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Phase 3a topics > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

MUST score

A

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

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2
Q

Define acute kidney injury

A

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.

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3
Q

What is uraemia pericarditis

A

pericarditis caused by build up of toxins as not being excreted eg aki/ckd

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4
Q

ECG pericarditis

A

Widespread concave ST elevation and PR depression

Reciprocal ST depression and PR elevation in lead aVR (± V1)

sinus tachy

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5
Q

Causes aki

A

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

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6
Q

Complication of pre-renal aki

A

acute tubular necrosis

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7
Q

urine sodium levels pre-renal aki

A

low as kidneys holding onto sodium to preserve volume

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8
Q

Invetsigation pre-renal aki

A
  • hydration assessment
  • renal artery doppler if suspect renovascular disease
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9
Q

When to suspect acute tubular necrosis

A

when there is renal hypoperfusion or a tubular nephrotoxin

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10
Q

Invetsigations for renal aki

A

Urine dip:
blood and protein suggest glomerulonephritis
normal may suggest ATN

Urine protein:creatinine ratio

nephritic screen
myeloma screen
CK if rhabdomyolysis

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11
Q

normal urine protein:creatinine ratio?

nephrotic?

A

<15mg/mmol =normal

> 300mg/mmol = nephrotic

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12
Q

Investigations post-renal aki

A

Bladder scan
Renal tract USS

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13
Q

Drugs that should be stopped in AKI as may worsen renal function

A

NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
Aminoglycosides
ACE inhibitors
Angiotensin II receptor antagonists
Diuretics

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14
Q

Drugs that may have to be stopped in AKI as increased risk of toxicity (but doesn’t usually worsen AKI itself)

A
  • Metformin
  • Lithium
  • Digoxin
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15
Q

Management hyperkalaemia

A
  1. IV calcium gluconate to stabilise cardiac membrane
  2. Combined insulin/dextrose infusion, Nebulised salbutamol
  3. Removal of K from body: Calcium resonium (orally or enema), Loop diuretics, Dialysis
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16
Q

does aki cause alkalosis or acidosis

A

acidosis

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17
Q

Define CKD

A

Presence of marker of kidney damage (e.g. proteinuria) or decreased GFR for > 3 months

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18
Q

Causes of CKD from most to least common

A

Diabetes (secondary glomerular disease)
Chronic hypertension
Chronic glomerulonephritis
Polycystic kidney disease

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19
Q

Invetsigations CKD

A

History
Urine dipstick
Renal USS
Renal biopsy if required

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20
Q

When is dialysis indicated CKD

A

when GFR is <15ml/minute, and there are symptoms or complications of kidney disease

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21
Q

Complications aki

A

Hyperkalaemia
Fluid overload, heart failure and pulmonary oedema
Metabolic acidosis
Uraemia (high urea) can lead to encephalopathy or pericarditis

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22
Q

Acute tubular necrosis, blood and urine test results

A

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

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23
Q

CKD stages

A

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.

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24
Q

When to refer CKD to specialist

A

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

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25
Q

First line drug CKD

A

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).

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26
Q

How does CKD cause anaemia?

A

damaged kidneys –> less EPO –> less production of RBC

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27
Q

What is renal bone disease

A
  1. High serum phosphate due to reduced excretion
  2. Low vitamin D due to kidneys not converting to active form
  3. Low serum calcium as there isn’t vit D to help absorb it

–> hyperparathyroidism –> PTH –> increased osteoclast activity –> resorption of calcium form bones

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28
Q

management of renal bone disease

A

Active forms of vitamin D (alfacalcidol and calcitriol)
Low phosphate diet
Bisphosphonates can be used to treat osteoporosis

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29
Q

Define postural hypotension

A

a fall of systolic blood pressure > 20 mmHg on standing

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30
Q

Causes postural hypotension

A

hypovolaemia

autonomic dysfunction: diabetes, Parkinson’s

drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives, bendoflurothiazide

Alcohol

Chronic hypertension: due to loss of baroreceptor reflexes

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31
Q

How to know if there is autonomic dysfunction associated with the postural hypotension

A

if Autonomic dysfunction - heart rate won’t increase to compensate

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32
Q

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

A

Vestibular neuronitis

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33
Q

Vertigo
Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected

A

Viral labyrinthitis

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34
Q

vertigo Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears

management?

A

MEnieres disease

antihistamines and bed rest

35
Q

FRAX tool categories

A

low risk: reassure and give lifestyle advice
intermediate risk: offer BMD test
high risk: offer bone protection treatment

36
Q

T score scoring

A

> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis

37
Q

Risk factors osteoporosis

A

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

38
Q

Secondary prevention of osteoporotic fractures in post menopausal women

A

Indicated when:
- Fragility fracture and DEXA scan < 2.5
- over 75 doesn’t require scan if unfeasible

  1. alendronate (+ calcium +vit D)
  2. risedronate or etidronate if can’t tolerate SE of alendronate
  3. strontium ranelate and raloxifene
  4. Denosumab
39
Q

SE alendronate

A

upper GI SE such as reflux in 25% of people

40
Q

When should patients taking steroids be given bone protection

A
  1. > 65 with history of fracture
  2. < 65 with T score < -1.5
  3. alendronate (+ calcium +vit D)
41
Q

Dressings for pressure ulcers

A

Hydrocolloid dressings

42
Q

What tool is used to screen for pressure ulcer risk

A

Waterlow score

It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.

43
Q

Garden system for grading hip fractures

A

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

44
Q

What type of bacteria is c.diff

A

Gram positive anaerobic bacilli

45
Q

features c.diff

A

diarrhoea
abdominal pain
a raised white blood cell count (WCC) is characteristic
if severe toxic megacolon may develop

46
Q

Pathophysiology c.diff

A

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

47
Q

Diagnosis c.diff

A

stool sample Clostridium difficile toxin (CDT)

48
Q

Management c.diff

A
  1. vancomycin 10 days
  2. oral fidaxomicin
  3. oral vancomycin +/- IV metronidazole

If recurrent:
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin

49
Q

Management life threatening c.diff eg toxic megacolon, hypotension

A

oral vancomycin AND IV metronidazole

50
Q

MMSE scoring

A

20-26 = mild cognitive impairment
10-20 = moderate impairment
less than 10 indicates severe impairment.

MMSE <25 supports dementia. 25-27 is borderline.

51
Q

What is FRAX tool

A

a fracture risk calculator that estimates an individual’s 10-year probability of incurring a hip or other major osteoporotic fracture.

52
Q

What is ABCD2 tool?

A

risk of stroke after TIA

53
Q

4 components of comprehensive geriatric assessment

A

Medical assessment

Functional assessment

Psychological assessment

Social and environmental assessment

54
Q

How long should you continue bisphosphonates

A

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.

55
Q

side effects bisphosphonates

A

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

56
Q

symptoms of digoxin toxicity

A

gastrointestinal disturbance (nausea, vomiting, abdominal pain), dizziness, confusion, blurry or yellow vision, and arrhythmias.

57
Q

Drugs which contribute to falls

A

Via postural hypotension:
diuretics
antihypertensives,
L-dopa
phenothiazines
antidepressants
sedatives
bendoflurothiazide

Via other mechanisms:
digoxin
antpsychotics
opiods
benzo
codeine
anti-convulsants

58
Q

tests for postural instability

A

‘Turn 180° test’ or the ‘Timed up and Go test’.

59
Q

initial step when someone prevents with altered cognition

A
  1. confusion screen
    FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels

Bone Profile (Calcium): hypercalcaemia can cause confusion

60
Q

symptoms hypercalcaemia

A

‘painful bones, renal stones, abdominal groans, and psychic moans’

61
Q

what drugs should you stop in dementia

A

TCAs

STOPP-START

62
Q

PRISMA-7

A

to assess frailty

> 3 suggests an increased risk of frailty and the need for further clinical review

63
Q

define frailty

A

Frailty is defined as a state of impaired homeostasis leading to increased vulnerability to minor stressor events.

64
Q

GPCOG

A

GP screening tool for dementia.

65
Q

NYHA

A

scale to classify the severity of heart failure

66
Q

HAS-BLED

A

score given to assess the risk of major bleeding in patients who are taking anticoagulants.

changed to orbit

67
Q

STOPP-START

A

what drugs to stop and start in a med review for someone who is 65 years or older.

68
Q

BPPV invetsigation and management

A

positive Dix-Hallpike manoeuvre

epley maneouvre

69
Q

1st line pain management EoL

A

morphine

70
Q

pain management EoL if renal failure

A

Alfentanyl
Useful for patients with renal failure who cannot take morphine

71
Q

medications EoL N&V

A

Levomepromazine
Cyclizine
Haloperidol
Metoclopramide

72
Q

medications secretions EoL

A

Hyoscine hydrobromide
Hyoscine butylbromide
Glycopyrronium

73
Q

What is an advanced statement?

A

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)

74
Q

presentation and management ramsay hunt

A

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.

75
Q

causes of ototoxicity

A

Caused by aminoglycoside antibiotics (eg. gentamicin, vancomycin) and loop diuretics (eg. furosemide), most commonly.

76
Q

causes of ototoxicity

A

Caused by aminoglycoside antibiotics (eg. gentamicin, vancomycin) and loop diuretics (eg. furosemide), most commonly.

77
Q

management vestibular neuritis

A

Treatment is supportive (e.g. Prochlorperazine or Cyclizine), as the condition usually self-resolves over 1 week

78
Q

calculating CHADSVASC

A

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

79
Q

Management AF

A

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.

80
Q

MoA warfarin

A

vitamin K antagonist

81
Q

INR target warfarin

A

between 2-3

82
Q

Components of ORBIT tool

A

Older then 75
Renal function GFR <60
Blood Hb or haematocrit low
Intracranial or GI bleed in past
Thrombo medications (anti-platlets)

83
Q

reversing a DOAC

A

Andexanet alfa (apixaban and rivaroxaban)

Idarucizumab (a monoclonal antibody against dabigatran)

84
Q

management anaemia CKD

A
  1. correct iron defiicney
  2. erythropoetin stimulatinga gents (EPO stuff)

Phase 3a topics (39 decks)

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