Geriatrics Flashcards
How have the trends in total fertility rate and life expectancy changed over the past seventy years?
- Total fertility rate has decreased
- Life expectancy at birth has increased
In which development regions has the population aged 60 or over increased the most?
Less developed regions
What are the causes of the increasing age of the population?
- Increased resources available
- Better economic conditions
- Improved screening programs
- Better outcome following major events (cardiac, stroke and surgery)
What are the consequences medically of the population getting older?
- More people survive a major event
- More people have several co-morbid conditions
What is the difference between primary and secondary ageing?
Primary - innate maturational processes
Secondary - the effects of environment and disease
What is the Stochastic theory of ageing?
That ageing is the result of accumulative damage and therefore is random
What is the Programmed theory of ageing?
That ageing is predetermined and changes in gene expression happen at various stages
Name the components that make up the physiology of ageing?
- Affects virtually every organ system
- Marked inter-individual variability in both development and magnitude of changes
What happens to blood pressure as you age?
- Systolic blood pressure increases
- Diastolic blood pressure increases until roughly 50 before it starts to decline
What happens to cardiac output with increasing age?
It tends to decrease with age
How is the respiratory system affected by age?
Total lung capacity stays the same but Vital Capacity (useful part) tends to decrease
What is frailty?
A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge
Name the “frailty syndromes”
Falls, delirium, immobility and incontinence
What happens to baroreflex sensitivity with age?
It tends to decrease
Why are frail people more likely to develop hypothermia?
Reduced peripheral vasoconstriction
Reduced metabolic heat production
Why are frail people more likely to develop hyperthermia than non frail people?
Reduced sweat cell production
Reduced skin blood flow
Smaller increase in cardiac output
Less diversion of blood flow from renal and splanchnic circulations
What is social dyshomeostasis?
Difficulty caused by environmental insults not only bio-medical (e.g. death of spouse or daughter going on holiday)
How do signs and symptoms change in people with frailty?
They can present with several conditions at once and even for one condition the presentation can be completely different
How is frailty measured?
Frailty index: 70 item CSHA Frailty index
Name the criteria of the frailty phenotype
Unintentional weight loss Exhaustion Weak grip strength Slow walking speed Low physical activity
List the 9 stages on the clinical frailty scale
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
Name the three stages on the scale of frailty in those with dementia
Mildly: common symptoms
Moderately: memory is severely impaired
Severe: cannot manage personal care
List the different health domains
Medical, psychological, functional, behavioural, nutritional, spiritual, environmental, social and societal
What is a Comprehensive Geriatric Assessment?
A process to assess and manage illness in older people with frailty
What does a Comprehensive Geriatric Assessment involve?
- 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
What are the extrinsic causes of incontinence?
- Physical state and co-morbidities
- Reduced mobility
- Confusion
- Drinking too much/wrong time
- Medications e.g. diuretics
- Constipation
- Home circumstances
- Social circumstances
What is the local innervation to the bladder?
Parasympathetic: S2-4
Sympathetic: T10-L2 and T10-S2
Somatic: S2-4
Which parts of the brain are involved in maintaining continence?
Pontine micturition centre, frontal cortex and caudal part of the spinal cord
Name the characteristic features of stress incontinence
- Urine leak on movement, coughing, laughing, squatting etc.
- Weak pelvic floor muscles
- Common in women with children esp. after menopause
How is stress incontinence treated?
Physio, oestrogen cream, duloxetine (SSR) and colposuspension/TVT
Name the characteristic features of urge incontinence
- Detrusor contracts at low volume
- Sudden urge to pass urine immediately
- Can be caused by bladder stones or stroke
How can urge incontinence be managed?
Bladder retraining can be useful
Anti-muscarinics e.g. oxybutinin, tolterodine, solifenacin
Name the characteristic features of urinary retention with overflow incontinence
- Poor urine flow, double voiding, hesitancy and post micturition dribbling
- Blockage to the urethra
- Older men with BPH
How can urinary retention with overflow incontinence be treated?
Alpha blocker or anti-androgen
May need catheterisation (often suprapubic)
Name the main drugs used to treat incontinence
- 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
What are the characteristic features of neuropathic bladder?
- “underactive bladder”
- Secondary to neurological disease (MS or stroke)
- No awareness of bladder filling resulting in overflow incontinence
How can neuropathic bladder be managed?
Parasympathomimetics may help
Catheterisation is only effective treatment
How can incontinence be assessed?
History (inc. good social history) Intake chart and urine output diaries General exam Urinalysis and MSSU Bladder scan Consider referall to incontinence clinic
What are the indications for referring someone with urinary incontinence to the specialists?
- 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
What are the indications for referring someone with faecal incontinence to specialists?
- Referral after failure of initial management
- At onset: suspected sphincter damage or neurological disease
What are the last resort management options for incontinence?
Incontinence pads, urosheaths, intermittent catheterisation, long term urinary catheter and suprapubic catheter
What are the key features of delirium?
- Disturbed consciousness
- Change in cognition
- Acute onset and fluctuant
What are the common (not key) features of delirium?
- Disturbance of sleep wake cycle
- Disturbed psychomotor behaviour (affects physical function)
- Emotional disturbance
What can precipitate delirium?
- 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
What are the consequences of delirium?
- Massive morbidity and mortality
- Increased risk of death
- Longer length of stay
- Increased rates of institutionalisation
- Persistent functional decline
Which screening tool can be used to check for delirium?
4AT
What do you do if you find delirium?
- Treat the cause: full history + exam and TIME bundle
- Explain the diagnosis
- Pharmacological measures
- Non-pharmacological measures
List the non-pharmacological options for treating delirium
- 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
What are the pharmacological options for managing delirium?
- 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)
Which basic measures can help prevent delirium?
- 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
What is the connection between delirium and falls?
- 4.5% more likely to fall if they have delirium
- Delirium prevention also reduces falls
Should urine dipsticks be used to diagnose UTIs in older people?
No
Should asymptomatic UTIs in older people be treated with antibiotics?
No
Name some of the causes of falls
-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
How do drugs cause falls?
Decrease: BP, HR and awareness
Increase: urine output, sedation, hallucinations, qTC and dizziness
Which drugs are responsible for falls?
Anti-hypertensives Beta blockers Sedatives Anticholinergics Opioids Alcohol
Which MDT members are present at a fall clinic and what is done?
Nurse: eye testm ECG, BP (lying + standing), incontinence questionnaire and MMSE
Physio: gait and balance
Doctor: history and exam
MDT Discussion
Which pathologies are associated with the following gaits:
- Ataxic
- Arthralgia
- Hemiplegic
- Small steps/shuffling
- High stepping
Cerebellar damage Arthritis Stroke Parkinsonism (vascular) Peripheral Neuropathy
How are falls assesses in A&E?
- 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
Which injuries do you check for when a patient has fallen?
- Head injury and extra dural
- Seizure
- C spine
- Abdo injury
- Pelvic injury
- Limb fracture
When is a head CT indicated immediately in patients who have fallen?
- 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
What causes falls in inpatients?
- Same things as outpatients
- Hypotension (postural or illness)
- New meds
- Low blood glucose
- Getting sicker
- Delirium
- Deconditioning
- Call bells, zimmer frames out of reach
Give examples of common iatrogenic drugs and the problems they cause
- 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
List the costly medication related problems in older patients
- Falls
- Cognitive loss/delirium
- Dehydration
- Incontinence
- Depression
- Loss of functional capacity
- Poor quality of life
- Nursing home placement
Why are older patients prescribed on average 2-3 times more prescriptions?
- More acute and chronic disease
- More doctors visits
- Given to counteract the side effect of another drug
- Prescribers, patients and the system
Which adverse drug effects can look like growing old?
- Unsteadiness
- Dizziness
- Confusion
- Nervousness
- Fatigue
- Insomnia
- Drowsiness
- Falls
- Depression
- Incontinence
Which healthcare provider factors can contribute to polypharmacy?
- 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
Which drugs have the highest admissions due to ADRs (highest to lowest)?
NSAIDs, diuretics, warfarin, ACEI, antidepressants, beta-blockers, opiates, digoxin, prednisolone and clopidogrel
What happens to absorption in older patients?
Rate is slower but the extent is the same - may lead to a delay in the onset of action
What happens to distribution in older patients?
- 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
How is the metabolism of drugs effected in older patients?
-Hepatic metabolism is reduced: may cause toxicity and reduced first pass metabolism
How is the excretion of drugs effected in older patients?
- Renal function decreases with age
- Reduced clearance and increases half-life of many drugs
How does the pharmacodynamics change in older patients?
- 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
Which psychiatric drugs are most likely to cause adverse drug effects?
- Sedatives (benzodiazepines): falls and confusion
- Anti-psychotic: postural hypotension, stroke, confusion and movement disorders
- Anti-depressants
Which analgesics are more likely to cause adverse drug effects?
- Opioids
- NSAIDS: renal impairment and GI bleeding
Which drugs are likely to cause cardio adverse drug reactions?
- Digoxin
- Diuretics
- Anti-hypertensives
- Anti-coagulants
Which adverse effects can antibiotics increase the risk of?
- Diarrhoea and C. diff
- Blood dyscrasias
- Delirium
- Seizures
- Renal impairment
