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Geriatrics Flashcards

1
Q

How have the trends in total fertility rate and life expectancy changed over the past seventy years?

A
  • Total fertility rate has decreased

- Life expectancy at birth has increased

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2
Q

In which development regions has the population aged 60 or over increased the most?

A

Less developed regions

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3
Q

What are the causes of the increasing age of the population?

A
  • Increased resources available
  • Better economic conditions
  • Improved screening programs
  • Better outcome following major events (cardiac, stroke and surgery)
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4
Q

What are the consequences medically of the population getting older?

A
  • More people survive a major event

- More people have several co-morbid conditions

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5
Q

What is the difference between primary and secondary ageing?

A

Primary - innate maturational processes

Secondary - the effects of environment and disease

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6
Q

What is the Stochastic theory of ageing?

A

That ageing is the result of accumulative damage and therefore is random

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7
Q

What is the Programmed theory of ageing?

A

That ageing is predetermined and changes in gene expression happen at various stages

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8
Q

Name the components that make up the physiology of ageing?

A
  • Affects virtually every organ system

- Marked inter-individual variability in both development and magnitude of changes

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9
Q

What happens to blood pressure as you age?

A
  • Systolic blood pressure increases

- Diastolic blood pressure increases until roughly 50 before it starts to decline

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10
Q

What happens to cardiac output with increasing age?

A

It tends to decrease with age

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11
Q

How is the respiratory system affected by age?

A

Total lung capacity stays the same but Vital Capacity (useful part) tends to decrease

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12
Q

What is frailty?

A

A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge

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13
Q

Name the “frailty syndromes”

A

Falls, delirium, immobility and incontinence

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14
Q

What happens to baroreflex sensitivity with age?

A

It tends to decrease

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15
Q

Why are frail people more likely to develop hypothermia?

A

Reduced peripheral vasoconstriction

Reduced metabolic heat production

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16
Q

Why are frail people more likely to develop hyperthermia than non frail people?

A

Reduced sweat cell production
Reduced skin blood flow
Smaller increase in cardiac output
Less diversion of blood flow from renal and splanchnic circulations

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17
Q

What is social dyshomeostasis?

A

Difficulty caused by environmental insults not only bio-medical (e.g. death of spouse or daughter going on holiday)

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18
Q

How do signs and symptoms change in people with frailty?

A

They can present with several conditions at once and even for one condition the presentation can be completely different

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19
Q

How is frailty measured?

A

Frailty index: 70 item CSHA Frailty index

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20
Q

Name the criteria of the frailty phenotype

A 
Unintentional weight loss
Exhaustion
Weak grip strength
Slow walking speed
Low physical activity
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21
Q

List the 9 stages on the clinical frailty scale

A

1: Very fit
2: Well
3: Managing well
4: Vulnerable
5: Mildly frail
6: Moderately frail
7: Severely frail
8: Very severely frail
9: Terminally ill

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22
Q

Name the three stages on the scale of frailty in those with dementia

A

Mildly: common symptoms
Moderately: memory is severely impaired
Severe: cannot manage personal care

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23
Q

List the different health domains

A

Medical, psychological, functional, behavioural, nutritional, spiritual, environmental, social and societal

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24
Q

What is a Comprehensive Geriatric Assessment?

A

A process to assess and manage illness in older people with frailty

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25
Q

What does a Comprehensive Geriatric Assessment involve?

A
  • Determine what the problems are:
    • Multiple medical problems
    • Multiple health domains
  • Determine what we can reverse and what we can make better
  • Produce a management plan
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26
Q

What are the extrinsic causes of incontinence?

A
  • Physical state and co-morbidities
  • Reduced mobility
  • Confusion
  • Drinking too much/wrong time
  • Medications e.g. diuretics
  • Constipation
  • Home circumstances
  • Social circumstances
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27
Q

What is the local innervation to the bladder?

A

Parasympathetic: S2-4
Sympathetic: T10-L2 and T10-S2
Somatic: S2-4

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28
Q

Which parts of the brain are involved in maintaining continence?

A

Pontine micturition centre, frontal cortex and caudal part of the spinal cord

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29
Q

Name the characteristic features of stress incontinence

A
  • Urine leak on movement, coughing, laughing, squatting etc.
  • Weak pelvic floor muscles
  • Common in women with children esp. after menopause
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30
Q

How is stress incontinence treated?

A

Physio, oestrogen cream, duloxetine (SSR) and colposuspension/TVT

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31
Q

Name the characteristic features of urge incontinence

A
  • Detrusor contracts at low volume
  • Sudden urge to pass urine immediately
  • Can be caused by bladder stones or stroke
32
Q

How can urge incontinence be managed?

A

Bladder retraining can be useful

Anti-muscarinics e.g. oxybutinin, tolterodine, solifenacin

33
Q

Name the characteristic features of urinary retention with overflow incontinence

A
  • Poor urine flow, double voiding, hesitancy and post micturition dribbling
  • Blockage to the urethra
  • Older men with BPH
34
Q

How can urinary retention with overflow incontinence be treated?

A

Alpha blocker or anti-androgen

May need catheterisation (often suprapubic)

35
Q

Name the main drugs used to treat incontinence

A
  • Antimuscarinics: relax detrusor e.g. oxybutinin, tolterodine, solifenacin
  • Beta-3 adrenoceptor agonists: relax detrusor e.g. mirabegron
  • Alpha blockers: relax sphincter and bladder neck e.g. tamsulosin, terazosin and indoramin
  • Anti-androgen drugs: shrink prostate e.g. finasteride and dutasteride
36
Q

What are the characteristic features of neuropathic bladder?

A
  • “underactive bladder”
  • Secondary to neurological disease (MS or stroke)
  • No awareness of bladder filling resulting in overflow incontinence
37
Q

How can neuropathic bladder be managed?

A

Parasympathomimetics may help

Catheterisation is only effective treatment

38
Q

How can incontinence be assessed?

A 
History (inc. good social history)
Intake chart and urine output diaries
General exam
Urinalysis and MSSU
Bladder scan
Consider referall to incontinence clinic
39
Q

What are the indications for referring someone with urinary incontinence to the specialists?

A
  • Failure of initial management (max 3 months of exercises, habit retraining and/or appropriate medication
  • At onset: fistula, palpable bladder, CNS disease, certain gynae conditions, severe BPH or prostatic carcinoma. PH of continence surgery and those without a diagnosis
40
Q

What are the indications for referring someone with faecal incontinence to specialists?

A
  • Referral after failure of initial management

- At onset: suspected sphincter damage or neurological disease

41
Q

What are the last resort management options for incontinence?

A

Incontinence pads, urosheaths, intermittent catheterisation, long term urinary catheter and suprapubic catheter

42
Q

What are the key features of delirium?

A
  • Disturbed consciousness
  • Change in cognition
  • Acute onset and fluctuant
43
Q

What are the common (not key) features of delirium?

A
  • Disturbance of sleep wake cycle
  • Disturbed psychomotor behaviour (affects physical function)
  • Emotional disturbance
44
Q

What can precipitate delirium?

A
  • Infection (not always UTI)
  • Dehydration
  • Biochemical Disturbance
  • Pain
  • Drugs
  • Constipation/ urinary retention
  • Hypoxia
  • Alcohol/Drug Withdrawal
  • Sleep Disturbance
  • Brain Injury: stroke, tumour, bleed etc.
  • Changes in environment/emotional distress
45
Q

What are the consequences of delirium?

A
  • Massive morbidity and mortality
  • Increased risk of death
  • Longer length of stay
  • Increased rates of institutionalisation
  • Persistent functional decline
46
Q

Which screening tool can be used to check for delirium?

A

4AT

47
Q

What do you do if you find delirium?

A
  • Treat the cause: full history + exam and TIME bundle
  • Explain the diagnosis
  • Pharmacological measures
  • Non-pharmacological measures
48
Q

List the non-pharmacological options for treating delirium

A
  • Re-orientate and reassure agitated patients
  • Encourage early mobility and self-care
  • Normalise sleep-wake cycle
  • Ensure continuity of care (avoid hospitalisation if possible and avoid frequent ward or room transfer)
  • Avoid urinary catheterisation/ venflons
  • Discharge people asap
49
Q

What are the pharmacological options for managing delirium?

A
  • Stop bad drugs
  • Only treat with drugs if danger to themselves/others or distress which cannot be settled any other way
  • 12.5mg quetiapine orally (senior doctor decision)
50
Q

Which basic measures can help prevent delirium?

A
  • Orientating patients
  • Ensuring patients have glasses/ hearing aids
  • Promoting sleep hygiene
  • Early mobilisation
  • Pain control
  • Prevention and treatment of post-op complications
  • Hydration and nutrition
  • Regulation of bladder and bowel function
  • Oxygen if appropriate
  • Medication review
51
Q

What is the connection between delirium and falls?

A
  • 4.5% more likely to fall if they have delirium

- Delirium prevention also reduces falls

52
Q

Should urine dipsticks be used to diagnose UTIs in older people?

A

No

53
Q

Should asymptomatic UTIs in older people be treated with antibiotics?

A

No

54
Q

Name some of the causes of falls

A

-MSK e.g. arthritis
-Drugs e.g. antihypertensives, sedatives and alcohol
-Neuro e.g. stroke, parkinsonism, dementia, delirium etc.
-Sensory e.g. visual impairment, inattention
-CVS e.g. postural hypotension, arrythmia, HF and aortic stenosis
Incontinence (rushing to the toilet)
-Generall unwellness

55
Q

How do drugs cause falls?

A

Decrease: BP, HR and awareness
Increase: urine output, sedation, hallucinations, qTC and dizziness

56
Q

Which drugs are responsible for falls?

A 
Anti-hypertensives
Beta blockers
Sedatives
Anticholinergics
Opioids
Alcohol
57
Q

Which MDT members are present at a fall clinic and what is done?

A

Nurse: eye testm ECG, BP (lying + standing), incontinence questionnaire and MMSE
Physio: gait and balance
Doctor: history and exam
MDT Discussion

58
Q

Which pathologies are associated with the following gaits:

  • Ataxic
  • Arthralgia
  • Hemiplegic
  • Small steps/shuffling
  • High stepping
A 
Cerebellar damage
Arthritis
Stroke
Parkinsonism (vascular)
Peripheral Neuropathy
59
Q

How are falls assesses in A&E?

A
  • ABCDE
  • Assess and Treat Injuries
  • How did they fall
  • Long lie
  • History of falls
  • Cognitive impairment, incontinence, syncope, seizure, drunkenness etc.
  • Ambulance sheet and relatives
  • Bloods
  • Exam (neuro/chest/heart/abdo)
  • Obs
  • ECG
  • 4AT for delirium
  • CT head if head injury + neurological signs or anticoagulated
  • Blood glucose
60
Q

Which injuries do you check for when a patient has fallen?

A
  • Head injury and extra dural
  • Seizure
  • C spine
  • Abdo injury
  • Pelvic injury
  • Limb fracture
61
Q

When is a head CT indicated immediately in patients who have fallen?

A
  • GCS <13
  • Still confused after 2 hrs (or not back to baseline)
  • Focal neurology
  • Signs of skull fracture
  • Basal skull fracture (CSF leak + bruising around eyes)
  • Seizure
  • Vomiting
  • Anti-coagulation
62
Q

What causes falls in inpatients?

A
  • Same things as outpatients
  • Hypotension (postural or illness)
  • New meds
  • Low blood glucose
  • Getting sicker
  • Delirium
  • Deconditioning
  • Call bells, zimmer frames out of reach
63
Q

Give examples of common iatrogenic drugs and the problems they cause

A
  • Anticholinergics: confusion, dry mouth, constipation, blurred vision, urinary retention and orthostatic hypotension
  • Tricyclics: confusion and unsteady gait
  • Digoxin: toxicity
  • Long acting benzodiazepines: CNS toxicity
  • Narcotics: confusion
64
Q

List the costly medication related problems in older patients

A
  • Falls
  • Cognitive loss/delirium
  • Dehydration
  • Incontinence
  • Depression
  • Loss of functional capacity
  • Poor quality of life
  • Nursing home placement
65
Q

Why are older patients prescribed on average 2-3 times more prescriptions?

A
  • More acute and chronic disease
  • More doctors visits
  • Given to counteract the side effect of another drug
  • Prescribers, patients and the system
66
Q

Which adverse drug effects can look like growing old?

A
  • Unsteadiness
  • Dizziness
  • Confusion
  • Nervousness
  • Fatigue
  • Insomnia
  • Drowsiness
  • Falls
  • Depression
  • Incontinence
67
Q

Which healthcare provider factors can contribute to polypharmacy?

A
  • No regular review of meds
  • Patient may expect meds
  • Lack of knowledge of geriatric pharmacology
  • Too many different people involved
  • Evidence doesn’t include co-morbidities
  • Repeat prescriptions
  • No effort to simplify regimen
68
Q

Which drugs have the highest admissions due to ADRs (highest to lowest)?

A

NSAIDs, diuretics, warfarin, ACEI, antidepressants, beta-blockers, opiates, digoxin, prednisolone and clopidogrel

69
Q

What happens to absorption in older patients?

A

Rate is slower but the extent is the same - may lead to a delay in the onset of action

70
Q

What happens to distribution in older patients?

A
  • Increased adipose tissue: any drug which is lipid soluble will have a greater distribution and as such a longer half life
  • Reduced body water: increased serum levels of water soluble drugs
  • Protein binding changes: decreased albumin leads to increased serum levels of acidic drugs
  • Increased permeability across the blood-brain barrier
71
Q

How is the metabolism of drugs effected in older patients?

A

-Hepatic metabolism is reduced: may cause toxicity and reduced first pass metabolism

72
Q

How is the excretion of drugs effected in older patients?

A
  • Renal function decreases with age

- Reduced clearance and increases half-life of many drugs

73
Q

How does the pharmacodynamics change in older patients?

A
  • Increased sensitivity to particular medicines
  • Changes in receptor binding, decrease in receptor number and altered translation of a receptor initiated cellular response into a biochemical reaction
74
Q

Which psychiatric drugs are most likely to cause adverse drug effects?

A
  • Sedatives (benzodiazepines): falls and confusion
  • Anti-psychotic: postural hypotension, stroke, confusion and movement disorders
  • Anti-depressants
75
Q

Which analgesics are more likely to cause adverse drug effects?

A
  • Opioids

- NSAIDS: renal impairment and GI bleeding

76
Q

Which drugs are likely to cause cardio adverse drug reactions?

A
  • Digoxin
  • Diuretics
  • Anti-hypertensives
  • Anti-coagulants
77
Q

Which adverse effects can antibiotics increase the risk of?

A
  • Diarrhoea and C. diff
  • Blood dyscrasias
  • Delirium
  • Seizures
  • Renal impairment

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