GERIATRICS Flashcards
DELIRIUM
Who are high risk patients that require screening on admission?
- > 65y, men, previous delirium
- Pre-existing cognitive deficit (dementia, PD, stroke)
- Sensory impairment (hearing/visual)
- Significant illness (hip #, cancer)
- Poor nutrition
- Hx of alcohol excess
DELIRIUM
What is the ICD-10 diagnostic criteria for delirium?
- Impaired consciousness + inattention (poor conc, memory deficit, “clouding of consciousness”)
- Perceptual OR cognitive disturbance (agitation, hallucinations > Lilliputian)
- Acute onset + fluctuating course (often worse at night = sundowning)
- Evidence it may be related to a physical cause
DELIRIUM
What is a suitable screening tool for delirium?
4AT (≥4 = likely) –
- Alertness
- AMT4 (age, DOB, hospital name, year)
- Attention (list months backwards)
- Acute change or fluctuating course
DEMENTIA
What type of imaging may be used in dementia?
- SPECT to differentiate between Alzheimer’s + frontotemporal
- DaTscan shows ‘comma’ in normal but 2 dots in Lewy body + Parkinson’s dementia at the basal ganglia
LEWY-BODY DEMENTIA
What is the management of Lewy-Body dementia?
- Conservative management
- AChEi used in mild–mod (rivastigmine 1st line), memantine last resort
- SENSITIVE to antipsychotics, can make worse + lead to neuroleptic malignant syndrome
POSTURAL HYPOTENSION
What is the pharmacological management of postural hypotension?
- Med review + stop causative agent
- Fludrocortisone (raises BP by raised Na+ levels + affecting blood volume) but can cause uncomfortable oedema
- Midodrine (when cause if autonomic dysfunction) but can cause retention, itchy scalp + paraesthesia
OSTEOPOROSIS
What is the mechanism of action of bisphosphonates?
- Analogues of pyrophosphate, a molecule which decreases demineralisation in bone
- Inhibit osteoclasts by reducing recruitment + promoting apoptosis
PHARMACOLOGY
What is the mechanism of action of N-methyl D receptor antagonists (NMDA)?
- Protects brain cells from excess glutamate (excitatory neurotransmitter) released from cells affected by Alzheimer’s to prevent further damage, good for agitation + BPSD
URINARY RETENTION
What are some causes of urinary retention?
- BPH (#1 cause in men)
- Urethral strictures
- Anticholinergics
- Alcohol
- Constipation
- Infection
- Cancer
ALZHEIMER’S DISEASE
What neurotransmitters are affected?
- ACh, noradrenaline, serotonin, somatostatin
FT DEMENTIA
What are some pathological features of frontotemporal dementia?
- Microscopic = ubiquitin + tau deposits
FALLS
What clinical scale can be used to assess frailty?
- Rockwood clinical frailty scale (from very fit, vulnerable, moderately frail to terminally ill)
POSTURAL HYPOTENSION
What are some endocrine causes of postural hypotension?
DM, hypoadrenalism, hypothyroidism
PHARMACOLOGY
What are the side effects of acetylcholinesterase inhibitors?
- D+V,
- nausea,
- abdo pain (work systemically so GI upset)
- bradycardia
PHARMACOLOGY
What are some side effects of NMDA?
- Confusion,
- hallucinations,
- agitation,
- paranoid delusions
BPPV
what are the causes?
50-70% = primary (idiopathic)
secondary
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines
HEART FAILURE
Explain how the sympathetic system is compensatory in heart failure and give one disadvantage of sympathetic activation
Improves ventricular function by increasing HR and contractility = CO maintained
BUT it also causes arteriolar constriction which increases afterload and so myocardial work
HEART FAILURE
Explain how the RAAS system is compensatory in heart failure and give one disadvantage of RAAS activation
Reduced CO leads to reduced renal perfusion, this activates RAAS –> increased fluid retention so increased preload
BUT it also causes arteriolar constriction which increase afterload and so myocardial work
HEART FAILURE
Give 3 properties of natriuretic peptides that make them compensatory in heart failure
- Diuretic
- Hypotensive
- Vasodilators
HEART FAILURE
what are the clinical signs of left heart failure?
- Pulmonary crackles
- S3 and S4 and murmurs
- Displaced apex beat
- Tachycardia
- fatigue
CONSTIPATION
what are the primary and secondary causes?
Primary
- disordered regulation of colonic and anorectal neuromuscular function
- IBS
Secondary
- metabolic - hypercalcaemia, hypothyroidism
- medicines - opiates, CCBs, antipsychotics
- neurological disorders - parkinsons, spinal cord lesions, DM
- bowel diseases - cancer, stricture, anal fissure
COTE ASSESSMENT
What is frailty?
- State of increased vulnerability resulting from ageing-associated decline in reserve + function across multiple physiological systems resulting in compromised ability to cope with everyday or acute stressors
COTE ASSESSMENT
What are the geriatric giants?
What do they represent?
4Is – - Instability (falls) - Immobility - Intellectual impairment (confusion) - Incontinence They are not diagnoses but more general things that COTE pts present with, often indicator of underlying problem
COTE ASSESSMENT
What are the geriatric 5Ms?
- Mind = dementia, delirium, depression
- Mobility = impaired gait + balance, falls
- Medications = polypharmacy, medication burden, adverse effects, de-prescribing/optimal prescribing
- Multi-complexity = multi-morbidity, biopsychosocial
- Matters most = individual meaningful health outcomes + preferences
POLYPHARMACY
Give some specific pharmacokinetic issues in geriatrics.
- Hepatic first pass metabolism declines
- Reduced absorption as gastric pH increases due to atrophy
- Vascular system less responsive due to calcification of vessels
MENTAL CAPACITY ACT
What is the two-step test in MCA?
- Does the person have an impairment of their mind or brain? E.g. dementia, severe LD, brain injury, coma
- Is this impairment significant enough to deem them unable of making a particular decision?
MENTAL CAPACITY ACT
What are the 5 principles underpinning the MCA?
- Assume capacity until proven otherwise
- Maximise decision-making capacity (all practical support to help them make decision given)
- Freedom to make seemingly unwise choice (unwise decision ≠ incapacity)
- All decisions on behalf of patient in best interests
- Least restrictive option should be chosen
DOLS
What is the acid test for DoLS?
Must meet 3 criteria –
- Lack of capacity to consent to the arrangements or their care
- Subject to continuous supervision + control
- Not free to leave their care setting
FALLS
What are the risk factors for falls in elderly?
DM
rheumatoid arthritis
>65
previous falls
depression
FALLS
What are the two recommended tests from NICE to assess patients at risk of falls?
- turn 180 test
- timed up and go test
FALLS
what are the management options to try and prevent further falls in future?
- strength and balance training
- home hazard assessment
- medication review
- vision assessment
