Geriatrics Flashcards
What is the physiology of ageing?
It affects every organ/system
Inter-individual variability increases with age
How does aging lead to dyshomeostasis?
Impaired function of organs makes homeostasis more difficult
Until it eventually fails
Frailty essentially progressive decrease in effective homeostasis
What are the changes in heat stress as you get older?
Reduced sweat gland output
Reduced skin blood flow
Smaller cardiac output increase
Less redistribution of blood from renal/splanchnic organs
What are the changes of cold stress as you get older?
Reduced peripheral vasoconstriction
Reduced metabolic heat production
What are the types of causes of incontinence?
Extrinsic to urinary system
Intrinsic
>Bladder or urinary outlet
What are the extrinsic factors of incontinence?
Physical state and co-morbidities Reduced mobility Confusion (delirium or dementia) Drinking too much or at the wrong time Diuretics Constipation Home circumstances Social circumstances
What functions does continence depend on?
Effective function of Bladder and urethra + integrity of neural connections that cause voluntary control
What muscle relaxes with urine storage?
Detrusor muscle
What is the local parasympathetic innervation of the bladder for continence?
Parasympathetic - S2-S4
Increases strength and frequency of contractions
What is the local sympathetic innervation of the bladder for continence? (Beta receptors)
T10-L2
Causes detrusor to relax
What is the local sympathetic innervation of the bladder (alpha receptors) for continence?
T10-S2
Causes contraction of bladder neck + Internal urehtral sphinter
What is the local somatic innervation of the bladder for continence?
S2-S4
Causes contraction of pelvic floor muscle + external urethral sphincter
How does the CNS promote bladder relaxation?
CNS centres inhibit parasympathetic tone
What centres are involved with continence?
Potine mitricition centre
Frontal cortex
Caudal part of spinal cord
What are the characteristic features of the bladder outlet being too weak>
Urine leak on movement, coughing, laughing, squatting, etc.
Due to Weak pelvic floor muscles
Who gets stress incontinence?
Women with children, especially after menopause
How do you treat stress incontinence?
Physio (kegel exercises)
Oestrogen cream
Duloxetine
Surgical options
What are teh characteristic features of overflow incontinence (with urinary retention)?
Poor urine flow, double voiding,
hesitancy, post micturition dribbling
Who gets overflow incontinence?
People with blockage in urethra
Older men with BPH
How do you treat overflow incontinence?
Treat with alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)
May need catheterisation, often suprapubic
What causes urge incontinence?
Detrusor muscle contracts at low volumes of urine
What are the symptoms of urge incontinence?
Sudden urge to pass urine immediately
(Patients often know every public toilet)
Bladder stones/stroke PMH?
How do you treat urge incontinence?
Treat with anti-muscarinics (relax detrusor)
e.g. oxybutinin, tolterodine, solifenacin
Bladder re-training sometimes helpful
What are the antimuscarinic drugs?
oxybutinin,
tolterodine,
solifenacin,
trospium
What are teh beta 3 adrenoceptor agonists?
Mirabegron
Which classes are used to relax the detrusor?
Antimuscurinics
Beta-3 adrenoceptor agonists
What are teh common alpha blockers used in incontinence?
tamsulosin,
terazosin,
indoramin
What are the common anti androgen drugs?
Finasteride
Dutasteride
What can cause a neuropathic bladder?
Neurological diseae (often MS/Stroke) Prolonged cathetarisation
What is neuropathic bladder?
No awareness of bladder filling resulting in overflow incontinence
How do you treat neuropathic bladder?
Medical unsatisfactory
Catheterisation only effective treatment
When do you refer urinary incontinence to specialists?
After failure of initial management
(Max 3 months pelvic floor exercise
Habit training
Appropriate medication)
What conditions do you refer straight away to a specialist for incontinence?
Vesico-vaginal fistula
Palpable bladder after micturition or confirmed large residual volume of urine after micturition
Disease of the CNS
Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
Severe benign prostatic hypertrophy or prostatic carcinoma
Patients who have had previous surgery for continence problems
Others in whom a diagnosis has not been made
When do you refer faecal incontinence?
Failure of initial management in constipation/diarrhoea with normal sphincter
Referal at onset in
>Sphincter damage (or suspected)
>Neurological disease
What can be used to manage incontinence if all else fails?
Incontinence pads Urosheaths Intermittent catheterisation Long term urinary catheter Suprapubic catheter
What is frailty?
A reduced ability to withstand illness without a loss of function
How do you diagnose “frailty”?
3 of 5 criteria
Unintentional weight loss Exhaustion Weak grip strength Slow walking speed Low physical activity
What are the intrinisic factors to falling?
Gait/balance problems Syncope (cardiac/vagal) Chronic diseases (MSK/neuro) Visual problems Acute illness Cognitive disorder Vit D deficiency
What is a fall?
Inadvertently coming to rest on a lower level (/ground) without loss of consciousness and not due to: sudden paralysis, epileptic seizure, excess alcohol or physical force
What medications can call falls?
Antidepressants (TCAs more than SSRIs) Antipsychotics Anticholinergics/muscarinics Benzondiapeines Anti-hypertensive Diuretics
How do we control balance?
Use of sensory input (prorioception, visual + vestibular) goes to processing centres in brain which causes corrections through muscle movements
How do we test gait/balance?
Sitting to standing ability Static standing balance Romberg test (balance issues when closed = positive) Dynamic standing balance Gait Get up and go test
What are the causes of syncope?
Reflex syncope Orthostatic hypotention Cardiac arrythmias Structural carciac/cariopulmonary disease Cerebrovascular
What is reflex (neurally-mediated) syncope?
Vasovagal syncope
>Subset: Carotid sinus hypersensitivity
Situational syncope
What is orthostatic hypotension?
Postural hypertension
>Due to autonomic failure or volume depletion
Collapse when stand up
What are the red falgs for syncope?
Heart failure Onset with exertion Family history of sudden cardiac death/inherited cardiac condition New/unexplained breathlessness Heart murmur On ecg: >Inappropriate, persistent bradycardia >Long/short QT >Abnormal T wave inversion
What indicated a fall may be a seizure?
Bitten tongue Head turning to one side during episode No memory of abnormal behaviour that was witnessed by another Unusual posturing Prolonged limb jerking Confusion after event Deja vu
What makes you think it is not a seizure?
Prodromal symptoms on other accasions settled by sitting own
Sweating before episode
Preciptated by prolonged standing
Pallor during episode
What cogntive disorders cna cause falls?
Dementia
Delerium
Depression/anxiety
How do you access the risk of osteoporosis?
FRAX or QFRACTURE tools
Assess BMD via DEXA scanning if greater than 10% risk at 10 years
What are the most common sites of fracture in falls?
Hip
Wrist
Vertebrae
What is the decline accronym?
Diabetes/insulin resistance Elderly Chronic disease Lack of use Inflammation Nutritional deficiency Endocrine dysfunction
How do you treat someone at risk of falls/history of falls?
Treat cause if possible Strength/balance training Home hazard/safety intervention Medication review Cardiac pacing
What are the physical complications of immobility?
Muscle wasting Muscle contractures Pressure sores Deep venous thrombosis Constipation / incontinence Hypothermia Hypostatic pneumonia Osteoporosis
What is sarcopenia?
Part of frailty syndrome
>Degenerative loss of muscle mass over time
DECLINE = risk factors
What are the psychological/social complications of immobility?
Psych >Depression
>Loss of confidence
Social
>Isolation
>Institutionalisation
In frail patients, what do they increasingly become?
Multimorbid
Old
Frail
Complex
What is the comprehensive geriatric assessment?
A process to assess/manage illness in older patients with frailty
Designed to determine what problems are, what we can reverse and make better
>Produce a management plan which is goal, not problem, centered
What are the risks of hospital?
Disorientation/delerium Leanred dependancy Deconditioning Iatrogenic harm HAI
What are the common consequences of ADRs in teh elderly?
Falls Cognitive loss/delerium Dehydration Incontinence Depression Poor quality of life Loss of functional capacity
What factors from the healthcare provider leads to polypharmacy?
No regular med review
Presumes that patient expects meds
Prescribes without sufficient investigation
Complex or incomplete instructions for med taking
No effort to simply med regime
Ordering automatic refills
How does absorption change in the elderly?
Pyshiological factors that effect rate but not extent of absorption from GI tract
Leads to delay in onset of action
>Example reduced saliva production
How does distribution change in the elderly?
Body composition changes >Reduced body mass >Increased adipose tissue >Reduced water Protein binding changes - decreased albumin Increased permeability across BBB
What are the metabolic changes in the elderly?
Hepatic metabolism affected by
>Decreased blood flow
>Decreaed liver mass
Leads to toxicity due to reduced excretion/metabolism
And reduced first pass metabolism
How does excretion change in the elderly?
Renal function decreases with age
So does hepatic ability
>Increaes half life of drugs
How does pharmocodynamics change in the elderly?
Increased sensitivity to particular medicines
>Due to receptor binding changes
>Decrease in receptor number
>Altered receptors
What are the principles for prescribing to the elderly?
Check if lower dose is recommended - titrate from lowest dose >Lower doses generally needed Review drug regularly Try to avoid drugs for adverse effects Keep regimes as simple as possible
What are the important questions regarding cognitive impairment in the elderly?
Onset - when + how rapid Course - does it fluctuate? Is it progressive? Are there any associated features? >Other illness? >Functional loss?
What is delirium?
Disturbed consciousness
Change in cognition
>Memory, perception, language, illusions, hallucinations
Acute onset and fluctuant
Disturbs sleep cycle
Emotional disturbance
Who gets delirium?
Extremes of age
What are some of the things that can precipitate delirium?
Infection Dehydration Biochemical disturbance Oain Drugs Constipation Hypoxia Alochol Brain injury
What is looked at when diagnosing delirium?
Alertness
AMT4
Attention
Acute change/fluctuating course
What is the AMT4?
Mini test checking cognition: 4 questions consisting of: Age DOB Place Current year
What are the treatment options for delirium?
Always try to treat cause first
Pharmacological
And non-pharmacologicla measures
What are potential triggers for confusion?
Sepsis six Blood glucose Medications Pain (do a review) Urinary retention Constipation
What are the non-pharmacological measures for managing delirium?
Re-orientate/reassure agitated patients using family/carers Encourage early mobility/self care Correction of sensory impairment Normalise sleep/wake cycle Ensure continuity of care Avoid urinary catheterisation
What are the pharmacological measures for managing delirium?
Stop bad drugs (sedatives/anticholinergics)
No evidence drugs help with dilirium, only use if danger to self/others and cannot be settled
What is dementia?
An acquired decline in memory/other cognitive functions in an alert persion severe enough to cause functional impairment
Present for 6+ months
Ie unable to use phone, difficulty washing/deressing
What are the causes of dementia?
Alzheimers Vascular dementia Mixed Alzeimers/Vascular Dementia with Lewy Bodies ‘Reversible’ causes
What are the symptoms of alzheimers?
Slow, insidious nset
Loss of recent memory first
Progressive functional decline
What are the risk factors for alzheimers?
Age
Vascular risk factors
Genetics
What are the signs for vascular dementia?
Classically stepwise deterioating
Executive function predominate (opposed to memory)
Associated with gait problems
Vascular risk factors common
What is the clinical picture of dementia with lewy bodies?
May have parkinsons
Often very fluctuant
Hallucinations common
Falls common
What is the clinical picture of fronto-temporal dementia?
Onset often at earlier age Early symptoms different to other typpes of fementia >Behaviour change >Language difficulties >Memory not affected early
Usually lack insight into ifficulties
What are the non-pharmacological treatments in dementia?
Support for person/carers Cognitive stimulation Exercise Avoid changes in environment Advanced care planning
What are the pharmacological treatments in dementia?
Choliesterase inhibitors (alzheimers) Anti-psychotics (avoid if possible)
What are the reversible causes f dementia?
Hypothyroidism Intracerebral bleeds B12 deficiency Hypercalcaemia Normal pressure hydrocephalus Depression!
