Geriatrics Flashcards
What is a comprehensive Geriatric Assessment?
A multidimensional, interdisciplinary
diagnostic process to determine the medical, psychological, and functional
capabilities of a frail older person in order to develop a coordinated and
integrated plan for treatment and long-term follow-up
What are the domains of a CGA ?
Problem list
Medication Review
Nutritional Status
Functional Capacity ( activities , gait , activity status)
Mental health
Social circumstances ( visitors, partners etc )
Environment ( accessibility, safety , transport facilities )
What is polypharmacy?
When a patient is on 6 or more medications at once. Many can have interactions and affect the patient negatively.
What does proper prescribing technique involve?
Check for drug allergies
Check for potential interactions
Write drug in CAPITALS
Ensure dose, fz, times, start date, route of administration are clearly identified
Write ‘Units’
Print name and sign
What is a Home First Form?
Its a referal to Social Services to access for funding or a package of care for older patients being discharged. A social worker will then be allocated to the patient.
What are falls classifies into ?
Syncopal ( loss of consciousness )
Non-syncopal
What is the process for history taking of a fall?
Before the fall - how did they fall, what were they doing, where where they, any dizziness/ palpitations/ sweating/ tachycardia/ chest pain/ SOB
During - what could they hear, any loss of consciousness, any injuries
After - how long did they take to recover, how did they feel after
Has is ever happened before?
Medication History
What investigations should be done for a fall?
CVS Exam + ECG + Lying/Standing BP
Neurological Exam
Muscoskeletal Exam
Mobility Assessment
What is it important to access in elderly falls patients?
Osteoporosis risk - DEXA scan
Those over 75 with fracture from minor trauma should be started on osteoporosis medication
What is the treatment for osteoporosis?
Bisphonates ( e.g Alendronate )
HRT
How does Lewy-Body Dementia present?
Periods of intermission and relapse of symptoms
Visual hallucinations
Can present with Parkinsonism symptoms present after cognitive decline
How does Alzheimer’s Dementia present?
Insidious onset with slow progression
Behavioural problems common
Hippocampal atrophy
How does Vascular Dementia present?
Step wise progression
Vascular disease risk factors ( Smoking, high cholesterol, male )
How does Frontotemporal Dementia present?
Early onset ( <65 )
Social disinhibition
Apathy
Executive dysfunction
Family history common
Hyperorality ( increased cigarette use )
How does Parksinson’s with Dementia present?
Typical Parkinsonian features ( resting tremor, bradykinesia, rigidity)
They precede Alzhemer’s symptoms by over a year
What is mixed dementia?
Alzheimer’s and Vascular
What are first line for mild/moderate Alzheimer’s Dementia? and 2 examples?
Acetylcholinesterase inhibitors e.g Donepazil / Rivastigamine
What drug class is contraindicated for both Parkinson’s and Lewy-Body Dementia patients? Give 2 examples of these
Dopamine antagonists e.g Metoclopramide or Haloperidol
What is the only treatment for Vascular Dementia?
Modify risk factors ; e.g stop smoking, reduce weight
What is Delirium?
Delirium is an acute confusional state, with a sudden onset and fluctuating
course. It develops over 1-2 days and is recognised by a change in
consciousness either hyper or hypoalert and inattention.
How do you differentiate between Delirium and dementia?
Take collateral history and
4AT Test ( Dementia Screening tool )
Whar are the common causes of acute confusion / delirium ?
THINK DELIRIUM
Trauma
Hypoxia
Infection
Neck of femur fracture
smoKer
Drugs
Environment ( new , scary )
Lack of sleep
Imbalances ( electrolytes )
Retention ( urinary / constipation )
Increased age
Uncontrolled pain
Medical conditions ( Hypoglycaemia, UTI, Liver Failure, Endocrine disorders )
What drugs can cause delirium?
Sedatives
ACEi
B-Blockers
Anticholinergics
Hypoglycaemics
Opiates
How do you manage a patient with acute confusion?
Treat underlying cause
Orientate to time and place
Pharmacological intervention is they are a harm to themselves or others
What are the types of incontinence?
Stress - when coughing/ laughing
Urge - frequent feeling of needing to void, nocturnal incontinence is common
Overflow - due to retention/obstruction , seen in BPH
Functional - due to cognitive impairment
How do you conduct a continence exam?
Bladder and Bowel diary review
Abdo Exam
Urine Dipstick
Mid-Stream Urine Sample
DRE
External genitalia review
Post-Micturition Bladder Scan
What is first line management for dealing with urinary incontinence?
Reducing caffeine intake
Pelvic floor exercises
Bladder training
What pharmacological interventions can be used for urinary incontinence after lifestyle modifications fail?
Anticholinergics e.g Oxybutynin ( not well tolerated by older patients )
B3 Agonist e.g. Mirabegron
What is the worst side effects of urinary incontinence drugs in older people?
Postural hypotension - increases risk of falls
How does faecal incontinence happen as we get older?
Anal sphincter can gape due to haemorrhoids and chronic constipation
What is the most common cause of faecal incontinence?
Faecal impaction with overflow diarrhoea
Why are older people more likely to be constipated?
They cannot exert the same amount of intra-abdominal pressure and muscle tension to push out constipated stool
Malnutrition
Dehydration
What do you do in the assessment for faecal incontinence?
DRE
Stool type assessment ( hard/ soft)
How can faecal impaction be fatal?
Stercoral perforation
Ischaemic Bowel
What is the management for foecal impaction?
Soft impaction - bulk-forming laxatives (Isphagula Husk), add osmotic (Lactulose) if still constipated
Hard impaction - stool softener laxatives ( (Docusate Sodium) or stimulant laxatives (Senna)
Use an enema
Manual evacuation should be utilised in difficult cases ( risk of perforation )
What are TIAs?
Transient ischaemic attacks are focal neurological deficits due to blockage of
blood supply to a part of the brain (focal brain dysfunction) lasting less than 24
hours
What is the ABCD2 score?
Risk assessment tool to predict the short-term risk of stroke after a TIA
What are the factors in the ABCD2 score?
Age
BP
Cinical features
Duration of symptoms
Diabetes y/n
Score >4 indicates high risk
What is the management for a TIA?
Aspirin 300mg daily immediately
Seen by TIA Clinic or Stroke Physician asap
Treat HTN and Hypercholesterolemia
What is a crescendo TIA?
Two or more TIAs in a week ( high stroke risk )
What is a stroke?
Stroke can be defined as a sudden onset of a focal neurological deficit lasting more than 24 hours or with imaging evidence of brain damage
What are the two types of stroke?
Ischaemic ( due to in situ thrombi, emboli or hypoxia )
Haemorrhagic
What is used to classify stroke vascular territory?
Bamford Classification
TACS ( Total Anterior Circulation Stroke )
PACS ( Partial Anterior Circulation Stroke
LACS ( Lacunar Stroke )
POCS ( Posterior Circulation Stroke )
What are the two rapid assessment tools for a patient with suspected stroke?
FAST - Face ( droop ), Arm ( weakness) , Speech ( slurred) , Time ( to call 999 )
ROSIER - helps ED staff distinguish between stroke and mimic stroke
What is NIHSS ?
Clinical Stroke Assessement tool - documents neurological status of acute stroke patient
Scores on levels of consciousness, language, neglect, visual-field loss, extra-ocular movement, motor strength, ataxia, dysarthria and sensory loss
What is the management for an ischaemic stroke?
Thrombolysis e.g Alteplase
Then started on Aspirin 300mg daily for two weeks , then a long term anti-thrombotic treatment should be initiated
What is the management for a haemorrhagic stroke?
Lower BP ( Labetolol STAT )
Reversal of coagulopathy ( IV Vitamin K 5mg and prothrombin complex concentrate )
Surgery only if
1) Hydrocephalus present
2) Lobar Haemmorhage and GCS >9
3) Cerebellar Haemorrhage
What are the restrictions on driving following a TIA or a stroke?
No driving for a month, can after as long as there is no permanent neurological defect
If you have crescendo TIAs no driving for 3 months and must be accessed by doctor prior to driving again
Patients with stable neurological symptoms from their TIA or stroke who have 50-99% carotid stenosis should receive what?
Referal for Carotid Endarterectomy within 1 week of symptoms
Undergo the surgery within 2 weeks of symptoms
What are patients with severe MCA infarct at risk of?
Malignant MCA Syndrome
Should be referred for a Decompressive Hemicranectomy within 24 hours if any deterioration takes place
What is Malignant MCA Syndrome?
Rapid neurological deterioration due the effects of space occupying oedema following infarct of MCA
What are the requirements for a decompressive hemicraniectomy?
Under 60
CT infarct of atleast 50% MCA
NIHSS score > 15
What can mimic a stroke?
Seizure
Space occupying lesion
Hemiplegic migraine
Multiple Sclerosis
What is the CHADS-VASC 2 Score?
Determines stroke risk in patients with Atrial FIbrillation
What are both the HAS-BLED and ORBIT scores used for?
Predicts the risk of bleeding on anticoagulation for patients with Atrial Fibrillation
What are the divisions of Anticoagulants?
Warfarin Vs DOACs ( Apixiban, Rivoraxaban, Edoxaban )
What are some complex decisions needed to be made in severe stroke patients?
DNAR
Enteral feeding ( NG/PEG tube )
When should Haloperidol be used to sedate a patient?
Verbal and Non-verbal deescalation has not worked
Danger to themselves or others
AND cause of the delirium is known
What should be used to sedate patients with known Parkinsonism?
IM Lorazepam
What tool accesses frailty?
PRISMA-7
What tool indicated the risk of pressure sores in patients?
Waterlow Score
When should antibiotics be used for pressure sores?
Signs of infection only ( warm, pus )
What is the STOPP-START tool
For polypharmacy patients. Identifies medications whee risk outweighs the therapeutic benefits. Identifies medications patient could benefit from being added or swapped into their current list.
What do the SALT team do ?
Help when patients have poor swallow
Can recommend thicker fluids / soft diets
What are alternative feeding methods available for patients with a poor swallow?
Hand feeding
NG / PEG tube ( enteral )
IV nutrition ( Paraenteral )
What are patients with a poor swallow at risk of?
Aspiration Pneumonia - food can enter the trachea and block airway , leading to pneumonia
What is Mental Capacity?
A patients’s ability to make decisions regarding their own health. Ability to understand, retain, communicate and weigh up their choices.
What is a best interest decision?
When a decision regarding a patient’s health is made of their behalf , when they are deemed to not have capacity.
What is Advance Care Planning?
When decisions about a patient’s health and future health are made whilst they have capacity to do so.
What is a RESPECT form?
A form about what kind of treatment the patient would want in an emergency . Usually done for palliative care patients.
What are the common consequences of falls?
Fractures ( Hip, Wrist, Ankle )
Severe Bleeds
Head Injuries
Soft tissue injury
Psychological repurcussions
What type of drug Memantine?
NMDA antagonist
Which parts of the brain are affected by Alzheimer’s?
Cortex
Hippocampus
What is second line for Alziemers?
Memantine
What is a short term side effect of Levodopa?
Abnormal dreams
What is the Triad of Parkinsons?
Resting tremor
Bradykinesia
Rigidity
What is the correct dose for breakthrough pain relief?
1/6 of their current dose
i.e they’re regularly on 15mg Morphine b.d, they should be started on 5mg (30/6) as required .
What is the best medication for Postural Hypotension?
Midodrine
Midodrine is an alpha-1-adrenergic receptor agonist. Activation of alpha-1-adrenergic receptors leads to an increase in vascular tone and an increase in blood pressure
What is delirium tremens?
Severe alcohol withdrawal happens 3-4 days after last drink
Rapid onset of confusion
Tremor
Sweating
Visual hallucinations
What are the 4 hallmarks of delirium?
1) acute onset with fluctuating course
2) inattention
3) disorganised thinking
4) altered level of consciousness
What signs are associated with increased oestrogen in the context of liver cirrhosis?
Oestrogen-> increased vascularisation
Palmar Erythema
Spider naevi
Gynecomastia
What does anisocytosis mean?
Mixed RBC cell size
What does anisocytosis with a normal MCV in the context of Coeliacs imply?
Mixed anaemia
Iron - micro
Folate/B12 = macro
Averages to a normal MCV
What is a Ceiling of Care?
This means that doctors should engage with the patient, those close to them and the healthcare team in order to determine what level of treatment is appropriate to give to a specific patient towards the end of their life.
Some treatments can be limited by a ceiling of care plan e.g CPR, limiting what ventilation may be given (e.g. non-invasive, invasive or none), and limiting life-prolonging drugs (e.g. antibiotics). In addition, the decision not to provide artificial nutrition (e.g. via PEG tube) may be taken.
What is an advance 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.
What is an advance decision?
An Advanced Decision, short for Advanced Decision to Refuse Treatment, is a legally binding document. Its purpose is to ensure that an individual can refuse a specific treatment(s) that they do not want to have in the future.
What is prescribed first line to help with terminal secretions of a palliative patient?
Hyoscine hydrobromide or hyoscine butylbromide
