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Finals > Geriatrics and palliative care > Flashcards

Geriatrics and palliative care Flashcards

1
Q

Risk factors for falls

A
  • History of falls
  • Visual impairment
  • Cognitive impairment
  • Depression
  • Alcohol misuse
  • Polypharmacy
  • Psychoactive drugs
  • Anti-hypertensive drugs
  • Environmental hazards
  • Frailty
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2
Q

Conditions that affect mobility and balance

A

o Arthritis
o Diabetes
o Incontinence
o Stroke
o Syncope
o Parkinson’s
o Muscle weakness

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3
Q

Investigations for falls

A
  • Timed Up and Go test
  • Turn 180 degrees test
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4
Q

Risk assessment for falls

A
  • 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
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5
Q

Criteria for CT head after falls

A

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

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6
Q

Management of falls

A
  • Strength and balance training  physio
  • Mobility aids
  • Home hazard assessment and intervention
  • Vision assessment and referral
  • Medication review
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7
Q

Complications of falls

A
  • 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
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8
Q

Definition of frailty

A

Diminished strength and endurance and reduced physiological function that increases an individual’s vulnerability for developing increased dependency and/or death

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9
Q

Risk factors for frailty

A
  • Disability
  • Comorbidities
  • Advancing age
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10
Q

Presentation of frailty

A
  • Unintentional weight loss
  • Weakness evidence by poor grip strength
  • Self-reported exhaustion
  • Slow walking speed
  • Low level of physical activity
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11
Q

Investigations for frailty

A
  • Increased inflammation
  • Elevated insulin and glucose levels in fasting state
  • Low albumin
  • Raised D dimer and alpha-antitrypsin
  • Low vitamin D levels
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12
Q

Assessment tools for frailty

A
  • PRISMA-7  Age, sex, health problems, help at home, mobility, social support
  • Gait speed
  • Self-reported health status
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13
Q

Management of frailty

A
  • Physical activity
  • Protein-calorie supplementation
  • Vitamin D
  • Reduction in inappropriate prescribing
  • Comprehensive geriatric assessment
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14
Q

Complications of frailty

A
  • Falls
  • Hospitalisations
  • Disability
  • Death
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15
Q

Causes of constipation in the elderly

A
  • 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
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16
Q

Medications causing constipation

A

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

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17
Q

Presentation of constipation in elderly

A
  • 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
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18
Q

Lifestyle management of constipation in elderly

A

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

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19
Q

Treatment of constipation in elderly

A
  • 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
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20
Q

Complications of constipation in elderly

A
  • 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
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21
Q

Causes of malnutrition in elderly

A
  • 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
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22
Q

Presentation of malnutrition in elderly

A
  • Wernicke’s
  • Anaemia
  • Gingivitis
  • Angular stomatitis, glottitis
  • Bruising
  • Koilonychia
  • Proximal myopathy, bone pain, fractures
  • Muscle wasting
  • Oedema
  • Polyneuropathy
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23
Q

Risk assessment of malnutrition in elderly

A
  • 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
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24
Q

Management of malnutrition in elderly

A

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

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25
Q

Complications of malnutrition in elderly

A

Refeeding syndrome

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26
Q

What is delirium

A

Fluctuating, impaired consciousness with onset over hours or days or rapid deterioration in pre-existing cognitive function with associated behavioural changes

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27
Q

Causes of delirium

A

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)

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28
Q

Types of delirium

A
  • Hypoactive
  • Hyperactive (hallucinations and delusions)
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29
Q

Presentation of delirium

A
  • 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
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30
Q

Diagnostic criteria for delirium

A
  • Impairment of consciousness and attention
  • Global disturbance in cognition
  • Psychomotor disturbance
  • Disturbance of sleep-wake cycle
  • Emotional disturbances
31
Q

Confusional assessment method

A
  • Acute and fluctuating course
  • Inattention
  • Disorganised thinking
  • Altered level of consciousness
32
Q

Confusion screen investigations

A
  • 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
33
Q

Management of confusion

A
  • 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
34
Q

What is dementia

A

Syndrome of progressive and global intellectual deterioration without impairment of consciousness

35
Q

Risk factors for dementia

A
  • Increased age
  • Female
  • Head injury
  • Depression
  • Lower intelligence/educational attainment
  • HTN
  • DM
  • Down’s syndrome
  • Apo E4
36
Q

Protective factors for dementia

A
  • Apo E2
  • High intelligence/education
  • ?Oestrogen
  • ?Anti inflammatory medications
37
Q

Causes of dementia

A
  • 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
38
Q

Presentation of dementia

A
  • 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
39
Q

Presentation of lewy body dementia

A

o Visual hallucinations
o REM sleep disorder
o Fluctuating cognition
o Autonomic dysfunction
o PD Sx = tremor, rigidity, bradykinesia

40
Q

Investigations for dementia

A
  • 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
41
Q

Non-pharmacological management of dementia

A

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

42
Q

Pharmacological management of dementia

A
  • 1st line ACE inhibitors = Donepezil, galantamine, rivastigmine
  • NMDA antagonists = memantine
  • Antipsychotics (short term use) = risperidone
    o Beware in lewy body dementia
  • Antidepressants
43
Q

Side effects on ACE inhibitors (donepezil)

A

bradycardia, diarrhoea, headache

44
Q

Side effects of memantine

A

confusion, dizziness

45
Q

Causes of depression in older adults

A
  • 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
46
Q

Principles of capacity

A
  • 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
47
Q

Assessment of capacity

A

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

48
Q

Risk assessment for confused patients

A
  • 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
49
Q

What is a pressure ulcer

A

Damage to area of skin caused by constant pressure on area for long time

50
Q

Risk factors for pressure ulcers

A
  • Limited movement
  • Sensory impairment
  • Malnutrition
  • Dehydration
  • Obesity
  • Cognitive impairment
  • Urinary and faecal incontinence
  • Reduced tissue perfusion
51
Q

Risk assessment tools for pressure ulcers

A
  • Waterlow score
    o BMI
    o Nutritional status
    o Skin type
    o Mobility
    o Continence
52
Q

Classification of pressure ulcers

A
  • 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
53
Q

Management of pressure ulcers

A
  • 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
54
Q

Prevention of pressure ulcers (SSKIN)

A
  • 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
55
Q

Complications of pressure ulcers

A

Infection = sepsis, osteomyelitis

56
Q

Causes of nausea and vomiting in palliative care

A
  • 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
57
Q

Management of N+V caused by reduced gastric motility

A

o Pro-kinetic agents (metoclopramide, domperidone)
o Not use metoclopramide in complete bowel obstruction, gastrointestinal perforation, immediately following gastric surgery

58
Q

Management of chemically mediated N+V

A

o Correct chemical disturbance
o Ondansetron, haloperidol, levomepromazine

59
Q

Management of visceral/serosal N+V

A

o Cyclizine and levomepromazine
o Anti-cholinergics (hyoscine)

60
Q

Management of N+V caused by raised ICP

A

o Cyclizine
o Dexamethasone
o Radiotherapy if due to cranial tumours

61
Q

Management of vestibular N+V

A

o Cyclizine
o Refractory vestibular causes  metoclopramide or prochlorperazine
o Olanzapine or risperidone

62
Q

Management of corticol N+V

A

o Anticipatory nausea  Lorazepam
o Cyclizine
o Ondansetron and metoclopramide

63
Q

Causes of confusion

A
  • Hypercalcaemia, hypoglycaemia, hyperglycaemia
  • Dehydration
  • Infection
  • Urinary retention
  • Medication
  • Change of environment
  • Any significant cardiovascular, respiratory, neurological or endocrine condition
  • Severe pain
  • Alcohol withdrawal
  • Constipation
64
Q

Management of agitation in palliative care

A
  • Haloperidol
  • 2nd line = chlorpromazine, levomepromazine,
  • Terminal phase = midazolam
65
Q

Management of hiccups

A
  • Chlorpromazine
  • Haloperidol, gabapentin
  • Dexamethasone (hepatic lesions)
66
Q

Management of pain in palliative care

A
  • 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%
67
Q

Side effects of opioids

A

Nausea, drowsiness, constipation

68
Q

Management of secretions

A
  • Stop IV or SC fluids
  • 1st line = Hyoscine hydrobromide
  • Glycopyrronium bromide
69
Q

Presentation of spinal cord compression

A
  • Back pain  may be worse lying down or coughing
  • Lower limb weakness
  • Sensory changes: sensory loss and numbness
  • Neuro signs
70
Q

Investigations for spinal cord compression

A

Urgent MRI of whole spine within 24 hrs

71
Q

Management of spinal cord compression

A
  • High dose dexamethasone
  • Urgent oncological assessment
  • Radiotherapy/ surgical decompression
72
Q

Causes of superior vena cava obstruction

A
  • Small cell lung cancer, lymphoma
  • Metastatic seminoma, Kaposi’s sarcoma, breast cancer
  • Aortic aneurysm
  • Mediastinal fibrosis
  • Goitre
  • SVC thrombosis
73
Q

Management of SVCO

A
  • Endovascular stenting
  • Radical chemotherapy or chemo-radiotherapy
  • Glucocorticoids
74
Q

Side effects of chemotherapy

A

Nausea and vomiting

Finals (23 decks)

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