Geriatrics Flashcards

Question

What should you think of in a patient with pneumonia and a stroke?

Answer 1

Aspiration pneumonia

Answer 2

``` Chest pain Coughing Fatigue Fever SOB Wheezing Breath odor Excessive sweating Problems swallowing Confusion Blue discolouration of skin ```

Answer 3

Affects edge of chest and lower lobes most Ground glass appearance ARDS - completely opaque chest

Answer 4

``` Isolate NO ABX O2 Supportive care - rest, VTE prophylaxis, management of co-morbidities, fluids, immunosuppressant alteration Early ID of illness monitoring ```

Answer 5

Post-pneumonia pleural effusion Lung abscess after pneumonia - consolidation can become neurotic has fluid level on MRI Pus in pleural sac - empyema

Answer 6

Diverticulitis +/- abscess | Peritonitis

Answer 7

Longer expiration

Answer 8

Pneumoperitoneum

Answer 9

Red skin caused by strep penicillin Tx

Answer 10

If systemic symptoms like sinus tachycardia, CPT, BP Fluid resuscitation (bolus saline 500mls over 15 mins) Reassess and repeat if required

Answer 11

``` FBC, CRP Blood cultures U&E, LFTs Lactate, blood glucose Lactate - raised if tissue damage CT abdo pelvis if abdo symptoms ```

Answer 12

Systemic inflammatory response to infection

Answer 13

``` Fluids - fluid balance chart, fluid resus Blood cultures Abx - IV Urine output Lactate O2 - 24% O2 PO2 > 94% ```

Answer 14

``` NBM Analgesia IV Anti-emetics if morphine Fluid balance - maintenance 30ml/kg/day KCl 1mmol/kg ```

Answer 15

Vital for regulating normal electrical activity of the heart

Answer 16

Reduced myocardial excitability, with depression of both pacemaking and conducting tissues

Answer 17

Suppression of impulse generation by SAN and reduced conduction by AVN and his-purkinje system leading to bradycardia and conduction blocks

Answer 18

K+ > 5.5 Moderate > 6.0 Severe > 7.0

Answer 19

``` 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) ```

Answer 20

``` MACHINE Medications Acidosis - metabolic/respiratory Cellular destruction Hypoaldosteronism (Addison's) or haemolysis Intake - excess Nephrons/renal failure Excretion impaired ```

Answer 21

ACEi NSAIDs Potassium sparing diuretics - spironolactone Trimethoprim

Answer 22

``` MURDER Muscle weakness Urine - oliguria, urea Respiratory distress Decreased cardiac contractility ECG changes Reflexes - hyper/areflexia ```

Answer 23

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

Answer 24

K+ < 3.5 Moderate < 3 Severe < 2.5

Answer 25

``` 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 ```

Answer 26

Body trying to DITCH K+ - Drugs - loop diuretics - Inadequate consumption - Too much water - Cushing's - Heavy fluid loss

Answer 27

7Ls (low) - Lethargic - Low, shallow respirations... failure - Lethal cardiac disrhythmias - Lots of urine (frequency and large volume) - Leg cramps - Limp muscles - Low BP (severe)

Answer 28

Oral or IV K+

Answer 29

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

Answer 30

1 in 15 people have diabetes - including 1 million people who have T2 but haven't been diagnosed

Answer 31

``` Clinical presentation Psychosocial environment Resource availability Living situation Degree of available social support ```

Answer 32

``` 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 ```

Answer 33

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

Answer 34

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

Answer 35

Urine dip | HbA1c, fasting glucose, random plasma glucose

Answer 36

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

Answer 37

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

Answer 38

``` Healthy lifestyle Eating healthy foods Active Weight loss Avoiding inactivity for long periods Medication to prevent progression from prediabetes ```

Answer 39

``` 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 ```

Answer 40

``` Skin conditions Slow healing Hearing impairment Sleep apnoea Dementia Macrovascular - IHD - PVD - Cerebrovascular disease Microvascular - Retinopathy - Nephropathy - Neuropathy ```

Answer 41

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

Answer 42

``` Cognitive dysfunction Depression Physical disability Pain Polypharmacy Urinary incontinence ```

Answer 43

Progressive loss of bone mass associated with change in bone micro-architecture Associated with reduced cross linking within trabecular bone resulting in cortical thinning

Answer 44

Osteoblasts - make bone Osteoclasts - destroy bone Balance between the two Allows bone to adapt to stressors and repair microdamage

Answer 45

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

Answer 46

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

Answer 47

Bloods - FBC, U&E, LFT, TFT, calcium, phosphate, vit D, PTH, coeliac serology, myeloma screen DEXA Spinal x-ray Bone turnover markers

Answer 48

``` Lifestyle changes Vitamin D and calcium Bisphosphonates Denosumab - monoclonal antibody Raloxifene - selective oestrogen receptor modulator Teriparatide - anabolic ```

Answer 49

Bone fractures | Hip fractures - disability, increased risk of death especially in elderly

Answer 50

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

Answer 51

Injury to skin and underlying tissue that predisposes patient to infection - life threatening

Answer 52

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

Answer 53

``` Limited mobility Sensory impairment Malnutrition Dehydration Obesity Cognitive impairment Urinary and faecal incontinence Reduced tissue perfusion ```

Answer 54

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

Answer 55

Tan/brown/black dead skin that sheds and falls of skin

Answer 56

``` Non-blanching erythema - Skin intact - Non-blanching redness - Localised - Painful - Bluish tinge - Warm May be difficult to detect in patients with deeper skin tones ```

Answer 57

``` 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 ```

Answer 58

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

Answer 59

``` 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 ```

Answer 60

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

Answer 61

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

Answer 62

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

Answer 63

Occur within care facility

Answer 64

Patient moves into facility with ulcer

Answer 65

Acquired/inherited Avoidable/unavoidable 95% unavoidable

Answer 66

Stages 2, 3, 4 | 3 and 4 serious

Answer 67

``` 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 ```

Answer 68

``` SSKIN Support surface Skin assessment Keep moving Incontinence and moisture Nutrition and hydration ```

Answer 69

Decreased iron intake Increased iron loss Increase iron requirements - not common in the elderly

Answer 70

``` Often asymptomatic and only causes mild symptoms Fatigue Dyspnoea Headache Palpitations Pale skin or conjunctiva ```

Answer 71

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

Answer 72

``` Conjunctival pallor Angular chellitis Atrophic glossitis Koilonychia Dry skin and hair ```

Answer 73

Hb < 130 in men | Hb < 120 in women

Answer 74

``` FBC - Hb and haematrocrit - MCV - MCH - RDW Ferritin Transferring saturation and total iron-binding capacity Blood film Urinalysis ```

Answer 75

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

Answer 76

More at risk of illness and infection | Higher risk of heart failure with severe anaemia

Answer 77

Vasovagal syncope Carotid sinus hypersensitivity Situational eg micturition

Answer 78

Postural hypotension | Arrhythmias eg bradycardia, tachycardia, hypotension, long QT

Answer 79

Heart block/sick sinus syndrome

Answer 80

Psychogenic Metabolic Medications

Answer 81

``` 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 ```

Answer 82

Persons blood pressure drops abnormally when they stand up after sitting or lying

Answer 83

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

Answer 84

Drop by S > 30, or D > 20 | S < 90

Answer 85

``` Cardiac causes Neural causes Metabolic causes Balance problems Muscle weakness Poor vision Heart disease Syncope Dementia Hypotension ```

Answer 86

``` Fractures Head injuries Pressure sores Becoming less active and therefore weaker and increased chance of falling - post fall syndrome Carpet burns ```

Answer 87

``` Dehydration Hypothermia Pneumonia - related to hypothermia AKI - from dehydration and rhabdomyolysis Rhabdomyolysis Death Distress ```

Answer 88

Syncope due to stress

Answer 89

Pain/heat Sight of blood Prolonged standing Mental stress

Answer 90

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

Answer 91

SAN cannot create a HR that is appropriate for body's needs Causes irregular heart rhythms Previous MI

Answer 92

Female Cognitive decline Visual problems Muscle weakness

Answer 93

Polypharmacy | Lots of hazards around home

Answer 94

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?

Answer 95

``` Asymptomatic Mild viral illness Pneumonia Anosmia Loss of taste Thrombotic effects Renal failure Skin manifestations Respiratory failure Mortality ```

Answer 96

``` Ethnicity BMI Co-morbidities - diabetes, CVS Immunosuppressed Age ```

Answer 97

Swab Bloods - FBC, U&E, CRP, LFT, PCT, ferritin, D dimer CXR - NAD, classic COVID change

Answer 98

Clinical frailty score Date of onset of symptoms Date of positive swab

Answer 99

``` Escalation plan DNAR Antibiotics Fluids Trail participant Phone family O2 Good nursing care Physio ```

Answer 100

``` General covid discussion Potential to suddenly deteriorate DNAR Escalation Regular follow-ups ```

Answer 101

``` 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 ```

Answer 102

``` O2 Rationalise medications Pre-emptive prescribing of drugs for symptoms control +/- syringe driver Update family ?visiting Support from whole MDT ```

Answer 103

Morphine Midazolam Hyoscine Haloperidol

Answer 104

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

Answer 105

66,500 hip fractures per year

Answer 106

``` 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 ```

Answer 107

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

Answer 108

Good nutrition Physical activity Avoid social isolation Not too much alcohol

Answer 109

``` Comprehensive geriatric assessment Pre-operative assessment Post-operative care Facilitate early rehabilitation Facilitate early supported discharge Communication - with patient, relative, friends, and carers ```

Answer 110

``` Functional status Cognitive status Medical problems/co-morbidities Geriatric syndromes Medications Nutritional status Social issues eg social support, finances, accomodation ```

Answer 111

Assess severity of co-morbidities Medications review and analgesia Optimise to prevent delay to theatre Escalation and resuscitation decisions

Answer 112

4AT Alertness AMT4 - ask the following - age, DOB, name of hospital, current year Attention - list months of year backwards Acute change or fluctuating course

Answer 113

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

Answer 114

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

Answer 115

``` Fascia iliaca nerve block Paracetamol Opioids (+laxative) at lowest effective dose - Buprenorphine patch - Dihydrocodeine or oxycodone Avoid NSAIDs/nefopam ```

Answer 116

FRAX | If < 70 request DEXA

Answer 117

``` Non-pharmacological - Weight bearing exercises and muscle strengthening - Falls prevention - Smoking cessation and avoid alcohol Pharmacological - Calcium and vit D replacement - Bisphosphonates ```

Answer 118

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%

Answer 119

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

Answer 120

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

Answer 121

Behavioural and psychological symptoms of dementia - heterogenous group of non-cognitive symptoms and behaviours eg agitation, irritability, depression, disinhibition, hallucinations

Answer 122

``` Agitation Delusions Hallucinations Wandering Aggression ```

Answer 123

``` Old age Dementia Past H/0 delirium Significant co-morbidities Sensory impairment Change of environment ```

Answer 124

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

Answer 125

``` 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 ```

Answer 126

``` Depression B12/folate Hypothyroid NPH Substance misuse SLO Syphillis ```

Answer 127

``` Lethargy Slowness with everyday tasks Excessive sleeping Inattention Can be confused with depression ```

Answer 128

High risk of death if untreated | Hypoactive has higher risk

Answer 129

Neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia without evidence of acute infarction with symptoms lasting less than 24 hours

Answer 130

At 2 days - 2-4.1% At 7 days 3.9-6.5%

Answer 131

Aspirin and refer to TIA clinic

Answer 132

ABCD2 score

Answer 133

``` Bloods - FBC, WCC, U&E, CRP/ESR, LFTs, TFTs, haematinics ECG USS carotid Brain imaging Consider ECHO Consider 24 hr vs 72 hours tape ```

Answer 134

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

Answer 135

Ischaemic - 85% Haemorrhagic - Primary 10% - SAH 5%

Answer 136

``` Migraine SDH Cancer Infection Hypoglycaemia Seizure PRES Functional ```

Answer 137

Atherosclerosis Cardio-embolism Dissection

Answer 138

Within 1 hour CT head MRI

Answer 139

``` 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 ```

Answer 140

Unblocking carotid Reduce 5 year absolute risk of ipsilateral ischaemic stroke by 16% in patients with 70-99% stenosis Many risks associated

Answer 141

``` 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 ```

Answer 142

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

Answer 143

``` Cerebral amyloid angiopathy HTN Aneurysms AVMs Trauma Blood thinners ```

Answer 144

BP management 140/80 Reverse anticoag Neurosurg referral If develop hydrocephalus consider insertion of external ventricular drain

Answer 145

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

Answer 146

Phenotype - Fried | Cumulative deficit - FI, CFS

Answer 147

``` 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 ```

Answer 148

Independently predictive over 3 years of incident falls, worsening mobility or ADL disability, hospitalisation, and death

Answer 149

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

Answer 150

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

Answer 151

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

Answer 152

``` Last 12 months Disease relentless Frailty predictor of mortality Unpredictable Irreversible frailty/decline should prompt discussion re end of life ```

Answer 153

``` Legal aspects Preferred place of care Treatment options acceptable to patient and suitable for patient DNAR Specific plan for complex scenarios ```

Answer 154

Open ended Personalised care - planning/stating preferences Avoids futile disease orientated treatment Patient-centred goals Improves co-ordination of care

Answer 155

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

Answer 156

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

Answer 157

Decreased nutrient intake (starvation) Increased nutrient requirements (sepsis or injury) Inability to utilise nutrients ingested (malabsorption) Or combination

Answer 158

``` 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 ```

Answer 159

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

Answer 160

Food first Oral nutritional supplements Enternal/parenteral nutrition

Answer 161

Liquid/powder/semi solid Macro/micronutrients Milkshakes, juice, soup, semi solid, high energy powders, high protein, low volume/high concentration Mainly sweet

Answer 162

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

Answer 163

Direct feeding into gut such as stomach/duodenum/jejunum Preserves gut mucosa and integrity Inexpensive compared to parenteral nutrition

Answer 164

Tolerance levels eg nausea, satiety, bowel function Tube can be uncomfortable QoL, personal appearance

Answer 165

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

Answer 166

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

Answer 167

Feeding IV when gut is inaccessible or unable to absorb sufficient nutrition to sustain nutritional status

Answer 168

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

Answer 169

PICC line or central line

Answer 170

Helpful to meet nutritional requirements and promote recovery if used appropriately Easily tolerated

Answer 171

More costly than enteral Risk of infection More invasive procedures Gut atrophy

Answer 172

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

Answer 173

Fluid retention Cardiac arrhythmias Respiratory insufficiency Death

Answer 174

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

Answer 175

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

Answer 176

``` Mood changes Changes in speech Sleep changes Disorientation and confusion Visual hallucinations (hyper) Physical issues ```

Answer 177

``` Memory loss Difficulty with ADLs Changes in mood Changes in ability to problem solve Increasing difficulty focussing or paying attention Changes to personality ```

Answer 178

Interrelationship People with dementia more likely to develop delirium and people with multiple episodes of delirium are more likely to develop dementia

Answer 179

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

Answer 180

``` 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 ```

Answer 181

``` FBC U&E LFT Ca CRP ```

Answer 182

``` TSH B12 Folate FBC LFT U&E ESR/CRP Syphillis serology Glucose ```

Answer 183

Syphilis serology | HIV screen

Answer 184

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

Answer 185

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

Answer 186

``` Instability (falls) Infirmity (confusion) Incontinence Immobility Inanition (frailty) Iatrogenic (polypharmacy) ```

Answer 187

Review with occupational therapists | Barthel index

Answer 188

``` Feeding Bathing Grooming Dressing Bowels Toilet use Transfers Mobility Stairs ```

Answer 189

Regular use of at least 5 medications

Answer 190

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

Answer 191

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

Answer 192

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

Answer 193

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

Answer 194

Reviewing doses Elimination duplicate medications Assessing for drug-drug interactions Removing medications that aren't required

Answer 195

Worsen kidney function Increased risk of GI bleeding Increased risk of CVS events

Answer 196

Aspirin 300mg | Clopidogrel in adults over 76 - 75mg