Geriatrics Flashcards
Theories of aging
Stochastic: random, cumulative damage
Programmed: predetermined changes in gene expression
Homeostatic failure
Frailty is…
A susceptibility state that leads to a person being more likely to lose function in the face of environmental challenge
effectively… Progressive dyshomeostasis
(impaired function of any organ system makes homeostasis more difficult)
The core concept of geriatric medicine is…
Frailty
Frailty syndromes:
Falls
Delirium
Immobility
Incontinence
(how patients present)
Fried’s criteria for frailness
3 of of 5 of the following... o Unintentional weight loss o Exhaustion o Weak grip strength o Slow walking speed o Low physical activity
Health domains
o Medical o Spiritual o Psychological o Functional o Behavioural o Nutritional o Environmental o Social o Societal
Benefits to being in hospital
o Access to clinical expertise
o Access to complex tests and interventions
o Rapid access to supervised care support
Risks to being in hospital
o Disorientation and delirium o Learned dependency o Deconditioning o Iatrogenic harm o Hospital acquired infection
Extrinsic causes of incontinence
o Co-morbidities o Reduced mobility o Confusion o Drinking too much/ at the wrong time o Medications o Constipation o Home/ social circumstances
Intrinsic causes of incontinence
Outlet too weak = stress incontinence
Outlet too strong (e.g. BPH) = Urinary retention with overflow incontinence
Bladder too strong = urge incontinence/ overactive bladder (OAB)
Bladder too weak = neuropathic bladder
- No awareness of bladder filling –> overflow incontinence (Secondary to neurological disease/ prolonged catheterisation)
Assessing incontinence
o History (inc. social history) o Urinary diary (fluid input + output) o General examination (inc. vaginal and rectal) o Urinalysis + MSSU o Bladder scan for residual volume
Risk factors/ causes of delirium
- Infection (NOT always a UTI!*)
- Dehydration
- Biochemical disturbance
- Pain
- Drugs
- Constipation/ urinary retention
- Hypoxia
- Alcohol/ drug withdrawal
- Sleep disturbance
- Brain injury (stroke, tumour, etc.)
- Change in environment/ emotional distress
*do not use dipstick test to diagnose UTI in the elderly
Presentation of delirium
Disturbed consciousness
- Hypoactive/ hyperactive/ mixed
Change in cognition
- Memory/ perceptual/ language/ illusions/ hallucinations
Acute onset and fluctuant
Diagnosis of delirium
4AT score (rapid clinical test for delirium)
Management of delirium
Prevention!!
Non-pharmacological measures
- Re-orientate and reassure
- Encourage early mobility and self-care
- Correction of sensory impairment
- Normalise sleep cycle
- Ensure continuity of care
- Avoid urinary catheterisations
- Discharge ASAP/ avoid hospitalisation
Pharmacological management:
- STOP BAD DRUGS
- 12.5mg quetiapine orally (ONLY if a danger, no evidence it improves delirium)
Types of causes of falls
Musculoskeletal Drugs Neurological Sensory Cardiovascular Illness Incontinence (rushing to toilet)
Clues in the history of a fall
- No memory = syncope/ cognition
- Clear history = sensory
- On turning = postural instability
- Near misses = unsteady on standing
- Syncope on exertion = aortic stenosis
CT immediately for a head injury with 1+ pf the following…
- GCS <13
- Still confused after 2 hours
- Focal neurology
- Signs of skull fracture
- Seizure
- Vomiting
- Anticoagulation
Common ADRs caused by anticholinergics in the elderly…
Confusion, dry mouth, constipation, blurred vision, urinary retention orthostatic hypotension
Common ADRs caused by Tricyclics in the elderly…
Confusion
Unsteady gait
Common ADRs caused by long acting benzodiazepines in the elderly…
CNS toxicity (falls + confusion)
Common ADRs caused by Narcotics in the elderly…
confusion
Changes in the Absorption of drugs from the GI tract in the elderly
Decreased rate of absorption (may lead to delayed onset of action)
No changes in extent of absorption
Changes in the Distribution of drugs in the elderly
↑adipose tissue –> ↑duration of action of fat-soluble drugs (e.g. diazepam)
↓body water –> ↑serum levels of water-soluble drugs (e.g. digoxin)
↓albumin –> ↓binding–> ↑serum levels of acidic drugs (e.g. furosemide)
↑permeability across blood-brain barrier
