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Systems > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Population increasing

A
  • Increased resources
  • Better economics
  • Better screening
  • Better outcomes following illness e.g. MI
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2
Q

Ageing

A
  • Progressive accumulation of damage to a complex system resulting in loss of system redundancy
  • Decreased resilience to overcome environmental stress (frailty)
  • Leads to increased risk of system failure: organ function decline -> dyshomeostasis
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3
Q

Frailty

A

A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge (dyshomeostasis)
- State of susceptibility to environmental stress

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4
Q

Frailty investigation

A

Medical conditions tend to present as functional decline (frailty syndromes): falls, delirium, immobility, incontinence.

Frailty index (>0.12)

Fried criteria (3/5) - phenotype:

  • Unintentional weight loss
  • Exhaustion
  • Weak grip strength
  • Slow walking speed
  • Low physical activity

Clinical frailty scale (spectrum)

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5
Q

Multimorbidity

A

Presence of 2 or more long-term health conditions

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6
Q

Causes of ill health in older people

A

Complex mix of factors:

  • Medical
  • Physical/functional
  • Psychological
  • Spiritual
  • Behavioural
  • Nutritional (MUST screen tool)
  • Environmental
  • Social
  • Societal
  • Sexual
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7
Q

Comprehensive Geriatric Assessment (CGA)

A

Inter-disciplinary approach to investigation and management important

  • Goal centred
  • Holistic approach
  • MDT
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8
Q

Incontinence

A

Symptom of lack of voluntary control over urination or defaecation.

Depends on effective function of bladder and integrity of neural connections of voluntary control.

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9
Q

Incontinence causes

A
  • Physical state and co-morbidities
  • Reduced mobility
  • Confusion
  • Abnormal intake
  • Medications
  • Constipation
  • Home/social circumstances
  • Bladder/urinary outlet pathology
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10
Q

Incontinence investigations and management

A
  • History and examination
  • Intake/output chart
  • Urinalysis and MSSU
  • Bladder scan (residual volume)

Management

  • Lifestyle/behavioural changes
  • Modify medications (diuretics)
  • Referral: physio, surgery
  • Medical options
  • Incontinence pads, urosheaths, catheter
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11
Q

Stress incontinence

A

Bladder outlet too weak (weak pelvic floor muscles + increased abdominal pressure)
- Women with children, after menopause

Management:

  • Physiotherapy (pelvic floor exercises)
  • Vaginal cones
  • Oestrogen scream
  • Duloxetine
  • Surgery: TVT, colposuspension
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12
Q

Urinary retention with overflow incontinence

A

Bladder outlet ‘too strong’ (urethral blockage, bladder unable to empty)
- Older men with BPH: poor flow, double voiding, hesitancy, post-micturition dribbling

Management:

  • Alpha blocker (relaxes sphincter)
  • Antiandrogen
  • Surgery e.g. TURP
  • Catheterisation
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13
Q

Urge incontinence

A

Bladder muscle ‘too strong’ (detrusor overactivity - low volume micturition)

  • Bladder stones, neurologic disorders, infection
  • Sudden urge to pass urine immediately

Management:

  • Antimuscarinics (relax detrusor)
  • B3 adrenoceptor agonist
  • Bladder retraining
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14
Q

Neuropathic bladder

A 
Underactive bladder (results in overflow incontinence)
- Neurological disease, prolonged catheterisation

Management:
- Catheterisation

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15
Q

Delirium

A

Acute, fluctuating change in mental status

  • Inattention
  • Disorganised thinking
  • Altered consciousness

Multifactorial

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16
Q

Delirium predisposing factors

A

Reduced functional reserve

  • Frailty
  • Older age
  • Dementia
  • Previous delirium
  • Dehydration
  • Polypharmacy
  • Co-morbidities
17
Q

Delirium precipitating insults

A

Illness

  • Neurological injury (stroke, tumour, haemorrhage)
  • Infection/fever
  • Cardiac
  • Constipation, urinary retention
  • Pain

Haemodynamics

  • Dehydration
  • Shock
  • Hypoxia

Environmental

  • Iatrogenic (surgery, medications)
  • Distress
  • Social
  • Alcohol/drug withdrawal
  • Sleep deprivation
18
Q

Delirium symptoms

A
  • Disturbed consciousness (hypo/hyperactive/mixed)
  • Change in cognition
  • Disturbed psychomotor behaviour
  • Functional decline: falls etc
  • Disturbed sleep-wake cycle
19
Q

Delirium investigations

A

TIME;

  • Think, treat triggers
  • Investigate (intervene)
  • Management
  • Engage, explore, explain (patient and family)

Screen:

  • Confusion assessment method (CAM)
  • 4AT score
20
Q

Delirium management

A

Treat cause
- Issue with capacity

Non-pharmacological

  • Reassure
  • Encourage early mobility
  • Correct sensory impairment
  • Normalise sleep-wake cycle
  • Avoid catheterisation

Pharmacological

  • Change medication
  • Anti-psychotics

MDT: CGA

Prevention

21
Q

Causes of falls

A

MSK: arthritis, sarcopenia, feet deformities

Medication: anti-hypertensives, b-blockers, sedatives, anticholinergics, opioids, alcohol

Neuro: stroke/TIA, parkinsonism, dementia, delirium, ataxia, seizure

Sensory: visual impairment, inattention

CVS: postural hypotension, HF, arrhythmia, aortic stenosis

Incontinence

22
Q

Investigation of falls

A

History: before/during/after fall
- Collateral

Examination
Bloods: glucose
ECG
Delirium screen (4AT, CAM)
Imaging: CT head, x-ray
23
Q

Management of falls

A

MDT

  • Correct medication
  • Physiotherapist
  • Specialist nurses

Prevention:

  • Vision
  • Mobility aids, call bell and possessions in reach
  • Bed rails
  • Height of bed
  • Regular obs
24
Q

CT indications after fall

A
  • GCS<13
  • Confusion after 2 hours
  • Focal neurology
  • Skull fracture signs (bruising around eyes, behind ears)
  • Seizure
  • Vomiting
  • Anticoagulation
25
Q

Polypharmacy and why it arises/prevention

A

Concurrent use of multiple medications by a patient

Prescriptions

  • Review regularly
  • Simplify

Diagnosis
- Correct

Medication

  • Correct
  • Lower doses
  • Reduced frequency
  • Clear instructions (compliance)
26
Q

Drug absorption (pharmacokinetic) differences in elderly

A

Reduced absorption (possible delayed onset)

  • Slower GI transit
  • Reduced saliva production
27
Q

Drug distribution (pharmacokinetic) differences in elderly

A

Body composition changes

  • Reduced muscle mass
  • Increased adipose (increased Vd, half-life, duration of fat-soluble drugs)
  • Reduced body water (decreased Vd, increased serum levels of water-soluble drugs - lower dose required)
Decreased protein (albumin) binding
- Increased serum levels acidic drugs (lower dose required)

Increased permeability across blood-brain barrier

28
Q

Drug metabolism (pharmacokinetics) differences in elderly

A

Decreased liver mass and liver blood flow

  • Toxicity
  • Increased bioavailability of some drugs (active longer) e.g. propranolol
  • Decreased bioavailability of pro-drugs e.g. enalapril
29
Q

Drug excretion (pharmacokinetics) differences in elderly

A

Renal function decreases -> reduced clearance and increases half-life (toxicity)

30
Q

Pharmacodynamic differences in elderly

A

Increased sensitivity to particular medicines

  • Change in receptor binding
  • Decrease receptor number
  • Altered translation

E.g. diazepam - increased sedation. Warfarin - increased anticoagulation.

31
Q

Guidance for clinicians regarding medication prescription in elderly patients

A
  • Beers’ criteria
  • START-STOPP criteria
  • NHS Scotland Polypharmacy Guidance
  • BNF
32
Q

Deprescribing

A

Reduce, substitute or discontinue a drug

  • ADR
  • Drug reaction
  • Better alternative
  • Not effective/indicated/ evidence-based
  • Minimise polypharmacy (proactive deprescribing)
33
Q

Drugs with most common ADRs

A

Anticholinergics/muscarinics
- Antidepressants, antiemetics, antipsychotics, overactive bladder

Sedatives
NSAIDs 
Diuretics
Warfarin 
Antihypertensives: ACEIs, b-blockers, digoxin, clopidogrel 
Antidepressants 
Opiates 
Prednisolone
34
Q

ADRs common in elderly people

A
  • Dizziness/falls
  • Delirium: cognitive loss, confusion
  • Nervousness
  • Dehydration
  • Incontinence (diuretics)
  • Depression
  • Toxicity (opioids, digoxin)

Systems (9 decks)

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