Geriatrics Flashcards
1
Q
What is the definition of frailty?
A
Increased vulnerability and decline (age related) in functional + psychological reserve
2
Q
What are the geriatric giants?
A
- Instability
- Inanition (poor nutrition)
- Immobility
- Intellectual impairment
- Iatrogenesis
- Incontinence
3
Q
What are the geriatric M’s?
A
- Mind
- Mobility
- Multicomplexity
- Medication
- Matters Most (ICE)
4
Q
Who is in the Geriatric MDT?
A
Medical - Drs, nurses, pharm, dietitian
Functional - OT, PT, SALT
Psych - Dr, Psychiatric nurse
Social - OT, social workers
Environmental - community nurse etc
5
Q
What is the ACB?
A
Anticholinergic burden
Score >3 can increase risk of falls, confusion, and overall morbidity
6
Q
What are some examples of ACB 3 medications?
A
- paroxetine
- amitriptyline
- oxybutynin
- clozapine
- promethazine
- quetiapine
6
Q
What are the symptoms of acetylcholine syndrome?
A
PNS - can’t see, pee, spit, shit
CNS - agitation, decreased GCIS, ataxia
7
Q
How do warfarin and NSAIDs interact?
A
Increased bleeding risk
8
Q
How do warfarin and macrolide’s (erythromycin, clarithromycin) interact?
A
Increased bleeding risk
9
Q
How do omeprazole and clopidogrel interact?
A
Omeprazole reduces the efficacy of clopidogrel?
10
Q
How do SSRIs and NSAIDs interact?
A
Increased GI bleed risk - co prescribe a PPI
11
Q
How do ACEi and spironolactone interact?
A
Increased AKI risk and hyperkalaemia
12
Q
How do methotrexate and trimethoprim interact?
A
Can cause myelosuppression
13
Q
How do statins and macrolides interact?
A
Causes myalgia
14
Q
How do statins and grapefruit juice interact?
A
Causes myalgia
15
Q
How do iron and tetracycline interact?
A
Iron decreases effects of tetracycline
16
Q
What is pharmacokinetics?
A
The effect of the body acting on the drug
17
Q
What is pharmacodynamics?
A
The effect of the drug on the body
18
Q
Why was the MCA 2005 made?
A
To empower >16year olds to make decisions in any future scenario where they may lack capacity
19
Q
What are the principles that you must adhere to with the MCA 2005?
A
- Acting in the patients best interest
- Assume capacity until otherwise proven
- Don’t cause undue harm
- Give all the info
- Least restrictive option
20
Q
What can an IMCA do for a patient?
A
- Enquire about medications and advocate for the patients best interest
- Cannot make decisions on the patients behalf
21
Q
What is an IMCA (Independent mental capacity advocate)?
A
NHS appointed role for any patient who doesn’t have a lasting power of attorney
22
Q
What is a LPA (Lasting Power of Attorney)?
A
Someone appointed by the patient to make decisions if lacking capacity
23
Q
What are the two types of LPA?
A
- Financial
- Health
24
What is an advanced directive?
A written statement by someone >18 detailing treatment preferences should they lack capacity in the future
25
What is a CAD (Court appointed deputy)?
There's no LPA and there's a dispute over best interests - can apply to the court for temporary decision maker
26
What is DoLS (Deprivation of Liberty Safeguards)?
Patient is supervised 24/7 and they are unfree to leave for up to seven days (can last up to 12 months)
27
What are the principles of DoLS?
- Must be in the best interest of the pt
- Patient must identifiably pose a risk to themselves
28
What info is needed if a pt with capacity is wanting to self discharge?
- Drug chart updated
- Input from OT
- Input from PT
- GP follow-up must be put in place
29
What can and can't be in and advanced directive?
- Can't demand treatment
- Can't refuse food/drink
30
What are the differences between delirium and dementia?
- Delirium is transient whereas dementia is chronic and progressive
- Delirium is acute
- Delirium has fluctuations whereas dementia does not
- Delirium's pathology does not involve CNS whereas dementia's does
- Delirium is reversible whereas dementia is not
31
What is delirium?
Transient (<6m) acute symptoms in consciousness and cognition due to underlying pathology, it is reversible
32
What are the causes of delirium?
P - Pain
I - Infection (UTI/URTI)
N - Nutrition decreased
C - Constipation
H - Hydration reduced
M - Metabolic
E - Endocrine + electrolytic + environmental
33
What are the risks for delirium?
- Increased age
- PMH of delirium
- Having dementia
34
What are the symptoms of delirium?
- Clouded consciousness + cognition acutely
- Fluctuations
- Disturbed sleep-wake cycle
- Disordered thinking
- Complex visual hallucinations
35
What are the types of delirium?
- Hyperactive
- Hypoactive
36
What are the symptoms of hyperactive delirium?
- Agitation
- persecutory delusions
- vivid hallucinations
37
What are the symptoms of hypoactive delirium?
- Withdrawn
- Reduced GCS
38
How is delirium diagnosed?
- Confusion bloods - FBC, U+E, Ca++, B12/Folate, TSH, Glucose, ESR/CRP
- Mid stream urine
- ECG
- Consider CXR, urine dip, CT head
- Confirmed with SHORTCAM
39
How is delirium screened?
4AT test:
- Alertness
- Attention
- AMT4 - age, DOB, time, place
40
How is delirium treated conservatively?
Re-orient them:
- decrease noise
- same staff
- clocks on walls
- sleep-wake cycle
- family time
41
How do you treat delirium if the pt is agitated?
- Verbally de-escalate
- Haloperidol - for parkinson pts use diazepam
42
What is dementia?
A progressive decline in cognitive function in an alert pt for >6m with brain pathology, irreversible
43
What are the two types of demetia?
- Cortical - Alzheimer's, fronto-temporal, vascular, lewy-body
- Subcortical - Parkinson's, Huntington's, alcohol, AIDS
44
What is Alzheimer's?
A type of cortical dementia in which you get beta-amyloid plaques with widespread axonal damage and decreased acetylcholine
45
What are the risk factors for Alzheimer's?
- Genetic predisposition - Down's, PSEN 1+2 genes, APP gene mutations
- Family history
- CVD
- Alcohol
46
What are the symptoms of Alzheimer's?
4A's:
- Aphasia
- Agnosia - can't recognise familiar objects
- Apraxia
- Amnesia
in Gradual decline
47
How common is ALzheimer's?
Makes up 60% of all dementias
48
How common is vascular dementia?
makes up 20-30% of dementias
49
What are the risk factors for vascular dementia?
- A result of a cardiovascular accident or repeated CVA causing cortical infarcts
50
What are the symptoms for vascular dementia?
4A's:
- Aphasia
- Agnosia - can't recognise familiar objects
- Apraxia
- Amnesia
STEPWISE DECLINE
51
How common is lewy-body dementia?
5% of all dementias
52
What is lewy-body dementia?
Deposits of ubiquitin and alpha-synuclein (lewy-bodies) in basal ganglia and cortex
53
What are the risk factors for Lewy-body dementia?
- Parkinson's
- Family history
- Increased age
54
What are the symptoms of Lewy-body dementia?
- REM sleep disorder
- Vivid visual hallucinations
- Parkinsonism
- Cognitive fluctuation
55
Which is the most rapidly declining dementia?
Lewy-body
56
How common is frontotemporal dementia?
5% of all dementias
57
What is frontotemporal dementia?
Pick bodies (TAU + ubiquitin) in frontal/temporal lobes
58
What are the risk factors for frontotemporal dementia?
- Family history
- Affects 50-60 year olds
- TDP43
- C9 of f72
- MAPT
- Associated with MND
59
What are the symptoms of frontotemporal dementia?
Frontal - apathy, mood disorders, eating changes
Temporal - troubles with grammar
60
How id dementia diagnosed?
- Confusion bloods + syphilis and HIV
- ADENBROOKE's test <82/100 is abnormal, >88 is fine
- MMSE >25/30 is fine
- Imaging - CT, MRI head
61
What is seen on an MRI head with Alzheimer's?
Diffuse cortical atrophy, sulcal widening, ventriculomegaly
62
What is seen on an MRI head with fronto-temporal dementia?
Deposits in the frontal and temporal lobes
63
What is seen on an MRI head with vascular dementia?
>1 white cortical infarct
64
What is seen on an MRI head with Lewy Body dementia?
Cortical deposits/ basal ganglia deposits/ normal
65
What can differentiate between frontotemporal and Alzheimer's?
SPECT scan
66
What scan can be used to diagnose Lewy body dementia or parkinsons?
Dat scan
67
What MDT is used to treat dementia?
- PT
- OT
- SALT
- Neuro
- GP
- Social care
- Family input
68
What is the treatment for Alzheimer's?
1st line - Acetylcholinesterase inhibitors - rivastigmine/ galantamine/ donepezil
2nd line - NDMA inhibitor - memantine
69
What is the treatment for fronto-temporal dementia?
SSRIs, do not give acetylcholinesterase inhibitors
70
How is vascular dementia treated?
- Manage vascular risk factors
- Statins and aspirin
71
How is Lewy body dementia treated?
Consider Rivastigmine/ galantamine/ donepezil
72
What are causes of falls in elderly patients?
M - MSK problems (fractures, osteoporosis)
I - Iatrogenic (high anticholinergic burden)
N - Neurological (TIA/stroke, seizures)
C - Cardiac (syncope, postural HTN)
73
What do you want to assess in someone who has had a fall?
Circumstances of fall (before, during, after)
74
What can be used to estimate frailty?
Rockwood Frailty score 0-9
1-4 mild 5-6 mod 7-9 severe frailty
75
What can be used to score a patients baseline quality of life?
Barthel index /100 e.g.feeding, bathing, toileting, dressing
<90 mild <60 severe dependence <20 total dependence
76
What can be used to calculate falls risk?
FRAT tool
77
What diagnostic investigations would you do for a pt presenting with falls?
- Bloods - FBC, U+Es, eGFR, CK, bone profile, B12 + folate, Vit d
- Lying/standing BP
- ECG
- CXR, CT head
78
What are the main complications of falls?
- Subdural haemorrhage
- Pneumothorax
- Fractures
- Rhabdomyolysis
79
What is rhabdomyolysis?
Increased muscle breakdown after trauma
80
What are the risk factors for rhabdomyolysis?
- Long lie
- anabolic steroids
- hyperthermia
81
What are the symptoms of rhabdomyolysis?
Coca Cola urine + muscle pain
82
How is rhabdomyolysis diagnosed?
- Increased CK in blood
- Increased myoglobin
83
How is rhabdomyolysis treated?
IV fluids and IV bicarb
84
What is postural hypotension?
A drop systolicaly of >20mmHg or >10mmHg diastolicaly in BP afer standing from sitting which isn't resolved in 3 mins
85
What are the risk factors for postural hypotension?
- Increased age
- CVD
86
What is the pathology of postural hypotension?
Impaired neuro-cardiac baroreceptor reflex causing blood to pool in the legs and decreased blood vessel plasticity, therefore reduced vasoaccomodation from blood vessels
87
What are symptoms of postural hypotension?
- Light-headedness + syncope after standing from sitting
- Dizzy
- Palpitations
88
What are the causes of postural hypotension?
CV - HF, AF, MI
Neuro - Parkinson's
Iatrogenic - BP meds (alpha and beta blockers)
Addison's
89
How is postural hypotension diagnosed?
- lying/standing bp
- ECG
- rule out other causes - bloods
90
How is postural hypotension treated?
Conservative - increased water, stand slow
Med (off license) - midodrine +fludrocortisone
91
Where is the most common area to get a pressure sore?
Sacrum + bony prominences
92
What are the risk factors for pressure sores?
- Bed bound
- Immobility
- BMI
- Diabetes
93
Why do pressure sores happen?
Increased friction/pressure resulting in ischaemia and necrosis
94
How is the severity of pressure sores scored?
Waterlow score:
1. non blanching erethymia
2. mucosal breach
3. full thickness skin involvement
4. bone/joint involvement
95
How are pressure sores diagnosed?
Bloods and site swab to identify if any infective organisms
96
How are pressure sores treated?
Prevent - reposition pt, barrier creams
Treatment:
grades 1+2 - pain ladder, consider IV fluclox
grades 3+4 - wound dressing + surgical debridement
97
What is malnutrition?
Nutritional defect resulting in functional effects
98
What are the causes of malnutrition?
- Increasing age
- EDs
- Malabsorption (coeliac etc)
- Poor diet
- Dysphagia
- Cancer
99
How can you screen for screen for malnutrition?
MUST score - BMI + unintentional wt loss + last time ate properly
Score > 2 - dietitians input
100
What are the symptoms of malnutrition?
- Anaemia (fatigue, breathlessness)
- Poor wound healing
- Dehydration
- Decreased libido
- Constipation and decreased urination
101
How would you diagnose malnutrition?
- MUST score
- Bloods - FBC, U+Es
- lying/standing bp
- ECG
102
What is the treatment for malnutrition?
Conservative - increase cal intake, fortisips
Dietitian - assess swallowing, monitor electrolytes, advice on diet, advise feeding method
103
What are the complications of malnutrition?
- Osteoporosis
- Falls + frailty
- refeeding syndrome
- CV - bradycardia, ECG signs, postural hypo
104
What is osteoporosis?
T score of <2.5 on a dexa scan, presents with a decreased fragility fracture due to decreased bone mineral density
105
What are the causes of osteoporosis?
S - steroids
H - hyperthyroidism
A - alcohol
T - thin
T - low testosterone
E - low oestrogen
R - renal/liver failure
E - rheumatoid arthritis
D - drugs (methotrexate, lithium, warfarin)
106
What are the symptoms of osteoporosis?
Pathological fractures
107
How is osteoporosis diagnosed?
Bloods - haem, U+E, bone profile, LFT
1. XR - fracture
2. DEXA scan
108
What does a DEXA scan do?
Compares BMD to healthy 30 yr old of same sex
109
What do different T scores mean (DEXA scan)?
0- -1 - normal
-1 - -2.5 - osteopenia
>-2.5 - osteoporotic
110
How is osteoporosis treated conservatively?
- Increase dietary intake (milk, dairy)
- sunlight exposure
- Ca++ supplement
111
How is osteoporosis treated medically?
1. Bisphosphonates - PO alendronate, IV zolendronate
2. Denosumab
Other - Raloxifene, HRT
112
How would you advise a pt to take PO Alendronate?
Take on empty stomach, first thing in the morning, stay sat up 30 mins after
113
What is urinary retetntion?
Acute (painful >600ml) or chronic (less painful, 1000-1500ml)
114
What are causes of urinary retention?
- BPH
- Prostate Ca
- Anticholinergics
- Faecal impaction
115
How can urinary retention be diagnosed?
- PR exam
- Urodynamic studies
116
How is urinary retention treated?
- Analgesia
- Catheterisation
117
What is the aim of palliative care?
- Trying to maximise a patients quality of life
- Encourage them to get their affairs in order
- Maximise a patients spiritual state
- Family time
118
What is hypothermia?
Core body temp <35 degrees
119
How is hypothermia diagnosed?
- Temp
- ECG - Osbourne J wave
120
What are the symptoms of hypothermia?
- Shivering
- Autonomic symptoms - tachycardia, HTN
121
How is hypothermia treated?
External rewarming
122
What is hyperthermia?
Core body temp >40 degrees
123
What are the symptoms of hyperthermia?
- Confusion
- Hot flushed skin
- Hypotension
124
How is hyperthermia diagnosed?
- Temp
- ECG
- BP
125
How is hyperthermia treated?
- External cooling
- IV fluid
