Geriatrics Flashcards
What are the 10 variables in the Modified Barthel index?
- Presence or absence of faecal incontinence
- Presence or absence of urinary incontinence
- Assistance required with:
- grooming
- toilet use
- feeding
- transfers
- walking
- dressing
- climbing stairs
- bathing
Scored out of 100
List two mobility screening tests.
- Timed up and go
2. The walk test
Describe the timed up and go test/
Time taken to stand up from chair, walk 3 metres and return to chair. Less than 10 seconds is normal
What is the functional independence measure?
Instrument used to assess personal activities of daily living - more complex than the Barthel Index. Includes 13 physical function items and 5 cognitive items.
What are the 5 criteria used to define frailty?
- Slow walking speed (more than 7 seconds every 5 metres)
- Poor endurance/feelings of exhaustion
- Low physical activity
- Unintentional weight loss (5% weight loss or more than 4 kg in last year)
- Weakness as measured by grip strength
What are the two types of delirium?
Hypoactive - more common in older people, sudden withdrawal of interaction
Hyperactive - manifested as severe confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity
List some precipitating risk factors for delirium
'HEADS' Hypoxia Electrolyte disturbances Alcohol Drugs e.g. anticholintergics, analgesics, antihypetensives, anticonvulsants, sedatives Sepsis and stool impaction
And lots of other things
What are the 1st line investigations for delirium? (6)
- Blood - UEC, glucose, LFTs, FVE, CMP, CRP
- MSU
- CXR - if clinically indicated
- Blood cultures - if clinically indicated
- Oxygen saturations
- drug levels - dig, lithium, anticonvulsants
What is the median duration of delirium?
7 days
What is the pharmacological management of delirium? (3)
- Haloperidol - 0.25mg-0.5mg 4/24 prn
OR - Atypical antipsychotics - risperidone, olanzapine (but be warned olanzapine can increase delirium)
- BZDS - only in alcohol withdrawal, as can increase risk of delirium
How can delirium be managed non-pharmacologically?
- Support person
- Single room with appropriate lighting and familiar objects
- Quiet environment with clock and calendar
What is the definition of polypharmacy?
The concurrent use of multiple medications (more than 5) and/or using more drugs than is clinically appropriate leading to undesirable outcomes
List 5 limitations of compliance aids
- Can only store up to 4 dose times per day
- Can only store solid oral meds
- Not suitable for PRN meds
- Individual medications are not easily identified within the pack - affects ability to match meds to special instructions e.g. with food, swallow whole
- Only suitable for patients oriented to time and place and with appropriate manual dexterity
List 10 intrinsic risk factors for falls/recurrent falls.
- Previous fall
- Polypharmacy i.e. more than 4 drugs
- Alcohol more than 1 unit/day
- Poor mobility/gait
- Psychotropic drug use
- Orthostatic hypotension
- Balance disorders
- Visual impairment
- Hearing impairment
- Cognitive impairment
Define urge incontinence
Involuntary loss of urine associated with, or immediately preceded by, a strong urge to void
Define functional or behavioural incontinence
Occurs in otherwise continent people who can’t get to the toilet in time - impaired mobility/dexterity, drugs that can affect balance, cognition and mental alertness
Define overflow incontinence
Involuntary loss of urine associated with an overdistended bladder. High post-voiding volume due to outlet obstruction or poor detrusor contractility causing overflow as a result of increased intravesical pressure
Define stress incontinence
Involuntary leakage on effort, exertion, sneezing or coughing
List two drugs that cause urge incontinence
Anticholinesterases e.g. donepezil - enhances detrusor activity (instability), urgency
Diuretics - polyuria, constipation, frequency
List two drugs that cause functional or behavioural incontinence
BZDs - sedation, impaired mobility
Opioids e.g. codeine, morphine
List two drugs that cause overflow incontinence
TCAs - sedation, anticholinergic effect, impaired mobility
Anticholinergics e.g. oxybutynin, tolterodine - reduce detrusor activity, voiding difficulty
List a class of drugs that can cause stress incontinence
Selective alpha blockers e.g. prazosin, tamsulosin - sphincter relaxation, block receptors in bladder neck and urethra - may help decrease outflow obstruction in males, may worse on precipitate incontinence in females
What immunisations are recommended for older people?
Influenza - recommended for all over age 65, all health care workers in contact with older people
Pneumococcal - Recommended for all unvaccinated people over age 65, single revaccination after 5 years
Non-pharmacological pain management (3)
- Hot or cold packs, massage and physical therapy for musculoskeletal pain
- Meditation, music therapy and CBT
- Psychotherapy, support groups and counselling - to deal with mood and psychological issues affection pain perception
What change in MMSE score would be suggestive of delirium? Resolution?
Decrease in 2 points - delirium
RIse in 3 or more - resolution
What change in AMTS score would be suggestive of delirium?
Change of two point
What are the memory impairments in Alzheimer disease? (initial vs late)
Memory for recent events and facts (difficulty learning new information) - initial
Procedural and long term memory + immediate memory - later in disease
What language dysfunction is present in early Alzheimer disease? (4)
- Word-finding difficulties
- Circomlocution
- Reduced vocabulary in spontaneous speech
- Anomia on confrontational naming tests
What is the reported mean survival after diagnosis with Alzheimer’s?
3- 8 years
What factors are associated with slower vs more rapid decline in Alzheimer’s?
Slower rate: older age of onset (more than 80 years)
Rapid rate: early neuropsychiatric symptoms
What are the hallmark neuropathologic changes associated with AD?
Diffuse plaques - b-amyloid deposition
Neurofibrillary tangles - p-tau protein
What are the two clinical patterns of vascular dementia?
Cortical and subcortical syndrome
What clinical features are present in cortical vascular dementia?
Cognitive features specific to the areas affected
medial frontal: executive dysfunction/apathy
Left parietal: aphasia, apraxia or agnosia
right parietal: hemineglect, confusion, visuospatial and constructional difficulty
medial temporal: anterograde amnesia
What clinical features are present in subcortical vascular dementia?
- Cognitive disorde characterised by relatively mild memory deficit, psychomotor retardation and abnormal executive function
- Focal motor signs
- Early presence of gait disturbance (not present in AD until much later)
What are the core features of Lewy body dementia? (3)
- Fluctuating cognition with pronounced variations in attention, alertness
- Recurrent visual hallucinations
- Spontaneous motor features of parkinsonism
MEMORY AFFECTED MUCH LATER
What are the clinical features of dementia?
Multiple cognitive deficits, including memory impairment and at least one of: aphasia apraxia agnosia disturbed executive functioning
Define apraxia
Inability to carry out purposeful movements even though there is no sensory or motor impairment
What does a diagnosis of delirium by CAM require?
Used for detection of delirium. looks at:
- Acute onset and fluctuating course
- inattention
- disorganised thinking
- altered level of consciousness
Presence of features 1 and 2 and either 3 or 4
What proportion of people with delirium will have persisting cognitive impairment on discharge from hospital?
A proportion may never completely recover
Are cholinesterase inhibitors disease-modifying in dementia?
e.g. donepezil, rivastigmine, galantamine
May improve memory in mild disease, but improvement tends to be modest lsting for 6-12 months before declining to pre-med levels. Not all patients respond to cholinesterase inhibitors
