geriatrics Flashcards
describe the 4AT Test
Alert -
AMT4- name, DOB, place, year
Attention - months backwards from december
Acute changes
what are consequences of decreased hepatic metabolism of drugs in the elderly
Toxicity
Reduced first pass metabolism
(↑ in bioavailability with some drugs e.g. propranolol
Can cause ↓ bioavailability of pro-drugs e.g. enalapril)
which sex is Urinary retention with overflow incontinence more common in
males
list some drugs that can increase your chances of falling
TCA antidepressants antipsychotics anticholinergics/ antimuscarinis benzodiazepines anti-hypertensives diuretics alcohol
what pathology arises when the bladder outlet is too weak
stress incontinence
list some causes of syncope
neurally mediated - vasovagal/ carotid sinus hypersensitivity, situational postural hypotension carotid arrhythmias seizure structural heart disease
what are causes of incontinence that are extrinsic to the urinary system
Physical state and co-morbidities Reduced mobility
Confusion (delirium/ dementia) Drinking too much or at the wrong time
Diuretics Constipation
Home/ social circumstances
what diseases common in the elderly decrease total serum a albumin
heart failure, renal disease, rheumatoid arthritis, hepatic cirrhosis and some malignancies.
what are some causes of incontinence that are necessary to refer from the onset
Vesico-vaginal fistula
Palpable bladder after micturition or confirmed large residual volume of urine after micturitionDisease 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
who is involved in a comprehensive geriatric assessment
Geriatrician Occupational therapy Physiotherapist Skilled Nurses GP Other doctors Social worker Home care Dietician
what is a positive romberg test
sway when eyes are closed
what in involved in the societal health domain
attitude - asset or burden
technology
politics - money
accessibility - bus pass, disabled
list some cardiac or cardiopulmonary diseases that may lead to syncope
Cardiac valvular disease i.e. aortic stenosis Acute myocardial infarction/ischaemia Obstructive cardiomyopathy Atrial myxoma Acute aortic dissection Pericardial disease/tamponade Pulmonary embolus/pulmonary hypertension
what are ECG abnormalities after syncope
inappropriate bradycardia
long QT >450ms
abnormal t wave inversion
what are characteristic features of urge incontinence
Detrusor contracts at low volumes
Sudden urge to pass urine immediately
Patients often know every public toilet/ never leave house due to fear – isolating
how would you investigate an unexplained seizure in an under 60
holter monitor
when is urine leaked during stress incontinence
movement, coughing, laughing, squatting
what things can precipitate delirium
Infection (but not always a UTI!) Dehydration
Biochemical disturbance (high low Na/Ca)
Pain
Drugs – opiates (indirect - NSAID/ ACEi > AKI)
Constipation/Urinary retention
Hypoxia Alcohol/drug withdrawal
Sleep disturbance Brain injury -Stroke/tumour/bleed etc
Changes in environment – new social set up
why is it more difficult to prescribe for the elderly
little evidence of drug efficacy and safety
multiple medications
adverse drug reactions
what symptoms may indicate a seizure over syncope
A bitten tongue
Head-turning to 1 side during episode
No memory of abnormal behaviour that was witnessed before, during or after episode by someone else
Unusual posturing
Prolonged, simultaneous limb-jerking
Confusion after the event
Prodromal déjà vu or jamais vu (recognisable but unfamiliar)
how would you investigate syncope
history/ collateral history examination 12 lead ECG BP echo/ halter monitor
what are some non pharmacological ways of managing dementia
Support for person and carers Cognitive stimulation
Exercise - fitenss slows down cognitive decline Environmental design
Avoiding changes in environment/social support
Advanced care planning – progressive decline, will lose capacity
what happens to rate of absorption of drugs in the elderly
declines
what are some prescribing guides for the elderly
BNF
Beer’s criteria
STOPP START criteria
NHS scotland polypharmacy
how common is delirium in in-pateitns
20-30%
Up to 50% of all post surgery, Up to 85% in last few weeks of life
who is incontince common in
3x more in woman
2 peaks at 50-59 and 80+
high in hospitalised/ nursing home
what does ‘start low, go slow’ mean when prescribing
start at lowest dose and titrate up slowly
how long must dementia symptoms be present for before daignsosis
6 months
what are psychological and social complications of immobility
Depression, Loss of confidence
Isolation Institutionalization
when is delirium normally worse
night time
what test is used to assess bone mass density
DEXA scanning
(T score
what type of memory is lost in vascular dementia
executive function eg planning rather than memory
what are the most co-morbidities in the 74-102 age group
hypertension previous solid tumour angina/ artery disease respiratory disease diabetes
can you make the diagnosis of osteoporosis without a DEXA scan
if patient has multiple fractures
what are screening tools for dementia
MOCA
MMSE
what is the treatment for Urinary retention with overflow incontinence
alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP) may need suprapubic catheterisation
how does the body composition change in the elderly that affects the way we metabolise drugs
Reduced muscle mass
Increased adipose tissue (increase distribution of fat soluble drugs)
Reduced body water (decreased distribution of water soluble drugs)
give examples of situational syncope
acute haemorrhage · cough, sneeze
· micturition (post-micturition) · post-exercise
- gastrointestinal stimulation (swallow, defaecation, visceral pain)
· others (e.g., brass instrument playing, weightlifting)
what are the 6 neurocognitive domains in the DSM 5
complex attention perceptual- motor function language function executive function learning/ memory social cognition
what percentage of people that fall will fall agin in the next year
66%
what are a drugs volume of distribution dependent on
bodys aqueous and lipid phases
what sit he stochastic theory of ageing
cumulative damage (micro-trauma), random, gradual degeneration, breakdown of systems e.g. oxidative damage to hair follicles makes hair grey
what are treatments for stress incontinence
physiological- kegel exercises oestrogen cream (atrophy) duloxetine (SSRI) TVT culposuspenison -
list some causes of cardiac arrhythmia
Sinus node dysfunction (including bradycardia/ tachycardia syndrome)
Atrioventricular conduction system disease
Paroxysmal supraventricular and ventricular tachycardias
Inherited syndromes (e.g., long QT syndrome, Brugada syndrome)
Implanted device (pacemaker, ICD) malfunction
Drug-induced proarrhythmias
which drugs can be given to relax the detrouser
antimuscarinics - oxybutinin, tolterodine, solifenacin, trospium
Beta-3 adrenoceptor agonists - mirabegron
bata 3 adrenoreceptors
why does alcohol increase chance of falling
diuretic
reduces cerebellar function
why do many drugs lead to confusion in the elderly
increased permeability across the blood brain barrier
what 2 things is continence dependent on
effective function of bladder
integrity of neural connections
what is the point of a comprehensive geriatric assessment
determine medical problems and health domains
determine what we can reverse and make better
produce a goal centred management plan
what is the most common cause of fainting
vasovagal syncope - overstimulation of vagus nerve with sweating, nausea and tunnel vision
what drugs produce a lot of adverse effects in the elderly
anticholonergics
sedative
what manoeuvre treats benign paroxysmal positional vertigo
dix- hall pike manoeuvre - see nystagmus after head
drop for 20s-1 min, do left and right (asymptomatic side first)
list some intrinsic causes that can precipitate a fall
gait and balance - postural instability, vertigo
syncope - cardiac, vagal
chronic disease - parkinson’s, peripheral neuropathy, osteoarthritis
visual problems
cognitive disorder
urge incontinence
vit D deficiency
what abuse are older people at higher risk for (social domain)
financial
physical
sexual
neglect
what neuroinnervation causes contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter.
somatic - S2-4
what % of falls result in hip fracture
1% - 1/4 will die as a result
why should you do a postural BP after syncope
postural hypotension common cause
what is poly pharmacy
use of many drugs
what is causing the demographic shift in age of population
fertility rates falling
better healthcare = higher life expectancy
more people surviving surgery, major events, disabilities
what are some reversible causes of confusion
Hypothyroidism Intracebral bleeds/ tumours
B12 deficiency Hypercalcaemia
Non pressure hydrocephalus (/cebral atrophy)
depression - irritable
which type of dementia has an early onset
fronto-temporal
can be as young as 30
what is dyshomeostasis
homeostasis failure
impaired function of organ systems makes difficult
(frailty)
what is the cost common form of incontinence
stress incontinence
what are reasons for de-prescribing drugs
Adverse drug reaction - Drug-drug interaction - Drug-disease interaction
Better alternative - Not effective
Not indicated
Not evidence-based - Minimise polypharmacy
why is stress incontinence common in women after menopause
lose protective effect of oestrogen and muscle begins to atrophy
what drugs can be given to relax bladder sphincters
alpha blockers - tamsulosin, terazosin, indoramin
what drugs should be stopped in delirium
anticholinergics, sedatives
indirectly harm brain - NSAIDs, ACEi
what is important to think about when assessing someones spiritual health domain
whats important to them
whats the meaning of life
how you fit in
how they protect self image
how does the effect of protein binding effect drug distribution
Decreased albumin, ↓ binding, ↑ serum levels acidic drugs e.g. furosemide (some drugs only active when unbound)
what are common outcomes of a fall
injury (50%) - fracture, subdural haemorrhage
rhabdomyolysis (high CK)
fear of falling
- dependency, carer stress, institutionalisation
list was to assess gait and balance
Sitting to standing ability (physio test) -
Static standing balance (control sway)
Gait (weak on one side) Tinetti gait and balance scale
Berg balance scale get up and go test (timed)
Romberg test - proprioceptive function
how are creatine levels affected with ageing
although kidney function drops and creatine clearance reduces, levels stay the same due to muscle loss
what is the optimal discharge time
when goals are met and before risks outweigh benefits
what neuroinnervation increases strength and frequency of bladder contractions
parasympathetic S2-4
what are some causes of urge incontinence
bladder stone (dehydration) stroke
what things are vital for balance
vision
hearing (vestibular)
proprioception
cerebellum
what negative outcomes are associated with delirium
¥ Increased risk of death
¥ Longer length of stay
¥ Increased rates institutionalisation
¥ Persistent functional decline
what causes reduced excretion of drugs by the kidneys in the elderly
renal function decreases with age
why do you become incontinent when you fit
lose sympathetic inhibitory tone that stops the bladder from contracting
what CNS connections mediated sphincter closure
reflex increase in a-adrenergic and somatic activity
why are older people more prone to hypothermia
reduced peripheral vasoconstriction
reduced metabolic heat production
what neuroinnervation causes detrouser to relax
sympathetic B-adrenoreceptor
T10-L2
what type of muscles are the internal/ external urethral sphincter and detrouser
detrouser + internat - smooth
external - striated
what is the ADME of pharmacology
absorption
distribution
metabolism
excretion
list healthcare provider factors that contribute to polypharmacy
•
No med review with patient on regular basis
Prescribes without sufficiently investigating clinical situation – short GP appointments
unclear, complex or incomplete instructions about how to take meds – less adherence
No effort to simplify medication regimen – re-prescribing without thought
Ordering automatic refills
Lack of knowledge of geriatric clinical pharmacology
how should you investigate incontinecne
history - extrinsic factors
fluid intake and output diary
examination - rectal and vaginal (atrophy, leakage)
urinalysis and MSSU
bladder scan for residual volume (>500/ 600 abnormal)
what pathology arises form an underachieve bladder
neuropathic bladder
what screening tool is used for delirium
4AT
where is a suprapubic catheter inserted
1cm above pubic symphis
why are older people more prone to heat stroke
reduced sweat gland output
reduced skin blood flow
smaller increase in cardiac output
less redistribution of blood flow from renal and splanchnic circulations
why is the half life of many drugs increased in the elderly
reduced excretion form kidney
why is assessing cognition important
relevant to current medical problems
Associated with increased risk death/increased length of stay/discharge to care home
May need to alter communication/information given/involvement of family members
Help you decide regarding capacity
May alter appropriateness of tests/investigations/certain treatments
May be able to improve it if cognitive impairment – reversible causes
what is involved in the non-paharmacological management of dementia
Re-orientate and reassure agitated patients – reitnroduce, USE FAMILIES/CARERS
Encourage early mobility and self-care – improves delerium symptoms
Correction of sensory impairment
Normalise sleep-wake cycle – natural light, owen clothes during day, keep active
Ensure continuity of care - avoid frequent ward or room transfers
Avoid urinary catheterisation/venflons- urinary incontinence/ retention not good enough reason
what drugs may be given if the delirious person is at harm to themselves or others
benzodiazepam
quetiapine (anti-psychotic)
what is the screening tool for undernutrition
MUST
what are risk factors for vascular dementia
vascular risk factors - T2DM, AF, IHD, PVD
list some extrinsic causes that can precipitate a fall
inappropriate footwear
environmental hazards - uneven paving, carpet, stairs
poor lighting
unfamiliar environment (hospital)
what are physical complications of immobility
Muscle wasting (over 80 10 days = 10 year) Muscle contractures
Pressure sores Deep venous thrombosis
Constipation/ incontinence hypothermia (may lead to pneumonia)
Hypostatic pneumonia Osteoporosis (lack of weight-bearing)
what are early symptoms of fronts-temporal dementia
behavioural change
language difficulties
less memory effects early on
what happens to the sensitivity of baroreceptors with age
reduce
what 5 things would make someone benefit form a comprehensive geriatric assessment (FRAIL)
F - functional impairment with multiple conditions
R - resident in care home
A - acute confusion
I- immobility/ falls in last 3 months
L - list of 6 or more medicines (poly pharmacy)
what are the benefits of being in hospital for the elderly
Access to clinical expertise
Access to complex tests and interventions
Rapid access to supervised care support
what are some side effects of anti-muscarinics
blurred vision constipation dry mouth reduced cognitions vasodilation - falls
how is the progression of vascular dementia
step wise
how frequent are fall related deaths in the UK
every 5 hours
what is frailty
A reduced ability to withstand illness without loss of function susceptible state, not an illness in its self
what are detrimental affects of physiological aging
systolic hypertension
decreased reaction time
what is the only effective treatment for a neuropathic bladder
catheterisation
what things can cause orthostatic hypotension
primary autonomic failure
secondary autonomic failure p diabetic neuropathy
volume depletion - haemorrhage, diarrhoea, addison’s
what things is a neuropathic bladder secondary to
near disease - MS, stroke
prolonged catheterisation
at how many drugs are you guaranteed an ADR
9 - most elderly on
what is the programmed theory of ageing
pre-determined, changes in gene expression during various stages (cell death – apoptosis)
what tools is used to assess risk of osteoporosis
QFRACTURE, FRAX
what is the name of the micturition centre in the brain
pontine micturition centre
what are risk factors for frailty (DECLINE)
D – diabetes/ insulin resistance E- elderly C – chronic disease L – lack of use (of muscle) I – inflammation N - nutritional deficiency E – endocrine dysfunction
what is frailty scored on
1 - very fit 2- well 3 - managing well 4 - vulnerable 5 - mildly frail 6- moderatley frail 7- severely frail 8- very severely frail 9 - terminally ill
what would you want to find in the history of cognitive impairment
onset - when , how rapid
course - fluctuating, progressive decline
associated - illnesses, functional loss
what is social dyshomeostasis
difficulty caused by environmental insults e.g different ability to compensate for situations such as death, social isolation
what does voluntary voiding of the bladder involve
voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder. (parasympathetic drive)
what are the 5 domains of the frailty phenotype
unintentional weight loss exhaustion weak grip strength slow walking speed low physical activity
list things that can cause vertigo
menieres labrynthitis benign paroxysmal positional vertigo acute ear infection cerebellar/ brainstem pathology
what is a safer way of treating urinary incontinence than long term catheterisation
intermittent catheterisation - 4x a day
what symptoms would indicate a syncope over a seizure
Prodromal symptoms that on other occasions have been abolished by sitting or lying down
Sweating before the episode
Precipitated by prolonged standing
Pallor during the episode.
what condition often co-exist with leeway body dementia
parkinsons
list symptoms of ADRs in the elderly
Unsteadiness/ falls - Dizziness/ drowsiness Confusion Nervousness Fatigue Insomnia Depression Incontinence
what are some pharmacological ways of managing dementia
Cholinesterase inhibitors - Mainly used in Alzheimers,
Galantamine licensed in mixed dementia
Rivastigmine in Dementia with Lewy Bodies
what is fear of falling syndrome
loss of confidence in ability to walk - develop distinctive gat that actually increases your chances of falling
what drug actually has a higher absorption in the elderly
levodopa (parkinsons) -
what are the worst drugs for poly pharmacy
- NSAIDs
- Diuretics
- Warfarin
- ACEI
- Antidepressants
- Beta blockers
- opiates
- Digoxin
- Prednosiolone/ clopidogrel
what are common symptoms of lewy body dementia
hallucinations (nightmares)
falls
very fluctuant
what is regarded as failure of initial management for urinary incontinence (refer)
3 month of pelvic floor , cone therapy, medication
what is subclavian steal syndrome (syncope)
blockage in subclavian artery, blood down verterbal artery to rigt arm instead of brain
what is involved in the psychological health domain
mood - low, anxiety
confidence - fear of falling
cognition - dementia, delirium
at what bladder volume do you become aware that you are full
250ml
what pathology arises when the bladder outlet is too strong
urinary retention with overflow incontinence
why does a neuopathic bladder lead to overflow incontinence
no awareness of bladder filling
what is a fall
Inadvertently coming to rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force
what pathology arises from the bladder muscle being too strong
urge incontinence
what 4 things contribute to good geriatric care
Early identification of need
Early Comprehensive Geriatric Assessment
Early provision of appropriate level of care for needs
Discharge plan or dignified death
what are the 9 health domains of a comprehensive geriatric assessment
medical psychological functional - mobility/ living behavioural nutritional spiritual environmental social societal
what are the key features of delirium
Disturbed consciousness – Hypoactive (sleepy)/hyperactive (up exploring)/mixed
Change in cognition - Memory/perceptual/language/illusions/hallucinations
Acute onset (few hours) and fluctuant
Affects extremes of age - smaller insults
what are red flags for syncope
An ECG abnormality
Heart failure (history or physical signs)
Onset with exertion
Family history of sudden cardiac death (<40) years and/or an inherited cardiac condition
New or unexplained breathlessness
A heart murmur.
how is urge incontinenc treated
anti-muscarinics (relax detrusor) e.g. oxybutinin, tolterodine, solifenacin
why is hepatic metabolism of drugs affected in the elderly
decreased liver mass
decreased liver blood flow
what neuroinnervation causes contractions of neck of bladder and internal urethral sphincter
sympathetic a-adrenoreceptor (T10-L2)
what are risk factors for a fall
muscle weakness history of falls gait/ balance deficit use of assistive devices visual deficit arthritis cognitive impairment age >80
what lung volume changes with ageing
vital capacity
why does the loading dose of digoxin have to be substantially lowered in the elderly
normally high Vd due to widespread distrubution into the muscle
The reduction in muscle mass in older people means there is a significant reduction digoxins Vd
what is th eMDT treatment of falls
treat cause where possible
Strength and Balance Training
Home Hazard and Safety Intervention – fall alarms, fall monitors
Medication review with modification/withdrawal
Cardiac pacing - In selected patients found to have cardio-inhibitory carotid sinus hypersensitivity and unexplained falls
what symptoms would indicate a syncope over a seizure
Prodromal symptoms that on other occasions have been abolished by sitting or lying down
Sweating before the episode
Precipitated by prolonged standing
Pallor during the episode.
what are causes of incontinence that are intrinsic to the urinary system
bladder outlet too weak or strong
urinary outlet too weak or strong
what are common causes of Urinary retention with overflow incontinence
blockage of urethra
men - BPH
women - cervical cancer survivor, urethral stricture from radiotherapy
what is involved int eh behavioural health domain
occupation
pastimes
habits - smoking, drinking unhealthy eating
what should you do regularly for an elderly patient on many drugs
review regularly
remove any unnecessary drugs
what are things you would want to gather from the collateral history after a syncope
Circumstances of the event
Posture immediately before loss of consciousness (sitting/ standing/ lying)
Appearance (pale,/ cold/ clammy)
Presence or absence of movement during the event (?limb-jerking)
Tongue-biting
Duration of the event (onset to regaining consciousness),
Presence or absence of confusion during the recovery period
Weakness down 1 side during the recovery period.
what are risks of being in hospital for the elderly
Disorientation and delirium
Learned dependency Deconditioning – lose muscle strength
Iatrogenic harm – drug side effects
Hospital Acquired Infection
what are characteristic features of Urinary retention with overflow incontinence
poor urine flow
double voiding
hesitancy
post micturition dribbling
what type of memory do you lose first in alzheimers
recent memory - functional decline in daily activities
