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geriatrics Flashcards

1
Q

Is urinary incontinence more common in males or females

A

3X more common in females

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2
Q

Name the types of urinary incontinence

A
  • stress
  • urge
  • overflow
  • neuropathic
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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
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4
Q

risk factors for stress incontinence

A

increasing age
obesity
pregnancy (and post pregnancy)
commonly associated with weak pelvic floor muscles

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5
Q

presentation of stress urinary incontinence

A

leakage of urine (small but frequent) on coughing, sneezing, laughing, exercising…

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6
Q

treatment for stress incontinence

A

1) physio for pelvic floor muscles
2) cone therapy
3) oestrogen cream
4) duloxetine
5) (surgical treatment)

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7
Q

presentation of overflow incontinence

A

poor urine flow
double voiding
post micturition bleeding

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8
Q

risk factors for getting overflow incontinence

A

benign prostatic enlargement (can also cause urge) causes blockage of the urethra

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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

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10
Q

presentation of urge incontinence

A

the sudden urge to pass urine immediately followed by uncontrollable and sometimes complete bladder emptying

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11
Q

precipitants for urge incontinence

A 
arriving home - a conditioned reflex
cold 
the sound of running water 
coffee, tea or cola
obesity
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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
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13
Q

treatment of urge incontinence

A
  • anti-muscarinics - oxybutinin, tolterodine, solifenacin
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14
Q

causes of neuropathic incontinence

A
  • secondary to neurological disease such as stoke/MS

- secondary to PROLONGED CATHETERISATION

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15
Q

which form of urinary incontinence is caused by prolonged catheterisation

A

neuropathic catheterisation

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16
Q

prostatectomy would be most likely to cause which kind of incontinence

A

stress incontinence

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17
Q

causes of overflow incontinence in women

A

ovarian tumour

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18
Q

which urethral sphincter is smooth muscle and which is striated

A

internal urethral sphincter is smooth muscle

external urethral sphincter is striated

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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)

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20
Q

role of the parasympathetic nervous system in micturition

A

S2-S4 increase the strength and frequency of contractions of detrusor muscle

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21
Q

What percentage of falls result in a hip fracture

A

1%

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22
Q

What factors relate to postural stability

A

Cardiac output
Vaso-motor tone
Posture and balance

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23
Q

Definition of syncope

A

Transient self limited loss of consciousness, usually leading to falling (loss of postural tone)

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24
Q

Underlying mechanism of syncope

A

Transient global cerebral hypo-perfusion

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25
Q

Premonitory symptoms of syncope

A

Visual blurring, nausea, vomiting, sweating, tinnitus

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26
Q

Causes for syncope

A

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

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27
Q

How can you differentiate between syncope and epilepsy

A

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

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28
Q

How vision may cause falls

A

Poor lighting
Cataract
Refractory errors
Hemianopia

29
Q

Which system controls balance

A

Vestibular system

30
Q

Causes of vertigo

A 
Labrynthitis
Acute ear infection 
Benign positional vertigo 
Menieres disease
Brainstem lesion
31
Q

How would you test for positional vertigo

A

Dix-Hallpike manouver

- nystagmus is positive sign

32
Q

Which drugs contribute to fall risk

A

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
Q

Investigations for syncope

A

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
Q

How many hip fractures are performed per year in the UK

A

100,000

35
Q

Risk factors for hip fracture

A 
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
Q

Interventions to increase bone mass

A

General - diet, exercise, stop smoking, reduce alcohol

Pharmacological - calcium and vitamin D supplements, bisphosponates, teriparatide (PTH), HRT, strontium, denosumab

37
Q

Define immobility

A

Any disease or disability that requires complete bed rest or extremely limits your activity

38
Q

Causes of immobility

A

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
Q

Physical complications of immobility

A 
Muscle wasting
Muscle contractures 
Pressure sores 
DVT
Constipation/incontinence 
Hypothermia 
Osteoporosis
40
Q

Psychological complications of immobility

A

Depression

Loss of consciousness

41
Q

Social complications of immobility

A

Isolation

Institutionalization

42
Q

Define confusion

A

Behaviour or speech that is inappropriate to the situation - symptom not a diagnosis

43
Q

Most common causes of cognitive impairment

A

Delirium

Dementia

44
Q

How would you measure cognitive functioning impairment

A

Memory - AMT (10 questions); MSQ; MMSE (mini mental state exam)
Executive function; clock drawing and functional assessment

45
Q

Clinical features of delirium

A

Altered level of consciousness
Cognitive deficit or perceptual disturbance
Acute onset and functional course
Evidence of cause
(Altered sleep-wake cycle, emotional liability)

46
Q

Delirium predisposing factors

A 
Old age 
Frailty 
Dementia 
Past history of delirium 
Visual/hearing impairment 
Malnutrition 
Polypharmacy 
Co-morbidity (renal/hepatic impairment)
47
Q

Precipitating factors for delirium

A 
Infection 
Dehydration 
Constipation
Pain 
Immobility 
Medication use/withdrawal 
Sleep deprivation 
Catheterisation
48
Q

Pharmacological management of delirium

A

Stop culprit medications

Small doses of dopamine antagonists (e.g. Haloperidol)
- sedation and antipsychotics are second line measures

49
Q

Which drugs can cause delirium

A 
Oxybutinin/tolterodine (for urinary incontinence)
Amitryptiline 
Prochlorperazine 
Hyoscine 
Codeine/tramadol 
Antihistamines e.g. Chlorphanamine
50
Q

Common kinds of dementia

A

Alzheimers disease
Vascular dementia
Lewy body dementia

51
Q

Presentation of alzheimer’s disease

A

Slow, insidious onset
Loss of recent memory first
Progressive functional decline

52
Q

Presentation of vascular dementia

A

Classically step-wise deterioration

53
Q

Presentation of lewy body dementia

A

Link with parkinson’s disease
Lewy bodies affect cortical neurones rather than basal ganglia
Fluctuating decline
Predominant visual hallucinations

54
Q

Which forms of dementia respond to cholinesterase inhibitors

A

The big 3!
Alzheimers
Vascular
Lewy body

–> drug boost Ach response

55
Q

What pathologies can present as dementia

A 
Structural brain lesion - e.g. frontal mengioma
Normal pressure hydrocephalus 
B12 deficiency
Chronic inflammatory disease
Pseudodementia
56
Q

Presentation of normal pressure hydrocephalus

A

TRIAD of

  • gait disturbance
  • incontinence
  • cognitive impairment
57
Q

What is pseudodementia

A

Classically depression presenting with apathy, poor concentration and functional decline

58
Q

Common iatrogenic drug problems caused by anticholinergics

A 
Confusion/disorientation/hallucinations
Dry mouth 
Constipation 
Blurred vision 
Urinary retention and constipation (reduced peristalsis)
Orthostatic hypotension

–> antimuscarinic effects

59
Q

Common iatrogenic drug problems caused by tricyclics

A

Confusion and unsteady gait

60
Q

Which drugs are deemed the worst in causing adverse drug reactions

A 
NSAIDS
Diuretics 
Warfarin 
ACEi
Antidepressants 
Beta blockers
Opiates
Digoxin 
Prednisolone
Clopidogrel
61
Q

How would hyperthyroidism present in an elderly person compared to a young person

A

Young person - tremor, anxiety, weight loss, diarrhoea

Elderly more common to be depressed, cognitively impaired, muscle weakness, heart failure, angina, atrial fibrillation

62
Q

How do body composition changes in an elderly person affect drug distribution

A

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
Q

How does protein binding change in an elderly person and why does this affect drug distribution

A

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
Q

How does total serum albumin in the elderly compare with the young

A

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
Q

What is the consequence of decreased liver mass and decreased liver blood flow in the elderly

A

Toxicity due to increased metabolism/excretion
Reduced first pass metabolism
–> increased bioavailability with some drugs
–> decreased bioavailablity of pro-drugs

66
Q

How does excretion differ in the elderly

A

Renal function deteriorates with age

–> reduces clearance and increases half-life of many drugs leading to toxicity

67
Q

Principles of prescribing in older people

A
  • 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
Q

What must you consider when prescribing warfarin to an older patient

A

They are more sensitive to warfarin and at greater risk of adverse effects - GI bleeding, falls

69
Q

What must you consider when prescribing anti-hypertensives in the elderly

A

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

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