geriatrics Flashcards
(69 cards)
1
Q
Is urinary incontinence more common in males or females
A
3X more common in females
2
Q
Name the types of urinary incontinence
A
- stress
- urge
- overflow
- neuropathic
3
Q
Extrinsic factors causing urinary incontinence
A
- immobility
- confusion
- drugs (e.g. furosemide)
- drinking too much or at the wrong time
- co-morbidities (diabetes, hypertension…)
- home circumstances (distance from bathroom…)
- social circumstances (may need assistance to bathroom)
- being sedated
4
Q
risk factors for stress incontinence
A
increasing age
obesity
pregnancy (and post pregnancy)
commonly associated with weak pelvic floor muscles
5
Q
presentation of stress urinary incontinence
A
leakage of urine (small but frequent) on coughing, sneezing, laughing, exercising…
6
Q
treatment for stress incontinence
A
1) physio for pelvic floor muscles
2) cone therapy
3) oestrogen cream
4) duloxetine
5) (surgical treatment)
7
Q
presentation of overflow incontinence
A
poor urine flow
double voiding
post micturition bleeding
8
Q
risk factors for getting overflow incontinence
A
benign prostatic enlargement (can also cause urge) causes blockage of the urethra
9
Q
treatment of overflow incontinence with urinary retention
A
an alpha blocker (tamsulosin) which relaxes sphincter
anti-androgen (finasteride) shrinks prostate
TURP
Suprapubic catheterisation
10
Q
presentation of urge incontinence
A
the sudden urge to pass urine immediately followed by uncontrollable and sometimes complete bladder emptying
11
Q
precipitants for urge incontinence
A
arriving home - a conditioned reflex cold the sound of running water coffee, tea or cola obesity
12
Q
cause of urge incontinence
A
detrusor overactivity
- e.g. from central inhibitory pathway malfunction or sensitisation of peripheral afferent terminals in the bladder; or a bladder muscle problem
- organic brain damage - stroke, parkinsons, dementia
- urinary infection
- diabetes
- diuretics
- urethritis
13
Q
treatment of urge incontinence
A
- anti-muscarinics - oxybutinin, tolterodine, solifenacin
14
Q
causes of neuropathic incontinence
A
- secondary to neurological disease such as stoke/MS
- secondary to PROLONGED CATHETERISATION
15
Q
which form of urinary incontinence is caused by prolonged catheterisation
A
neuropathic catheterisation
16
Q
prostatectomy would be most likely to cause which kind of incontinence
A
stress incontinence
17
Q
causes of overflow incontinence in women
A
ovarian tumour
18
Q
which urethral sphincter is smooth muscle and which is striated
A
internal urethral sphincter is smooth muscle
external urethral sphincter is striated
19
Q
describe the physiology of voluntary voiding
A
involves voluntary relaxation of the external sphincter (striated) and involuntary relaxation of internal sphincter and contraction of the bladder (detrusor)
20
Q
role of the parasympathetic nervous system in micturition
A
S2-S4 increase the strength and frequency of contractions of detrusor muscle
21
Q
What percentage of falls result in a hip fracture
A
1%
22
Q
What factors relate to postural stability
A
Cardiac output
Vaso-motor tone
Posture and balance
23
Q
Definition of syncope
A
Transient self limited loss of consciousness, usually leading to falling (loss of postural tone)
24
Q
Underlying mechanism of syncope
A
Transient global cerebral hypo-perfusion
25
Premonitory symptoms of syncope
Visual blurring, nausea, vomiting, sweating, tinnitus
26
Causes for syncope
A. Neurally mediated reflex - Vasovagal syncope, situational syncope (acute haemorrhage, GI stimulation...)
B. Orthostatic hypotension - post exercise, diabetic neuropathy, drug and alcohol induced, volume depletion - haemorrhage, diarrhoea, addisons
C. Cardiac arrhythmia - sinus node dysfunction (bradycardia), long QT syndrome, implanted device malfunction
D. Cardiac or cardiopulmonary disease - valvular, pulmonary embolus, acute aortic dissection
E. Cerebrovascular
27
How can you differentiate between syncope and epilepsy
Often no trigger for epilepsy
Experience an aura with epilepsy (change in senses commonly); may feel visual blurring, nausea, tinnitus in syncope
Seizures happen as fast tonic gall, cyanosis, frothing, rigitity, tonic clonic jerking; syncope is slow fall, pallor, bradycardia, limpness
Drowsiness and confusion following epilepsy while rapid recovery with syncope
28
How vision may cause falls
Poor lighting
Cataract
Refractory errors
Hemianopia
29
Which system controls balance
Vestibular system
30
Causes of vertigo
```
Labrynthitis
Acute ear infection
Benign positional vertigo
Menieres disease
Brainstem lesion
```
31
How would you test for positional vertigo
Dix-Hallpike manouver
| - nystagmus is positive sign
32
Which drugs contribute to fall risk
Analgesics - especially morphine
Psychoactive drugs - anti-depressants, long acting benzodiazepines
Anti-hypertensives (especially vasodilators)
Diuretics (especially when dehydrated)
Aminoglycosides - contribute to vestibular toxicity
Phenothiazines - induce extrapyramidal syndromes
33
Investigations for syncope
Visual assessment
Gait and balance assessment
Neuro-cardiovasular tests: orthostatic BP, carotid sinus sensitivity (hypersensitivity is diagnosed when carotid sinus massage causes a 3 second+ pause in heart beat), tilt table testing
34
How many hip fractures are performed per year in the UK
100,000
35
Risk factors for hip fracture
```
Bone mass/ low bone mass density
Falls/postural integrity
Falls dynamics/orientation
Sedentary lifestyle
Advanced age
High BMI
Previous fractures
Drugs: benzodiazepines, anti-convulsants, steroids, caffeine
```
36
Interventions to increase bone mass
General - diet, exercise, stop smoking, reduce alcohol
| Pharmacological - calcium and vitamin D supplements, bisphosponates, teriparatide (PTH), HRT, strontium, denosumab
37
Define immobility
Any disease or disability that requires complete bed rest or extremely limits your activity
38
Causes of immobility
Pain/stiffness - bones, joints (arthritis), muscles (myalgia, parkinsonism), PVD
Weakness - neurological (stroke), myopathy, hypothyroidism
Dyspnoea - cardiac, pulmonary
Psychological - fear, anxiety, depression, dementia
Frequent falls/fear of falling
Iatrogenic - sedation, surgery (amputation)
Foot care - bunions, nail neglect
Inadequate aids/improper use
Chronic disease
39
Physical complications of immobility
```
Muscle wasting
Muscle contractures
Pressure sores
DVT
Constipation/incontinence
Hypothermia
Osteoporosis
```
40
Psychological complications of immobility
Depression
| Loss of consciousness
41
Social complications of immobility
Isolation
| Institutionalization
42
Define confusion
Behaviour or speech that is inappropriate to the situation - symptom not a diagnosis
43
Most common causes of cognitive impairment
Delirium
| Dementia
44
How would you measure cognitive functioning impairment
Memory - AMT (10 questions); MSQ; MMSE (mini mental state exam)
Executive function; clock drawing and functional assessment
45
Clinical features of delirium
Altered level of consciousness
Cognitive deficit or perceptual disturbance
Acute onset and functional course
Evidence of cause
(Altered sleep-wake cycle, emotional liability)
46
Delirium predisposing factors
```
Old age
Frailty
Dementia
Past history of delirium
Visual/hearing impairment
Malnutrition
Polypharmacy
Co-morbidity (renal/hepatic impairment)
```
47
Precipitating factors for delirium
```
Infection
Dehydration
Constipation
Pain
Immobility
Medication use/withdrawal
Sleep deprivation
Catheterisation
```
48
Pharmacological management of delirium
Stop culprit medications
Small doses of dopamine antagonists (e.g. Haloperidol)
- sedation and antipsychotics are second line measures
49
Which drugs can cause delirium
```
Oxybutinin/tolterodine (for urinary incontinence)
Amitryptiline
Prochlorperazine
Hyoscine
Codeine/tramadol
Antihistamines e.g. Chlorphanamine
```
50
Common kinds of dementia
Alzheimers disease
Vascular dementia
Lewy body dementia
51
Presentation of alzheimer's disease
Slow, insidious onset
Loss of recent memory first
Progressive functional decline
52
Presentation of vascular dementia
Classically step-wise deterioration
53
Presentation of lewy body dementia
Link with parkinson's disease
Lewy bodies affect cortical neurones rather than basal ganglia
Fluctuating decline
Predominant visual hallucinations
54
Which forms of dementia respond to cholinesterase inhibitors
The big 3!
Alzheimers
Vascular
Lewy body
--> drug boost Ach response
55
What pathologies can present as dementia
```
Structural brain lesion - e.g. frontal mengioma
Normal pressure hydrocephalus
B12 deficiency
Chronic inflammatory disease
Pseudodementia
```
56
Presentation of normal pressure hydrocephalus
TRIAD of
- gait disturbance
- incontinence
- cognitive impairment
57
What is pseudodementia
Classically depression presenting with apathy, poor concentration and functional decline
58
Common iatrogenic drug problems caused by anticholinergics
```
Confusion/disorientation/hallucinations
Dry mouth
Constipation
Blurred vision
Urinary retention and constipation (reduced peristalsis)
Orthostatic hypotension
```
--> antimuscarinic effects
59
Common iatrogenic drug problems caused by tricyclics
Confusion and unsteady gait
60
Which drugs are deemed the worst in causing adverse drug reactions
```
NSAIDS
Diuretics
Warfarin
ACEi
Antidepressants
Beta blockers
Opiates
Digoxin
Prednisolone
Clopidogrel
```
61
How would hyperthyroidism present in an elderly person compared to a young person
Young person - tremor, anxiety, weight loss, diarrhoea
Elderly more common to be depressed, cognitively impaired, muscle weakness, heart failure, angina, atrial fibrillation
62
How do body composition changes in an elderly person affect drug distribution
reduced muscle mass and increased adipose tissue means fat soluble drugs such as diazepam have a longer duration of action as the adipose acts as a resevoir for the drugs
Reduced total body water means that water soluble drugs are at higher concentration in the serum (such as digoxin, atenolol, theophylline)
Protein binding changes
63
How does protein binding change in an elderly person and why does this affect drug distribution
Decreased albumin so less binding of the drug - free drug concentrations determine the pharmacological effect as bound drugs cannot bind to target tissues. Acidic drugs are bound to serum albumin and there will be greater unbound concentrations (cimetidine, furosemide, NSAIDs, diazepam)
64
How does total serum albumin in the elderly compare with the young
Albumin decreases with age
Furthermore, some diseases common in the elderly depress albumin - heart failure, renal disease, rheumatoid arthritis, hepatic cirrhosis and some malignancies. Also malnutrition or acute illness
65
What is the consequence of decreased liver mass and decreased liver blood flow in the elderly
Toxicity due to increased metabolism/excretion
Reduced first pass metabolism
--> increased bioavailability with some drugs
--> decreased bioavailablity of pro-drugs
66
How does excretion differ in the elderly
Renal function deteriorates with age
| --> reduces clearance and increases half-life of many drugs leading to toxicity
67
Principles of prescribing in older people
- Lower doses or reduced frequency of doses
- be sure to be treating condition to avoid prescribing to manage an adverse effect
- start at lowest dose ad titrate up slowly (start low, go slow)
- review regularly
- consider compliance issues
- bear in mind clinical trials are often performed in a younger population hence benefits may not translate
68
What must you consider when prescribing warfarin to an older patient
They are more sensitive to warfarin and at greater risk of adverse effects - GI bleeding, falls
69
What must you consider when prescribing anti-hypertensives in the elderly
May have exaggerated effects on BP and HR
More likely to be issues with postural hypotension
ACE-inhibitors often prodrugs which may not be metabolised to active form
Renal adverse effects
