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Third > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What are the causes of acute confusion?

A

PINCH ME

Pain - severe
Infection  - UTI 
Nutrition 
Constipation 
hydration

Medication, Metabolic disorder - hypoglycaemia, hypercalcaemia
Environment

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2
Q

What are the drugs given for palliative end of life care?

A
  1. Morphine - for pain
  2. Antiemetic - for nausea and vomiting
  3. Hyoscine - for reducing secretions
  4. Midazolam (Benzo) - for agitation
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3
Q

What are the causes of pleural effusion?

A
  1. Pulmonary embolism
  2. Heart failure
  3. Infection
  4. Cancer - mostly unilateral
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4
Q

What are the 4 geriatric giants?

A
  1. Immobility
  2. Instability
  3. Incontinence
  4. Intellectual impairment
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5
Q

What is the a comprehensive geriatric assessment?

A

A process used by healthcare practitioners to assess the status of people who are frail & older in order to optimize their subsequent mx

Component:
1. Medical assessment - Doctor, Nurse, Pharmacist, Dietician, SaLT

  1. Functional assessment - OT, PT, SaLT
  2. Psychological Assessment - Doctor, Nurse, OT, Psychologist
  3. Social and environmental assessment - OT, SW
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6
Q

What is the responsibility of the lasting power of attorney?

A

People to make decisions on your behalf if you are unable to make decision (Lack capacity). Decisions made must be in the person’s best interests

o Cannot demand Rx
o Only to refuse / accept Rx

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7
Q

What are the alternatives if there is no lasting power of attorney?

A
  • Check for court appointed deputy - For relatives to gain power over decisions when patient has no capacity & no LPA. Cannot demand Tx and can only accept or refuse it
  • Independent mental capacity advocate - if the patient has no relatives or family -
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8
Q

What is an advanced decision?

A

A person over 18 can set out what types of treatment they would not want to have and in what circumstances, should they lack capacity to refuse consent in future

o Applies even in life. / death situations
o Must be valid (Not overridden by appointing an LPA)

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9
Q

What are part of basic care and cannot be stopped?

A

Oral food, fluids, warm, dry, clean, washing

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10
Q

What are part of basic medical care ?

A

Must be given if there is overall benefit to patient; can be stopped as it’s seen as not giving Rx :
Tube feeding, Parenteral fluids

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11
Q

What is the effect of BDZ and opioids in the elderly?

A

Can acutely cause confusion

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12
Q

What is the effect of anticholinergics in the elderly?

A
  • Dry mouth
  • Blurred vision
  • Urinary retention
  • Constipation
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13
Q

What is the effect of antihypertensives in the elderly?

A

Postural hypotension

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14
Q

What is the difference in pharmocokinetics of drug metabolism in the elderly?

A

Absorption:

  • Delayed gastric emptying due to immobility, thus reduced intestinal blood flow
  • Variable chg in 1st pass metabolism due to reduced hepatic blood flow

Distribution:

  • Increased serum concentration of water soluble drugs due to reduced volume of distribution
  • Increased half life of fat soluble drugs due to increased body fat
  • Increased free serum, decrease in serum albumin

Elimination:

  • eGFR < reliable with age
  • Creatine clearance > accurate
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15
Q

What is the definition of malnutrition? and criteria for it?

A

A state in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on body’s form, function and clinical outcome

BMI <18.5 kg/m2
/Unintentional weight loss >10% in last 3-6 mths
/BMI <20kg/m2 + Unintentional weight loss >5% in last 3-6 mths

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16
Q

What are the broad causes of malnutrition?

A
  • Starvation
  • Increased nutritional requirements - sepsis
  • Inability to use the nutrients ingested - malabsorption
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17
Q

How do you calculate Malnutrition universal screening tool scores when BMI or weight is not available?

A

Subjective data

OR

 Can estimate height from ulna length
 Can estimate BMI from mid upper arm circumference (MUAC)

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18
Q

How is a low risk MUST score managed?

A

• Provide green leaflet (‘Eating well’)

• Review/Re-screen:
o Care homes (Monthly)
o Community (Annually)

  • Consider > frequent re-screening in high risk groups
  • If BMI >30kg/m2 (Obese) = Rx according to local policy / National guidelines
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19
Q

How is a medium risk MUST score managed?

A

• Dietary advice to maximize nutritional intake; encourage:
o Small frequent meals & snacks
o With high energy & protein food and fluids

• Powdered nutritional supplements to be made up with water/milk are available

• Review progress/Repeat screening:
o After 1-3 mths (According to the clinical condition)
o /Sooner if the condition requires

  • If improving = Continue until ‘Low risk’
  • If deteriorating = Consider treating as ‘High risk’
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20
Q

How is a high risk MUST score managed?

A
  • Provide dietary advice as ‘Medium risk’
  • Prescribe oral nutritional supplements (ONS) & monitor (Consider local formularies)
  • If improve = Consider Mx as ‘Medium risk’

• Refer to dietitian if:
o No improvement
o />Specialist support is required

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21
Q

How do you check if the NG tube is the right position?

A

1st line - Gastric aspirate pH <5.5

2nd line - CXR

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22
Q

What are the risk of NG tube and PEG tube?

A

NG tube: (short term)

  • Tubes often easily displaced
  • Risk of aspiration
  • CI in Paralytic ileus

Percutaneous Endoscopic Gastrotomy tube: (long term)

  • Bowel perforation
  • Wound infection
  • Peritonitis
  • Aspiration
  • Death
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23
Q

What are the indications of TPN?

A 
• Non-functioning GI tracts; eg:
Obstruction
Perforation
Ileus
High output fistulas
• Short bowel syndrome
• Severe pancreatitis
• Malabsorption
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24
Q

What are the complications of refeeding syndrome?

A
  • Arrhythmias (Commonest cause of death)
  • HF
  • Seizures
  • Cardiac arrest
  • Delirum
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25
Q

What is the management of refeeding syndrome?

A

Before feeding & in the first 10d of refeeding; give:
o IV Pabrinex (Thiamine)
+ Vit B Compound Strong

  • Start nutrition at 10kCal/kg for first 24h
  • Monitor PO42-, K+, Mg2+ (PPM) daily & correct as appropriate
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26
Q

What are the drugs that can cause osteoporosis?

A
  • Steroids
  • Heparin
  • Warfarin
  • Phenytoin
  • GnRH agonist
  • PPI
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27
Q

What are the endocrine causes of osteoporosis?

A 
• Hypogonadal states; eg:
o Turner
o Klinefelter
o Testosterone deficiency 
o Premature ovarian failure
  • Cushing’s syndrome
  • Hyperparathyroidsm
  • Hyper/Hypothryoidism
  • T1DM
28
Q

What are the GI and renal causes of osteoporosis?

A

GI - malabsorption disorders

Renal causes - Renal osteodystrophy (Impaired Vit D & Ca2+ metabolism)

29
Q

What are the risk factors of osteoporosis?

A

Risk Factors: ‘SHATTERED’

Steroid use (>5mg/d Prednisolone)
Hyperthyroidism / Hyperparathyroidism / Hypercalciuria
Alcohol & Smoking
Thin (BMI <22) / T1DM
Testosterone ↓
Early menopause (Eg: Premature ovarian failure)
Renal / Liver failure
Erosive inflammatory bone disease (Eg: MM, RA)
Dietary Ca2+ ↓ / Malabsorption

30
Q

What are the common areas of osteoporotic fractures?

A 
• Distal radius (Colles’ fracture) 
• Neck of femur fracture 
• (Wedge) Fracture of thoracic vertebrae which may lead to:
     o Loss of height 
     o Exaggerated dorsal kyphosis
     o Pain
31
Q

What is the DEXA score and what are the results important?

A

-1 to -2.5 = Osteopenia = Offer lifestyle advice

<2.5 = Osteoporosis = Offer Lifestyle Advice +Rx +Repeat DEXA in 2yrs

32
Q

What is the medical management of osteoporosis?

A

1st line - Bisphosphonates - alendronate / if cannot be taken due to upper GI problems –> use risedronate or etidronate

2nd line - strontium ranelate or raloxifene (SERM)
3rd line - Denosumab

vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete

33
Q

What is the diagnostic investigation for lewy body dementia? What is the management?

A

Diagnosis:

  • Usually clinical
  • Single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan.

Management

  • Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine
  • Neuroleptic medication is to be avoided in LBD -a s tehy may develop irreversible parkinsonism
34
Q

What antipsychotic is CI in parkinson’s disease?

A

Haloperidol

35
Q

What is the diagnostic criteria for orthostatic hypotension?

A

a. A drop in systolic BP of 20mmHg or more (with or without symptoms)
b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
c. A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).

36
Q

What are the medications associated with orthostatic hypotension?

A
  • Nitrates
  • Diuretics
  • Anticholinergic medication
  • Antidepressants
  • Beta-blockers
  • L-dopa
  • ACE-inhibitors
37
Q

What are the medications that can cause falls?

A
  • Benzodiazepines
  • Antipsychotics
  • Opiates
  • Anticonvulsants
  • Codeine
  • Digoxin
38
Q

What is the NICE recommendation for falls?

A
  • Identify all individuals who have fallen in the last 12 months
  • For those with a falls history or at risk complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.

Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:

  • More than 2 falls in the last 12 months
  • A fall that requires medical treatment
  • Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’

Individuals who fall but do not meet these criteria should be reviewed annually and given written information on falls.

39
Q

What are the side effects of digoxin toxicity?

A

Digoxin has a narrow therapeutic index and toxicity can be potentiated by renal failure and hypokalaemia - can be triggered by infection

Symptoms of acute digoxin toxicity include gastrointestinal disturbance (nausea, vomiting, abdominal pain), dizziness, confusion, blurry or yellow vision, and arrhythmias.

40
Q

What are the side effects of amitriptyline ?

A

Side-effects of an anticholinergic drug such as amitriptyline, including dry eyes, dry mouth, hypotension (often postural) and delirium. Amitriptyline is a commonly prescribed neuropathic painkiller.

Constipation, urinary retention, arrhythmias (including QT interval prolongation) and hypothermia.

41
Q

What are the side effects of Indapamide ?

A

Indapamide and other thiazide diuretics can precipitate gout, and strong consideration should be made with regards to stopping the drug in patients with gout

42
Q

What are the blood tests that are part of the confusion screen?

A

FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia)
Blood cultures (e.g. sepsis)

43
Q

What is the score used to screen for pressure ulcers?

A

The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.

44
Q

What are the factors that predispose old people to pressure ulcers?

A
  • Malnourishment
  • Incontinence
  • Lack of mobility
  • Pain (leads to a reduction in mobility)
45
Q

What is the management of pressure ulcers?

A
  • A moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
  • Wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
  • Consider referral to the tissue viability nurse
  • Surgical debridement may be beneficial for selected wounds
46
Q

Why are tricyclic antidepressants to be stopped if dementia is suspected?

A

Risk of worsening cognitive impairment

When it needs to be stopped: wean off gradually over 4 weeks

47
Q

How to differentiate delirium from dementia?

A
  • Impairment of consciousness
  • Fluctuation of symptoms: worse at night, periods of normality
  • Abnormal perception (e.g. illusions and hallucinations)
  • Agitation, fear
  • Delusions
48
Q

What are the features of Pick’s disease?

A
  • Personality change
  • Impaired social conduct.
  • Hyperorality
  • Disinhibition
  • Increased appetite
  • Perseveration behaviours.
49
Q

What is the management of most dementia except FTD?

A
  • Three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
  • Memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, NICE recommend it is used in the following situation reserved for patients with:
       → moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
   → as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's
   → monotherapy in severe Alzheimer's

NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia

50
Q

Who is donepezil CI in and what are its side effects?

A

CI in bradycardia

Adverse effects include insomnia

51
Q

An elderly, frail woman is admitted to the ward following a fall at home. What is the most appropriate way to assess her risk of developing a pressure sore?

A

Waterlow score

52
Q

What do you use to for a woman in delirium with a background of parkinsons disease?

A

Lorazepam

Haloperidol can make the parkinson’s worse

53
Q

Which drugs can reduce the seziure threshold?

A
  • Tramadol
  • Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid
  • Antipsychotics
  • Antidepressents: Bupropion, Tricyclics, Venlafaxine
  • Fentanyl
  • Ketamine
  • Lidocaine
  • Lithium
  • Antihistamines
54
Q

A 77 year old man with a history of benign prostatic hyperplasia presents to clinic with nausea after eating some undercooked chicken last night. He is given some antiemetics but returns the next day with new symptoms of urinary retention. Which antiemetic could be responsible?

A

Cyclizine - has anticholinergic effects

Can enhance a high from opiates - especially with methadone so it is avoided in IVDU

55
Q

Why are the adverse effects of ondensetron?

A

Often used to prevent nausea in chemotherapy

Can be given PO/IV and IM which makes it useful

Can increase the QT interval and can induce Torsades de pointes

56
Q

What is the non-pharmacological management of postural hypotension?

A
  • Modifying or removing medications that cause or worsen postural hypotension such as anti-hypertensives
  • Encouraging fluid and salt intake
  • Compression stockings and abdominal binders
57
Q

What are the side effects of fludrocortisone?

A

Hypokalaemia, fluid retention and supine hypertension

58
Q

A 72-year-old man with end stage renal disease on haemodialysis was admitted following a fracture of his left radius. In the ED he was given some painkillers. Which of medication would be appropriate to give him as a painkiller?

A

Tramadol - excreted during dialysis - elimination of tramadol is primarily by the hepatic route

If not use fenatanyl - stronger

Avoid morphine

59
Q

A 67 year old man presents to your clinic after having his BP measured at a local health fair. His reading today is 164/84 which is similar to his previous records. His medical history is notable for angina, CKD stage 1 and T2DM (last HbA1c 8%). His only medication is occasional sublingual nitrate and metformin. What is your first line treatment for his newly diagnosed hypertension?

A

ACE-i

Improve heart failure and reduces the progression of renal disease and albuminuria

60
Q

A 90 year old man with Parkinson’s disease comes into the A&E after suspected food poisoning. He feels sick and has vomited four times. His family have all had similar symptoms earlier today after eating a salad at the local takeaway. He is given something for his nausea when he arrived at triage. 3 hours his family are worried as he is not speaking as easily as he was before, looks more unsteady on his feet and is having difficulty moving. What treatment was he given at triage?

A

Metaclopramide - prokinetic and induces gastric contractions

In parkinson’s patients, it can make the symptoms worse

61
Q

What medication is CI if sildenafil is being adminstered?

A

Nitrates

62
Q

What are the medications that can cause acute confusion?

A 
Benzodiazepines
Opiates
Antiparkinsonian agents
Tricyclic antidepressants
Digoxin
Beta blockers
Steroids
Antihistamines such as Chlorphenamine
63
Q

Which antibiotic used in UTI can transiently increase the creatinine levels?

A

Trimethoprim

64
Q

What are the likely precipitators of postural hypotension?

A

Diuretics (46%)
Sedatives (17%)
Centrally acting adrenergic blockers (15%)
Peripheral acting adrenergic blockers (10%)
Vasodilators (9%)
β blockers (5%)
Nitrates (5%)

65
Q

What are the reversible causes of dementia?

A

DEMENTIA: mnemonic

D- Drugs (barbiturates)
E - Eyes and Ears (visual/hearing impairment may be confused with dementia)
M - Metabolic (Cushing’s, hypothyroidism)
E - Emotional (depression can present as a pseudodementia),
N - Nutritional deficiencies/Normal pressure hydrocephalus,
T - Tumours/Trauma
I - Infections (e.g. encephalitis)
A - Alcoholism/Atherosclerosis (vascular).

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