best interests” decision on someone’s behalf under the Mental Capacity Act (MCA), 2005. This is because one of the criteria of the MCA is that a patient’s “wishes, feelings, beliefs and values” must be taken into consideration; an Advanced Statement provides evidence of this.
Information that can be included in an Advanced Statement can be anything that is important to the individual. This might include:
Religious or spiritual views, and those that might relate to care
Food preferences
Information about your daily routine Where you would like to be cared for (in hospital, at home, in a care home etc.)
Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)
presentation and management ramsay hunt
Ramsay Hunt syndrome features
Herpetic infection of the facial nerve causes a facial nerve palsy, with or without vertigo, tinnitus, and hearing loss.
This is treated with aciclovir and prednisolone.
causes of ototoxicity
Caused by aminoglycoside antibiotics (eg. gentamicin, vancomycin) and loop diuretics (eg. furosemide), most commonly.
causes of ototoxicity
Caused by aminoglycoside antibiotics (eg. gentamicin, vancomycin) and loop diuretics (eg. furosemide), most commonly.
management vestibular neuritis
Treatment is supportive (e.g. Prochlorperazine or Cyclizine), as the condition usually self-resolves over 1 week
calculating CHADSVASC
Congetsive heart failure
Hypertension
Age > 75 = 2
Diabetes
Stroke or VTE in past = 2
Vascular disease
Age >65
SC sex category (female)
0: no anticoagulation
1: consider anticoagulation
>1: offer anticoagulation
Management AF
Rate control
1. beta blocker
Rhythm control
Cardioversion with Flecanide or amiadarone or electrical cardioversion
Do immediately if AF< 48 horus and delayed if > 48 hours
after ^ 1. beta blocker
Anticoagulant
1. warfarin
1. DOAC eg Apixaban and dabigatran are taken twice daily, rivaroxaban is taken once daily.
MoA warfarin
vitamin K antagonist
INR target warfarin
between 2-3
Components of ORBIT tool
Older then 75
Renal function GFR <60
Blood Hb or haematocrit low
Intracranial or GI bleed in past
Thrombo medications (anti-platlets)
reversing a DOAC
Andexanet alfa (apixaban and rivaroxaban)
Idarucizumab (a monoclonal antibody against dabigatran)
management anaemia CKD
- correct iron defiicney
- erythropoetin stimulatinga gents (EPO stuff)
