Geriatrics- Additional conditions (Many covered in Neurology) Flashcards

Question

Heart failure 3 - ACUTE Left Ventricular Failure: - definition of acute heart failure? - triggers? - ABG findings and presentation? - 3 key things

Answer 1

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. //// **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

Answer 2

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 /// 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

Answer 3

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 /// 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.

Answer 4

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.... /// 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

Answer 5

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

Answer 6

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!!! /// 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

Answer 7

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

Answer 8

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 //// 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

Answer 9

**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. ///// 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** ///// Fluid overload, heart failure and pulmonary oedema Hyperkalaemia Metabolic acidosis Uraemia (high urea), which can lead to encephalopathy and pericarditis

Answer 10

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

Answer 11

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. /// 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.

Answer 12

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

Answer 13

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...

Answer 14

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) //// 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 //// 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.

Answer 15

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**

Answer 16

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

Answer 17

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

Answer 18

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.

Answer 19

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

Answer 20

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.