Geriatrics

Question 1

What are the recent and future trends of old age?

Answer 1

Reproducing less
Life expectancy increasing
Life expectancy at 60yo increasing eg keeping alive longer
Increased number of people over 60yo worldwide

Question 2

What are the different aspects of the ageing process?

Answer 2

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

Question 3

What is frailty?

Answer 3

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

Question 4

How does physiological decline impact other disease processes?

Answer 4

Frailty can lead to dramatic functional loss through falls, delirium, immobility and incontinence

Question 5

How does frailty impact the delivery of individualised healthcare?

Answer 5

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

Question 6

What is illness in older people often due to?

Answer 6

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

Question 7

What is the multidimensional and multidisciplinary holistic approach important to assess and address problems in the elderly?

Answer 7

The comprehensive geriatric assessment

The process to assess and manage illness in older people with frailty (a goal centred approach)

Question 8

What evidence is there that supports this approach?

Answer 8

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

Question 9

What is the impact of incontinence on people’s lives?

Answer 9

Can be disabling: socially, physically
Stigmatising
It is common and treatable

Question 10

What are the multiple and multifactorial causes of incontinence?

Answer 10

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

Question 11

What is the typical symptom pattern associated with each kind of incontinence?

Answer 11

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

Question 12

How would you take a history, examination and relevant investigations for incontinence?

Answer 12

History: good, social history, intake and output diary
Investigations: urinalysis, MSSU, bladder scan

Question 13

What are the common treatment options for the main types of incontinence?

Answer 13

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

Question 14

What are the main clinical features of delirium, it’s investigation and management?

Answer 14

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)

Question 15

How do you differentiate delirium from other kinds of cognitive impairment?

Answer 15

4AT score: alertness, AMT4 (age, dob, place), attention, acute change or fluctuating

Question 16

What are the main principles of capacity assessment and adults with incapacity legislation?

Answer 16

Capacity is decision specific

Check if they have a welfare POA or guardian

Question 17

What conditions mainly cause immobility and falls in the elderly, and what is the clinical approach to their assessment?

Answer 17

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

Question 18

How do pharmacokinetics and pharmacodynamics differ in elderly patients?

Answer 18

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

Question 19

What are the principles which underpin prescribing in the elderly?

Answer 19

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

Question 20

What help is available for clinicians in choosing and adjusting drug dosage in elderly patients?

Answer 20

BNF
Beers Criteria
START-SROP criteria
NHS Scotland Polypharmacy Guidance

Question 21

What common medicines are elderly patients likely to respond to differently in comparison to younger patients?

Answer 21

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

Question 22

What is poly pharmacy, how prevalent is it and why does it arise?

Answer 22

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

Question 23

What drugs are most commonly implicated in adverse drug reactions?

Answer 23

ANTICHOLINERGICS
SEDATIVES
NSAIDs
Diuretics
Warfarin
ACEIs
Antidepressants

Question 24

What is delirium?

Answer 24

A state of disturbed consciousness (hypo/hyperactive/mixed), a change in cognition (memory/perception) that has acute onset and is fluctuant

Question 25

What are the culprit drugs causing falls?

Answer 25

Anti HTNs
Beta blockers
Sedatives
Anti cholinergics
Opioids
Alcohol