Geriatrics Flashcards
What is the pathophysiology of benign paroxysmal positional vertigo?
calcium carbonate crystals called otoconia become displaced in the semicircular canals which disrupt the usual flow of endolymph triggering vertigo
what are the 4 possible causes of BPPV?
viral infection
trauma
aging
idiopathic
what are 3 features of BPPV?
20-60 second duration
triggered by movement
no hearing loss or tinnitus
what does the Dix-Hallpike manouver test for?
Benign paroxysmal positional vertigo
what is a positive Dix-Hallpike?
nystagmus is observed - beating is towards affected ear
what manoeuvre is used to test for BPPV?
Dix-Hallpike manoeuvre
what manoeuvre is used to treat BPPV?
epley manoeuvre
what exercises can be done by patients to improve BPPV?
Bradt-daroff exercises
what are the 4 most common causes of peripheral (vestibular) vertigo?
Benign paroxysmal positional vertigo
Menieres disease
vestibular neuritis
labrinthitis
What is Meniere’s disease?
excessive build up of endolymph in semicircular canals which causes high pressure and sensory signals
what are 8 features of menieres disease?
hearing loss
tinnitus
vertigo
sensation of fullness in ear
Nystagmus during attack
last several hours
not associated with movement
unilateral hearing loss
drop attacks
what is acute vestibular neuritis?
inflammation of the vestibular nerve usually due to viral infection. Typically presents as acute onset vertigo which improves within a few weeks. No hearing loss
what is labrynthitis?
inner ear inflammation usually due to viral infection which causes acute onset vertigo which improves within a few weeks and can causes hearing loss
what are the 4 most common central causes of vertigo?
posterior circulation stroke
tumour
MS
vestibular migraine
what kind of vertigo do you get with central casues?
non-positional
doesn’t affect hearing
no tinnitus
what is a test that can be used to determine a peripheral cause of vertigo?
the head impulse test
what is the head impulse test?
for peripheral causes of vertigo
ask patient to fix eyes on nose, move head rapidly 10-20 degrees to one side then slowly back to middle then to other side
Positive if eyes saccade (rapidly move back and forth) before fixing back on nose
what is the test of skew?
tests for central cause of vertigo
ask patient to look at nose, cover one of their eyes then the other alternating, if eye has to refix on nose after being uncovered - may indicate central vertigo
what test can be used to determine a central cause of vertigo?
the test of skew
what medications can be used to manage peripheral vertigo acutely?
prochlorperazine 5-30mg TDS
antihistamines
what medication can be used prophylactically for Menieres disease?
Betahistine
what is the classical triad of menieres disease?
hearing loss
vertigo
tinnitus
what is the increased pressure in the semicircular canals in menieres disease called?
endolymphatic hydrops
what is the T score in osteoporosis?
<-2.5
what are 8 risk factors for osteoporosis?
Increased age
Female
Reduced mobility
Low BMI
FHx
Rheumatoid arthritis
alcohol and smoking
long term corticosteroids
Post menopause
what tool is used to identify risk of osteoporotic fracture in the next 10 years?
FRAX score
what is the T-score range for osteopenia?
-1 to -2.5
what are 7 lifestyle changes that can help in the management of osteoporosis?
increased exercise
maintain healthy weight
good ca intake
good Vit D intake
avoiding falls
stopping smoking
How do bisphosphonates work?
reduce osteoclastic activity
what are 3 examples of bisphosphonates?
Alendronate (70mg once week)
risedronate (35mg once a week)
Zoledronic acid (5mg once yearly IV)
what are 4 side effects of bisphosphonates?
reflux and oesophageal erosions
atypical fractures
osteonecrosis of the jaw
osteonecrosis of external auditory canal
How should bisphosphonates be taken?
First thing in the morning on an empty stomach at least 30 mins before eating
Sit upright for 30 mins
With at least 240ml of water
what are 4 non-bisphosphonate medications for osteoporosis?
Denosumab - prevents osteoclast activity
Strontium ranelate - stimulates osteoclasts, increase VTE risk
Raloxifene - secondary prevention, stimulates oestrogen receptors on bone
HRT
what follow up is necessary in osteoporosis?
follow up DEXA in 3-5 years
what is the first line tx for osteoporosis?
lifestyle management
Bisphosphonates
Vitamin D (colecalciferol) and calcium
what are 9 risk factors for constipation?
social
- low fibre ditet
- changes in normal routine
- lack of exercise/reduced mobility
what are the 4 different types of laxitives?
Bulk forming
osmotic
stimulat
Softening
what are 2 examples of bilk forming laxitives?
fybrogel - ispaghula
methylcellulose
take a few days to work
what are 3 examples of osmotic laxitives
Lactulose
macrogol
Polyethylene glycol
take a few days to work
what are 3 stimulant laxitives?
Bisacodyl
senna
sodium picosulfate
take 6-12 hours to work
what are 2 stool softeners?
arachis oil
docusate
which type of laxitives are first line?
bulk forming
what type of laxitives should be used in opiate induced constipation?
osmotic (macrogol, lactulose) and stimulant
what counts as chronic constipation?
> 3 months
what is faecal loading?
retention of faeces to the extent that spontaneous evacuation is unlikely
which sided heart failure causes pulmonary oedema?
right
which sided heart failure causes peripheral oedema?
left
what is a normal ejection fraction?
50%
what is ejection fraction?
the percentage of blood pumped out of LV with each ventricular contraction
equation for ejection fraction?
EF = (stroke volume/end diastolic volume) X 100
cardiac output equation
CO = stroke volume x HR
what kind of cough can be characteristic of heart failure?
produces white/pink frothy sputum
what is paroxysmal nocturnal dyspnoea?
suddenly waking in night with severe SOB, cough and wheeze caused by heart failure
what is the new york heart association classification of severity of heart failure symptoms?
Class I - no limitation on activity
Class II - comfortable at rest, symptomatic with ordinary activity
Class III - comfortable at rest, symptomatic with any activity
Class IV - symptomatic at rest
What assessment guides heart failure referral time?
BNP
400 - 2000 ng/L - seen + echo in 6 weeks
>2000 ng/L seen + echo in 2 weeks
what is the medical management for heart failure?
ABAL
ACEI/ARB
Beta blocker
Aldosterone antagonist (spiro, eplerenone)
Loop diuretic (furosemide or bumetanide)
what is frailty?
health state related to aging in which multiple body systems gradually lose their built in reserves
what is the phenotype model of frailty? (5)
unintentional weight loss
weakness
exhaustion
low levels of activity
slow gait
what is the cumultive deficit model of frailty?
a count of health deficits which accumulate increasing the risk of deterioration and death. Can be calculated in a frailty index
what are 5 possible physiological markers of frailty?
raised inflammatory markers
raised insulin and glucose
low albumin
raised D dimers and alpha antitrypsin
low vit d
what are 4 interventions for frailty?
physical activity
protein-calorie suplementation
Vitamin D supplementation
Polypharmacy prevention
what are the 5 domains of the comprehensive geriatric assessment?
physical health
mental health
functional ability
social circumstance
environment
what is meant by 2 stage mental capacity test?
stage 1 - is there an impairment or disturbance in mental functioning?
stage 2 - does the person lack capacity?
what are the 4 components of capacity?
understand information
retain information
weigh up
communicate decision
what are the 4 pillars of medical ethics?
non-maleficence
autonomy
justice
beneficence
what are 4 different types of justice?
legistlative (legal)
rights based
distributive
what are 7 different types of elder abuse?
physical
financial
psychological
neglect
sexual
discrimination
institutional
what is elder abuse?
a single or repeated act or lack of appropriate action occuring in any relationship where there is an expectation of trust which causes harm or distress to an older person
what are 5 causes of secondary osteoporosis?
rheumatoid arthritis
hyperthyroid/parathyroid
premature menopause <45
chronic malabsoption/malnutrition
chronic liver disease
what are 7 intrinsic risk factors for falls?
female
neurological disease
cognitive decline
visual deficit
muscle weakness
impaired proprioception
impaired vestibular system
what are 5 extrinsic risk factors for falls?
polypharmacy
bifocals
walking aids
poor footwear
home hazards
what are 4 complications of long lies?
rhabdomyolysis
hypothermia
pneumonia
pressure sores
what is classed as polypharmacy?
> 4 drugs
what investigations should be done after a fall?
ECG - arrythmias/cardiac causes
Lying and standing BP
FBC - anaemia, infection
U+E - dehydration, rhabdo, drug clearance
CK - long lie
Bone biochem - serum Ca2+, phosphate vit D, PTH
Tilt table test
ECHO
what is postural hypotension?
drop >20mmHz systolic or >10mmHz diastolic
what medication can help venous return in orthostatic hypotension?
fludrocortisone
what are 6 types of urinary incontinence?
stress
urge
overflow
fistulae
functional
mixed
what are 5 storage LUTS?
Nocturia
Urgency
Frequency
Stress incontinence
Overflow incontinence
what are 4 voiding LUTS?
terminal dribbling
weak stream
incomplete emptying
hesitancy
what is the link between alcohol and urniary incontinence?
causes polyuria, frequency and delerium
what is the link between ACEI and incontinence?
causes cough => stress incontinence
what is the link between anticholinergics and urinary incontinence?
urinary retention and overflow incontinence
what is the link between diuretics and urinary incontinence?
frequency, polyuria, urgency
what is the link between opiates and urinary incontinence?
delerium, sedation, constipation, urinary retention
what is the link between tricyclic antidepressants and urinary incontinence?
urinary retention and overflow incontinence
what are 4 investigations for urinary incontinence?
urinalysis
Dipstick, MCS
Post void bladder scan
frequency/volume chart
what are 3 specialist investigations for urinary incontinence?
uroflowmetry
urodynamics
imaging
what is the management of stress incontinence?
lifestyle - smoking cessation, Wt loss, reduce caffeine
Pelvic floor training
1st - surgery
2nd line - Medical - duloxetine
what are 4 surgical options for stress incontinence?
colposuspension
autologous rectus fascial sling
retropubic mid-urethral mesh sling
intramural urethral bulking agents
what are 5 side effects of duloxetine?
difficulty sleeping
headache, dizziness, blurred vision
GI upset - constipation/diarrheoa/sickness
dry mouth
sexual problems
what is the management for urge incontinence?
lifestyle - wt loss, reduce caffeine, monitor timing of drinks, regular bowel habits
behavioural - bladder retraining
pelvic floor exercise
Meds - anticholinergics (tolteridone), B3 adrenoceptor agonists (mirabegron), botox injections
intravaginal oestrogen
4 causes of overflow incontinence?
idiopathic
neurogenic
infective
bladder outlet obstruction
what are the 5 components of the complete geriatric assessment?
Physical health
mental health
function
social circumstances
Environment
what are 2 risk assessments for nutrition in the elderly?
Malnutrition universal screening tool (MUST)
Mini nutritional assessment
how to calculate a MUST score?
BMI - 18.5-20 (1), <18.5(2)
Wt loss score - 5-10% (1), >10% (2)
+2 => if acutely unwell
what is the management for a medium risk MUST score?
document dietary intake for 3 days
what is the management for a high risk MUST score?
refer to dietition, nutritional support team
set goals to improve and increase overall nutrition
Monitor
what are 13 causes of malnutrition in the elderly? Mneumonic
MEALS ON WHEELS
Medication
Emotion (depression)
Annorexia/Alcohol
Late life paranoia
Swallowing problems
Oral and dental disorders
No money
Wandering (dementia)
Hyperthyroid
Enteric problems
Eating problems
Low salt/cholesterol diet
Social problems
what are 8 symptoms of refeeding syndrome?
arrythmia, HTN, CHF
abdo pain, constipation, vomiting
Musc weakness, myalgia, rhabdo
SOB, resp muscle weakness
what is the pathophysiology of refeeding syndrome?
chronic malnutrition leads to protein catabolism
total body phosphate depletion despite normal serum phosphate
intro of carbs leads to anabolic state which unmasks phosphate deplesion leading to drop in serum phosphate leading to arrythmia
what are 4 symptoms of hypothermia?
cognitive impairement
shivering
frostbite
tachypnoea, tachycardia, hypertension
what are 6 complications of hypothermia?
rhabdomyolysis
hyperkalemia
Frostbite
AKI
Pulmonary oedema
Ataxia
what are 3 managements of hypothermia?
supportive care - blankets
warmed IV fluids
extracorporeal life support
what is the management for malnutrition?
refeeding
social support
what counts as hypothermia?
core temp <35 degrees
what is heat stroke?
core temp >40 and CNS dysfunction (coma, confusion, seizure)
what is the treatment for heatstroke?
wetting and fanning the skin
wetted ice packs
whole body cold/iced water immersion (in exertion)
What is inappropriate prescribing?
prescribing contraindicated drugs
prescribing inappropriate dose/duration
Prescribing drug with likely adverse affect
failure to use drug that could improve outcome
what are the risks of polypharmacy?
increased risk of side effects
increased risk of drug-drug interactions
therapuetic cascade
increased risk of failure to review medications properly
what is a stage one pressure ulcer?
non-blanching erythema, may be warm and darkly pigmented
what is a stage 2 pressure ulcer?
partial thickness with loss of dermis presenting as shallow open ulcer
what is stage 3 pressure ulcer?
full thickness - with loss of subcutaneous fat some f which may still be visible. May slough
what is stage 4 pressure ulcer?
full thickness and affecting bone/tendon/muscle which is visible/palpable, may slough
what are 6 non-blood investigations for falls?
ECG
Lying and standing BP
ECHO
tilt table test
24 hour tape
Imaging (for injury)
what are 5 bloods for falls?
FBC - anaemia, infection
U+E - dehydration, rhabdo, drug clearance
CK - rhabdo
Bone biochem - serum calcium, phosphate, vit D, PTH
TFTs - thyroid disease
what is carotid sinus hypersensitivity?
in elderly people when the carotid sinus is stimulated at its bifurcation this can cause bradycardia and a reduction in BP leading to ventricular pause and fall in BP >50mmHg associated with syncope
what is sick sinus syndrome?
arrythmia due to disfunction of sinus node often caused by ischemic changes which causes bradycardia, arrythmia and dropped beats leading to syncope, fatigue and SOB
what are the 3 different types of delerium?
hyperactive
hypoactive
mixed
what are 5 risk factors for delerium?
dementia
comorbidities
physical frailty
older age
sensory impairment (blind/deaf)
what are 7 causes of delirium? mneumonic
PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment
what are 4 key features of delirium?
disturbance of consciousness (inattention)
changes in cognition or perceptual disturbance
develops over short period of time and fluctuates
hx suggests underlying medical cause
what medication can be used if a delirious patient is aggitated?
1 - haloperidol 0.5mg
what medication should be used in an aggitated patient with parkinsons or lewy body dementia?
lorazepam
