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Y4 OPIC > Geriatrics (Falls, Osteoporosis, Continence) > Flashcards

Geriatrics (Falls, Osteoporosis, Continence) Flashcards

1
Q

What classes of drugs are known to increase falls risk?

A

Main Ones:

  • Opioids
  • Anxiolytics
  • Antidepressants
  • Antipsychotics
  • Sedatives (e.g. Benzos)
  • Any cardiac medications
  • Anti-cholinergic
  • Hypoglycaemics

Others:

  • BP medications (esp RAMIPRIL)
  • Anti-inflammatories
  • Diuretics

Therefore look for fall risks in elderly patients with CVD, mental health issues or pain issues.

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2
Q

What battery of tests should be ordered in a delirium patient?

A
  • Obs monitoring
  • Bloods
  • DRE (constipation)
  • Urine dip/MSU (UTI)
  • CXR (infection)
  • Medication review
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3
Q

What are the four components of a Comprehensive Geriatrics Assessment?

A
  • Physical assessment (e.g. falls risk, sensory loss, footwear, continence, gait, balance, L/S BP, pain, weight, nutrition)
  • Functional, social, environmental assessment
  • Psychological assessment (e.g. depression, anxiety, dementia)
  • Medication review
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4
Q

How would you take a Postural BP measurement?

A
  • Lie patient down for at least 5 minutes
  • Record blood pressure
  • Have them stand up
  • Record pressure instantly
  • Then again at 1 minute, 3 minutes, and 5 minutes.
  • A drop of more than 20 syst or 10 dyas + symptoms (e.g. dizzyness, light-headedness) is sufficient for a diagnosis of Postural Hypotension
  • Standing BP below 90 w/o symptoms is also suficient for diagnosis
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5
Q

What are the two most commonly used cognitive screening tools?

A
  • AMTS
  • MMSE

Both are used in primary care settings as rapid measures of cognitive dysfunction. While not diagnostic, they can be useful for guiding interventions in patients suspected of having dementia, delirium or a traumatic head injury.

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6
Q

What is MoCA?

A

Another tool for the screening of cognitive impairment.

Again not diagnostic, but the score is a better indicator of normal vs mild cognitive impairment vs Alzheimer’s disease

A MoCA score below 26 is indicative of abnormal cognitive function, which COULD be caused by dementia.

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7
Q

Take a Falls history?

A
  • What were they doing?
  • How did the fall happen?
  • How did they feel before the fall?
  • Was there any dizziness or lightheaded feeling?
  • Did they lose consciousness?
  • Did they have any cardiac symptoms?
  • Are they weak anywhere?
  • Has this happened before?
  • Any near misses?
  • What medications do they take
  • How do you normally mobilise?
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8
Q

What are the crucial sections in a falls history?

A
  • History of the fall; What were they doing, how did it happen
  • Symptoms before the fall; light-headedness, palpitations, aura…
  • Symptoms during; shaking, loss of continence, LoC
  • Symptoms after the fall; post-ictal state, muscular pain, cardiac
  • Cardiac symptoms + history
  • Neuro symptoms + history
  • MSK symptoms + history
  • Falls history; both falls and near misses
  • MEDICATION: What are they on, anything new, anything they’ve forgotten
  • SHx: Normal mobilisation, bungalow, independence…
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9
Q

What are some common anti-cholinergic drugs?

A
  • TCAs (e.g. Amitriptaline)
  • Antipsychotics (e.g. Clozapine, Chlorpromazine, Olanzapine, Quetiapine)
  • Antiemetics (e.g. Cyclizine)
  • Antihistamines
  • Many anti-Parkinsons drugs
  • Antispasmodics (e.g. Tolterodine, Oxybutinin, Atropine).

All increase falls risk in an elderly patient.

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10
Q

What examinations/ investigations should be considered in a Falls patient?

A
  • Functional assessment looking into their mobility (gait analysis, do they mobilise normally or hold onto things, can they get up from a chair safely)
  • Full body exam looking for any injuries
  • Cardio: full exam, L/S BP, 12- lead ECG, consider 24 hour tape
  • Full neuro examination (look for TIAs)
  • MSK assessment (hip, knee, ankle joints)
  • Visual assessment
  • Psychological assessment (depression and anxiety, fear of falling, confidence)
  • Bloods (FBC for anaemia, Us and Es and BMs for metabolic causes, LFTs for alcohol)
  • Osteoporosis risk assessment (Bone health review, FRAX score)
  • Medication review
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11
Q

How can falls be categorised?

A
  • Syncopal vs Non-syncopal
  • Simple vs Multi-factorial

DO NOT use the word ‘mechanical’

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12
Q

What is a syncopal fall and what conditions might cause one?

A

Fall caused by a sudden, transient and self-resolving loss of consciousness.

Examples:

  • Vasovagal syncope
  • Carotid sinus syncope
  • Situational syncope
  • Orthostatic hypotension
  • Falls due to arrhythmia
  • Falls due to valvular disease
  • Vascular steal syndromes
  • MI
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13
Q

What are some non-syncopal causes of Falls in the elderly?

A

W/ partial or total LoC:

  • Epilepsy
  • Metabolic disturbance (most common is hypoglycaemia)
  • Respiratory causes (hyperventilation, hypoxia, hypercapnia)
  • Intoxications

W/O any LoC:

  • Simple falls
  • Cataplexy
  • TIAs
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14
Q

What is the FRAT tool and what are it’s key components?

A

Falls Risk Assessment Tool. Gives a score based off..

  • Recent falls
  • Medications currently on
  • Psychological factors (depression, anxiety…)
  • Cognitive status (using the AMTS)

Also accounts for risk factors including visual difficulties, mobility issues, transfers, behaviours etc

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15
Q

What are some other falls risk assessments worth considering?

A

Multifactorial risk assessment (incorporates balance, gait, mobility, weakness, osteoporosis, fear of falling…)

Timed up and go test.

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16
Q

What Osteoporosis related steps should be taken in a falls patient?

A
  • All patients who experience a fall should be assessed for osteoporosis risk
  • Any patients over 75 who fractures a large bone with minimal trauma should be automatically commenced on osteoporosis treatment
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17
Q

What are some common risk factors for Osteoporosis?

A
  • Advanced age
  • Female
  • Chronic oestrogen deficiency
  • Chronic glucocorticoid therapy
  • Low BMI
  • White/Asian
  • Family History
  • Smoking
  • Inadequate calcium or vitamin D
  • Hypogonadism in men
  • Kidney failure
  • Chronic GI conditions e.g. Crohn’s
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18
Q

What investigations are used in Osteoporosis?

A
  • X-rays can show signs although low specificity
  • DEXA scan- bone densiometry. Provides T score, number of SDs away from healthy bone density.
  • Bloods e.g. Calcium, Phosphate, PTH, Thyroid
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19
Q

How do you interpret DEXA scan results (T score)?

A
  • Greater than 0 = bones denser than healthy comparison.
  • Between 0 and -1 = Normal range of bone density
  • Between -1 and -2.5 = Osteopenia. Offer lifestyle advice
  • Lower than -2.5 = Osteoporosis. Lifestyle advice + treatment + redo DEXA in two years
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20
Q

What are the SHATTERED risk factors for Osteoporosis?

A 
Steroid use
Hyperthyroidism (/parathyroidism)
Alcohol and Tobacco
Thin (low BMI)
Testosterone (low)
Early menopause
Renal/liver failure
Erosive/inflam bone disease
Dietary (reduced Ca)
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21
Q

How is Osteopenia managed?

A

Lifestyle advice e.g.

  • Quit smoking
  • Reduce alcohol consumption
  • Weight bearing exercises (can improve bone density)
  • Balance exercises (reduce falls risk)
  • Calcium and Vit D rich diet or supplements
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22
Q

How is Osteoporosis managed?

A

Lifestyle advice +

  • Alendronic Acid, 10mg/d, with plenty of water, sat up, 30 mins before eating or taking other drugs (risk of GORD and other GI issues) (also given prophylactically in cases of long term steroids). Can also be given as a single weekly 70mg dose if patient is forgetful.
  • IV Zoledronate or Denosumab can be given if AA not tolerated
  • Calcium and Vit D can be used as supplementation, not effective by themselves
  • HRT/Testosterone if low test or oestrogen are identified as causative factors
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23
Q

How is Polypharmacy defined?

A

Differs depending on who you ask:

  • Most commonly 4+ drugs
  • Some studies suggest 6+ is the more correct answers
  • But many geriatricians will say just 1 unnecessary drug = polypharmacy
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24
Q

Why is polypharmacy such a significant issue in the elderly?

A

Polypharmacy increases risk of developing a number of conditions to which the elderly are already at an increased risk of e.g.

  • Falls
  • Delirium
  • Constipation
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25
Q

What questions are important to ask in an incontinence history?

A

Timing:

  • when started
  • gradual vs sudden onset
  • duration
  • progression
  • intermittent or continuous nature

Incontinence itself:

  • pattern e.g. urge, sudden release, do they have any control over it at all
  • can they feel the need to urinate
  • volume?
  • bowel habits e.g. constipation?

LUTS:

  • prostatic symptoms in men e.g. dribbling, hesitancy, feeling of incompletion
  • haematuria, dysuria
  • nocturia
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26
Q

How from a history can you distinguish between the forms of incontinence?

A

Urge = Urge to pass urine followed by uncontrolled and total bladder emptying

Stress = Small losses caused by stress e.g. coughing, laughing, bending down

Overflow = Associated with dribbling, poor flow, hesitancy (generally older men)

True Incontinence = Constant urine leak

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27
Q

What are the most common causes of Urge incontinence?

A

Detrusor instability e.g

  • Idiopathic
  • Cystitis
  • Stone

Hyperreflexia e.g.

  • MS
  • CVA
  • Injury to the spinal cord
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28
Q

What are the most common causes of Stress incontinence?

A

Incompetent sphincter:

  • Common post child birth (RF= multiple pregnancies)
  • Also can simply occur with age
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29
Q

What are the most common causes of Overflow incontinence?

A
  • Prostatic Hypertrophy
  • Stone
  • Stricture
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30
Q

What are the most common causes of True incontinence?

A

Fistulae (between bladder and vagina/urethra)

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31
Q

What investigations should be performed in a patient with suspected Urinary Incontinence?

A

Basics:

  • Review bladder and bowel diary
  • Abdo Exam
  • MS Urine dip (look for haematuria/infection)
  • Post-void bladder scan
  • PR exam should always be performed (constipation + prostate)
  • External genitalia exam (atrophic vaginitis)
  • Can do a 24h pad tests to quantify leakage in ml/hour

If Aetiology remains unclear:

  • Urodynamic assessment (look for abnormal detrusor activity e.g. Urge UI)
  • Outflow Urodynamics (can suggest Overflow)
  • Cystoscopy/MRI for greater imaging of urinary tract abnormalities (e.g. tumours or stones)
  • Urinalysis can show UTI, an unusual but potential cause of UI.

QUALITATIVE TOOLS e.g. Short Form 36 (measures QoL)

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32
Q

Outline the Cons, Pharm and Surg management of Urge UI?

A

Cons = Forms of behavioural therapy e.g. bladder drill, alarms and timers for 6 weeks

Pharm = Anti-muscarinics (e.g. oxybutynin or tolterodine). Side effects = dry mouth, vision blurring, constipation (reduced with slow release)

Surg = Botulinum A toxin injection, PC Sacral nerve stimulation, Diversion via Ileal Conduit

33
Q

Outline the Cons, Pharm and Surg management of Stress UI?

A

Cons = Pelvic Floor Muscle Training for 3 months (can be augmented with biofeedback, cones, electrical stimulation)

Pharm = SNRIs (e.g. Duloxetine) can be given and high rate of improvement, but side effects are common (falls) and most improvers aren’t cured. Most women who fail Cons go to Surg

Surg = Tension-free vaginal tape (good because day case), Intramural bulking agents, Artificial urinary sphincter

34
Q

How is Overflow Incontinence managed?

A

Remove cause of obstruction (almost always refer to Urology)

35
Q

What generic lifestyle advice should be given to all Stress and Urge UI sufferers?

A
  • Weight loss
  • Smoking cessation
  • Caffeine reduction
  • Good bowel habit
  • Maintain a sensible fluid intake (1500-2500 mLs/day)
  • Regular toileting
36
Q

What is problematic about Oxybutynin?

A

Anti-muscarinic, therefore increases falls risk (+ has unpleasant side effects such as dry mouth) in older people (therefore more commonly given for Urge UI in younger patients)

Alternatives = Solifenacin, Tolterodine

37
Q

What are some common side effects of the common Incontinence medications e.g. Oxybutynin, Solifenacin, Tolterodine…

A

Constipation, Dizziness, Drowsiness, Dry mouth, Nausea, Palpitations, Vision disorders and Vomiting

N.B: Drowsiness + Dizziness = Falls risk

38
Q

Why does faecal incontinence occur commonly in older individuals?

A
  • As the body ages the rectum can become more vacuous and the anal sphincter can gape due to a number of factors including haemorrhoids and chronic constipation
  • Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool
39
Q

What are the most common causes of faecal incontinence?

A

Most common = Faecal impaction w/ Overflow Diarrhoea (look for faeces in the rectum, or impaction on scans)

Second = Neurogenic Dysfunction (look for loss of anal tone and sensation, treat as EMERGENCY)

40
Q

What is the most important examination to perform in a faecally incontinent patient and what are you looking for?

A

PR:

  • rectum (for faeces, describe type)
  • prostate
  • anal tone
  • anal sensation
41
Q

Why is faecal impaction such a serious issue in the elderly?

A
  • FI can kill, through stercoral perforation and ischaemic bowel.
  • FI in the rectum will almost always lead to urinary retention which can lead to AKIs
  • Commonly missed; many people assume that a patient passing small amounts of type 1/6/7 stool or smearing is a sign they aren’t impacted but this isn’t the case
42
Q

What management options should be considered in an impacted patient?

A
  • Enemas for rectal loading
  • Stool softeners if hard (e.g. Arachis oil)
  • Stimulants (e.g. Senna)
  • Macrogol (an osmotic laxative) is commonly used first line
  • Fybogel can be used (bulk-forming agent)

Should be noted that stimulants usually work within 6-12 hours, whereas Macrogol or Fybogel tend to take longer, 2-3 days

43
Q

How can impaction be prevented?

A
  • Good diet, rich in fibre
  • Adequate hydration
  • Co-prescription of a laxative with any drug that could lead to constipation (normally a stimulant such as Senna or a stool softener such as Sodium Docusate are used)
44
Q

What to look for in a history that is diagnostic of constipation?

A
  • 3 or fewer bowels movements a week
  • Straining on more than 25% of bowel movements
  • Subjective feeling of hard stool
  • Sensation of incomplete bowel evacuation
45
Q

How should cases of chronic diarrhoea in the elderly be managed?

A
  • Bowel imaging, stool culture to look for potential causes
  • Look for any potentially causative medications
  • Scan/PR to rule out impaction
  • Regular toileting + Dietary review trialled
  • Low doses of Loperamide can be trialled
  • If unsuccessful, constipating regimes can be trialled.
46
Q

What are the diagnostic criteria for a TACS stroke?

A

Requires all 3 of…

  • Unilateral WEAKNESS of the face, arms or legs (with or without sensory disturbances)
  • Homonymous Hemianopia
  • Higher cerebral dysfunction (most common are VS disorder and dysphasia)
47
Q

What are the diagnostic criteria for a PACS stroke?

A

Any two of….

  • Unilateral WEAKNESS of the face, arms or legs (with or without sensory disturbances)
  • Homonymous Hemianopia
  • Higher cerebral dysfunction (most common are VS disorder and dysphasia)
48
Q

What are the diagnostic criteria for a POCS stroke?

A

One of the following….

  • Cranial nerve palsy with contralateral motor/sensory deficit
  • Bilateral motor or sensory deficit (normally just in one territory; the legs)
  • Conjugate eye movement disorder (e.g. gaze palsy)
  • Cerebellar dysfunction (e.g. ataxia, nystagmus, vertigo)
  • Isolated homonymous hemianopia
  • Isolated cortical blindness
49
Q

What are the diagnostic criteria for a LACS stroke?

A

One of the following:

  • Pure motor stroke (hemimotor stroke with no other neurological symptoms)
  • Pure sensory stroke (hemisensory stroke with no other neurological symptoms)
  • Sensori-motor stroke
  • Ataxic hemiparesis
  • Clumsy hand syndrome
50
Q

At what point is anticholinergic burden too high, requiring medication adjustment (or at least review)?

A

3 and over.

51
Q

What is the anticholinergic burden?

A

Cumulative side effects that occur when a patient is on multiple medications affecting the AcH system.

52
Q

What are some drugs that cause ACB?

A

Medications used because they directly affect the AcH system e.g. atropine, benztropine, and oxybutynin

Medications with AcH activity as a side effect e.g. diphenhydramine, cyclobenzaprine, olanzapine, amitriptyline, chlorpromazine, and hyoscyamine

53
Q

What are the common side effects of a high AcH burden?

A

Blurred vision, dry eyes, constipation, dry mouth, urinary retention, decreased sweating, heat intolerance, cognitive impairment, confusion, delirium, dizziness, drowsiness, and increased heart rate.

Especially concerning for older patient is the fact many of these such as the visual and cognitive issues lead to increased falls risk.

54
Q

How is ACB calculated?

A

Have to use an online calculator, can’t be done simply by looking at drugs list as dosages, patient age, patient renal function and certain formulations all affect ACB score.

55
Q

How can issues around anti-cholinergic burden be solved?

A
  • Avoid use of ACB drugs in the elderly
  • If absolutely essential, use them at lowest possible doses.
  • As much as possible try and replace high ACB drugs with low ACB drugs or non-pharmacological options
56
Q

How can orthostatic hypotension be managed?

A

Cons: Lifestyle changes including drinking enough water, reducing alcohol, not overheating, elevating the head of the bed, standing up slowly and waiting a bit before walking off, high salt diet (if not already hypertensive)

Non-invasive: Above knee compression stockings can help avoid blood pooling.

Pharm: Midodrine or Droxidopa (however should be avoided in people with OH on top of HTN).

57
Q

What is a pharmacological option for the management of Postural Hypotension?

A

Fludrocortisone. Increases BP by retaining Sodium.

SEs:

  • Fluid retention
  • Hypernatraemia
  • Hypokalaemia (tell patient to eat more bananas/tomatoes)
58
Q

At what age do you stop urine dipping patients, why, and what should be done instead?

A

65+, most patients have asymptomatic bacteria at that age anyway so doesn’t tell you anything.

Urine Culture + Sensitivity test instead.

59
Q

What are the crucial steps in a continence assessment?

A
  • Review bladder and bowel diaries
  • Abdominal exam
  • PR exam
  • External genitalia (mainly looking for atrophic vaginitis)
  • Dip/MSU/Cultures
  • PV Bladder scan
60
Q

How do you treat Atrophic Vaginitis?

A

Vagifem vaginal inserts.

61
Q

Define a frailty fracture?

A

Any fracture from a height or speed that shouldn’t normally cause a fracture.

Normal bones = Vertebrae, Hip, Wrist, Humerus, Pelvis

N.B: In any unexpected fracture consider bone mets as a possibility, not technically a FF in that case (pathological fracture)- important not to miss.

62
Q

When should a patient have a FRAX assessment?

A
  • Any female over 65
  • Any male over 75

Anyone over the age of 50 with..

  • History of FF
  • Secondary Osteoporosis
  • BMI below 18.5
  • Systemic glucocorticosteroids
  • Heavy smoking
  • Alcohol (14+ units for a woman, 21+ for a man)
63
Q

What drugs can cause secondary osteoperosis?

A
  • STEROIDS
  • PPIs (cause malabsorption)
  • Sodium Valproate and other anti-epileptics
  • Thyroid medications (if dosage too high)
  • Tamoxifen, and other Breast cancer meds
  • Prostate cancer meds
64
Q

What are some causes of secondary osteoperosis?

A

Hormones:

  • Hyperthyroidism
  • Hypogonadism
  • Early menopause
  • TI diabetes (if managed with insulin)

Organs:

  • Liver failure
  • Renal failure
  • GI malabsorption (e.g. IBD or caeliac)
  • Inflammatory or Erosive bone disease

DRUGS (PPIs, Steroids, Anti-epileptics, Cancer meds)

65
Q

If a patient can’t tolerate Alendronic Acid, what are some options for bone protection?

A

IV Zolendronate:

  • 30 mins, once a year, 3-5 years
  • Can give infusion for frail patients in hospital
  • Good if cognitive impairment as doesn’t rely on memory too much

Denosumab:

  • For patients who can’t take Bisphosphonates at all (e.g. renal issues)
  • MOAB that inhibits osteoclast formation
  • SE: Cellulitis

Teriparitide:

  • PTH analogue
  • Given if severely low T score or FF while on other meds
66
Q

Why should a patient starting Bisphosphonates go see a dentist?

A
  • Worst SE of BPs = Osteonecrosis of the jaw
  • ONJ tends to be triggered by trauma e.g. dental work
  • Therefore BPs should be avoided if patient has severe dental issues likely to require work anytime soon.
67
Q

Why shouldn’t you co-prescribe ACE inhibitors and NSAIDs?

A
  • Both reduce renal function, potentially compounding each other into an AKI
  • Can also severely drop blood pressure, causing falls
  • NSAIDs also reduce the effect of ACE inhibitors potentially
68
Q

What are the pros and cons of the CGA?

A

Pros:

  • Evidence based, supports its use over other forms of assessment
  • Known to reduce frailty risk, falls risks

Cons:

  • Complex, stuff often gets missed
  • No criteria given for identifying who should and shouldn’t have one
  • Often difficult in patients with cognitive issues, no workaround for this
69
Q

What are the principal components of the CGA?

A 
Functional capacity
Fall risk
Cognition
Mood
Polypharmacy
Social support
Financial concerns
Goals of care
Advance care preferences
70
Q

What symptoms are often experienced immediately before a vasovagal syncope?

A 
Pale skin
Light-headedness
Tunnel vision
Nausea
Feeling warm
A cold, clammy sweat
Yawning
Blurred vision
71
Q

How is urinary frequency defined?

A

8+ per day

72
Q

How is nocturia defined?

A

2+ per night

73
Q

What are the most important history points in incontinence?

A
  • Predominantly stress or urge?
  • Frequency of episodes, amount of leakage
  • Lifestyle modifications (e.g. pad use)
  • Fluid intake
  • Associated symptoms e.g. prolapse or faecal symptoms.
  • Obstetrics history (e.g. bforceps, perineal trauma)
  • Previous surgery (esp. hysterectomy)
  • FH of diabetes
74
Q

What does Cystometry analysis show?

A

Detrusor muscle activity during the urination process.

75
Q

What would stress UI show on cystometry

A
  • Normal capacity bladder
  • Leakage in absence of detrusor pressure rise!!
  • Leakage provoked by cough test
  • Small to moderate loss
76
Q

What are predisposing factors to gynae prolapse?

A
  • Age
  • Menopause
  • Parity
  • Connective tissue disease
  • Obesity
  • Smoking
77
Q

What are the symptoms/ complaints of prolapse?

A

Most patients report the prolapse themselves e.g. a lump or something bulging or coming down

Others:

  • Backache
  • Lower abdo pain
  • UI/ FI
  • Difficulty micturating, defaecating
  • Bleeding or discharge
  • Pain on intercourse
78
Q

What are the management options for prolapse?

A

Pessaries are easy, effective, with minimal side effects.

Surgery can also work, wide range of procedures depending on organ prolapsing, location of prolapse, complications, continence and desire to preserve sexual function.

Y4 OPIC (5 decks)

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