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year 3 specialties > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What are the 3 theories of ageing?

A

Stochastic
Programmed
Homeostasis failure

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2
Q

What is the stochastic theory of ageing?

A

Cumulative damage in cells with occurring randomly leading to replicative errors

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3
Q

What is the programmed theory of ageing?

A

Predetermined changes in gene expression at different points in life

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4
Q

Outline some of the etiological theories with regards to ageing

A
  • Improved screening outcomes
  • increased resource availability
  • increased availability of resources and economic availability
  • more people survive a major event and have several co-morbidities (better outcomes for surgery, stroke and cardiac disease)
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5
Q

What is classed as primary ageing?

A

Arthritis

Reduced GFR

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6
Q

What is Classed as secondary ageing?

A

accumulating more time at risk of certain diseases

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7
Q

Outline the functional decline in the pathophysiology of ageing

A

% of maximum function declines with age but this varies a lot between individuals and this variability increases with age

  • EVIDENCE GAP for >80 yo
    most drugs used to treat elderly are not actually trialled in elderly
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8
Q

What is the effect of ageing on the renal system?

A
  • Decreased creatinine clearance so decreased GFR

- BUT less creatinine to clear as less muscle mass

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9
Q

What is the effect of ageing on the CVS system?

A
  • Increased systolic BP, decreased diastolic BP

- decreased CO

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10
Q

What is the effect of ageing on the respiratory system?

A
  • Decreased peak flow and gas exchange
  • decreased lung function tests e.g. FVC, TV, VC
  • Weakening of resp muscles
  • decreased effectiveness of defence mechanisms
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11
Q

Outline the definition of frailty

A
  • Cycle of decline, crisis, admission and reablement
  • A SUSCEPTIBILITY STATE that leads to a person being more likely to lose function in the face of a given environmental challenge
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12
Q

3 or more of the these = the frailty phenotype

A
  • Unintentional WL
  • Exhaustion
  • Weak grip strength
  • Low physical activity
  • Slow walking speed
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13
Q

What are the 4 frailty syndromes (system failure presentations)?

A
  • Falls
  • Immobility
  • Functional loss
  • Delirium
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14
Q

What is the aim of a comprehensive geriatric assessment?

A

Assessment & management of illness in the frail elderly with a PERSON/GOAL CENTRED approach (multi-dimensional)

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15
Q

What kind of things are included in a CGA?

A
  • preserve autonomy - goal centredness
  • deal with multi-morbidities and competing clinical priorities
  • determine problems and identify what is reversible or can be improved
  • produce management plan
  • MDT
  • improves outcomes and earlier discharge
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16
Q

What are the affected health domains in ageing the?

A
  • Medical
  • Psychological
  • Functional
  • Behavioural
  • Social
  • Environmental
  • Nutritional
  • Societal
  • Spiritual (person centred care)
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17
Q

Describe the link between frailty and dyshomeostasis

A
  • Frailty = progressive dyshomeostasis

- impaired function of ANY organ makes maintenance of a steady state more difficult

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18
Q

What is senescence?

A

Impaired organ function so dyshomeostasis so susceptibility to environmental stress and frailty

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19
Q

What medical aspects of health are covered in the CGA?

A
  • Reversible or irreversible
  • Multi-morbidity
  • Iatrogenic harm
  • Curable (infection or iatrogenic)
  • Physiological (normal ageing) or pathological (disease)
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20
Q

What psychological aspects of health are covered in the CGA?

A
  • Mood - low mood or anxiety
  • Cognition - dementia or delirium
  • Confidence - fear of falling syndrome
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21
Q

What functional aspects of health are covered in the CGA?

A
  • Mobility
  • ADLs - transfers, mobility, toileting, washing, dressing, meal prep, feeding
  • community living skills
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22
Q

What behavioural aspects of health are covered in the CGA?

A
  • determinants e.g. smoking
  • activities/hobbies
  • occupation
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23
Q

What social aspects of health are covered in the CGA?

A
  • support networks: practical/emotional, formal/informal

- potential for abuse (financial/physical/ sexual/ neglect)

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24
Q

What environmental aspects of health are covered in the CGA?

A
  • Housing and heating
  • Sanitation
  • Adaptations
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25
Q

What nutritional aspects of health are covered in the CGA?

A
  • MUST screening tool

- Poor health and poor nutrition lead to one another

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26
Q

What societal aspects of health are covered in the CGA?

A
  • Political/regulations
  • attitudes
  • technological advances
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27
Q

What spiritual aspects of health are covered in the CGA?

A
  • Bigger picture, what is important to you
  • project self-image
  • meaning in life
  • what is important to you
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28
Q

What are the benefits of being admitted to hospital as an elderly person?

A
  • clinical expertise
  • complex tests and interventions
  • rapid access to supervised care and support
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29
Q

What are the risks of being admitted to hospital as an elderly person?

A
  • Disorientation and delirium
  • learned dependency
  • deconditioning
  • iatrogenic harm
  • healthcare associated infection
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30
Q

How is absorption affected in older people (pharmacokinetics)?

A
  • reduced RATE of action but NOT extent (delayed onset)

- Levodopa = exception - quicker to peak plasma level due to less metabolism in saliva

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31
Q

How is distribution affected in older people (pharmacokinetics)?

A
  • changes in body composition
  • increased adipose tissue - increases Vd, T1/2 and duration for fat soluble drugs
  • decreased body water - decreased Vd and increased serum levels for water double drugs
  • changes to protein binding - reduced binding and increased serum levels of acidic drugs
  • increased serum levels of highly protein bound drugs
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32
Q

How is metabolism affected in older people? (pharmacokinetics)

A
  • Reduced liver mass and blood flow - increased toxicity

- reduced 1st pass metabolism - different bioavailability of certain drugs

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33
Q

How is excretion affected in older people (pharmacokinetics)?

A

Renal function declines so reduced clearance and increased half-life - Increased TOXICITY

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34
Q

Outline the changes in pharmacodynamics in the elderly

A

Increased sensitivity due to
1) changes in receptor binding
2) reduced receptor number
Altered translation of receptor-initiated response to biochemical reaction

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35
Q

What is Beer’s criteria?

A

Inappropriate drugs for older people

but has many weaknesses

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36
Q

What prescribing tools are there for prescribing in the elderly?

A
  • Beer’s criteria
  • Polypharmacy guidance
  • START-STOPP criteria
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37
Q

What is START-STOPP criteria?

A

Tool used in prescribing for elderly
Optimisation advice
e.g. stop codeine for diarrhoea as may mask gastroenteritis, start a fibre supplement in diverticular disease

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38
Q

Which drugs are a falls risk?

A
  • Tolterodone - anticholinergic
  • Bendroflumethiazide - hyponatraemia, hypotension
  • Omeprazole - hyponatraemia, osteoporosis
  • Sertraline - orthostatic hypotension, hyponatraemia
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39
Q

What are the central side effects of anticholinergics?

A
  • Memory impairment
  • Confusion
  • Agitation
  • Disorientation
  • Delirium
  • Hallucinations
  • Falls
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40
Q

What are the peripheral side effects of anticholinergics?

A
  • Dry mouth and eyes
  • Constipation
  • Visual accommodation problems and pupil dilatation
  • Urinary retention
  • Decreased sweating
  • Inhibition of penile erection
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41
Q

Outline the problems with psychiatric drugs in the elderly

A
  • care treating agitation
  • Benzos have increased effects wrt falls, sedation and confusion
  • anti-psychotics can cause postural hypotension, stroke, confusion and movement disorders
  • Anti-depressants less effective and more dangerous
  • sedatives are problematic
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42
Q

Outline the problems with analgesia in the elderly

A
  • Opioids are more sensitive so given in lower doses (but may be less sensitive to tramadol and pethidine)
  • NSAIDs - increased SEs of renal impairment and GI upset/bleeding
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43
Q

Outline the problems with antibiotics in the elderly

A
  • Increased SE:C diff, diarrhoea
  • Co-trimazole causes delirium
  • Quinolones cause seizures/delirium
  • Aminoglycosides contraindicated due to renal impairment
  • Blood dyscrasia (trimethoprim, co-trimox)
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44
Q

Outline the problems with cardio drugs in the elderly

A
  • DIGOXIN - increased toxicity
  • DIURETICS - reduced peak effect and reduced clearance, cause continence and immobility
  • Anti-hypertensives have exaggerated effect on BP and HR
  • Anti-coags - more sensitive to Warfarin, great risk from Warfarin - GI bleed, falls
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45
Q

How may a frail person present with hyperthyroidism compared to a normal person?

A

Frail: depression, CI, weakness, A Fib, HF, angina

Not frail: tremor, anxiety, WL, diarrhoea

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46
Q

When may deprescribing be useful?

A
  • Some evidence that it is safe to stop antihypertensives, benzodiazepines, antipsychotics
  • Stop statins in last year of life
  • most ADRs events from anticholinergics and sedatives
47
Q

Outline the pathology of Alzheimers

A

Amyloid plaques in brain

48
Q

Outline the aetiology of dementia

A
  • Alzheimer’s (50%)
  • Vascular dementia (25%)
  • Mixed Alzheimer and vascular (15%)
  • Lewy Body dementia (5%)
  • Others ie frontotemporal dementia, brain disorders such as Huntington’s and Parkinsons , head injury
49
Q

What are reversible causes of dementia?

A
  • Hypothyroidism
  • Intracerebral bleeds/tumours
  • B12 deficiency
  • Hypercalcaemia
  • Normal pressure hydrocephalus
50
Q

What is dementia by definition?

A

Chronic global cognitive impairment; progressive

51
Q

Describe the ABCD clinical syndrome of dementia

A

A - Activities of daily living
B - behavioural and psychiatric symptoms of dementia (BPSD)
C - cognitive impairment
D - decline

52
Q

Outline Alzheimer’s disease in Dementia

A

Slow insidious onset
Loss of recent memory first
progressive functional decline

53
Q

Outline Vascular dementia in Dementia

A

Step wise deterioration
Executive function may predominate
often associated w/ gait problems

54
Q

Outline Lewy Body dementia in Dementia

A

Deficits of Attention, frontal executive and visuospatial

  • amnesia NOT prominent
  • 2 = probable, 1 = possible of fluctuation, visual hallucinations, Parkinsonisms
55
Q

What is suggestive of Lewy body dementia? and what is it supported by?

A

Suggestive - REM sleep disorder, severe antipsychotic sensitivity, abnormal DAT scan

Supported by: falls, syncope, LOC, other psych symptoms, autonomic dysfunction, scans

56
Q

Outline fronto-temporal dementia in Dementia

A

Tends to have a younger onset

  • behavioural disorder (personality change)
  • speech disorder
  • neuropsychology (frontal dysexecutive syndrome)
  • Neuroimaging - abnormalities on temporal lobes
  • Neurological signs absent early, later get Parkinsonism, sometimes MND, autonomic, incontinence, primitive reflexes
57
Q

What is the criteria for dementia?

A
  • Present for > 6 months
  • Acquired cognitive decline - memory (dysmnesia) + 1 of :

Dysphasia (expressive or receptive)
Dyspraxia
Dysgnosia
Dysexecutive functioning

FUNCTIONAL DECLINE IN ADLs - forgetting to take tablets, unable to use phone, problem’s washing/dressing

58
Q

How would you diagnose dementia?

A
  • History and collateral
  • Risk assessment
  • MMSE/MOCA
  • Bloods: FBC, ESR/CRP, U&E, LFTs, Glucose, Ca, TFT, B12, red cell folate
  • neuroimaging
59
Q

What are the side effects of cholinesterase inhibitors in the treatment of dementia?

What are the contraindications?

A

Generally safe but SEs:

  • N&V, diarrhoea
  • Fatigue, insomnia
  • Muscle cramps
  • headache
  • dizziness

Contraindications:
- bradycardia, syncope, gastric ulcer, respiratory problems

60
Q

Outline how dementia will affect driving?

A

Notify DVLA at Dx

Should not drive if:

  • poor ST memory
  • disorientation
  • lack of insight
61
Q

Assessing capacity in dementia involves..

A

Can they:

  • act
  • make
  • communicate
  • understand
  • retain memory of

Task specific e.g medical treatment, hospitalisation

62
Q

What is the epidemiology of delirium?

A
  • Commonest complication of hospitalisation
  • 20-30% of all hospital inpatients
  • 50% post-surgery
  • 85% of EOL
  • Large morbidity & mortality
  • Preventable in 30% of cases
63
Q

What precipitates delirium? Aetiology

A
  • infection
  • dehydration
  • biochemical disturbance
  • pain
  • drugs
  • constipation/urinary retention
  • hypoxia
  • drug/alcohol withdrawal
  • sleep disturbance
  • brain injury: stroke/tumour/bleed
  • SLE
  • cerebral vasculitis
  • vitamin deficiencies
  • endocrinopathies
  • paraneoplastic syndrome
64
Q

Outline the pathophysiology of delirium

A
  • acute organic confusional state

- maladaptive sickness response involving systemic inflammation

65
Q

Why bother with delirium?

A
  • Massive M&M
  • increased risk of death
  • longer length of stay
  • increased rates of institutionalisation
  • persistent functional decline
  • acute or subacute onset characterised by global cognitive impairment
66
Q

What are the key features of delirium?

A
  • Disturbed consciousness
  • Change in cognition (memory/perceptual/ language/hallucination)
  • Acute onset and fluctuant
67
Q

What are other common features of delirium?

A
  • Disturbance of sleep wake cycle
  • disturbed psychomotor behaviour (affects your physical function)
  • emotional disturbances
  • delusion
68
Q

What are the symptoms of delirium?

A
  • Impaired attention/concentration
  • Anterograde memory impairment
  • disorientation in time, place or person
  • fluctuating levels of arousal (often nocturnal exacerbations)
  • disordered sleep/wake cycle
  • increased/decreased psychomotor activity
  • disorganised thinking
  • perceptual distortions, leading to misidentification, illusions and hallucinations
  • changes in mood such as anxiety, depression and lability
69
Q

What test is used to diagnose delirium?

A

4AT
4 or > = possible delirium or cognitive impairment
1-3 = possible CI
0 = delirium/cognitive impairment unlikely

70
Q

Should you use a dipstick for the diagnosis of UTI in older people?

A

NO

Sign 88 guidelines

71
Q

What is the TIME bundle when assessing/managing delirium?

A

T - think exclude & treat poss triggers
I - investigate and intervente to correct underlying cause
M - management plan
E - engage and explore; talk to and involve family

72
Q

What things may trigger delirium that you should assess in your full examination and TIME bundle?

A
  • NEWS - sepsis 6
  • Blood glucose
  • Medication Hx: new medication, dose changes, medication recently stopped
  • assess for urinary retention
  • assess for constipation
73
Q

How should you investigate and intervene when assessing for delirium?

A
  • assess hydration, start fluid balance chart
  • pain review (Abbey pain scale)
  • Bloods (FBC, U&E, Ca, LFTs, CRP, Mg, Glucose)
  • Symptoms and signs of infection and perform appropriate investigations
  • ECG for ACS
74
Q

What is the pharmacological treatment of delirium?

A

STOP anti-cholinergic & sedatives
Drug tx not usually necessary but if absolutely needed (danger to self and others and cannot be settled in any other way) - QUETIPINE - 12.5mg oral - cons/reg decision

75
Q

What is a non-pharmacological treatment of delirium?

A
  • Re-orientate and reassure
  • Use families and carers
    Get them in at meal times
  • early mobility and self care
  • correct sensory impairment
  • ensure continuity (avoid room/ward transfers)
  • avoid catheters and venflon
76
Q

What is the trajectory and FU for delirium?

A
  • usually settles quickly with management of underlying cause
  • increasingly recognise that a lot of people don’t get back to previous level
  • may unmask previously undiagnosed cognitive impairment
  • more likely to go on and develop dementia
  • RF for further episodes of delirium/dementia/frailty syndromes
77
Q

Do people with delirium have capacity?

A

Capacity is decision specific

Welfare POA or guardian ?

78
Q

Outline the epidemiology of falls

A

Annually effects 30% of >65
40% of >80
50% in hospital or care homes

  • more mortality than sepsis in elderly
79
Q

Aetiological causes of falls are made up of ______, ______, _____ and other factors

A

Intrinsic
Extrinsic
Situational

80
Q

Name some extrinsic factors of falls

A
  • Inappropriate footwear
  • Environmental hazards (uneven paving, carpets, walking aids, stairs)
  • Poor lighting
81
Q

Name some situational factors of falls

A
  • Alcohol
  • Urgency of micturition
  • Medications- change BP, HR, awareness, increase UO, sedation, qTC, dizziness
82
Q

Name some intrinsic factors of falls

A
  • Gait and balance
    = postural instability
    = cerebral perfusion (reduced CO, reduced vasomotor tone e.g. by GTN
    = Vestibular: dizziness due to unsteadiness, vertigo - labyrinthitis, acute OM, BPPV, Menieres disease, cerebellar or brainstem pathology
83
Q

Name some other factors of falls

A
  • syncope (CVS, vagal, other) - think Aortic stenosis
  • chronic disease (MSK or neurological)
  • Acute illness - limited physiological reserve leading to hypoxia, impaired central processing and correction of imbalance
  • cognitive disorder (dementia, delirium, depression)
  • Vitamin D deficiency
84
Q

What 2 things need excluding in someone who has had a fall?

A

Syncope

Seizure

85
Q

In someone who has had a fall, what should you examine?

A
  • Injuries (hip, wrist, vertebrae # most common)
  • chronic disease
  • acute illness (LRTI, UTI, dehydration)
  • Cognitive dysfunction
  • Look at feet (footwear, toenails), check vibration sense, sensation and proprioception
  • gait and balance assessment
  • syncope assessment
  • seizure assessment
86
Q

Suspect a seizure if 1 or more of the following are present:

A
  • bitten tongue
  • head turning
  • no memory
  • unusual posture
  • prolonged
  • simultaneous limb jerking
  • confusion after
  • prodromal deja vu or jamais vu
87
Q

When may a seizure be unlikely in a fall?

A
  • If prodromal
  • other occasions resolved by lying down
  • precipitated by standing
  • sweating or pallor during episode
88
Q

As well as a full examination, what else should be investigated in a fall?

A
  • Basic bloods: FBC, U&E, LFT, TFT, B12 and vit D, folate, CK
  • Random blood glucose
  • 4AT delirium
  • consider CT head if fall + head injury and Neuro signs or anticoagulated
  • assess fracture risk
89
Q

If you have delirium, you are ___ times more likely to fall

A

4.5

90
Q

______ prevention interventions also reduces falls

A

Delirium

91
Q

In the falls clinic where an MDT is present, what kind of things are done?

A
  • Eye test, ECG, L/SBP, incontinence questionnaire, MMSE
  • full assessment of gait and balance
  • thorough hx and examination, consider bone health and osteoporosis screening
92
Q

If a patient falls on exertion what should you assume is the cause?

A

Aortic stenosis

93
Q

If a patient falls on turning what should you assume is the cause?

A

Postural instability

94
Q

Are there any drugs you should specifically ask about when assessing falls?

A

OTC antihistamines, alcohol

95
Q

Those with a history of falls should be managed how?

A
  • treat underlying cause
  • strength and balance training
  • home hazard intervention
  • medication review with modification and deprescribing
  • cardiac pacing: selected patients with cardio-inhibitory carotid sinus sensitivity and unexplained falls
  • treat fractures
  • treat osteopenia/porosis
96
Q

What should you treat all those with osteopenia/porosis who have fallen?

A
  • Calciumn and vitamin D supplementation

- Consider IV bisphosphonates, teriparatide or densosumab

97
Q

What may an ataxic gait suggest?

A

Cerebellar damage

98
Q

What may an arthralgic gait suggest?

A

arthritis

99
Q

What may a hemiplegic gait suggest?

A

Stroke

100
Q

What may small steps/shuffling gait suggest?

A

Parkinsonism

101
Q

What may a high stepping gait suggest?

A

Peripheral neuropathy

102
Q

When should you perform a CT head after an inpatient fall?

A

If:

  • Low GCS <13
  • Still confused after 2 hours (or not back to baseline)
  • Focal neurology
  • Signs of skull fracture
  • Basal skull fracture - CSF leak, bruising around eyes
  • Seizure
  • vomiting
  • anti-coagulation
103
Q

What are the RFs for immobility?

A
  • diabetes or insulin resistant
  • elderly
  • chronic disease
  • lack of use
  • inflammation
  • nutritional deficiency
104
Q

Outline the pathophysiology with immobility/falls

A

SARCOPENIA - loss of skeletal muscle mass and strength as a result of ageing
- sarcopenia, elimination problems, lead to loss of confidence, injury and pain

105
Q

What are some of the physical complications of immobility/falls?

A
  • Muscle wasting
  • contractures
  • pressure sores
  • DVT
  • constipation/incontinence
  • hypothermia
  • hypostatic pneumonia
  • osteoporosis
106
Q

What are some of the psychological complications of immobility/falls?

A
  • depression

- loss of confidence

107
Q

What are some of the social complications of immobility/falls?

A
  • Isolation

- Institutionalisation

108
Q

Anticholinergics cause _____, dry mouth, ______, blurred vision, ______ retention and orthostatic _______

A

confusion
constipation
urinary retention
orthostatic hypotension

109
Q

Tricyclics cause _____ and _____ gait in the elderly

A

confusion

unsteady

110
Q

Digoxin causes ______ with normal serum concentration

A

toxicity

111
Q

Long acting benzodiazepines cause ____ toxicity in the elderly

A

CNS

112
Q

Narcotics in the elderly cause ______

A

confusion

113
Q

ADRs in the elderly look like ‘_______ ___’

A

growing old

  • unsteadiness
  • dizziness
  • confusion
  • nervousness
  • fatigue
  • insomnia
  • drowsiness
  • falls
  • depression
  • incontinence
114
Q

What is the therapeutic range known to be between?

A

MTC and MEC

year 3 specialties (1 decks)

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