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Conditions + definitions > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What is the physiology of ageing?

A

It affects every organ/system

Inter-individual variability increases with age

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2
Q

How does aging lead to dyshomeostasis?

A

Impaired function of organs makes homeostasis more difficult
Until it eventually fails
Frailty essentially progressive decrease in effective homeostasis

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3
Q

What are the changes in heat stress as you get older?

A

Reduced sweat gland output
Reduced skin blood flow
Smaller cardiac output increase
Less redistribution of blood from renal/splanchnic organs

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4
Q

What are the changes of cold stress as you get older?

A

Reduced peripheral vasoconstriction

Reduced metabolic heat production

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5
Q

What are the types of causes of incontinence?

A

Extrinsic to urinary system
Intrinsic
>Bladder or urinary outlet

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6
Q

What are the extrinsic factors of incontinence?

A 
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
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7
Q

What functions does continence depend on?

A

Effective function of Bladder and urethra + integrity of neural connections that cause voluntary control

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8
Q

What muscle relaxes with urine storage?

A

Detrusor muscle

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9
Q

What is the local parasympathetic innervation of the bladder for continence?

A

Parasympathetic - S2-S4

Increases strength and frequency of contractions

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10
Q

What is the local sympathetic innervation of the bladder for continence? (Beta receptors)

A

T10-L2

Causes detrusor to relax

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11
Q

What is the local sympathetic innervation of the bladder (alpha receptors) for continence?

A

T10-S2

Causes contraction of bladder neck + Internal urehtral sphinter

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12
Q

What is the local somatic innervation of the bladder for continence?

A

S2-S4

Causes contraction of pelvic floor muscle + external urethral sphincter

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13
Q

How does the CNS promote bladder relaxation?

A

CNS centres inhibit parasympathetic tone

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14
Q

What centres are involved with continence?

A

Potine mitricition centre
Frontal cortex
Caudal part of spinal cord

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15
Q

What are the characteristic features of the bladder outlet being too weak>

A

Urine leak on movement, coughing, laughing, squatting, etc.

Due to Weak pelvic floor muscles

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16
Q

Who gets stress incontinence?

A

Women with children, especially after menopause

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17
Q

How do you treat stress incontinence?

A

Physio (kegel exercises)
Oestrogen cream
Duloxetine
Surgical options

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18
Q

What are teh characteristic features of overflow incontinence (with urinary retention)?

A

Poor urine flow, double voiding,

hesitancy, post micturition dribbling

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19
Q

Who gets overflow incontinence?

A

People with blockage in urethra

Older men with BPH

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20
Q

How do you treat overflow incontinence?

A

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

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21
Q

What causes urge incontinence?

A

Detrusor muscle contracts at low volumes of urine

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22
Q

What are the symptoms of urge incontinence?

A

Sudden urge to pass urine immediately
(Patients often know every public toilet)
Bladder stones/stroke PMH?

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23
Q

How do you treat urge incontinence?

A

Treat with anti-muscarinics (relax detrusor)
e.g. oxybutinin, tolterodine, solifenacin
Bladder re-training sometimes helpful

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24
Q

What are the antimuscarinic drugs?

A

oxybutinin,
tolterodine,
solifenacin,
trospium

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25
Q

What are teh beta 3 adrenoceptor agonists?

A

Mirabegron

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26
Q

Which classes are used to relax the detrusor?

A

Antimuscurinics

Beta-3 adrenoceptor agonists

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27
Q

What are teh common alpha blockers used in incontinence?

A

tamsulosin,
terazosin,
indoramin

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28
Q

What are the common anti androgen drugs?

A

Finasteride

Dutasteride

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29
Q

What can cause a neuropathic bladder?

A 
Neurological diseae (often MS/Stroke)
Prolonged cathetarisation
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30
Q

What is neuropathic bladder?

A

No awareness of bladder filling resulting in overflow incontinence

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31
Q

How do you treat neuropathic bladder?

A

Medical unsatisfactory

Catheterisation only effective treatment

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32
Q

When do you refer urinary incontinence to specialists?

A

After failure of initial management
(Max 3 months pelvic floor exercise
Habit training
Appropriate medication)

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33
Q

What conditions do you refer straight away to a specialist for incontinence?

A

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

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34
Q

When do you refer faecal incontinence?

A

Failure of initial management in constipation/diarrhoea with normal sphincter
Referal at onset in
>Sphincter damage (or suspected)
>Neurological disease

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35
Q

What can be used to manage incontinence if all else fails?

A 
Incontinence pads
Urosheaths 
Intermittent catheterisation 
Long term urinary catheter
Suprapubic catheter
36
Q

What is frailty?

A

A reduced ability to withstand illness without a loss of function

37
Q

How do you diagnose “frailty”?

A

3 of 5 criteria

Unintentional weight loss
Exhaustion
Weak grip strength
Slow walking speed
Low physical activity
38
Q

What are the intrinisic factors to falling?

A 
Gait/balance problems
Syncope (cardiac/vagal)
Chronic diseases (MSK/neuro)
Visual problems
Acute illness
Cognitive disorder
Vit D deficiency
39
Q

What is a fall?

A 
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
40
Q

What medications can call falls?

A 
Antidepressants (TCAs more than SSRIs)
Antipsychotics
Anticholinergics/muscarinics
Benzondiapeines
Anti-hypertensive
Diuretics
41
Q

How do we control balance?

A

Use of sensory input (prorioception, visual + vestibular) goes to processing centres in brain which causes corrections through muscle movements

42
Q

How do we test gait/balance?

A 
Sitting to standing ability
Static standing balance
Romberg test (balance issues when closed = positive)
Dynamic standing balance
Gait
Get up and go test
43
Q

What are the causes of syncope?

A 
Reflex syncope
Orthostatic hypotention
Cardiac arrythmias
Structural carciac/cariopulmonary disease
Cerebrovascular
44
Q

What is reflex (neurally-mediated) syncope?

A

Vasovagal syncope
>Subset: Carotid sinus hypersensitivity
Situational syncope

45
Q

What is orthostatic hypotension?

A

Postural hypertension
>Due to autonomic failure or volume depletion
Collapse when stand up

46
Q

What are the red falgs for syncope?

A 
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
47
Q

What indicated a fall may be a seizure?

A 
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
48
Q

What makes you think it is not a seizure?

A

Prodromal symptoms on other accasions settled by sitting own
Sweating before episode
Preciptated by prolonged standing
Pallor during episode

49
Q

What cogntive disorders cna cause falls?

A

Dementia
Delerium
Depression/anxiety

50
Q

How do you access the risk of osteoporosis?

A

FRAX or QFRACTURE tools

Assess BMD via DEXA scanning if greater than 10% risk at 10 years

51
Q

What are the most common sites of fracture in falls?

A

Hip
Wrist
Vertebrae

52
Q

What is the decline accronym?

A 
Diabetes/insulin resistance
Elderly
Chronic disease
Lack of use
Inflammation
Nutritional deficiency
Endocrine dysfunction
53
Q

How do you treat someone at risk of falls/history of falls?

A 
Treat cause if possible
Strength/balance training
Home hazard/safety intervention
Medication review
Cardiac pacing
54
Q

What are the physical complications of immobility?

A 
Muscle wasting
Muscle contractures
Pressure sores
Deep venous thrombosis
Constipation / incontinence
Hypothermia
Hypostatic pneumonia
Osteoporosis
55
Q

What is sarcopenia?

A

Part of frailty syndrome
>Degenerative loss of muscle mass over time
DECLINE = risk factors

56
Q

What are the psychological/social complications of immobility?

A

Psych >Depression
>Loss of confidence

Social
>Isolation
>Institutionalisation

57
Q

In frail patients, what do they increasingly become?

A

Multimorbid
Old
Frail
Complex

58
Q

What is the comprehensive geriatric assessment?

A

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

59
Q

What are the risks of hospital?

A 
Disorientation/delerium
Leanred dependancy
Deconditioning
Iatrogenic harm
HAI
60
Q

What are the common consequences of ADRs in teh elderly?

A 
Falls
Cognitive loss/delerium
Dehydration
Incontinence
Depression
Poor quality of life
Loss of functional capacity
61
Q

What factors from the healthcare provider leads to polypharmacy?

A

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

62
Q

How does absorption change in the elderly?

A

Pyshiological factors that effect rate but not extent of absorption from GI tract
Leads to delay in onset of action
>Example reduced saliva production

63
Q

How does distribution change in the elderly?

A 
Body composition changes
>Reduced body mass
>Increased adipose tissue
>Reduced water
Protein binding changes - decreased albumin
Increased permeability across BBB
64
Q

What are the metabolic changes in the elderly?

A

Hepatic metabolism affected by
>Decreased blood flow
>Decreaed liver mass

Leads to toxicity due to reduced excretion/metabolism
And reduced first pass metabolism

65
Q

How does excretion change in the elderly?

A

Renal function decreases with age
So does hepatic ability
>Increaes half life of drugs

66
Q

How does pharmocodynamics change in the elderly?

A

Increased sensitivity to particular medicines
>Due to receptor binding changes
>Decrease in receptor number
>Altered receptors

67
Q

What are the principles for prescribing to the elderly?

A 
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
68
Q

What are the important questions regarding cognitive impairment in the elderly?

A 
Onset - when + how rapid
Course - does it fluctuate? Is it progressive?
Are there any associated features?
>Other illness?
>Functional loss?
69
Q

What is delirium?

A

Disturbed consciousness
Change in cognition
>Memory, perception, language, illusions, hallucinations
Acute onset and fluctuant

Disturbs sleep cycle
Emotional disturbance

70
Q

Who gets delirium?

A

Extremes of age

71
Q

What are some of the things that can precipitate delirium?

A 
Infection
Dehydration
Biochemical disturbance
Oain
Drugs
Constipation
Hypoxia
Alochol
Brain injury
72
Q

What is looked at when diagnosing delirium?

A

Alertness
AMT4
Attention
Acute change/fluctuating course

73
Q

What is the AMT4?

A 
Mini test checking cognition:
4 questions consisting of:
Age
DOB
Place
Current year
74
Q

What are the treatment options for delirium?

A

Always try to treat cause first

Pharmacological
And non-pharmacologicla measures

75
Q

What are potential triggers for confusion?

A 
Sepsis six
Blood glucose
Medications
Pain (do a review)
Urinary retention
Constipation
76
Q

What are the non-pharmacological measures for managing delirium?

A 
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
77
Q

What are the pharmacological measures for managing delirium?

A

Stop bad drugs (sedatives/anticholinergics)

No evidence drugs help with dilirium, only use if danger to self/others and cannot be settled

78
Q

What is dementia?

A

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

79
Q

What are the causes of dementia?

A 
Alzheimers
Vascular dementia
Mixed Alzeimers/Vascular
Dementia with Lewy Bodies
‘Reversible’ causes
80
Q

What are the symptoms of alzheimers?

A

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

81
Q

What are the risk factors for alzheimers?

A

Age
Vascular risk factors
Genetics

82
Q

What are the signs for vascular dementia?

A

Classically stepwise deterioating
Executive function predominate (opposed to memory)
Associated with gait problems
Vascular risk factors common

83
Q

What is the clinical picture of dementia with lewy bodies?

A

May have parkinsons
Often very fluctuant
Hallucinations common
Falls common

84
Q

What is the clinical picture of fronto-temporal dementia?

A 
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

85
Q

What are the non-pharmacological treatments in dementia?

A 
Support for person/carers
Cognitive stimulation
Exercise
Avoid changes in environment
Advanced care planning
86
Q

What are the pharmacological treatments in dementia?

A 
Choliesterase inhibitors (alzheimers)
Anti-psychotics (avoid if possible)
87
Q

What are the reversible causes f dementia?

A 
Hypothyroidism
Intracerebral bleeds
B12 deficiency
Hypercalcaemia
Normal pressure hydrocephalus
Depression!

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