Geriatrics - Investigations and treatment Flashcards
Benign paroxysmal positional vertigo
Investigations
Treatment
Diagnostic test/investigation-
- Dix-Hallpike manoeuvre
–> Patient sits upright with head turned 45 degrees to one side (testing that specific ear). Patient is then rapidly lowered to a supine position with their head hanging off the bed - CHECK FOR NYSTAGMUS
Treatment
(usually resolves spontaneously after a few weeks or months)
Symptomatic relief via the Epley manoeuvre
- Dix-hall pike manoeuvre for 30 seconds then tilt head 90 degrees in the opposite direction for 30 seconds –> with head still turned, the patient turns the entire body to lay on his side with his head facing down for 30 seconds –> patient sits up with head aligned in midline and flexed for 30 seconds.
Can give betahistine (but limited effect) - reduces fluid in the inner ear
Falls
What is included in a falls risk assessment?
What investigations should be done after a fall?
What are some fall prevention strategies?
Risk assessment includes:
1) A previous history of falls
2) Motor problems
- Gait, balance and mobility
- Muscle weakness
3) Osteoporosis risk
4) Fear related to falling
5) Sensory problems
- Visual/hearing impairment
6) Cognitive impairment - delirium, dementia, depression
7) Polypharmacy
8) Home hazards
Some investigations after the fall
- Bloods (FBC, U+E, LFTs)
- Chest X-ray, CT head
- ECG
- Blood glucose
Fall prevention
- Address risk factors
- Address environmental hazards at home (turn light on, take up rugs)
- Advocate exercise (strength and balance training)
- Ensure good fitting of footwear
(Alcohol service referral)
- Hearing and visual assessment (then hearing aids or visual aids)
- Medication review
Frailty
Tool to identify frailty and disability
Interventions
- Regular medication review
- Exercise
- Adequate nutrition
1) Fried criteria (phenotype)
If you have 3 or more you are considered frail
- Unintentional weight loss
- Self-reported exhaustion
- Weakness (grip strength)
- Slow walking speed
- Low physical activity
2) Rockwood (clinical) frailty scale
(1-9 - 9 being terminally ill)
3) Electronic frailty index
- Identifying the presence of absence of 36 deficits e.g. osteoporosis, diabetes, CKD, hypertension, heart failure. (number of deficits present divided by 36)
4) Prisma 7 (3 or more positive answers is indicative of frailty)
Incontinence
Investigations
Treatment
- Cough stress test
- Urine dipstick and culture
- Examination to check ability to initiate pelvic floor muscle contraction (check for pelvic organ prolapse)
- Bladder diaries (for minimum 3 days)
Tx (depends on whether stress or urge)
Stress incontinence
- Pelvic floor muscle training (kegel exercise)
- Avoid caffeine
Last resort - surgery
(Duloxetine can increase sphincter contraction)
Urge incontinence
- Bladder retraining
- Oxybutynin (anticholinergic) - blocks muscarinic receptors on the detrusor muscle
Osteoporosis
Investigations
What is the tool used to assess 10 year fracture risk?
Treatment
Investigations
- DEXA scan
- Bloods - FBC, U+E CSR, serum calcium, phosphate, TFTs, ALP
Primary prevention - FRAX score
Secondary prevention - Weight bearing exercises, falls prevention, smoking cessation
Tx
Bisphosphonates e.g. alendronic acid (+ calcium and vitamin D3 supplements) —– Take with plenty of water, while in an upright position, to be taken on an empty stomach at least 30 mins before eating
Teriparatide- for patients at very high risk of fracture. (Parathyroid hormone)
Denosumab if patient has kidney disease
What are the scores for DEXA scan?
T : >-1 = normal
<-1 - 2.5 = osteopenia
<-2.5 = osteoporosis
Side effects of bisphosphonate
Osteonecrosis of the jaw, oesophagitis, oesophageal ulcers
Cardiac failure
Investigations
Treatment
1st line - Blood test for NT-pro BNP
GS - TTE
ECG - possible signs of LVH
Chest X-ray
Alveolar oedema
B - Kerly B lines - interstitial oedema
Cardiomegaly
Dilated vessels
E - Pleural effusion
Treatment (started one at a time)
First line
Ace inhibitor
+
Beta blocker - bisoprolol
Second line
Aldosterone antagonist - spironolactone
SGLT2 inhibitors - dapagliflozin
Loop diuretics - furosemide
Third line
Ivabradine - inhibits SAN reducing HR without reducing BP
Malnutrition scoring tool
Malnutrition university scoring tool (MUST)
- BMI (<18.5 =2, 18.5-20 = 1)
- Acute disease effect (if patient is acutely ill and has no nutrition intake for >5 days = 2pts)
- Unplanned weight loss in the last 3-6 months. >10% = 2, 5-10% = 1
Malnutrition treatment
Food first approach e.g. snacks, nourishing food and drinks
2nd line - Oral nutritional supplementation
- Fortisip (nutritional drink)
- High protein jellies
3rd line - Enteral/Parenteral e.g. Nasogastric feeding, parenteral feeding
Advantages and disadvantages of enteral nutrition and parenteral nutrition
1) Relatively cheap compared to parenteral feeding
2) Preserves gut mucosa and integrity
3) Improves patient’s nutritional status
Disadvantages
1) Tolerance
2) Quality of life and personal appearance
Parenteral
1) Helpful to meet nutritional requirements
2) Easily tolerated
Disadvantages
1) Line could get infected
2) More invasive procedure
3) Gut atrophy (as its not being used)
Pressure ulcers/sores
Which scoring tool is used for patients at risk?
Treatment
Clinical diagnosis
Waterlow score is used for patients at risk of developing pressure sores. (National Pressure Ulcer Advisory Panel - NPUAP)
Grade 1 - Non blanching erythema of intact skin
Grade 2 - Partial thickness skin loss involving the epidermis or dermis. (presents clinically as an abrasion or blister)
Grade 3 - Full thickness skin loss involving damage or necrosis of subcutaneous tissue.
Grade 4 - Extensive destruction, tissue necrosis or damage to muscle/bone.
Tx
- High specification foam mattresses
- Hydrocolloid dressing to promote wound healing (waterproof and provides a moist environment for the wound)
- Change position of the patient regularly (shouldn’t be positioned on the wound)
(Nutritional assessment)
(Antibiotics and analgesia if needed)
(Surgical debridement if needed)
Squamous cell carcinoma (of the skin)
Investigations
Treatments
Investigations
- Excisional biopsy
(CT scan to assess extent of disease)
Poor prognosis
- >20mm in diameter
- >4mm deep
- Immunosuppression
Tx
- Surgical excision with 4mm margin (if tumour <20mm in diameter). 6mm margin if >20mm in diameter.
For cosmetically important areas/ tumours >20mm in diameter
1st line - Mohs surgery. (removing layer by layer of cancer cells using microscope to see)
Constipation in children
Potential causes
Investigations
- Clinical
- Digital rectal examination only in cases of faecal impaction - to be carried out by a SPECIALIST
Tx
1st line - Movicol paediatric plain - Escalating dose regimen
2nd line - Add stimulant laxative e.g. Senna
If 1st line not tolerated, an osmotic laxative can be substituted e.g. Lactulose
First line FAECAL IMPACTION- macrogol laxative + electrolytes - ESCALATING DOSE REGIMEN of Polyethylene glycol + Movicol paediatric plain - if not working after 2 weeks –> 2nd line
(High fibre diet and receive sufficient fluids - and maintenance laxatives)
Hirschsprung’s disease
Investigations
Treatment
Investigations
First line - Abdominal X-ray - dilated intestine
GS - Rectal biopsy - absence of ganglion cells
Tx
First line - rectal washout/bowel irrigation
Definitive - Surgery (anastomose normally innervated bowel to the anus)
Coeliac disease in children
Investigations
Treatment
Investigations
- Serology - Anti tissue transglutaminase antibodies
(anti gliadin antibodies and anti-endomysial antibodies)
GS - Jejunal biopsy - shows subtotal villous atrophy
Tx - Gluten free diet for life
Intussusception
Investigations
Treatment
Investigations
- Ultrasound
(doughnut/target sign - concentric rings)
Tx
- Reduction by air insufflation under radiological control – unfolds the bowel
If signs of peritonitis/failure to reduce –> Surgery
Cow’s milk protein allergy/intolerance
Investigations
Treatment
Investigations
- Often clinical
Can do
- Skin prick test (positive in allergy, negative in intolerance?)
- Specific IgE for cow’s milk protein
Tx
If formula fed
First line - Extensive hydrolysed formula (eHF)
Second line - amino acid based formula
For breastfed - continue breastfeeding + eliminate cow’s milk protein from maternal diet
- can consider calcium supplements for breastfeeding mothers to prevent deficiency when they exclude dairy from diet.
For IgE mediated - symptoms resolve by 5 years old
For non IgE mediate - by 3 years old
Biliary atresia
Investigations
Treatment
Investigations
- Serum bilirubin - Conjugated bilirubin is abnormally high
- Liver biopsy - bile duct proliferation with bile plugs
(Other tests to eliminate differentials - Serum A1AT, sweat chloride test)
- Intraoperative cholangiography
Tx
Surgical treatment (anastomosis creation - jejunum and porta hepatis)
If fails - liver transplant
