Geriatrics Flashcards
What is included in a Comprehensive Geriatric Assessment?
-
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
4 As of Alzheimer’s
- 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)
Main diffrences in Px of diff types of dementia
- 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
Key diff in pathophys of diff dementia’s
- 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
Dementia Tx
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
Pseudodementia
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
What is included in a Confusion screen
- FBC
- U+E
- LFTs
- TFT’s
- Coag / INR
- CALCIUM
- B12 + FOLATE
- GLUCOSE
- CULTURES
Should also do urinalysis + consider imaging depending on Sx + suspected pathology
Benign Paroxysmal Positional Vertigo + Px
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
Mx of benign paroxysmal positional vertigo
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
RFx for Falls
- 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)
Examples of drugs which can contribute to falls
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
Tests for underlying cause of falls
- Turn 180 / Timed up and go test
- Muscle TONE
- INjuries / deformaties
- VISION ASSESSMENT
- Dementia screen
+ general bloods / urinalysis if confusion etc
Frailty definition
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
Frailty assessment
- 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
Common causes of urinary incontinence
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
Urinary incontinence Ix
- LUTS + bladder diary
- Examination: Vaginal, rectal, neuro (as suspected)
- Urinalysis + midstream urine
(surely a bladder scan would be useful??)
Urinary Incontinence Mx
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
When are catheters indicated?
- Urinary RETENTION
- Obstructed outflow + DETERIORATING RENAL FUNCTION
- Acute RENAL FAILURE
- If in intensive care
Complications of catheterisation
- Blockage
- Bypassing
- Infection
What mechanisms maintain fecal continence?
- Sigmo-rectal sphincter
- Ano-rectal angle + anal sphincters
- Ano-rectal sensation
Causes for fecal incontinence
- 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)
Fecal incontinence Mx
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
Constipation
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
RFx for constipation
- Increased AGE
- Inactivity
- Low calorie intake
- Low fibre diet
- MEDS
- OPIATES, antidepressants, antacids, antihistamines, iron supplements - FEMALE SEX
Px of constipation
- 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
Rome IV criteria for constipation
- 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
Causes of constipation
- 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)
Constipation Mx
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
Alarm features which may indicate GI malig
- Weight loss
- Loss of appetite
- Abdo mass
- DARK stool
Ix for constipation
- 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)
Malnutrition
State in which deficiency of energy, protein and/or other NUTRIENTS causes MEASURABLE ADVERSE EFFECTS on body’s FORM, COMPOSITION, FUNCTION + CLINICAL OUTCOME
Causes of malnutrition
- Decreased intake
- Increased nutrient requirements (SEPSIS / INJURY)
- Malabsorption / impaired metabolisation
Dx of Malnutrition
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
Features of malnutrition
Reduced electrolytes (Hypophosphataemia, Hypokalaemia)
- Thiamine def
- Abnormal glucose metabolism
Complications of malnutrition
- Cardiac arrhythmias
- Cardiac failure (also a risk of refeeding as contractility reduces while malnourished)
- Coma
- Convulsions
Mx of malnutrition
- Monitor bloods (biochem)
- esp GLucose, Na, K+, Mg, Phosphate - Refeed within guidelines
- Nutritional team / dietitian support
- Supportive care
RFx for pressure sores
- Lack of mobility (e.g. due to Pain)
- Malnutrition
- Incontinence
Assessing risk of pressure sores
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
Prevention of pressure sores
- Barrier creams (esp for incontinence)
- Pressure redistribution + Repositioning (for mechanical causes)
REGULARLY assess skin
Mx of pressure sores
- 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
Classification / Stages of pressure ulcers
- Non-blanching localised erythema (skin intact)
- PARTIAL THICKNESS skin loss involving dermis, epidermis or both
- Full thickness skin loss (Damage / NECROSIS of SUB-CUT tissue)
- Extensive loss, destruction / necrosis of Muscle, BONE or SUPPORT structures
Unstagable = depth unknown as base covered in debris / necrosis
START and STOPP
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
Summary of Parkinson’s
- 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
Parkinson’s plus syndrome
- 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)
What are the 5 key principles of the MCA 2005
- 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
What is necessary for an individual to have capacity?
Depends on their ability to:
- Understand relevant information
- Retain information
- Weigh up information
- Communicate decision
Which article is relevant to deprivation of liberty
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
What conditions must be met for a DoLs to be legal?
- 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
Independant Mental Capacity Advocate job role
- 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
What to consider when making a best interests decision
- 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)
RFx for osteoporosis
SHATTERED
- Steroids
- Hyperthyroid / Hyperparathyroid
- Alcohol + SMOKING
- Thin (BMI < 22)
- Testosterone def
- Early menopause
- Renal / LIVER FAILURE
- EROSIVE / Inflam BONE DISEASE (rheumatoid)
- DIABETES
+ FHx
DDx for increased fracture risk
- 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
FRAX Score
Fracture Risk Assessment Tool
- estimates 10-year probability of MAJOR OSTEOPOROTIC FRACTURE
- Normal = <10%
- Osteopenia = 10-20%
- Osteoporosis = >20%
DEXA scan
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)
Lifestyle modifications for osteoporosis
- Diet (+ consider vit supps)
- stop smoking
- WEIGHT bearing exercise
- DIABETIC CONTROL
- Hip protectors in nursing home patients
Bisphosphonates Indications, SE + How to take
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
2nd line Tx for osteoporosis
- Denosumab
- Raloxifene
- HRT
- Teriparatide
- Strontium ranelate
Advanced statement vs advanced decision
- 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
What information can be included in an advanced statement
- 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)
