Geriatrics Flashcards
Define delirium
An acute fluctuating syndrome of encephalopathy, causing disturbed consciousness, attention, cognition, or perception, usually developing over hours to days
What are the risk factors for delirium?
- Older age (over 65)
- Cognitive impairment (e.g. dementia)
- Frailty/multiple comorbidities
- Significant injuries (e.g. hip fracture)
- Functional impairment (e.g. immobility)
- Iatrogenic events (e.g. surgery, catheterisation, polypharmacy)
- Substance misuse
- Hearing or visual impairment
- Poor nutrition
- Lack of stimulation or social isolation
- Terminal phase of illness
- Movement to a new environment
What are the causes/precipitating factors of delirium?
PINCH ME
- Pain (severe, uncontrolled)
- Infection (UTI, pneumonia, sepsis, viral infections, pressure sore)
- Nutrition (inadequate nutrition, vitamin deficiencies)
- Constipation/continence (urinary retention)
- Hydration (dehydration)
- Medications (benzodiazepines, anticholinergics, anticonvulsants, steroids, opioids, anti-Parkinson’s)
- Environment (new, disorientation, sensory impairment, poor sleep)
Others:
- surgery
- toxic substances (alcohol, drug misuse or withdrawal, CO poisoning)
- vascular disorders (stroke, intracranial haemorrhage, vasculitis, cardiac failure or ischemia)
- metabolic (hypoxia, hyponatraemia, hypercalcaemia, hypo/hyperglycaemia, hepatic/renal impairment)
- endocrine (hypo/hyperthyroid, hypo/hyperparathyroid, hypopituitarism, cushing’s)
- neurological (trauma, tumours, epilepsy, cognitive impairment)
- emotional stress/trauma
What are the clinical features of delirium?
- Altered cognition: disorientated, memory and language impairment, slow responses, confusion
- Inattention: worsened concentration, easily distractable, unable to maintain conversations/follow commands
- Disorganised thinking: rambling or irrelevant conversation, unclear/illogical flow of ideas, difficulty expressing needs
- Altered perception: paranoid delusions, misperceptions, visual or auditory hallucinations
- Altered physical function: hyperactive (agitation, restlessness, increased sensitivity), hypoactive (lethargic, reduced mobility/appetite , lack of interest, withdrawn), mixed
- Altered behaviour: intermittent and liable changes in mood/emotion, non-cooperative or inappropriate behaviour
- Altered level of consciousness: reduced awareness, sleep disturbances (daytime drowsiness, insomnia, complete sleep cycle reversal)
How is delirium assessed and investigated?
- Gain collateral history of events and background (will provide onset and details of their baseline cognition)
- Physical examination: vital signs, and all systems
- 4AT (four-item test of alertness, cognition, attention, and presence of acute change/fluctuating course)
- Bloods: FBC, U&E, creatinine, glucose, calcium, magnesium, LFTs, TFTs, vitamin B12, cardiac enzymes, cultures (if indicated)
- MSU
- ECG
- Bladder scan/stool chart (if indicated)
- CXR (if indicated)
- Further imaging e.g. head CT (if indicated)
What are the supportive and environmental managements of delirium?
Supportive:
- clear communication (adapted if needed)
- reorientation with reminders of day, time, location, people
- access to familiar objects (especially glasses, hearing aids, mobility aids)
- involvement of family
- consistency of staff
- relaxation
Environmental:
- avoid sensory extremes (over/under stimulation of noise, light, temperature etc.)
- adequate sleep (encourage a normal sleep/wake cycle)
- private space if possible or near to nurses station
- maintain competence e.g. walking
- adequate nutrition (assistance with oral intake, calorie rich foods, monitor weight)
What are the medical and pharmacological managements of delirium?
Medical: (correct underlying precipitants)
- infection (antibiotics)
- constipation (laxatives)
- urinary retention (catheterisation, address any anticholinergics/immobility)
- dehydration and electrolyte abnormalities (monitor fluids, offer oral rehydration, correction of severe electrolyte imbalances)
- pain (regular and adequate analgesia, with careful monitoring with opiates)
- regular medications (consider recent changes)
Pharmacological:
- in patients who are aggressive or not responding to verbal de-escalation techniques (antipsychotics haloperidol or olanzapine may be used at the lowest possible dose for the shortest time)
- in delirium tremens (benzodiazepines diazepam or chlordiazepoxide are used)
Define vertigo and its causes
The hallucination of movement, and sensation of rotatory motion with respect to the patient and their environment, described as…
- peripheral: problems with the vestibular system, presenting as abrupt onset with nausea/vomiting and tinnitus (e.g. viral labyrinthitis, benign paroxysmal positional vertigo, Meniere’s disease, ototoxicity)
- central: problems with cerebral cortex, cerebellum or brain stem, presenting more gradually with less positional episodes, usually with other neurological signs (acoustic neuroma, stroke, vestibular migraine, MS)
Define benign paroxysmal positional vertigo
Most common cause of vertigo, occurring due to inner ear dysfunction when otoliths become detached from the macula into the semi-circular canals, causing hair cells on the detatched otoliths to be stimulated after the head has stopped moving which gives conflicting sensory inputs
What are the causes of benign paroxysmal postural vertigo?
- Idiopathic (in 60%)
- Head injury
- Spontaneous degeneration of the labyrinth
- Post-viral illness
- Complication of stapes surgery
- Chronic middle ear disease
What are the clinical features of benign paroxysmal positional vertigo?
- Vertigo provoked by head movements (often worse on a particular side)
- Sudden onset lasting 20-60 seconds, with a 5-20 second delay after the provocative movement
- Commonly associated with nausea, but not vomiting, tinnitus, hearing loss, or pain
- May present as a fall or non-specific dizziness in the elderly
What investigations are needed for benign paroxysmal postural vertigo?
- Examination of external ear and tympanic membrane
- Examine eye movements for nystagmus and saccades
- Hearing test
- Neurological examination (e.g. cranial nerves)
- Hallpike manoeuvre (50-80% sensitive for BPPV)
- Neuroimaging if any diagnostic uncertainty
What is the management of benign paroxysmal positional vertigo?
- General advise: limit symptoms by getting out of bed slowly and reducing head movements
- Consider safety e.g. driving, occupational hazards, risks of falls
- Repositing techniques (e.g. Epley’s manoeuvre, or Brandt-Daroff exercises)
- Avoid vestibular suppressant medications or surgery
What factors increase the frequency and severity of falls?
Frequency:
- intrinsic factors (balance, muscle strength, sensory input, peripheral and central nervous system)
- extrinsic factors (environment, lighting, obstacles, grab rails, height of steps, softness and grip of floor)
- lower threshold of stressors (e.g. pre-existing orthostatic hypotension, syncope)
Severity:
- multiple system impairments (leading to less effective saving mechanisms)
- osteoporosis
- secondary injury due to post-fall immobility (e.g. pressure sores, dehydration, pneumonia)
- psychological adverse effects (e.g. loss of confidence)
What medicals conditions associated with falls?
- Affecting mobility, strength or balance (benign paroxysmal positional vertigo, Parkinson’s, orthostatic hypotension, arthritis
- Affecting cognition: dementia, neurological conditions
- Affecting sensory elements: visual impairment, peripheral neuropathy
- Affecting bone health: osteoporosis (increased fracture risk)
- Leading to urgent movement: urinary frequency, incontinence, infection
- Cardiac conditions: aortic stenosis, atrial fibrillation, pacemakers, arrhythmias
What medications are associated with falls?
- Antihypertensives e.g. ramipril, amlodipine (increased risk of hypotension)
- Sedating drugs e.g. benzodiazepines, antipsychotics, opioids, anti-epileptics (increasing risk of drowsiness causing fall)
- Diuretics e.g. furosemide, indapamide (increased risk of hypotension and electrolyte disturbances)
- Antidepressants e.g. SSRIs, TCAs (increased risk of postural hypotension, sedation, and electrolyte disturbances)
- Skeletal muscle relaxants e.g. baclofen (increased muscle weakness)
- Diabetic medication e.g. insulin, SGLT2 inhibitors (increased risk of hypoglycaemia)
What investigations are needed for falls?
- Functional assessment (e.g. stand from chair, walk, turn around)
- Cardiovascular examination (lying and standing BP, pulse rate and rhythm, murmurs)
- Neurological examination (identify stroke, Parkinson’s, vestibular disease, cognitive impairment, etc.)
- Bloods (FBC, B12, folate, U&Es, calcium, phosphate, glucose, TFT)
- ECG (24hr if patient has frequent near-syncope)
- Echo (if systolic murmur)
Define syncope and presyncope
- Syncope is a sudden transient loss of consciousness due to reduced cerebral perfusion, where the patient is unresponsive and loses postural control (falls)
- Presyncope is a feeling of light-headedness that would lead to syncope if corrective measures were not taken (e.g. sitting or lying down)
What are the causes of syncope?
Neurally mediated syncope (reflex syncope)…
- vasovagal (simple faint): caused by emotional stress (fear, pain etc.) or orthostatic stress (prolonged standing, crowded, hot places)
- situational syncope: caused by cough, sneeze, GI stimulation, micturition
- carotid sinus hypersensitivity: occurs when rotating head, if collar is tight, if neck tumour present
Orthostatic hypotension (drop of >20 systolic or 10 diastolic within 3 mins of standing) …
- autonomic: Parkinson’s, multi system atrophy, diabetic neuropathy, medications, post-exercise, postprandial
- hypovolaemia: haemorrhage, vomiting, diarrhoea, dehydration, Addison’s disease
Cardiac causes…
- arrhythmias: VT, SVT, fast AF, complete heart block, long QT syndrome
- structural cardiopulmonary causes: acute coronary syndrome, obstructive cardiac valve disease, PE, pulmonary hypertension
What are the additional features in a history of syncope?
- Was there loss of consciousness? (syncope has brief complete LOC lasting usually under 30 seconds, but may be several minutes)
- What was the situation? (standing = orthostatic hypotension, exercise = cardiac, in pain/frightened = vasovagal, on the toilet = defecation/micturition syncope)
- Was there a prodrome? (palpitations = arrhythmia, chest pain or SOB = ischemia, light-headedness = hypotension)
- Description of the attack from eye witness (pale/clammy = systemic hypoperfusion, ictal features = seizure)
- How was recovery? (long recovery, with prolonged drowsiness and confusion suggests seizure)
What is the management of falls?
- Treat the underlying cause (often not found, multifactorial)
- Drug review (reduce polypharmacy, reduce dose or stop medications that could contribute)
- Treatment of orthostatic hypotension (advise to stand slowly, lie down at prodrome, fluid and salt replacement if needed, consider fludrocortisone or alpha-agonist)
- Physiotherapy (strength and balance training, walking aids)
- Occupational therapy (environmental assessment and modification)
- Prevent adverse consequences (osteoporosis treatment, alarms, supervision, change of accommodation)
Define osteoporosis
Reduction in the bone mass density and disruption of the bone architecture, due to a prolonged imbalance of bone remodelling where resorption exceeds deposition, resulting in increased bone fragility and fracture risk
What are the risk factors for a fragility fracture?
- Increasing age
- Female
- Low BMI
- Parental history of hip fracture
- Past history of fragility fractures
- Corticosteroid therapy
- Cushing’s syndrome
- Alcohol intake of more than 3 units/day
- Smoking
- Conditions which increase falls risks (e.g. visual impairment, lack of neuromuscular co-ordination and strength, cognitive impairment, sedatives)
- Secondary osteoporosis (rheumatoid arthritis, type 1 diabetes, premature menopause, chronic liver disease, IBD, coeliac, hyperthyroidism, hypogonadism)
What are the clinical features of osteoporosis?
- The pathological process itself is asymptomatic
- Often presents with fragility fractures (e.g. wrist, femoral neck, vertebral body)
- Wedging of the vertebrae caused by higher load bearing by the anterior potion of the vertebral body, presenting as acute painful fracture, progressive kyphosis, or incidental findings
What are the investigations for osteoporosis?
- DEXA scan: gives T score which compare BMD to peak bone mass (<-2.5 indicated osteoporosis)
- X-ray: shows fractures
- Bloods: identify treatable cause and rule out other causes (FBC, CRP, U+Es, LFTs, TFTs, calcium, testosterone in men)
What is the management of osteoporosis?
- Calcium and vitamin D supplements if required
Antiresorptive therapy…
- oral bisphosphonates: e.g. alendronate, once weekly, taken 30 minutes before food/drink remaining upright for 30 mins, SE of GI issues, CI in oesophageal issues and hypocalcaemia
- IV bisphosphonates: e.g. zoledronate, 1st line in hip fractures, given as yearly infusion, possible SE of acute phase reaction, CI in hypocalcaemia and severe renal impairment
- monoclonal antibodies: e.g. denosumab, given as s/c injection every 6 months, SE of skin reactions, hypocalcaemia
Anabolic therapy…
- teriparatide: recombinant PTH, 1st line in postmenopausal women or men >50 at very high risk, given as daily s/c injection, SE of nausea, dizziness, postural hypotension, CI in hypercalcaemia, severe renal impairment, bone malignancy, pregnancy
What factors support a diagnosis of normal aging rather than pathological cognitive decline?
- Ability to maintain function in normal life through aids (e.g. lists, calendars), or adaptation (e.g. of the environment, of one’s expectations)
- A very long time scale of decline (10-30 years, rather than months-short years)
- A relative decline to the person’s previous cognition
Define dementia
A syndrome of generalised decline of memory, intellect and personality, without impairment of consciousness, leading to functional impairment
