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geriatrics Flashcards

1
Q

describe the 4AT Test

A

Alert -
AMT4- name, DOB, place, year
Attention - months backwards from december
Acute changes

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2
Q

what are consequences of decreased hepatic metabolism of drugs in the elderly

A

Toxicity
Reduced first pass metabolism
(↑ in bioavailability with some drugs e.g. propranolol
Can cause ↓ bioavailability of pro-drugs e.g. enalapril)

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3
Q

which sex is Urinary retention with overflow incontinence more common in

A

males

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4
Q

list some drugs that can increase your chances of falling

A 
TCA antidepressants
antipsychotics 
anticholinergics/ antimuscarinis 
benzodiazepines
anti-hypertensives 
diuretics 
alcohol
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5
Q

what pathology arises when the bladder outlet is too weak

A

stress incontinence

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6
Q

list some causes of syncope

A 
neurally mediated - vasovagal/ carotid sinus hypersensitivity, situational
postural hypotension 
carotid arrhythmias 
seizure
structural heart disease
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7
Q

what are causes of incontinence that are extrinsic to the urinary system

A

Physical state and co-morbidities Reduced mobility
Confusion (delirium/ dementia) Drinking too much or at the wrong time
Diuretics Constipation
Home/ social circumstances

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8
Q

what diseases common in the elderly decrease total serum a albumin

A

heart failure, renal disease, rheumatoid arthritis, hepatic cirrhosis and some malignancies.

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9
Q

what are some causes of incontinence that are necessary to refer from the onset

A

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

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10
Q

who is involved in a comprehensive geriatric assessment

A 
Geriatrician 			Occupational therapy 
Physiotherapist 			Skilled Nurses
GP					
Other doctors
Social worker			
Home care
Dietician
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11
Q

what is a positive romberg test

A

sway when eyes are closed

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12
Q

what in involved in the societal health domain

A

attitude - asset or burden
technology
politics - money
accessibility - bus pass, disabled

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13
Q

list some cardiac or cardiopulmonary diseases that may lead to syncope

A 
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
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14
Q

what are ECG abnormalities after syncope

A

inappropriate bradycardia
long QT >450ms
abnormal t wave inversion

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15
Q

what are characteristic features of urge incontinence

A

Detrusor contracts at low volumes
Sudden urge to pass urine immediately
Patients often know every public toilet/ never leave house due to fear – isolating

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16
Q

how would you investigate an unexplained seizure in an under 60

A

holter monitor

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17
Q

when is urine leaked during stress incontinence

A

movement, coughing, laughing, squatting

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18
Q

what things can precipitate delirium

A

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

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19
Q

why is it more difficult to prescribe for the elderly

A

little evidence of drug efficacy and safety
multiple medications
adverse drug reactions

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20
Q

what symptoms may indicate a seizure over syncope

A

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)

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21
Q

how would you investigate syncope

A 
history/ collateral history 
examination 
12 lead ECG 
BP
echo/ halter monitor
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22
Q

what are some non pharmacological ways of managing dementia

A

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

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23
Q

what happens to rate of absorption of drugs in the elderly

A

declines

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24
Q

what are some prescribing guides for the elderly

A

BNF
Beer’s criteria
STOPP START criteria
NHS scotland polypharmacy

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25
Q

how common is delirium in in-pateitns

A

20-30%

Up to 50% of all post surgery, Up to 85% in last few weeks of life

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26
Q

who is incontince common in

A

3x more in woman
2 peaks at 50-59 and 80+
high in hospitalised/ nursing home

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27
Q

what does ‘start low, go slow’ mean when prescribing

A

start at lowest dose and titrate up slowly

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28
Q

how long must dementia symptoms be present for before daignsosis

A

6 months

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29
Q

what are psychological and social complications of immobility

A

Depression, Loss of confidence

Isolation Institutionalization

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30
Q

when is delirium normally worse

A

night time

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31
Q

what test is used to assess bone mass density

A

DEXA scanning

(T score

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32
Q

what type of memory is lost in vascular dementia

A

executive function eg planning rather than memory

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33
Q

what are the most co-morbidities in the 74-102 age group

A 
hypertension 
previous solid tumour 
angina/ artery disease
respiratory disease 
diabetes
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34
Q

can you make the diagnosis of osteoporosis without a DEXA scan

A

if patient has multiple fractures

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35
Q

what are screening tools for dementia

A

MOCA

MMSE

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36
Q

what is the treatment for Urinary retention with overflow incontinence

A 
alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)
may need suprapubic catheterisation
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37
Q

how does the body composition change in the elderly that affects the way we metabolise drugs

A

Reduced muscle mass
Increased adipose tissue (increase distribution of fat soluble drugs)
Reduced body water (decreased distribution of water soluble drugs)

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38
Q

give examples of situational syncope

A

acute haemorrhage · cough, sneeze
· micturition (post-micturition) · post-exercise
- gastrointestinal stimulation (swallow, defaecation, visceral pain)
· others (e.g., brass instrument playing, weightlifting)

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39
Q

what are the 6 neurocognitive domains in the DSM 5

A 
complex attention 
perceptual- motor function 
language function 
executive function 
learning/ memory 
social cognition
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40
Q

what percentage of people that fall will fall agin in the next year

A

66%

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41
Q

what are a drugs volume of distribution dependent on

A

bodys aqueous and lipid phases

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42
Q

what sit he stochastic theory of ageing

A

cumulative damage (micro-trauma), random, gradual degeneration, breakdown of systems e.g. oxidative damage to hair follicles makes hair grey

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43
Q

what are treatments for stress incontinence

A 
physiological- kegel exercises
oestrogen cream (atrophy)
duloxetine (SSRI)
TVT 
culposuspenison -
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44
Q

list some causes of cardiac arrhythmia

A

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

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45
Q

which drugs can be given to relax the detrouser

A

antimuscarinics - oxybutinin, tolterodine, solifenacin, trospium

Beta-3 adrenoceptor agonists - mirabegron

bata 3 adrenoreceptors

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46
Q

why does alcohol increase chance of falling

A

diuretic

reduces cerebellar function

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47
Q

why do many drugs lead to confusion in the elderly

A

increased permeability across the blood brain barrier

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48
Q

what 2 things is continence dependent on

A

effective function of bladder

integrity of neural connections

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49
Q

what is the point of a comprehensive geriatric assessment

A

determine medical problems and health domains
determine what we can reverse and make better
produce a goal centred management plan

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50
Q

what is the most common cause of fainting

A

vasovagal syncope - overstimulation of vagus nerve with sweating, nausea and tunnel vision

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51
Q

what drugs produce a lot of adverse effects in the elderly

A

anticholonergics

sedative

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52
Q

what manoeuvre treats benign paroxysmal positional vertigo

A

dix- hall pike manoeuvre - see nystagmus after head

drop for 20s-1 min, do left and right (asymptomatic side first)

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53
Q

list some intrinsic causes that can precipitate a fall

A

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

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54
Q

what abuse are older people at higher risk for (social domain)

A

financial
physical
sexual
neglect

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55
Q

what neuroinnervation causes contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter.

A

somatic - S2-4

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56
Q

what % of falls result in hip fracture

A

1% - 1/4 will die as a result

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57
Q

why should you do a postural BP after syncope

A

postural hypotension common cause

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58
Q

what is poly pharmacy

A

use of many drugs

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59
Q

what is causing the demographic shift in age of population

A

fertility rates falling
better healthcare = higher life expectancy
more people surviving surgery, major events, disabilities

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60
Q

what are some reversible causes of confusion

A

Hypothyroidism Intracebral bleeds/ tumours
B12 deficiency Hypercalcaemia
Non pressure hydrocephalus (/cebral atrophy)
depression - irritable

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61
Q

which type of dementia has an early onset

A

fronto-temporal

can be as young as 30

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62
Q

what is dyshomeostasis

A

homeostasis failure
impaired function of organ systems makes difficult
(frailty)

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63
Q

what is the cost common form of incontinence

A

stress incontinence

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64
Q

what are reasons for de-prescribing drugs

A

Adverse drug reaction - Drug-drug interaction - Drug-disease interaction
Better alternative - Not effective
Not indicated
Not evidence-based - Minimise polypharmacy

65
Q

why is stress incontinence common in women after menopause

A

lose protective effect of oestrogen and muscle begins to atrophy

66
Q

what drugs can be given to relax bladder sphincters

A

alpha blockers - tamsulosin, terazosin, indoramin

67
Q

what drugs should be stopped in delirium

A

anticholinergics, sedatives

indirectly harm brain - NSAIDs, ACEi

68
Q

what is important to think about when assessing someones spiritual health domain

A

whats important to them
whats the meaning of life
how you fit in
how they protect self image

69
Q

how does the effect of protein binding effect drug distribution

A

Decreased albumin, ↓ binding, ↑ serum levels acidic drugs e.g. furosemide (some drugs only active when unbound)

70
Q

what are common outcomes of a fall

A

injury (50%) - fracture, subdural haemorrhage
rhabdomyolysis (high CK)
fear of falling
- dependency, carer stress, institutionalisation

71
Q

list was to assess gait and balance

A

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

72
Q

how are creatine levels affected with ageing

A

although kidney function drops and creatine clearance reduces, levels stay the same due to muscle loss

73
Q

what is the optimal discharge time

A

when goals are met and before risks outweigh benefits

74
Q

what neuroinnervation increases strength and frequency of bladder contractions

A

parasympathetic S2-4

75
Q

what are some causes of urge incontinence

A 
bladder stone (dehydration) 
stroke
76
Q

what things are vital for balance

A

vision
hearing (vestibular)
proprioception
cerebellum

77
Q

what negative outcomes are associated with delirium

A

¥ Increased risk of death
¥ Longer length of stay
¥ Increased rates institutionalisation
¥ Persistent functional decline

78
Q

what causes reduced excretion of drugs by the kidneys in the elderly

A

renal function decreases with age

79
Q

why do you become incontinent when you fit

A

lose sympathetic inhibitory tone that stops the bladder from contracting

80
Q

what CNS connections mediated sphincter closure

A

reflex increase in a-adrenergic and somatic activity

81
Q

why are older people more prone to hypothermia

A

reduced peripheral vasoconstriction

reduced metabolic heat production

82
Q

what neuroinnervation causes detrouser to relax

A

sympathetic B-adrenoreceptor

T10-L2

83
Q

what type of muscles are the internal/ external urethral sphincter and detrouser

A

detrouser + internat - smooth

external - striated

84
Q

what is the ADME of pharmacology

A

absorption
distribution
metabolism
excretion

85
Q

list healthcare provider factors that contribute to polypharmacy
•

A

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

86
Q

how should you investigate incontinecne

A

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)

87
Q

what pathology arises form an underachieve bladder

A

neuropathic bladder

88
Q

what screening tool is used for delirium

A

4AT

89
Q

where is a suprapubic catheter inserted

A

1cm above pubic symphis

90
Q

why are older people more prone to heat stroke

A

reduced sweat gland output
reduced skin blood flow
smaller increase in cardiac output
less redistribution of blood flow from renal and splanchnic circulations

91
Q

why is the half life of many drugs increased in the elderly

A

reduced excretion form kidney

92
Q

why is assessing cognition important

A

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

93
Q

what is involved in the non-paharmacological management of dementia

A

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

94
Q

what drugs may be given if the delirious person is at harm to themselves or others

A

benzodiazepam

quetiapine (anti-psychotic)

95
Q

what is the screening tool for undernutrition

A

MUST

96
Q

what are risk factors for vascular dementia

A

vascular risk factors - T2DM, AF, IHD, PVD

97
Q

list some extrinsic causes that can precipitate a fall

A

inappropriate footwear
environmental hazards - uneven paving, carpet, stairs
poor lighting
unfamiliar environment (hospital)

98
Q

what are physical complications of immobility

A

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)

99
Q

what are early symptoms of fronts-temporal dementia

A

behavioural change
language difficulties
less memory effects early on

100
Q

what happens to the sensitivity of baroreceptors with age

A

reduce

101
Q

what 5 things would make someone benefit form a comprehensive geriatric assessment (FRAIL)

A

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)

102
Q

what are the benefits of being in hospital for the elderly

A

Access to clinical expertise
Access to complex tests and interventions
Rapid access to supervised care support

103
Q

what are some side effects of anti-muscarinics

A 
blurred vision 
constipation 
dry mouth 
reduced cognitions
vasodilation - falls
104
Q

how is the progression of vascular dementia

A

step wise

105
Q

how frequent are fall related deaths in the UK

A

every 5 hours

106
Q

what is frailty

A

A reduced ability to withstand illness without loss of function susceptible state, not an illness in its self

107
Q

what are detrimental affects of physiological aging

A

systolic hypertension

decreased reaction time

108
Q

what is the only effective treatment for a neuropathic bladder

A

catheterisation

109
Q

what things can cause orthostatic hypotension

A

primary autonomic failure
secondary autonomic failure p diabetic neuropathy
volume depletion - haemorrhage, diarrhoea, addison’s

110
Q

what things is a neuropathic bladder secondary to

A

near disease - MS, stroke

prolonged catheterisation

111
Q

at how many drugs are you guaranteed an ADR

A

9 - most elderly on

112
Q

what is the programmed theory of ageing

A

pre-determined, changes in gene expression during various stages (cell death – apoptosis)

113
Q

what tools is used to assess risk of osteoporosis

A

QFRACTURE, FRAX

114
Q

what is the name of the micturition centre in the brain

A

pontine micturition centre

115
Q

what are risk factors for frailty (DECLINE)

A 
D – diabetes/ insulin resistance
E- elderly
C – chronic disease
L – lack of use (of muscle)
I – inflammation 
N - nutritional deficiency 
E – endocrine dysfunction
116
Q

what is frailty scored on

A 
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
117
Q

what would you want to find in the history of cognitive impairment

A

onset - when , how rapid
course - fluctuating, progressive decline
associated - illnesses, functional loss

118
Q

what is social dyshomeostasis

A

difficulty caused by environmental insults e.g different ability to compensate for situations such as death, social isolation

119
Q

what does voluntary voiding of the bladder involve

A

voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder. (parasympathetic drive)

120
Q

what are the 5 domains of the frailty phenotype

A 
unintentional weight loss
exhaustion 
weak grip strength 
slow walking speed
low physical activity
121
Q

list things that can cause vertigo

A 
menieres
labrynthitis
benign paroxysmal positional vertigo
acute ear infection 
cerebellar/ brainstem pathology
122
Q

what is a safer way of treating urinary incontinence than long term catheterisation

A

intermittent catheterisation - 4x a day

123
Q

what symptoms would indicate a syncope over a seizure

A

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.

124
Q

what condition often co-exist with leeway body dementia

A

parkinsons

125
Q

list symptoms of ADRs in the elderly

A 
Unsteadiness/ falls	-
Dizziness/ drowsiness		
 Confusion
Nervousness		
Fatigue			
 Insomnia
Depression
Incontinence
126
Q

what are some pharmacological ways of managing dementia

A

Cholinesterase inhibitors - Mainly used in Alzheimers,
Galantamine licensed in mixed dementia
Rivastigmine in Dementia with Lewy Bodies

127
Q

what is fear of falling syndrome

A

loss of confidence in ability to walk - develop distinctive gat that actually increases your chances of falling

128
Q

what drug actually has a higher absorption in the elderly

A

levodopa (parkinsons) -

129
Q

what are the worst drugs for poly pharmacy

A
  1. NSAIDs
  2. Diuretics
  3. Warfarin
  4. ACEI
  5. Antidepressants
  6. Beta blockers
  7. opiates
  8. Digoxin
  9. Prednosiolone/ clopidogrel
130
Q

what are common symptoms of lewy body dementia

A

hallucinations (nightmares)
falls
very fluctuant

131
Q

what is regarded as failure of initial management for urinary incontinence (refer)

A

3 month of pelvic floor , cone therapy, medication

132
Q

what is subclavian steal syndrome (syncope)

A

blockage in subclavian artery, blood down verterbal artery to rigt arm instead of brain

133
Q

what is involved in the psychological health domain

A

mood - low, anxiety
confidence - fear of falling
cognition - dementia, delirium

134
Q

at what bladder volume do you become aware that you are full

A

250ml

135
Q

what pathology arises when the bladder outlet is too strong

A

urinary retention with overflow incontinence

136
Q

why does a neuopathic bladder lead to overflow incontinence

A

no awareness of bladder filling

137
Q

what is a fall

A

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

138
Q

what pathology arises from the bladder muscle being too strong

A

urge incontinence

139
Q

what 4 things contribute to good geriatric care

A

Early identification of need
Early Comprehensive Geriatric Assessment
Early provision of appropriate level of care for needs
Discharge plan or dignified death

140
Q

what are the 9 health domains of a comprehensive geriatric assessment

A 
medical
psychological 
functional - mobility/ living
behavioural
nutritional
spiritual 
environmental 
social
societal
141
Q

what are the key features of delirium

A

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

142
Q

what are red flags for syncope

A

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.

143
Q

how is urge incontinenc treated

A

anti-muscarinics (relax detrusor) e.g. oxybutinin, tolterodine, solifenacin

144
Q

why is hepatic metabolism of drugs affected in the elderly

A

decreased liver mass

decreased liver blood flow

145
Q

what neuroinnervation causes contractions of neck of bladder and internal urethral sphincter

A

sympathetic a-adrenoreceptor (T10-L2)

146
Q

what are risk factors for a fall

A 
muscle weakness 
history of falls
gait/ balance deficit 
use of assistive devices 
visual deficit 
arthritis
cognitive impairment 
age >80
147
Q

what lung volume changes with ageing

A

vital capacity

148
Q

why does the loading dose of digoxin have to be substantially lowered in the elderly

A

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

149
Q

what is th eMDT treatment of falls

A

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

150
Q

what symptoms would indicate a syncope over a seizure

A

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.

151
Q

what are causes of incontinence that are intrinsic to the urinary system

A

bladder outlet too weak or strong

urinary outlet too weak or strong

152
Q

what are common causes of Urinary retention with overflow incontinence

A

blockage of urethra
men - BPH
women - cervical cancer survivor, urethral stricture from radiotherapy

153
Q

what is involved int eh behavioural health domain

A

occupation
pastimes
habits - smoking, drinking unhealthy eating

154
Q

what should you do regularly for an elderly patient on many drugs

A

review regularly

remove any unnecessary drugs

155
Q

what are things you would want to gather from the collateral history after a syncope

A

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.

156
Q

what are risks of being in hospital for the elderly

A

Disorientation and delirium
Learned dependency Deconditioning – lose muscle strength
Iatrogenic harm – drug side effects
Hospital Acquired Infection

157
Q

what are characteristic features of Urinary retention with overflow incontinence

A

poor urine flow
double voiding
hesitancy
post micturition dribbling

158
Q

what type of memory do you lose first in alzheimers

A

recent memory - functional decline in daily activities

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