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Geriatrics Flashcards

1
Q

Why are people getting older?

A

Increased resources
Better economic environment
Screening and diagnosis improved
Better outcomes following majorr events

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2
Q

Compare primary and secondary ageing.

A

Primary = caused by being biologically old e.g osteoarthritis and secondary = consequence of primary ageing e.g reduced mobility from OA

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3
Q

What is the stochastic theory of ageing?

A

Random cumulative damage e.g from oxidative stress and micro trauma

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4
Q

What is the programmed theory of ageing?

A

Predetermined from changes in gene expression during various stages

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5
Q

What happens with inter-individual variability with age?

A

Increases

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6
Q

Why does serum creatinine stay roughly the same?

A

creatinine clearance goes down and you have less muscle mass

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7
Q

What happens to blood pressure with age?

A

SBP tends to increase

DBP peaks around 60 and then starts to drop

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8
Q

Why is there more side effects from antihypertensives in those over 60?

A

SBP tends to increase

DBP peaks around 60 and then starts to drop

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9
Q

What happens to CO with age in general?

A

Gets worse

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10
Q

What happens to lung capacity with age?

A

Total lung capacity stays the same but vital capacity reduces over time

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11
Q

Discuss frailty and homeostasis?

A

Frailty = progressive dyshomeostasis

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12
Q

Define frailty.

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

What are “frailty syndromes”?

A

Falls, delirium, immobility, incontinence

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14
Q

Why might elderly be unable to compensate for a change in BP?

A

problems with carotid sensitivity (OVER OR UNDER), sympathetic nervouse system may be less effective (e.g due to meds), heart less able to pick up rate

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15
Q

What are the consequences of frailty for thermoregulation?

A

reduced peripheral vasoconstriction, don’t sweat as much, reduced metabolic heat production, little change in basal body temperature, smaller increase in CO, less redistribution of blood flow from renal and splanchnic circulations

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16
Q

What is “social” dyshomeostasis?

A

Difficulty caused by environmental insults e.g social

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17
Q

How does hyperthyroidism presentation differ in people with frailty?

A 
Depression 
Cognitive impairment 
AF 
Muscle weakness
Delirium 
Falls 
Immobility 
Incontinence
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18
Q

What are two main implications of an ageing population?

A

Multimorbidity Frailty

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19
Q

What is frailty?

A

A susceptibility state which is the end result of acquired problems. Overlaps multi morbidity and disability

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20
Q

What is ageing?

A

Progressive accumulation of damage to a complex system resulting in loss of system redundancy

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21
Q

Define frailty.

A

A reduced ability to withstand illness without loss of function

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22
Q

How do you identify someone with frailty?

A

Frailty index

Fried criteria

“Frailty syndromes”

HIS ‘Think Frailty’

Clinical frailty scale

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23
Q

What is the Fried criteria?

A

3 of 5 of:

Unintentional weight loss 
Exhaustion 
Weak grip strength 
Slow walking speed 
Low physical activity
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24
Q

Name the frailty syndromes.

A

Falls
Immobility
Delirium
Functional loss

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25
Q

What causes decompensated frailty syndromes?

A

Reoccuring problems with illness/insult

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26
Q

What is health?

A

A dynamic process rather than a binary state

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27
Q

Describe the illness trajectory for frailty.

A

Decline -> crisis -> admission -> reablement

reoccurs over time

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28
Q

What is a comprehensive geriatric assessment?

A

Process to asses and manage illness in older people with frailty.

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29
Q

What does the comprehensive geriatric assessment do?

A

Determine what problems are
Determine what can be reversed/made better
Produce a management plan

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30
Q

What is the comprehensive geriatric assessment centred around?

A

Person-centred/ Goal centred (NOT problem centred)

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31
Q

Name some health domains important to consider in a geriatric assessment.

A 
Medical 
Spiritual (= person-centred)
Psychological 
Functional 
Environmental 
Behavioural
Nutritional
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32
Q

Who are important members of the MDT responsible for a comprehensive geriatric assessment?

A

Geriatrician, OT, PT, skilled nurse

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33
Q

Can CGA only be done in hospital?

A

No, also in community

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34
Q

Why is an early CGA important?

A

More likely to get patient back up to pr-morbid level of function. Better outcomes!

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35
Q

What are risks of hospital?

A 
Disorientation and delirium 
Learned dependency 
Deconditioning 
Iatrogenic harm 
HAI
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36
Q

At what ages does the incidence of incontinenece increase?

A

Postmenopausal and extreme age

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37
Q

What are potential causes of incontinence?

A

Extrinsic to the urinary system (environment, habit, physical fitness, medications, constipation)
Intrinsic to urinary system (bladder or urinary outlet problems)
Bit of both

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38
Q

What are extrinsic factors for incontinence in elederly?

A 
Medications
Constipation 
Home circumstance
Social circumstances 
Confusion 
Reduced mobility
Physical state and co-morbidities
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39
Q

What is the normal capacity of the bladder?

A

400-600ml (sensation of needing at 250ml, 400ml is urgent)

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40
Q

What does the SNS do to the detrusor muscle?

A

Relax

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41
Q

Summarise intrinsic factors that can cause incontinenece.

A

Problem with bladder or outlet.

They are either too weak or too strong,

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42
Q

What happens if bladder outlet too weak?

A

Stress incontinenece —> Urine leak on movement, weak pelvic floor muscles

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43
Q

What are treatments for stress incontinenece?

A

Physio, oestrogen cream and duloxetine
Surgery: TVT/colposuspension
Pelvic floor exercises
Pelvic floor stimulators

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44
Q

Why is oestrogen cream or pessaries given for stress incontinenece?

A

After menopause, no oestrogen which is a natural catabolic hormone which builds up pelvic floor muscles

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45
Q

What happens if the bladder outlet is too strong?

A

Urinary retention with overflow incontinence

-> poor urine flow, double voiding

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46
Q

who commonly gets urinary retention and overflow incontinence?

A

Older men with BPH

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47
Q

Who commonly gets stress incontinence?

A

Females who have had children or after menopause

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48
Q

How do you treat urinary retention in a male with BPH?

A 
Alpha blocker (relaxes sphincter e.g tamsulosin) or anti-androgen (shrinks prostate e.g finasteride) or surgery (TURP)
May need suprapubic catheter
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49
Q

What happens when the bladder muscle is too strong?

A

Urge incontinenece

detrusor contracts at low volumes

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50
Q

How do you treat urge incontinence?

A

Anti-muscarinics e.g oxybutinin, tolterodine, solfineacin

b3 adrenoceptor agonists (relix detrusor) e.g mirabegron

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51
Q

What is the only type of incontinence most common in males?

A

Urinary retention with overflow incontinence

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52
Q

What drugs can be given to relax sphincter, bladder neck i.e stop overflow incontinenece?

A

Alpha-blockers e.g tamsulosin, terazosin, indoramin

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53
Q

What is a neuropathic bladder?

A

Underactive bladder (rare)

54
Q

What causes an underachieve/neuropathic bladder?

A

Neurological disease e.g MS or stroke

Prolonged catheterisation

55
Q

What may help neuropathic bladder?

A

Parasympathomimetics may help. Catheterisation is only effective treatment option.

56
Q

How do you assess incontinence?

A 
Hx
Social Hx (for extrinsic factors)
Intake chart and UO diary
General ex  + rectal and vaginal
Urinalysis and MSSU
Bladder scan for residual vol
physio 
medical Rx 
Surgical Rx
57
Q

When should you refer to specialist for incontinence?

A

After failure of initial management (max 3 months of pelvic floor exercises, cone therapy, habit retraining and/or appropriate medication)

58
Q

When should you refer to specialist at onset?

A 
Vesico-vaginal fistula
Palpable bladder after micturition 
Disease of CNS 
Certain gynaecology conditions e.g fibroids
If previous surgery for continence
59
Q

If all treatments fail for incontinenece, what next?

A 
Incontinence, 
Urosheaths
intermittent catheterisation 
Long term urinary catheter 
Suprapubic catheter
60
Q

What are the key features of delirium?

A

Disturbed consciousness
Change in cognition
Acute onset
Fluctuation

61
Q

What are other common features of delirium?

A

Disturbance of sleep wake cycle
Disturbed psychomotor behaviour
Emotional disturbance
Physical function affected

62
Q

Who is at risk of delirium?

A

Extremes of age although anyone can get it.

63
Q

What is important when assessing delirium?

A

History especially collateral.

Generally, if normal very intelligent and fit (usually precipitated by large insult e.g space occupying lesion, severe sepsis) whereas if normally frail then likely to be lots of smaller insults causing it

64
Q

What precipitates delirium?

A

ANYTHING
OFTEN MULTIPLE TRIGGERS

Infection 
Hypo and hypernatraemia
Hypercalcaemia
Hypoxia
Pain 
Alcohol/drug withdrawal, 
Brain injury 
Drugs
Dehydration 
Social/emotional distress
65
Q

What is the most common complication of hospitalisation?

A

Delirium

66
Q

Why do we care about delirium?

A 
Increased mortality 
Increased hospital admission 
Increased chance of nursing home admission
Increased risk of developing dementia 
Persistent functional decline
67
Q

What is the delirium screening tool?

A

4AT score

68
Q

What do you do when you confirm delirium?

A

Full history and exam
TIME bundle
Explain diagnosis (give leaflet)

69
Q

What is the main stay of delirium management?

A

Non-pharmacological: re-orientate and reassure (use family/carers)

Encourage early mobility and self care 
Normalise sleep-wake cycle 
Ensure continuity of care 
Avoid catheters and venflons
Discharge asap
70
Q

What is the pharmacological treatment of delirium?

A

Stop bad drugs

Drug treatment usually not necessary unless danger to themselves (12.5mg quetiapine orally, start low and slow)

71
Q

How can you reduce the risk of delirium?

A 
Promote sleep hygiene
Pain control
prevention of post-op complications 
Regulation of bladder and bowel function 
Medication review
Early mobilisation
72
Q

What are important points to remember for people with delirium?

A

Capacity
Do they have a POA or guardian
Risk of falls

73
Q

Is there an association between delirium and falls?

A

Yes, 4.5x more likely to fall if have delirium

Therefore delirium prevention reduce falls also

74
Q

What is the relationship between UTIs and delirium?

A

More likely to be an over diagnosis of UTI - High percentage with asymptomatic bacteriuria

75
Q

Should you dipstick urine to diagnose a UTI in older people?

A

No, Sign 88 guidelines

76
Q

What drugs commonly cause falls?

A 
Antihypertensives
Beta blockers 
Sedatives
Anticholinergics
Opioids
Alcohol
77
Q

wHat are potential causes of falls?

A 
MSK
Drugs
Neurological
Sensory 
CVS
Being generally unwell
Incontinence
Alcohol
78
Q

What MSK problems could cause falls?

A

Arthritis
Sarcopenia
Deformities of feet e.g Charcot’s
Muscle weakness (POLYMYALGIA RHEUMATICA)

79
Q

What neurological conditions commonly cause falls?

A

Stroke
Parkinsons
Dementia
Delirium

80
Q

What CVS problems can cause falls?

A

Postural hypotension
Arrhythmia
HF
Aortic stenosis

81
Q

Why do drugs increase the risk of falls?

A 
Increase UO
Increase sedation 
Hallucination
qTC
Dizziness
82
Q

What should you ask about in a falls history?

A 
Detail of fall
What were they doing 
Who with?
What happened? 
What happened next?
How did they get up?
Systematic symptoms - before e.g palpitations could suggest cardiac causes
83
Q

What should be included in a systematic enquiry for falls?

A

Memory
Urinary symptoms
Has walking changes recently

84
Q

How do you examine a patient with a history of falls?

A 
Get patient on couch 
Top to toe
Cranial nerves
Check for neglect and cerebellar signs 
Check for Parkinsonism 
Pulse 
Heart sounds
Kyphosis
Look at feet 
Vibration sense (for peripheral neuropathy)
Test co-ordination 
Romberg's 
Assess gait
85
Q

What does an ataxic gait suggest?

A

Cerebellar damage

86
Q

What does an arthralgia gait suggest?

A

Arthritis

87
Q

What does a hemiplegic gait suggest?

A

Stroke

88
Q

What does small steps, shuffling suggest?

A

Vascular Parkinsons

89
Q

What does a high stepping gait suggest?

A

Peripheral neuropathy

90
Q

What would you do for someone admitted to A&E after a fall?

A 
ABCDE
Secondary survey 
Check CK if long lie (checks for rhabdomyolysis) 
Any cognitive impairment 
Any incontinence 
any syncope 
Are they drunk?
Look at ambulance sheet 
Talk to relative
91
Q

What Ex and IX would you carry out in A&E for a patient who has fallen?

A 
Neuro exam 
Look at legs
Full set of abs 
ECG
Bloods for B12, Folate, CK, TFTs
4AT
ECG
Consider CT head
92
Q

When should you do a CT head after fall?

A 
If Anticoagulated
Neurological signs 
Head injury 
If GCS <13
Focal neurology
Seizure
Vomiting
93
Q

What are the three main things you should do to assess a fallen patient?

A

ABCDE
Check glucose
Top to toe survey

94
Q

What should you do if you are called to a patient who has fallen in hospital?

A

Immediately assess for serious injury (post fall assessment sheet)
Consider cause of fall

95
Q

What must you not miss after an inpatient fall?

A
  • Subdural haemorrhage

- Hip fracture

96
Q

When should you do an X-Ray after a fall?

A

Pain on moving a joint have low threshold of X-ray

Pain on weight-bearing

97
Q

Mary 88 has had a fall. She is on apixaban, levothyroxine, bisoprolol, donezipezil. What could have caused her fall?

A

Bisoprolol - postural hypotension, bradycardia
Donezipezil - bradycardia
Underrated hypothyroidism - bradycardia

98
Q

What can antidepressants cause in elderly?

A

Falls

99
Q

What can codeine cause in elderly patients?

A

Constipation –> delirium, falls, hyponatraemia and hypercalcaemia

100
Q

List some common iatrogenic drug problems.

A 
Confusion 
Dry mouth 
Constipation 
Blurred vision 
Urinary retention 
Orthostatic hypotension 
Falls
Loss of function
Incontinenece 
Depression
101
Q

Why is polypharmacy more common in elderly?

A
  • Increase in co-morbidities
  • More doctor visits
  • Drugs often given to counteract SEs, - little continuity of care,
  • Prescriber issues (e.g not getting right diagnosis, little time for appointment, assuming patient wants a quick fix tablet)
  • diseases have different symptoms in elderly
102
Q

Name 3 drugs with ADRs associated with hospital admission.

A

NSAIDs
Diuretics
Warfarin

103
Q

What two types of drugs have the most ADRs?

A

Anticholinergics

Sedatives

104
Q

What are common anti-muscarinic drug effects?

A 
Dry mouth and eyes
Constipation 
Pupillary dilation 
Tachycardia 
Inhibition of erection 
Memory impairment 
Confusion 
Hallucinatiosn 
Falls 
Delirium
105
Q

Discuss the clinical pharmacology of old age relating to absorption.

A
  • Absorption: rate changes as you get older since GI system slower, less saliva e.g affects absorption go GTN
106
Q

Discuss the clinical pharmacology of old age relating to distribution.

A

-Distribution: body composition changes (increase in adipose, reduce body water), protein binding changes, increased BBB permeability

107
Q

Discuss the clinical pharmacology of old age relating to metabolism.

A
  • Metabolism: decreased liver mass and blood flow
108
Q

Discuss the clinical pharmacology of old age relating to excretion.

A

Kidneys lose function as we get older
Renal function decreases with age
Increased half life of drug –> increased toxicity

109
Q

What is generally needed when prescribing drugs in elderly?

A

Low doses or reduced frequency administration

“Start low and go slow”

110
Q

What is Beer’s criteria?

A

List of ‘inappropriate’ drugs for older people, updated occasionally but many weakness

111
Q

What us the START-STOPP criteria?

A

Screening tool for older persons prescriptions, advice on medical optimisation

112
Q

What happens when prescribing opioids in elderly?

A

More sensitive to effects

113
Q

What happens when prescribing NDAIDs in elderly.

A

Increased renal impairment and GI bleeding

114
Q

What happens when you prescribe Digoxin to elderly?

A

Increased toxicity

Lower doses needed

115
Q

What happens to elderly on anti-hypertensives?

A

Exaggerated effects on BP and HR e.g postural hypotension

renal adverse effects

116
Q

What is the difference of elderly taking warfarin compared to young and healthy?

A

More sensitive, greater risk of bleeding

117
Q

What happens when giving antibiotics to elderly.

A

Increased ADRs, diarrhoea and c.diff infection, seizures, renal impairments

118
Q

What can quinolone cause in elderly patients?

A

Delirium

119
Q

What can trimethoprim and co-trimoxazole cause in elderly patients?

A

Blood dycrasias

120
Q

Who are most at risk from medication errors?

A
  • Those undergoing cardiothoracic surgery, vascular surgery or neurosurgery
  • Thos with complicated conditions
  • Those in A&E
  • Those looked after by inexperienced doctors
  • Elderly
121
Q

What are people related causes of medication errors?

A

Fatigue, hungry, concentration, stress, distraction, lack of training, lack of access to info, other factors (e.g alcohol, drugs, illness etc)

122
Q

Where do medication errors occur?

A

Prescribing
Transcribing
Dispensing
Administering

123
Q

What are common prescribing errors?

A 
Wrong dose
Wrong drug 
Inappropriate units 
Poor/illegible prescriptions
Failure to take into account drug-drug interactions, omission, calculation errors
Illegible handwriting
124
Q

How do you prevent medication errors?

A

5 Rs:

Right patient 
Right drug 
Right dose
Right route 
Right time
125
Q

Who assess and authorise medicinal products in the UK?

A

MHRA (Medicines and Healthcare products Regulatory Agency)

126
Q

What is the European equivalent of the FDA?

A

European Medicines Agency

127
Q

Who makes decisions on the cost effectiveness of new/existing pharmaceutical products in respect of their use in NHS Scotland?

A

Scottish medicines consortium

128
Q

Who makes decisions on the cost effectiveness of new/existing pharmaceutical products in respect of their use in NHS England?

A

NICE

129
Q

What doe the patient access schemes assessment group (PASAG)?

A

Advise on acceptability of patient access schemes within NHS Scotland

130
Q

Why do we have local formularies (Area drugs and therapeutics committees - ADTCs) in Scotland under the Scottish medicines consortium?

A

Local ownership of decisions, implement SMC advice and SIGN guidelines, deal with drugs not on SMC agenda, deal with unlicensed products, education and communication, patient group directives, prescribing errors

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