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semester 2 year 2 week 9-16 > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

common geriatric syndrome

A

incontinence, confusion, falls( high order function)

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2
Q

what cause reduced organ reserve( reduce ability to response to physiology stress)

A
  1. aged related changes

2. disease related changes

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3
Q

difference in elderly

A

reduced thermoregulation, cognitive reserve, postural instability, cardiac reserve, resp reserve, glucose intolerance, immune responses

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4
Q

pharmacokinetics changes in elderly

A

hepatic and renal clearance, little change of VD, increased T1/2, slower absorption

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5
Q

drug absorption changes?

A

delayed gastric emptying, slow transit time, increase PH( gastric congestion reduce absorption of diuretics, and PPI affects VB12 absorption)

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6
Q

drug metabolism changes

A

reduce hepatic size and hepatic blood flow

drug hepatic-ally metabolised has long T1/2

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7
Q

drug has longer T1/2 in the elderly due to liver changes?

A

lignocaine, propranolol, warfarin, barbiturates, verapamil, chlormethiazole, quinine

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8
Q

increase bio-availability of drug?

A

nortiptyline, metoprolol, diazepam

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9
Q

more drug and drug interaction in elderly?

A

paracetamol and warfarin

PPi and clopidogrel

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10
Q

drug excretion changes?

A

renal clearance decreased with ageing

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11
Q

renally excreted drug clearance reduced( require small dose), the drug include?

A 
digoxin
cephalexin
morphine
aminoglycosides
pethidine
lithium
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12
Q

what drug renal excretion enhanced in elderly

A

diuretics

trimethoprim, ACEI, spironolactone

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13
Q

what is triple whammy acute renal dysfunction

A

ACEi, NASIDS, and diuretics

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14
Q

how dose decreased albumin affects drug dose

A

higher free drug concentration( more toxicity esp digoxin) but total concentration to be measured is normal

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15
Q

body compartment

A

fat content increase, tissue volume stable, intracellular water drop, albumin drop
( shorter, fatter, drier, less muscly)

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16
Q

larger VD OR longer T1/2 for lipid soluble drug

A

diazepam

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17
Q

water soluble drug increased serum levels

A

digoxin and paracetamol

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18
Q

decreased muscle, shorter, surface area changed

A

chemotherapeutics agent prescription based on surface area

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19
Q

phrarmodynamic change

A

beta receptor down regulated

larger baroreceptor response ( risk of hypotension)

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20
Q

altered cerebral auto regulation( shift in range of MAP regulation)—> increase orthostatic hypotension

A

more resistant to Hypertension but more sensitive to low BP

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21
Q

why elderly have altered volume regulation( less able to maintain volume)

A

reduced renin and aldosterone, salt wasting, increase ANP, loss of thirst sense

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22
Q

systole dysfunction in elderly

A

cardiac muscle becomes stiff, restricted ventricular filing during diastole

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23
Q

ADR of diuretics?

A

dehydration, hyponatremia, falls

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24
Q

ADR of CCBs

A

oedema, falls

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25
Q

ADR of statins

A

muscle pain, rhabdomyolysis, ARF

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26
Q

ADR of amiodorone

A

thyroid, lung, taste alteration

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27
Q

ADR of verapamil

A

constipation

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28
Q

class 1 anti- arrhythmic

A

fall confusion

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29
Q

ADR of NSAIDS

A

oedema, ARF, CCF

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30
Q

ADR of atypical antipsychotics

A

stroke and CVD

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31
Q

high use of what drugs in elderly?

A

Psychotropics, hypnotics, sedatives, laxatives , CVS drug, OTC

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32
Q

effects of poly pharmacy?

A

increased ADR, drug interaction, noncompliance, complicated drug regimen, confusion and unreliable history

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33
Q

high risk drugs in elderly

A

anticholinergic drug( confusion , constipation risk0: anti-psychotropics, anti-depressants, antihypertensive ( increase risk of fall): diuretics, digoxin( narrow therapeutics window), narcotics,CNS acting drugs causing sedation ( antihistamine, Benzo, NSADIS, narcotics, stemetil

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34
Q

medications causing falls

A 
central acting, anti-HTN
benzo, antidepressant, antipsychotics, anti-HTN, anti-arrhythmic class 1( low dose, short time)
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35
Q

paucipharmacy condition

A

pain, HF, IHD, OP, AF

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36
Q

common error ( anti-HTN, sedative, anticholinergics)

A
  • Oral hypoglycaemia: Increase mortality and falls
  • Metformin in renal impairment
  • Cox2 or NSAIDS with known heart or renal failure
  • Develop oedema reduce plasma volume–> risk of hypotension and fall ( use compression stocking)
  • Prescribe narcotic but not think of constipation ( treat pre-emptively)
    -Cox2 or diuretics affect lithium clearance
  • Use anti-cholinergic drug (e.g. also digoxin) in confusion patient
    -Verapamil not in pt with constipation
    -Undetected postural hypotension ( change to do postural bp)
    Failure to adjust dose in real impairment
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37
Q

diagnostic criteria of major neurocognitive disorder (DSM-V)

A
  1. evidence of cognitive decline
  2. infers with independence in DAL
  3. not due to delirium
  4. not explained by another mental disorders
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38
Q

mild cognitive impairment= minor NCD

A
  1. subjective cognitive concern or by relatives
  2. reduce 1-2SD below
  3. precursor for dementia,( better or the same)
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39
Q

Screening tool for dementia?

A

MMSE, MOCA, RUDAS, KICA, ACE

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40
Q

aspects of screening tool?

A

memory, orientation, judgment and problem solving, community affairs, home ad hobbies, personal care

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41
Q

types of dementia?

A
  1. alzheimer’s disease
  2. vascular dementia
  3. Lewy body dementia
  4. frontal temporal dementia
  5. alcohol
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42
Q

how to treat dementia?

A

advance care planing, risk factors modification

  1. cholinesterase inhibitor( Donepezil for AD MMSE>10)
  2. memantine( NMDA receptor, for severe AD mmse10-14)
  3. SSRI/SNRI
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43
Q

what is BPSD( Behavioural and psychological symptoms of dementia) =responsive behaviours

A

symptoms of disturbed perception, though content, mood, and behaviours frequently occurs in pt with dementia

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44
Q

behavioural symptoms in BPSD?

A 
vocally disruptive behaviours
agitation
wandering
aggression 
apathy
hoarding
sexual disinhibition
culturally inappropriate behaviour
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45
Q

psychological symptoms in BPSD

A 
depression 
anxiety
hallucination
delusions
sleep disturbance
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46
Q

consequence of BPSD

A 
cognitive impairment
increased vulnerability stress-or
unmet need( sleep, sleep)
pain
QOL, greater hospitalisation early institutionalisation
caregiver burden
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47
Q

how to rate BPSD

A

Tier 1-7 ( common.y 4-5 in hospitalization)

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48
Q

1st line in mx BPSD

A

Non-pharmocologically strategies

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49
Q

patient factors contribute to BPSD

A

1 pre-morbid personality/ psychiatric illness
2 acute medical problem ( UTI, pneumonia, dehydration, constipation)
3 unmet needs( pain, sleep, fear, boredom, loss of control or purpose)

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50
Q

modifiable proximal factors in needs-driven dementia compromised behaviours (NDB)

A

physiological needs
psychological need
social environmental
physical environment

51
Q

background factors in NBD

A

neurocongnitive factors
general health
personal characteristics
demographics

52
Q

two models to explain BPSD (stress, unaddressed need)

A
  1. NDB: needs-driven dementia compromised behaviours

2. PLST: progressively lowered stress threshold

53
Q

PLST means?

A

stress threshold lowered
environmental demands exceed a person ability to cope–>impaired function and behavioural symptoms
stressor accumulate during the day and pt can cycle between anxious and impaired function
need reduction of stress through intervention to diminish anxious behaviour and prevent impaired functioning

54
Q

assessment tool for syndrome of dementia?

A 
CMAI, RAWS-CD
cornell depression scale
geriatric Depression scale
NPI (neuropsychiatric inventory)
behave-AD
55
Q

3 important foci for assessment and evaluate behaviours

A

antecedent( triggering events)

  1. behaviours( description of behaviours
  2. consequence( happen afterwards)
56
Q

how to treat BPSD

A
  1. Address unmet needs (NBD)
  2. non-pharmacological strategies( address environmental precipitants, physical precipitants, psychological precipitants)
  3. sedation if extreme distress
  4. 12 wk anti-psychotropics drug
57
Q

how to address under-treated pain in dementia

A

analgesic trails

self report if MMSE>19 using visual analogue an faces scale, simple verbal or numerical scales( recommended)

58
Q

damage to pain processing networks in dementia

A
  1. sensory discriminative
  2. motivation affective
  3. behavioural responses
    white matter lesion causing chronic neuropathic pain causing allodynia and hyperalgesia
59
Q

PAINAD scale

A

1, breathing independent of vocalisation

  1. negative vocalisation
  2. facial expression
  3. body language
  4. consolability
60
Q

pain management in dementia

A

paracetamol, opiates, adjuvants pregabalin

61
Q

constipation treatment in dementia

A

bulking forming agents, stool softeners, osmotics, stimulants, enemas

62
Q

cholinergic toxicity

A

sedation, confusion, cognitive decline, hallucination

63
Q

anti psychotics in dementia

A

start low go slow( review at 12 wk)

  • cause akathesia
  • C/I for true psychosis, hallucination and delusion
  • haloperidol,risperidone, olanzapine, quetiepine
64
Q

anti psychotics side effect

A

neuroleptic sensitivity in lewy body dementia
increased risk of stroke and CVS if long term use
increased risk of falls, EPSE, tardive dyskinesia, long QT, stroke and death
respiratory depression , sedation

65
Q

medications in dementia

A

anti-psychotics, anticonvulsants, antidepressants, cholineraserase inhibitor

66
Q

what causes incontinence in general

A

reduced bladder capacity

atrophy of tissue post menopausal

67
Q

why micturition is high order function

A

involves cortex, pons, spinal cord, peripheral autonomic, somatic and sensory afferent innervation of lower urinary tract

68
Q

contience depends on

A

integrity of lower urinary tract system

adequate mentation, mobility, motivation and manual dexterity

69
Q

incontinence a manifestation of

A

urological disease
neurological disease
gyn disease

70
Q

why continence happens in elderly

A 
cognitive impairment
poor mobility 
heart failure
prostate enlargement
oestrogen deficiency
increased detrusor involuntary contractions
change in ADH secretion so nocturia
71
Q

incontinence more common in M or F

A

F

72
Q

effect of incontinence

A 
Social Effects
• social embarrassment because of odor
• social withdrawal
• stress on carer
• Mood changes
• early institutionalisation
Physical Effects
• Skin excoriation
• Skin infection
• Pressure ulceration
• Urinary Tract Infection
• Sleep deprivation
• Falls and fracture
73
Q

types of incontinence

A

• stress (eg wetting with activity)
• urgency (eg wetting when unable to reach
bathroom in time)
• overflow (eg constant wetness without the urge
to void)
• sphincteric (eg loss of urine with upright posture)
• spasticity of an obstructed bladder overcoming cortical
control

74
Q

stress incontinence causes

A

mechanical problem with weak pelvic floor structure, intrinsic sphincter deficiency( when intra-vesicle pressure> urethral pressure)

75
Q

urge incontinence ( most common) causes

A

detrusor instability/ over-activity

detrusor hyperreflexia if SC above S2

76
Q

overflow incontinence

A

obstrunction duet o BPH,

atonic bladder due to DM, alcoholics, SC below S2

77
Q

how is urine volume in each incontinence

A

stress: small
urge: large
overflow: small dribbling

78
Q

how to treat each incontinence

A

stress: pelvic floor exercise
urge: alpha agonist. bladder relexant ( anti-cholinergic, TCA, oxybutynin)
stress: remove obstrunction, finisteride, caterization

79
Q

what drug precipitates each incontinence

A

urge: diuretics, caffeine, sedative, hypotics, alcohol
overflow: anticholinergic, alpha agonist, nacrotics, CCB

80
Q

Neuro related cause of incontinence

A 
Lesions above S2
produce detrusor
hyperreflexia
• Lesions below S2
produce detrusor
areflexia
81
Q

Aggravating Condition of incontinence

A 
Acute medical illness
• Rectal loading
• Delirium
• poor mobility
• stroke
• arthritis
• hip fracture
• pneumonia, CCF
• Depression
• Dementia
• Diabetes with
hyperglycemia
• Obesity
• alcohol excess
• Drugs
82
Q

what drug induces incontinence

A

hypnosedatives–>Excessive sedation
diuretics–>Frequency, urgency
Alpha blockers –>Bladder neck relaxation
anti-depressants–>constipation
Major Tranquillizers–>constipation, confusion
Analgesics –>constipation
Anti-hypertensives–>postural hypotension
NSAID’s–>Frequency, urgency

83
Q

Functional Incontinence

A 
• Environmental
• sedatives/ hypnotics
• physical mobility or
access problems
• drugs inducing diuresis
84
Q

Neurological causes of incontinence

A
  • dementia
  • Stroke
  • Muscle weakness
  • Parkinson’s Disease
  • peripheral neuropathy
  • diabetes
  • alcohol
  • spinal cord injury
  • Multiple sclerosis
  • Brain Tumour
  • Head Injury
  • Hydrocephalus
85
Q

normal pressure hydrocephalus triad

A

dementia, gait disturbance, and urinary incontinence.

86
Q

Transient Cause for

UI

A

Delirium or other confusional state
• Infection
• Atrophic urethritis or vaginitis
• Drugs: diuretics, anticholinergics, opiods, alpha
blockers in women, alpha agonists in men, Ca
channel blockers
• Psychological, severe depression

87
Q

Detrusor Instability

A

Commonest cause of incontinence in elderly
• usually assoc with strong sense of urgency
• uninhibited bladder contractions
• if assoc with CNS disease labelled Detrusor hyperreflexia
• may be assoc with impaired bladder contractility in the elderly

88
Q

Urge Incontinence:

A

• Detrusor overactivity and uninhibitable bladder
contractions cause leakage
• Patient may describe sudden sensation of urgency
to void then involuntary loss of urine
• Voiding reflex is initiated when bladder volume is
well below capacity
• Associated with frequency due to small voiding
volumes

89
Q

Drugs contributing to urge

incontinence:

A
  • Diuretics
  • Caffeine
  • Sedative-hypnotics
  • Alcohol
90
Q

Drugs contributing to overflow

incontinence:

A 
• Anticholinergics 
Calcium channel blockers
• Alpha-adrenergic agonists
• Beta-adrenergic blockers
Antidepressants
• Antipsychotics
• Sedative-hypnotics
• Antihistamines
• CNS depressants
• Narcotics
• Alcohol
91
Q

Atonic Bladder

A
  • diabetes
  • alcoholic neuropathy
  • sacral spinal cord lesions below S2
  • drugs blocking bladder contraction
92
Q

Neurogenic

A

association with other neurol disease
Either idiopathic or caused by sacral LMN dysfunction
Leads to high post void residuals
• Mainstay of management is self-catheterisation

93
Q

Stress incontinence: situational involuntary loss of urine with

A

• lifting, coughing,laughing,running

94
Q

anatomical problem in stress incontinence

A

often due to loss of urethrovesical angle with descent of

bladder neck into pelvis

95
Q

Ix for stress incontinence

A

• Marshall or Bonney test shows control of stress incontinence
when bladder elevated manually by the examiner

96
Q

Pelvic floor excercises

A

for stress incontinence

for urge incontinence

97
Q

drug for incontinence

A

• Anticholinergics, including tricyclic
antidepressants, relax the bladder and increase
its capacity
• Elderly people more sensitive to adverse effects
such as blurred vision, dry mouth, GOR,
constipation and confusion

98
Q

Oxybutynin

A

Nonselective antimuscarinic agent that relaxes

bladder muscles and has local anaesthetic activity

99
Q

atonic bladder tx

A

muscarinic agonist Bethanechol

100
Q

Outlet obstruction tx

A

α₁-blocker: prazocin

101
Q

Stress incontinence drug tx

A

oestrogens -topical

102
Q

Two principles of Bladder Retraining

A
  1. Frequent voiding to keep the volume of urine in the
    bladder low
  2. Retraining of the CNS and pelvic mechanisms to
    inhibit detrusor contractions
103
Q

Kegel exercises

A

learned skill of muscle
contraction and relaxation that reduces urinary
incontinence by producing urethral closure by
contraction of the periurethral and other pelvic
muscles

104
Q

why does women live longer( tho higher disability than man)

A
  1. biological( oestrogen protective against CVD), T4 Causes immunosuppresion, longevity enhancing genes on X chromosome
  2. social and behavioural factors
    ( risk, healthcare, nutrition)
105
Q

why do women have poorer health status

A

more susceptible to chronic il, high risk of depression and anxiety, high prevalence of dementia( mitochondria protected against amyloid beta toxicity in younger, education and exercise)
childbirth impact

106
Q

theory of ageing

A

complex system with lots of redundancy has higher rate of failure but still higher reserve

107
Q

what is frailty

A

a state of increased vulnerability to stressor

reduced physiological reserve and ability to compensate for homeostasis disruption

108
Q

frailty has increased risk of

A

disability, institutionalisation and death

109
Q

3 main approaches to measure frailty

A
  1. clinical syndrome and phenotype
  2. subjective option ( checklist of age ass changes in appearance, combination and mobility)
  3. multidimensional risk state
110
Q

frailty using fried phenotype include ( not consider depression , cognition and performance based)

A

3 or more of

  1. unintentional weight loss
  2. self reported exhaustion
  3. weak grip strength
  4. slow walking speed
  5. low physical activity
111
Q

what measure to you need under subjective option (limited generality and rely on judgement)

A

clinical frailty scale

112
Q

multi-dimensional risk states means

A

measure quantity when various deficits accumulate during the life( person becomes more frail)

113
Q

what is deficits in deficits accumulation

A

symptoms, signs, disease, disability, abnormal lab measurement
accumulate with age, ass with AE, do not saturate, cross different domains, using the same item

114
Q

how to measure deficits accumulation

A

frailty index

115
Q

what is frailty index

A

construct from different numbers and the off variables

define risk of adverse outcomes ( than phenotype definition)

116
Q

complex system= older person redundancy has been lost, what function fails first

A

high order function
upright bipedal ambulation
divided thinking

117
Q

frailty predict what and not what

A

predict mortality

not predict hospital readmission

118
Q

CAM sampled DSM 5 for delirium dx

A
  1. acute change and fluctuate in mental state and hehaviours
  2. inattention
  3. disorganised thinking
  4. altered consciousness ( not alert)
119
Q

how to assess depression in elderly

A

geriatric depression scale( GDS)

120
Q

Presentation of depression in late lif

A

§ No-sadness depression:

□ irritable, multiple complaints ( underlying mood problem can cause the presentation)

121
Q

Treatment of delirium

A

Neuroleptics

Benzo is only tx if alcohol withdrawa

122
Q

Delirium aetiology

A

§ Pre-exposing factors RF:
Old age, Male, lots of medication, severe illness ( UTI, pain, fracture)
Frailty: More fragility, more likely to have delirium
Pre-morbid cognitive impairment or dementia : limited cognitive reserve( new precipitating factors will make them more likely to delirium)

Precipitating factors
Look infection : UTI, chest infection, skin infection, IE, meningitis
Electrolytes : Na( hypoNa know chronic or acute, need to have significant drop acutely ), Ca( hyperCa)
Alcohol: alcohol withdrawal cause DT

123
Q

Types of delirium

A

Active psychomotor
hypoactive
mixed

semester 2 year 2 week 9-16 (11 decks)

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