geriatrics Flashcards
how can frailty be prevented
nutrition, physical acticity, avoid social isolation, reduce alcohol
what is frailty
multiple body systems gradually lose their reserves
less ability to withstand an insult
assessing frailty
clinical frailty scale (1-9)
timed up and go test - <12s
poor grip strength
what is included in the comprehensive geriatric assessment
Medical: Problem List, Co-morbid conditions & Disease Severity, Medication Review, Nutritional Status
Mental Health: Cognition, Mood & Anxiety (Depression screen), Fears
Functional Capacity: Activities of Daily Living, Gait & Balance, Activity/Exercise Status
Social & Environmental Assessment: Informal support from friends & family, Social network (visitors & daytime activities), Care resource eligibility, Home safety & facilities,Transport facilities
geriatric giants
Instability (falls)
Immobility
Intellectual impairment (confusion)
Incontinence
dementia
Syndrome of progressive and global intellectual deterioration without impairment of consciousness
mx dementia
Exclude treatable and manage exacerbating factors
Support – psychological work, promote independence, relative support
Manage RF (vascular dementia)
Alzheimer’s Disease Medications: Acetylcholinesterase inhibitors - Donepezil (1st line,) Rivastigmine (better for hallucinations) AND NMDA receptor antagonist - Memantine
alzheimers pathophysiology
Most common form of dementia in the UK. Onset may be from 40 years or earlier.
Abnormal phosphorylation of tau protein leads to build-up as B-amyloid plaques in the neural cortex (neuritic plaques) and vessel walls (amyloid angiopathy). Tau protein would usually protect the neurones against calcium influx.
Neurofibrillary Tangles cause necrosis to neural tissue.
A deficit of acetylcholine develops, due to damage to the forebrain.
vascular dementia features
Caused by vascular damage to the brain, so should be suspected in patients with signs of cerebrovascular disease e.g. hypertension, IHD and PVD.
Often starts suddenly, following a TIA/ CVA.
Similar to Alzheimer’s, but there are also focal neurological signs e.g. aphasia or weakness.
Can be static, or have a step-wise deterioration.
frontotemporal dementia features
Also known as ‘Pick’s Disease’. It is mainly early-onset and 10% is familial.
Involves atrophy of the frontal and temporal lobes. Neurones in this area have abnormal swelling: Pick’s bodies – due to a mutation in the tau gene of the microtubules.
Causes early changes in personality and behaviour. Relative preservation of memory and visuo-spatial functioning.
Stereotypical, repetitive and compulsive behaviour; emotional blunting; abnormal eating; language problems.
what is lewy body dementia
If dementia symptoms 12-months before motor symptoms = Lewy Body Dementia.
Accounts for >0-15% of dementias.
Caused by alpha-synuclein protein deposits in the brainstem and neocortex, known as ‘Lewy bodies’. Lewy bodies lead to reduced levels of acetylcholine and dopamine in the brain.
These patients may also have tangles and plaques present on histology.
causes of frontal lobe syndrome
Head injury, Cerebrovascular event, Infection, Neoplasm, Degenerative Disorders (e.g., Pick’s disease)
presentation frontal lobe syndrome
“He’s not the father I know”
Symptoms: Decreased lack of spontaneous activity, Loss of attention, Perseveration
Signs: Neglect (right-sided brain lesions typically neglect the left hemispace)
ix frontal lobe syndrome
Bloods – B12 levels, TFTs, serology for syphilis and antinuclear antibodies
Consider MRI/CT scanning
pseudodementia
Cognitive Impairment secondary to mental illness- Most commonly depression
presentation pseudodementia
“Don’t know” answers
Impairments in executive functioning and attention
Frontal lobe changes
White matter hyperintensities on MRI
delirium
Clinical syndrome of confusion, variable degree of clouding of consciousness, visual illusions and/or visual hallucinations, lability of affect, and disorientation
RF and precipitating factors of delirium
Post-op, elderly, very young
Precipitating factors: Infection: particularly urinary tract infections, Metabolic: e.g., Hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration, Change of environment, Constipation, Medication/Drugs: benzodiazepines, opiates, alcohol , Hypoxia
presentation delirium
Fluctuating, impaired consciousness with onset over hours or days, or a rapid deterioration in pre-existing cognitive function with associated behavioural changes
ix delirium
Delirium Screen Bloods – ‘Confusion Screen’ = Routine bloods: FBC, U&E + CRP, LFTs, Clotting, Calcium , TFTs (TSH), B12/Folate + Haematinics , Glucose
Abbreviated Mental Test (AMT)
Non-invasive – CXR, ECG, Urine dipstick
mx delirium
Holistic approach – Treat cause, Avoid sedation, Optimise surroundings
Haloperidol (0.5 mg) – first-line sedative, NO Haloperidol in Parkinson’s – Lorazepam
types of delirium
Hypoactive:
Lethargy
Apathy
Excessive sleeping
Inattention
Withdrawn
Motor retardation
Drowsy
Unrousable
Hyperactive:
Agitation
Aggression
Restlessness
Rapidly distracted
Wandering
Delusions
Hallucinations
RF for ischaemic stroke
HYPERTENSION, Hypercholesterolaemia, Diabetes, Smoking, Atrial fibrillation, Previous TIA, Carotid stenosis
rf haemorrhagic stroke
Hypertension – often causes bleeds in the basal ganglia, AVM, Aneurysm , If taking anticoagulants, Recreational drugs/substance abuse
common presentation stroke
Unilateral weakness – often in arms and face, Slurred speech (dysarthria), Dysphasia (unable to understand words or communicate what they mean), MCA stroke – leg sparing
ix stroke
CT: Hyperdense MCA, Loss of grey white matter differentiation and sulcal effacement (squishing) – cortical infarction, Hypodense basal ganglia (deep vessel infarct)
mx ischaemic stroke
Aspirin – 300mg for 2 weeks, Potential for thrombolysis – alteplase, cut off time 4.5h, Control BP
mx haemorrhagic stroke
Control bleeding & Control blood pressure
TIA
Sx for less than 24h (usually less than 60 mins),
primary prevention stroke/tia
Smoking cessation, Control hypertension – medications and diet (reduce salt intake), Control hypercholesterolaemia (diet and medications) , Control diabetes (diet and medications) , Encourage active lifestyle and weightloss, Reduce alcohol intake
secobdary prention stroke/tia
Investigations – 72 hour ECG to look for paroxysmal AF, carotid doppler to look for carotid stenosis, BP, echo (to look for patent foramen ovale or endocarditis – can throw clots), if neck pain – investigate for dissectino with CTA/MRA
Drugs – aspirin, clopi, antihypertensives, statins, dietary controla nd diabetes management
stroke risk in AF
CHADSVASC: Congestive heart failure – 1, Hypertension – 1, Age > 75 – 2, Previous stroke/TIA/VTE – 2 , Vascular disease – 1, Age > 65, Sex category female – 1
ci thrombolysis
On anticoagulants (can if on warfarin and below 1.7)
Haemorrhagic stroke
> 6 hours after onset of symptoms
Recent surgery or GI bleed
If active cancer
Hypertension – cut off 185/110
complications of a stroke
Raised ICP – cerebral oedema, haemorrhage (signs = hypertension, new neurological signs, reduced GCS)
Aspiration (if the stroke affects their swallowing
Pneumonia
VTE due to immobility
Pressure sores
Depression
Cognitive impairment
Long-term disability
total anterio circulation stroke
Involves middle and anterior cerebral arteries
All 3 of:
unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
homonymous hemianopia
higher cognitive dysfunction
partial anterior circulation stroke
Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of:
unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
homonymous hemianopia
higher cognitive dysfunction
lacunar stroke
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
pure sensory stroke.
ataxic hemiparesis
posterior circulation stroke
involvesvertebrobasilar arteries
presents with 1 of the following:
cerebellar or brainstem syndromes
loss of consciousness
isolated homonymous hemianopia
lateral medullary syndrome
posterior inferior cerebellar artery) aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
webers syndrome
ipsilateral III palsy
contralateral weakness
basilar artery stroke
locked in” syndrome
BPPV
is one of themost common causesof vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients
features BPPV
vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
each episode typically lasts 10-20 seconds
positive Dix-Hallpike manoeuvre, indicated by: patient experiences vertigo, rotatory nystagmus
mx BPPV
Epley manoeuvre(successful in around 80% of cases)
teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for exampleBrandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.
RF falls
Previous fall, Lower limb muscle weakness, Vision problems, Balance/gait disturbances (DM, RA, PD etc), Polypharmacy (4+ medications), Incontinence, >65, Have a fear of falling, Depression, Postural hypotension, Arthritis in lower limbs, Psychoactive drugs, Cognitive impairment
falls assessment
Identify those at risk and why
‘Turn 180° test’ or the ‘Timed up and Go test’
MDT assessment in falls clinic
medications causing postural hypotension
Nitrates, Diuretics, Anticholinergic medications, Antidepressants, Beta-blockers, L-Dopa, Angiotensin-converting enzyme inhibitors - (ACE) inhibitors
medications associated with falls
Benzodiazepines, Antipsychotics, Opiates, Anticonvulsants, Codeine, Digoxin, Other sedative agents
features digoxin toxicity
blurry/yellow vision
diagnising postural hypotension
A drop in systolic BP of 20mmHg or more (with or without symptoms)
A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).
complications of a long lie
Pressure ulcers, Dehydration, Rhabdomyolysis , Hypothermia
frailty
State of increased vulnerability resulting from ageing-associated decline in functional reserve, Across multiple physiological systems, Resulting in compromised ability to cope with everyday or acute stressors
frailty assessment
gait speed, self-reported health status, or the PRISMA-7 questionnaire
osteoporosis
Decreased bone mineral density due to imbalance between remodelling and resorption
RF osteoporosis
Smoking, Early menopause, Steroid use, Underweight, Inactivity, Alcohol, ALL ELDERLY PEOPLE
risk osteoporosis
FRAXX: Parent hip fracture, Height and weight (BMI), Smoking, Alcohol >3 units a day , Steroids, Previous hip fracture, Femoral neck bone mineral density , Female gender, Age, RA, Secondary osteoporosis
ix osteoporosis
DEXA scan
Serum biochemistry – calcium, phosphate, alkaline phosphatase (normal)
diagnosing osteoporosis
DEXA scan: -1 to +1 = healthy , - 1 to -2.5 = osteopenia, ≤ -2.5 = osteoporosis, ≤ 2.5 and a current fragility fracture = severe osteoporosis
mx osteoporossi
Bisphosphonates (zoledronate, alendronate)
common sites osteoporitic fractures
Thoracic vertebrae – fractures here may lead to kyphosis and loss of height, Lumbar vertebrae , Proximal femur, Distal radius (Colles’ fracture)
causes urinary incontinence
Age-related changed: reduced total bladder capacity, reduced bladder contractile function, reduced ability to postpone voiding, atrophy of vagina and urethra, loss of pelvic floor and urethral sphincter musculature, hypertrophy of prostate
Comorbidity: reduced mobility, medication, constipation, impaired cognition
Reversible: UTI, delirium, drugs, constipation, polyuria, urethral irritability, prolapse, bladder stones and tumours
Environmental: bed bound, toilet too far/hard to access
ix urinary incontinence
Symptoms (stress, urgency, obstructive), bladder diary
Examination: vaginal, rectal, neuro
Urinalysis and midstream urine
mx urinary incontinence
Depends on cause
Bladder retraining, regular toileting, pelvic floor exercises. Overactive bladder->oxybutynin, BPH->finasteride/tamsulosin
inidcations for catheter
Sx urinary retention, obstructed outflow and deteriorating renal function, acute renal failure, intensive care
complications catheterisation
Blockage, bypassing, infection
faecal continence mechanisms
sigmo-rectal sphincter, ano-rectal angle, anal sphincters, ano-rectal sensation
caause faecal incontinnce
most commonly faecal impaction or neurogenic. Others include haemorrhoids, rectal prolapse, tumours, IBD, drugs
mx faecal incontinence
Treat constipation
Neurological: toilet at appropriate time, planned evacuation (loperamide)
Overflow incontinence: rehydrate, enema (phosphate agent), complete colonic washout, manual evacuation, laxatives
Prevention: once or twice weekly enema
malnutrition
State in which a deficiency of energy, protein, and/or other nutrients causes measurable adverse effects on the body’s form, composition, function and clinical outcome.
causes malnutrition
Decreased nutrient intake (starvation), Increased nutrient requirements (sepsis or injury), Inability to utilise ingested nutrients (malabsorption)
diagnosis malnutrition
BMI <18.5kg/m2, Unintentional weight loss >10% last 3-6mths , BMI <20kg/m2 AND unintentional weight loss >5% within last 3-6mths
refeeding syndrome
Metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished
biochemical features refeeding syndrome
Hypophosphataemia, Hypokalaemia, Thiamine deficiency, Abnormal glucose metabolism
complications of refeeding syndrome
Cardiac arrhythmias, Coma, Convulsions, Cardiac failure
mx refeeding syndrome
Monitor blood biochemistry, Commence re-feeding with guidelines , Recognise electrolytes (phophate, K+, Mg), Monitor glucose and Na levels, Supportive care, Refer to nutritional support team/dietician
RF pressure sores
Malnourishment, Incontinence, Lack of mobility, Pain (leads to a reduction in mobility)
assessint risk of pressure sores
The Waterlow score: includes a number of factors including body mass index, nutritional status, skin type, mobility and continence
prevention pressure sores
Barrier creams , Pressure redistribution , Repositioning , Regular skin assessment
mx pressure sores
Moist wound environment encourages ulcer healing: Hydrocolloid dressings and hydrogels
Surgical debridement
antibiotics only if there are signs of infection
classification of pressure sores
Grade 1 – non-blanching erythema with intact skin
Grade 2 – partial thickness skin loss involving epidermis, dermis or both (abrasion/blister)
Grade 3 – full-thickness skin loss involving damage/necrosis of sub-cut tissue
Grade 4 – extensive loss, destruction/necrosis of muscle, bone or support structures
Unstageable – depth unknown, base of ulcer covered by debris
polypharmacy
4+ medications
tools used to prevent polypharmacy
START tool: Suggests medications that may provide additional benefits i.e., proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
STOPP tool: Used to assess which drugs can be potentially discontinued in elderly patients undergoing polypharmacy
assessing capctiy
Understand the information relevant to the decision, Retain the information , Weigh up the information, Communicate the decision
key parts of mental capacity act
Assume capacity – person assumed to have capacity until proven otherwise
Maximise decision-making capacity – all practical support to help a person make a decision should be given
Freedom to make seemingly unwise decisions
Best interests – all decisions taken on behalf of the person must be in their best interests
Least restrictive option – when making a decision on another person’s behalf, the alternative that achieves the necessary goal and interferes the least with the person’s rights and freedom of action must be chosen
deprivation of liberty
occurs when a person does not consent to care or treatment, for example, a person with dementia who is not free to leave a care home and lacks capacity to consent to this
lastign power of attorney
A document which a person can nominate someone else to make certain decision on their behalf (for example on finances, health and personal welfare) when they are unable to do so themselves. To be valid, it needs to be registered with the Office of the Public Guardian
indepndent mental capacity advocate
support and represent people who lack capacity and they do not have anyone else to represent them in decisions about changes in long-term accommodation or serious medical treatment. They can also be present for decisions regarding care reviews or adult protection.
what to consider in best intersts
Whether the person is likely to regain capacity and can the decision wait
How to encourage and optimise the participation of the person in the decision
The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
Views of other relevant people
advanced directives
Used to authorise or request specific procedures and refuse treatment in a predefined future situation (advance directive)
Advance refusals of treatment are legally binding if: The person is an adult, Was competent and fully informed when making the decision, The decision is clearly applicable to current circumstances, and There is no reason to believe that they have since changed their mind
sx lewy body dementia
Fluctuating cognitive impairment.
Classically, there are visual hallucinations, gait and sleep disturbances. Patients may be restless at night.
