Geriatrics Flashcards
What is the classification of hyponatraemia
<135mmol/L
What is the classification of severe hyponatraemia
<125mmol/l
What are the three types of hyponatraemia?
hypovolaemic
euvolaemic
hypervolaemia
List some causes of hypervolaemic hyponatraemia
-Heart failure
- liver cirrhosis
- kidney failure
-nephrotic syndrome
List some causes of hypovolaemic hyponatraemia
-GI loss: diarrhoea and vomiting
-renal loss: salt wasting nephropathies, diuretics
-third space losses- e.g. pancreatitis, sepsis.
- Skin loss: sweating, burns
-primary adrenal insufficiency
-cerebral salt wasting syndrome
List some causes of euvolaemic hyponatraemia
-SIADH
-high fluid intake
-medications
Presentation of hyponatraemia
lethargy, headaches, irritability, nausea and vomiting, confusion, seizures, coma, loss of consciousness, signs of causes (e.g. if HF- SOB)
How is hyponatraemia treated
- if acute with neurological signs: replace sodium with hypertonic saline
- if chronic: treat cause
hypervolaemia and euvolaemic- fluid restriction or ADH receptor antagonist (tolvaptan)
hypovolaemic- IV fluids.
Complication of hyponatraemia
cerebral oedema
At what rate should sodium be replaced and if too quick what could be caused?
- no quicker than 8mmol/L/day
- cerebral pontine myelinisation (osmotic demyelination syndrome)
What is delirium?
An acute fluctuating change in mental status with inattention, disorganised thinking and altered levels of consciousness.
List some predisposing factors for delirium
old age
dementia
visual or hearing impairment
immobility or functional impairment
past history of delirium
dehydration
polypharmacy
co-existing medical condition
physical frailty
List some precipitating insults that may cause delirium
Medications (alcohol, sedatives, narcotics)
Primary neurological injury- e.g. stroke, meningitis
acute illness- infection (pneumonia, UTI), hypoxia, shock, dehydration, constipation
metabolic abnormalities- hypo/hyperglycaemia, electrolyte abnormalities,
surgery
iatrogenic events- e.g. catheters, being in intensive care
pain
prolonged sleep deprivation
drug withdrawal- e.g. alcohol
What are the three types of delirium?
hyperactive, hypoactive and mixed
How would hyperactive delirium present?
patient has heightened arousal with restlessness, agitation, hallucinations and inappropriate behaviour
How would hypoactive delirium present?
patient may be lethargic, have reduced motor activity, incoherent speech and lack of interest
Features of delirium in the DSM classification
- A disturbance in attention with reduced ability to focus, sustain or shift attention.
- A change in cognition or the development of a perceptual disturbance not better accounted for by pre-existing or evolving dementia
- The disturbance developed over a short period of time, represents an acute change from baseline and tends to fluctuate through the day
- There is evidence from the history, physical exam, or lab findings that the disturbance is caused by consequences of a general medical condition, substance intoxication, or substance withdrawal.
Key differentials for delirium
Depression
mental illness (psychosis)
dementia
thyroid disease
How can delirium be prevented on a ward?
- care by a familiar team
-avoid moving around the ward - appropriate lighting
- orientation: a clock/ calender
- cognitively stimulating activities
-regular visits with family
-address risk factors- hydration, hypoxia, infection, immobility, pain, medication
What medication may be considered if severe distress caused by delirium
haloperidol.
what is benign paroxysmal positional vertigo
a common cause of recurrent vertigo triggered by head movements
What is the pathophysiology of benign paroxysmal positional vertigo
otoconia- loose debris of calcium carbonate within the semilunar canals of the inner ear (mainly in the posterior semicircular canal)
The attacks are triggered by head movements which cause movement of the otoconia, abnormal motion of the endolymph and a feeling of vertigo
Presentation of BPPV
short episodes of vertigo lasting typically less than 1 minute
Episodes are triggered by head movements such as rolling over in bed
They may cause nausea and vomiting
No change in hearing or tinnitus
How is BPPV diagnosed?
the Dix-Hallpike manoeuvre
Describe the Dix-Hallpike manoeuvre
Patient sits with head turned 45 degrees to the side
The patient is lowered rapidly to laying with their head still turned to 45 degrees to a point where their head hangs off the edge of the couch extended to 20-30 degrees
The patient is held in this position for 30-60 seconds and their eyes are watched for nystagmus (BPPV causes rotational nystagmus towards the affected ear and feelings of vertigo)
How is BPPV treated?
the Epley manoeuvre and Brandt- Daroff exercises
Describe the Epley manoeuvre
Begins the same as the Dix-Hallpike manoeuvre (patient starts sitting with head 45 degrees to side and is then lowered to laying rapidly)
The patients head is then turned 90 degrees past central to face the other side
The patient is then turned onto their side to that their head rotates another 90 degrees
The patient then sits up sideways with legs over the side of the couch
The head is then placed centrally with the chin flexed towards the chest
What are Brandt-Daroff exercises
exercises that can be performed by the patient at home
The patient sits on the end of the bed and lies sideways then moves from side to the other side while rotating the head slightly to face the ceiling
What is the definition of polypharmacy
taking over 5 different medications
What two types of polypharmacy are there?
appropriate polypharmacy- prescribing for complex medical conditions where the medicines have been optimised and prescribed according to best evidence
problematic polypharmacy - prescribing multiple medications inappropriately
SE of beta blockers
cool peripheries, bradycardia
can you give metformin in low eGFR
no
metabolic abnormality of ACEi
hyperkalaemia
SE of statins
muscle cramps
confusion
LFT changes
RF for falls
previous falls
conditions that effect mobility and balance-> rheumatoid arthritis, diabetes, stroke, syncope, parkinsons
visual impairment
cognitive impairment
polypharmacy
depression
psychoactive drugs
drugs that cause postural hypotension
frailty
What medications can cause postural hypotensions (7)
nitrates
duiretics
ACEi
anti- cholinergics
antidepressants
beta blockers
Levodopa
what medications can cause falls (that dont cause postural hypotension)
benzodiazepines
antipsychotics
opiates
codeine
anticonvulsants
digoxin
sedatives
what two tests does NICE recommend to assess falls risk ?
time up and go test
turn 180 test
what is a complication of falls that results from laying on the floor for a long period of time
rhabdomyolysis
How does the timed up and go test work?
measure the time it takes the person to get up out of the chair without using arms, walk 3 metres, turn and return to chair
a time over 12-15 seconds indicates high risk of falls
how does the turn 180 test work?
as the patient to stand up and turn around to face the other direction- if they take more than 4 steps to do is it indicated increased risk of falls
what is rhabdomyolysis?
the breakdown of skeletal muscle leading to the release of its intracellular contents into the blood (myoglobin and potassium)
how might rhabdomyolysis present?
red/brown urine (myoglobinuria)
muscle pain and swelling
AKI
how does rhabdomyolysis present on bloods?
creatinine kinase that is at least 5 times upper limit
hypercalaemia
hypocalcaemia
high LDH
hyperphosphataemia
how is rhabdomyolysis treated?
IV fluids
manage potassium- IV calcium gluconate to stabilise membranes, insulin dextrose to move potassium intracellular
RF for pressure ulcers
reduced mobility
nutritional deficiencies
vascular disease
older age
diabetes
incontinence
reduced sensation of pain
Where do pressure ulcers usually occur?
on bony prominences or where medical devices are
How might pressure ulcers present?
an area of non-blancheable erythema
marked localised skin changes
a wound of varying severity
What tools can be used to assess the risk of pressure ulcers ?
Braden
Waterlow- key one to remember
Norton
PURPOSE T
How are pressure ulcers treated?
- keep environment moist: hydrocolloid dressings and hydrogels may help facilitate this
- surgical debridement may be needed in severe
- antibiotics if infected
- pressure redistributing devices
What are the 4 stages of severity of pressure ulcers
stage 1: non-blanching erythema
stage 2: partial thickness of skin
stage 3: full thickness of skin
stage 4: full thickness of tissue
complications of pressure ulcers
infection
osteomyelitis
cellulits
sepsis
what are some RF for malnourishment in elderly :
- acute illness
- frailty
- appetite and eating difficulties - medications, oral health, dentures
- progressive neurological difficulties- parkinsons, dementia
- neurodisability
- emotional and psychological factors- depression
- evironmental factors- difficulty preparing food
- socioeconomical factors- low income
how is malnourishment defined (3)
- A BMI of less than 18.5
- unintentional weight loss greater than 10% in the past 3-6 months
- a BMI of less than 20 with unintentional weight loss of > 5% in the last 3-6 months
What is the screening tool for malnutrition
MUST (malnutrition universal screening tool)
what is given to those with a MUST score greater than 2
oral nutrition supplements
describe oral nutrition supplements
provide about 300 calories, 12g of protein, plus vitamins and minerals
taken between meals not instead
if oral nutrition supplements do not work, what can be used instead
enteral tube feeding
TPN
what are some complications of malnutrition
increased vulnerability to infection
pressure ulcers
falls and frailty
hypothermia
VTE
define hypothermia
core body temperature of less than 35 degrees
what stages of hypothermia are there?
mild : 35-32
moderate- 28-32
severe: 20-28
profound: <20
What are some RF for hypothermia
general anaesthesia
substance abuse
hypothyroidism
impaired mental status
homelessness
extremes of age
pathophysiology of body response to hypothermia
- thermoreceptors in skin sense low temperature and cause vasoconstriction
- they stimulate the hypothalamus to release TSH and ACTH
- they also stimulate shivering
how might hypothermia present?
shivering
cold pale skin
slurred speech
tachycardia and tachypnoea if mild
resp repression, bradycardia and hypotension if severe
confusion
What might an ECG show in severe hypothermia?
ST elevation
J waves (osborn waves)
MAnagement of hypothermia
mild:
- remove patient from cold environment
- remove wet cold clothing
- warm body with blankets
severe: active warming
- external: warm air (Bair hugger)
- core: warm IV fluids
What can rapid re-warming cause?
peripheral vasodilation and shock
