Geriatrics Flashcards
What is geriatric medicine?
Branch of general medicine concerned with older people
Older people are main users of both health and social services
Challenges of frailty, complex co-morbidities, different patterns of disease presentation, slower response to treatment and requirements for social support call for special medical skill
What is frailty?
State of increased vulnerability resulting from ageing associated decline in reverse and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised
- Not inevitable
- Not simply due to multiple long term conditions
- Not irreversible
- Poor functional reserve
- Vulnerable to decompensation when faced with illness, drug S/E, metabolic disturbance
How do complex co-morbidities relate to geriatrics?
Often people who are older have more diagnoses than those who are younger
Can be linked
Can be unlinked
Acute presentations on top of this
People with frailty and co-morbidities often have prolonged death and their decline often more unpredictable
How important is it to start treatments that take months to work?
What conditions may present differently in older people?
Falls Confusion Off legs - generally unwell Incontinence Chest pain, SOB, urinary symptoms Social admission
What are the 5M’s of geriatric giants?
Mind Mobility Medications Multi-complexity Matters most
What does mind mean?
Dementia
Delirium
Depression
What does mobility mean?
Impaired gait and balance
Falls
What do medications mean?
Polypharmacy
Deprescribing/optimal prescribing
Adverse effects
Medication burden
What does multi-complexity mean?
Multi-morbidity
Bio-psych-social situations
What does matters most mean?
Individual meaningful health outcomes and preferences
What is a social admission?
Non-specific presentations are tricky
Medical slang
Used to describe patients unable to cope with ADLs
No acute medical problem, inappropriate admission
Negative
Often have serious underlying pathology that will be missed if you don’t search
What is the treatment like in geriatric medicine?
Essentially the same Much more prone to S/E and interactions Reduced organ function Lack of evidence for treatment in older patients Often multiple patholgies to balance How relevant is secondary prevention when you're old Polypharmacy Slower response to treatment
What is deconditioning?
Bedbound for days/weeks
Confused
Poor nutritional state even prior to admission, made worse by acute illness
Can’t walk, falls, can’t look after themselves
Need more than just medicines
Comprehensive geriatric assessments
- Tailor social and environmental assessment to patient
- Require MDT
What do you need to take into account in rehabilitation?
Process of restoring patient to max function (need to know pre-morbid function)
Can happen in variety of settings, in and out of hospital
Involves MDT, including doctors
Leads to process of discharge planning
What are the legal and ethical issues?
Care at end of life (fluids, feeding, antibiotics)
Discharge destination
Dementia/delirium
MCA
What is important to take into account with vulnerable patients?
Safeguarding
Abuse
Physical - neglect, psychological, financial, discriminatory, institutional, sexual
What is important to take into account with death and dying?
Lots of patients die Inevitable consequence of illness Important we recognise dying and act appropriately One chance to get it right May be difficult or upsetting
What is the NEWS score?
Score that determines illness of a patient and how quickly we need to act
What assessments should you do during ABCDE?
NEWS
GCS
AMI
What investigations should you do for pneumonia?
Disability - GCS, AMT, blood glucose
Bloods + culture, ABG
Raised neutrophils - bacterial infections
CXR - to see R lower lobe do lateral film
ECG
Sputum culture
Urine for pneumococcal antigen and legionella in moderate and severe CAP
CURB65
What are the scores in CURB65?
Confusion AMT = / 7 Urea > 7 RR > 30 BP S < 90 D = / < 60 Age > 65 Score - 0-1 < 3% mortality - 2 9% mortality
How do you manage pneumonia?
High flow O2
Antibiotics - clarithromycin + co-amox IV
Paracetamol if pyrexic
Fluids if AKI
What are the features of consolidation?
Dull to percussion
Crepitations
Bronchial breathing
Describe limitations of consolidation
What is HAP?
More than 48 hours after admission
Different antibiotic approach - broad spectrum
G -ve MRSA
AB policy will tell you what to prescribe depending on C/HAP and CURB65
What should you think of in a patient with pneumonia and a stroke?
Aspiration pneumonia
What are the symptoms of aspiration pneumonia?
Chest pain Coughing Fatigue Fever SOB Wheezing Breath odor Excessive sweating Problems swallowing Confusion Blue discolouration of skin
What does COVID pneumonia look like?
Affects edge of chest and lower lobes most
Ground glass appearance
ARDS - completely opaque chest
How do you manage COVID pneumonia?
Isolate NO ABX O2 Supportive care - rest, VTE prophylaxis, management of co-morbidities, fluids, immunosuppressant alteration Early ID of illness monitoring
What are the complications of pneumonia?
Post-pneumonia pleural effusion
Lung abscess after pneumonia - consolidation can become neurotic has fluid level on MRI
Pus in pleural sac - empyema
What should you look out for in a geriatric with infection?
Sepsis
What could LIF pain with pyrexia suggest?
Diverticulitis +/- abscess
Peritonitis
What is vesicular breathing?
Normal
What is bronchial breathing?
Longer expiration
What is air under the R diaphragm called?
Pneumoperitoneum
What is erysepilas?
Red skin caused by strep penicillin Tx
When should you give fluids in sepsis? And what would you prescribe?
If systemic symptoms like sinus tachycardia, CPT, BP
Fluid resuscitation (bolus saline 500mls over 15 mins)
Reassess and repeat if required
What antibiotic should you give for intra-abdominal sepsis?
Tazacin
What investigations should you do for someone with sepsis?
FBC, CRP Blood cultures U&E, LFTs Lactate, blood glucose Lactate - raised if tissue damage CT abdo pelvis if abdo symptoms
What is sepsis?
Systemic inflammatory response to infection
What is the sepsis 6?
Fluids - fluid balance chart, fluid resus Blood cultures Abx - IV Urine output Lactate O2 - 24% O2 PO2 > 94%
How else should you treat sepsis?
NBM Analgesia IV Anti-emetics if morphine Fluid balance - maintenance 30ml/kg/day KCl 1mmol/kg
Why is potassium needed in the body?
Vital for regulating normal electrical activity of the heart
What happens when K+ increases in the body?
Reduced myocardial excitability, with depression of both pacemaking and conducting tissues
What happens with progressively worsening hyperkalaemia?
Suppression of impulse generation by SAN and reduced conduction by AVN and his-purkinje system leading to bradycardia and conduction blocks
What is the definition of hyperkalaemia?
K+ > 5.5
Moderate > 6.0
Severe > 7.0
What does an ECG of hyperkalaemia look like?
Tall tented T waves (repolarisation abnormalities) > 5.5 Absent P waves (progressive paralysis of atria) > 6.5 Prolonged QRS and bradycardia > 7 Cardiac arrest > 9 Tall tented T waves Prolonged PR segment Loss of P waves Bizarre QRS Sine wave (pre-cardiac arrest)
What are the causes of hyperkalaemia?
MACHINE Medications Acidosis - metabolic/respiratory Cellular destruction Hypoaldosteronism (Addison's) or haemolysis Intake - excess Nephrons/renal failure Excretion impaired
What medications can cause hyperkalaemia?
ACEi
NSAIDs
Potassium sparing diuretics - spironolactone
Trimethoprim
What are the signs and symptoms of hyperkalaemia?
MURDER Muscle weakness Urine - oliguria, urea Respiratory distress Decreased cardiac contractility ECG changes Reflexes - hyper/areflexia
What is the management of hyperkalaemia?
AIRED
Administer IV calcium gluconate 10ml IV slowly with ECG monitoring/repetition
Increased excretion - calcium resonium 15g 8hr intervals to help excrete through gut
Remove sources of potassium - IV/oral
Enhance potassium uptake into cells - insulin 10 units in 50ml 50% dextrose over 15 mins in large vein OR 10/20% dextrose in 250ml over 60 mins
Dialysis if severe
Also add salbutamol 10mg nebuliser
What is the definition of hypokalaemia?
K+ < 3.5
Moderate < 3
Severe < 2.5
What are the ECG changes in hypokalaemia?
Increased amplitude and width of P wave Prolongation of PR interval T wave flattening and inversion ST depression Prominent U waves Apparent long QT interval due to fusion of T and U waves Ectopics Supraventricular tachyarrhythmias
What are the causes of hypokalaemia?
Body trying to DITCH K+
- Drugs - loop diuretics
- Inadequate consumption
- Too much water
- Cushing’s
- Heavy fluid loss
What are the signs and symptoms of hypokalaemia?
7Ls (low)
- Lethargic
- Low, shallow respirations… failure
- Lethal cardiac disrhythmias
- Lots of urine (frequency and large volume)
- Leg cramps
- Limp muscles
- Low BP (severe)
What is the management of hypokalaemia?
Oral or IV K+
What is diabetes?
Chronic health condition where blood glucose level is too high
Happens when the body doesn’t produce enough insulin or when you can’t produce any at all
In older adults most likely to be T2
How common is diabetes?
1 in 15 people have diabetes - including 1 million people who have T2 but haven’t been diagnosed
How do older adults differ in diabetes?
Clinical presentation Psychosocial environment Resource availability Living situation Degree of available social support
What are the signs and symptoms of T2DM?
Polyuria and polydipsia Increased hunger Unintended weight loss Fatigue Blurred vision Slow healing sores Frequent infections Numbness or tingling in hands or feet Areas of darkened skin - usually in armpits and neck Repeatedly getting thrush
How is diabetes management in the elderly different?
Individualised care plan - take into account age, preferences, co-morbidities, and risk of adverse effects from medications
Lifestyle modification but not restrictive diets
Medication - consider drug interactions and risk of hypoglycaemia
Exercise - consider physical abilities
HbA1c goal equivalent to co-morbidities/end of life
What special considerations should you make for elderly with diabetes?
Presence of age-related conditions and interference with ability to perform diabetes self care
Polypharmacy - increased risk of drug interactions
Visual impairments - social isolation, errors in treatment, traumatic falls, disability
Risk of hypoglycaemia and risk of triggering CVS events and increased falls and fracture risk
What investigation should you do for diabetes?
Urine dip
HbA1c, fasting glucose, random plasma glucose
How is diabetes diagnosed?
If symptomatic - single abnormal HbA1c or fasting glucose
If asymptomatic - repeat testing
HbA1c > 48
Fasting > 7
Random > 11.1 in presence of S&S of diabetes
What is the cause of diabetes?
Cells in muscle, fat and liver become insulin resistant
Cells don’t make enough sugar as don’t respond to insulin
Pancreas can’t make enough insulin due to fatty deposits in beta-cells and cells become impaired
How can you prevent diabetes?
Healthy lifestyle Eating healthy foods Active Weight loss Avoiding inactivity for long periods Medication to prevent progression from prediabetes
What are the risk factors for diabetes?
Overweight Fat distribution Inactivity Family history Black, hispanic, native american, asian, and pacific islander ethnicities High levels of trigylcerides Increasing age Prediabetes Pregnancy-related risks POCS
What are the complications of diabetes?
Skin conditions Slow healing Hearing impairment Sleep apnoea Dementia Macrovascular - IHD - PVD - Cerebrovascular disease Microvascular - Retinopathy - Nephropathy - Neuropathy
What are the complications of diabetes in older adults?
More at risk for acute and chronic vascular complications
Major lower extremity amputations, MI, visual impairments, ESRD
Over 75 more likely to develop complications, higher rates of death from hyperglycaemic crises, and increased rate of ED visits
Higher risk of geriatric syndromes
Name 4 examples of geriatric syndromes
Cognitive dysfunction Depression Physical disability Pain Polypharmacy Urinary incontinence
What is osteoporosis?
Progressive loss of bone mass associated with change in bone micro-architecture
Associated with reduced cross linking within trabecular bone resulting in cortical thinning
How does remodelling work?
Osteoblasts - make bone
Osteoclasts - destroy bone
Balance between the two
Allows bone to adapt to stressors and repair microdamage
What happens in osteoporosis?
Shift towards bone resorption leading to net bone loss
Osteoclasts function in less regulated manner perforating through trabecular plate
No framework for osteoblast activity and structural integrity lost
Loss of connectivity between trabecular plates typical of microstructural changes associated with osteoporosis
What are the risk factors for osteoporosis?
SHATTERED
Steroid use of > 5mg for > 3 months
Hyperthyroidism, hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin BMI < 18.5
Testosterone decreased eg in prostate cancer treatment
Early menopause
Renal or liver failure
Erosive/inflammatory bone disease eg myeloma or rheumatoid arthritis
Dietary calcium decreased/malabsorption, diabetes mellitus type 1
What investigations should you do in osteoporosis?
Bloods - FBC, U&E, LFT, TFT, calcium, phosphate, vit D, PTH, coeliac serology, myeloma screen
DEXA
Spinal x-ray
Bone turnover markers
What is the management of osteoporosis?
Lifestyle changes Vitamin D and calcium Bisphosphonates Denosumab - monoclonal antibody Raloxifene - selective oestrogen receptor modulator Teriparatide - anabolic
What are the complications of osteoporosis?
Bone fractures
Hip fractures - disability, increased risk of death especially in elderly
How does skin protect against pressure damage?
Pacinian corpuscles - receptors that detect pressure changes/vibration on skin
pH mantle between 4-6 maintaining normal flora
Sebum production - antimicrobial and sealant properties
Langerhans cells providing tissue immunity
Effective perfusion to skin
What is a pressure ulcer?
Injury to skin and underlying tissue that predisposes patient to infection - life threatening
How do pressure ulcers form?
Localised external pressure on skin - occlusion of capillaries and tissue compression
- Insufficient O2 and nutrients reaching tissues
- Altered soft tissue hydration - fluid pushed away from viable cells
Can affect any area of the body put under pressure - most common on bony areas of body
What are the risk factors for pressure ulcers?
Limited mobility Sensory impairment Malnutrition Dehydration Obesity Cognitive impairment Urinary and faecal incontinence Reduced tissue perfusion
What is slough?
Yellow-green layer with pale pink base - mixture of fibrin, cell breakdown products, serous exudate, leukocytes and bacteria, doesn’t necessarily imply infection and can be part of normal healing process
What is eschar?
Tan/brown/black dead skin that sheds and falls of skin
What are stage 1 ulcers like?
Non-blanching erythema - Skin intact - Non-blanching redness - Localised - Painful - Bluish tinge - Warm May be difficult to detect in patients with deeper skin tones
What are stage 2 ulcers like?
Partial thickness tissue loss Loss of dermis - shallow open ulcer Red/pink wound bed - no slough May also present as blisters - open/ruptured, serum fulled Not to be confused with moisture lesions
What are stage 3 ulcers like?
Full thickness tissue loss
Subcutaneous fat may be visible
Bone, tendon, or muscle NOT visible or directly palpable
Slough or eschar may be present
Wounds with 100% eschar or slough at least stage 3
What is a moisture lesion?
Redness or partial thickness skin loss of epidermis, dermis or both Caused by excessive moisture - Urine - Faeces - Sweat Not to be confused with pressure ulcers
What is a stage 4 pressure ulcer?
Full thickness tissue loss
Exposed bone, tendon or muscle - visible or directly palpable
Depth of stage 3 and 4 can depend of anatomical structure
High risk for osteomyelitis
What is an unstageable pressure ulcer?
Base of ulcers need to be visible in order to stage
Some can be completely covered by slough or eschar
Cannot be stage but must be 3 or 4
What does a deep tissue injury look like?
Damage of underlying soft tissue
Purple localised area of discoloured intact skin
Blood-filled blister
May be painful or warm
May expose additional layers of tissue despite optional treament
What is an acquired pressure ulcer?
Occur within care facility
What is an inherited pressure ulcer?
Patient moves into facility with ulcer
What can pressure ulcers to classified as?
Acquired/inherited
Avoidable/unavoidable
95% unavoidable
When are pressure ulcers reported as clinical incidents?
Stages 2, 3, 4
3 and 4 serious
How are pressure ulcers treated?
Changing positions to relieve pressure on already developed ulcers and prevent more Mattress and cushions Dressings Barrier creams Antibiotics if required Diet and nutrition Hydration Debridement - surgical or maggots Surgery
How do you prevent pressure ulcers?
SSKIN Support surface Skin assessment Keep moving Incontinence and moisture Nutrition and hydration
What are the causes of iron deficiency anaemia?
Decreased iron intake
Increased iron loss
Increase iron requirements - not common in the elderly
What are the signs and symptoms of iron deficiency anaemia?
Often asymptomatic and only causes mild symptoms Fatigue Dyspnoea Headache Palpitations Pale skin or conjunctiva
What are the symptoms of underlying conditions that could be associated with iron deficiency anaemia?
Dysphagia - oesophageal malignancy
Dyspepsia - gastric cancer, PUD
Abdominal pain - coeliac disease, intrabdominal malignancy, IBD
Change in bowel habit - bowel cancer, coeliac disease, IBD
Rectal bleeding - anal fissure, rectal cancer, haemorrhoids, IBD
Weight loss - IBD, bowel cancer
What is the clinical presentation of iron deficiency anaemia?
Conjunctival pallor Angular chellitis Atrophic glossitis Koilonychia Dry skin and hair
What is the criteria for iron deficiency?
Hb < 130 in men
Hb < 120 in women
What are the investigations for iron deficiency?
FBC - Hb and haematrocrit - MCV - MCH - RDW Ferritin Transferring saturation and total iron-binding capacity Blood film Urinalysis
What is the treatment for iron deficiency anaemia?
Eat more iron-rich foods eg dark-green leafy vegetables
Oral iron binding replacement therapy
S/E - nausea, GI irritation, constipation or diarrhoea
Ascorbic acid supplementation
IV iron replacement
Red cell transfusion
What are the complications of iron deficiency anaemia?
More at risk of illness and infection
Higher risk of heart failure with severe anaemia
What are the common neural causes of syncope?
Vasovagal syncope
Carotid sinus hypersensitivity
Situational eg micturition
What are the common cardiac causes of syncope?
Postural hypotension
Arrhythmias eg bradycardia, tachycardia, hypotension, long QT
What types of bradycardias can cause syncope?
Heart block/sick sinus syndrome
What types of tachycardia can cause syncope?
VT/SVT
What are the common non-cardiogenic causes of syncope?
Psychogenic
Metabolic
Medications
What are the clinical features suggesting cardiac causes of syncope?
SOB Reduced exercise tolerance or happened during exercise Chest pain or palpitations Oedema Heart murmurs No prodrome Symptoms occur when sitting and lying down FHx of sudden cardiac death
What is postural hypotension?
Persons blood pressure drops abnormally when they stand up after sitting or lying
How do you test postural hypotension?
Symptomatic gives diagnosis
Standing for more than 3 minutes - check multiple times over these minutes
First thing in the morning and check a few times throughout the day as they can be situational
What is the rate of drop to diagnose postural hypotension?
Drop by S > 30, or D > 20
S < 90
What are the causes of falls in older people?
Cardiac causes Neural causes Metabolic causes Balance problems Muscle weakness Poor vision Heart disease Syncope Dementia Hypotension
What are the complications of falls?
Fractures Head injuries Pressure sores Becoming less active and therefore weaker and increased chance of falling - post fall syndrome Carpet burns
What are the complications of long stays on the floor following falls?
Dehydration Hypothermia Pneumonia - related to hypothermia AKI - from dehydration and rhabdomyolysis Rhabdomyolysis Death Distress
What is vasovagal syncope?
Syncope due to stress
What stressors can cause vasovagal syncope?
Pain/heat
Sight of blood
Prolonged standing
Mental stress
What is carotid sinus hypersensitivity?
When external pressure is placed on the carotid sinus automatically reduced HR - normal
In hypersensitivity - overreacts to pressure causing HR to slow down or BP to drop significantly
Can be by wearing tight clothing around neck or turning head
What is sick sinus syndrome?
SAN cannot create a HR that is appropriate for body’s needs
Causes irregular heart rhythms
Previous MI
Name 2 intrinsic risk factors for falls
Female
Cognitive decline
Visual problems
Muscle weakness
Name 2 extrinsic risk factors for falls
Polypharmacy
Lots of hazards around home
What are the causes of postural hypotension?
Age related impairment of baroreflex mediated vasoconstriction and chronotropic responses of heart
Deterioration of diastolic filling of heart
Dehydration
Hypoglycaemia - secondary
Adrenal disease - secondary
Eating meals - postprandial hypotension
Medications - recent changes?
How does COVID present?
Asymptomatic Mild viral illness Pneumonia Anosmia Loss of taste Thrombotic effects Renal failure Skin manifestations Respiratory failure Mortality
What are the risk factors for a more severe covid?
Ethnicity BMI Co-morbidities - diabetes, CVS Immunosuppressed Age
What investigations do you do in a suspected covid case?
Swab
Bloods - FBC, U&E, CRP, LFT, PCT, ferritin, D dimer
CXR - NAD, classic COVID change
What should you note about a covid patient?
Clinical frailty score
Date of onset of symptoms
Date of positive swab
What management should you put in place for covid patients?
Escalation plan DNAR Antibiotics Fluids Trail participant Phone family O2 Good nursing care Physio
What should you monitor in covid patients?
Sats
RR
What should you discuss with family?
General covid discussion Potential to suddenly deteriorate DNAR Escalation Regular follow-ups
What are the s/e of covid?
Delirium General decline and rapidly increased frailty Poor oral intake Unpredictable deterioration - Sudden increase in RR and drop in sats - Florid new changes on CXR - Check PCT again, give antibiotics if any indication - Increase O2 as needed - Most died, often very rapidly
What do you put in place for palliation?
O2 Rationalise medications Pre-emptive prescribing of drugs for symptoms control +/- syringe driver Update family ?visiting Support from whole MDT
What pre-emptive medications should you give someone who is dying?
Morphine
Midazolam
Hyoscine
Haloperidol
What is the background of major trauma in the elderly?
Don’t always present typically - often different mechanisms of injury
Older patients have less senior reviews
Most common cause of major trauma is small falls in elderly
Frail patients with severe injuries are at risk of under-triage, delayed diagnosis, and sub-optimal care
Osteoporosis under-diagnosed and under treated
How common are hip fractures?
66,500 hip fractures per year
What is the 30 day mortality for hip fractures?
7%
What is the year mortality for hip fractures?
30%
What are the NICE guidelines for hip fractures?
Orthogeriatric assessment within 72 hours Surgery within 36 hours Rehabilitation to as best function as possible Prompt mobilisation after surgery Pre-operative cognitive testing Delirium assessment post-operatively Return to original residence by 120 days Fracture prevention assessments Nutritional assessment
What are the two types of orthogeriatric care?
Fracture liaison services
- Admitted under ortho
- Provides input within 72 hours
Dedicated orthogeriatric ward
- Admitted directly to dedicated hip fracture ward
- Usually admitted under ortho but transferred post-op
- Both specialities provide input during admission
How can frailty be prevented?
Good nutrition
Physical activity
Avoid social isolation
Not too much alcohol
What is the role of an orthogeriatrician?
Comprehensive geriatric assessment Pre-operative assessment Post-operative care Facilitate early rehabilitation Facilitate early supported discharge Communication - with patient, relative, friends, and carers
What happens in a geriatric assessment?
Functional status Cognitive status Medical problems/co-morbidities Geriatric syndromes Medications Nutritional status Social issues eg social support, finances, accomodation
What happens in a pre-operative assessment?
Assess severity of co-morbidities
Medications review and analgesia
Optimise to prevent delay to theatre
Escalation and resuscitation decisions
What is the delirium assessment called and what does it assess for?
4AT
Alertness
AMT4 - ask the following - age, DOB, name of hospital, current year
Attention - list months of year backwards
Acute change or fluctuating course
How can you prevent delirium?
Ensure adequate CNS O2 delivery
Correct any hypoperfusion, hypoxaemia, anaemia
Maintain normal fluid and electrolyte balance
Treat any fluid overload or dehydration
Treat with analgesia appropriately through appropriate route
Deprescribe any unnecessary or harmful medications
Ensure bladder and bowel function
Adequate nutritional intake
Proper position for meals
Nutritional supplements
Detect and treat and major complications
Ensure appropriate environmental stimuli
Reassurance
Early rehab and mobilisation
When should you administer analgesia in a hip fracture?
Immediately
Assess within 30 mins of initial analgesia
Hourly on ward
Assess pain regularly to allow for movement, nursing care, and rehab
At times of routine nursing obs
What analgesia should you give for a hip fracture?
Fascia iliaca nerve block Paracetamol Opioids (+laxative) at lowest effective dose - Buprenorphine patch - Dihydrocodeine or oxycodone Avoid NSAIDs/nefopam
What is the primary prevention of osteoporosis?
FRAX
If < 70 request DEXA
What is the secondary prevention of osteoporosis?
Non-pharmacological - Weight bearing exercises and muscle strengthening - Falls prevention - Smoking cessation and avoid alcohol Pharmacological - Calcium and vit D replacement - Bisphosphonates
What is important to remember when prescribing bisphosphonates?
Ensure no serious dental issues (risk of osteonecrosis of jaw)
CI if CrCl < 30ml/min
PO if probability > 1% unless GORD/PUD
IV if probability > 10%
What is delirium?
Acute confusional state that fluctuates in severity and usually reversible, usually result of other organic process
1/3 will resolve quickly
1/3 will recover but much more slowly
1/3 will not recover to baseline
What is dementia?
Syndrome of acquired. chronic, global impairment of higher brain function, is an alert patient, which interferes with ability to cope with daily living
Decline in memory with impairment of at least one other cognitive function such as skilled movements, language or executive function
What is BPSD?
Behavioural and psychological symptoms of dementia - heterogenous group of non-cognitive symptoms and behaviours eg agitation, irritability, depression, disinhibition, hallucinations
What are the symptoms of hyperactive delirium?
Agitation Delusions Hallucinations Wandering Aggression
What are the risk factors for delirium?
Old age Dementia Past H/0 delirium Significant co-morbidities Sensory impairment Change of environment
What are the causes of delirium?
PINCH ME
- Pain
- Infection
- Nutrition
- Constipation
- Hydration
- Medication
- Environment
DELIRIUM
- Drug - introduction or adjustments
- Electrolyte and physiological imbalances
- Infection
- Reduced sensory input
- Intracranial problems
- Urinary retention and constipation
- Myocardial problems
How do you manage hyperactive delirium?
Non-pharmacological first line - Orientation, reassurance - Continuity of care - staff/environment Sedation may be required if at risk to themselves or others Use lowest possible dose Usually quite reversible
What are causes of a reversible dementia?
Depression B12/folate Hypothyroid NPH Substance misuse SLO Syphillis
What are the symptoms of hypoactive delirium?
Lethargy Slowness with everyday tasks Excessive sleeping Inattention Can be confused with depression
What are the complications of delirium?
High risk of death if untreated
Hypoactive has higher risk
What is a TIA?
Neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia without evidence of acute infarction with symptoms lasting less than 24 hours
What is the risk of stroke following a TIA?
At 2 days
- 2-4.1%
At 7 days
3.9-6.5%
What treatment should you start with TIA immediately?
Aspirin and refer to TIA clinic
What should influence the speed of your referral to TIA clinic?
ABCD2 score
What investigations should you do following a TIA?
Bloods - FBC, WCC, U&E, CRP/ESR, LFTs, TFTs, haematinics ECG USS carotid Brain imaging Consider ECHO Consider 24 hr vs 72 hours tape
What is a stroke?
Clinical syndrome characterised by sudden onset of rapidly developing or focal or global neurological disturbance which lasts more than 24 hours or leads to death, with no apparent cause other than that of vascular origin
What are the 2 types of stroke and how common are they?
Ischaemic - 85%
Haemorrhagic
- Primary 10%
- SAH 5%
What are the differentials of stroke?
Migraine SDH Cancer Infection Hypoglycaemia Seizure PRES Functional
What are the causes of an ischaemic stroke?
Atherosclerosis
Cardio-embolism
Dissection
What imaging should you do for a stroke?
Within 1 hour
CT head
MRI
What is the management of an ischaemic stroke?
Short term - Anti-platelets - Manage BP + acute management keep BP < 220/110 unless end organ damage - Thrombolysis - Thrombectomy - Endartectomy Long term - Lifestyle - salt, exercise, smoking, alcohol - Lipids aim to reduce by 40% - BP long term 130/80 Driving none for 1 month
What is carotid endarterectomy?
Unblocking carotid
Reduce 5 year absolute risk of ipsilateral ischaemic stroke by 16% in patients with 70-99% stenosis
Many risks associated
What is thrombolysis?
Use of drugs to break up clot Considered if present within 4.5 hours Number of CI - High BP > 185/110 - Blood thinners - Bleeding - Major surgery - Unconfirmed stroke
What is mechanical thrombectomy?
Use of catheter fed up into brain to aspirate clot or remove
Indications
- Proximal intracranial large vessel occlusion
- Causing disabling neurological deficit
- Procedure can begin within 5 hours of known onset
What causes haemorrhagic strokes?
Cerebral amyloid angiopathy HTN Aneurysms AVMs Trauma Blood thinners
What is the management of haemorrhagic strokes?
BP management 140/80
Reverse anticoag
Neurosurg referral
If develop hydrocephalus consider insertion of external ventricular drain
What is frailty?
Distinct health state characterised by reduction in physiological reserve syndrome characterised by sudden onset of rapidly developing or focal or global neurological disturbance which lasts more than 24 hours or leads to death, with no apparent cause other than that of vascular origin
Evidence linking frailty with mortality
What are the different methods of scoring frailty?
Phenotype - Fried
Cumulative deficit - FI, CFS
What is the fried criteria for frailty?
Description of a phenotype Clinical syndrome of > 3 of - Unintentional weight loss - Self-reported exhaustion - Weakness (grip strength) - Slow walking speed - Low physical activity If 2 then pre-frailty
What does the Fried criteria predict?
Independently predictive over 3 years of incident falls, worsening mobility or ADL disability, hospitalisation, and death
What is the clinical frailty scale?
Overall trend of increasing mortality with increasing frailty
Not validated for measuring improvement in individuals after acute illness or for < 65
Practicality uses eg assessment for ITU admission suitablity
What is the e-FI3?
Calculated by presence of absence of individual deficits as a proportion of 36 total possible deficits
Mixture of co-morbidities, self reported symptoms and social factors
Robust predictive validity for outcomes of 1, 3 ,and 5 year mortality, hospitalisation, and nursing home admission
What is palliative care?
Treatment recognises irreversible nature of underlying disease process - holistic approach, symptoms control
Disparity of access to palliative care for frail patients
Benefit of palliative care is avoid futile treatment
What is end of life care?
Last 12 months Disease relentless Frailty predictor of mortality Unpredictable Irreversible frailty/decline should prompt discussion re end of life
What could advance care planning include?
Legal aspects Preferred place of care Treatment options acceptable to patient and suitable for patient DNAR Specific plan for complex scenarios
What are the advantages of advanced care planning?
Open ended
Personalised care - planning/stating preferences
Avoids futile disease orientated treatment
Patient-centred goals
Improves co-ordination of care
What is the role of a registered dietician?
Only qualified health professional that assesses, diagnoses and treats dietary and nutritional problems
Works closely with MDT and covers a range of settings
Therapeutic diets
Improving nutrition
Diagnosing nutritional problems
Advising on feeding routes
Advising on refeeding syndrome management
Creon adjustments
How common is malnutrition?
35% patients admitted to hospital at risk of malnutrition
70% patients weigh less on hospital discharge
Affects over 3 million people in UK
Cost 19.6 billion per year
What are the causes of malnutrition?
Decreased nutrient intake (starvation)
Increased nutrient requirements (sepsis or injury)
Inability to utilise nutrients ingested (malabsorption)
Or combination
What are the consequences of malnutrition?
Weakened immune system Muscle wasting - increased falls, chest infection, decreased mobility/inactivity Impaired wound healing Micronutrient deficiencies Poorer prognosis Reduced QOL Increased length of stay Increased complications More re-admission Greater healthcare needs in community
What is MUST?
Malnutrition universal screening tool
Scores based on BMI, history of weight loss, acute disease effect
Allows for development of care plan and monitoring
BMI
% unplanned weight loss
Acute disease effect and score - acutely ill and has been or likely to be no nutritional intake for > 5 days
If score 2 or more - high risk so treatF
How do you treat malnutrition?
Food first
Oral nutritional supplements
Enternal/parenteral nutrition
What oral nutritional supplements are used?
Liquid/powder/semi solid
Macro/micronutrients
Milkshakes, juice, soup, semi solid, high energy powders, high protein, low volume/high concentration
Mainly sweet
What is the IDDSI?
International dysphasia diet standardisation initiative
SLT recommended
Dysphasia - ensure feeding is in line with IDDSI
Need different textures for different abilities to swallow or can lead to asphyxiation
What is enteral nutriton?
Direct feeding into gut such as stomach/duodenum/jejunum
Preserves gut mucosa and integrity
Inexpensive compared to parenteral nutrition
What are the disadvantages of enteral nutrition?
Tolerance levels eg nausea, satiety, bowel function
Tube can be uncomfortable
QoL, personal appearance
What are the routes of enteral feeding?
NG - feeds into stomach, inserted at ward level, for short term use < 30 days, gold standard check pH aspirate, second line confirmation x-ray
NJ - feeds into jejunum, short term use < 60 days, radiologically guided, can only check position with x-ray
What are long term forms of enteral feeding and what are the indications for each?
PEG - dysphasia, CF, oral intake inadequate and likely to be long term
Post pyloric/PEJ/surgical JEJ - delayed gastric emptying, upper GI/pancreatic surgery, high risk of aspiration, severe acute pancreatitis
What is parenteral nutriton?
Feeding IV when gut is inaccessible or unable to absorb sufficient nutrition to sustain nutritional status
What are the indications for parenteral nutrition?
Inadequate absorption
GI fistula
Bowel obstruction
Prolonged bowel rest
Severe malnutriton, significant weight loss and/or hypoproteinaemia when enteral therapy not possible
Other disease states or conditions in which oral or enteral feeding is not an option
What are the methods of giving parenteral nutrition?
PICC line or central line
What are the advantages of parenteral nutrition?
Helpful to meet nutritional requirements and promote recovery if used appropriately
Easily tolerated
What are the disadvantages of parenteral nutrition?
More costly than enteral
Risk of infection
More invasive procedures
Gut atrophy
What is refeeding syndrome?
Group of clinical symptoms/signs that can occur in malnourished/starved patient when reintroducing nutrition
Shift in use of energy stores from fat metabolism to carbohydrate metabolism
Initiates insulin increase and cellular uptake of potassium, phosphate, and magnesium
Shifts in fluid and electrolytes
What are the results of refeeding syndrome?
Fluid retention
Cardiac arrhythmias
Respiratory insufficiency
Death
What is the treatment of refeeding syndrome?
IV pabrinex or thiamine + vit B co-strong to feeding and for first 10 days
STH refeeding syndrome guidelines
Slow reintroduction of nutrition
Daily monitoring of refeeding bloods including U&Es, PO4, Mg and correct as necessary
What are the differences between dementia and delirium?
Delirium has a sudden and severe onset, it is a brief episode, reversible, fluctuating consciousness, disorganised conversation, altered sleep-wake cycle
Dementia is irreversible, increasing loss of cognition and brain function, alert, engages well, altered sleep wake cycle
What are the symptoms of delirium?
Mood changes Changes in speech Sleep changes Disorientation and confusion Visual hallucinations (hyper) Physical issues
What are the symptoms of dementia?
Memory loss Difficulty with ADLs Changes in mood Changes in ability to problem solve Increasing difficulty focussing or paying attention Changes to personality
What is the relationship between delirium and dementia?
Interrelationship
People with dementia more likely to develop delirium and people with multiple episodes of delirium are more likely to develop dementia
What are the different types of dementia?
Alzheimer’s disease
Vascular dementia eg stroke (step-wise decline)
Parkinson’s disease
Dementia with lewy body (Parkinsonism features)
Frontotemporal dementia (disinhibition, progressive aphasia)
Severe head injury
How do you assess mental state?
History - Collateral - Onset - DHx, FHx - Effect on ADLs - CVS/previous delirium/TIA/stroke - Symptoms - SHx - smoking/alcohol General examination - Chest, HS, ect - Parkinsonism features MMSE AMT
What investigations should you do in a confusion screen?
FBC U&E LFT Ca CRP
What investigations should you do in dementia screen?
TSH B12 Folate FBC LFT U&E ESR/CRP Syphillis serology Glucose
What should you do for someone under 50 with dementia symptoms?
Syphilis serology
HIV screen
How is dementia managed?
Medications
- Acetylcholinesterase inhibitors eg rivastigmine or donepezil
- Mmeantine for severe dementia 12/less on MMSE
Cognitive stimulation therapy
Cognitive rehabilitation
Reminiscence and life story work
How does geriatric medicine differ from medicine for younger people?
More co-morbidities leading to polypharmacy
Social issues so complex discharges
Different atypical presentations
Difficult to take histories - confusion, contralateral histories
Ethical issues - high degree of mortality
Slower response to treatment
Non-specific signs and symptoms - longer admission, MDT involvement
Silent issues - MI, PUD
What are the 6I’s of geriatric giants?
Instability (falls) Infirmity (confusion) Incontinence Immobility Inanition (frailty) Iatrogenic (polypharmacy)
How is activity of daily living assessed?
Review with occupational therapists
Barthel index
What does the Barthel index assess?
Feeding Bathing Grooming Dressing Bowels Toilet use Transfers Mobility Stairs
What is polypharamacy?
Regular use of at least 5 medications
Why is polypharmacy more likely to occur in older people?
Need to treat various disease states that develop with age
More likely to have multiple conditions that need treating or conditions that require multiple medications to treat
Drs often over prescribe
What is the affect of aging on pharmacokinetics?
With age, increased body fat, and total body water decreased. Increased fat increased volume of distribution of highly lipophilic drugs
Increased water decreases volume of distribution of highly hydrophilic drugs
Hepatic metabolism of many drugs through cytochrome P-450 enzyme decreases with age - first pass metabolism decreased
Decreased renal elimination of drugs
Decreased albumin so less drug bound to it - less distribution
Absorption is not affected
What is the effect of aging on pharmacodynamics?
Effects of similar drug concentrations at the site of action may be greater or smaller than those in younger people
Due to changes in drug-receptor interaction, in post-receptor events, or in adaptive homeostatic responses and among frail elderly often due to pathological changes in organs
Response depends on specific drugs eg increased anti-cholinergic drug effects and hypoglycaemic drugs
Most drugs have increased effect
What are the complications of polypharmacy?
Increased risk of adverse drug events
Increased risk of drug interactions
Increased risk of medication non-adherence
Reduced function capacity
Multiple geriatric syndromes - cognitive impairment, falls, incontinence
Increased healthcare costs
How can polypharmacy be avoided?
Reviewing doses
Elimination duplicate medications
Assessing for drug-drug interactions
Removing medications that aren’t required
Why should you stop NSAIDs in the elderly asap?
Worsen kidney function
Increased risk of GI bleeding
Increased risk of CVS events
When should you stop clopidogrel after an MI?
12 months
What should you prescribe after an MI?
Aspirin 300mg
Clopidogrel in adults over 76 - 75mg
