Geriatrics Flashcards
Why are people getting older?
Increased resource availability Better economic conditions Improved screening programmes Better outcomes following major events (stroke) Consequences
Beneficial ageing
Increased experimental learning.
Neutral ageing
Grey hair
Pastime preference
Detrimental
Hypertension
decreased reaction time
Physiology of ageing: Affects?
Virtually every organ/system
Marked inter-individual variability in both development and magnitude of changes.
Inter-individual variability INCREASES with age.
Evidence very limited for 80+
What is frailty?
Progressive dyshomeostasis.
Susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge.
What are the Frailty syndromes?
Falls
Delirium
Immobility
Incontinence
Social dyshomeostasis
Difficulty caused by environmental insults not only bio-medical.
Different presenting signs and symptoms in people with frailty e.g. Hyperthyroidism?
Classic = Tremor, Anxiety, weight loss, diarrhoea Person = Depression, Cognitive impairment, Muscle weakness, Atrial fib, Heart failure, Angina.
What are the practical implications of ageing?
Increasing no. of older people with multiple co-existing medical conditions.
Increased inter-individual variability in organ function and homeostatic reserve.
Different presenting symptoms and signs.
Multiple medications.
Little evidence of drug efficacy and safety for patients 80+.
What are the typical syndromes of presentation seen in elderly?
Falls
immobility
Functional decline
Delirium
What does illness in frail people lead to?
Disruption in multiple health domains.
Can be triggered by disruption in any health domain.
What needs to be looked at medically in elderly?
Pathological - disease
Physiological - normal ageing
Reversible
Non-reversible
Multiple concomitant problems
Latrogenic harm
What needs to be looked at psychologically?
Mood - low mood and anxiety.
Confidence - “fear of falling syndrome”
Cognition - delirium and dementia.
Functional needs?
Mobility - transfers and mobilising.
Activities of Daily living
Community living skills
Behavioural needs?
Behavioural determinants of ill health. - unhealthy eating, smoking, drinking.
Activities / pastimes
Occupation
Nutritional needs?
Poor nutrition leads to ill health.
ill health leads to poor nutrition.
MUST screening tool.
Spiritual needs?
How do i fit into the bigger picture?
What’s important to individual?
Self-image
Meaning of life?
Environmental needs?
Housing
Heating
Sanitation
Adaptation
Social needs?
Support networks
- practical/emotional
- formal / informal
Potential for abuse
- financial
- physical
- sexual
- neglect
Societal needs?
Attitudes to ageing/the aged
- asset vs. burden
- paternalism
Technological advance
- enabling vs disabling
Political / Regulations
- Money (winter heating allowance/ pensions)
- Accessibility (free bus passes/ disabled access)
What is good geriatric care?
Early identification of need
Early comprehensive Geriatric assessment
Early provision of appropriate level of care for needs.
CGA - produce a plan to try and make the patient feel better.
What is frailty?
Increased risk of death or debility following exposure to an environmental stressor.
A reduced ability to withstand illness without loss of function.
What can cause incontinence?
Extrinsic to the urinary system:
- environment, habit, physical fitness.
Intrinsic to the urinary system:
- Problem with bladder or urinary outlet.
Often a bit of both.
What supports continence?
Effective function of the bladder and the integrity of the neural connections which bring it under voluntary control.
- Bladder and Urethra
- Local innervation
- CNS Connections
Characteristic features of stress incontinence?
Relaxed pelvic floor, increased abdominal pressure.
Urine leak on movement,
coughing, laughing, squatting.
Weak pelvic floor muscles.
Common in women with children, especially after menopause.
Treatment = physio, oestrogen cream and duloxetine.
Surgical option = TVT/ colposuspension 90% cure at 10 years.
Characteristic features of urinary retention with overflow incontinence?
Bladder outlet “too strong”
Urethral blockage - bladder unable to empty properly.
- poor urine flow, double voiding, hesitancy, post micturition dribbling.
- Blockage to urethra
Older men BPH
Treat with alpha blocker, anti-androgen or surgery.
May need catheterisation.
Characteristic features of urge incontinence?
Bladder muscle “too strong”
Bladder oversensitivity from infection. Neurological disorders.
- Detrusor contracts at low volumes.
- sudden urge to pass urine.
- Can be caused by bladder stones or stroke.
Treat with anti-muscarinics
Neuropathic Bladder?
RARE
Secondary to neurological disease (MS/ STROKE)
Secondary to prolonged catheterisation.
No awareness of bladder filling resulting in overflow incontinence.
Catheterisation only effective treatment.
How do you assess incontinence?
- History.
- Social history very important.
- Intake chart and urine output diaries.
- General exam to include rectal and vaginal exam.
- Urinalysis and MSSU.
- Bladder scan for residual volume
- Consider referral to incontinence clinic.
- Lifestyle / behavioural changes and stopping unnecessary drugs.
- consider physio, medical treatment, surgical options.
What are the indications for referral to specialists?
Failure of initial management.
- max 3 months of pelvic floor exercise, cone therapy, habit retraining, medication
What indicates referral straight away at onset?
Vesico-vaginal fistula.
Palpable bladder after micturition or confirmed large residual volume of urine after micturition.
Disease 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.
If all fails what options are there?
Incontinence pads. Urosheaths. Intermittent Catheterisation Long term urinary catheter. Suprapubic catheter.
What are Delirium key features?
Disturbed consciousness - hypoactive/hyperactive.
Change in cognition - Memory / perceptual / language / illusions / hallucinations.
Acute onset and fluctuant.
What are some common features of Delirium?
Disturbance of sleep wake cycle.
Disturbed psychomotor behaviour.
Emotional disturbance.
What are some of the causes of Delirium?
Infection Dehydration Biochemical disturbance Pain Drugs Constipation / urinary retention Hypoxia Alcohol / drug withdrawal Sleep disturbance Brain injury Changes in environment / emotional distress.
How common is delirium?
Commonest complication of hospitilisation.
20-30% of all in-patients
Up to 50% of people post surgery
Up to 85% of people at end of their life.
Why is delirium so important?
Massive morbidity and mortality. Increased risk of death. Longer length of stay. Increased rates institutionilisation. Persistent functional decline.
How is it diagnosed?
Using NICE guidelines - 4AT. LADY Location Age Date of birth Current year.
What should you do when you diagnose delirium?
Treat the cause.
Full history and exam.
TIME bundle.
Explain diagnosis.
What are the non-pharmacological treatments for delirium?
Re-oriantate and reassure agitated patients (use family)
encourage early mobility and self-care. Correction of sensory impairment. Normalise sleep-wake-cycle. Ensure continuity of care.(avoid hospitilisation, and room transfers) Avoid urinary catherterisation.
What are the pharmacological treatment for delirium?
Stop bad drugs. (anything directly or indirectly affecting the brain)
Only if danger to themselves or others or distress which cannot be settled in any other way - start low and go slow - 12.5mg quetiapine orally.
What can delirium lead to?
Some don’t get back to previous level.
May unmask undiagnosed cognitive impairment.
More likely to go and develop dementia.
Risk factors to further episodes of frailty/delirium/dementia.
What is the relationship between delirium and falls?
4.5x more likely to fall if have delirium.
Delirium prevention reduce falls.
What do guidelines say in regards to UTI in elderly?
Do not use dipstick tests for diagnosis of UTI in elderly.
How do you assess a fall depeding on location?
Clinic - likely well patients, difficult and multifactorial falls.
A+E - more likely to be acutely unwell.
Hospital inpatient - very likely to be acutely unwell. Significant injury is possible.
Which gait matches which pathology:
- Ataxic
- Arthralgia
- Hemiplegic
- Small steps, shuffling
- High stepping
- Cerebellar damage
- Arthritis
- Stroke
- Parkinsonism (vascular)
- Peripheral neuropathy
How do you assess a fallen patient?
ABCDE approach
Check glucose
Top to toe survey
How can you tell if a CT is needed for a head injury?
Low GCS <13 Still confused after 2 hours Focal neurology Signs of skull fracture Basal skull fracture - CSF leak, bruising around eyes Seizure Vomiting Anti-coagulation
How can falls be prevented in hospitals?
Ensure vision and mobility aids and call bell are in reach.
Consider bed rails
Regular obs
Tell people
What are some of the common iatrogenic drug problems?
Confusion, dry mouth, constipation, blurred vision, urinary retention.
- confusion and unsteady gait with triyclics.
- CNS toxicity with long-acting benzodiazepines.
What are some of the worst drugs that cause adverse reactions?
NSAIDs Diuretics Warfarin Ace inhib Antidepressants.
What can effect the rate of drug absorption?
Physiological changes effect the rate - delay in onset of action. e.g. A reduction in saliva production may result in reduction of rate of GTN.
What effects do changes in body composition and protein binding have on drug distribution?
Reduced muscle mass, Increased adipose tissue
- Fat soluble drugs - increased duration of action e.g. diazepam
- Reduced body water - water soluble drugs.
Protein binding changes.
Decreased albumin = decreased binding.
Increased permeability across the blood-brain barrier.
What is hepatic metabolism affected by?
Decreased liver mass
Decreased liver blood flow
- toxicity due to reduced metabolism / excretion
- reduced first pass metabolism.
How is excretion affected?
Renal function decreases with age.
Reduces clearance and increases half-life of many drugs leading to toxicity.
