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Phase 3a > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What is included in a Comprehensive Geriatric Assessment?

A
  • MEDICAL:
    - problems list / Co-morbidities + Disease SEVERITY
    - MEDICATION review
    - NUTRITIONAL status
  • MENTAL HEALTH:
    - COGNITION
    - Mood + anxiety + Fears
  • FUNCTIONAL CAPACITY:
    - Daily living
    - Gait + BALANCE
    - Activity status
  • SOCIAL / ENVIRONMENTAL ASSESSMENT
    - Social support (family + friends)
    - Social network (visitors + activities)
    - CARE RESOURCE ELIGIBILITY
    - Home safety + FACILITIES
    - TRANSPORT
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2
Q

4 As of Alzheimer’s

A
  • Amnesia (short term memory loss is usually 1st presenting feature)
  • Aphasia (language impairment)
  • Apraxia (inability to do task despite physically having the faculties to do it and understanding what must be done)
  • Agnosia (Inability to identify objects despite knowing what the object/thing/person is)
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3
Q

Main diffrences in Px of diff types of dementia

A
  • Alzheimer’s is mc - typically in elderly
    - starts with short term memory loss - memory loss is defining feature
  • Vascular
    - step wise / sudden deterioration after cva
    - change in behaviour / impaired memory
  • Frontotemporal - oft HEREDITARY and earlier onset (between 40s-65 ish)
    - Personality + Behavioural change is key factor - stereotypical, repetitive + compulsive actions; emotional blunting; abnormal eating + sleeping; Language problems
    - Memory is preserved more comparatively
  • Lewy body (memory loss for at least 12 months before parknisonism movement issues start
    - cognitive impairment is FLUCTUATING
    - HALLUCINATIONS + Sleep disturbance
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4
Q

Key diff in pathophys of diff dementia’s

A
  • Alzheimers
    - abnormal phosphorylation of tau protein -> deposits -> B-amyloid plaques in brain + blood vessels (neuritic plaques + amyloid angiopathy)
    - Neurofibrillory tangles -> neuronal NECROSIS
    - Acetylcholine deficiency
  • Vascular = CVD
  • Frontotemporal
    - Frontotemporal atrophy
    - Pick’s bodies - mutated tau gene -> abnormal swelling of neurones
  • Lewy body
    - Lewy bodies = ALPHA-SYNEUCLIN protein deposits in brain stem + neocortex -> reduce Acetylcholine + dopamine
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5
Q

Dementia Tx

A

ACETYLCHOILEESTERASE INHIB ie Donepezil = 1st for Alzheimer’s + Lewy body dementia
- NB: DO NOT use in Frontotemporal (can make worse); little effect for vascular

  • Rivastigmine = good for hallucinations
  • MEMANTINE (N-Methyl-D-Aspartate (NMDA) receptor ANTagonists) = good for any dementia (tho only officially recommended for alzheimers)

NB - vascular dementia can’t really be treated with dementia meds - need to Tx underlying

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6
Q

Pseudodementia

A

Cognitive impairment secondary to mental illness
- oft respond with “don’t know”

  • Impaired EXECUTIVE FUNCTION + ATTENTION

May see frontal lobe changes + white matter hyperintensity on MRI

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7
Q

What is included in a Confusion screen

A
  • FBC
  • U+E
  • LFTs
  • TFT’s
  • Coag / INR
  • CALCIUM
  • B12 + FOLATE
  • GLUCOSE
  • CULTURES

Should also do urinalysis + consider imaging depending on Sx + suspected pathology

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8
Q

Benign Paroxysmal Positional Vertigo + Px

A

MC of vertigo - average age of onset 55

  • Vertigo triggered by change in head position (rolling over, gazing upwards)
  • Potentially associated nausea
  • Each episode typically lasts 10-20 seconds
  • DIX-HALLPIKE manouver +ve (get patient to lie down, head hanging over side, with ear pointed to ground for 1-2 min) -> Vertigo + ROTATORY NYSTAGMUS
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9
Q

Mx of benign paroxysmal positional vertigo

A

Sx releif only

  • Epley manouver
  • Vestibular rehabilitation exercises (patient can learn themselves) e.g. Brandt-Daroff exercises
  • Medication oft prescribed but limited effect
    • BETAHISTINE

~50% get recurrance of Sx 3-5yrs post-diagnosis

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10
Q

RFx for Falls

A
  • Previous fall / fear of falling
  • Muscle weakness / Balance/gait disturbances / Arthritis
  • Vision problems
  • Postural hypotension
  • Depression / Cognitive impairment
  • POLYPHARMACY (4+) or any PSYCHOACTIVE DRUGS
  • Incontinence
  • (Age > 65)
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11
Q

Examples of drugs which can contribute to falls

A

Postural hypotension (bascially all HTN meds in this catagory):

  • Nitrates
  • DIURETICS
  • ANTICHOLINERGIC
  • Antidepressants
  • BET-BLOCKERS
  • L-DOPA
  • ACE-I

Also (all the usual stuff with big side effects):

  • BENZODIAZEPINES
  • Antipsychotics
  • Opiates
  • Anticonvulsants
  • Codeine
  • Digoxin
  • Sedatives
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12
Q

Tests for underlying cause of falls

A
  • Turn 180 / Timed up and go test
  • Muscle TONE
  • INjuries / deformaties
  • VISION ASSESSMENT
  • Dementia screen

+ general bloods / urinalysis if confusion etc

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13
Q

Frailty definition

A

State of increased VULNERABILITY due to AGEING-ASSOCIATED decline in FUNCTIONAL RESERVE, Across MULTIPLE PHYSIOLOGICAL systems, Resulting in COMPROMISED ability to COPE with everyday activites / acute stressors

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14
Q

Frailty assessment

A
  • GAIT speed
  • Self-reported health status
  • PRISMA 7 questionnaire (7 Qs)
    - > 85 y/o; male; limited activity; regular support; house-bound; social support; walking aid
    - 1 point for each ‘yes’
    - 3 or more = risk of frailty
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15
Q

Common causes of urinary incontinence

A

Age-related:

  • Reduced bladder capacity / contractility
  • Reduced ability to post-pone voiding
  • Loss of pelvic floor + urethral sphincter musculature
  • Atrophy of vagina / urethra
  • Prostate hypertrophy

Co-morbs:

  • Reduced mobility / Impaired COGNITION
  • MEDS
  • Constipation

Reversible:

  • UTI / urethral irritability
  • DELERIUM / DRUGS
  • CONSTIPATION
  • Polyuria
  • Prolapse
  • Bladder stones / tumours

Environment:

  • Toilet too far/hard to access
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16
Q

Urinary incontinence Ix

A
  • LUTS + bladder diary
  • Examination: Vaginal, rectal, neuro (as suspected)
  • Urinalysis + midstream urine

(surely a bladder scan would be useful??)

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17
Q

Urinary Incontinence Mx

A

Depends on cause:

  • Bladder retraining
  • Regular toileting
  • Pelvic floor exercises

Stress:

  • Transvaginal pessaries if prolapse; COLPOSUSPENSION / FASCIAL SLINGS; Mid-urethral slings
  • bulking agents to bladder neck if surgery too much for patient
  • DULOEXETINE if nowt else works

Urge:

  • Avoid caffine + sugary drinks + excessive fluids
  • OXYBUTININ / TOLTERODINE for OVERACTIVITY (anticholinergic)
  • Consider MIRABEGRON (Beta-3 agonist) in elderly but caution if HTN
  • Botox
  • Sacral neuromodulation

Overflow:

  • FINASTERIDE / TAMSULOSIN for BPH
  • Prostatectomy
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18
Q

When are catheters indicated?

A
  • Urinary RETENTION
  • Obstructed outflow + DETERIORATING RENAL FUNCTION
  • Acute RENAL FAILURE
  • If in intensive care
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19
Q

Complications of catheterisation

A
  • Blockage
  • Bypassing
  • Infection
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20
Q

What mechanisms maintain fecal continence?

A
  • Sigmo-rectal sphincter
  • Ano-rectal angle + anal sphincters
  • Ano-rectal sensation
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21
Q

Causes for fecal incontinence

A
  • Fecal impaction (so constipated the more liquidy stuff is just leaking out)
  • Neurogenic (loss of sphincter control)
  • Haemorrhoids
  • Rectal prolapse
  • Tumours
  • IBD
  • Drugs
    - esp ACETYLCHOLINESTERASE INHIBITORS (Rivastigmine, Donepezil) e.g. for dementia / parkinson’s
  • Functional incontinence (can’t make it to toilet; too cognitively impaired etc)
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22
Q

Fecal incontinence Mx

A

Neuro:

  • Planned evacuation at appropriate time (e.g. with LOPERAMIDE)

Overflow from impaction:

  • REHYDRATE
  • ENEMA (Phosphate agent)
  • Complete colonic washout
  • Manual evacuation
  • Laxatives

Prevention:

  • Once / Twice weekly enema

+ Tx underlying cause of CONSTIPATION obvs

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23
Q

Constipation

A

Typically Type 1 and 2 on Bristol stool chart (rabbit droppings/clumped together)
- Type 7 if over flow (liquid)

Primary = no organic cause - probs due to colon / anorectal muscle function dysregulation

Secondary = due to other underlying cause

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24
Q

RFx for constipation

A
  • Increased AGE
  • Inactivity
  • Low calorie intake
  • Low fibre diet
  • MEDS
    - OPIATES, antidepressants, antacids, antihistamines, iron supplements
  • FEMALE SEX
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25
Q

Px of constipation

A
  • Infrequent bowel movement - < 3 /wk
  • Difficulty passing bowel movements / excessive straining
  • TENESMUS
  • Abdo distension / mass felt at lower quadrant
  • Rectal bleeding
  • Anal fissures
  • Haemorrhoids
  • Presence of hard stool / impaction on PR exam
26
Q

Rome IV criteria for constipation

A
  • Fewer than three bowel movements per week
  • Hard stool in >25% of bowel movements
  • Tenesmus (sense of incomplete evacuation) in >25% of bowel movements
  • Excessive straining in >25% of bowel movements
  • A need for digital evacuation of bowel movements

Don’t need all to Dx

27
Q

Causes of constipation

A
  • Dietary (inadequate fibre / fluid)
  • Behavioural (inactivity / avoidance of defecation)
  • Electrolyte disturbance (HYPERcalcaemia)
  • Drugs
    - Opiates
    - CCB
    - some Antipsychotics
  • Neuro disorder
    - Spinal cord lesions; Parkinson’s; Diabetic neuropathy
  • Endocrine (HYPOTHYROID)
  • Colon (stricture / malig)
  • Anal disease (Fissure; proctitis)
28
Q

Constipation Mx

A

Depends on underlying cause

  • Life style changes (fibre, fluids, activity)
  • Bulkening agents
    - Ispaghula husk
    - Methylcellulose
  • Stool softners
    • Docusate sodium
  • Osmotic laxatives
    - LACTULOSE
    - Macrogol
  • Stimulant laxatives
    - SENNA
    - Bisacodyl
  • Enemas if impaction (sodium citrate)
  • Suppositories (glycerol)

Refer to specialist for gut motility evaluation if not resolved by laxatives

29
Q

Alarm features which may indicate GI malig

A
  • Weight loss
  • Loss of appetite
  • Abdo mass
  • DARK stool
30
Q

Ix for constipation

A
  • Bloods:
    • FBC, Electolytes, TFTs, GLUCOSE
  • Abdo x-ray if suspect 2ndary cause e.g. obsttruction
  • Barium enema (if suspect impaction / RECTAL mass)
  • Colonoscopy (if suspect MALIG)
31
Q

Malnutrition

A

State in which deficiency of energy, protein and/or other NUTRIENTS causes MEASURABLE ADVERSE EFFECTS on body’s FORM, COMPOSITION, FUNCTION + CLINICAL OUTCOME

32
Q

Causes of malnutrition

A
  • Decreased intake
  • Increased nutrient requirements (SEPSIS / INJURY)
  • Malabsorption / impaired metabolisation
33
Q

Dx of Malnutrition

A

Any of following:

  • BMI < 18.5kg/m^2
  • Weight loss > 10% of weight in last 3-6 months
  • BMI < 20 kg/m2 AND weight loss >5% in last 3-6 months
34
Q

Features of malnutrition

A

Reduced electrolytes (Hypophosphataemia, Hypokalaemia)
- Thiamine def
- Abnormal glucose metabolism

35
Q

Complications of malnutrition

A
  • Cardiac arrhythmias
  • Cardiac failure (also a risk of refeeding as contractility reduces while malnourished)
  • Coma
  • Convulsions
36
Q

Mx of malnutrition

A
  • Monitor bloods (biochem)
    - esp GLucose, Na, K+, Mg, Phosphate
  • Refeed within guidelines
  • Nutritional team / dietitian support
  • Supportive care
37
Q

RFx for pressure sores

A
  • Lack of mobility (e.g. due to Pain)
  • Malnutrition
  • Incontinence
38
Q

Assessing risk of pressure sores

A

Waterlow score:

  • BMI
  • Nutritional status
  • Skin type
  • Mobility
  • Continence
  • Sex / Age
  • Neurological deficit
  • Surgery
  • Medication (steroids, cytotoxics + high dose anti-inflam)

Score of >=10 = at RISK
- >= 15 = HIGH risk
- >= 20 = very High

39
Q

Prevention of pressure sores

A
  • Barrier creams (esp for incontinence)
  • Pressure redistribution + Repositioning (for mechanical causes)

REGULARLY assess skin

40
Q

Mx of pressure sores

A
  • Hydrocoloid dressings (moist wound environment -> ulcer healing)
    • be mind full of what dressings are used - strong adhesive may tear skin more
  • SURGICAL DEBRIDEMENT (tho sometimes better to leave hard necrotic cap in place to allow healing/prevent)

Abx only given if signs of infection

41
Q

Classification / Stages of pressure ulcers

A
  1. Non-blanching localised erythema (skin intact)
  2. PARTIAL THICKNESS skin loss involving dermis, epidermis or both
  3. Full thickness skin loss (Damage / NECROSIS of SUB-CUT tissue)
  4. Extensive loss, destruction / necrosis of Muscle, BONE or SUPPORT structures

Unstagable = depth unknown as base covered in debris / necrosis

42
Q

START and STOPP

A

Tools to help optimize medications

  • START suggests meds which may provide ADDITIONAL benefits
  • STOPP assess which drugs could be DISCONTINUED

NB polypharmacy = 4 or more meds

43
Q

Summary of Parkinson’s

A
  • Pathophys = Progressive reduction of dopamine in basal ganglia
  • Classic triad = resting tremor (oft unilateral); cogwheel rigidity; BRADYKINESIA
  • Also:
    - SLEEP DISTURBANCE;
    - mask-like face;
    - POSTURAL insability / POSTURAL HYPOTENSION /
    - shuffling gait + reduced arm swing;
    - Depression;
    - Anosmia;
    - Cognitive impairment / memory problems
  • Mx:
    - LEVODOPA (less effective over time, SE = dyskinesia)
    - COMT inhibitors = Entacapone / Tolcapone
    - Dopamine agonists = Bromocryptine - SE = Pulm fibrosis
44
Q

Parkinson’s plus syndrome

A
  • Progressive supranuclear palsey (vertical gaze palsey)
  • Multiple system atrophy
    - Early autonnomic features
    - Postural hypotension; Incontinence; Impotence
  • Cortico-basal degeneration
    - Spontaneous activity in affected limb OR Akinetic rigidity
  • Lewy body dementia (notably cognitive impairment + visual HALLUCINATIONS)
45
Q

What are the 5 key principles of the MCA 2005

A
  • Assume capacity
  • Maxise / enable decision-making capacity
  • Freedom to make seemingly unwise decisions
  • All decisions must be taken in BEST interests
  • Choose least restrictive option
46
Q

What is necessary for an individual to have capacity?

A

Depends on their ability to:

  • Understand relevant information
  • Retain information
  • Weigh up information
  • Communicate decision
47
Q

Which article is relevant to deprivation of liberty

A

Article 5 of Human Rights Act
- ‘everyone has the right to liberty and security of person. No one shall be deprived of his or her liberty [unless] in accordance with a procedure prescribed in law’

Deprivation of LIberty occurs when:

  • Person is subject to CONTINUOUS SUPERVISION / control AND person is NOT FREE to leave
48
Q

What conditions must be met for a DoLs to be legal?

A
  • Only for ADULTS (>18)
  • Suffering from mental disorder
  • Must be PATIENT / Care home resident
  • LACKS CAPACITY
  • Restrictions deprive liberty BUT are in person’s BEST INTERESTS
  • No valid advance decision to refuse Tx /support that would be overridden by a DoLs (Advance directive would take precidence)

Consider whether person should be sectiond under Mental Health Act instead

49
Q

Independant Mental Capacity Advocate job role

A
  • represents individual who lacks capacity but has no one else to represent them
  • present for decisions regarding:
    • changes in Long-term accomodation
    • Serious medical decision
    • Care reviews
    • Adult protection
50
Q

What to consider when making a best interests decision

A
  • is individual likely to regain capacity and can decision wait
  • How to encourage / optimise patient involvement in decision making
  • Past + present wishes, feelings, beliefs + values of person (+ any other relevant factors)
  • Views of other relevant people (e.g. patient’s family)
51
Q

RFx for osteoporosis

A

SHATTERED

  • Steroids
  • Hyperthyroid / Hyperparathyroid
  • Alcohol + SMOKING
  • Thin (BMI < 22)
  • Testosterone def
  • Early menopause
  • Renal / LIVER FAILURE
  • EROSIVE / Inflam BONE DISEASE (rheumatoid)
  • DIABETES

+ FHx

52
Q

DDx for increased fracture risk

A
  • Metabolic bone disease (osteomalacia + hyperparathyroid)
  • 1ry Osteoporosis
  • 2ndry oseoporosis
    • Cushing’s syndrome
    • Hyperthyroid (high bone turnover)
    • Meds e.g. Glucocorticoids, anticonvulsants
  • MALIGNANCIES:
    • Multiple myeloma / METS
53
Q

FRAX Score

A

Fracture Risk Assessment Tool

  • estimates 10-year probability of MAJOR OSTEOPOROTIC FRACTURE
    • Normal = <10%
    • Osteopenia = 10-20%
    • Osteoporosis = >20%
54
Q

DEXA scan

A

looks at bone density and generates:

  • T score (bone density against agaverage bone density of healthy group)
    - >-1.0 = normal
    - -1.0 to -2.5 = Osteopenia
    - <-2.5 = Osteoporisis
  • Z score (bone density against average bone density in your age group)
55
Q

Lifestyle modifications for osteoporosis

A
  • Diet (+ consider vit supps)
  • stop smoking
  • WEIGHT bearing exercise
  • DIABETIC CONTROL
  • Hip protectors in nursing home patients
56
Q

Bisphosphonates Indications, SE + How to take

A

1st line for osteoporosis (DEXA <-2.5 OR DEXA < -1 AND FRAX >20%)

SE: GI (dyspepsia; Oesophagitis)
- MSK pain
- Sometimes: Osteonecrosis of jaw + atypical femoral fractures

Take:

  • On EMPTY stomach
  • Full glass of water
  • Upright for 30 mins after
57
Q

2nd line Tx for osteoporosis

A
  • Denosumab
  • Raloxifene
  • HRT
  • Teriparatide
  • Strontium ranelate
58
Q

Advanced statement vs advanced decision

A
  • Decision is referring to future decision to deny some kind of treatment (e.g. DNAR) so must be written down + signed with witnesses
    • Legally binding (except they can’t refuse psych Tx)
  • Statement is a statement of people personal preferances which must be legally taken into consideration when making a best intersts decision but is not a legally binding document itself
    • can be made verbally but better to write down
59
Q

What information can be included in an advanced statement

A
  • Religious or spiritual views, and those that might relate to care

​ - Food preferences

​- Information about your daily routine​ Where you would like to be cared for (in hospital, at home, in a care home etc.)

-​ Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)

60
Q
A

Phase 3a (26 decks)

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