Geriatrics Flashcards
What are the recent and future trends of old age?
Reproducing less
Life expectancy increasing
Life expectancy at 60yo increasing eg keeping alive longer
Increased number of people over 60yo worldwide
What are the different aspects of the ageing process?
Stochastic ageing eg cumulative damage like micro damage to joints, oxidative stress (random)
Programmed ageing eg predetermined and cannot avoid due to changes in gene expression
Leads to progressive homeostatic failure, affects all systems and has an interindividual variability which increases as you age
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
Essentially progressive dyshomeostasis, not only due to biomedical causes but also social causes eg family member moving away
How does physiological decline impact other disease processes?
Frailty can lead to dramatic functional loss through falls, delirium, immobility and incontinence
How does frailty impact the delivery of individualised healthcare?
Frailty increases the number of people with multiple coexisting conditions and multiple medications
Frailty increases the inter individual variability in organ function and homeostatic reserve
People with frailty can present differently
What is illness in older people often due to?
It is triggered: usually due to the disruption in any health domain, which leads to disruption in multiple domains
Domains: medical, spiritual, psychological, functional, behavioural, nutritional, environmental, social, societal
What is the multidimensional and multidisciplinary holistic approach important to assess and address problems in the elderly?
The comprehensive geriatric assessment
The process to assess and manage illness in older people with frailty (a goal centred approach)
What evidence is there that supports this approach?
Ellis G et al: meta analysis in BMJ 2011
More likely to be alive and at home @ 6m and 12m
ARI 2011 v 2013
Decreases stay in hospital, number of patients in beds, deaths and increases discharge rate
What is the impact of incontinence on people’s lives?
Can be disabling: socially, physically
Stigmatising
It is common and treatable
What are the multiple and multifactorial causes of incontinence?
Extrinsic factors to urinary system eg environment, habits, comorbidities, confusion, medications, constipation, social circumstances
Intrinsic factors eg bladder or urinary outlet, urge incontinence, stress incontinence
Mixed
What is the typical symptom pattern associated with each kind of incontinence?
Stress incontinence: leak on movement, laugh, cough, squat due to weak pelvic floor.
Urinary retention with overflow incontinence: poor urine flow, double voiding, hesitancy, post micturating dribble. Due to blockage of urethra
Urge incontinence: detrusor contracts at low volumes = sudden urge, can be due to bladder stones or stoke
How would you take a history, examination and relevant investigations for incontinence?
History: good, social history, intake and output diary
Investigations: urinalysis, MSSU, bladder scan
What are the common treatment options for the main types of incontinence?
Stress I: Treat with physiotherapy, oestrogen cream/cones, duloxetine. Surgical options are TVT, culposuspension
UR with overflow I: alpha blocker, anti-androgen. Surgical is TURP, may need catheter
Urge I: antimuscarinics, bladder retraining
What are the main clinical features of delirium, it’s investigation and management?
Clinical features: cognitive change, psychotic symptoms eg hallucinations, fluctuating symptoms, reversal of sleep wake cycle, personality change
Investigation: 4AT score
Management: treat the cause eg full history and exam, TIME bundle, explain diagnosis, non pharmacological (reorient, reassure, encourage mobility, self care, correct sensory impairment, normalise sleep wake cycle, ensure continuity of care, avoid catheter, discharge ASAP) and pharmacological (stop bad drugs, usually no other TM required)
How do you differentiate delirium from other kinds of cognitive impairment?
4AT score: alertness, AMT4 (age, dob, place), attention, acute change or fluctuating
What are the main principles of capacity assessment and adults with incapacity legislation?
Capacity is decision specific
Check if they have a welfare POA or guardian
What conditions mainly cause immobility and falls in the elderly, and what is the clinical approach to their assessment?
MSK: arthritis, sarcopenia, deformities
Neuro: delirium, stroke, Parkinson’s, dementia
Drugs: alcohol, anti-HTN, sedatives
Sensory: visual impairment, inattention, hearing
CVS: postural hypotension, arrhythmia, heart failure
Assessment depends where
Clinic:
- nurse: eye test, ecg, lying and standing BP, incontinence, MMSE
- PT: gait, balance
- doctor: history, examination
- MDT: treatment plan
A+E: ABCDE, bloods, imaging, gait, obs, ecg, BP, 4AT
How do pharmacokinetics and pharmacodynamics differ in elderly patients?
Pharmacokinetics
Absorption: rate decreases
Distribution: increased fat soluble drugs binding due to increased adipose, water soluble drugs increase in serum levels due to decreased body water
Metabolism: decreases due to decreased liver mass and blood flow to liver, gives rise to toxicity and decreases first pass metabolism
Excretion: decreases due to impaired renal clearance and increased half life means toxicity
Pharmacodynamics
Increased sensitivity to particular mechanisms due to changes in receptor binding
What are the principles which underpin prescribing in the elderly?
Be clear why prescribing (condition not S/E)
Consider whether drug is best therapeutic action
Low dose or decreased frequency of administration
Any drug problems in elderly?
Check whether lower dose is recommended
Review new drugs and if they work
Review all medications
Keep simple
Consider compliance
What help is available for clinicians in choosing and adjusting drug dosage in elderly patients?
BNF
Beers Criteria
START-SROP criteria
NHS Scotland Polypharmacy Guidance
What common medicines are elderly patients likely to respond to differently in comparison to younger patients?
Fat soluble drugs
Water soluble drugs
Acidic drugs
Increased sensitivity to diazepam, warfarin, opioids
Increased ADRs to: antipsychotics, antibiotics, NSAIDs
Increased effects from anti-HTNs
Increased toxicity from digoxin
What is poly pharmacy, how prevalent is it and why does it arise?
PP= multiple medications, or inappropriate amounts for that patient
>50yo 2-3x prescriptions
Arises through: increase in acute and chronic disease, increased drs visits, counter SEs, prescribing cascade, no medical review, automatic refills, lack of knowledge, patient may want medication
What drugs are most commonly implicated in adverse drug reactions?
ANTICHOLINERGICS SEDATIVES NSAIDs Diuretics Warfarin ACEIs Antidepressants
What is delirium?
A state of disturbed consciousness (hypo/hyperactive/mixed), a change in cognition (memory/perception) that has acute onset and is fluctuant
What are the culprit drugs causing falls?
Anti HTNs Beta blockers Sedatives Anti cholinergics Opioids Alcohol
