Geriatrics Flashcards
Causes of falls
DAME
Drugs:
Polypharmacy
Age-related changes:
Nerves, muscles, gait, posture, neuro
Medical comorbidities:
Hypotension, faint, HF, arrhythmia, valve disorders
Environmental
Contributing factors:
Vision, hearing, sensation, central processing and coordination, muscle, balance, posture, gait, psychological, infection, vitamin D deficiency, low sugar, poor fitness
Consequences of falls
Immobility
Injury:
Fractures, head injury
Psych:
Fear, reduced confidence, loss of independence, low mood, loneliness
Secondary:
Chest infection, pressure sore, dehydration, muscle atrophy, pains, burns, hypothermia, rhabdomyolsis
Fall history
Before:
Pre-symptoms, what were they doing, mobility
PMH:
Diabetes, HTN, epilepsy, previous falls, cardiac problems
Meds:
Increasing risk
During:
Remember, witnessed, LOC, mechanism of fall (hands out, hit head)
After:
Jerking, incontinence, well-orientated, able to mobilise, how long on the floor
Examination of a patient who has fallen
Functional:
Assess gait, use of walking aids and hazard perception
Cardio:
Murmurs, BP, peripheral oedema, carotid bruits
Neuro:
Cerebellar signs, joint position sense, proximal/focal weakness, foot drop, spatial neglect, Parkinson’s
Vision
Investigations after falls
Bloods Urine dip Postural BPs Cardiac assessment, ECG/ECHO ECR Pelvic XR CT head Visual acuity Gait Check feet and footwear Assess home environment Assess cognition
Prevention of falls
Drug review
Treatment of cause: orthostatic hypotension
Strength and balance training
Walking aids
Environmental assessment
Vision
Reducing stressors (limiting walking to indoors, using a walking aid properly and reliably)
Define delirium
Acute or subacute, usually reversible, syndrome of impaired higher cortical functions hallmarked by generalised cognitive disturbance and caused by one or more aetiologies
Confusion, disorientation, agitation
Management of delirium
Treat in low stimulus, well lit room, Relative present Clock and window Reduce distress Prevent accidents Nursing/family care Improve orientation in time and place
Treat precipitant:
Minimise medication
Antibiotics for HAP
Chlorodiazepoxide for alcohol dependency
Drug:
Haloperidol
Lorazepam
Signs and symptoms of delirium
DELIRIUM
Disordered thinking Euphoric, fearful, depressed, angry Language impaired Illusions/delusions/hallucinations Reversal of sleep-awake cycle Inattention Unaware/disorientated Memory deficits
Causes of delirium
PINCH’S ME
Pain
Infection (pneumonia, UTI)
Nutrition (thiamine, nicotinic acid, B12 deficiency)
Constipation
Hydration (+urine retention)
Sleep
Medication (opiates, anticonvulsants, sedatives)
Electrolytes (AKI/uraemia, liver failure, Na, glucose)
Delirium vs. dementia
attention/memory, affect, hallucinations, delusions
DELIRIUM
Attention:
Inattention with poor memory
Affect:
Lability
Hallucinations:
Usually visible, can be auditory, tactile, gustatory, olfactory
Delusions:
Fleeting, fragmented, persecutory
DEMENTIA
Attention:
Poor memory without inattention except in end stage
Affect:
No clear pattern
Hallucinations:
Visual or auditory
Delusions:
Paranoid, often fixed
Investigations for delirium
History Drugs, last timings, severity of withdrawal Coexisting medical/psychiatric disorders Physical examinations Urine dip and drug screen FBC, Ca, U&E, LFT, blood glucose, folate, B12, INR, PT, malaria films, ammonia, septic screen ABG EEG LP ECG CT/MRI Check for dehydration, hyponaturia, hypokalaemia, hypomagnesaemia, hypo/hypernatraemia
Define dementia
Overall decline in intellectual function including difficulty with language, calculation, planning, judgement, motor skills as well as loss of memory
Causes of dementia
Traumatic:
Major head injury, dementia pugilistica
Vascular:
Post stroke dementia, small vessel disease
Infection:
Herpes simplex virus, HIV, syphilis, Lyme disease
Toxic:
Alcohol, heavy metals
Metabolic:
B12, deficiency, hypothyroidism
Genetic:
Huntington’s disease, familial AD
Neurodegenerative:
Alzheimer’s disease, frontotemporal dementia
Inflammatory:
Autoimmune diseases, MS
Risk factors for dementia
Increasing age Female Family APO E4 allele Low education TBI CVS RF Down's syndrome
Differentials of dementia
Delirium Depression Infection (meningitis, encephalitis, neurosyphilis, HIV) Intracranial SOL Temporal lobe seizures Normal ageing Obstructive sleep apnoea Endocrine (hypothyroidism, Addison's) Metabolic (B12/folate/thiamine deficiency) Normal pressure hydrocephalus
Dementia vs. mild cognitive impairment
Mild cognitive impairment is intermediate stage between normal ageing and more serious decline of dementia
Not usually severe enough to interfere with everyday life
Presentation of dementia
Forgetfulness/unreliability/navigational problems Decline in social cognition Language disintegration Visuospatial problems Dyspraxia
Deficits:
Memory (LT and ST)
Executive function
Language (word finding, speech, distortion, loss of word comprehension)
Visuospatial (complex visual impairment, misinterpretation, loss of visual judgement)
Praxis (writing or using appliances impaired)
Behaviour (disinhibition, apathy, obsessionality)
Symptoms of dementia
Hippocampal:
Episodic memory
Frontal lobes:
Personality, executive functions
Temporal lobes:
Language comprehension, face recognition
Parietal lobes:
Calculations/praxis, visuospatial
Behavioural and psychological symptoms of dementia
Agitation Apathy Depression Psychosis Sleep problems Wandering Managed with drugs (donepezil, AchEI), targeting specific symptoms
Investigations in dementia
Bloods:
FBC, U&E, LFTs + GGT, ESR, calcium, glucose, TFTs, vitamin B12 and folate levels, VDRL
Imaging:
CT head, MRI
LP:
Exclude inflammatory causes (CJD/infection/cancer)
Look for markers of Alzheimer’s disease
Scoring systems:
MMSE, MoCA, ACE
Management of dementia
Adaptations for patients Social support Support carers Optimise physical health Psychological therapies Psychotropic medications
