Geriatrics: general Flashcards
Challenges of geriatrics
- Frailty
- Cognitive dysfunction
- Co-morbidity
- Polypharmacy
- Different patterns of disease presentation
- Different responses to treatment
- Requirements for interdisciplinary support
- Social issues
- Discharge planning
- Rehabilitation
- End of life care
- Chronic illness
Comprehensive geriatric assessment:
a) What is it?
b) What is its function?
c) Give the 4 aspects
a) A multidimensional, multidisciplinary diagnostic process which is focused on determining a frail older person’s medical, psychological and functional capability.
b) The aim is to develop a co-ordinated, integrated plan for treatment and long term follow-up.
c) Medical, functional, psychological, social
Frailty
a) What is it?
b) What does it put patients at risk of?
c) Grading
a) Frailty in the elderly is described as reduced physiological reserves involving multiple organs
b) Vulnerable to decompensation when faced with illness, drug side effects and metabolic disturbances
c) Rockwood scale: from 1 (very fit) to 9 (terminally ill)
Geriatric giants
a) The 5 Ms
b) The 4 Is
- Mind - dementia, delirium, depression
- Mobility - impaired gait, instability, falls
- Medications - polypharmacy, deprescribing/optimal prescribing, adverse effects, medication burden
- Multicomplexity - multi-comorbidities, biopsychosocial components
- Matters most - individual meaningful outcomes and preferences
b) - Intellectual impairment
- Immobility
- Incontinence
- Instability (falls, dizziness)
Acopia
a) What does it mean? (derogatory)
b) What are the common problems in those patients deemed ‘acopic’ in hospital
a) ‘Social admission’, no acute medical problem
b) The majority DO have a medical problem but the presentation is often non-specific (Intellectual impairment and other geriatric giants), also commonly a lack of social care
Medication issues in the elderly
- Much more prone to side effects and interactions
- Reduced organ function (renal, liver clearance, etc.)
- Lack of evidence for treatment in older patients
- Co-morbidities
- Polypharmacy
- Secondary prevention when you’re 102? (e.g. acute risk of falls vs. long-term risk of HTN)
Deconditioning
a) What is it? What is it caused by?
b) How does it present/ what does it result in?
c) How is it prevented?
a) Deconditioning is a complex process of physiological change following a period of inactivity, bedrest or sedentary lifestyle, resulting in functional losses
b) - It results in functional losses in such areas as mental status, degree of continence and ability to accomplish ADLs.
- May be confused,
- have poor nutritional state (even prior to admission, made worse by acute illness),
- immobility,
- falls,
- can’t look after themselves,
- Loss of muscle mass (sarcopenia)
c) Rehab: early mobilisation and PT, good nutrition and MUST assessment
Malnutrition Universal Screening Tool (MUST)
a) Three domains
b) What is it used to assess?
c) What is malnutrition?
d) Which patients are likely to score ‘yes’ on ‘disease effect’ (i.e. likely to have no nutritional intake for 5 days)
a) Body mass index (BMI), percentage weight loss in past 3-6 months, and disease effect (select yes if acutely ill and if there has been or is likely to be no nutritional intake for more than 5 days)
b) Patients at risk of malnutrition
c) A state of nutritional deficiency resulting in adverse effects on body composition, function or clinical outcome
d) Critically ill, awaiting abdominal surgery, head injury, post-stroke (dysphagia)
MUST: scoring
Step 1: BMI (how might BMI be estimated if cannot assess?)
Step 2: % weight loss in past 3-6 months
Step 3: disease effect
Step 4: calculation of malnutrition risk (low, mod, high)
Step 5: management based on risk
- Step 1: BMI >20 = 0, 18.5 -20 = 1, <18.5 = 2 (may be estimated from mid upper arm circumference [MUAC] or clinical impression)
- Step 2: <5% = 0, 5-10% = 1, >10% = 2
- Step 3: If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days, score = 2
- Step 4: 0 = Low Risk Score, 1 = Medium Risk
2 or more = High Risk
MUST: management
a) Low risk
b) Moderate risk
c) High risk (exception?)
a) Low-risk - ROUTINE CARE, Repeat screening (Hospital – weekly, Care Homes – monthly, Community – annually for over 75s)
b) Mod-risk - OBSERVE, Document dietary intake for
3 days: If adequate – little concern, repeat screening as above. If inadequate – clinical concern, follow local policy, set goals, increase nutritional intake, monitor and review care plan regularly
c) High risk - TREAT and REFER TO DIETICIAN, Set goals, improve and increase overall nutritional intake, Monitor and review care plan.
Exception: no treatment if imminent death or lack of anticipated benefit
CGA: (who and what is involved at each stage)
a) Medical
b) Functional
c) Psychological
d) Social
a) Doctor & nurse, (Problem list, co-morbid conditions and disease severity), pharmacist (medication review) dietician & SALT (Nutritional status)
b) OT/PT (Activities of daily living, Activity/exercise status, Gait and balance) and SALT (eating, drinking, communicating)
c) Doctor, nurse, OT, psychologist: Cognitive status testing, Mood/depression testing
d) Doctor, OT and social worker: Informal support needs and assets, Eligibility/need for carers, Home safety
Rehabilitation
a) What is it?
b) What do you need to know?
a) Process of restoring a patient to maximum function
b) Need to know pre-morbid function
Vulnerable patients
a) What is abuse
b) Types of abuse
a) A single or repeated act, or lack of appropriate action, that occurs in a relationship where there is an expectation of trust, which causes harm or distress
b) Physical, neglect, psychological, financial, discriminatory, institutional, sexual.
Important aspects of geriatric social history
ADLs: Personal care, Meals, Shopping, Cleaning, Accommodation, Mobility and walking aids Finances Smoking Drinking Driving
What are the 5 ADLs
- Personal hygiene – bathing/showering, grooming, nail care, and oral care
- Dressing - the ability to make appropriate clothing decisions and physically dress/undress oneself
- Eating - the ability to feed oneself, though not necessarily the capability to prepare food
- Maintaining continence - both the mental and physical capacity to use a restroom, including the ability to get on and off the toilet and cleaning oneself
- Transferring/Mobility- moving oneself from seated to standing, getting in and out of bed, and the ability to walk independently from one location to another
https: //www.mdcalc.com/barthel-index-activities-daily-living-adl
