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
