Geriatrics- Additional conditions (Many covered in Neurology) Flashcards
Delirium Card 1
What is delirium?
3 types of delirium?
Compare dementia with delirium? - 4 key things to remember
Delirium is an acute confusional state, characterised by a disturbed consciousness and reduced cognitive function, usually in people over the age of 65.
There are 3 main types of delirium:
Hypoactive delirium (most common) – marked by lethargy and reduced motor activity
Hyperactive delirium (most recognised) – marked by agitation and increased motor activity
Mixed agitation – marked by fluctuations throughout the day
Comparison with Demmentia:
- Attention - poor in delirium vs good in demmentia
- Onset- acute in delirium (sudden change over days) not slow and insidious over months like in demmentia
- consistency - delirium fluctuates, demmentia is very stable in its presentation
- delusions and hallucinations - far more common in delirium (apart from lewy body)
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Note - Sensory impairmeent, underlying demmentia and renal impairement are all major risk factors
Delirium Card 2
- Common causes of delirium
- management
- management of acute agitation
The common causes for delirium are:
PINCH ME Mnemonic
- Pain
- Infection - UTI or LRTI
- Nutrition and Hydration
- Constipation
- Medication induced or withdrawal - BZN, opiates
- Electrolyte abnormalities (e.g. hyponatraemia, hypernatraemia, or hypercalcaemia)
Management:
- Reversing the cause
- conserative measures to keep patients orientated
If patients become acutely agitated - de-esclation techniques!
However, if required Haloperidol 1st line and Lorazopam may be used to sedate aggitated patients. Antipsychotics should be avoided. THIS WAS TESTED IN THE MOCK
Screening Ix for Delirium?
What is included in a confusion screen? (13 - 9 are blds - try your best, not that deep)
An assessment of mental status can be completed using recognised cognitive assessment tools - e.g. 4A’s test, abbreviated mental test score AMT or MMSE
Once confusion is suspected a confusion screen can be completed to help identify the cause:
Urinalysis — to identify conditions such as infection or hyperglycaemia (diabetes). NOTE - A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium.
Sputum culture — to identify chest infection.
Full blood count — to identify infection or anaemia.
Folate and B12 — to identify vitamin deficiency.
Urea and electrolytes — to identify acute kidney injury and electrolyte disturbance (such as hyponatraemia or hypokalaemia).
HbA1c — to identify hyperglycaemia.
Calcium — to identify hypercalcaemia or hypocalcaemia.
Liver function tests — to identify hepatic failure and rule out hepatic encephalopathy.
Inflammatory markers (ESR & CRP) — these tests are non-discriminatory but can help to identify infection or inflammation.
Drug levels — to identify drug toxicity, for example if the person has taken digoxin, lithium, or alcohol.
Thyroid function tests — to identify hyperthyroidism or hypothyroidism.
Chest X-ray — to identify conditions such as pneumonia and heart failure.
Electrocardiogram — to identify cardiac conditions including arrhythmias.
Define Orthostatic hypotension - including values?
Causes? - 5
Diagnosis?
Management?
Orthostatic hypotension
In simple terms, orthostatic hypotension refers to a fall in blood pressure (BP) on standing. It is broadly defined as:
Fall in systolic BP ≥ 20 mmHg or more (with or without symptoms)
Fall in systolic BP to <90mmHg on standing
Fall in diastolic BP ≥ 10 mmHg with symptoms (clinically much less significant)
Causes:
- decreased baroreceptor reflex sensitivity with age. (Normally when we stand blood pools in the lower extremities, and barorecptors fire less leading to activation of the autonomic nervous system)
- Antihypertensive and diuretic medicaitons
- hypovolemia - reduced aldosterone, Renin, increased naturetic petides with age.
- autonomic disfuntion - parkinson’s, diabetes
- cardiovascular disease - arrhythmia, heart failure, MI, aortic stenosis
The symptoms of postural hypotension are caused by cerebral hypoperfusion. They include:
Dizziness
Weakness
Confusion
Blurred vision
Nausea
In severe cases, syncope. When older patients present with syncope, a lying and standing blood pressure measurement is essential to identify postural hypotension as a potential contributor.
Diagnosis - made with lying and stading BP readings
note - possibly an ECG to rule out cardiac arrthymias
Management:
- conservative - increase hydration, compression stockings and stand more slowly
- Medication review- anti-hypertensives and diuretics…
Medical management:
- Fludrocortisone - increase plasma volume can cause hypokalaemia and supine hypertension (Remember its like mineralocorticoid (aldosterone) which retains Na in exchange for K)
- Midodrine - vassopressor used for neurogenic causes (parkinsons or diabetes) but SE of urinary retention
- pyridostigmine
Postural hypotension is a significant contributor to falls in older adults.
What is syncope?
What are the 3 causes of syncope?
Presentation?
4 Ix for syncope?
Syncope refers to a transient loss of consciousness. The loss of consciousness is usually due to a brief reduction in cerebral perfusion due to an abrupt fall in blood pressure. The loss of consciousness inevitably leads to a collapse with subsequent recovery as perfusion is restored (~8-10 seconds).
Causes:
1. Neurogenic/Vasovagal - When the vagus nerve receives a strong stimulus, such as an emotional event, painful sensation or change in temperature it can stimulate the parasympathetic nervous system. As the blood vessels delivering blood to the brain relax, the blood pressure in the cerebral circulation drops, leading to hypoperfusion of brain tissue.
- Postural/Orthostatic hypotension (fall in BP on standing)
- Cardiac syncope -Aortic stenosis (strucrual syncope) or arrthymia (arrhythmic syncope)
Other causes of loss of conciousness not syncope (not cerebral hypoperfusion):
- seizsure
- hypoglycemia/electrolyte
- intoxication
Presentation - before during and after:
- vasovagal often has prodromal symptoms - (e.g. nausea, dizziness, visual changes, feeling hot/cold)
- Sudden collapse without warning is concerning for a cardiac cause- as is prodromal chestpain, SOB or palpatations
-A collateral history from someone that witnessed the event is essential to get an accurate impression of what happened. During a vasovagal episode they may describe the person:
Suddenly losing consciousness and falling to the ground
Unconscious on the ground for a few seconds to a minute as blood returns to their brain
There may be some twitching, shaking or convulsion activity, which can be confused with a seizure
The patient may be a bit groggy following a faint, however this is different from the postictal period that follows a seizure. Postictal patients have a prolonged period of confusion, drowsiness, irritability and disorientation.
There may be incontinence with both seizures and syncopal episodes. However tongue biting, eyes open and moving are suggestive of seizsure.
Investigations
ECG, particularly assessing for arrhythmia and the QT interval for long QT syndrome
24 hour ECG if paroxysmal arrhythmias are suspected
Echocardiogram if structural heart disease is suspected
Bloods, including a full blood count (anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)
ME- Remeber CT head for elderly?/blood thinners with head injury
Management:
- Dependant on cause…
- if a simple vasovagal episode is diagnosed, reassurance and simple advice can be given - avoid dehydration, missing meals, standing for long periods
Differnetial Dx for Falls
Ix for mechanical falls (4)
Management for mechanical fall (4)
The differential diagnosis of falls is very broad. It is important to determine whether the patient has suffered a transient loss of consciousness or a simple mechanical fall.
- MSK - arthritis and osteoperosis, muscle weakness
- visual impairement or balance issues (inc BPPV)
- Neuro - Parkinsons, Stroke and TIA, congitive impairment
- cardiac syncope and orthostatic hypertension
- incontinence
- Iatrogenic - Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).
- environmental hazzards
Ix:
- ECG- cardaic causes
- LSBP these two are key
- CT head , if hit
- assess their gait and balance - for example by using the Timed Up & Go test (max 15 seconds) and/or the Turn 180° test (max 4 steps)
- comprehensive falls risk assessmenet - the FRAT tool (falls risk assessement tool)
Management of mechanical falls:
- Physio - Strength and balance training
- OT - home risk assessmenet
- medication review
- visual assessmenet
Rhabdomyelsis following a fall and long lie (risk increases with duration):
- what is rhabdomyelsis
- why is it dangerous
- presentation
- key Ix
- management
Rhabdomyolysis involves skeletal muscle breaking down and releasing various chemicals into the blood. Muscle cells (myocytes) undergo cell death (apoptosis), releasing:
Myoglobin - can cause AKI
Potassium - hyperkalaemia causes cardiac arthymias
Phosphate
Creatine kinase
Other causes - rigerous exercise, crush injuries, seizsures, statins
Presentation:
- red-brown (coca cola) urine
- oligouria (AKI)
- muscle pain and weakness
Ix:
- KEY- serum creatine kinase rises in first 12 hours and remains elevated for 1-3 days
- urinalysis for myoglobinurea - shows as blood
- U+E for hyperkalaemia and ECG
Managment:
- IV fluids - filtration of breakdown products
- manage hyperkalaemia - IV insulin and dextrose infusion
- optional Intravenous sodium bicarbonate for myoglobinurea
Define Frailty?
Phenotype model : what are the 5 signs of frailty?
4 clinical tests used for frailty?
What is sarcopenia?
Frailty – - A state of increased vulnerability and compromisd ability to cope with everyday stressors, resulting from ageing-assocaited decline in functional reserve, across multiple physiological systems.
Phenotype model:
- Weight loss
- Lethargy
- Slow gait
- Weak grip
- Reduced activity
Having three or more indicates frailty.
Frailty tests:
- Rockwood frailty index - ranges from very fit (1), to terminally ill (9)
- PRISMA 7 Questionnaire
- Gait speed
- Timed up and go test
Sarcopenia:
- Loss of muscle mass or function
- Based on gait speed and grip strength
- Some loss of muscle loss and power is normal with ageing, but sarcopenia is pathological. Muscle loss can be acute or chronic.
- Acute loss happens with disuse atrophy/deconditioning – rapidly loosing muscle strength and power when in hospital for example.
- Chronic- dissuse, insuffieicient protein intake, inflammation, age related reduction in muscle synthesis
- Also leads to VO2 max reduction because the lungs are also powered by muscle too.
What is the Rockwood Frailty index
outline 4,5,6,7!
1 - very fit (active and exercise regularly)
2- well - active occasionally
3- managing well - controlled medical problems, not regularly active
4- vulnerable - independent but symptoms limit activity
5- mildly frail - evident slowing and support with higher ADLs (finances, medications, transport)
6- moderately frail - need help to leave house and tidy house, help with bathing
7 - severely frail - totally dependent for personal hygeine
8 - very severely fail - approaching end of life
9 - terminal ill (<6 months) regardless of other capacibilities
look at teh bold and outlien them
Frailty: what are the five domains of a comprehensive geriatric assessment?
Outline the roles of the MDT in heloping with this?
Allows for the identification of health problems and establishment of management plans in older patients with frailty. It involves an MDT approach with doctors, nurses, physios, OTs and social workers.
- Medical: problems list, medications review, nutritional status, frailty index
- Functional capacity: PTs and OTs – Activities of Daily Living, Gait & Balance, Activity/exercise status
- Mental health – cognition, mood and anxiety, and fears (falling)
- social - carers, power of attorney, community team invovlement
- environmental - housing, transport, safety fetatures (personal alarms), equiptment.
MDT approach:
Physiotherpist - Exercises/weight-bearing exercises/strength and balance training/structured exercise programme
Occupational Therapist - Assessment and provision of aids or adaptations to improve independence with ADLs/assessment and provision of care package to assist with ADLs/therapy to practise and improve independence with ADLs
Dietician - Assessment of nutritional state and provision of appropriate diet and advice
Ward nurse - Day-to-day encouragement to be independent and maintain activity levels
Medical - Medication review and problems list, mental health
Social workers…
What are the 4 geriatric giants?
Me - the geriatric giants are a group of common conditions that lead to significant morbidity (disability) and mortality amognth the eldery.
The Is:
- instability - falls
- immobility
- intellectual (cognitive) impairment
- incotinence (urinary or faecal)
Mnemonic - all Im or In
Some also now add iatrogenic for polypharmacy to this list
Osteoperosis:
- Define Osteoperosis and Osteopenia
- What scan is used to diagnose Osteoperosis and what score is used as the cut off for each condition?
- Z score vs T score?
- Risk factors - 10 things - including a protective medication used to treat breast cancer
Osteoporosis involves a significant reduction in bone density. Osteopenia refers to a less severe decrease in bone density. Reduced bone density makes the bones weaker and prone to fractures.
The World Health Organization (WHO) provide definitions based on the T-score of the femoral neck, measured on a DEXA scan. The T-score is the number of standard deviations the patient is from an average healthy young adult. A T-score of -1 means the bone mineral density is 1 standard deviation below the average for healthy young adults.
Osteopenia - -1 to -2.5
Osteoporosis - Less than -2.5
Bone mineral density (BMD) is measured using a DEXA scan (dual-energy x-ray absorptiometry). DEXA scans are a type of x-ray that measures how much radiation is absorbed by the bones, indicating how dense the bone is. The bone mineral density can be measured anywhere on the skeleton, but the femoral neck reading is most important.
Bone density can be represented as a Z-score or T-score. The Z-score is the number of standard deviations the patient is from the average for their age, sex and ethnicity. The T-score is the number of standard deviations the patient is from an average healthy young adult. The T-score is used to make the diagnosis.
T is before Z so T is for young health, Z is fot actual age (older)
Risk Factors
Older age
Post-menopausal women
Reduced mobility and activity
Low BMI (under 19 kg/m2)
Low calcium or vitamin D intake
Alcohol and smoking
Personal or family history of fractures
Chronic diseases (e.g., chronic kidney disease, hyperthyroidism and rheumatoid arthritis)
Long-term corticosteroids (e.g., 7.5mg or more of prednisolone daily for longer than 3 months)
Certain medications (e.g., SSRIs, PPIs, anti-epileptics and anti-oestrogens)
TOM TIP: Post-menopausal women are an important group where osteoporosis should be considered. Oestrogen is protective against osteoporosis but drops significantly after menopause. Hormone replacement therapy (HRT) is protective against osteoporosis. Tamoxifen is a selective oestrogen receptor modulator (SERM) used to treat breast cancer. It blocks oestrogen receptors in breast tissue but stimulates oestrogen receptors in the uterus and bones. It helps prevent osteoporosis but increases the risk of endometrial cancer. Raloxifene is a SERM used to treat osteoporosis (but not breast cancer in the UK).
Osteoperosis 2 - Assessement
- 4 groups that NICE recomends assessing for osteoperosis?
- How are people assessed?
- Who is bypasses this screening and who can start treatment without screening?
The NICE clinical knowledge summaries (April 2023) recommend assessing:
Anyone on long-term oral corticosteroids or with a previous fragility fracture
Anyone 50 and over with risk factors
All women 65 and over
All men 75 and over
The 10-year risk of a major osteoporotic fracture and a hip fracture can be calculated using either:
QFracture tool (preferred by NICE)
FRAX tool (NICE say this may underestimate the risk in some patients - but remember made in sheffield).
Patients are categorised as low, intermediate or high risk based on the risk calculator. For QFracture, this is based on the percentage, and patients above 10% are considered for a DEXA scan. For FRAX, this is based on the NOGG guideline chart (linked to on the online FRAX tool), which advises whether to arrange a DEXA scan or start treatment.
These suggestions do not apply to specific groups. For example, NICE CKS (April 2023) suggest:
Bypass:
A DEXA may be arranged without calculating the risk in patients over 50 with a fragility fracture
Treatment may be started without a DEXA in patients with a vertebral fracture
Osteoperosis 3 - Management:
- Step One?
- Step Two?
- First line - when is medical management started and what is used?
- What is their mechanism of action and name two key side effects?
- How long does this treatment window last?
- What other options are there and how do they work? 3 to learn
The first step is to address reversible risk factors. For example, increase physical activity, maintain a healthy weight, stop smoking and reduce alcohol consumption.
The second step is to address insufficient intake of calcium (less than 700mg per day) and inadequate vitamin D (e.g., limited sun exposure) with additional:
Calcium (at least 1000mg)
Vitamin D (400-800 IU)
Bisphosphonates are the first-line treatment for osteoporosis. They are recommended for patients with osteoporosis based on a DEXA scan - T score -2.5. They are considered in patients on long-term steroids. They work by interfering with the way osteoclasts attach to bone, reducing their activity and the reabsorption of bone. Me - Bisphosphonates attach to hydroxyapatite binding sites on bony surfaces, especially surfaces undergoing active resorption. When osteoclasts begin to resorb bone that is impregnated with bisphosphonate, the bisphosphonate released during resorption impairs the ability of the osteoclasts to resorb the bone. They also promote the actions of osteoblasts but that is less significant
Bisphosphonates have some important side effects:
Reflux and oesophageal erosions
Atypical fractures (e.g., atypical femoral fractures)
Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
Osteonecrosis of the external auditory canal
Oral bisphosphonates are taken on an empty stomach with a full glass of water. Afterwards, the patient should sit upright for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions.
Examples of bisphosphonates are:
Alendronate 70 mg once weekly (oral)
Risedronate 35 mg once weekly (oral)
Zoledronic acid 5 mg once yearly (intravenous)
The NICE CKS (2023) recommend reassessing treatment with bisphosphonates after 3-5 years. They suggest a repeat DEXA scan and stopping treatment if the T-score is more than -2.5. Treatment is continued in high-risk patients. A TREATMENT HOLIDAY
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Other specialist options for treating osteoporosis (where bisphosphonates are not suitable) include:
Denosumab (a monoclonal antibody that targets RANK lingand) - RANKL is produced by osteoblasts (the cells that build bone) and binds to its receptor RANK on the surface of osteoclast precursors, which stimulates these precursors to mature into fully functional osteoclasts. As such Desomab also inibits osteoclast function.
Romosozumab (a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation)
Teriparatide (acts as parathyroid hormone) - dont get because PTH fires in low calcium and causes increase bone resorbtion, increased vitmain D. This is in parathyroid hormone - continuous high levels promote bone reosbtion but pulsaltile low doses given as teripartide actually promote bone formation.
Hip Fractures:
- two major risk factors for hip fracture
- two categories of hip fractures
Sidenote - If not sure on the basic anatomy of the NOF check the ZTF website.
- describe the blood supply to the head of the femour. How does this affect the management of intracapsular fractures?
- hemiathroplasty vs total hip replacement?
- management of extracapsular fractures?
- other features of management?
Hip fractures are an important topic in trauma and orthopaedics. They are common and lead to significant morbidity and mortality. The 30-day mortality is 5-10%. Half of patients become less independent after a hip fracture. Due to the morbidity and mortality with hip fractures, they are generally prioritised on the trauma list with the aim to perform surgery within 48 hours.
Increasing age and osteoporosis are major risk factors for hip fractures. Females are affected more often than males.
Hip fractures can be categorised into:
Intra-capsular fractures
Extra-capsular fractures
The capsule of the hip joint is a strong fibrous structure. It attaches to the rim of the acetabulum on the pelvis and the intertrochanteric line on the femur. It surrounds the neck and head of the femur.
The head of the femur has a retrograde blood supply. The medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line. Branches of this artery run along the surface of the femoral neck, within the capsule, towards the femoral head. They provide the only blood supply to the femoral head. A fracture of the intra-capsular neck of the femur can damage these blood vessels, removing the blood supply to the femoral head, leading to avascular necrosis.
Therefore, patients with a displaced intra-capsular fracture need to have the femoral head replaced with a hemiarthroplasty or total hip replacement. Non-displaced intra-capsular fractures may have an intact blood supply to the femoral head, meaning it may be possible to preserve the femoral health without avascular necrosis occurring. They can be treated with internal fixation (e.g., with screws) to hold the femoral head in place while the fracture heals.
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Hemiarthroplasty involves replacing the head of the femur but leaving the acetabulum (socket) in place. Cement is used to hold the stem of the prosthesis in the shaft of the femur. This is generally offered to patients who have limited mobility or significant co-morbidities.
Total hip replacement involves replacing both the head of the femur and the socket. This is generally offered to patients who can walk independently and are fit for surgery.
Intertrochanteric fractures - dynamic hip screw
subtrochanteric fractures - intermedullary nail
I wouldnt worry too much about all this - if all you can remember is that displaced (seperated) intercapsular means need to replace the head.
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Other features of management:
The NICE guidelines (updated 2017) say that surgery should be carried out either the same day or the day after the patient is admitted (within 48 hours).
VTE prophalaxis - low molecular weight heparin
Appropriate Analgesia - The operation should allow the patient to weight bear straight away. This allows the physiotherapists to start mobilisation and rehabilitation as soon as possible after the operation. Post-operative analgesia is important to encourage the patient to mobilise as quickly as possible.
ME - Comense bone protection for osteoperosis. Can assume any gracture above 65 (I think) is a fragility
3 functions of Parathyroid hormone?
Other name for active Vit D
Parathyroid hormone increases serum calcium by:
1. PTH stimulates osteoclast activity in the bone causing increased resorption of calcium from the bone into the blood
2. PTH stimulates the kidneys to increase the reabsorption of calcium (and decrease phosphate reabsorption) so that less calcium is excreted in the urine
3. PTH stimualtes the kidneys to converts 25-hydroxyvitamin D (calcidiol) into 1,25-dihydroxyvitamin D (calcitriol). Calcitriol increase the absorption of calcium from food in the intestines - therefore PTH indirectly increase calcium absorption in the intestines
Hip Fractures 2:
- presentation of a hip fracture? Including the 3 signs on examination?
- Ix for hip fracture?
- what Xray sign is seen in fractured NOF?
The typical scenario is an older patient (over 60) who has fallen, presenting with:
Pain in the groin or hip, which may radiate to the knee
Not able to weight bear
Shortened, abducted and externally rotated leg
Not for learning but good to note - An essential part of assessing patients with a new hip fracture is to determine any other acute illnesses. There is often a good reason for them to fall and break a hip. They may also be suffering with: Anaemia, Electrolyte imbalances, Arrhythmias, Heart failure, Myocardial infarction, Stroke and Urinary or chest infection
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X-rays are the initial investigation of choice. Two views are essential, as a single view can miss the fracture. Anterior-to-posterior (AP) and lateral views are standard.
MRI or CT scanning may be used where the x-ray is negative, but a fracture is still suspected.
Disruption of Shenton’s line is a key sign of a fractured neck of femur (NOF). Shenton’s line can be seen on an AP x-ray of the hip. It is one continuous curving line formed by the medial border of the femoral neck and continues to the inferior border of the superior pubic ramus.
What is a fragility fracture and where do they commonly occour?
What two types of wrist fracture can occour due to falling on an outstretched hand?
Fragility fractures occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone. For example, a patient may present with a fractured femur after a minor fall.
TYPES OF FRAGILITY FRACTURES
Hip fractures
Vertebral fractures
Wrist fractures?
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Answer - scaphoid and distal radius/colle’s
Extra info:
A Colle’s fracture refers to a transverse fracture of the distal radius near the wrist, causing the distal portion to displace posteriorly (upwards), causing a “dinner fork deformity”. This is usually the result of a fall onto an outstretched hand (FOOSH).
A scaphoid fracture is often caused by a FOOSH. The scaphoid is one of the carpal bones and is located below the base of the thumb. A key sign of a scaphoid fracture is tenderness in the anatomical snuffbox (the groove between the tendons when extending the thumb). It is worth noting that the scaphoid has a retrograde blood supply, with blood vessels supplying the bone from only one direction. This means a fracture can cut off the blood supply, resulting in avascular necrosis and non-union.
TOM TIP: Some key bones have vulnerable blood supplies, where a fracture can lead to avascular necrosis, impaired healing, and non-union. These are the scaphoid bone, the femoral head, the humeral head and the talus, navicular and fifth metatarsal in the foot.
What is polypharmancy?
Why is it important?
What two criteria are used when prescribing and reviewing medications for the elderly?
Polypharmacy is the concurrent use of multiple medications.
No standard definition but ususally > 5 medications
Importance:
Elderly patients often receive multiple drugs for their multiple diseases. This greatly increases the risk of drug interactions as well as adverse reactions and compliance. The most important effect of ageing is reduced renal clearanceand impaired hepatic funtion. Many aged patients thus excrete drugs slowly, and are highly susceptible to nephrotoxic drugs.
STOPP/START criteria are evidence-based criteria used to review medication regimens in elderly people.
START tool: Suggests medications that may provide additional benefits and prevent omission of indicated medicines for specific conditions - i.e., proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk. Note super sure where you find this.
STOPP tool: Used to assess which drugs can be potentially discontinued in elderly patients undergoing polypharmacy to reduce the incidence of adverse drug events. Note - you can find the STOPP tool in the cautions section on the BNF - lists the contraindications for that drug in the elderly.
Pressure Ulcers:
- what are pressure ulcers?
- risk factors?
- 2 risk assessment tools?
- prevention - 4 things?
- management?
- classification of pressure ulcers?
A pressure ulcer is defined as localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear (stretching/tearing). They usually occur over a bony prominence but may also be related to a medical device or other objects.
Risk factors:
- limmited mobility - unconcious, pain or hip fracture
- inability to independantly reposition
- malnutrition
- loss of sensation
- incontinence - moisture
- medical devices
Risk assessment - Braden Risk Assessment tool or Waterlow score - take account of BMI, mobility, continence, nutrition…
Important differentials are diabetic/neurovascular and vascular ulcers, and moisture leasions.
Prevention:
- barrier creams for moisture if incontinence
- regular repositioning - every 6 hours
- additional pressure relief - high specification foams, heel devices
- regular skin assessment
Management:
- assess nutritional status and need for pressure redistributing devices
- Wound dressing - Moist wound environment encourages ulcer healing: Hydrocolloid dressings and hydrogels
- consider surgical debridement
- antibiotics only if there are signs of infection - systemic symptoms, osteomylitis or spreading cellulitis
Classification
Category/Stage I: nonblanchable erythema with intact skin
Category/Stage II: partial thickness skin loss
Category/Stage III: full-thickness skin loss (down to the sub-cut tissue and fat)
Category/Stage IV: full-thickness tissue loss inolving muscle, bone or other structures
Unstageable: depth unknown.
Geritatric medico-legal:
- Key parts to the MCA
- are advanced directives legally binding
- do patients have to consent to a DNACPR
- what is a lasting power of attorney
- what is imca
- what is a DOLS
- name a couple of things to consider when making a best interests decision.
MCA:
2 stage mental capacity test:
- Decision specific and time specific
- stage 1: impairment of mind or brain
- stage 2: impairment constitues a loss of capacity - understand, retain, weigh-up, communicate
Key parts of the MCA:
Assume capacity – person assumed to have capacity until proven otherwise
Maximise decision-making capacity – all practical support to help a person make a decision should be given
Freedom to make seemingly unwise decisions
Best interests – all decisions taken on behalf of the person must be in their best interests
Least restrictive option – when making a decision on another person’s behalf, the alternative that achieves the necessary goal and interferes the least with the person’s rights and freedom of action must be chosen
Advanced directives
- Used to authorise or request specific procedures and refuse treatment in a predefined future situation (advance directive)
- Advance refusals of treatment are legally binding if: The person is an adult, Was competent and fully informed when making the decision, The decision is clearly applicable to current circumstances, and There is no reason to believe that they have since changed their mind
DNACPR:
- is an ADVANCE decision to refuse CPR in the attempt of cardiac or respiratory arrest. If there is no DNACR in place then doctors will generally attempt CPR unless it is futile, even for the elderly i think
- patients cannot demand CPR is doctors believe it will be futile - doctors can make DNACPR orders against the wishes of the patient (usually a second opinion is offered), but the patient must be notified
Lasting Power Of Attorney: A document which a person can nominate someone else to make certain decision on their behalf (for example on finances, health and personal welfare) when they are unable to do so themselves. To be valid, it needs to be registered with the Office of the Public Guardian. NEED TO HAVE CAPACITY TO APPOINT THIS (BEFORE COGNITIVE DECLINE)
Independent Mental Capacity Advocate (Imca) Role: support and represent people who lack capacity and they do not have anyone else to represent them in decisions about changes in long-term accommodation or serious medical treatment. They can also be present for decisions regarding care reviews or adult protection. FOR PEOPLE WITHOUT NEXT OF KIN BASICALLY…
Deprivation Of Liberty Safetyy: is used to when a person who lacks capacity and it is in the best interests to deprive them of their liberty without their consent (keep them detained in hospital/a care home, 1 to 1 supervison). It is NOT required to give treatment, that is a best interests decisions, unless the treatment would deprive them of their liberty
Best Interests
Consider:
Whether the person is likely to regain capacity and can the decision wait
How to encourage and optimise the participation of the person in the decision
The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
Views of other relevant people
Which two bones are involved in an ankle fracture
Ankle fractures involve the lateral malleolus (distal fibula) or the medial malleolus (distal tibia).
Note - Webers classification is used to describe fractures in relation to the distal syndesmosis (fibrous join) between the tibia and fibula. This tibiofibular syndesmosis is very important for the stability and function of the ankle joint. If the fracture disrupts the syndesmosis (type C- above rather than below the syndemosis - A/B), surgery is more likely to be required in order to regain good stability and function of the joint.
Heart failure 1- Pathophysiology:
- What is heart failure?
- Main Causes? 5
- Main Symptoms?
- Key - systolic vs diastolic failure? How is ejection fraction and cardiac remodelling affected?
- importance of starlings law of the heart in heart failure?
Inability of the heart to maintain adequate cardiac output, specifically the function of the left ventricle to pump blood out of the heart and around the body.
Unfortunately, HF is a progressive disorder associated with high morbidity and mortality. Prognosis is generally poor; approximately 50% die within five years.
Main Causes:
Ischaemic heart disease
Valvular heart disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)
Cardiomyopathy
Main symptoms:
- Shortness of breath (orthopnoea and Paroxysmal nocturnal dyspnoea) - due pulmonary oedema/congestion
- cough - white/pink frothy sputum
- fatigue
- fluid overload/odema
Acute vs chronic heart failure:
Acute heart failure is characterised by a rapid onset of symptoms of heart failure that is usually life-threatening. The most common causes are acute myocardial infarction, acute valvular, pericardial tamponade and subacute decompensation of chronic heart failure. Chronic heart failue is caused by progressive cardiac dysfuntion structual or functional abnormalities. Such as valvular disease, cardiomyopathy, ischemic heart disease, arrhythmias.
Systolic failure vs diastolic.
The ejection fraction is the percentage of blood in the left ventricle squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal.
Heart failure with reduced ejection fraction is when the ejection fraction is less than 50%, this is known as systolic heart failure. In other words, the heart is pumping out a reduced proportion of the blood that fills its ventricles during diastole. The increase in blood at the end of systole leads to ventricular dilatation (eccentric).
Heart failure with preserved ejection fraction is when someone has the clinical features of heart failure but an ejection fraction greater than 50%. This is the result of diastolic dysfunction, where there is an issue with the left ventricle filling with blood during diastole (the ventricle relaxing). The contraction during systole is unaffected, which means the LVEF is preserved. Ventricular hypertrophy (concentric) tends to develop - pumping against a bigger afterload, e.g. in hypertension.
Starling’s law:
During heart failure: As a heart fails the amount of blood left after each contraction increases i.e. the ejection fraction decreases. This increased end-systolic volume (ESV) means the myocardium experiences greater stretch. In a normal heart, this would lead to an increase in myocardial contractility by the Frank-Starling principle (increased stretch on mycoytes increases contractility). However, in a failing heart, the cardiomycoctes get stretched beyond the physiological limmit. This causes a reduction in stroke volume (and thus cardiac output).
Heart Failure - 2:
- Investigations
- CXR findings?
- what is the New york heart association classification
- 4 key drugs in management
- key complication of two?
Establishing a diagnosis of heart failure involves:
1. BNP (N-terminal pro-B-type natriuretic peptide) blood test - helps stratify patients (if negative can exclude heart failure, below 2000 see in 6 weeks, above 2000 see within 2 weeks)
2. ECG
3. Echocardiogram - gold standard - gives an ejection fraction to classify into HFrEF (50%) or HFpEF
Other investigations include:
Bloods for anaemia, renal function, thyroid function, liver function, lipids and diabetes
**Chest x-ray **and lung function tests to exclude lung pathology
NYHAC
- 1 - no limmitation on physical activity
- 2- symptomatic with ordinary activities but comfortable at rest
- 3- symptomatic with any activity but comfortable at rest
- 4- symptomatic **at rest. **
CXR findings:
A- Alveolar (pulmonary) oedema
B - Kerley B lines - fluid in septae of lobules
C - Cardiomegaly
D- Dilated upper lobe vessels
E- Effusion pleural
MANAGEMENT
The first-line medical treatment of chronic heart failure can be remembered with the “ABAL” mnemonic:
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
ME - Remember the neurohumeral blockade (Beta Blocker - (neuro) + ACEi)
A – Aldosterone antagonist - when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
L – Loop diuretics (e.g., furosemide or bumetanide)
Can also add more specialist treatments - Dapagliflozin, Entresto (ACEi and an ARB), Digoxin..
KEY SIDE EFFECT: both ACE inhibitors and Aldosterone antagonists can cause hyperkalaemia (high), partiuclarly when used together. Remember they both inhibit aldosterone.
Procedural and surgical interventions include:
- treating valvular heart disease
- implantable defibrillators for ventricular tachycardias
- Cardiac resynchronisation therapy (CRT) with biverntricular pacemarkers in severe heart failure
- heart transplant - severe disease
No treatment has been shown to convinsingly reduce mortality and morbidity in patients with HFpEF. Screen for specific underlying causes, and treat any that are present. Diuretics are recommended in congested patients with HFpEF in order to alleviate symptoms.
Heart failure 3 - ACUTE Left Ventricular Failure:
- definition of acute heart failure?
- triggers?
- ABG findings and presentation? - 3 key things
Acute left ventricular failure occurs when an acute event results in the left ventricle being unable to move blood efficiently through the left side of the heart and into the systemic circulation.
When blood cannot flow efficiently through the left side of the heart, there is a backlog of blood waiting in the left atrium, pulmonary veins and lungs. As these areas experience an increased volume and pressure of blood, they start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema. This interferes with normal gas exchange in the lungs, causing shortness of breath and reduced oxygen saturation.
Triggers:
- Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function)
- Myocardial infarction
- Arrhythmias
- Sepsis
- Hypertensive emergency (acute, severe increase in blood pressure)
TOM TIP: Acute left ventricular failure and pulmonary oedema are common in the acute hospital setting. When a nurse asks you to review a breathless and desaturating patient, ask yourself how much fluid that patient has been given and whether they will be able to cope with that amount. For example, an 85 year old patient with chronic kidney disease and aortic stenosis is prescribed 2 litres of fluid over 4 hours and then starts to drop her oxygen saturation. This is a common scenario, and a dose of IV furosemide can work like magic to clear the excess fluid and resolve the symptoms.
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Acute LVF causes a type 1 respiratory failure (low oxygen without an increased carbon dioxide).
Presentation:
- Acute LVF typically presents with acute shortness of breath. This is exacerbated by lying flat and improves on sitting up.
- Cough with frothy white or pink sputum
Others stuff:
Signs on examination include:
Raised respiratory rate
Reduced oxygen saturations
Tachycardia (fast heart rate)
3rd heart sound
Bilateral basal crackles (sounding “wet”) on auscultation of the lungs
Hypotension in severe cases (cardiogenic shock)
There may also be signs and symptoms related to the underlying cause, for example:
Chest pain in acute coronary syndrome
Fever in sepsis
Palpitations with arrhythmias
If they also have right-sided heart failure, you could find:
Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
Peripheral oedema of the ankles, legs and sacrum
Acute Left ventricular failure 2 - Management:
- Assessement? - KEY 6 things
- Define ejection fraction and what is a normal ejection fraction?
- Side note - CXR findings
- KEY - Managment
Assessment in patients with acute left ventricular failure includes:
- Clinical assessment (history and examination, starting with an ABCDE approach in any acutely unwell patient)
ECG to look for ischaemia and arrhythmias
Bloods for anaemia, infection, kidney function, BNP, and consider troponin if suspecting myocardial infarction
Arterial blood gas (ABG)
Chest x-ray
Echocardiogram
A note on BNP - B-type natriuretic peptide (BNP) is a hormone released from the heart ventricles when the cardiac muscle (myocardium) is stretched beyond the normal range. A raised BNP blood result indicates the heart is overloaded beyond its normal capacity to pump effectively. The action of BNP is to relax the smooth muscle in blood vessels. This reduces systemic vascular resistance, making it easier for the heart to pump blood through the system. BNP also acts on the kidneys as a diuretic to promote water excretion in the urine. This reduces the circulating volume, helping to improve the function of the heart in someone that is fluid-overloaded.
Echo - Ejection fractions is defined as the percentage of blood in the left ventricle that is squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal.
Extra- CXR findings:
- A alveolar oedema
- B - kerley b lines - gluid in the septal lines (and interlobular fissueres)
- C - cardiomegaly (heart is more than 50% diameter of lung fields)
- D - KEY - diversion (venous) in upper lober vessels. Usually the lower lobe veins contain ore blood and the upper lobe vessels remain smore. In acute LVHF there is venous congestion and back pressure causing upper lobe diversion
- Effussions - pleural
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Management - they are very acutely unwell - admission!!
The “sodium” mnemonic can be used for remembering the basic management of acute LVF:
**S – Sit up **
O – Oxygen
D – Diuretics - IV furosemide
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance
There is more experienced specialist management that i am not going to learn - IV opiates (vasodilators), nitrates, ionotropes (dobutamine)
This is very much an ABCDE approach kind on thing - thing of sam fox training
KEY - MOCK
Geriatrics: Constipation
Definition - 3 things?
Causes of constipation?
Red flag Sx?
What is faecal impaction?
Management - Key - including the type and order of laxatives
management of faecal impaction?
Constipation is a common complaint that refers to the infrequent passage of stool, difficulty passing stool, and/or a sensation of incomplete emptying.
Primary constipation - This refers to constipation without a clear underlying cause. It is broadly referred to as chronic idiopathic constipation or functional constipation. Usually it is caused by inadequet fibre intake, inadequet fluid intake and inadequete activity.
Secondary constipation
This refers to constipation due to an underlying cause:
- medication-induced: Opioids, calcium channel blockers, oral iron supplements, antacids and anticholinergics
- hypothyroidism
- hypercalcaemia
- Parkinson’s disease
- colorectal carcinoma - RED FLAG
Red flags for underlying malignancy:
- palapable mass in the RIF
- weightloss, unexplained fever or night sweats
- rectal bleeding
- family history of colorectal cancer
- sudden changes in bowel habbit
- Iron deficiency anaemia
- me- tenesmus - sensation after going
Faecal impaction
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently. They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum. Over time the rectum stretches as it fills with more and more faeces. This leads to further desensitisation of the rectum. The longer this goes on, the more difficult it is to treat the constipation and reverse the problem. Faecal impaction can lead to overflow incontinence - a very common cause of faecal incotinence in the elderly. Treatment is below - disimpaction regime
PR examination is important for excluding a structural problem contributing to constipation (mass, haemorrhoids) and assess spincter and defeacation mechanism.
Ix- Faecal calprotectin, qFIT, FBC, TFTs, Renal profile, HBa1c…
Colonoscopy is for red flag features - new change in bowel habit over 60.
wouldnt bother testing these
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Management:
- lifestyle modification - 30g of dietary fibre daily. Good fluid intake, exercise. Regular, unhurried toiletting.
Laxatives:
- 1st line - Bulk forming - fybogel/ispagula husk (increase the bulk of the stool to stimulate bowel funtion).
- 2nd line - Osmotic laxatives - macrogol, lactulose - draw water into the bowel lumen
- 3rd line - stimulant laxatives - senna - stimulates the bowel wall to contract
Faecal impaction may require a disimpaction regimen with high doses of osmotic laxatives (macrogol) at first. Then sodium phosphate enemas if unsuccessful.
Urinary Incontinence 1:
- 5 types
- investigations
One of the Geriatric Giants!
Urinary incontinence refers to the loss of control of urination. There are two MAIN types of urinary incontinence, urge incontinence and stress incontinence. Establishing the type of incontinence is essential, as this will determine the management.
TYPES:
- Urge incontinence - dretrousser (bladder) overactivity. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. nomrally idiopathioc or UTI…
- Stress incontinence - weakness of the pelvic floor (sling of muscles that support the pelvic organs) and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder - laughing, coughing or surprised. Causes - childbirth, prostatectomy, vaginal prolapse
- Mixed incontinence refers to a combination of urge incontinence and stress incontinence
- Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine (as well as overflow, also causes overactive bladder due to irritant effect of urine) - pelvic tumours, BPH, anti-cholinergic mediciations, fibroids, CONSTIPATION OMG
- Functional incontinence - due to cognitive impairment and demmentia
Specific issues of elderly- reduced bladder capcity, BPH, redcued pelvic floor stregnth, reduced motility, UTI, congitive impairment, prolapse….
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Investigations:
- A bladder diary
- Urine dipstick testing - infection, microscopic haematuria and other pathology
- Post-void residual bladder volume - to assess for incomplete emptying
- Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.
- Men - PR examination, PSA test as well as above
Urinary Incontinence 2 :
- management of two main types
- side effects of a relevant medication class
Management- identify cause first!
Management of Stress incontinence:
- lifestyle measures- avoid caffeine, excessive or restricted fluid intake, weight loss
- supervised (physio or specialist nurse) pelvic floor exercises
- duloxetine
- surgery - autologous sling
Management of Urge incontinence:
- 1st line - bladder retraining
- Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
- Mirabegron as an alternative to anticholinergic medications
- Invasive procedures - Botilinum toxin A, sacral nerve stimulation, Augmentation cystoplasty….
NOTE - Anticholinergic medications need to be used carefully, as they have anticholinergic side effects. These include dry mouth, dry eyes, urinary retention, constipation and postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia, which can be very problematic in older, more frail patients.
Indications For Catheters:
Sx urinary retention, obstructed outflow and deteriorating renal function/AKI
BPH - Urinary incontence 3:
- Ix
- Management?
- notable side effects of medical management
Remember that men can also have overactive bladder, UTI!
Presents with LUTS symptoms - urgency
Ix:
- PR and Abdo examination
- PSA test - unreliable
- Urinary frequency volume chart
- Urine Dipstick - UTI!!!
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Management
- Patients with mild and manageable symptoms may not require interventions.
- Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms - used initially
- 5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate - work gradually
- Surgical Management: TURP, TEVAP, Prostatectomy
TOM TIP: The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure. The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
Note - 5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone
BPH vs Prostate cancer which areas of the prostate are affected?
The transition zone is the exclusive site of benign prostatic hyperplasia (BPH). Me - Transitional zone is around the urethra which is why they get LUTS
The peripheral zone is the most common site of prostate cancer. Me - can feel cancer on a PR
Criteria for diagnosing an AKI?
Causes of a UTI?
Acute kidney injury (AKI) refers to a rapid drop in kidney function, diagnosed by measuring the serum creatinine. Acute kidney injury is most common in acutely unwell patients (e.g., infections or following surgery).
The NICE guidelines (2019) criteria for diagnosing an acute kidney injury are:
Rise in creatinine of more than 25 micromol/L in 48 hours
Rise in creatinine of more than 50% in 7 days
Urine output of less than 0.5 ml/kg/hour over at least 6 hours
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Pre-renal causes are the most common. Insufficient blood supply (hypoperfusion) to kidneys reduces the filtration of blood. This may be due to:
Dehydration
Shock (e.g., sepsis or acute blood loss)
Heart failure
Renal causes are due to intrinsic disease in the kidney. This may be due to:
Acute tubular necrosis
Glomerulonephritis
Acute interstitial nephritis
Haemolytic uraemic syndrome
Rhabdomyolysis
Post-renal causes involve obstruction to the outflow of urine away from the kidney, causing back-pressure into the kidney and reduced kidney function. This is called an obstructive uropathy. Obstruction may be caused by:
Kidney stones
Tumours (e.g., retroperitoneal, bladder or prostate)
Strictures of the ureters or urethra
Benign prostatic hyperplasia (benign enlarged prostate)
Neurogenic bladder - including medications that cause retention
Ix for AKI (2)
Rx for AKI (4)
Complications of an AKI (4)
Urinalysis assesses for protein, blood, leucocytes, nitrites and glucose:
Leucocytes and nitrites suggest infection
Protein and blood suggest acute nephritis (but can be positive in infection)
Glucose suggests diabetes
Ultrasound of the urinary tract assesses for obstruction when a post-renal cause is suspected.
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Treating an acute kidney injury involves reversing the underlying cause and supportive management, for example:
IV fluids for dehydration and hypovolaemia
Withhold medications that may worsen the condition (e.g., NSAIDs and ACE inhibitors)
Withhold/adjust medications that may accumulate with reduced renal function (e.g., metformin and opiates)
Relieve the obstruction in a post-renal AKI (e.g., insert a catheter in a patient with prostatic hyperplasia)
Dialysis may be required in severe cases
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Fluid overload, heart failure and pulmonary oedema
Hyperkalaemia
Metabolic acidosis
Uraemia (high urea), which can lead to encephalopathy and pericarditis
Mnemonic for nephrotoxic medications
DAMN
Diuretics
ACE inhibitors
Metformin
NSAIDs
ACE inhibitors - vasodilation of the efferent arteriole (to remember think no activation of angiotensin).
NSAIDs - causes vasoconstriction of the afferent renal arteriole. Prostaglandins cause vasodilation (think about inflammation).
Mnemonic - nsAids dont have an E so Afferent, acE - Efferent
What is obstructive uropathy and how can it affect kidney function?
How do LUT vs UUT obstructions present?
Causes of each?
Obstruction leads to back-pressure in the urinary system, causing areas proximal to the site of obstruction to become swollen with urine. For example, obstruction at the opening of the ureters in the bladder, from a bladder tumour, will result in swelling of the ureter and kidney on that side. Swelling of the kidney is known as hydronephrosis. Vesicoureteral reflux (VUR) refers to urine refluxing from the bladder back into the ureters.
When obstructive uropathy leads to an acute reduction in kidney function, it is referred to as a “post-renal” acute kidney injury (AKI). This is different from “pre-renal” AKI, which is caused by hypoperfusion of the kidneys (e.g., due to dehydration, sepsis or acute blood loss), and “renal” AKI, which refers to damage within the kidney itself (e.g., due to glomerulonephritis or nephrotoxic medications).
TOM TIP: Whenever someone asks you the cause of renal impairment, always answer: “the causes are pre-renal, renal or post-renal”. This will impress them and allow you to think through the causes more logically.
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Upper urinary tract obstruction presents with:
- flank pain
- vomiting
- reduced urine output
- impaired kidney function
Causes:
- tumours - bladder, or pushing agianst ureters
- kidney stones
- others…
Lower urinary tract obstruction:
- difficulty passing urine
- urinary retention (increasingly full bladder)
- impaired renal function
Causes - KEY CAME UP:
- Benign prostatic hyperplasia (benign enlarged prostate)
- Prostate cancer
- Bladder cancer (blocking the neck of the bladder)
- Urethral strictures (due to scar tissue)
- Neurogenic bladder - Another card…
An ultrasound of the kidneys, ureters and bladder can be helpful in diagnosing obstructive uropathy.
What causes a neurogenic bladder?
Key medications - CAME UP
Neurogenic bladder refers to abnormal function of the nerves innervating the bladder and urethra. It can result in overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra. It can lead to urge or overflow incontience, or obstructive uropathy leading to a AKI.
On another card there are other cuases of obstructive uroapthy - BPH, bladder cancer…
Key causes are:
- Multiple sclerosis
- Diabetes
- Stroke
- Parkinson’s disease
- Brain or spinal cord injury
- Spina bifida
MY OWN LIST - medicines may cause urinary retention, including:
- tricyclic antidepressants - Anti-cholinergic SEs
- Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin - used for urge incontince and can worsen cognitive impairement.
- Im guessing Mirabegron B3 agonist used for urge incontiend
- Midodrine - used for neurogenic causes (parkinsons or diabetes) of orthostatic hypotension
- anti-psychotics - clozipine, olanzipine - anti-cholinergic effects
- Nasal decongestants - ephedrine (stimualte symapthetic)
- Other drugs with anti-cholinergic effects: Antihistamines, some Parkinsons drugs, Opiods
Management of obstructive uropathy/neurogenic bladder?
Management involves removing or bypassing the obstruction to protect kidney funciton:
- urethral catherterisation or suprapubic (if fails) for LUT obstruction, inclduing neurogenic bladder
- nephrostomy (tube into the ureter, through the skin) for upper obstruction
Treat underlying cause - prostate, neurogenic disease, reverse anticholinergic medications…
Malnutrition in the Elderly:
- 2 types
- 3 causes
- Screening tool for Malnutrition - cut off
- 3 other criteria for nutritional support:
- management of malnutrition
Note - Refeeding syndrome is tested on the next card….
Malnutrition is a state in which a deficiency of nutrients such as energy, protein, and vitamins and minerals causes measurable adverse effects on body composition, function, or clinical outcome. It is both a cause and a consequence of ill health and can be caused by social factors
Me - includes wound healing, immune duntion, sarcopenia, altered vital signs
Types:
Acute malnutrition: brief inadequate nutrition (e.g., due to illness) leading to muscle wasting and rapid weight loss.
Chronic malnutrition: prolonged inadequate nutrition (over three months) often related to social, behavioural, economic, and illness-related causes.
Causes:
1. Inadequate nutrient intake
2. Difficulty absorbing nutrients (e.g., gastrointestinal dysfunction)
3. Increased nutritional demands (e.g., post-surgery for healing, infection)
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All patients admitted to hospital should be screened for malnutrition including measurement of their weight, body mass index (BMI) and appetite. Several standardised screening tools exist including the Malnutrition Universal Screening Tool (MUST).
MUST :
- Uses BMI: 20 -1; 18.5 -2
- degree of unplanned weight loss 5%-1; 10%-2
- Acute disease score - 2+ if acutely ill and unlikely to have dietary intake for 5 days.
Treat if they score 2 or more
Nutrition support should be considered in people who are malnourished, defined by any of the following:
- A body mass index (BMI) of less than 18.5 kg/m2.
- Unintentional weight loss greater than 10% within the last 3 to 6 months.
- A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months.
Nutrition support should also be concidered in people at risk of malnutrtion:
- Eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer.
- A poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs due to illness or surgery
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Management - Nutrition support refers to methods to improve or maintain nutritional intake, which include:
- Oral nutrition support — such as fortified food, additional snacks, and/or sip feeds. These should be given to people when the MUST score is 2. Oral nutrition should be used as long as it is possible
- NG tube -if a patient is unable to safely swallow or is unable to take sufficient calories orally, nasogastric feeding should be considered. For long-term feeding, a gastrostomy (PEG or RIG) or jejunostomy should be considered.
- Parenteral nutrition — the delivery of nutrition intravenously, should be reserved for patients with intestinal failure or inaccessible digestive tracts.
Malnutrition:
- what is the pathophysiology of refeeding syndrome
- management of refeeding syndrome
Refeeding syndrome is a condition caused by a rapid re-introduction of normal nutrition in patients who are chronically malnourished. In the context of chronic malnutrition, a patient’s intracellular stores of key electrolytes such as potassium, magnesium and phosphate become depleted.
As a result, if a patient is suddenly provided with normal levels of nutrition, there is a sudden shift of these electrolytes from the extracellular to the intracellular compartment driven by a large insulin response and other factors. This can ultimately lead to a sudden drop in extracellular levels of key electrolytes resulting in hypokalaemia, hypomagnesemia and hypophosphataemia. This can subsequently lead to cardiac complications (e.g. arrhythmias) and seizures. It also leads to fluid overload as Na is shifted into the blood (the opposite direction to potassium).
There is a risk of arrhythmia and heart failure. Rarely, it can be fatal.
To prevent refeeding syndrome, nutrition is re-introduced more gradually under the guidance of a dietician and the patient’s electrolytes are monitored closely, allowing deficiencies to be identified early and replaced appropriately.
Management will be according to the local protocol under specialist (dietician) supervision:
- Slowly reintroducing food with limited calories
- Magnesium, potassium, phosphate and glucose monitoring
- Fluid balance monitoring
- ECG monitoring in severe cases
- Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine - PABRINEX
Depression in Older adults
- 2 core symptoms
- Screening?
- management - 3 main things
The core symptoms of depression are:
- Low mood
- Anhedonia (a lack of pleasure or interest in activities)
But also feeling hopeless, irriatable, poor concentration, poor sleep….
Why depression affects older adults:
- chronic illness
- loneliness
- grief
- demmentia
- parkinson’s
- moving into a care-home
- alcohol
- vascular depression
When someone gets older, there are changes that happen in their lives that need to be considered if they have a mental illness. Older people might have:
multiple health issues
frailty, which means they find it harder to recover from illnesses or injuries
experienced bereavements and other losses.
PHQ-9 Questionnaire
PHQ-9 questionnaire is used to assess the severity of depression. There are nine questions about how often the patient is experiencing symptoms in the past two weeks. The higher the score, the more severe the depression:
5-9 indicates mild depression
10-14 indicates moderate depression
15-19 indicates moderately severe depression
20-27 indicates severe depression
Management
Management options for depression include:
Active monitoring and self-help
Address lifestyle factors (exercise, diet, stress and alcohol)
Therapy (e.g., cognitive behavioural therapy, counselling or psychotherapy)
Antidepressants (selective serotonin reuptake inhibitors are first-line) - not offered for people scoring less than 16 (moderate) on the PHQ-9
Squamous cell carcinoma:
What is SCC?
What causes SCC?
Is it ususally metastatic?
Ix?
Cutaneous squamous cell carcinoma (SCC) is a malignant tumour of keratinocytes, arising from the epidermal layer of the skin. SCC is the second most common form of skin cancer, after basal cell carcinoma, accounting for 20% of all cutaneous malignancies.
Most SCC arise from cumulative prolonged exposure to ultraviolet (UV) radiation and as such are found on the head, neck, arms and legs. Exposure to UV radiotion causes mutiple DNA mutation in tumour suppressor genes.
It is uncommon for SSC to metastasise, but it can occour via the lymphatic system to any organ.
The can appear nodular, indurated, or keratinised with associated ulceration or bleeding.
Ix - dermoscopy and biopsy
If suspicion of metasasis then imagine and biospy of lyphatics - similar to breast.
Management - excision biopsy with peripheral margins taken (healthy tissue)
Key Points:
Squamous cell carcinoma (SCC) is a malignant tumour of keratinocytes
Its main risk factor is cumulative prolonged exposure to UV light
Definitive diagnosis is made via biopsy and surgical excision forms the mainstay of management
Other forms of skin cancer:
What is Basal cell carcinoma
What is melanoma
Include appearance of each.
BCC is the most common form of skin cancer, however fortunately it is the least likely to metastasise.
They present typically as small slow-growing lesions, with raised pearly edges and evident telangiectasia.
Melanoma:
Melanoma is a malignant tumour of melanocytes, the melanin-producing cells of the body. It commonly arises from melanocytes in the stratum basale of the epidermis but can also arise from melanocytes at other sites
Melanoma most commonly affects the trunk or legs and they metastasise early (relative to other skin cancer types), partly due to their vertical growth (as opposed to radially).
Melanoma presents as a new skin lesion or a change in the appearance of a pre-existing mole. There may be associated bleeding or itching.
Upon examining the skin lesion, the ABCDE rule is helpful:
Asymmetry
Border irregularity
Colour uneven
Diameter >6mm
Evolving lesion
Me:
BCC - looks like little pink legions
SCC - bit like a cyste, raised lump
Melanoma - ireegular dark brown moles.
Geriatrics Hyper vs Hypothermia:
- criteria for diagnosis
- Sx
- Rx
Hypothermia
- CBT< 35 e.g. w/ rectal probe
- Sx: Shivering, pilo-erection, Initially - Tachy + HTN, eventually Brady and Hypotension)
- Note- Osbourne J wave on ECG
Rx: ABCDE, External rewarming
Hyperthermia
- CBT >40 w/ CNS dysfunction
- occurs due to high heat exposure in the elderly and impaired thermoregulation with aging, in younger patients usually due to excessive exertion
- Sx: Altered mental state, hot flushed skin, hypotensive
- Rx: ABCDE approach with IV fluids + cooling
Advanced decision vs statement?
Legally binding?
Advanced Decision: Legally binding and must be followed by healthcare professionals.
Expl - An advance decision to refuse treatment can be made while you have
mental capacity. It lets you choose and explain which medical treatments
you do not want doctors to give you, if a time comes when you lack
capacity and cannot make the decision or communicate your wishes. I
Advanced Statement: Not legally binding, but provides guidance.
Expl - An advance statement lets you make general statements, describing
your wishes and preferences about future care, should you be unable to
make or communicate a decision or express your preferences at the
time.
