Geriatrics Flashcards
Define a fall
Unintentional loss of balance resulting in coming to rest on the floor or an object below knee level
Not as a consequence of force, sudden onset paralysis, seizure or XS alcohol
What is the biggest risk factor for falls?
Previous fall
What assessments help in falls risk assessment?
Timed up and go test
Turn 180 test
What are the causes of transient loss of consciousness?
Syncope
Epilepsy
What are the potential causes of unconsciousness?
Trauma
Metabolic
Infection
Neuro
What are the potential causes of apparent unconsciousness?
Dizziness
Vestibular
Mechanical
Pseudo
What extrinsic factors may contribute to falls risk?
Drugs Footwear Obstacles Inappropriate walking aids Gravity Lighting conditions Furniture
What intrinsic factors contribute to falls risk?
BP HR Neurology Muscle strength Joint integrity Vision Vestibular dysfunction Reflexes
What are the components of a falls clinic appt?
History of falls, syncope, neuro, msk, cardiac, vestibular Focused examination Bone health/osteoporosis review Drug / polypharmacy review Investigations: bloods, ECG, X-rays etc Physio and ot assessment
Define syncope
Transient loss of consciousness Loss of voluntary muscle tone Rapid onset with spontaneous prompt recovery on lying down Full recovery (no focal deficit) Transient global cerebral hypoperfusion
What are the causes of syncope?
- Neurally-mediated reflex: situational / vasovagal faint / carotid sinus syndrome
- Orthostatic hypotension
- Cardiac syncope
What questions should you ask a witness to a ?syncopal episode?
Posture just before Appearance / colour Any abnormal movement Tongue biting or incontinence Duration Post-event confusion
What factors make cardiac syncope the likely diagnosis?
CHESS... Congestive heart failure Haematocrit <30% ECG abnormality Shortness of breath Systolic BP <90 on triage
What investigations would you request for a patient with syncope related to a tachy or bradyarrhythmia?
24h tape or consider inpatient monitoring
How do you investigate suspected orthostatic hypotension?
Postural drop in BP: lying/standing BP
Accompanied by increase in HR
Define orthostatic hypotension
= postural hypotension
Systolic BP fall of more than 20 or diastolic fall more than 10
Within 10 minutes of standing
How do you measure lying/standing BPs?
Measure BP at 0, 3 and 5 minutes
What are the potential underlying causes of orthostatic hypotension?
Hypovolaemia Autonomic failure eg PD or DM Prolonged bed rest Drugs eg anti-hypertensives Alcohol
How do you manage orthostatic hypotension?
Treat underlying cause, recognise precipitating factors
Conservative: education, bed tilt, increase salt
Medical: fludrocortisone
Averting action: recognise pre-syncope and sit/lie down
Describe tilt table testing
Moving from supine to upright causes shift of 300-800ml blood to venous capacitance system within 10 seconds
Reduced venous return and cardiac filling which decreases stroke volume
Compensatory increase in HR not enough
Sympathetic increase in TPR is key
Failure of compensatory mechanism is the cause of vasovagal
What are the contraindications to carotid sinus massage?
Heterogenous plaque disease
Stenosis
How do you manage carotid sinus sensitivity?
Dual chamber pacing if cardio-inhibitory
Vasodepressor: education, reassurance, drugs alteration
Define delirium
Global impairment of cognition and awareness / concentration
What are the signs of delirium?
Disordered thinking Euphoric / depressed (labile mood) Language impaired Illusions, delusions, hallucinations Reversal of sleep-awake cycle Inattention Unaware/disorientated Memory deficits
What are the criteria required for delirium diagnosis?
Disturbance of consciousness
Change in cognition
Disturbance develops over a short period of time
What are the risk factors for delirium?
Older age Multiple comorbidities Dementia Physical frailty Renal impairment Sensory impairment
What are the common causes of delirium?
DIMES: Drugs Infection Metabolic Environmental Structural
What are the common investigations in a delirium screen?
FBC, U&E, LFT, BM, ABG
Septic screen
ECG
AMT
What tests of cognition are commonly used for delirium?
AMTS: 10 Qs, if score less than 8 then proceed to
CAM: confusion assessment method
How do you manage delirium?
Identify and treat underlying cause Reduce distress Mod.lit, quiet room with same staff Improve orientation: clock, daylight Hearing aids and glasses No physical restraints, catheters, IV lines etc Music, massage, muscle relaxation Minimise medication Haloperidol 0.5mg if required, only as last resort
What are the types of delirium?
Hypo active
Hyperactive
Mixed
What are the features of hypo active delirium?
Lethargy and reduced motor activity
Can be mistaken for depression
What are the features of hyperactive delirium?
Increased motor activity, agitation, hallucinations
More likely to be recognised
What is mixed delirium?
Fluctuations between hypo and hyperactive, often fluctuates during the day
What questions should you ask about in a history of incontinence?
Ability to stop midstream Soreness Prolapse LUTS: frequency, nocturia, urgency Stress Obstructive: hesitancy, stream, dribbling Bowels
What are obstructive urinary symptoms?
Hesitancy
Straining
Terminal dribbling
Complete bladder emptying
Define overflow incontinence
Leakage of urine at greater than normal bladder capacity
What is the underlying mechanism of overflow incontinence?
Either
incomplete bladder emptying
impaired detrusor contractility
bladder outlet obstruction
What are the causes of overflow incontinence?
Prostatic hyper trophy
Faecal impaction
Urinary retention
Atonic bladder
Why do women get incontinence post-menopause?
Oestrogen deficiency leads to... Atrophic urethritis Decreased vascularity Decreased sphincter resistance Weakened skeletal muscle and pelvic floor Sensory urgency
At what ml do you get desire to void?
150-300
What is the normal bladder capacity?
400-600ml
What is the average void?
250-400ml
Describe parasympathetic control of the bladder
Pees Detrusor muscle S2-4 Pelvic splanchnic nerve ACh muscarinic
Describe sympathetic control of the bladder
Stores Bladder neck/upper urethra T10-L2 Hypgastric nerve Alpha receptors noradrenaline
How do you manage stress incontinence?
Pelvic floor exercises
Duloxetine
Surgery
How do you manage detrusor over activity?
Bladder retraining, regular toiletting regime
Anticholinergic drug: tolterodine, oxybutynin
How do you manage overflow incontinence?
Remove the obstruction
Catheterisation: intermittent or permanent
What are the different types of urodynamic studies?
Flow rate
Cystometry
Urethral pressure profile
What are the risk factors for incontinence?
Constipation Childbirth Surgery Obesity Pregnancy Activity level Post menopause Dietary irritants: caffeine, alcohol Meds: diuretics, Anticholinergics, antiDs, alpha blockers
What are the underlying causes of faecal incontinence?
Sphincter weakness Ano-rectal pathology Neurological disease Acute or chronic confusion Diarrhoea Constipation
What are the different categories of laxatives?
Bulking and softening
Stimulant
Faecal softeners
Osmotic
Give an example of a bulking laxative
Ispaghula husk - fybogel
Give an example of a stimulant laxative
Senna
Sodium picosulfate
Give an example of a faecal softener
Arachis oil (enema)
Give an example of an osmotic laxative
Lactulose
Movicol
Phosphate enema
What lifestyle changes help with constipation?
Diet
Fluid
Exercise
Comfort, privacy, relaxation
