Geriatrics Flashcards
What are the geriatric giants?
The biggest problems faced in care of the older person. These are falls/mobility issuses, mind/cognitive problems, medications/polypharmacy, multicomplexity, and matters most.
An elderly patient comes in with a #NOF. Where can you access information on the patient before you talk to them?
GP summary letter - ask ward clerk to request it.
System One
ICE discharge summaries
Pt may have a care plan with them.
An elderly patient comes in with a #NOF. Who can you talk to before going to see the patient?
Nursing staff
GP if it’s the right time of day
Whoever was with him when he was brought in
Carers if available
What kinds of hidden issues may you need to uncover in a pt with complex care needs?
Not coping
Loneliness
Depression
Struggling with living in their home
Where can you get a collateral history from?
Family
Friends
Carers
GP if it’s the right time of day
How should a falls history start? What follow-up questions can you ask to flesh this out?
What happened? Tell me the story.
Follow up with specific questions about before the fall, during the fall/episode, and after the fall.
What is the difference between a fall and a syncopal episode?
There is LoC with a syncopal episode
What are the big causes of syncopal episodes, from least sinister to most?
Vasovagal syncope
Postural hypotension
Cardiac
Irregular heart beat/cardiac
What questions do you want to ask about the period before a fall?
Where were they, what were they doing, was anyone else there, were they otherwise well, symptoms before the fall, what was the environment of the fall, had they been drinking enough fluids, had they drank any alcohol or taken any illicit drugs?
What symptoms would be important to ask about before a fall?
Cardiac - palpitations, chest pain, SoB
Epilepsy - prodrome e.g. a certain smell
Vertigo (vestibular, proprioceptive, or visual cause?)
Light-headedness
What do we want to know about the during part of a fall?
Was there LoC?
If so how long did it last?
Collateral - muscle tone (reduced tone or increased)
Other injuries - did they hit their head, how did they land?
Incontinence?
Tongue biting?
What do we want to know about the period after the fall?
How long were they on the floor?
Confusion/incontinence/tongue biting - post ictal?
Pain
Neurological symptoms (stroke/TIA)?
What do we want from the PMHx of a person who has fallen?
Anything that increases the risk of falls, osteoporosis, bleeding, and pretty much everything else too. Vision Cognitive impairment Cardiac conditions Epilepsy Arteriopath
What else do we want to know about the situation surrounding a fall, apart from the immediate before during and after?
Baseline - mobility, are they coping at home, is there anyone else at home (to care for them or who they are a carer for)
?PoC
Hydration
Other signs - infective signs (e.g. temperature, SoB, urinary symptoms) leg oedema
Previous falls
Why is a drug history important in a falls patient?
Some medications increase risk of falls, osteoporosis, and bleeds.
Polypharmacy can contribute to falls risk.
May not be taking medications
Allergies :)
Which drugs may increase risk of falls, and why?
Sedatives Opiates Other analgesics e.g. for neuropathic pain Antihypertensives Anticholinergics Antiarrhythmics Antipsychotics Other psychoactive drugs Duiretics
What is postural hypotension?
A symptom of an underlying problem.
Unsteadiness due to drop in blood pressure when moving from lying to standing of systolic 20mmHg or more, or diastolic 10mmHg or more.
Who is at risk of postural hypotension?
The elderly Those with autonomic neuropathy Pts on antihypertensives Pts on diuretics Multi-system atrophy
An elderly pt is brought into A and E after a fall.
What clues in the history would lead you to suspect a fall secondary to postural hypotension?
Fall occured after change in position e.g. standing from a chair, getting out of bed. Hx of recent dehydration Lightheadedness or weakness Loss of consiousness Blurred vision or changes in hearing. Older person Extensive drug hx
Which conditions that affect BP regulation can increase falls risk?
Anaemia Arrythmias Carotid sinus hypersensitivity COPD Dehydration Infections Metabolic disturbance Micturition syncope Postural hypotension Postprandial hypotension Valvular heart disorders
Which conditions that affect central processing/cognition can increase falls risk?
Dementia
Delirium
Stroke
Which conditions that affect gait can increase falls risk?
Arthritis
Foot deformities
Muscle weakness
Which conditions that affect postural/neuromotor function can increase falls risk?
Cerebellar degeneration/stroke Myelopathy Parkinson’s Peripheral neuropathy Stroke Vertebrobasilar insufficiency
Which conditions that affect proprioception can increase falls risk?
Peripheral neuropathy
Vitamin B12 deficiency
Which conditions that affect otolaryngological function can increase falls risk?
Acute labyrinthitis
BPPV
Hearing loss
Meniere disease
Which conditions that affect vision can increase falls risk?
Cataract
Glaucoma
Macular degeneration
What do we want to examine in a patient following a fall?
Anything that could:
- Explain the fall
- Check for complications/consequences of the fall
What might we look for on examination/assessment to find a cause for a fall?
Obs and bedside tests - PR and rhythm, L/S BP, ECG, urine dip Neuro examination Cognitive assessment Cardiac inc. murmurs Gait assessment Sign of infection - chest, UTI Abdomen - pain, constipation Hydration status and nutrition
Depends on the history and the pt - pick and choose.
What might we look for on examination/assessment to find any consequences following a fall?
Head - haematoma, level of consiousness, battle/raccoon sign, bruising or abrasions/lacerations.
Joints (depending on how they landed or where pain is) - e.g. hip, wrist/hand, shoulder… could be any of them.
Other lacerations/bruises.
What tool can we use to help us do a medication review on a patient who has fallen?
STOPP-START tool
What might we start drugs wise for a pt who has had a fall?
Bone protection - vitamin D, calcium, and bisphosphonates
Adjust drugs to maximise control of risk factor conditions.
What are the risk factors for osteoporosis?
Non modifiable: Post menopausal Increasing age Ethnicity Previous #
Modifiable: Vitamin D deficiency Reduced mobility BMI under 18.5 Smoking Alcohol
Iatrogenic: Steroids PPIs Antipsychotics/antiepileptics Breast/prostate cancer drugs
Other: CKD Chronic liver disease Thyroid/endocrine disease Malabroption
What is the difference between osteoporosis and osteopenia?
Bone density - osteopenia has higher bone density.
Where can I revise Parkinson’s disease?
In my N and SS deck for Neurology
Why do elderly patients and pts in hospital need slightly different proportions of the food groups to everyone else?
They have higher metabolic demands for healing etc, they may have a deficit that needs correcting, or if they have malabsorption they will need to maximise calorie and vitamin intake. Priorities!
Which group of patients are at risk of dehydration?
Pts with cognitive impairment Pts who are NBM Pts who are unable to feed themselves Pts who have dysphagia Pts on diuretics Pts with D+V Pts on fluid restriction e.g. for CKD/HF
What conditions has evidence shown good hydration helps with?
Pressure ulcers Constipation Blood clots Kidney and gallstones Heart disease Low BP Managing diabetes Poor oral health Confusion UTIs Incontinence
Basically everything :)
How can we make a hospital a good environment for a person to eat in?
Sit them upright at a table Good lighting Good table height Suitable eating and drinking equipment Protected mealtimes
What 3 ways does a patient become malnourished?
Nutritional intake falls
Nutritional requirement increases
Nutritional losses increase
Why might patients eat or drink less in hospital?
- Dislike hospital food
- Immobility -> less nutritional demand
- Cognitive problems -> forget to eat
Who can assess a patient if they have nutritional needs or eating probkems?
What can they do?
- Dietician - maximise nutritional value of food
- SALT - modify food consistency, assess swallowing
- Occupational therapy - suggest ways to aid pt in eating with home modifications
- Physiotherapy - mobility for reduced pressure sores and risk of aspiration
What different feeding methods are there?
- Oral +/- supplementation
- NG tube
- NJ tube
- PEG
- TPN
What is refeeding syndrome?
Metabolic and physiological consequence of depletion and repletion, compartmental shifts and interrelatioship between phosphate, Magnesium, potassium, glucose metabolism, vitamin deficiency, and fluid restriction.
When is a pt at risk of refeeding syndrome?
Little or no nutritional input for 5 days
When is a pt at HIGH risk of refeeding syndrome?
One of:
- BMI under 16
- Over 15% weight loss
- No nutritional intake for 10+ days
- Low blood K/Mg/phosphate
How should a pt at risk of refeeding syndrome be refed?
Consider starting feeds at 10kcal/kg/day and increase slowly over 4-7 days
How should a pt at HIGH risk of refeeding syndrome be refed?
Consider starting feeds at 5kcal/kg/day and increase slowly while monitoring cardiac rhythmn continually.
What % of pts over 85 die within a year of a hospital admission?
50%
What needs to be considered when transferring a pt from an acute setting to a community hospital?
Why are they being transferred, is it appropriate?
What are the alternatives?
Has home first been considered?
Consider bed-blocking risk
What are the 5 most common problems causing disability in people over 65?
- Foot problems
- Arthritis
- Cognitive impairment
- Heart problems
- Vision problems
How does the body change as it gets older?
There is change in body composition (reduced muscle bulk and lean body mass) Bone mass and strength reduces Blood volume reduces Ventilatory capacity reduces Motility of bowel changes
What are the general priniciples to managing older patients?
- Treat unstable medical problems and things contributing to disability
- Review drugs
- Early mobilisation
- Nutritional support
- Comprehensive rehabitilation
- Social support
- Psychological support
What simple measures can improve an elderly persons quality of life?
Hearing aids Glasses Good footwear Home adjustments Pain management Friendship
What is chronic pain?
Pain that persists depsite adequate healing time, or pain that lasts for longer than 12 weeks.
How common is it for a patient with chronic pain to also have depression?
50% of patients with chronic pain also have depression
What socioeconomic factors increase a patients risk of chronic pain?
Unemployment
Family stress
Lack of social support
Are traditional analgesics effective at treating chronic pain?
No - in fact they can sometimes worsen the problem by adding additional factors e.g. stomach ulcers, addiction to opiates etc.
What is the approach usually taken to chronic pain?
Hollistic approach woth focus on all factors and general improvement of QoL.
What are the 3 aspects of assessment for a patient with chronic pain?
- Biomedical factors
- Psychological factors
- Social factors
What is meant by the yellow flags of chronic pain?
Features associated with poor outcomes in chronic pain.
What biomedical yellow flags might there be for a patient in chronic pain?
Multiple sites of pain
Non-organic signs
Increased severity at presentation
Severe disability at presentation
What psychological yellow flags might there be for a patient in chronic pain?
- Belief that pain indicates physical harm
- Lack of motivation
- Preferring passive over active treatment
- Avoidance of activity
- Catastrophising
- Belief in alternative therapies
What social yellow flags might there be for a patient in chronic pain?
- Expecting not to return to work
- Manual worker
- Poor work relationships
- Lack of control over working hours
- Medico-legal issues
What are the most common underlying causes of chronic pain?
- RA
- OA
- Lower back pain
- IBS
- Polymyalgia rheumatica
- Chronic fatigue syndrome
- Somatic symptoms
- Fibromyalgia
- Thyroid disease
Why should overinvestigation be avoided in a chronic pain case?
Can lead to heightened anxiety which can worsen pain
What are the basic principles of managing chronic pain?
- Treat underlying cause
- MDT approach inc. social care
- Consider neuropathic pain management options
- Encourage active participation by the patient
- Minimise use of medication
- Improve QoL
Should opiate or non-opiate analgesia be the mainstay of pharmacological treatment of chronic pain?
Non-opiate - opiates have poor evidence for chronic pain and can easily be abused.
What psychological interventions can we employ for chronic pain management?
- CBT
- Relaxation therapies/mindfullness
Other than medical and psychological intervetnions, what simple measures can we recommend to help with chronic pain?
- Encourage regular exercise and activity
- Physiotherapy
- Occupational therapy assessment
Where do pressure ulcers tend to develop?
Over bony prominences such as the sacrum or the heel
What 4 factors predispose someone to pressure ulcers?
- Malnourishment
- Incontinence
- Reduced mobility
- Pain
How is risk of pressure ulcers assessed?
Using Waterlow score
What is a grade 1 pressure ulcer?
Non-blanchable erythema of intact skin
What is a grade 2 pressure ulcer?
Partial thickness of skin loss i.e. superficial ulcer.
What is a grade 3 pressure ulcer?
Full thickness skin loss + damage to/necrosis of subcut tissues (but not the underlying fascia)
What is a grade 4 pressure ulcer?
Extensive destruction/tissue necrosis/damage to muscle, bone, or supporting structures
How should a pressure ulcer be managed?
- Consider referral to tissue viability nurse
- Use of hydrocolloid dressings and hydrogels
- Surgcal debridement or swabbing can be considered if indicated
What is Paget’s disease of the bone?
A common degenerative bone disease characterised by increased bone remodelling at localised sites leading to reduced bone integrity.
How is Paget’s disease of the bone usually picked up?
Incidentally, usually from raised ALP or from abnormal x-ray.
Which parts of the body does Paget’s disease of the bone usually affect?
Skull
Spine
Pelvis
Long bones of legs
Is Paget’s disease of the bone the most common degenerative bone disorder?
No, osteoporosis is.
Which demographic groups is Paget’s disease of the bone common in?
Anglo-saxon heritage i.e. UK, Australia, NZ, and North America.
How does Paget’s disease of the bone typically present?
It doesn’t!
But if one of the 15-40% of cases that have symptoms presents:
- Bone pain most commonly
- Deformity
- Pathological fracture
- Deafness/headaches if skull affected
- Bowing deformity of long bones
Is Paget’s disease of the bone systemic?
No - unlike osteoporosis it only affects one site in the body.
What is the pathophysiology of Paget’s disease of the bone?
Increased number and size of osteoclasts, and increased activity of osteoblasts causing accelerted bone turnover causing disorganised matrix.
Bone increases in size but becomes more brittle and thus more prone to fracture.
What blood tests support a diagnosis of Paget’s disease of the bone?
Raised ALP (ask for bone specific ALP to exclude liver origin, or include GGT to rule out liver related causes).
Are calcium and phosphate derrnged in Paget’s disease of the bone?
No, they are usually normal.
How does Paget’s disease of the bone appear on x-ray?
- Widened bone cortex
- Mixed areas of sclerosis and lysis
- Bone thickening and bone deformities
Why should vitamin D be checked if you suspect Paget’s disease of the bone?
- To rule out other pathology/cause of raised ALP
2. To assess appropriateness of bisphosphonate therapy
When should Paget’s disease of the bone be treated?
If it is causing symptoms, or there is significant biochemical abnormality.
What qualifies as a significant biochemical abnormality in Paget’s disease of the bone?
ALP >2x normal
How is Paget’s disease managed?
Bisphosphonates to inhibit osteoclast activity, alongside supplementation of Calcium and Vitamin D.
Treat any complications.
What is the bisphosphonate of choice for Paget’s disease of the bone?
Zolendronic acid - 5mg over 15 minutes infusion, induces remission for 2-3 years.
If a patient with Paget’s disease of the bone cannot tolerate a bisphosphonate what drug can be given to reduce disease progression?
Calcitonin
What are the possible side effects of bisphosphonates?
- Osteonecrosis of the jaw
- Bone pain
- Flu-like symptoms
What is the main complication of Paget’s disease of the bone, aside from pathological fractures?
Increased risk of bone tumours, particularly osteosarcoma.
Why are older patients at risk of polypharmacy?
Higher prevalence of chronic and multiple illness so more likely to be prescribed multiple medications.
What tools can we use to reduce risk of ADRs and polypharmacy in the elderly?
STOPP START tool
What medications should we consider stopping according to the STOPP START tool?
- Digoxin
- Diuretics and thiaides
- Beta blocker + verapamil
- Aspirin + warfarin
- Sedatives and central acting agents
- NSAIDs
- Opiates
- Drugs causing Parkinsonism
