Geriatrics Flashcards

1
Q

What is delirium?

A

Delirium, also known as an ‘acute confusional state’, is an acute, fluctuating syndrome of disturbed consciousness, attention, cognition, and perception.

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2
Q

Is delirium reversible?

A

Yes, delirium is often reversible and typically secondary to an underlying medical condition, substance intoxication or withdrawal, or medication side effects.

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3
Q

Who is most affected by delirium?

A

Delirium is a common and serious condition, especially in hospitalised and elderly patients.

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4
Q

What are the two types of presenations for delirium? Which one is more common?

Consider cognitive, perceptual, emotion/psychomotor changes and sleep

A

Hyperactive delirium: Agitation, restlessness, mood lability, wandering, hypervigilance, aggressive

Hypoactive delirium (most common but often missed): Lethargy, reduced motor activity, person may seem withdrawn, lack of interest, excessively sleepy, lack of focus. Worse outcomes with returning to normal cognitive levels.

Clinical Features of delirium
* Acute onset and fluctuating course: Symptoms can vary over the course of a day, often worsening at night.
* Disturbance in attention and awareness: Difficulty focusing, sustaining, or shifting attention.
* Cognitive impairment: Disorientation, memory deficits, language disturbances, impaired concentration and slow responses.
* Perceptual disturbances: Hallucinations (auditory or visual), illusions, paranoid delusions, misperceptions
* Altered sleep-wake cycle: Fragmented sleep, daytime drowsiness.
Emotional disturbances and psychomotor features: Anxiety, fear, irritability, apathy. Agitation or reduced motor activity.

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5
Q

What are the consequences of delirium?

A

Delirium is associated with increased morbidity, mortality, and length of hospital stay.

Increases risks of dementia, delirium and causes functional decline.

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6
Q

What are some common causes of delirium? Which mnemonic is used?

A

The causes of delirium are multifactorial and include infection, medications, recent surgery, metabolic imbalances, hypoxia, substance abuse, neurological disorders, discomfort, environmental factors, and chronic illnesses.

PINCH ME: Pain, Infection, Nutrition, Constipation, Medication, Environment

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7
Q

What infections can cause delirium?

A

Any Infection, especially urinary tract infections (UTIs) and pneumonia.

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8
Q

What medications can contribute to delirium?

A

Medications such as strong analgesics, anti-cholinergics, steroids, Parkinson’s medication, and those causing adverse effects or polypharmacy can contribute to delirium.

Including alcohol

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9
Q

What metabolic imbalances can lead to delirium?

A

Metabolic imbalances such as dehydration, electrolyte disturbances - commonly sodium fluctuations, hypercalcaemia, hypoglycaemia, and deranged LFTs, TFTs.

Hepatic encephalopathy, hyper/hypothyroidism

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10
Q

What role does hypoxia play in delirium?

A

Hypoxia due to respiratory or cardiac failure can contribute to the development of delirium.

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11
Q

What neurological disorders are associated with delirium?

A

Neurological disorders such as stroke, seizures, head injury, and intracranial bleeds are associated with delirium.

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12
Q

What discomfort factors can lead to delirium? Consider things related to constipation

A

Constipation, urinary retention.

Discomfort from skin wounds/ulcers/blisters, catheters, and soiled nappies can lead to delirium.

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13
Q

What environmental factors can contribute to delirium?

A

Environmental factors such as sleep deprivation, sensory deprivation or overload, and unfamiliar surroundings can contribute to delirium.

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14
Q

What chronic illnesses are linked to delirium?

A

Chronic illnesses, particularly advanced organ failure (renal, hepatic), are linked to delirium.

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15
Q

What may cause pain in delirium?

A
  • Chronic illnesses/ underlying disease – e.g. abdominal pain
    • Orthopaedic fractures eg. Hip
    • Neurologic conditions
      ○ Head injury
      ○ Mass, stroke, epilepsy, dementia
  • Surgery
  • Devices: catheters, cannulas
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16
Q

What are some risk factors for developing delirium? List at least 5 (unmodifiable, acquired, iatrogenic)

A

Several risk factors increase the likelihood of developing delirium:
* Age: Older adults, particularly those over 65 years.
* Pre-existing cognitive impairment: Dementia, mild cognitive impairment.
* Comorbidity/frailty
* Prexisting psychiatric illness e.g. depression
* Polypharmacy: particularly psychoactive drugs, alcohol
* Sensory impairments: Vision or hearing loss.
* Dehydration and malnutrition
* Previous delirium
* Environmental factors: Changes in environment, poor lighting, lack of familiar objects.
* Surgery and medical procedures e.g. catheterisation
Major injuries e.g. hip fracture

17
Q

What are some preventative measure for patients who are at higher risks of delirium?

Include screening/monitoring, and interventional methods

A
  • Early detection and monitoring of precipitators e.g. looking for and treating infections, bowel and bladder monitoring, avoiding constipation, manage nutrition and fluid intake, sleep hygiene.
  • Address cognitive impairment/disorientation with supportive care e.g. appropriate lighting, use of clocks, address sensory impairment
  • Assess for pain and medication review. Avoidance of polypharmacy.
18
Q

How is it typically diagnosed?

A

4AT score: Alertness (Alertness, confusion, response to stimuli, movement), Attention (recite the months in a backward order), AMT-4 (cognition), acute/fluctuation

If the 4AT indicates delirium then can be diagnosed by someone with the relevant expertise after making a final diagnosis

19
Q

What are some bedside tests to investigate for underlying causes of delirium?

A
  • Glucose (e.g. hypoglycaemia/hyperglycaemia)
  • ECG/ABG: cardiac abnormalities, hypoxia, metabolic disturbances
  • Urinalysis/urine culture:
    ○ A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium.
    ○ Look for other evidence supporting the diagnosis (WCC↑/supra-pubic tenderness/dysuria/offensive urine/positive urine culture).
20
Q

What blood tests may be requested to investigate causes of delirium? List 7.

A
  • FBC (e.g. infection, anaemia, malignancy)
  • Inflammatory markers
  • U&Es (e.g. hyponatraemia, hypernatraemia)
  • Calcium (e.g. hypercalcaemia)
  • LFTs (e.g. liver failure with secondary encephalopathy)
  • Coagulation/INR (e.g. intracranial bleeding)
  • TFTs (e.g. hypothyroidism)
  • Blood cultures (e.g. sepsis)
  • folate/B12
21
Q

What are considerations for ordering CT scans or chest X-rays?

A

Changing environments may increase risk of disorientation and worsen/trigger delirium.

22
Q

What are supportive measures to manage delirium?

A

○ Ensure adequate hydration and nutrition. Encourage mobility, hydration, nutrition (dentures clean)
○ Maintain a regular sleep-wake cycle.
○ Reorient the patient frequently using clocks, calendars, and familiar objects.
○ Minimise sensory impairments with appropriate use of glasses and hearing aids.
Ensure a calm, well-lit environment, reducing noise and avoiding unnecessary room changes

SIGN guidelines: checklist of communicating with patient relatives

23
Q

If delirium is persistent, what medications could be tried?

A
  • Haloperidol 0.5mg in elderly, 2.5-10mg(start low dose to avoid extra-pyrimidal/dystonic reactions)
  • Lorazepam
  • Risperidone
24
Q

What is osteoporosis?

A

Osteoporosis is a systemic skeletal disorder characterized by low bone mass (osteopenia) and microarchitectural deterioration of bone tissue, leading to increased bone fragility (susceptibility to fractures, particularly in the hip, spine, and wrist.)

Normal bone consists of a matrix of collagen fibers and hydroxyapatite, maintained by a balance between osteoblasts (bone-forming cells) and osteoclasts (bone-resorbing cells).

25
Q

What are some causes of secondary osteoporosis? What are some specific lifestyle factors?

PMH, DH, SH

A
  • Chronic GI diseases (lack of calcium/vit D) (e.g., rheumatoid arthritis - chronic inflammation, IBD - reduced absorption, liver/renal disease, hyperthyroidism - increasing rate of bone metabolism, hyperparathyroidism),
  • Bone lesions : Multiple myeloma, metastatic bone cancer
  • medications (e.g., glucocorticoids, anticonvulsants),
  • lifestyle factors (e.g. sedentary, alcohol abuse, smoking)

Primary osteoporosis results from aging (leading to loss of bone mass) and the reduction in estrogen levels, especially post-menopause in women.

26
Q

What is the pathophysiology of osteoporosis?

A

An imbalance between bone resorption and bone formation.

Increased osteoclast activity and/or decreased osteoblast activity lead to a loss of bone density and strength.

27
Q

How can osteoporosis negatively affect a person’s quality of life?

A

Fractures –> chronic pain, height loss, spinal deformities – leading to disability, and loss of independence

28
Q

What are the key investigations and diagnostic tools for osteoporosis? Which blood tests are ordered to rule out secondary causes — which should be normal?

A
  • Dual-energy X-ray Absorptiometry (DEXA) Scan for measuring Bone Mineral Density (BMD),
  • blood tests to rule out secondary causes e.g. (calcium, vitamin D, thyroid function tests, renal function, and testosterone in men. In primary osteoporosis due to aging, these are typically normal.),
  • vertebral imaging (X-rays, MRI, CT scans)
29
Q

Which tool is used to assess the 10-year probability of osteoporotic fractures?

A

FRAX Tool

https://frax.shef.ac.uk/FRAX/tool.aspx?country=9
Measures a sum comprised of risk factors.

30
Q

What are some non-pharmacological management strategies for osteoporosis?

A

Lifestyle modifications (regular weight-bearing and muscle-strengthening exercises, smoking cessation, moderation of alcohol intake, fall prevention strategies) and dietary changes (adequate intake of calcium and vitamin D).

31
Q

What are the most common sites of osteoporotic fragility fractures?

A

Spine/vertebrae, wrist, hip, and other long bones, after low-energy trauma.

It is estimated that around one in three women and one in five men aged 50 and over will suffer from an osteoporotic fracture.

32
Q

T-score to establish osteoporosis diagnosis

A

-2.5 or below

Levels:
* Normal Bone Density: -1.0 or above
* Osteopenia (Low Bone Mass): Between -1.0 and -2.5
* Osteoporosis: -2.5 or below
* Severe (Established) Osteoporosis: -2.5 or below with one or more fragility fractures

33
Q

What are some pharmacological treatments for osteoporosis? Which two options are specific to women?

A
  • Bisphosphonates(e.g., alendronate, risedronate), calcium and vitamin D supplements,
  • Injections e.g. denosumab if bisphosphonates unsuitable,

For women:
- selective estrogen receptor modulators (SERMs) e.g. raloxifene which mimics oestrogen action on bone,
- hormone replacement therapy (HRT).

They work by inhibiting osteoclast-mediated bone resorption, which helps to maintain or increase bone density.

Common bisphosphonates include alendronate, risedronate, and ibandronate.

34
Q

How does osteomalacia differ from osteoporosis?

A

Osteomalacia: softening of bones, often due to vitamin D deficiency, presenting with diffuse bone pain and muscle weakness.

Laboratory findings include elevated serum alkaline phosphatase, low serum calcium, and low serum phosphate.

35
Q

How are bisphosphonates usually taken? Why?

A

Patients should take it with a full glass of water, remain upright for at least 30 minutes, and avoid eating or drinking anything else during this time to enhance absorption and reduce the risk of gastrointestinal side effects.

36
Q

What is denosumab?

A

A monoclonal antibody that targets RANKL, a protein involved in the formation and function of osteoclasts.

It is used in patients who cannot tolerate bisphosphonates. Denosumab is administered as a subcutaneous injection every six months.

37
Q

What are some common side effects of bisphosphonates?

A

GI issues (e.g., esophagitis, gastric ulcers), musculoskeletal pain, and, rarely, osteonecrosis of the jaw and atypical femoral fractures.

Osteonecrosis of the jaw (ONJ) is a rare but serious condition where the jawbone starts to die due to reduced blood flow.