Geriatrics and palliative care Flashcards
Risk factors for falls
- History of falls
- Visual impairment
- Cognitive impairment
- Depression
- Alcohol misuse
- Polypharmacy
- Psychoactive drugs
- Anti-hypertensive drugs
- Environmental hazards
- Frailty
Conditions that affect mobility and balance
o Arthritis
o Diabetes
o Incontinence
o Stroke
o Syncope
o Parkinson’s
o Muscle weakness
Investigations for falls
- Timed Up and Go test
- Turn 180 degrees test
Risk assessment for falls
- History of falls
- Gait, balance, mobility, muscle weakness
- Osteoporosis risk
- Perceived impaired functional ability and fear related to falling
- Visual impairment
- Cognitive, neurological and cardiovascular problems
- Urinary continence
- Home hazards
- Polypharmacy
- Acute event (PE, intra-abdominal bleed)
- Injuries
- Why have they fallen?
o Tripped
o Arrhythmia
o LSBP
Criteria for CT head after falls
Focal neurological deficit
Anticoagulated
GCS score of 12 or less on initial assessment
GCS score of <15 2 hrs after injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
>1 episode of vomiting
Dangerous mechanism of injury
>30 mins retrograde amnesia
Aged 65 or older
Management of falls
- Strength and balance training physio
- Mobility aids
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review
Complications of falls
- Major lacerations
- Traumatic brain injuries
- Fractures
- Distress
- Pain
- Loss of self-confidence
- Reduced quality of life
- Loss of independence
- Activity avoidance
- Social isolation
- Increasing frailty
- Functional decline
- Depression
- Institutionalisation
Definition of frailty
Diminished strength and endurance and reduced physiological function that increases an individual’s vulnerability for developing increased dependency and/or death
Risk factors for frailty
- Disability
- Comorbidities
- Advancing age
Presentation of frailty
- Unintentional weight loss
- Weakness evidence by poor grip strength
- Self-reported exhaustion
- Slow walking speed
- Low level of physical activity
Investigations for frailty
- Increased inflammation
- Elevated insulin and glucose levels in fasting state
- Low albumin
- Raised D dimer and alpha-antitrypsin
- Low vitamin D levels
Assessment tools for frailty
- PRISMA-7 Age, sex, health problems, help at home, mobility, social support
- Gait speed
- Self-reported health status
Management of frailty
- Physical activity
- Protein-calorie supplementation
- Vitamin D
- Reduction in inappropriate prescribing
- Comprehensive geriatric assessment
Complications of frailty
- Falls
- Hospitalisations
- Disability
- Death
Causes of constipation in the elderly
- Inadequate diet
- Dehydration
- Weakness or dyspnoea
- Confusion
- Depression
- Inactivity
- Unfamiliar toilet arrangements or lack of privacy
- Using a bedpan
- Medications
- GI = Diverticular disease, IBD, IBS
- Endocrine and metabolic conditions = DM1/2, hypercalcaemia, hypothyroidism, hypokalaemia
- Inguinal and abdominal hernia
- Colonic strictures
- Rectal = Rectocele, Rectal prolapse, Rectal ulcer, Anal fissure or stenosis, Haemorrhoids
- Dyssynergic defecation
- Weak levator muscles
- Spinal cord damage
- Severe neurological diseases
- Severe intellectual disability
Medications causing constipation
Opioids
o Drugs with antimuscarinic effects (cyclizine, TCA, hyoscine)
o Antacids
o Diuretics
o Iron
o Antihypertensive agents
o Cytotxics
o 5HT-3 antagonists
o Platinium-based chemotherapy agents
Presentation of constipation in elderly
- Stools
o dry, hard, maybe abnormally large/small
o Difficult to pass
o Less frequent than usual (every 3 days or more)
o Sense of incomplete evacuation after defecation - Malaise
- Flatulence
- Colickly abdominal pain and distension
- Anorexia
- Nausea, vomiting
- Halitosis
- Faecal incontinence
- Urinary frequency or retention
- Agitated or confused
Lifestyle management of constipation in elderly
o Adequate fluid intake and appropriate diet
o Alleviate contributing factors
o Gradually increase fibre intake
o Increase activity and exercise levels
o Advice on toilet routine
Treatment of constipation in elderly
- Laxative
o Senna or dantron-containing laxative
o Add osmotic laxative (lactulose or macrogol)
o Or surface-wetting laxative (docusate) - Treat any faecal loading or impaction
- Rectal treatment
o Soft loading = bisacodyl suppository or sodium citrate
o Hard loading = glycerol suppository
o Very hard loading = arachis oil enema overnight
Complications of constipation in elderly
- Increased agitation and/or confusion
- Bowel obstruction
- Pain and abdominal distension
- Urinary retention and UTI
- Faecal incontinence
- Faecal retention, distension of rectum, loss of sensory and motor function
- Faecal impaction (particularly if immobile)
- Rectal bleeding
- Rectal prolapse
Causes of malnutrition in elderly
- Depression, Cognitive impairment/dementia, Delirium, psychosis
- Alcohol use
- Medication
- Dysphagia, swallowing problems
- Malabsorption
- Any long term conditions (COPD, HR, renal failure, thyrotoxicosis)
- Poverty, social isolation
- Poor oral hygiene
Presentation of malnutrition in elderly
- Wernicke’s
- Anaemia
- Gingivitis
- Angular stomatitis, glottitis
- Bruising
- Koilonychia
- Proximal myopathy, bone pain, fractures
- Muscle wasting
- Oedema
- Polyneuropathy
Risk assessment of malnutrition in elderly
- MUST (Malnutrition Universal Screening Tool)
o Measure weight and height (BMI)
o Note percentage unplanned weight loss
o Establish acute disease effect and score
o Add scores
o Develop appropriate care plan
Management of malnutrition in elderly
MEALS ON WHEELS
- Medication = stop digoxin, psychotropics, theophylline
- Emotions (depression)
- Anorexia/alcoholism
- Late life paranoia
- Swallowing problems SALT, NG or PEG feeding
- Oral and dental disorders
- No money (poverty)
- Wandering (dementia)
- Hyperthyroidism/hyperparathyroidism
- Enteric problems (malabsorption)
- Eating problems
- Low salt/low cholesterol diet
- Social problems
Complications of malnutrition in elderly
Refeeding syndrome
What is delirium
Fluctuating, impaired consciousness with onset over hours or days or rapid deterioration in pre-existing cognitive function with associated behavioural changes
Causes of delirium
PINCH ME
- Pain (trauma, surgery)
- Infection (UTI)
- Nutrition (hypoglycaemia, vitamin deficiency, alcohol withdrawal)
- Constipation
- Hydration
- Medication = Benzodiazepines, Opiates, Anticonvulsants, Digoxin, L-dopa
- Environment/electrolytes (decreased O2)
Types of delirium
- Hypoactive
- Hyperactive (hallucinations and delusions)
Presentation of delirium
- Cognitive function
o Worsened concentration
o Slow responses
o Confusion
o Disorientation in time
o Fluctuating consciousness - Perception
o Visual or auditory hallucinations
o Persecutory delusions - Physical function
o Reduced mobility
o Reduced movement
o Restlessness
o Agitation
o Changes in appetite
o Sleep disturbance
o Social behaviour - Lack of cooperation with reasonable requests, withdrawal or alterations in communication, mood and/or attitude
- Physically aggressive
Diagnostic criteria for delirium
- Impairment of consciousness and attention
- Global disturbance in cognition
- Psychomotor disturbance
- Disturbance of sleep-wake cycle
- Emotional disturbances
Confusional assessment method
- Acute and fluctuating course
- Inattention
- Disorganised thinking
- Altered level of consciousness
Confusion screen investigations
- Bloods = U+Es, FBC, blood gas, glucose, cultures, LFT, TFTs, vitamin D, folate and B12, HbA1c, calcium, CRP and ESR
- Urinalysis
- Sputum culture
- Drug toxicity
- ECG
- CXR
- LP
Management of confusion
- Treat cause and other exacerbating factors
- Non-pharmacological
o Staff training to recognise delirium
o Use familiar staff members
o Use non-verbal and verbal management
o Reduce emotional arousal or agitation by using appropriate space
o Optimise supportive surroundings and nursing care
o Distraction
o Regular review and follow up - Benzos = Avoid sedation unless extreme agitation, risk
- Anti-psychotics = Consider haloperidol or olanzapine
What is dementia
Syndrome of progressive and global intellectual deterioration without impairment of consciousness
Risk factors for dementia
- Increased age
- Female
- Head injury
- Depression
- Lower intelligence/educational attainment
- HTN
- DM
- Down’s syndrome
- Apo E4
Protective factors for dementia
- Apo E2
- High intelligence/education
- ?Oestrogen
- ?Anti inflammatory medications
Causes of dementia
- Irreversible
o Alzheimer’s disease (amyloid plaques and neurofibrillary tangles)
o Vascular
o Mixed
o Lewy body (M>F)
o Fronto-temporal (e.g. Pick’s disease) - Reversible
o Subdural haematoma
o Hydrocephalus
o Hypothyroidism
Presentation of dementia
- Memory loss
- Personality changes = sexual inhibition, social gaffes, shoplifting, blunting
- Speech = syntax errors, dysphasia, mutism
- Thinking = slow, muddled, poor memory, no insight
- Cognitive
o 4As = amnesia, aphasia, agnosia, apraxia
o Executive dysfunction
o Other deficits = dyslexia, dysgraphia, acalculia - Non-cognitive
o Perception = illusions, hallucinations
o Mood = anxiety, depression, irritable, emotional incontinence
o Behaviour = restlessness, repetitive and purposeless activity, rigid, fixed routines, apathy, agitation, wandering, aggression
o Misidentification - Deterioration in emotional control and behaviour
- Impairment to functioning
Presentation of lewy body dementia
o Visual hallucinations
o REM sleep disorder
o Fluctuating cognition
o Autonomic dysfunction
o PD Sx = tremor, rigidity, bradykinesia
Investigations for dementia
- Formal cognitive testing (ACE III)
o Attention
o Memory
o Fluency
o Language
o Visuospatial - Confusion blood screen = FBC, B12, Folate, ESR, U+E, LFT, Ca2+, TSH
- Syphilis, HIV
- CT/MRI head
Non-pharmacological management of dementia
o Full assessment (inc functional and social needs)
o Exclude treatable and manage exacerbating factors
o Psychological work
o Cognitive enhancement, reminiscence therapy
o Supportive work
o Relative support and carer referrals
o Third sector organisations = Age UK, Alzheimer’s org
o Lasting power of attorney
o Future planning = driving
Pharmacological management of dementia
- 1st line ACE inhibitors = Donepezil, galantamine, rivastigmine
- NMDA antagonists = memantine
- Antipsychotics (short term use) = risperidone
o Beware in lewy body dementia - Antidepressants
Side effects on ACE inhibitors (donepezil)
bradycardia, diarrhoea, headache
Side effects of memantine
confusion, dizziness
Causes of depression in older adults
- Drugs = betablockers, opioids, anti-psychotics, benzos, methyl-dopa, digoxin, nifedipine
- Metabolic = anaemia, B12/folate deficiency, hypercalcaemia, hypothyroidism, hyper/hypokalaemia
- Infective = post-viral, neurosyphilis
- Intracranial = post stroke, SDH, Parkinson’s, dementia
Principles of capacity
- Assume person has capacity unless proved otherwise
- Must use all practicable steps to aid to make capacitous decision
- Person with capacity is allowed to make unwise decision
- If a person lacks capacity, must act in their best interests
- Use least restrictive approach
Assessment of capacity
o Understand information given
o Retain information long enough to be able to make decision
o Weight up information available to make decision
o Communicate their decision
Risk assessment for confused patients
- Wandering
- Leaving appliances or utilities on/unattended
- Risks of exploitation
- Caring responsibilities
- Agitation/aggression to others
- Driving
- Forgetting to take medication
- Self neglect/ inability to care for one-self
What is a pressure ulcer
Damage to area of skin caused by constant pressure on area for long time
Risk factors for pressure ulcers
- Limited movement
- Sensory impairment
- Malnutrition
- Dehydration
- Obesity
- Cognitive impairment
- Urinary and faecal incontinence
- Reduced tissue perfusion
Risk assessment tools for pressure ulcers
- Waterlow score
o BMI
o Nutritional status
o Skin type
o Mobility
o Continence
Classification of pressure ulcers
- Stage 1: Non-blanching erythema
o Intact skin with non-blanchable redness of localised area over bony prominence
o Darkly pigmented skin = bluish tinge, painful, feel warmer - Stage 2: Partial thickness
o Loss of dermis presenting as shallow open ulcer with red pink wound bed without slough - Stage 3: Full thickness
o Tissue loss with loss of subcutaneous fat
o Bone, tendon or muscle is not visible or directly palpable
o Slough or eschar may be present
o May be undermining or tunnelling - Stage 4: Full thickness
o Tissue loss with exposed bone, tendon or muscle visible or palpable
o Osteomyelitis high risk - Suspected deep tissue injury: Skin intact
o Purple localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear - Moisture lesion: NOT pressure ulcer
o Redness or partial thickness skin loss involving epidermis, upper dermis or both
Management of pressure ulcers
- Moist wound environment encourages ulcer healing
o Hydrocolloid dressings and hydrogels
o Discourage use of soap - Tissue viability nurse (TVN)
- Topical antimicrobial therapy Silver/honey/iodine-impregnated dressings
- Systemic Abx If sepsis or deep infection (osteomyelitis, tissue collections)
- Surgical debridement
Prevention of pressure ulcers (SSKIN)
- Support surface
o Pressure-redistributing support surface must be provided for patients who cannot move independently - Skin assessment
o Early detection of pressure damage
o Skin tolerance test
o Keep moving
o Movement through active repositioning for patients with limited mobility - Incontinence and moisture
o Incontinent patients must have continence assessment before implementing appropriate management
o Skin constantly moist from urine, faeces, sweat or wound exudate increases risk of infection - Nutrition and hydration
o Nutritional assessment
o Undernourished or dehydration increases risk
Complications of pressure ulcers
Infection = sepsis, osteomyelitis
Causes of nausea and vomiting in palliative care
- Reduced gastric motility
o Opioid
o Serotonin
o Dopamine - Chemically mediated
o Hypercalcaemia
o Opioids
o Chemotherapy - Visceral/serosal
o Constipation
o Oral candidiasis - Raised intra-cranial pressure
o Cerebral metastases - Vestibular
o Activation of acetylcholine and histamine receptors
o Motion related
o Base of skull tumours - Cortical
o Anxiety, pain, fear, anticipatory nausea
o Related to GABA and histamine receptors in cerebral cortex
Management of N+V caused by reduced gastric motility
o Pro-kinetic agents (metoclopramide, domperidone)
o Not use metoclopramide in complete bowel obstruction, gastrointestinal perforation, immediately following gastric surgery
Management of chemically mediated N+V
o Correct chemical disturbance
o Ondansetron, haloperidol, levomepromazine
Management of visceral/serosal N+V
o Cyclizine and levomepromazine
o Anti-cholinergics (hyoscine)
Management of N+V caused by raised ICP
o Cyclizine
o Dexamethasone
o Radiotherapy if due to cranial tumours
Management of vestibular N+V
o Cyclizine
o Refractory vestibular causes metoclopramide or prochlorperazine
o Olanzapine or risperidone
Management of corticol N+V
o Anticipatory nausea Lorazepam
o Cyclizine
o Ondansetron and metoclopramide
Causes of confusion
- Hypercalcaemia, hypoglycaemia, hyperglycaemia
- Dehydration
- Infection
- Urinary retention
- Medication
- Change of environment
- Any significant cardiovascular, respiratory, neurological or endocrine condition
- Severe pain
- Alcohol withdrawal
- Constipation
Management of agitation in palliative care
- Haloperidol
- 2nd line = chlorpromazine, levomepromazine,
- Terminal phase = midazolam
Management of hiccups
- Chlorpromazine
- Haloperidol, gabapentin
- Dexamethasone (hepatic lesions)
Management of pain in palliative care
- Breakthrough dose 1/6 of daily dose
- All patients on opioids should be prescribed laxatives
- Use opioids in caution in CKD
o Oxycodone preferred to morphine
o Severe renal impairment alfentanil, buprenorphine, fentanyl - Metastatic bone pain strong opioids, bisphosphonates, radiotherapy, denosumab
- Increase doses by 30-50%
Side effects of opioids
Nausea, drowsiness, constipation
Management of secretions
- Stop IV or SC fluids
- 1st line = Hyoscine hydrobromide
- Glycopyrronium bromide
Presentation of spinal cord compression
- Back pain may be worse lying down or coughing
- Lower limb weakness
- Sensory changes: sensory loss and numbness
- Neuro signs
Investigations for spinal cord compression
Urgent MRI of whole spine within 24 hrs
Management of spinal cord compression
- High dose dexamethasone
- Urgent oncological assessment
- Radiotherapy/ surgical decompression
Causes of superior vena cava obstruction
- Small cell lung cancer, lymphoma
- Metastatic seminoma, Kaposi’s sarcoma, breast cancer
- Aortic aneurysm
- Mediastinal fibrosis
- Goitre
- SVC thrombosis
Management of SVCO
- Endovascular stenting
- Radical chemotherapy or chemo-radiotherapy
- Glucocorticoids
Side effects of chemotherapy
Nausea and vomiting
