Geriatrics Flashcards
Acute confusional state aka
delirium or acute organic brain syndrome
Delirium affects what % of the elderly admitted to hospital?
30%
Predisposing factors to delirium?
> 65yrs
Background of dementia
Signif injury eg. hip fracture
Frailty or multimorbidity
polypharmacy
Delirium= The precipitating events are often multifactorial and may include….
infection: particularly urinary tract infections
metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
change of environment
any significant cardiovascular, respiratory, neurological or endocrine condition
severe pain
alcohol withdrawal
constipation
Features of delirium?
a wide variety of presentations…
memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention
Mx of delirium?
treatment of the underlying cause
modification of the environment
haloperidol 0.5 mg as the first-line sedative or olanzapine
Mx of delirium in pt with parkinsons?
antipsychotics can often worsen Parkinsonian symptoms
careful reduction of the Parkinson medication may be helpful
if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred
1st line sedative Mx for delirium?
0.5mg haloperidol
Delirium (sometimes called ‘acute confusional state’) is….
an acute, fluctuating encephalopathic syndrome of inattention, impaired level of consciousness, and disturbed cognition
Delirium can be classified into subtypes based on symptoms= list the types?
Hyperactive delirium
Hypoactive delirium
Mixed delirium
Hyperactive delirium?
can present with inappropriate behaviour, hallucinations, or agitation.
Hypoactive delirium?
can present with inappropriate behaviour, hallucinations, or agitation.
Mixed delirium?
presents with signs and symptoms of both hyperactive and hypoactive subtypes.
Delirium typically occurs in people with …
predisposing factor (such as advanced age or multiple comorbidities) when new precipitating factors (such as some medications or infection) are added.
A diagnosis of delirium can be made using…
an assessment tool such as the short Confusion Assessment Method (short-CAM) or the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are met.
Most people with delirium require..
admission to hospital for urgent assessment and multidisciplinary management.
Management of delirium in primary care may be appropriate if all of the following apply…
The benefits of management in primary care outweigh the benefits of hospital admission, or the person is clinically well enough to stay at home.
The symptoms of delirium are not harmful to the person or others, and can be managed safely in primary care.
The cause of delirium is known and treatable.
Constant supervision and care are available.
Close clinical follow up can be arranged.
Management of delirium in primary care involves…
Correcting any precipitating factors (for example infection or constipation).
Optimizing treatment of comorbidities such as heart failure.
Giving advice to carers and families on: reorientation strategies, mobilizing safely, normalizing the person’s sleep-wake cycle.
Use of verbal and non-verbal de-escalation techniques to deal with challenging behaviour (such as aggression, agitation, or shouting).
Pharmacological treatment such as antipsychotics or benzodiazepines should be avoided, if possible.
Giving verbal and written information on delirium to the person and their carer.
Reviewing the person’s response to treatment within 24 hours and regularly thereafter until symptoms have resolved, and adjusting treatment if appropriate.
Arranging admission or seeking advice from an elderly care physician or psychiatrist (as appropriate) if the person fails to improve or deteriorates.
Delirium= If admission is not appropriate, advice should be sought from an elderly care physician or psychiatrist when?
There is doubt about the diagnosis.
The person has severe delirium.
Detention under the Mental Health Act (1983, amended 2007) is being considered.
Further investigations not available in primary care are needed.
The person does not respond to initial treatment in primary care.
The CAM criteria for delirium?
Confusion that has developed suddenly and fluctuates, and
Inattention — ask if the person is easily distracted or has difficulty in focusing attention, and either
Disorganised thinking — ask if the person’s thinking is disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation), or
Altered level of consciousness — ask about changes in level of consciousness from alertness to: lethargy (drowsy, easily aroused); stupor (difficult to arouse); comatose (unable to be aroused); or hypervigilant (hyper-alert).
The DSM-5 criteria for delirium?
A. Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during a day.
C. An additional disturbance in cognition (such as memory deficit, disorientation, language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by a pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication, or withdrawal (due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple aetiologies.
The 4A’s test (4AT) for delirium?
This is a short, four-item tool designed for use in clinical practice.
The four items are alertness, cognition (a short test of orientation), attention (recitation of the months in backwards order), and the presence of acute change or fluctuating course.
Specialists such as elderly care psychiatrists, the challenging behaviour team, or elderly care physicians may suggest pharmacological measures as a last resort for severe agitation or psychosis if ….
Verbal and non-verbal de-escalation techniques are inappropriate or have failed, and
The person is a danger to themselves or others, and
The cause of delirium is known and being treated, and
The benefit outweighs the risk to the person, and
There is enough care in place for the person to be continually monitored.
Medication for dleirium?
Short-term (for 1 week or less) low-dose haloperidol
Antipsychotic drugs should be avoided, or used with caution in Parkinson’s disease or dementia with Lewy bodies
If medication is prescribed for delirium short term then…
The risks (for example with haloperidol, an increased risk of stroke, transient ischaemic attack, and changes in cognition) and benefits (a small reduction in psychosis, aggression, and agitation) of treatment must be discussed with the person and their carers.
Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.
The aim of drug treatment is to calm (not sedate) the person.
The need for one-to-one supervision and information on when to seek urgent medical help (for example if the person deteriorates, or adverse effects develop) should be explained to carers.
Antipsychotic drugs should be avoided, or used with caution in…
Parkinson’s disease or dementia with Lewy bodies
Malnutrition?
an important consequence of and contributor to chronic disease. It is clearly a complex and multifactorial problem that can be difficult to manage.
NICE defines malnutrition as the following:
a Body Mass Index (BMI) of less than 18.5; or
unintentional weight loss greater than 10% within the last 3-6 months; or
a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
Is malnutrition common?
Around 10% of patients aged over 65 years are malnourished, the vast majority of those living independently, i.e. not in hospital or care/nursing homes.
Screening for malnutrition is mostly done using what?
MUST (Malnutrition Universal Screen Tool).
MUST screening tool for malnutrition?
it should be done on admission to care/nursing homes and hospital, or if there is a concern. For example an elderly, thin patient with pressure sores
it takes into account BMI, recent weight change and the presence of acute disease
categorises patients into low, medium and high risk
Management of malnutrition is difficult. NICE recommend the following points?
dietician support if the patient is at high-risk
a ‘food-first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’), rather than just prescribing oral nutritional supplements (ONS) such as Ensure
if ONS are used they should be taken between meals, rather than instead of meals
Malnutrition is a state in which a deficiency of what?
nutrients such as energy, protein, vitamins, and minerals causes measurable adverse effects on body composition, function, or clinical outcome. It is both a cause and a consequence of ill health.
Nutrition support should be considered in people at risk of malnutrition, defined as those who have:
Eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer.
A poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs.
Reasons for malnutrition include
acute illness; frailty; increasing age; appetite; eating and swallowing difficulties; neurological disease; other chronic conditions; and psychological and socioeconomic factors.
Cx of malnutrition?
increased vulnerability to disease and infection; reduced wound healing; pressure ulcers; frailty and falls; reduced function; anxiety; depression; cognitive impairment; and social and healthcare costs
A person should be screened for malnutrition using a validated screening tool opportunistically in primary care when?
Initial registration in general practice.
Routine health checks and immunisations.
Structured medication reviews.
Contact with a community or district nurse.
Admission to a new care setting, such as a care home.
A person should be screened for malnutrition if there is clinical concern, such as:
Unintentional or unplanned weight loss.
Apathy or fatigue.
Poor appetite; early satiety; altered taste sensation; or difficulty swallowing.
Altered bowel habit or gut function.
Prolonged intercurrent illness or recurrent infections.
Reduced physical function or frequent falls.
Thin appearance; sarcopenia; or loose-fitting clothes, jewellery, or dentures.
Fragile skin or poor wound healing or pressure ulcers.
Assessment of a person with, or at risk of, malnutrition should include:
Asking about nutritional intake; unintentional weight loss; energy, strength, and activity levels; swallowing or appetite issues; mood or cognitive changes; gastrointestinal symptoms; comorbidities; drugs and alcohol intake; and social situation.
Examination for signs of malnutrition, acute illness, and dehydration; mobility and muscle strength; and trend in weight loss and BMI.
Consideration of baseline blood tests.
Management of a person with, or at risk of, malnutrition should include:
Providing a nutritional care plan, including nutrition support such as dietary advice.
Managing underlying conditions, causes, risk factors, and/or complications of malnutrition.
Setting individualized treatment goals.
Providing sources of information and support.
Prescribing oral nutritional supplementation if clinically indicated, and stopping when appropriate.
Referring to a dietitian, speech and language therapist, occupational therapist, physiotherapist, mental health team, or adult social care if indicated.
Monitoring progress, the frequency depending on clinical judgement.
Pressure ulcers develop in patients who….
patients who are unable to move parts of their body due to illness, paralysis or advancing age.
Where do pressure ulcers typically develop?
over bony prominences such as the sacrum or heel
What factors predispose to the development of pressure ulcers?
- malnourishment
- incontinence= faecal and urinary
- lack of mobility
- pain (leads to reduction in mobilitiy)
What is used to screen pts who are at risk of developing pressure ulcers?
Waterlow score
What is the waterlow score?
screens pts who are at risk of developing pressure ulcers
It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
How many grades of pressure ulcer are there?
4
Grade 1 pressure ulcer?
Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.
Grade 2 pressure ulcer?
Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister.
Grade 3 pressure ulcer?
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 pressure ulcer?
Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss.
Mx of pressure ulcer?
a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
consider referral to the tissue viability nurse
surgical debridement may be beneficial for selected wounds
Definition of pressure ulcer?
localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. They usually occur over a bony prominence but may also be related to a medical device or other objects.
Pressure ulcer can range in…
severity, from patches of discoloured skin to extensive wounds filled with necrotic tissue and involving fascia, muscle, and bone.
RFs for pressure ulcers?
reduced mobility, nutritional deficiency, older age, and conditions that cause inadequate blood flow to the skin and soft tissues (such as diabetes and peripheral vascular disease).
Cx of pressure ulcers?
pain, infection, and increased mortality
Can anyone develop a pressure ulcer?
yes
A validated risk assessment scale, such as the ……, should be used to support clinical judgement when assessing pressure ulcer risk.
Braden or PURPOSE T risk assessment tool
A diagnosis of pressure ulcer is typically obvious when a person with risk factors develops evidence of skin damage over a bony prominence. Pressure damage is supported by the presence of one of the following:
An area of non-blanchable erythema. Note that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.
Marked localized skin changes.
A wound of varying severity on an anatomical site that is known (or suspected) to have previously been exposed to significant unrelieved pressure.
Assessment of a person with a pressure ulcer includes:
Documenting the surface area of the pressure ulcer.
Estimating the depth of the pressure ulcer and documenting the presence of undermining.
Categorizing the pressure ulcer using a validated classification tool. This should be used to guide ongoing preventative strategies and management.
Investigations are not used to make the diagnosis of pressure ulcers but may be required if
the diagnosis is uncertain or to exclude complications and/or differential diagnoses (such as venous ulcers, osteomyelitis, peripheral arterial disease, or malignancy). Wounds should only be swabbed if infection is suspected.
Prevention of pressure ulcers includes:
Offering timely, tailored information on pressure ulcers, including information on risk reduction.
Offering a skin assessment to the person assessed as being at risk of developing a pressure ulcer.
Developing an individualized care plan for the person, considering the outcome of the risk and skin assessments, pressure relief, the need for additional pressure relief at specific at-risk skin sites, and the person’s mobility, ability to reposition, comorbidities, and preference.
Considering the use of a barrier preparation to prevent skin damage if there are concerns with moisture or incontinence.
Management of people with a pressure ulcer, includes:
Offering a nutritional risk assessment.
Considering the need for pressure redistributing devices.
Debriding the wound if indicated.
Prescribing systemic antibiotics if indicated. The choice of antibiotic should be discussed with microbiology specialists.
Recommending appropriate wound dressings.
What to document when looking at a pressure ulcer?
The surface area of the pressure ulcer, preferably using a validated measurement technique (such as a photograph).
An estimate of the depth of the pressure ulcer and the presence of undermining. Do not routinely measure the volume of a pressure ulcer.
The NPUAP-EPUAP system classifies pressure ulcers into 6 categories/stages:
Category/Stage I: nonblanchable erythema.
Category/Stage II: partial thickness skin loss.
Category/Stage III: full-thickness skin loss.
Category/Stage IV: full-thickness tissue loss.
Unstageable: depth unknown.
Suspected deep tissue injury: depth unknown.
Use the classification to guide ongoing preventative strategies and management.
Repeat and document the classification each time the ulcer is assessed.
Consider or suspect ….. as a contributory factor to (or cause of) pressure ulcers in children and adults.
abuse or neglect (particularly malnourishment, lack of repositioning, or poor continence management)
Examining pressure ulcers- check for?
Skin integrity in areas of pressure.
Colour changes or discolouration. Be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.
Variations in heat, firmness, and moisture (for example due to incontinence, oedema, and dry or inflamed skin).
Prevention of pressure ulcers?
1) Consider the person’s mobility and their ability to reposition themself= Encourage the person to change their position at least every 6 hours if they have been assessed as being at risk of developing a pressure ulcer, or at least every 4 hours if assessed as being at high risk of developing a pressure ulcer; If they are unable to reposition themselves, they should be offered help to do so, using appropriate equipment if needed.
2) Consider the need for pressure relief, including additional pressure relief at specific at-risk body sites (such as the heel). =
Recommend a high-specification foam mattress for people assessed as being at high risk of developing pressure ulcers; Consider the seating needs of people who are sitting for prolonged periods; Consider a high-specification foam or equivalent pressure redistributing cushion for people who use a wheelchair or who sit for prolonged periods.
3) Consider prescribing a barrier preparation to prevent skin damage in people who are at high risk of developing a moisture lesion or incontinence-associated dermatitis (such as those with incontinence or oedema). If the skin is dry or inflamed, an emollient should be used.
What to NOT offer to prevent pressure ulcers?
Do not offer:
- Skin massage or rubbing to prevent pressure ulcers.
- Subcutaneous or intravenous fluids specifically to prevent pressure ulcers in adults whose hydration status is adequate.
- Nutritional supplements specifically to prevent pressure ulcers in adults whose nutritional intake is adequate.
Heel-specific pressure-reducing devices can be categorized as:
Constant low-pressure (CLP) devices, such as gel or foam heel pads/cups and booties, that aim to distribute the pressure over a larger surface area.
Offloading devices, such as pillows, wedges, or splints, that prevent contact between the heel and the bed.
Low friction devices, such as dressings or booties, that reduce friction and sheer when the person moves their foot.
Devices with combinations of functions, for example, prophylactic dressing or devices that reduce pressure and/or friction and shear, such as multilayer heel dressings and medical-grade sheepskin.
Effect of falls?
Around one-third of elderly people living in the community fall every year. Not only do falls often lead to injuries they also impact patients confidence and independence.
Normal gait involves?
The neurological system - basal ganglia and cortical basal ganglia loop.
The musculoskeletal system (which must have appropriate tone and strength).
Effective processing of the senses such as sight, sound, and sensation (fine touch and proprioception).
Gait and risk of falls?
As individuals get older they are more likely to experience medical problems affecting these systems, which leads to gait abnormalities and increases the risk of falls.
Falls often occur due to a range of factors and individuals who have fallen previously are at a significantly higher risk of falling again. Other risk factors include:
Lower limb muscle weakness
Vision problems
Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
Polypharmacy (4+ medications)
Incontinence
>65
Have a fear of falling
Depression
Postural hypotension
Arthritis in lower limbs
Psychoactive drugs
Cognitive impairment
Ideally, all patients should be screened for falls risk in order to establish the level of support they need, particularly when they are in a hospital or a home.
It is important to establish the following from the history:
Where was the patient when they fell?
When did they fall?
Did anyone else see the patient fall? (collateral history)
What happened? Were there any associated features before/during/after
Why do they think they fell?
Have they fallen before?
Systems review
Past medical history (especially issues related to balance/sight/gait)
Social history
Reviewing a patients medication is crucial to reduce the chances of
falls
Patients on more than …. drugs are more likely to fall therefore any suspect or unnecessary medications should be stopped or swapped.
4
Medications that cause postural hypotension?
Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-Dopa
ACE inhibitors
Medications associated with falls due to other mechanisms (not postural hypotension)?
Benzodiazepines
Antipsychotics
Opiates
Anticonvulsants
Codeine
Digoxin
Other sedative agents
What meds may increase risk of falls?
Medications that cause postural hypotension:
Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-Dopa
ACE inhibitors
Medications associated with falls due to other mechanisms:
Benzodiazepines
Antipsychotics
Opiates
Anticonvulsants
Codeine
Digoxin
Other sedative agents
It is essential that patients who have fallen are assessed thoroughly. Therefore what it is important to do?
a full A to E approach and assessment of all systems is important to rule out the cause
Investigations to consider in pt who has had a fall?
Bedside tests= Basic observations, blood pressure, blood glucose, urine dip and ECG
Bloods= Full Blood Count, Urea and Electrolytes, Liver function tests and bone profile
Imaging= X-ray of chest/injured limbs, CT head and cardiac echo
Mx of pt who has had a fall?
Identify all individuals who have fallen in the last 12 months.
Identify why they are at risk.
For those with a falls history or at risk complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.
Sometimes MDT assessment
Mx of pt who has had a fall= who would be offered a MDT assessment?
all patients over 65 with:
- >2 falls in the last 12 months
- A fall that requires medical treatment
- Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
Individuals who fall but do not meet these criteria should be reviewed annually and given written information on falls.
A fall is defined as
an event which causes a person to, unintentionally, rest on the ground or other lower level.
a simple fall is defined as
one occurring as a result of a chronic impairment of cognition, vision, balance, or mobility. It is distinguished from a collapse caused by an acute medical problem, such as an acute arrhythmia, transient ischaemic attack, or vertigo.
Falls are common in older people, especially those aged
65 years and over, and the prevalence increases with age.
one of the strongest risk factors for a fall?
history of falls
all older people in regular contact with healthcare professionals should be asked routinely whether they have
fallen in the past year
risk factors for falls in older people include:
history of falls
Conditions that affects mobility or balance, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson’s disease.
Other conditions, including muscle weakness, poor balance, visual impairment, cognitive impairment, depression, and alcohol misuse.
Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).
Home hazards, such as loose rugs or mats, poor lighting, wet surfaces (especially in the bathroom), and loose fittings (such as handrails).
About 40–60% of falls result in
major lacerations, traumatic brain injuries, or fractures. Other complications of falls include distress, pain, loss of self-confidence, reduced quality of life, loss of independence, and mortality.
Older people who present for medical attention because of a fall, report recurrent falls in the past year, or have other risk factors for falls should be assessed for
gait and balance abnormalities (for example by using the Timed Up & Go test and/or the Turn 180° test)
A multifactorial risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service) should be offered to older people who have had one or more falls in the past year or demonstrate abnormalities of gait and/or balance. This assessment should be part of what…
an individualized, multifactorial intervention.
A multifactorial risk assessment may include assessing for home hazards, visual impairment, and drug treatments.
Interventions commonly offered by specialist falls services include strength and balance training, home hazard assessment and intervention, vision assessment and referral, and medication review (with modification or withdrawal).
People who do not have an indication to be referred for a multifactorial risk assessment should be reassessed at least annually.
Falls= Timed Up & Go test and Turn 180° test?
Time the person getting up from a chair without using their arms, walking 3 metres, turning around, returning to the chair, and sitting down. If the person usually uses a walking aid, this can be used during the test.
During the test, observe the person’s postural stability, gait, stride length, and sway.
Standardized cut-off scores to predict risk of falling have not yet been established.
However, a score of 12—15 seconds or more (depending on the study) has been shown to indicate high risk of falls in older people.
Use clinical judgement to interpret the test, and consider the time taken to complete the test as well as other factors, such as age of the person, the type of footwear, the use of a walking aid, and the general health of the person
Falls= Turn 180° test ?
Ask the person to stand up and step around until they are facing the opposite direction. If the person takes more than four steps, further assessment should be considered
Falls= A multifactorial risk assessment may include assessment of the following?
History of falls.
Gait, balance and mobility, and muscle weakness.
Osteoporosis risk.
Perceived impaired functional ability and fear relating to falling.
Visual impairment.
Cognitive, neurological, and cardiovascular problems.
Urinary incontinence.
Home hazards.
Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example, drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants).
Interventions commonly offered by specialist falls services include:
Strength and balance training — most likely to benefit older community-dwelling people with a history of recurrent falls or balance and gait deficit.
Home hazard assessment and intervention — should be offered to older people who have received treatment in hospital following a fall.
Vision assessment and referral.
Medication review — psychotropic drugs are reviewed, with specialist input if appropriate, and discontinued if possible.
Multimorbidity?
defined as the presence of two or more long term health conditions and is a growing public health issue.
Definition of multimorbidity?
The presence of two or more long-term health conditions, including: Defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse
Prevalence of multimorbidity?
In older adults, multimorbidity is very common
Prevalence has been estimated as 27.2% in a retrospective cohort of 403,985 adults
Prevalence is higher in females than in males
Combined mental and physical comorbidity is more common in younger adults
Socioeconomic deprivation is associated with multimorbidity, particularly when involving mental health disorders
Multimorbidity= Most common comorbid conditions?
Hypertension is the most prevalent disorder that exists comorbidly with other disorders such as pain, diabetes and hearing loss
Depression and anxiety are the most common mental health disorders that exist comorbidly with other conditions such as pain, hypertension and irritable bowel syndrome
Other conditions that are found in multimorbidity include chronic pain, prostate disorders, thyroid disorders and coronary artery disease
RFs for multimorbidity?
Increasing age
Female sex
Low socioeconomic status
Tobacco and alcohol usage
Lack of physical activity
Poor nutrition and obesity
Cx of multimorbidity?
Decreased quality of life and life expectancy
Increased treatment burden: Difficulties in understanding and self-managing condition as well as adherence to lifestyle changes
Mental health issues: Those with cognitive impairment are particularly vulnerable
Polypharmacy: Adverse drug events increase in prevalence as the number of chronic conditions increases
Negative impact on carers welfare
The assessment of multimorbidity?
Identify those who may benefit from the recognition of multimorbidity, opportunistically in routine care or through healthcare records
Establish the extent of disease burden: Discuss mental health issues, wellbeing and the interaction between their health and quality of life
Investigate how their treatment burden affects their daily activities
Ask about social circumstances and assess their health literacy
Assess the adequacy of pain management particularly in chronic pain conditions
Assess fraility
Patients may require a multimorbidity approach if they?
Have difficulties with daily activities, are frail, are prescribed over 10 medications, or frequently seek emergency care services
Assessment of multimorbidity= assess frailty?
Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire: The PRISMA-7 involves questions considering the age, sex, health problems, assistance required and walking aid use of the patient
Mx of multimorbidity?
- maximise benefits of existing Tx
- offer alternative follow up if struggling to meet them
- consider non-pharmacological Tx
- reduce number of high risk meds
- consider bisphosphonate holiday if applicable
- Consider the use of screening tools such as STOPP/ START in older people to recognise medicine safety concerns
- Ask patients about the benefits and harms of their individual treatments, considering the overall prognostic benefit
- Develop an individualised management plan: Record what actions will be taken, include goals, prioritise healthcare appointments, anticipate changes and explore other areas of importance to the patient
- Promote self-management through education and engagement strategies
- Support carers and families of patients
- Use the action plan to follow up with the patient at agreed points
Goal of managing multimorbidity?
reducing Tx burden and optimising care
Mx of multimorbidity= what if pt is on bisphosphonates?
Consider a ‘bisphosphonate holiday’ in those taking bisphosphonates for longer than three years as there is no consistent evidence of continued benefits after this point. Discuss stopping bisphosphonates after 3 years and include patient choice, fracture risk and life expectancy in the discussion.
Mx of multimorbidity= consider using what in older pts to recognise med safety concerns?
STOPP/START
Mx of multimorbidity= STOPP and START screening tools?
STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions and START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
Mx of multimorbidity= Especially consider stopping the use of medications such as…
NSAIDS, warfarin and aspirin in patients with peptic ulcer disease, and pay particular attention to the prescription of reno-toxic or renally cleared drugs in reduced renal function
Mx of multimorbidity= follow up?
Use the action plan to follow up with the patient at agreed points: NHS England recommends a yearly review of all medications for people aged over 65, however, medications should be reviewed periodically to ensure that patients are being informed, given adequate laboratory tests and that treatments are optimised
The Mental Capacity Act of 2005?
came into force in 2007. It applies to adults over the age of 16 and sets out who can take decisions if a patient becomes incapacitated (e.g. following a stroke). Mental capacity includes the ability to make decisions affecting daily life, healthcare and financial issues.
Mental Capacity Act= 5 key principles?
A person must be assumed to have capacity unless it is established that he lacks capacity
A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have
been taken without success
A person is not to be treated as unable to make a decision merely because he makes an unwise decision
An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
Mental capacity act= sets out a clear test for assessing what?
whether a person lacks capacity. It is a ‘decision-specific’ and ‘time-specific’ test. An adult can only be considered unable to make a particular decision if:
- He or she has an ‘impairment of, or disturbance in, the functioning of the mind or
brain’ whether permanent or temporary AND - He or she is unable to undertake any of the following
a. understand the information relevant to the decision
b. retain that information
c. use or weigh that information as part of the process of making the decision
d. communicate the decision made by talking, sign language or other means
Can someone lack capacity simply as a result of a particular medical condition?
No individual can be labelled ‘incapable’ simply as a result of a particular medical condition. Section 2 of the Act makes it clear that a lack of capacity cannot be assumed by a person’s age, appearance, or any condition or aspect of a person’s behaviour
The following should be considered when assessing what is in someone’s best interests?
- Whether the person is likely to regain capacity and can the decision wait.
- How to encourage and optimise the participation of the person in the decision.
- The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
- Views of other relevant people
Lasting Powers of Attorney (LPAs)?
The Act allows a person to appoint an attorney to act on their behalf if they should lose capacity in the future, replacing the current Enduring Power of Attorney (EPA). In addition to property and financial affairs the Act also allows people to empower an attorney make health and welfare decisions. The attorney only has the authority to make decisions about life-sustaining treatment if the LPA specifies that. Before it can be used an LPA must be registered with the Office of the Public Guardian
Advance decisions?
Advance decisions can be drawn up by anybody with capacity to specify treatments they would not want if they lost capacity. They may be made verbally unless they specify refusing life-sustaining treatment (e.g. Ventilation) in which case they need to be written, signed and witnessed to be valid. Advance decisions cannot demand treatment
Syncope may be defined as?
transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery. Note how this definition excludes other causes of collapse such as epilepsy.
Most common cause of syncope?
Reflex syncope
Subtypes of reflex syncope? (3)
vasovagal
situational
carotid sinus syncope
Vasovagal reflex syncope?
the most common cause of syncope and may account for up to 50% of cases of syncope
often referred to as ‘fainting’
typically occurs in the sitting or standing position and may be triggered by emotion, pain or stress
the patient may feel warm/hot prior to loss of consciousness or feel ‘light-headed’
brief myoclonic jerks can occur during uncomplicated vasovagal syncope
syncope duration of < 1-2 minutes is typical
prolonged fatigue / amnesia is unusual after regaining consciousness and may suggest an alternative cause
Durations of vasovagal syncope (fainting)?
<1-2mins
CP of vasovagal syncope?
often referred to as ‘fainting’
typically occurs in the sitting or standing position and may be triggered by emotion, pain or stress
the patient may feel warm/hot prior to loss of consciousness or feel ‘light-headed’
brief myoclonic jerks can occur during uncomplicated vasovagal syncope
Reflex syncope (neurally mediated)?
vasovagal: triggered by emotion, pain or stress. Often referred to as ‘fainting’
situational: cough, micturition, gastrointestinal
carotid sinus syncope
Orthostatic syncope?
primary autonomic failure: Parkinson’s disease, Lewy body dementia
secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
drug-induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhage, diarrhoea
Cardiac syncope?
arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
structural: valvular, myocardial infarction, hypertrophic obstructive cardiomyopathy
others: pulmonary embolism
Types of syncope?
Reflex syncope (neurally mediated)
Orthostatic syncope
Cardiac syncope
Most common cause of syncope?
Reflex syncope is the most common cause in all age groups although orthostatic and cardiac causes become progressively more common in older patients.
Ix of syncope?
cardiovascular examination
postural blood pressure readings: a symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic
ECG for all patients
other tests depend on clinical features:
- patients with typical features, no postural drop and a normal ECG do not require further investigations
The term ‘blackout’ is sometimes used to describe?
transient loss of consciousness with complete recovery.
Transient loss of consciousness is defined as?
‘a state of real or apparent loss of consciousness with loss of awareness, characterized by amnesia for the period of unconsciousness, abnormal motor control, loss of responsiveness, and a short duration’.
Syncope is defined as?
‘transient loss of consciousness due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery’.
There are multiple possible causes of blackouts and syncope, and symptoms may be due to more than one mechanism. In up to one-third of cases, the underlying cause may not be identified.
The main causes of syncope are what?
‘reflexes’ (neurally mediated) such as vasovagal, situational syncope, or carotid sinus syndrome; orthostatic hypotension (OH); and cardiac syncope.
Non-syncopal causes of blackout include?
epilepsy or seizure, and psychogenic pseudosyncope or non-epileptic seizures.
Low-risk and younger people with vasovagal syncope and situational syncope generally have an
excellent prognosis
Assessment of a person presenting with blackout or syncope includes:
Assessment of vital signs; lying and standing blood pressure while standing for at least 1 minute; blood glucose level; cardiac and neurological examination.
Asking the person and any first-hand witnesses about the circumstances of the event; posture beforehand; any prodromal symptoms; appearance, movement, or injury during the event; any tongue-biting or loss of bladder/bowel control; any associated symptoms; duration of loss of consciousness; any confusion afterwards; any triggers; any previous episodes or unexplained falls; history or family history of cardiac disease or sudden death; drug treatment(s).
Arranging a 12-lead electrocardiogram and additional tests (such as bloods, 24-hour ambulatory blood pressure monitoring, or echocardiogram) depending on clinical judgement.
Suggesting the person/carer makes a video recording of future events.
Management of a person presenting with blackout or syncope includes:
Providing education and advice on sources of information and support.
Advising on the person’s fitness to drive and safety at work.
Arranging referral to an appropriate specialist if there is a suspected cardiac cause, carotid sinus syndrome, or epilepsy.
Advising on triggers, early recognition of prodromal symptoms, lifestyle modification (such as adequate fluids and physical counter-pressure manoeuvres), and reviewing drug treatment(s) if there is suspected reflex syncope or OH.
Providing additional lifestyle modification advice (such as small frequent meals, drinking a fluid bolus, dietary salt supplementation, regular physical activity, head-up tilt sleeping, and use of compression garments) if there is suspected OH.
Specialist referral to a falls and syncope service or cardiologist should be arranged, depending on clinical judgement, if there is:
Diagnostic uncertainty.
Unexplained syncope.
Vasovagal syncope during a high-risk activity or affecting quality of life.
Reflex syncope with an absent or short prodrome.
Suspected but unconfirmed OH.
Persistent OH despite lifestyle modification.
Mx of syncope= If there is suspected carotid sinus syndrome?
Arrange referral to a falls and syncope service for consideration of carotid sinus massage as a first-line investigation if the person is over 40 years of age.
Mx of syncope= If there is suspected uncomplicated vasovagal syncope or situational syncope (‘reflex syncope’)?
Provide reassurance that the prognosis is usually good.
Advise on possible trigger events and strategies to avoid them.
If triggers are unclear or unknown, advise the person to keep a record of their symptoms, when they occur, and what they were doing at the time.
Advise on early recognition of prodromal symptoms in order to sit or lie down to prevent events, if needed.
Advise on lifestyle modifications that may reduce symptoms
Review drug treatments and consider reducing or stopping any potentially causative drugs, particularly if symptoms are severe or recurrent.
Mx of suspected uncomplicated vasovagal syncope or situational syncope (‘reflex syncope’)= Advise on lifestyle modifications that may reduce symptoms?
Ensure adequate fluid intake of around 2 litres of water per day.
Use physical counter-pressure manoeuvres such as leg and knee crossing, squatting, hand gripping, and arm tensing, if the person has prodromal symptoms.
Mx If there is suspected orthostatic hypotension (OH)?
Advise on possible trigger events and strategies to avoid them.
If triggers are unclear or unknown, advise the person to keep a record of their symptoms, when they occur, and what they were doing at the time.
Advise on early recognition of prodromal symptoms in order to sit or lie down to prevent events, if needed.
Advise on lifestyle modifications that may reduce symptoms
Review drug treatments and consider reducing or stopping any potentially causative drugs.
Mx If there is suspected orthostatic hypotension (OH)= Advise on lifestyle modifications that may reduce symptoms?
Sit rather than stand, where possible, and sit first when moving from a lying to standing position.
Eat frequent, small meals to lessen postprandial drops in blood pressure.
Ensure adequate fluid intake of 2–3 litres of water per day. Advise to drink a 500 mL bolus of water if an immediate rise in blood pressure is needed, depending on clinical judgement and comorbidities.
Consider dietary salt supplementation of up to 10 g a day, if there are no contraindications such as hypertension.
Encourage regular physical activity to prevent physical deconditioning, where possible.
Encourage head-up tilt sleeping (raise the head of the bed by at least 10 degrees or 15–23 cm).
Use physical counter-pressure manoeuvres such as leg and knee crossing, squatting, hand gripping, and arm tensing, if the person has prodromal symptoms.
Consider use of compression garments, such as abdominal binders or support stockings (worn to waist level to provide abdominal compression), if there are no contraindications such as peripheral arterial disease
Mx If there is suspected orthostatic hypotension (OH)= Review drug treatments and consider reducing or stopping any potentially causative drugs eg?
Consider using or switching to angiotensin-converting enzyme (ACE)-inhibitors, angiotensin receptor blockers (ARBs), or calcium-channel blockers, if antihypertensive treatment is needed.
Charles-Bonnet syndrome (CBS)?
characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
RFs for Charles-Bonnet syndrome?
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
Charles-Bonnet syndrome more common in who?
CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.
The most common ophthalmological conditions associated with Charles-Bonnet syndrome are?
age-related macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of individuals with
severe visual impairment.
Prevalence of CBS in visually impaired people is thought to be between
11 and 15 per cent.
Prognosis of Charles-Bonnet syndrome?
Around a third find the hallucinations themselves an unpleasant or disturbing experience. In a large study published in the British Journal of Ophthalmology, 88% had CBS for 2 years or more, resolving in only 25% at 9 years (thus it is not generally a transient experience).
ICD10 definition of hallucination:
false sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.
The definition of a pseudohallucination?
false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
There is no mention of pseudohallucinations in either the ICD10 nor the DSM-5.
There is disagreement among specialists about not only the definition but also the role in the treatment of pseudohallucinations. Many specialists feel that it is more appropriate to think about hallucinations on a ….
spectrum from mild sensory disturbance to hallucinations to prevent symptoms from being mistreated or misdiagnosed.
An example of a pseudohallucination is?
hypnagogic hallucination
Psuedohallucinations= hypnagogic hallucination?
occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone. These are pseudohallucinations as the affected person is able to determine that the hallucination was not real.
The relevance of pseudohallucinations in practice?
patients may need reassurance that these experiences are normal and do not mean that they will develop a mental illness.
Pseudohallucinations commonly occur in people who are?
grieving
Factors favouring delirium over dementia?
acute onset
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
Frontotemporal lobar degeneration (FTLD)?
third most common type of cortical dementia after Alzheimer’s and Lewy body dementia.
Frontotemporal lobar degeneration (FTLD)= 3 types?
Frontotemporal dementia (Pick’s disease)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
Frontotemporal lobar degeneration (FTLD)= common features?
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
Frontotemporal lobar degeneration (FTLD)= Pick’s disease?
This is the most common type and is characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
Frontotemporal lobar degeneration (FTLD)= Pick’s disease- what is characteristic?
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease.
Frontotemporal lobar degeneration (FTLD)= Pick’s disease- macroscopic changes?
Atrophy of the frontal and temporal lobes
Frontotemporal lobar degeneration (FTLD)= Pick’s disease- microscopic changes?
Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques
Frontotemporal lobar degeneration (FTLD)= Pick’s disease- Mx?
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia
personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
Pick’s disease (frontotemporal dementia)- a type of Frontotemporal lobar degeneration (FTLD)
What is Pick’s disease?
(frontotemporal dementia)- a type of Frontotemporal lobar degeneration (FTLD)
Frontotemporal lobar degeneration (FTLD)= Progressive non fluent aphasia (chronic progressive aphasia, CPA)?
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
Frontotemporal lobar degeneration (FTLD)= what type…
chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
Progressive non fluent aphasia (chronic progressive aphasia, CPA)?
Frontotemporal lobar degeneration (FTLD)= Semantic dementia?
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
Frontotemporal lobar degeneration (FTLD)= what type…
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
Semantic dementia
