Geriatrics Flashcards
What proportion of >75 are in care homes?
7%
How may old people present?
• Complexity • Frailty • Functional / psychosocial • Non-specific presentations / syndromes – eg Falls
What affects balance?
Inputs
- Vision
- Vestibular
- Joint position
- Muscle stretch
- Peripheral sensation
Outputs
- skeletal muscles
(joints)
- eye movements
What in the environment will affect balance?
- Floor
- Lighting
- Obstacles
- Distractions
How does higher function affect balance?
- Intention and plan
- Concentration
- Memory
- Confidence and fear
What is reserve?
Extra capacity that everyone has to cope with external stress
What is frailty?
A loss of reserve
What is the process of accelerated ageing?
- Loss of muscle
- Age related change
- Illness
- Reduced function
- Reduced confidence
What happens when a frail person gets a minor illness?
- Is not functionally able
- May result in later inability to acquire functional ability
- Longer period of recovery
What factors are poor outcome predictors in frailty?
– Age, sex, smoking status
– Comorbidities (Cardioresp, CKD, CA)
– Biomarkers (albumin, creatinine…)
– Function
When is a Comprehensive Geriatric Assessment (CGA) used?
– On inpatients in specialist units
– To high-risk (frail) outpatients
How do you do a Comprehensive Geriatric Assessment (CGA)?
Falls history Balance & Gait, mobility Cognition, mood and capacity Social situation and support (Ask who they are happy for us to talk to ) Medication - review and consider Nutrition and hydration Skin Continence & elimination Feet & footwear Sensory ( Vision, hearing, peripheral)
What would you look at in a medication review in a CGA?
Removing unnecessary Antihypertensives Antipsychotics Diuretics Sedatives and night sedation
Adding
Ca&Vit D
DVT prophylaxis
Antihypertensives per HYVET (indapamide +/- perindopril)
How do we look at the bigger picture?
- Acute change vs progression
- How far from baseline*?
- Is the new problem the main problem?
- Declining? Dying?
- What can we achieve?
- How can we improve QOL / independence?
How do you take a history with CGA in mind?
- Background (in a nutshell)
- Presentation
- Initial assessment & diagnosis
- Course of admission / treatment so far
- Current status
- Problems, issues, gaps, questions & revisions
- Plan
What could the causes of a fall be?
• Environmental • Visual • Gait – Strength & fitness – Pain? – Peripheral sensory loss • Drops in blood pressure? • Medication? • Acute illness?
What is delirium?
- “Acute Confusion”
- Inattention
- Cognitive impairment
- Alertness
What is the pathophysiology for delirium?
- Poorly understood but common
- Inflammatory cascade
- Neurotransmitter changes
- Hormonal (Thalamic / Pituitary / Adrenal)
- Cellular / Intracellular
How do you tell if a non english speaker has delirium?
– Distractible / Inattentive – Drowsy / Hyperalert – Picking at clothes/sheets (carphologia) – Not getting out of bed – Not interacting with others – Unwell!
What is CAM?
• 1: Acute Onset
– Until proven otherwise?
• 2: Inattention
– Distractible
• 3: Disorganised thinking
– Rambling?
• 4: Altered Consciousness
– Drowsy / Hypervigilant
What is the 4AT?
Test for delirium 4 A's Alertness AMT4 Attention Acute change or fluctuating cause
What are the consequences of delirium?
– Twice as likely to die
– Twice as likely to be in institutional care
– 12 times more likely to have a dementia diagnosis
What can cause delirium?
– Hypoxia – Constipation – Urinary retention – Urosepsis – Change of environment – Withdrawal from sedatives / alcohol / analgesia – Sedatives / alcohol / analgesia – Anticholinergics*
Why do anticholinergics cause delirium?
– Cholinesterase inhibitors (Dementia drugs) increase ACh
– Many drugs have anticholinergic properties
• Bladder antispasmodics (eg oxybutynin)
• Tricyclic antidepressants (eg amitryptilline)
• Furosemide
• Digoxin
• Cyclizine
What is the treatment of delirium?
• Make the diagnosis, then consider cause(s) – Make a list! • Treat the underlying cause(s) • Also: – Supportive care – Orientation – Appropriate environment – Stop making it worse!
Why can benzo’s cause delirium?
Benzo withdrawal
