Geriatrics Flashcards
What is delirium?
An acute fluctuating syndrome of encephalopathy causing disturbed consciousness, attention, cognition and perception.
What are the 3 subtypes of delirium and how are they defined?
Hypoactive - reduced motor activity, lethargy, withdrawal, drowsiness and staring into space (most common in the elderly)
Hyperactive - increased agitation, delusions and disorientation
Mixed - switching back and forth between hypo and hyperactive states
What are the major risk factors for delirium? (x6)
- age 65+
- male
- pre-existing cognitive deficit e.g. dementia, stroke
- multiple comorbidities
- previous episodes of delirium
- recent surgery
What are some potential causes of delirium? (x5)
- acute infections (e.g. UTI, pneumonia, sepsis)
- prescribed drugs (e.g. benzodiazepines, analgesics, anti-parkinsons meds)
- toxic substances (e.g. alcohol, CO, substance misuse/withdrawal)
- metabolic causes (e.g. hypoxia, electrolyte imbalance, hypoglycaemia)
- surgery - due to problems with cranial bv’s, reduced bp during/after surgery, stress, increased inflammation in body/brain
What are the 8 signs of delirium?
Disordered thinking
Euphoric, fearful or angry
Language impairment
Illusions/delusions/hallucinations
Reversed sleep/wake cycle
Inattention
Unaware/disorientated
Memory impairment
What are the common differentials for delirium diagnosis? (x5)
- dementia
- depression
- bipolar disorder
- functional psychoses e.g. schizophrenia
- thyroid disease
What are the 4 categories of management which must be considered when treating delirium?
- supportive management
- environmemntal measures
- medical management
- management post-discharge
What are some supportive management measures for delirium? (x3)
- clear communication
- reminders of the day, time, location and identification of people
- readily visible clocks and calendars
- familiar objects in surroundings
- staff consistency
What are some environmental measures taken in delirium management? x4
- avoid sensory extremes
- encouragement of normal sleep/wake cycle
- control and maintenance of environment e.g. noise, lighting, temperature
- adequate nutrition
- maintain competence (e.g. walking in ambulant patients)
What are the aims in medical management of delirium? x3
- optimised treatment of comorbidities
- correct underlying precipitants (e.g. treat UTI, constipation etc.)
- only use pharmacological management in select patients who will benefit (e.g. antipsychotics)
What are the diagnostic tools used in assessing patients for delirium?
- CAM (confused assessment method)
- 4AT (4 A’s test = alertness, AMT4, attention, acute change or fluctuating course)
- DSM-5 (diagnostic and statistical manual of mental disorders)
What are the 6 main precipitants of delirium?
Pain
Infection
Nutrition
Co-morbidities
Hydration
Medication
Environment
+ bladder
What is dementia?
not a specific disease but a syndrome defined by memory impairment, some aspects of cognitive decline and difficulties with activities of daily living - it is caused by a number of brain disorders.
What are the 3 groups of symptoms seen in dementia patients?
- cognitive impairment (difficulties with memory, language, attention, orientation etc.)
- psychiatric or behavioural disturbances (changes in personality, emotional control, social behaviour)
- difficulties with ADLs (e.g. driving, shopping, eating, dressing)
What are the 4 main causes of dementia?
- Alzheimer’s disease (≈50%)
- Vascular dementia (≈25%)
- Lewy body dementia (≈15%)
- Fronto-temporal dementia (<5%)
What are some of the causes of potentially treatable dementias? (x5+)
- substance misuse
- hypothyroidism
- space-occupying intracranial lesions
- normal pressure hydrocephalus
- syphilis
- vit B12 deficiency
- folate deficiency
- pellagra (vit B3 deficiency)
What are the diagnostic criteria for all types of dementia?
There are cognitive or behavioural symptoms which:
- affect ability to function in normal activities
- represent a decline from a previous level of function
- cannot be explained by delirium or other major psychiatric disorder
- have been established by history-taking from patient and informant, and formal cognitive assessment
- involve impairment of at least two of the following domains:
- ability to acquire and remember new information
- judgement, ability to reason or handle complex tasks
- visuospatial ability
- language functions
- personality and behaviour
What are some examples of non-pharmacological treatments for dementia? x5
- cognitive stimulation programmes
- music/art/dance therapy
- aromatherapy
- structured exercise programmes
- multisensory stimulation
What are the 2 main groups of medications used in dementia treatment?
- ACE inhibitors e.g. donepezil, galantamine (most used in AD)
- N-methyl-D-aspartate (NMDA) antagonists e.g. ketamine, memantine, dextromethorphan
What are the questions in the 6 CIT test for dementia?
What year is it?
What month is it?
Give an address with 5 parts (John, Smith, 42, High, St, Bedford)
Count 20-1
Say months of year in reverse
Repeat address
What is depression?
the presence of depressed mood or diminished interest in activities occurring most of the day, nearly every day, for at least 2 weeks accompanied by additional characteristic symptoms
What are the characteristic symptoms seen in patients with depression? x8
- reduced ability to concentrate and sustain attention, or marked indecisiveness
- beliefs of low self-worth or excessive and inappropriate guilt
- hopelessness about the future
- recurrent thoughts of death or suicidal ideation
- significantly disrupted sleep or excessive sleep
- significant changes in appetite or weight
- psychomotor agitation or retardation
- reduced energy or fatigue
What are the 4 categories of depression severity?
- subthreshold symptoms - <5 symptoms
- mild depression - few symptoms in excess of the 5 required for diagnosis, symptoms resulting in minor functional impairment
- moderate depression - symptoms or functional impairment between mild and severe
- severe depression - most symptoms present + symptoms which interfere significantly with normal function
What is the definition of chronic depressive symptoms ?
people with chronic depressive symptoms include those who
1. continually meet the criteria for the diagnosis of a major depressive episode for at least 2 yrs
2. have persistent subthreshold symptoms for at least 2 yrs
3. have persistent low mood with or without concurrent episodes of major depression for at least 2 yrs
What are some of the major risk factors for depression? 5+
- chronic co-morbidities
- other mental health problems
- female
- older age
- recent childbirth
- psychosocial issues
- family or personal history of depression
- adverse childhood experiences
- personality factors
- past head injury
What are some of the non-pharmacological treatments for depression? x5
- CBT and or group behavioural activities
- interpersonal psychotherapy (IPT)
- counselling
- short-term psychodynamic psychotherapy (STPP)
- electroconvulsive therapy (ECT)
What are three classes of medications commonly used in depression treatment?
- selective serotonin reuptake inhibitors (SSRIs) e.g. citalopram, escitalopram, fluoxetine, sertraline
- serotonin and norepinephrine reuptake inhibitors (SNRIs) e.g. duloxetine, desvenlafaxine, levomilnacipram
- tricyclic antidepressants (TCAs) e.g. amitryptyline, clomipramine, dosulepin
What are the major risk factors for falls in the elderly? 5+
- age 80+
- female
- low weight
- previous fall
- polypharmacy/medications (commonly benzodiazepines, antidepressents, bp-lowering drugs, anticonvulsants)
- cognitive impairment
- orthostatic hypotension
- vision problems
- chronic health conditions affecting mobility
What is frailty?
a clinical state of increased vulnerability and reduced ability to cope with everyday/acute stressors resulting from aging-associated decline in reserve and function across multiple physiological systems
What are the acute presentations of frailty? (also known as frailty syndromes)
- falls
- sudden reduced mobility
- new or accelerated state of confusion (delirium)
- acute change in continence
- sensitivity to a new medication
What are the most common comorbidities contributing to frailty? 5+
- stroke
- CHD
- Diabetes Mellitus
- Alzheimer’s Disease
- urinary problems
- depression
- visual loss
- hearing and visual impairment
- falls
What are the key focuses of frailty management? x5
- treatment of unstable medical conditions and any treatable problems
- reviewing drug treatment (including polypharmacy)
- early mobilisation
- nutrional support
- comprehensive rehabilitation
What are the 6 types of incontinence?
- stress incontinence (weakness of urinary outlet)
- urge incontinence (failure of bladder storage due to high pressure)
- mixed incontinence (combination of stress and urge incontinence)
- overflow incontinence (bladder outlet obstruction)
- abnormal communications of the urinary tract (i.e. fistulae)
- functional incontinence (due to more general impairment e.g. cognitive)
What are the storage symptoms of incontinence? x 5
- frequency
- urgency
- stress incontinence
- urge incontinence
- nocturia
What are the voiding symptoms of incontinence? x 5
- post-micturition dribble
- hesitancy
- terminal dribbling
- incomplete emptying
- intermittent stream
What are the main risk factors for incontinence? x7
- female
- increased age
- post-menopausal state
- increased BMI
- previous pregnancies + vaginal deliveries
- neurological conditions
- cognitive impairment and dementia
What are the 4 main management strategies for incontinence?
- lifestyle changes (avoid caffeine, diuretics and overfilling of bladder, weight loss)
- pelvic floor exercises
- anticholinergic drugs (oxybutinin, tolterodine, solifenacin)
- surgery (tension-free vaginal tape, autologous sling procedure)
How do pressure ulcers form?
They occur when skin and underlying tissues are placed under pressure that impairs blood supply leading to tissue damage. They can be caused by pressure, shear, friction or a combination.
What is the most important risk factor for pressure ulcers?
immobility
What are some other risk factors for pressure ulcers?
malnourishment
incontinence (urinary and faecal)
pain –> mobility reduction
alzheimer’s
What assessment scales are used for pressure ulcers?
The Norton, Braden and Waterlow scales
What are the factors considered in pressure ulcer assessment? x11
- cause of ulcer
- site/location
- dimensions of ulcer
- stage or grade
- exudate amount and type
- signs of infection
- pain
- wound appearance
- surrounding skin
- undermining/tracking (sinus/fistula)
- odour
What are the 5 grades of pressure ulcers?
1: non-blanchable erythema of intact skin
2: partial-thickness skin loss involving epidermis and/or dermis - superficial ulcer which presents as an abrasion or blister
3: full-thickness skin loss involving damage/necrosis of subcut tissue
4: extensive destruction, tissue necrosis, or damage to muscle/bone/supporting structures without or without full thickness skin loss
Unstageable: full-thickness tissue loss in which the base of the ulcer is covered by slough and or eschar in the wound bed so it is unstageable
What are the key focuses of pressure ulcer treatment? x6
- respositioning of the patient
- treatment of concurrent conditions which may delay healing
- pressure-relieving support surfaces
- local wound management
- pain relief
- infection control
What is polypharmacy?
the prescribing or taking of too many medicines
What are some of the risks associated with polypharmacy?
- adverse drug events
- hospital admissions
- increased health care costs
- non-adherence
What are the 4 geriatric giants?
- Instability
- Immobility
- Incontinence
- Intellectual impairment
What is benign paroxysmal positional vertigo?
an inner ear problem which causes short periods of vertigo when the head is moved in certain positions
What are the causes of BPPV?
mostly idiopathic but can be caused by:
- head injury
- spontaneous degeneration of the labyrinth
- post-viral illness
- complication of stapes surgery
- chronic middle ear disease
What are the risk factors for BPPV?
older age
female
meniere’s disease
anxiety disorders
migraine
What is the management for BPPV?
symptoms are usually self-limiting over a few weeks
limit symptoms by getting out of bed slowly and reducing head movements
Epley’s manoeuvre
What is Epley’s manoeuvre?
used to reposition otoliths back into the utricles from the posterior semicircular canals
